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Women’s Mental
Health
A Clinical and Evidence-Based
Guide
Joel Rennó Jr.
Gislene Valadares
Amaury Cantilino
Jeronimo Mendes-Ribeiro
Renan Rocha
Antonio Geraldo da Silva
Editors
123
Women’s Mental Health
Joel Rennó Jr.
Gislene Valadares
Amaury Cantilino
Jeronimo Mendes-Ribeiro
Renan Rocha
Antonio Geraldo da Silva
Editors

Women’s Mental Health

A Clinical and Evidence-Based Guide
Editors
Joel Rennó Jr. Gislene Valadares
University of São Paulo Women’s Mental Health Clinic
São Paulo Incestuous Families Treatment
Brazil Clinic of Clinica’s Hospital
Federal University of Minas Gerais
Brazilian Association of Belo Horizonte, MG
Psychiatry (ABP) Brazil
Rio de Janeiro
Brazil Jeronimo Mendes-Ribeiro
Brazilian Association of Psychiatry
Amaury Cantilino Rio de Janeiro
Federal University of Pernambuco Brazil
Recife, Pernambuco
Brazil Antonio Geraldo da Silva
Brazilian Association of
Renan Rocha Psychiatry (ABP)
Private Practice, São Lucas Medical Rio de Janeiro
Institute Criciúma, Brazil
Santa Catarina
Brazil

ISBN 978-3-030-29080-1    ISBN 978-3-030-29081-8 (eBook)

https://doi.org/10.1007/978-3-030-29081-8

© Springer Nature Switzerland AG 2020

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Contents

An Introduction to Women’s Mental Health ����������������������������������������   1

Jeronimo Mendes-Ribeiro, Antonio Geraldo da Silva,
and Joel Rennó Jr.
Those We Should Remember: The Pioneers
of Mother-Infant Psychiatry ������������������������������������������������������������������   7
Ian Brockington
Epidemiology of Psychiatric Disorders in Women�������������������������������� 17
Maria Carmen Viana and Rafael Bello Corassa
Psychometric Instruments and Women’s Mental Health�������������������� 31
Jeronimo Mendes-Ribeiro, Mario Juruena, Luisa Caropreso,
Maha M. Eltayebani, and David L. Streiner
Schizophrenia in Women������������������������������������������������������������������������ 49
Mario R. Louzã and Helio Elkis
Bipolar Disorder in Women: Menstrual Cycle, Perinatal Period,
and Menopause Transition���������������������������������������������������������������������� 59
Lauren F. Forrest, Mara Smith, Joao Quevedo, and Benicio N. Frey
Premenstrual Dysphoric Disorder���������������������������������������������������������� 73
Gabriella Francesca Mattina and Meir Steiner
Depressive and Cognitive Disorders in Climacteric Women��������������� 95
Joel Rennó Jr., Juliana Pires Cavalsan, and Leiliane Aparecida
Diniz Tamashiro
Anxiety Disorders in Women������������������������������������������������������������������ 111
Amaury Cantilino and Carla Fonseca Zambaldi
Obsessive-Compulsive Disorder in Women ������������������������������������������ 125
Albina R. Torres, Ricardo C. Torresan, Maria Alice de Mathis, and
Roseli G. Shavitt
Trauma and Stressor-Related Disorders in Women ���������������������������� 141
Andrea Feijó de Mello, Mariana Rangel Maciel, Sara Motta Borges
Bottino, José Paulo Fiks, and Marcelo Feijó de Mello
Sexual Dysfunctions and Gender Dysphoria in Women���������������������� 151
Carmita H. N. Abdo

v
vi Contents

Eating Disorders and Personality Disorders in Women���������������������� 175

Michele de Oliveira Gonzalez, Fábio Tápia Salzano, Alexandre
Azevedo, Andreza Carla Lopes, Mirella Baise,
and Athanássios Cordás Táki
Alcohol and Substance Use Disorders in Women��������������������������������� 191
Silvia Brasiliano, Adriana Trejger Kachani, Fabio Carezzato,
and Patricia Brunfentrinker Hochgraf
Attention-Deficit/Hyperactivity Disorder and Women������������������������ 215
Antonio Geraldo da Silva, Leandro Fernandes Malloy-Diniz,
Marina Saraiva Garcia, and Renan Rocha
Suicide and Suicidality in Women���������������������������������������������������������� 221
Alexandrina Maria Augusto da Silva Meleiro and Humberto Correa
Psychopharmacology and Women���������������������������������������������������������� 227
Marcelo Allevato and Juliana Bancovsky
Medical Conditions Affecting Women’s Mental Health ���������������������� 241
Sarah Rückl, Tiago Couto, Juliana Parada, and Carlos Eduardo Rosa
Diet, Nutrition, and Women’s Mental Health���������������������������������������� 265
Adriana Trejger Kachani and Yvone Alves de Lima Furtado
Assisted Reproduction: General Concepts
and Psychological Aspects Involved ������������������������������������������������������ 275
Artur Dzik, Alcina Meirelles, Ludmila Machado Neves, Nilka
Fernandes Donadio, Mario Cavagna, and Luiz Henrique Gebrim
Violence and Women’s Mental Health �������������������������������������������������� 291
Gislene Valadares, Erika de Oliveira Neves, Caroline Moreira,
Priscila de Almeida Costa, and Sarah Mendes
Neuroimaging Research in Women’s Mental Health:
Current Research and Emerging Trends in Women
and Transgender Women’s Psychiatry and Mental Health ���������������� 323
Luciano Minuzzi, Maiko A. Schneider, and Sabrina K. Syan
Telehealth and Women’s Perinatal Mental Health ������������������������������ 335
Dawn Kingston and Renan Rocha
Maternal Mental Health and Peripartum Depression�������������������������� 349
Gislene Valadares, Austen Venancio Drummond,
Carolina Cassiano Rangel, Eduardo Santos, and Gisele Apter
Psychopharmacology in Pregnancy and Lactation������������������������������ 377
Jennifer L. Payne
FDA Rules for Pregnancy and Lactation Labeling
and Their Clinical Implications�������������������������������������������������������������� 397
Lauren M. Osborne, Nicole Leistikow, and Renan Rocha
Critical Assessment of Observational Studies
and Shared Decision Making in Perinatal Psychiatry�������������������������� 405
Lauren F. Forrest and Ryan J. Van Lieshout
Index���������������������������������������������������������������������������������������������������������� 419
Contributors

Carmita H. N. Abdo Department of Psychiatry, University of São Paulo,

School of Medicine, São Paulo, Brazil
Marcelo Allevato European College of Neuropsychopharmacology,
Utrecht, The Netherlands
The American Psychiatric Association, Washington, DC, USA
Gisele Apter Rouen Normandy University, Rouen, France
Perinatal, Infant and Child Psychiatry Chief, Le Havre Hospital, Le Havre,
France
Alexandre Azevedo Eating Disorders Group, Institute of Psychiatry –
University of São Paulo, School of Medicine, São Paulo, Brazil
Mirella Baise Eating Disorders Group, Institute of Psychiatry – University
of São Paulo, School of Medicine, São Paulo, Brazil
Juliana Bancovsky The American Psychiatric Association, Washington,
DC, USA
Sara Motta Borges Bottino Department of Psychiatry of the Federal
University of São Paulo, São Paulo, Brazil
Silvia Brasiliano Women Drug Dependent Treatment Center – Psychiatry
Institute – Clinicas Hospital – Medical School – University of São Paulo, São
Paulo, Brazil
Ian Brockington University of Birmingham, Birmingham, UK
Amaury Cantilino Federal University of Pernambuco, Recife, Pernambuco,
Brazil
Fabio Carezzato Women Drug Dependent Treatment Center – Psychiatry
Institute – Clinicas Hospital – Medical School – University of São Paulo, São
Paulo, Brazil
Luisa Caropreso McMaster University – Women’s Health Concerns Clinic
(WHCC) – St. Joseph’s Healthcare, Hamilton, ON, Canada
Mario Cavagna Human Reproduction Women’s Health Reference Center,
University of the State of São Paulo UNESP, São Paulo, Brazil

vii
viii Contributors

Juliana Pires Cavalsan Department of Psychiatry, Faculty of Medicine,

University of São Paulo and Women’s Mental Health Program of the Institute
of Psychiatry of the Hospital das Clinicas, Faculty of Medicine, University of
São Paulo, São Paulo, SP, Brazil
Rafael Bello Corassa Section of Psychiatric Epidemiology, Postgraduate
Program in Public Health, Federal University of Espírito Santo, Vitória,
Brazil
Humberto Correa Department of Mental Health, Federal University of
Minas Gerais (UFMG), Belo Horizonte, Brazil
University Louis Pasteur, Strasbourg, France
Tiago Couto Federal University of Uberlandia, Uberlandia, MG, Brazil
Antonio Geraldo da Silva Brazilian Association of Psychiatry (ABP),
Rio de Janeiro, Brazil
Alexandrina Maria Augusto da Silva Meleiro Brazilian Association of
Psychiatry – ABP, Rio de Janeiro, Rio de Janeiro, Brazil
Department of Psychiatry, FMUSP, São Paulo, Brazil
ABP Suicide Prevention and Study Commission, São Paulo, Brazil
Commission of Attention to the Mental Health of the Physician of the ABP,
São Paulo, Brazil
Brazilian Association of Carriers Affective Disorder – ABRATA, São Paulo,
Brazil
Brazilian Association for the Study and Prevention of Suicide – ABEPS, São
Paulo, Brazil
Priscila de Almeida Costa Regional Public Hospital Mayor Osvaldo
Rezende Franco, Betim, MG, Brazil
Maria Alice de Mathis Department and Institute of Psychiatry, Faculty of
Medicine, University of São Paulo (USP), São Paulo, SP, Brazil
Andrea Feijó de Mello Department of Psychiatry of the Federal University
of São Paulo, São Paulo, Brazil
Marcelo Feijó de Mello Department of Psychiatry of the Federal University
of São Paulo, São Paulo, Brazil
Michele de Oliveira Gonzalez Eating Disorders Group, Institute of
Psychiatry – University of São Paulo, School of Medicine, São Paulo, Brazil
Erika de Oliveira Neves Federal University of Minas Gerais, Belo
Horizonte, MG, Brazil
Nilka Fernandes Donadio Assisted Reproduction Laboratory, Pérola
Byington Hospital (CRSM), São Paulo, Brazil
Austen Venancio Drummond Fundação Hospitalar do Estado de Minas
Gerais, Belo Horizonte, MG, Brazil
Artur Dzik Women’s Health Reference Center, Pérola Byington Hospital
(CRSM), São Paulo, Brazil
Contributors ix

Helio Elkis Department of Psychiatry, Faculty of Medicine of the University

of São Paulo, São Paulo, Brazil
Maha M. Eltayebani Women’s Health Concerns Clinic (WHCC), Mood
Disorder Program – St. Joseph’s Healthcare, Hamilton, ON, Canada
McMaster University – Women’s Health Concerns Clinic (WHCC) – St.
Joseph’s Healthcare, Hamilton, ON, Canada
Department of Neuropsychiatry, Faculty of Medicine, Alexandria University,
Alexandria, Egypt
José Paulo Fiks Department of Psychiatry of the Federal University of São
Paulo, São Paulo, Brazil
Lauren F. Forrest Department of Psychiatry and Behavioural
Neurosciences, McMaster University, Hamilton, ON, Canada
Benicio N. Frey Department of Psychiatry and Behavioural Neurosciences,
McMaster University, Hamilton, ON, Canada
Women’s Health Concerns Clinic, St. Joseph’s Healthcare, Hamilton, ON, Canada
Marina Saraiva Garcia Federal University of Minas Gerais, Belo Horizonte,
Brazil
Luiz Henrique Gebrim Women’s Health Reference Center, Pérola Byington
Hospital (CRSM), São Paulo, Brazil
Patricia Brunfentrinker Hochgraf Women Drug Dependent Treatment
Center – Psychiatry Institute – Clinicas Hospital – Medical School –
University of São Paulo, São Paulo, Brazil
Yvone Alves de Lima Furtado Women’s Menthal Health Program -
Psychiatry Institute - Clinicas Hospital - Medical School - University of São
Paulo, São Paulo, Brazil
Mario Juruena Department of Psychological Medicine, Institute of
Psychiatry, Psychology and Neurosciences-King’s College London, London,
UK
Adriana Trejger Kachani Women Drug Dependent Treatment Center –
Psychiatry Institute – Clinicas Hospital – Medical School – University of São
Paulo, São Paulo, Brazil
Dawn Kingston University of Calgary, Calgary, AB, Canada
Nicole Leistikow Division of Consultation-Liaison, Department of
Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
Andreza Carla Lopes Eating Disorders Group, Institute of
Psychiatry – University of São Paulo, School of Medicine, São Paulo, Brazil
Mario R. Louzã Instituto de Psiquiatria, Hospital das Clínicas, Faculdade
de Medicina da Universidade de São Paulo, São Paulo, Brazil
Mariana Rangel Maciel Department of Psychiatry of the Federal University
of São Paulo, São Paulo, Brazil
x Contributors

Leandro Fernandes Malloy-Diniz Federal University of Minas Gerais,

Belo Horizonte, Brazil
Gabriella Francesca Mattina Neuroscience Graduate Program, McMaster
University, Hamilton, ON, Canada
Women’s Health Concerns Clinic, St. Joseph’s Healthcare, Hamilton, ON,
Canada
Alcina Meirelles Institute of Childhood Cancer Treatment (ITACI) of the
Childrens Institute of the Clinical Hospital-FMUSP, Charité University
Berlin, Berlin, Germany
Sarah Mendes Clinicas’ Hospital of Federal University of Minas Gerais,
Belo Horizonte, MG, Brazil
Jeronimo Mendes-Ribeiro Brazilian Association of Psychiatry, Rio de
Janeiro, Brazil
Luciano Minuzzi Department of Psychiatry and Behavioural Neurosciences,
McMaster University, Hamilton, ON, Canada
Caroline Moreira Clinicas’ Hospital of Federal University of Minas Gerais,
Belo Horizonte, MG, Brazil
Ludmila Machado Neves Women’s Health Reference Center, Pérola
Byington Hospital (CRSM), São Paulo, Brazil
Lauren M. Osborne Women’s Mood Disorders Center, The Johns Hopkins
University School of Medicine, Baltimore, MD, USA
Juliana Parada Independent Scholar, Belo Horizonte, MG, Brazil
Jennifer L. Payne Department of Psychiatry and Behavioral Sciences,
Johns Hopkins University School of Medicine, Women’s Mood Disorders
Center, Baltimore, MD, USA
Joao Quevedo Translational Psychiatry Program, Department of Psychiatry
and Behavioral Sciences, McGovern Medical School, The University of
Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
Center of Excellence on Mood Disorders, Department of Psychiatry and
Behavioral Sciences, McGovern Medical School, The University of Texas
Health Science Center at Houston (UTHealth), Houston, TX, USA
Neuroscience Graduate Program, The University of Texas MD Anderson
Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston,
TX, USA
Translational Psychiatry Laboratory, Graduate Program in Health Sciences,
University of Southern Santa Catarina (UNESC), Criciúma, SC, Brazil
Carolina Cassiano Rangel Brazilian Air Force, Rio de Janeiro, Brazil
Joel Rennó Jr. University of São Paulo, São Paulo, Brazil
Brazilian Association of Psychiatry (ABP), Rio de Janeiro, Brazil
Contributors xi

