Uncover Peace: Managing Sleep & Anxiety

Introduction and Speaker Background 0:00

Welcome back to the Sleep Deep Summit. New Approaches For Beating Insomnia And Sleep Apnea. I'm your host, Dr. Audrey Wells. And today I'm thrilled to introduce our next speaker, Dr. Nishi Bhopal. Dr. Nishi, welcome. And I wonder if you can tell our listeners and our audience who you are, what you care about, and where you practice. Well, thank you so much for having me here. So I'm Dr. Nishi Bhopal, I'm a psychiatrist and sleep physician. I'm also board certified in integrative holistic medicine, and I practice in the San Francisco Bay Area.

I have an online practice called Pacific Integrative Psychiatry. And I also have an online platform teaching clinicians about clinical sleep medicine, because I'm really passionate about sleep because it truly is the foundation of physical health and mental health. We all know how it feels to not get good sleep and it has real significant impacts on our health. So I'm really excited about sharing knowledge, about sleep, about teaching other clinicians because there are very few board certified sleep medicine clinicians in the U.S.

and worldwide. So I think it's really important that this knowledge is disseminated so that we can all optimize our own sleep and if we're working with patients, that we can help them optimize theirs. Excellent point. And I love talking to you because I think we both love sleep medicine and the impact that it can deliver to everybody who sort of up levels their sleep practices. So over the course of the last year, as we've discussed,

Anxiety vs. Anxiety Disorder 1:51

you know, different aspects of sleep and how to elevate the communication not only to physicians, but to people just living in the community. I really endorse your mission and I sort of consider us working shoulder to shoulder on this problem. I want to delve right into today's topic, which is how to sleep. Despite anxiety and the feeling of anxiety can really compete with a person's ability to get to sleep. And I think most people kind of have an understanding of what anxiety feels like. But I want to ask you.

For anyone who may not understand, you know, what is the difference between anxiety and anxiety disorder? It's a great question, and it can be hard for people to tease that out on their own. So I recommend to anyone who is even wondering about that for themselves, go and talk to somebody because anxiety is highly treatable. So, you know, just preface this by saying go see a therapist or a psychiatrist. And if you're not sure, see one or the other and they can help guide you. But the difference is truly that anxiety is more of a persistent response.

It's a stress response that happens outside of specific stressors, right? So our nervous system has adapted and evolved to respond to stressors in a specific way. So that's that's happened to keep us safe. So, for example, let's say you're faced with a threat. Your nervous system is going to respond either by increasing its physiological response. So you might have an increased heart rate or digestive issues, or you might notice that your breathing is more shallow. You might notice that you're worrying a little bit more about the situation.

So, for example, you know, there's a lot of layoffs recently here in the Bay Area. And so that has been a significant stressor for many people. So it's only natural that they would have these kinds of responses. You know, excessive worry and thinking and difficulty sleeping can come along with that. But when that stressor result leaves, then those symptoms resolve as well. Right. With an anxiety disorder, those symptoms are persistent, even in the absence of the stressor or those symptoms might be out of proportion to a specific stressor.

And there's lots of different reasons for that as well. Sometimes it could be a trauma response. Sometimes it could be due to sleep deprivation, which we are going to talk about. There could be genetic factors as well. But that's really kind of in a nutshell. The main difference is that anxiety is a persistent and pervasive disorder that affects your functioning in your daily life, whereas stress for an anxiety response related to a specific stressor is usually in proportion to that stressor, and it's not as pervasive.

That makes sense. So you're looking for the stimulus, for the anxiety, to kind of anchor that feeling as appropriate for this situation. And the second thing I heard you mentioned was that when this stressor goes away, the anxiety resolves as well. So that's a really important point.

