Talk:Excited delirium/Archive 1

Archive 1

Archive 2

"Berserker-Rage" - anticholinergic substances can cause an excited delirium

"Blind as a bat, mad as a hatter, red as a beet, hot as Hades, dry as a bone, the bowel and bladder lose their tone, and the heart runs alone." The anticholinergic mnemonic

There was a typical form of "Excited delirium" back in days called "Berserkerwut" (german). It is described that "Berserkers" were fighters who were in a delirious tantrum of rage. They felt no pain and did not recognized wounds. It seemed that these "Berserkers" had developed "superhuman powers".

(Additional information:
-- About the effects of Atropa Belladonna: At high dosage, the effects are restlessness, need to move, strong euphoria, emotional mood swings (laughing and crying), mania, anger and a possible tantrum of rage. Body manifestations are increased body temperature, increased heart rate, increased blood pressure and accelerated and deepened breathing. There is also a decreased sensitivity to pain.^[1]
-- About the effects of Datura: At high doses appear strong excitement, frenzy, raving madness and a possible tantrum of rage. In a Delirium, the hallucinations are frightening and indistinguishable from reality.^[2])

ANTICHOLINERGIC SUBSTANCES CAN CAUSE AN EXCITED DELIRIUM
Deliriants are f.e.: Tropan-alkaloids(Atropine, Hyoscyamine, Scopolam­ine) and anticholinergic substances like Benztropine (Cogentin), Dicloverine, Trihexyphenidyl (Artane), Oxybutynin, Tolterodine, Chlorphenamine, Diphenhydramine (Benadryl, Sominex), etc. etc.
(Additional information: Also alcohol and barbiturates can cause a delirium in high dosage or by withdrawal.)

Deliriants (anticholinergic substances) (f.e. Hyoscyamine, Dicycloverine, etc.) can cause an excited delirium by eliminating the parasympathetic nervous system in its dampening function -> acute anticholinergic syndrome (AAS): Increased body temperature, Increased heart rate, strong excitement, aggression, restlessness, irritability, rage and raving madness etc.
An anticholinergic syndrome can be caused by tropan alkaloids (f.e.: hyoscyamine), antidpressants, antipsychotics (neuroleptic), antihistamines ^[3]
For better understanding: anticholinergic substances make at low dosage tired, but at high dosage, when the parasympathetic system is complete blocked in its function, it creats a delirium
f.e.: the sleeping aid Sominex (Diphenhydramine):

• low dosage (100 - 200mg) -> it makes tired
  
• higher dosage (300mg - 400mg) -> it makes restless and delirious
  
• high dosage (500mg - 800mg) -> it causes a delirium -> loss of control (possible "Berserker Rage")
  
  

In military experiments was used 3-Quinuclidinyl benzilate (Nato-code: BZ):
"Early central nervous system manifestations include heightened deep tendon reflexes, ataxia, incoordination, slurring of speech, dizziness and headache. Nausea, usually without vomiting, is frequent. During the first phase (1-4 hours), discomfort and apprehension are present. Extreme restlessness occurs, sometimes with involuntary clonic spasms of the extremities and birdlike flapping of the arms. Errors of speech and scattered moments of confusion may be noted."^[4]
(Additional information: About how a delirious person reacts on amphetamines:
"I vividly recalled a senior officer who had swallowed a large handful of sleeping pills and was admitted to Letterman Army Hospital. He was out of danger, but also very much out of touch with reality. Grossly disoriented, he sat mumbling and picking at various objects in the bed. It was impossible to interview him so, to counteract the sleeping pills, I decided to order a hefty dose of amphetamines. This not-sobright idea turned him into a non-stop radio commentator on every disconnected subject crossing his mind."^[5]
This also means:
1. (Methyl-)Amphetamines are widely ineffective by a delirious person.
2. (Methyl-)Amphetamines can not cause a delirium.)

About the deffinition of the term Anticholinergic Syndrome:
"The term central anticholinergic syndrome (CAS) describes a symptom complex, which was first mentioned by Longo in 1966. Hereby, the neurotransmitter acetylcholine plays a central role.
If the effect of the acetylcholine is blocked by anticholinergic substances, such as medicines or drugs, a range of central nervous system manifestations can result. This antagonistic effect results directly from the competitive displacement from the acetylcholine receptor or by indirect anticholinergic processes. One differentiates between peripherial and central manifestations. The following case report discusses the problem of identifying CAS, which is not unusual in emergency and intensive care medicine. Approximately 70% of all medicines (for example, tricyclic antidepressants, antihistamines, neuroleptics) used in suicide attempts have an anticholinergic substance." ^[6]
(Additional information: Acute Anticholinergic Syndrom (AAS) is the same as Central Anticholinergic Syndrom)

Anticholigernic Syndrome is distinguished in two different forms ^[7]:

1. Delirious form:
(central manifestations)

• hyperactivity
• excitability, restlessness
• hallucinations
• anxiety
• aggressions
• tantrum of rage
  

(peripherial manifestations)

• hyperthermia
• tachycardia
  

2. Comatose form:
(central manifestations)

• psychomotor damping -> decreased vigilance -> somnolence -> coma
  

(peripherial manifestations)

• seizures
  
  

Characteristical manifestations of an anticholinergic syndrome are colloquially described:
"Blind as a bat, mad as a hatter, red as a beet, hot as Hades, dry as a bone, the bowel and bladder lose their tone, and the heart runs alone."⁸

References:
^{1, 2} Raetsch C. The Encyclopedia of Psychoactive Plants: Ethnopharmacology and Its Applications. AT-Verlag; 2004. p.82, 84, 201, 278.
³ Pranger H. Neurologische Intensivmedizin: Praxisleitfaden für Neurologische Intensivstationen und Stroke Units. Georg Thieme Verlag; 2004. p.211ff. online version
^{4, 5} Ketchum JS. Chemical Warfare - Secrets almost forgotten; A Personal Story of Medical Testing of Army Volunteers. Authorhouse; 2006. p.46-47.
^{6, 7} Hochreuther S, et al. Zentral anticholinerges Syndrom (central anticholinergic syndrome). Intensivmedizin und Notfallmedizin 2010 April; Volume 47, Issue 3, pp 211-214. online version
⁸Stead LG, et al. First Aid for the Emergency Medicine Clerkship. 2nd ed. McGraw-Hill Professional Publishing; 2006. p.395–6

--Stefan Bach77 (talk) 00:35, 27 August 2014 (UTC)

Plagiarism/POV

This article is basically identical to the one at zarc.com (http://www.zarc.com/english/other_sprays/reports/excited_delirium.html) Apart from the copyright issues this might cause, the zarc article has obvious POV issues to be used as the sole source for this page, being that it is published by a pepper spray manufacturer. This page should probably be tagged as POV in dispute (sorry, I don't know how to do that). 140.107.169.117 01:54, 28 February 2007 (UTC)

If I helps, I went through the article and tried to re-write several portions and fix any issues that did not convey the story with adequate neutrality. If there is anything else that should be changed, go ahead and do so or say so and I'll try and fix it. -- 72.54.124.78

I reverted the article to the version before the copyrighted text was added. Modifying the content does not work well for resolving copyright issues. Unless the content is entirely rewritten, some of the content is always still unaltered, and violating copyright just "a little bit" does not make it acceptable. -- Kjkolb 12:34, 3 March 2007 (UTC)

Not to be obscene, but if you're going to remove most of the content of the page, even if it is because of copyright issues, at least leave a stub notice on it. --8472

And this doesn't seem to be a very neutral POV. --198.164.151.6 12:04, 12 March 2007 (UTC)

ACEP Recognizes Excited Delirium Syndrome

With the recent recognition of Excited Delirium Syndrome (ExDS) by the ACEP, there can be more focus on treatment rather than as a blunt instrument to use against police or care providers.

I

I invite anyone else to edit this page, as I just really threw a lot of it together based off of news articles and general information I could find on it. If anyone has better information or a better format, go nuts.

A suggestion

speaking as someone who stumbled onto this page with no prior knowledge of the concept, I found this article quite confusing due to the fact that there is no description of the proposed mechanisms that cause the deaths of the victims of excited delirium. I had to read the external article before I could understand the concept as a whole. As it is, this article just says that there it is controversial and was involved in the deaths of police restraining victims. It would be helpful if it mentioned somewhere that it's theorized the brain causes cardiac arrest - some guy —Preceding unsigned comment added by 125.238.202.95 (talk) 14:14, 26 November 2007 (UTC)

Why are the majority of Wikipedia articles so liberal and slanted? I'm sure the handful of people that have their deaths labeled as Sudden Cardiac Death Due to Excited Delirium each year are clean, healthy, normal people. There's no possibility they could have prior medical problems due to drug abuse, mental illness, or prior injury. In fact, it is very unlikely that those people being restrained and tased by police officers have been violent or dangerous to themselves or others. They probably were walking to church when the police tased and sat on them until they died for no good reason. Why not give a medical description of Excited Delerium instead of a biased forgery of an article. ?? —Preceding unsigned comment added by 66.169.189.110 (talk) 21:18, 26 November 2007 (UTC)

Well, actually, most of them are high on drugs at the time. The proposed mechanism is adrenaline overload. Supposedly if you can get them to the emergency room, there are some reasonably efficacious treatments. WhatamIdoing (talk) 23:09, 11 January 2008 (UTC)

NPOV

To maintain neutrality on this topic, I suggest that every line in the article have a reference. We should have both side of the issue present with each given its own space. --Richard Arthur Norton (1958- ) 17:56, 30 April 2007 (UTC)

Support: Although I am not particularly inclined to encourage differing "sides" on the matter carving out their own little partitioned subsections within the article. dr.ef.tymac 19:36, 30 April 2007 (UTC)

It's main cause is a rush of adrenelin, believe me I have had gone through this lots of times, either that or its a genetic defect, in that case get me an honorable death.

