Psychiatry Case Challenge: A 60-Year-Old Woman With Sleep Problems and Odd Behavior

Donald M. Hilty, MD, MBA; Jose Feliberti, MD


May 15, 2023

A biopsychosociocultural (BPSC) model has been suggested.[13] This was in response to Engel's biopsychosocial model in medicine, which was an attempt to "educate a truly scientific physician…closer to reality."[14] That model also attempted to shift clinicians from a purely "biomedical model" to one that had more of a systems approach and included contributions from behavioral science, cognitive science, neurobiology, medical sociology, and health psychology. It offers a comprehensive view of the patient within a social and environmental context.

The BPSC model has an expanded definition and delineation of culture and diversity components, as well as such biological concepts as the stress-diathesis model, psychobiology, and hypothalamic-pituitary-adrenal axis activation in response to environmental stress (often chronic). An outline approach of the BPSC aspects makes for a more meaningful, systematic treatment plan.[15]

Fortunately for the patient in this case, the primary care clinic was part of a health system with mental health staff embedded for warm handoffs to provide brief therapies, case management, and other services for depression, pain management, and suicide prevention. An interdisciplinary care team with physicians, mental health, nursing, pharmacy and other healthcare professionals is suggested.[16] This patient requires a team approach that should also include the patient's daughter.

A mental health clinician worked with the primary care provider to use motivational techniques (ie, motivational interviewing) and basic relapse prevention techniques, in combination with a referral to a 12-step program (ie, Alcoholics Anonymous). The BAM-R was completed monthly. Her mirtazapine dose was safely raised to 45 mg to help with sleep, and she was provided with sleep hygiene education. She was also told that medication for reducing craving was available, if needed.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.