How Anxiety Disrupts Sleep 5:07

Now, I know that any time I've been stressed, problems with sleeping comes up for me almost with 100% fidelity. And I'm sure I'm not alone. One of the fun things about dealing with sleep issues is everybody sleeps and everybody has a bad night of sleep once in a while. So I'd like to hear from you and drawing on your clinical experience, if someone is describing anxiety as a barrier to getting to sleep or getting back to sleep, how do you advise them? Again, that's a great question and it's super common issue because anxiety disorders are the most common mental health disorders worldwide.

Right. And about 50% of people who have anxiety disorder have issues with insomnia or some form of sleep disturbance. So that's a huge number. The interesting thing is that anxiety and sleep go hand-in-hand. There's a bi directional relationship. They both affect each other. Traditionally, it was thought that sleep or insomnia disorders were caused by anxiety. But now we know that the relationship goes both ways. So when people are struggling with insomnia, it also increases their risk of developing anxiety or experiencing more intense anxiety symptoms.

So the first thing I tell people is that this is a normal response to anxiety. Again, it's your nervous systems way of keeping you safe. So again, if we think from an evolutionary standpoint, when we were living out in out in exposed terrain, if there was a threat or a stressor, our nervous system wanted us to wake up in response to that. Right. Otherwise, if we just slept through, let's say, an attack or an invasion or there was a saber tooth tiger coming into our cave, we wanted to be able to wake up to keep ourselves safe.

So that's what's happening when we're experiencing stress or anxiety or a nervous system is keeping us safe by keeping us awake. So sometimes even just recognizing that that you don't have to fight against your nervous system can be really helpful for people as they're navigating this problem. The next thing we do is we look at what are the causes of this nervous system, hyper activation. Is it because you're sleep deprived that can cause nervous system hyper activation? Is it because you're struggling with managing all of the demands and stressors that are happening in your life right now?

And are there ways that we can address that? Sometimes these are behavioral. Sometimes there's lifestyle measures. Sometimes medications can be helpful. There are lots of different approaches that can happen. But I just want people, you know, if you're listening to this and you're struggling with this issue, know that you're not alone with this. It can feel very helpless and isolating when you're lying in your bed and your mind is active or your body just won't sleep or your nervous system is activated and you're all alone.

It can feel very, very isolating and scary. But this is a highly treatable and highly common problem. I think that's so reassuring to hear. And I also like to kind of bring people to that space where they're lying in their bed. It's dark, it's quiet, or reasonably so. And having that sensation of anxiety is in direct conflict with the relaxation and calm that you need to sleep. Sometimes I feel like it comes down to feeling not safe or like something's not enough, which is going to stimulate your nervous system.

So in that moment, are there any actionable measures that a person can take in order to relax? Absolutely. So here it really depends on what is relaxing for that person. It's one of the mistakes that I see is that someone will say to me,

Calming Techniques for Bedtime Anxiety 8:55

you know, I was listening to this guided meditation because I heard that it's good for relaxation, but I actually find it really annoying. I find it really irritating, but I'm trying it because I heard that's what I'm supposed to do. So again, you know, for anyone who's listening, you want to figure out what helps you relax, what helps your partner relax or your friend relax might not be the same for you. So that's the first thing. But there are several things that can be helpful. One is just breathing.

When we're in a state of stress, our breathing actually changes. We tend to breathe more quickly and more shallow. So focusing on slower breaths, longer exhalations can be quite calming. One of the mistakes, again, I see people making here is focusing on a deep inhalation. Sometimes that can make people more anxious, actually. And I hear this from my patients who have anxiety, but they tried deep breathing and it made them more wrapped up. So really focus on a long exhalation and there are certain techniques you can try.

So things like 478 breathing or box breathing, which is where you inhale four counts before you hold it for a count of four, exhale for four and then hold again for four. And that's a practice that is done by Navy SEALs in their training to help regulate their nervous system. So those are just some examples. So breathing is one thing. Another thing is that if you're tossing and turning and you're lying in the bed and you're stressed out, then the recommendation is to actually get out of the bed and move to a different area, like a comfortable chair or your couch.