The only genetic defect it could be is a defect from my fathers side, possibly caused by agent orange during vietnam.

Or its because I have a lack of L-Tryptophan in my diet.

Or it was caused by my sister.

Or it was caused by Geodon withdraw.

Or it was caused by behavior modification in therapy.

Or it was caused by reverse gender rolls.

Or arguing with bad teachers.

Or getting graded down in college because of my political views.

Or it was caused by James Carvill (that man scares the crap out of me, and not because of all the people he's killed).

Good grief someone help me out here, and I don't need psychological help, I met all the goals on my goals sheet in thearapy.

Darrell Porter did not die from this, he was always a very calm and collective person when I knew him.

There is no evidence of any of this, just personal observation on my side.

Ok. You have shared your personal observation. Thank you for giving people a chance to see what you have to say. It is much better than erasing the whole page and silencing everyone else.

Just remember, before putting words in the Wikipedia article or taking words out, you need to have some evidence so people can learn more. That way, no one can blame you or discredit you saying, "He's just writing from his own personal opinion." Even if there is some misleading information in the article, it takes calm and collected research and time to reach our goal to improve it. It's not always easy, but if we cooperate, it works. Regards. dr.ef.tymac 02:40, 1 May 2007 (UTC)

No matter, I was just testing you guys(I never had any malicious intent), I have never bothered exploring this side of wikipedia so I was unaware of all of this. My experiences with the psychiatric community did happen, and I am not lying about my opservations, I should not have been on Geodon in the first place. I will stay on the front side, just paint my future a good one for me, I will add my e-mail address and my real full name to my page so people can contact me when they need me to vouch for anything. My username page is a little unorganized because it didn't save character returns, but etom needs to be in the Iraq Dinar folklore somehow so I know I can trust you guys to take care of it. Just remember, I am not a meddler nor am I an infidel. I am very convinced that all of you have something going with this wikipedia project, and you will recieve donations from me on a regular basis. I just want to stay off those psychiatric meds and sleeping pills, they scare girls away. Oh yeah and I am a man FYI. Good luck to you all, and don't get too technical on things, and don't stear away from the fundamentals. All the evidence of my psychiatric experience's are in my medical records, which remain private, but quite frankley I would not mind making them public to some people so we can put an end to some of this.

Thank You All

etom

I edited the page to remove the implication that tasering caused death ("tasered to death"). It could be a contributing factor, but the direct link hasn't been proven. —Preceding unsigned comment added by 76.67.16.177 (talk) 18:01, 5 December 2007 (UTC)

^ Please get back on Geodon, bro. Trust me. Charles35 (talk) 07:44, 25 November 2012 (UTC)

Is there a gender link?

All the people listed as being examples are men. I wonder if this is significant or just co-incidental. Is there any reliable info out there on this aspect? If so, it should be included or at least referenced. —Preceding unsigned comment added by Grandma Roses (talk • contribs) 11:44, 23 April 2008 (UTC)

add a link

I feel that there should be at least one link to Police_brutality. This article certainly implies the possibility of such. There are many ways an officer of the law can go beyond that law, and this is one of them. --82.93.172.114 (talk) 07:44, 21 July 2008 (UTC)

Thank you for your suggestion. When you feel an article needs improvement, please feel free to make those changes. Wikipedia is a wiki, so anyone can edit almost any article by simply following the edit this page link at the top. The Wikipedia community encourages you to be bold in updating pages. Don't worry too much about making honest mistakes — they're likely to be found and corrected quickly. If you're not sure how editing works, check out how to edit a page, or use the sandbox to try out your editing skills. New contributors are always welcome. You don't even need to log in (although there are many reasons why you might want to). WhatamIdoing (talk) 20:49, 22 July 2008 (UTC)

Bot report : Found duplicate references !

In the last revision I edited, I found duplicate named references, i.e. references sharing the same name, but not having the same content. Please check them, as I am not able to fix them automatically :)

• "abc" :
  • {{cite web |url=http://abcnews.go.com/Health/story?id=2919037&page=1&CMP=OTC-RSSFeeds0312 |title=Excited Delirium: Police Brutality vs. Sheer Insanity |accessdate=2007-03-13 |publisher=[[ABCNews]] |date=2007-03-02 }}
  • {{cite web |url=http://abcnews.go.com/Health/story?id=2919037&page=1&CMP=OTC-RSSFeeds0312 |title=Excited Delirium: Police Brutality vs. Sheer Insanity |accessdate=2007-03-13 |publisher=[[ABCNews]] |date=[[March 2]], [[2007]] }}

DumZiBoT (talk) 18:46, 12 August 2008 (UTC)

 Done WhatamIdoing (talk) 04:48, 3 September 2008 (UTC)

Sudden death after arrest

This news story is interesting, and might be related (directly or indirectly) to this article, but I can't find a proper scientific paper for it. It may not have been published just yet, since it was only presented at the conference today. WhatamIdoing (talk) 04:46, 3 September 2008 (UTC)

Deaths From Excited Delirium

In an interview on CBC's The Current Calgary alderman Diane Colley-Urquhart justified expanded use of the Taser in Calgary. At one point she stated that you can die from excited delirium without the use of a Taser. Is anyone aware of anyone dying from excited delirium that didn't have some sort of physical interaction with the police? Stephen Rasku (talk) 16:36, 24 February 2009 (UTC)

Answer,

Yes there are many many cases of people dying without police being involved. I find the very first part of this entry to be badly distorted to give the view that this is something ONLY related to police. It isn't. It is just that when these incidents happen in public, police are invariably called and become involved. It's akin to saying houses burning down are the fault of firemen spraying water because they are always found to be there when the house has burned down. The confusion in the public is caused because the media only reports those occurrences that have happened in public. In fact there are numerous documented cases of people dying in places such as hospitals and psychiatric wards who clearly are exhibiting the same state, however these are not reported by the media and in fact they are seldom aware of them. There are papers written on these deaths in psychiatric wards back in the early 1800's. Interestingly there is a very similar condition that has caused sudden death in wild animals when captured (such as by game wardens or wildlife biologists). In those fields it is know as Capture Myopathy or Exertional Myopathy.'

-- Death due to "excited delirium" has not happened in the clinical psychiatric setting since the development of parenteral antypsychotics. Can you provide even one case in the last hundred years? My wife was a psychiatric nurse, I am an emergency physician. We have both seen numerous patients in acute psychosis. In a medical setting the acute psychotic is spoken to in a calming voice, and if he remains clearly hostile he is briefly restrained and a parenteral antipsychotic (e.g. haloperidol) or dissociative agent (e.g. ketamine) is administered by IM injection. The patient becomes calm and pulse oxymetry is monitored. In ther law enforcement setting tghe patient is restrained until he stops struggling and in many cases a spit hood is applied. He is then left unmonitored and later discovered unresponsive. I'm not aware of a single case in which video is available in which the cause of death was anything other than asphyxiation.Danwoodard (talk) 23:12, 25 October 2020 (UTC)

The second part of the confusion is due to the term itself, "Excited Delirium". This is a relatively modern term. Because the medical profession does not quite understand what EXACTLY is going on, there is no true medical term for it. It's like Sudden Infant Death Syndrome, or Died of Natural Causes. It's real, you know what it means and looks like, but it's not a proper medical term. Over the years, and even today, it can be labelled with several different terms and has historically been called such things as Positional Asphyxiation, Exhaustion, Sudden Exhaustive Death in Excited Manics, and so on.—Preceding unsigned comment added by Johnaevans (talk • contribs) 19:05, 1 March 2009 (UTC))

While the article states that "excited delirium" is no longer used to explain a medical condition by the Metropolitan Police, the same condition is now referred to as "Acute Behavioural Disorder". ABD is known to medical professionals, especially EMTs, etc, who deal with the public on a regular basis. As I understand it, one of the reasons for changing the term was that not enough people understood it, which may explain the (frankly unwarranted) scepticism on the other side of the Atlantic. —Preceding unsigned comment added by 158.143.138.27 (talk) 19:27, 10 March 2010 (UTC)

Of all the forms of acute behavioural disorder, excited delirium is the most extreme and potentially life threatening.--195.137.93.171 (talk) 08:54, 16 August 2016 (UTC)

The topic of the article, really, is The Social Construction of Reality, after Peter L. Berger laid out this sociological construct many years ago. I believe it the first episode of such a social process to mimic the plot and content of George Orwell's book 1984. The police of the Ministry of Truth who held up three fingers and yelled "four fingers" before applying high voltage shock to some subject in need of "education" have now emerged from the book pages and are walking up your driveway. Excited delirium as a "self evident" stand alone phenomenon would not make it into the A.P.A. Diagnostic and Statistical Manual. This is going to require the expenditure of megabucks to procure a myriad credentialed shills and whores to swear up and down the phenomenon exists, who will then run to the bank. By one tally the USA is up to 476 taser deaths as this note is written. The autopsies have all been done by police coroners. It brings new meaning to the concept of a Protection Racket.

