Howard Hyde died on November 22, 2007.

As a young man, Hyde had been diagnosed with schizophrenia, and in the throes of a relapse, was arrested by Halifax Regional Police on November 21, 2007.

During the 30-odd hours between the time of his arrest and his death, Hyde was shocked with a conducted energy weapon several times, stopped breathing and had to be transported to the ER after being revived through CPR, and died after having been restrained by police repeatedly. He was 45 years old.

Nova Scotia’s Chief Examiner, Matthew Bowes, who was appointed in 2006, concluded that Hyde’s death was caused by “excited delirium due to paranoid schizophrenia,” with “restraint during a struggle” as just one of the contributing factors.

Myles Gray died on August 13, 2015, in Burnaby, BC.

Gray, who had bipolar disorder, sprayed a neighbour with a lawn house. Multiple Vancouver police officers responded, beating Gray so badly that they ruptured his testicles, broke his voice box and one of his eye sockets, and left his body covered with extensive bruising. One officer told the coroner’s inquest into Gray’s death that he punched him in the head repeatedly as hard as he could, because he thought the only alternative would have been to shoot him. Gray was 33 when he was killed.

Several police officers told the inquest into Gray’s death, which concluded last week, that they believed he was suffering from excited delirium.

The fact that the deaths of both of these men, years apart, could be attributed to this syndrome rather than to the violence they suffered at the hands of police is a testament how widespread entrenched bullshit ideas can become, and how difficult it can be to dislodge them.

But, nearly 15 years after the inquiry into Hyde’s death called into question the role of excited delirium, change may finally be coming.

What is excited delirium?

The American College of Emergency Physicians is one of the few medical groups to acknowledge the existence of excited delirium. In their 2009 “White Paper Report on Excited Delirium Syndrome,” the members of the ACEP Excited Delirium Task Force write:

Based upon available evidence, it is the consensus of the Task Force that ExDS is a real syndrome of uncertain etiology. It is characterized by delirium, agitation, and hyperadrenergic autonomic dysfunction, typically in the setting of acute on chronic drug abuse or serious mental illness.

ACEP no longer endorses the term, but, in a statement released last month, assured readers that “hyperactive delirium syndrome” is real.

Excited delirium is hard to define because, well, because it is not recognized as a medical condition by the American Medical Association or the American Psychiatric Association.

It does not appear in DSM-5, the Diagnostic and Statistical Manual of Mental Disorders — the psychiatric profession’s diagnostic bible. It should be noted, however, that delirium itself is a genuine, serious, and often under-reported condition. (Yvette d’Entremont recently wrote about it here.)

A landmark Physicians for Human Rights report called “‘Excited Delirium’ and Deaths in Police Custody: The Deadly Impact of a Baseless Diagnosis,” released in March of last year, outlines the various symptoms that have been considered indicative of excited delirium:

It might be described as a state of agitation, excitability, or paranoia.[331] It might include bizarre behavior, confusion, delusions, hyperactivity, incoherence, or yelling.[332] It is often, although not necessarily, associated with drug use.[333] And, ultimately, it is so broadly defined that it might include the observable manifestation of almost every psychiatric or drug-induced behavior. Beyond even this, “excited delirium” has been described by courts to include superhuman strength and imperviousness to pain.[334] While this is generally asserted to be brought on by an underlying history of drug use or mental illness, it has also been described as being initiated by “physical stress.”[335] One court even found excessive “sweating” to be indicative of “excited delirium.”[336]

Since there is no clinical definition, excited delirium is like the old “I know it when I see it” definition of obscenity.

Police and excited delirium

From blood spatter analysis, to the “science” of determining which 911 callers are lying, to connections between “hip hop graffiti” and gang violence, myths perpetrated through police training can be extremely harmful and persist for decades. Excited delirium seems to fall into this category.

Doctors say there is no evidence excited delirium syndrome exists. Canadian coroners are increasingly rejecting it as a cause of death. But given the prevalence of junk science in policing, I’m not optimistic we will see its end anytime soon. Maybe, like ACEP, the cops will just change the term., a website that describes itself as “provid[ing] law enforcement with the information and resources they need to better protect their communities and come home safe every day,” offers tips on dealing with people suffering from excited delirium, An article from 2022 says excited delirium represents “a significant challenge to the safety of both officers and suspects. It requires rapid recognition and coordinated response from police and EMS personnel to assess, restrain and sedate the person.” (People have died after being injected with ketamine by police.)

