Anamnesis: definition and 8 clinical basics

The process by which the therapist gathers clinical information from the patient.

Practicing as a psychologist requires the presence of a consistent body of knowledge, both with respect to the usual functioning of the human mind and to non-typical or even pathological processes.The process by which the therapist gathers clinical information about the patient.

It also requires knowing and knowing how and in which cases to apply the various techniques and procedures available. However, the presence of knowledge is not the only essential requirement to practice as a good professional, requiring observation skills, empathy and initiative, among other characteristics. All this is necessary to be able to offer a good service to the client or patient, being the improvement of this and the problems and demands that can present the main objective of the professional. Knowing why you have decided to come for consultation, the story behind the problem you may have and what you expect from the interaction with the psychologist is fundamental.

To this end the psychologist must be able to collect all the data he/she may need to start working on the case, i.e. to take the anamnesis.i.e. to perform the anamnesis.

Defining anamnesis

Anamnesis is the process by which the professional obtains information from the patient through a dialogue in which the professional has to obtain basic information about the patient's disorder or problem, his/her life habits and the presence of family antecedents in order to establish a diagnosis of the problem to be treated or worked on.

This is the first stage of the diagnostic process, essential for the psychologist to be able to understand the individual's life situation, his or her problem and how it affects or is affected by events and personal history.

The subsequent development of the anamnesis allows the professional to detect symptoms and signs, observing not only what is being said but also what is being said.The subsequent development of the anamnesis allows the professional to detect symptoms and signs, observing not only what is said but also what is avoided, the reticence or ease of expression and the elaboration of certain themes. It is not only a matter of observing what is said, but also how it is expressed and the non-verbal communication performed.

In general, the anamnesis is performed on the subject to be treated or end user, but sometimes it is advisable to do it also to relatives, close people or even teachers, as in the case of different childhood pathologies.

Anamnesis is not only limited to the field of clinical psychology, but is also used to diagnose problems in other branches of psychology (it can be extrapolated to educational psychology, for example) as well as in other disciplines such as medicine. However, the use of this term tends to be applied especially in the clinical setting.

Main elements to be taken into account in an anamnesis

The dialogue established during the anamnesis should gather a variety of information.It is essential that certain fundamental aspects are reflected in it, specifically the following.

Identification

This is the person's basic data, such as name, sex, age or address.. It is also essential to establish a communication mechanism, such as a contact number.

2. Reason for consultation

Although it may seem obvious, the reason for which the subject comes to consultationThe main information to be obtained in the anamnesis is the problem or the request that the patient wants to make.

3. History of the current problem

The reason for the consultation is an essential piece of knowledge.However, in order to fully understand the situation, the psychologist or professional who carries out the anamnesis needs to know how and when it has appeared in the patient's life, in which situation or situations it appears, what causes the subject considers to have provoked it, what symptoms he/she suffers from and which ones seem most relevant to him/her.

4. Affect on daily life

The problems presented by the subjects have an effect on their daily life.The problems presented by the subjects have an effect on their daily life, generally producing a decrease in their quality of life in areas such as social, work or family relationships. Knowing this information can help to direct the type of strategies to be used, directing the therapeutic objectives both to the resolution of the problem itself and to the effects of these on daily life.

5. Psychosocial history

The life history of the individual who comes for consultation is usually closely linked to the appearance of certain phenomena and problems. and problems. The type of education received, the process of socialization of the subject, the events that have marked or shaped his personality and the elements that the individual himself associates with the onset or maintenance of a problem can be very useful.

6. Personal background

Sometimes people who come for consultation do so because of problems arising from previous phenomena, events or illnesses or whoseevents or previous illnesses or whose effects have produced a change in one's own life. In this sense it is useful to know the existence of previous problems.

7. Family history and family situation

Knowing the presence or absence of family history of a problem, or how the family is structured or how the family is structured may allow to refine the diagnosis and focus on some intervention strategies or others. It may be relevant in order to observe risk factors, effects or causes of certain problems.

8. Expectations regarding the results of the intervention

This section is relevant in the sense of making explicit what the patient expects to happen.The presence of motivation to follow a treatment and what he/she considers that he/she can or cannot achieve with professional help. Apart from knowing their expectations regarding the functioning of the therapy and its results, it also allows us to see the user's vision regarding their own future and the existence of cognitive biases that underestimate or overestimate what the treatment can achieve (they may have unrealistic expectations or cause a self-fulfilling prophecy), and these issues can be worked on in the therapy itself.

Considerations

The performance of the anamnesis is, as we have mentioned, of great importance for the practice of the profession. However, it cannot be carried out without taking into account a series of considerations.

Assessment of the extent and completeness of the anamnesis.

It may be tempting to consider the idea of obtaining as much information as possible from the patient from the outset in order to establish a firm strategy to follow from this. However, although it is obvious that the acquisition of information about the case is essential.

An overly exhaustive anamnesis can be extremely aversive for the patient, who may feel uncomfortable and reduceThe patient may feel uncomfortable and reduce the emission of information and even abandon the search for help. We must not forget that this is the first step in the diagnostic process, requiring the establishment of a good therapeutic relationship in order to maximize the acquisition of information. The data collected in the anamnesis should be sufficient to get an idea of the patient's situation, problem and vital state, but this collection should not be carried out as an interrogation.

In certain cases it may also be necessary to abbreviate or even postpone it, as in the case of patients with suicidal ideation.

Immodifiability of the information received

It should also be considered that the information obtained during the anamnesis does not have to be unchangeable.. The patient may not know exactly what is wrong, may need more time to reflect on how it affects his or her life, or may even need to feel more comfortable with the therapist in order to confide certain information to him or her.

Respecting ethical boundaries

The collection of data and information by the professional is a fundamental and essential part of the therapeutic process. However, the anamnesis or collection of information cannot be done in an indiscriminate manner.. 

It should be borne in mind that the patient should have the right to privacy, and should be limited to the phenomenon causing discomfort or the reason for the consultation or, failing that, to aspects of the patient's life that are considered to affect the patient and compliance with therapy.

Bibliographical references:

• Borreli, C.F. & Boschi, F.J.M. (1994). Clinical interview. In: Martín ZA, Cano JF, eds. Primary care: concepts, organization and clinical practice. 3 ed. Barcelona: Doyma:158-69.

• Rodriguez, G.P.L.; Rodriguez, P.L.R. and Puente, M.J.A. (1998). Practical method for taking a medical history. Rev Electron Innov Tecnol, Las Tunas;4(2). 6 .

• Rodríguez, P.L. y Rodríguez, L.R. (1999). Technical principles to perform the anamnesis in the adult patient. Cuban Rev. Med. Gen. Integr.; 15(4); 409-14.