I feel that a part of this page should be edited.

The part i feel that should be edited is

Toney Steele, was one of the first high-profile cases involving the cause of death as "excited delirium", this drug addict died in San Diego after being restrained in the back of a patrol car.[16]

I do not feel it necessary to label the victim as a drug addict. It is neither here nor there with regards to this topic. If no one changes it or offers an explanation to why it should not be changed then I will change it on my own accords. —Preceding unsigned comment added by GeneralChoomin (talk • contribs) 01:14, 1 September 2009 (UTC)

POV vs. OR -- I don't like the tone of this page.

There are a lot of OR-based edits I would like to make to this page, so I am "venting" here. I googled on "Excited delirium" because I was doing some OR. The Seattle (WA, US) police just called the medics for a man who is exhibiting signs of "excited delirium." He is in a 7-11 with a handgun, taking off his clothes, and drinking all the gatorade. He will not come outside or obey their orders. So, they have sent for officers with tasers and bean-bag shotguns in order to perhaps subdue him given the opportunity. These are what the police call "less-lethal devices." In the beginning of tonight's stand-off, there were a few tense moments during which the armed and delirious suspect might have walked out of the store while waving a gun. In that case, he would have been killed. So, the arrival of police with tasers and other less-lethal means has been a relief. Anyway, the police just called a precautionary ambulance because the person showed the signs of what the called "Excited delirium" as he began to [remove his clothes, and start drinking all the gatorade]. It sounds like they think he is going to pass out pretty soon of his own devices, and then they will have him treated. Or perhaps they are worried that they will try to tase him, if he comes outside wielding the firearm, and then he will collapse or something.

Anyway, the article has a strong bias that 'excited delirium' is a made-up term. Whatever the case, it seems like a term that police use as part of their jargon, and it means something useful and observation-oriented for them. The police won't be using a DSM-IV based term when they run across a man in a 7-11 who is wielding a firearm, disrobing, and drinking all of the gatorade. "Delirious" and "excited" both sound applicable to such individuals.

The tone of the article is so anti-establishment and biased I think it could use a major rewrite at best. Heathhunnicutt (talk) 07:38, 31 January 2010 (UTC)

Thank you for your suggestion. When you believe an article needs improvement, please feel free to make those changes. Wikipedia is a wiki, so anyone can edit almost any article by simply following the edit this page link at the top. The Wikipedia community encourages you to be bold in updating pages. Don't worry too much about making honest mistakes—they're likely to be found and corrected quickly. If you're not sure how editing works, check out how to edit a page, or use the sandbox to try out your editing skills. New contributors are always welcome. You don't even need to log in (although there are many reasons why you might want to). WhatamIdoing (talk) 01:36, 27 March 2010 (UTC)

It's a poor article, and it shows signs of biased editing from both sides.  Randall Bart   Talk  01:07, 16 February 2011 (UTC)

How much of the controversy has to stay in the intro? Right now virtually everything in the controversy section is also in the intro, which suggests undue weight and also looks messy. 101.171.170.151 (talk) 03:03, 24 March 2013 (UTC)

Dead links

There are many dead links in the references of this article. An article like this needs better references.  Randall Bart   Talk  01:09, 16 February 2011 (UTC)

Don't delete other people's talk page discussion, Randall.

Excited delirium is a fake affliction that the Taser Corporation invented and pays doctors to testify about to describe why people shocked by tasers die of a condition entirely unrelated to the taser shortly after receiving that shock. I've never even heard of excited delerium being referenced outside of the United States and it's embarrassing that Wikipedia has to pretend it's something worthy of any respect in order to satisfy NPOV requirements.Torka1 (talk) 07:31, 29 May 2011 (UTC)

How exactly can a human have "superhuman strength"?

Isn't superhuman by definition more than a human could achieve? -98.84.129.253 (talk) 17:31, 2 February 2012 (UTC)

(S)he makes a good point. A very good point. That should be removed as it is literally a contradiction. Charles35 (talk) 07:47, 25 November 2012 (UTC)

The sources that are currently cited, use the name "superhuman strength" - other sources refer to this as "hysterical strength". I've linked the words in the article, to make that clearer.

We have an article on hysterical strength which is need of improvement (please help!), and some unrelated pages that include disambiguating information, such as superhuman strength. HTH. –Quiddity (talk) 21:33, 29 November 2012 (UTC)

I'd be glad to help. I don't think I'd be of much use with disambiguation pages though. That is out of my league. I checked out both articles. For the article "superhuman strength", the definition says that it is fictional strength exceeding that of a normal human, while nonfictional strength exceeding that of a normal human is hysterical strength. If that's the case, then why don't we just change superhuman strength in this article to hysterical? I've read that you are allowed to base edits off of other articles in place of sources.

On a different note, what exactly do you want to add to the hysterical strength page? I see the tag that says it needs sources, but sources on what? What type of material do you want to add?

On another unrelated note, I didn't get an answer from you on the medical info in the BCA page that we were discussing. Would you mind letting me know? Charles35 (talk) 23:31, 29 November 2012 (UTC)

The disputed nature of the syndrome, means we should be careful about changing words. One of the organizations that officially defines the condition, the American College of Emergency Physicians, uses the word "superhuman", so we probably should, too.

I'll reply to the other questions, at the relevant talkpages. –Quiddity (talk) 00:14, 30 November 2012 (UTC)

It is not a good idea to support a hypothetical syndrome with an improbable, unsupported phenomenon such as "hysterical strength." The use of the term "superhuman strength," as it was in the article, may still be the better choice, without the reference to "hysterical strength." In the context in which it originally appeared (the reference), it may have been used for convenience, or emphasis, and not as any type of accurate, scientific description of "excited delirium." For example, I think that Robert Dziekanski had been throwing heavy objects around during his rage in the Vancouver Airport. Although it would require considerable exertion, Mr. Dziekanski's actions were all still within the range of human strength, but certainly out of character for anyone behaving normally. The RCMP reports may have used terms like "superhuman strength," as anyone watching someone throw furniture around may well have described it the same way. The fact that Excited Delirium does not appear in the DSM-IV, or any similar manual, described in well-defined, verifiable, medical terms, does not mean that we have to supplant this by using pseudoscientific terms to do so. Rather than just heavy-handedly revert your edit, I would like to discuss this.

I'm afraid I can be of no assistance with the article on "hysterical strength," as I know of no evidence for it other than the anecdotal evidence that is already in the article. Unfortunately, actual empirical studies of hysterical strength would be completely unethical.StopYourBull (talk) 04:24, 30 November 2012 (UTC)

I know I'm late to this party, but from the looks of it, 'excited delirium' may be best thought of as an older term for a condition modern medicine calls by multiple different names--this happens every so often as medical knowledge improves. The white paper cited in the article would be useful here, but it's a dead link; my suspicion that the list would include the codes for Substance-induced_psychosis and this could accurately enough be used for when you've got somebody who seems to be high and psychotic but you somehow doubt they'll tell you what they took if you just asked nicely. Werhdnt (talk) 04:42, 24 December 2015 (UTC)

Treatment ?

Needs a section on treatment - medical rather than Law Enforcement, preferably!--195.137.93.171 (talk) 08:57, 16 August 2016 (UTC)

Done. Doc James (talk · contribs · email) 23:01, 1 July 2017 (UTC)

Capture Myopathy

For more information on the subject research Capture Myopathy a simular condition which occurs in animals, specifically highly stressed wildlife when immobilized. — Preceding unsigned comment added by 75.154.96.31 (talk) 03:33, 27 November 2011 (UTC)

First sentence

"Excited delirium is a condition..." (my italics) seems too certain for what is a controversial and maybe speculative condition. I'm trying to think of an adjective to qualify it. "Excited delirium is a proposed condition..." or something like that (though we'd have to find a source proposing it).--94.193.231.87 (talk) 13:06, 31 January 2012 (UTC)

Core Issue

The article does not really address the core issue: if many (most?) cases of death from "Excited Delirium" occur in police custody, how can police procedures be modified so as to reduce the likelihood of death? In particular, it would seem logical that in those conditions (e.g. young male using certain adrenaline-enhancing drugs) the police should avoid procedures that seem to be associated with ED, and instead use medically-recommended procedures.Paulhummerman (talk) 12:45, 1 February 2012 (UTC)

US- Specific?

The opening sentence says

"Excited delirium is a controversial term used to explain deaths of individuals in police custody"

I believe from reading the rest of the article that this is a US-specific article about a phenomenon happening locally. As usual an American author has assumed that all english speakers live in the USA. The article goes on to mention two things called "NPR" and "ABC" respectively, but does not link to anything else or attempt to clarify these TLAs.