How can officers identify people supposedly in the throes of this condition? According to Fred Farris, police chief in Gladstone, Missouri (a suburb of Kansas City), “You know it when you see it, but you might not actually be able to put a definition to it.”

Well, that’s convenient.

Isn’t it interesting that people, often suffering from mental illness, die of this unusual condition that only seems to be fatal when accompanied by severe beatings at the hands of police? And that condition that is not recognized by psychiatrists, and that may not even exist, has been embraced by police, particularly in the age of the Taser and other similar weapons? (We’ll come back to Axon, the company that makes the Taser, below.)

Miles Gray and Howard Hyde are far from the only two Canadians in whose deaths police have claimed excited delirium played a role

In a CBC story from April 17 of this year, Bethany Lindsay writes:

Excited delirium has also been cited by Ottawa police officers in connection with the death of Abdirahman Abdi during a violent arrest, a coroner’s jury looking into a death in a New Brunswick jail, senior RCMP officers after the death of Robert Dziekanski at Vancouver’s airport, and defence lawyers for the American officer who murdered George Floyd.

Despite the non-existence of the condition, police continue to be trained in looking for signs of excited delirium syndrome, and the syndrome remains a pressing concern.

An article on excited delirium published by Police1 last year, offers this potted history of the syndrome:

Delirium is a complex syndrome that affects a person’s orientation, memory, thought process, consciousness, perception and behavior. A unique subset of individuals experiencing delirium exhibit erratic behavior and an extreme fight-or-flight response by the nervous system, labeled as excited delirium (ExD).

Cases of ExD were first described in the mid-1800s, but it was not until 1985 that the term “excited delirium” was first published in reference to cocaine-induced psychosis. Since that time, excited delirium has become common vernacular to describe individuals who are agitated, hyperaggressive, displaying bizarre behavior, tachycardic and hyperthermic.

Excited delirium is said to cause people to have super-human strength and even make them immune to pain, meaning police need overpowering force to restrain them. If the person dies after suffering, say, repeated electrical shocks, being punched repeatedly in the head, or injected with ketamine (or some combination thereof), well, you can’t blame the officers.

The racist history of excited delirium

YouTube video
An online forum held to mark the launch of the “Debunking Excited Delirium” report by Physicians for Human Rights.

The Physicians for Human Rights report notes that “the diagnosis of ‘excited delirium’ has come to rest on racist tropes of Black men and other people of color as having ‘superhuman strength’ and being ‘impervious to pain,’ while pathologizing resistance to law enforcement, which may be an expected or unsurprising reaction of a scared or ill individual (or anyone who is being restrained in a position that inhibits breathing).” 

The modern origins of the excited delirium theory arise from the deaths of Black men and women in Miami in the 1980s, as characterized by forensic pathologist Charles Wetli, who coined the term in connection with cocaine intoxication.

Wetli and University of Miami psychiatry professor David Fishbain studied the deaths of seven people who had used cocaine and died while being restrained (including being hog-tied) by police or ER staff. Autopsies were inconclusive, and Wetli and Fishbain, the PHR report says, speculated that a state of hyperactive or “excited” delirium may have been to blame. Wetli would go on to use the term “excited delirum” repeatedly, in particular with respect to the deaths of Black people.

The Physicians for Human Rights report spends some time on Wetli’s work and influence, and I’ll quote a few paragraphs here:

In the 1980s, “excited delirium” was defined as hyperactive delirium, with aggressive behaviors, and associated with cocaine intoxication. A few years later, Dr. Charles Wetli extended his theory to explain how more than 12 Black women in Miami, who were presumed sex workers, died after consuming small amounts of cocaine.[9] “For some reason the male of the species becomes psychotic and the female of the species dies in relation to sex,” he postulated.[10] As to why all the women dying were Black, he further speculated, without any scientific basis, “We might find out that cocaine in combination with a certain (blood) type (more common in blacks) is lethal.”[11]

After a 14-year-old girl was found dead in similar circumstances but without any cocaine in her system, Wetli’s supervisor, chief medical examiner Dr. Joseph Davis, reviewed the case files.[12] Davis concluded that all of the women – 19 by that point – had actually been murdered, pointing to evidence of asphyxiation in many of the cases.[13] Investigators eventually came to hold a serial killer responsible for the murders of as many as 32 women from 1980 to 1989.[14]

