In 2021, the Royal College of Psychiatrists (RCPsych) issued a position statement on Acute Behavioural Disturbance / Excited Delirium. It caused a little consternation which I covered briefly on the blog, and today, they have issued a much more comprehensive, 45-page document on the same topic, replacing last year’s publication (which is now withdrawn from the internet). The reaction to the 2021 document was almost as problematic as the document itself, so for what my view’s worth, I’m glad they revisited it and have published something much more comprehensive. It’s worth noting, this latest position statement comes in the same year the Royal College of Emergency Medicine updated its guidelines on ABD (2022).
ABD / ExD, as the new document points out, has always been a difficult topic to consider – these are terms without a precise definition. On occasion, they are offered as if they are a diagnostic label, but which do not relate to any recognised mental or medical disorder that is contained within the International Classification of Disease or the Diagnostic and Statistics Manual, the major manuals classifying mental health conditions and disorders of various kinds.
Further confusion arises from fact there are two terms: ADB / excited delirium – are inter-changeable, relating to the same concept or is ExD just one type of ABD amongst others? Arising from all of this, medical argument has always been fairly tricky because professions use these terms in various ways, for differing reasons and it is acknowledged there is a gap in research and understanding about what, precisely is doing on for people to whom this label is correctly and incorrectly ascribed.
I first covered this topic on the blog in its earliest days (2011/12) and have written about it a number of times as various inquests and position statements have been issued over the years —
“You’ve may heard the term ‘Excited delirium’? I wrote a post 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?”
Here’s the punchline from a legal point of view: HM Coroner’s give these labels as contributory factors to death, often after hearing expert medical evidence so regardless of the research gaps acknowledged by the RCPsych report, it’s not safe or practical to just argue “this is not a thing” and whilst that scientific debate goes on, police, paramedics and others will be answering 999 calls where they must make complex decisions in time-critical situations about whatever they think is going on and this RCPsych document has a wider scope than anything that precedes it – 45 pages of material gives us that obvious clue. The first chapter covers the history of the terms; the second sets out why RCPsych believe a psychiatric perspective on this is crucial; the third chapter sets out the evidence base for what we currently understand and the fourth covers broader social contexts and how they influence the use of the terms. The fifth and final chapter argues what needs to happen next.
The first thing to note is the report’s argument is that whilst further research and inter-agency guidance is developed, the key is to understand that some people to whom the ABD label can be applied are in a physical healthcare emergency and need rapid removal to an Emergency Department for skilled care. However, it also notes that the vague nature of some guidance on the topic means the label will be misapplied as well. My immediate reaction to this was to wonder if it could ever be otherwise based on current knowledge? – if we know that ABD is not well-defined and that agencies use the term differently, how could we have a situation where police or paramedics reacting in a perceived emergency get it right even most of the time? If you do contrast this document even with the RCEM guidance published only a few months before, you will see how even the most up-to-date guidance from emergency medicine specialists has the scope to lead to false positives.
But this is true with other healthcare issues, isn’t it? – I’m assuming we know much more about heart-attacks and strokes, which each require urgent removal to emergency departments, but not every suspected heart attack proves to be one, but it’s usually best not to take the risk if you think it may be!
We have always known cases of suspected ABD / ExD can become controversial because of restraint – people exhibiting the signs or indicators to which RCEM and RCPsych allude are liable to find the police are called because of concerns around disorder and potential harms. As this report makes clear in an appendix, there have been a number of inquests in His Majesty’s Coroner’s Courts which have had to understand incidents where restraint was used and it has been found in a number of those cases that restraint was disproportionate in one or more ways and that consideration of emergency medical care was absent or insufficient rapid. We’ve always known: restraint interventions are not without risk, even if a judgement has been formed that it may be justified, relative to other risks a person would face or pose at the time.
Of course, the report re-emphasises what has been a feature of guidance for some time, that restraint should be avoided where possible and minimised (both in nature / duration) where it cannot be avoided. Before restraint or as soon as possible following any intervention that cannot be delayed, (para)-medical support should be sought to assist in safe management and, often undiscussed, as a contingency for any untoward, adverse developments whilst being conveyed to an emergency department.