Renan Rocha Private Practice, São Lucas Medical Institute Criciúma, Santa
Catarina, Brazil
Carlos Eduardo Rosa Division of Psychiatric, Neuroscience and Behavior
Department, and Division of Radiology, Internal Medicine Department,
Hospital of Clinics, Ribeirão Preto Medical School, University of São Paulo,
Ribeirão Preto, SP, Brazil
Sarah Rückl Department of Mental Health, Federal University of Minas
Gerais, Belo Horizonte, MG, Brazil
Fábio Tápia Salzano Eating Disorders Group, Institute of Psychiatry –
University of São Paulo, School of Medicine, São Paulo, Brazil
Eduardo Santos Medical Psychiatrist, UFMG Clinical Hospital, Belo
Horizonte, MG, Brazil
Maiko A. Schneider Department of Psychiatry and Behavioural
Neurosciences, McMaster University, Hamilton, ON, Canada
Roseli G. Shavitt Department and Institute of Psychiatry, Faculty of
Medicine, University of São Paulo (USP), São Paulo, SP, Brazil
Mara Smith Department of Psychiatry and Behavioural Neurosciences,
McMaster University, Hamilton, ON, Canada
Meir Steiner Women’s Health Concerns Clinic, St. Joseph’s Healthcare,
Hamilton, ON, Canada
Department of Psychiatry & Behavioural Neurosciences, McMaster
University, Hamilton, ON, Canada
David L. Streiner Department of Psychiatry and Behavioural Neurosciences,
McMaster University, Hamilton, ON, Canada
Sabrina K. Syan Department of Psychiatry and Behavioural Neurosciences
& Department of Psychology, Neuroscience and Behaviour, McMaster
University, Hamilton, ON, Canada
Athanássios Cordás Táki Eating Disorders Group, Institute of
Psychiatry – University of São Paulo, School of Medicine, São Paulo, Brazil
Leiliane Aparecida Diniz Tamashiro Department of Psychiatry, Faculty of
Medicine, University of São Paulo and Women’s Mental Health Program of
the Institute of Psychiatry of the Hospital das Clinicas, Faculty of Medicine,
University of São Paulo, São Paulo, SP, Brazil
Albina R. Torres Department of Neurology, Psychology and Psychiatry,
Botucatu Medical School, São Paulo State University (UNESP), Botucatu,
SP, Brazil
Ricardo C. Torresan Department of Neurology, Psychology and Psychiatry,
Botucatu Medical School, São Paulo State University (UNESP), Botucatu,
SP, Brazil
xii Contributors

Gislene Valadares Women’s Mental Health Clinic, Incestuous Families

Treatment Clinic of Clinica’s Hospital, Federal University of Minas Gerais,
Belo Horizonte, MG, Brazil
Ryan J. Van Lieshout Department of Psychiatry and Behavioural
Neurosciences, McMaster University, Hamilton, ON, Canada
Maria Carmen Viana Department of Social Medicine, Federal University
of Espírito Santo, Vitória, Brazil
Section of Psychiatric Epidemiology, Postgraduate Program in Public Health,
Federal University of Espírito Santo, Vitória, Brazil
Carla Fonseca Zambaldi Clinical Hospital of the Federal University of
Pernambuco, Recife, Brazil
 An Introduction to Women’s
Mental Health

Jeronimo Mendes-Ribeiro, Antonio Geraldo da Silva,

and Joel Rennó Jr.

 omen’s Mental Health:

W Dysregulation of the HPA system has been
A Comprehensive Approach associated as central to understanding the devel-
opment of mood disorders. Sexual hormones pro-
Are women weaker than men? We do not look for mote a wide range of neuronal response and
answers like that. At least not by this angle [1]. actions on hypothalamic-pituitary-adrenal (HPA)
Neuroscientists and clinicians have struggled with and hypothalamic-pituitary-gonadal (HPG) cir-
the brain because it is such a complex organ that cuitry. Estrogen receptors are widely distributed
interacts with the whole body. Even so, over the throughout the brain – paraventricular nucleus
last 30 years, an emerging body of research has (PVN), ventromedial nucleus (VMN), central
achieved great improvements on the way we amygdala, hippocampus, and subgenual area.
understand not only psychosocial and cultural Moreover, sex differences are prominent in the
aspects of sex differences, but also biological basis symptomatology and the course of mental disor-
and how this knowledge could advance preventive, ders [4]. Evidence from neuroimaging and
diagnostic, public policies, and therapeutic health- molecular research have shown the influence of
care practices on mental disorders [2, 3]. genetic and epigenetic mechanisms of hormone-­
Although the physiology and neurobiology of dependent transcriptional factors on stress
women and men are almost identical, studies on response and emotion regulation circuitry [5–7].
sex and gender as critical variables related to the Not only female brain anatomical structure,
causes and expression of medical conditions are functioning, and disease processing – but also the
established for a number of diseases, including way several mechanisms such as early life pro-
selected mental disorders. gramming, perinatal stress, hormones (e.g., preg-
nancy, hormonal-based contraceptives, hormonal
therapy), genetics, epigenetics, and psychosocial
J. Mendes-Ribeiro
stressors like trauma, child abuse, and domestic
Brazilian Association of Psychiatry, violence interfere with brain activity and stress
Rio de Janeiro, Brazil circuits are currently considered “hot topics” for
A. G. da Silva a comprehensive undertanding on why preva-
Brazilian Association of Psychiatry (ABP), lence of some mental disorders are higher in
Rio de Janeiro, Brazil women than men [8–10]. Depressive disorders
J. Rennó Jr. (*) tied to reproductive events may partially account
University of São Paulo, São Paulo, Brazil for this higher risk, and pathophysiological
Brazilian Association of Psychiatry (ABP), mechanisms include an increased vulnerability to
Rio de Janeiro, Brazil fluctuations in gonadal steroids, but other neuro-

© Springer Nature Switzerland AG 2020 1

J. Rennó Jr. et al. (eds.), Women’s Mental Health, https://doi.org/10.1007/978-3-030-29081-8_1
2 J. Mendes-Ribeiro et al.

endocrine mechanisms may play a role [11]. ognized by endocrine disorders and then by
Women are also more exposed to emotional, infertility issues, mood fluctuations at late luteal
physical, and sexual violence, including intimate phase of menstrual cycle, postpartum, and transi-
partner violence and trauma. Sex-specific bio- tion to menopause. Infertility, breast cancer, and
logical components may also be involved on why other comorbid diseases have direct – interfering
women get depressed more often or why they with physiology, interfering with treatment – and
attempt suicide with more frequency since indirect impact, acting as life stressor, on mood
women are exposed to more high-impact trauma and on prevalence of mental disorders.
(e.g., sexual trauma) than men, and at a younger Given HPA and HPG circuitry have been his-
age [12–14]. torically linked to changes in mood dysregula-
Preclinical and clinical research have recently tion, thought processing, and behavior,
started to address relevant methodological con- understanding the mechanisms of diseases of
founders since results were obtained from over- mental disorders is of utmost importance for
represented males subjects. Clinical studies have development of new biological targets. Respect
incorporated on their design controlling for men- of such complexity enables us to discuss with
strual cycle phase (follicular or luteal), either pre- patients the current clinical practices based on
menopause or postmenopause given the the best evidence available.
inconsistencies and heterogeneity of literature in
the past [12]. Research on imaginology, molecu-
lar aspects, epigenomics, proteomics, and aspects  elevant Topics, Inconsistent or
R
of systems biology have been leading greater Insufficient Data: Is “State-of-the-­
improvements and complexity to the current Art” Care Still Possible?
understanding of the underlying mechanisms of
vulnerability and sex-specific differences on Some of the common frustrating topics to less
prevalence, onset, timing, severity of clinical pre- experienced clinicians in this field are questions
sentation, and course of mental disorders [8, 15]. regarding uncertainty, such as “Which antide-
Hormonal milieu over reproductive years and pressants and/or drugs for treatment for bipolar
mainly during transition periods such as premen- disorders are safe during pregnancy and lacta-
strual, perinatal period, and perimenopause pres- tion?”, “How should I proceed with women who
ents challenges to some vulnerable women and find out pregnancy and are on antidepressants?”,
may cause negative impact on mood, behavior, or “What is the best therapeutic option for women
and coping mechanisms, which further increase who struggle with depressive and vasomotor
the risk for mental disorders. Major depressive symptoms during the menopausal transition?.”
disorder (MDD), anxiety disorders, and bipolar There is no single answer for these questions. But
disorders (BP) are some of the leading causes of first is worth deepening our sense of what this is
disease burden worldwide, and the rate of MDD about. When it comes to the perinatal period,
in women of reproductive age is double that of such complexity is even magnified.
men’s [14, 16]. Eating disorders, anxiety disor- Methodological and ethical barriers on conduct-
ders, obsessive-compulsive disorder (OCD), and ing studies in the perinatal period and the way
posttraumatic stress disorder (PTSD) are also one should interpret results are of critical impor-
more prevalent in women than men [14]. tance since even well-designed studies released
Although the prevalence of bipolar disorder is on high impact factor journals might show a spe-
similar for both sexes, the impact of hormonal cific association but not cause and consequence
fluctuation on course, severity, and clinical pre- [18].
sentation is relevant in women [17]. The knowledge regarding safety issues may
Clinical conditions may also interfere with modify over time. The approach of clinically rel-
women’s mental health. The association between evant vasomotor and depressive symptoms
gonadal steroids and mood was also initially rec- throughout the menopausal transition and its con-
An Introduction to Women’s Mental Health 3

sequences regarding safety issues on early the mothers with severe mental illness called “Mother
2000s are also applicable argument for this theme and Baby Units” – promoting treatment and
[19]. Thus, overinterpretation of results of studies attachment in a safe environment, while risks are
due to heterogeneity, insufficient data – sample still high – are another example of the lack of
too small or biased – recommendation based on mental health services worldwide. As a conse-
absolute vs. relative risk, and inadequate quence, development of public policies and
­disclosure (e.g., based on risk categories) may effective services and programs built for women
influence informed consent and quality of care. with severe mental disorders and alcohol and
Indeed, misinformation regarding uncertainty in other substance use disorders is imperative.
the field of women’s mental health and the way Screening and monitoring of symptoms
we interpret observational studies may bring within the perinatal period on primary care have
excessive media attention which might contribute shown to reduce depressive symptoms in women
to stigma [20]. On the other hand, risks of non-­ with depression and also the prevalence of
treated disorders and other relevant comorbid major depression [31]. A number of sex-specific
issues such as substance use, poor nutrition, or screening tools are available for clinicians,
obesity are commonly underestimated [21–23]. some of which have also been validated for use
The reader interested on approaching com- during pregnancy. Self-administered rating
mon mental disorders during the perinatal period scales and other sources of information includ-
and perimenopause will understand the proper ing E-health-­based resources have been on the
steps of obtaining informed consent not based on focus of current and future research for increas-
risk categories but on the best evidence available ing acceptance to highly stigmatized medical
[24]. conditions. The use of psychometric instru-
ments in clinical practice and their usefulness
will be discussed – not only as screening tools
 ack of Services Designed
L but also as instruments to validate diagnosis of
for Women’s Mental Health Issues: mental disorders (such as premenstrual dys-
A Still Neglected Subpopulation phoric disorder (PMDD) – in which diagnosis is
prospective).
In the field of women’s mental health, giving a
better support for women who suffer from
trauma, domestic violence, and other prevalent  evising Standard Diagnostic
R
mental disorders – such as posttraumatic stress Manuals and Future Directions
disorder (PTSD), eating disorders, and substance
use – is of remarkable importance. Even though After decades of its recognition, premenstrual
female brain sensitivity to alcohol can cause dysphoric disorder (PMDD), a recurrent and
early brain damage and dysregulation on stress-­ severe form of premenstrual syndrome that
related circuitry [25, 26] and fetus exposition to involves a combination of emotional and physi-
alcohol and other substance during pregnancy cal symptoms that result in significant functional
can lead to developmental long-term negative impairment, is listed as a distinctive depressive
outcomes [27, 28], most community services do disorder by the DSM-5 Work Group. The
not take into consideration sex differences. acknowledgment that in these circumstances it
Cultural aspects of substance use in women are could be considered as necessary for the purpose
also of interest since cannabis use during preg- of overdiagnosis prevention and detection and to
nancy has increased over the last decade [29] and temporarily set aside in order to obtain relevant
withdrawal from mental and psychosocial care in data, political aspects must be considered as part
women subpopulation may cause a strong impact of this issue. Although research efforts have dem-
on public health systems worldwide [30]. Limited onstrated specific links of sex influence on men-
inpatient facilities for the care of postpartum tal disorders and increasing data availability from
4 J. Mendes-Ribeiro et al.

