What is ‘excited delirium’ — and why did California ban the term?

This week, California became the first U.S. state to ban the term “excited delirium” as an official cause of death.

A growing number of doctors and medical associations have distanced themselves from using it as a diagnosis, stating that it has no scientific or medical validity.

In addition, the term has been used most often to describe the deaths of men and women of color, adding a racial element to the controversial diagnosis.

“The only place where this term is continuously used is to describe deaths that occur in police custody,” California Assemblymember Mike Gipson, who sponsored the bill banning the term, said in a news release.

“From the beginning, this terminology has been disproportionately applied to communities of color and has only been used in specific contexts pertaining to encounters with law enforcement,” Gipson added.

California Gov. Gavin Newsom signed the bill into law on Sunday, Oct. 8.

What is excited delirium?

Excited delirium is a vaguely defined term that describes symptoms including aggressive behavior, a high tolerance for pain, extreme agitation and emotional distress.

The diagnosis appeared on death certificates, police records and coroners’ reports during the crack cocaine epidemic of the 1980s, according to a report from Physicians for Human Rights. Soon, the term was used as a catch-all for deaths that occurred in the context of law enforcement restraint, often coinciding with substance use or mental illness.

By 2009, the American College of Emergency Physicians (ACEP) had endorsed excited delirium as a legitimate cause of death.

The term was adopted by police training manuals and promoted at conferences of medical examiners and police chiefs, the Physicians for Human Rights report also noted.

Is excited delirium real?

Despite the endorsements and widespread use, excited delirium was never recognized by psychiatrists or other mental health experts.

“Excited delirium is not a reliable, independent medical or psychiatric diagnosis,” said Gipson.

“There are no diagnostic guidelines, and it is not recognized in the DSM-5 [Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition], which is the main diagnosis guide for mental health providers,” he added. “Neither the American Medical Association nor the American Psychiatric Association recognizes this term as a legitimate diagnosis.”

Indeed, the AMA and APA never acknowledged “excited delirium” as an actual syndrome, and critics have repeatedly called it unscientific and rooted in racism.

Abuse of the term

“Excited delirium is often used when there’s a death associated with a physical altercation between a citizen and law enforcement,” Dr. Roger A. Mitchell Jr., chair of the pathology department at Howard University in Washington, D.C., told the Associated Press.

“It’s not a real explanation for the death,” Mitchell added.

In recent years, the term has surfaced as an explanation for the deaths of black, Latino and other people at the hands of white police officers.

In 2021, excited delirium was cited in the death of Daniel Prude, a 41-year-old black man in Rochester, New York. A grand jury rejected charges against police officers in that case.

Excited delirium came up again in the 2021 trial of former Minneapolis police officer Derek Chauvin, who was later convicted in the death of George Floyd. And the term has resurfaced in the ongoing trials of police officers charged in the deaths of Elijah McClain in Colorado and Manuel Ellis in Washington state.

“In 2020, Angelo Quinto, a Filipino-American Navy veteran dealing with a mental health crisis, stopped breathing while two police officers knelt on his back and neck. Mr. Quinto’s official cause of death was determined to be excited delirium,” Gipson said. “That is absolutely absurd.”

Excited delirium declared outdated

By March of this year, the National Association of Medical Examiners took a stand against the controversial term, declaring that “excited delirium” or “excited delirium syndrome” should not be used as a cause of death.

And yesterday, ACEP formally disavowed any use of excited delirium as a legitimate diagnosis. calling its 2009 endorsement outdated.

“This means if someone dies while being restrained in custody … people can’t point to excited delirium as the reason and can’t point to ACEP’s endorsement of the concept to bolster their case,” Dr. Brooks Walsh, a Connecticut emergency doctor, told the Associated Press.

Dr. Joyce deJong, president of the National Association of Medical Examiners, said the group’s disavowal of excited delirium arose from concerns that the phrase might be used to justify excessive force by police.

“Anything we can do to avoid perpetuation of a phrase that might be causing harm,” said deJong, a medical examiner in Michigan.