Uncover Peace: Managing Sleep & Anxiety

Nishi Bhopal, MD

Well, thank you so much for having me here. 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. I also have an online platform for teaching clinicians about clinical sleep medicine because I’m passionate about sleep. After all, it truly is the foundation of physical and mental health. We all know how it feels to not get good sleep, and it has real, significant impacts on our health. I’m excited about sharing knowledge about sleep and about teaching other clinicians because there are very few board-certified sleep medicine clinicians in the U.S. and worldwide. I think it’s important that this knowledge be disseminated so that we can all optimize our sleep and if we’re working with patients, help them optimize theirs. 

Audrey Wells, MD

Excellent point. I love talking to you because I think we both love sleep medicine and the impact that it can have on everybody who up-levels their sleep practices. Over the last year, as we’ve discussed, different aspects of sleep and how to elevate communication not only to physicians but to people just living in the community. I endorse your mission, and I consider us working shoulder to shoulder on this problem. I want to delve into today’s topic, which is how to sleep despite the anxiety. The feeling of anxiety can compete with a person’s ability to get to sleep. I think most people have an understanding of what anxiety feels like. But I want to ask you. For anyone who may not understand, what is the difference between anxiety and anxiety disorder?

Nishi Bhopal, MD

It’s a great question, and it can be hard for people to tease that out on their own. I recommend that anyone who is even wondering about that for themselves go and talk to somebody because anxiety is highly treatable. Just preface this by saying, Go see a therapist or a psychiatrist. If you’re not sure, see one or the other, and they can help guide you. But the true difference is that anxiety is more of a persistent response. It’s a stress response that happens outside of specific stressors. Our nervous system has adapted and evolved to respond to stressors in a specific way. That’s what’s happened to keep us safe. For example, let’s say you’re faced with a threat. Your nervous system is going to respond either by increasing its physiological response or 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. For example, there have been a lot of layoffs recently here in the Bay Area. So that has been a significant stressor for many people. It’s only natural that they would have these kinds of responses. Excessive worry and thinking and difficulty sleeping can come along with that. But when that stressor resolves, then those symptoms resolve as well. 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. There are 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 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.

Audrey Wells, MD

That makes sense. You’re looking for the stimulus—the anxiety—to anchor that feeling as appropriate for this situation. The second thing I heard you mention was that when this stressor goes away, the anxiety resolves as well. That’s an important point. Now, any time I’ve been stressed, problems with sleeping come up for me almost with 100% fidelity. I’m sure I’m not alone. One of the fun things about dealing with sleep issues is that everybody sleeps, and everybody has a bad night of sleep once in a while. I’d like to hear from you. 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?

Nishi Bhopal, MD

That’s a great question, and it’s a super common issue because anxiety disorders are the most common mental health disorders worldwide. About 50% of people who have anxiety disorders have issues with insomnia or some form of sleep disturbance. 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. When people are struggling with insomnia, it also increases their risk of developing anxiety or experiencing more intense anxiety symptoms. The first thing I tell people is that this is a normal response to anxiety. It’s your nervous system’s way of keeping you safe. Again, if we think from an evolutionary standpoint, when we were living out in exposed terrain, if there was a threat or a stressor, our nervous system wanted us to wake up in response to that. Otherwise, if we just slept through, let’s say, an attack or an invasion or a saber-tooth tiger was coming into our cave, we wanted to be able to wake up to keep ourselves safe. That’s what happens when we’re experiencing stress, anxiety, or a nervous system that keeps us safe by keeping us awake. Sometimes even just recognizing that you don’t have to fight against your nervous system can be helpful for people as they’re navigating this problem. The next thing we do is look at what the causes of this nervous system hyperactivation are. Is it because you’re sleep-deprived that can cause nervous system hyperactivation? Is it because you’re struggling with managing all of the demands and stressors that are happening in your life now? Are there ways that we can address that? Sometimes these are behavioral. Sometimes there’s a lifestyle measure. Sometimes medications can be helpful. There are lots of different approaches that can happen. But I just want people, if you’re listening to this and you’re struggling with this issue, to know that you’re not alone with this. It can feel very helpless and isolating when you’re lying in bed and your mind is active, your body just won’t sleep, 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.

