CIWA-Ar (alcohol withdrawal)
Severity of alcohol withdrawal, for symptom-triggered treatment
Sources last checked: 2026-10-13
CIWA-Ar (alcohol withdrawal)
Severity of alcohol withdrawal, for symptom-triggered treatment
Requires a patient who can communicate; it is not valid in delirium, sedation or language barriers. Cut-offs for treatment vary between protocols — the 10 and 15 thresholds here are the commonly quoted ones. Vital signs are recorded but not scored.
Interpretation
| 0–9 — minimal to mild | Per the CIWA-Ar form, scores below 10 usually do not need additional medication for withdrawal. |
|---|---|
| 10–15 — moderate | Moderate withdrawal with autonomic arousal; the range in which symptom-triggered protocols commonly provide pharmacotherapy (thresholds vary by protocol). |
| ≥ 16 — severe | Scores above 15 carry a markedly increased risk of severe withdrawal, seizures and delirium. |
What is the CIWA-Ar (alcohol withdrawal)?
The CIWA-Ar is a ten-item clinician-rated scale for the severity of alcohol withdrawal. Sullivan and colleagues shortened the earlier CIWA-A in 1989; nine items are rated 0–7 and orientation 0–4, for a maximum of 67. It underpins symptom-triggered benzodiazepine protocols on many wards.
When to use it
- Monitoring patients at risk of or in alcohol withdrawal
- As the scoring basis of symptom-triggered benzodiazepine protocols
- Documenting withdrawal severity over time
When not to use it
- In patients who cannot communicate (intubated, delirious, sedated, language barrier)
- To diagnose alcohol withdrawal — other causes of the same signs must be excluded
How it is calculated
| Criterion | Points |
|---|---|
| Nausea and vomiting | |
| 0 — no nausea, no vomiting | 0 |
| 1 — mild nausea, 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, 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 — none, at ease | 0 |
| 1 — mildly anxious | 1 |
| 2 | 2 |
| 3 | 3 |
| 4 — moderately anxious or guarded | 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 or constantly thrashes about | 7 |
| Tactile disturbances (itching, pins and needles, burning, numbness, formication) | |
| 0 — none | 0 |
| 1 — very mild | 1 |
| 2 — mild | 2 |
| 3 — moderate | 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 (not dizziness) | |
| 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, can do serial additions | 0 |
| 1 — cannot do serial additions or uncertain about date | 1 |
| 2 — disoriented for date by ≤ 2 calendar days | 2 |
| 3 — disoriented for date by > 2 calendar days | 3 |
| 4 — disoriented for place and/or person | 4 |
Clinical pearls and limitations
- Requires a patient who can communicate; it is not valid in delirium, sedation or language barriers. Cut-offs for treatment vary between protocols — the 10 and 15 thresholds here are the commonly quoted ones. Vital signs are recorded but not scored.
- The trend over repeated scores is more informative than a single value.
- Anxiety, agitation and hallucination items can be driven by other conditions (sepsis, hypoglycaemia, head injury).
- Low scores do not exclude complications if the patient has a history of withdrawal seizures or delirium tremens.
- German units often use the AWS scale instead; thresholds are not interchangeable.
Frequently asked questions
What do CIWA-Ar scores mean?
Per the CIWA-Ar form, below 10 usually needs no additional medication; 10–15 is moderate and above 15 is severe withdrawal. Exact treatment thresholds depend on the local protocol.
How often should CIWA-Ar be scored?
Commonly every 1–4 hours depending on severity and protocol, more often when scores are rising.
Is the CIWA-Ar copyrighted?
No. The form states it is not copyrighted and may be reproduced freely.
Evidence and guidelines
- Primary source: Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). Br J Addict 1989;84(11):1353-1357.
- CIWA-Ar form with scoring anchors (ASAM News Supplement 2001;16(1)) — “not copyrighted and may be reproduced freely”; < 10 usually no additional medication; > 15 increased risk of severe withdrawal.
Have a follow-up question?
Medelix answers clinical questions from current guidelines and studies — every statement with its source.
Ask Medelix about the CIWA-Ar (alcohol withdrawal)Related calculators
Embed this calculatorFree to use on your website, intranet or teaching page. Copy the code below.
<iframe src="https://medelix.ai/en/embed/ciwa-ar" title="CIWA-Ar (alcohol withdrawal) – Medelix" width="100%" height="620" style="border:0;max-width:720px" loading="lazy"></iframe>
<p><a href="https://medelix.ai/en/calculators/ciwa-ar">CIWA-Ar (alcohol withdrawal) calculator by Medelix</a></p>For healthcare professionals and medical students. These tools support, and do not replace, clinical judgement. Always check results against the original source and your local protocols.