Excited Delirium: Arjun Byju on History of an "Invented Disease" Used to Justify Police Use of Force

ROCHESTER NY--Recently-released transcripts have shed new light on a grand jury decision not to indict any Rochester police officers involved in the death of Daniel Prude.

The transcripts released last Friday reveal that the New York State Attorney General's office undercut the case for prosecuting officers by hiring an outside medical expert who testified Daniel Prude's death was not caused by asphyxiation through police restraint, as the medical examiner in the case had previously determined, but rather by cardiac arrest brought on by something called "excited delirium."

On Sunday, local defense attorney and racial justice activist Danielle Ponder responded on Facebook, "Attorney General James intentionally threw the Daniel Prude case. Why as the prosecution would you call a witness to testify that officers weren't responsible for his death? Why would you introduce the junk science 'excited delirium.' Her office was not trying to win the case. They were trying to exonerate the cops."

To talk more about the history of this controversial term "excited delirium," Reclaiming the Narrative's Darien Lamen reached out to Arjun Byju, a medical student in New York City whose article "Excited Delirium: How Cops Invented a Disease" was recently published in Current Affairs.

Rush transcript

Darien Lamen: You write in your article that, as a medical student, you were curious about this diagnosis of excited delirium, which you say you never read about in any of your text books or heard on the wards. Can you begin by briefly explaining what excited delirium is supposed to be, and what led you to question that?

Arjun Byju (photo provided)

Arjun Byju: I was sort of looped into this narrative like many of us last year, as the topic of police brutality and deaths in police custody gained even more traction. And I was following what was happening in Rochester with the case of Daniel Prude and I read about excited delirium, this term being thrown around as one of the causes of death or one of the things implicated in Mr. Prude's death. I had just finished my psychiatry clerkship. And I'm a third-year medical student and I had never heard of excited delirium. So I just started Googling the term and quickly stumbled upon a lot of literature that raised concerns about the veracity and the legitimacy of this clinical entity. It always seems to be invoked, or almost always is invoked when people die in police custody. But it's actually not recognized by a large swath of the medical establishment. And I think that's what really got me interested, is when I read that the American Medical Association, the World Health Organization, the Diagnostic and Statistical Manual DSM-5 that's sort of the Bible for psychiatric disorders, you know, none of those acknowledged excited delirium as a quote real or legitimate clinical entity so I started to do some digging myself.

DL: And so, as you say in your piece, whether or not this is a "real" clinical entity, it's doing some troubling work within the context of criminal justice and policing. You write, "The trouble with excited delirium, whether it's 'real' or not, is that its therapeutic directive is one of complete force that simultaneously lays culpability at the foot of the afflicted person." Can you explain what you mean there, and why you think in the hands of police officers the concept has been so dangerous?

AB: So as I was reading the last few months, a lot of media and other publications try to tackle whether excited delirium was real or not. That is, whether there is a pathophysiological, biological, or chemical basis for it. And it was covered in 60 Minutes and the New England Journal of Medicine, which is sort of the premiere journal in our field. But as you alluded to, I kind of wanted to take a step back and say, whether it's real or not, I think the way that we're employing it helps us to dehumanize the individuals who find themselves in police custody. And I think that's why it's so dangerous. A lot of the descriptions of excited delirium describe somebody who is animalistic. They use the word animalistic. They create this picture of a raving menace. Also the state is supposed to be characterized by an apparent inability to feel pain. Traditional pain compliance techniques may not work with them. And I think what's troubling is what I call an "illness script" in the piece, or the narrative of the disease, is that we create a narrative of somebody who's so strong, so hard to control, so dangerous that they necessitate us taking this extra level of force. They necessitate us using a taser or even using a firearm. And I think that's what's most troubling and most dangerous about excited delirium, whether it's real in a biological or biochemical sense or not.

DL: So take us through some of the history of this term that you lay out in the piece. How far back were you able to trace the history and who were some of the key figures in popularizing its use?

AB: In almost all histories of excited delirium, Luther Bell, a psychiatrist who worked at McLean Hospital, affiliated with Harvard Medical School, is the first person to describe it in the mid 1800s. And then it dropped out of the medical literature for over a hundred years. Charles Wetli, who was a medical examiner in Miami, Florida, is credited with repopularizing the term in the 1980s. And he described a series of people, overwhelmingly people of color, who died in mysterious circumstances, otherwise inexplicable circumstances. It later turned out that many of these people he said had died of "excited delirium" which he attributed to drug use, were actually killed by serial killer. But nevertheless Wetli was one of the big people who promoted that, and there are a few other scientists and researchers who similarly from that time period looked into excited delirium.

One of the things I discovered in my research is that there's been significant industry influence in promoting excited delirium as well, which I think is definitely something that most people should know about, both within the medical profession and outside. I write a good deal about Taser, the company that makes the stun guns which now goes by the name Axon. Axon has benefited a lot from the use of excited delirium in trials as a sort of medical-legal explanation for people who died after being tased. And they've definitely benefited from this diagnosis or so-called disease existing. So I try to explore that in the piece and I definitely encourage listeners to read up on that as well.

DL: I want to ask you a little bit further about that. As you mentioned, although excited delirium is not recognized by the American Medical Association and others, there are at least two groups of medical professionals who do use the term, including medical examiners and emergency medical professionals. And significantly in the Daniel Prude grand jury, two of the state's medical experts who were asked to talk about excited delirium were the Monroe County Medical Examiner and UCSD Emergency Medicine Physician Gary Vilke. So can you talk about those two particular subfields, why excited delirium seems to be more widespread as an explanatory term in those circles?

AB: It's a good question. I think a charitable explanation is that emergency room physicians will say, we see these kinds of cases, we see people who are acutely psychotic to intoxicated, we commonly see agitated people. And I think they work more closely perhaps with law enforcement and first-responders like EMTs. And by that same token then, medical examiners, forensic pathologists are I think a bit more tied in. And so the American College of Emergency Physicians and the NAME, the National Association for Medical Examiners, both acknowledge excited delirium as real. And I think that probably has to do with their work with law enforcement. I think though that, as I write in the piece, there has also been significant industry influence in both of those specialties. Of course industry influence is in many specialties and in many professions outside of medicine too. But I think particularly with emergency physicians, one of the white papers that was published a few years ago that really put the American College of Emergency Physicians behind excited delirium, Reuters investigative journalists later discovered that some of the key architects of that white paper were funded or had received payment by Taser they had not disclosed at the time of writing. Which is definitely troubling for everyone within and outside of medicine. So I think more research can happen on this disease, but definitely conflicts of interest should always be kept at the forefront as we move forward.

DL: As we begin to wrap up, I wanted to ask you what is the takeaway here for people who are thinking about medicine in this kind of broader social and political context?

AB: For all us within medicine it's important to remember why we got into this. When we examine terms like excited delirium and how they are used by law enforcement, the medical community, and society-at-large, it does seem to be antagonistic to our goals of taking care of patients and approaching them with compassion, humility, and respect. I think that one of the troubling things about excited delirium for me is that, even if it is real, there doesn't seem to be a protocol for treatment. Many other difficult diseases and disease states, we approach with a framework of treatment, whether it be pharmacological or otherwise. And I think that's my final takeaway, is to remember that treating people and making them themselves again is always of course the backbone of what we're pursuing in medicine. And I end the piece with a line from the Hippocratic Oath and sort of the ethos of modern medicine which is, "primum non nocere" or Latin for "first do no harm." I think that if I if I had to end with one note in this interview it would be the same idea, that police, medical professionals, we should all try to keep that close to our heart. We don't want to do more harm than good when we're trying to take care of people.