Abstract

Excited delirium, also known as agitated delirium, is a condition that presents with psychomotor agitation, delirium, and sweating. It may include attempts at violence, unexpected strength, and very high body temperature. Complications may include rhabdomyolysis or high blood potassium.

The cause is often related to long term drug use or mental illness. Commonly involved drugs include cocaine, methamphetamine, or certain substituted cathinones. In those with mental illness, rapidly stopping medications such as antipsychotics may trigger the condition. The underlying mechanism is believed to involve dysfunction of the dopamine system in the brain. The diagnosis is recognized by the American College of Emergency Physicians but is not in the Diagnostic and Statistical Manual of Mental Disorders or the International Classification of Diseases.

Treatment initially includes medications to sedate the person such as ketamine or midazolam and haloperidol injected into a muscle. Rapid cooling may be required in those with high body temperature. Other supportive measures such as intravenous fluids and sodium bicarbonate may be useful. The risk of death among those affected is less than 10%. If death occurs it is typically sudden and cardiac in nature.

How frequently cases occur is unknown. Those who die from the condition are typically male with an average age of 36. Often law enforcement has used tasers or physical measures in these cases. A similar condition was described in the 1800s and was referred to as Bell's mania. The term "excited delirium" did not come into use until the 1980s.

Signs and symptoms

The signs and symptoms for excited delirium may include:

- Paranoia

- Disorientation

- Dissociation

- Hyper-aggression

- Tachycardia

- Hallucination

- Diaphoresis

- Incoherent speech or shouting

- Seemingly superhuman strength or endurance (typically while trying to resist restraint)

- Hyperthermia (overheating)/profuse sweating (even in cold weather)

- Inappropriately clothed e.g. having removed garments

Cause

Excited delirium occurs most commonly in males with a history of serious mental illness or acute or chronic drug abuse, particularly stimulant drugs such as cocaine and MDPV. Alcohol withdrawal or head trauma may also contribute to the condition.

A majority of fatal case involved men.

People with excited delirium commonly have acute drug intoxication, generally involving PCP, methylenedioxypyrovalerone (MDPV), cocaine, or methamphetamine. Other drugs that may contribute to death are antipsychotics.

Mechanisms

The pathophysiology of excited delirium has been unclear, but likely involves multiple factors. These may include positional asphyxia, hyperthermia, drug toxicity, and/or catecholamine-induced fatal cardiac arrhythmias.

Diagnosis

Other medical conditions that can resemble excited delirium are panic attack, hyperthermia, diabetes, head injury, delirium tremens, and hyperthyroidism.

Treatment

Treatment initially may include ketamine or midazolam and haloperidol injected into a muscle to sedate the person. Rapid cooling may be required in those with high body temperature. Other supportive measures such as intravenous fluids and sodium bicarbonate may be useful.

History

In 1849 a similar condition was described by Luther Bell as "Bell's mania".

It was first described under the name "excited delirium" in 1985 as a condition relating to acute cocaine intoxication.

Controversy | Classification

Excited delirium is not found in DSM-5 or the ICD-10 (the 2013 publication of the "Diagnostic and Statistical Manual of Mental Disorders" and the 1992 publication of the International Classification of Diseases, respectively). The condition "excited delirium", however, has been accepted by the National Association of Medical Examiners and the American College of Emergency Physicians, who argue in a 2009 white paper that "excited delirium" may be described by several codes within the ICD-9.

Eric Balaban of the American Civil Liberties Union argued in 2007 that excited delirium was not recognized by the American Medical Association or the American Psychological Association and that the diagnosis served "as a means of white-washing what may be excessive use of force and inappropriate use of control techniques by officers during an arrest." Melissa Smith of the American Medical Association stated in 2007 that the organization had "no official policy" on the condition.

Controversy | Taser use

Some civil-rights groups argue that excited delirium diagnoses are being used to absolve law enforcement of guilt in cases where alleged excessive force may have contributed to patient deaths. In 2003, the NAACP argued that excited delirium is used to explain the deaths of minorities more often than whites.

In Canada, the 2007 case of Robert Dziekanski received national attention and placed a spotlight on the use of tasers in police actions and the diagnosis of excited delirium. Police psychologist Mike Webster testified at a British Columbia inquiry into taser deaths that police have been "brainwashed" by Taser International to justify "ridiculously inappropriate" use of the electronic weapon. He called excited delirium a "dubious disorder" used by Taser International in its training of police. In a 2008 report, the Royal Canadian Mounted Police argued that excited delirium should not be included in the operational manual for the Royal Canadian Mounted Police without formal approval after consultation with a mental-health-policy advisory body.

A 2010 systematic review published in the Journal of Forensic and Legal Medicine argued that the symptoms associated with excited delirium likely posed a far greater medical risk than the use of tasers, and that it seems unlikely that taser use significantly exacerbates the symptoms of excited delirium.