Talk:Excited delirium

WP:REDFLAG issues

First up, recall as you think about this that "EXD" is not accepted by the WHO, American Psychiatric Association, American Medical Association, EUSEM, is not in the DSM and is not in ICD-10. It is accepted in the US only by the American College of Emergency Physicians (ACEP). Michael Baden calls it "a boutique kind of diagnosis created, unfortunately, by many of my forensic pathology colleagues specifically for persons dying when being restrained by law enforcement". Most cases - almost all, and all deaths as far as I can see - are in police custody. The principal advocate for the condition is Axon, formerly known as Taser corporation, makers of the stun guns.

I'd argue that this widespread rejection, absence from ICD-10 and DSM, negligible incidence outside police custody, and advocacy paid for by a company with a vested interest in excusing deaths in police restraint, qualifies it as a fringe diagnosis - and even if you don't accept that, it's clearly a massive WP:REDFLAG.

There are a number of sources that were used in this article, which I have removed, although at face value they pass MEDRS. The reasons are explained in the edit summaries, but I'll go into them here.

• Sources authored by Charles Wetli cannot be taken at face value. Wetli coined the term after investigating 19 Black prostitutes who died in what he described as a combination of cocaine use and "sexual ecstasy", but when another woman died of the same thing and was found to have no cocaine in her body, his supervisor re-examined the previous cases and found them all to be the strangled victims of a serial killer. I cannot find any record that Wetli has changed his position on the diagnosis despite incontrovertible evidence that the cases on which he based his origin of the diagnosis, were actually the work of a serial killer, and his misdiagnosis probably contributed to the deaths of up to thirty women. Wetli was (and I think still is) on the payroll of Axon, per Reuters.
• A 2009 white paper by ACEP had at least three co-authors with undeclared conflicts of interest (all paid by Axon). At the time of publication, ACEP did not require conflicts to be declared.
• Sources authored by Jeffrey Ho are similarly tainted. Ho is a physician-cop on the payroll of Axon who was also involved with the Hennepin ketamine study, administering ketamine without informed consent to treat excited delirium in a Minneapolis hospital. This was terminated due to ethical concerns (Nature).
• Sources authored by Deborah Mash are also tainted. Mash, a protégé of Wetli, is on the payroll of Axon, and Axon appear to have a standard pack they send to police forces when a suspect dies after being tased, asking them to send tissue samples to Mash, whose tests (amazingly!) always seem to show that there is evidence of EXD and the Taser didn't kill them. Taser do not inform police of the conflict of interest.(Reuters and others)

There's also strong reporting from Reuters, Brookings and numerous other RS undermining the diagnosis. There have been over 1,000 deaths following Taser use in the US, and Taser is significantly responsible for promoting the diagnosis of excited delirium. Another paid consultant and stockholder, Mark Kroll, has described Tasers as "therapy" for EXD. One reason this is suddenly getting serious attention is because the term was used by police during the murder of George Floyd ("Man Dies After Medical Incident During Police Interaction").

Mash and Wetli cite "Bell's mania" (which redirects here) as an earlier observation of the same symptoms, but Bell's paper is from 1850 and it seems likely that most of those who died in Bell's care were actually suffering from encephalitis - notably, the diagnosis more or less disappeared in the 1950s with the advent of antipsychotics and antibiotics. Wetli claims that it resurged due to cocaine use - rhetoric very much in line with the "war on drugs", and, again, strongly associated with the use of crack (more used by Black people) rather than pure cocaine (more used by white people). Diagnosis is disproportionately seen in Black men, and is closely associated with the racially biased differential treatment of crack vs. white cocaine. While most accidental cocaine toxicity deaths are in white people, those dying of "cocaine-induced EXD" were more likely to be Black, with lower levels of cocaine in their bodies, under restraint by police. "In all 21 cases of unexpected death associated with excited delirium, the deaths were associated with restraint (for violent agitation and hyperactivity), with the person either in a prone position (18 people [86%]) or subjected to pressure on the neck (3 [14%]). All of those who died had suddenly lapsed into tranquillity shortly after being restrained".[1]

Axon's involvement is inescapable. They are quite open about their payments to medical experts to promote narratives of the safety of their products. They placed Robert Stratbucker on a DoJ study on safety of Tasers, until he was rumbled.[2] Their SEC filings[3] acknowledge the impact of litigation on their bottom line, and they call out their investment in paid medical spokespeople and their aggressive strategy of suing MEs who cite Tasers as a cause of death, as turning this round. "Continued aggressive litigation defense to protect our brand equity. We have an assembled team of world class medical experts at our disposal and hired additional internal legal resources during 2005 to provide an efficient means of defending us against numerous product liability claims. We have had a total of 12 cases dismissed or defense judgments in our favour. We view a continued record of successful litigation defense as a key factor for our long term growth." They sued a number of medical examiners and expert witnesses for defamation, product disparagement and tortious interference with trade, when they stated that Tasers had contributed to or caused deaths. And EXD is their go-to in deaths after Taser use.

We have a condition here which is based on an original misdiagnosis of murder, overwhelmingly rejected by the medical profession, where the UK's regulator of forensic pathology has said that is "has been applied in some cases where other important pathological mechanisms, such as positional asphyxia and trauma may have been more appropriate" and should not be used as a cause of death, which is cited as a cause of death in up to 50% of cases where someone dies in police restraint but is almost never seen elsewhere, and whose notable proponents include several people on the payroll of Axon including a couple of cases where there have been massive ethical concerns. That argues very strongly against relying on those advocates as sources. Guy (help! - typo?) 10:20, 9 May 2021 (UTC)

Guy is right, this article's stance is was absurd. --Hob Gadling (talk) 10:43, 9 May 2021 (UTC)

Corrected the tense after I looked at the newest version. --Hob Gadling (talk) 10:46, 9 May 2021 (UTC)

All interesting stuff. I'm inclined to think that Emergency doctors have enough of their own reasons to want medicate agitated patients to not necessitate too much lobbying. Though I do find the argument that taser benefits from the diagnose of excited delerium plausible - both to justify the user of tasers ("I can't shoot him it's not his fault") and to disown responsibility ("there was nothing else we could do he had a disorder").

As every WP:RS and WP:MEDRS constrain us. If the experts are wrong we only get to document the controversy and make everything as exact as possible - we can't decide for ourselves that something is an equivalent diagnose for a number of behaviours.

I would note that UK's NHS, [4] has a diagnosis for excited delerium. I have a suspicion that this diagnosis really means "that which justifies chemical restraints", rather than a distinct psychological diagnosis. There's a question about the blurry line between "policy" and diagnosis that exists is health care in general.

Psychiatric and psychological diagnosis seems like a thorny business in general. It's mostly a game of trying to find consistencies between behaviour, response to drugs, and responses to talking therapy to try and create some halfway consistent theory. (with an added dose of policy, social, and psychological constraints for what you get to classify as a psychological disorder). I sort of feel like much of the specific criticism here could be equally well applied to many other psychiatric diagnosis.

I personally think there may be issues with the use of ketamine instead of benzodiazapines and that ketamine might be more *useful* for sedation, but come with it's own risk. It's to be noted that ketamine is referred to as a psychotomimetic drug, which seems to increase psychotic symptoms in those diagnosed with schizophrenia, and it is also medium term (weeks) dopaminergic (see dopamine hypothesis) - so giving those with psychotic disorders ketamine may not be the best of ideas. If I remember correctly it contradicted as a pain killer for those psychiatric diagnoses.

Anyway, that's a lot of opining from me for now. If you can get some reliable sources together than talk about the funding of research by Axon (though preferrably contextualized with general funding information), or link to some general critique of psychiatric diagnosis, or point at the controversy from reliable sources, then that would be good.

I would note that many psychiatric diagnoses have gendered and racial effects. More men are diagnosed as psychotic, more women as anxious and borderline (i think - double check before you quote me). Talpedia (talk) 15:01, 9 May 2021 (UTC)

To the MEDRS question, a 2009 study with convincing evidence of concealed coi seems like an easy exclude, especially when there is equall compelling evidence that it’s not recognised by almost all doctors’ groups, or indeed many members of the group that does. So what I have done is exactly to document the controversy. But not inna “teach the controversy” stylee. Guy (help! - typo?) 16:45, 9 May 2021 (UTC)

I felt that this article was well put together and provided some really interesting insight into excited delirium. The only thing that I think could use some editing is the history page. Most of the history listed is from before 1990, and I think there are still some important events from the past couple decades that could provide further information.

- Maxwellallen1235 (talk) 20:43, 3 October 2022 (UTC)

Major edits

I think the last major edit has removed some material from the old article, as well as added some new material. That's okay, wikipedia is not a finished product and often moves in big changes - but I want to restore material from the older version of the article.

I think [[5]] is the version of the article before major editing so I'm going to compare to this version and restore edit as appropriate, and let's see if we can reach aggreement.

Deleted infobox

I'm not really a fan of just deleting an infobox really, so I've restored that.

WP:Synth

While police are routinely taught to look for excited delirium, especially in cases where the victim has been Tasered, excited delirium is not recognized by the vast majority of medical professionals.

looks like WP:Synth to me. I'm restoring the initial sentence about the acceptance of the criteria (which incidentally is far more compelling to me than the new version, which comes across as a bit polemical).

References

Casting aspersions about authors of papers

If aspersions have been cast about an author and they are referenced and relevant they should be included. But can we try to find newer sources too! For example there is this recent(ish) and open access systematic review: https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13330

Talpedia (talk) 19:19, 10 May 2021 (UTC)

As I mentioned in my edit summary, the problem with the infobox is that it presents "excited delirium" as though it were a real phenomenon, which appears to go against the preponderance of reliable sources. Generalrelative (talk) 19:46, 10 May 2021 (UTC)

Talpedia, the aspersions are cast by Reuters and others. This is not our problem to fix. I've explained the edits extensively above. I note, for example, that you reintroduced sources by Mash (a paid consultant to Axon) and ACEP (a 2009 paper robustly contradicted by other sources and subject to undeclared COI as documented by Reuters and others). It's a really bad idea to cite that document. Especially since Axon have openly admitted that paid medical advisers are a core part of their defence against product liability suits.

I will grant you, though, that most of these deaths do seem to be very much like the original cases identified by Wetli. Just not inthe wway he still seems to think. Guy (help! - typo?) 20:36, 10 May 2021 (UTC)

I mean... there are an awful lot of edits, and the discussion above is quite long. I sort of want split this up into different sections.

How about we find another systematic review that like the 2018 one [6]. I kind of dislike removing sources from the medical literature with no attempt to find alternatives.

On "this is duplicative - the lead had been buried and replaced by basically the old on" I would argue that it moved overly length material out of the lead and summarized it. I don't think a length discussion of lobbying and the history of the term appears in the lead.