The year after the suspected killer’s arrest, Wetli continued to assert that at least some of the women had died from a combination of sex and cocaine: “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.”[15] He also continued to promote a corresponding theory of Black male death from cocaine-related delirium, without any scientific basis: “Seventy percent of people dying of coke-induced delirium are black males, even though most users are white. Why? It may be genetic.”[16]

To summarize: A forensic pathologist speculated that there was some particular physiological particularity of Black people that caused them to die suddenly, particularly when under the influence of cocaine. Although several of the people whose deaths he speculated were the result of this condition turned out to have been murdered, he persisted in thinking genetic factors played a role, and the theory of excited delirium leading to sudden death continued to spread for decades.

The Taser connection

The company formerly known as TASER International is now called Axon Enterprise. As the highest-profile maker of conducted energy weapons, it might have an interest in the belief that people who die after being repeatedly shocked with electricity may have suffered from excited delirium.

The PHR report spends some time on the connections between the company and some of the leading proponents of excited delirium as a cause of death:

A small cohort of authors, many working as researchers or legal defense experts for TASER International (now Axon Enterprise)… increased the broader use of the term by populating the medical literature with articles about “excited delirium.” In 2007, TASER/Axon purchased many copies of a book entitled Excited Delirium Syndrome written by one of its defense experts, Dr. Vincent Di Maio, and his wife Theresa Di Maio, that built on Wetli’s description of “excited delirium” by describing an “excited delirium syndrome.”[17] They distributed the book for free and also gave out other materials on “excited delirium” at conferences of medical examiners and police chiefs.[18] Seven years later, during a deposition, Dr. Di Maio acknowledged that he and his wife had “come up with” the term “excited delirium syndrome.”[19] The term has come to be used as a catch-all for deaths occurring in the context of law enforcement restraint, often coinciding with substance use or mental illness, and disproportionately used to explain the deaths of young Black men in police encounters.[20]

And what about the American College of Emergency Physicians — the folks whose 2009 white paper gave its imprimatur to excited delirium syndrome? The task force includes doctors Theodore Chan and Gary Vilke, both of whom, the PHR report says, “have ties with TASER/Axon and/or work as defense experts in death-in-custody litigation.[107]

The report continues:

In 1997, Chan and Vilke sought to determine whether the “hobble” or “hog-tie” restraint position results in clinically relevant respiratory dysfunction. Fifteen healthy volunteers — a small sample size with a questionable ability to generate valid or reliable results — were hogtied. Measurements of lung function decreased by up to 23 percent, which were statistically significant, but the authors deemed them not clinically significant.[108]

Vilke took on work as a defense expert in several wrongful death cases against TASER/Axon and law enforcement. Vilke acknowledged in a 2018 deposition that he had worked as a defense expert on behalf of TASER International in “certainly a number of cases” and said he believed that whenever he had testified in cases involving the use of a Taser, he had always testified on behalf of the defense. [112] Further evincing his defense sympathies, Vilke even told a journalist in 2021 that it was “doubtful” that Minneapolis police officer Derek Chauvin had killed George Floyd by pressing his knee on his neck.[113] The New York Times reported that in a deposition in summer 2021, “Dr. Vilke said it had been 20 years since he had last testified that an officer was likely to have contributed to a death.”[114]

Likewise, in a 2014 deposition, Chan acknowledged that he had been retained by the defence in cases involving the use of a Taser “probably four or five times.”[115]

The end of excited delirium?

On May 1, the jury at the Myles Gray inquest Gray rejected the claims of excited delirium, and ruled his death a homicide.

Speaking with Matt Galloway on CBC Radio’s The Current two days later, Gray’s sister, Melissa Gray, a psychiatric nurse, expressed relief. Asked by Galloway if she has heard of the condition, Gray said:

Well, I’m a psychiatric nurse, so I’ve heard of it. I mean, it’s not medically recognized. It’s not in the DSM, which is the Diagnostic and Statistical Manual of Mental Disorders. So when they threw that out there, I thought, of course they did. It’s just a blanket term used for deaths in police brutality. And when they threw that out there, I thought, this is just such a cover up…

Like come on. Fourteen guys couldn’t hold him down, couldn’t contain him? This is just to paint a picture that he couldn’t feel pain. Well, first of all, what did they know what he was feeling? Second of all, you could hear him screaming in the audio… In the recording, you could hear him screaming. So how can you say he doesn’t feel pain? It was disgusting. They made it like he was the Incredible Hulk. They said they were hitting him with batons and it wasn’t even affecting him. Well, I think that his injuries would speak otherwise.

