Equations

(Open Calc) Clinical Institute Withdrawal Assessment for Alcohol Revised Scale

Background

• Clinical quantitation of the severity of alcohol withdrawal syndrome
• This scale provides an increase in efficiency and retains clinical usefulness, validity and reliability
• Can be incorporated into the usual clinical care of alcohol withdrawal patients and into clinical drug trials of alcohol withdrawal

Questions/Parameters

1. Nausea and vomiting (Ask: "Do you feel sick to your stomach? Have you vomited?"; observe pt)
   • No nausea and no vomiting (0 points)
   • Mild nausea without vomiting (1 point)
   • Intermittent nausea with dry heaves (4 points)
   • Constant nausea, frequent dry heaves, and vomiting (7 points)
2. Tremor (Observe patient with arms extended and fingers spread apart)
   • No tremor (0 points)
   • Not visible, but can be felt fingertip to fingertip (1 point)
   • Moderate, with patient's arms extended (4 points)
   • Severe, even with arms not extended (7 points)
3. Paroxysmal sweats
   • No sweat visible (0 points)
   • Barely perceptible sweating, palms moist (1 point)
   • Beads of sweat obvious on forehead (4 points)
   • Drenching sweats (7 points)
4. Anxiety (Ask: "Do you feel nervous?", observe)
   • No anxiety, at ease (0 points)
   • Mildly anxious (1 point)
   • Moderately anxious, or guarded, so anxiety is inferred (4 points)
   • Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reaction (7 points)
5. Agitation
   • Normal activity (0 points)
   • Somewhat more than normal activity (1 point)
   • Moderately fidgety and restless (4 points)
   • Paces back and forth during most of interview, or constantly thrashes about (7 points)
6. Tactile disturbances (Ask: "Have you any itching, pins and needles sensations, burning, numbness, or do you feel bugs crawling on or under your skin?")
   • None (0 points)
   • Very mild itching, pins and needles, burning or numbness (1 point)
   • Mild itching, pins and needles, burning or numbness (2 points)
   • Moderate itching, pins and needles, burning or numbness (3 points)
   • Moderately severe hallucinations (4 points)
   • Severe hallucinations (5 points)
   • Extremely severe hallucinations (6 points)
   • Continuous hallucinations (7 points)
7. Auditory disturbances (Ask: "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things that you know are not there?")
   • Not present (0 points)
   • Very mild harshness or ability to frighten (1 point)
   • Mild harshness or ability to frighten (2 points)
   • Moderate harshness or ability to frighten (3 points)
   • Moderately severe hallucinations (4 points)
   • Severe hallucinations (5 points)
   • Extremely severe hallucinations (6 points)
   • Continuous hallucinations (7 points)
8. Visual disturbances ("Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things that you know are not there?")
   • Not present (0 points)
   • Very mild sensitivity (1 point)
   • Mild sensitivity (2 points)
   • Moderate sensitivity (3 points)
   • Moderately severe hallucinations (4 points)
   • Severe hallucinations (5 points)
   • Extremely severe hallucinations (6 points)
   • Continuous hallucinations (7 points)
9. Headache or fullness in head ("Does your head feel different? Does it feel like there is a band around your head?")
   • NOTE: Do not rate for dizziness or lightheadedness
   • Not present (0 points)
   • Very mild (1 point)
   • Mild (2 points)
   • Moderate (3 points)
   • Moderately severe (4 points)
   • Severe (5 points)
   • Very severe (6 points)
   • Extremely severe (7 points)
10. Orientation and clouding of sensorium (Ask: "What day is this? Where are you? Who am I?")
    • Oriented and can do serial additions (0 points)
    • Can't do serial additions, or is uncertain about date (1 point)
    • Disoriented for date by no more than 2 calendar days (2 points)
    • Disoriented for date by more than 2 calendar days (3 points)
    • Disoriented for place and/or person (4 points)

Score/Interpretation

• Max possible score: 67
• < 8: Low-Mild alcohol withdrawal (medication usually not indicated)
• 8-15: Moderate alcohol withdrawal
• > 15: Severe alcohol withdrawal

References

1. Sullivan JT, Sykora K, Schneiderman J, et al. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Brit J Addiction. Nov 1989;84(11):1353-1357

Updated/Reviewed: July 2022