How a term widely debunked by medical groups came up in D’Vontaye Mitchell’s death inquiry

George Floyd, Elijah McClain, Daniel Prude – and now D’Vontaye Mitchell – all share something beyond being Black men who died at the hands of public safety personnel: Authorities described the possibility of “excited delirium” in connection with the victims’ behavior just before death.

The diagnosis used by first responders and others across the country is a controversial one.

“There is not a single major US medical association that supports the term,” said Joanna Naples-Mitchell, a Physicians for Human Rights US research advisor and co-author of the group’s 2022 report calling the phrase “scientifically meaningless” and advocating its abandonment.

“Medical examiners and coroners – as well as law enforcement and the courts – should no longer use this baseless term to explain deaths in police custody,” she told CNN on Thursday; Naples-Mitchell is not related to D’Vontaye Mitchell, the group’s spokesperson said.

Still, “excited delirium” remains in use.

While it was not a cause of death given for Mitchell – who died June 30 after workers at a Wisconsin hotel pinned him to the ground – the Milwaukee County Medical Examiner’s investigator wrote in a report released with his death certificate she’d been advised “the initial behaviors of Dvontaye (sic) (were) appearing to possibly be excited delirium in nature.” The agency declined Thursday to comment further on why it used the phrase.

Officers in many police departments have been taught to look for “superhuman strength” and “police non-compliance” as some symptoms of excited delirium: a syndrome that could kill the subject of an emergency call or induce that person to kill emergency responders.

The term, however, has become a “catch-all for deaths occurring in the context of law enforcement restraint, often coinciding with substance use or mental illness, and disproportionately used to explain the deaths of young Black men in police encounters,” states the Physicians for Human Rights report also authored by doctors at Harvard, the University of Michigan, Massachusetts General Hospital and a civil rights lawyer.

The National Association of Medical Examiners does not endorse or recognize the term, though it acknowledges forensic pathologists have used it as a cause of death, its president Dr. J. Keith Pinckard told CNN on Friday, pointing to his group’s 2023 statement on the issue.

“Instead, NAME endorses that the underlying cause, natural or unnatural (to include trauma), for the delirious state be determined (if possible) and used for death certification,” he said, adding his organization doesn’t comment on particular cases.

The reference again to excited delirium in connection with Mitchell’s death perhaps owes to the term’s decades-long use among US first responders. And, as with the cases of Floyd, McClain and Prude, it could be key to how the public and the courts come to view the encounter that ended in his death.

Mitchell, 43, died after he was dragged across the floor, punched and kicked moments before the four hotel workers – who have since been charged with felony murder in connection with his death – pinned him down for about eight to nine minutes outside the hotel, surveillance footage shows.

Just before that, Mitchell had entered the building in what appeared to be a frantic state, hid behind objects in the lobby, tried to lock himself in a women’s restroom and became combative with security, according to the medical examiner’s investigation report, which mentions excited delirium once and doesn’t draw any conclusion about it.

But nothing about Mitchell or what he did right before he died reflects excited delirium, Mitchell’s family lawyer said Thursday, noting the term itself has been “debunked.”

“No, Mitchell was not experiencing excited delirium,” attorney William Sulton wrote to CNN. “Excited delirium has been debunked as a theory. It was shameful for the medical examiner to even suggest it. But it is consistent with how government officials in Milwaukee have treated Mr. Mitchell’s death from the beginning.

“The first public statements from the police department were that the circumstances did not give rise to a criminal investigation. … He died because he was beaten to death and jumped on, as shown by the clear video footage.”

Mitchell died from “restraint asphyxia and toxic effects of cocaine and methamphetamine,” according to an autopsy report released August 2 by the medical examiner’s office. The manner of death is homicide, the report states.

While in Mitchell’s case it was the medical examiner’s office mentioning the victim’s behaviors as “appearing to possibly be excited delirium in nature,” the term also has roots in policing instruction.

