In March of 2020, Daniel Prude died in police custody in Rochester, New York. When body camera footage was released that fall—showing Prude as he lay unarmed and handcuffed, hooded and pinned to the asphalt, snowflakes melting on his naked skin—protests erupted across the country, and found common cause with an already roiling Black Lives Matter movement. 

Prude’s death was, in many ways, depressingly similar to the litany of police killings that had inspired a year of dramatic demonstrations and calls for systematic reform. Documents later revealed how officials took over four months to release arrest footage to the victim’s family and refrained from disciplining police leadership in the face of mounting public pressure. That Prude’s death had so much in common with George Floyd’s, both men subdued and asphyxiated in the street, offered a symbolic reminder of the ubiquity of injustice.  

Yet, Daniel Prude’s demise was also distinct because among the causes of death listed at his autopsy was “excited delirium.”

As a medical student who had recently begun clinical clerkships, I was curious about this diagnosis, which I had never read about in my textbooks or heard on the wards. A quick internet search revealed a host of explanations. From the Seattle Police Department, excited delirium was: “A state of extreme mental and physiological excitement, characterized by extreme agitation, hyperthermia, hostility, exceptional strength and endurance without apparent fatigue.” Variously referred to as “agitated delirium,” “Bell’s mania,” “lethal catatonia,” and “acute exhaustive mania,” proponents of the syndrome defined it  as a constellation of fear, panic, exaggerated strength, hyperthermia, respiratory arrest and death—chiefly in the context of drug use, physical restraint, and police custody. 

Although excited delirium has been invoked to write-off dozens of deaths at the hands of police in the last decade—including, in another morbid parallel to the case of George Floyd, as a possible defense in the trial of Derek Chauvin—it is not recognized as a veritable clinical entity by the American Medical Association, the American Psychiatric Association, the World Health Organization’s International Classification of Diseases (ICD), or the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 

Despite this lack of recognition, “excited delirium” helps police absolve themselves of deaths that occur during arrest. Outlets ranging from Mother Jones to Slate to NPR have reported on how this “questionable diagnosis” provides a medicolegal explanation for what otherwise might be considered murder. In the last few months alone, the controversy has gained broader coverage and has been featured on the television news program (and bulwark of mainstream, bourgeois journalism) 60 Minutes. Nearly simultaneously, the paragon New England Journal of Medicine published a critical (albeit guardedly so) editorial about Prude’s death and excited delirium—written by a Black neurosurgeon who works in Rochester and, remarkably, also happens to be a cousin of Daniel Prude. 

While these recent critiques are laudable, I couldn’t help but think they still fell short. Focused on proving why excited delirium is not “real,” they missed a broader point: why are diseases like excited delirium manufactured in the first place, and how are cultural beliefs and stereotypes reflected in the process of categorizing, diagnosing, and treating illness? Put another way, surely something suspicious is going on when a bunch of  young Black men die suddenly upon encountering the police—whether it’s a “legitimate” clinical syndrome or not. In fact, if excited delirium is, as advocates maintain, a sterile, biochemical process—which remains doubtful—then the phenomenon is still a tragedy. For here are sick people, receiving not a hospital bed and medication but a hogtie and electroshock. Even if we accept the (very) debatable idea that excited delirium is real, it requires compassion and a dedication to better outcomes. For every sickness—manmade or not—has its own narrative, a parable of suffering and diagnosis, and hopefully, triumph. 

How Excited Delirium Became ‘Real’

Most histories of excited delirium begin with Luther Bell, a psychiatrist working at the McLean Hospital in Belmont, Massachusetts. During the mid-1800s Bell described what he believed to be a novel presentation of mania and delirium typified by “exceedingly great overactivity; marked sleeplessness…transient hallucinations that border on illusions” which frequently culminated in death of the patient. (The paper’s title, “On a form of disease resembling some advanced stages of mania and fever, but so contradistinguished from any ordinary observed or described combination of symptoms as to render it probable that it may be overlooked and hitherto unrecorded malady,” gives you a good sense of what 19th century science was like.)

