There are some new documents worth noting on the subject of Acute Behavioural Disturbance —
You will find a number of posts on this topic across the history of the blog (open the site menu, top right corner, for a search function if you wish to look them up using that search term of ‘ABD’). This post will be necessarily brief just to provide the hyperlinks and the highlights but I’m going to quote from one of my own posts from December 2015 to remind us where we started and where it seems we still are, on the science and terminology of all this —
“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?”
ABD remains a subject of medical and legal contention, reflected in these documents and the second document in particular highlights the need for more research and collaboration to improve multi-agency responses to incidents where we sometimes find this term is considered of some relevance.
- Firstly, the Royal College of Emergency Medicine has published updated guidance about ABD in the Emergency Department (2022) – this replaces guidance published by them on this topic in 2016 and which is quite widely linked throughout this blog. I will try to update the hyperlink on the posts where possible, but I’ve certainly updated it on the “BIG REPORTS” page in the resources (see menu).
- Finally, the Royal College of Psychiatrists has published a position statement on ABD / Excited Delirium (2022) – this follows from a previous statement published in 2021 which received some critical attention. I will be blogging more specifically on this report, but suffice to say it is a definitive improvement on what it replaces and it calls for greater inter-agency collaboration to formulate joint protocols for responses and for a change in terminology.
WHERE ARE WE NOW?
As I noted years ago, it’s still worth remembering that ABD is “not a thing” – at best, it’s still just a descriptive term and no kind of official medical diagnosis or disease condition. I’ve heard some describe it as a syndrome, but you’ll see these new publications stay away from that, for the most part. Not withstanding the ongoing medical debates about how to define and taxonomise ABD, including considerations across specialities like psychiatry, emergency medicine and pathology, the fact remains that legal systems end up reflecting on ABD as a concept is often because medical experts of various kinds in those cases have used the term or something that amounts to it. It is often (but not always) raised in cases where the patients were from minority ethnic groups and the RCPsych document and that adds extra considerations about attitudes in both health and criminal justice towards young black men, in particular.
This has always been my major point: regardless of this ongoing and ultimately unresolved debate which I know will outlast me, we do know (and both documents highlighted here state) that some of the people to whom this label is attached are at risk of physiological collapse and death. I’ve heard some emergency physicians in delivering CPD to advanced paramedics state that there is a 10% mortality rate (albeit the RCPsych document states it is not, of itself a cause of death) and that adverse outcome rate increases if there is an intervention by restraint to protect that person or others. Whatever is going on here, it’s very serious business deserving of close attention, whether or not it is a “thing” and both documents take this forward.
The latest advice, however, appears to remain essentially the same: de-escalation; avoid or at least minimise restraint to the degree that you can (nature and duration); ensure emergency medical attention from paramedics and swift removal to an Emergency Department for full clinical consideration – agencies and professionals need to support each other whilst leaders in those agencies continue to work on ensure better system conditions across professions to maximise the probability of safe outcomes.
My question of all this: the RCPsych document highlights a number of cases in an appendix where ABD has featured as a consideration, of course each of which occurred in a locality and there was obvious learning to be had in many of them, reflected in Preventing Future Death reports from coroners.
Has area X learned the lessons from area Y’s tragic incident?
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the Royal College of Psychiatrists.
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All views expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2022
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