This post was originally written in the middle of 2021 and I recently went looking for it on the site and couldn’t find it … it turns out I forgot to publish, having completed it! It’s relevant to something coming up soon in 2022, so I’m publishing late. Just bear in mind it’s already over a year old and the Royal College of Psychiatrists has taken down the position statement to which this post relates from its website – the first hyperlink in the piece doesn’t work!
In addition, this piece referenced the 2016 guidance from the Royal College of Emergency medicine, noting it’s use of the word ‘illness’. Since writing, RCEM have updated their guidance and removed use of this word, which continues to help make the point of the post. The RCEM link below is to the 2022 guidance, the previous edition having been removed from the internet.
I also note with sadness my reference to Her Majesty’s Coroner’s Courts – now His Majesty’s.
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This week’s statement from the Royal College of Psychiatrists (RCPsych) on use of the terms “ABD” (acute behavioural disturbance) and “excited delirium” re-opens a debate that has been running, literally, for decades. What do these terms mean, if anything; and can they or should they be used? The statement’s publication adds weight to how I’ve chosen to look at this topic since I began writing this blog ten years ago which is to suggest it leaves questioned unanswered. If you open the menu function of the blog (top right hand corner) there is a search box which works like Google, for this website. Search against the three letters “ABD” and it will bring back at least six posts with that in the title and various others where such alphabet appears in the post itself. If you search for the two terms covered by the RCPsych statement (“Acute Behavioural Disturbance” and “Excited Delirium”), it will return even more, including one written as long ago as 2011.
Re-reading them as I have, they collectively highlight a large number of cases which tragically ended up in Her Majesty’s Coroners’ courts. Those cases consistently highlight the discussions, debates and controversies which exist around the terminology and the “lack of awareness” and inconsistency amongst agencies. There are various Preventing Future Death reports which call for increased awareness, not just within the policing but including ambulance and probation services. I don’t recall writing about this before without making the point front and centre that terminology, classification and concepts are disputed and debated. My post from December 2015 opened a tounge-in-cheek way of thinking about it all —
“You’ve may heard the term ‘Excited delirium’? I wrote a blog on it a few years ago. You may also have heard the term ‘acute behavioural disturbance’ or ‘acute behavioural disorder’? … these things may, in fact, be the same thing. Or they may not be the same thing. Actually, it may be three separate things or they may not even be a thing. Or things.
I hope I’ve cleared up the science behind these terms for you?”
MORE UNCERTAINTY
The RCPsych statement adds more to this observation because of what it doesn’t say and it’s very specific in what it does. We have, frankly, heard psychiatrists say things along these lines before sometimes attributing the use of terminology to policing and offering its quasi-diagnostic sounding existence to attempts to justify or even medicalise deaths during restraint or following contact. Of course, the potential complexity of all this is exceeded only by its sensitivity – this has been the stuff of high-profile inquests for decades and at the point where I learned of this statement and a supporting statement by a major mental health trust, my immediate thought was to wonder what the Royal College of Emergency Medicine (RCEM) and the College of Paramedics (CoP) thought of it all?
Both organisations have made their own contributions to this debate in the last five years – RCEM has issued a guideline on this topic and updating their 2016 guidance in which they described ABD as an “illness”, a word now absent from the 2022 edition; the College of Paramedics issued a position statement on their website in 2018. This might not be the obvious contradiction it may seem at first: RCEM is not advocating that ABD is a diagnosis or syndrome and that’s what RCPsych seem to be refuting. I’m not aware that anyone thinks it’s a diagnosis or a syndrome, do they? RCEM acknowledge there is no standardised definition but their use of the word “illness” gets us in to distinctions I’m not sure I’m qualified to make or that I need to make, but it’s interesting to note they removed this word in the 2022 edition.
“ABD, or as it is also known ‘Excited Delirium,’ is the presentation of features of “acute delirium” and hyper-adrenergic autonomic dysfunction and must be considered a medical emergency. Its presentation is associated with sudden death in approximately 10% of cases. High profile deaths of individuals displaying features of ABD have occurred whilst they have been in police custody. This has attracted much media coverage and ABD has become a controversial and emotive illness with significant distress to families involved. The early recognition, intervention and proactive treatment of ABD, with a collaborative response between the Emergency Services (police, paramedics), is likely to result in fewer deaths.” [Bold emphasis is mine.]
