Anamnesis: Definition And 8 Basic Clinical Aspects
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 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 thing to practice as a good professional, requiring observation skills, empathy and initiative, among other characteristics. All of this is necessary to be able to offer good service to the client or patient, with its improvement and the problems and demands that it may present being the main objective of the professional. Knowing why you have decided to go for a consultation, the story 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 take the anamnesis.
The process by which the professional obtains information from the patient about the patient through a dialogue in which the professional must obtain basic information about the patient’s disorder or problem, his or her lifestyle habits, and the presence of family history is called anamnesis. 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, their problem and the way in which 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 also what is avoided mentioning, the reluctance or ease in expressing oneself and elaborating on certain themes. It is not just about observing what is said, but also how it is expressed and the non-verbal communication it makes.
In general, the anamnesis is carried out on the subject to be treated or the end user, but sometimes it is advisable to also take it on family members, close friends or even teachers, as in the case of different childhood pathologies.
The anamnesis is not limited only to the field of clinical psychology, but is also used to diagnose problems both 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 an anamnesis
The dialogue established during the anamnesis must gather diverse information it being essential that certain fundamental aspects appear reflected in it, specifically the following.
1. Identification
These are 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 what causes 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 essential knowledge but to fully understand the situation, the psychologist or professional who takes 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 considers that have caused it, what symptoms he suffers from and which They seem more relevant to you.
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 direct the type of strategies to be used, directing therapeutic objectives both to the resolution of the problem itself and to its effects 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 problematic. The type of education received, the subject’s socialization process, the events that have marked or shaped their personality and the elements that the individual associates with the beginning or maintenance of a problem can be very useful.
6. Personal background
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 background and family situation
Know the presence or absence of a family history of a problem or how the family is structured can allow the diagnosis to be refined 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 explaining what the patient expects to happen. the presence of motivation to follow a treatment and what you consider you 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 undervalue or overvalue what the treatment can achieve (they may have expectations unrealistic or provoke a self-fulfilling prophecy), and these issues can be worked on 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 series of considerations.
Assessment of the length 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 beginning in order to establish a firm strategy to follow from this. 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. and the latter may 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 patient’s situation, his problem and his vital status, but this collection should not be carried out as an interrogation.
In certain cases it may also be necessary to shorten or even postpone its completion, as in the case of patients with suicidal ideation.
Unchangeability 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 her, need more time to reflect on how it affects her 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. 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 it to the phenomenon causing discomfort or the reason for consultation or, failing that, to aspects of the patient’s life that are considered to affect him or her. therapy compliance.