It was not until roughly 130 years later, in the 1980s, that a medical examiner in Miami named Charles Wetli revived interest in excited delirium, and launched its modern association with drug use and police interactions. Wetli described a phenomenon of psychosis and hyperactivity, culminating in sudden death, among seven habitual cocaine users, five of whom died while in police custody. His syndromic description took hold and led a handful of researchers, including Deborah Mash, to seek to identify excited delirium’s pathophysiology—the biological and chemical explanation of how it arises. Mash and others posited “chaotic dopamine signalling” and aberrant quantities of proteins in the brain, like heat shock protein 70, as the cause of excited delirium. Although a singular theory has never been promulgated, Mash also proposed that excited delirium’s etiology was tied to changes in kappa opioid receptors as well as an over-expression of alpha-Synuclein, a protein linked to Parkinson’s, in the brain. 

On the surface, these findings grant a veneer of scientific rigor and legitimacy to excited delirium. See, these people aren’t just killed by the police, there are distinct differences in their brains! But upon closer inspection, these justifications falter on multiple fronts. First, as Meabh O’Hare, Joseph Budhu, and Altaf Saadi of MGH and Harvard Medical School explain, delirium—which is a legitimate and commonplace diagnosis (just delirium, not the supposed “excited” type)—does not by itself cause rapid death. Delirious patients have a “fluctuating disturbance in attention and cognition, typically provoked by an underlying medical condition such as infection, drug intoxication, a medication’s adverse effects or organ failure” but their condition, crucially, “is not associated with sudden unexpected death.” 

Moreover, the two neuropsychiatric conditions which proponents of excited delirium most commonly compare it to—Neuroleptic Malignant Syndrome (NMS) and Malignant Hyperthermia—both have identifiable triggers: antipsychotic medications and anesthetic drugs, respectively. By way of analogy, the only possible “trigger” for excited delirium would be confrontation by the police. And, as O’Hare, Budhu, and Saadi note, the proposed biomarkers of excited delirium are not specific to that condition, repudiating claims to a unique category of illness. 

Dubious biochemistry aside, since its forensic debut, excited delirium has also proved diagnostically inaccurate. During the 1980s, over 30 women—all of them Black—were found dead in Miami. Most were sex workers and habitual cocaine users and even though evidence pointed to assault, Wetli, who was then working in Miami as a medical examiner, concluded that they all were killed by a variant of excited delirium relating to sex and cocaine use. As reported in the Miami New Times, Wetli told journalists that the women had died in relation to “a terminal event that follows chronic use of crack cocaine affecting the nerve receptors in the brain” and even more puzzlingly, that “the male of the species becomes psychotic [after chronic cocaine use] and the female of the species dies in relation to sex.” 

Despite Wetli’s ludicrous implication that all 32 women had died in the heat of intercourse (!?), by 1992 police had identified a serial killer behind the gruesome murders, revealing the more obvious fact—that marginalized people like sex workers, drug users, and women of color are not only consistently disregarded by contemporary society, but are also routinely blamed for their own victimhood. 

Remarkably, Wetli clung to his diagnosis and excited delirium continued to gain traction as industry influences bolstered the shaky diagnosis. As Reuters investigative journalists report in a fascinating series, research into excited delirium got a major boost from a dubious source: TASER International (now known innocuously as Axon Enterprise). In the last several decades, the company has spent millions of dollars on research to defend its eponymous electroshock gun in court, deliberately promoting a nexus of research, law enforcement, and medicine that establishes excited delirium—and not the company’s weapon—as a legitimate cause of death.

Reuters found that excited delirium was: 

listed as a factor in autopsy reports, court records or other sources in at least 276 deaths that followed Taser use since 2000…in at least 30 of 128 lawsuits against the company, the condition was cited as a factor, either by Taser, its expert witnesses or municipalities whose police used the weapon. In all but one of those cases, Taser’s defense prevailed…with excited delirium often one plank in the winning legal argument.