You want to minimize light exposure and you can do something quietly there, like read a book or look at a magazine or even, you know, people always say, Oh, I'm not supposed to look at screen screens, but sometimes screens can be useful in this regard. You don't want to be looking at a brightly lit screen, but putting on a movie or something that you've seen before that you find relaxing, that you're not going to be listening to because you don't know what's going to happen next or know a rerun of one of your favorite shows that you find really calming.

Just put the screen face down if you're watching on your iPad or phone and just hearing that can sometimes calm the mind. So things like that. I have patients who tell me they don't want to get out of bed in the middle of the night when they can't sleep because it's cold out there and they're so cozy in their bed. So what I tell them in that case is really focus on how comfortable you are. Don't even worry about trying to get back to sleep. Just focus on noticing the sensation of your cover. Your bed covers how soft your pillow is and just enjoy that moment.

It's quiet. You're alone. Nobody's bothering you. You don't have to check your emails. Right. And so really relish in that moment, take the attention away from trying to fall asleep and just notice how comfortable and relaxed you are. And again, you can listen to something music or a podcast or something like that that is going to be relaxing and not stimulating for you. I love what you're saying because there is an element of personalization that applies here and kind of self-awareness as a person is working out what is going to work for me.

I think that can be really empowering and I wonder if you have a favorite technique when you can't sleep. Yeah. So I don't like to get out of bed and full transparency because I'm one of those people that yeah, it's really cozy and comfortable in my bed and I don't want to be cold and I don't want to get out of bed. And so if it's middle of the night and I can't sleep, I do just that. So I'll relax in the bed, I'll do some breathing, and if I really can't sleep, I'll put something on to listen to again.

Something that I've heard before that's not going to keep me up because I'm wondering, you know, what they're going to say next or what's going to happen. But those are the techniques that I use. But another one is that's really important, is reframing, recognizing that, okay, I can't sleep right now. It's not a big deal. I'll be okay. You know, my my nervous system is doing what it's supposed to do, and I'll be able to sleep again tomorrow night or later. And so just taking the pressure off is a really big one because the more pressure we put on ourselves to force sleep, the more elusive sleep becomes.

Exactly right. It's kind of like the will to sleep. Trying harder is incompatible with sleep. And so I think that's a really good point that you have to have some awareness of when your mind is slipping into that mode because you're doing yourself a disservice. You mentioned four, seven, eight breathing, and I wonder if you can demonstrate that for us. Sure. So essentially what it is, is you're inhaling for a count of four, you're holding it for a count of seven. And then you do an exhale through the mouth, the inhalation is through the nose, then an exhalation through the mouth for a count of eight.

So should we try it together? Let's do it. Okay. All right. So you can start

Breathing Demo and Sleep-Anxiety Link 14:02

filming for seven. That was an exhalation for eight. I was counting in my mind. I didn't count out loud, but even just doing that feels really relaxing, right? I immediately feel a little bit more loose. Yes. And I love that about breathing. It's always available to you. And it's kind of at the interface between conscious and subconscious. So I've had the experience of doing some breathing techniques and as my mind is a little bit distracted with the counting, I fall asleep and then the next day I realize, Oh, that worked for me.

I love that. It's so it's so powerful. And breathing is like you said, it's really interesting because it's the only sort of physical at one of the only physiological processes that is under voluntary and involuntary control. Like we can't control our heart rate or our digestion or how our kidneys are working, but we can control how we breathe or breathing just happens automatically without us thinking about it. So it's it's really fascinating process in that way. Absolutely. Now, you mentioned that anxiety affects sleep and sleep affects anxiety.

Can you elaborate more? Yes. So I can share some statistics here. This was from a study out of University of California, Berkeley, and they found that people who have insomnia, whether it's trouble falling asleep or staying asleep, were more than twice as likely to develop anxiety disorders. Right. So I'll say that in a different way, which is that when people are struggling with sleep disturbances, specifically insomnia, even if they don't have anxiety before they're more likely to develop anxiety, they're more than twice as likely to develop anxiety as somebody who isn't struggling with insomnia.

