ICD-11 Prolonged Grief Disorder, Physical Health, and Somatic Problems: A Systematic Review Systematic Reviews and Meta-analyses ICD-11 Prolonged Grief Disorder, Physical Health, and Somatic Problems: A Systematic Review James Cunningham 1 , Mark Shevlin 1 , Catalina Cerda 1 , Eoin McElroy 1 [1] School of Psychology, Ulster University, Coleraine, United Kingdom. Clinical Psychology in Europe, 2025, Vol. 7(1), Article e14351, https://doi.org/10.32872/cpe.14351 Received: 2024-04-09 • Accepted: 2024-08-26 • Published (VoR): 2025-02-28 Handling Editor: Winfried Rief, Philipps-University of Marburg, Marburg, Germany Corresponding Author: Mark Shevlin, Ulster University (Psychology), Room H256, Cromore Road, Coleraine, Northern Ireland, BT52 1SA. Phone: +442870123141. E-mail: m.shevlin@ulster.ac.uk Supplementary Materials: Materials, Preregistration [see Index of Supplementary Materials] Abstract Background: Since Prolonged Grief Disorder’s (PGD) inclusion as a mental health disorder in the ICD-11 in 2018, much of the peer-reviewed research has focused on its prevalence, assessment, and co-occurrence with other mental health disorders. There is also emerging research literature on the association between PGD and physical and somatic health outcomes. In light of this, the objective of this review was to identify and summarise the extant research on the association between PGD, and outcomes related to physical health and somatic complaints among bereaved individuals. Method: A systematic review utilized electronic databases (Web of Science, MEDLINE, Cochrane Library, PsycINFO) up to October 10, 2023. Included were cohort and cross-sectional studies since 2018 exploring links between ICD-11 PGD and physical/somatic health outcomes. Two researchers independently identified eligible studies meeting inclusion/exclusion criteria, employing quality assessment instruments to evaluate methodological rigor. Results: From the 418 articles that were initially screened, 18 met the inclusion criteria. The studies reported significant associations between PGD and physical health, somatic symptom distress, insomnia severity, blood pressure, bodily distress syndrome, chronic physical diseases, and poor- caregiver health profiles. Conclusion: Out of the 18 studies eligible for analysis, 13 (72%) established a significantly strong or moderate association between PGD and physical or somatic illness, highlighting the intricate nature of this connection. Further research is required to assess the breadth of physical and somatic health problems associated with PGD and to understand the psychological and biological mechanisms that underpin these observed relationships. This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License, CC BY 4.0, which permits unrestricted use, distribution, and reproduction, provided the original work is properly cited. https://crossmark.crossref.org/dialog/?doi=10.32872/cpe.14351&domain=pdf&date_stamp=2025-02-28 https://orcid.org/0009-0003-2630-5670 https://orcid.org/0000-0001-6262-5223 https://orcid.org/0009-0008-7738-0159 https://orcid.org/0000-0001-5466-8522 https://www.psychopen.eu/ https://cpe.psychopen.eu/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ Keywords prolonged-grief, bereavement, PGD, physical, somatic, somatization, illness Highlights • Most studies found a strong to moderate link between PGD and physical/somatic illness. • PGD impacts caregiver health, somatic distress, insomnia, and comorbid chronic diseases. • Findings align with PTSD, with clinically relevant psychological and medical effects. Physical health is defined by the Centers for Disease Control and Prevention as the condition of one’s body, with the ability to carry out daily activities without experiencing pain, discomfort, or limitation (Elgaddal et al., 2022). Somatic problems, on the other hand, are physical symptoms that are not caused by an identifiable medical condition (Kolappa et al., 2013). The association between mental health disorders and physical health or somatic symptoms has been consistently reported in the research literature. For example, depression has been identified as a risk factor for long-term physical conditions such as diabetes (Cosgrove et al., 2008; Gonzalez et al., 2008), cancer (Massetti et al., 2017; Massie, 2004), and cardiac disease (Berg et al., 2018; Chaddha et al., 2016; Dhar & Barton, 2016). Studies conducted by Haug et al. (2004) and Carlehed et al. (2017) have also explored how depression relates to physical symptoms in large community samples, revealing a strong and significant relationship between depression and experiencing functional so­ matic symptoms. Moreover, Gili et al. (2010) reported a higher prevalence of depression among primary care patients with chronic somatic diseases compared to their physically healthy counterparts. One disorder that has consistently been found to be associated with physical and somatic problems is post-traumatic stress disorder (PTSD). The ICD-11 outlines PTSD as a mental health condition that can emerge after experiencing a threatening or horrifying event or a sequence of such events (Barbano et al., 2019) and the associated allostatic load has been argued to cause physical morbidity (McFarlane, 2010). There has been a plethora of studies examining the association between PTSD, trauma exposure, physical illness, and somatization, and various systematic reviews have analyzed and described the extant research evidence. An early systematic review by Qureshi et al. (2009) found evidence for a consistent association between PTSD and arthritis, however, mixed results were observed for conditions such as diabetes, coronary heart disease, and stroke. In a more comprehensive systematic review of 62 studies, Pacella et al. (2013) reported a significant association between PTSD and overall poorer physical health outcomes. This encompassed general health symptoms, medical conditions, and health-related quality of life. Gupta’s (2013) review further emphasized the link between PTSD and diverse Prolonged Grief, Physical and Somatic Health: Review 2 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ medical conditions by highlighting the severity of PTSD symptoms to be significantly associated with an increased risk of physical conditions such as hypertension and coro­ nary heart disease. Sleep disturbances, such as sleep paralysis, were also prevalent in PTSD patients, suggesting a multifaceted impact on physical health. Afari et al.’s (2014) systematic review of 71 studies indicated that individuals with reported exposure to trau­ ma were more likely to have functional somatic syndromes, with PTSD also identified as a contributor to cardiovascular and immune-mediated disorders. Lastly, Ryder et al.’s (2018) meta-analysis underscored a robust association between PTSD and increased risks of cardiovascular, metabolic, and musculoskeletal disorders. Collectively, these studies emphasize the intricate connection between PTSD and various physical health outcomes. Poorer physical and somatic health status also appear to be associated with stressful life experiences such as bereavement. Parkes (1964) was among the first to show a signif­ icant correlation between bereavement and physical health in older adults by reporting a 65% increase in medical consultation rates among a sample of widows following bereavement. Large-sample cross-sectional research from Thimm et al. (2020) also dem­ onstrated that severe grief reactions in elderly individuals were significantly associated with self-reported physical health problems as well as an increased use of health services. Additionally, Sillis et al. (2022) and Toblin et al. (2012) have shown that this association was also present in samples of younger people by reporting significant associations between grief and somatic complaints among bereaved university students and infantry soldiers. Moreover, a systematic review by Ennis and Majid (2021) found a significant, positive relationship between bereavement and adverse physical and physiological health outcomes, including inflammation, cardiovascular