The horror that Elisabeth Fritzl has endured is etched into her aging face.
The gruesome details made headlines in European papers this week when she was found in an Austrian basement after 24 years of imprisonment.
Reportedly raped by her father at age 11, drugged and cast in a dungeonlike cellar at 18, and for months tied to a pole and offered the choice of sex or starvation, the daughter of Josef Fritzl has paid a heavy price.
In her underground prison, Elisabeth Fritzl bore seven children through incest and was never allowed to see daylight or interact with anyone other than her tormentor father and her children.
Now above ground and reunited with her mother and the three children she did not see for years, Fritzl looks haggard, hunched over, lined and gray. European media reports say the 42 year-old looks more like the sister of her 67-year-old mother than her daughter. And doctors say she will need an extensive, well-structured system of physical and psychiatric rehabilitation.
"This case is so unique, we can only look for approximations," Dr. Stuart Goldman, a psychiatrist at Harvard University's Children's Hospital in Boston, told ABCNEWS.com. "This would include long-term prisoners subject to extreme mental anguish and parents who have witnessed horrendous acts in some of the genocidal conflicts around the world."
Goldman has worked with Cambodian survivors of the atrocities of the Khmer Rouge. Like Fritzl, they appeared to function normally but were plagued with residual symptoms.
"Some say they 'died' back when the events were occurring and felt like the walking dead," he said. Similar effects of post-traumatic stress disorder have been observed among Holocaust survivors.
In her first medical exam since she was found in the basement, Austrian doctors said Fritzl's teeth were horrifically decayed. She and her three children have complicated medical problems, including vitamin D deficiency, anemia and bad posture. Kerstin, her 19-year-old daughter, is in an induced coma after collapsing last week. She is still in a critical condition and fighting for her life.
Vitamin D deficiency can cause rickets, a disease of malnutrition caused by lack of sun exposure that is rarely seen today, according to Goldman. As a result, her bones are likely weakened and deformed. Because of the cramped space, low ceilings and little opportunity to exercise, Fritzl may also have problems with movement.
"If you don't use muscles and stretch them out, your motion is limited," said Goldman. Muscles can be retrained, but senses like vision and hearing could be permanently impaired.
"All our senses are trophic," said Goldman. "You have to use nerves for nerves to develop. If you patch an eye, you eventually go blind, even if the eye is mechanically normal."
Doctors worry most about the family's cognitive and language development. The brain is also a sensory organ and needs stimulation to develop. While Fritzl spoke German, her children learned to talk to themselves in animal-like growls and coos, according to Austrian police.
Though a team of Austrian doctors is worried about the three children, Fritzl may have suffered worse -- despite the fact that she had 18 years in the real world.