Talpedia (talk) 21:02, 10 May 2021 (UTC)

Hmm... I think there are some subtle decisions to be made here, and I'm afraid that I don't have enough focus by myself this week to ensure that these are made. Let me see if anyone in the medicine wikiproject is keen to help! Talpedia (talk) 21:26, 10 May 2021 (UTC)

Talpedia, the lede you introduced is closer to the ACEP version than the non-ACEP version I wrote. I am happy to tighten the lead (always good) but not reintroduce any uncritical presentation of the ACEP (minority, really fringe) position, due to the numerous problems I note above. Guy (help! - typo?) 17:49, 11 May 2021 (UTC)

Sources

Emergency doctors diagnosis in the lede

I sort of feel like the fact that emergency doctors recognise this as a "diagnosis" or maybe a symptom should be in the lead. It does seem to be the case that the diagnosis is used in emergency medicine.

Is this source, [7] tainted, if not perhaps the conclusion from this paper, which would seem to be the best source under WP:MEDRS, would be a good thing to summarize into a sentence or two in the lead. I think the fact that emergency doctors are injecting people with ketamine, antipsychotics and benzodiazapines based on this diagnosis is important enough to be included in the lead.

In conclusion, this unique systematic review of the literature on excited delirium syndrome shows a global predominance of low to very low levels of evidence. Our results suggest that excited delirium syndrome is a real clinical entity, that it still kills people, and that it probably has specific mechanisms and risk factors. The numerous unresolved questions that remain warrant further investigations. A universal and objective definition must be urgently developed to allow for more structured and standardized research with a better level of evidence, such as with prospective cohorts comprising toxic, metabolomic, and genetic aspects. Randomized and controlled trials on the treatment and care of these patients are essential.

Talpedia (talk) 21:22, 10 May 2021 (UTC)

I concur. What do you propose? Innican Soufou (talk) 21:34, 10 May 2021 (UTC)

I (or someone else) needs to read the source more fully to think of a good summary! Talpedia (talk) 21:52, 10 May 2021 (UTC)

Talpedia, the APA's statement is very robust: https://webcache.googleusercontent.com/search?q=cache:JbxyyK3efNgJ:https://www.psychiatry.org/File%2520Library/About-APA/Organization-Documents-Policies/Policies/Position-Use-of-Term-Excited-Delirium.pdf+&cd=16&hl=en&ct=clnk&gl=uk&client=firefox-b-d.

The ACEP position is heavily influenced by Ho and Mash, bot paid consultants for Axon.

If you want to understand why this is such a problem, consider homeopathy. There are literally thousands of studies, conservatively at least hundreds per year, studying how hoemopathy works and the conditions it works for and the best remedies for specific conditions. These include trials, meta-analyses and case reports. The problem? Homeopathy doesn't work. It's contradicted by the laws of physics, chemistry, biology and biochemistry. It's bullshit.

Here you ave a condition which is seen almost exclusively in people being restrained by police. Red flag. It is seen disproportionately in young Black men. Red flag. It is promoted by a company whose products are frequently used in such encounters, and whose product liability defense strategy rests heavily on promoting this condition. Massive red flag. The leading proponents, including the man who made up the term, are on that company's payroll. Massive red flag. It's rejected by the APA and AMA and is not listed in ICD or the DSM. Red flag visible from space. Did you read the Reuters report? Guy (help! - typo?) 00:08, 11 May 2021 (UTC)

We don't need to follow the APAs guidance and different sections of medicine can have differences of opinion, as is the case here with the APA and emergency doctors. For example, the UK equivalent of the APA wrote a letter to the government saying that people with psychotic disorders should not be banned from driving - and yet - they are still banned from driving.

Yes parallel literature is a potential problem (as you describe with homeopathy) but I don't think it's fair to describe emergency medicine as pseudoscientific parallel literature, I would imagine it links up with the main body of medical literature and will be critiqued accordingly given enough time.

CPTSD doesn't show up in the DSM and is not in ICD-10 (though appears to be in ICD-11) but many people in the APA would think it was a real diagnosis.

Why is this paper not reasonable to quote from https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13330?

Novel psychological diagnoses can be frustrating, my personal opinion is that the construct of excited delirium is not a good one and is picking up people from all sorts of other psychological constructs that would better describe the behaviour. I'm not sure we just get to ignore a section of medicine's belief in the construct though. I get the impression that psychologists dislike a whole bunch of psychiatric constructs as well (though to be clear excited delirium seems to be a construct of emergency doctors rather than psychiatrists)

Isn't it enough to just say clearly that only emergency doctors think it's a good diagnosis and no one else agrees right at the beginning of the lede? Even if the diagnosis is garbage it's useful to know that emergency doctors will try to diagnose you with it so you can avoid doing what will cause you to be diagnosed with it...

Talpedia (talk) 00:47, 11 May 2021 (UTC)

Talpedia, but it's not just a difference of opinion between medical bodies, is it? It's a diagnosis that is promoted only by one body but not in DSM-V or ICD-10 and explicitly rejected by others, including through public statements from both US and UK saying that the diagnosis should not be used, especially as a cause of death. Both note the tendency for the diagnosis to be disproportionately used in cases of Black men and almost exclusively in police custody.

You call it "novel", but the ACEP position is over a decade old, and the UK forensic science regulator statement is from 2020, so is the APA position paper and the Brookings paper, and the Reuters report is 2021. It's slid under the radar, and the recent killings of Black men have brought the issue tot he fore, to the point that authoritative bodies are standing up and saying this is not a thing.

It would be a gross violation of NPOV to start by saying it's accepted only by one group of doctors and rejected by others, and then go on to describe it with their in-universe framing, when there's so much external reporting of conflicts of interest around ACEP's promotion of the disorder.

The dominant mainstream opinion is that it's not a thing. External reporting indicates really serious concerns of racist undertones and deliberate protection of police, by the group of doctors closest to police, including one prominent advocate who is a member of ACEP, a police officer, an author of the original ACEP position paper, and a paid consultant to Axon. The closest analogy I can think of is chronic Lyme disease, which is assiduously promoted by a very small group of doctors, to the point of lobbying for laws to protect them from discipline for using inappropriate treatments for a "disease" with no objective evidence outside of tests they themselves conduct, no clear diagnostic criteria, and no plausible aetiology. Guy (help! - typo?) 08:01, 11 May 2021 (UTC)

I need to read more literature. My feeling is that it is a diagnosis people use in ERs when they want to use chemical restraints because the patient is very agitated and not responding to argument or "behavioural management" - also when they are afraid of the patient. But if the same patient is moved to a psych ward they'll probably start picking up labels like "drug-induced psychosis", "drug-triggered bipolar disorder", "first episode psychosis", "schizoaffective dosorder" or "schizophrenia". The treatment will largely be the same - antipsychotics and benzodiazapines (though not ketamine) and they will probably be more effective at cajoling people to take the drugs and with smaller doses - I guess being able to lock people in a small rooms and prevent them from leaving until they do what you want will do that.

I don't think it will be a small group of doctors exactly. It will be everyone in the trauma wards and accident and emergency medicine (plus the police because they kind of have to deal with same situations).

See for example this advice in the UK : https://www.rcem.ac.uk/docs/College%20Guidelines/5p.%20RCEM%20guidelines%20for%20management%20of%20Acute%20Behavioural%20Disturbance%20(May%202016).pdf

Talpedia (talk) 08:23, 11 May 2021 (UTC)

Talpedia, in most cases the "diagnosis" appears to be initiated by police, socialised by them, and planted with the EMTs. But I encourage you again: look at the parallel with chronic Lyme disease - or electromagnetic hypersensitivity for that matter. We have explicit statements from the APA, who are the relevant professional body, challenging it. As the other sources make clear, it's a catch-all term used for patients with a broad and heterogeneous range of underlying conditions (or in some cases none at all), and the only repeatable common factor, the only thing that more than a quarter of patients have in common, in studies, appears to be the use of forced restraint, generally not following any involvement even of EMTs, and certainly not doctors.

Or maybe you prefer autistic enterocolitis? Widely publicised, discussed and studied in its day, until it was shown to be a fraud perprtrated by a doctor on the payroll of plaintiffs' attorneys.

Note also that while CPTSD appears for the first time in ICD-11, PTSD is in ICD-10, and "excited delirium" is in neither - because, as the sources make clear, it's not a medical diagnosis, it's a description of perceived behaviour - basically "acting up while Black".

In that context, the view of the subset of ACEP members who support this looks very much like a fringe view. Guy (help! - typo?) 10:38, 11 May 2021 (UTC)

Let me see if I can dig up some more sources from emergency and trauma doctors from an international perspective - perhaps I'll try to dig up some textbooks. This will make clearer whether this is just something that ACEP wrote, or if it is regularly used as a diagnosis in day-to-day emergency medicine. Talpedia (talk) 11:47, 11 May 2021 (UTC)

Okay, I've started looking at some textbook to see how much excited delirium shows up in mainstream emergency medicine. From two emergency medicine textbooks it is not mentioned (though there are citations to journal pieces entitlted with the term). If editors have access to the same sources as I do, they could look at some of the following.

*Peter Cameron, Mark Little, Biswadev Mitra Conor Deasy - Textbook of Adult Emergency Medicine* has a section on "Pharmacological management of the aroused patient" and mentions "chemical restraint" and talks about treatment with ketamine, antipsychotics and benzodiazapines (those discussed in the context of excited delirium). This makes me think we might like to ascertain the overlap between excited delirium and "aroused patients" and maybe link to the chemical restraint page.

This source looks interesting from UKs college of emergency medicine. From this

The terms ABD and ‘excited delirium’, or ‘excited delirium syndrome’ (ExDS), are sometimes used interchangeably but only about a third of cases of ABD present as ExDS.

Let me create a new section for this so that we can discuss how to approach the question of medicines and societies responses to agitation in patients - be it here or in a new article. Since the question here is quite specific and I think the solution we might want could be adding information to another article. Talpedia (talk) 07:14, 12 May 2021 (UTC) Talpedia (talk) 07:02, 12 May 2021 (UTC)

"First identified"

The condition was first identified by pathologist Charles Wetli to account for the deaths of nineteen Black prostitutes due to "sexual excitement" while under the influence of cocaine. The women were later found to have been strangled by serial killer Charles Henry Williams.

I don't like this phrasing. I would prefer "the term was first used". This feels a bit WP:NPOVishy because you it assumes that the condition identified then is the same as what is identified now. Going ORy extreme mania in bipolar disorder could look quite like the construct of excited delirium and this has been around forever. I'm fine with this information being included but it seems to imply that the current diagnosis is the same as the historic one.

Talpedia (talk) 21:52, 10 May 2021 (UTC)

Talpedia, or coined. Guy (help! - typo?) 00:00, 11 May 2021 (UTC)

I think "first used" is appropriate and meets npov standards. Innican Soufou (talk) 00:04, 11 May 2021 (UTC)

Innican Soufou, or coined. Which is accurate. The important part, of course, is where he invented the diagnosis based on 19 Black women who had asphyxiated with low levels of cocaine in their systems, based on the idea that women on crack who had sex could die of "excited delirium" - but it turns out they were strangled by a serial killer.

