Anamnesis: definition and 8 basic clinical aspects

Practicing as a psychologist requires the presence of a consistent body of knowledge, both regarding the normal functioning of the human mind and non-typical or even pathological processes.

It also requires knowing and knowing how and in what cases to apply the different techniques and procedures available. However, the presence of knowledge is not the only essential thing to practice as a good professional, requiring the ability to observe, 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 may present the main objective of the professional. Knowing why you have decided to go for a consultation, the history behind the problem you may have and what you expect from the interaction with the psychologist is essential.

To this end the psychologist must be able to collect all the data he may need to start working on the case, that is, to carry out the anamnesis.

Defining anamnesis

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

It is the first stage of the diagnostic process, essential for the psychologist to be able to understand the life situation of the individual, his problem and the way in which it affects or is affected by events and history personal.

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 to mention, the reluctance or ease to express oneself and elaborate certain topics. It is not about observing only what is said, but also how it is expressed and the non-verbal communication it carries out.

In general, the anamnesis is carried out on the subject to be treated or the end user, but sometimes it is recommended also do it to family members, close friends or even teachers, as in the case of different pathologies children.

The anamnesis is not confined solely to the field of clinical psychology, but is also used for the diagnosis of problems both in other branches of psychology (it can be extrapolated at the level of educational psychology, for example) as in other disciplines such as medicine. However, the use of this term is usually applied especially in the clinical field.

Main elements to take into account in an anamnesis

The dialogue established during the anamnesis has to gather diverse informationIt is essential that certain fundamental aspects are reflected in it, specifically the following.

1. ID

It is the basic data of the person, 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 be obvious, the reason why the subject comes for consultation, that produces a problem or the demand that you want to make is one of the main information to obtain in the anamnesis.

3. History of the current problem

The reason for consultation is a primary knowledge, but to fully understand the situation, the psychologist or professional who performs the anamnesis needs to know how and when it has appeared in the life of the patient, in what situation or situations does it appear, what causes does the subject consider to have caused it, what symptoms he suffers and which ones seem more relevant.

4. Affection in habitual 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 guide the type of strategies to be used, directing the therapeutic objectives both to solve the problem itself and to the effects of these on life everyday.

5. Psychosocial history

The vital history of the individual who comes to the consultation is usually closely linked to the appearance of certain phenomena and problematic. The type of education received, the subject's socialization process, the events that have marked or configured their personality and the elements that the individual himself associates with the initiation or maintenance of a problem can be great utility.

6. Personal history

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

7. Family history and family situation

Know the presence or absence of a family history of a problem or as the family is structured, it can allow to refine the diagnosis and focus on some intervention strategies or others. It can 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 explaining what the patient expects to happen, the presence of motivation to follow a treatment and that it considers that it can or cannot be achieved with professional help. Apart from knowing their expectations regarding the operation of the therapy and its results, it also allows to see the user's vision regarding their own future and the existence of cognitive biases who underestimate or overestimate what the treatment can achieve (they may have unrealistic expectations or cause self-fulfilling prophecy), being able to work on these issues in the therapy itself.

Considerations

Taking the anamnesis is, as we have mentioned, of great importance for the exercise of the profession. However, this cannot be done without taking into account a number of considerations.

Assessment of the extent and completeness of the anamnesis

It can be tempting to consider the idea of ​​getting as much information as possible from the patient up front in order to establish a firm strategy to follow from there. However, although it is evident that the acquisition of information regarding the case is essential.

An overly exhaustive history can be extremely aversive for the patient, this being able to feel uncomfortable and reduce the emission of information and even abandon the search for help. We must not forget that we are facing a 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 situation of the patient, his problem and his vital status, but this compilation should not be made as a interrogation.

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

Unmodifiability of the information received

It must also be considered that the information obtained during the anamnesis does not have to be unchangeable. The patient may not know exactly what is happening to him, he may need more time to reflect on how it affects your life or even need to feel more comfortable with the therapist to entrust certain information.

Respecting ethical limits

The collection of data and information by the professional is a fundamental and essential point of the therapeutic process. However, the anamnesis or collection of information cannot be done indiscriminately.

It must be taken into account that the patient must have the right to preserve privacy, trying to limit himself to the phenomenon causing the discomfort or the reason for consultation or, failing that, aspects of the patient's life that are considered to affect the patient and compliance with the therapy.

Bibliographic 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.

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

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