clinical and epidemiological studies, some men- to human health: does sex matter? Washington, DC:
The National Academies Press; 2001.
tal disorders are not covered by the existent stan- 3. Blehar MC. Public health context of women’s
dard diagnostic manuals [32]. Such has been mental health research. Psychiatr Clin North Am.
greatly underestimated and has direct adverse 2003;26(3):781–99.
effects on fetal, obstetric, and neonatal 4. McEwen BS. Invited review: estrogens effects on the
brain: multiple sites and molecular mechanisms. J
outcomes. Appl Physiol. 2001;91(6):2785–801.
Regardless of consensus, DSM-5 Task Force 5. Syan SK, Minuzzi L, Smith M, Costescu D, Allega
included a specifier denominated “with peripar- OR, Hall GBC, et al. Brain structure and function in
tum onset” (from pregnancy to 4 weeks postpar- women with comorbid bipolar and premenstrual dys-
phoric disorder. Front Psych. 2017;8:301.
tum) despite evidence showing differences 6. Holsen LM, Lancaster K, Klibanski A, Whitfield-­
between pregnancy and postpartum period on Gabrieli S, Cherkerzian S, Buka S, et al. HPA-axis
etiology, risk factors, clinical presentation, and hormone modulation of stress response circuitry
response to pharmacological and non-­ activity in women with remitted major depression.
Neuroscience. 2013;250:733–42.
pharmacological interventions [33, 34]. Revising 7. Jessen HM, Auger AP. Sex differences in epigenetic
future diagnostic classification systems for termi- mechanisms may underlie risk and resilience for men-
nology is critical in a means to provide increasing tal health disorders. Epigenetics. 2011;6(7):857–61.
awareness, early identification, correct diagnosis, 8. Hodes GE. Sex, stress, and epigenetics: regulation of
behavior in animal models of mood disorders. Biol
and appropriate management. Sex Differ. 2013;4(1):1.
9. Monk C, Feng T, Lee S, Krupska I, Champagne FA,
Tycko B. Distress during pregnancy: epigenetic regu-
Final Considerations lation of placenta glucocorticoid-related genes and
fetal neurobehavior. AJP. 2016;173(7):705–13.
10. Bowers ME, Yehuda R. Intergenerational transmis-
Over the following chapters, the reader will learn sion of stress in humans. Neuropsychopharmacology.
key terms and concepts, including some of the 2015;41(1):232–44.
emerging trends on this interdisciplinary area of 11. Lokuge S, Frey BN, Foster JA, Soares CN, Steiner
M. Depression in women: windows of vulnerability
women’s mental health. The contributors, all and new insights into the link between estrogen and
leading scholars, practicing educators, and serotonin. J Clin Psychiatry. 2011;72(11):e1563–9.
researchers in the field, bring a perspective to the 12. Abrahams N, Devries K, Watts C, Pallitto C, Petzold
theme. This book is divided into 28 chapters, and M, Shamu S, et al. Worldwide prevalence of non-­
partner sexual violence: a systematic review. Lancet.
it is a definitive source of evidence-based infor- 2014;383(9929):1648–54.
mation on women’s mental health. It contains 13. Ellsberg M, Arango DJ, Morton M, Gennari F,
comprehensive information which is in line with Kiplesund S, Contreras M, et al. Prevention of vio-
DSM-5 criteria throughout. lence against women and girls: what does the evi-
dence say? Lancet. 2015;385(9977):1555–66.
All chapters were elaborated by experienced 14. Kessler RC, McGonagle KA, Swartz M, Blazer
practitioners in the field. As such, they are DG, Nelson CB. Sex and depression in the National
intended to serve as valuable reference for clini- Comorbidity Survey. I: lifetime prevalence, chronicity
cians, family medicine physicians, gynecologists and recurrence. J Affect Disord. 1993;29(2–3):85–96.
15. Joel D, McCarthy MM. Incorporating sex as a
and obstetricians, pediatricians, psychiatrists, biological variable in neuropsychiatric research:
psychologists, and other mental health where are we now and where should we be?
providers. Neuropsychopharmacology. 2017;42(2):379–85.
16. Lopez AD, Murray CC. The global burden of disease,
1990–2020. Nat Med. 1998;4(11):1241–3.
17. Dias RS, Lafer B, Russo C, Del Debbio A, Nierenberg
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 Those We Should Remember:
The Pioneers of Mother-Infant
Psychiatry

Ian Brockington

Introduction In Thasos the wife of Philinus gave birth to a

daughter. On day 14 she was seized with fever and
a rigor. At first she suffered in the stomach and
Mother-infant (perinatal) psychiatry is a rela- right hypochondrium, and from pains in the geni-
tively new specialty, but has deep roots. Over tals, head, neck and loins. Six days later she had
the course of centuries, its knowledge base has much delirium at night. On the 8th day of the ill-
ness she had another rigor and many painful con-
been constructed through the work of clinicians vulsions with much delirium. She had no sleep.
and researchers from many nations and a multi- She had more convulsions on the 9th day and lucid
tude of disciplines. This chapter focuses on the intervals on the 10th day. On the 11th day she had
pioneers – those who have introduced key meth- a complete recovery of her memory, quickly fol-
lowed by renewed delirium. Her urine contained
ods of study and drawn attention to the main much sediment. About the 14th day there were
disorders. twitchings over all the body, and much wandering
with lucid intervals followed by renewed delirium.
On the 17th day she became speechless. On the
20th day she died, 34 days after delivery.
Hippocrates
Clinical description has been woefully
In the fifth century BC, he pioneered clinical neglected in this area of psychiatry; in my mono-
description, which is the foundation of scientific graph published in August this year [2], I was
medicine: the 42 brief cases in the first and third able to find just over 4000 childbearing psycho-
books of Epidemics [1] are among the greatest ses, many of the descriptions brief and of poor
scientific achievements of ancient Greece. They quality. Moreover, their number is declining. In
include only 17 cases in women, of whom 8 suf- spite of the great opportunity provided by the
fered from severe or fatal postpartum or posta- development of mother-infant psychiatry as a
bortion infections, all complicated by delirium. speciality, and the establishment of many psychi-
Since Hippocrates covered the whole of medicine atric mother and baby units – offering a golden
and surgery, the link he noticed between psycho- opportunity to observe unusual phenomena –
sis and childbirth had a prominence it has never only 475 cases have been reported since 1975.
regained. This example is case 4 in the first book Nevertheless, most of what we know about these
of Epidemics: psychoses is based on ‘case lore’, which displays
their complexity, with a high proportion associ-
ated with an organic disease; as for non-organic
cases, there is not one postpartum trigger, but a
I. Brockington (*) group of reproductive triggers that includes abor-
University of Birmingham, Birmingham, UK tion; pregnancy; the early puerperium (from
e-mail: [email protected]

© Springer Nature Switzerland AG 2020 7

J. Rennó Jr. et al. (eds.), Women’s Mental Health, https://doi.org/10.1007/978-3-030-29081-8_2
8 I. Brockington

p­ arturition to the 15th day), later in the first post- in self-composed verses with gestures of the finest
partum year; and weaning. There is a high relapse and deepest emotion. Every movement of her
facial muscles, eyes, arms, hands and fingers were
and recurrence rate and a link with menstruation. the eloquent portrayal of the most ardent love
In the collateral study of menstrual psychosis, under the finest veil of wistfulness. It was moving:
clinical observation alone has directed attention everyone who heard her stirring songs was irresist-
to a small area in the hypothalamus, containing ibly moved to tears. No actress in the world, not
even a Garrick, could have improved on her perfor-
only a few hundred cells. mance – on the fine nuances of muscular move-
The study of single cases is the basis for the ment, on her indescribable originality, and the
classifications that simplify clinical practice and exaltation of her soul. But her peaceful mood
research. Nosologists, reviewing a large number would suddenly change to terror, and her tender
nostalgia to fearful anger and the rage of a Medusa.
of cases and examining their symptoms and She would hit out with arms of bronze, grasp what-
course, search intuitively for homogeneous pat- ever she could grab with an iron grip, let out heart-­
terns, which can be proposed as disease entities rending screams, bark and roar. A human being
and submitted for validation. The classification that had seemed, from her singing, to be a heavenly
creature, sank to the level of a beast.
of mental illness related to childbearing, offered
by the International Classification of Diseases This is a graphic description of some features
and American Diagnostic and Statistical Manual, of puerperal mania – lability of mood and elo-
leaves much to be desired, and this offers an quence with rhyming speech or singing. Osiander
opportunity for progress by further observation. was an obstetrician, and this reminds us that the
The role of the clinician is not just to pigeonhole first observations in our speciality were not made
patients into a local or contemporary classifica- by psychiatrists – they preceded the establish-
tion, but to be inquisitive and alert to the unusual, ment, by Pinel and Esquirol, of psychiatry as a
searching for aetiological clues. A renewed rec- discipline. The original descriptions of eclamptic
ognition of the value of clinical observation will psychosis [5], recurrent puerperal insanity [6],
empower all clinicians. In the childbearing and late postpartum psychosis [7] and parturient
menstrual psychoses, this approach has led to delirium [8] were all written by physicians, and
sharper definitions, an improved classification, a the distinction between puerperal mania and
radical revision of the problems to be solved and infective delirium was first made by Burns [9],
fresh lines of enquiry. another obstetrician.
Osiander’s work, the first clear description of
one of our most important disorders, on which
Osiander about 2000 works have since been published, is
almost unknown: it has been cited only 15 times
In 1797 this obstetrician from Tübingen described in 220 years; but the widespread recognition of
two cases of postpartum psychosis – one infec- ‘puerperal insanity’ dates from the beginning of
tive and one probably non-organic, descriptions the nineteenth century.
unequalled in this literature, and, in their exem-
plary detail, among the classics of medical his-
tory [3]. There is a full translation of both in my Esquirol
monograph What is Worth Knowing about
‘Puerperal Psychosis’ [4] and of the psychiatric In his Maladies Mentales considérées sous les
manifestations of the second case in The Rapports Médical, Hygiénique et Médico-Légal
Psychoses of Menstruation and Childbearing [2]. (1838) [10], he pioneered descriptive psychopa-
This paragraph is a sample of his account: thology, but his publications on the psychiatry of
childbearing are earlier (1816–1819). He pro-
During these attacks this lady (a splendid singer) vided statistics on postpartum admissions to the
sang with a clear, elegant and melodic voice, and
an expression of the highest enthusiasm. She sang Salpêtrière hospital in the 4 years 1811–1814: 92
or declaimed scenes from the time of her betrothal mothers (8% of all female admissions) became
Those We Should Remember: The Pioneers of Mother-Infant Psychiatry 9

insane after childbirth, 37 of whom had onset onsets seem almost interchangeable. Esquirol
between the 1st and 15th days. He considered the briefly described this case with four triggers – puer-
causes, which included heredity, episodes earlier peral, seasonal, weaning and abortion [11]:
in their lives, previous postpartum episodes and, A 26-year old gave birth to her 1st child. On day 3
especially, emotional causes. These insanities she developed furious mania that lasted for two
had a much higher cure rate and a much lower months. Every spring she showed exaltation with-
fatality rate than was found in other female out psychosis. At 30, when weaning her second
child aged one year, she developed mania, from
patients. He noticed a tendency to relapse soon which she soon recovered, but a few days later
after recovery. His most important contribution relapsed. At 34 she had a 2-month miscarriage; the
was to pioneer long-term studies. He reported next day she became loquacious and developed a
cases with 11 and 13 episodes, much more than brief episode of mania.
any other author. This is his patient with 13 epi- The Psychoses of Menstruation and
sodes [11]: Childbearing published matrices demonstrating,
A woman, whose sister suffered from puerperal in 265 recurrent cases from the literature and 118
psychosis, was married at the age of 25. At 26 she from my own series, the high proportion with
gave birth to her 1st child, after which she suffered episodes starting within at least two different
from furious mania until her 2nd pregnancy, which
was normal. She had 12 further pregnancies, all onset periods. This is an example from a recent
with hard labours, after which she was insane for German thesis [12], of a woman, followed for
4–6 weeks. At 39 she had an attack of apoplexy 20 years, who suffered from episodes related to
followed by hemiplegia. At 47 she suffered a weaning, menstruation, the early puerperium and
severe febrile illness that was followed by furious
mania lasting five months. At 50 her menses pregnancy as well as unrelated episodes:
ceased. At 51 her husband died and she was impris- At the age of 28, a woman with a strong family
oned. This was followed by mania from which she history of mental illness, gave birth to her 1st child,
recovered after a month. and breast-fed for 4 months. After weaning she
developed insomnia and restlessness; her ideas
This research strategy has been shamefully were lively, she feared that her house was on fire
neglected. There are numerous ‘follow-up stud- and thought she was under surveillance because of
ies’, but, as shown in Table 1, only 57 cases with her poor child-care. In hospital, she was perplexed
full clinical details have been followed for more and confused, had difficulty in distinguishing
dream from reality, believed was still pregnant and
than 20 years. The Psychoses of Menstruation misidentified people. She improved, relapsed,
and Childbearing provides data on 73 mothers recovered and had several premenstrual deteriora-
followed for at least 20 years, of whom 38 at least tions. Three years later she gave birth to her 2nd
30 years. It reflects no credit on psychiatry that, child. On day 3 she was unable to sleep, lost her
appetite, and believed the child was starving. In
in 200 years of research, the majority of mothers, hospital she was depressed and agitated, perplexed
studied in detail and followed for over 20 years, and had delusions of guilt; two months after recov-
have been collected by one clinician. ery she became hypomanic, spent a lot of money
Long-term studies of cases from the literature and gave presents to everybody. A year later she
became pregnant for the 3rd time. In the 2nd tri-
and my series have provided much evidence of an mester she became depressed, then manic, with
association between the reproductive triggers: abor- auditory hallucinations of neighbours discussing
tion and prepartum and early and late postpartum her; God and his angels were protecting her. In
hospital, she was anxious and retarded, had mem-
ory difficulties and was under instruction by good
Table 1 Comparison of my series of puerperal psychosis and bad voices. She suffered a 5-month foetal
with those in the literature death in utero, then became hypomanic. She had
Category Literature My series three unrelated episodes.
Total cases 4029 321
Prolonged 10–20 years 137 66 This case illustrates another finding of these
observation 21–30 years 43 45 long-term case studies – the variable clinical man-
More than 14 28 ifestations, which included delusional depression,
30 years mania and cycloid (acute polymorphic) episodes.
10 I. Brockington

There is a long-standing controversy about the the effect of reproductive events, the menopause,
nosology of puerperal insanity – whether it intercurrent medical disorders, surgical interven-
belongs in the bipolar spectrum or whether it is a tion and stress on the natural history of the dia-
disease in its own right, with specific features. thesis. This is work that requires no funding, just
These ‘specific features’ – ‘confusion’, bewilder- a good standard of clinical practice. Menstrual
ment or perplexity and a mixture of symptoms psychosis, which usually presents in the second
from all the main syndromes (mania, depression, decade, also cries out for the longitudinal study
delusions, hallucinations, catatonia, thought dis- of the effect of pregnancy, childbirth and other
order) – are typical of cycloid psychosis. events.
Approaching this problem in a review of pub- Psychoses are not the only disorders of moth-
lished cases and my own series of psychotic erhood that lack information on prognosis and
mothers, I was unsure whether the cycloids would long-term effects. This is very much true of the
be a separate group or linked to bipolar disorder. ‘bonding disorders’ (emotional rejection of the
In the event it proved impossible to separate the infant), which are discussed below.
bipolars (40%) from the cycloids (25%); many
episodes had features of both, and many mothers
had presentations typical of both at different times Marcé
in their reproductive lives; thus these clinical
forms appeared to be interchangeable. This In the prodigious output of his short and tragic
mother, followed for 42 years, had two postpar- career, this young Frenchman wrote the first
tum episodes, the first cycloid and the second monograph giving a complete account of the
manic: insanity of childbearing, as then known (mainly
A 31-year old, with a history of a psychotic epi- the psychoses) [13], and for this he is venerated
sode while at university, was delivered by forceps all over the world, with ‘Marcé Societies’ estab-
of her 1st child. After the birth, she became sleep- lished in a number of countries. He had superior
less, euphoric and perplexed. Her perceptions
became heightened and distorted. She had ideas of powers of observation, as shown by his descrip-
reference about the television, radio and newspa- tion of the hypnagogic and hypnopompic halluci-
pers – the election of the Pope, his death and nations that are an almost unique feature of
another election had a special message for her. She chorea psychosis [14]:
was disorientated, and confused at what she was
seeing, hearing and reading. Nothing made sense. A 22-year old congenital syphilitic presented with
She forgot she had a baby. She recovered after one a 15-day history of chorea. Her sleep was inter-
relapse. Three years later she gave birth to her 2nd rupted by ‘dreams’. Before falling asleep she saw
child. A week later she became hypomanic: she devils, headless corpses, ravens, bats and other ter-
was sleepless, writing poetry and rearranging the rifying objects. She believed they were going to
bookshelves. She wanted to communicate with strangle her, and found it hard to breathe. These
someone on another planet. Admitted to a mother hallucinations also occurred at the moment of wak-
& baby unit, she was euphoric, and talked non-­ ing, when she would cry out and disturb other
stop. There was a hint of a relapsing pattern, and patients. She believed her food was poisoned and
she recovered after 9 months. During the next heard voices telling her she was damned. She
30 years she had two further episodes, and at 64 recovered after a few weeks.
was perfectly well.
He also had the intuition, often found in
Facts cannot be established on the basis of one French physicians, to spot important clues. He
investigation, and there is a need to replicate this considered the causes of postpartum psychosis
longitudinal study; here there are opportunities and was among the first to draw attention to the
for all clinicians, caring for mothers in specialist role of menstruation. In his textbook of psychia-
services, who have the long-term care of moth- try [15], there is this paragraph:
ers, and a span of 20 years or more in practice. The first postpartum menses exercises, on the
With forethought they can form an alliance with development of puerperal insanity, an influence
their patients for long-term follow-up, clarifying that Baillarger was the first to notice, and which
Those We Should Remember: The Pioneers of Mother-Infant Psychiatry 11

