A knee in the neck of excited delirium

March 11, 2008
Amanda Truscott
Canadian Medical Association Journal

Some call it an entirely manufactured psychological condition. The police believe it is not only legitimate, but potentially fatal.

The latter, though, may have a vested interest in perpetuating the notion that "excited delirium" is a valid medical condition, given the heat they've taken following last year's death of Polish citizen Robert Dziekanski at Vancouver International Airport after being shot by a taser, a hand-held weapon that uses compressed air to direct a jolt of electricity up to 10.6 metres away.

Did Dziekanski die from "excited delirium" or multiple taser shocks? And what about the officer's knee pressed into his neck?

Dziekanski touched down in Vancouver on Oct. 14, 2007, following a 13-hour flight from Poland and for 8 hours roamed the immigration lounge, steadfastly insisting that his mother would soon meet him. She, meanwhile, awaited his arrival in the baggage claims area, while airport officials did nothing to ensure the pair could connect. Lost, confused and unable to speak English, Dziekanski used office chairs to build a makeshift barricade between a pair of glass doors as if to ensure that no one could remove him from his meeting place with his mother. Obviously frustrated, he began to throw computer equipment onto the floor and against a glass wall. The police were summoned and in stunning sequence of events captured on video by an eyewitness's cell phone, Dziekanski was pinned the floor, shot by a taser and eventually died.

Public outrage prompted the federal government to call an investigation into officers' use of tasers. The Commission for Public Complaints Against the RCMP [Royal Canadian Mounted Police] released an interim report on Dec. 12, 2007, recommending restrictions on the weapon's use. A coroner's inquest will commence in May.

The RCMP claim excited delirium was the cause of death. Media and civil liberties groups are skeptical about both the cause, and the condition.

A controversial condition, "excited delirium" has been defined as being characterized by agitation, incoherence, bizarre behaviour, high temperature, superhuman strength, a high tolerance for pain — and sometimes, the compulsion to break or bang on glass. Those who study it say it can be brought on by drug use, alcohol withdrawal, low blood sugar, mental illness or extreme fatigue. It does not, however, appear in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).

But "delirium" — minus the "excited"— does.

Dr. Ian Dawe, director of Psychiatric Emergency Services at St. Michael's Hospital in Toronto, explains delirium as "a fluctuating level of consciousness," a set of symptoms that stereotypically appear together as a result of intoxication or an underlying medical condition.

The DSM says most sufferers of delirium fully recover but some don't as "delirium may progress to stupor, coma, seizures, or death, particularly if the underlying cause is untreated."

Dawe says there are 2 kinds of delirium: active and hypoactive. People suffering from the former might behave more or less as Dziekanski did: they can be agitated, irrational, and hard to communicate with. The hypoactive form, meanwhile, makes people quiet and withdrawn.

Active delirium can increase risks associated with physical restraints, Dawe says. But when someone suffering from delirium dies, determining the cause is problematic. Was it delirium? The taser? Restraint? A complex interplay of all the above?

Dawe says "excited delirium" is a pop culture phenomenon and doesn't have much currency among psychiatrists, although police, coroners and forensic pathologists use it.

University of Miami Professor of Neurology Dr. Deborah Mash, who has studied the condition for 20 years, says "sudden death in the context of emotional stress is well-known. Just because there isn't something called 'agitated delirium' or 'excited delirium' — that vernacular is not in the DSM-IV — doesn't mean that the symptom set is not in the DSM, because it is. We have evidence to suggest it's a brain disease."

Mash argues the condition is the result of an interaction between genes and environment: the gene remains silent until triggered by something like alcohol, drugs, stress or sleep deprivation — anything that affects dopamine. "It's always the same. The presentation is the same, the behavioural syndrome is the same, the hyperthermia is there, and the phenomenon of sudden death is there. And it doesn't matter whether they were restrained, or hogtied, or pepper sprayed or tasered — it's the same."

"This is a condition where law enforcement doesn't have a lot of options ... now, if you just left someone with excited delirium in the woods, I mean, what would happen to them? We don't know the answer. We've had purported excited delirium deaths where there were no police involved."

Yet, here's the rub. Those who die of "excited delirium" usually do so while in police custody, often after having been tasered.

