Excited Delirium Syndrome: Causes, Symptoms, Treatment - Mental Health Daily

Excited delirium is considered a relatively uncommon health condition characterized by severe agitation, aggression, distress, and is often fatal.  In many cases of excited delirium, individuals will have displayed noticeable increases in body temperature (fever), utilized drugs that altered dopaminergic functioning, and exhibit overtly bizarre behavior.  Although the condition is rare, those with excited delirium are often misdiagnosed, and end up dying before they receive proper medical treatment.

Some research suggests that individuals with excited delirium generally die as a result of heart attacks; this may be subject to individual variation.  The condition is sometimes referred to by other names such as: “Bell’s mania,” agitated delirium, acute exhausted mania, and lethal catatonia.  While many individuals that experience excited delirium are identified by law enforcement and treated by medical professionals, some cases prove to be fatal.

A clinical diagnosis for “excited delirium” (EXD) is difficult due to the fact that the psychiatric community, World Health Organization, and International Classification of Diseases doesn’t recognize excited delirium as a condition.  Many experts believe that excited delirium is a condition related to neuroleptic malignant syndrome.  Despite the lack of medical diagnostic criteria, cases of excited delirium should be recognized by professionals.

A Brief History of Excited Delirium (Syndrome)

Excited delirium is a condition that was first documented in the mid-1800s in which it was originally referred to as “Bell’s Mania.”  A physician named Luther Bell noted a set of symptoms characterized by fever and manic symptoms that didn’t fit other medical diagnoses.  While cases of Bell’s Mania in the 1800s were rare, approximately 75% (3/4) of individuals with this condition ended up dying.

The diagnostic term “excited delirium” wasn’t formally coined until 1985 in Maryland.  It was associated with symptoms such as: aggression, bizarre behaviors, violence, fever, shouting, and uncanny levels of physical strength.  Those who exhibited excited delirium were considered violent, intoxicated, and required police restraint.

A majority of these cases were associated with stimulant drug reactions, not those formally diagnosed with mental illnesses.  Though many drugs are capable of provoking “excited delirium,” cocaine appears to have the strongest link.  Most autopsies of those who died from this condition had ingested cocaine.

Excited delirium shares symptomatic overlap with both stimulant psychosis as well as neuroleptic malignant syndrome.  It differs from neuroleptic malignant syndrome in that it isn’t caused by an adverse reaction to antipsychotic or neuroletpic drugs, and it differs from stimulant psychosis in that it is considered highly fatal with a few other symptomatic differences.

Stages of Excited Delirium

Those that experience excited delirium typically go through various stages including: severe agitation, potential violence, police restraint, struggle, respiratory failure, and usually death.  While death does not always occur, most cases of excited delirium are associated with mortality.

Stage #1: Delirium & Psychomotor Agitation

The first stage of excited delirium is that of delirium with psychomotor agitation.  This means that the person will appear delirious, disoriented, yet hyperactive.  They may be pacing back and forth, yelling, or engaging in violent behavior.  They may also be inappropriately clothed and profusely sweating as a result of their elevated body temperature.  The individual may appear to be plagued with delusions and act very combative.

Stage #2: Disturbing the Peace

The second stage of the condition that may be occur relatively simultaneously with the onset is that of disturbing the peace.  The individual with excited delirium may shout obscenities, display bizarre behavior, and may appear violent.  In this case, someone generally takes notice and contacts police.  Once the police are notified, they’ll then show up and attempt to restrain the individual as to prevent the person from harming others.

Stage #3: Restraint & Struggle

The police may attempt to restrain the individual with excited delirium, and the person may appear resistant to pain, with high levels of both endurance and strength.  The police may have a difficult time getting the person with excited delirium to cooperate.  In some cases a taser will be used if the person refuses to cooperate with law enforcement.  Eventually the police will restrain the individual, but hopefully not as to constrict the diaphragm as this can lead to death.