my observations confirm beyond doubt: of 44 and also the champion of menstrual psychosis.
mothers who developed puerperal psychosis, and His first publication on this subject was in 1878
who did not lactate, eleven became ill in the 6th
week, precisely at the return of the menses. [19], and in the year of his death (1902) [20], he
Sometimes the psychosis preceded the menses by published a monograph, Psychosis Menstrualis
5–6 days, but it usually began at the onset of bleed- (1902), which, for 100 years, remained the most
ing or during menstrual flow. I have also seen it complete exposition of the subject: he had col-
break out when the menses were expected, but
failed to appear. Mothers, who breast-feed for lected 68 cases, most of them from his own prac-
some months, become ill after weaning, very often tice. My interest was aroused by a mother
at the moment the menses reappear after a long admitted with puerperal psychosis in 1981, who
interval. rapidly recovered and suddenly relapsed at the
This is an important contribution that has been first menses. I have also collected at least 60
completely neglected by Marcé Society mem- cases, mainly from e-mail correspondence with
bers, none of whom recognize these two forms of sufferers or their mothers, most of whom pre-
postpartum psychosis or have followed his lead sented as teenagers. Including this series and spo-
on the role of menstruation. In the subsequent lit- radic case reports from the literature, The
erature, there is much to support his ideas: among Psychoses of Menstruation and Childbearing
the non-organic psychoses, there are 1015 start- analyses 250 cases.
ing between day 1 and day 15 of the puerperium, These psychoses are complex: within the
92 in the 3rd week (a sharp fall) and 447 in weeks menstrual cycle, there are probably two triggers:
4–13. Eight mothers had two 4–13 week onsets about two thirds have onset during the necrotic
and no other reproductive episodes. Surveys have phase and one third at the mid-cycle. Their occur-
found a raised admission rate in the second and rence within the life cycle is instructive. There
third months [16, 17]. The association with the are 26 cases with monthly episodes before the
return of menstrual bleeding, which he claimed, menarche. The following teenager had two epi-
has never been investigated, but a few mothers sodes before the menarche and four further epi-
with early postpartum episodes have suffered sodes (three psychosis and one depression) at
repeated relapses – ten had at least five – and monthly intervals between the first two menstrual
these have been linked to the menstrual cycle, as bleeds, after which she remained well [21]:
in this extreme example [18]:
On June 24th 1888, a cheerful and good-humoured
A 26-year old, with a strong family history of men- 15-year old complained of headache and insomnia,
tal illness, developed a depressive psychosis after refused to eat and started to shout, sing, pray and
giving birth to her 1st child. After her 3rd birth she rush about the neighbourhood. In hospital she was
again became depressed with religious, persecu- anxious and bewildered, restless, incoherent and
tory and sexual delusions; she believed God or the disorientated. She spoke little, wept, laughed and
Devil would arrange for her suicide, and that fam- appeared to be listening to voices. She started ham-
ily members were sexually abusing her children. mering on the doors and windows, and had to be
She recovered in two weeks, but suffered 33 identi- isolated. She began to improve on July 3rd and
cal monthly depressions, all starting in the premen- recovered by the 8th (15 days after the onset). On
strual phase and ending three days after the August 21st she relapsed: this attack resembled the
menses. During her 8th episode she set fire to her- first except that anxiety and confusion were greater;
self, suffering 20% burns. She eventually she was sleepless and restless, sighed, groaned and
recovered. made defensive gestures, ate little and lost 6 lb in
weight. She recovered on September 2nd (after
13 days). From September 20th – 25th she had her
first menstrual period, and remained well. On
v. Krafft-Ebing October 21st she relapsed –weeping, anxious, eat-
ing nothing, restless, jumping and dancing, speak-
It is convenient here, out of the chronological ing rapidly and excessively, singing, praying,
smearing and hitting out; she had to be isolated. She
sequence, to remember the work of Baron v. recovered on the 27th (after six days). On November
Krafft-Ebing, celebrated for his Psychopathia 25th, she became anxious and monosyllabic, and
Sexualis and contributions to forensic psychiatry, the next day was singing, dancing, crying, laughing
12 I. Brockington

and praying, and again had to be isolated; she after four days she recovered. She had three more
recovered on the 29th (after four days). On identical relapses, then remained well. She gave
December 18th she suffered from headache and birth at the end of November.
vomiting, and complained of depression and home-
sickness, but recovered on the 21st. On January Thirteen other authors have described one or
22nd in the next year she relapsed – unresponsive, two episodes starting in the first month of preg-
sleepless, restless, singing and declaiming; she had nancy, and in my series, there are six possible
rapid mood changes – cheerful and anxious, weep-
ing and laughing. She recovered on February 2nd cases, one of which had four episodes and much
(after 10 days). From February 20th – 25th she had other evidence of menstrual psychosis.
her 2nd menstrual period, and remained well, with Menstruation-like bleeding during pregnancy
regular menstruation, thereafter. occurs when the gonadorelin neuronal complex
Premenarchal episodes may seem incredible, resists heavy inhibition by chorionic gonadotropic
but are supported by the same phenomenon in hormones. A Münster Inaugural-­Dissertation col-
four medical disorders – diabetes, epilepsy, lected 45 cases [24].
hypersomnia and migraine psychosis. There is one example of monthly periodicity
There are several patients who have suffered a in a psychosis developing in a girl without a pitu-
monthly periodic illness during amenorrhoea. itary [25]:
This young woman had six premenstrual epi- A girl of seven developed diabetes insipidus, and
sodes and eight during amenorrhoea [22]: was found to have a large pinealoma, which was
treated by irradiation. Growth and menstruation
A 20-year old, with a family history of paranoia
were achieved by hormone replacement. At 19
and depression, stopped menstruating while she
she stopped taking oestrogen and progesterone
was working on an anti-aircraft battery in Vienna.
because of side-effects and became amenor-
After the war she started medical training, but
rhoeic. One month after stopping the ovarian ste-
became depressed and tried to hang herself. Her
roids, she became inactive, sleepless and deluded
menses again failed. During ten months of amenor-
about a demon with a blood-red body and glitter-
rhoea, her illness took on a regular, periodic qual-
ing eyes hiding behind the door. In hospital she
ity, with a sudden change from confusion,
was expressionless and gave fragmentary
restlessness and inaccessibility to complete and
answers. She recovered after eight days. The fol-
full recovery. A chart showed the monthly timing,
lowing month she was again unable to sleep and
with onsets August 13th, September 6th, October
gave low monosyllabic answers after a long
4th, October 27th, November 17th (premenstrual),
pause. In hospital she remained silent and showed
December 9th, January 22nd 1948 (a doubled
no emotion; she thought orange juice was poi-
interval), February 12th, March 7th, March 30th
soned, and tried to drink out of the toilet. She
(premenstrual from now on), April 22nd, May
recovered in 12 days. A month later she suddenly
17th, June 15th and July 14th. All six episodes that
relapsed, and refused to see her family, eat or take
occurred during regular menstruation cleared up
medicine. She claimed that her parents had been
during menstrual flow. In July 1947, she dramati-
cremated, a nurse had killed her mother and poi-
cally improved after an injection of blood from a
soned the thermometer and her coffee, that staff
woman in the 5th month of pregnancy.
controlled the television programs, and a firework
Another remarkable instance of monthly peri- was a sign that the murder had been successful
executed. She recovered in 13 days. She had three
odic episodes during amenorrhoea is their occur- similar episodes lasting 17, 12 and 11 days at
rence in the first months of pregnancy. This is the monthly intervals. Treated with carbamazepine,
best example, with five episodes [23]: she remained well.

A 20-year old, with a mentally ill mother and sis- These cases, and the possible occurrence in
ter, became pregnant, with her last period at the
beginning of March. Four weeks later she became
males, suggest a role for the hypothalamic neu-
disturbed with restlessness, pressure of speech and rones that control the pituitary.
destructiveness; this lasted eight days. After a Once again the work of this pioneer has been
month she relapsed, tore her clothes and ran naked largely forgotten, even by German authors; since
into the street, cycled off in garters and slip, hit out,
bit, scratched and smashed windows, sang and
1925 Psychosis Menstrualis has been cited only
spoke incoherently. In hospital she was disorien- 12 times. Menstrual psychosis is recognized by
tated, heard voices and said she had seen the Devil; few psychiatrists.
Those We Should Remember: The Pioneers of Mother-Infant Psychiatry 13

Tardieu Table 2 Frequency of symptoms of emotional rejection

Number of
The sixth pioneer was one of three French cases Symptom
nineteenth-­century leaders of forensic pathol- 39 The desire for a transfer of infant care to
another person (usually an expressed wish
ogy – Orfila, Tardieu and Brouardel. In 1868 he for relinquishment)
wrote a classic text on infanticide and in 1860 an 25 Aversion, hatred or complaints about the
article under the title, ‘Étude médico-légale sur smell or ugliness of the baby
les sévices et mauvais traitements exercés sur des 25 Absconding or running away from home
enfants’ [26], in which he described injuries to 32 22 Estrangement
22 Wish for the death of the child
children who had been subjected to brutality or
15 Dysphoria relieved by escaping from the
maltreatment, 24 of them at the hands of their child, for example, by returning to work
parents; 5 were still breast-fed and 1 was only 14 Avoidance, including gaze avoidance
15 days old. There had been earlier accounts of 13 Other ways of escape (wish that the child
single cases in the German literature, including be stolen, abandonment, wish to escape by
maternal death)
the deliberate starvation of infants; most were
pathology reports without information about the
mother’s mental state, but in this report from legion – a summation or interaction of many fac-
Fulda [27], the death of the infant was tors; but child abuse is a disease with a single
deliberate: cause – parental assault – which is necessary and
sufficient to account for everything that follows.
A child died at the age of 6 months. The corpse
weighed 6½ lb, with no trace of fat and a com- Parental aggression itself is of complex origin,
pletely empty gut. His mother was dominant, the but vicious assault and callous neglect are the
father weak-willed. She completely lacked human common pathway leading to child maltreatment.
sympathy and motherly feelings; the children were
It is a disgrace that ‘the battered child syndrome’
just a burden to her. She threatened to kill her
eldest son (who was reared by his grandparents) was not finally accepted until 1962 [28].
because he surreptitiously tried to give his baby Tardieu knew that the mother-infant relation-
brother some milk. It was rumoured that earlier ship could be severely disturbed and attributed
children had died the same way.
this to mental illness. We can now identify the
Tardieu knew about the parents’ behaviour symptoms of this ‘sort of madness’: the most
and mental state and wrote: common symptoms in a series of 100 cases are
shown in Table 2:
When we consider the tender age of these poor
defenceless beings, subjected daily and almost There are two main themes – an abnormal
hourly to savage atrocities, unimaginable tortures emotional response and a wish to escape from the
and harsh privation, their lives one long martyr- crushing burden of caring for an unloved child.
dom – when we face the fact that their tormenters The following cases illustrate some of these
are the very mothers who gave them life, we are
confronted with one of the most appalling prob- symptoms. First there is an example of the rather
lems that can disturb the soul of a moralist, or the common symptom of estrangement:
conscience of justice. This mindless and ferocious
brutality can only be explained by a sort of A mother had an unwanted pregnancy, and asked
madness. for a termination, but too late. “All I could see was
gaol bars – a prison sentence”. After the birth she
Tardieu’s discovery was ignored for nearly felt trapped. After some improvement, at 7 months,
she said, “I still do not feel she is mine. I am look-
100 years, until forced on the medical profession ing after her as if for somebody else, as if I was
by overwhelming evidence, especially from pae- baby-sitting”.
diatric radiology. To get this resistance into per-
spective, one must remember that the highest The next mother, after recovery, wrote about
aspirations of medicine are to discover the aeti- her hatred of the infant and wish for a cot death:
ology of disease, so that it can be eliminated at This mother, at the age of 32, had a planned and
source. For many diseases, the causes are welcomed pregnancy, but the birth was ‘barbaric’.
14 I. Brockington

She blamed her son for this, and wanted to leave ful exploration of the mother’s experience. If
the house and run away. She wished he would die emotional rejection is confirmed, steps must
a cot death – “something I knew I would not be
blamed for, and nobody would know how I hated urgently be taken to reduce the risk to the infant,
him”. She repeated this phrase – “I hated him”. because of the strong association with anger
After four months her feelings changed. “I realised directed at the child; even the apparently mild
he was mine and I loved him, the most precious symptom of estrangement is associated with
thing in the world”. For a year she was unable to
tell anyone how she had been feeling. “I feel so loss of control to the point of shouting or
deeply ashamed. I am frightened he might know screaming at the infant in 70% and severe abuse
how I felt towards him when he grows up. I can’t in 20%. These urgent steps were outlined in
bear to visit friends, and see them happy with tiny Chap. 6 (pages 336–360) of Motherhood and
babies. Every time I see babies on the television, I
cry because of the way I felt towards my baby – Mental Health [31]: they start with frank dis-
such a terrible hate.” cussion with both parents about the alternatives
of relinquishment and therapy. If, as in most
‘Inexplicable’ running away from home is a cases, the mother wants to overcome the prob-
characteristic symptom. In this case its signifi- lem, she must (until she develops a positive
cance was missed: relationship) be relieved of the irksome burden
A multiparous mother became depressed after the of child care – by her husband or relatives or (in
birth of her 3rd baby, and was unable to cope. She countries that have the great asset of conjoint
took a train to London for no clear reason. She was
in-patient hospitalization) by nursing staff. She
admitted to hospital without her baby for 3 weeks,
and investigated in the usual way. She seemed must always be supported when caring for the
quite well and was discharged without the bonding baby, and, if she has aggressive impulses, must
disorder being suspected. After her return home never be left alone with the child. When the infant
she ran away on two more occasions, and made a
is calm and content, and the mother feels at ease,
suicide attempt. She could not tolerate the pres-
ence of her infant. She was reluctantly persuaded she is encouraged and helped to cuddle, talk to
to accept admission to the mother & baby unit and and play with the baby. Here techniques like baby
rapidly formed a normal relationship with her massage and play therapy are helpful. Although
baby.
there are no treatment trials in these severe disor-
The wish for relinquishment is characteristic ders, and a dearth of information about outcomes,
of severe rejection, as in this case: many mothers recover completely.
Just as the medical profession ignored
A 35-year old mother became pregnant for the first
time – a planned pregnancy about which she and
Tardieu’s work and turned a blind eye to the evi-
her husband were very happy. But, after an emer- dence of child abuse for a century, ‘perinatal’
gency Caesarean section, she developed no feel- psychiatrists have dragged their feet in recogniz-
ings for her son. She began to feel that it would be ing that some mothers hate their infants and want
much better if he was taken away. “I have made a
big mistake by having this baby; I wake in the
to get rid of them.
morning and wish he had a cot death. I feel nothing
for him and want him adopted”; she wanted this so
much that she looked up the telephone number of In-Patient Mother and Baby Units
social services, and considered leaving her hus-
band, so long as he took the baby.
About 70 years ago, two British pioneers inde-
We now know that 25% of mothers present- pendently admitted children with their mothers to
ing to mother-infant services have emotional psychiatric hospitals. In 1948 Main admitted a
rejection of some degree [29]. If a mother pres- toddler to the Cassel Hospital, where its mother
ents with any of these symptoms, it is essential was under in-patient treatment [32]; as a psycho-
thoroughly to explore the mother-infant rela- analyst he realized that this gave an unusual
tionship. An interview like the Stafford opportunity for studying disturbances of mother-
Interview [30] is helpful in modelling the tact- ing; he wrote:
Those We Should Remember: The Pioneers of Mother-Infant Psychiatry 15

