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Excited Delirium and its medical status, Part 2: If excited delirium isn't in the DSM, what is?

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In my last column I outlined the "status" of excited delirium (ED) within the medical literature. The obvious question is:

If ED isn't in the DSM (American Psychiatric Association, 2000), what is?

As stated in the previous article, "[A]n ability to make a diagnosis is dependent on information derived from three sources: patient records, informants, and interviews with patients themselves" (Morrison, 1994). Psychiatrists prefer to say that they obtain a collateral history from family and friends rather than use the term "informants."

This process is dependent upon a living patient, someone who survived his or her experience.

Take the typical "ED" scenario - the subject is naked, ripping up the neighborhood and shouting incoherently.

Police and paramedics arrive, restrain the subject and death does not occur.

The subject arrives at hospital and ultimately a physician makes an assessment.

This subject now becomes a patient of the facility. A doctor will make a decision on how to best treat this person. She may even offer a "presumptive working diagnosis."

However, the process does not stop there.

Over the course of the patient's stay at the hospital, the physician will review whatever patient's medical records are available. Once the patient is more cooperative the doctor will interview them to try to determine what event(s) or diseases state(s) may have caused the incident, and where the patient is on the continuum of their illness.

Depending on the information obtained various tests may be ordered.

Informants will be recruited. These people can come from several areas, both within the medical facility as well as outside.

From outside the hospital the patient's friends and family members will be interviewed to determine past behavior in an effort to bring the patient's current state into better perspective.

Witnesses to whatever event(s) immediately preceded the medical intervention will also be spoken to, where they are available. Not every situation creates "witnesses."

From inside the medical facility, nursing staff will note the patient's progress or lack thereof. Pharmacists may interview the patient to explain the medication the doctor has prescribed. They will also document within the patients medical records their observations and whether or not the patient seemed to comprehend the information provided.

Hospital staff will watch the patient interact with other patients, other staff members, with the patient's families, as well as the patient's behavior when they are left to them self.

The information collected will be combined with interviews of the patient's family and friends. This package will all be pieced together to inform the physician when making a diagnosis.

This process can take time, often days to weeks.

The front of the current DSM reminds the reader that as of the date of "publication of this manual" the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is the official coding system in use in the United States. Most DSM-IV-TR maladies have a corresponding ICD-9-CM code. The use of these codes is "fundamental to medical record keeping" (American Psychiatric Association, 2000, p.1). The fact is the World Health Organization has published the ICD 10 (2003).

The DSM lists 17 areas of classification, including ones which can appear to be similar to ED-type behaviors:

• Delirium, Dementia and Amnestic and Other Cognitive Disorders (p. 135).

• Mental Disorders Due to a General Medical Condition (p. 181).

Within this section there is a category, "Personality Change Due to the General Medical Condition" such as Aggressive Type and Paranoid Type (p.190).

• Substance Related Disorders (p. 191).

       • Alcohol-Related Disorders

       • Alcohol Intoxication Delirium;

       • Alcohol Withdrawal Delirium;

       • Alcohol Induced Psychotic Disorder;

            • With Delusions

            • With Hallucinations

     • Amphetamine (or Amphetamine-like)-Related Disorders

       • Amphetamine Intoxication Delirium;

       • Amphetamine Withdrawal Delirium;

       • Amphetamine Induced Psychotic Disorder;

            • With Delusions

            • With Hallucinations

     • Cannabis-Related Disorders

       • Cannabis Intoxication Delirium;

       • Cannabis Induced Psychotic Disorder;

            • With Delusions

            • With Hallucinations

     • Cocaine-Related Disorders

         • Cocaine Intoxication Delirium;

         • Cocaine Withdrawal Delirium;

          • Cocaine Induced Psychotic Disorder;

              • With Delusions

              • With Hallucinations

This list continues in a similar manner and includes:

• Hallucinogen-Related Disorders

• Inhalant-Related Disorders

• Opioid-Related Disorders

• Phencyclidine (or Phencyclidine-like)- Related Disorders

as well as

• Schizophrenia and Other Psychotic Disorders (p. 297)

• Mood Disorders [Depressive, Bipolar] (p. 345).

When you begin to look through the reference book you will notice that the "DSM" lists are parallel to much of the information associated with ED.

The text also mentions "Mental Disorders Due to a General Medical Condition Not Elsewhere Classified" (p. 181). I've learned that it is possible to suffer a head injury and become confused and aggressive. This does not mean the subject has ED, but they may appear that way to a lay person or a police officer. There is also a case mentioned in Exertional Heat Illnesses (Armstrong, 2003), (a book I highly recommend to anyone interested in ED related deaths or anyone supervising persons who work in the heat), that closely resembles an ED episode.

A man working in a hot, dry environment left work after lunch stating he did not feel well. During the ride home on public transit, he began acting strangely. Witnesses said he "acted like a crazy man." The subject was restrained and transported to hospital where he was assessed as a "potential psychiatric patient." This man was sedated and secluded.

