Dying of Excited Delirium

Excited delirium is a cause of death that you may not have heard before. It sounds pretty far out: being so delirious with excitement that (presumably) your heart just straight-up fails. Sounds like it would have to be something that's drug induced, or caused by a criminal mania. Sounds like something only the most wild and psychotic person would be diagnosed with. And being diagnosed with it they are: hundreds of people have this listed on their death certificate. But the kicker is the other things they have in common. They're nearly all people who die while in police custody, and they're nearly all people for whom the use of a taser was involved in their apprehension. But there are three more things they also have in common: they're nearly all men, they're mostly young, and they're disproportionately Black. Suddenly something that sounded merely far out and wild begins to also sound suspicious. Today we're going to find out which it is.

In May of 2020 in Minneapolis, George Floyd lay on the ground while a senior officer knelt on his neck for nine minutes, causing his death. A junior officer nearby, following his training, asked if Floyd's death was due to excited delirium. In 2019, young Elijah McClain was killed by a 500mg overdose of ketamine administered by emergency responders after police pinned him to the ground in a choke hold for allegedly walking home from a convenience store. The paramedics told investigators the injection was necessary because McClain had excited delirium. Where did these responders learn about this supposed diagnosis? (Note: tasers were not used on either Floyd or McClain.)

The cynical view of excited delirium would be that it is a fake diagnosis, invented or distorted by the manufacturers of tasers, to falsely claim that people who died from being tasered actually died from some internal delirium, in order to protect the manufacturer from liability. That's the basic implication made by a series of special reports published by Reuters in 2017. It's a pretty serious charge, but then charges of such magnitude are found throughout Skeptoid and the skeptical literature in general – everything from alternative medicine schemes deceiving people away from life saving medical treatment and resulting in their deaths, to psychic predators who take money from the grieving with the false promise of connecting them with their deceased loved ones, all the way to ivory tower environmental groups lobbying African nations to reject donations of genetically modified crops that could have saved tens of thousands of lives lost to drought. Make no mistake: pseudoscience can be not just immoral, but literally deadly. And if excited delirium is indeed a pseudoscientific diagnosis meant to shield those responsible for actual deaths from liability, then it deserves the full force of our skeptical eye. (It would probably deserve much more, but all we can do here is all we can do.)

Compounding all of this, and in fact escalating it, are two other claims that raise the urgency: First, that nearly everyone to whom this diagnosis has been applied has been a person who died in police custody; and second, that far too many of these have been young Black men. I feel every reasonable person would agree that if these charges are false, then they deserve a thorough debunking; and if they're true, they deserve the scrutiny of the brightest sunlight we can shine.

To establish the validity of this claim, here is a short list of things I'd want to check out:

1. Is this indeed a new thing being listed on death certificates, and are they truly made up mostly of young Black men in police custody?
2. Is it a real medical diagnosis, and is it consistent with post-mortem examinations of these deaths?
3. What evidence is there that taser manufacturers are somehow influencing medical examiners to write "excited delirium" instead of "death by taser"?

The first of these — whether excited delirium is actually newly being listed as a cause of death for young Black men in police custody – is unfortunately beyond the scope of my ability to personally verify within our weekly production schedule. But we can at least turn to the Reuters report to see what they had to say.

Excited delirium has been listed as a factor in autopsy reports, court records or other sources in at least 276 deaths that followed Taser use since 2000, Reuters found.

Considering the size of the United States, 276 doesn't sound like very many deaths, especially over a 20 year period. But this is a sample from the pool of deaths that occurred in police custody, which is going to be a very small number comparatively. And when you refine it further to only deaths in police custody in which a taser had been used, it becomes smaller still. Reuters didn't give whatever number they may have turned up, but 276 of it would seem to be a pretty big proportion. So I think we can safely answer our first question with yes, it does appear to be the case that excited delirium is indeed being listed on the death certificates of people who died in police custody after being tasered.

But are they really disproportionately young Black men? The answer appears to be yes, but my research has turned up this answer a lot more than it has any data behind it. In its official position paper on excited delirium, the APA (American Psychiatric Association) says only:

The concept of "excited delirium"... has been invoked in a number of cases to explain or justify injury or death to individuals in police custody, and the term excited delirium is disproportionately applied to Black men in police custody.

Where I was able to find some data, though with pretty small numbers, was in a 2020 paper published in the journal Forensic Science, Medicine and Pathology. Of 104 people who died in police custody and were listed with excited delirium as the cause of death, the majority (58%) had no race recorded; 12% were Black; and the remaining 30% were either white or "other". We have to extrapolate – somewhat precariously given the small sample size – to arrive at a number of some 29% of police deaths by excited delirium being suffered by Black arrestees. Given that only 13% of the US population is Black, we find that a Black person is 123% more likely than anyone else to be assigned excited delirium as their cause of death.

