July, 2020

Excited Delirium Syndrome Challenged
in Recent Article

In a recent article in The Washington Post, the several authors concluded that excited delirium syndrome – a syndromal disorder attributed to many sudden-deaths occurring during or shortly after physical police encounters – is largely a manipulated construct used to shield law enforcement officers from accountability.

Excited delirium syndrome (“ExDS”), the description of symptoms of which began in 1849 – then called Bell’s mania or acute exhaustive mania – is characterized by a sudden onset of delirium, paranoia, violent and/or bizarre behavior, abnormal strength, loss of the feeling of pain, hyperactivity, and hyperthermia, among other symptoms, and is followed by cardiopulmonary arrest. The majority of cases occur following chronic stimulant abuse and bingeing, and – while the exact mechanisms of deaths are yet unknown – post-mortem examinations suggest primary causes are dysregulated central dopamine transporter functions and increased levels of heat shock proteins. Most of the cases stemming from stimulant drug abuse occur from cocaine use, particularly binged crack cocaine, but cases have been reported where the user ingested methamphetamine, PCP, LSD, and synthetics. Cocaine was described in 1985 as a cause of “excited delirium” leading to psychosis and sudden death. Extreme environmental stress and acute mania from a bipolar disorder may also trigger ExDS, as they adversely impact regulation of synaptic dopamine. Death from ExDS usually occurs quickly; two-thirds of the victims die either at the scene where confronted by police or during transport by EMS personnel.

Police action, either through physical restraint, positional asphyxia, or Taser-use, is often suspected as a cause of death because many of the ExDS victims die at the scene. Studies conflict as to whether body positioning can be a cause, and Taser use does not appear to be a supported cause. Research shows that persons suffering from ExDS are prone to be more violent than drunks, and de-escalation techniques are likely ineffective. One Canadian study, cited in a recent article, showed that in 89% of the situations where a person suffering likely ExDS had police involvement the situation became a struggle that ended up on the ground. Since there is no definitive diagnostic test readily available to law enforcement responding to a situation, the officers may look for certain characteristics. Overall, a person suffering ExDS is likely male; on average about 30 years of age; suffering an elevated core body temperature, often causing the victim to strip down to try and cool; suffering an elevated heart-rate, profuse sweating; and visibly under the influence of drugs/alcohol.

In the Washington Post article, the authors noted it is not entirely clear how often ExDS is diagnosed as a cause of sudden death, but that one study from Florida showed, over a ten-year period, 53 deaths of persons in police custody were attributed to ExDS. The authors noted that the pathologist who diagnosed cocaine-as-cause of excited delirium and sudden death had also described the deaths of 32 Black women as having been caused by cocaine use and sexual intercourse. Subsequent investigations, however, attributed the women’s deaths to a serial killer. 

The authors of the Post article also noted that ExDS is disproportionately diagnosed in young black men and that some of the characteristics of the syndrome, e.g., violent behavior, superhuman strength, imperviousness to pain, become after-the-fact justifications for possibly unwarranted police aggression. Also, where law enforcement officers are taught that traditional techniques may not work, more severe tactics, such as “knee-to-neck chokeholds” or hogtie restraints are likely to be applied.

The article authors concluded that ExDS “implies that there is a medical condition that predisposes certain individuals, often black men, to die in police custody. It draws upon aspects of real medical conditions such as delirium, psychosis, drug intoxication and sudden cardiac death. But it manipulates them to form a broadly applicable blanket diagnosis that serves the interests of law enforcement and absolved officers of accountability.”

Sources:  Méabh O'Hare, Joshua Budhu, and Altaf Saadi, “Police keep using ‘excited delirium’ to justify brutality. It’s junk science,” washingtonpost.com, July 17, 2020:
FBI Law Enforcement Bulletin:  Brian Roach, M.D., Kelsey Echols, M.D., and Aaron Burnett, M.D., “Excited Delirium and the Dual Response: Preventing In-Custody Deaths,” leb.fbi.gov, July 8, 2014: 
Deborah C. Mash, “Excited Delirium and Sudden Death: A Syndromal Disorder at the Extreme End of the Neuropsychiatric Continuum,” frontiersin.org, October 13, 2016:
American College of Emergency Physicians: “White Paper Report on Excited Delirium Syndrome,” missouriena.org, September 10, 2009:
Lexipol Team: “Understanding Excited Delirium: 4 Takeaways for Law Enforcement Officers,” lexipol.com, January 6, 2020:

by Neil Leithauser
Associate Editor