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'Excited delirium' police defense is scientifically meaningless, humanitarian physicians organization says

Did the controversial term originate in a missed serial killing? Contested diagnosis is commonly cited in cases of death while in police custody, but a new report says it arose from a failure to spot murders at the hand of a mid-1980s, Miami-based killer of Black women.

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Troy Becker / Forum News Service
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ROCHESTER, Minn. — A new 95-page report has concluded that "excited delirium," a purportedly lethal state of extreme agitation commonly cited in connection to death while in police custody, "is scientifically meaningless," and "cannot be disentangled from its racist and unscientific origins."

The new report, produced by the U.S.-based international humanitarian nonprofit Physicians for Human Rights (PHR), stemmed from multiple interviews, a formal review of the scientific literature and "hundreds of pages" of archival newspapers and legal documents, according to Joanna Naples-Mitchell, a human rights lawyer and researcher for PHR.

"Part of what the report does is aggregate all the evidence out there and try to get it one place," says Naples-Mitchell. "So I think it is the most comprehensive study to date in looking at excited delirium, and its history and origins in the medical literature."

The term has arisen in news reports of late during the federal trials of three former Minneapolis Police Department officers convicted of violating the civil rights of George Floyd, as part of defense arguments noting the officers' exposure to the term within training.

It also arose in a Star Tribune report last month that the continued teaching of excited delirium in violation of a change to city policy was cited as the reason for Mayor Jacob Frey's direction that the city terminate its contract with a police medical trainer, a physician at Hennepin Healthcare.

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Naples-Mitchell credits what she believes is the report's more notable archival material to its partnership with California-based civil rights attorney and coauthor Julia Sherwin , who Naples-Mitchell says provided "a trove of documents, 400 pages, that were news archives from the time."

"We pulled out some quotes that I don't think have been published in a very long time," says Naples-Mitchell. "I haven't seen them anywhere. They are quotes that were published back in 1988 to 1990. But I think some of those quotes are going to be news to a lot of people."

'Excited delirium,' term misapplied to Black victims of serial killer

The archival quotes in question appear in the opening pages of "Excited Delirium and Deaths in Police Custody," as PHR authors describe the first modern use of the term "excited delirium."

Though a similar condition was described in the mid-1800s by a physician at the McLean Asylum for the Insane, the condition known as "Bell's Mania" progressed over days and weeks, according to the authors, and was consistent with modern psychiatric diagnoses not yet developed.

The new report traces the modern use of excited delirium to early- and mid-1980s case reports of cocaine users exhibiting a cluster of symptoms including a "disturbance of attention with impaired perception," and later, "fear, panic, violent behavior, hyperactivity, hyperthermia, and/or unexpected strength," events that included police restraint and which resulted in sudden death.

As co-author of those papers, the now-deceased Miami forensic pathologist Dr. Charles Wetli would go on to begin using this symptom cluster he termed excited delirium "as a cause of death, diagnosis, and unique disease," according to PHR, despite "no indication in his writings that he had access to new scientific evidence underpinning this change."

Amidst Wetli's continued interest in "cocaine psychosis" or alternately "cocaine-induced excited delirium," according to PHR, the physician would apply the concept to the deaths in Miami between 1986 and 1988 of 12 Black women presumed to be sex workers and who were found with small amounts of cocaine in their system.

According to archival press clippings obtained by PHR, Wetli speculated to a reporter at the time that, while using cocaine, "the male of the species becomes psychotic and the female of the species dies in relation to sex."

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Following a Miami chief medical examiner's determination that the women appeared to have been murdered by a serial killer, "Wetli continued to assert that at least some of the women had died from a combination of sex and cocaine."

In an interview cited by PHR as evidence of that belief, the pathologist stated his additional view that the reason for a disproportionate percentage of Black males to have died of cocaine-induced delirium, "may be genetic."

"He's suggesting that Black men have a racial predisposition to dying from cocaine," says Naples Mitchell, "without any kind of scientific basis. So that's really, really concerning."

"This is the person who originated the term. This is how he thought about it and conceived of it. How can we disentangle this theory from the person who created it when he's saying these kinds of things?"

As for the true medical explanation for the oftentimes bizarre and unpredictable behavior noted by proponents of excited delirium, coauthor Dr. Altaf Saadi, a neurologist at Harvard Medical School, describes the term as "a wastebasket diagnosis" reflecting a variety of underlying conditions.

"Someone can be using cocaine, or methamphetamine, or can be intoxicated from alcohol, or withdrawing from alcohol, or have mental illness and that could look a lot of different ways," Saadi says. "Mania or schizoaffective disorder, all of these different conditions can result in different symptoms where someone can be very agitated."

The idea of "superhuman strength" as a symptom of excited delirium, according to PHR, not only reflects "racist tropes of Black men," but constitutes "pathologizing resistance to law enforcement" by scared or ill individuals.

As Naples-Mitchell says, continued teaching of "excited delirium" also places law enforcement in a bind.

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"They are being asked to diagnose pseudo-scientific, baseless medical conditions without medical training, and they're being told that people experiencing this condition ...have superhuman strength and are impervious to pain. That is going to prompt a fearful and violent response in a lot of cases."

"So it's not good for anyone involved for this concept to persist. Emergency response needs to be grounded in reality and in science."

Paul John Scott is the health correspondent for NewsMD and the Forum News Service. He is a novelist and was an award winning magazine journalist for 15 years prior to joining the FNS in 2019.
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