risk, chronic pain, and mortality. A significant issue in the field of bereavement has been the lack of acknowledgment of enduring, distressing grief reactions as specific conditions related to grief. There has been a warranted reluctance to pathologize any form of grief, leading to inconsistencies in its definitions and measurement. As a result, depression was often diagnosed instead. However, the inclusion of Prolonged Grief Disorder (PGD) in the 11th Revision of the International Classification of Diseases (ICD-11: WHO, 2019) and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) (American Psychiatric Association, 2022) has facilitated a more standardized approach to the study of grief. On the other hand, the published peer-reviewed literature exploring PGD and physi­ cal health problems has also not been systematically examined since PGD was officially classified as a mental health disorder. To address this, we conducted a systematic review of the scientific literature to investigate the association between ICD-11 PGD, and out­ comes related to physical health and somatic complaints among bereaved individuals. By synthesizing existing research, this review aims to provide a clearer understanding of the impact of PGD on physical and somatic health, which could inform clinical practices, guide future research, and ultimately contribute to improved care for bereaved Cunningham, Shevlin, Cerda, & McElroy 3 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ individuals. This review represents the first comprehensive assessment of the evidence for associations between ICD-11 PGD, and physical and somatic health outcomes since PGD’s inclusion in the ICD-11. Method The protocol for this systematic review was preregistered at the PROSPERO repository (CRD42023471080) on 10/10/2023 (for access, see Cunningham et al., 2023S). To ensure transparency and completeness in the processing and reporting of the results, the PRIS­ MA 2020 guidelines (Page et al., 2021) were adhered to. Inclusion and Exclusion Criteria This systematic review incorporated any form of quantitative studies that met the fol­ lowing inclusion criteria: 1. The study reported original, empirical research published in peer-reviewed journals, that utilized quantitative and validated measures of Prolonged Grief Disorder (PGD) and physical or somatic illness. 2. Investigated the association between PGD symptoms from standardized assessment tools and physical and somatic health symptoms. 3. Included a report of quantitative measures of association or group difference such as correlations, odds ratio, t-test, etc. The exclusion criteria were: 1. Non-peer reviewed published research studies. 2. Research that did not employ a quantitative methodology. 3. Single-item quantitative scale measurement of PGD or physical or somatic illness. 4. Non-English language. 5. Studies prior to 2018. Search Strategy Four electronic databases Web of Science, MEDLINE, Cochrane Library, and PsycINFO up to the 10th of October 2023 were searched using full-text terms to identify studies reporting an association between PGD, and physical and somatic health symptoms. The search was limited to research studies published in the English language since 2018 that underwent peer review. Searches were conducted using Boolean operators of the following search terms: “prolonged grief disorder” OR “prolonged grief” OR “traumatic grief” AND “somatic symptoms” OR “physical illness”. Prolonged Grief, Physical and Somatic Health: Review 4 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ In addition, reference lists of selected studies were screened for any other relevant study. Reporting Guidelines This article was prepared in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (Page et al., 2021). Adherence to PRISMA standards ensures that the research was reported with transparency and rigor, providing a clear, comprehensive, and reproducible account of the systematic review process. Following these guidelines enhanced the quality and integrity of our research findings. Data Collection, Extraction and Quality Assessment After identifying studies that met the inclusion/exclusion criteria, the researchers re­ trieved the full-text articles. Two independent reviewers (J.C and C.C) assessed the articles for eligibility, and any disagreements were resolved by consensus. The reviewers were not blinded to the journals or authors of the studies. The researchers created a standardized data extraction sheet to gather information on publication details, study location, methodological features (such as sample size and study design), exposure and outcome measures, PGD type, and the scales used for physical and somatic health out­ comes (Supplementary Table 3). The evaluation then focused on the appropriateness of quality assessment tools to measure the level of bias in each study. The resultant tool was a modification of the two most relevant instruments. The Joanna Briggs Institute critical appraisal checklist for analytical cross-sectional studies (JBI) (Joanna Briggs Institute, 2017a) (Supplementary Table 1) was applied to cross-sectional studies, while the JBI criti­ cal appraisal checklist for cohort studies (Joanna Briggs Institute, 2017b) (Supplementary Table 2) was employed for longitudinal studies. The description of effect sizes were based on Cohen (1988) descriptions of mean difference (small d = 0.20, medium d = 0.50, and large d ≥ 0.80) and correlations (small r = .10, medium r = 0.30, and large r ≥ .50). Results Details of the search and selection of studies is presented in Figure 1. Out of the initial screening based on title and abstract, 418 articles were identified, 112 of which were du­ plicates, and once removed, 306 articles remained. There was a high degree of agreement between the two reviewers (24 and 25 articles) in selecting articles that met the inclusion criteria (kappa = .62, t = 10.90, p < .001). After full-text screening and discussion, a final set of 18 articles were selected to take forward to full review. Cunningham, Shevlin, Cerda, & McElroy 5 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ Figure 1 PRISMA Flow Diagram Showing the Process for Search and Selection of Studies Results of the reviewed studies are summarized in Table 1, covering information on asso­ ciations between PGD, and physical and somatic health outcomes, mode of bereavement, sample characteristics, study design, measures, main findings, and risk of bias. Prolonged Grief, Physical and Somatic Health: Review 6 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ Ta bl e 1 Su m m ar y of A ss oc ia tio ns B et w ee n PG D a nd P hy si ca l, So m at ic H ea lth O ut co m es St ud y M od e of be re av em en t (n at ur al , s ud de n/ un ex pe ct ed / sp ec if ic il ln es s) Ti m e si nc e be re av em en t Sa m pl e Si ze a nd C ha ra ct er is ti cs St ud y D es ig n (C ro ss -s ec ti on al /lo ng it ud in al ) Si ng le g ro up o r ca se -c on tr ol / co m pa ri so n M ea su re s of P G D a nd P hy si ca l a nd So m at ic H ea lt h M ai n fi nd in gs R is k of B ia s Lu nd or ff e t a l. (2 02 0) D en m ar k Lo ss o f a s po us e (N at ur al ) 2, 6 , a nd 1 1 m on th s po st -l os s N = 8 57 Fe m al e: 6 9. 8% M al e: 3 0. 2% M ea n ag e: 7 0. 30 Pr os pe ct iv e Lo ng itu di na l Si ng le g ro up 11 -m on th s po st lo ss T he 1 3- ite m P ro lo ng ed G ri ef -s ca le (P G -1 3; P ri ge rs on e t a l., 2 00 9) ; R ev is ed IC G -R (P ri ge rs on & Ja co bs , 2 00 1) ; T he S ho rt -F or m H ea lth S ur ve y (W ar e et al ., 19 96 ) Ph ys ic al h ea lth s ig ni fi ca nt ly p re di ct ed th e m od er at e- st ab le c la ss , E ST = -0 .0 41 , S E = 0. 01 6, p = .0 08 w hi ch a ls o in cl ud ed s ub st an tia l pr op or tio ns o f p ro ba bl e PG D c as es , a nd ap pr oa ch ed s ig ni fi ca nt ly a s a pr ed ic to r of th e pr ol on ge d gr ie f c la ss E ST = -0 .0 41 , S E = 0. 01 6 p = .0 52   Lo w K ill ik el ly e t a l. (2 02 0) C ro ss -N at io na l st ud y C hi na , S w itz er la nd an d th e U ni te d St at es Lo ss o f a lo ve d on e (N at ur al ) 6 to 3 6 m on th s N = 5 39 C hi ne se S pe ak in g: 32 5 G er m an s pe ak in g: 21 4 Fe m al e: 7 2. 