Is there some way to clarify this? —Preceding unsigned comment added by 86.173.102.43 (talk) 19:29, 28 June 2010 (UTC)

Clarify what "ABC" or "NPR" means? "ABC" = "American Broadcasting Company", you know, just like "BBC" means "British Broadcasting Company" ...it's not that hard to figure out. By the way, if you search "ABC" guess what the first link is? Searching "NPR" actually takes you right to the article for National Public Radio. And what is with "USA" ? enough with the three letter acronyms already!! Lime in the Coconut 16:05, 7 July 2010 (UTC)

Almost half the examples and a good fraction of the rest of the article features purely Canadian sources. Canada is not part of the USA. WhatamIdoing (talk) 04:22, 8 July 2010 (UTC)

The Robert Dziekański Taser incident was in Canada! Excited delirium does it not exists. It was a euphemism for 'death by excessive police force'. → "Excited delirium entered into the public and media lexicon around the time that increased use of electrical weapons ignited controversy in the United States, Canada, and the UK. As a result, both medical task forces and public inquiries into the connection between police use of force, excited delirium, and in-custody deaths have recurred throughout the past decade." --217.234.71.31 (talk) 23:43, 4 July 2020 (UTC)

Diagnosis

The source says "The diagnosis does not specifically exist by name in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) or in the 10th edition of the International Classification of Diseases (ICD-10) coding system. Both publications have other diagnoses which describe the population of patients exhibiting signs and symptoms of ExDS."[1]

This is a better summary of that IMO "The diagnosis does not go by this specific name in either the Diagnostic and Statistical Manual of Mental Disorders or the International Classification of Diseases as of 2016."

It is not a psyc diagnosis so not expecting it to be in the DSM (try calling a psychiatrist about a case and they will direct you to the ER). The ICD10 is from 1992. Doc James (talk · contribs · email) 11:06, 14 October 2017 (UTC)

If it is not recognized, it is not recognized. That is why it is listed as a medical controversy. If it goes by a secret name that does have a code for a recognized medical diagnosis, then the article should be moved to the officially recognized name. I can also find articles by HIV deniers, so a few articles claiming it is recognized under a secret name are WP:Undue weight. --RAN (talk) 14:42, 14 October 2017 (UTC)

It is recognized within the field of emergency medicine. Yes it is newer than 1992 and yes it is not a psyc condition.

This 2012 review says "Based upon available evidence, it is the consensus of an American College of Emergency Physicians Task Force that Excited Delirium Syndrome is a real syndrome with uncertain, likely multiple, etiologies." [2]

Fairly clear. Doc James (talk · contribs · email) 16:14, 14 October 2017 (UTC)

Also, with the DSM, the general rule has been to only cover things that are persistent mental health problems, in part because of the stigma a psychiatric diagnosis can carry. If there's a good chance it may be a one-off episode and/or not actually a mental health problem, it probably won't be included, and it won't be included separately if it doesn't appear on its own as a persistent mental health problem. ICD-10's not quite designed to deal with uncertain etiologies if it might fall into different chapters. Werhdnt (talk) 22:53, 7 November 2018 (UTC)

"Hypothetical"

See #Diagnsos and https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13330: "Our results suggest that excited delirium syndrome is a real clinical entity, that it still kills people, and that it probably has specific mechanisms and risk factors."

But we should note that "probably" leaves room for EXD being florid psychosis by another name.

Talpedia (talk) 17:49, 9 September 2020 (UTC)

Or that different people with similar symptoms should have different diagnoses. WhatamIdoing (talk) 02:06, 17 May 2021 (UTC)

Editing the Controversy Section

Hello! I am considering adding more to the controversy section to address the recent attention to Excited Delirium and police brutality. I have some potential sources on my user talk page. Let me know if you have any suggestions.MCJones20 (talk) 04:04, 11 September 2020 (UTC)

I added a quick mention of the use of ED to justify tranquilization, but that's kind of tangential and there is much more in the rest of the sources. Unfortunately I have noticed some nasty threatening vandalism, also some well referenced mentions of police involvement being removed, one of them removed part of a reference code and broke it so it seems they were not taking much care. So I'm a little concerned that the public controversy and politics may work it's way into the editing of this page. MasterTriangle12 (talk) 12:33, 28 September 2020 (UTC)

"First identified"

The condition was first identified by pathologist Charles Wetli to account for the deaths of nineteen Black prostitutes due to "sexual excitement" while under the influence of cocaine. The women were later found to have been strangled by serial killer Charles Henry Williams.

I don't like this phrasing. I would prefer "the term was first used". This feels a bit WP:NPOVishy because you it assumes that the condition identified then is the same as what is identified now. Going ORy extreme mania in bipolar disorder could look quite like the construct of excited delirium and this has been around forever. I'm fine with this information being included but it seems to imply that the current diagnosis is the same as the historic one.

Talpedia (talk) 21:52, 10 May 2021 (UTC)

Talpedia, or coined. Guy (help! - typo?) 00:00, 11 May 2021 (UTC)

I think "first used" is appropriate and meets npov standards. Innican Soufou (talk) 00:04, 11 May 2021 (UTC)

Innican Soufou, or coined. Which is accurate. The important part, of course, is where he invented the diagnosis based on 19 Black women who had asphyxiated with low levels of cocaine in their systems, based on the idea that women on crack who had sex could die of "excited delirium" - but it turns out they were strangled by a serial killer.

Very much on point, when you hear that the police tried to write George Floyd's murder off to "excited delirium". Guy (help! - typo?) 00:12, 11 May 2021 (UTC)

WP:ASPERSIONS / WP:SEALIONing
The following discussion has been closed. Please do not modify it.
It wouldn't be a day that ends in "y" if someone didn't need to remind you of WP:NOFORUM Innican Soufou (talk) 00:34, 11 May 2021 (UTC) @Innican Soufou: Then I suppose you need to be reminded to Comment on content, not on the contributor. Guy's points pertain directly the the content discussion at hand and are in no way a violation of WP:FORUM. Generalrelative (talk) 00:57, 11 May 2021 (UTC) Sorry, I must have missed the relevance of this "george floyd" guy in the topic. Innican Soufou (talk) 03:50, 11 May 2021 (UTC) Yes you certainly did. Generalrelative (talk) 04:34, 11 May 2021 (UTC) Do you mind showing me? Since you're so well-informed. Innican Soufou (talk) 04:38, 11 May 2021 (UTC) Um, sure, here you go: [3] Generalrelative (talk) 04:54, 11 May 2021 (UTC) Oh, ok. So the answer is I'm right and you're just acting childish. Got it. Innican Soufou (talk) 05:07, 11 May 2021 (UTC) Were we supposed to be acting like adults here? Because you started by saying I must have missed the relevance of this "george floyd" guy in the topic in response to Guy's comment Very much on point, when you hear that the police tried to write George Floyd's murder off to "excited delirium". If there is a good-faith reason for that kind of WP:SEALIONing I cannot fathom what it might be. But perhaps you wouldn't mind showing me. Since you're so well-informed. Striking rhetorical comment. Generalrelative (talk) 06:18, 11 May 2021 (UTC) Generalrelative (talk) 05:22, 11 May 2021 (UTC)

Well, I'm not convinced that he did invent the diagnosis based on only this case. He might have also been considering other cases of stimulant induced psychosis that he had come across and applying these experiences to the case at hand. Also I wouldn't be surprised if the concept had been floating around in the medical community before he used the term. But I need to read the sources. Talpedia (talk) 00:30, 11 May 2021 (UTC)

Talpedia, you may be right. It's what the sources say, but they could be wrong. It would be interesting to find the original paper. In the mean time, perhaps it should be attributed. Guy (help! - typo?) 07:38, 11 May 2021 (UTC)

Casting aspersions about authors of papers

If aspersions have been cast about an author and they are referenced and relevant they should be included. But can we try to find newer sources too! For example there is this recent(ish) and open access systematic review: https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13330

Talpedia (talk) 19:19, 10 May 2021 (UTC)

As I mentioned in my edit summary, the problem with the infobox is that it presents "excited delirium" as though it were a real phenomenon, which appears to go against the preponderance of reliable sources. Generalrelative (talk) 19:46, 10 May 2021 (UTC)

Talpedia, the aspersions are cast by Reuters and others. This is not our problem to fix. I've explained the edits extensively above. I note, for example, that you reintroduced sources by Mash (a paid consultant to Axon) and ACEP (a 2009 paper robustly contradicted by other sources and subject to undeclared COI as documented by Reuters and others). It's a really bad idea to cite that document. Especially since Axon have openly admitted that paid medical advisers are a core part of their defence against product liability suits.

I will grant you, though, that most of these deaths do seem to be very much like the original cases identified by Wetli. Just not inthe wway he still seems to think. Guy (help! - typo?) 20:36, 10 May 2021 (UTC)

I mean... there are an awful lot of edits, and the discussion above is quite long. I sort of want split this up into different sections.

How about we find another systematic review that like the 2018 one [4]. I kind of dislike removing sources from the medical literature with no attempt to find alternatives.

On "this is duplicative - the lead had been buried and replaced by basically the old on" I would argue that it moved overly length material out of the lead and summarized it. I don't think a length discussion of lobbying and the history of the term appears in the lead.

