Dying of Excitement

Police often blame suspects’ deaths on “excited delirium.” Is that a diagnosis or a cover-up?

"Excited delirium"
Medical examiners have cited “excited delirium” as the cause of death for several people in police custody, even when they had broken bones or police used Tasers to subdue them.

Photo by Lucy Nicholson/Reuters

When Natasha McKenna was in police custody at the Fairfax County, Virginia, jail in February, the mentally ill woman was restrained by six deputies who, unable to subdue her, shocked her with a Taser. She died several days later. But as the Washington Post reported recently, when the Virginia medical examiner’s office ruled on the cause of death, the conclusion was that a rare and mysterious syndrome known as “excited delirium” had actually killed her, and not the Taser or the extreme force used by six officers against a woman suffering from schizophrenia and bipolar disorder who weighed just 130 pounds.

“Excited delirium” is the name given to a condition in which a person, either as a result of mental illness or protracted use of stimulants such as cocaine or methamphetamines, becomes extremely violent; hyperaggressive; and is often found naked, agitated, incoherent, feverish, and displaying extraordinary strength. The phenomenon is reported most often in police encounters, requiring, on average, four officers to restrain the suspect. In approximately 10 percent of cases, according to the literature, the person with excited delirium may die suddenly. The heart or breathing simply stops. So when someone dies in that agitated state and no other cause of death is found, the medical finding is that excited delirium was the cause. It accounts for approximately 250 deaths in the United States each year, with one expert speculating that about 800 cases occur each year nationwide.

The obvious problem is this: What do we make of a syndrome that seems to occur almost unerringly when a police officer is choking, hog-tying, or stunning with a Taser someone with a mental illness or drug addiction? And why do many experts dispute that the diagnosis even exists? While excited delirium is used to explain a significant number of deaths occurring in police custody, the term has not been recognized as a genuine mental health condition by the American Medical Association, the American Psychological Association, or the World Health Organization. Excited delirium—which sounds, to the naked ear, something like “crazy-craziness”—is not found in the current version of the Diagnostic and Statistical Manual of Mental Disorders, either. Yet medical examiners and police departments keep claiming it as the cause of death of people in custody. In 2014, the International Association of Chiefs of Police issued a white paper that tried to bridge the gap, concluding, “Despite what it is called or whether it has been formally recognized, it is a real clinical concern for both law enforcement and the medical communities.” But is it a real medical phenomenon? Is it a convenient way to blame the victim, as civil liberties and prison reformers claim? Or is this a genuine syndrome that occurs largely in fights between the mentally ill and the cops? Now more than ever, when suspicious deaths in police custody are making headlines, should we consider excited delirium an illness or a cover for police abuse?

Medical examiners and police departments say it’s a genuine syndrome. The National Association of Medical Examiners has recognized the condition for more than two decades. And in 2008, the Council of the American College of Emergency Physicians declared that excited delirium is “a real syndrome of uncertain etiology.” Emergency room doctors and medical examiners insist that members of the larger mental health community don’t acknowledge the condition because they never see it.

All of this looks like it pits the medical and mental health community (minus ER docs) against the police and forensic investigators. And it raises questions about whether this diagnosis is that of a singular medical phenomenon or an imprecise post-hoc explanation for mysterious deaths that, almost invariably, as NPR noted, “involve people who are fighting with police.”

There may be a plausible, relatively innocent explanation for the fact that most deaths in excited delirium cases arise when the police are restraining someone. Doctors in hospitals have successfully tranquilized people with symptoms of excited delirium, and the patients have survived. But when cops—armed with nightsticks and Tasers—try to subdue someone with excited delirium by force, the person may die. This doesn’t mean cops are causing the deaths, but merely that they are not in a position to avoid them.

A restraint chair in the Fairfax County jail.
A restraint chair in the Fairfax County, Virginia, jail similar to one used to hold Natasha McKenna after deputies shocked her four times with a Taser on Feb. 3, 2015. She later died, and police are investigating.

Photo by Washington Post/Getty Images

The genesis of the term excited delirium goes back to 1849, when it was used by Luther Bell to describe psychiatric patients who developed agitation and mania while in the grip of a fever, then died abruptly. Charles Wetli revived the term in the drug-addled 1980s to explain sudden death in recreational cocaine users. It was quickly adopted by police to explain cases like Tony Steele, who was high on cocaine and died suddenly in the back of a patrol car in 1991. Now excited delirium is diagnosed routinely. Nathaniel Jones died in police custody in 2003 after being wrestled to the ground and beaten with nightsticks; his death was blamed on excited delirium. Randy Escobedo’s autopsy in 2003 revealed two broken bones around his throat, eight broken ribs, and internal bleeding. The coroner ruled the cause of death excited delirium. Same ruling for Keith Graf in 2005 in Phoenix, Arizona. Patrick Lee in 2005 in Nashville, Tennessee. Or Polish citizen Robert Dziekanski at Vancouver International Airport in 2007. Or 35-year-old Efrain Carrion in 2010 in Connecticut. Or Kevin Campbell in Florida in 2011. Kevin L. Ellis in 2013.