Very much on point, when you hear that the police tried to write George Floyd's murder off to "excited delirium". Guy (help! - typo?) 00:12, 11 May 2021 (UTC)

WP:ASPERSIONS / WP:SEALIONing
The following discussion has been closed. Please do not modify it.
It wouldn't be a day that ends in "y" if someone didn't need to remind you of WP:NOFORUM Innican Soufou (talk) 00:34, 11 May 2021 (UTC) @Innican Soufou: Then I suppose you need to be reminded to Comment on content, not on the contributor. Guy's points pertain directly the the content discussion at hand and are in no way a violation of WP:FORUM. Generalrelative (talk) 00:57, 11 May 2021 (UTC) Sorry, I must have missed the relevance of this "george floyd" guy in the topic. Innican Soufou (talk) 03:50, 11 May 2021 (UTC) Yes you certainly did. Generalrelative (talk) 04:34, 11 May 2021 (UTC) Do you mind showing me? Since you're so well-informed. Innican Soufou (talk) 04:38, 11 May 2021 (UTC) Um, sure, here you go: [8] Generalrelative (talk) 04:54, 11 May 2021 (UTC) Oh, ok. So the answer is I'm right and you're just acting childish. Got it. Innican Soufou (talk) 05:07, 11 May 2021 (UTC) Were we supposed to be acting like adults here? Because you started by saying I must have missed the relevance of this "george floyd" guy in the topic in response to Guy's comment Very much on point, when you hear that the police tried to write George Floyd's murder off to "excited delirium". If there is a good-faith reason for that kind of WP:SEALIONing I cannot fathom what it might be. But perhaps you wouldn't mind showing me. Since you're so well-informed. Striking rhetorical comment. Generalrelative (talk) 06:18, 11 May 2021 (UTC) Generalrelative (talk) 05:22, 11 May 2021 (UTC)

Well, I'm not convinced that he did invent the diagnosis based on only this case. He might have also been considering other cases of stimulant induced psychosis that he had come across and applying these experiences to the case at hand. Also I wouldn't be surprised if the concept had been floating around in the medical community before he used the term. But I need to read the sources. Talpedia (talk) 00:30, 11 May 2021 (UTC)

Talpedia, you may be right. It's what the sources say, but they could be wrong. It would be interesting to find the original paper. In the mean time, perhaps it should be attributed. Guy (help! - typo?) 07:38, 11 May 2021 (UTC)

Where to talk about what the medical best practice does to agitated patients

So... it does seem to be the case that excited delirium may show up more in coroners reports and in the testimony of lay witnesses than in medical discussions, *but* there are also situations under which medical doctors will sedate patients against their will due to what they identify as agitation. The suggested treatments in this case seem similar to those for excited delirium. Antipsychotics, benzodiazapines and ketamine. The term "acute behavioural disturbance" links to this article.

Taking quotes from the section "The challenginge patient" of

...

A behavioural emergency can be defined as an unarmed threat by a patient or others character-ized by agitation, aggression, violence and irra-tional or altered behaviour.

...

The aetiology of acute behavioural disturbance in the ED is largely mental illness or substance intoxication and often a combination of the two.17A smaller number have an organic illness, includ-ing dementia, manifesting as a behavioural emer-gency.19 Most patients are male (approximately 65%) and under the age of 40,17,20 and around 20% are brought to the ED in police custody.17,21The majority of unarmed threats occur in the late afternoon, evening and overnight, with a weekly peak on Saturdays.17 Between 58% and 80% of these require some form of chemical or physical restraint as part of management

...

The pharmacological management of the acutely aroused patient is discussed in detail elsewhere (see Chapter 20.6), but the principles should be emphasized. The least traumatic measures are advocated, depending on the desired end point of chemical restraint and the risks to staff and patient in administration.Oral benzodiazepines are preferred where possible and may allow patients a small sense of control if they are able to choose this option ahead of parenteral sedation. Choice between intramuscular or intravenous administration of sedation depends on perceived risks to staff, ease of obtaining intravenous access, need for blood tests or other intravenous therapy and desired rapidity of sedative effect. A standardized intramuscular sedation protocol can be effec-tive and safe.29 Where rapid tranquillization is desired, the intravenous route of administration is required, as the onset of action is within the first 5 minutes rather than the approximate 15 to 20 minutes of intramuscular drugs.30 Commonly used drugs for rapid tranquillization include benzodiazepines (diazepam and midazolam), neuroleptics (droperidol and haloperidol) and antipsychotics (olanzapine). Increasingly, ket-amine is used in patients who are difficult to sedate and in transport situations.31 A combina-tion of intravenous midazolam with droperidol or olanzapine has been shown to be more effective than midazolam alone or than high-dose droperi-dol or olanzapine alone with respect to time to adequate sedation and need for re-sedation.32,33Intravenous midazolam alone may cause more adverse events relating to airway obstruction and over-sedation and is more likely to require re-sedation within an hour. High-dose parenteral midazolam is not supported due to concerns about effect and safety.34 Careful monitoring in a high-acuity area of the ED is required when parenteral chemical restraint is used

Where should this information exist, and I found this source^[9] that says:

The terms ABD and ‘excited delirium’, or ‘excited delirium syndrome’ (ExDS), are sometimes used interchangeably but only about a third of cases of ABD present as ExDS

I feel like we need to discuss this somewhere and the similarities to excited delirium should be acknowledged. It feels a bit like we are denying the existence of a clinical diagnosis and the involuntary treatment associated with it because a related concept is being used forensically in questionable ways.

Talpedia (talk) 07:23, 12 May 2021 (UTC)

Hmm... think I might create an article called "acute behavioral disturbance" mention it in the lede and discuss treatment. Something like "The term Excited Delirium is sometimes use interchangeably with Acute behavioural disturbance, a diagnosis used in medicine with many underlying causes that often involves the use Chemical restraint with anti-psyuchotics, benzodiazapines and ketamine." Dunno if this would count as a content fork but this distinguished excited delirium as a possible cause of ABD Talpedia (talk) 17:46, 12 May 2021 (UTC)

Talpedia, I have no strong opinion on that, other than that we need to avoid the tendency of certain parties in the medical field to portray violent police actions towards mentally ill people as some kind of defensible response to fear of their behaviour. Guy (help! - typo?) 17:55, 12 May 2021 (UTC)

References

Acute behavioural disturbance

I've started to put together a draft for acute behavioural disturbance: Draft:Acute Behavioral Disturbance to deal with the "official" medical response for aroused behaviour potentially resulting in Chemical restraint or physical restraint. It's not quite there yet, but when it's ready I'm planning to stop disambiguating acute behavioural disturbance and link to this page in the lede. Talpedia (talk) 01:47, 18 May 2021 (UTC)

They kill the person twice:

Related:

• They kill the person twice: police spread falsehoods after using deadly force, analysis finds --The Guardian

"A review of police killings in California showed that law enforcement spokespeople frequently publish highly misleading or sometimes false information about the people they have killed. Over the last five years, the Guardian found at least a dozen examples in the state of initial police statements misrepresenting events, with major omissions about the officers’ actions, inaccurate narratives about the victims’ behaviors, or blatant falsehoods about decisive factors.

In some cases, police cited vague “medical emergencies” without disclosing that officers had caused the emergencies through their use of force. In others, departments falsely claimed that the civilians had been armed or had overdosed. In most instances, media outlets repeated the police version of events with little skepticism."

--Guy Macon (talk) 16:16, 22 May 2021 (UTC)

I don't think that's something to be extensively addressed on the page, although it would be worth briefly noting. I would hope that this is detailed on a page that is about more general police misconduct and a link to there would be good. MasterTriangle12 (talk) 01:45, 8 August 2021 (UTC)

I notice that this report is about the "initial" police statements. Breaking news is often filled with misrepresentations, omissions, inaccuracies, etc., because people don't always have full information at hand. I think the way to approach this problem for this article is to not use WP:PRIMARYNEWS. WhatamIdoing (talk) 07:04, 22 June 2023 (UTC)

Short description

The short description was "state of extreme agitation". Although excited delirium is often used interchangeable with Acute behavioural disturbance which is state of agitation, excited delirium is considered to be a well-defined diagnosis in other literuate (particularly when talking about death).

I'm changing this to "Condition accompanied by...". Talpedia (talk) 17:41, 10 July 2021 (UTC)

Biased article

This article was written with a clear bias against law enforcement and is based almost entirely on opinion and false information and not fact. 2600:387:5:814:0:0:0:14 (talk) 09:44, 17 December 2021 (UTC)

As far as I can tell from a glance, everything is sourced. Can you point out a single sentence that you have a problem with?--Megaman en m (talk) 10:20, 17 December 2021 (UTC)

So... I think there might be some subtly misleading things going on with terminology. Chemical restraint is accepted within psychiatry, they will just often use psychotic diagnoses rather than excited delirium to treat people, and the treatment is very much similar to that described for excited delirium (I'm not really sure about ketamine use though). You can have criticisms of excited delirium, which sort of should be considered together with criticisms of any form of chemical restraint, but aren't merely because of terminology. One point I do think is unique to the phrase excited delirium is the forensic diagnosis of death by excited delirium, or death due to self-defense arising because of excited delirium, so the use of the term excited delirium can implicitly legitimise the diagnosis in cases of death (because the term is used more generally for "that thing that happened before chemical restraint") or conversely smear the practice of chemical restraint with the use of the diagnosis in what might be police killings. This sort of "content fork within the literature itself" can be quite difficult to deal with, because you often lack the sources to equate "the same" concept in different settings.

It's also worth noting that things that more or less amount to chemical restraint can occur after anaesthesia due to agitation: https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2044.2006.04791.x I get the impression that who is involved in chemical restraint can affect how people view the practice. Talpedia (talk) 14:53, 19 December 2021 (UTC)

Section blanking

User:82.112.138.191, would you please discuss your reasons for repeatedly blanking the "Position of the American College of Emergency Physicians" section of this article? Thanks, Generalrelative (talk) 05:28, 28 December 2021 (UTC)

I would guess the concern is the ACEPs statements inconveniently legitimise the use of a diagnosis that can be used to drug agitated people, and incorrectly justify the death of people in custody. So it would be convenient to obliterate this position from the literature (the advent of ketamine with its psychomimetic and long term dopaminergic properties is particularly unfortunate)

I'm pretty dubious myself and think the diagnosis is probably subsumed by various psychiatric diagnoses.

Unfortunately, the obliteration of the diagnosis requires a whole bunch of research and I'm not quite sure anyone is going to do it. Psychiatrists don't necessarily care because it's outside of their literature and emergency doctors probably find it convenient to be able to shove needles filled with ketamine into disruptive patients. Perhaps an emergency medicine doctor who has had a relative harmed by mental health services will make inside the citadel of "professional moats" that surround any medical profession's literature and rip up this stuff.

More plausible is that psychiatry gets into the accident and emergency ward a little more and the diagnosis fades from memory.