What they also found in this study that was really interesting was that one night, one single night, a deep sleep, reduced anxiety that the participants felt the next day. Mm hmm. So again, one night of restorative sleep can significantly reduce the anxiety that you feel the next day. And deep sleep is that stage three and three sleep that happens predominantly in the first half of the night. Mm hmm. So this is why it's really important that you are prioritizing your sleep and your sleep schedule.

And, you know, I have I have a lot of patients, and I'm guilty of this myself, where sometimes anxiety or stress will drive me to stay up a little bit later to get that one last project done or finish those last few emails or let me just know quickly go and take care of this one task and then we're missing out or we're cutting off that deep sleep because our sleep follows a certain architecture. So we're cutting off that deep sleep in the first half of the night, and that can contribute to more anxiety the next day for sure.

And I think what the sort of subtext is, is that a regular sleep pattern kind of allows the brain to anticipate the timing for that slow wave deep sleep. So if you make it an exception to your regular bedtime and stay up later than you intended, you actually end up missing out on some of that slow wave deep sleep that's going to help your brain dampen the anxiety and sort of reduce the nervous activation that you experience. That's exactly right. And when somebody is coming to my practice for help with anxiety, whether they're seeing our therapist or a nutritionist or they're working with one of our psychiatrists, one of the focuses is really getting their sleep back online.

Mm hmm. Because without getting their sleep back on track, it's really hard to treat anxiety. It's really hard to treat depression. And people might fall into this category of being labeled as having treatment resistant depression or anxiety. But their sleep hasn't been addressed in. Oftentimes when we address that sleeping and get that sleep system back online and get them into restorative sleep again, we see significant improvements in their mood. I think that gives people hope that, you know, this is not going to be this way forever.

Sleep Architecture, REM, and Emotional Regulation 18:38

And we've talked about some behavioral interventions that you can do in the moment. I'm wondering, what do you do when a person start seeing a pattern of anxiety, sleep problems, sleep problem, anxiety? It's not going away. It's starting to take on a life of its own. What are the steps that you would go through in evaluating that and approaching that type of patient? Absolutely. So the first thing is really getting a good understanding of what is going on with the person. So when we have a patient in front of us in our practice, we go through their whole day.

So again, for anyone who's listening, just think about this. You can walk yourself through your day and just ask yourself, okay, what do I what time do I get up and out of bed? What do I do first thing in the morning? When do you eat your meals? When do you get light exposure or when do you get physical activity? How do you feel physically and mentally in the morning? How's your nervous system feeling in the morning? So we'll go through the entire day. Oftentimes when patients come to us for help with sleep, they're really focused on that hour before bed and they forget that there's a whole day.

And actually that good sleep starts during the day. So they forget there's a whole day before that. That impacts how our sleep system works. Right? So we'll go through the entire day. We'll look at what's going on in their life, how they're thinking about things, the nutrition there, nutrition and gut health as well. Medications sometimes people are on medications that can affect sleep negatively. So we'll look at that. But sometimes medications can be helpful to address anxiety and calm the nervous system so they can get restorative sleep.

So in our practice, we're an integrative psychiatry practice, which means that we blend holistic and complementary medicine with integrative medicine, with conventional medicine. So we really want to give people the best personalized approach. But those are kind of the initial steps that we would go through with somebody. If someone is specifically struggling with sleep, we'll also have them do a sleep diary or if they're using some sort of a wearable, like an aura ring or a Fitbit or something like this, we can help them understand the data and what that means and how to use that effectively for tracking, because it also can be counterproductive in some cases and cause more anxiety and then sometimes will refer patients for sleep, study because we find that, you know, so about one in five people with depression have undiagnosed sleep apnea.