4% M al e: 2 7. 6% M ea n ag e to ta l: 35 .3 9 C hi ne se s am pl e: 33 .1 4 G er m an s am pl e: 38 .7 1   C ro ss -s ec tio na l C om pa ri so n gr ou p In te rn at io na l I C D -1 1 Pr ol on ge d G ri ef D is or de r Sc al e (K ill ik el ly & M ae rc ke r, 20 17 ) T he S om at ic S ym pt om s ca le (G ie rk e t a l., 20 14 ) C or re la tio n co ef fi ci en ts b et w ee n PG D (I PG D S) an d so m at ic s ym pt om s (S SS -8 ) s ho w ed m od er at e- le ve l r el at io ns hi ps fo r ea ch o f t he th re e IP G D S sc al es fo r bo th s am pl es . C hi ne se Sp ea ki ng s am pl e: IP G D S 32 it em s & S SS -8 = .5 38 , I PG D S 13 it em s & S SS -8 = .4 80 , a nd IP G D S st an da rd w ith c ul tu ra l s up pl em en t & SS S- 8 = .5 40 . G er m an S pe ak in g sa m pl e: IP G D S 32 it em s & S SS -8 = .5 08 , I PG D S 13 it em s & SS S- 8 = .4 58 a nd IP G D S st an da rd w ith c ul tu ra l su pp le m en t & S SS -8 = .5 14 Lo w Vo ge l e t a l. (2 02 1) G er m an y Lo ss o f a lo ve d on e N at ur al a t l ea st 6 m on th s pr ev io us ly N = 2 0 Fe m al e: 8 0% M al e: 2 0% M ea n ag e: 5 6 Pr os pe ct iv e Lo ng itu di na l Si ng le g ro up 3 m on th PG -1 3 (P ri ge rs on e t a l., 2 00 9) T he S cr ee ni ng fo r So m at of or m D is or de rs (S O M S- 7D ; R ie f & H ill er , 2 00 3) T he re w er e no s ig ni fi ca nt d iff er en ce s be tw ee n th e PG D g ro up b ef or e an d af te r th e pe rs on - ce nt er ed th er ap y in te rv en tio n in r eg ar d to so m at of or m s ym pt om s (S O M S- 7D ) t 0- t1 d = 0. 07 , t 0- t2 d = 0 .2 9 p = .6 65   M od er at e M ill er e t a l. (2 02 0) U ni te d St at es Lo ss o f a lo ve d on e Ill ne ss : C an ce r 6 to 1 5 m on th s po st -l os s N = 1 98 Fe m al e: 6 1% M al e: 3 9% M ea n ag e: 6 4. 40 Pr os pe ct iv e Lo ng itu di na l Si ng le g ro up s tu dy : H ow ev er la te nt c la ss m ix tu re m od el in g is u se d to c ha ra ct er iz e ca re gi ve r he al th b y id en tif yi ng d is tin ct pr of ile s 15 m on th s po st lo ss PG -1 3 (P ri ge rs on e t a l., 2 00 9) O ve ra ll he al th w as a ss es se d w ith 3 se pa ra te m ea su re s: a s in gl e se lf- re po rt ite m , T he h ea lth s ub sc al e of C ar eg iv er Re ac tio n A ss es sm en t ( G iv en e t a l., 1 99 2) , an d T he M ee tin g Ph ys ic al D em an ds su bs ca le o f t he P er ce iv ed S el f- C ar e an d D ai ly L iv in g C om pe te nc ie s Sc al e (C as er ta et a l., 2 00 4; U tz e t a l., 2 01 2) . Tw o di st in ct h ea lth p ro fi le s w er e id en tif ie d in th e to ta l s am pl e. P oo re r H ea lth p ro fi le g ro up (n = 4 9; 2 5% ) h ad s ig ni fi ca nt ly g re at er h ea lth im pa ct fr om c ar eg iv in g d = 0. 85 (p < .0 00 1) , m or e se lf- re po rt ed h ea lth p ro bl em s d = 0. 53 (p = .0 02 ), an d gr ea te r di ff ic ul ty m ee tin g th e ph ys ic al d em an ds o f d ai ly li fe d = 1 .1 6 (p < .0 00 1) th an th e di st in ct p ro fi le (n = 1 49 ). Re gr es si on m od el s sh ow ed th at h av in g a po or er c ar eg iv er h ea lth p ro fi le w as a si gn if ic an t p re di ct or o f h ig he r le ve ls o f g ri ef sy m pt om s d = 4. 62 (p < .0 01 ) i n th e su bs am pl e of p ar tic ip an ts w ho w er e el ig ib le fo r th e be re av em en t a na ly se s (N = 8 1) .   M od er at e Cunningham, Shevlin, Cerda, & McElroy 7 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ St ud y M od e of be re av em en t (n at ur al , s ud de n/ un ex pe ct ed / sp ec if ic il ln es s) Ti m e si nc e be re av em en t Sa m pl e Si ze a nd C ha ra ct er is ti cs St ud y D es ig n (C ro ss -s ec ti on al /lo ng it ud in al ) Si ng le g ro up o r ca se -c on tr ol / co m pa ri so n M ea su re s of P G D a nd P hy si ca l a nd So m at ic H ea lt h M ai n fi nd in gs R is k of B ia s M ar cu ss en e t a l. (2 02 1) C ro ss -N at io na l st ud y D en m ar k, A us tr al ia a nd N or w ay Lo ss o f a p ar en t C an ce r, su dd en un ex pe ct ed , s ui ci de an d ch ro ni c di se as e do es n ot p ro vi de da ta o n th e tim e si nc e be re av em en t N = 19 0 Fe m al e: 9 1% M al e: 9 % M ea n ag e: 1 7. 90 C ro ss -s ec tio na l C om pa ri so n gr ou p T he P G -1 3 (P ri ge rs on e t a l., 2 00 9) T he C M D Q 3 6 (L u et a l., 2 00 8; T eb ek a et al ., 20 16 ). (B od ily d is tr es s sy nd ro m e su bs ca le ) Pr ol on ge d gr ie f a nd b od ily d is tr es s sy nd ro m e sh ow ed a w ea k co rr el at io n at .2 4. T he re w as a si gn if ic an t d iff er en ce b et w ee n th e di vo rc ed pa re nt al d ea th g ro up n = 5 2 co m pa re d to th e no n- di vo rc ed p ar en ta l d ea th g ro up n = 1 30 o n bo di ly d is tr es s sy nd ro m e d = 0. 37 5 p = .0 4. T he r is k of b od ily d is tr es s sy nd ro m e w as fo un d to b e si gn if ic an tly a ss oc ia te d w ith pa re nt al d iv or ce b ef or e pa re nt al d ea th B = 3. 53 , p = .0 09 .   M od er at e Le ng er e t a l. (2 02 0) D en m ar k Lo ss o f a p at ie nt ca re gi ve rs w ho ex pe ri en ce d th e de at h of p at ie nt s 6 m on th s af te r be re av em en t N = 2 ,1 25 Fe m al e: 7 0% M al e: 3 0% M ea n ag e: 6 2. 00 Pr os pe ct iv e Lo ng itu di na l Si ng le -g ro up H ow ev er , s am pl e sp lit in to w ith P G D a nd w ith ou t P G D 6 m on th s po st -l os s T he P G -1 3 (P ri ge rs on e t a l., 2 00 9) Sh or t F or m H ea lth S ur ve y- 36 (S F- 36 ) (W ar e, 1 99 9) Su bs ca le s: P hy si ca l f un ct io ni ng , r ol e- ph ys ic al b od ily p ai n, a nd g en er al h ea lth Po or p hy si ca l h ea lth s ta tu s du ri ng c ar eg iv in g pr ed ic te d pr ol on ge d gr ie f d is or de r: o dd s ra tio 1. 05 (9 5% C I [ 1. 04 , 1 .0 7] ). T he p hy si ca l su bs ca le s of p hy si ca l f un ct io ni ng o dd s ra tio 1. 02 , ( 95 % C I [ 1. 02 , 1 .0 3] ). Ro le p hy si ca l o dd s ra tio , 1 .0 2, (9 5% C I [ 1. 01 , 1 .0 2] ). Bo di ly p ai n od ds r at io 1 .0 3, (9 5% C I [ 1. 02 , 1 .0 3] ). an d ge ne ra l h ea lth o dd s ra tio 1 .0 4, (9 5% C I [ 1. 03 , 1. 04 ]) . a ll pr ed ic te d pr ol on ge d gr ie f d is or de r.   M od er at e Z ho u et a l. (2 02 0) C hi na Lo ss o f a n on ly ch ild V io le nt a nd n on - vi ol en t 6 m on th s af te r be re av em en t N = 1 ,0 30 Fe m al e: 6 2% M al e: 3 8% M ea n ag e: 5 9. 91 C ro ss -s ec tio na l Si ng le -g ro up T he P G -1 3 (P ri ge rs on e t a l., 2 00 9) T he p re se nc e of c hr on ic p hy si ca l d is ea se s w as a ss es se d th ro ug h a se ri es o f b in ar y qu es tio ns . ( Yi n et a l., 2 01 8) . C um ul at iv e Ill ne ss R at in g Sc al e (L in n et al ., 19 68 ) T he n um be r of c hr on ic p hy si ca l d is ea se s w as c al cu la te d an d co de d in to a s co re ra ng in g fr om z er o to s ix .   M or e co m or bi d ch ro ni c ph ys ic al d is ea se s w er e si gn if ic an tly r el at ed to th e in cr ea se d ri sk o f Pr ol on ge d gr ie f d is or de r t = 1 0. 25 , β = .3 3 (9 5% C I [ 1. 03 , 1 .5 1] ) Lo w Z ha ng e t a l. (2 02 0) C hi na Lo ss o f a n on ly ch ild D is ea se a nd ac ci de nt m ea nt im e po st -l os s 7. 6 ye ar s N = 1 49 Fe m al e: 6 0% M al e: 4 0% M ea n ag e: 6 2. 25 C ro ss -s ec tio na l C om pa ri so n st ud y T he P G -1 3 (P ri ge rs on e t a l., 2 00 9) In fo rm at io n ab ou t w he th er th e pa rt ic ip an ts h ad u nd er ly in g ch ro ni c di se as es w as r ec or de d. N um be r of o ut pa tie nt v is its fo r ph ys ic al he al th o r ot he r re as on s in th e pa st y ea r. It w as r an ke d in 4 le ve ls .   T he o ve ra ll m or bi di ty o f o st eo ar th ro si s in th e PG D -p os iti ve g ro up w as s ig ni fi ca nt ly h ig he r th an th at in th e PG D -n eg at iv e gr ou p (χ 2 = 7. 18 , p < .0 07 ). T he re w as n o si gn if ic an t di ff er en ce in th e nu m be r of h os pi ta l v is its be tw ee n th e tw o gr ou ps . Lo w Po hl ka m p et a l. (2 01 9) Sw ed en Lo ss o f a c hi ld C an ce r 1 to 5 y ea rs a ft er lo ss N = 2 25 Fe m al e: 5 9% M al e: 4 1% M ea n ag e: 4 6. 