CIWA-Ar: Clinical Institute Withdrawal Assessment for Alcohol, revised

Rate each item from observation and the questions shown. Intermediate points (e.g. 2, 3, 5, 6) are used when severity falls between the described anchors. Repeat at intervals to guide symptom-triggered treatment.

1. 1Nausea and vomitingAsk: “Do you feel sick to your stomach? Have you vomited?” Observation.

   0No nausea and no vomiting1Mild nausea with no vomiting2between3between4Intermittent nausea with dry heaves5between6between7Constant nausea, frequent dry heaves and vomiting
2. 2TremorArms extended and fingers spread apart. Observation.

   0No tremor1Not visible, but can be felt fingertip to fingertip2between3between4Moderate, with patient’s arms extended5between6between7Severe, even with arms not extended
3. 3Paroxysmal sweatsObservation.

   0No sweat visible1Barely perceptible sweating, palms moist2between3between4Beads of sweat obvious on forehead5between6between7Drenching sweats
4. 4AnxietyAsk: “Do you feel nervous?” Observation.

   0No anxiety, at ease1Mildly anxious2between3between4Moderately anxious, or guarded, so anxiety is inferred5between6between7Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions
5. 5AgitationObservation.

   0Normal activity1Somewhat more than normal activity2between3between4Moderately fidgety and restless5between6between7Paces back and forth during most of the interview, or constantly thrashes about
6. 6Tactile disturbancesAsk: “Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?” Observation.

   0None1Very mild itching, pins and needles, burning or numbness2Mild itching, pins and needles, burning or numbness3Moderate itching, pins and needles, burning or numbness4Moderately severe hallucinations5Severe hallucinations6Extremely severe hallucinations7Continuous hallucinations

   Tactile hallucinations are present. Watch closely for evolving delirium tremens.

7. 7Auditory disturbancesAsk: “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?” Observation.

   0Not present1Very mild harshness or ability to frighten2Mild harshness or ability to frighten3Moderate harshness or ability to frighten4Moderately severe hallucinations5Severe hallucinations6Extremely severe hallucinations7Continuous hallucinations

   Auditory hallucinations are present. Consider delirium tremens or alcoholic hallucinosis, and review the level of supervision.

8. 8Visual disturbancesAsk: “Does the light appear to be too bright? Is its colour different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?” Observation.

   0Not present1Very mild sensitivity2Mild sensitivity3Moderate sensitivity4Moderately severe hallucinations5Severe hallucinations6Extremely severe hallucinations7Continuous hallucinations

   Visual hallucinations are present. Watch closely for evolving delirium tremens.

9. 9Headache, fullness in headAsk: “Does your head feel different? Does it feel like there is a band around your head?” Do not rate for dizziness or light-headedness. Otherwise, rate severity.

   0Not present1Very mild2Mild3Moderate4Moderately severe5Severe6Very severe7Extremely severe
10. 10Orientation and clouding of sensoriumAsk: “What day is this? Where are you? Who am I?”

    0Oriented and can do serial additions1Cannot do serial additions or is uncertain about date2Disoriented for date by no more than 2 calendar days3Disoriented for date by more than 2 calendar days4Disoriented for place and/or person

    Disorientation is present. Consider delirium tremens and Wernicke’s encephalopathy (give parenteral thiamine), and look for other medical causes. The CIWA-Ar is not valid once the patient cannot communicate reliably.