Talpedia (talk) 21:02, 10 May 2021 (UTC)

Hmm... I think there are some subtle decisions to be made here, and I'm afraid that I don't have enough focus by myself this week to ensure that these are made. Let me see if anyone in the medicine wikiproject is keen to help! Talpedia (talk) 21:26, 10 May 2021 (UTC)

Talpedia, the lede you introduced is closer to the ACEP version than the non-ACEP version I wrote. I am happy to tighten the lead (always good) but not reintroduce any uncritical presentation of the ACEP (minority, really fringe) position, due to the numerous problems I note above. Guy (help! - typo?) 17:49, 11 May 2021 (UTC)

Sources

Emergency doctors diagnosis in the lede

I sort of feel like the fact that emergency doctors recognise this as a "diagnosis" or maybe a symptom should be in the lead. It does seem to be the case that the diagnosis is used in emergency medicine.

Is this source, [5] tainted, if not perhaps the conclusion from this paper, which would seem to be the best source under WP:MEDRS, would be a good thing to summarize into a sentence or two in the lead. I think the fact that emergency doctors are injecting people with ketamine, antipsychotics and benzodiazapines based on this diagnosis is important enough to be included in the lead.

In conclusion, this unique systematic review of the literature on excited delirium syndrome shows a global predominance of low to very low levels of evidence. Our results suggest that excited delirium syndrome is a real clinical entity, that it still kills people, and that it probably has specific mechanisms and risk factors. The numerous unresolved questions that remain warrant further investigations. A universal and objective definition must be urgently developed to allow for more structured and standardized research with a better level of evidence, such as with prospective cohorts comprising toxic, metabolomic, and genetic aspects. Randomized and controlled trials on the treatment and care of these patients are essential.

Talpedia (talk) 21:22, 10 May 2021 (UTC)

I concur. What do you propose? Innican Soufou (talk) 21:34, 10 May 2021 (UTC)

I (or someone else) needs to read the source more fully to think of a good summary! Talpedia (talk) 21:52, 10 May 2021 (UTC)

Talpedia, the APA's statement is very robust: https://webcache.googleusercontent.com/search?q=cache:JbxyyK3efNgJ:https://www.psychiatry.org/File%2520Library/About-APA/Organization-Documents-Policies/Policies/Position-Use-of-Term-Excited-Delirium.pdf+&cd=16&hl=en&ct=clnk&gl=uk&client=firefox-b-d.

The ACEP position is heavily influenced by Ho and Mash, bot paid consultants for Axon.

If you want to understand why this is such a problem, consider homeopathy. There are literally thousands of studies, conservatively at least hundreds per year, studying how hoemopathy works and the conditions it works for and the best remedies for specific conditions. These include trials, meta-analyses and case reports. The problem? Homeopathy doesn't work. It's contradicted by the laws of physics, chemistry, biology and biochemistry. It's bullshit.

Here you ave a condition which is seen almost exclusively in people being restrained by police. Red flag. It is seen disproportionately in young Black men. Red flag. It is promoted by a company whose products are frequently used in such encounters, and whose product liability defense strategy rests heavily on promoting this condition. Massive red flag. The leading proponents, including the man who made up the term, are on that company's payroll. Massive red flag. It's rejected by the APA and AMA and is not listed in ICD or the DSM. Red flag visible from space. Did you read the Reuters report? Guy (help! - typo?) 00:08, 11 May 2021 (UTC)

We don't need to follow the APAs guidance and different sections of medicine can have differences of opinion, as is the case here with the APA and emergency doctors. For example, the UK equivalent of the APA wrote a letter to the government saying that people with psychotic disorders should not be banned from driving - and yet - they are still banned from driving.

Yes parallel literature is a potential problem (as you describe with homeopathy) but I don't think it's fair to describe emergency medicine as pseudoscientific parallel literature, I would imagine it links up with the main body of medical literature and will be critiqued accordingly given enough time.

CPTSD doesn't show up in the DSM and is not in ICD-10 (though appears to be in ICD-11) but many people in the APA would think it was a real diagnosis.

Why is this paper not reasonable to quote from https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13330?

Novel psychological diagnoses can be frustrating, my personal opinion is that the construct of excited delirium is not a good one and is picking up people from all sorts of other psychological constructs that would better describe the behaviour. I'm not sure we just get to ignore a section of medicine's belief in the construct though. I get the impression that psychologists dislike a whole bunch of psychiatric constructs as well (though to be clear excited delirium seems to be a construct of emergency doctors rather than psychiatrists)

Isn't it enough to just say clearly that only emergency doctors think it's a good diagnosis and no one else agrees right at the beginning of the lede? Even if the diagnosis is garbage it's useful to know that emergency doctors will try to diagnose you with it so you can avoid doing what will cause you to be diagnosed with it...

Talpedia (talk) 00:47, 11 May 2021 (UTC)

Talpedia, but it's not just a difference of opinion between medical bodies, is it? It's a diagnosis that is promoted only by one body but not in DSM-V or ICD-10 and explicitly rejected by others, including through public statements from both US and UK saying that the diagnosis should not be used, especially as a cause of death. Both note the tendency for the diagnosis to be disproportionately used in cases of Black men and almost exclusively in police custody.

You call it "novel", but the ACEP position is over a decade old, and the UK forensic science regulator statement is from 2020, so is the APA position paper and the Brookings paper, and the Reuters report is 2021. It's slid under the radar, and the recent killings of Black men have brought the issue tot he fore, to the point that authoritative bodies are standing up and saying this is not a thing.

It would be a gross violation of NPOV to start by saying it's accepted only by one group of doctors and rejected by others, and then go on to describe it with their in-universe framing, when there's so much external reporting of conflicts of interest around ACEP's promotion of the disorder.

The dominant mainstream opinion is that it's not a thing. External reporting indicates really serious concerns of racist undertones and deliberate protection of police, by the group of doctors closest to police, including one prominent advocate who is a member of ACEP, a police officer, an author of the original ACEP position paper, and a paid consultant to Axon. The closest analogy I can think of is chronic Lyme disease, which is assiduously promoted by a very small group of doctors, to the point of lobbying for laws to protect them from discipline for using inappropriate treatments for a "disease" with no objective evidence outside of tests they themselves conduct, no clear diagnostic criteria, and no plausible aetiology. Guy (help! - typo?) 08:01, 11 May 2021 (UTC)

I need to read more literature. My feeling is that it is a diagnosis people use in ERs when they want to use chemical restraints because the patient is very agitated and not responding to argument or "behavioural management" - also when they are afraid of the patient. But if the same patient is moved to a psych ward they'll probably start picking up labels like "drug-induced psychosis", "drug-triggered bipolar disorder", "first episode psychosis", "schizoaffective dosorder" or "schizophrenia". The treatment will largely be the same - antipsychotics and benzodiazapines (though not ketamine) and they will probably be more effective at cajoling people to take the drugs and with smaller doses - I guess being able to lock people in a small rooms and prevent them from leaving until they do what you want will do that.

I don't think it will be a small group of doctors exactly. It will be everyone in the trauma wards and accident and emergency medicine (plus the police because they kind of have to deal with same situations).

See for example this advice in the UK : https://www.rcem.ac.uk/docs/College%20Guidelines/5p.%20RCEM%20guidelines%20for%20management%20of%20Acute%20Behavioural%20Disturbance%20(May%202016).pdf

Talpedia (talk) 08:23, 11 May 2021 (UTC)

Talpedia, in most cases the "diagnosis" appears to be initiated by police, socialised by them, and planted with the EMTs. But I encourage you again: look at the parallel with chronic Lyme disease - or electromagnetic hypersensitivity for that matter. We have explicit statements from the APA, who are the relevant professional body, challenging it. As the other sources make clear, it's a catch-all term used for patients with a broad and heterogeneous range of underlying conditions (or in some cases none at all), and the only repeatable common factor, the only thing that more than a quarter of patients have in common, in studies, appears to be the use of forced restraint, generally not following any involvement even of EMTs, and certainly not doctors.

Or maybe you prefer autistic enterocolitis? Widely publicised, discussed and studied in its day, until it was shown to be a fraud perprtrated by a doctor on the payroll of plaintiffs' attorneys.

Note also that while CPTSD appears for the first time in ICD-11, PTSD is in ICD-10, and "excited delirium" is in neither - because, as the sources make clear, it's not a medical diagnosis, it's a description of perceived behaviour - basically "acting up while Black".

In that context, the view of the subset of ACEP members who support this looks very much like a fringe view. Guy (help! - typo?) 10:38, 11 May 2021 (UTC)

Let me see if I can dig up some more sources from emergency and trauma doctors from an international perspective - perhaps I'll try to dig up some textbooks. This will make clearer whether this is just something that ACEP wrote, or if it is regularly used as a diagnosis in day-to-day emergency medicine. Talpedia (talk) 11:47, 11 May 2021 (UTC)

Okay, I've started looking at some textbook to see how much excited delirium shows up in mainstream emergency medicine. From two emergency medicine textbooks it is not mentioned (though there are citations to journal pieces entitlted with the term). If editors have access to the same sources as I do, they could look at some of the following.

*Peter Cameron, Mark Little, Biswadev Mitra Conor Deasy - Textbook of Adult Emergency Medicine* has a section on "Pharmacological management of the aroused patient" and mentions "chemical restraint" and talks about treatment with ketamine, antipsychotics and benzodiazapines (those discussed in the context of excited delirium). This makes me think we might like to ascertain the overlap between excited delirium and "aroused patients" and maybe link to the chemical restraint page.

