Alcohol Withdrawal Symptoms

Alcohol Treatment Acute Withdrawal

ALCOHOL WITHDRAWAL SCALE

Clinical Institute Withdrawal Assessment of Alcohol Scale
Patient_______________________Date_____________Time____________
Pulse or heart rate taken for 1 minute
Blood pressure___________

Nausea and Vomiting

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

Tremor

Arms extended and fingers spread apart
Observation:
0.No tremor
1.Not visible but can be felt fingertip to fingertip
2.
3.
4.Moderate, with arms extended
5.
6.
7.Severe, even with arms not extended

Sweating

Observation:
0.No sweat visible
1.Barely perceptible sweating, palms moist
2.
3.
4.Beads of sweat obvious on forehead
5.
6.
7.Drenching sweats

Anxiety

Ask “Do you feel nervous?”
Observation:
0.No anxiety, at ease
1.Mildly 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

Agitation

Observation:
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

Tactile Disturbances

Ask “Have you had any itching, pins-and-needles sensations, burning, or numbness? Do you feel bugs crawling on or under your skin?”
Observation:
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

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?”
Observation:
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

Visual Disturbances

Ask “Does the light appear to be too bright? Is the 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?”
Observation:
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

Headache, Fullness in Head

Ask “Does your head feel different? Does it feel like there is a band around your head?” Do not rate dizziness or lightheadedness. Otherwise, rate severity.
Observation:
0.Not present
1.Very mild
2.Mild
3.Moderate
4.Moderately severe
5.Severe
6.Very severe
7.Extremely severe

Orientation and Clouding of Sensorium

Ask “What day is this? Where are you? Who am I?”
Observation:
0.Oriented and can do serial additions
1.Cannot do serial additions or is uncertain about date
2.Disoriented about date by no more than 2 calendar days
3.Disoriented about date by more than 2 calendar days
4.Disoriented about place and/or person

Total Score
Rater’s Initials
Maximum Possible Score = 67

A score higher than 25 indicates severe withdrawal (impending delirium tremens). If score is lower than 10 after two 8-hour reviews, then monitoring can stop. If score is higher than 20, then the patient should be assessed hourly until the symptoms are under control.

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