As Foundation for ‘Excited Delirium’ Testimony by Police Cracks, Fallout Spreads

Lambert here: Forty years to debunk the junk science that gave cops a rationalization for whacking people.

By Renuka Rayasam, Senior Correspondent at KFF Health News, Markian Hawryluk, Senior Colorado Correspondent for KFF Health News, and Samantha Young, Senior Correspondent for KFF Health News. Originally published at KFF Health News.

When Angelo Quinto’s family learned that officials blamed his 2020 death on “excited delirium,” a term they had never heard before, they couldn’t believe it. To them, it was obvious the science behind the diagnosis wasn’t real.

Quinto, 30, had been pinned on the ground for at least 90 seconds by police in California and stopped breathing. He died three days later.

Now his relatives are asking a federal judge to exclude any testimony about “excited delirium” in their wrongful death case against the city of Antioch. Their case may be stronger than ever.

Their push comes at the end of a pivotal year for the long-standing, nationwide effort to discard the use of excited delirium in official proceedings. Over the past 40 years, the discredited, racially biased theory has been used to explain away police culpability for many in-custody deaths. But in October, the American College of Emergency Physicians disavowed a key paper that seemingly gave it scientific legitimacy, and the College of American Pathologists said it should no longer be cited as a cause of death.

That same month, California’s Democratic Gov. Gavin Newsom signed the nation’s first law to ban the term “excited delirium” as a diagnosis and cause of death on death certificates, autopsy reports, and police reports. Legislators in other states are expected to consider similar bills next year, and some law enforcement agencies and training organizations have dropped references to excited delirium from their policy manuals and pulled back from training police on the debunked theory.

Despite all that momentum, families, attorneys, policing experts, and doctors say much remains to be done to correct the mistakes of the past, to ensure justice in ongoing trials, and to prevent avoidable deaths in the future. But after years of fighting, they’re heartened to see any movement at all.

“This entire thing, it’s a nightmare,” said Bella Collins, Angelo’s sister. “But there are silver linings everywhere, and I feel so fortunate to be able to see change happening.”

Ultimately, the campaign against excited delirium seeks to transform the way police deal with people undergoing mental health crises.

“This is really about saving lives,” said Joanna Naples-Mitchell, an attorney who worked on an influential Physicians for Human Rights review of excited delirium.

Changing Law Enforcement Training

The use of the term “excited delirium syndrome” became pervasive after the American College of Emergency Physicians published a white paper on it in 2009. It proposed that individuals in a mental health crisis, often under the influence of drugs or alcohol, can exhibit superhuman strength as police try to control them, and then die suddenly from the condition, not the police response.

The ACEP white paper was significant in catalyzing police training and policy, said Marc Krupanski, director of criminal justice and policing at Arnold Ventures, one of the largest nonprofit funders of criminal justice policy. The theory contributed to deaths, he said, because it encouraged officers to apply greater force rather than call medical professionals when they saw people in aggressive states.

After George Floyd’s 2020 death, which officers blamed on excited delirium, the American Medical Association and the American Psychiatric Association formally rejected it as a medical condition. Then came disavowals from the National Association of Medical Examiners and the emergency physicians’ and pathologists’ groups this year.

The moves by medical societies to renounce the term have already had tangible, albeit limited, effects. In November, Lexipol, a training organization used by thousands of public safety agencies in the U.S., reiterated its earlier move away from excited delirium, citing the California law and ACEP’s retraction of the 2009 white paper.

Lexipol now guides officers to rely on what they can observe, and not to guess at a person’s mental status or medical condition, said Mike Ranalli, a lawyer and police trainer with the Texas-based group. “If somebody appears to be in distress, just get the EMS,” he said, referring to emergency medical services.

Patrick Caceres, a senior investigator at the Bay Area Rapid Transit’s Office of the Independent Police Auditor, successfully pushed to remove excited delirium from the BART Police Department’s policy manual after learning about Quinto’s death in 2020 and seeing the American Medical Association’s rejection of it the following year.

Caceres fears that rooting out the concept — not just the term — more broadly will take time in a country where law enforcement is spread across roughly 18,000 agencies governed by independent police chiefs or sheriffs.

“The kinds of training and the kinds of conversations that need to happen, we’re still a long way away from that,” said Caceres.

In Tacoma, Washington, where three police officers have been charged with the 2020 death of Manuel Ellis, The Seattle Times reported that local first responders testified as recently as October that they still “embrace” the concept.

But in Colorado, the state’s Peace Officer Standards and Training board ruled on Dec. 1 to drop excited delirium training for new law enforcement officers, KUSA-TV reported.