This source looks interesting from UKs college of emergency medicine. From this

The terms ABD and ‘excited delirium’, or ‘excited delirium syndrome’ (ExDS), are sometimes used interchangeably but only about a third of cases of ABD present as ExDS.

Let me create a new section for this so that we can discuss how to approach the question of medicines and societies responses to agitation in patients - be it here or in a new article. Since the question here is quite specific and I think the solution we might want could be adding information to another article. Talpedia (talk) 07:14, 12 May 2021 (UTC) Talpedia (talk) 07:02, 12 May 2021 (UTC)

Where to talk about what the medical best practice does to agitated patients

So... it does seem to be the case that excited delirium may show up more in coroners reports and in the testimony of lay witnesses than in medical discussions, *but* there are also situations under which medical doctors will sedate patients against their will due to what they identify as agitation. The suggested treatments in this case seem similar to those for excited delirium. Antipsychotics, benzodiazapines and ketamine. The term "acute behavioural disturbance" links to this article.

Taking quotes from the section "The challenginge patient" of

...

A behavioural emergency can be defined as an unarmed threat by a patient or others character-ized by agitation, aggression, violence and irra-tional or altered behaviour.

...

The aetiology of acute behavioural disturbance in the ED is largely mental illness or substance intoxication and often a combination of the two.17A smaller number have an organic illness, includ-ing dementia, manifesting as a behavioural emer-gency.19 Most patients are male (approximately 65%) and under the age of 40,17,20 and around 20% are brought to the ED in police custody.17,21The majority of unarmed threats occur in the late afternoon, evening and overnight, with a weekly peak on Saturdays.17 Between 58% and 80% of these require some form of chemical or physical restraint as part of management

...

The pharmacological management of the acutely aroused patient is discussed in detail elsewhere (see Chapter 20.6), but the principles should be emphasized. The least traumatic measures are advocated, depending on the desired end point of chemical restraint and the risks to staff and patient in administration.Oral benzodiazepines are preferred where possible and may allow patients a small sense of control if they are able to choose this option ahead of parenteral sedation. Choice between intramuscular or intravenous administration of sedation depends on perceived risks to staff, ease of obtaining intravenous access, need for blood tests or other intravenous therapy and desired rapidity of sedative effect. A standardized intramuscular sedation protocol can be effec-tive and safe.29 Where rapid tranquillization is desired, the intravenous route of administration is required, as the onset of action is within the first 5 minutes rather than the approximate 15 to 20 minutes of intramuscular drugs.30 Commonly used drugs for rapid tranquillization include benzodiazepines (diazepam and midazolam), neuroleptics (droperidol and haloperidol) and antipsychotics (olanzapine). Increasingly, ket-amine is used in patients who are difficult to sedate and in transport situations.31 A combina-tion of intravenous midazolam with droperidol or olanzapine has been shown to be more effective than midazolam alone or than high-dose droperi-dol or olanzapine alone with respect to time to adequate sedation and need for re-sedation.32,33Intravenous midazolam alone may cause more adverse events relating to airway obstruction and over-sedation and is more likely to require re-sedation within an hour. High-dose parenteral midazolam is not supported due to concerns about effect and safety.34 Careful monitoring in a high-acuity area of the ED is required when parenteral chemical restraint is used

Where should this information exist, and I found this source^[6] that says:

The terms ABD and ‘excited delirium’, or ‘excited delirium syndrome’ (ExDS), are sometimes used interchangeably but only about a third of cases of ABD present as ExDS

I feel like we need to discuss this somewhere and the similarities to excited delirium should be acknowledged. It feels a bit like we are denying the existence of a clinical diagnosis and the involuntary treatment associated with it because a related concept is being used forensically in questionable ways.

Talpedia (talk) 07:23, 12 May 2021 (UTC)

Hmm... think I might create an article called "acute behavioral disturbance" mention it in the lede and discuss treatment. Something like "The term Excited Delirium is sometimes use interchangeably with Acute behavioural disturbance, a diagnosis used in medicine with many underlying causes that often involves the use Chemical restraint with anti-psyuchotics, benzodiazapines and ketamine." Dunno if this would count as a content fork but this distinguished excited delirium as a possible cause of ABD Talpedia (talk) 17:46, 12 May 2021 (UTC)

Talpedia, I have no strong opinion on that, other than that we need to avoid the tendency of certain parties in the medical field to portray violent police actions towards mentally ill people as some kind of defensible response to fear of their behaviour. Guy (help! - typo?) 17:55, 12 May 2021 (UTC)

References

Acute behavioural disturbance

I've started to put together a draft for acute behavioural disturbance: Draft:Acute Behavioral Disturbance to deal with the "official" medical response for aroused behaviour potentially resulting in Chemical restraint or physical restraint. It's not quite there yet, but when it's ready I'm planning to stop disambiguating acute behavioural disturbance and link to this page in the lede. Talpedia (talk) 01:47, 18 May 2021 (UTC)

Short description

The short description was "state of extreme agitation". Although excited delirium is often used interchangeable with Acute behavioural disturbance which is state of agitation, excited delirium is considered to be a well-defined diagnosis in other literuate (particularly when talking about death).

I'm changing this to "Condition accompanied by...". Talpedia (talk) 17:41, 10 July 2021 (UTC)

Biased article

This article was written with a clear bias against law enforcement and is based almost entirely on opinion and false information and not fact. 2600:387:5:814:0:0:0:14 (talk) 09:44, 17 December 2021 (UTC)

As far as I can tell from a glance, everything is sourced. Can you point out a single sentence that you have a problem with?--Megaman en m (talk) 10:20, 17 December 2021 (UTC)

So... I think there might be some subtly misleading things going on with terminology. Chemical restraint is accepted within psychiatry, they will just often use psychotic diagnoses rather than excited delirium to treat people, and the treatment is very much similar to that described for excited delirium (I'm not really sure about ketamine use though). You can have criticisms of excited delirium, which sort of should be considered together with criticisms of any form of chemical restraint, but aren't merely because of terminology. One point I do think is unique to the phrase excited delirium is the forensic diagnosis of death by excited delirium, or death due to self-defense arising because of excited delirium, so the use of the term excited delirium can implicitly legitimise the diagnosis in cases of death (because the term is used more generally for "that thing that happened before chemical restraint") or conversely smear the practice of chemical restraint with the use of the diagnosis in what might be police killings. This sort of "content fork within the literature itself" can be quite difficult to deal with, because you often lack the sources to equate "the same" concept in different settings.

It's also worth noting that things that more or less amount to chemical restraint can occur after anaesthesia due to agitation: https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2044.2006.04791.x I get the impression that who is involved in chemical restraint can affect how people view the practice. Talpedia (talk) 14:53, 19 December 2021 (UTC)

Section blanking

User:82.112.138.191, would you please discuss your reasons for repeatedly blanking the "Position of the American College of Emergency Physicians" section of this article? Thanks, Generalrelative (talk) 05:28, 28 December 2021 (UTC)

I would guess the concern is the ACEPs statements inconveniently legitimise the use of a diagnosis that can be used to drug agitated people, and incorrectly justify the death of people in custody. So it would be convenient to obliterate this position from the literature (the advent of ketamine with its psychomimetic and long term dopaminergic properties is particularly unfortunate)

I'm pretty dubious myself and think the diagnosis is probably subsumed by various psychiatric diagnoses.

Unfortunately, the obliteration of the diagnosis requires a whole bunch of research and I'm not quite sure anyone is going to do it. Psychiatrists don't necessarily care because it's outside of their literature and emergency doctors probably find it convenient to be able to shove needles filled with ketamine into disruptive patients. Perhaps an emergency medicine doctor who has had a relative harmed by mental health services will make inside the citadel of "professional moats" that surround any medical profession's literature and rip up this stuff.

More plausible is that psychiatry gets into the accident and emergency ward a little more and the diagnosis fades from memory.

Regardless, all wikipedia can do is follow the literature and waits (and hope that a complete, noticed and and accurate understanding of the literature will drive research). Talpedia (talk) 12:13, 28 December 2021 (UTC)

If you look closely you will see that they blanked both legitimizing and critical remarks. Also: I've indented your comment for you per WP:TALK. Please indent your own comments in the future. If you need help with this, see Help:Talk_pages#Indentation. Thanks, Generalrelative (talk) 15:36, 28 December 2021 (UTC)

It wasn't me who blanked the section just commenting on the likely motivations and issues (and why this is likely to come up a few times - and indeed has). The indentation was due a limitation in the mobile app that has "reply" button but then does not indent, you could bring it up with mediawiki maybe. I don't really care what you tell me to do... and will probably ignore you whenever you do so. However, I shall bear this limitation of the app in mind going fowrard. Talpedia (talk) 15:46, 28 December 2021 (UTC)

WP:REDFLAG issues

First up, recall as you think about this that "EXD" is not accepted by the WHO, American Psychiatric Association, American Medical Association, EUSEM, is not in the DSM and is not in ICD-10. It is accepted in the US only by the American College of Emergency Physicians (ACEP). Michael Baden calls it "a boutique kind of diagnosis created, unfortunately, by many of my forensic pathology colleagues specifically for persons dying when being restrained by law enforcement". Most cases - almost all, and all deaths as far as I can see - are in police custody. The principal advocate for the condition is Axon, formerly known as Taser corporation, makers of the stun guns.