Critics have blamed the uptick in excited delirium diagnoses largely on the Taser industry. In 2013, Amnesty International, the only organization that has compiled data on this issue, claimed there were 552 incidents since 2001 where a Taser was used on a victim who then died, yet autopsies cited Taser use as a cause or contributing cause of death in only 60 of those cases.. Excited delirium diagnoses have also protected Taser from liability in many use-of-force suits against the company. In a 2007 interview with NPR, Taser International spokesman Steve Tuttle said that each year his company “sends hundreds of pamphlets to medical examiners explaining how to detect excited delirium. Taser also holds seminars across the country, which hundreds of law-enforcement officials attend.” Tuttle went on to add: “We’re not telling departments [that] excited delirium is always the cause of death following a Taser application. … We’re simply pointing out the facts: that excited delirium is an issue out there, and they need to treat this as a medical emergency if they see these signs.” A piece in Mother Jones details the extent to which ER doctors and medical examiners get most of their information about excited delirium from Taser.

This kind of self-interested advocacy has enraged some mental health experts and prison reform advocates. Eric Balaban, senior counsel with the ACLU’s National Prison Project, told NPR that it could lead cops to use more force when they should be calming things down: “If police officers are being trained about this condition known as excited delirium, and are being told the people suffering from it have superhuman strength, and [these people] are being treated as if they are somehow not human, it can lead officers to escalate situations.”

At a Canadian public inquiry set up in 2008 to study the appropriateness of allowing cops to use Tasers, Mike Webster, a police psychologist, went further. He blamed Taser International for “brainwashing” cops and testified that “police and medical examiners are using the term [excited delirium] as a convenient excuse for what could be excessive use of force or inappropriate control techniques during an arrest.” He went on to add that members of the law enforcement community “have created a virtual world replete with avatars that wander about with the potential to manifest a horrific condition characterized by profuse sweating, superhuman strength, and a penchant for smashing glass that appeals to well-meaning but psychologically unsophisticated police personnel.”

The results of that two-year official 2009 inquiry, chaired by a retired British Columbia appeals court justice, Thomas Braidwood, concluded that the term excited delirium had been rejected by medical professionals and was being used to cover up actual causes of deaths in custody, especially those involving excessive restraint and Tasers. Braidwood wrote that it was “not helpful to characterize people displaying these behaviors as suffering from excited delirium. Doing so implies that excited delirium is a medical condition or diagnosis, when mental health professionals uniformly reject that suggestion.” Taser International sued to have the Braidwood findings quashed, but the company lost.

Part of the ambiguity is that, much like in cases of sudden infant death syndrome, a medical examiner who diagnoses excited delirium can’t point to a clear cause of death in the autopsy. As Vincent Di Maio, a retired forensic pathologist, explains in his book on the subject, excited delirium is only determined after an autopsy “fails to reveal evidence of sufficient trauma or natural disease to explain the death.” You work backward to the diagnosis.  

Researchers are still trying to find biological signals of excited delirium. Wired reported in 2009 that a study by Deborah Mash and colleagues at the University of Miami and published in Forensic Science International looked at samples of brain tissue for 90 people who had apparently died of excited delirium. The researchers found the signatures of two distinctive “biomarker” proteins that were common to all 90 cases. But subsequent research found that these proteins are evidence of drug use and not specific to excited delirium.

The ACLU is having none of it. Balaban told the Washington Post that the syndrome is simply an easy way to “whitewash” excessive use of force by cops on suspects with serious mental health problems. The notion that mentally ill or drugged suspects who are behaving wildly need to be restrained and beaten is finally getting deserved attention. A horrifying new study from Human Rights Watch shows the extent of abuse of mentally ill prisoners in the American prison and jail systems.

A note in the 2012 Saint Louis University Law Journal by Michael L. Storey blames journalists for perpetuating the idea that excited delirium is a myth. He wrote that they “favor controversy and blame rather than balance and exploration.” But any medical diagnosis that shifts blame from the living to the dead, and from cops onto victims, based on a condition that is diagnosed only in the absence of other clear causes is really not to be blamed on reporters. Apparently while we’re busy hog-tying the prisoner, we should pause to shoot the messenger as well.

Perhaps the final paradox of the excited delirium craze is that it may be leading to better police procedures in the long term. Whether excited delirium rests on junk science pushed by Taser International or is a legitimate diagnosis of a genuine disease, some police departments have begun to enact more effective law enforcement training. As Storey notes, cops in Dallas are being trained to call an ambulance when they come across a person displaying symptoms of excited delirium, and they are asked to defuse the situation with suspected mentally ill persons “by slowing things down, and using the suspect’s first name and trying to avoid the use of force.” By training cops to see excited delirium as a medical emergency instead of a fight to the death with a hulking superpredator, the police may be learning to better handle these crises using nonlethal force.  

After Randy Escobedo died in police custody, the San Diego Police Department retrained its officers to ensure that suspects were never detained face down, and suspects were monitored after their arrests.  In British Columbia, as a result of the Braidwood hearings, a cop is prohibited from deploying a Taser unless “the subject is causing bodily harm or the officer is satisfied, on reasonable grounds, that the subject’s behavior will imminently cause bodily harm.” In Toronto, a hospital has partnered with two downtown police divisions to create a “mobile crisis intervention team”—a police officer and a mental health nurse—to deal with emergencies involving emotionally disturbed people. If a diagnosis of excited delirium, whatever it is, works in the long term toward treating mental health crises as mental health crises rather than crimes, perhaps it’s a step toward more humane and safe policing.