00 C ro ss -s ec tio na l Si ng le -g ro up s tu dy T he P G -1 3 (P ri ge rs on e t a l., 2 00 9) T he In so m ni a Se ve ri ty In de x (M or in , 19 93 ) In s ym pt om s of in so m ni a, th er e w as n o si gn if ic an t e ff ec t o f y ea rs s in ce lo ss , F 4 = 1 .1 2, .3 5 an d no d iff er en ce b et w ee n ge nd er s, F 1 = 1. 92 , . 17 . T he re w as n o si gn if ic an t i nt er ac tio n be tw ee n ye ar s si nc e lo ss a nd g en de r on in so m ni a F 4 = 1. 16 , . 33 .   M od er at e Prolonged Grief, Physical and Somatic Health: Review 8 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ St ud y M od e of be re av em en t (n at ur al , s ud de n/ un ex pe ct ed / sp ec if ic il ln es s) Ti m e si nc e be re av em en t Sa m pl e Si ze a nd C ha ra ct er is ti cs St ud y D es ig n (C ro ss -s ec ti on al /lo ng it ud in al ) Si ng le g ro up o r ca se -c on tr ol / co m pa ri so n M ea su re s of P G D a nd P hy si ca l a nd So m at ic H ea lt h M ai n fi nd in gs R is k of B ia s Sv ee n et a l. (2 02 0) Sw ed en Lo ss o f a s ig ni fi ca nt ot he r Tr au m at ic ev en t, in th e pa st 5 y ea rs N = 1 23 Fe m al e: 8 1% M al e: 1 9% M ea n ag e: 3 7. 85 Pr os pe ct iv e Lo ng itu di na l Su bs am pl es : c om pa ri so n gr ou p O ng oi ng lo ng itu di na l s tu dy (T RA C ES st ud y) T he P G -1 3 (P ri ge rs on e t a l., 2 00 9) T he S ym pt om C he ck lis t 2 7 (S C L- 27 ) (H ar dt e t a l., 2 00 4) PG -1 3 co rr el at io ns w ith th e so m at iz at io n su bs ca le w er e st ro ng er in th e be re av em en t gr ou p 0. 57 (p < .0 01 ) c om pa re d to th e co m pa ri so n gr ou p 0. 29 : Z v al ue = 1 .7 7. T he re w er e no s ig ni fi ca nt d iff er en ce s be tw ee n th e be re av em en t g ro up n = 7 2 an d th e co m pa ri so n gr ou p n = 51 o n So m at iz at io n, D = -0 .1 45 .   M od er at e de L an g et a l. (2 02 3) N et he rl an ds Lo ss o f a lo ve d on e, N at ur al a cc id en t an d su ic id e 1 m on th to m or e th an 5 ye ar s N = 3 43 Fe m al e: 8 8% M al e: 1 2% M ea n ag e: 5 4. 00 Pr os pe ct iv e Lo ng itu di na l Si ng le -g ro up 1 ye ar p os t- lo ss Tr au m at ic G ri ef In ve nt or y Se lf- Re po rt Pl us (T G I- SR ; L en fe ri nk e t a l., 2 02 2) . Ba se d on th e TG I- SR (B oe le n & S m id , 20 17 ) T he In so m ni a Se ve ri ty In de x (M or in , 19 93 ) C or re la tio ns b et w ee n pr ol on ge d gr ie f a nd in so m ni a sy m pt om s al l s ho w ed a m od er at e re la tio ns hi p be tw ee n th e tw o va ri ab le s ac ro ss th e th re e tim e po in ts a t 6 m on th in te rv al s. PG S at ti m e 1 di sp la ye d a w ea ke r co rr el at io n ov er ti m e ag ai ns t i ns om ni a sy m pt om s ov er tim e (T 1 .3 9) , ( T 2 .3 7) (T 3 .3 5) P G S at ti m e 2 eb be d an d flo w ed a s a co rr el at io n ov er ti m e ag ai ns t i ns om ni a sy m pt om s ov er tim e (T 1 .3 5) , (T 2 .4 7) (T 3 .4 2) P G S at ti m e 3 di sp la ye d a st ro ng er c or re la tio n ov er ti m e ag ai ns t in so m ni a sy m pt om s ov er ti m e (T 1 .3 6) , ( T 2 .4 4) (T 3 .4 9) . A ll co rr el at io ns a re s ig ni fi ca nt , p < .0 01 Pa rt ic ip an ts w ith h ig he r tr ai ts o f p ro lo ng ed gr ie f s ym pt om s al so r ep or te d hi gh er tr ai ts o f in so m ni a sy m pt om s b = .0 22 (p < .0 01 ). Fo r in so m ni a sy m pt om s, th er e w as a s ig ni fi ca nt au to re gr es si ve p at h (p = .0 11 ) a nd a c ro ss - la gg ed e ff ec t f ro m in so m ni a to p ro lo ng ed g ri ef sy m pt om s b = .0 23 (p = .0 28 ).   M od er at e H en ne m an n et a l. (2 02 3) C ro ss -N at io na l st ud y G er m an y, Sw itz er la nd a nd Ir el an d Lo ss o f a c lo se lo ve d on e na tu ra l, ac ci de nt , su ic id e, s ub st an ce ab us e, h om ic id e, an d na tu ra l d is as te r. N o sp ec if ic d ur at io n si nc e th e lo ss N = 1 ,3 37 Fe m al e: 7 6% M al e: 2 4% M ea n ag e: 2 3. 74 C ro ss -s ec tio na l Si ng le -g ro up In te rn at io na l I C D -1 1 Pr ol on ge d G ri ef D is or de r Sc al e (K ill ik el ly & M ae rc ke r, 20 17 ) So m at ic S ym pt om S ca le (G ie rk e t a l., 20 14 ) T he d ir ec t e ff ec t o f P G D o n so m at ic s ym pt om di st re ss r em ai ne d si gn if ic an t w he n in cl ud in g m ed ia to rs (c = 0 .0 3, p = .0 03 ), in di ca tin g a pa rt ia l m ed ia tio n of s om at ic s ym pt om di st re ss . 2 3% o f t he v ar ia nc e in e xp la in in g so m at ic s ym pt om d is tr es s w as e xp la in ed b y pr ol on ge d gr ie f d is or de r b = 0. 48 p = < .0 01 . Tw o- th ir ds o f i nd iv id ua ls w ith p os si bl e PG D re po rt ed h ig h or v er y hi gh le ve ls o f s om at ic sy m pt om d is tr es s in th e SS S- 8, w hi ch is re m ar ka bl y hi gh er th an p re va le nc es in th e ge ne ra l p op ul at io n N on -P G D M = 6 .8 8 PG D M  = 1 2. 91 p < .0 01 , d = 0 .9 0.   Lo w C ar ls so n et a l. (2 02 3) Sw ed en Lo ss o f f am ily m em be r ca rd ia c ar re st si x m on th s af te r lo ss N = 1 08 Fe m al e: 6 9% M al e: 3 1% M ea n ag e: 6 1. 50 C ro ss -s ec tio na l Si ng le -g ro up : H ow ev er , s ub sa m pl es o f Sp ou se s an d no n- sp ou se s w er e co nd uc te d 11 it em s of th e 13 -i te m P G -1 3 (P ri ge rs on et a l., 2 00 9) T he R A N D -3 6 m ea su re d he al th -r el at ed qu al ity o f l ife (H ay s & M or al es , 2 00 1) Sp ou se s re po rt ed m or e pr ob le m s w ith sy m pt om s of p ro lo ng ed g ri ef a nd s el f- re po rt ed he al th th an n on -s po us es (p < .0 01 ). N o si gn if ic an t d iff er en ce s w er e fo un d be tw ee n sp ou se s an d no n- sp ou se s in te rm s of sy m pt om s of p ro lo ng ed g ri ef a nd s el f- re po rt ed H ig h Cunningham, Shevlin, Cerda, & McElroy 9 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ St ud y M od e of be re av em en t (n at ur al , s ud de n/ un ex pe ct ed / sp ec if ic il ln es s) Ti m e si nc e be re av em en t Sa m pl e Si ze a nd C ha ra ct er is ti cs St ud y D es ig n (C ro ss -s ec ti on al /lo ng it ud in al ) Si ng le g ro up o r ca se -c on tr ol / co m pa ri so n M ea su re s of P G D a nd P hy si ca l a nd So m at ic H ea lt h M ai n fi nd in gs R is k of B ia s he al th . 2 5% o f f am ily m em be rs in th e pr es en t st ud y re po rt ed th ei r ge ne ra l h ea lth a s fa ir o r po or a nd th ei r he al th to b e w or se c om pa re d to a ye ar a go   Pa lit sk y et a l. (2 02 3) U ni te d St at es Lo ss o f c lo se re la tiv e N at ur al w ith in th e pa st y ea r N = 5 9 Fe m al e: 6 9% M al e: 3 1% M ea n ag e: 6 6 C ro ss -s ec tio na l Si ng le -g ro up T he P G -1 3 (P ri ge rs on e t a l., 2 00 9) G E D in am ap P ro 1 00 B P M on ito rs : Pr ov id ed m ea su re s of S BP S ys to lic b lo od pr es su re a nd D ia st ol ic b lo od p re ss ur e D BP In cr ea se s w er e ob se rv ed in S BP fr om b as el in e (m ea n [s ta nd ar d er ro r] , o r M [ SE ] = 12 4. 32 [1 5. 01 ] m m H g) to im m ed ia te ly p os t- G R (m ea n [s ta nd ar d de vi at io n] , M [ SD ] = 14 5. 43 [2 5. 17 ], p < .0 01 , 9 5% C I [ 16 .6 8, 2 5. 52 ]) . D BP al so in cr ea se d fr om b as el in e (M [ SD ] = 69 .0 5 [8 .4 7] ) t o im m ed ia te ly p os t- G R (M [ SD ] = 77 .1 5 [1 0. 67 ], p < .0 01 , 9 5% C I [ 5. 87 , 1 0. 34 ]) . Pr ol on ge d gr ie f d is or de r al so s ig ni fi ca nt ly pr ed ic te d SB P (B = 0 .4 47 , S E = 0. 21 5, p = .0 42 , 95 % C I [ 0. 02 4, 0 .8 71 ]) .   Lo w K ai se r et a l. (2 02 2) G er m an y Lo ss o f a lo ve d on e he m at ol og ic al ca nc er tim e si nc e lo ss n ot ou tli ne d N = 8 7 Fe m al e: 8 3% M al e: 1 7% M ea n ag e: 4 7. 32 In te rv en tio n G = 47 .8 0 W C G = 4 6. 84   Pr os pe ct iv e Lo ng itu di na l A r an do m iz ed c on tr ol le d tr ia l w ith a w ai tli st c on tr ol g ro up 1 ye ar p os t- lo ss T he G er m an v er si on o f t he IC G (P ri ge rs on e t a l., 1 99 5) 12 -i te m S ho rt -F or m H ea lth S ur ve y (B ul lin ge r, 19 95 ) N o si gn if ic an t g ro up in te ra ct io n w as fo un d fo r pr ol on ge d gr ie f a nd p hy si ca l h ea lth , s le ep qu al ity , o r so m at iz at io n. A s ig ni fi ca nt w ith in -g ro up e ff ec t o f t im e w as fo un d in th e IG a nd th e W C G fo r pr ol on ge d gr ie f a nd s om at iz at io n at p = .0 3 (W C G ) a nd p < .0 01 (I G ) D = -0 .0 1   Lo w C om te ss e et a l. (2 02 0) G er m an y Lo ss o f a c hi ld , pa rt ne r, pa re nt a nd ot he r. na tu ra l a nd u n- na tu ra l 6 m on th s po st -l os s N = 1 13 Fe m al e: 8 1% M al e: 1 9% M ea n ag e: 5 1. 