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'Excited delirium' as a cause of death

The controversial condition is increasingly blamed when someone dies in police custody or in other stressful situations. Rights groups call it a scapegoat.

April 21, 2003|Daniel Costello | Special to The Times

In the 1960s, psychiatrists documented cases in patients taking large amounts of antipsychotic medications who suddenly became manic and aggressive and later died, usually after being restrained. (Some suspect antipsychotic medications may have the same effects as stimulants for those susceptible to excited delirium.)

It wasn't until the 1980s that a link to cocaine was found, and that was by chance. A medical examiner in Miami noticed similarities between several cases of people who died suddenly and had cocaine in their system and what psychiatrists were describing in the patients they said died of excited delirium. The examiner, Dr. Charles Wetli, quickly noticed another link: A large number of the same victims had died while in police custody.

There were other similarities. In most cases, the cause of death was a heart attack or, less frequently, respiratory failure. A more thorough look at police reports showed that several had become agitated or delirious before getting involved in a struggle with police.

Many of the similarities, from the heart attacks to the erratic behavior, coincided with what psychiatrists had noticed in the patients they believed died of excited delirium.

Wetli concluded that what he was seeing was the same thing and began using the condition as a cause of death for in-custody cases in Miami. By the early 1990s, others such as Karch in San Francisco did the same. Now it's used by medical examiners in most major cities around the country.

Experts suspect the number of cases may be rising, not just the number of diagnoses. One reason: Use of cocaine has climbed as much as 20% in the U.S. since 1990, according to the most recent Department of Health and Human Services' National Household Survey on Drug Abuse.

Even a small number of cases may have a large significance. In-custody deaths draw enormous media attention and can severely raise tensions between police and the public, who often assume the police are at least partially responsible if only because of their proximity. And if police knew what to look for, it's possible they could save some victims by getting medical attention more quickly. The Berkeley Police Department now trains its officers to look for excited delirium symptoms and requires them to get immediate medical attention.

Most medical examiners who diagnose the syndrome say it's hard to know for sure if it has occurred just by doing an autopsy. Much as they do with sudden infant death syndrome, they rely on symptoms and police reports and work backward to the cause. But they do point to a clear and successive set of symptoms in all of the cases.

First, body temperature skyrockets as high as 107 degrees. Not long after, the victim shows signs of delirium and mania, and many talk too fast and uncontrollably for anyone to understand. If they become agitated or involved in a struggle, they may demonstrate unusual strength and often show signs of labored breathing. Many soon suddenly collapse and can die within an hour of first showing signs of dementia. Some victims have just one-fifth the amount of drugs in their system than what's normally believed to cause an overdose.

Critics are quick to counter that the drugs could easily cause some of these characteristics, such as the agitation and bizarre behavior and speech. And they ask: Wouldn't the fact that many of these deaths happen during or soon after restraint clearly imply police abuse?

Jones, of the Ella Barker Institute, and others such as the ACLU remain adamant that most in-custody deaths are the result of excessive force and improper restraint techniques, such as hogtying and the use of pepper spray. For years, there has been concern that suspects who are hogtied while face down could die of something called "positional asphyxia." For that reason, many departments, though not all, have banned the practice.

In its place, more are using pepper spray, but that's becoming equally controversial. The chemical spray has only been legal for police use in states for about a decade, and some worry its effects are just starting to be known. According to the ACLU, several dozen people in the U.S. have died of allergic reactions to pepper spray since the early 1990s.

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Men more at risk

A 2001 study published in the Journal of Emergency Medicine found there might be some statistically significant patterns to those most at risk for excited delirium. Researchers in Los Angeles studied 18 cases of documented excited delirium that occurred from 1992 to 1998 in the U.S. They found that almost all were men, many were overweight and the average age was 32. (Much like those most likely to be involved in altercations, critics add.) Researchers also noted that the cases were almost evenly divided among whites, Latinos and African Americans.

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