Wow. Right. So it's a lot more significant. I see this a lot in my patients with anxiety as well, that they have undiagnosed or untreated sleep apnea. They've been going from psychiatrist to psychiatrist, trying different medications. Nothing's really working. Their sleep is suffering. And it turns out they've got undiagnosed sleep apnea or they have something else periodic limb movement disorder or restless legs and roam, all of which they can all look a little bit like anxiety, difficulty falling asleep, waking up at night, feeling a little bit anxious.

So we we like to look under the hood to see what's going on. That's such a smart approach. And it's true. I think one of the challenges for anybody who assesses a person's sleep is what to do when a person says, I just don't sleep well, because that's a very nonspecific assessment. So sometimes we have to engage some tools like the sleep study, the Sleep Diary or wearable devices to kind of peek a little bit deeper into what might be causing the problems with sleep. One of the things that I really like to advocate for is evaluation for sleep apnea in the atypical person.

So people who are not overweight, people who don't have all of these stereotypical symptoms of sleep apnea or women, women don't present like men do when they have sleep apnea. Can you tell us more about what your approach is? I love that you mentioned that it's really, really important because I'll hear this from people where, you know, I might suspect sleep apnea or I'll bring up sleep apnea to them. And they say, well, no, I don't have that. My husband has that because he snores. And I hear him choking at night and then he got a CPAP and now he's fine, but I don't have those symptoms.

But in women, sleep apnea can show up very differently. It can show up like depression, it can look like anxiety, it can't look like fibromyalgia or chronic pain. And in my practice, we've seen so many eight atypical presentations of sleep apnea. As you said, people who are maybe not overweight or they don't have the thick neck that is thought to be, you know, typical for patients who have sleep apnea, people who don't snore or they're not necessarily waking up with those gasping arousal or, you know, their partners never noticed that that they had apnea during their sleep or things like this.

But they're tired all the time. They're fatigued. They have trouble. Their brain fog, they're trouble concentrating at work or their psychiatric medications are not working

Evaluating Chronic Sleep and Anxiety Problems 23:58

and they're doing therapy and they're spinning their wheels. So we have actually pretty low threshold for doing sleep studies in our patients. For this reason. It's the way to go. And now the accessibility of home sleep apnea testing really kind of lowers the entry point for people who need to get screened. I think it's worthwhile to point out that sleep deprivation of any cause can exacerbate your anxiety or perpetuate your anxiety. So getting that really nailed down addressed is going to be helpful, not only to feel refreshed in the morning, but also to help your brain to settle.

Yes, that's that's exactly right. And what happens with sleep deprivation is that we get hyper activation of the amygdala, which is I mean, very simply put, is kind of like the fear center of the brain. It's little bit more complicated than that. But that's sort of our anxiety center of the brain. So that becomes hyper activated when we're sleep deprived, whether we're sleep deprived by choice. Like you're just not prioritizing sleep or it's from insomnia. And then the frontal lobes, the frontal cortex starts to shut down a little bit.

And those are our emotional regulating parts of the brain. So this predisposes us to experiencing more anxiety or more heightened anxiety in response to stressors, whereas when we have gotten restorative sleep, we may be less reactive, right? And so I think most people know that feeling of getting up on the wrong side of the bed or just being sleep deprived and being irritable and snappy the next day, right? With your loved ones. Maybe not your best self. Not your best self. Difficulty focusing at work and all of these kinds of things just more emotionally reactive.

So yes, that restorative sleep helps to actually quiet down regions of the brain that are involved in anxiety. I like to talk to people about the effect that REM sleep or dream sleep can have on emotions, dampening emotions, helping with emotional processing at night. Why is it important to talk about REM, especially when you consider the sleep schedule going to bed and waking up in the morning? Yes. So as we talked about sleep architecture, that deep sleep stage three sleep happens predominantly in the first half of the night.

REM sleep happens predominantly in the second half of the night, and our REM periods get longer as the night goes on. And if we're cutting off our sleep in the morning or if you're getting up at different times on different days. So, for example, if you're getting up at six M on a workday and then you're sleeping until 9 a.m. on a weekend, that's a three hour time difference. So it can create a jet like effect, but it also cuts off that REM sleep in the morning. So that's that's one area to be mindful of, is that consistent sleep schedule so that you're getting your full sleep architecture every night.

