Excited Delirium Syndrome: Causes, Symptoms, Treatment

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.

• Alcohol
• Amphetamines
• Cocaine
• LSD
• Phencyclidine (PCP or “angel’s dust”)

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).

• Dopamine: Abnormally high levels of dopamine are known to cause agitation, aggression, paranoid behavior, and may lead a person to act violently.  Since dopamine stimulates activity in the CNS, this may lead to speeding of heart rate, rapid breathing, and elevated body temperature.

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.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/19541436

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.

• Aggression: Many individuals with this condition appear hyperaggressive in their behaviors and actions. This aggression may be channeled by shouting obscenities and/or engaging in violent behavior.  For this reason, it is important to contact the police if you suspect a person may be dealing with excited delirium.
• Agitation: A hallmark symptom of excited delirium is that of psychomotor agitation. In other words, the person is unable to sit still, and will likely exhibit movements such as: pacing back and forth (or in circles), shaking of the hands, flapping of the tongue, chewing on something, or moving the lips.
• Anxiety: In some cases a person with this condition may resemble someone with high levels of anxiety to the point that you think they may be having a panic attack. While this is different from a panic attack, the person may still have a high level of psychological anxiety; this is due to the stimulant that was ingested and the way their body is reacting.
• Combativeness: Most people find out about cases of excited delirium when the individual is restrained by the police. They are highly combative and are difficult to restrain due to the fact that their pain tolerance is elevated.  They are likely to display overt combativeness to other individuals as well as law enforcement.
• Delirium: This is a condition characterized by fever, bizarre behavior, disorientation and intoxication. The individual will appear highly delirious, but will generally have a lot of energy, hence the term is prefaced with “excited.”
• Delusions: In some cases the person may experience delusions, thinking that others are out to get them (persecution) or that they are being watched. In many cases these delusions contribute to potential violence and an unwillingness to cooperate with others.  Due to these delusions, it is important to be cautious of someone with excited delirium.
• Difficult to restrain: In most cases, individuals with excited delirium remain difficult to restrain. Law enforcement will typically attempt to get the individual under control by strapping them down at various points of their body.  Prior to the strapping, a taser is often utilized due to their increased tolerance to pain.
• Disorientation: The person may appear highly disoriented and exhibit confusing behavior. They may not know where they are, what they’re doing, or have a conscious motive for any action.  This disorientation is a result of the drug they ingested and can be exacerbated by lack of oxygen or increased body temperature.
• Endurance increase: The stimulation from the drug that they’ve ingested often leads to an increase in physical endurance. They may be difficult to restrain due to the fact that they are highly aroused and their nervous system is primed for action.
• Fever: Another common characteristic of those with excited delirium is that of a temperature increase. They may feel physically hot and are often running a high fever (hyperthermia).  The person may be actively making attempts to cool themselves by removing layers of clothing or looking for cold water or ice.
• Hallucinations: In a number of cases, people experience hallucinations such as hearing voices or seeing things that aren’t based in reality. These often go hand-in-hand with the delusions that a person is experiencing and may provoke violent behaviors.
• Pain tolerance: Increased pain tolerance by people with excited delirium may make it difficult to properly restrain them. They may appear completely impervious to any modality of inflicting pain.  Therefore if they get into a fight, they may not feel punches or damage inflicted upon their body.  This makes it tougher for police to get individuals with this condition under control.
• Panic: The anxiety that a person experiences as a result of being overstimulated may lead to panic attacks. These panic attacks can make the person hyperventilate or contribute to restlessness.
• Paranoia: The thinking and behavior of individuals with this condition is often fueled by paranoia. Dopaminergic dysfunction is likely contributing to this symptom, which makes a person feel as if others and law enforcement are out to harm them.
• Incoherent speech: People with excited delirium may have incoherent or disorganized speech to the point that it becomes difficult or confusing to decipher.
• Inappropriate clothing: The condition is characterized by fever, increased body temperature, and psychomotor agitation. The combination of a temperature increase and agitation often leads a person to frantically take off their clothes and make attempts to cool themselves down.  Even in cold temperatures, they may remain unclothed due to the fact that they are overheating.
• Odd behavior: The behavior displayed by a person with excited delirium may appear extremely odd. Not everyone fits the exact same mold with the condition and therefore it is impossible to predict the behavior of each case.
• Shouting: A person with excited delirium may draw significant attention to themselves by yelling in the streets, at their home, or in public. This shouting may be obscene and insensitive to others – including complete strangers.  As a person makes a scene of themselves with yelling, it is important to contact authorities.
• Strength increase: The person experiencing this condition may believe that they are superhuman or incredibly strong. In part this is due to the fact that they are highly stimulated and their nervous system is primed for action.  While they aren’t generally significantly stronger than normal, the increased stimulation may contribute to a strength increase.  In part, they may appear stronger to others due to their heightened pain tolerance.
• Sweating: Those with excited delirium often experience profuse sweating to the point that they are literally dripping with sweat. Even in cold temperatures, the individual will appear to sweat an incredible amount.  This is due to the fact that their body is so overstimulated and their physiological response is uncontrollable.
• Violence: Due to the fact that many individuals with excited delirium are violent towards others (and sometimes themselves), it is important to notify police as soon as possible. The individual is so disoriented and physiologically altered, that they may not care about damage they inflict on another person and have no regard for consequences.

