Achieving a Consensus on the Diagnosis of Excited Delirium Syndrome: A Scoping Literature Review

Abstract: BACKGROUND

Excited Delirium Syndrome (ExDS) remains a controversial diagnosis involving altered mentation, agitation, and, frequently, substance abuse that lacks a unified diagnostic criterion (Wetli, 1985; APA 2022; AMA 2022). Its use as a justification for use of force and/or medication administration has increased as it has become a more prominent pre-hospital diagnosis (Gonin 2018).



METHODS

We conducted a scoping review across three databases (Ovid Medline, PsycInfo, and Scopus) in order to delineate frequently reported ExDS diagnostic criteria, and to assess related deaths of persons in law enforcement custody.



RESULTS

The above databases were searched in March 2021, with analysis being finalized by December 2021. Inclusion criteria included peer-reviewed publications in English which described 1) ExDS symptoms, 2) substance intoxication with 2 or more present ExDS symptoms (as delineated in DeBard, 2009), or 3) dealing with ExDS deaths in law enforcement custody. Data was extracted and qualitatively summarized. In total, Key study data were extracted and the current literature described qualitatively. In total, 97 studies included after secondary full-text review.



DISCUSSION/CONCLUSION

There was a documented difference in criteria for ExDS diagnosis across organizations, with a concomitant difference in pre-hospital clinical care. In turn, this leads to a varied impact on patients, especially those of minority racial or ethnic groups. Given the current lack of diagnostic consensus, ExDS should not be utilized as a clinical diagnosis, nor as a rationale for medication administration or use of force. It is incumbent on major medical organizations to unify in consensus-based diagnostic criteria for ExDS so as to transform the care of these patients, improve the related education of trainees and practicing physicians, and to provide best practice guidelines for treatment, both in hospital and pre-hospital settings. It is by this consensus and resultant educational changes that we may have the largest impact on future patient care.



REFERENCES

1. Wetli CV, Fishbain DA. Cocaine-Induced Psychosis and Sudden Death in Recreational Cocaine Users. J Forensic Sci. 1985;30(3):873-880.

2. APA Council on Psychiatry and Law. Position Statement on Concerns About Use of the Term “Excited Delirium” and Appropriate Medical Management in Out-of-Hospital Contexts. Accessed January 18, 2022. https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-Use-of-Term-Excited-Delirium.pdf

3. AMA. New AMA policy opposes “excited delirium” diagnosis. Accessed January 18, 2022. https://www.ama-assn.org/press-center/press-releases/new-ama-policy-opposes-excited-delirium-diagnosis

4. Gonin P, Beysard N, Yersin B, Carron P. Excited Delirium: A Systematic Review. Caterino JM, ed. Acad Emerg Med. 2018;25(5):552-565. doi:10.1111/acem.13330

5. DeBard ML, Adler J, Bozeman W, et al. White Paper Report on Excited Delirium Syndrome. American College of Emergency Medicine. Published online September 2009:22.