Two hours later he was found unconscious. He was found to have a core body temperature of 107.60F (Armstrong, 2003 p.17). This patient was re-diagnosed as suffering exertional heatstroke, which was later "confirmed after the patient regained conscious and recounted the events leading to his collapse" (p.18).

I wonder what might have transpired if this patient had died without anyone measuring his core temperature?

According to the National Association of Medical Examiners Ad Hoc Committee on the Definition of Heat-Related Fatalities the criteria for the diagnosis of heat-related deaths includes a measured antemortem body temperature of 105oF (>=40.6oC) (1997). The relationship between heat and ED will be the subject of a future article.

The point is that such factors can be considered when a subject has survived long enough for medical practitioners to make an informed diagnosis. In short, if the subject survives, then the situation and patient/subject can be assessed with the assistance of the DSM-IV-TR and the ICD-10-CM. If he dies, pathologists will use a different body of research in fulfilling their role.

A notable exception to the exclusive reliance upon the DSM in making a survivor's diagnosis exists. Stratton, Rogers, Brickett & Gruzinski (2001) reported that the survival rate in the group of cases reviewed was 196 of 214 (91.6%). Despite the survival of over 90 percent of the subjects studied, the authors are of the opinion that each person fit the criteria for ED.

"Police restrain citizen who lives" is a news article you will likely wait some time to see. "Citizen dies after struggle with police" is the type of story we tend to see more often. The fact is until very recently no person or entity has been keeping track of the number of deaths per year for this type of event, nor the number of survivors for that matter.

An often referenced series of articles written by Weiss (1998), outlined cases that occurred in various facilities throughout the United States rather than incidences involving the police. The number of deaths relating to ED-like behavior are currently estimated to be in the range of 50 to 150 per year in the US, although the "incidence of death in persons exhibiting characteristics of excited delirium prior to or during the arrest process is not known, nor is the relative risk of death in persons exhibiting excited delirium features as compared to those simply resisting arrest" (Manojlovic et al., 2005, p. 39).

Informed estimates made by my colleagues speculate the number of ED related deaths in Canada is somewhere between 6 and 10 per year. As I said, no one has any idea of how many cases occur each year where the subject survives. Efforts are underway to collect this type of information but those efforts are in their infancy.

I've had the privilege of communicating with a number of physicians, researchers and interested persons who are working to better understand these deaths. Good research takes time and cannot be hurried. In the meantime communication, sharing of information and improving the appreciation of the problem is vital to understanding what some physicians are calling excited delirium.

Note: During the months of December and January past I had the opportunity to read recently released texts on the subject of sudden deaths in custody (Ross & Chan, 2006) and excited delirium (Di Maio & Di Maio, 2005). Both books are a must read for anyone seriously interested in the problem of sudden deaths related to excited delirium. The authors have sifted through much of the existing research associated with this subject matter. In essence the books outline the multitude of factors that may be involved in the death of a subject. The body of information is substantial. Readers will require a basic understanding of human physiology, a good medical dictionary, and patience.

The opinions expressed are those of the author and do not necessarily reflect the opinions or policies of the Ontario Police College or the Ministry of Community Safety and Correctional Services.


American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision ed.). Washington, DC: American Psychiatric Association.
Armstrong, L. E. (Ed.). (2003). Exertional heat illnesses. Champaign, IL: Human Kinetics.
Di Maio, V. J. M., & Di Maio, T. G. (2005). Excited delirium syndrome: Cause of death and prevention. Baca Raton, FL: CRC Press.
Manojlovic, D., Hall, C., Laur, D., Goodkey, S., Lawrence, C., Shaw, R., et al. (2005). Review of Conducted Energy Devices (No. TR-01-2006). Ottawa, ON: Canadian Police Research Centre.
Morrison, J. R. (1994). DSM-IV made easy. New York: Guilford Press.
National Association of Medical Examiners Ad Hoc Committee on the Definition of Heat-Related Fatalities, Donoghue, E. R., Graham, M. A., Jentzen, J. M., Lifschultz, B. D., Luke, J. L., et al. (1997). Criteria for the diagnosis of heat-related deaths: National Association of Medical Examiners: Position Paper. American Journal of Forensic Medicine and Pathology, 18(1), 11-14.
Ross, D. L., & Chan, T. (Eds.). (2006). Sudden deaths in custody. Totowa, NJ: Humana Press.
Stratton, S. J., Rogers, C., Brickett, K., & Gruzinski, G. (2001). Factors associated with sudden death of individuals requiring restraint for excited delirium. American Journal of Emergency Medicine, 19(3), 187 - 191.
Weiss, E. M. (1998, 11-15 October). Deadly restraint: A nationwide pattern of death. Hartford Courant.
World Health Organization. (2003). International Statistical Classification of Diseases and Related Health Problems, 10th Revision. Retrieved December 7, 2005, from http://www3.who.int/icd/vol1htm2003/fr-icd.htm

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