May 2, 2008 -- 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."
The 'Walking Dead'
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.
Years of Deprivation
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.
"She was older when it started happening, but at the same time, she had years and years of deprivation and limited stimulus," said Jay Reeve, associate professor of psychology at Florida State University and executive vice president of the Apalache Center for Mental Health. "It's exactly as if she was held in captivity in jail."
In Fritzl's case, the trauma may have been more "insidious" because her captor was her father, someone she trusted. In typical cases of captivity and cruelty, victims can direct their fear and anger toward an "anonymous attacker."
"She couldn't unequivocally hate that person because he was her father," said Reeve.
In other abuse cases, victims have other people to turn to for trust, such as a teacher, to mitigate the trauma. "But in her situation she had nothing coming from the environment to help her recover from the effects," he said.
"She had some period of her life when, presumably, she was able to interact with others and be in school and have some social interchange," said Reeve. "But the rape and sexual abuse that she experienced was a pretty stark betrayal of trust."
With the complexity of her trauma, Fritzl most likely has shut down emotionally as a way to cope with the pain and may need myriad therapies and time "to handle her memories and make sense of how why this happened," said Reeve.
Starvation or Sex
Josef Fritzl reportedly hatched the plot to lock up his daughter as a sex slave just after his first sexual assault, when Elisabeth was 11. Seven years later, in 1984, he drugged her with ether, dragged her downstairs and locked her up.
He reportedly handcuffed Elisabeth to a metal pole and kept her in total darkness, returning only to bring her food or to rape her. Often she had to decide whether to have sex or starve.
Police said her mother, Rosemarie Fritzl, said she was completely unaware of the "house of horrors" below. Fritzl reportedly told his wife, who had six other children with her husband, that he was building a nuclear shelter and that Elisabeth had left to join a religious cult.
According to British reports, Elisabeth Fritzl told police she was so afraid of her father that she "submitted herself to him entirely."
Police told the media, "We understand that Elisabeth was his favorite child because she was so pretty."
Jeff Dolgan, senior psychologist at Denver Children's Hospital, said he had never heard of a case this horrific.
"It's beyond creepy," he said. "This takes the cake. Trauma is like throwing a big rock into a pond. The waves go out and we are all sadly traumatized."
Dolgan said Elisabeth Fritzl's mental, physical and emotional wounds will require a network of case managers. "She will need a system of care, not just one person but an adult psychiatrist who will coordinate the rehabilitation. Her world has been this basement. It's like our waking up 500 years from now. This is all she's known."
But doctors see a ray of hope in this demonic scenario. Elisabeth Fritzl may well have been a good caregiver to her children -- Kerstin, Stefan, 18, and Felix, 5 -- and established close bonds with them that will help her heal.
A Sadistic Father
Austrian authorities are trying to get to the bottom of why Josef Fritzl -- a seemingly capable engineer who hid his secret for decades -- could commit such a crime.
"It's an astounding story and not so different from mass murderers," said Harvard's Goldman. "Most pathological behavior stems from group mentalities -- like the Nazi regime -- but individual sociopaths are "out of the ordinary," he said.
"Clearly, he has major trouble organizing himself with a sense of reality," Goldman said. "It's hard to speculate, but I have to think that he has something with power and control and sadism."
Since its rescue, the family has been living in an isolated room in a psychiatric unit near their home. Doctors have placed a cargo container outside so that Josef Fritzl's captives can retreat there if they feel too traumatized by the daylight and the open space.
"She needs reassurance that she has not lost everything," said psychologist Dolgan.