Stage #4: Diagnosis & Treatment

Next it will be up to the police officer to properly diagnose the individual with excited delirium and contact medical responders.  Due to the fact that this condition is difficult to diagnose and may resemble other conditions such as intoxication, panic attacks, etc. – it is important that proper diagnosis is given to save the patient.  With proper diagnosis, a police should attempt to help the patient stay calm, relax, and should use the minimal amount of restraint.

When medical responders arrive, they will need to have a correct diagnosis as well so that proper treatment can be administered.  Using beta blockers is a mistake in this situation, but benzodiazepines can be an effective way to induce relaxation.  The patient’s fever should be cooled and all therapeutic options should be considered.

Stage #5: Recovery vs. Death

In most cases of excited delirium, the patient ends up dying.  This is due to difficulty of diagnosis as well as the fact that death may be inevitable for some individuals with preexisting medical conditions or drug-induced physiological changes.  With proper treatment by both police and medical responders, there is a chance the individual may experience a full recovery.

On the other hand, respiratory failure and cardiac arrest are also common outcomes.  Nearly 2/3 individuals with excited delirium end up dying in police custody or while being transported by paramedics to the hospital.

Excited Delirium Causes (List)

The exact causes of excited delirium for each individual remain unknown.  The commonality among most cases is that individuals had ingested a stimulatory drug – most often cocaine.  Various cofactors that have been considered include: cocaine metabolites (e.g. benzoylecgonine), neurotransmission (particularly of dopamine), genetic polymorphisms, and sometimes preexisting psychiatric conditions.

Blood : In the blood of those who have died from excited delirium, the presence of stimulant drugs (usually cocaine) and/or alcohol is common.  In 1985, deaths of excited delirium as a result of cocaine revealed that average blood concentrations of cocaine differed from standard overdose deaths.  Blood concentrations of cocaine among those with excited delirium were significantly lower than average.

Furthermore, blood concentrations of cocaine were on par with those who used cocaine on an infrequent, recreational basis.  In other words, most individuals with excited delirium weren’t abusing or overdosing, but they were experiencing an abnormal reaction.  Upon analysis of these patients, a metabolite of cocaine called “benzoylecgonine” appeared to be significantly higher than infrequent users.

This implied that pre-death cocaine usage was chronic.  Researchers speculate that cocaine binges may make a person more susceptible to death as a result of excited delirium.

Drugs : Autopsy analyses among those who died from excited delirium syndrome often reveal the ingestion of stimulant drugs and alcohol.  As was mentioned, the drug most associated with this condition is cocaine, but methamphetamine is another common culprit.  That said, clearly not everyone who abuses stimulants experiences excited delirium.  They may experience a similar condition known as “stimulant psychosis” which isn’t generally fatal and is treated differently.

Neurotransmitter levels : Research suggests that those who experience excited delirium generally have altered neurotransmission of dopamine.  Cocaine functions as a dopamine reuptake inhibitor, thereby increasing extracellular levels of the neurotransmitter.  This can lead to many characteristics that resemble positive symptoms of schizophrenia (e.g. hallucinations).

Genetics : There is some evidence that the c-Fos protein may be responsible for dopaminergic dysfunction as a result of stimulant drug abuse and significant physiological stress.  Some have speculated that certain genetic polymorphisms may alter functioning of c-Fos, making some individuals more susceptible to excited delirium than others.

Mental illness : While having a mental illness isn’t always a prerequisite for experiencing excited delirium, it may increase susceptibility. It has been speculated that individuals on psychiatric medications that simultaneously abuse illicit stimulants may disrupt the transportation of dopamine, leading to high dopamine levels.  Psychiatric conditions most associated with this condition include: mania, schizophrenia, and depression.

Note : Another important note is that excited delirium occurs most commonly in men compared to women, particularly those with a history of stimulant drug use (e.g. cocaine).  In some cases alcohol withdrawal or head trauma may influence the condition.

Excited Delirium Symptoms

There are many behavioral, physical, and psychological symptoms associated with the condition known as excited delirium.  While all symptoms need not be present for diagnosis, if the condition isn’t quickly identified and treated, it may result in mortality.  Hallmark symptoms include: psychomotor agitation, delirium, shouting, fever, and heightened strength.

Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2695211/

Death from Excited Delirium Syndrome

It is often difficult to determine the exact mechanisms by which a person may die as a result of excited delirium.  When a person dies as a result of this condition, the cause of death is generally listed as “excited delirium syndrome.”  It is estimated that 2/3 individuals experiencing excited delirium will die at the scene of their legal restraint or in transportation to the hospital by paramedics.  The two most common causes include: cardiac arrest and respiratory failure.

In many cases the individuals experiencing excited delirium don’t know what’s going on or how to cope with their experience.  Many victims are found after having made attempts to cool themselves (i.e. their fever) by using ice, water, removal of clothing, etc.

At the Hospital

There are a few causes of death that a person may experience once they get transported to the hospital.  These include: clotting of the small blood vessels, breakdown of skeletal muscle tissue, and ultimately kidney failure. These stem from heightened catecholamine stress on the heart and other cardiac alterations.

Police Restraint

Some speculate that police restraint and handling of the individual with excited delirium may contribute to their death.  Since most individuals are violent, display heightened pain tolerance, and are dangerous, restraints are often administered by law enforcement.  Too much compression as a result of the restraints may lead to lack of oxygen, arrhythmias, or exacerbation of symptoms as a result of hyperventilation.

In some cases, chest and neck compression, blunt trauma, and/or atherosclerosis may increase the likelihood of fatality resulting from this condition.  In many cases of excited delirium, there is no specific cause of death, but a coalescing of potential contributing factors.  Things to consider include: handling by police, diagnosis and treatment from paramedics, and speed by which the condition was identified.

Excited Delirium Treatment

It is difficult to properly treat those with excited delirium due to the fact that the condition must first be correctly diagnosed.  Excited delirium is often mistaken for other conditions such as: panic attacks, delirium tremens, and stimulant psychosis.  The first step involves properly restraining the individual so that they do no harm to themselves or others, and secondly a medical professional will administer treatment as they see fit.

Physical restraint (Police)

Due to the fact that individuals experiencing excited delirium are often difficult to control, combative, and have a high degree of both strength and endurance, they first need to be restrained.  Without restraint, they may engage in unexpected violent behavior or be a danger to others.  Therefore contacting law enforcement is generally the best first step to get a person with excited delirium under control.

Law enforcement should be knowledgeable of individuals experiencing excited delirium.  Those that are knowledgeable of this condition will often restrain the individual with sensitivity to this mental condition.  This will involve first securing the individual by handcuffing them and strapping them down at various regions of the body (e.g. hips, knees, stomach).  This will allow medical professionals to administer treatment via intramuscular injections.

Medical treatment (Paramedics)

After the police have gotten an individual with excited delirium under control, a medical team will generally assess their current state and come up with a modality of treatment.  Treatment most often is delivered via intramuscular (IM) or intravenous (IV) injection.  Due to the fact that each case of excited delirium tends to have a unique cause, treatment modalities will be subject to individual variation.

During this time, the paramedics will be working in conjunction with the police to determine how the individual should be handled.  Police should focus on the safety aspect, while the medical responders should be focused on the treatment.

Other possibilities:

Source: http://www.ncbi.nlm.nih.gov/pubmed/19785904
Source: http://www.ncbi.nlm.nih.gov/pubmed/22908610

Is excited delirium dangerous?

[A resounding] YES. Not only is excited delirium dangerous to the individual experiencing the condition, but it may be dangerous to others in their presence.  Due to the fact that individuals with excited delirium may engage in violent behavior, it is important to contact the police as well as a medical team as soon as these cases are identified or speculated.  Additionally, it is known that excited delirium may be fatal for the individual experiencing the condition.

Have you ever experienced excited delirium?

While few people experience drug-induced psychosis, an even fewer number of individuals experience excited delirium.  If you experienced excited delirium, feel free to share a comment below describing your experience to provide others with some insight.  For us to get a better understanding of your situation, discuss how you know you experienced excited delirium, what caused it, and how you were treated (or dealt with it).