And two Colorado lawmakers, Democratic state Reps. Judy Amabile and Leslie Herod, have drafted a bill for the 2024 legislative session banning excited delirium from other police and EMS training and prohibiting coroners from citing it as a cause of death.

“This idea that it gives you superhuman strength causes the police to think they should respond in a way that is often completely inappropriate for what’s actually happening,” Amabile said. “It just seems obvious that we should stop doing that.”

She would like police to focus more on de-escalation tactics, and make sure 911 calls for people in mental health crisis are routed to behavioral health professionals who are part of crisis intervention teams.

Taking ‘Excited Delirium’ Out of the Equation

As the Quinto family seeks justice in the death of the 30-year-old Navy veteran, they are hopeful the new refutations of excited delirium will bolster their wrongful death lawsuit against the city of Antioch. On the other side, defense lawyers have argued that jurors should hear testimony about the theory.

On Oct. 26, the family cited both the new California law and the ACEP rebuke of the diagnosis when it asked a U.S. District Court judge in California to exclude witness testimony and evidence related to excited delirium, saying it “cannot be accepted as a scientifically valid diagnosis having anything to do with Quinto’s death.”

“A defense based on BS can succeed,” family attorney Ben Nisenbaum said. “It can succeed by giving jurors an excuse to give the cops a way out of this.”

Meanwhile, advocates are calling for a reexamination of autopsies of those who died in law enforcement custody, and families are fighting to change death certificates that blame excited delirium.

The Maryland attorney general’s office is conducting an audit of autopsies under the tenure of former chief medical examiner David Fowler, who has attributed various deaths to excited delirium. But that’s just one state reviewing a subset of its in-custody deaths.

The family of Alexander Rios, 28, reached a $4 million settlement with Richland County, Ohio, in 2021 after jail officers piled on Rios and shocked him until he turned blue and limp in September 2019. During a criminal trial against one of the officers that ended in a mistrial this November, the pathologist who helped conduct Rios’ autopsy testified that her supervisor pressured her to list “excited delirium” as the cause of death even though she didn’t agree. Still, excited delirium remains his official cause of death.

The county refused to update the record, so his relatives are suing to force a change to his official cause of death. A trial is set for May.

Changing the death certificate will be a form of justice, but it won’t undo the damage his death has caused, said Don Mould, Rios’ stepfather, who is now helping to raise one of Rios’ three children.

“Here is a kid that’s life is upside down,” he said. “No one should go to jail and walk in and not be able to walk out.”

In some cases, death certificates may be hard to refile. Quinto’s family has asked a state judge to throw out the coroner’s findings about his 2020 death. But the California law, which takes effect in January and bans excited delirium on death certificates, cannot be applied retroactively, said Contra Costa County Counsel Thomas Geiger in a court filing.

And, despite the 2023 disavowals by the main medical examiners’ and pathologists’ groups, excited delirium — or a similar explanation — could still show up on future autopsy reports outside California. No single group has authority over the thousands of individual medical examiners and coroners, some of whom work closely with law enforcement officials. The system for determining a cause of death is deeply disjointed and chronically underfunded.

“One of the unfortunate things, at least within forensic pathology, is that many things are very piecemeal,” said Anna Tart, a member of the Forensic Pathology Committee of the College of American Pathologists. She said that CAP plans to educate members through conferences and webinars but won’t discipline members who continue to use the term.

Justin Feldman, principal research scientist with the Center for Policing Equity, said that medical examiners need even more pressure and oversight to ensure that they don’t find other ways to attribute deaths caused by police restraint to something else.

Only a minority of deaths in police custody now cite excited delirium, he said. Instead, many deaths are being blamed on stimulants, even though fatal cocaine or methamphetamine overdoses are rare in the absence of opioids.

Yet advocates are hopeful that this year marks enough of a turning point that alternative terms will have less traction.

The California law and ACEP decision take “a huge piece of junk science out of the equation,” said Julia Sherwin, a California civil rights attorney who co-authored the Physicians for Human Rights report.

Sherwin is representing the family of Mario Gonzalez, who died in police custody in 2021, in a lawsuit against the city of Alameda, California. Excited delirium doesn’t appear on Gonzalez’s death certificate, but medical experts testifying for the officers who restrained him cited the theory in depositions. 

She said she plans to file a motion excluding the testimony about excited delirium in that upcoming case and similar motions in all the restraint-asphyxia cases she handles.