Remarkably little has been written about mother- severe and intractable disorders and serve as a
ing and its disturbances. Psychiatry needs opportu- focus for medicolegal opinion, education, service
nities to study severe disturbances of the
mother-child relationship. development and research.
All nations should have at least one specialist
The admission of even younger children was mother-infant service, and large nations should
pioneered by a young female psychiatrist, Dr. have services in major cities and conurbations. At
Gwen Douglas: she admitted six mothers with psy- present, we are far from that minimal objective: no
choses, who, after recovery, commonly relapsed nation has come near to meeting the needs of moth-
when again required to care for their babies [33]. ers and their infants. An area of specialization,
These initiatives led to the widespread develop- developed over the course of 200 years, which
ment of mother and baby units in Britain, Australia offers unusual opportunities for research and pre-
and a few other countries. By concentrating moth- vention of mental disorders in the mother and child,
ers with all kinds of postpartum mental illness, they is still in the early stages of development.
fostered the recognition of many milder disorders,
which has helped to make childbearing, from the
standpoint of psychological medicine, the most
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 Epidemiology of Psychiatric
Disorders in Women

Maria Carmen Viana and Rafael Bello Corassa

Introduction Among mental disorders, unipolar depression

leads as the main cause of disability in both gen-
Mental disorders are a serious public health prob- ders, although the burden of depression is 50%
lem in the world, due to their high prevalence higher in women, who also suffer with a greater
rates, early age of onset, multiple recurrence/ burden of anxiety disorders, migraines, and
chronicity, and frequent association with physi- dementias, compared to men. Among men, alco-
cal conditions and disability [1–5]. hol and drug use disorders are the second largest
It was only after the publication of the World cause of disability, six times higher than among
Health Organization (WHO) Global Burden women, and corresponding to approximately
of Disease (GBD) study that mental disorders 30% of the total burden of mental disorders [9].
started counting as important causes of morbid- Out of the 20 leading causes of YLDs, six cor-
ity and disability [3]. The GBD disclosed that respond to neuropsychiatric disorders: major
neuropsychiatric disorders are among the leading depression (1st), anxiety disorders (6th), schizo-
causes of disability in the world, corresponding phrenia (11th), autism and Asperger syndrome
to about 20% of the years lived with disability (16th), Alzheimer’s and other dementias (17th),
(YLDs), and the fifth cause of disability-adjusted and substance use disorders (18th) [10, 11].
life years (DALYs), approximately 7% of the Furthermore, it is estimated that diseases related
total [6–8]. However, these figures are likely to to tobacco use will lead the causes of disability in
be underestimated and can reach over 30% of the developing countries by 2020 [12].
YLDs and 13% of the DALYs, making mental In Brazil, mental disorders are also among
disorders the second leading cause of disability the main causes of disease burden, with the
in the world [7]. highest proportion of DALYs occurring in adults
and among females [7, 13]. Neuropsychiatric
conditions, included in the group of non-­
M. C. Viana (*) communicable diseases, are the main causes of
Department of Social Medicine, Federal University of disease burden (DALYs), accounting for 34% of
Espírito Santo, Vitória, Brazil the total morbidity (YLDs). Their impact, there-
Section of Psychiatric Epidemiology, Postgraduate fore, is mainly due to the consequent disability,
Program in Public Health, Federal University of with premature death playing a less important
Espírito Santo, Vitória, Brazil role [14]. For women, depression is the lead-
R. B. Corassa ing cause of DALYs (13.4%), Alzheimer’s
Section of Psychiatric Epidemiology, Postgraduate and other dementias come in sixth (3.1%), fol-
Program in Public Health, Federal University of
Espírito Santo, Vitória, Brazil lowed by bipolar affective disorder (2.9%),

© Springer Nature Switzerland AG 2020 17

J. Rennó Jr. et al. (eds.), Women’s Mental Health, https://doi.org/10.1007/978-3-030-29081-8_3
18 M. C. Viana and R. B. Corassa