Galloway also spoke with forensic Michael Freeman, one of the authors of a 2020 paper that reviewed cases of death in which excited delirium was cited as a cause. Freeman said:

We couldn’t find any cases where excited delirium was a cause of death that was separate from restraint…

So you have the behaviour which is deemed excited delirium, you have the restraint which is associated with the behavior, and then you have the death. And the term excited delirium allows you to basically leapfrog over the restraint, which is a plausible and realistic and known cause of death as restraint can result in acidosis and other issues that can physiologically become a cause of sudden cardiopulmonary collapse. Our gaze, as you say, gets turned away from that, and we look at the event that actually caused the restraint. And that’s the problem. This is like waving a wand and saying we’re going to take all the attention off the conduct of the police who were actually hands on this person when they died and point to something where we have absolutely no evidence, all we have to do is invoke the name. It’s like waving a wand and saying abracadabra… There’s no relationship between the term excited delirium and the actual death.

Following the publication of the Physicians for Human Rights report, the medical journal The Lancet published a piece by some of the authors of the report, called “End the use of ‘excited delirium’ as a cause of death in police custody.” Their message is clear:

Medical and public health professionals must join calls to end the use of “excited delirium” to explain deaths in police custody. The medical associations that have not
yet publicly repudiated “excited delirium” as a cause of death… should join those that have. There should be independent oversight, investigation, and high-quality medical documentation of all deaths in police custody. Health professionals need to be the primary responders and decision makers for people who are experiencing mental health and substance use crises. One crucial step, however, towards preventing future deaths in police custody is ensuring that baseless medical diagnoses do not impede possible treatment, obscure the true cause of death, or provide cover to those responsible.

It’s promising that the tide seems to be turning against excited delirium. But it is also frustrating, because so little of this is new.

Following the death of Howard Hyde, the then-provincial court judge Anne Derrick was appointed to investigate Hyde’s death and its causes. In her 460-page report, delivered almost three years to the day after Hyde died, Derrick put the blame for Hyde’s death, not on the use of a conducted energy weapon, and not on excited delirium, but simply on the police use of force against him.

She, too, had strong words about excited delirium.

Derrick, writing, remember in 2010, said the Hyde case “should sound a loud alarm that resorting to ‘excited delirium’ as an explanation for a person’s behaviour and/or their death may be entirely misguided.”

She noted excited delirium “is not recognized in the reliable psychiatric literature or the DSM IV.”

Furthermore, she argued that the most likely result of training police to look for excited delirium, is that it will lead to greater harm. It is worth quoting Derrick at some length on this:

There are considerable risks associated with educating first responders to identify “excited delirium”. Not only are there concerns that first responders are not qualified to make diagnoses, and may “see” something that is not there; as I firmly believe happened in Mr. Hyde’s case, there is the potential for more people being subjected to the overwhelming force that is recommended as being required to rapidly subdue the individual. Dr. Bowes, a member of the Nova Scotia Mental Health and Medical Experts’ Panel that reviewed excited delirium, explained the Panel’s recommendation for the use of overwhelming force to restrain notwithstanding the risks associated with restraint because of the danger that the struggle itself will worsen the hyperadrenergic state. Assuming that an agitated psychiatric patient is experiencing a delirium may lead to a decision that “they need to be ‘controlled’ for that” when ideally they should be assessed and treated specifically for whatever condition they have.

Identifying excited delirium may mean that responders don’t try to de-escalate even though highly psychotic people can, with appropriate intervention, reduce their level of agitation. Promoting the use of overwhelming force to restrain an extremely agitated person carries significant risks both from the effects of the restraint and in the use of a CEW [conducted energy weapon, such as a Taser] to shorten the struggle.

I am not optimistic that police are ready to learn this lesson, but perhaps the courts are.

Philip Moscovitch is a freelance writer, audio producer, fiction writer, and editor of Write Magazine.

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  1. Excellent article, Phil. This was a ton of research.
    I hope the people designing curriculum for future police officers and municipal councils pay attention to this issue. Police are not the best to respond to a mental health crisis is an understatement. There are exceptions, but it makes the need for a differentcteam imperative. Especially considering the lack of mental health resources in the province.