“And, in every case, lawyers around the country should be doing that,” Sherwin said.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. GramSci

    According to KFF, the 2009 white paper, linked in text, was funded by the Taser manufacturer Axon. At least one of the authors appears to have personally profited from providing expert testimony on behalf of police officers accused of brutality. I doubt there’s one.

    KFF is not as upbeat as this article. Even in California, expert medical witnesses can still use a variety of synonyms to similar effect.

  2. carolina concerned

    As long as people with authority are allowed to believe correctly that their behaviors will be defended and dismissed as protecting the shield, some of them will engage in inhumane actions. This will not be limited to killing people and will include filing false charges against innocent citizens, etc. It will also include flagrant overuse of tasers. Most people with authority will probably not engage in these violations of the rights and liberty of others, but behavior such as taser abuse and illegal search and seizure suggest that sufficient encouragement will mean that such behavior can become common. This suggests that the burden of preventing controlling this behavior falls to a great extent on supervisors. It is important that we realize that blaming the policeman on the beat, for example, rather than supervisors is wrong and counterproductive.

    1. Neutrino

      Pre- and post-event coaching, done well out of earshot, part of training and culture. Advanced version is done while on Overtime. Expert version incorporates Pension Spiking.

      1. NYMutza

        You are so right. Law enforcement agencies are occupying forces in our neighborhoods and they behave accordingly. The use of the word “enFORCEment” needs to end. That would be a step forward. Remember the now very quaint term “peace officer”? That needs to return. Words matter. As does recruitment and training. Recruiting from the military is a big mistake.

        1. Kouros

          “Changing Law Enforcement Training”

          Are they going to stop using Israeli IDF tactics for policing? Are they going to stop seeing everyone around them as Palestinians or pro-Palestinians?

        2. Vicky Cookies

          I’m glad you brought up recruitment from the military. To me, this is nonsensical and an obvious route to an abusive, aggressive police force. Police are now generally required to have a BA, usually in criminal justice, which some (who have not been exposed to the reactionary drivel coming out of criminal justice departments in the academy) see as putting more thoughtful, considerate people on the force. But, an easy way around this requirement is to serve in the military. So, many who do not want to become loaded down with student debt will instead enlist in the military and try to get posted to South Korea – where we can read what those boys get up to, and it’s not pretty. The type of mindset inculcated by being a foreign soldier with impunity is then brought home. Then, there are the combat veterans from our MENA adventures, who in my opinion should obviously be banned from domestic policing. This all beyond the 1033 program, through which domestic police recieve military equipment.

          Once these material issues are addressed, then I agree that the terminology is important to address amd change. But culture has a material basis, and if you want to change the culture which gives us our roided-up, fearful, skinhead tough guy cops and their gangster internal solidarity, you’ve got to affect a material change, such as ending 1033, the pipeline from the military to the police; you’ve got to redirect their funding, &c.

          To the example from the article: the ‘excited delirium’ bunk is being challenged, and that’s great. One of many pseudo-scientific justifications those intellectual titans in uniform trot out regularly. But what first had to happen was banning certain holds; here again I’ll assert the need for change in the base, so as to effect the superstructure, so to speak.

  3. begob

    A couple of interesting issues related to restraints that I couldn’t see addressed in the article or in the links I clicked: the cause of the undoubted phenomenon of freakish strength in, say, 5% of cases; and the duties of the responders in such cases.

    In NHS psych wards in the UK any full restraint requires ideally 7 responders: 1 head, 2 arms, 1 thighs, 2 feet, plus a director who stands to one side. The highest risk to everyone, including the restrained person, is in getting to the floor, when joints are popping and legs flailing. Even after that, when resistance and restraint are sustained, the responders eventually get creaky and the risks keep shifting. Tough stuff.

  4. cwe

    Police are not medical experts and are not trained to recognize the difference between people who are non-responsive because of drugs versus folks with epilepsy who are post ictal (not fully conscious or in control of their faculties following a seizure event). The “obey now or suffer” training LEOs get has resulted in many good people who were not mentally capable of processing or responding to LEO commands to suffer great harms under this “exited delirium” get out of jail free card to abuse folks.

  5. Lamped.usa

    She would like police to focus more on de-escalation tactics, and make sure 911 calls for people in mental health crisis are routed to behavioral health professionals who are part of crisis intervention teams.

    This great post would be incomplete if we don’t get some insights about the protocols and procedures used by the EMS and crisis intervention teams.