and alcohol-related disorders in 13th (1.1%). mental disorders [16, 21–23]. A further concern
Among men, alcohol abuse/dependence is the regarding gender differences in prevalence and
third leading cause of DALYs (5.0%), depres- clinical profile of mental disorders is related to
sion comes in seventh (3.5%), bipolar affective questions of gender bias in diagnostic instru-
disorder in tenth (2.7%), and Alzheimer’s and ments, clinical assessments, and diagnostic cri-
other dementias in 15th (1.3%) [15]. Between teria [24].
1990 and 2015, mental and substance use dis- Population-based studies conducted in
orders were the third leading cause of DALYs Western countries have showed that 35% to 45%
(9.5% of the total) and greatest cause of dis- of the general adult non-institutionalized popu-
ability (24.9%) among Brazilians. Depression is lation present some mental disorder throughout
the main cause of disease burden among mental life. In Brazil, important gender differences in the
disorders (35.0%), followed by anxiety (28.0%) prevalence of mental disorders have been iden-
and alcohol use disorders (7.0%). There is still tified in the Sao Paulo Megacity Mental Health
an important contribution of schizophrenia and Study (SP Megacity), a cross-sectional study that
bipolar affective disorder, each corresponding to assessed a probabilistic sample (N = 5037) of the
6.0% of disability [13]. general adult population (18 years or older) resi-
dent in the São Paulo Metropolitan Area, with a
response rate of 81.3% [25, 26]. The occurrence
Gender Differences of mental disorders was assessed using the WHO
in the Occurrence of Mental Composite International Diagnostic Interview
Disorders (CIDI 3.0) [27]. Lifetime prevalence estimates
on the total sample and by sex are presented in
Epidemiological studies have consistently identi- Table 1. The prevalence of at least one mental dis-
fied gender differences in incidence rates and life- order was 44.8% (SE 1.4), and almost a quarter
time prevalence estimates of mental disorders, as presented comorbid diagnoses (23.2%; SE 0.9).
well as in their psychosocial and biological deter- The global prevalence estimate of mental disor-
minants, course of illness, and consequences [16, ders was 1.8 times higher for women compared
17]. In general, women present higher rates of to men (51.5% versus 37.7%). Women pres-
mood, anxiety and eating disorders, and border- ent higher rates of mood and anxiety disorders,
line personality, while men present higher rates being almost three times more likely to suffer
of substance use disorders, antisocial and schizo- from post-traumatic stress disorder, agoraphobia,
typal personality, and impulse control, conduct, panic, and major depression. On the other hand,
and attention deficit and hyperactivity disorders. men present higher prevalence estimates of sub-
Regarding disorders similarly affecting men and stance use disorders (18.5% versus 4.7%; OR
women, different age of onsets, symptom pro- 4.4, 95% CI 3.3–5.8), with significantly higher
files, and treatment responses have also been odds ratios for alcohol abuse (4.7) and depen-
reported [16]. Additionally, differential patterns dence (6.0) and for drug abuse (2.9) and depen-
of mental or mental/physical comorbidity have dence (2.5). Except for conduct disorders, which
also been recognized [18]. Evidence supporting were more frequent among men (OR 2.9, 95%
the implication of biological or hormonal causal CI 1.8–4.5), there were no gender differences in
mechanisms accounting for sex differences has the distribution of all other impulse control dis-
not yet been demonstrated [19, 20], although orders investigated. Depression, specific phobias,
numerous studies have identified triggering fac- and alcohol abuse were, individually, the most
tors related to the reproductive cycle or to gen- prevalent conditions, and anxiety disorders were
der-specific stressors [21]. Social disadvantages the most prevalent class of disorders. Specific
associated with being a woman, including higher phobias and impulse control disorders presented
exposure to domestic violence, lesser educational an early onset, while mood disorders showed a
and employment opportunities, and higher fam- later onset [26]. Regarding depressive disorders,
ily burdens, may account to increase the risk of while women have presented high prevalence
Exploring the Variety of Random
Documents with Different Content
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passer après, li conestable des soldoiers qui les avoient costoiez
jusque iluec cuiderent avoir trouvé leur point, si se descochent ^ et
fièrent en celé partie de Tost qui n'estoit mie passée, et furent trop
plus gent que li nostre n'estoient. Li huz leva et la noise moût grant.
Tancre/., qui moût estoit apers et hardiz, avoit jà passé plus de la
moitié du gué qui bien estoit granz. Mais quand il oï ce, il feri des
espérons arriers tant com il pot, et ai. mille des plus preuz
retornerent avec lui; il se ferirent en ceus qui \enu estoient moût
viguereusement, sique il les desconfirent tantostet mistrent à la voie.
Assez en ocistrent, aucuns en pristrent vis que il amenèrent devant
Buiemont. Il leur demanda, volant touz, porquoi il qui crestien
estoient, avoient coreu sus à Tost des Crestiens, et meismement,
puis qu'iLestoient de la gent l'Empereur qui si estoit leur sires et leur
amis. Il respondirent que voirement estoient il home TEmpereur ' et
si soldoier; pour ce leur covenoit à fere son commandement, car par
lui avoient-il ce fet. Ici s'aperceurent, tuit cil qui ce oïrent, que les
bêles paroles que li Empereres disoit n'estoient que decevement et
tricherie. Mais Buiemons qui sages estoit et savoit que par
TEmpereur les covenoit à passer, fesoit semblant que il ne s'en
aperceust mie; ains fesoit bêle chiere à ses genz por covrir son
corage; et si ne plaisoit ce mie à teus i avoit des barons. XV. —
Cornent Buiemons, par la prière le Duc, ala à l'Empereur qui l'avoit
mandé querre. Buiemons et sa gent trespasserent Macédoine et les
autres terres, jusque il aprocherent à Costantinoble. Quant li
Empereres lias re/eretis Imperalori fro eo q od Je statu aiii il estoient
: si respondirent ainsi qu'il essuo dignaretur esse sollicitus. toient de
latent l'empereor; et mcismement 1 si Décoclient leurs nèches. puis
qu'il estoient de la gent l'empereor qu • L'édition précédente est ici
peu satisfai- estoit leur sires et leur amis; il li respond santé : • Il
leur demanda, voiant lous por- rent que voirement estoient-il home
de l'empequoi il avoient coru sus à l'ost des crestiens et reor et si
soudaier... »
 LIVRE SECOND. 75 le sot, il envoia derechief granz
messages à lui et li prioit moût efforciement que il lessast son ost et
venist parler à lui à pou de gent. Li Dux ne savoit que fere, car il
estoit eu pooir et eu dangier à ce grant home; si le dotoit moût à
corrocier. D'autre pari, il savoit sa fausseté et sa decevance, et avoit
bien aperceu que il ne Famoit mie : por ce si cremoit à aler à lui.
Tandis coni il estoit einsi entre deus, ezvos le duc Godefroi qui vint à
Buiemont le jor du Juesdi absolu '; car li Empereres ot tant prié le
Duc, porce que il doutoit que Buiemonz n'}' venist mie volentiers,
que li Dux ala encontre lui por li fere \enir à TEmpercur. Quant li Dux
et Buiemons s'entrevirent, moût fu grans la joie que il s'entrefirent;
puis parlèrent de maintes choses. Après, entra li Dux en la prière
que il venist à [son père] l'Empereur. Buiemons le fist moût à grant
peine, mes toutevoies le vainqui la prière le Duc et li fist aler. Li
Empereres le receut à grant enncur et à grant joie, et le besa; puis
parla tant au Duc et à lui, que Buiemon/., par le conseil le Duc, fist à
l'Empereur homage de ses mains, et li jura féeuté com à son
seigneur '. Lors véissiez venir du trésor l'Empereur trop granz
richesces, or et argent, et pierres, vessiaus et dras de soie, tant et
teus que à peine les peust l'en prisier. Tandis com Buiemonz
demoroit eu palais, Tancrez ses niés filz de sa sereur, qui moût estoit
sages et de grant cuer, n'ot cure de veoir l'Empereur ne de parler à
lui ; ainçois fist passer tost l'ost outre le Braz saint Jorge et logier en
Bithine, près de Calcédoine, où li oz aus autres barons estoit pieça.
Li Empereres quant il sot que Tancrez l'avoit eschivé en fu moût iriez
; mes il n'en fist onques semblant, corne cil qui bien savoit covrir son
cuer : aus barons que il avoit avec lui faisoit moût grant joie, et '
Ainsi, trois mois s'étaient écoulés depuis Boamundus vero fecit ei
fidxiciam terrœ sucv. que Boémond avait gagné Castoria. quoi non
auferret chteque consentiretauferri. » C'est-à-dire, apparemment, il
prêta d'avance Si l'on en croit Ricliard le Pèlerin, Boémond hommage
lige ou non lige, pour les terres de avait, aussi bien que Tancrèdc.
refusé de voir l'Empire qu'il reprendrait aux Sarrasins. Tu- l'Empereur
: debode,quc Guillaume de Tvr ne suit pas d'or- p,i,„^q„^, ^^
partirent Buiemons et Tangrès, dinairc, ajoute : Imperalor quidem
pron:isil n-„s d'iaus ne vout aine estre ses drus ne ses priviSs.
Boamundo quindecim dietas (iournées j Icrrœ L'Empercres s'en est
moût forment atr^s. in longiUldine Romania, et ncto in latiludine.
{Antioche, ch. II.)
 76 GUILLAUME DE TYR. A- 1097. chascun jor leur donoit
granz dons et noveles choses; puis s'en partirent par son congié et
passèrent le Braz avec les autres. Iluec estoient à sejor et atendoient
la venue des autres barons. Grant plenté leur aportoit l'en de
viandes et d'autres choses de la cité de Costantinoble et du pais
entor. X\'I. — La setisme muctc qui fu du conte Jl- Flandres par mer.
Roberz, li cuens de Flandres, qui ain/. l'yver estoit venuz à Bar, une
cité en Puille [où li cors monseigneur Saint Nicolas gist] avoit passé
mer et estoit descenduz à Duraz. Iluec en moût beaus leus et moût
plentéis avoit iverné. Mais si tost com li noviaus tens vint, il se mist à
la voie après les autres, et moût se hasta d'eus aconsuivre. Mais ainz
que il venist en Costantinoble, ausi com il estoit avenu aus autres
barons, il receut les messages l'Empereur qui li distrent de par lui
que il lessast son ost et venist veoir l'Empereur et parler à lui à pou
de gent. Il demanda et sot bien coment li autre baron s'estoient
contenu de celé chose : por ce fist-il autel, et vint en Costantinoble à
pou de compaignie. Li Empereres le receut à moût grant joie et à
moût grant enneur; moût parlèrent ensemble; puis, si com li autre
avoient fet, il li iist homage et serment de féeuté. Li Empereres li
dona granz dons et à touz ceus de sa compaignie. Quant il et ses
genz orent iluec esté une pièce cà sejor, parla volenté l'Empereur fist
passer ses genz; il méismes ala après les autres barons qui à grant
joie le receurent. Moût parlèrent ensemble de leur aventures de la
voie, et moût prenoient conseil sovent que il feroient d'ilec en avant.
Forment leur desplesoit la demeure des autres barons qu'il
atendoient; mais ne tarda guères que li message le conte de
Toulouse et l'evesque du Pui vindrent, qui leur noncierent que leur
seigneur venoient et que il estoient si près que par tens seroient en
Costantinoble.
 A« 1097. LIVRE SECOND. 77 XVII. — De la uitisme muete
qui fu du conte de Toulouse et de l'evesque du Pui et d'autres. Cil
dui preudome estoient meu ensemble de leur païs atout moût grant
gent. Avec eus s'estoient acompaignié pluseur vaillant home et
puissant de ces terres : il estoient Guillaumes li evesques d'Orenge;
Raimboz, li cuens de celé cité; Gasces [li cuensjdeBediers, Girars [li
cuens] de Rossillon, Guillaumes de Montpellier, Guillaumes li cuens
de Forés, Raimonz Pelez, Centons de Bearz, Guillaumes Amaneus et
maint autre baron, qui por le servise Jhesu-Crist lessierent leur païs
et leur lignage et touz leur deliz. Cist vindrent tuit en Lombardie et
passèrent delez Aquilée, puis vindrent en la terre qui a non Istre';
d'iluec en Dalmace qui est moût grant terre entre Hongrie et la mer
Adriane. Iluec à quatre arceveschiez, Jadres, Spalete, Antibare et
Raguse. Li pueples de la terre est crueus, acostumez à rober et à
ocire; montaignes i a et forez moût granz; la terre est pleine de
parfondes eaues coranz et de lées mareschieres : si que petit i a de
terres gaaignables. Restes y ont à grant plenté par les pastures de
quoi il se vivent. Nequedent cil qui abitent près de la mer sont
d'autre manière, d'autre habit et d'autre vie et de Jangage ; car cist
parloient romanz ^; li autre ne parolent se esclavonois non^ Li
preudome dont je vos parle vindrent en celés terres; moût i orent
granz travaus et granz meseses, por Tiver qui moût estoit aspres, et
por les voies qui trop estoient desaivées. De viandes y orent
merveilleuse soufrete % car toute la gent de la terre, por peor des
pèlerins, avoient lessié citez, chastiaus et villes, por foïr et repondre '
ez forez et ez montaignes; et là en avoient toutes leur ' Istrie. —
Dalmatie. — La mer Adriatique. l'iver qui moût estoit aspres, et por
les terres — Zara. — Spalatro. — Antivari. qui trop estoient
desaîviees de viandes, i orent * Latinum habent idioma.
merveilleuses soufretes. » Desaivées; inégales, ^ Sinon slave.
défoncées. ' Propter hyemis imtantiam et locorum ni- '• Ad montes
et sylvarum condensa... confumiam inatjualitatem, et alimentorum
susti- g^ienîes.Ed.précéd.uetporrepandre es forez ». nentes gravem
Jefectum... V.i. précéd. « Por Répondre a le sens de « se cacher ».
 78 GUIIJ.AlîME DE TYR. A" 1097. choses portées. D'ilcc
porsuivoient les pèlerins; cens que il trovoient febles, vicus ou
malades" qui demoroient après Test, ocioient touz. Li Cuens, qui
estoit sages, se prenoit garde de Test : les autres barons cnvoioit
avant; il fesoit touzjorz Tarrere garde o grant plenté de sa gent bien
armée entour lui. Li airs de la terre estoit si plains de broïne et si
espés que cil d'arrère pooient à peine suivre ceus d'avant; car celé
terre, si com je vos ai dit, est si pleine de russiuus et de paluz que
une si grosse niele en sordoit chascun jor que il sembloit que l'en la
peust enpoignier\ et cremoit chascuns que il ne déust esteindre ^
D'autre part li Esclavon et cil de Dalmace, qui savoient les leus et le
pais, leur fesoient maintes saillies aus pas % et ocioient assez de la
gent desarmée. Li Cuens et li autre preu chevalier de l'ost les
forclooient, tele eure ert, et en depeçoient assez; mais plus en
océissent se il n'eussent les bois et les recés si près. Aucune foiz
avint que li Cuens en prist ne sai quanz touz vis; si leur fist couper
les piez et les mains et les lessa enmi la voie, por espoenter les
autres qui après vendroient. En ceste manière furent .ni. semaines
parmi celé terre, en grant péril et en grant mesese. Puis vindrent à
un chastel qui a non Scodre'"; iluec trouvèrent le roi d'Esclavonie. Li
Cuens qui estoit moût sages et moût acointanz, parla moût bel à lui,
et li dona largement de ses joïaus et granz dons; car il avoit
espérance que par ce li féist tenir pais à sa gent, et commandast
que il eussent marchié de viandes. Mais ne valut rien : onques por
nul servise ne porent adoucir son cuer, ne amoloier les genz de la
terre; ainçois les troverent plus crueus et plus vilaines que devant.
Ainsi refurent après trois semaines en celé doleur; car il mistrent
quarante jorz à passer celé terre; puis vindrent à Duraz. 1 Guillaume
de Tyr ajoute ; Anus ^itojue grandxvas. ' Tenebriv conlinuœ pêne
palfabiles. — Niele, brouillard. " Il y a ici une mciprise commune à
tous les manuscrits que j'ai pu voir. Il fallait et le traducteur avait
sans doute écrit : » Que il ne déust les autres atteindre. » Ita ut qui
sequehanlur prcfcedentium vix tenerent vestigia >• f Aux étroits
passages, aux défilés. I» Scutari d'.VIbanie. Cm Scodra nomen.
 A» 1097. LIVRE SECOND. 79 XVIII. — Cornent li Empercres
manda ses messages au cuens de Toulouse, que venist à lui. Li
Empcreres avoit sospeçoneuse la venue le Conte, por ce que il savoit
celui à sage home et de grant cuer : et bien avoit 01 dire que meut
avoit avec lui grant plenté de bone gent. Por ce li envoia à
rencontre, jusqu'à Duraz, hauz liomes de sa terre qui vindrent à lui
et li baillèrent les lettres PEmpereur, qui parloient en ceste manière,
[après le salut :] « La bonne renomée qui cort « de toi par tout le
monde nos a dites certeinnes noveles que tu « es hom de grant
sens, de grand pooir et de grant proesce. Por « ce, nos te dcsirrons
moût à véoir et à ennorer, com celui que « nos amons de bon cuer
et prisons. Si, te fesons prier moût « acertes et requérons à grant