It may come as no surprise to some, then, that Taser has paid both Wetli and Mash to appear as expert witnesses in various defense cases. 

At this point, proponents of excited delirium like to proffer the condition’s recognition by the American College of Emergency Physicians (ACEP) and the National Association of Medical Examiners (NAME); both organizations, on this point, are in opposition to the other major professional groups in their insistence on excited delirium’s existence. 

Yet, it’s now known that at least three of the authors of the ACEP white paper on excited delirium were paid Taser consultants, including Mash and an E.R. doctor named Jeffrey Ho—and that according to Reuters, the trio’s links to Taser were not revealed until two years after the paper’s publication. Ho, who is a physician and police officer in Minnesota, served for many years as Taser’s medical director. In this capacity he was paid hundreds of thousands of dollars to research and travel and teach about excited delirium and the relative safety of Taser guns. In June of 2019, facing sharp public backlash, Ho’s hospital finally terminated the contract that allowed him to serve as Taser’s medical director. As one local official bemoaned, “What hospital has a relationship with, you know, a gun manufacturer?” 

As it turns out, the same hospital where George Floyd died. 

But what about the medical examiners? Don’t they recognize excited delirium as a real clinical entity? In this specialty, too, Taser exerts its influence. According to Reuters, Taser has on its payroll at least one former president of NAME, and actively sues officials who link deaths to their guns, including an examiner in Indiana and another in Ohio. Accordingly, Amnesty International, in its review of over 300 cases of deaths following Taser use and subsequent industry challenges to autopsy findings, concludes that “medical examiners may be subject to pressure by companies or other entities with an interest in protecting a product or reducing their liability in potential lawsuits.”  

Nevertheless, several high-profile physicians have spoken out against excited delirium, including Werner Spitz, a forensic pathologist who investigated the deaths of JFK and MLK, as well as Paul Applebaum, former president of the American Psychiatric Association. As Applebaum states, excited delirium is a “a wastebasket phrase…a way of explaining what happened without necessarily bearing responsibility for it.” Homer Venters, former CMO of NYC Jails, gets even closer to the inherent frailty of excited delirium as a diagnosis when he notes that, “The most consistent feature of excited delirium deaths seems to be contact with law enforcement.” 

Indeed, other than a Taser shock, physical restraint appears to be the only thread linking all excited delirium fatalities—the sine qua non, to borrow from medical parlance (where Latin likes to elevate all discourse.) As a student, I’m encouraged to remember the essential and indispensable condition for a disease, the sine qua non, without which it would not be. You can’t have the seizures of eclampsia without high blood pressure, nor are you likely to have the fevers of malaria without a mosquito bite. So, what about excited delirium? A meta-analysis from 2020 concludes that “there is no evidence to support ExDS (excited delirium syndrome) as a cause of death in the absence of restraint” (italics mine). Rather than an occult pathophysiologic process, the authors suggest “restraint-related asphyxia must be considered a likely cause of death.”

Why the Police Love Excited Delirium 

While understanding excited delirium’s murky genesis is important, it is equally revealing to consider how the syndrome is conceived of by those who lean on it the most: law enforcement. Take for instance this description of a typical case of excited delirium, which comes from a police department in Indiana:

…the subjects will generally exhibit extreme strength and most likely will not respond to law enforcement efforts in the area of pain compliance techniques.  Law enforcement will commonly identify these behaviors as an attempt to defeat their efforts for a safe apprehension of the subject.  Eventually, a greater number of law enforcement personnel or a successful application of a CEW (Taser) will most likely allow for an apprehension.  Routinely, the subject might remain in the prone position or be secured in a transport vehicle for a few minutes while law enforcement continues gathering information for report purposes.  In most ExDS incidents, during transport or during the restraint process the individual will suddenly become calm, unconscious, or go into respiratory distress/cardiac arrest.  