And as you mentioned, REM sleep is really important for emotional regulation, emotional processing, also memories, memory of learning. So if you're learning something or studying, you're working on a project, you want to make sure you get that REM sleep so that your brain can function at its best. Sleep apnea is also very disruptive to REM sleep. We there's different forms of sleep apnea, but there is a form called REM dominant sleep apnea where our body is paralyzed. It's supposed to be paralyzed during REM sleep.

So we're not flailing and acting out our dreams. That also makes the airway more susceptible to collapse, and then we're more likely to have opinions in our REM sleep. And again, you know, when we see patients with untreated sleep apnea, they're more likely to have emotional dysregulation. For sure. And also, if the sleep apnea is only occurring during REM, the bed partner may not perceive gasping or snoring because presumably they're asleep in the early morning hours as well. So I think that creates a blindspot when you're taking your patient's history.

I want to kind of ask you something that's been posed to me a number of times, which is at what point do you consider medication, medication that's prescribed for anxiety or medicate and that's prescribed for sleep? Great question. So with anxiety, I look at how pervasive the symptoms are and how much they're impeding a person's functioning and also the person's preference. Of course, in our practice, sometimes we'll see patients who really don't want to take medication for one reason or another, so we'll explore that with them.

So there are non medication treatments that we can implement, but sometimes anxiety for medication can be really, really helpful just to calm things down. So again, it has to do with third level of functioning, how long the anxiety has been going on for. So if someone comes to us having had significant anxiety for a few months and they've tried everything and nothing's working, that's probably the time to to look at using a medication to kind of calm things down. In some cases, anxiety can be anxiety.

Sleep Apnea, Sleep Deprivation, and Brain Effects 29:28

Medication can be used for a short period of time. So there are different classes of medications that can be used. There's as needed, and then there's maintenance medication. So we'll do an assessment to see what would be appropriate for that person if something just once in a while would be helpful if they had intermittent flare ups or if it is again that more pervasive type of anxiety, maintenance, medication could be helpful. We would do that in conjunction with other measures, though medication is not the only treatment will implement medication in conjunction with lifestyle interventions with nutrition, looking at gut health, working on coping skills, working through trauma, which is also not uncommon in people who are struggling with anxiety.

So there's lots of different pieces. So medication is one piece with sleep. It's kind of a similar approach. If someone has been struggling with sleep for a long time and they're becoming increasingly anxious about it, sometimes using medication short term just to give them a bit of relief can be quite helpful. So I'm not against using sleeping medications. I don't advocate for using them long term because long term use of sleep aids can sometimes start to cause more problems, or even they can start to cause the very issues that we were trying to treat in the first place, because there are things like tolerance, independence and rebound, insomnia and things like this that can occur with long term use of sleep aids.

But short term they can be very helpful or sometimes intermittently. So her patients will use them just once in a while, you know, if they're traveling or if they have a you know, they're going through a divorce or something, they're going through a major stressor in their life and they could use that more support. Medications can be a really useful tool in that way. It makes so much sense. I mean, you're describing a very conscientious and smart way to go about using prescription medications to treat the acute issue and really support that with behavioral measures, you know, good practices around sleep and kind of highlighting the relationship that takes place between the physician and the person who's struggling.

You know, that trust needs to be there in order to make the most use of all of the treatments that we've talked about. Really fantastic. I wonder, too, if you can talk about your way of using nutritional tools to support anxiety and sleep? Definitely so. Nutrition is often overlooked when it comes to sleep optimization or even treatment of insomnia. Right. But there's a few aspects to nutrition that are helpful. So one thing that we do in our practice is we do blood work on every patient who comes in because we want to make sure they have optimal levels of micronutrients.