don que tu, par nos terres, faces « passer ta gent, sanz outrages et
sanz torfez. Si te haste de venir « à nous, touz seurs d'avoir nostre
grâce et nos bontez. Nos avons a commandé à ces messages que il
facent avoir à ta gent viandes « et touz lor estovoirs à pris
resnables. » Quant li Cuens et toit li autre baron oïrent ces letres,
moût en furent joieus et lié, car trop avoient eu longues soufretes. Il
se mistrent à la voie par forez et par montaignes; passèrent la terre
d'Epire, puis vindrent en Pelagoine où il troverent moût grant plenté
de touz biens. Li vaillanz evesques du Pui se fu logiez un pou loing
de l'ost, por un beau liu que il y trova. La nuit saillirent à ses
héberges li Bougre de hi terre et le pristrent; mais, por ce qu'il
devoit encore avoir grant mestier à laCrestienté, le garda Nostre
Sires qu'il ne Tocistrent mie'; car li uns des Barbarins li demandoit de
For, et por ce le defendoit et se combatoit aus autres qu'il ne
l'océissent. Endementres, la noise fu oie ez héberges : li oz s'estormi
et crièrent aus armes; puis ' Cela en emprunté de Tiidebode, qui
scm- que exyoUai'eriitil, et in verlicc capilh militeble avoir été de ce
corps d"armée ; « Dum l'o- raverunt. Sed quia tantus pontifes adimc
diensis episcopus hospitatus fuisset, coniigit populo Dei erat
necessarius, per ejus înisequoJ a Pincinactis caplus est, qui continuh
ricordiam vila reservatus est. » ejecerunl illum de mulâ in qun
sedebit. eum 
 80 GUII.I.AIMK DK IVR. A° io((7. corurent sus à ccus qui là
s'estoient embatu, et rcscoustrent TEvesque à toutes ses choses.
L'endemain repristrent leur chemin; si trespasserent Salenique et
toute Macédoine, puis après granz travaus et maintes jornées,
vindrent à une cité qui a non Redost^ et siet seur le Bras saint-
Jorge, et est loing de Costantinoble à .iiii. jornées. Iluec revindrent li
message l'Empereur au Conte, qui moût li prièrent, de par leur
seigneur, que il venist avant son ost à pou de compaignie à
Costantinoble. Messages i avoit ausi de par les barons qui avoient
passé le Braz, et requeroientce meismesetde bouche et par les letres
leur seigneurs. Li Cuens meismes i avoit messages envoiez avant,
por savoir Festre de la terre et des Barons. Icil message estoient
iluec retourné à lui qui moût s'accordoient à ceste chose, et moût li
looient que il féist ce que li Empereres li requeroit. XIX. — Cornent li
cuens de Toulouse vint en Costantinoble. Par la force des proieres
covint que li Cuens le feist einsi. Il lessa i'ost en la garde aus autres
barons et vint à Costantinoble à pou de gent. Pluseurs messages
encontroit en la voie qui tuit le venoient querre. Quant il vint devant
l'Empereur, moût fu receuz à bêle chiere et à grant joie, et de lui et
de touz les barons du palais. Après fistli Empereres parler à lui; il le
requist moût doucement que il, por avoir à touzjors amistié et
aliance à lui, et por son preu que il i auroit grant, féist homage à
l'Empereur, si com li autre avoient fet. 11 respondi tout
estrousseément ' que il ne le feroit mie. Li Empereres en ot grant
desdaing et moût en fu iriez. Il envoia querre les connestables de
ses sodoiers^ et ceus qui s'entremetoient de sa gent à armes; puis
leur commanda à conseil moût celeément que il agaitassent leur
point, et se ferissent en l'ost le Conte, et leur féissent tout le mal
que il porroient, ' Aujourd'hui Rodosto, lîntre Gallipoli et ' Nettement,
sans hiisitation. Constantinople. M. Peyre lui donne à tort le ■'
Legioiium suarum primiceriis.Mà. précéd. nom moderne de
Tekirdagh. — Le reste de la « ses connestables el ses souJaiers ».
phrase est omis dans l'édition précédente.
 A» 1007. LIVRE SECOND. bl et en océissent grant plenté.
Ce comanda li Empereres plus seurement', por ce que il savoit que
cil d'outre le Braz ne leur porroient venir aidier, et, por ce que il
estoient si home, ne li nuiroient mie si legierement. Si avoit
commandé que toutes les nés qui passeroient de là, por porter
viandes ou por autres choses, s'en revenissent tantost à la cité, si
que cil de là en eussent touzjorz soufrete, ne ne peussent retorner
de çà, se il bien vousissent. Car touzjorz avoit-il sospeçoneuse la
grant assemblée de noz genz,se il fussent en leu où il li poissent
nuire. Por ce les avoit fet passer delà, l'un après l'autre. La bêle
chiere qu'il lor avoit mostrée et li grant don que il leur donoit,
venoient plus de barat et de peor que d'amor ne de largesce. Mes
nostre gent, [meismement li François,] ne pooient croire que celé
joie que il leur fesoit ne celé grant richesce que il leur espandoit,
venist de traïson ne de mal : [il ne savoient pas, espoir lors, tant
come il font ore.] XX. — Cornent la gent l'Empereur vindrent tbrfaire
à la gent le Conte. Cil connestable qui avoicnt eu le commandement
l'Empereur parlèrent à leur gent et les embuschierent près de l'ost le
conte de Toulouse. La nuit, quant cil cuidoient estre tout asseur, la
gent l'Empereur se ferirent entre eus, et assez en ocistrent et
dechacierent, ainz qu'il se fussent esveillié ne aperceu. Mes quant li
criz leva et li preudome de l'ost connurent la traïson, il s'armèrent et
retindrent leur genz qui s'enfuioient; puis corurent sus à celé gent
l'Empereur et en ocistrent assez, et le remanant chacierent. Quant
vint au matin, moût se comencierent cil de l'ost à esmaier du travail
que il avoient soufert et de la traïson des Greus; si leur comencierent
moût li cuer à refroidier de celé voie, et li proposemens du
pèlerinage leur failloit touz; si que, ne mie la menue gent, mes
pluseur des granz genz avoient oblié leur veuz et leur enneurs, et
s'en voloient retorner en leur pais. Mes li preudome', [li evesques du
Pui et li evesques [d'Orenge] ■' Ea fretus JiJucia quoJ... ' .1*
episcopis et clero moniti.
 82 GUILLAUME DE TYR. estoientencontr'eus, et maint clerc
preudomcet religicus, qui leur disoient !a parole Nostre Seigneur, et
les reconfortoient moût bien, et leur mostroient qu'en cclc retournée
perdroient-il l'enneur de cest siècle et de Tautre. Einsi les retindrent
à quelque peine. Quant li Cuens qui estoit en Costantinoble oï la
traïson que l'en li avoit faite en son ost, tout fu desvez, et tantost
envoïa de ses homes à l'Empereur, et li manda que il Tavoit traï; car
tandis corn il le retenoit avec lui et li fesoit grant feste, li avoit fet ses
genz ocirre en traïson. Aus barons meismes d'outre le Braz qui
l'avoient fet venir en Costantinoble manda-il la desloiauté que li
Empereres li avoit feite, dont il les requeroit bien, com ses frères et
ses compaignons, qui il la li aidassent à vengier. Bien poez entendre
que se li Cuens eust le pooir de ce amender en celé terre, à peines
alast avant, jusque la chose eust été chier comparée; car il estoit
hom de grant cuer, qui moût à peine oblioit honte que l'en li féist, et
moût voloit ouvrer de soi, par son conseil et par sa volenté. Li
Empereres vit que la chose estoit trop alée avant, si se repenti moût
de ce que il avoit commandé en son corroz, et moût se hâta de
mètre conseil en celé chose; et manda Buiemont et le conte de
Flandres que il venissent à lui, porce que il les voloit envoler por
apaisier le conte de Toulouse. Cil vindrent qui moût estoient irié de
ce qui estoit avenu, et alerent au Conte de par l'Empereur; mes plus
li distrent de par eus meismes que de par lui : bien li mostrerent que
n'estoit mie ne tens ne leus de vengier les hontes que l'en leur fesoit
eu service Nostre Seigneur, car ce seroit empeeschier la grant
besoigne que il avoient emprise por sauver leur armes % et d'autre
part, se il le voloient fere n'en avoient-il mie le pooir : por quoi mieuz
estoit aceler leur pensers que descovrir leur cuers à leur domage et
à leur honte. Li Cuens, encore fust-il iriez, n'estoit mie fous, ainz
soufri que ses sens vainquist son corroz, et dist que il s'en nietoit sur
ces deux preudeshomes qui à lui parloient, et les en creroit. Il
vindrent cà l'Empereur, et priveément li mostre 
 A" 1097. LIVRE SECOND. rent auques durement la lede
revre qui estoit avenue : l'Empereres entendi la grant ire que il en
avoient ez cuers, et fist venir le Conte au palais, et s'escusa devant
touz, et privez et estranges, en jurant, quecefet il ne Tavoit voulu ne
commandé, ainz li desplaisoit moût; et, encor n'i eust-il coupe, près
estoit de restorer au Conte les domages que l'en li avoitfez en son
ost, selonc ce que il porroit. Einsi chascun jor plus et plus se pooit-
Fen aparcevoir de la grant haine que li Grec avoient aus Latins, et de
la desloïal félonie que li Empereres avoit en son cuer contre nos
gens. Mes à soufrirle convenoit, car l'en ne le pooit amender'. XXI.
— Cornent li cuens de Toulouse, par la prière aus autres barons, fist
homaige à l'Empereur. Selonc le conseil aus autres barons, li Cuens
fu à ce menez, par les granz prières l'Empereur, que il li fist homage
et li jura féeuté, si com li autre avoient fet; et fu entr'eus afermée la
pais et Tamor. Li Empereres li dona si granz dons et tant, que tuit
s'en esbahirent, et merveillcrent cil qui le virent. Li autre baron
meismes, qui estoient passé de ça, receurent noviaus presenz et
riches; puis passèrent le Braz et retornerent en Bithine. Moût orent
prié le Conte qu'il ne demorast mie après eus. Li oz le Conte vint en
Costantinoble; il les fist passer outre le Bras et logier avec les autres.
Il se demora en la ville, por aferes que il i avoit à atorner; et, com cil
qui estoit sages hom, semonoit et prioit souvent l'Empereur que il
empréist le servise Nostre Seigneur, et vousist estre sires et
chevetainnes de ce grant ost où il avoit tant de preudeshomes; et
eust espérance que Nostre Sires li feist tel enneur que il delivrast son
pueple et sa terre par lui. Bien li savoit mostrer li Cuens, selonc ce
que li autre baron li avoient mostré qu'il parlast; et il meismes en
avoient parlé. Li Empe' La conduite d'Alexis était facile à com- raient
pas de lui faire hommage des terres de prendre. Il avait de ses vœux
appelé les croi- l'Empire qu'ils reprendraient aux Sarrasins, ses; il les
aidait et de ses hommes et de ses Les chefs qui refusaient de
s'engager étaient trésors; mais à la condition qu'ils ne refuse- dès
lors traités en ennemis.
 84 GriI.I.AUME DF. TYK. A° 10117. reres leur rcspondoit ù
touz en une manière : que moût cstoit haute chose et granz de ce
pèlerinage, et moût desirroit-il à deservir le pardon, et, sur toute
rien, li plairoit la compaignie de si hauz preudeshomes ; mes entour
lui et entour son empire avoit, se disoit-il, moût crueles genz et moût
desloiauz, les Bougres, les Comains, les Pincenels, qui moût
volentiers feroient mal à ses genz et conquerroient de son empire
volentiers ce que il en porroient prendre; et por ce li seroit granz
péril d'esloignier sa terre. Beau le disoit par dehors; mes ce que il
pensoit vers nostre gent n'estoit se tricherie non et desloiautez; ne il
n'avoit talent d'aidier à nostre gent : ainz avoit bien en son cuer que
il leur nuisist à son pooir. Cil qui estoient outre le Braz, Godefroiz li
dux, Buiemons, li cuens Roberz de Flandres, li evesques du Pui,
atornerent leur afere par eus, et distrent qu'il se treroient vers Nique
por atendre iluec les autres barons qui venoient. Quant il
aprochierent d'une cité qui a non Nicomede, qui est la plus ancienne
de Bithine, estesvos Perron Termite, à tout un pou de sa gent qui li
estoit remese, qui issirent d'un povre leu où il s'estoient tapi por
l'iver, et vindrent encontre ces barons; si les saluèrent. Cil leur firent
trop grant joie, et moût leur demandèrent de leur voies; Granz dons
leur donerent, si que il orent à plenté touz leur estovoirs. Pierres leur
conta toutes ses mésaventures, et bien leur dist que ce avoit esté
plus par la folie et par l'outrage de ses genz que par autre chose \
Cil preudome, dont )e vos ai dit, orent gent assez, et vindrent à
Nique et l'assistrent le quinziesme jor de mai. Places lessierent assez
à logier les autres barons que il atendoient. Li cuens de Toulouse ot
fêtes ses besoignes en Costantinoble, puis pristcongié à l'Empereur
qui li donna riches dons touz noviaus, et vint après les autres "
hastivement au siège de Nique. 2 Estes-vous Eor son nsne l'ermite
dont Pierron, » Or pensés del vengier, franc chevalier baron ! » " Nos
barons appela, s'es a rais à raison : EtKrançois respondirent: .. Jà,
ne vous en faurons. » .< Seigneur, en cel grant val que voyez
environ {Aittiochc, ch. Il, xiv.) •I Fumes-nos descontit, si m'aist saint
Simon! . , , . ,„ !>-;„,„„ ' 3 Mes eni'or ni a niir del bon conte Raimon.
.. La fu ocis li prestres par dessous al perron; ^. ^^^^ ^^^^^ ^^
^^.^ ^^^ _^_^ - Je cuis ocis i furent trente mile par non, . Et
nnlnnl en menèrent Tur en chaitivoison. '•'•'■• '''■'■'
 LIVRE SECOND. 85 XXII. — La neuvisme muete qui fu du
duc de Normendie et de pluseurs autres barons. Endementres que il
fesoient ce, Roberz, li dux de Normendie et li autre haut home qui
estoient avec lui, c'est à dire Estiennes, li cuens de Chartres et de
Blois, et Eustaces, li frères le duc Godefroi, envolèrent à F Empereur
et aus autres barons leurs messages, et mandèrent que il venoient.
En leur compaignie estoit li cuens Estiennes d'Aubermale', Alains
Ferganz et Conains-, dui haut baron de Bretaigne; li cuens Rotrous
du Perche, Rogiers de Barneville. Tuit cist et autre chevalier assez
estoient, en Tan devant à l'entrée d'iver, venu en Puille avec le conte
de Flandres et avec Huon le maine. Mes quant li autre passèrent
jusqu'à Duraz, cil, por l'aspresce de l'iver, se remestrent en Puille et
en Calabre qui sont moût plentéives terres. Quant li noviaus tens fu
venus, il assemblèrent leur genz et atornerent leur passage : en mer
se mistrent et vinrent à Duraz; pour ce que il avoient demoré, se
hastereni moût, et passèrent Macédoine et les deux Traces; par
granz jornées et par granz travaus vindrent en Costantinoble. Li
Empereres les manda devant soi. Cil qui bien avoient seu coment li
autre s'estoient contenu envers lui, vindrent en son palais; il les
receut à moût grant joie; tuit si baron leur firent moût grant feste ; il
parla à chascun par soi moût dolcement et moût bien, et moût bel
les acointa; puis leur fist requerre que de l'omage et du serement le
féissent, einsi come li autre avoient fet qui avant estoient passé. Cil
en orent conseil entr'eus, et distrent que il ne leur estoit nule honte
de suivre l'essample à si preudeshomes, ne de fere ce que plus haut
home et plus sage d'eus avoient fet. Il devindrent si home, et féeuté
li jurèrent. Li Empereres les receut en sa grâce et leur dona tant que
il s'en esbahirent tuit; car li don estoient si riche et si divers que il I
« Li fius au conte Odon. » (Anlioche.) Et dans Alain de Nantes et
Conains li 5 Fergandus. C'est Alain VI, dit Ferment. [breton, père de
Conan. lAnlinclu-j
 86 OriI.I.AVMF. DE TYR. n'avoient oncqucs mais teus veuz.
Puis pristrent congié à rEmpereur, passèrent .le Braz saint Jorge et
vindrent en grant haste à Nique, là où li oz de la Crestienté les
atendoit. Granz fu la joie quant cil furent venu qui li darrenicr
cstoicnt; il se logierent ez places que l'en leur a\'oit gardées. XXIII.
somme de l'ost quant il furent tuit ensemlile au siège de Nique.
Tatins estoit uns Greus trop bien de TEmpereur, la plus desloiaus
riens et la plus fausse qui onques'fust; et bien le sembloit, car il avoit
unes narilles remulées'. Icist par le commandement son seigneur se
mist avec nos genz et dist que il les conduiroit; car il sa voit trop
bien tout le pais et touz les trespas oij il voloient aler. Mes li
Empereres ne l'avoit fet se por mal non; car il se fioit si en la
desloiauté cestui, que il savoit bien que il leur sauroit touzjorz
porchacier leur pis et conseillier à fere leur domage. Si estoit einsi
corne la coluevre entre les anguiles^ Et li avoit commandé li
Empereres que tout Testre et le proposement des Barons li féist
chascun jor savoir; et si li manderoit, selonc ce sa volenté. Ici furent
premièrement les genz ensemble, et firent un ost de ceus qui de
tantes parties et par tantes voies estoient venu en ce leu. Lors
aprimes s'entrevirent li baron chevetaine , et porent parler des
communes besoignes; car onques-mès ne s'es' Nares habens mutilas
in signum mentis perversœ. Il fallait dire seulement : par l'efl'et d'un
châtiment à lui infligé. Remulé, mutilé, n'est pas dans les glossaires.
La Chanson d' Antioche est plus favorable à ce Tatin qu'elle nomme
« Estatin l'esnasé ». Elle le représente comme le plus sage et le plus
honnête conseiller de l'Empereur, et l'ami des barons croisés qu'il
accompagna au siège de Nicée. Anne Comnène écrit son nom
