Anamnesis: definition and 8 basic clinical aspects
Exercising as a psychologist requires the presence of a consistent body of knowledge , both with respect to the normal functioning of the human mind and of non-typical or even pathological processes.
It also requires knowing and knowing how and in which cases to apply the different techniques and procedures available. However, the presence of knowledge is not the only essential to exercise as a good professional, requiring observation skills, empathy and initiative, among other characteristics. All this is necessary in order 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 to 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 gather all the data he may need to start working on the case , that is, to make the anamnesis.
Anamnesis is the process by which the professional obtains information from the patient's patient through a dialogue in which the professional has to obtain the basic information of the patient's disorder or problem, their life habits and the presence of a family history. to be able to establish a diagnosis of the problem to be treated or to work.
It is the first stage of the diagnostic process, essential for the psychologist to be able to understand the life situation of the individual, their 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 said but what is avoided to mention, the reticence or facility to express oneself and elaborate certain themes. It is not about observing only what is said, but also how it expresses itself and the non-verbal communication it makes.
In general, the anamnesis is done to the subject to be treated or the final user, but it is also advisable to ask it to relatives, relatives or even teachers, as in the case of different childhood pathologies.
The anamnesis is not confined solely to the field of clinical psychology, but it is also used to diagnose problems in other branches of psychology (it can be extrapolated to the level of educational psychology, for example) and in other disciplines such as medicine. However, the use of this term is usually applied especially in the clinical setting.
Main elements to take into account in a medical history
The dialogue established during the anamnesis has to gather diverse information , being fundamental that they appear reflected in her certain fundamental aspects, concretely the following ones.
This is the basic information 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 to consultation , which produces a problem or the demand 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 primordial 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 patient's life, in what situation or situations it appears, what causes the subject that caused it, what symptoms it suffers and which they seem more relevant to you.
4. Affectation in the habitual life
The problems presented by the subjects have an effect on their daily lives , 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 to consultation is usually closely linked to the appearance of certain phenomena and problematic. 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 start or maintenance of a problem can be very useful.
6. Personal history
Sometimes people who come to consultation do so because of problems arising from phenomena , previous events or diseases 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 background and family situation
Know the presence or absence of a family history of a problem or how the family is structured can 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 that considers that it may or may not achieve with professional help. Regardless of 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 that undervalue or overestimate what the treatment can achieve (they can have expectations unrealistic or provoke a self-fulfilling prophecy), being able to work on the therapy itself these issues.
The realization of the anamnesis is, as we have mentioned, of great importance for the exercise of the profession. But nevertheless, this can not be done 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 the maximum possible information from the patient from the beginning in order to establish a firm strategy to follow from it. However, although it is evident that the acquisition of information regarding the case is essential.
A too exhaustive anamnesis can be extremely aversive for the patient , this may feel uncomfortable and reduce the issuance of information and even abandon the search for help. We must not forget that this is 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 patient's situation, their problem and their vital state, but this collection should not be done as an interrogation.
In certain cases it may also be necessary to abbreviate or even postpone its implementation, as in the case of patients with suicidal ideation.
Modifiability of the information received
It must also be considered that the information obtained during the anamnesis does not have to be unmodifiable . The patient may not know exactly what is happening to him, need more time to reflect on how it affects his life or even need to feel more comfortable with the therapist to trust him with certain information.
Respecting ethical limits
The collection of data and information by the professional is a fundamental and essential point of the therapeutic process. But nevertheless, the anamnesis or collection of information can not be done indiscriminately .
It must be taken into account that the patient must have the right to preserve privacy, trying to circumscribe the phenomenon causing discomfort or the reason for consultation or, failing that, to aspects of the patient's life that are considered to affect the patient and the patient. compliance with therapy.
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- Rodríguez, P.L. and Rodríguez, L.R. (1999). Technical principles to perform the anamnesis in the adult patient. Rev. Cubana. Med. Gen. Integr .; 15 (4); 409-14