With law enforcement often required to make split-second decisions to preserve their own and their subject’s safety – potentially by using force – an umbrella term like excited delirium can help facilitate training, Sgt. Tony Lockhart, crisis intervention trainer for King County, Washington, told CNN in 2022.

“You call it whatever you want; I see these behaviors.” Aggregating them into one idea, he said, is “helpful in some areas, to at least give us a different title to think about.”

In Lockhart’s 40-hour classes on excited delirium, he told officers: “You are not here to learn how to diagnose. You’re looking at these behaviors so that you may alter your techniques to get a good solution so everybody’s safe.”

“Pain tolerance,” “unusual strength,” “agitation” and being “inappropriately clothed” were potential features of the syndrome listed in a 2009 American College of Emergency Physicians white paper of which the group last year officially withdrew its approval.

Police officers also learn in academy training to restrain and control a subject until medics – who are supposed to make any medical diagnosis – get to the scene.

“Training typically involves recognizing signs of ED (excited delirium) and summoning emergency medical services immediately in such cases,” Sherri Martin, national director of wellness services for the National Fraternal Order of Police, told CNN in 2022. CNN reached out last week to the 373,000-member organization for any update on its position.

But a disconnect between first responder training – based on the handful of studies that validate excited delirium – and most academic medical literature can have first responders acting out of step with the medical community.

“Police officers often feel like they’re caught in the middle,” Martin previously told CNN. “They’re not thinking about all of these other voices. They show up to work every day to answer the calls, to do their job, and they want to have the tools and the knowledge to do the best job that they can.”

The problem with excited delirium goes deeper than the phrase itself, Dr. Michele Heisler, the Physicians for Human Rights medical director and a professor of public health and internal medicine at the University of Michigan said in 2022.

“People can become agitated or delirious due to multiple factors, ranging from alcohol withdrawal, drug overdose, psychosis,” she explained to CNN at the time.

Indeed, the term is not listed in the World Health Organization’s International Classification of Diseases nor the Diagnostic and Statistical Manual of Mental Disorders, tools seen as the standard for medical diagnosis across the world. The American Medical Association does not support it as a diagnosis, and the American Psychiatric Association, which does not recognize it as a mental disorder, referred to it in 2020 as “too non-specific” and its criteria unclear, adding no rigorous studies had been done to validate it.

Beyond that, “this pseudo-diagnosis is scientifically meaningless and rooted in racism,” Naples-Mitchell said last week.

While there is no national database tracking cases of “excited delirium” deaths in police custody, data in one study cited by the Virginia Law Review showed that from 2010 to 2020, “there were 166 reported instances where a person died in police custody and excited delirium was described as a possible cause of death.” Black people made up 43% of those deaths but only 13.7% of the US population, US Census data show.

Physicians for Human Rights argues the “underlying causes” often associated with excited delirium “require medical attention rather than forcible restraint by police,” Heisler has said.

The perspective is spreading. The American College of Emergency Physicians last year took excited delirium off the table in court cases – in which it had become influential – making the group “the final professional medical or psychological or psychiatric association to repudiate the term,” Heisler said at the time.

Meanwhile, California in October became the first state to ban official use of the term, with Colorado and Minnesota doing the same this year, Physicians for Human Rights told CNN this week. New York and Hawaii are considering legislation to follow suit.

“‘Excited delirium’ has been entirely debunked,” Naples-Mitchell said, noting “it will take time to undo this damage and educate individual physicians and police agencies across the country.”

As to its citation in the medical examiner’s report of D’Vontaye Mitchell’s death: “‘Excited delirium’ is not a valid medical condition,” she said. “So, it is inappropriate, inaccurate and harmful to describe D’Vontaye Mitchell’s behavior as potentially ‘excited delirium in nature.’”

Correction: An earlier version of this story attributed a quote to the wrong Physicians for Human Rights staff member.