Audrey Wells, MD

I think that’s so reassuring to hear. I also like to bring people to that space where they’re lying in their beds. It’s dark; it’s quiet, or reasonably so. 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 unsafe or like something’s not enough, which is going to stimulate your nervous system. At that moment, are there any actionable measures that a person can take to relax?

Nishi Bhopal, MD

It depends on what is relaxing for that person. It’s one of the mistakes that I see that someone will say to me, I was listening to this guided meditation because I heard that it’s good for relaxation, but I find it annoying find it irritating, but I’m trying it because I heard that’s what I’m supposed to do. Again,  for anyone who’s listening, you want to figure out what helps you relax; what helps your partner or your friend relax might not be the same for you. That’s the first thing. But several things can be helpful. One is just breathing. When we’re in a state of stress, our breathing changes. We tend to breathe more quickly and more deeply. Focusing on slower breaths and longer exhalations can be quite calming. Again, one of the mistakes I see people making here is focusing on a deep inhalation. Sometimes that can make people more anxious. I hear this from my patients who have anxiety, but they tried deep breathing, and it made them more wrapped up. Focus on a long exhalation, and there are certain techniques you can try. things like four seven, eight 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. That’s a practice that is done by Navy SEALs in their training to help regulate their nervous system. Those are just some examples. Breathing is one thing. Another thing is that if you’re tossing and turning and you’re lying in bed and you’re stressed out, then the recommendation is to get out of 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, as 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 a rerun of one of your favorite shows that you find 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. 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. What I tell them in that case is to 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.    So relish in that moment, take your attention away from trying to fall asleep, and just notice how comfortable and relaxed you are. Again, you can listen to music, a podcast, or something like that that is going to be relaxing and not stimulating for you.

Audrey Wells, MD

I love what you’re saying because there is an element of personalization that applies here and self-awareness as a person is working out what is going to work for me. I think that can be empowering and I wonder if you have a favorite technique when you can’t sleep.

Nishi Bhopal, MD

Yes. I don’t like to get out of bed and have full transparency because I’m one of those people who, yes, it’s cozy and comfortable in my bed, and I don’t want to be cold, and I don’t want to get out of bed. So if it’s the middle of the night and I can’t sleep, I do just that. I’ll relax in bed, I’ll do some breathing, and if I can’t sleep, I’ll put something on to listen to again. Something that I’ve heard before isn’t going to keep me up because I’m wondering what they’re going to say next or what’s going to happen. But those are the techniques that I use. But another important one is reframing and recognizing that, okay, I can’t sleep now. It’s not a big deal. I’ll be okay. My nervous system is doing what it’s supposed to do, and I’ll be able to sleep again tomorrow night or later. So just taking the pressure off is a big one because the more pressure we put on ourselves to force sleep, the more elusive sleep becomes.

Audrey Wells, MD

Exactly. It’s like the will to sleep. Trying harder is incompatible with sleep. So I think that’s a 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, and eight breathing, and I wonder if you can demonstrate that for us.

Nishi Bhopal, MD

Sure. Essentially, what it is is that you’re inhaling for a count of four, and you’re holding it for a count of seven. 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. Should we try it together?

Audrey Wells, MD

Let’s do it.

Nishi Bhopal, MD

Okay. All. You can start 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 relaxing. I immediately feel a little bit more loose.

Audrey Wells, MD

Yes. I love that about breathing. It’s always available to you. It’s at the interface between the conscious and the subconscious. 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.

Nishi Bhopal, MD

I love that. It’s so powerful. As you said, breathing is interesting because it’s the only physical and one of the only physiological processes that are under voluntary and involuntary control. We can’t control our heart rate, our digestion, or how our kidneys work, but we can control how we breathe, or breathing just happens automatically without us thinking about it. It’s a fascinating process in that way.

