Agree to Disagree: Excited Delirium Syndrome as Volatile as the Term Itself

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CONFERENCE REPORTER

There is universal confusion around excited delirium syndrome (ExDS): What is it and how should it be treated? The short answer is we do not know the answers, and there are no comprehensive treatment guidelines or formal criteria, according to a panel presenting at the 2021 American Psychiatric Association (APA) Annual Meeting.

Representing the fields ofemergency medicine, psychiatry, psychology, and emergency medical service (EMS), the expert panel consisted of Leslie Zun, MD, MBA; Thom Dunn, PhD; Julie Owen, MD, MBA; and Sarah E. Slocum, MD.

The Rationale for Consensus

Events in the recent past bring to light the importance of clarifying the differential diagnosis, signs and symptoms, and universal treatment protocols of ExDS, which to date remain unclear.

In the last year, the world witnessed George Floyd dying at the hands of a police officer. In 2019, Elijah McClain, a 23-year-old massage therapist, was placed in a chokehold by law enforcement and sedated by EMS with 500 mg of ketamine, a tactic that is legal in Colorado to control ExDS. By the time he arrived at the hospital, he was brain dead; he died 3 days later.

How McClain died is a matter of dispute, but one thing is clear. These and countless other incidents in the public eye have brought to the forefront use of force by police and in emergency settings.

Dunn, a psychologist who is also experienced in EMS, shared a stark example of excited delirium in a hospital setting where an adult male Black patient demonstrated signs of the condition. The presence of police seemed to intensify the patient’s agitation: He sweat profusely, stripped naked, shouted incomprehensibly, and flailed his arms. After multiple attempts to restrain him; police tased him. Emergency staff then administered ketamine; he subsequently died.

A Question of Criteria

In 2020, the APA released a position statement on the matter, stating: “DSM-5 recognizes Delirium, hyperactive type, but the symptoms of this condition differ in many ways from the symptoms typically attributed to excited delirium (eg, superhuman strength, impervious to pain, etc.).”¹

They further noted that ExDS itself “is too non-specific to meaningfully describe and convey information about a person.” They concluded that “excited delirium” should not be used until a clear set of diagnostic criteria are validated.”

The panel concurred: The American Medical Association, the APA, the National Association of Medical Examiners, and the American College of Emergency Physicians still diverge in their recognition of ExDS.^1,2

With all this confusion, the panelist concluded with Slocum’s call for action: “We really need to address this condition as a group and figure out what’s going to be best for that patient.”

References

1. Council on Psychiatry and the Law. Position Statement on Concerns About Use of the Term “Excited Delirium” and Appropriate Medical Management in Out-of-Hospital Contexts. American Psychiatric Association. December 2020. Accessed May 13, 2021. https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-Use-of-Term-Excited-Delirium.pdf

2. ACEP Excited Delirium Task Force: White Paper Report on Excited Delirium Syndrome. American College of Emergency Physicians. September 10, 2009. Accessed May 13, 2021. https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/ems-and-disaster-preparedness/ems-resources/acep-excited-delirium-white-paper-final-form.pdf