  6. Susan the other

    Kinda asks the question, Which one is in a state of excited delirium, the police or the perp? How is it that police training leaves out factoids like putting pressure on someone’s chest can stop the heart. I’d guess with a small chest it only takes seconds but with a large raging freak maybe a minute or two. Everybody knows how to kill an attack dog – you grab its lower jaw, twist its body right side down and push on its left rib cage with your knee and your full weight. Result? One dead dog. I don’t see much difference between pressure on the chest and strangling somebody. They certainly do not train officers of the peace to strangle delirious people. Really it’s a lot simpler and safer to just put Frankenstein in handcuffs, isn’t it?

    1. Sean O'Connor

      >>>How is it that police training leaves out factoids like putting pressure on someone’s chest can stop the heart.

      This is not happenstance. American police training seems more about population control and not about public safety or even law enforcement, which is why so factoids are mentioned. Just as with qualified immunity and excited delirium, the policy, whether stated or not, is to protect the police from the consequences of any actions, no matter how unreasonable. Deliberately cultivated ignorance of biology and facts of the law gives the courts a greater ability to protect the police. This is strangely what the general population does not get as “ignorance of the law is no excuse.”

      As with much of American governance, the police have been repurposed into population control, which includes suppression of any dissent and wealth extraction or theft from the community. The police use often arbitrarily, even capriciously, and frequently illegally, applied searches, arrests, fees, fines, and civil asset forfeitures done to assist in driving residents out for developers, raise funds to replace tax cuts, and to fund their own operations; the government often ignores such because it benefits their patrons and voters, if it does not encourage or colludes with the police.

      That all this encourages the terrorizing, injuring, and even murder of often innocent people seems to be a feature, not a fault. After all, if someone busts through your door at o’dark something before the sunrise, just how are you going to react? Please, note that the police are often reported by eyewitnesses to be lacking in identification or in giving warning, which is occasionally backed up by video, but any injuries or deaths usually leads to the victims/suspects being charged and not the police.

      I have noticed that the more corrupt the country has become, the more corrupt, abusive, and murderous the police become. The police have always been in the service of the elites, but in the past, a clean society encouraged clean policing.

      Anyways, thank you Lambert for posting this.

  7. ThirtyOne

    hmm, Lexipol:

    The Riverside Company, a private equity firm, purchased Lexipol in 2014.[16][17] In 2019, Lexipol merged with Praetorian Digital, which brought with it multiple news media sites and online learning academies.[18] The company saw an increase in interest in 2020, prompted by orders like that of New York Governor Andrew Cuomo in response to George Floyd protests that began in Minneapolis.[19] In December 2020, Lexipol acquired Cordico, a wellness technology firm,[20] [21][22] and in February, 2023, it acquired National Emergency Responder & Public Safety Center, which offers clinician courses and certification.[23]

  8. Rip Van Winkle

    Chicago Police case Jason Van Dyke – Laquan McDonald, 2014. Mayor Rahm Emanuel concealed the video until after he was re-elected. For some odd reason the local mainstream media gave Rahm a pass and there were no riots.

  9. britzklieg

    I think the term is perfectly suited to US military hubris, especially the part about superhuman strength followed by expiration.

  10. David in Friday Harbor

    Folks are going to jump all over me, but I spent many years reviewing police misconduct before my retirement. “Excited Delirium” is indeed hokum junk science that covers up a bigger problem: amphetamine-induced psychosis among poor and downtrodden people forced to live on the streets.

    I’ve personally observed police attempting to calm a person acting bizarrely because they’re under the influence of amphetamines, animal tranquilizers, or free-base cocaine — in order for them to be safely be transported to a hospital or lock-up for their own safety. It’s basically impossible, but the cops would be disciplined for dereliction of duty if they simply let the uncooperative person go on their merry way — especially if the person (like so many of the poor) is also subject to a court-mandated arrest warrant. So we give the cops a choice: who is going to wind-up in the ER and who is going home for dinner?

    We need to work backwards: Why are there so many people on the streets whacked-out on meth and ketamine, acting-out and presenting a danger to themselves and others? If you’ve ever spent any time “on the street” you’d know the sad truth that very often these folks actually are quite psychotic. Why do we expect a couple of over-worked cops to “bring them in” when the reality is that a dozen burley nurse-orderlies wouldn’t be able to safely subdue them without putting them into cardiac arrest?

    It’s a Lose/Lose proposition that proves Lambert’s Second Law of Neoliberalism.

  11. John Anthony La Pietra

    Here’s hoping that this bit of progress will rapidly become clearly established law nationwide, so excited delirium will disappear from the list of excuses LEOs can use to try for qualified immunity.

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