The occupational roles of women with anorexia nervosa

This study’s objective was to understand how occupational roles of individuals with anorexia nervosa are configured. The sample was composed of a control group and 11 adult women with anorexia nervosa being cared for by the Eating Disorders Care Group in a hospital in Ribeirão Preto, SP, Brazil. Socio-demographic and anthropometric data were collected and the Role Checklist was applied. The results revealed a significant loss of roles for women with anorexia nervosa in relation to the performance of the roles worker, friend, and amateur/hobbyist, supporting the idea that psychosocial harm may arise from this eating disorder. The evaluation of occupational roles in the treatment of eating disorders is an important strategy for planning Occupational Therapy activities and supporting the creation of healthier spaces to enable individuals to resume occupational roles, and acquire independence and autonomy.


Introduction
In Portuguese, the etymological origin of the word role* comes from the Greek word papyros and from the Latin word papyrus, the meaning of which is www.eerp.usp.br/rlae Quiles-Cestari LM, Ribeiro RPP.
One of the main theoretical references in the profession is the Model of Human Occupation (MHO) that strongly explores the concept of role and occupational role (3) . This model seeks to recover a humanistic perspective in Occupational Therapy, associated with the General Theory of Systems, according to which the Human Being is seen as an open system, cyclical, and able to change and develop through events experienced in the environment. One view is that these systems cannot work as isolated parts; the environment and the systems result from a dynamic network of relationships (4) .
An instrument called "Role Checklist" was based on the MHO's theoretical assumptions to assess occupational roles. It was originally written by the American occupational therapist Francês Oakley in 1986.
The instrument was translated and culturally adapted to Brazil, and was validated by a sample composed of individuals with chronic obstructive pulmonary disease (5) .
This inventory is intended to address information concerning ten roles individuals may have; the individuals' perceptions concerning the roles played over their lifetimes, and also the importance individuals attribute to each role (4)(5)(6) .
Even though there are several Brazilian studies using the Role Checklist in different clinical situations, the configuration of occupational roles in situations of eating disorders are not sufficiently documented, particularly Anorexia Nervosa (AN) (7) . Therefore, it is a fertile ground to explore the theme. People with AN present changed eating behavior closely linked to an excessive concern with their weight and body, in addition to an intense fear of gaining weight () .
The etiology of these conditions is still unknown, though studies have shown that the cause may be multifactorial, including genetic, sociocultural, family and individual factors, such as some adverse experience, personality, and psychological vulnerability (9)(10) .
AN has severe consequences and negatively affects individuals' organic and mental states. Hence, it is considered a disease the treatment of which is highly complex and requires the assistance of a multidisciplinary staff to provide integral care to both patients and families (11) . Hospitalization is a modality of care frequently used to reestablish the nutritional and emotional states of patients who have a more severe condition (9) . In this context, nurses are essential members of the staff who offer care to patients and families (12)(13) , going beyond clinical aspects, such as assessing vital signs, and administering medication and organizing a diet, among others. Psychosocial aspects of the patient's functioning are also observed in order to favor interpersonal relationships, supporting and establishing the limits necessary to promote patient autonomy, self-care, and increased wellbeing (14) .
It is believed that AN leads to psychosocial losses in daily life, as reported in cases of chronic renal failure (15) and schizophrenia (16) . Such losses include failure to play occupational roles and difficulty carrying on social relationships. Even though there are reports addressing difficulties faced in these areas (14,17) , there are no studies     Fischer's exact test was used to compare the EG and CG. The probability of type I error (alpha) was fixed at 5% (21) .

Results
The EG was composed of 11 women with a median age of 29 years old (Q1=22 years old; Q3=38 years old Quiles-Cestari LM, Ribeiro RPP.

Discussion
This study's hypothesis was that women with AN lose occupational roles with the onset of the disease.
The results seem to support such a hypothesis as they show the loss of some roles in the present, among them, that of worker, friend, and amateur/hobbyist. achieve social and financial acknowledgement (22) .
Labor has individual value and social function.
Through it one attains a living, social participation and status, in addition to health when it is performed with www.eerp.usp.br/rlae Quiles-Cestari LM, Ribeiro RPP.
pleasure (23) . Social relationships are increased with a job and such relationships can entail both happiness and suffering (24) .
At this point, one might consider the difficulties patients with AN may have relating with another person and how difficult this relationship may be to oneself and to the other people these patients live with. Occupational therapy shows that the difficulties faced by these patients in regard to their performance at work are not only caused by their times of leave and absences, but also due to difficulties they face in maintaining interpersonal relationships (17) .

Individuals with AN may show less knowledge
and differentiation of themselves with another, and can also have difficulty defining their own identity and recognizing emotions. They tend to become isolated, have difficulties maintaining meaningful and significant social relationships, while potential impoverishment of interpersonal communication may occur together with a lack of empathy (14,25) . These conditions, however, cannot be generalized to all those affected with AN, though individualized care is required by those presenting these signs.
These relationship difficulties interfere in the performance of other roles, such as friend and also amateur/hobbyist since most of the time, these are performed together with other people. Difficulties in carrying on interpersonal relationships greatly harm one's participation in social activities and leisure, distancing these individuals from friends and family members (25) .
In regard to roles to be performed in the future,

Final considerations
The configuration of occupational roles identified among the studied women with AN seem to support this study's hypothesis. The performance of occupational roles that structure these women's occupational life was hindered, especially in relation to activities in social life.
New studies, however, are required to identify whether this characteristic is prior to the diagnosis, that is, to verify whether these women already had difficulties relating to people or that their ability to give continuity to these roles was hampered by the onset of disease.
These results, unpublished in this field of knowledge, make an important contribution to the improvement of care provided to patients with eating disorders from the perspective of integrality of care.