In medical school, we are taught to recognize a multitude of “illness scripts:” an array of clinical signs and symptoms which, in concert with a patient’s history and risk factors, can lead us to a diagnosis. Some illness scripts are straightforward. A woman who went hiking in Connecticut and now has a bullseye rash? That’s Lyme disease. Others are a bit more opaque, and have a broad differential. A child with dull, aching bone pain? It depends. It could be an infection, avascular necrosis, perhaps cancer—or something completely benign, like “growing pains.” Such cases warrant further history-taking (When did the pain start? Does anything make it better?) as well as blood tests and imaging. 

Unfortunately, such measured analysis doesn’t happen with excited delirium, a syndrome without clear diagnostic criteria or biomarkers, and whose sufferers often die in custody. And apart from the question of how accurate diagnostic constellations are—that is, what percentage of people with X symptoms actually have Y disease, and what percentage of people with Y disease don’t have X symptoms—is the question of what cultural messages our scripts impart. 

Lexipol, a private company that provides training manuals and consulting services to thousands of police agencies across the country, offers a primer on excited delirium in which it explains that sufferers are likely to assault officers due to a lack of “remorse, normal fear or understanding of surroundings and rational thoughts of safety.” Lexipol adds that “pain compliance techniques are not likely to be effective as ExDS subjects are often impervious to pain.”

Authors of other descriptions of excited delirium seem to lack even more self-awareness in their role as peddlers of the script of intractable violence and danger. The Indiana police department mentioned above includes among the cardinal symptoms of excited delirium: “unfounded fear and panic…hyperactivity and thrashing (especially after being restrained)…unexplained strength/endurance.” Of course, exhibiting fear and panic in the face of violent arrest and struggling while being forcibly restrained seem to be natural responses, rather than evidence of pathology. And in the context of a literal life and death struggle—the adrenergic system ramped up in “flight or fight”—it is not unreasonable to expect individuals to demonstrate more than normal strength or endurance (e.g., people surviving in the wilderness despite amputation injuries or cases of parents lifting cars off their children—although evidence for such “hysterical strength” is admittedly scant).

The belief on the part of law enforcement that individuals afflicted by excited delirium have exaggerated strength and a diminished response to pain is one of the most striking features of the diagnosis, and perhaps predictably, can be traced to Wetli, who once proclaimed, “It’s as if they’re impervious to pain — to pepper spray, to batons, to numchucks [sic]. You spray them with pepper spray and they just sort of look at you.” It remains unclear why Wetli believed individuals with excited delirium would be impervious to nunchuks, an obscure oriental weapon that despite the increasing militarization of the police would appear to be reserved mainly for YouTube compilations and strip-mall martial artists. Oh wait, nevermind. The cops use them now, too. 

Outlandish weaponry notwithstanding, it’s easy to appreciate how an illness script that highlights a supposed lack of response to traditional policing tactics paves the way for dangerous, and potentially fatal, escalations in force. Every disease narrative comes with a concomitant therapeutic repertoire. For the guy with the crushing left-sided chest pain radiating to the jaw—chew an aspirin and head to the E.R. For the kid with intermittent wheezing and shortness of breath—try an albuterol inhaler. Such directives have the ability to affirm the severity of illness (rush him to the cath lab, stat!) or dismiss it entirely (a 24-year old who normally drinks eight cups of coffee shows up on New Year’s Day with a splitting headache and a resolution to kick caffeine cold turkey. Rx: go to Starbucks).

The trouble with excited delirium—whether it’s “real” or not—is that its “therapeutic” directive is one of complete force that simultaneously lays culpability at the foot of the afflicted person. The Journal of Emergency Medical Services emphasizes this point in its description of excited delirium, creating a caricature of a violent, raving menace: 

…excited delirium patients will, for no known reason, strike out at objects made of glass. They display what some describe as animalistic behavior by grunting, groaning and exhibiting strength that seems superhuman. They aren’t actually stronger; rather, they don’t recognize the implication of any painful stimulus. This includes CEDs, pepper spray and physical compliance holds.