Regardless, all wikipedia can do is follow the literature and waits (and hope that a complete, noticed and and accurate understanding of the literature will drive research). Talpedia (talk) 12:13, 28 December 2021 (UTC)

If you look closely you will see that they blanked both legitimizing and critical remarks. Also: I've indented your comment for you per WP:TALK. Please indent your own comments in the future. If you need help with this, see Help:Talk_pages#Indentation. Thanks, Generalrelative (talk) 15:36, 28 December 2021 (UTC)

It wasn't me who blanked the section just commenting on the likely motivations and issues (and why this is likely to come up a few times - and indeed has). The indentation was due a limitation in the mobile app that has "reply" button but then does not indent, you could bring it up with mediawiki maybe. I don't really care what you tell me to do... and will probably ignore you whenever you do so. However, I shall bear this limitation of the app in mind going fowrard. Talpedia (talk) 15:46, 28 December 2021 (UTC)

Disputed edit

I encourage Burner50 to discuss this edit and attempt to gain consensus rather than edit warring. The edit in question appears to violate our policy against original synthesis by using an article which does not mention excited delirium to imply something about excited delirium. Indeed, the article in question studies rats, not humans, and makes only tenuous suggestions about avenues for further research in humans, rather than sweeping claims anything approaching what Burner50 has been seeking to add. Generalrelative (talk) 19:00, 6 January 2023 (UTC)

Wikipedia's own page on ketamine directly contradicts the information presented as well as the scientific community as a whole. The original information was based solely on bias and the source presented was non-authoritative and did not even refer to ketamine's effect on respiratory drive. I would encourage the people reverting my edits to examine the information presented instead of reverting to the vandalized article. Burner50 (talk) 19:06, 6 January 2023 (UTC)

Wikipedia is not a reliable source. The study you cited is, but not for this article, and wherever it's used it should be done with care per WP:PRIMARY. The APA is a near-top quality source, and it's specifically about this topic. Firefangledfeathers (talk / contribs) 19:09, 6 January 2023 (UTC)

I further submit this as a source for discussion: https://emergency.med.ufl.edu/files/2013/02/KetamineReview-JonesVanDillen.pdf

Among the conclusions reached, this study states "It is among the most hemodynamically stable anesthetics and does not cause respiratory depression".

To claim otherwise is to dispute science and the medical community as a whole and rely on opinions not founded in reality and based on bias. Burner50 (talk) 19:10, 6 January 2023 (UTC)

The scientific community as a whole thinks that ketamine is safe when the dosage is correct and there are no other substances in patient's system. When you're giving it to a random person on the street and you don't know what they've been doing and what drugs may already be in their system, respiratory arrest is definitely a possibility. MrOllie (talk) 19:11, 6 January 2023 (UTC)

Note that I've substituted in a much more reliable source for the claim: [10]: Excited delirium, a diagnosis not found in the DSM and lacking clear criteria, has been used to explain fatalities of people in police custody, especially deaths of young Black men, and to exculpate police officers from responsibility. The label has also been invoked to justify the forceful restraint and sedation of people who may fail to obey the orders of law enforcement; ketamine, a dissociative anesthetic with potent sedative properties and a high rate of causing respiratory distress, is often used in these situations. This combination of a dubious diagnosis and a medication with serious side effects has set the stage for tragic outcomes. Generalrelative (talk) 19:19, 6 January 2023 (UTC)

An abstract of an article cannot in and of itself be an authoritative source on a topic. The methodology and data cannot be accessed as it is behind a paywall. Burner50 (talk) 19:21, 6 January 2023 (UTC)

See WP:PAYWALL - Wikipedia allows the use of paywalled sources. MrOllie (talk) 19:24, 6 January 2023 (UTC)

It's true that paywalled sources are acceptable, though citing an abstract is not ideal either. I've been trying to access the article but apparently my university does not subscribe to Psychiatric Services. Still, the fact that the claim linking ketamine to respiratory distress appears unqualified in the abstract, and the paper is by a leading expert, should lay to rest any notion that it is a controversial claim. Generalrelative (talk) 19:30, 6 January 2023 (UTC)

I would assume that by posting to that as a source, you have thoroughly reviewed and evaluated the material in its entirety? Psychiatrists are not medical doctors or pharmacological experts. The author of this article has offered nothing more than an opinion on a subject (pharmacology not psychiatry) that he is presumably not an expert in.

In contrast, this source: (https://emergency.med.ufl.edu/files/2013/02/KetamineReview-JonesVanDillen.pdf) is a medical doctor. Burner50 (talk) 19:31, 6 January 2023 (UTC)

Apologies, I reviewed the source again, and see that the author is indeed a medical doctor working in the field of psychiatry. Burner50 (talk) 19:33, 6 January 2023 (UTC)

Thanks for posting the correction after reviewing. You may be surprised then to learn that all psychiatrists are medical doctors. And indeed, as I observed below, Paul S. Appelbaum is preeminently qualified. Generalrelative (talk) 19:39, 6 January 2023 (UTC)

Yet, his single author article which, from what I can tell, has not been evaluated or peer reviewed contradicts all other sources. Please remember that Andrew Wakefield was at one time preeminently qualified as well. Without being able to access the article and evaluate the data used as well as the author's sources and most specifically a conflict of interest statement, I urge caution when accepting opinions from preeminently qualified persons who have made a career out of a controversial topic Burner50 (talk) 19:50, 6 January 2023 (UTC)

Specifically a career as an "expert witness". Burner50 (talk) 19:52, 6 January 2023 (UTC)

Huh? Psychiatric Services is a peer-reviewed journal. What makes you think that article isn't? MrOllie (talk) 19:57, 6 January 2023 (UTC)

Given that the author claims that ketamine has a "high rate of causing respiratory distress", when the claim is patently false led me to believe that the article would not have been published with such glaring falsehoods had it been peer reviewed. Burner50 (talk) 20:14, 6 January 2023 (UTC)

however the source added only states that it can cause respiratory distress, and goes on to suppose causality of respiratory depression (2 different pathologies) based only on intubation rates, which this analysis states is lower than cited, and could be caused by many different things. There is no doubt that ketamine contributes to and can cause respiratory effects, however there is no conclusive evidence in the earlier cited paper or any other reputable source that it causes arrest 155.98.164.36 (talk) 22:33, 18 August 2023 (UTC)

@MrOllie that means the respiratory distress would be from an interaction of the other drugs, not ketamine. Ketamine does not cause respiratory arrest. That is the whole reason it's used for emotional crises. FeverGlitch (talk) 03:56, 26 May 2023 (UTC)

I think the main reason that it's being used as Chemical restraint is because it acts fast (I seem to remember some papers saying as much) in contrast to antipsychotics like haliperidol. Though perhaps that's a factor, I'm also suspicious that it might be something that Emergency departments have and are more familiar with because it's used for pain... but I should do some reading here. I suspect the fact that it's a psychomimetic, which is dopaminergic for weeks following administration might also be a reason for it not to be a good choice for chemical restraint. Anyway regarding respiration, the source I added at the end of the paper seemed to be pretty good on this topic and could be cited, it argues that ketamine is consistently administered together with a benzodiazapine and the these suppress respiration. Talpedia 10:28, 27 May 2023 (UTC)

Please cite your source. Ketamine is an NMDA receptor antagonist (https://www.ncbi.nlm.nih.gov/books/NBK470357/) which does not exacerbate or amplify the respiratory depression experienced with opioid overdoses which are the common and normal cause of respiratory depression among street drug users. In fact, a study on the topic (https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1046/j.1365-2044.1998.00519.x) revealed that there was no evidence of increased respiratory depression when mixed with an opioid. Burner50 (talk) 19:19, 6 January 2023 (UTC)

Please see my comment just above. My source is by Paul S. Appelbaum, who holds a named chair in psychiatry at Columbia and a former president of the American Psychiatric Association. Generalrelative (talk) 19:23, 6 January 2023 (UTC)

Apologies, we were editing at the same time. Please see my previous response to that source that directly contradicts the rest of the medical and scientific community. Burner50 (talk) 19:24, 6 January 2023 (UTC)

See for example Overdoses and deaths related to the use of ketamine and its analogues: a systematic review. Or, really, just type 'Ketamine' and 'Polydrug' or 'Poly-substance' into your favorite journal search engine. MrOllie (talk) 19:31, 6 January 2023 (UTC)

I have reviewed the abstract of the article which leads to the conclusion that Ketamine is dangerous in a recreational setting, but in a medical setting it is considered safe.

In addition, the LD50 of 11.3mg/kg (https://www.ncbi.nlm.nih.gov/books/NBK541087/) by IV is a far higher dose than is acceptable to administer in a medical setting (such as an ambulance or from a paramedic) and that's completely discounting that patients in "excited delirium" don't commonly receive the medication by IV, but rather IM with reduced bioavailability due to route.

This means that an average 100kg person would need 1,130mg by IV, and between 1,130mg and 1,412.5mg by intramuscular injection for the dose to be fatal approximately 50% of the time. Burner50 (talk) 19:43, 6 January 2023 (UTC)

Comparing Ketamine used during surgery in a hospital on a person with a known medical history (a typical medical setting) to Ketamine used as a chemical restraint on an agitated person with an unknown history is comparing apples and oranges. And we cannot do our own original research (WP:OR) or use rat studies (WP:MEDRS) to undercut the sources we have that do meet our guidelines. MrOllie (talk) 19:48, 6 January 2023 (UTC)

That's assuming that the animal study undercut the existing source that did not reference ketamine's effect on respiratory drive at all. I believe that the rat studies are far more authoritative as they specifically studied ketamine administration instead of a news article that does not reflect on the effects of Ketamine on respiratory drive at all. Burner50 (talk) 19:55, 6 January 2023 (UTC)

You can believe that if you like, but that is the opposite of what Wikipedia's guidelines for medical sourcing require us to do. MrOllie (talk) 19:58, 6 January 2023 (UTC)

What I'm saying is that the existing source does not meet the Wikipedia guidelines as a source as the claim is not ever made in the original source. Furthermore, the source is a transcript of an interview with the family member of a victim, not an expert in the field. The rat study is acceptable per https://en.wikipedia.org/wiki/Wikipedia:MEDRS as long as it is supported with secondary studies which I have further identified in this talk. Burner50 (talk) 20:02, 6 January 2023 (UTC)

Are you aware that I've substituted out the source you appear to be complaining about and replaced it with the Applebaum paper? That source is no longer "existing". Generalrelative (talk) 20:05, 6 January 2023 (UTC)

I recently checked and found that the CBS news article is still cited, even after clearing the cache, and there is still questions about your Applebaum paper. Burner50 (talk) 20:08, 6 January 2023 (UTC)

Go ahead and remove the CBS article wherever you find it then. You may have questions about the Applebaum paper but they've been addressed by two of us. Perhaps others will come along who agree with you, but frankly you've shown that there are real limitations to your understanding of how peer review and the discipline of psychiatry work. Generalrelative (talk) 20:12, 6 January 2023 (UTC)

I'll be happy to admit that my experience in the discipline of psychiatry is extremely limited. However, I am capable of rational thought and evaluation of sources and I find that source is in direct contradiction with established and proven science that clearly demonstrates that respiratory depression is not an effect experienced with ketamine administration. Burner50 (talk) 20:16, 6 January 2023 (UTC)

I have identified several authoritative sources that directly refute the statement in question. I would like to put this situation to bed. I propose the following edit and sources:

"In rare circumstances, Ketamine can cause respiratory depression [11]https://emergency.med.ufl.edu/files/2013/02/KetamineReview-JonesVanDillen.pdf and in some cases there is no medical condition that would justify it's use."

