Beyond the excited delirium controversy: two forensic cases and contemporary literature review

Excited Delirium Syndrome remains one of the most controversial topics in contemporary forensic pathology. Although the term has been increasingly challenged because of the lack of universally accepted diagnostic criteria and formal recognition within major nosological systems, episodes of severe psychomotor agitation associated with sudden death continue to represent a significant clinical and medico-legal concern. We report two cases of sudden death occurring during physical restraint in individuals presenting with severe agitation. The first case involved a 60-year-old man with a history of depression who threatened suicide by defenestration and was restrained by family members in a prone position with his limbs bound. The second case concerned a 40-year-old man with psychiatric comorbidities and a history of alcohol abuse who exhibited aggressive behaviour in a public setting and was restrained by police officers and healthcare personnel during transport to the hospital. These cases highlight the diagnostic challenges associated with deaths occurring during episodes of extreme agitation and restraint. In the absence of pathognomonic post-mortem findings, diagnosis requires a thorough multidisciplinary evaluation and careful exclusion of alternative causes of death. A narrative review is also provided to outline the current state of knowledge on the issue. Furthermore, the ongoing debate surrounding the terminology should not obscure the existence of a clinically recognisable syndrome characterised by acute agitation, altered mental status, and autonomic dysregulation. Collaboration among forensic pathologists, clinicians, toxicologists, psychiatrists, and law-enforcement personnel is essential to improve diagnostic accuracy, patient management, and medico-legal assessment in these complex cases.