The Guardian newspaper in the United Kingdom recently published an article about Acute Behavioural Disturbance (ABD) and also referencing Excited Delirium, which may or may not be the same thing – we might get on to that in a moment. The article “reveals” what anyone reading this blog will have known for over a decade: that these terms and the incidents, humans and other contextual and involved “things” which give rise to their use are controversial, unagreed and subject to ongoing debate and discussion within medicine and science.
So, I wearily write … “Here we go again.” Because none of this is new and none of this is a revelation, either. It’s an article of the type we seem to regularly see, pointing out problems, offering no solutions and telling us nothing new. It’s valid to keep chipping away at problems after all: that’s what this website has been trying to do for over twelve years now(!) and I first wrote about this topic in my fourth ever-post, in November 2011, the month the website began.
The very first paragraph of that post reads —
“The question of whether excited delirium (ED) is a real medical condition is way above my pay-grade. But in reality, police officers find themselves refereeing an aetiological debate by arbitrating various doctors’ views. Decisions about how to respond to someone suffering from this ‘syndrome’ contain no shades of grey: because ED (syndrome) is either a real medical condition which needs to be regarded as a medical and psychiatric emergency where life may be at risk, or it is not.
The Guardian article invokes the United States’s handling of this term to help us understand whatever point they’re trying to make, pointing out California has banned use of “excited delirium as a diagnosis” or any kind of term to explain the deaths of “mostly black and brown people in police custody”. I’m not sure how this helps us much, quite honestly – the UK’s medical authorities have never, to my knowledge, stated excited delirium was a “diagnosis” so we don’t need to ban it and notwithstanding the disproportionality arguments about race, ABD is a term encountered in medical, non-police contexts.
The article acknowledges this, as it does acknowledge the use of ABD as an “umbrella term” by mental health services.
A ROSE BY ANOTHER NAME
Whatever ABD is or isn’t, whether it’s a “thing” or not, whatever name you want use to describe people presenting where the question arises … what everyone seems to be agreed on is emergency medical intervention is required. Yes, restraint only makes thing more difficult and precarious and time is of the essence, but that doesn’t mean it’s avoidable and I know this from years professional experience.
I’d prefer to suggest ABD is nothing more than a descriptive term – think of the words: Acute. Behavioural. Disturbance.
It should, in my view, be used only where someone’s behaviour is acutely disturbed, for whatever reason – and I do mean acutely. And we know behaviour can be acutely disturbed for a range of reasons, including mental illness, head injury, brain infection, Addison’s disease (a kidney condition) and drug use to name just a few. I’ve never thought of ABD as the condition or the “thing” but a consequence in some cases of other conditions, for whatever reason. And whenever I’ve talked about it in that way without those who stuck in at school and know more about this than me, I’ve never known disagreement – for whatever that’s worth.
I’ve recently created a specific page of resources for ABD and you can read more about all of this there — not that it settles any debates about controversial or disputed medical terms! But what you will find there, for example, is an emergency medical blog called St Emlyn’s — it is a properly serious attempt by professionals in emergency medicine to use social media for educative purposes within their professions. Their post on ABD points out that whatever is going on, those presenting in a way where the ABD label gets use have a 10% mortality rate – ten percent! I’ve heard that figure elsewhere, too – from a consultant in emergency medicine who lecturers on advanced paramedic training in which I was also involved.
So when we are discussing actions taken by the police, ambulance or other emergency services, we have to remember that doing nothing is also playing with risk, of poor and fatal outcomes. Yes, intervention can raise risks because of restraint and its impact on someone physiologically, but this doesn’t mean it’s not the appropriate decision.
THOUGHT EXPERIMENT
Imagine you’re the police officer or paramedic. Think about this thought thing —
“You have someone, possibly mentally ill or on drugs or both, possibly suffering from another medical condition – you just don’t know. He’s running about in a busy public road with a high speed limit in the dark, he’s obviously disoriented and distressed, perhaps psychotic and he’s resistant to communication, interaction or de-escalation and harming himself by hitting his head on the floor … police or paramedics on scene have been told about risky behaviours leading to the 999 call and feel the person may be someone to whom the ABD label may apply and he needs emergency medical intervention, possibly involving drugs which only doctors can provide.
If fearful of ABD it means there could be fatal outcome from whatever is going on for the patient, the environment and context adds risk (vehicles, nearby ditches other members of the public) and an intervention by restraint can also add risk.”
What do you want these frontline emergency workers to do, specifically — containment and negotiation may or may not be possible and even if it were, remember the potential for a fatal outcome if you do nothing because of whatever’s happening medically and remember time can be of the essence.
Are you going to —
- Do something – which brings the person in to an emergency medical setting where RCEM guidelines on ABD can be considered by consultant’s in emergency medicine.
- Do nothing – which doesn’t bring them there for that? … and what do you do instead?!
Remember: waiting for medical Royal Colleges or the Guardian to settle uncertainties in the science is not an option that will help you tonight — you’re either doing something to get this person to ED or you’re not. If you are going to do something, how and when you do it will matter, but the are secondary considerations which apply after you’ve made the crucial decision about whether to intervene or not.
Don’t confuse the two things.
ADAM STONE
Nobody in these discussions talks about the tragic death of Adam Stone in 2019, do they? It’s not a name which anyone remembers, alas – apart from the poor guy’s family who I met on the night Adam died. I was the duty inspector for the incident in Solihull, Adam having been detained by two of my officers who recognised everything in need of recognition and whose considered, fast actions involved getting him Heartlands’ Hospital in Birmingham – Adam’s situation was the “thought experiment” used above.
He presented in extreme, acute distress and my police officers called for an ambulance and did their best for him until it arrived – they absolutely attempted to contain, not restrain but eventually that became untenable. I’m not going to summarise things any more than that because I’d like all of you still reading to look at the actual Preventing Future Deaths report from Her (now His) Majesty’s Coroner for Birmingham and Solihull, Emma Brown. It is detailed and addresses everything I’ve written above and elsewhere including the adequacy of police training and the appropriateness of restraint in that circumstance.
You’ll notice, despite the fact restraint may have impacted negatively upon Adam’s situation, the Coroner has described it as “appropriate in the circumstances” and the PFD notice was not sent to the Chief Constable of West Midlands Police – it was sent to the ambulance service. And nobody is telling you about the cases where officers and paramedics have intervened on these kinds of basis and removed people to Emergency Departments where they were treated effectively and recovered from all manner of conditions which gave rise to their ABD, inc drug use, brain infections, serious mental illness and head injury, using exmamples made known to me over the years.
Nobody wants to talk about the lives saved or at least helped, usually because they don’t know about them because they weren’t there in the dark, doing it and helping people. Whilst this scientific debate rumbles on, people will keep presenting to the emergency system, Coroners will keep talking about this, demanding training and “awareness” and people will be losing their lives. Whatever the labels you want to use, can we please have constructive debate about what we want the police, paramedics and mental health professionals to do, when they are dealing.
Answers to that are still required even if you don’t have all the answers you’d like to scientific questions.
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, 2024
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 