The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) is a validated instrument used to quantify the severity of the alcohol withdrawal syndrome. It helps clinical personnel recognize the withdrawal process before it progresses to advanced stages like delirium tremens, allowing for appropriate pharmacotherapy and treatment modification. The scale consists of 10 signs and symptoms and typically takes about 2 minutes to perform.

Patient Information

  • Patient Name:
  • Date:
  • Time (24-hour clock):
  • Blood Pressure:
  • Pulse or Heart Rate (one minute):

Assessment Items

1. Nausea and Vomiting

Ask: “Do you feel sick to your stomach? Have you vomited?”

  • 0: No nausea and no vomiting
  • 1: Mild nausea with no vomiting
  • 4: Intermittent nausea with dry heaves
  • 7: Constant nausea, frequent dry heaves, and vomiting

2. Tremor

Observation with arms extended and fingers spread apart.

  • 0: No tremor
  • 1: Not visible, but can be felt fingertip to fingertip
  • 4: Moderate, with the patient’s arms extended
  • 7: Severe, even with arms not extended

3. Paroxysmal Sweats

Observation.

  • 0: No sweat visible
  • 1: Barely perceptible sweating, palms moist
  • 4: Beads of sweat are obvious on the forehead
  • 7: Drenching sweats

4. Anxiety

Ask: “Do you feel nervous?” Observation.

  • 0: No anxiety, at ease
  • 1: Mildly anxious
  • 4: Moderately anxious, or guarded, so anxiety is inferred
  • 7: Equivalent to acute panic states (as seen in severe delirium)

5. Agitation

Observation.

  • 0: Normal activity
  • 1: Somewhat more than normal activity
  • 4: Moderately fidgety and restless
  • 7: Paces back and forth or constantly thrashes about

6. Tactile Disturbances

Ask: “Do you have any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?” Observation.

  • 0: None
  • 1: Very mild itching, pins and needles, burning, or numbness
  • 2: Mild itching, pins and needles, burning, or numbness
  • 3: Moderate itching, pins and needles, burning, or numbness
  • 4: Moderately severe hallucinations
  • 5: Severe hallucinations
  • 6: Extremely severe hallucinations
  • 7: Continuous hallucinations

7. Auditory Disturbances

Ask: “Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything disturbing? Are you hearing things you know are not there?” Observation.

  • 0: Not present
  • 1: Very mild harshness or ability to frighten
  • 2: Mild harshness or ability to frighten
  • 3: Moderate harshness or ability to frighten
  • 4: Moderately severe hallucinations
  • 5: Severe hallucinations
  • 6: Extremely severe hallucinations
  • 7: Continuous hallucinations

8. Visual Disturbances

Ask: “Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything disturbing? Are you seeing things you know are not there?” Observation.

  • 0: Not present
  • 1: Very mild sensitivity
  • 2: Mild sensitivity
  • 3: Moderate sensitivity
  • 4: Moderately severe hallucinations
  • 5: Severe hallucinations
  • 6: Extremely severe hallucinations
  • 7: Continuous hallucinations

9. Headache, Fullness in Head

Ask: “Does your head feel different? Does it feel like there is a band around your head?” (Do not rate for dizziness).

  • 0: Not present
  • 1: Very mild
  • 2: Mild
  • 3: Moderate
  • 4: Moderately severe
  • 5: Severe
  • 6: Very severe
  • 7: Extremely severe

10. Orientation and Clouding of Sensorium

Ask: “What day is this? Where are you? Who am I?”

  • 0: Oriented and can do serial additions
  • 1: Cannot do serial additions or is uncertain about date
  • 2: Disoriented for date by no more than 2 calendar days
  • 3: Disoriented for date by more than 2 calendar days
  • 4: Disoriented for place and/or person

Scoring and Interpretation

The maximum possible score is 67.

ScoreInterpretation
< 8 – 10Minimal to mild withdrawal. Patients scoring less than 10 usually do not need additional medication.
8 – 15Moderate withdrawal (marked autonomic arousal).
> 15Severe withdrawal (impending delirium tremens). Scores >15 indicate an increased risk for severe complications.

Total CIWA-Ar Score: ________ Rater’s Initials: ________