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CIWA Alcohol Withdrawal Scale: Understanding the Assessment Tool

Medical Providers:
Dr. Michael Vines, MD
Alex Spritzer, FNP, CARN-AP, PMHNP
Clinical Providers:
Natalie Foster, LPC-S, MS
Last Updated: January 8, 2026

Alcohol withdrawal can be serious. It happens when someone who has been drinking heavily stops or cuts back too quickly. Symptoms can begin within hours and may change fast. About 5% of people with severe alcohol withdrawal experience dangerous complications like seizures.

Some people experience mild symptoms like shaking, nausea, or anxiety. Others develop severe complications such as seizures or delirium tremens. Medical monitoring during detox is critical for safety.
To guide care, clinicians use the CIWA alcohol withdrawal scale to track symptoms and adjust treatment. Scottsdale Detox explains how the CIWA tool for managing alcohol withdrawal supports safe, symptom-guided care.

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Understanding The Alcohol Withdrawal Scale

CIWA stands for Clinical Institute Withdrawal Assessment for Alcohol. CIWA-Ar refers to the revised version used today. This alcohol withdrawal scale helps clinicians measure symptom severity during detox.​

CIWA-Ar does not diagnose alcohol use disorder. It is used to monitor withdrawal symptoms over time. Scores help guide decisions about medication, level of care, and how often a patient should be reassessed. NIAAA notes that structured withdrawal assessment tools improve safety and targeting of treatment.

Common Symptoms of Alcohol Withdrawal

Body-Tremors-are-a-common-symptom-of-delirium-tremens-a-late-stage-of-alcohol-detox

Tremors

Icon Representing An Anxiety Disorder Coupled

Anxiety

icon showing dizziness

Nausea

icon depicting nausea and vomiting

Vomiting

Icon depicting insomnia

Insomnia

icon hallucination

Hallucinations

icon depicting seizure symptom

Seizures

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How To Use The Alcohol Withdrawal Assessment

Components of the Alcohol Withdrawal Scale

The alcohol withdrawal assessment scale comprises several items, each evaluating a specific symptom of alcohol withdrawal syndrome. The CIWA-Ar includes the following components:

  1. Nausea and Vomiting: Assessed by asking the patient about their nausea and observing any vomiting.
  2. Tremors: Observed by asking the patient to extend their arms and fingers.
  3. Paroxysmal Sweats: Evaluated by observing visible sweating.
  4. Anxiety: Assessed by asking the patient to rate their level of anxiety.
  5. Agitation: Observed through the patient’s activity level.
  6. Tactile Disturbances: Involves asking about any sensations of itching, pins and needles, or numbness.
  7. Auditory Disturbances: Assessed by inquiring about any hearing difficulties or sounds that aren’t there.
  8. Visual Disturbances: Involves asking about any visual hallucinations.
  9. Headache: Assessed by asking the patient to rate the severity of their headache.
  10. Orientation and Clouding of Sensorium: Evaluated by asking questions related to time, place, and person to assess cognitive function.

Process of Alcohol Withdrawal Assessment

Initial Assessment

Patients undergo evaluation to determine their alcohol use patterns and overall health status.

CIWA-Ar Administration

Healthcare professionals interview patients about their symptoms. Each symptom will be scored depending on the severity.

Developing a Treatment Plan

Based on the CIWA-Ar score, doctors will develop a treatment plan that may include medications and regular reassessment.

CIWA-Ar Questionnaire

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

0 No nausea and no vomiting

1 Mild nausea with no vomiting

2

3

4 Intermittent nausea with dry heaves

5

6

7 Constant nausea, frequent dry heaves and vomiting

Observe by letting patients extend their arms and spread their fingers apart

0 No tremor

1 Not visible, but can be felt fingertip to fingertip

2

3

4 Moderate, with patient’s arms extended

5

6

7 Severe, even with arms not extended

Doctors will note the presence of sweat on patients.

0 No visible sweat

1 Barely perceptible sweating, palms moist

2

3

4 Beads of sweat obvious on forehead

5

6

7 Drenching sweats

Question: “Do you feel nervous?

0 No anxiety, at ease

1 Mild anxious

2

3

4 Moderately anxious, or guarded, so anxiety is inferred

5

6

7 Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions

Doctors will observe patients for any signs.

0 Normal activity

1 Somewhat more than normal activity

2

3

4 Moderately fidgety and restless

5

6

7 Paces back and forth during most of the interview or constantly thrashes about

Question: “Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling or under your skin?”

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

Question: “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 you know are not there?”

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

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

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

Question: “Does your head feel different? Does it feel like there is a band around your head?”

0 No present

1 Very mild

2 Mild

3 Moderate

4 Moderately severe

5 Severe

6 Very severe

7 Extremely severe

Question: “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/or person

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CIWA Score Interpretation Guide

How Does CIWA Scoring Work?

CIWA scoring is straightforward. Each symptom category receives a score on a scale based on its severity. For example, a score of 0 means no symptoms, while a score of 7 indicates very severe symptoms. The total score determines the overall severity of withdrawal as well as the necessary level of care and treatment.

Alcohol Withdrawal Assessment Scoring Interpretation

icon sweating

0-9 (Mild Withdrawal)

Patients may experience anxiety, tremors, and slight sweating. They usually do not need medication. Regular monitoring is sufficient.

icon anxiety and depression

10-18 (Moderate Withdrawal)

Symptoms are more pronounced. Patients might need medication to manage anxiety, tremors, and other symptoms.

Body-Tremors-are-a-common-symptom-of-delirium-tremens-a-late-stage-of-alcohol-detox

18+ (Severe Withdrawal)

High risk of complications like seizures and delirium tremens. Immediate medical intervention is necessary.

What are the Challenges of Using the Alcohol Withdrawal Scale?

CIWA-Ar relies in part on patient reporting. This can be difficult if someone is confused, overly sedated, or unable to communicate clearly. Scores may also vary depending on staff experience.​

For this reason, CIWA-Ar is used alongside clinical judgment and ongoing observation, not by itself. NIAAA recommends pairing structured tools with continuous clinical monitoring for best outcomes.

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Alcohol Detox Near Me

Alcohol detox should not be handled alone. Medical supervision reduces the risk of serious complications and allows symptoms to be treated as they change. Scottsdale Detox provides personalized alcohol detox programs in Scottsdale, Arizona, including 24/7 monitoring and medication support during withdrawal.​At Scottsdale Detox, medically supervised care follows evidence-based guidelines to manage withdrawal safely and prepare people for ongoing treatment. Their CIWA protocol for alcohol withdrawal explains how structured scoring is integrated with medical decision-making.​

If you or someone you know is struggling with alcohol use, seeking help early can prevent serious health risks. NIAAA’s fact sheets on treatment for alcohol problems can also help you understand your options and next steps.

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