Prior to George Floyd’s death, Officer Thomas Lane reportedly said, “I am worried about excited delirium or whatever” to his colleague, Officer Derek Chauvin. 1 For those of us who frequently work with law enforcement and in correctional facilities, “excited delirium” is a common refrain. It would be too facile to dismiss the concept as an attempt by police officers to inappropriately use medically sounding jargon to justify violence. “Excited delirium” is a reminder of the complex situations faced by police officers and the need for better medical training, as well as the attention of research on this commonly used label.
Dr. Benjamin Amendolara
Many law enforcement facilities, in particular jails that receive inmates directly from the community, will have large posters educating staff on the “signs of excited delirium.” The concept is not covered in residency training programs, or many of the leading textbooks of psychiatry. Yet, it has become common parlance in law enforcement. Officers in training receive education programs on excited delirium, although those are rarely conducted by clinicians.
In our practice and experience, “excited delirium” has been used by law enforcement officers to describe mood lability from the stress of arrest, acute agitation from stimulant or phencyclidine intoxication, actual delirium from a medical comorbidity, sociopathic aggression for the purpose of violence, and incoherence from psychosis, along with simply describing a person not following direction from a police officer.
Our differential diagnosis when informed that someone was described by a nonclinician as having so-called excited delirium is wider than the Diagnostic and Statistical Manual (DSM). In addition, the term comes at a cost. Its use has been implicated in police-related deaths and brutality. 2 There is also concern of its disproportionate application to Black people. 3,4
Dr. Sahana Malik
Nonetheless, the term “excited delirium” can sometimes accurately describe critical medical situations. We particularly remember a case of altered mental status from serotonin syndrome, a case of delirium tremens from alcohol withdrawal, and a case of life-threatening dehydration in the context of stimulant intoxication. Each of those cases was appropriately recognized as problematic by perceptive and caring police officers. It is important for police officers to recognize these life-threatening conditions, and they need the language to do so. Having a common label that can be used across professional fields and law enforcement departments to express medical concern in the context of aggressive behavior has value. The question is: can psychiatry help law enforcement describe situations more accurately?
As physicians, it would be overly simple to point out the limited understanding of medical information by police and correctional officers. Naming many behaviors poses significant challenges for psychiatrists and nonclinicians. Examples include the use of the word “agitation” to describe mild restlessness, “delusional” for uncooperative, and “irritable” for opinionated. We must also be cognizant of the infinite demands placed on police officers and that labels must be available to them to express complex situations without being forced to use medical diagnosis and terminology for which they do not have the license or expertise. It is possible that “excited delirium” serves an important role; the problem may not be as much “excited delirium,” the term itself, as the diversion of its use to justify poor policing.