I'd argue that this widespread rejection, absence from ICD-10 and DSM, negligible incidence outside police custody, and advocacy paid for by a company with a vested interest in excusing deaths in police restraint, qualifies it as a fringe diagnosis - and even if you don't accept that, it's clearly a massive WP:REDFLAG.

There are a number of sources that were used in this article, which I have removed, although at face value they pass MEDRS. The reasons are explained in the edit summaries, but I'll go into them here.

• Sources authored by Charles Wetli cannot be taken at face value. Wetli coined the term after investigating 19 Black prostitutes who died in what he described as a combination of cocaine use and "sexual ecstasy", but when another woman died of the same thing and was found to have no cocaine in her body, his supervisor re-examined the previous cases and found them all to be the strangled victims of a serial killer. I cannot find any record that Wetli has changed his position on the diagnosis despite incontrovertible evidence that the cases on which he based his origin of the diagnosis, were actually the work of a serial killer, and his misdiagnosis probably contributed to the deaths of up to thirty women. Wetli was (and I think still is) on the payroll of Axon, per Reuters.
• A 2009 white paper by ACEP had at least three co-authors with undeclared conflicts of interest (all paid by Axon). At the time of publication, ACEP did not require conflicts to be declared.
• Sources authored by Jeffrey Ho are similarly tainted. Ho is a physician-cop on the payroll of Axon who was also involved with the Hennepin ketamine study, administering ketamine without informed consent to treat excited delirium in a Minneapolis hospital. This was terminated due to ethical concerns (Nature).
• Sources authored by Deborah Mash are also tainted. Mash, a protégé of Wetli, is on the payroll of Axon, and Axon appear to have a standard pack they send to police forces when a suspect dies after being tased, asking them to send tissue samples to Mash, whose tests (amazingly!) always seem to show that there is evidence of EXD and the Taser didn't kill them. Taser do not inform police of the conflict of interest.(Reuters and others)

There's also strong reporting from Reuters, Brookings and numerous other RS undermining the diagnosis. There have been over 1,000 deaths following Taser use in the US, and Taser is significantly responsible for promoting the diagnosis of excited delirium. Another paid consultant and stockholder, Mark Kroll, has described Tasers as "therapy" for EXD. One reason this is suddenly getting serious attention is because the term was used by police during the murder of George Floyd ("Man Dies After Medical Incident During Police Interaction").

Mash and Wetli cite "Bell's mania" (which redirects here) as an earlier observation of the same symptoms, but Bell's paper is from 1850 and it seems likely that most of those who died in Bell's care were actually suffering from encephalitis - notably, the diagnosis more or less disappeared in the 1950s with the advent of antipsychotics and antibiotics. Wetli claims that it resurged due to cocaine use - rhetoric very much in line with the "war on drugs", and, again, strongly associated with the use of crack (more used by Black people) rather than pure cocaine (more used by white people). Diagnosis is disproportionately seen in Black men, and is closely associated with the racially biased differential treatment of crack vs. white cocaine. While most accidental cocaine toxicity deaths are in white people, those dying of "cocaine-induced EXD" were more likely to be Black, with lower levels of cocaine in their bodies, under restraint by police. "In all 21 cases of unexpected death associated with excited delirium, the deaths were associated with restraint (for violent agitation and hyperactivity), with the person either in a prone position (18 people [86%]) or subjected to pressure on the neck (3 [14%]). All of those who died had suddenly lapsed into tranquillity shortly after being restrained".[7]

Axon's involvement is inescapable. They are quite open about their payments to medical experts to promote narratives of the safety of their products. They placed Robert Stratbucker on a DoJ study on safety of Tasers, until he was rumbled.[8] Their SEC filings[9] acknowledge the impact of litigation on their bottom line, and they call out their investment in paid medical spokespeople and their aggressive strategy of suing MEs who cite Tasers as a cause of death, as turning this round. "Continued aggressive litigation defense to protect our brand equity. We have an assembled team of world class medical experts at our disposal and hired additional internal legal resources during 2005 to provide an efficient means of defending us against numerous product liability claims. We have had a total of 12 cases dismissed or defense judgments in our favour. We view a continued record of successful litigation defense as a key factor for our long term growth." They sued a number of medical examiners and expert witnesses for defamation, product disparagement and tortious interference with trade, when they stated that Tasers had contributed to or caused deaths. And EXD is their go-to in deaths after Taser use.

We have a condition here which is based on an original misdiagnosis of murder, overwhelmingly rejected by the medical profession, where the UK's regulator of forensic pathology has said that is "has been applied in some cases where other important pathological mechanisms, such as positional asphyxia and trauma may have been more appropriate" and should not be used as a cause of death, which is cited as a cause of death in up to 50% of cases where someone dies in police restraint but is almost never seen elsewhere, and whose notable proponents include several people on the payroll of Axon including a couple of cases where there have been massive ethical concerns. That argues very strongly against relying on those advocates as sources. Guy (help! - typo?) 10:20, 9 May 2021 (UTC)

Guy is right, this article's stance is was absurd. --Hob Gadling (talk) 10:43, 9 May 2021 (UTC)

Corrected the tense after I looked at the newest version. --Hob Gadling (talk) 10:46, 9 May 2021 (UTC)

All interesting stuff. I'm inclined to think that Emergency doctors have enough of their own reasons to want medicate agitated patients to not necessitate too much lobbying. Though I do find the argument that taser benefits from the diagnose of excited delerium plausible - both to justify the user of tasers ("I can't shoot him it's not his fault") and to disown responsibility ("there was nothing else we could do he had a disorder").

As every WP:RS and WP:MEDRS constrain us. If the experts are wrong we only get to document the controversy and make everything as exact as possible - we can't decide for ourselves that something is an equivalent diagnose for a number of behaviours.

I would note that UK's NHS, [10] has a diagnosis for excited delerium. I have a suspicion that this diagnosis really means "that which justifies chemical restraints", rather than a distinct psychological diagnosis. There's a question about the blurry line between "policy" and diagnosis that exists is health care in general.

Psychiatric and psychological diagnosis seems like a thorny business in general. It's mostly a game of trying to find consistencies between behaviour, response to drugs, and responses to talking therapy to try and create some halfway consistent theory. (with an added dose of policy, social, and psychological constraints for what you get to classify as a psychological disorder). I sort of feel like much of the specific criticism here could be equally well applied to many other psychiatric diagnosis.

I personally think there may be issues with the use of ketamine instead of benzodiazapines and that ketamine might be more *useful* for sedation, but come with it's own risk. It's to be noted that ketamine is referred to as a psychotomimetic drug, which seems to increase psychotic symptoms in those diagnosed with schizophrenia, and it is also medium term (weeks) dopaminergic (see dopamine hypothesis) - so giving those with psychotic disorders ketamine may not be the best of ideas. If I remember correctly it contradicted as a pain killer for those psychiatric diagnoses.

Anyway, that's a lot of opining from me for now. If you can get some reliable sources together than talk about the funding of research by Axon (though preferrably contextualized with general funding information), or link to some general critique of psychiatric diagnosis, or point at the controversy from reliable sources, then that would be good.

I would note that many psychiatric diagnoses have gendered and racial effects. More men are diagnosed as psychotic, more women as anxious and borderline (i think - double check before you quote me). Talpedia (talk) 15:01, 9 May 2021 (UTC)

To the MEDRS question, a 2009 study with convincing evidence of concealed coi seems like an easy exclude, especially when there is equall compelling evidence that it’s not recognised by almost all doctors’ groups, or indeed many members of the group that does. So what I have done is exactly to document the controversy. But not inna “teach the controversy” stylee. Guy (help! - typo?) 16:45, 9 May 2021 (UTC)

I felt that this article was well put together and provided some really interesting insight into excited delirium. The only thing that I think could use some editing is the history page. Most of the history listed is from before 1990, and I think there are still some important events from the past couple decades that could provide further information.

- Maxwellallen1235 (talk) 20:43, 3 October 2022 (UTC)

They kill the person twice:

Related:

• They kill the person twice: police spread falsehoods after using deadly force, analysis finds --The Guardian

"A review of police killings in California showed that law enforcement spokespeople frequently publish highly misleading or sometimes false information about the people they have killed. Over the last five years, the Guardian found at least a dozen examples in the state of initial police statements misrepresenting events, with major omissions about the officers’ actions, inaccurate narratives about the victims’ behaviors, or blatant falsehoods about decisive factors.

In some cases, police cited vague “medical emergencies” without disclosing that officers had caused the emergencies through their use of force. In others, departments falsely claimed that the civilians had been armed or had overdosed. In most instances, media outlets repeated the police version of events with little skepticism."

--Guy Macon (talk) 16:16, 22 May 2021 (UTC)

I don't think that's something to be extensively addressed on the page, although it would be worth briefly noting. I would hope that this is detailed on a page that is about more general police misconduct and a link to there would be good. MasterTriangle12 (talk) 01:45, 8 August 2021 (UTC)

I notice that this report is about the "initial" police statements. Breaking news is often filled with misrepresentations, omissions, inaccuracies, etc., because people don't always have full information at hand. I think the way to approach this problem for this article is to not use WP:PRIMARYNEWS. WhatamIdoing (talk) 07:04, 22 June 2023 (UTC)

What to do

This article seems to spend a lot of time talking about what not to do, but I didn't see any positive recommendations. Imagine the classic EXD story: a man is behaving very strangely, walking unsafely through a public area (e.g., into the path of oncoming vehicles), making incoherent noises, and breaking windows.