Again, official descriptions of excited delirium prove unabashedly dehumanizing. And while Lexipol contends that those with excited delirium are “remorseless,” it is actually the officers, fed an overwhelming narrative of pain imperceptibility, who are empowered to feel no guilt. Don’t feel bad about shocking and body slamming that guy—he couldn’t even feel it.

Those who defend excited delirium’s clinical veracity—particularly within the medical profession—would be wise to consider the narrative they are peddling. If it is a real clinical syndrome, then why not treat it as such? With treatment comes compassion and a willingness to heal, to see people as patients rather than perpetrators, and the ability to refrain from vindictiveness and proactive strikes.

Here then I may break rank with some who criticize police brutality by contending that it is not the sadism of individual officers that enables episodes of extreme violence—at least, perhaps, not in the case of excited delirium—but the prevailing pseudo-medical rhetoric relating to pain. The sheer universality of the claim that those with excited delirium have a heightened if not infinite tolerance for pain, and the doggedness with which it is preached, from manuals to all manner of online police training videos, exposes, I believe, a subconscious discomfort with the tactics being used, and a need for a buffer on conscience. 

Excited Delirium and the Question of Pain

In an episode of the popular Netflix series Black Mirror, a soldier discovers that the zombie-like humanoids that he has been hunting and killing (nicknamed “Roaches”) are actually human beings, their faces and voices transmogrified into grotesque monstrosities and awful howls by a neural implant placed surreptitiously in each soldier. If an analogy to pop culture is allowed, excited delirium—or rather, the medical mythology that surrounds it—serves in our society as the neural implant: a gimmick without which we would be unable to tolerate our own atrocity. As Mark Greif writes in his essay Seeing Through Police, “The restraints in civilization on attacking anyone, especially a citizen who portends no harm or threat, are fairly high. For most forms of violence that breach civilized norms, even if it is one’s art or profession, steps of habituation are needed.” Imbibing the legend of excited delirium, a narrative of irrevocable insanity and subhuman sensation, is for many, a first step in habituation to violence. 

History offers examples, too numerous to count, of how (pseudo)science, with its connotations of impartiality and inevitability, permits extreme cruelty, namely by telling us, “That is how they are.” And in the case of excited delirium, “This is how they must be handled.”

At the same time, it doesn’t take a Ph.D. in critical race theory to appreciate the tropes at play in institutional descriptions of excited delirium. Emphasizing “superhuman strength” and the ability to “overcome multiple officers,” the literature around excited delirium hearkens back to the myth of the superpredator. Perpetually conflating drug use and violence feeds into the same moral panic that fueled the War on Drugs. In almost every way, the ritualized description, diagnosis, and management of excited delirium—the unpredictable, wild threat that needs to be forcefully subdued—evinces characteristic anxieties about Black bodies that have shaped American culture, politics, and criminal justice since our country’s inception.

In particular, the question of pain—who can and can not feel it—has a troubled history in medicine, which undoubtedly imbues the modern conception of excited delirium. As Linda Villarosa details in New York Times magazine, white physicians have long believed that Black people are not as capable of feeling pain, a conclusion which for many years supported not only slavery, but the practice of outright medical experimentation on people of color. Villarosa cites, among others, the work of Dr. Benjamin Moseley, a British physician who proudly described his experiments on racial discrepancies in perception of pain in 1787: “What would be the cause of insupportable pain to a white man, a Negro would almost disregard.” He continued, “I have amputated the legs of many Negroes who have held the upper part of the limb themselves.”