Audrey Wells, MD

Absolutely. Now, you mentioned that anxiety affects sleep, and sleep affects anxiety. Can you elaborate more?

Nishi Bhopal, MD

Yes. I can share some statistics here. This was from a study out of the 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. 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 interesting was that one night, one single night, a deep sleep reduced the anxiety that the participants felt the next day. Mm hmm. Again, one night of restorative sleep can significantly reduce the anxiety that you feel the next day. Deep sleep is that stage-three sleep that happens predominantly in the first half of the night.

Audrey Wells, MD

Mm hmm.

Nishi Bhopal, MD

This is why you must prioritize your sleep and your sleep schedule. I have a lot of patience, 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, finish those last few emails, or let me just know quickly to 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. We’re cutting off that deep sleep in the first half of the night, and that can contribute to more anxiety the next day.

Audrey Wells, MD

I think what the subtext is is that a regular sleep pattern allows the brain to anticipate the timing for that slow-wave deep sleep. If you make it an exception to your regular bedtime and stay up later than you intended, you end up missing out on some of that slow-wave deep sleep that’s going to help your brain dampen the anxiety and reduce the nervous activation that you experience.

Nishi Bhopal, MD

That’s exactly it. When somebody comes 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 getting their sleep back online.

Audrey Wells, MD

Mm hmm.

Nishi Bhopal, MD

Because without getting their sleep back on track, it’s hard to treat anxiety. It’s hard to treat depression. People might fall into this category of being labeled as having treatment-resistant depression or anxiety. But their sleep hasn’t been addressed. Oftentimes, when we address that sleeping, get that sleep system back online, and get them into restorative sleep again, we see significant improvements in their mood.

Audrey Wells, MD

I think that gives people hope that this is not going to be this way forever. We’ve talked about some behavioral interventions that you can do at the moment. I’m wondering, what do you do when a person starts seeing a pattern of anxiety, sleep problems, or 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 and approaching that type of patient?

Nishi Bhopal, MD

The first thing is getting a good understanding of what is going on with the person. When we have a patient in front of us in our practice, we go through their whole day. Again, for anyone who’s listening, just think about this. You can walk yourself through your day and just ask yourself, Okay,  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? We’ll go through the entire day. Oftentimes, when patients come to us for help with sleep, they’re focused on that hour before bed, and they forget that there’s a whole day. That good sleep starts during the day. They forget there’s a whole day before that. That impacts how our sleep system works. We’ll go through the entire day. We’ll look at what’s going on in their lives, how they’re thinking about things, the nutrition there, and gut health as well. Medications: sometimes people are on medications that can affect sleep negatively. 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. In our practice, we’re an integrative psychiatry practice, which means that we blend holistic and complementary medicine with integrative medicine and conventional medicine. We want to give people the best-personalized approach. But those are 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 something 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 can also be counterproductive in some cases and cause more anxiety, and then sometimes we will refer patients for sleep. We study because we find that about one in five people with depression have undiagnosed sleep apnea.

Audrey Wells, MD

Wow.

Nishi Bhopal, MD

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 working. Their sleep is suffering. It turns out they’ve got undiagnosed sleep apnea or they have something else, like periodic limb movement disorder or restless legs and roaming, all of which can look a little bit like anxiety, difficulty falling asleep, waking up at night, and feeling a little bit anxious. We like to look under the hood to see what’s going on.

Audrey Wells, MD

That’s such a smart approach. 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. Sometimes we have to engage some tools, like the sleep study, the sleep diary, or wearable devices, to peek a little bit deeper into what might be causing the problems with sleep. One of the things that I like to advocate for is the evaluation of sleep apnea in an atypical person. 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?