We cannot leave unmentioned the issue of disproportionality in racial terms either, and the report doesn’t. Highlighting various concerning narratives, the report reminds us that ABD / ExD labels and incidents involving restraint disproportionately apply to vulnerable black men with mental health problems (and who, incidentally, have often had difficult experiences with mental health services prior to police contact). That needs acknowledging in the context of the work called for by the report, that agencies continue to improve their guidance and training in coming years.
MENTAL HEALTH EXPERTS
The only issues I have with this report and those which arise from the real world reality of this work. Accepting that psychiatrists and mental health nurses often have considerable experience in the management of patients in acute distress, exhibiting signs consistent with ABD / ExD, it’s also fair to remember those cases where things went badly wrong in psychiatric care where restraint interventions were undertaken. I do think it’s also fair to wonder about the reality check of including greater input from mental health experts in training of agencies. We know coroner’s have had to advise recently about the perception that mental health professionals are experts and I also note the report’s observation that ABD can arise from physical healthcare emergencies OR be the cause of physical healthcare emergencies. We know, for example, that police have dealt with ABD emergencies only to learn latter the patient was suffering from pre-existing brain injury or illness, nothing to do with their mental health, per se.
There is then the reality check of how available mental health professionals or experts are in these kinds of cases. If we imagine police officers called to a situation where they believe ABD pathways are required, they may do their best to contain, not restrain and call for an ambulance to assist them. In case someone is thinking about the potential for so-called street triage schemes to secure that expertise, it’s worth remembering they cannot physically attend most incidents referred to them and where they do, it’s often a one-hour response time, way longer than 999 crews have to use when responding to an ABD incident. Mostly, even where done correctly, officers will secure an ambulance if they can and remove someone to an Emergency Department where the first mental health professional may be available, from psychiatric liaison in ED – that will usually be 30-60mins after first contact in the street.
Finally, a short point on de-escalation: it’s been common over the last decade to hear discussion of the need for the police to improve de-escalation training for officers, especially when dealing with those of us affected by our mental health. Whenever I hear about this, I always remember conversations with restraint experts, including those who researched restraint in mental health nursing, and their view that police officers are often very good at de-escalation and remembering my own view which I expressed at a Home Affairs Select Committee inquiry that the police do train de-escalation, but they simply don’t call it that. There are plenty of examples of where officers have patiently negotiated with people to avoid restraint or where restraint has been minimised whilst removal to emergency settings occurs and I have direct personal experience of this — none of which means anyone should be complacent or that training in any agency is perfect, because it’s not.
ACUTE BEHAVIOURAL DISTRESS
Once upon a time, ABD meant acute behavioural disorder and it was use of ‘disorder’ which led to objections the term was overly clinical in nature, despite being unmentioned in diagnostic, medical manuals. We now find the current terminology is ‘disturbance’, which has various connotations of its own. The RCPsych report calls for a more “humanising” term, whilst recognising the utility of a short phrase or acronym which is understood consistently across professions to enable swift responses. For what my two penneth is still worth, I’d put in an argument the D should mean ‘distress’, for that, in my experience is usually what is going on. Disorder is too medicalised; disturbance is two legalised – distress is about people and their experience and it remains descriptive in nature, focussed on the person themselves, not perceptions of them or their impact on others, whilst being neither overly-medicalised or legalised.
This position statement is welcome: but much remains to be done and until then, police officers need to remember that not all the healthcare professionals with whom they come in to contact are trained as we might imagine and it’s important officers understand that where they think ABD is in play:
- Avoid or minimise restraint (its nature and duration) – de-escalate to the extent you can, taking as long as you must to do so.
- Call for an ambulance and ensure swift removal to ED
- Ensure a clear legal basis for the intervention (whether that be s136 MHA or arrest).
- For any healthcare professional advising against ED or unclear about what may be required: “Are you able to confirm ED is not required, despite my concerns about an ABD emergency?” — and get that on the record somewhere (like BWV).
Winner of the President’s Medal,
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
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.
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