Clinical Institute Withdrawal Assessment for Benzodiazepines

Overview

The Clinical Institute Withdrawal Assessment for Benzodiazepines (CIWA-B) is a clinician-administered tool used to assess the severity of benzodiazepine withdrawal symptoms and guide treatment decisions. While less widely validated than its counterpart for alcohol (CIWA-Ar), CIWA-B offers a structured approach to monitor symptom progression and response to therapy.

Components

CIWA-B typically includes scoring across the following domains:

Anxiety
Sensory disturbances (e.g., hyperacusis, photophobia)
Headache or fullness in head
Tremor
Nausea/vomiting
Tension or restlessness
Depersonalization or derealization
Visual or auditory disturbances
Tactile disturbances
Paranoia/delusions
Orientation and clouding of sensorium

Each item is rated on a scale (usually 0–4 or 0–7), and total scores are used to categorize severity:

Mild: < 20

Moderate: 20–40

Severe: > 40

Clinical Use

Best applied in inpatient or closely monitored outpatient settings.

Can be used with symptom-triggered therapy: benzodiazepines are administered based on threshold scores rather than a fixed schedule.

Assists in tailoring tapering protocols, especially when transitioning patients from high-dose or short-acting benzodiazepines.

Limitations

Not as commonly used or validated as CIWA-Ar.

May be more complex to administer due to the cognitive and perceptual domains assessed.

Requires clinical judgment and experience to distinguish withdrawal symptoms from psychiatric comorbidity.

References

Loebstein R, Shirazi I, Gomolin IH, et al. Clinical Institute Withdrawal Assessment–Benzodiazepines (CIWA-B): a tool for measuring benzodiazepine withdrawal. J Clin Psychopharmacol.

American Psychiatric Association. Practice Guideline for the Treatment of Patients with Substance Use Disorders. 2nd ed. 2006.

Authors:

Cole Ettingoff