68 Pr os pe ct iv e Lo ng itu di na l C om pa ri so n gr ou p T he P G -1 3 (P ri ge rs on e t a l., 2 00 9) T he S cr ee ni ng fo r So m at of or m D is or de rs (S O M S7 D ; R ie f & H ill er , 2 00 3) T he re w as n o si gn if ic an t d iff er en ce b et w ee n th e PG D /P G D e m p gr ou ps a nd n on -P G D / PG D e m p gr ou ps in s om at iz at io n t = 2 .1 6 D = 0. 64 3 an d t = 1 .6 2 D = 0 .3 9. T he p er si st en t co m pl ex b er ea ve m en t d is or de r gr ou p sh ow ed an a pp ro ac hi ng s ig ni fi ca nc e di ff er en ce r es ul t p = .0 55 c om pa re d to th e no n- PC BD g ro up D  = 0 .1 36   H ig h M ac ca llu m a nd Br ya nt (2 02 0) A us tr al ia Lo ss o f a p ar tn er , ch ild , p ar en t Si bl in g or o th er m ed ic al , a cc id en t, su ic id e an d H om ic id e, 6 m on th s af te r lo ss   N = 2 15 Fe m al e: 8 2% M al e: 1 8% M ea n ag e: 4 9. 24 C ro ss -s ec tio na l Si ng le -g ro up T he P G -1 3 (P ri ge rs on e t a l., 2 00 9) T he W H O Q O L- BR IE F (P ow er e t a l., 1 99 9) Re gu la ri ze d pa rt ia l c or re la tio n ne tw or k an al ys is s ho w ed a s ig ni fi ca nt n eg at iv e as so ci at io n be tw ee n pr ol on ge d gr ie f d is or de r an d ph ys ic al h ea lth E L = -0 .0 2 M od er at e Yı ld ır ım (2 02 3) Tu rk ey Lo ss o f f ir st -d eg re e re la tiv e C O V ID -1 9, na tu ra l a nd un na tu ra l d ea th s 12 -2 4 m on th s af te r lo ss N = 6 8 Fe m al e: 8 5% M al e: 1 5% M ea n ag e: 4 5. 35 PG D g ro up = 4 1. 90 N on P G D g ro up = 48 .8 0 C ro ss -s ec tio na l Si ng le -g ro up : h ow ev er , s ub gr ou ps o f P G D an d N O P G D w er e us ed T he P G -1 3 (P ri ge rs on e t a l., 2 00 9) In so m ni a Se ve ri ty In de x (M or in , 1 99 3) Po si tiv e co rr el at io ns b et w ee n PG D s ev er ity an d in so m ni a (r = 0 .5 01 ; p < 0 .0 1) T he re w as a s ig ni fi ca nt d iff er en ce b et w ee n th e PG D g ro up n = 3 0 an d th e N on P G D g ro up N = 3 8 in s ev er ity o f i ns om ni a t = 2 .6 3 p = .0 11 Lo w Prolonged Grief, Physical and Somatic Health: Review 10 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ Across the 18 studies eligible for examination, 13 (72%) demonstrated a significantly strong or moderate association between PGD and physical or somatic illness. This was displayed across divergent research designs, types of loss and different somatic and phys­ ical health problems. Cross-sectional and longitudinal designs were used in all studies. Using a cross-sectional design Killikelly et al. (2020) reported a moderate correlation between PGD (three IPGDS sub-scales) and somatic symptoms, and this is consistent with Hennemann et al. (2023) who reported that a significant proportion of variance (R 2 = 23%) in somatic related distress was attributed to PGD. In contrast, Maccallum and Bryant (2020) identified a negative association between prolonged grief and physical health. In prospective longitudinal studies, Comtesse et al. (2020) found no significant differences in somatization between individuals with PGD and those without it. In contrast, Sveen et al. (2020) highlighted stronger correlations between prolonged grief and somatization in bereavement. Vogel et al. (2021) showed no significant differences in somatoform symptoms pre and post-person-centered therapy, while Kaiser et al. (2022) found no significant group interaction but observed within-group effects over time. However, both intervention studies featured small sample sizes and a 4:1 ratio of females to males, impacting statistical power and generalizability. The types of loss reported in the studies included in this review were mostly losing a child, spouse/partner, or parent as well as the losses of patients and family members. Zhou et al. (2020) and Zhang et al. (2020) examined Chinese parents who had lost an only child and they reported associations between an increased risk of PGD and chronic physical diseases. Studies on spousal loss by Lundorff et al. (2020) and Carlsson et al. (2023) identified spousal grief symptoms as a predictor of physical health problems. Marcussen et al. (2021) found a strong correlation between prolonged grief and bodily distress syndrome in a sample who had experienced parental loss. Similarly, Lenger et al. (2020) and Miller et al. (2020) showed a significant association between prolonged grief symptoms and poorer physical health in a sample of bereaved caregivers. These findings suggest that the type of relationship with the deceased may influence the nature and severity of health outcomes associated with prolonged grief, with different relationships potentially leading to specific patterns of physical and somatic symptoms. There were specific health outcomes that were found to be associated with grief. Yıldırım (2023) and de Lang et al. (2023) both reported a significant association between grief severity and insomnia, although this was not replicated in the Pohlkamp et al. (2019) study. The diversity of outcome types that have been investigated is reflected in the study by Palitsky et al. (2023) who found a significant association between PGD and systolic and diastolic pressure. Supplementary Tables 1 and 2 show the comprehensive evaluation of bias risk for each study, conducted through the Joanna Briggs Institute critical appraisal checklist for analytical cross-sectional and cohort studies. This showed that 40% of cross-sectional studies exhibited moderate to high levels of bias, in contrast to the higher rate of 75% for Cunningham, Shevlin, Cerda, & McElroy 11 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ the longitudinal studies. Significant heterogeneity was also noted. The primary bias in cross-sectional studies stemmed from the lack of control over confounding variables. Few studies controlled for participant’s previous physical health status, which is significant since individuals experiencing loss tend to be older, and older individuals tend to have more physical health complaints (James et al., 2018; Wu et al., 2022). In contrast, incom­ plete follow-up in cohort studies contributed to the most common element of potential bias. Discussion This is the first systematic review of peer-reviewed published studies assessing the association between ICD-11 prolonged grief disorder (PGD) and outcomes related to physical and somatic health among bereaved individuals since PGD was included in the ICD-11. Among the 18 eligible studies, 13 (72%) reported moderate (Carlsson et al., 2023; de Lang et al., 2023; Killikelly et al., 2020; Lenger et al., 2020; Lundorff et al., 2020; Sveen et al., 2020) to strong associations (Hennemann et al., 2023; Marcussen et al., 2021; Miller et al., 2020; Palitsky et al., 2023; Yıldırım, 2023; Zhang et al., 2020; Zhou et al., 2020) between PGD and physical or somatic illness. There were a number of studies that reported non-significant associations, or failed to report p-values and were unclear in describing effect sizes (Comtesse et al., 2020; Kaiser et al., 2022; Maccallum & Bryant, 2020; Pohlkamp et al., 2019; Vogel et al., 2021). It appears that there is reliable scientific evidence, with a relatively low risk of bias, that the experience of prolonged grief is associated with poorer physical health and a higher risk of somatization. This prompts inquiry into the underlying mechanisms connecting these phenomena. Several theoretical frameworks, including attachment theory, the stress response syndrome, and the dual-process model, offer potential explanations for these observed associations. First, attachment theory (Bowlby, 1958, 2018) provides a conceptual basis for under­ standing the substantial and moderate associations observed between PGD and intimate types of loss. The loss of a child, especially for mothers, has been shown to produce higher rates of PGD compared to other close loved ones (Buur et al., 2024; Goldstein et al., 