“Excited Delirium:” Diagnostic Contradictions and Structural Racism

Abstract

According to autopsy reports, the cause of death for Daniel Prude—a Black man who was hooded, restrained, and pinned face-down for over 2 minutes by police officers in Rochester, New York—was “excited delirium.” [1] The same diagnosis has been invoked to explain dozens of deaths at the hands of police, and may even become part of the defense of the officer who killed George Floyd [2]. Proponents claim that excited delirium represents a potentially fatal clinical constellation that arises in the context of drug use, autonomic hyperactivity, and police custody [3]. Yet, despite its ubiquity among police reports, excited delirium (also known as agitated delirium, Bell’s mania, or lethal catatonia) is not recognized as a veritable medical entity by the American Medical Association, the American Psychiatric Association, the DSM-V, or the World Health Organization [2]. Troublingly, several researchers responsible for perpetuating the diagnosis have ties to Taser International, a corporation that has repeatedly used excited delirium as a defense against wrongful death suits [4]. In this paper we address the contradictions and structural racism inherent to excited delirium, starting with the tautology of its proposed mechanism: sympathetic arousal during a period of physical restraint, which only emerges in the context of violent submission. Police beg the question by maintaining that individuals suffering from excited delirium acquire extraordinary strength and a diminished response to pain—thereby necessitating a greater degree of force in submission [2]. Furthermore, given that the majority of individuals diagnosed with excited delirium are people of color, we explore how the promulgated pathophysiology plays on racial tropes about black bodies which have plagued the medical community for centuries [5, 6]. We end with a call to action for students, physicians, and their professional organizations. If excited delirium is not a legitimate clinical entity, then the medical community ought to speak out against structural violence masquerading as objective diagnosis [7]. If, after careful scrutiny, excited delirium is deemed a legitimate medical condition, clinicians are equally obligated to reclaim a role in its diagnosis, and provide humane treatment.