To be sure, it's not a disease invented by the RCMP. In fact, they are late to the adoption of "excited delirium" as a condition. As early as 1849, Dr. Luther Bell described the inexplicable sudden death of psychotic patients as "acute exhaustive mania," while Dr. Charles Wetli coined the term "excited delirium" in 1985 to explain sudden death in recreational cocaine users.

Yet, so convinced are police that "excited delirium" is a legitimate condition that PoliceOne.com, an international information website for police officers, includes a direct link to an excited delirium training video created by the Las Vegas Police Department. In the video, Sherriff Bill Young even asserts that excited delirium leads people to blame police for deaths they didn't cause.

The video explicitly recommends using tasers to override the central nervous system, incapacitating the suspect just long enough for officers to properly restrain him. In a dramatization, a handcuffed suspect lies on the ground, surrounded by 7 officers. They place no weight on him and eventually turn him on his back and sit him upright. Nothing is done that might constrain the suspect's breathing, a point PoliceOne.com is careful to caution against.

The latter is by no means moot — the link between restraint, excited delirium and oxygen supply has long been the subject of debate and concern.

A 1998 review of 21 cases of unexpected deaths in people in a state of excited delirum — 18 of which were people in police custody — found that all "suddenly lapsed into tranquility shortly after being restrained (CMAJ 1998:158[12]: 1603-07). In all 21 cases, the victims had been restrained either face-down or through pressure applied to their necks. In 12 cases, excited delirium was brought on by a psychiatric disorder. In 8 cases, cocaine was the culprit. In 8 cases, the victims suffered chest compression from the weight of 1–5 people.

The study concluded that "the possibility that positional asphyxia contributes to unexpected death in people in states of excited delirium cannot be ignored." Those suffering from excited delirium were in need of more than the usual amount of oxygen, yet the techniques used to restrain them could restrict their ability to breathe.

Dawe is sympathetic to people faced with the task of controlling situations like Dziekanski's. "I wouldn't want to lay blame on anyone." He'd like to enhance cooperation between police, paramedics and mental-health professionals, so that police could have "a broader range of options" when dealing with such cases. St. Michael's has partnered up with 2 downtown Toronto police divisions to create a "mobile crisis intervention team" — a constable and a mental-health nurse who deal with 911 dispatches involving emotionally disturbed people. The idea is to decriminalize mental health issues and reduce visits to the prison and the hospital.

"If something good can come out of tragedy, it's that perhaps we can develop a different approach to these situations," Dawe adds.

Is 'excited delirium' at the root of many Taser deaths?

January 26, 2008
Armina Ligaya, CBC News

When police arrived at the Right Spot bar in downtown Moncton on May 5, 2005, Kevin Geldart was acting strangely. The 34-year-old had a history of bipolar disorder and had somehow walked away from the psychiatric unit of a nearby hospital earlier that night. Police said Geldart was acting combative and violent, and seemed to possess superhuman strength. However, witnesses testified Geldart was talking to himself in a corner but wasn't aggressive to those around him, according to his sister, Karen.

Officers used pepper spray and a Taser, as many as four times, to try and subdue the six-foot-six, 300-pound man. Then four officers pinned Geldart down, tied his feet and cuffed his hands. It was then that the police noticed Geldart had stopped breathing. He was later pronounced dead at a Moncton Hospital.

Fast forward to Oct. 14, 2007. A similar scene, except this time the setting is at the other side of the country — Vancouver International Airport. Robert Dziekanski had just flown in from Poland and couldn’t speak a word of English. The 40-year-old came to start a new life in Canada with his mother and was waiting in the customs area for her to pick him up. By 1:00 a.m., he had been waiting more than eight hours. For reasons that are still unclear, he never saw her.

It was at that point that Dziekanski started acting confused and agitated and began throwing around computer equipment. RCMP were called to the scene. According to an eyewitness video, four officers approached Dziekanski, who stood calmly while talking to them. Dziekanski then walked away and stood by a wall. Seconds later, a loud crack is heard. Dziekanski is shocked by a Taser, wails and collapses to the ground. The officers kneel on top of him, pinning him down as he struggles. He died minutes later.

In both of these sudden deaths, what's the culprit?