2019). Attachment theory helps explain these findings due to the intense emotional bonds between parents and children, making such losses especially devastating. More­ over, the significant associations in our review studies by (Zhang et al., 2020; Zhou et al., 2020), indicate an increased risk of PGD and chronic physical diseases among Chinese parents who had lost an only child. Attachment anxiety has also been shown to predict membership into PGD groups over depression and low-symptom groups, dem­ onstrating incremental predictive ability for both prolonged grief and somatic symptoms (Field et al., 2005; King & Werner, 2012; Maccallum & Bryant, 2018). In light of this, future research could employ quantitative measurement scales and tools for assessing attachment styles based on attachment theory. This could explore associations between Prolonged Grief, Physical and Somatic Health: Review 12 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ attachment types and physical and somatic health outcomes for individuals meeting ICD-11 PGD criteria. If an association between attachment styles and physical/somatic health outcomes were found to be consistent, such findings may help shape practices and policies, such as identifying profiles of attachment types that pose a high risk of physical/somatic health outcomes. Second, Horowitz’s (1986) stress response syndrome (SRS) offers a robust framework for understanding the significant associations between PGD, insomnia, and excessive blood pressure. The SRS delineates between psychological and physiological responses that individuals may undergo following traumatic or highly stressful events. This persis­ tent state of hypervigilance has the potential to magnify the grieving process and con­ tribute to mental health challenges, adversely impacting somatic and physical well-being (Joiner et al., 1999; Riemann et al., 2010). Regarding insomnia, the SRS would explain heightened emotional distress during nighttime, exacerbating the challenges of coping with complicated grief in solitude (Baker et al., 2016; Germain et al., 2005, 2006; Lancel et al., 2020). Furthermore, elevated blood pressure in prolonged grief sufferers may stem from persistent emotional distress and difficulties in adapting to loss, triggering complex stress responses (Mason & Duffy, 2019). In consideration of this evidence, future research could utilize biological markers and neuroimaging techniques to study hyperarousal in PGD, insomnia, and elevated blood pressure. Objective sleep monitoring (polysomnogra­ phy or actigraphy) could quantify disruptions in sleep architecture. Results may show correlations between hyperarousal markers and specific sleep parameters, supporting interventions such as cognitive-behavioral therapy for insomnia (CBT-I). Advocating for CBT-I inclusion in treatment plans and workplace policies accommodating insomnia due to prolonged grief could be significant. Identifying factors moderating prolonged grief and elevated blood pressure may also inform tailored interventions and prevention strategies. A broader perspective on the association between PGD and physical health may also be gained by examining how chronic stress and inflammation, which elucidate similar relationships in other mental disorders such as Post-Traumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDE), apply to PGD. Both PTSD and MDE are linked to prolonged activation of the stress response, leading to increased inflammation (Ehlert et al., 2001; Slavich & Irwin, 2014; Wichmann et al., 2017). This inflammatory process con­ tributes to various physical health issues, including cardiovascular disease and metabolic disorders (Black & Garbutt, 2002; Liu et al., 2017). Given that PGD involves sustained emotional distress, analogous stress-induced inflammatory pathways may also underlie the physical health problems observed in PGD. Moreover, PTSD and MDE are associated with somatic complaints such as chronic pain and gastrointestinal issues (Gupta, 2013; Thom et al., 2019), which may similarly manifest in PGD as physical symptoms due to intense grief and emotional turmoil. By exploring these parallels, researchers may Cunningham, Shevlin, Cerda, & McElroy 13 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ gain a deeper understanding of the mechanisms through which PGD impacts physical well-being, thus guiding future research and clinical practice. Lastly, the dual process model of coping with bereavement (Stroebe & Schut, 1999) offers a bidirectional insight into the significant associations between PGD and physi­ cal/somatic illness following unnatural loss through loss-oriented and restoration-orien­ ted stressors (Tur et al., 2022). Unnatural or traumatic loss poses unique challenges to the grieving process, triggering intense emotions such as shock, disbelief, and intrusive thoughts (Layne et al., 2018; Lobb et al., 2010; Walsh, 2007). These emotions fall under loss-oriented stressors, as they prompt individuals to face the reality of their abnormal loss. Simultaneously, coping with the aftermath of unnatural loss involves practical challenges, such as legal processes, funeral arrangements, and dealing with the societal aftermath. It is highly plausible that individuals experiencing unnatural loss may oscil­ late between addressing their emotional pain and engaging in such constructive tasks. For instance, someone grieving the sudden abnormal loss of a loved one in an accident may alternate between processing the emotional trauma and dealing with the adminis­ trative aspects, such as legal procedures or insurance matters. This consistent fluctuation may create cognitive dissonance (Festinger, 1957) in those experiencing unnatural loss which may elucidate the substantially significant associations observed between PGD and physical and somatic illness through abnormal loss circumstances. For example, Dickerson and Kemeny (2004) have shown how stressors that involve social-evaluative threats a key component of cognitive dissonance lead to significant increases in cortisol levels, which has been shown to suppress the immune system, making individuals more vulnerable to illness. In the context of PGD, the ongoing internal conflict and chronic stress may result in a sustained physiological response, thereby weakening immunity and increasing susceptibility to physical ailments. Additionally, cognitive dissonance has also been linked to an increased risk of cardiovascular disease. Linden et al. (2007) found that stress arising from conflicting emotions or behaviours which are key elements of cognitive dissonance significantly heightens the risk of hypertension and other cardio­ vascular problems. For individuals with PGD, the persistent cognitive dissonance they experience may intensify their stress, thereby increasing the likelihood of developing cardiovascular issues. Keeping this in consideration, future research could refine and adapt existing prolonged grief and coping scales to better align with the nuances of the dual process model. A dual-process model questionnaire could focus on addressing spe­ cific components of prolonged grief that contribute to cognitive dissonance and potential physical and somatic health complications. Policymakers could integrate such screening tools into routine health assessments, while employers and community organizations could offer more targeted support programs. The studies under review exhibited both strengths and limitations. They notably demonstrated consistency in measuring PGD, alongside showcasing geographical and cultural diversity, which enriched external and ecological validity. However, this cultural Prolonged Grief, Physical and Somatic Health: Review 14 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ diversity may explain the assorted findings found across the reviewed studies regarding the strength of the association between PGD and physical and somatic health outcomes. Future research could investigate this by examining how cultural factors influence this relationship, potentially through incorporating culturally sensitive