"Excited Delirium": Women's Murders Blamed on Sex and Cocaine
The junk science that still gets officers off the hook for in-custody deaths.
In the mid-1980s, women’s dead bodies began to appear in decrepit buildings around Miami. Most of them were naked below the waist with their legs pulled apart.
Their deaths perplexed detectives. The women didn’t have bruises on their necks. They hadn’t been shot, stabbed, drowned, or beaten to death. There were no needle marks suggesting a fatal overdose.
“When you talk about mysteries in deaths, these are by far the most mysterious you’ll ever find,” Miami Police Sgt. David Rivero, who worked some of the first cases, told the Los Angeles Times in 1989. “I mean, usually you have a motive or a witness or at least a good cause of death. Here, forget it.”
With no leads, police briefly entertained a theory set forth by the criminologist and medical examiner Charles Wetli: Excited delirium.
In the late 1970s, Wetli claimed that too much cocaine could put a person in a state of “excited delirium” resulting in death. Many of the women, all of whom were Black, had done sex work; Wetli surmised that they’d been so pumped up from cocaine that a single sex act was enough to kill them.
When the body of a young teenager—who had never done sex work and had no drugs in her system—was discovered, Wetli’s already tenuous theory fell apart. Soon, detectives determined that the women had been murdered by a serial killer, who asphyxiated them to death by putting his weight on them until they stopped breathing. “You're talking about little girls on the street, and it's not too hard to asphyxiate them, especially when you have their backs on the ground and your weight on their abdomen," a pathology professor told the Los Angeles Times at the time.
They never found the killer. Instead, police found use in a dubious catch-all theory to explain away fatalities.
The excited delirium theory stuck as paid experts duked it out in cases of in-custody deaths. “Excited delirium became embraced by law enforcement in the late 1980s and early 1990s after restraint-related asphyxia became an accepted cause of death theory in civil rights cases against the police,” Erik Heipt, a Seattle-based civil rights lawyer, tells me. “Restraint-related asphyxia became scientifically accepted following some studies in the late 1980s by a King County (Seattle) medical examiner named Donald Reay, M.D. To counter the cause of death in these cases, defendants hired high-priced experts who commissioned bogus studies in San Diego—to cast doubt on the dangers of prone restraint.”
Excited delirium (ED) became a convenient explanation that absolved officers of any wrongdoing.
“They needed an alternative explanation for the cause of death. If it wasn’t asphyxia, how could they explain why the person suddenly died during a prone restraint?” Heipt adds. “Whenever a plaintiff would allege that a death was caused by restraint-related asphyxia, with support from forensic pathologists, the defense would hire opposing experts who would invoke the San Diego study, which involved healthy subjects in a controlled setting, and bring in Dr. Wetli or other hired guns who embraced his theory.”
As video evidence of jail and policy custody deaths proliferated—at least in comparison to the pre-Internet era—it’s clear that so-called ED death often occurs when officers or jail staff restrain suspects in a way that restricts their breathing. That might include multiple officers kneeling on the suspects back or stomach; the use of “spit hoods,” in which the suspect has a bag placed over their head; and handcuffing people in the prone position, including the wrists bound to ankles hog-tie restraint.
To this day, excited delirium pops up in news coverage of in-custody deaths. In an otherwise stellar New York Times investigation of how paid experts influence police brutality cases, excited delirium is stamped with validity. “In a civil case over Mr. Ruiz’s death, Dr. Vilke attested to the safety of neck holds that cut off blood flow to the head by compressing arteries, and another researcher, Dr. Charles Wetli, discussed excited delirium, a condition that some doctors say can suddenly kill drug users or the mentally ill.” [emphasis mine] The Times cites a single neurologist, Dr. Deborah Mash, who claimed she could determine whether excited delirium was a cause of death by inspecting a dead person’s brain, but her work has not been replicated by other scientists.
While the Times story suggests the diagnoses may be misused by paid experts, it nevertheless suggests that it exists—even though it’s not recognized by the American Medical Association or the American Psychiatric Association, and does not appear in the Diagnostic and Statistical Manual of Mental Disorders (DSM).
“It's really a shame because not only did this make it much more difficult for plaintiffs to prevail in these cases, but it also caused police agencies to start teaching their officers that it was perfectly safe to restrain people in a prone position and to put pressure on their backs,” Heipt says.
“Prior to that, they had begun training officers to turn people on their sides—immediately after they were handcuffed—and to be careful about putting pressure on their backs.”
The AMA took a position against excited delirium last year which was good since police appologists would point to a 2009 statement on tasers as an indication of AMA acknowledging the existence of excited delirium. It says:
"Confirms the AMA’s stance that current evidence does not support “excited delirium” as an official diagnosis, and opposes its use until a clear set of diagnostic criteria has been established
Denounces “excited delirium” as a sole justification for law enforcement use of excessive force
Underscores the importance of emergency physician-led oversight of medical emergencies in the field
Opposes the use of sedative/hypnotic and dissociative drugs—including ketamine—as an intervention for an agitated individual in a law enforcement setting, without a legitimate medical reason
Recognizes the risk that sedative/hypnotic and dissociative drugs have in relation to an individual’s age, underlying medical conditions, and potential drug interactions when used outside of a hospital setting by a non-physician "
Oakland and Antioch CA both now have very strong policy language protecting residents from positional asphyxia during police custody. It hasn't been reported on but other jurisdictions should be encouraged to follow suit.
Interesting subject. I looked at one 1998 CMAJ paper that reviewed these deaths:
Results: 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%]).
That was from this paper: https://pubmed.ncbi.nlm.nih.gov/9645173/
I have also seen a systematic review that suggested it is a real thing and I haven’t studied this in depth but I think you are right to express scepticism. The conclusion above rather leads me towards an Occam’s razor approach… Rather than some mystery and hard to define ‘delirium’ it seems far more likely people were simply asphyxiated. And one rather fears the system has colluded in hiding that fact.