The Debate Over “Excited Delirium” Heats Up

Does this potentially fatal form of excitement exist?

Posted May 08, 2015

Does a potentially fatal form of excitement – sometimes called “excited delirium” – exist?  It’s hard to imagine there’s a debate about this because, yes, it exists without question.  But two things are exasperating:

1. The blithe ignorance of a number of supposedly expert clinicians who, when asked for an opinion by the Washington Post, said no, it doesn’t exist. For example:  “They’ve come up with the concept that the individual is so excited they bring on their own death," said Douglas Zipes, a professor of medicine at Indiana University. “That you can be excited is without question. That you can be delirious is without question. But the concept of this being a syndrome causing death is incorrect and false.” Dr Zipes is no doubt expert in his own field but here he is on thin ice, and is obviously unfamiliar with the literature.

2.  Exasperating as well is that “excited delirium” is sometimes used as a pretext to cover up police violence. “Oh, the prisoner died of excited delirium” goes the official story, whereas in reality he or she was beaten or choked to death. It is this misuse of the diagnosis as a cover-up by the authorities that has cast a veil of suspicion upon the entire concept.

To be clear, we have known since the early 19th century that there is a form of manic excitement, or “manic delirium,” that may end fatally. It is usually heralded by a rise in temperature; in those days it was often accompanied by an intense longing for the homeland – among those in mercenary military service abroad, for example – and just like that, an otherwise healthy young man would become morose, turn his face to the wall, and die. (“Manic delirium” is the term I prefer, and it goes back to a time when mania meant insensate violence, not euphoria.)

German psychiatrist Karl Kahlbaum coined the term “catatonia” in 1874, and manic or excited delirium became known as a form of catatonia.

Excited delirium with a fatal outcome was recognized in 1934 as a distinct syndrome by Munich psychiatrist Karl Heinz Stauder, and became known subsequently as “Stauder’s catatonia.”  (Karl Heinz Stauder, “Die tödliche Katatonie,” Archiv für Psychiatrie und Nervenkrankheiten, 102 [1934], 614-634)

Alas, this century of learning was forgotten in 1980 by the maladroit designers of DSM-3, who simply left it all out. Maybe it was because they had been steeped in a culture of psychoanalysis where Stauder’s catatonia was definitely not a familiar concept. Maybe it was because they saw themselves as very modern and had little use for these old-fangled diagnoses of which no one that counted had ever heard anyway.

But if something is not in DSM, US psychiatry doesn’t know about it. And excited delirium with a potentially fatal outcome remained familiar only to a small band of nosology enthusiasts. (Nosology means the classification of illness.)

Yet excited (manic) delirium did not go away in the real world, and plenty of cases end fatally, to the bafflement of the authorities and the psychiatric big domes (who actually are somewhat at sea once they venture away from “depression,” “schizophrenia,” and any phenomenon said to be caused by child abuse).

In the “debate” about excited delirium, there is therefore no actual debate, only misunderstanding. But for journalists to set the comments of the misinformed alongside those of the fully informed, and to hint that the truth may lie somewhere in-between, is irresponsible. The Washington Post gets credit for bringing the whole concept of excited delirium to public attention, but one might have wished for a bit less “balance” in the story.

There is one more thing. I’m not just unhappy that the gems of history have been forgotten. Who really cares? What matters is that Stauder’s catatonia, as with all forms of catatonia, is really treatable, with benzodiazepines and convulsive therapy. The patients respond quickly and get better, and go on to have productive lives, if they can avoid being killed first by the police.

So this is the tragedy: that one of the most treatable illnesses in psychiatry is misdiagnosed, not treated, and the patients gunned down. I gave this problem a lot of attention in my recent book, What Psychiatry Left Out of the DSM-5: Historical Mental Disorders Today (Routledge, 2015), and if just a few lives are saved as a result of this academic effort I shall consider it all worthwhile.