What is excited delirium?

By Christopher Baxter | NJ Advance Media for NJ.com

October 1, 2014

Kenwin Garcia was walking alongside Interstate 287 in Hanover Township.

Charles Arroyo was choking his mother on her bed in Egg Harbor City.

Mark Keseleski was standing near his burning car on the New Jersey Turnpike in Woodbridge.

Each wound up dead after a fight with police.

An NJ Advance Media analysis found they were among 10 people during the past decade in New Jersey who authorities said died after a case of excited delirium, a controversial medical syndrome, usually cited after struggles with police, that results in heart or respiratory failure.

Some police experts, physicians, researchers and medical examiners say the condition is real, and police officers are often wrongly accused of excessive force as a result of it. Critics say it’s poorly understood, vague and open to abuse by police or prosecutors.

“There is a very sharp split, even among forensic pathologists, who are the only ones to really use the diagnosis,” said Michael Baden, a former chief medical examiner for New York City and former director of the New York State Police Medicolegal Investigation Unit. Most recently, Baden conducted a private autopsy of Michael Brown, whose shooting by police in August in Ferguson, Mo., prompted widespread protests.

Limited research exists on excited delirium. Most journal articles and other published reports conclude it is real in some form, though they acknowledge the split in the medical community and the fact the exact cause and why it afflicts certain people is unknown.

It most often occurs when people become disoriented and delusional after taking drugs such as cocaine, and then become agitated and violent when approached by police, experts said. Proponents say it also occurs absent police, but those situations gain less attention and are poorly documented.

Delirium itself among drug users and the mentally ill has been recognized and accepted in scientific communities for years. But the more recent phenomenon of delirium leading to death after encounters with police has prompted confusion and heated debate.

‘Not oriented to reality’

Vincent Di Maio — who was the chief medical examiner in Bexar County, Texas, which includes San Antonio, for 25 years and who co-authored the leading book on excited delirium — said in most cases, police are called because someone is acting bizarrely, and officers intervene to restrain the person.

Forensic pathologist Vincent Di Maio explains excited delirium.

“He’s not oriented to reality,” Di Maio said. “He has hallucinations. He can’t think straight. And then he begins to wander around. And usually they start becoming violent, not necessarily toward other people, but they’ll smash out windows, they’ll run through traffic.”

Inside the body, Di Maio said, the effects of drugs combined with the “fight or flight” response triggered by an intense struggle can cause the heart to be bombarded with chemicals such as adrenaline, making it race, damaging the muscle and causing cardiac arrest.

About 10 to 20 percent of excited delirium cases involve someone with mental illness, almost always schizophrenia, Di Maio said. In those instances, people already have heightened levels of chemicals and, when combined with what’s produced during a struggle, those levels reach extreme highs and cause death, he said.

Proponents of the syndrome say it kills anywhere from 250 to 600 people nationwide every year, and, while still considered rare, it has during the past decade increasingly surfaced in cases when police are accused of causing heart failure by using a stun gun.

In New Jersey, nine of the cases occurred during arrest situations from 2004 to 2009, according to an analysis of reports filed by the state Attorney General’s Office with the U.S. Bureau of Justice Statistics. The reports were obtained from the Attorney General’s Office by NJ Advance Media under the state Open Public Records Act. In eight of the nine cases, death was attributed to excited delirium. In the ninth case, Curtis Good was shot and killed by police and was later said to have been suffering from the syndrome.

Five cases involved cocaine, and none involved stun guns, according to the reports. Six cases involved black men, two white and one Hispanic, the reports indicate. In most cases, authorities released little information about the incident or their investigation. The excited delirium cases made up about 6 percent of the 150 arrest-related deaths from 2004 through July 31 of this year, records show. Most of the other arrest-related fatalities involved suspects who were shot by police while threatening themselves or others.

The 10th case of excited delirium did not occur during an arrest but at a county jail. Earlier this year, the Union County Medical Examiner’s Office said William Parisio, 25, of Cranford, died of cardiac dysrhythmia “due to excited delirium and physical restraint” after an altercation with officers in his cell, where he was awaiting trial for murder. His death was ruled an accident, but his mother subsequently filed court papers indicating she intends to sue the county claiming that her son was beaten to death.

Civil lawsuits in cases involving excited delirium have resulted in big payouts.

In 2008, Perth Amboy agreed to pay $1.35 million to the estate of Good, who was shot six times and killed in his apartment by a police officer in 2004, reportedly while Good was delirious from cocaine and charging the officer.

Last year, the Attorney General’s Office and Hanover Township agreed to pay a combined $700,000 to the estate of Garcia, 25, of Newark, who broke two patrol car windows after being arrested, and then lost consciousness after being restrained by State Police troopers on the ground for about 15 minutes. Garcia died a week later after being taken off life support. Four medical experts subsequently interviewed by NJ Advance Media questioned the finding of excited delirium because of Garcia’s extensive internal injuries and suggested that he might have suffocated while being restrained.

Diagnosis by exclusion

Identifying the syndrome relies almost entirely on symptoms and behavior exhibited before death because there is no known anatomical evidence of it, Di Maio said. Medical examiners call it a diagnosis by exclusion because it is cited when there are no other explanations for someone’s death, he said.

Deborah Mash, a professor of neurology at the University of Miami and one of a handful of researchers studying excited delirium, said the phenomenon was described in psychiatric literature in the 1850s, but emerged most recently in the 1980s in Florida with a surge in cocaine use.

Her research focuses on finding a genetic marker or other process for medical examiners to identify the syndrome after death.

“There’s so much misinformation on this front, it’s just mind-boggling,” Mash said. “You’re crossing the fields of psychiatry, forensic medicine, toxicology, and we don’t have a unified understanding of this disorder. Because why? It’s rare. It’s a rare disease.”

The unanswered questions about excited delirium have led many to reject the term as an obscure explanation for a death.

Cardiologist Douglas Zipes explains why he is doubtful Kenwin Garcia died from excited delirium.

The National Association of Medical Examiners and the American College of Emergency Physicians recognize the syndrome, and in April, the International Association of Chiefs of Police issued a white paper concluding, “despite what it is called or whether it has been formally recognized, it is a real clinical concern for both law enforcement and the medical communities.” But the American Medical Association and the American Psychological Association, among others, have taken no position.

“More research on the concept of ‘excited delirium’ needs to be undertaken,” said Kim Mills, spokeswoman for the psychological association.

The International Classification of Diseases, the gold-standard for medical diagnoses, makes no mention of excited delirium, nor does its counterpart, the Diagnostic and Statistical Manual of Mental Disorders, though it does describe disorders similar to it.

Douglas Zipes, a internationally renowned cardiologist and distinguished

professor at Indiana University School of Medicine, said that while excited delirium may be real, particularly among drug users, it often does not adequately — and scientifically — explain someone’s death.

“It’s a catch-all group of signs and symptoms of individuals and the only common denominator is agitated delirium,” said Zipes, an expert in heart rhythm and sudden death. “I find that very unacceptable.

“I am a clinician but also a scientist, and without having a scientific underpinning that would explain the mechanism as to how this happens, I find the diagnosis difficult to make and to accept.”