So while Black men do not constitute a majority of this group, they are absolutely "disproportionately" represented, exactly as the APA position paper states. This same paper also finds that nearly all people with this cause of death are male, and half of them are under 30; and so we can confirm that excited delirium, when listed as a cause of death while in police custody following the use of a taser, is indeed disproportionately applied to young Black men.

The official Skeptoid analysis of this data point is that it's gravely concerning.

Moving onto our second question: Is excited delirium a real medical diagnosis? Meaning, is it a real thing, compared to words simply made up by taser manufacturers or anyone else?

This one is a little easier to research. We can go directly to all the major medical boards in the world and see if they list it. First of all, it's easy to find that there's nothing like it in the DSM, the Diagnostic and Statistical Manual of Mental Disorders published by the APA. But we're talking about causes of death, so maybe a mental disorder isn't the place to look. How about the ICD-10, the World Health Organization's International Classification of Diseases? Nope, not listed there – in fact, its lack of an ICD code makes it difficult to track, and has confounded efforts of researchers to study its use. Neither the American Medical Association, the American Academy of Emergency Medicine, nor the National Association of Medical Examiners recognize excited delirium as a legitimate medical condition either.

However, one outlying group did recognize excited delirium in 2009. The American College of Emergency Physicians published a white paper which described excited delirium sufferers as:

…Usually agitated, often speaking or yelling uncontrollably and pacing or running with no purpose. They often threaten others verbally or physically; they sweat profusely, appear ill, and are unable to control themselves. Often, their condition is associated with mental disorders or the use of drugs such as cocaine.

To me, that sounds like the emergency physicians were stepping out of their lane a bit, into the realm of psychiatry. So did the psychiatrists. The American Psychiatric Association responded in 2020:

The concept of "excited delirium" (also referred to as "excited delirium syndrome" (ExDs)) has been invoked in a number of cases to explain or justify injury or death to individuals in police custody, and the term excited delirium is disproportionately applied to Black men in police custody. Although the American College of Emergency Physicians has explicitly recognized excited delirium as a medical condition, the criteria are unclear and to date there have been no rigorous studies validating excited delirium as a medical diagnosis.

In their special report, Reuters looked into this white paper, and in doing so, they turned up the answer to our third question: whether there is evidence that taser manufacturers are influencing law enforcement to turn first to the diagnosis of excited delirium. Astonishingly, the Reuters investigators found that of the ACEP task force members, three were paid consultants of a company that's now called Axon Enterprise. Who in the heck is Axon?

Prior to April 2017 when they changed their name, Axon was known as Taser International, Inc., manufacturers of the taser implicated in these deaths. One of the three consultants, University of Miami neurology professor Dr. Deborah Mash, had long been a highly paid expert witness for Taser International, testifying in at least eight lawsuits that it was not the taser that had caused the death, but excited delirium. Reuters also uncovered a case in which within four hours of a teenager dying after having been tasered by Miami police, the VP of Communications of Taser International sent them an email advising:

The attending medical examiners should urgently know that the University of Miami Brain Endowment Bank is available with [a] cutting edge research center that can determine drug abuse and look for excited delirium markers... Dr. Deborah Mash is the lead researcher on this matter. This is one critical act that many MEs miss out on because of delays… I attached some of Dr. Mash's research on Excited Delirium issues.

As Taser/Axon's involvement with pushing the excited delirium diagnosis in deaths involving their product became more well known, researchers began to take a closer look. In March of 2023, the Western Journal of Emergency Medicine published an article critical of the diagnosis that stated:

Our evaluation of the diagnostic criteria for ExD proposed in the 2009 report shows that it relies on persistent racial stereotypes: eg, unusual strength, decreased sensitivity to pain, and bizarre behavior. Research indicates that use of such stereotypes could encourage biased diagnosis and treatment.

And concluded:

We suggest that the emergency medicine community avoid use of the concept [of] ExD and that ACEP withdraw implicit or explicit support of the report.

Accordingly, seven months later, the ACEP formally retracted its recognition of excited delirium. In a public statement, they said:

ACEP's 2009 White Paper Report on Excited Delirium Syndrome is outdated and does not align with the College's position based on the most recent science and better understanding of the issues surrounding hyperactive delirium. ACEP has withdrawn its approval of this paper. The term excited delirium should not be used among the wider medical and public health community, law enforcement organizations, and ACEP members acting as expert witnesses testifying in relevant civil or criminal litigation.

This left the world with not a single scientific body recognizing excited delirium as a thing. And much to their credit, a number of US states are in the process of banning the term from being used as a cause of death. California was first in March 2024, followed by Colorado in April 2024, which also banned the term's use in training. As of this writing, a bill to do the same is underway in Hawaii. Let's hope many more states follow these early examples. Justice is never served by covering up a cause of death.

By Brian Dunning
Follow @BrianDunning