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Alcohol Detox – The Signs of Mild, Moderate or Dangerously Severe Alcohol Withdrawal

Here’s a common attitude…”I’ll tough-out alcohol detox at home – and if things get too serious, then I’ll just head to the ER.”

OK... so this can work, but since things can slide downward faster than you might realize, this exposes you to a lot of very avoidable risk. Here are 4 good reasons to get a doctor involved right from the start:

  • Alcohol withdrawal can kill you, so it’s worth taking seriously.
  • Though you may think you could just head to the ER if needed, withdrawal symptoms can go from moderate to life threatening quickly and without warning.
  • If you get medical management from the start, you can stop withdrawal symptoms from spiraling out of control – increasing the safety and comfort of the process.
  • In most cases, you can detox safely at home, after spending a few hours getting medicated in a clinic or with your doctor – and in cases where this wouldn’t be an option – you definitely wouldn’t want to be detoxing on your own anyway.

Read on to learn more about what to expect from alcohol detox and about predicting your risks of serious (complicated) withdrawal symptoms, specifically:

  • The risks of alcohol detox and what you can expect from the first few days
  • Signs that indicate you’re at risk of serious withdrawals
  • The CIWA-Ar – a common alcohol withdrawal screening tool that’s used to gauge the severity of the symptoms
  • A common treatment plan
  • Information on ambulatory (home) detox – are you an appropriate candidate to detox at home?

Why Is Alcohol Withdrawal Taken So Seriously?

Alcohol withdrawal can kill you. This is why anyone at risk of complicated withdrawals needs medical observation and prophylactic medications before symptoms get severe.

Severe alcohol withdrawal can lead to life threatening delirium tremens:

  • Roughly 5% of people presenting with alcohol withdrawal symptoms will progress to a syndrome known as the delirium tremens, or the DTs. Left untreated, the DTs have a 15%-20% lethality rate, but with appropriate treatment, that rate falls to between 1% and 5%.1

And the DTs are only one of many life-threatening scenarios to worry about. Other life-threatening complications can include:

  • Accident trauma (you fall over and bang your head)
  • Severe dehydration and electrolyte imbalance
  • Seizures 
  • Alcohol withdrawal symptoms combining with other conditions, such as diabetes, kidney disease or other acute infections2

Problematically, alcohol withdrawal symptoms can change quickly – going from mild to severe within a period of hours, not days.

Since symptoms can change quickly, and since you could go from moderate discomfort to life-threatening distress within a few hours, it’s important that anyone at risk of serious complications start out under medical observation, receiving medications that can stop serious symptoms before they get started.

Alcohol Withdrawal Symptoms

These symptoms occur due to CNS hyperactivity. Typical symptoms include:

  • Mental symptoms like confusion, irritability, mood swings, depression, nightmares and anxiety or agitation.
  • Physical symptoms like tremor and shakiness, headache, clammy skin, loss of appetite, nausea and vomiting, insomnia, fast heart rate, sweating and pallor

More severe symptoms Include:


Hallucinations can be visual, tactile or auditory. If present, these typically occur from 12 to 24 hours after your last drink.


  • Seizures are usually generalized tonic clonic and if present, typically occur within 24 - 48 hours of your last drink.
  • Roughly 2% to 3% of people in alcohol withdrawal will experience a seizure. You are most likely to have a withdrawal seizure if you’ve previously had a withdrawal seizure.
  • Other significant risk factors for seizure include having had 3 or more significant periods of alcohol withdrawal, having drunk for 2 decades or longer, having a history of head injuries, being in poor health, being malnourished and presenting with electrolyte imbalances.3

Delirium Tremens

The DTs are characterized by severely altered mental functioning, extreme confusion, agitation, hallucinations and delusions, and usually occur within 24-72 hours of the last drink.

The Timeline

  • You can start experiencing alcohol withdrawal symptoms from 6 to 8 hours after your last drink, or in serious cases, whenever your blood alcohol level falls below a certain point.
  • For most people, symptoms will intensify to a peak at between 24 and 48 hours and then dissipate at between 3 and 5-7 days.1
  • Though acute withdrawal symptoms dissipate within a week, protracted or subacute withdrawal symptoms, such as insomnia, irritability and cravings can persist for many weeks.4

Are You at Risk of Severe Withdrawal?

In addition to an elevated CIWA-Ar score (see below to take the test), other signs that indicate a risk for complicated withdrawal include:5

High risk signs (at presentation):

  • Having a body temperature of 101 Fahrenheit or greater
  • Having a pulse rate of 115 or greater
  • Having a systolic blood-pressure measurement of 170 or higher
  • Experiencing alcohol withdrawal symptoms when blood alcohol levels drop to 0.15 or higher

Additional risk factors for complicated withdrawal:6

  • Stopping after a period of drinking 20 or more units per day (13 or more standard drinks per day, such as 13 or more cans of regular strength beer.)
  • Having a history of needing to drink in the mornings to stave-off withdrawal symptoms
  • Abusing both alcohol and another substance – particularly benzodiazepines
  • Having a history of complicated alcohol withdrawal symptoms
  • Having concurrent physical or mental illness
  • Being older


The Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar) is probably the most commonly used instrument to measure the severity of alcohol withdrawal symptoms – If admitted to a hospital with suspected alcohol withdrawal, you’d almost certainly get measured for a CIWA-Ar score.7

For your education only (it’s not a good idea to try to self-doctor yourself through alcohol withdrawal) here is the measurement scale. Take the test yourself, or better yet, have a loved one ask you the questions and help you through it.

Pick the numerical score for each of the 10 categories that best represents your current experience, and at the end of the test, add up your scores. The maximum possible score is 67, but anything over an 8 indicates a possible need for medical intervention.

