Arthur Hamilton Crisp

Arthur Crisp died on 13 October 2006, aged 76, at his home in Wimbledon, London. He was born in Wood Green, London on the 17 June 1930 and was an only child.

For the greater part of his professional life, Arthur Crisp held the Chair of Psychiatry at St George's Hospital Medical School. From there he established an eating disorder unit which became well known for the quality of its clinical service. With a minimum of outside funding, he pursued broadly based research which had a worldwide impact.

Arthur spoke well of Watford Grammar School where he excelled, especially in sporting activities. At school he captained the first XV rugby team. At the age of 19, and shortly before joining the army, he was playing for the school ‘ Old Boys’ when he suffered a horrendous injury to the ligaments of his left knee and the lateral popliteal nerve. As a result he spent 9 months of 1950 in hospital and was left with a weak knee joint and a foot-drop. At his final medical examination he was exempted from military service.

Arthur gave a whimsical account of his troubled attempts to obtain a place at medical school. He attributed his later success at the Westminster Hospital to pulling out of his pocket during his interview the intact semicircular canals of a dogfish which he had prepared during his recent biology practical studies.

He graduated MB BS in 1956. After house posts at the Westminster Hospital he became senior house officer in neurosurgery to Sir Wylie McKissock. There was an interlude of 1 month when he provided medical help to refugees of the Hungarian uprising on their journey to the UK. From neurosurgery it was but a short step to psychiatric training at Atkinson Morley's Hospital, a position he preferred to a post at the Maudsley.

After passing the DPM he was appointed senior registrar at King's College Hospital, where Dr Denis Hill became his mentor. After Denis Hill became professor of psychiatry at the Middlesex Hospital, Arthur followed him in 1961 as his lecturer and then senior lecturer. In 1967, at the youthful age of 37, he was appointed Professor of Psychiatry at St George's Hospital Medical School.

During the early years of his academic career Arthur pursued wide-ranging research in the area of psychosomatic disorders. He had already made his mark while at the Middlesex Hospital where he was co-designer of the Crown – Crisp self-rating scale for patients with neurosis. He also introduced the term ‘weight phobia’, a concept which he later developed as a core feature of anorexia nervosa.

It was indeed in anorexia nervosa that Arthur Crisp conducted his most important research. His clinical method was to enquire painstakingly into the patient's illness at the first interview which lasted 3 hours. He would not normally assess a patient with anorexia without also seeing their family. Several more hours were spent on formulating the underlying psychopathology. In the early days, the treatment was often admission to hospital for an average of 4 months. Out-patient treatments were gradually developed and were based on a specific form of psychotherapy and family therapy. He prescribed 50 sessions as a ‘minimum viable number’ extended over the course of 6 years. He agreed that this programme sounded daunting to some patients and their families – as well as to hospital managers.

Arthur considered his most important work to be his explanatory model for anorexia nervosa which he first presented in his book Let Me Be which was published in 1980. He thought the illness was a result of a faulty development, a morbid reaction to puberty. He used a telling phrase – a flight from growth – to explain that the illness enabled the adolescent to regress to a simpler existence with fewer emotional upheavals and less personal responsibility. The patient achieved all this by eating less and maintaining a pre-pubertal weight: ‘the avoidant position’ of anorexia nervosa which had the capacity to reverse the pubertal process. Although he made skilful use of metaphorical phrases, Arthur did not look upon his model as a mere metaphor. He believed in its truly aetiological validity. The model has the characteristics of an internally coherent system, but Arthur did not limit it to such a system for it became the foundation of his therapeutic programme at St George's. The main principle of the treatment was for the patient to abandon the avoidant position of anorexia nervosa: this was achieved through psychotherapy.

Arthur conducted a key controlled trial which was published in 1991. Its initial aim was to compare the benefits of three forms of active treatment with each other and with a ‘treated elsewhere’ group of patients who were merely assessed in the unit. The design of the trial was ingenious and kept within ethical boundaries. The three active treatments were: a mainly inpatient admission; an out-patient individual and family treatment; and an outpatient group therapy programme. The three active treatments were similar in their effectiveness at 1-year follow-up. There was no doubt, however, about the poor response of patients ‘treated elsewhere’. This finding has become a powerful endorsement of specialised eating disorder units.

Arthur relied on another way of appraising his treatment, and hence his model for anorexia nervosa: he assessed the outcome of his patients’ illnesses. He carefully preserved a database of 903 patients. He published follow-up studies in 1979 and 1992 with favourable results, finding a lower standard mortality rate than in comparable studies.

Towards the end of his life, he had a further burst of research activity and published a final set of eight papers in the May 2006 issue of the European Review of Eating Disorders. One of these papers was on a 30-year follow-up and yielded the surprising finding that the mortality rate among his patients was the same as for the general population. He deduced that, although their cause of death might be linked to anorexia nervosa, they had been protected from other potentially fatal disorders. At the same time the mortality rate in his patients was lower than in other series, from which he tentatively concluded that his treatment programme might carry significant advantages over others.

Arthur's outstanding contributions to the diagnosis and treatment of eating disorders were recognised by a Lifetime Achievement Award from the Academy of Eating Disorders, and a National Award from the Eating Disorder Association.

He also undertook much valuable work outside the field of eating disorders. Most recent was his leadership of the Royal College of Psychiatrists’ campaign against the stigma associated with mental illness, culminating in the influential book Every Family in the Land. For his contributions to psychiatry and his work for the College he was elected Honorary Fellow in 1996.

For someone with as brilliant an academic career as Arthur's it may be superfluous to mention committee work. Yet Arthur shone in this sphere as well and was most influential in the advancement of medical education. As Dean of the London Faculty of Medicine (1976–80) he helped to establish the standards of medical education in 33 schools within the University of London. He was Chairman of the Education Committee of the General Medical Council (1982–88). He was President of the Psychiatry Section of the Royal Society of Medicine (1999–2000).

After retiring Arthur extended his hobby of carving complex symbolic figures in wood, photos of which he sent to friends on Christmas cards.

When Arthur had his final eight papers on anorexia nervosa published in a special issue of the European Review of Eating Disorders he sent a copy to close colleagues with a touching accompanying letter saying that this was his swansong as he had been found, out of the blue, to be harbouring a carcinoma of the kidney. He maintained this stoicism throughout his relatively short illness and bore the final stages with great courage. He was buried in the village of Friston, Suffolk.

Above all, Arthur was an outstanding clinical psychiatrist with the hallmarks of sincerity and integrity. He was an agreeable companion at conferences, with stimulating ideas and conversation, and unfailing courteousness. Our warmest sympathy is extended to his wife, Irene, his three sons and their families, whose strong support he found invaluable.