A rare condition

Some psychologists say the cause is a rare condition called "excited delirium" and not the obvious common element — the use of a Taser. According to some psychologists, a person with excited delirium acts agitated, violent, sweats profusely and is unusually strong and insensitive to pain. Then, the victim's heart races and eventually stops beating.

A coroner’s inquest into Geldart’s death concluded he was suffering from excited delirium on the night he died. And while the B.C. coroner’s service has not yet determined what killed Dziekanski — an autopsy failed to reveal a clear cause — RCMP have speculated the 40-year-old was also suffering from excited delirium.

"This is not due to a Taser," says Deborah Mash, a neurology professor at the University of Miami who has been studying excited delirium for 20 years. "This is in the brain and they die because the mechanisms that control the heart and the lungs fail."

In recent years, the condition has been showing up in coroner’s reports around the world as a cause of death. Yet, this condition is the subject of fierce debate in psychiatric circles.

Dr. Ian Dawe, the director of psychiatric emergency services at St. Michael’s Hospital in Toronto, says excited delirium is not a recognized mental disorder. In fact, the term is not listed in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, a handbook for professional psychologists and psychiatrists. "The term 'excited delirium' has been co-opted over the course of popular culture, perhaps over the past 15 to 20 years, to refer to this group of people who experience agitation and violence," Dawe told CBC News.

Delirium on its own, however, is a well known disorder, which is marked by confusion and agitation and can be associated with violence. It's usually triggered by another factor such as drugs or a predisposed medical illness, says Dawe.

He's not sure where the prefix "excited" comes from. And in his experience, he says it is uncommon to see patients with delirium suddenly die. "It is rare. Certainly we don’t see it happen in hospitals per se because of the way that we are approaching things."

First reported in the 1800s

According to Dr. Mash, however, individuals with excited delirium symptoms were first reported in the 1800s by Dr. Luther Bell. Bell and his team described it as "exhaustive mania" or "agitated delirium," Mash says. "People would present with this bizarre behaviour — extremely agitated, incoherent speech — really like a manic phase. Then, all of a sudden they become hot and they would have an autonomic system failure. Their cardio-respiratory system would fail and they would collapse."

But the key study that described the phenomenon was released in 1985 by Dr. Charles Wetli, Mash said. It looked into excited delirium and cocaine abuse in Miami, which was experiencing the first wave of the crack-cocaine epidemic that swept through North America. Mash said Wetli outlined the same set of behaviours — agitation, superhuman strength, high pain tolerance — and determined that the condition could be triggered by drugs, alcohol or other stimulants.

"These can sort of trip the switch in vulnerable individuals," she said. "You can also see this with alcohol withdrawal, you can see it in psychiatric patients. It's always the same pattern."

However, these substances don't need to be present to trigger the condition. Excited delirium can also manifest itself in vulnerable patients who are under unusual stress or are sleep-deprived, she says.

Sudden death

While the underlying mechanism of this disease is still unclear, this brain-based illness can lead to sudden death, Mash notes. "The reason people question it is because law enforcement is involved," she argues. "When Dr. Bell described these conditions in the mid-1800s, law enforcement was not involved. These people died in the institutions where they were being housed."

At the time, because these patients were difficult to reason with, they were restrained. The difference today, she says, is the method. "Over the years, they've used various forms of restraints. Some have been hog-tied, some have been in hobble restraints, some have had baton strikes, some have had pepper spray, and more recently now the Taser," Mash says. "What I've seen is that there's no difference from pre-Taser times to the present when Tasers are used."

For his part, however, Dawe says it's uncommon to have patients with delirium suddenly die at facilities such as St. Michael's Hospital. All medical staff are trained how to handle patients who are acting agitated and they can usually be talked down from their state, he says. Medical staff use a technique that includes speaking in calm tones, no matter the reaction of the patient, and neutral body language such as uncrossed arms. They try to figure out why the person is acting agitated and treat it.

Restraint is a last resort, he says. "We believe that we are very successful in helping someone come down from an agitated place in a safe and controlled manner," Dawe says.

Dr. Peter Bieling, manager of the mood disorders program at St. Joseph's Health Care in Hamilton, Ont., said some of the responsibility rests with the police force or those who are called to deal with people with this condition. "If you do know that somebody is in a vulnerable state, maybe you shouldn't use that level of force. Maybe there's something else that could be done. You have to conclude, and this is true for all mental illness, a person can have the disorder, but usually it doesn't fully manifest, it doesn't hit its full impact without a stressor being in place," he says.