Claiming "most cases" implies that a preponderance of incidents where ketamine has been used in behavioral emergencies has been reviewed and in >50% there was no medical condition that would justify its use, which is an uncited statement. Burner50 (talk) 20:07, 6 January 2023 (UTC)

I have to run, but I appreciate your good-faith effort to argue your case. Suffice it to say, I'm not convinced that updating to a better source hasn't solved the problem. For background on this issue, Burner50, I'll suggest that you read this article from Physicians for Human Rights. But for now, signing off. Generalrelative (talk) 20:16, 6 January 2023 (UTC)

Have a great evening! Burner50 (talk) 20:17, 6 January 2023 (UTC)

Where and when was that Jones / Van Dillen paper published? MrOllie (talk) 20:17, 6 January 2023 (UTC)

Coming back here for a final comment because I now see that I'd missed the significance of FFF's comment above. The APA statement is indeed a near-top quality source per WP:MEDRS and it speaks to this issue directly: Many sedating medications, used in outside of hospital contexts, including ketamine, have significant risks, including respiratory suppression. Supporting respiration may be challenging outside of a hospital setting, where it may require intensive medical oversight or involvement. Seems to me that the issue is settled. Generalrelative (talk) 20:42, 7 January 2023 (UTC)

Late to the party. But just my standard moaning about about the desire for "authoratitive" sources from one field to push out opinions from the other fields, when I would prefer to have disagreements between fields rub uncomfortably against one another for all to see. Position statements by professional organizations are in my opinion pretty dodgy sources because they can be politically motivated, so I would prefer systematic reviews for statements about medical facts, and reserve such position statements to discuss what professional bodies care about. Also... psychiatrists aren't the one's administering the ketamine in this cae I don't think.

I don't think it's good idea to have psychiatry "own" the effects of ketamine. I suspect anaesthesiolgists have a lot to say about the effects of ketamine on respiration and it seems a bit silly to stop their opinions coming into the article, provided we can make it clear that the apply to general administration of ketamine. (See also WP:NOTJUSTANYSYNTH). That said... I would really prefer reviews to a single source. And it'd be better if we could establish more of a link between the two literatures to establish that the material is WP:DUE. My take on excited delirium is that it's a "psychiatric diagnosis" (in the sense that it diagnosis behaviour) constructed outside of psychiatry for use in forensic and emergency medicine, so we shouldn't be surprisied if fields start disagreeing with one another. Talpedia (talk) 21:59, 7 January 2023 (UTC)

However, the prevailing opinion on this article seems to be that based on the opinions of a few psychiatrists, science is incorrect, and that outside of a hospital ketamine does the opposite of what it does inside a hospital despite the complete lack of evidence other than opinions. Burner50 (talk) 05:10, 8 January 2023 (UTC)

Okay, this 2018 review (https://doi.org/10.1002/phar.2060) might be useful. It comes out of emergency medicine rather than psychiatry - I still might like some anaesthetists in the mix. It seems to be angling for the argument that respiratory problems of ketamine are due to ketamine consistently being administered together with a benzodiazapine like midazolam to deal with psychotomimetic effects of ketamine which suppress respiration (giving potentially psychotic people a psychotomimetic might also be a problem, along with its tendency to cause mania for weeks at a time - but let's leave this to the sources).

Another interesting point is that the argument for ketamine use is mostly that it acts quickly. Talpedia (talk) 20:11, 8 January 2023 (UTC)

What to do

This article seems to spend a lot of time talking about what not to do, but I didn't see any positive recommendations. Imagine the classic EXD story: a man is behaving very strangely, walking unsafely through a public area (e.g., into the path of oncoming vehicles), making incoherent noises, and breaking windows.

This page sort of implies: Don't sedate him, don't restrain him, don't give him ketamine, don't taser him, don't don't don't don't don't.

What I'm missing is: What should be done? Evacuate the area around him and wait until he collapses, at which point someone can sweep up the glass? What's the best path towards having this person alive at the end of this event? WhatamIdoing (talk) 07:46, 22 June 2023 (UTC)

I think part of the issue is that Excited delirium is a diagnosis used by forensic scientists, and emergency doctors and an amateur diagnosis by police officers and the press. In psychiatry you have Acute behavioural disturbance as well as specific diagnoses like mania and psychosis. Do Chemical restraint or Acute behavioural disturbance speak to your topic? I get the impression it's more of a "they just died / we had to do it" diagnosis applied post hoc - combined with a "let us use ketamine" diagnosis. One thing to bear in mind is that psychiatry can already have people detained and may have more training for interpersonal deescalation so the desire to use something quick-acting like ketamine might be reduced. My personal opinion... which I don't think is very well covered in the discussion - is that ketamine is a psychotomimetic with medium term dopamine increasing effects - so if you've got people with psychotic symptoms it might be a bad idea to give them ketamine.

Going from my memory of sources and filing the gaps. I think the correct response would be something like "engage in behavioural interventions - listen and try to be boring etc - there are likely nuances surrounding manic and psychotic thought processes versus normal thought processes versus those in an emotion state plus things like distraction; try to get people to voluntarily take benzodiazapines; eventually detain people; eventually hold them down and get inject them with haloperidol; pay careful attention to perverse effects of drugs and misdiagnosis thereafter (e.g. cognitive impairment, akathisia and stress of detention versus mania and psychosis)"

I'm a little suspicious of the "wait until they collapse" part. Having a diagnosis were "just dying" is one of the symptoms is somewhat... convenient. I quite agree that mania (or whatever diagnosis you want to use for the behaviour) might increase the risk of heart disorders, but I think having a heart disorders as a feature of a behaviour-based diagnosis is suspicious.

There is a horrible (if unlikely) pipelines that goes)agitation caused by valid reasons that would self resolve -> drugged with ketamine -> induced psychotic symptoms + medium term manic symptoms -> antipsychotics -> akathisia as a side effect mistaken for mania combined with perverse effects of second generation antipsychotics causing symptoms resembling psychosis -> psychosis diagnosis -> life long antipsychotic use initially enforced with a community treatment order for a number of years and thereafter through compliance -> horrible side effects plus potentially (though controversially) inducing a permanent psychotic condition due to dopamine sensitivity in response to antipsychotic use.

The "knowledge gaps" that it might be good for us to address are good behavioural interventions for emergency doctors and police officers as well maybe more of a knowledge of the standard diagnoses. Talpedia 08:59, 22 June 2023 (UTC)

How do you "listen to" someone who is only capable of making incoherent noises?

The pipeline that is described here could be simplified down to:

• restrain him, with the goal of taking him to the hospital → dies of positional asphyxia

The pipeline I'm thinking about is:

• do nothing → untreated drug-induced hyperthermia kills him
• do nothing → untreated drug-induced hallucinations kill him (e.g., he runs into traffic to 'escape' from a frightening hallucination)

The pipeline I'd like to hear more about is:

• ______ → he survives!

What belongs in that blank? WhatamIdoing (talk) 19:41, 22 June 2023 (UTC)

Well you attempt to listen to them first before bundling them to the floor and injecting haliperidol into their leg (or ketamine) in case you don't need to. People have a habit of forgetting the don't need to use force.

I guess the short answer might be "mental health nurses arrive and administer haliperidol following physical restraint by a large enough number of people trained in physical restraint"

I've summarised some of this and linked to sources in Acute behavioural disturbance. I wrote to the UK paramedic organization (cant remember their name) requesting their guidelines on the use of ketamine... they said they could not provide them. I considered buying a copy of their guidelines but did not.

You then have questions about what happens if you can't do this or have insufficient mental health resources

• Benzos vs antipsychotic vs ketamine
• How many people to the physical restraint to administer tge chemical restraint
• Under what circumstances do police engage in physical restraint or chemical restraint (e.g. in the UK the police await paramedics for chemical restraint). Medical advice encourages minimizing physical restraint in preference to chemical restraint... but you might want to avoid giving police access to drugs.
• Where someone is detained (e.g. in a hospital vs a prison)
• Do you think "excited deliriumx while doing this or "agitated". I'd say you abandon the use of excited delirium for all purposes besides social science in preference for other diagnoses.

Talpedia 21:05, 22 June 2023 (UTC)

So... the answer is that people with acute behavioral disturbances are going to die? Because I started with:

• restrain him, with the goal of taking him to the hospital → dies of positional asphyxia

and you have changed it to:

• see if he is saying anything intelligible, then restrain him, with the goal of taking him to the hospital → dies of positional asphyxia

This does not seem to be much of a difference in the end. WhatamIdoing (talk) 09:27, 23 June 2023 (UTC)

I guess some of them maybe :/... perhaps this is true for all medical interventions - all you get to do is reduce the risk. From Acute behavioural disturbance

National Institute for Health and Care Excellence suggest supine rather than prone restraint and that physical restraint should ideally not last longer than 10 minutes.

so maybe that could prevent some deaths. I guess you have to weigh up the risk respiratory risks of police restraint, benzodiazapines, antipsychotics and ketamine. I sometimes wonder if asphyxia due to police restraint is due to unnecessary restraint whe you could use handcuffs. In a hospital physical restraints can be used... which likely reduce the risk of asphyxia... so perhaps you could have physical restraint vans if you handcuffs aren't doing the job. You have to weight this up against the risk of abuse - is it better having 1 in 1000 physical restraints end up in asphyxia or risk having people who don't need physical restraint held in physical restraint for hours in police vans - civil liberties have never come without a corresponding risk to life. If you want to start giving people more powers and capabilities to use physical force and coercion you start having to set up a system of checks and balance, ensuring that is funded and the people advocated for, making sure that the values of the organization are in line with their job (mixing mental health and crime prevention can be a stretch) and ensuring that your legal of advocacy system does not get captured and used as a means of coercion by medicine, the police or society as a whole.Talpedia 11:18, 23 June 2023 (UTC)

Did NICE give a reason for recommending supine instead of the Recovery position? Or just sitting up?

Does their recommendation for a 10-minute limit on restraints just accidentally happen to be paired with a preference for haloperidol, which takes 20–30 minutes to have a clinically significant effect, thus making their recommendations self-contradictory? WhatamIdoing (talk) 20:01, 23 June 2023 (UTC)

They don't provide reasons, but they do provide evidence used in their deliberations (https://www.nice.org.uk/guidance/ng10/resources/violence-and-aggression-shortterm-management-in-mental-health-health-and-community-settings-pdf-1837264712389)

Prone restraint was a factor in some deaths and there are some theoretically linked studies that show "prone" bad. There is rather less "supine good" compared to "prone bad" and indeed, some of the studies are of the form "sitting good prone bad". I don't think they've considered the recovery position; there may be issues with how much control the restrainer has. (page 7)

Yes, it does sound like they haven't really thought the period of restraint through. Much of the evidence on the choice of sedative agents talks about effects after two hours and there is no consideration of ketamine. Haloperidol plus lorazepam is standard practice apparently so there may be some status quo bias. Much of the research comes from psychiatric wards. I suspect there may be bias in terms of what sort of drugs people tend to prescribe and access to resources. E.g. I could imagine it might be bureaucratically painful to bring people familiar with the use of ketamine to a psych ward.