So simple things like Vitamin D, Bodmin B12, iron levels and iron is implicated in sleep disorders like restless leg syndrome, period, limb movement disorder. Even the Restless Leg Foundation has recommended to treat with iron supplementation and if patients have relapse or restless leg syndrome in the absence of anemia. So these are simple things that we can look at, but we also like. So these are micronutrients, but we also look at macronutrients. So those are your proteins, carbs, fats. And are you getting enough nutrition for your body to function?

Sometimes people forget that the fuel for a body is the food that we eat, and if we don't have good quality fuel, our body isn't able to make

When to Use Medication and Nutrition Support 33:08

the neurotransmitter hours that it needs to function optimally and to sleep. So things like serotonin and GABA and acetylcholine, dopamine, all of these things are, at least in part, synthesized from the food that we eat. Right? So that's why it's really important to look at this. We also look at the timing of meals, which has an impact on the circadian rhythm, which is our body clock. And so for eating at all different times every day or for eating heavy foods right before bed, then that's going to impact our sleep system as well.

The science on nutrition and sleep is emerging, so a lot of the research right now is still preliminary. So I'm really interested to see how the research unfolds over the coming years as more attention is paid to this right now. What is it's thought that eating fiber helps to increase deep sleep. Many of us aren't getting enough fiber in the standard American diet. The sad diet, right? So just increasing your intake of fiber can be helpful. And then also increasing your intake of healthy fats can be helpful as well.

So these are things like omega 3's, avocado nuts, seeds, things like that. And again, for anyone who's listening, this is not medical advice. So do talk to your health care practitioner about your specific needs. But generally speaking, these things can be helpful for sleep. And so much common sense too. I mean, really what you're describing is a comprehensive approach to not only anxiety, but a person's sleep and well-being. So I love all of it. As we wrap up here, I wonder if there's something that you really wish anybody who struggles with anxiety and sleep can know about.

What is the take home message from you? Yeah, so the take home message is that these issues are highly treatable. Sometimes when we're struggling with sleep or anxiety, we just write it off as I'm just an anxious person or I'm just a bad sleeper, and that's simply not the case. Help is available whether you are open to working with a therapist individually or a psychiatrist, but there's lots of amazing apps out there as well. There's so many tools these days, so educate yourself, see what's available, see what works for you.

And if you're really not sure, go and talk to somebody. Talked to a therapist or a psychiatrist or a sleep specialist, of course. And they can help point you in the right direction. Fantastic advice. So today I want to recap. We've just gone over we talked about anxiety versus anxiety disorders. We've talked about the way anxiety can impact your sleep. And the reverse is also true. Your sleep can exacerbate start problems with anxiety. You named several behavioral treatments that are effective, so guided meditation breathwork focusing on the exhale to really get that nervous system calm using sound, using mindfulness, getting up out of bed and also just normalizing being awake in bed.

So all of those things are really actionable. You also discuss the way that you spend your day impacts the way you spend your night. So for anyone with sleep issues, this is really a issue that can be addressed all around the clock. You can adjust your light exposure, you can adjust your stress levels, you can adjust your relationships, your meal timing and I love what you're really highlighting about the relationship between the physician or clinical provider and the patient. What you're describing is really a fundamental trust in the relationship and kind of looking at the whole person as a way of interacting, treating

Takeaways and Where to Find Dr. Bhopal 37:18

and really honoring the preferences of the person who's struggling. I wonder if you can tell us where people might find you or work with you if they wanted to? Definitely. Well, thank you for for this discussion. I really enjoyed it. So people can find my practice is called Pacific Integrative Psychiatry and it's online. We serve patients all across California and we offer therapy, psychiatry and nutrition services. And then I also have an online platform called IntraBalance, and that's where I teach health care practitioners about the fundamentals of, sleep, medicine.

I love it and everybody needs to check that out because it's a really great way to kind of encapsulate what's important about sleep medicine and get good information out there. Thank you so much, Dr. Bhopal, for talking to me today. And I wish you all the best. Thank you.