The real challenge

Excited delirium hasn't officially made its way into the medical books yet, but Mash believes it's only a matter of time. "It will be recognized," she says. "But these cases are rare. We're seeing more of them now for various reasons, including because people are recognizing the condition."

However, Bieling is skeptical. "When you look at the other things that can resemble excited delirium, such as panic, hypomania, I would say that probably in most cases, those other things are likely going to be the explanation. If I were a betting person, I would think it's not going to make it into the next diagnostic manual," he says.

Bieling also argues that there hasn't been enough research on excited delirium to warrant classification. "I just don't think we know," he says. "And the usual way that we figure these things out is we do studies. We do careful studies to look at prevalence."

But that's where the problem lies. Because deaths of people with these specific symptoms are rare, research in this area is automatically limited. What's more, "what's going to make this one tough is it's so tied to a specific set of circumstances," Bieling says. "We're not talking about something that's going to affect a huge amount of people in the general population, like depression or anxiety. What we're talking about is a specific set of circumstances when people are in police custody. That's going to make it really, really challenging."

Is 'excited delirium' at the root of many taser deaths?

November 21, 2007
CBC News

When police arrived at the Right Spot bar in downtown Moncton on May 5, 2005, Kevin Geldart was acting strangely. The 34-year-old had a history of bipolar disorder and had somehow walked away from the psychiatric unit of a nearby hospital earlier that night. Police said Geldart was acting combative and violent, and seemed to possess superhuman strength. However, witnesses testified Geldart was talking to himself in a corner but wasn't aggressive to those around him, according to his sister, Karen.

Officers used pepper spray and a Taser, as many as four times, to try and subdue the six-foot-six, 300-pound man. Then four officers pinned Geldart down, tied his feet and cuffed his hands. It was then that the police noticed Geldart had stopped breathing. He was later pronounced dead at a Moncton Hospital.

Fast forward to Oct. 14, 2007.

A similar scene, except this time the setting is at the other side of the country — Vancouver International Airport. Robert Dziekanski had just flown in from Poland and couldn’t speak a word of English. The 40-year-old came to start a new life in Canada with his mother and was waiting in the customs area for her to pick him up. By 1:00 a.m., he had been waiting more than eight hours. For reasons that are still unclear, he never saw her. It was at that point that Dziekanski started acting confused and agitated and began throwing around computer equipment. RCMP were called to the scene. According to an eyewitness video, four officers approached Dziekanski, who stood calmly while talking to them. Dziekanski then walked away and stood by a wall. Seconds later, a loud crack is heard. Dziekanski is shocked by a Taser, wails and collapses to the ground. The officers kneel on top of him, pinning him down as he struggles. He died minutes later.

In both of these sudden deaths, what's the culprit?

A rare condition

Some psychologists say the cause is a rare condition called "excited delirium" and not the obvious common element — the use of a Taser. According to some psychologists, a person with excited delirium acts agitated, violent, sweats profusely and is unusually strong and insensitive to pain. Then, the victim's heart races and eventually stops beating. A coroner’s inquest into Geldart’s death concluded he was suffering from excited delirium on the night he died.

And while the B.C. coroner’s service has not yet determined what killed Dziekanski — an autopsy failed to reveal a clear cause — RCMP have speculated the 40-year-old was also suffering from excited delirium. "This is not due to a Taser," says Deborah Mash, a neurology professor at the University of Miami who has been studying excited delirium for 20 years. "This is in the brain and they die because the mechanisms that control the heart and the lungs fail."

In recent years, the condition has been showing up in coroner’s reports around the world as a cause of death. Yet, this condition is the subject of fierce debate in psychiatric circles.

Dr. Ian Dawe, the director of psychiatric emergency services at St. Michael’s Hospital in Toronto, says excited delirium is not a recognized mental disorder. In fact, the term is not listed in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, a handbook for professional psychologists and psychiatrists. "The term 'excited delirium' has been co-opted over the course of popular culture, perhaps over the past 15 to 20 years, to refer to this group of people who experience agitation and violence," Dawe told CBC News. Delirium on its own, however, is a well known disorder, which is marked by confusion and agitation and can be associated with violence. It's usually triggered by another factor such as drugs or a predisposed medical illness, says Dawe.

