Forty Years of Untreated Anorexia Nervosa: How Bad Can It Get?

Eating disorders (EDs) are marked by abnormal eating or weight-control behaviors and disturbed attitudes and thoughts about weight, body shape, and eating.^1–3 EDs have been on the rise over the past years, with changes in food environment being a contributing factor.⁴ Cultural ideals of beauty can trigger disordered eating in vulnerable individuals who are genetically predisposed to anxiety and perfectionism.⁵

Anorexia nervosa (AN) is characterized by an intense fear of gaining weight and a distorted and erroneous self-perception of body image. This leads to food restriction and behaviors aimed at weight loss, as purging/excessive exercise. There are 2 types of AN: restrictive and binge/purge.^3,6,7 As AN becomes severe and chronic, there is no body system out of danger from its sequelae.^3,4 It is a multisystemic disorder, with medical complications primarily resulting from the physiological impact of low weight, nutritional deficiencies, and purging behaviors.^4,7 The medical consequences of AN can be life-threatening, making it one of the mental disorders with the highest mortality rates.³ We present a case of a patient with nontreated AN for more than 40 years, who developed severe medical complications secondary to the untreated psychiatric illness.

Case Report

The patient was a 63-year-old woman with a diagnosis of chronic restrictive AN of 40 years duration, with erratic follow-up. The disorder started at age 23 years and was never properly treated, largely due to poor insight into the illness, as well as underlying cluster C (anankastic/obsessive-compulsive) personality traits characterized by marked rigidity and inflexibility. Three years before the present observation, she described an increase in restriction pattern, excessive laxative use, and onset of balance changes, leading to multiple falls at home with several head traumas. The most pronounced weight loss occurred from January to June 2023, when she lost 10 kg (22 lb) during this period, weighing 33.5 kg (73.9 lb) in June. Her height is 1.67 m, and this was her lowest weight, corresponding to a body mass index (BMI) of 12 kg/m².

We found records of chronic subdural hemorrhages consistent with head trauma in home settings and multiple computed tomography (CT) scans reporting an enlargement of the extra-axial frontoparietal space on the right and frontal space on the left hemisphere, slightly denser than the cerebrospinal fluid, which may result in chronic subdural hematoma, and sequelae lesions in fronto-basal and fronto-opercular topography on the right. After these multiple falls, the patient started having generalized tonic-clonic seizures. Although seizures in EDs can have multiple etiologies, including electrolyte abnormalities, Wernicke encephalopathy, and psychogenic nonepileptic seizures among others, a diagnosis of structural epilepsy, secondary to multiple head trauma, due to hypoglycemia from intake restriction was made. She started levetiracetam 1,000 mg twice daily.

In June 2023, she was admitted to an inpatient internal medicine unit presenting with shortness of breath and fatigue with small efforts, increased weight loss and disorientation, and slower speech periods. At admission, she presented her lowest weight (BMI: 12 kg/m²) and multiple tonic-clonic seizures despite antiepileptic medication. She started valproic acid 500 mg twice daily and was maintained on levetiracetam.

Secondary to malnourishment, pericarditis was diagnosed, with no other etiologic factors found. Serological and autoimmune studies were negative. Transthoracic cardiac ultrasound was performed showing relevant changes, and cardiac CT angiography indicated significant coronary calcifications. She was started on colchicine 1 mg/day and ibuprofen 600 mg twice daily, with improvement in shortness of breath and fatigue and fewer periods of disorientation. There were episodes of convulsive seizures, generalized tonic-clonic, in the internal medicine inpatient unit; she was still taking levetiracetam and valproic acid. A new head CT was performed, which showed ischemic/traumatic sequelae and chronic subdural hematomas related to multiple falls due to hypoglycemia.

During hospitalization, caloric intake was gradually optimized using safe refeeding practices, with careful monitoring for electrolyte disturbances and other complications associated with refeeding syndrome. After 20 days of internal medicine hospitalization, considering the patient’s improvement, she was transferred to the psychiatry unit for continued care. At admission to the inpatient psychiatric unit, her weight was 37.7 kg (83.11 lb). The electrocardiogram showed no significant alteration. Blood test results were hemoglobin: 11.8 g/dL, blood glucose: 49 mg/dL, cholesterol: 169 mg/dL, triglycerides: 147 mg/dL, high-density lipoprotein: 82 mg/dL, and low-density lipoprotein: 58 mg/dL.

She was started on olanzapine 10 mg and paroxetine 20 mg. A psychotherapy approach was used, aiming to increase the patient’s insight for her disorder. She slowly increased her body weight and started to understand her disorder. At discharge, the patient left the hospital with a body weight of 48.5 kg (106.9 lb), corresponding to a BMI of 17.5 kg/m², and started outpatient appointments provided by the ED unit of Hospital Santa Maria, Lisbon, to continue to improve her weight and mental health status. Current follow-up includes monthly psychiatric appointments, biweekly psychology sessions, and internal medicine reviews every 3 months.

Discussion

This clinical case exposes the impact of a chronic and never properly treated AN, illustrating possible irreversible complications of this illness. Pericardial effusion can develop in about one-third of individuals with AN,^4,8 and pericarditis has an unclear etiology, being commonly correlated with malnutrition level. It is usually reversible after refeeding.4,8 This condition, a common cause of sudden death in AN, is a poor prognostic sign and requires close monitoring.4,8 Our patient, even after an inpatient intervention and close monitoring with re-established glucose levels and increase of BMI close to normal levels, maintained the need for life-long antiepileptic medication. This case shows that an early intervention in these disorders is of major importance to reduce irreversible complications. An understanding of the possible complications is crucial for safer approaches.

Article Information

Published Online: October 13, 2026. https://doi.org/10.4088/PCC.26cr04240
© 2026 Physicians Postgraduate Press, Inc.
Prim Care Companion CNS Disord 2026;28(5):26cr04240
Submitted: March 28, 2026; accepted June 2, 2026.
To Cite: Romão J, Rebelo M, Baronet P, et al. Forty years of untreated anorexia nervosa: how bad can it get? Prim Care Companion CNS Disord 2026;28(5):26cr04240.
Author Affiliations: Department of Psychiatry and Mental Health, Unidade Local de Saúde de Santa Maria, Lisbon, Portugal (Romão, Rebelo, Baronet, Duarte); Faculty of Medicine, University of Lisbon, Lisbon, Portugal (Romão, Rebelo, Baronet, André, Duarte); Unidade Local de Saúde Almada Seixal, Setúbal, Portugal (André).
Corresponding Author: Joana Romão, MD, Department of Psychiatry and Mental Health, Unidade Local de Saúde de Santa Maria, Lisbon, Portugal ([email protected]).
Financial Disclosure: None.
Funding/Support: None.
Author Contributions: Literature review, writing of the manuscript (Romão, Rebelo, Baronet, André). Writing  and critical review of the manuscript (André, Romão, Duarte).
Patient Consent: Consent was received from the patient to publish the case report, and information, including dates, has been de-identified to protect patient anonymity.