CIWA-Ar

Date:

Name:

Clinical Institute Withdrawal Assessment of

Alcohol Scale - Revised

NAUSEA AND VOMITING TACTILE DISTURBANCES

Ask “Do you feel sick to your stomach? Have you vomited?” Observation. Ask “Have you any itching, pins and needles sensations, any burning, any
numbness, or do you feel bugs crawling on or under your skin?” Observation.
0 No nausea and no vomiting
1 Mild nausea with no vomiting 0 None
2 1 Very mild itching, pins and needles, burning or numbness
3 2 Mild itching, pins and needles, burning or numbness
4 Intermittent nausea with dry heaves 3 Moderate itching, pins and needles, burning or numbness
5 4 Moderately severe hallucinations
6 5 Severe hallucinations
7 Constant nausea, frequent dry heaves and vomiting 6 Extremely severe hallucinations
7 Continuous hallucinations

TREMOR
Arms extended and fingers spread apart. Observation. AUDITORY DISTURBANCES
Ask “Are you more aware of sounds around you? Are they harsh? Do they
0 No tremor frighten you? Are you hearing anything that is disturbing to you? Are you
1 Not visible, but can be felt fingertip to fingertip hearing things you know are not there?” Observation.
2
0 Not present
3
1 Very mild harshness or ability to frighten
4 Moderate, with patient’s arms extended
2 Mild harshness or ability to frighten
5
3 Moderate harshness or ability to frighten
6
4 Moderately severe hallucinations
7 Severe, even with arms not extended
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations
PAROXYSMAL SWEATS
Observation.
VISUAL DISTURBANCES
0 No sweat visible Ask “Does the light appear to be too bright? Is its colour different? Does it
1 Barely perceptible sweating, palms moist hurt your eyes? Are you seeing anything that is disturbing to you? Are you
2 seeing things you know are not there?” Observation.
3
4 Beads of sweat obvious on forehead 0 Not present
5 1 Very mild sensitivity
6 2 Mild sensitivity
7 Drenching sweats 3 Moderate sensitivity
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
ANXIETY 7 Continuous hallucinations
Ask “Do you feel nervous?” Observation.

0 No anxiety, at ease
HEADACHE, FULLNESS IN HEAD
1 Mild anxious
Ask “Does your head feel different? Does it feel like there is a band around
2
your head?” Do not rate for dizziness or lightheadedness. Otherwise, rate
3
severity.
4 Moderately anxious, or guarded, so anxiety is inferred
5 0 Not present
6 1 Very mild
7 Equivalent to acute panic states as seen in severe delirium or acute 2 Mild
schizophrenic reactions 3 Moderate
4 Moderately severe
5 Severe
AGITATION 6 Very severe
Observation. 7 Extremely severe

0 Normal activity
1 Somewhat more than normal activity ORIENTATION AND CLOUDING OF SENSORIUM
2 Ask “What day is this? Where are you? Who am I?”
3
4 Moderately fidgety and restless 0 Oriented and can do serial additions
5 1 Cannot do serial additions or is uncertain about date
6 2 Disoriented for date by no more than 2 calendar days
7 Paces back and forth during most of the interview, or constantly thrashes 3 Disoriented for date by more than 2 calendar days
about 4 Disoriented for place/or person

Withdrawal scales were developed to assist the monitoring and management of withdrawal Total CIWA-Ar Score:
symptoms. It is important to note that withdrawal scales are not diagnostic tools.

Interpretation of scores. The maximum score is 67. Patients scoring less than 10 do not usually need
additional medication for withdrawal.

Source: Sulivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: The Revised Clinical Institute Withdrawal Assess-
ment for Alcohol scale (CIWA-Ar). British Journal of Addiction to Alcohol and Other Drugs. 1989;84(11):1353-7. doi: 10.1111/j.1360-0443.1989.tb00737.x

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