[Table], Alcohol Withdrawal Scale8 - Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings

	Date
Time
PERSPIRATION
No abnormal sweating	0
Moist skin	1
Localised beads of sweat e.g. on face and chest	2
Whole body wet from sweat	3
Profuse maximum sweating – clothes, sheets are wet	4
TREMOR
No tremor	0
Slight tremor upper extremities	1
Constant light tremor upper extremities	2
Constant marked tremor upper extremities	3
ANXIETY
No apprehension or anxiety	0
Slight apprehension	1
Apprehension or understandable fear	2
Anxiety occasionally accentuated to state of panic	3
Constant panic-like anxiety	4
AGITATION
Rests normally no sign of agitation	0
Slight restlessness, cannot sit or lie still, awake when others sleep	1
Moves constantly, looks tense, wants to get out of bed but obeys requests to stay into bed	2
Constantly restless, gets out of bed for no obvious reason, returns to bed if taken	3
Maximally restless, aggressive, ignores requests to stay in bed	4
TEMPERATURE
37.0°C or less	0
37.1 – 37.5°C	1
37.6 – 38.0°C	2
38.1 – 38.5°C	3
above 38.5°C	4
HALLUCINATIONS
No evidence of hallucinations	0
Distortion of real objects, aware these are not real if this is pointed out	1
Appearance of totally new objects or perceptions, aware that these are not real if this is pointed out	2
Believes hallucinations are real but still orientated in place and person	3
Believes himself to be in a totally non-existent environment, preoccupied and cannot be diverted or reassured	4
ORIENTATION
Fully orientated in time place and person	0
Orientated in person but not sure where he is or what time it is	1
Orientated in person but not time and place	2
Doubtful personal orientation disoriented in time and place; there maybe short bursts of lucidity	3
Disoriented in time, place and person, no meaningful contact can be obtained	4
	Total score

Date

Time

PERSPIRATION

No abnormal sweating

Moist skin

Localised beads of sweat e.g. on face and chest

Whole body wet from sweat

Profuse maximum sweating – clothes, sheets are wet

TREMOR

No tremor

Slight tremor upper extremities

Constant light tremor upper extremities

Constant marked tremor upper extremities

ANXIETY

No apprehension or anxiety

Slight apprehension

Apprehension or understandable fear

Anxiety occasionally accentuated to state of panic

Constant panic-like anxiety

AGITATION

Rests normally no sign of agitation

Slight restlessness, cannot sit or lie still, awake when others sleep

Moves constantly, looks tense, wants to get out of bed but obeys requests to stay into bed

Constantly restless, gets out of bed for no obvious reason, returns to bed if taken

Maximally restless, aggressive, ignores requests to stay in bed

TEMPERATURE

37.0°C or less

37.1 – 37.5°C

37.6 – 38.0°C

38.1 – 38.5°C

above 38.5°C

HALLUCINATIONS

No evidence of hallucinations

Distortion of real objects, aware these are not real if this is pointed out

Appearance of totally new objects or perceptions, aware that these are not real if this is pointed out

Believes hallucinations are real but still orientated in place and person

Believes himself to be in a totally non-existent environment, preoccupied and cannot be diverted or reassured

ORIENTATION

Fully orientated in time place and person

Orientated in person but not sure where he is or what time it is

Orientated in person but not time and place

Doubtful personal orientation disoriented in time and place; there maybe short bursts of lucidity

Disoriented in time, place and person, no meaningful contact can be obtained

Total score

From: 4, Withdrawal Management

Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings.

Geneva: World Health Organization; 2009.

Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; e-mail: tni.ohw@sredrokoob). Requests for permission to reproduce WHO publications, in part or in whole, or to translate them – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: tni.ohw@snoissimrep). For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines, fax: +632 521 1036, e-mail: tni.ohw.orpw@snoitacilbup

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.