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CIWA-Ar Alcohol Withdrawal Scale

The CIWA-Ar rates 10 alcohol withdrawal signs (nine scored 0–7, orientation 0–4), total 0–67. Scores below 10 usually need no medication; 10–15 is moderate withdrawal, and ≥16 is severe withdrawal with higher risk of seizures and delirium tremens.

Nausea and vomiting: 0: No nausea and no vomiting (0); 1: Mild nausea with no vomiting (1); 2 (2); 3 (3); 4: Intermittent nausea with dry heaves (4); 5 (5); 6 (6); 7: Constant nausea, frequent dry heaves and vomiting (7)
Tremor (arms extended, fingers spread): 0: No tremor (0); 1: Not visible, but can be felt fingertip to fingertip (1); 2 (2); 3 (3); 4: Moderate, with arms extended (4); 5 (5); 6 (6); 7: Severe, even with arms not extended (7)
Paroxysmal sweats: 0: No sweat visible (0); 1: Barely perceptible sweating, palms moist (1); 2 (2); 3 (3); 4: Beads of sweat obvious on forehead (4); 5 (5); 6 (6); 7: Drenching sweats (7)
Anxiety: 0: No anxiety, at ease (0); 1: Mildly anxious (1); 2 (2); 3 (3); 4: Moderately anxious, or guarded, so anxiety is inferred (4); 5 (5); 6 (6); 7: Equivalent to acute panic states (7)
Agitation: 0: Normal activity (0); 1: Somewhat more than normal activity (1); 2 (2); 3 (3); 4: Moderately fidgety and restless (4); 5 (5); 6 (6); 7: Paces back and forth or constantly thrashes about (7)
Tactile disturbances: 0: None (0); 1: Very mild itching, pins and needles, burning or numbness (1); 2: Mild itching, pins and needles, burning or numbness (2); 3: Moderate itching, pins and needles, burning or numbness (3); 4: Moderately severe hallucinations (4); 5: Severe hallucinations (5); 6: Extremely severe hallucinations (6); 7: Continuous hallucinations (7)
Auditory disturbances: 0: Not present (0); 1: Very mild harshness or ability to frighten (1); 2: Mild harshness or ability to frighten (2); 3: Moderate harshness or ability to frighten (3); 4: Moderately severe hallucinations (4); 5: Severe hallucinations (5); 6: Extremely severe hallucinations (6); 7: Continuous hallucinations (7)
Visual disturbances: 0: Not present (0); 1: Very mild sensitivity (1); 2: Mild sensitivity (2); 3: Moderate sensitivity (3); 4: Moderately severe hallucinations (4); 5: Severe hallucinations (5); 6: Extremely severe hallucinations (6); 7: Continuous hallucinations (7)
Headache, fullness in head: 0: Not present (0); 1: Very mild (1); 2: Mild (2); 3: Moderate (3); 4: Moderately severe (4); 5: Severe (5); 6: Very severe (6); 7: Extremely severe (7)
Orientation and clouding of sensorium: 0: Oriented and can do serial additions (0); 1: Cannot do serial additions or is uncertain about date (1); 2: Disoriented for date by no more than 2 calendar days (2); 3: Disoriented for date by more than 2 calendar days (3); 4: Disoriented for place and/or person (4)

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Interpretation

Result	Meaning
0–9	Absent or minimal
10–15	Moderate
≥ 16	Severe

Formula

Nausea/vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile, auditory and visual disturbances, headache (each 0–7) + orientation (0–4). Range 0–67.

Clinical pearls

Medication thresholds vary by institutional protocol (commonly ≥8 or ≥10); follow your local symptom-triggered protocol.
CIWA-Ar requires a patient who can communicate; it is unreliable in delirium, intubation or severe illness, and symptoms from other causes inflate the score.
A low score does not exclude impending severe withdrawal in a patient with prior seizures or DTs; reassess frequently.

Examples

ciwa nausea 1 tremor 4 sweats 1 anxiety 4 agitation 1 tactile 0 auditory 0 visual 0 headache 2 orientation 0 CIWA-Ar score: moderate tremor, beads of sweat on forehead, moderately anxious, oriented alcohol withdrawal score tremor 7 sweats 7 anxiety 4 agitation 4 nausea 4

FAQ

What CIWA score needs treatment?

Most symptom-triggered protocols give a benzodiazepine at a CIWA-Ar of 8–10 or higher; scores under 10 usually need no medication.

What is a severe CIWA score?

Scores of 16 or more indicate severe withdrawal with increased risk of seizures and delirium tremens.

Evidence

Sullivan JT et al. Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). Br J Addict 1989;84:1353–7.

Psychiatry & Substance Use · Reviewed 2026-10-14 · Methodology