The royal college of emergency medicine are very pro-ketamine https://rcem.ac.uk/wp-content/uploads/2022/01/Acute_Behavioural_Disturbance_Final.pdf but they also mention the antipsychotic droperidol (random web pages talk about a 5-10 minutes action period). It's noticeable that RCEM are paranoid about interactions with other antipsychotics when discussing droperidol; when discussing the use of ketamine they talk about resusitation equipment being present. I suspect ED workers might be more blaze about resuscitation but more paranoid about interactions of psychoactive drugs, while psychiatric nurses might really dislike the idea of breathing issues. This article repeats the critique of prone restraint but claims that new evidence does not support conclusions.

Droperidol likely does not have the psychotomimetic effects of ketamine and may well not have the respiritarory problems of benzodiazapines (which apparently accompany ketamine use)... nor the mania simulating effects of second-generation "partial agonists" antipsychotics it could have some peverse effects (e.g. aripiprazole has case reports of gambling addiciton and hypersexuality ).

We should probably discuss some of this of the page on Acute behavioural disturbance. It would be good to mention droperidol as well as the advice to have resus equipment on hand for ketamine. I would like to find something talking about the psychomimetic effects of ketamine in the context of chemical restraint.

Talpedia 23:13, 23 June 2023 (UTC)

We might like to summarize this review on Physical restraint. This sites a study of a "supported prone" form of restraint that shows that proxy's for respiratory problems are less affected by this. It also explicitly criticises Hogtie restraint positions. Talpedia 18:49, 24 June 2023 (UTC)

References

Ketamine and its efficacy

The article claims that there is likely no medical reason to use Ketamine. At the VERY least this should be clarified to pertain only to ExDS, but I'll make the case that this statement should be removed entirely.

Ketamine, while controversial after the death of Elijah McClain, does have significant benefits in the treatment of an ExDS patient, particularly with an onset of acidosis. Without APPROPRIATE treatment, acidosis to the degree seen in ExDS is lethal. Any drug that, when responsibly used, can prevent irreversible cardiac arrest due to acidosis should be considered.

Additionally, to put it bluntly, the sources for this claim are pretty garbage.

The APA public statement makes the claim that Ketamine can cause respiratory arrest. It's a sedative.....OF COURSE IT CAN CAUSE RESPIRATORY DISTRESS. ExDS patients are a danger to themselves and others and are normally acidotic, sedation is the most appropriate treatment, in our out of hospital. The timing of the article also clearly makes it a response to the death of Elijah McClain.

The other article explicitly uses the death of Elijah McClain as an example as to why Ketamine is bad. Well yeah: if you overdose a kid on a sedative, you'll probably kill him. The Paramedic who OD'd him will probably go to prison for it. Malpractice happens, it's not evidence that a drug or procedure is dangerous, it's evidence that humans are gonna human.

Both sources criticize the use of ExDS as a term, citing loose definitions and diagnosis. That's fair, because Doctors rarely have an opportunity to observe someone with the symptoms. But the presentation in a prehospital scenario is usually pretty clear, and there doesn't necessarily have to be a clear diagnosis to know that a sedative is necessary to both make the scene safe for emergency personnel, and prevent further harm to the patient, either in the form of self(or law enforcement) inflicted trauma or cardiac arrest.

The death of anyone due to malpractice is a tragedy, particularly when there was an unjustified and overbearing police response. But the EM case is really the only one cited as to why "Ketamine Bad" and it's also clearly a malpractice case. If an anesthesiologist ODs someone on propofol, are we going to outlaw that too?

I'm not an MD, or any kind of Dr, but the literature speaks for itself. Mefirefoxes (talk) 20:34, 23 July 2023 (UTC)

On Wikipedia we follow what the reliable sources say (in this case that means WP:MEDRS sourcing). We can't undercut the sources with original arguments put together by Wikipedia editors, particularly not ones based on claims (like this acidosis claim) that we don't have sourcing for. MrOllie (talk) 21:31, 23 July 2023 (UTC)

Although the original arguments by editors often are indicative of what could be found in reliable sources if anyone had the time or energy to go look. OP claims to have literature - perhaps some of it could be found. With acidosis, I'm not that sure.

Regarding ketamine use in general, page 7 of this UK guidance for emergency medicine argues for rapid tranquilization to avoid the risks of *asphyxia* due to restraint and discusses rapid tranquilisation with ketamine - as well as with a fast acting antipsychotic. This is a pretty good source as far as WP:MEDRS goes. Personally, i think that ketamine is a bad drug to give to people because it is a psychomimetic with medium term dopaminergic effects (I can provide sources - though none of in the context of rapid tranquilization - so proably not WP:DUE - we might need to wait until psych wards start complaining about having people delivered to them with the side effects of ketamine 5-7 years will probably do it :/ - but given the bureaucratic imcompetence of the health sector and power of pyschiatrists they'll probably just assume that the patients have taken the ketamine themselves). I'd also note the likely disagreement between psychiatry and psychology. Talpedia 22:30, 23 July 2023 (UTC)

There are MANY sources linking ExDS to Acidosis. Here just one: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088378/ Mefirefoxes (talk) 23:04, 23 July 2023 (UTC)

I'll add: What then is the grounds for utilizing a source that itself provides no sources. One can easily argue that the APA's statement is a matter of opinion of the organization and not a medical fact. Mefirefoxes (talk) 23:09, 23 July 2023 (UTC)

Not sure I can address the general point. An APA position statement is pretty low down as far as evidential standards go, but it's difficult to argue that it isn't political relevant / newsworthy. If we've got systematic reviews we can include them potentially directly next to the source. "Force drugging with ketamine is great; APA disagree".

That source looks interesting - a secondary source that summarizes this literature in the context on other literature would be great... because WP:MEDRS. But given this, I suspect some MEDRS literature will exist. Talpedia 23:40, 23 July 2023 (UTC)

@Mefirefoxes: Please read WP:MEDRS carefully. Many (even most) peer-reviewed journal articles don't meet that standard. MrOllie (talk) 00:54, 24 July 2023 (UTC)

Indeed. Though, I guess the hope is that most peer-reviewed articles eventually get contextualised in a systematic review or other MEDRS source (even if just to say the source is poor quality). So if we follow the citation change we can hopefully find some MEDRS source that contextualises the paper. Talpedia 08:08, 24 July 2023 (UTC)

About using a source that itself provides no sources: See the next to last item in the Wikipedia talk:Verifiability/FAQ. WhatamIdoing (talk) 23:22, 19 August 2023 (UTC)

References

Excited delirium is dead, long live hyperactive delirium

It looks like the ACEP might mostly be switching out names [12]. I'm unclear what the name change means exactly; they likely want to keep some aspects of the diagnosis while getting rid of some of those from excited delirium. As to whether, it just amounts to "name washing" depends on how much of the concept of excited delirium and the literature gets applied to the concept.

This could be a bit of a pain to source correctly, because sources might sayd hyperactive delirium, mean excited delirium, be understood as excited delirium but never actually say so. Talpedia 09:29, 10 October 2023 (UTC)

This document looks good on the topic: .

By their nature, syndromes represent a constellation of signs and symptoms without a clearly elucidated singular cause or pathophysiologic definition. This diagnostic uncertainty, along with the dual use of the nomenclature both to describe the initial patient presentation and to provide a causative etiology on post-mortem examination, has led to controversy over use of the term, “Excited Delirium Syndrome,” within medicine and the lay press. Critics of this terminology have raised concern that it has been employed to explain away preventable in-custody deaths as inevitable outcomes, without proper consideration of other contributing factors and alternative management strategies that might have resulted in survival. Supporters of the use of “Excited Delirium Syndrome” have observed patients with agitated or combative behavior that is associated with a delirious state where the individual is not capable of interacting with other individuals or the environment. They recognize such behavior is frequently associated with physiologic abnormalities and high rates of death, warranting immediate treatment to improve patient outcomes. Moreover, the term is only definitively applied as a postmortem cause of death, rather than prospectively at presentation. Given the increasingly charged nature of the term, ACEP is concerned that its use in this document may distract from the intended delivery of critical information surrounding therapeutic options and best practices focused on the patient’s care and survival. Consequently, explicit discussion of “Excited Delirium Syndrome” will only occur in the context of ACEP Task Force Report on Hyperactive Delirium evidence surroundings its existence as a distinct pathophysiologic phenomenon. Rather, in this paper, we use the term “hyperactive delirium with severe agitation” to describe presentations of interest.

Seems like they are trying to split the forensic diagnosis from the syndrome itself. Talpedia 10:21, 10 October 2023 (UTC) Talpedia 10:21, 10 October 2023 (UTC)

Pseudoscientific

I had a look at a couple sources used to support the use of the word pseudoscientific and neither of them mentioned the word. Are there any sources that talk about whether excited delirium is pseudoscientific? "Convenient umbrella diagnosis existing outside of psychiatry and neurology without a specific mechanism and potentially confused with other preexisting psychotic diagnoses which are already associated with misdiagnosis" is probably what I would go for, but I would not say it is pseudoscientific Talpedia 16:55, 10 October 2023 (UTC)

If we don't have a significant number of sources on hand that actually use the word pseudoscientific, then IMO we shouldn't use it. It's turned into a generic smear word, and we don't need that. WhatamIdoing (talk) 04:47, 16 October 2023 (UTC)

I found a peer reviewed source that says "pseudoscience", so I am putting that word back in. Ironic sensibilities (talk) 22:08, 19 October 2023 (UTC)

A single source doesn't show that including this label would be Wikipedia:Due weight for the subject.

The source says "By relying on pseudoscience with little evidence, medical examiners and coroners have given life to a false medical condition that is often used to shield police officers from accountability when they use unacceptably harsh and unlawful force" and "Focusing on excited delirium in this context is using pseudoscience to blame victims for their own deaths."

I didn't see anything in it that explains what, precisely, about this idea makes it pseudoscientific (as opposed to, e.g., Emerging science or Bad science). It's just a label the source uses, without explanation or context, as a sort of emotive insult.