So what is the difference between what RCEM call an illness and what RCPsych say is not a diagnosis or syndrome? I’ve no idea and would welcome clarification. But whilst others are pondering that, RCPsych are staying these terms are used to “describe people who are behaviourally disturbed and have a physiological deterioration including risk of death, because of their behavioural disturbance and/or psychoactive substance use”. So if what we agree we’re discussing is people who may die (with or without restraint), I’m not sure I’m too concerned about whether terminology means something very specific in a particular medical context or whether three Colleges agree or are just saying the same thing in different ways. It strikes me as much more important to just ensure the ability of police, paramedics and probation (etc) to spot those people at risk of such deterioration from those who are not; and being alert to the potential for an intervention to make things more difficult. Nobody seems to be contradicting the notion that presentations which are subject to these labels don’t require urgent removal to an Emergency Department, preferably by ambulance in circumstances where we have tried to the maximum to de-escalate situations and minimise restraint.
THE REAL QUESTION
It shouldn’t need pointing out, that where Coroners and their juries have concluded with findings that involve use of those terms, they have invariably heard expert medical evidence. This will often include multiple opinions from various consultants in such specialisms as pathology, psychiatry and emergency medicine as well as other experts in toxicology where necessary as they investigate a cause of death. Coroners who have gone on to produce Preventing Future Death reports which touch upon these matters calling for training and awareness (and not just within policing) after specifying ABD as at least one factors in a cause of death, often alongside others including restraint.
That’s been the key issue at inquests (including one named by RCPsych) – the conclusion of the Leon Briggs inquest did not mention “ABD” as a cause of death, but it was discussed in some detail during proceedings. One of the findings in that case was that police and paramedics had failed to recognise Mr Briggs’s presentation as a medical emergency or potential ABD and to remove him swiftly with minimised restraint to an Emergency Department. Call this whatever you like … classify things however you think best – it’s not the most important thing to the professionals who have to make decisions. What we’re asking them to do is spot those at risk of physiological collapse and whose collapse may be increased in likelihood by the use of restraint. Be as careful as possible whilst removing them to an Emergency Department but get them there quickly – that is what needs emphasising in cases where the “ABD” question arises. I’ve never seen this label as anything other for short-hand that there’s an agitated state that amounts to an emergency.
And that brings us to the big discussion:
RESTRAINT
I don’t think anyone questions that all restraint is inherently risky – and I do mean ANY degree of restraint, even if the risk is just minor injury, it’s always there. The more prolonged or intense any restraint may be, the more it may add to a situation which may already be inherently risky, if not precarious. But that also does not mean that restraint is avoidable.
In some situations where Coroner’s conclusions have involved use of ABD terminology, police were responding to situations where we might wonder if restraint could have been avoided or minimised. Of course, there have been situations where juries have made it clear they were being highly critical of unnecessary and / or excessive force, amounting to neglect in law. There have also been inquests around situations where someone was covered in blood. Who’s to say on first arrival whether that is someone seriously bleeding because of injury or who is covered in someone else’s blood, for whatever reason? Either way, it either means we have someone who could be bleeding out (exanguinating) or who has potentially harmed others seriously and poses an ongoing risk. Difficult to see how you can always de-escalate a situation if you have to comprehend either (or both) of those possibilities and be responsible for broader public safety without using any restraint at all. Of course, not all situations are anything like as grave – some presentations which have given rise to question around ABD are about someone’s agitated presentation and no doubt, their frightened response to being confronted or restrained by police officers has exacerbated a situation.
It has to be right that we consider the potential for police presence or restraint to have escalated a situation and whether that was avoidable or manageable in a less restrictive way but we also need to recognise the complexity of what we ask professionals to deal with. In a recent inquest conclusion, a jury found that police restraint of a man had contributed to his death (along with other medical factors). However, they also made the point that restraint was justified in the circumstances. This sounds at least a little counter-intuitive, doesn’t it? – it’s not absolutely clear from the coverage but I suspect it would come down to whether or not the police use of force was considered reasonable on its own terms because officers did not know of an underlying heart condition and other complicating factors.
POST-SCRIPT
Having co-presented on advanced paramedic training alongside Consultant Paramedics and Emergency Medicine Consultants, I vividly recall hearing such qualified people outlining to those qualifying that ABD carries a 10% mortality rate; and that 10-20% of ABD results from acute psychiatric disturbance. College of Policing guidance on ABD is derived from medical guidance (inc the RCEM document) and it’s available publicly. It’s open to challenge if we want to be picky because it lists those factors indicating ABD as ‘symptoms’ and presumably there could be objection to that if it’s not a disease or syndrome? But RCEM (whose document is linked in the guidance) says it’s an “illness”, so how wrong is it, precisely?! … and if it helps prompt alarm bells around RED FLAGS which require removal to ED, how much does it matter as long as restraint is minimised as care is sought to ensure more skilled assessment and treatment?
No doubt, this debate will continue – it’s decades old already and I do wonder if this latest contribution tells us anything new?
There is more ABD content on my specific ABD resources page.
Winner of the President’s Medal,
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2021
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
Mental Health Cop 