In-Custody Deaths: Excited Delirium

Excited delirium is a medical emergency that can lead to a sudden in-custody death. It is paramount that law enforcement officers can recognize the symptoms of excited delirium and insidious sudden death to respond immediately and appropriately.


The dispatch call may be for a disturbance or for a mentally ill subject. There will probably be several reporting parties. A man is yelling and screaming downtown; he has smashed in several stores' windows; he is nude. When you arrive you find you cannot communicate with him. He is grossly incoherent, obviously hallucinating. The subject is either acutely mentally ill, under the influence of drugs, or both. He advances towards citizens who have stopped for the show. It is time to contain and control him. He needs to go somewhere--jail or a mental health facility. As you approach he immediately initiates a fight with apparent superhuman strength. You may have already employed a less-lethal weapon to little or no effect. Other officers respond and six of you engage in a protracted physical encounter. You finally get him handcuffed, and apply leg restraints. Paramedics have been called to the scene. While you wait, the subject still fights the restraints. Suddenly he stops struggling, and you realize he has also stopped breathing and has no pulse. Attempts by officers and paramedics to resuscitate him are futile. The subject is pronounced dead at the hospital. On autopsy, the coroner cannot find sufficient evidence to establish a cause of death.

It is estimated that there are between 50 and 125 in-custody deaths in the United States that correlate with excited delirium symptoms every year. Similar deaths also occur in psychiatric and geriatric care facilities.

Three groups of subjects are more prone to the sudden and unexpected death associated with excited delirium: people with a mental illness, (bipolar disorder or schizophrenia), chronic illicit stimulant (cocaine, methamphetamine) abusers and ecstasy, marijuana, or alcohol abusers, or a combination of mental illness and substance abuse. Other causes of excited delirium include infection, head trauma, and adverse reactions to medication. Most subjects the police will encounter with excited delirium are males between the ages of 30 and 40. It is rarely seen in females.

The Excited Delirium Syndrome

There is no medical or psychiatric diagnosis of excited delirium. The International Association of Chiefs of Police has not acknowledged the syndrome, either. It is the subject's behavior that indicates the syndrome. However, annually, excited delirium is increasingly determined to be the cause of in-custody deaths.

Any person experiencing delirium requires prompt medical attention as it is a result of life threatening medical conditions. Delirium is characterized by an insidious disturbance in the level of consciousness and a change in mental status. People in delirium will likely manifest acute behavior problems, including becoming oppositional, defiant, angry, paranoid and aggressive. Attempts to calm or contain them will result in further aggression and violence. Control techniques can be difficult because subjects often demonstrate unusual strength and insensitivity to pain, as well as instinctive resistance to the use of force.

Signs and Symptoms of Excited Delirium

Excited Delirium presents as a cluster of physiologic and behavioral symptoms which include:

  • Unbelievable strength
  • Imperviousness to pain
  • Ability to offer effective resistance against multiple officers over an extended period of time
  • Hyperthermia (temperatures can spike to between 105-113°F)
  • Sweating
  • Shedding clothes or nudity
  • Bizarre and violent behavior
  • Aggression
  • Hyperactivity
  • Extreme paranoia
  • Incoherent shouting or nonsensical speech
  • Hallucinations
  • Attraction to glass (smashing glass is common)
  • Confusion or disorientation
  • Grunting or animal-like sounds while struggling with officers
  • Foaming at the mouth
  • Drooling
  • Dilated pupils
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