Nishi Bhopal, MD

I love that you mentioned that it’s important because I’ll hear this from people where I might suspect sleep apnea, or I’ll bring up sleep apnea to them. They say, Well, no, I don’t have that. My husband has that because he snores. I heard 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, and it can’t look like fibromyalgia or chronic pain. In my practice, we’ve seen so many atypical presentations of sleep apnea. As you said, people who are maybe not overweight or don’t have the thick neck that is thought to be typical for patients who have sleep apnea, people who don’t snore or they’re not necessarily waking up with those gasping arousals, or their partners never noticed 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 fogs, they’re having trouble concentrating at work, or their psychiatric medications are not working, and they’re doing therapy and spinning their wheels. We have a pretty low threshold for doing sleep studies on our patients. For this reason.

Audrey Wells, MD

It’s the way to go. Now, the accessibility of home sleep apnea testing 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 or perpetuate your anxiety. Getting that nailed down addressed is going to be helpful, not only to feel refreshed in the morning but also to help your brain settle.

Nishi Bhopal, MD

Yes, that’s exactly it. What happens with sleep deprivation is that we get hyperactivation of the amygdala, which, I mean, very simply put, is like the fear center of the brain. It’s a little bit more complicated than that. But that’s our anxiety center in the brain. that becomes hyperactivated when we’re sleep deprived, whether we’re sleep deprived by choice. Like you’re just not prioritizing sleep, or it’s from insomnia. then the frontal lobes and the frontal cortex start to shut down a little bit. Those are the emotional-regulating parts of the brain. This predisposes us to experience more anxiety or more heightened anxiety in response to stressors, whereas when we have gotten restorative sleep, we may be less reactive. 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. With your loved ones.

Audrey Wells, MD

Maybe not your best self.

Nishi Bhopal, MD

Not your best self. Difficulty focusing at work, and all of these kinds of things are just more emotionally reactive. Yes,  restorative sleep helps to quiet down regions of the brain that are involved in anxiety.

Audrey Wells, MD

I like to talk to people about the effect that REM sleep or dream sleep can have on emotions, dampening emotions and helping with emotional processing at night. Why is it important to talk about REM, especially when you consider the sleep schedule of going to bed and waking up in the morning?

Nishi Bhopal, MD

Yes. As we talked about sleep architecture, 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. if we’re cutting off our sleep in the morning or if we’re getting up at different times on different days. For example, if you’re getting up at six a.m. on a workday and then you’re sleeping until 9 a.m.. On a weekend, that’s a three-hour time difference. It can create a jet-like effect, but it also cuts off REM sleep in the morning. That’s one area to be mindful of having a consistent sleep schedule so that you’re getting your full sleep every night. As you mentioned, REM sleep is important for emotional regulation, emotional processing, and also memories and learning. If you’re learning something, studying, or 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. There are 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. 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. Again,  when we see patients with untreated sleep apnea, they’re more likely to have emotional dysregulation.

Audrey Wells, MD

For sure. 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. I think that creates a blind spot when you’re taking your patient’s history. I want to ask you something that’s been posed to me several times: at what point do you consider medication—medication that’s prescribed for anxiety or medication that’s prescribed for sleep?

Nishi Bhopal, MD

Great question. With anxiety, I look at how pervasive the symptoms are, how much they’re impeding a person’s functioning, and also the person’s preferences. In our practice, sometimes we’ll see patients who don’t want to take medication for one reason or another, so we’ll explore that with them. There are non-medication treatments that we can implement, but sometimes anxiety over medication can be helpful just to calm things down. Again, it has to do with the third level of functioning—how long the anxiety has been going on. 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 look at using medication to calm things down. In some cases, anxiety can be anxiety. Medication can be used for a short time. Different classes of medications can be used. There’s as-needed, and then there’s maintenance medication. We’ll assess 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, or medication could be helpful. We would do that in conjunction with other measures, though medication is not the only treatment. We will implement medication in conjunction with lifestyle interventions with nutrition, looking at gut health, working on coping skills, and working through trauma, which is also not uncommon in people who are struggling with anxiety. There are lots of different pieces. Medication is one piece with sleep. It’s a similar approach. If someone has been struggling with sleep for a long time and they’re becoming increasingly anxious about it, sometimes using short-term medication just to give them a bit of relief can be quite helpful. 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 cause the very issues that we were trying to treat in the first place. After all, there are things like tolerance, independence, 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 intermittent. Her patients will use them just once in a while if they’re traveling or if 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 useful tool in that way.