If you take this test and score above 8-10, take this seriously and get medical help right away!

Nausea and Vomiting

  1. no nausea and no vomiting
  2. mild nausea with no vomiting

  3. intermittent nausea with dry heaves

  4. constant nausea, frequent dry heaves and vomiting

Tactile Disturbances

Do you have any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?

  1. none
  2. very mild itching, pins and needles, burning or numbness
  3. mild itching, pins and needles, burning or numbness
  4. moderate itching, pins and needles, burning or numbness
  5. moderately severe hallucinations
  6. severe hallucinations
  7. extremely severe hallucinations
  8. continuous hallucinations


With you arms extended and fingers spread apart.

  1. no tremor
  2. not visible, but can be felt fingertip to fingertip

  3. moderate, with patient's arms extended

  4. severe, even with arms not extended

Auditory Disturbances

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?

  1. not present
  2. very mild harshness or ability to frighten
  3. mild harshness or ability to frighten
  4. moderate harshness or ability to frighten
  5. moderately severe hallucinations
  6. severe hallucinations
  7. extremely severe hallucinations
  8. continuous hallucinations

Paroxysmal Sweats

  1. no sweat visible
  2. barely perceptible sweating, palms moist

  3. beads of sweat obvious on forehead

  4. drenching sweats

Visual Disturbances

Does the light appear to be too 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?

  1. not present
  2. very mild sensitivity
  3. mild sensitivity
  4. moderate sensitivity
  5. moderately severe hallucinations
  6. severe hallucinations
  7. extremely severe hallucinations
  8. continuous hallucinations


Do you feel nervous?

  1. no anxiety, at ease
  2. mild anxious

  3. moderately anxious, or guarded, so anxiety is inferred

  4. equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions

Headache, Fullness in Head

Does your head feel different? Does it feel like there is a band around your head?

  1. not present
  2. very mild
  3. mild
  4. moderate
  5. moderately severe
  6. severe
  7. very severe
  8. extremely severe


  1. normal activity
  2. somewhat more than normal activity

  3. moderately fidgety and restless

  4. paces back and forth during most of the interview, or constantly thrashes about

Orientation and Clouding of Sensorium

"What day is this? Where are you? Who am I?"

  1. oriented and can do serial additions
  2. cannot do serial additions or is uncertain about date
  3. disoriented for date by no more than 2 calendar days
  4. disoriented for date by more than 2 calendar days
  5. disoriented for place/or person

Interpreting Scoring

A score of:

  • 0 to 9 indicates no or very minimal alcohol withdrawal
  • 10 – 19 indicates mild to moderate alcohol withdrawal (Some groups, like the VA, consider 15 the upper cut-off for moderate withdrawal)
  • 20+ indicates severe withdrawal (The VA considers a score of 15 or more indicative of severe withdrawal)8

Relating scoring to treatment:

  • Scoring over 8 indicates a possible need for medications.
  • Early intervention (the early use of certain medications, such as benzodiazepines) can keep withdrawal symptoms from progressing to a dangerous levels.
  • Some people who score low on the CIWWA-Ar go on to have complicated withdrawals regardless (this speaks to the danger of self diagnosing your situation and limiting medical involvement in the early stages.)
  • People scoring over 35 may require treatment in an ICU

Treatments to Reduce the Dangers

Your individual treatment will depend on your individual situation, alcohol use history, physical and mental health and use of other drugs – but in general, most people in alcohol withdrawal who score high enough on the CIWA-Ar to warrant medication receive spaced (loading) doses of diazepam (or similar) until symptoms dissipate or you feel sedated.

For example, according to the Canadian Centre for Mental Health and Addiction, people in alcohol withdrawal needing medication should9:

  • Receive 20 mg of diazepam every 1-2 hours until symptoms abate. If withdrawal symptoms persist after 80 mg of diazepam, hospitalization is indicated.
  • If there is any history of withdrawal seizure, the person should receive at least 3 time-spaced 20 mg doses of diazepam.

People coming off extended binges can have severe dehydration and electrolyte imbalances. Certain symptoms of withdrawal – such as heavy sweating, vomiting or diarrhea – can exacerbate this situation. Maintaining fluid intake is essential, and in some cases, this may require I.V. rehydration.10

When Is the Danger Past?

According to the Center for Mental Health and Addiction, people who score less than 10 on 3 consecutive  CIWA-Ar assessments – each separated by a period of hours – no longer need retesting, though they still need informal monitoring to ensure no reemergence of symptoms. 

Ambulatory (Home) Detoxification?

People who aren’t expected to experience severe or complicated withdrawal symptoms can generally stay at home throughout the process (an ambulatory - detox), while checking in with a doctor periodically (likely daily) for evaluation.

You may be a candidate for ambulatory detoxification if:

  • Your doctor doesn’t expect severe or complicated withdrawals.
  • You can travel relatively quickly and easily to a hospital or clinic if need be (if you live 3 hours from the nearest doctor you may not want to try this at home).
  • You have a stable support person willing and able to help monitor your progress through the period and able to summon help/transport you if need be.

Ambulatory detox is obviously much more affordable than hospitalization. If you decide on ambulatory detoxification, you will probably:

  • Spend several hours in a doctor’s office or clinic on the first morning (after having had your last drink the evening before) getting medicated until your symptoms are under control.
  • Have to return to the office or clinic the following day for reevaluation.
  • Be given instructions for warning signs of worsening withdrawal to watch for, such as confusion or hallucinations (a warning sign of impending DTs), fever, etc.11

Caution – You will feel very shaky during withdrawal and this can frequently lead to accidents around the home, which can be small (spilling hot coffee on yourself) or larger (falling in the bath and banging your head). Please take extra care during these few days to avoid making an already tough situation worse.12

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