This page sort of implies: Don't sedate him, don't restrain him, don't give him ketamine, don't taser him, don't don't don't don't don't.

What I'm missing is: What should be done? Evacuate the area around him and wait until he collapses, at which point someone can sweep up the glass? What's the best path towards having this person alive at the end of this event? WhatamIdoing (talk) 07:46, 22 June 2023 (UTC)

I think part of the issue is that Excited delirium is a diagnosis used by forensic scientists, and emergency doctors and an amateur diagnosis by police officers and the press. In psychiatry you have Acute behavioural disturbance as well as specific diagnoses like mania and psychosis. Do Chemical restraint or Acute behavioural disturbance speak to your topic? I get the impression it's more of a "they just died / we had to do it" diagnosis applied post hoc - combined with a "let us use ketamine" diagnosis. One thing to bear in mind is that psychiatry can already have people detained and may have more training for interpersonal deescalation so the desire to use something quick-acting like ketamine might be reduced. My personal opinion... which I don't think is very well covered in the discussion - is that ketamine is a psychotomimetic with medium term dopamine increasing effects - so if you've got people with psychotic symptoms it might be a bad idea to give them ketamine.

Going from my memory of sources and filing the gaps. I think the correct response would be something like "engage in behavioural interventions - listen and try to be boring etc - there are likely nuances surrounding manic and psychotic thought processes versus normal thought processes versus those in an emotion state plus things like distraction; try to get people to voluntarily take benzodiazapines; eventually detain people; eventually hold them down and get inject them with haloperidol; pay careful attention to perverse effects of drugs and misdiagnosis thereafter (e.g. cognitive impairment, akathisia and stress of detention versus mania and psychosis)"

I'm a little suspicious of the "wait until they collapse" part. Having a diagnosis were "just dying" is one of the symptoms is somewhat... convenient. I quite agree that mania (or whatever diagnosis you want to use for the behaviour) might increase the risk of heart disorders, but I think having a heart disorders as a feature of a behaviour-based diagnosis is suspicious.

There is a horrible (if unlikely) pipelines that goes)agitation caused by valid reasons that would self resolve -> drugged with ketamine -> induced psychotic symptoms + medium term manic symptoms -> antipsychotics -> akathisia as a side effect mistaken for mania combined with perverse effects of second generation antipsychotics causing symptoms resembling psychosis -> psychosis diagnosis -> life long antipsychotic use initially enforced with a community treatment order for a number of years and thereafter through compliance -> horrible side effects plus potentially (though controversially) inducing a permanent psychotic condition due to dopamine sensitivity in response to antipsychotic use.

The "knowledge gaps" that it might be good for us to address are good behavioural interventions for emergency doctors and police officers as well maybe more of a knowledge of the standard diagnoses. Talpedia 08:59, 22 June 2023 (UTC)

How do you "listen to" someone who is only capable of making incoherent noises?

The pipeline that is described here could be simplified down to:

• restrain him, with the goal of taking him to the hospital → dies of positional asphyxia

The pipeline I'm thinking about is:

• do nothing → untreated drug-induced hyperthermia kills him
• do nothing → untreated drug-induced hallucinations kill him (e.g., he runs into traffic to 'escape' from a frightening hallucination)

The pipeline I'd like to hear more about is:

• ______ → he survives!

What belongs in that blank? WhatamIdoing (talk) 19:41, 22 June 2023 (UTC)

Well you attempt to listen to them first before bundling them to the floor and injecting haliperidol into their leg (or ketamine) in case you don't need to. People have a habit of forgetting the don't need to use force.

I guess the short answer might be "mental health nurses arrive and administer haliperidol following physical restraint by a large enough number of people trained in physical restraint"

I've summarised some of this and linked to sources in Acute behavioural disturbance. I wrote to the UK paramedic organization (cant remember their name) requesting their guidelines on the use of ketamine... they said they could not provide them. I considered buying a copy of their guidelines but did not.

You then have questions about what happens if you can't do this or have insufficient mental health resources

• Benzos vs antipsychotic vs ketamine
• How many people to the physical restraint to administer tge chemical restraint
• Under what circumstances do police engage in physical restraint or chemical restraint (e.g. in the UK the police await paramedics for chemical restraint). Medical advice encourages minimizing physical restraint in preference to chemical restraint... but you might want to avoid giving police access to drugs.
• Where someone is detained (e.g. in a hospital vs a prison)
• Do you think "excited deliriumx while doing this or "agitated". I'd say you abandon the use of excited delirium for all purposes besides social science in preference for other diagnoses.

Talpedia 21:05, 22 June 2023 (UTC)

So... the answer is that people with acute behavioral disturbances are going to die? Because I started with:

• restrain him, with the goal of taking him to the hospital → dies of positional asphyxia

and you have changed it to:

• see if he is saying anything intelligible, then restrain him, with the goal of taking him to the hospital → dies of positional asphyxia

This does not seem to be much of a difference in the end. WhatamIdoing (talk) 09:27, 23 June 2023 (UTC)

I guess some of them maybe :/... perhaps this is true for all medical interventions - all you get to do is reduce the risk. From Acute behavioural disturbance

National Institute for Health and Care Excellence suggest supine rather than prone restraint and that physical restraint should ideally not last longer than 10 minutes.

so maybe that could prevent some deaths. I guess you have to weigh up the risk respiratory risks of police restraint, benzodiazapines, antipsychotics and ketamine. I sometimes wonder if asphyxia due to police restraint is due to unnecessary restraint whe you could use handcuffs. In a hospital physical restraints can be used... which likely reduce the risk of asphyxia... so perhaps you could have physical restraint vans if you handcuffs aren't doing the job. You have to weight this up against the risk of abuse - is it better having 1 in 1000 physical restraints end up in asphyxia or risk having people who don't need physical restraint held in physical restraint for hours in police vans - civil liberties have never come without a corresponding risk to life. If you want to start giving people more powers and capabilities to use physical force and coercion you start having to set up a system of checks and balance, ensuring that is funded and the people advocated for, making sure that the values of the organization are in line with their job (mixing mental health and crime prevention can be a stretch) and ensuring that your legal of advocacy system does not get captured and used as a means of coercion by medicine, the police or society as a whole.Talpedia 11:18, 23 June 2023 (UTC)

Did NICE give a reason for recommending supine instead of the Recovery position? Or just sitting up?

Does their recommendation for a 10-minute limit on restraints just accidentally happen to be paired with a preference for haloperidol, which takes 20–30 minutes to have a clinically significant effect, thus making their recommendations self-contradictory? WhatamIdoing (talk) 20:01, 23 June 2023 (UTC)

They don't provide reasons, but they do provide evidence used in their deliberations (https://www.nice.org.uk/guidance/ng10/resources/violence-and-aggression-shortterm-management-in-mental-health-health-and-community-settings-pdf-1837264712389)

Prone restraint was a factor in some deaths and there are some theoretically linked studies that show "prone" bad. There is rather less "supine good" compared to "prone bad" and indeed, some of the studies are of the form "sitting good prone bad". I don't think they've considered the recovery position; there may be issues with how much control the restrainer has. (page 7)

Yes, it does sound like they haven't really thought the period of restraint through. Much of the evidence on the choice of sedative agents talks about effects after two hours and there is no consideration of ketamine. Haloperidol plus lorazepam is standard practice apparently so there may be some status quo bias. Much of the research comes from psychiatric wards. I suspect there may be bias in terms of what sort of drugs people tend to prescribe and access to resources. E.g. I could imagine it might be bureaucratically painful to bring people familiar with the use of ketamine to a psych ward.

The royal college of emergency medicine are very pro-ketamine https://rcem.ac.uk/wp-content/uploads/2022/01/Acute_Behavioural_Disturbance_Final.pdf but they also mention the antipsychotic droperidol (random web pages talk about a 5-10 minutes action period). It's noticeable that RCEM are paranoid about interactions with other antipsychotics when discussing droperidol; when discussing the use of ketamine they talk about resusitation equipment being present. I suspect ED workers might be more blaze about resuscitation but more paranoid about interactions of psychoactive drugs, while psychiatric nurses might really dislike the idea of breathing issues. This article repeats the critique of prone restraint but claims that new evidence does not support conclusions.

Droperidol likely does not have the psychotomimetic effects of ketamine and may well not have the respiritarory problems of benzodiazapines (which apparently accompany ketamine use)... nor the mania simulating effects of second-generation "partial agonists" antipsychotics it could have some peverse effects (e.g. aripiprazole has case reports of gambling addiciton and hypersexuality ).

We should probably discuss some of this of the page on Acute behavioural disturbance. It would be good to mention droperidol as well as the advice to have resus equipment on hand for ketamine. I would like to find something talking about the psychomimetic effects of ketamine in the context of chemical restraint.

Talpedia 23:13, 23 June 2023 (UTC)

We might like to summarize this review on Physical restraint. This sites a study of a "supported prone" form of restraint that shows that proxy's for respiratory problems are less affected by this. It also explicitly criticises Hogtie restraint positions. Talpedia 18:49, 24 June 2023 (UTC)

References