In a comprehensive review of the history of this term, Bhatia, et al. writing for the advocacy organization Physicians for Human Rights note that “there is no clear or consistent definition, established etiology, or known underlying pathophysiology.”² They also summarize literature showing that it was identified as the cause of death in over one out of every six deaths in police custody in Texas, that 62 percent of deaths attributed to excited delirium in Florida involved the use of force by law enforcement, and that from the period 2010-2020, deaths in custody attributed to excited delirium were predominantly made up of people of color.

In October 2023, the ACEP Council and the Board of Directors issued statements withdrawing support for the 2009 white paper and affirming that that the term “excited delirium should not be used among the wider medical and public health community, law enforcement organizations, and ACEP members acting as expert witnesses testifying in relevant civil or criminal litigation.”¹⁰ This shift followed publication of a new 2021 position paper adopted by the Council and authored by a new task force convened to reexamine the issue. This more recent work uses the DSM-derived “hyperactive delirium with severe agitation” to highlight that patients with a variety of underlying causes of delirium may be “at high risk of direct physical trauma, not only unintentional harm from trauma such as falls, but also the metabolic stress that may result from physical restraint that may be required to facilitate the safety of the patient, bystanders, and responding professionals.”¹¹

ACEP followed several other professional organizations in revoking formal support for “excited delirium,” including the National Association of Medical Examiners¹² and the American College of Medical Toxicology.¹³ To examine the death of Elijah McClain, in which excited delirium was ruled as the cause of death and in which two paramedics and a police officer have been convicted of homicide, the Colorado Department of Public Health and the Environment appointed an independent review committee on emergency use of ketamine.¹⁴ In recommending the rejection of excited delirium as a diagnosis, they identified the lack of clear criteria and the biased racial associations with some of the features often attributed to the syndrome, such as “’hyper aggression,’ ‘increased strength,’ and ‘police noncompliance.’”¹⁵

In refocusing on the clinical relevance of hyperactive delirium as a secondary syndrome with underlying primary causes, the 2021 ACEP position paper also walked away from its use as a postmortem diagnostic entity.¹¹ “The 2021 report strives to highlight that ‘excited delirium with severe agitation’ is not a diagnosis in the living or the deceased,” explained Dr. Jeffrey Goodloe, who serves as an EMS Chief Medical Officer, ACEP Board member, and one of the authors of this recent work. “The terminology change is very purposeful to get everyone focused on the medical needs of these patients and not trapped in debates about older semantics. It’s important that we focus quickly and intently on stabilizing these patients, especially in the out of hospital environment, so that we can safely get them to an emergency department.”