Saturday, May 21, 2016

Excited delirium: Cause or excuse for deaths in custody?

This NY Times piece on a Georgia death-in-custody didn't use the phrase "excited delirium," but it's precisely the type of circumstance from which that diagnosis can arise.

Grits' contributing writer Amanda Woog asked me recently about "excited delirium," having seen the term come up in death in custody reports she's curating as part of her Texas database project. (Look for a big announcement soon as she releases new datasets beyond just recent police shootings.) I first heard the term when I directed the ACLU of Texas' Police Accountability Project around the turn of the century and it represents one of the most curious and bizarre distortions of medical terminology in service to a political agenda I've ever personally run across. Really, excited delirium is not a diagnosis at all so much as an acknowledgement of the lack of other diagnoses. It's what authorities say when someone dies after being restrained or Tazed by police, they don't want to blame the officer(s), but there are no other explanations for the outcome. One often sees the term suggested in the press by unions before medical examiners ever release their findings.

Excited delirium is a medical condition which seemingly only manifests itself when the patient is being beaten, Tazed, or otherwise physically restrained by law enforcement, which makes it an atypical diagnosis, to say the least. Cynics contend it's a fake diagnosis created to cover up police misconduct. Among professional associations, those fields more closely associated with law enforcement - medical examiners and emergency physicians - accept the term, while the AMA, APA, the DSM, and the World Health Organization do not. The chairman of Texas' Forensic Science Commission, Vincent Di Maio, wrote the principal, professional text making the case for the diagnosis (though clearly it wasn't enough to convince the AMA, etc.).

Anyway, debates over the diagnosis reignited in the last year - with major pieces in the Washington PostSlate, and Vice/The Influence - in light of renewed interest in death-in-custody cases inspired by the rise of the Black Lives Matter movement. If someone as well-read as Amanda was unfamiliar with the term, then perhaps others aren't, either. So I thought it'd be good to compile some key links on the topic.

One of the earliest significant MSM pieces I remember on it was from 60 Minutes in December 2003; that sort of put the debate on the map, for me, anyway. Mother Jones in 2009 attributed the rise of the term to the company Taser International, which reportedly employed Di Maio as an expert witness and handed out free copies of his book at law enforcement trainings.

The website PoliceOne has covered the issue quite a bit over the years. Here are a few key items:
Here's a white paper on the topic from the American College of Emergency Physicians, which recognizes the "syndrome."

The since-fired Austin officer who shot and killed David Joseph, a black teenager who was buck naked sprinting down the street, said he thought the young man may have suffered from "excited delirium."

Grits is very much a skeptic here. If we had people dying of excited delirium under other circumstances besides being taken into custody by law enforcement, I'd consider the idea to have more merit. But it's awfully convenient to blame some vague "syndrome" that can't be verified while ignoring violent actions immediately preceding a death as the most likely cause. No civilian would ever get such consideration.

OTOH, it almost doesn't matter. The truth is that police wouldn't be held accountable for those deaths even if no one had ever heard of "excited delirium." (Taser is probably the chief beneficiary of such blame shifting; they don't enjoy qualified immunity.) Meanwhile, pretending the syndrome exists may result in training recommendations for de-escalation techniques which are beneficial regardless of the terminology used.

For example, recently the missus ran across a case from 2015 in which Robert Brandon Edwards was restrained by police and died in transit to the hospital. See Statesman coverage from when the officers were no-billed, the APD incident report and autopsy report, which concluded that Edwards "died as a result of the combined effects of methamphetamine and phencyclidine toxicity and physiologic stress associated with restraint procedures." Though the medical examiner didn't cite "excited delirium" as a cause of death, the detective taking a statement from one of officers used the term to describe Mr. Edwards' condition.

If the department were to alter procedures aimed at preventing deaths like Mr. Edwards, the benefits would not be reduced because they adopted a trendy catch phrase.

These situations are arising and people are dying, whatever we call it. If it takes acquiescing to use of a pseudoscientific buzzword to convince police to embrace de-escalation and/or restraint techniques that minimize loss of life, I suppose we shouldn't mind. In the meantime, though, "excited delirium" still strikes me as less a diagnosis than a strained defense.


Unknown said...

Scott, that's a good summary of the pros and cons.

There's one more thing to add. Suppose, hypothetically, that there are people who combine adrenaline and drugs to such an extent that they were dying already before the police got to them. Is it evidence against that hypothesis that the same people aren't dying in mental hospitals?

Not necessarily, because in a hospital a sedative is minutes or even seconds away. That, by itself, might account for the difference.

That line of thought leads to the desirability of psychiatric ambulances staffed with people with reassuring voices and beta blockers.


Anonymous said...

Maybe we should make up some term to describe when a cop gets killed? Perhaps Concitatus Mortem Autem Malum. Not as catchy as Excited Delirium to be sure, but an accurate description nonetheless.

Anonymous said...

When I took the Texas mental health peace officer course, there was discussion about excited delirium as a cause of death while in custody. The lesson was that, when someone was in a state of mental health crisis (whatever the cause), their breathing and heart rate change. When taking someone into custody, it's important to recognize this physical state, get the offender restrained, and then immediately sit them up so they can breathe. I've seen many videos online of arrests in which the suspect is clearly in a state of excited delirium, but the officers don't immediately sit them up once restrained. The offender complains about not being able to breathe, gets more agitated, and the officers continue to hold the offender face and chest down on the ground. In this whole talk of excited delirium, I think the first place to start is train officers to get the arrested person into a seated position to limit that risk. BTW, great post.

Gritsforbreakfast said...

Wow, so the MH peace officer course specifically trains on it! Are there any other preventives besides sitting them up? Do they discuss de-escalation in that context?

BTW, I just watched another video of a man who died in restraints at an HEB in Austin last year which would fall within this nexus of circumstances. As you suggest, they had him laying on his back instead of sitting up; he began vomiting then died in transit. I wonder if sitting him up would have saved the guy's life?

Anonymous said...

De-escalation should be a no-brainer when dealing with folks in mental health crisis, and the MH peace officer course actually emphasizes that. The course I took also recommended steps to take should the decision to go "hands on" be made and covered what to look for with someone experiencing excited delirium. Death in those situations is often caused by "positional asphyxia," not the delirium itself (which is often brought on by substance abuse and/or mental health issues). The course even listed several behaviors too look for to identify someone who might be in that temporary state so that dealing with them can be more effective.

I would recommend contacting Ofc. Frank Webb and Ofc. Rebecca Skillern with the Houston PD Mental Health Division. They conducted the training I went through and are a great resource.

Gritsforbreakfast said...

Good to know, thank you!

Anonymous said...

I recall that at one time the insurance industry classed diabetes as a 'mental' condition for no other reason than it was a very effective means of denying liability.

I should note that more recently the same approach was used for Lyme Disease and other medical problems.