He's not sure where the prefix "excited" comes from. And in his experience, he says it is uncommon to see patients with delirium suddenly die. "It is rare. Certainly we don’t see it happen in hospitals per se because of the way that we are approaching things."

First reported in the 1800s

According to Dr. Mash, however, individuals with excited delirium symptoms were first reported in the 1800s by Dr. Luther Bell. Bell and his team described it as "exhaustive mania" or "agitated delirium," Mash says. "People would present with this bizarre behaviour — extremely agitated, incoherent speech — really like a manic phase. Then, all of a sudden they become hot and they would have an autonomic system failure. Their cardio-respiratory system would fail and they would collapse."

But the key study that described the phenomenon was released in 1985 by Dr. Charles Wetli, Mash said. It looked into excited delirium and cocaine abuse in Miami, which was experiencing the first wave of the crack-cocaine epidemic that swept through North America. Mash said Wetli outlined the same set of behaviours — agitation, superhuman strength, high pain tolerance — and determined that the condition could be triggered by drugs, alcohol or other stimulants. "These can sort of trip the switch in vulnerable individuals," she said. "You can also see this with alcohol withdrawal, you can see it in psychiatric patients. It's always the same pattern." However, these substances don't need to be present to trigger the condition. Excited delirium can also manifest itself in vulnerable patients who are under unusual stress or are sleep-deprived, she says.

Sudden death

While the underlying mechanism of this disease is still unclear, this brain-based illness can lead to sudden death, Mash notes. "The reason people question it is because law enforcement is involved," she argues. "When Dr. Bell described these conditions in the mid-1800s, law enforcement was not involved. These people died in the institutions where they were being housed." At the time, because these patients were difficult to reason with, they were restrained. The difference today, she says, is the method. "Over the years, they've used various forms of restraints. Some have been hog-tied, some have been in hobble restraints, some have had baton strikes, some have had pepper spray, and more recently now the Taser," Mash says. "What I've seen is that there's no difference from pre-Taser times to the present when Tasers are used."

For his part, however, Dawe says it's uncommon to have patients with delirium suddenly die at facilities such as St. Michael's Hospital. All medical staff are trained how to handle patients who are acting agitated and they can usually be talked down from their state, he says. Medical staff use a technique that includes speaking in calm tones, no matter the reaction of the patient, and neutral body language such as uncrossed arms. They try to figure out why the person is acting agitated and treat it. Restraint is a last resort, he says. "We believe that we are very successful in helping someone come down from an agitated place in a safe and controlled manner," Dawe says.

Dr. Peter Bieling, manager of the mood disorders program at St. Joseph's Health Care in Hamilton, Ont., said some of the responsibility rests with the police force or those who are called to deal with people with this condition. "If you do know that somebody is in a vulnerable state, maybe you shouldn't use that level of force. Maybe there's something else that could be done. "You have to conclude, and this is true for all mental illness, a person can have the disorder, but usually it doesn't fully manifest, it doesn't hit its full impact without a stressor being in place," he says.

The real challenge

Excited delirium hasn't officially made its way into the medical books yet, but Mash believes it's only a matter of time. "It will be recognized," she says. "But these cases are rare. We're seeing more of them now for various reasons, including because people are recognizing the condition."

However, Bieling is skeptical. "When you look at the other things that can resemble excited delirium, such as panic, hypomania, I would say that probably in most cases, those other things are likely going to be the explanation. "If I were a betting person, I would think it's not going to make it into the next diagnostic manual," he says. Bieling also argues that there hasn't been enough research on excited delirium to warrant classification. "I just don't think we know," he says. "And the usual way that we figure these things out is we do studies. We do careful studies to look at prevalence."

But that's where the problem lies. Because deaths of people with these specific symptoms are rare, research in this area is automatically limited. What's more, "what's going to make this one tough is it's so tied to a specific set of circumstances," Bieling says. "We're not talking about something that's going to affect a huge amount of people in the general population, like depression or anxiety. What we're talking about is a specific set of circumstances when people are in police custody. That's going to make it really, really challenging."