Since it's a single source, the most we could really write is that "Osagie K. Obasogie said it is based on pseudoscience", and I'm not sure that even mentioning this one scholar's passing mention would be appropriate anyway. WhatamIdoing (talk) 23:37, 19 October 2023 (UTC)

Yeah, but this isn't the only source that says this. It's just the one I gave, because Talpedia asked if there were any sources using that word. The New York Times says that "a number of major medical associations in the United States, including the American Medical Association and the American Psychiatric Association, have dismissed the term as pseudoscience. In March, the National Association of Medical Examiners became one of the latest to say that it should not be used as a cause of death." We're not just talking about one scholar. Ironic sensibilities (talk) 00:59, 20 October 2023 (UTC)

‘Excited delirium’: California Bans Term as a Cause of Death - The New York Times (nytimes.com) Ironic sensibilities (talk) 01:00, 20 October 2023 (UTC)

You can't cite a source that doesn't actually contain the word pseudoscience to claim that someone calls it pseudoscience. WhatamIdoing (talk) 01:26, 20 October 2023 (UTC)

My fault: The ^F Find settings in my web browser were screwed up. WhatamIdoing (talk) 01:33, 20 October 2023 (UTC)

@Generalrelative: Hey. So I'm not quite sure on the pseudoscientific thing. The ACEM are basically using excited delirium as a diagnosis, they've just changed it's name to distinguish it from the forensic diagnosis, so I don't think we can say that there is consensus on the diagnosis being pseudoscientific. As there isn't consensus I'm not sure pseudoscientific should go in thelead. I think it's perfectly fine to say that some people described it as pseudoscientific in the article tho, IMO. Talpedia 17:08, 6 November 2023 (UTC)

Fair enough. I don't have strong feelings about the matter, just reverted the IP because I was aware of this conversation. Including the fact that some have described it as pseudoscientific, with attribution, seems like a good compromise for now. Generalrelative (talk) 17:22, 6 November 2023 (UTC)

Yeah. I sorta disagreed with pseudoscientific being put back before - but didn't get around to / decide to disagree. Talpedia 17:38, 6 November 2023 (UTC)

I'm doubtful about this being in the first sentence. With something like Homeopathy, pseudoscience is a first-sentence descriptor in many sources and there are literally textbooks using it as an example of which features make it pseudoscience and why it's classified that way.

With this, the main complaint is that people are dying. Pseudoscience, if it's mentioned at all (looks like 4 out of 1,279 sources about "excited delirium" in a JSTOR search; there are many more talking about racism, and half talk about restraint), is a subject that seems to be far down on the list, and I haven't seen anything more than a single sentence. (Example: "He later died, with the medical examiner citing "excited delirium," a racist and pseudoscientific diagnosis used to justify police brutality.") WhatamIdoing (talk) 18:46, 6 November 2023 (UTC)

Just seeing this after tagging the recently added phrase "according to some". Seems to me that nearly all major medical associations call it pseudoscience. It's much more recently classified as pseudoscience than say, homeopathy. So that accounts for there being fewer sources that discuss it that way. The whole thing is relatively new, starting in the 80s. The ACEP position is problematic since there has been a COI. But if people want to attribute it, it should clear who calls it pseudoscience. Something like "most major medical associations." Ironic sensibilities (talk) 22:35, 6 November 2023 (UTC)

AFAIK "nearly all major medical associations" don't say anything at all about it, but if you'd like to check, then I suggest starting with List of medical organizations#United States and seeing how many of them have a page on their website that uses all three of the words: excited delirium pseudoscience. First one's free: The AMA doesn't use that language. (The claim in the NYT article links to this press release, which does not use that language.) WhatamIdoing (talk) 01:55, 7 November 2023 (UTC)

I'm sure we've been through this before, but my take on what is going on is i) psychiatrists have their own diagnosis so don't like this diagnosis and they don't necessarily deal so much with unmedicated agitated people in a public setting; ii) it's been used and potentially misused as a forensic diagnosis to explain deaths so it is controversial; iii) it is convenient for emergency doctors to have a diagnosis that justifies rapid sedation and to some degree they seem to have ignored preexisting psychiatric literature in preference for something new - and perhaps this "new diagnosis" ignores some naunce. Of course we should follow what the sources actually say.

Ironic, why do you think ACEP has a conflict of interest? Talpedia 09:33, 7 November 2023 (UTC)

I believe the claim isn't that ACEP (the organization) has a COI, but that some people on the 2009 ACEP task force have a COI. It's probably inevitable and unavoidable. When you're working with a small population (~35K members), most of whom aren't doing research at all or aren't available to do committee work, and you're writing about a niche subject (in the last decade, there have been just 20 secondary sources published on this subject in MEDLINE-indexed journals, and three of those aren't even in English), then they might well have been filling the task force with anyone who volunteered and knew something about the subject matter. This will inevitably mean people who have some sort of tie with the companies blamed for it.

See also the perennial (but routinely rejected) complaint that doing research on a drug pre-marketing approval is a conflict of interest. The options then are "get the drug from the manufacturer" or "don't do the research", but if you get what someone deems to be the "wrong" results, then you are obviously a paid shill for the drug company. WhatamIdoing (talk) 18:09, 7 November 2023 (UTC)

As for the COI, yes the ACEP as a whole doesn't have a COI, but the organization endorsed the 2009 white paper partially authored by members who were paid by Axon. The AP article I shared below says, "sentiment is growing among emergency physicians that the 2009 ACEP white paper has resulted in real harm and injustices...." This puts the ACEP in an awkward situation. If they disavow the paper too thoroughly, it looks like they are at fault for the harm this paper has caused, but every other association is calling them out for promoting pseudocience (junk science, whatever). So they have to withdraw it. So they do it in a way that makes it look like they weren't completely in error. They've been the last holdout [13] on this issue for years against consensus, so they are not a reliable source on this topic. Ironic sensibilities (talk) 18:47, 7 November 2023 (UTC)

and this has nothing to do with people doing research on a drug pre-approval. This has to do with people who authored a paper while on the payroll for Axon. Ironic sensibilities (talk) 18:49, 7 November 2023 (UTC)

That's exactly the line we hear about pre-approval drug research: "This has nothing to do with people doing research. This has to do with people who authored a paper while on the payroll for That Pharma, Inc." WhatamIdoing (talk) 20:37, 7 November 2023 (UTC)

Axon isn't a pharmaceutical company that would understandably be doing and funding medical research. They are an arms manufacturer. This is not an apt comparison. Ironic sensibilities (talk) 21:42, 7 November 2023 (UTC)

Lots of companies pay for medical research on their products, and it's totally understandable that in the US's product liability atmosphere, they'd want to be able to say that university-based research proves their product doesn't cause harm, or that the harms are balanced out by the benefits. Consider the role of tobacco companies in funding medical research. WhatamIdoing (talk) 01:27, 8 November 2023 (UTC)

Yes, the tobacco industry's attempts to undermine scientific consensus about the health effects of smoking are a much better analogy to Axon's participation in this field of research. Thank you for this apt comparison. Ironic sensibilities (talk) 20:59, 8 November 2023 (UTC)

If I were to do what you just described and look it up on every associations' website, that would be original research. We don't look up all the primary sources and draw conclusions. The New York Times does that, and we say whatever the NYT says. Ironic sensibilities (talk) 18:30, 7 November 2023 (UTC)

Also, not every source will say "pseudoscience", as WhatamIdoing points out about the AMA press release, but it amounts to the same thing. If NYT says that press release amounts to the label "pseudoscience", then so do we. But some people say "junk science". This article (by the associated press) says that there is "consensus building" for this label. So we don't have to (and shouldn't) look up every medical association's website and do our own research, because the AP did it for us. It's fine if people want to say "junk science" instead of pseudoscience, but it doesn't work as well as an adjective, so it would make the sentence unnecessarily awkard. Ironic sensibilities (talk) 18:37, 7 November 2023 (UTC)

If you were to do that and put the results in the article(!), then that would be a NOR problem. But if you were to do that and discover whether your beliefs do (or don't) align with reality, then you might be more informed, and therefore better able to contribute to the article in ways that are more likely to accurately reflect sources. At minimum, I'd expect you not to repeat sweeping generalizations like "nearly all major medical associations" call this pseudoscience, when many of them cover fields such as dermatology, sleep medicine, orthodontia, hospice, radiology, gastroenterology, gynecology, plastic surgery, reproductive medicine, etc. and are unlikely to have any particular interest in this subject at all.

It might also be useful for you to know that Junk science is not the same as Pseudoscience. WhatamIdoing (talk) 20:48, 7 November 2023 (UTC)

Fair enough. Major medical associations who are relevant to this conversation then. The ones that aren't relevant...aren't relevant. And if there's a difference between junk science and pseudoscience, I don't care too much which one we use. The main point is that we should convey to our readers that a consensus of relevant scientists have determined that it isn't a legitimate diagnosis. Ideally with a single adjective in the first sentence, because the consensus is pretty clear. Ironic sensibilities (talk) 21:34, 7 November 2023 (UTC)

Well, we could just say "is a controversial diagnosis...", with controversial being a single adjective. We could also say "is a controversial and widely rejected diagnosis...", "is a disputed diagnosis...", or get rid of the medicalese and say "is a purported set of behaviors..." If the sources support it, we might be able to say "is the claim that the deaths of extremely agitated and delirious people are due to the process that caused the symptoms, and not due to restraint asphyxia". WhatamIdoing (talk) 01:22, 8 November 2023 (UTC)

"controversial" doesn't work on its own. Climate change is controversial, but there's a clear scientific consensus about which side of that controversy has merit. Same with "disputed". "Widely rejected" would be better, and I'm not entirely opposed to it, though I prefer something like Pseudoscientific that can be linked. Could change the sentence entirely as you suggest. See below. Ironic sensibilities (talk) 21:16, 8 November 2023 (UTC)

The UK's, Royal College of Emergency medicine are also activiely referring to the diagnosis as a real thing. Do we really want to believe the new New York Times over guidelines from professional bodies? There seems to be a bit of WP:BESTSOURCE and WP:MEDRS going on here. I probably wouldn't even use the new york times to make this sort of claim if there were *no* other sources, and here we have medical guidelines by professional bodies that use the diagnosis. I guess theresa bit of OR that goes into "they are treating this as a real thing so clearly don't think it's pseudoscience" but it is a very very small amount of OR. Talpedia 11:37, 8 November 2023 (UTC)

So... I feel like this by the royal college of psychiatrists in the UK which gives a fairly lengthy discussion of ExD and its relation to acute behaviour disturbance and other disorders should probably be used in preference to the new york times. https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/position-statements/ps02_22.pdf

Talpedia 17:46, 8 November 2023 (UTC)

I hadn't seen this statement. Thanks for finding it. We can possibly use both this and NYT. I don't think they're mutually exclusive or contradicting. This statement renounces ExD pretty firmly ("ExD should never be used"). It's unclear what it says about ABD, or rather it says that ABD is unclear and there's no consensus about its meaning. It states clearly that "ABD is not a diagnosis or cause of death." So this is consistent with saying that ABD is a pseudoscientific diagnosis, because if one were to diagnose someone with ABD, that would conflict with this statement that ABD is not a diagnosis.

The Wikipedia article starts with the sentence "ExD is a [adjectives disputed] diagnosis." We could change the sentence entirely and say that ExD is something else. But if we say it's a diagnosis, we have to use an adjective that reflects this paper, and the NYT, and other sources that say it is NOT a valid diagnosis. Ironic sensibilities (talk) 21:08, 8 November 2023 (UTC)

So Talpedia, when you say that "here we have medical guidelines by professional bodies that use the diagnosis", I think you may have misread the paper or something, because this paper says ExD should never be used, and ABD is "not a diagnosis." Ironic sensibilities (talk) 21:10, 8 November 2023 (UTC)

About ABD is not a diagnosis: Fever isn't a diagnosis, either. That doesn't make it pseudoscience. WhatamIdoing (talk) 21:19, 8 November 2023 (UTC)

It would be pseudoscience (or bad science or junk science) if someone attempts to use fever as a diagnosis. The article on Fever doesn't say "Fever is a diagnosis" Ironic sensibilities (talk) 21:22, 8 November 2023 (UTC)

The fact that a sign or symptom is "not a diagnosis" does not invalidate anything at all about the symptom.