Moseley’s writing has disquieting parallels with Wetli’s, as both men describe with frank, almost cheerful prose, how individuals can tolerate what seems surely impossible—post-amputation stoicism or unflinching eyes in the wake of pepper spray. And though doctors might have (mostly) evolved beyond such insensitive pronouncements, the question of how to judge and treat pain remains particularly difficult for those in medicine, leaving plenty of room for implicit (and explicit) bias to run free [1]. As Villarosa and others have pointed out, Black patients’ descriptions of pain, in many medical contexts, are still rated less seriously and treated less meaningfully by providers. Most embarrassingly to me as a student, outdated beliefs in physical differences relating to pain perception—the same myths that were first proposed in the era of Moseley—continue to abound. A recent survey revealed that nearly 40 percent of first and second year medical students endorsed a false statement like “black people’s skin is thicker than white people’s” or “black people’s nerve endings are less sensitive than white people’s.”

Perhaps the most appropriate historical parallel for excited delirium, then, is Drapetomania—a once-proposed “mental illness” that sought to explain why Black slaves ran away from their masters. Initially described by Samuel Cartwright, a physician who practiced in the antebellum South, Drapetomania was suggested to be the mental derangement that led wayward slaves to seek liberation; for prophylaxis, Cartwright unironically suggested whipping [2].

Although Cartwright’s proposed clinical syndrome seems laughable today (someone runs for freedom and they called that Drapetomania?), I wonder whether future generations will look at contemporary defenses of excited delirium in the same light (someone was killed by the cops and they called that “excited delirium”?).

I’m cautious about disregarding a purported clinical entity like excited delirium just because it appears at first glance improbable and its pathophysiology may not be fully elucidated. We don’t know why exactly some people are stricken with inflammatory bowel diseases (IBD), although as anyone suffering from daily bouts of abdominal pain, cramping, or bloody diarrhea can attest—it is very much real.

However, when a disease category is unbelievable, has a murky explanation, and seems to exist to exculpate police officers and a shock gun company, we are warranted to raise our eyebrows. Some who take a critical stance toward the medical diagnostic schema contend that an increasing “medicalization” of life has been pushed to service the bottom line of pharmaceutical corporations (e.g., an explosion in the diagnosis of depression, or sleep problems, or even obesity—which now can all be treated with a pill, rather than say, talk therapy, better sleep hygiene, or more exercise). While there is undoubtedly some truth to this argument, in all of these cases there existed at least an a priori substrate for the pathology—some suffering on the part of people that brings them to their doctor. And even when they are sold pills, these potions have at least the intention of cure. No one comes to their doctor saying, “I’m agitated and unruly and violent, can you please choke me or taser me to death?”

Nosology—the field of medicine dedicated to categorizing disease—is like all other human enterprises in that it is informed by our virtues and vices, prejudices and stereotypes. And while Drapetomania and excited delirium represent the use of diagnosis as a means of oppression, it’s worth mentioning that withholding disease recognition can also adversely affect disenfranchised groups. For example, consider fibromyalgia and chronic fatigue syndrome, both of which are poorly understood conditions that predominantly affect women. It took significant effort and much too long for the medical establishment to recognize these disorders, although this is slowly starting to change. Similarly, posttraumatic stress disorder (PTSD) was only formally recognized by the medical community in 1980, despite having been described since at least the time of Gilgamesh. 

While it’s doubtful that excited delirium is a “real” disease in the conventional sense, it would perhaps prove helpful to conceive of the social milieu from which it arises as one. Last year, many in my profession began to call systemic racism a “deep-rooted disease” and a “public health crisis.” The skeptic eyerolls at virtue signaling. Yet the optimist thinks that maybe this is the way to move forward, to make progress the only way we know how. If calling the structural forces that give rise to excited delirium a disease is what it takes to finally address them, then perhaps that’s a medicalization of everyday life we should be willing to accept. 

When approached with benevolence, and not as a tool of oppression, formal recognition of illness can be incredibly salubrious for those suffering: it gives a name to their struggle, it provides a sense of relief in discovering others who share their burden, it opens doors to government and private research, and it begins the quest for an underlying etiology, treatment, and hopefully cure. Those who stand by the “diagnosis” of excited delirium, invoking a facade of science and biology—Tasers (and sometimes nunchuks) at the ready—would be wise to remember another bit of Latin that lies at the core of modern medicine: primum non nocere. First, do no harm.