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.

• Cardiac arrest: The person experiencing excited delirium may experience cardiac arrest as a result of an arrhythmia (irregular heartbeat). Typically the person’s nervous system is so overstimulated, that their heart rate is abnormally fast.  If paramedics do not quickly identify and treat the problem, the individual may experience heart failure.
• Cardiovascular toxicity: Those that use cocaine on a frequent basis may experience “cardio toxicity.” As was mentioned, nearly half of all deaths from excited delirium are associated with cardiac failure.  Many researchers theorize that prolonged cocaine usage may elicit cumulative, detrimental effects on heart function.  It is believed that toxic levels of catecholamines may be responsible for many of these changes.
• Respiratory failure: In other cases, a person with excited delirium may die as a result of respiratory failure. They may be unable to get sufficient levels of oxygen and eliminate sufficient carbon dioxide.  Often times there are low levels of oxygen in the blood as a result of respiratory inadequacies.

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.

• Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088378/
• Source: http://www.ncbi.nlm.nih.gov/pubmed/20190633

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.

• Disseminated Intravascular Coagulation: Of the individuals that actually get transported to the hospital, many experience clotting of the small blood vessels, resulting in death.
• Rhabdomyolysis: Skeletal muscle tissue may breakdown, enter the bloodstream, and ultimately cause kidney failure.
• Renal Failure: Some individuals experience renal failure as a result of rhabdomyolysis. The kidneys become unable to filter waste from the bloodstream, which can lead to death. This can also result in metabolic acidosis, which can cause heart arrhythmias.

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.

• Positional asphyxia: It has been suggested that in some cases, the position by which the police restrain the individual with excited delirium may lead to asphyxiation, or respiratory failure.  For this reason, it is recommended that police learn how to properly restrain individuals with this condition.  Those that believe positional asphyxia may be a contributing cause think that the individual with excited delirium requires more oxygen and isn’t able to breathe effectively as a result of restraint or compression on the diaphragm.
• Struggle: The degree to which the individual struggles or hyperventilates may lead to greater cardiac activation and problems inhaling sufficient oxygen.  Therefore even in cases of restraint from police, restraint may not be the only factor, rather the degree to which a person struggles or hyperventilates may contribute to their demise.
• Taser usage: It has also been hypothesized that since many patients with excited delirium are likely tasered prior to getting restrained, that the taser shock may disrupt heart rhythms, leading to cardiac failure.

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.

• Source: http://www.ncbi.nlm.nih.gov/pubmed/19237843
• Source: http://www.ncbi.nlm.nih.gov/pubmed/24526411

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.

• Benzodiazepines: Most commonly, benzodiazepines are injected due to the fact that they slow activity in the central nervous system and sedate the individual – decreasing the likelihood that they’ll harm anyone.  A common medication like Versed (Midazolam) is believed to have a favorable profile for individuals with excited delirium due to the fact that its dose response is well-understood. Upon administration of benzos, medical professionals will carefully monitor the individual in case of a respiratory depression.
• Sodium bicarbonate: Should the individual be experiencing cardiac arrest or shock, sodium bicarbonate will be administered.  This can also help mitigate severe acidosis that an individual may be experiencing.
• Lowering body temperature: In many cases, hyperthermia (elevated body temperature) may contribute to death.  Therefore it is important to make an effort to reduce the person’s body temperature by using cold packs (at various bodily regions), water sprays, and fanning them.  Another common intervention is that of intravenous (IV) saline – which can reduce body temperature, which can also help with metabolic acidosis.

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:

• Dantrolene: This is a drug that can be used as an adjunct for the treatment of excited delirium.  It minimizes muscle cell expansion and contraction via inhibition of calcium release.  It has often been used as a treatment for related conditions like neuroleptic malignant syndrome.
• Neuroleptics: Sometimes neuroleptic drugs are thrown into the equation in combination with benzodiazepines as a means to minimize catecholamine activity.  The resulting effect should be extreme sedation, making it easier to manage the individual with excited delirium. Evidence is mixed as to whether a benzodiazepine, neuroleptic, or a combination of both yields optimal outcomes.
• Ketamine: Another intervention strategy is that of administering intramuscular injections of ketamine.  This is a drug that has a quick onset of action and results in significant sedation. There appear to be relatively few side effects associated with ketamine and it can work.  However, co-administration with a benzodiazepine will significantly hamper ketamine’s effect.  That said, heightened catecholamine levels should be ruled out prior to administration due to the fact that ketamine could intensify this problem.
• Stress reduction: If the person with the condition is receptive to stress reduction techniques, any natural methods that can be utilized to reduce stress may have some benefit.  Paramedic responders are instructed to use a calming voice in attempt to avoid provoking an increased stress response in the individual.  The goal is to make the surrounding environment as stress free as possible to increase the likelihood of survival.  Blindfolds and/or dimming of lights may be effective strategies.

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).

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