You said about that "ABD is not a diagnosis" and that this statement was "consistent with saying that ABD is a pseudoscientific diagnosis". It's not. These are contradictory statements. If ____ is not a diagnosis at all, then it is not any kind of <insert adjective here> diagnosis. WhatamIdoing (talk) 21:36, 8 November 2023 (UTC)

They're not contradictory statements if people have actually been diagnosed with _____. That is, if ____ is not a legitimate diagnosis at all, and then someone is diagnosed with ____ anyway, (maybe the doctor didn't get the memo) what kind of diagnosis is that? Because ExD certainly HAS BEEN a diagnosis, and it's not clear that no one's continuing to use it in this way. And our article currently says it's a diagnosis. So if the relevant medical associations say, "this is not a legitimate diagnosis". And then someone flouts consensus and uses it as a diagnosis anyway, or maybe used it as a diagnosis before the current consensus was clear, what do we call those diagnoses that have actually occurred? "Pseudoscientific" is supported by some sources. I haven't seen anything say "deprecated", but maybe that's ok? Widely rejected?

We could just avoid saying "ExD is a <insert adjective> diagnosis. We could say that it's a medical emergency, for example. But I'm not totally comfortable with that, because RCPsych says ExD shouldn't be used at all. So it's not really even a legitimate term for signs and symptoms, according to that source. Maybe we should say that it WAS a diagnosis, but it's possible that it continues to be used.

Some of this feels a little like we're talking past each other. I hope I'm being clear enough...Thanks. Ironic sensibilities (talk) 16:47, 9 November 2023 (UTC)

If it's not a diagnosis, it's not a diagnosis.

If it's a diagnosis, then it could be a bad one, an irrelevant one, an outdated one, a racist one, a junk science one, etc.

But if it's not a diagnosis, then it's not any kind of diagnosis. WhatamIdoing (talk) 19:03, 9 November 2023 (UTC)

Well I guess ExD is, but shouldn't be anymore, and ABD isn't. But we still need an adjective for ExD. So I'm going to put "widely rejected". WhatamIdoing suggested that above, and I'm hearing that neither Talpedia nor WhatamIdoing like "pseudoscientific". So hopefully that works? Ironic sensibilities (talk) 20:45, 9 November 2023 (UTC)

have misread the paper or something

Yeah, I'm probably being a little confusing. I was referring to the ACEP statement and the 2016 paper from the royal college of emergency medicine. I tried to look the 2016 RCEM statement and found that it had been pulled from the site - so then found this more recent statement by the royal college of psychiatry.

Looking through this newer report it seems to be the case that people are moving away from the *name* ExD because of the associations with forensic medicine. I think the report by Rpsych gives a good summary of what people think of the concept - which if I read correctly is sort of "[in some cases of ABD there is a risk of death that should be treated]" as well as some history and discussion of the controversy. I think this would be a good source for us to use when discussing the status of ExD.

Similarly the ACEP have moved away from the name ExD but are using "hyperactive delirium" as a diagnosis concept.

I agree that ABD is an umbrella concept where certain interventions are suggested. Talpedia 21:33, 8 November 2023 (UTC)

The overall sense I get from skimming the RCP paper is that in-hospital psychiatrists are using "acutely disturbed behavior" to mean a wide range of abnormal behaviors, and out-of-hospital emergency personnel are using "acute behavioral disturbance" to mean a smaller and more extreme set of behaviors that indicate that the person is at risk of dying if they restrain him to get him to the hospital, and is also at risk of dying if they don't. And then the first group says to the second, "Well, why don't you try some de-escalation techniques, like speaking gently to the person?" and the second replies "How about I call you the next time we have someone screaming inarticulately while running naked through a snowstorm, and you see whether speaking gently prevents cardiac arrest?" They seem to be talking past each other, and the psychiatrists are applying in-hospital medical expectations (e.g., an extra nurse who can be assigned to do nothing except watch a sedated person's vital signs) to an out-of-hospital setting.

Overall, it makes me think that a sensible approach to this article would be to say as little as possible for now, and try again in a few years, when hopefully they'll have figured out what the facts are and what's reasonable. WhatamIdoing (talk) 21:54, 8 November 2023 (UTC)

I agree that this mismatch exists. It's also worth noting that in in-patient psychiatric facilities it can be easier to restrain / sedate people than wait for deescalation to work (had a conversation with a mental health nurse of precisely this topic last week). So in a sense the psychiatric advice might be be written in the knowledge of overdiagnosis.

Psych wards can actually impair access to certain non-mental health interventions in some countries compared to public spaces because physicians may be unwilling to attend and there are security concerns. So I don't think it is necessarily correct to assume that psych wards are safer from a respiritory etc perspective.

I imagine emergency departments may be an area where psychiatrists and emergency medicine physicians can form a common understanding to some degree.

Yeah, perhaps waiting is a good approach. If you look at the ACEP, their approach has been to rename ExD to hyperactive delirium, try to break the link to forensic medicine and presumably until hyperactive delirium can be used without the unfortunate association to detahs. I'm personally a little concerned about emergency heatlhcare workers using ketamine as we've spoken about before - but note your points about the value of rapid sedation which were shared by the RCEM in the literature I read. Talpedia 22:09, 8 November 2023 (UTC)

Small update: The Times article uses the word pseudoscience, but neither of the linked pages do. Also, the journalist specializes in breaking news (he's not even a science journalist), so he's probably using the term as a generic "rejected bad thing" term. That's pretty far down the reliability scale as far as WP:MEDPOP is concerned. I don't think we should be talking about pseudoscience at all in this article, and I doubt that we should be citing that source. WhatamIdoing (talk) 19:08, 9 November 2023 (UTC)

Organization

This sentence:

While diagnosis is habitually of men under police restraint, medical preconditions and symptoms attributed to the syndrome are far more varied.

is in the ==Deaths== section, but I can't figure out what it has to do with the deaths. I also couldn't figure out where else to put it. The structure of this article is unusual, and I'm not sure that it's serving us well. WhatamIdoing (talk) 22:43, 4 November 2023 (UTC)

I don't have time to look into it deeply right now so maybe there's more to it, but I don't even know what that sentence means at first glance. More varied than what? Seems like the kind of sentence that could be deleted without much loss. Though the source looks like it might have some potential use if it isn't used elsewhere. Ironic sensibilities (talk) 23:53, 4 November 2023 (UTC)

I think that it means when you look at the people who've been claimed to have excited delirium, some of them have psychotic illnesses, some of them have acute drug problems, some of them have brain injuries, some of them have physiological problems (e.g., encephalopathy), etc. In nosological terms, you want one disease/one set of symptoms/one etiology (or at least one set of risk factors). This sort of has one set of symptoms, but it doesn't seem to have one set of risk factors. WhatamIdoing (talk) 01:57, 5 November 2023 (UTC)

That is probably what it means, but I can't access the source to be sure. I tried to reorganize things. Let me know if this looks better? Feel free to revert or discuss. Ironic sensibilities (talk) 21:45, 5 November 2023 (UTC)

Update to reflect the current state of ExDS (2024) and be more neutral (Not Red Flag)

The wording of this article, while understandable in its desire to highlight the controversial and disputed nature of the topic, does not accurately reflect the level of practice and acceptance of Excited Delirium or Hyperactive Delirium with Severe Agitation. I am seeking to rework this article in a manner that reflects both the deep divide in the medical community, ethical and discriminatory history, and the reality for millions of people who are served by emergency physicians and emergency medical providers who do routinely confront what they believe to be a serious medical issue.

It is important to delineate between ExDS/AgDS/ABD as a concept used to train medical professionals and guide the treatment of individuals suffering from an acute mental health crisis, and ExDS as a label for deaths in police or state custody of individuals who were improperly restrained or otherwise abused and died as a result. I do not feel the article as written makes any clear distinction.

We are right to point out that ExDS is widely derided by psychologists and other mental health professionals, who do not believe ExDS to be a semantically appropriate diagnosis. However, the American Academy of Emergency Physicians’ (ACEP) recognition of AgDS should not be minimized, nor is the AECP the only body to recognize AgDS/ExDS. ACEP represents over 38,000 emergency physicians in the United States, over half of all practicing emergency physicians. ACEP publishes The Annals of Emergency Medicine which is the most widely circulated and referenced peer-reviewed journal in the profession. Additionally, 12 US states still list Excited Delirium in their EMS protocols, meaning that the residents of those states are serviced by emergency medical providers who are trained to recognize and treat what they understand to be Excited Delirium. This year ACEP released clinical policies for dealing with patients suspected of suffering from ExDS/AgDS.

This divide can be attributed to the simple fact that mental health professionals do not treat or see individuals suspected of suffering from ExDS. Paramedics, EMTs, and Emergency Physicians are the only ones treating severely agitated and aggressively combative individuals in an emergency setting.

Given what I’ve laid out above, I do not believe that the mere concept of ExDS/AgDS falls under the red flag or fringe policies:

• Surprising or apparently important claims not covered by multiple mainstream sources;

• ExDS/AgDS is not only widely reported on and litigated, but tens of thousands of medical professionals are trained to recognize and treat it. It does exist as ‘mainstream’ and

• Challenged claims that are supported purely by primary or self-published sources or those with an apparent conflict of interest;

• I understand the current article’s heavy focus on Taser’s (AXON’s) involvement in the promotion of ExDS/AgDS as an explanation for deaths caused by police misconduct, especially when their own products are involved. However it does not qualify as a strong enough conflict of interest for red flag to apply; especially given the names on ACEP’s new published materials not having any reported involvement with AXON.

• Reports of a statement by someone that seems out of character or against an interest they had previously defended;
• Claims contradicted by the prevailing view within the relevant community or that would significantly alter mainstream assumptions—especially in science, medicine, history, politics, and biographies of living and recently dead people. This is especially true when proponents say there is a conspiracy to silence them.

• The prevailing view in emergency medicine (and emergency medicine is THE most relevant community here) is that ExDS/AgDS exists, is supported by clinical observations, and that certain prescribed clinical policies are appropriate in its treatment.

Simplyglad (talk) 10:53, 15 December 2024 (UTC)

I'll just reply to say what should be obvious: the current article is the result of extensive discussion and consensus-building based on reliable sources. If you have additional sources to present or new points that haven't been raised before, consensus can change, but it will behoove you to familiarize yourself with past discussions above, including the talk page archive, before attempting bold changes. If you're not satisfied with the reception you receive here, you can always take the matter up at the Fringe Theories Noticeboard. Generalrelative (talk) 22:10, 15 December 2024 (UTC)