Audrey Wells, MD

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 supporting that with behavioral measures, good practices around sleep, and highlighting the relationship that takes place between the physician and the person who’s struggling. That trust needs to be there to make the most use of all of the treatments that we’ve talked about. I wonder, too, if you can talk about your way of using nutritional tools to support anxiety and sleep.

Nishi Bhopal, MD

So. Nutrition is often overlooked when it comes to sleep optimization or even the treatment of insomnia. But there are a few aspects of nutrition that are helpful. One thing that we do in our practice is do blood work on every patient who comes in because we want to make sure they have optimal levels of micronutrients. Simple things like Vitamin D, B12, and iron levels are implicated in sleep disorders like restless leg syndrome, period, and limb movement disorder. Even the Restless Leg Foundation has recommended iron supplementation if patients have a relapse or restless leg syndrome in the absence of anemia. These are simple things that we can look at, but also like. These are micronutrients, but we also look at macronutrients. Those are your proteins, carbs, and fats. 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 the neurotransmitter hours that it needs to function optimally and to sleep. Things like serotonin, GABA, acetylcholine, and dopamine—all of these things are, at least in part, synthesized from the food that we eat. That’s why it’s 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. So if we eat at different times every day or eat heavy foods before bed, then that’s going to impact our sleep system as well. The science of nutrition and sleep is emerging, so a lot of the research is still preliminary. I’m interested to see how the research unfolds over the coming years, as more attention is paid to this now. 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. Just increasing your intake of fiber can be helpful. then increasing your intake of healthy fats can be helpful as well. These are things like omega-3s, avocado nuts, seeds, and things like that. Again, for anyone who’s listening, this is not medical advice. Do talk to your healthcare practitioner about your specific needs. But generally speaking, these things can be helpful for sleep.

Audrey Wells, MD

So much common sense too. I mean, what you’re describing is a comprehensive approach to not only anxiety but also a person’s sleep and well-being. I love all of it. As we wrap up here, I wonder if there’s something that you wish anybody who struggles with anxiety and sleep could know about. What is the take-home message from you?

Nishi Bhopal, MD

Yes, 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 are lots of amazing apps out there as well. There are so many tools these days, so educate yourself, see what’s available, and see what works for you. If you’re not sure, go and talk to somebody. I talked to a therapist, a psychiatrist, or a sleep specialist, of course. They can help point you in the right direction.

Audrey Wells, MD

Fantastic advice. Today I want to recap. We’ve just gone over and talked about anxiety versus anxiety disorders. We’ve talked about the way anxiety can impact your sleep. The reverse is also true. Your sleep can exacerbate problems with anxiety. You named several behavioral treatments that are effective, such as guided meditation, breathwork, focusing on the exhale to get that nervous system calm using sound, mindfulness, getting up out of bed, and also just normalizing being awake in bed. All of those things are actionable. You also discuss how the way you spend your day impacts the way you spend your night. For anyone with sleep issues, this is an issue that can be addressed around the clock. You can adjust your light exposure, your stress levels, your relationships, and your meal timing. I love what you’re highlighting about the relationship between the physician or clinical provider and the patient. What you’re describing is a fundamental trust in the relationship and looking at the whole person as a way of interacting, treating, and honoring the preferences of the person who’s struggling. I wonder if you can tell where people might find you or work with you if they want to.

Nishi Bhopal, MD

Definitely. Well, thank you for this discussion. I enjoyed it. People can find my practice called Pacific Integrative Psychiatry, and it’s online. We serve patients all across California, and we offer therapy, psychiatry, and nutrition services. Then I also have an online platform called Intra Balance, and that’s where I teach healthcare practitioners about the fundamentals of sleep medicine.

Audrey Wells, MD

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

Nishi Bhopal, MD

Thank you.