A total of 14 patients were enrolled, all from Bologna and its province, and all with a history of admission to Public Psychiatric Services (100%). Five patients (35.7%) were still in psychiatric service care, while four patients dropped out of services (28.6%). One patient had died. At the time of data collection, four patients (8.6%) were no longer followed within a psychiatric pathway. A summary of the main clinical and social characteristics of the patients is presented in Tables 2 and 3.

The patients were all female (100%). The sample had an average age of 42.2 years old (ranging from 24 to 63 years old). Only four out of 14 patients (28.6%) were married and none of them had gone through a divorce. Three patients (21.4%) had at least one child, and only one had more than one. Therefore, the majority of candidates with SE-AN were not married (71.4%) and had no children (78.6%). However, 86% of the patients lived with someone: six lived with their partner/husband, and six with the family of origin.

Almost all of the patients had a job during their lifetime (78.6%), including seven employees (who carried out office work, without any specific responsibility), two hairdressers, one bartender, and one lawyer. Among those who had never worked, two were University students. Therefore, only one out of 14 patients never worked or pursued a college career. Among the 11 individuals who had had a job, however, only three people were known to be employed at the time of the analysis (27.3%). For two people, no data regarding their working life were available on their medical records.

Among the 14 patients, seven (50%) had a cigarette smoking habit, while two (14.2%) had a history of alcohol abuse. Three (21.4%) had a history of self-injury.

The average age of onset of ED symptoms in our sample was 22.7 years (range 11–47), while the average age at which a diagnosis of AN was made in public services (Psychiatry or Dietetics) was 31.5 years (range 16–51). The patients had a mean disease duration of 17 years (range 8–31) combined, in the vast majority of cases (85.7%), with a series of unsuccessful therapeutic attempts. The latency period between the onset of the disease and its recognition by public health services was 8.79 years (range 1–34 years); in nine out of 12 cases (64.3%) the diagnosis was made after at least three years of illness, while in 6 cases (42.9%) after at least seven years.

The most frequent AN subtype in the considered sample was AN-Restrictive (85.7%), while only two patients (14.3%) suffered from the AN-Binge/Purging subtype. The most frequently reported caloric restriction methods were reduced caloric intake and intense physical exercise; this was followed by laxative use, self-induced vomiting, and diuretic use.

The average patient’s Body Mass Index (BMI) reported was 13.43 kg/m2 (range 7.53–16.94 kg/m2), highlighting the extreme severity of the cases described (according to the DSM-5 [1], AN patients with BMI < 15 kg/m2 are classified as showing “extreme severity”). The patient with the lowest BMI included in the case series reached a value of 7.15 kg/m2.

Eleven patients (78.6%) had been hospitalized at least once in an internal medicine department because of their ED, due to their severe malnutrition; in addition, among the three patients who had never faced hospitalization, two had previously refused it several times despite the need expressed by their caregivers. In contrast, at least two out of 14 (14.3%) had multiple accesses and one patient was hospitalized at the time of data collection. In parallel, seven of the patients (50%) were admitted at least once to a psychiatric department to manage their disorder. In the examined clinical context, six patients (42.9%) received enteral nutrition through nasogastric tube administration on at least one occasion, while an additional six patients (42.9%) required parenteral nutrition. The purpose of the parenteral nutrition intervention was to augment daily caloric intake and provide supplementary support to oral nutrition exclusively.

Common complications of AN, such as anemia and hypokalemia, and their treatment needs, were also investigated. In 50% of the patients, the occurrence of at least one episode of anemia during the natural history of the disease was reported. Anemia was most commonly macrocytic (57%). Regarding treatment, at least 42.9% of anemia cases were of such severity that they required blood transfusion, 28.6% required only iron and vitamin supplementation. 21.4% had no history of anemia. For the 28.6% no data about the occurrence of anemia as a complication of their disorder was found examining the available clinical records, while several patients refused to take blood tests. At least one episode of hypokalemia was reported in 50% of cases. Of the seven confirmed cases of hypokalemia, 100% required treatment, and at least three were of such severity as to require intravenous infusion therapy.

Other ED complications present within the considered sample, consequences of persistent malnutrition and secondary hormonal disorders typical of AN, included osteoporosis and secondary amenorrhea. In 57.1% of the cases frank osteoporosis was shown and in 28.6% osteopenia was demonstrated. In 93% of patients there was at least one period of secondary amenorrhea during the natural history of the disease (no data regarding one individual); these included two patients taking an Estrogen-Progestin (EP) pill and two who reached menopause before having the diagnosis of AN (one of whom was in early menopause).

The presence of psychiatric comorbidities in the history of these subjects was assessed (Table 4), founding that 100% had at least one other psychiatric diagnosis in comorbidity to the ED (not necessarily present to date); three out of 14 patients (21.4%) had only one psychiatric comorbidity, nine (64.3%) had two, and two patients (14.2%) had up to three psychiatric disorders in addition to AN.

It was reported that 50% of patients had a history of familial psychiatric illness, and 14.2% had a parent with severe obesity.

With respect to the therapeutic approaches used for these patients, previous drug therapy attempts employed in ED treatment (in part related to the management of the various psychiatric comorbidities present in the individual cases), and the execution of ED-specific therapeutic pathways (e.g., Dietary care), were evaluated as far as possible.

Nine patients had experienced at least one ED-specific pathway, while five had never been through one; among the latter, four out of five had rejected the proposed ED treatment course, while one was considering the proposal at the time of the data collection. The setting most frequently used by those who had embarked on an ED treatment course was outpatient (100%), followed by semi-residential and residential (44.4%). Among those who started an ED pathway: six completed it, two dropped out, and one moved away.

Regarding the pharmacological therapies taken by patients during their treatment course, the use of three pharmacological classes mainly used in AN treatment (antidepressants, antipsychotics, and benzodiazepines) was analyzed, also considering the possible combined therapeutic indication with respect to the individuals' psychiatric comorbidities.

Nine out of 14 (64.3%) patients used at least one antipsychotic drug, while 28.6% never used antipsychotics; of one out of 14 patients no data were found about antipsychotic administration from the examined clinical documentations. Among users, at least three used more than one antipsychotic in their history, and the most frequently prescribed drug was olanzapine (66.7%), followed by risperidone (22%) and aripiprazole (22%).

11 of 14 patients (78.6%) used at least one antidepressant drug to manage their psychiatric disorders; two patients never used it (n = 14.3%), and one rejected the suggested treatment. Among antidepressant users, 36.4% used more than one. The most commonly prescribed antidepressant was sertraline (77.8%), followed by venlafaxine (44.4%).

Nine out of 14 individuals (64.3%) used at least one benzodiazepine during their course of treatment in psychiatric services. Four patients (28.6%) never used benzodiazepines: three had not been prescribed and one refused to take them. There was one reported case of benzodiazepine abuse, while for one patient no data was found in the available clinical records regarding sedative medications. The most commonly used benzodiazepine appears to be alprazolam (40%).

Lastly, the information obtained showed that all patients (100%) undertook individual psychotherapy during their treatment process, even though duration, frequency, and type of psychotherapeutic courses were not reported in the records.