Acute Behavioural Disturbance

Authors: Lauren Katherine Fraser, Alun Marc Henry, Nicola Moultrie / Editor: Johann Grundlingh / Reviewers: Stewart McMorran, Nicola Moultrie, Jessie Lynch / Codes: A5 / Published: 20/12/2021 / Reviewed: 25/04/2024

This module identifies the clinical features of acute behavioural disturbance (ABD) and covers the initial assessment and management of patients with ABD in the Emergency Department (ED).

After completing this session you will be able to:

  • Recognise the clinical features of acute behavioural disturbance (ABD)
  • Describe the main causes of ABD and its possible underlying pathophysiology
  • Describe the initial assessment and management of patients with ABD in the ED
  • List potential pitfalls in the management of patients with ABD


    1. The Royal College of Emergency Medicine (RCEM) Best Practice Guideline. Acute Behavioural Disturbance in Emergency Departments. February 2022.
    2. Royal College of Psychiatrists, College Position Statement PS02/22: ‘Acute behavioural disturbance’ and ‘excited delirium, 2022.
    3. American College of Emergency Physicians. White Paper Report on Excited Delirium Syndrome. ACEP Excited Delirium Task Force. September 10, 2009.
    4. Weapons and Protective Systems Technologies Centre. Special Panel Review of Excited Delirium. December 2011
    5. Mash DC. Excited Delirium and Sudden Death: A Syndromal Disorder at the Extreme End of the Neuropsychiatric Continuum. Front Physiol. 2016;7:435. Published 2016 Oct 13.
    6. Wetli CV, Fishbain DA. Cocaine-induced psychosis and sudden death in recreational cocaine users. J Forensic Sci. 1985 Jul;30(3):873-80.
    7. Mash DC, Staley JK, Izenwasser S, et al. Serotonin transporters upregulate with chronic cocaine use. J Chem Neuroanat. 2000 Dec;20(3-4):271-80.
    8. Ruttenber AJ, McAnally HB, Wetli CV. Cocaine-associated rhabdomyolysis and excited delirium: different stages of the same syndrome. Am J Forensic Med Pathol. 1999 Jun;20(2):120-7.
    9. Takeuchi A, Ahern T, Henderson S. Excited Delirium. West Journal of Emergency Medicine. 2011;12(1):77-83.
    10. Mash DC, Staley JK. D3 dopamine and kappa opioid receptor alterations in human brain of cocaine-overdose victims. Ann N Y Acad Sci. 1999 Jun 29;877:507-22.
    11. Schmauss C, Haroutunian V, Davis KL et al. Selective loss of dopamine D3-type receptor mRNA expression in parietal and motor cortices of patients with chronic schizophrenia. Proc Natl Acad Sci 1993; 90(19):8942-8946.
    12. Mash DC, Duque L, Pablo J, Qin Y, et al. Brain biomarkers for identifying excited delirium as a cause of sudden death. Forensic Sci Int. 2009 Sep 10;190(1-3):e13-9.
    13. Chan TC, Vilke GM, Neuman T, Clausen JL. Restraint position and positional asphyxia. Ann Emerg Med. 1997 Nov;30(5):578-86.
    14. Pollanen MS, Chiasson DA, Cairns JT, Young JG. Unexpected death related to restraint for excited delirium: a retrospective study of deaths in police custody and in the community. CMAJ. 1998 Jun 16;158(12):1603-7.
    15. Spraker T. Stress and Capture Myopathy in Artiodactylids. Zoo and Wild Animal Medicine. Current Therapy. 1993.
    16. Hall CA, Kader AS, Danielle McHale AM, et al. Frequency of signs of excited delirium syndrome in subjects undergoing police use of force: Descriptive evaluation of a prospective, consecutive cohort. J Forensic Leg Med. 2013 Feb;20(2):102-7.
    17. Calver LA, Stokes B, Isbister GK. Sedation assessment tool to score acute behavioural disturbance in the emergency department. Emerg Med Australas. 2011 Dec;23(6):732-40.
    18. Battaglia J, Moss S, Rush J, Kang J, et al. Haloperidol, lorazepam, or both for psychotic agitation? A multicenter, prospective, double-blind, emergency department study. Am
      J Emerg Med. 1997 Jul;15(4):335-40.
    19. Allam S, Noble JS. Cocaine-excited delirium and severe acidosis. Anaesthesia. 2001 Apr;56(4):385-6.
    20. McGugan EA. Hyperpyrexia in the emergency department. Emerg Med (Fremantle). 2001 Mar;13(1):116-20.
    21. Strayer RJ, Nelson LS. Adverse events associated with ketamine for procedural sedation in adults. Am J Emerg Med. 2008 Nov;26(9):985-1028.
    22. Parveen N, Excited delirium: term linked to police restraint in UK medical guide condemned. The Guardian [Internet]. 2021 July. [Accessed 2021 Sept 13].
    23. The Royal College of Psychiatrists. Follow-up on our statement regarding Acute Behavioural Disturbance (ABD), 2021.
    24. Dame Elish Angiolini. Report of the Independent Review of Deaths and Serious Incidents in Police Custody. Home Office. January 2017.

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