Tatikos , et nous apprend qu'il était Sarrasin d'origine. Il iouissait de
la confiance d'Alexis et paraît en avoir été digne. - Les Croisés ne
pardonnèrent pas à Alexis de les avoir empêchés de piller et retenir
la ville de N'icée. De là leurs préventions contre les Grecs. Mais quel
intérêt pouvait avoir l'Empereur à nuire aux croisés, qui venaient
pour reprendre aux Sarrasins et avaient juré de lui remettre les
terres autrefois dépendantes de l'empire, la Syrie exceptée? Nicée
était assurément la première des villes qui devaient retourner aux
Grecs, et il avait été très-probablement convenu que Tatin en
prendrait possession aussitôt qu'elle serait emportée.
 A" loyj LIVRE SECOND. 87 toient entreveu. Selonc ce que il
fu ilec certainement seu, par nombre et par esme, il orent devant
Nique, quant il furent assemblé, .VI.'' mil homes à pié '; de
chevaliers et de serjanz à chevaus et à haubers orent. c."'. Moût
furent en grant volenté trestuit des estraines de leur guerre bien
emploier'; et moût desirroient si hautement emprendre leur premier
fet [que toutes autres genz les en doutassent.] Peditum fromiscui
sexiis, Liiborum suorum vrimitias clan owni Jcvotione Domino
consecrantes.
 LI TIERS LIVRES. I. — Du la cité de Nique. : la cité de
Nique sachiez qu'ele fu desouz l'arceveschié de Nicomede; mes li
Empereres Costantins la fist oster du pooir à cel arcevesque, et fu
exemte, por enneur de ce que 11 primerains des quatre granz
conciles avoit iluec sis. Car eu tens saint Sllvestre Tapostoilc estolt
patriarches de Costantlnoble Allxandres, empereres Costantins.
Arrius estolt uns mescréanz qui mesprenoit ez polnz de la foi ', et
mainte gent le suivoient en ce. Por ce s'assemblèrent en la cité de
Nique au concile .iii.'^- et .xviii. prelaz, et fu iluec desputé contre ces
popelicans. Par les tesmoins des Escriptures et p-ir Tacort des sainz
homes qui là estoient, fu dampnez Arrius et sa mescréance. Puis
après, eu tens à un autre Costantin empereur qui fu tilz Yrenc, se
rasembla un autre concile iluec meisrnes, qui fu setiesmes : lors etoit
Adrlens apostoiles de Rome, Tareses patriarches de Costantlnoble'-.
Là furent dampné une manière de mescréanz qui disoient que toutes
les images que l'en fet en Sainte église estoient contre foi, [et cil
estoient desloial et faus crestien qui les 1 soufroient.] Celé cité de
Nique siet en un plain; mes les montaignes sont près : ne s'en faut
guères qu'eles ne soient tout entour. La terre est moût bêle et moût
plentéive. Les granz forez sont delez ; uns lais est près de la cité
moût lez et moût Ions devers Ocident. Par I L'hércsie d'Ariiis
consistait à soutenir le plus grand des liommes. (comme la lait de
notre temps M. Renan), 2 Hn 7S7. Constantin Porphyrogiinéte
empeque Jesns-Christ était non pas un Dieu, mais reur, Tharasius
patriarclie.
 LIVRE TROISIÈME. 89 iluec vient à nés la viande et l'autre
marchéandise en la cité. Quant il vente, moût fièrent ces ondes
grosses aus murs. De Fautre part de la \ ille sont li fossé lé et
parfont et piain de Teauc du lai et d'autres fonteines. Li mur estoient
entour fort et haut et espés, et plains de grosses torneles. Les genz
de la ville estoient fier et hardi et bien aiisé ' d'armes, et grant plenté
en i avoit. Et quant nos genz aprochierent, moût se merveilJerent de
la force de la ville". II. — Qui estoit lors seigneur de Nique.
Solimanz, dont je vos ai parlé desus', qui moût estoit puissanz Turs,
avoit la seigneurie de celé cité et de toute la terre entour. Moût
estoit sages et hardiz et preuz du cors. Dès lors que il oï la venue de
nostre gent, s'estoit garniz de ses amis et de sodoiers', por défendre
sa cité et sa terre. Uns suens oncles qui avoit non Belfeth . moût
puissanz et moût riches soudans de Perse, avoit conquise, n'avoit
guères, toute la terre qui est du Braz saint Jorge jusques en Surie,
oij il a .xxx. jornées de lonc. En ce tens estoit Romains Diogenes
empereres, qui avoit esté devant ccst Ale.xe qui ore avoit l'empire.
Icil Belfeth avoit doné la greigneur partie de celé terre à Soliman son
neveu, si que il tenoit toute la terre dez la cité de Tarse qui est en
Cilice jusqu'au Braz saint Jorge : en tel manière neis qu'il avoit ses
bailliz de l'autre part ens ens la veue de Costantinoble, qui
recevoient ses paages et ses costumes des marchéanz de la ville et
des autres. Icil Solimanz s'estoit trez aus montaignes, à tant de gent
com il pooit avoir, près de l'ost à .x. milles; ne ne fesoit que espier
coment il poïst trouver son point de l'ost assaillir et alever le siège,
se li pooirs fust siens. ' Aiisé. éprouver. Assueti. Le participe pré-
pitre premier, sent aûsant , qu'on trouse dans Philippe ' Cognomento
Sa (SI. al;), quod Pasarum .Mouské (V. ;63i), a piohablement le
même lingua Rex interprelatiir. *ens. ' Multo antc in Oricnlem
JcsccnJerat... im* Les textes latins continuent ici le clia- ploraturus
auxiliunt. T. I. i;UII-r.VUME »t rvR. — l'J
 90 Gl'ILl.AUMK I)i: IVR. 111. ■ Comunt Soliman/, envcoit
ses mcssaiges ii la cité por eus conforter. Nostre gent vindrent
devant la ville à dcsroi', sans acort; et san/. commandement
comencierent à assaillir. Mes' li chevetaine , sur qui li fèt de la
besoigne estoit, recomencierent à livrer les places, por fere la ville
bien asseoir; si que cil dedenz iVen poissent issir et gens dehors n'i
entrassent mie. Mèsli granz lais qui touchoit à la ville ' les destorboit
moût, car il pooient, maugré l'ost, aler et venir par nés tant com il
leur plaisoit. Nostre gent n'avoient nules nés, ne ne leur pooient le
lai défendre; par terre voirement les avoient-il bien assis. Soliinanz
qui vit sa cité einsi avironée de teus genz et de tant, ne fu mie à
aise, et douta moût que cil de la ville ne s'esmaiassent. Por ce
envoia deus de ses privez messages et leur comanda que par le lai
entrassent en la ville et leur déissent teus paroles : « Je vos tieng à
si « vaillanz homes et de tel proesce, que je croi bien que vos ne «
prisiez guères celé gent maleureuse qui vos ont assis; car ce « sont
unes foies genz qui sont venu de moût lointains pais « devers soleil
couchant; si sont las et desaaisié, mal atirié et « desgarni; ne
chevaus n'ont mie qui grant travail poissent soua frir. Nos somes frès
et noz chevauchéures reposées en noz « pais : dont il n'est nule
doute que noz ne vaillons mieuz que « eus; et ce poez-vos savoir:
car n'a mie grant tens que nos en « desconfiismes en un jor plus de
cinquante mille. Por ce, si vos « confortez et maintenez corne
preudome; car demain, dedens « Teure de none, serez-vos sanz
faille délivre d'eus touz. Mes « soiez bien apensé et bien appareillé
que quant nos nos ferrom « en Fost, vos issicz à porte overte sur
eus, si que vos aidiez « à la victoire, et soiez parçonnier de l'enneur
et du preu'. » < Sans ordre. Confusis npminibus. ' L'édition
précédente a assé la plirase suivante jusqu'au mot si Amis, dist
SoHnians, h Nique m'en irés. « Mes homes qui lii sont moult bien me
conforttSs. Et cil se part de lui, h Nique en est tornés. Corne faus
pèlerin est el chemin entrés. L'ost des François trespasse, si s'en vint
Cs fossés. Ceux qui sont Ifi-dedens .a soef apelés : ■< Seigneur, que
faites-vous? Ne vous espoentez: " Rois Solimaus vous mande qu'en
vertu vous teué .1 Ne vous psmniés mie, car lions secors aurés.
 A" 1097. LIVRE TROISIÈME. 9I IV. — Coment nostro gunt
pnstrent les messages Soliman. Li message Soliman vindrent par le
lai et arrivèrent un peu loingnet de la ville : puis comencierent à
esgarder et à espier par oi^i il porroicnt mieuz entrer enz. Noz gens
les aparceurent, si leur corurcnt sus. Li uns d'eus fu ocis au prendre,
li autres fu amenez touz vis devant les Barons. Il le mistrent à
gehine, si leur connut la vérité, et dist que Solimanz les envéoit en la
cité por eus garnir, et por dire que leur sires vendroit rcndemain
atout grant genz et se ferroit sodainement en Fost. Li Baron le
crurent bien, si le commandèrent à garder, et pristrent conseil entre
eus que il feroient. Li cuens de Toulouse et li evesques du Pui
n'estoient mie encore venu jusqu'en Tost; li Baron les envolèrent
qucrre, et leur mandèrent qu'il se hastassent por tel chose. Cil se
mistrent tantost à la voie et chevauchierent toute nuit, si que il
vindrent ainz le soleil levant en l'ost, les banieres levées et sonoient
les trompes. Moût i avoit granz genz et bien atornées. A peine
s'estoient-il logié ez places qu'on leur avoit gardées, quant Solimanz
vint en tor eure de tierce, com cil avoit dit qui pris estoit. Jà estoient
descendu des montaignes au plain. La nostre gent qui en estoient
tuit apensé s'armèrent et firent soner les trompes. Chascuns se trest
à sa bataille, si com il estoit devisé, et furent li conroi atirié ' moût
vistement. V. — Cornent Solimans et sa gent envaïrent la nostre
gent. De la gent Soliman se parti une bataille des autres où il avoit
X."- chevauchéeurs; et s; trestrent vers la ville, endroit la porte
devers Midi. Làs'estoit logié li cuens de Toulouse et li avoit l'en baillié
celé porte à garder. Mes Solimanz qui, le jor devant, avoit été espier
celé voie, ne n'i avoit nului veu , cuidoit - Aina que soit deniaia
vespres, bien cent mille vernis " N'en remanrn un seul ne soit uml
atornt*s. >• ■' Qui tost vous secorront des bons brans acérés. «
Com (le Pieron fesistes. aussi de ces fer^-s : * I.es rangs ordonnés.
 92 GUILLAUME DE TYR A» 1097. encore que la porte fust
délivre, car il ne savoit riens de la venue le Conte ne de sa gent.
Celé bataille se feri en la gent qui estoit venue. Cil les receurent
meut fièrement aus glaives et aus espées, et assez legierement les
domagiercnt et firent resortir arrières. Solimans qui les suivoit de
près les list retorner avec soi, et assembla à celé gent le Conte
meismes. Li dux Godefrois, Buiemonz et li cuens de Flandres' virent
que trop i avoit des Turs et que li cuens de Toulouse" nés porroit pas
soufrir; si adrecierent leur batailles celé part et se ferirent en eus.
Moût i ot fier chapléiz et espesses meslées, et assez i ot morz des
Turs. Moût le firent bien iluec Tancrés, Guiz' de Garlande li
seneschaus le roi de France, Guiz de Possesse, Rogier de Bafneville :
cist emportèrent le pris devant touz. Celé bataille dura bien une eure
toute entière. A la fin li Tur ne porent plus nostre gent soufrir, ainz se
mistrent à la voie et se desconfirent laidement. Nostre gent nés
suivirent guères, car les montaignes et li bois estoient près où cil se
ferirent. Mors i ot le jor des Turs quatre mille et aucuns en pristrent-
il vis. Nostre gent orent moût grant joie de celé victoire et revindrent
à leur siège. Si aceinstrent la ville au mieus que il porent. Por
correcier et esbaubir ceus dedenz qui leur secors avoient atendu, il
firent giter à mangoniaus dedens la ville grant plenté des testes aus
Turs qui mors estoient en la bataille'. Les prisons vis et mille des
testes aus mors envolèrent de par les barons à l'Empereur; il leur en
sot moût bon gré et trop en ot grant joie. Noviaus dons de joiaus et
de dras de soie renvoia à touz les barons moût largement, et
commanda que vitailles portast-Fen assez en l'ost et autres choses,
si que rien ne leur fausist. ' Éd. précéd. « Toulouse ». ' Éd. précéd. «
Flandres ». 3 Éd. précéd. « moût le firent bien ilec tant que Guiz. ..
■> Notre traducteur est ici plus correct que l'original, où Gh_>- est
nommé Gailerus. Au reste, le nom varie dans chaque :;uteur. La
Chanson d'Antioche donne Payen : le père Anselme et Morcri
soutiennent qu'il lallail é.rirc : Gilberl. V Puis ont prises les lestes de
la gent mescréant El mangonel les mêlent no crestien vaillant. En la
cité de Nique les jetent en lançant. Por CDU le fout François que Tur
soient dotant. Trois mil prisrent no Franc de Turs qui sont vivant .
Tous les ont envoies par haute mer najant Droit à Cûstantinoble k
l'empereur poissant. Quant les voit l'empereres, le cuer en ot riant,
Puis prist escus et lances, pain, vin, a espendant. Si l'envoie h l'ost
Dieu, doucement merciant. (11. Il, s :l7.i
 .V 1097- LIVRE TROISIEME. 93 VI. — Cornent li Crestien
drecierent perrieres et mangoniaus cntour Nique. Mout pensèrent li
Baron cornent celé cite poïst estre assise de toutes parz ; car
autrement ne leur sembloit mie qu'il poissent la ville destreindre. Par
commun conseil se logierent tuit. Devers soleil levant mistrent le Duc
et ses .11. frères atoute leur gent; devers Bise fu logiez Buiemonz,
Tancrés et li autre baron qui estoient venu en leur compaignie; li
cuens de Flandres et li dux de Normendie et leur est se logierent de
lez eus; devers Midi fu li cuens de Toulouse, Hues li maines, li
evesques du Pui, li cuens de Chartres et autre baron assez, atoutes
leur genz; si que la cité fu toute enclose, fors devers le lai qui estoit
en la partie de soleil couchant. Puis envolèrent hastivement à la
forest et en firent venir grant plenté de merrien, por fere les engins.
Tuit li charpentier de Tost et li fevre se trestrent avant, de quoi il i
avoit assez. En pou de tens levèrent en pluseurs leus perrieres et
mangoniaus, et firent chaz et voies covertes', por emplir les fossez et
por mètre les mineurs aus murs. Assez i ot gité de grosses pierres
aus hordeiz" et au.x tourneles, si que durement furent desfroissié li
mur en pluseurs parties. A ces choses fere mistrent bien .vu.
semaines. Assez i ot souvent saillies et bons poignéiz devant les
portes. Un jor s'accordèrent li Baron que l'en assausist; mes à cel
assaut ne domachierent pas mout ceus dedenz, ainz i perdirent
entre les autres .11. mout vaillant home : li uns avoit non Baudoins
Chauderons'', riches hom et bons chevaliers, [nez de Berri], li autres
[de Flandres] qui avoit non Baudoins de Gant, preuz et hardiz : cil
dui s'estoient tret mout avant le jor, tant que li uns fu morz du cop
d'une pierre, li autres de saiete; et remest li assauz. Un autre jor fu
recommenciez li assauz par l'acort des Barons; et fu ocis d'une
saiete Guillaumes, li cuens de ' Machinas ûd suffociienditm murum
babi- * Remparts, te, quas vulgo scrophas appellanl. Ce mot ^
Cognomeiito CaUeron. i:d. précéd. > Baudoit répondre aux 1- voies
couvertes ■• du Ira- doiu Chanderon ", ducteur.
 94 GUII.I.Al'ME DE TYR. A" 10C17. Fore/,, et Gales de Lisle,
d'une autre. Cil dui estoient haut home et moût assailloient le jor
hardiement. En ce tens meismes fu mor/, en Tost de sa maladie Guis
de Possesse, uns bers [de Champaigne] , larges moût et bons
chevaliers'. De la perte de ces barons furent moût adoulé en Tost;
[mes moût les reconfortoit ce que tuit avoient ferme espérance que
Nostre Sire qui en son servise les prenoit, les guerredoneroit moût
hautement à touzjors] ; noblement les enterrèrent, puis
r'entendirent à la besoigne. Vil. — Comc-nt H Crestien furent mort
eu chastel de Fust. Un jor se furent acordé li chevetaine de Tost que
les chastiaus' que Ten avoit fet fussent tret avant et approchié des
murs; car chascuns des gran/. homes avoit commandé à fere aucun
engin errant en sa partie. Li cuens Hermanz nez de Tiesche-terre et
Henris de Asque^ qui estoient bon chevalier et emprenant, avoient
devisé et fet fere un chastel de gros très de chesne : desus avoient
mis .xx. chevaliers touz en covert; desouz avoit sergenz et mineurs
assez pour piquer le mur. Il aprochierent ce chastel, si que il il le
joinstrent au mur\ Li chevalier desus lecomencierent à défendre, et
cil desoz pecoioient le mur à grant esploit. Li Tur ' Vir iioUlis de regno
Francorum. V.ar. Porcesse. Le traducteur ajoute ici heureusement à
Toriginal. Gui était en effet de la province de Cliampagne. De Castro
Porcessa, dit Albert d'Aix. Porcesse est à cinq lieues de Vitry. Chans.
d'Antioche, ch. U, § K : De Guion de Porcesse vous doi dire la vie : Li
bers se flst sainier, ce fut moult grand folie. Car si corn Dieus le volt,
mors fu de la sainie. Li bers fu moult malades, ne pooit garir mie. En
sa tente gisoit qui toute estoit série : Tur gietent lor perieres qui lii
tente ont Dans Guis 11 ber en ot la teste peçoie. Devant lui flst
mander Buiemont où se fie. Et le conte de Tlandres, Robert de
Normand' l-:t Tangré le puillant h la chiere hardie. •i Uaron, dist
Bauduins. france gent seigneurii ■I Or convient départir la nostre
compaignie, ., Et les grans amistiés qui furent sans boisdit .■ Sire
Roberz de Flandres et vous de Norman i. Dieus vous reuge l'oiinor et
la grant seignei .. Quai f\i entor vous et o l.i bai-nnie. ■. A iceste
parole en est l'arme parlie. Puis suit rintéressant récit des funérailles
lluec, defors la ville, a un marbrin perron, La avoit un moustier, el
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