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For decades, the term "excited delirium" has been erroneously used as a catch-all medical diagnosis for people who have died in police custody, despite having no legitimate scientific roots, a new investigative report has found.

While delirium and its subtypes are recognized by the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there is no clear definition or diagnostic standard put forth for "excited delirium." Likewise, neither the American Medical Association nor the American Psychiatric Association recognizes the validity of the diagnosis, reported Harvard neurologist Altaf Saadi, MD, MSc, and colleagues.

In a of the report, released in conjunction with a commentary on it in , Saadi called excited delirium a "convenient diagnosis," as the symptoms that are said to be indicative of the condition are wide-ranging. Agitation, confusion, hallucination, elevated temperature, rapid heart rate, and sweating profusely are just a few of its supposed symptoms -- all of which can be characteristic of numerous other conditions and disorders that are medically sound.

"Law enforcement can use it to describe virtually anyone with a wide variety of underlying conditions, exhibiting a wide variety of symptoms shared by many common conditions, justifying the use of super-aggressive tactics," Saadi said. "And then [it can be used] to hide behind medical terminology that shifts the blame from the person that's exerting the force to the person that's dying."

The , published by U.S.-based non-profit Physicians for Human Rights (PHR), detailed the term's history as one almost always used to describe Black and Brown Americans who died in police custody. Thus, they argued, the term "cannot be disentangled from its racist and unscientific origins."

"Excited delirium" was by pathologist Charles Wetli, MD, with psychiatric professor David Fishbain, MD, in the early 1980s. Saadi's group wrote that Wetli used the false diagnosis to explain how more than 12 Black women -- presumed sex workers -- died in Miami after consuming small amounts of cocaine.

When a 14-year-old girl was murdered under similar circumstances without any cocaine in her system, Wetli's supervisor concluded that all the women had been murdered. A serial killer was later tried and found guilty of these crimes. But even though alternate causes of death were discovered and proven, Wetli apparently continued to push the "excited delirium" theory, arguing that the combination of sex and cocaine must have contributed to their deaths.

"I have trouble accepting that you can kill someone without a struggle when they're on cocaine ... cocaine is a stimulant. And these girls were streetwise," Wetli reportedly said.

"Seventy percent of people dying of coke-induced delirium are black males, even though most users are white. Why? It may be genetic," he added, according to the PHR report.

The term was given a new life in 2007, when Taser International -- the company behind the hand-held Taser and stun weapons, now called Axon Enterprise -- purchased and distributed many copies of a book called Excited Delirium Syndrome, written by Vincent Di Maio, MD, a pathologist who has testified on behalf of Taser/Axon. The book, the PHR report states, was given out at conferences attended by medical examiners and police chiefs.

The diagnosis has been ascribed to a number of people of color who died at the hands of police force in recent years, including Manuel Ellis, Elijah McClain, Natasha McKenna, and Daniel Prude. It also came up as a for Derek Chauvin's murder trial over the death of George Floyd.

An conducted by the Austin American-Statesman found that more than one in six of the 289 deaths during police custody in Texas from 2005-2017 were attributed to "excited delirium." A from Florida Today showed that, of the 85 deaths attributed to "excited delirium" since 2010, 62% involved the use of force by law enforcement.

When University of California Berkeley law and bioethics professor Osagie Obasogie, JD, PhD, conducted a of available databases, he found 166 in-custody deaths attributed to "excited delirium" from 2010-2020. Of them, 43.3% were Black people; Black and Latinx people together made up at least 56% of these deaths.

At the PHR panel, Joye Carter, MD, a forensic pathologist and the first woman and Black American to be appointed chief medical examiner in the U.S., explained why she has never used the term in her many years on the job.

"My training was, if you had somebody who died ... with documented activity such as attraction to shiny objects, elevated body temperature, not being able to relate to their physical environment, perhaps enduring pain, but then you found the cocaine in their system, that was termed 'complications of cocaine use' or even 'cocaine psychosis,'" Carter said. "The use of 'excited delirium' takes away from the ability of doing neutral, fact-finding death investigation."

Researchers recounted the death of Martin Harrison in 2010 as an example of the term's consequences. Harrison was arrested in Oakland, California, for jaywalking; officers discovered an outstanding warrant for failing to appear in court for another offense and took him into custody.

Harrison, who was visibly intoxicated at the time of his arrest, told a nurse during his intake that he drank daily and has previously experienced alcohol withdrawal. Despite knowing this, he was sent to a cell without any medical treatment. A few days later, he began experiencing symptoms of severe alcohol withdrawal, also known as delirium tremens, which is treatable through medical intervention. According to the report, Harrison's hallucinations brought 10 deputies to his cell, where they then restrained and beat him until he died.

In the subsequent trial against Alameda County, Di Maio and Wetli were both called in as expert witnesses. Although neither party disputed that Harrison was experiencing delirium tremens at the time of his death or that he'd been severely beaten, Wetli still clung to his "excited delirium" theory. In his testimony, Wetli said that Harrison's death was a "classic example of death due to excited delirium." The case was settled for $8.3 million after an 8-week trial.

The PHR report concluded with a number of recommendations, including the implementation of alternative emergency responses to people in crisis. They also called on the American College of Emergency Physicians to revise its position on "excited delirium" and rescind its previous white papers that supported the term as its own diagnosis, separate from other types of delirium.

"There's increasing recognition in the physician community that this is something we need to be speaking more about," Saadi said.

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