Sleep Onset Anxiety: Mechanisms and Evidence-Based Approaches in Clinical Practice

Sleep-onset anxiety is a transdiagnostic contributor to difficulty initiating sleep that is maintained through interconnected cognitive, physiological, and neurobiological processes. This narrative review synthesizes current evidence on mechanisms and behavioral interventions for sleep-onset anxiety, highlighting pre-sleep worry, rumination, conditioned arousal, autonomic dysregulation, and brain network alterations as key mechanisms. Evidence-based interventions are reviewed, including cognitive behavioral therapy for insomnia (CBT-I), mindfulness and acceptance-based approaches, relaxation strategies, and environmental optimization. Clinical considerations are examined for individuals with comorbid anxiety disorders, across developmental stages, and across diverse cultural contexts. Digital delivery formats are reviewed as scalable approaches to extend treatment access. Much existing evidence derives from broader insomnia populations rather than sleep-onset anxiety as a distinct construct, limiting mechanistic specificity. Future research directions include mechanistic trials integrating objective biomarkers with clinical outcomes, component optimization studies, and scalable implementation approaches. This review provides an integrative framework linking mechanisms to evidence-based interventions for sleep-onset anxiety across diverse clinical populations and settings.