measures in assess­ ments. The majority of studies also presented substantial sample sizes, often supported by reported power analyses. On the other hand, the bias risk evaluation revealed dif­ ferences in bias levels. Cross-sectional studies tended to have lower bias than longitudi­ nal studies. Moderate bias was noted in cross-sectional studies, while higher bias was observed in cohort studies. Both designs exhibited relatively low levels of high bias. Future studies, especially in cohort designs, can benefit from proactive strategies and experimental designs to mitigate bias and enhance generalizability. However, given the intrinsic difficulty in manipulating grief as an emotional state in experimental settings, researchers must approach this challenge with caution and creativity. Methodologically, it’s noteworthy that the majority of studies relied on self-reported measures that lacked control for confounding variables, while only 44% utilized longitudinal methodology, potentially impacting internal validity and result interpretability. Substantial heterogene­ ity was observed among the studies analyzed, with four distinct scales employed to evaluate physical health and five to measure somatic health outcomes. Moreover, three studies adopted alternative quantification methods, including the use of monitors, chron­ ic disease assessments, and outpatient visits. This disparity in measurement complicates direct result comparisons, as it’s unclear if differences stem from variable characteristics or scale usage. Developing universal physical and somatic health scales could address this, offering standardized measures across cultures. This would aid cross-cultural com­ parisons and deepen our understanding of physical and somatic health outcomes. The included studies also exhibited a fairly high mean age of 50 which may not capture the unique prolonged grief experiences of younger individuals who may have different coping mechanisms, support structures, and life contexts compared to older adults. In conclusion, this pioneering review on PGD’s association with physical and somat­ ic illness exhibited numerous strengths such as the consistent measurement of PGD, substantial sample sizes, and a high level of regional diversity. However, limitations included disparities in bias levels between transverse and cohort studies, heterogeneity in attaining the measurement of physical and somatic illness and the use of self-reported measures that lacked control for confounding variables. The reviewed results revealed a hierarchy of associations. Most studies demonstrated a significantly strong or moderate association between PGD and physical or somatic illness. Notable findings include PGD’s impact on caregiver health decline, somatic symptom distress, insomnia severity, and comorbid chronic diseases such as osteoarthrosis and elevated blood pressure. These results are consistent with PTSD findings and highlight the clinically relevant effect sizes both psychologically and medically. These findings may assist in the differential diagnosis of PGD by emphasizing the unique combination of psychological and physio­ Cunningham, Shevlin, Cerda, & McElroy 15 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ logical symptoms, which can help distinguish PGD from other disorders such as PTSD. Given the significant impact of PGD on physical health, it is important to consider these physiological symptoms more prominently in the diagnostic process to ensure comprehensive assessment and appropriate treatment. An important additional consideration is the impact of behavioural changes associ­ ated with PGD on overall health. PGD has been shown to cause behavioural changes that contribute to poor physical and mental health. For instance, individuals with complicated grief may engage in behaviours such as binge drinking, smoking, and a lack of physical activity (Stroebe et al., 2007). These behaviours can exacerbate chronic illness, which in turn impacts an individual's mental health and affects their ability to participate effectively in therapy (Lando, 2006). Understanding these interactions is crucial, as social withdrawal known as a common response in PGD (Szuhany et al., 2021) can lead to fur­ ther physical and mental health problems. A comprehensive approach to PGD treatment must consider these behavioural changes and their impact on overall health to enhance therapeutic outcomes and support holistic recovery. Future research avenues include integrating quantitative tools based on attachment theory for intimate losses in routine PGD screenings or employing biological markers and neuroimaging techniques to study hyperarousal in PGD, insomnia, and elevated blood pressure. Additionally, the dual process model of coping with bereavement could be utilized through a standardized questionnaire tailored to measure the framework, potentially predicting physical or somatic health issues among prolonged grief sufferers. However, future studies must prioritize methodological rigor, diverse participant sam­ ples, and ethical standards to ensure valid and applicable findings in clinical practice. Prolonged Grief, Physical and Somatic Health: Review 16 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://www.psychopen.eu/ Funding: The authors have no funding to report. Acknowledgments: The authors have no additional (i.e., non-financial) support to report. Competing Interests: The authors have declared that no competing interests exist. Ethics Statement: This article includes studies that involved human participants, all of which received appropriate ethical approval from their respective ethics committees. Ethical approval was not required for this review, as it involved the analysis of publicly available data. Social Media Accounts: @mark_shevlin_ Preregistration: The protocol for this systematic review was preregistered at the PROSPERO repository (CRD42023471080), and is available at https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=471080 Reporting Guidelines: This article was prepared following the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) (Page et al., 2021). Data Availability: All materials are freely available from the corresponding author on request. Supplementary Materials The Supplementary Materials contain the following items: • Preregistered PROSPERO Protocol (Cunningham et al., 2023S) • Online Appendices (Cunningham et al., 2025S): ◦ Appendix A: JBI Critical Appraisal Checklist for Analytical Cross-Sectional Studies. ◦ Appendix B: JBI Critical Appraisal Checklist for Cohort Studies. ◦ Appendix C: Standardized Data Extraction Sheet. ◦ Appendix D: Descriptions of the included studies. ◦ Appendix E: References from Systematic Review. Index of Supplementary Materials Cunningham, J., Shevlin, M., Cerda, C., & McElroy, E. (2023S). ICD-11 prolonged grief disorder, physical health and somatic problems: A systematic review [Preregistration]. PROSPERO. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=471080 Cunningham, J., Shevlin, M., Cerda, C., & McElroy, E. (2025S). Supplementary materials to "ICD-11 prolonged grief disorder, physical health, and somatic problems: A systematic review" [Online appendices]. PsychOpen GOLD. https://doi.org/10.23668/psycharchives.16037 Cunningham, Shevlin, Cerda, & McElroy 17 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://x.com/mark_shevlin_ https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=471080 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=471080 https://doi.org/10.23668/psycharchives.16037 https://www.psychopen.eu/ References Note. References marked with an asterisk (*) are the articles included in the systematic review. Afari, N., Ahumada, S. M., Wright, L. S., Mostoufi, S., Golnari, G., Reis, V., & Cuneo, J. G. (2014). Psychological trauma and functional somatic syndromes. Psychosomatic Medicine, 76(1), 2–11. https://doi.org/10.1097/PSY.0000000000000010 American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text revision). American Psychiatric Association Publishing. Baker, A. W., Keshaviah, A., Horenstein, A., Goetter, E. M., Mauro, C., Reynolds, C. F., Zisook, S., Shear, M. K., & Simon, N. M. (2016). The role of avoidance in complicated grief: A detailed examination of the Grief-Related Avoidance Questionnaire (GRAQ) in a large sample of individuals with complicated grief. Journal of Loss and Trauma, 21(6), 533–547. https://doi.org/10.1080/15325024.2016.1157412 Barbano, A. C., Van Der Mei, W. F., Bryant, R. A., Delahanty, D. L., deRoon‐Cassini, T., Matsuoka, Y., Olff, M., Qi, W., Ratanatharathorn, A., Schnyder, U., Seedat, S., Kessler, R. C., Koenen, K. C., & Shalev, A. Y. (2019). Clinical implications of the proposed ICD-11 PTSD diagnostic criteria. Psychological Medicine, 49(3), 483–490. https://doi.org/10.1017/S0033291718001101 Boelen, P. A., & Smid, G. E. (2017). The Traumatic Grief Inventory Self-Report Version (TGI-SR): Introduction and preliminary psychometric evaluation. Journal of Loss and Trauma, 22(3), 196– 212. https://doi.org/10.1080/15325024.2017.1284488 Bowlby, J. (1958). The nature of the child’s tie to his mother. The International Journal of Psycho- Analysis, 39, 350–373. Bowlby, J. (2018). The nature of the child’s tie to his mother. In A. C. Furman & S. T. Levy (Eds.), Influential papers from the 1950s (pp. 222–273). Routledge. Berg, S. K., Rasmussen, T. B., Thrysoee, L., Thorup, C. B., Borregaard, B., Christensen, A. V., Mols, R. E., Juel, K., & Ekholm, O. (2018). Mental health is a risk factor for poor outcomes in cardiac patients: Findings from the National Denheart survey. Journal of Psychosomatic Research, 112, 66–72. https://doi.org/10.1016/j.jpsychores.2018.07.002 Black, P. H., & Garbutt, L. D. (2002). Stress, inflammation and cardiovascular disease. Journal of Psychosomatic Research, 52(1), 1–23. https://doi.org/10.1016/S0022-3999(01)00302-6 Bullinger, M. (1995). German translation and psychometric testing of the SF-36 health survey: Preliminary results from the IQOLA project. Social Science & Medicine, 41(10), 1359–1366. https://doi.org/10.1016/0277-9536(95)00115-N Buur, C., Zachariae, R., Komischke-Konnerup, K., Marello, M. M., Schierff, L. H., & O’Connor, M. (2024). Risk factors for prolonged grief symptoms: A systematic review and meta-analysis. Clinical Psychology Review, 107, Article 102375. https://doi.org/10.1016/j.cpr.2023.102375 Carlehed, G., Katz, J., & Nordin, S. (2017). Somatic symptoms of anxiety and depression: A population-based study. Mental Health & Prevention, 6, 57–62. https://doi.org/10.1016/j.mhp.2017.03.005 Prolonged Grief, Physical and Somatic Health: Review 18 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://doi.org/10.1097/PSY.0000000000000010 https://doi.org/10.1080/15325024.2016.1157412 https://doi.org/10.1017/S0033291718001101 https://doi.org/10.1080/15325024.2017.1284488 https://doi.org/10.1016/j.jpsychores.2018.07.002 https://doi.org/10.1016/S0022-3999(01)00302-6 https://doi.org/10.1016/0277-9536(95)00115-N https://doi.org/10.1016/j.cpr.2023.102375 https://doi.org/10.1016/j.mhp.2017.03.005 https://www.psychopen.eu/ *Carlsson, N., Alvariza, A., Bremer, A., Axelsson, L., & Årestedt, K. (2023). Symptoms of prolonged grief and self-reported health among bereaved family members of persons who died from sudden cardiac arrest. OMEGA – Journal of Death and Dying, 87(1), 66–86. https://doi.org/10.1177/00302228211018115 Caserta, M. S., Lund, D. A., & Obray, S. J. (2004). Promoting self-care and daily living skills among older widows and widowers: Evidence from the Pathfinders Demonstration Project. OMEGA – Journal of Death and Dying, 49(3), 217–236. https://doi.org/10.2190/9BH0-N565-Y40G-QDN9 Chaddha, A., Robinson, E. A., Kline–Rogers, E., Alexandris-Souphis, T., & Rubenfire, M. (2016). Mental health and cardiovascular disease. The American Journal of Medicine, 129(11), 1145– 1148. https://doi.org/10.1016/j.amjmed.2016.05.018 Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Lawrence Erlbaum Associates. *Comtesse, H., Vogel, A., Kersting, A., Rief, W., Steil, R., & Rosner, R. (2020). When does grief become pathological? Evaluation of the ICD-11 diagnostic proposal for prolonged grief in a treatment-seeking sample. European Journal of Psychotraumatology, 11(1), Article 1694348. https://doi.org/10.1080/20008198.2019.1694348 Cosgrove, M. P., Sargeant, L. A., & Griffin, S. J. (2008). Does depression increase the risk of developing type 2 diabetes? Occupational Medicine, 58(1), 7–14. https://doi.org/10.1093/occmed/kqm105 *de Lang, T. A., Buyukcan‐Tetik, A., de Jong, P. J., Lancel, M., & Eisma, M. C. (2023). Cross-lagged analyses of prolonged grief and depression symptoms with insomnia symptoms. Behavior Therapy, 54(3), 510–523. https://doi.org/10.1016/j.beth.2022.12.004 Dhar, A. K., & Barton, D. A. (2016). Depression and the link with cardiovascular disease. Frontiers in Psychiatry, 7, Article 33. https://doi.org/10.3389/fpsyt.2016.00033 Dickerson, S. S., & Kemeny, M. E. (2004). Acute stressors and cortisol responses: A theoretical integration and synthesis of laboratory research. Psychological Bulletin, 130(3), 355–391. https://doi.org/10.1037/0033-2909.130.3.355 Ehlert, U., Gaab, J., & Heinrichs, M. (2001). Psychoneuroendocrinological contributions to the etiology of depression, posttraumatic stress disorder, and stress-related bodily disorders: The role of the hypothalamus–pituitary–adrenal axis. Biological Psychology, 57(1–3), 141–152. https://doi.org/10.1016/S0301-0511(01)00092-8 Elgaddal, N., Kramarow, E. A., & Reuben, C. A. (2022). Physical activity among adults aged 18 and over: United States, 2020. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Ennis, J., & Majid, U. (2021). “Death from a broken heart”: A systematic review of the relationship between spousal bereavement and physical and physiological health outcomes. Death Studies, 45(7), 538–551. https://doi.org/10.1080/07481187.2019.1661884 Festinger, L. (1957). A theory of cognitive dissonance. Stanford University Press. Cunningham, Shevlin, Cerda, & McElroy 19 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://doi.org/10.1177/00302228211018115 https://doi.org/10.2190/9BH0-N565-Y40G-QDN9 https://doi.org/10.1016/j.amjmed.2016.05.018 https://doi.org/10.1080/20008198.2019.1694348 https://doi.org/10.1093/occmed/kqm105 https://doi.org/10.1016/j.beth.2022.12.004 https://doi.org/10.3389/fpsyt.2016.00033 https://doi.org/10.1037/0033-2909.130.3.355 https://doi.org/10.1016/S0301-0511(01)00092-8 https://doi.org/10.1080/07481187.2019.1661884 https://www.psychopen.eu/ Field, N. P., Gao, B., & Paderna, L. (2005). Continuing bonds in bereavement: An attachment theory-based perspective. Death Studies, 29(4), 277–299. https://doi.org/10.1080/07481180590923689 Germain, A., Caroff, K., Buysse, D. J., & Shear, M. K. (2005). Sleep quality in complicated grief. Journal of Traumatic Stress, 18(4), 343–346. https://doi.org/10.1002/jts.20035 Germain, A., Shear, K., Monk, T. H., Houck, P. R., Reynolds, C. F., Frank, E., & Buysse, D. J. (2006). Treating complicated grief: Effects on sleep quality. Behavioral Sleep Medicine, 4(3), 152–163. https://doi.org/10.1207/s15402010bsm0403_2 Gierk, B., Kohlmann, S., Kroenke, K., Spangenberg, L., Zenger, M., Brähler, E., & Löwe, B. (2014). The Somatic Symptom Scale–8 (SSS-8). JAMA Internal Medicine, 174(3), 399–407. https://doi.org/10.1001/jamainternmed.2013.12179 Gili, M., Comas, A., García-García, M., Monzón, S., Serrano‐Blanco, A., & Roca, M. (2010). Comorbidity between common mental disorders and chronic somatic diseases in primary care patients. General Hospital Psychiatry, 32(3), 240–245. https://doi.org/10.1016/j.genhosppsych.2010.01.013 Given, C. W., Given, B., Stommel, M., Collins, C. E., King, S., & Franklin, S. (1992). The Caregiver Reaction Assessment (CRA) for caregivers to persons with chronic physical and mental impairments. Research in Nursing & Health, 15(4), 271–283. https://doi.org/10.1002/nur.4770150406 Goldstein, R. D., Petty, C. R., Morris, S. E., Human, M., Odendaal, H., Elliott, A., Tobacco, D., Angal, J., Brink, L., Kinney, H. C., & Prigerson, H. G. (2019). Pre-loss personal factors and prolonged grief disorder in bereaved mothers. Psychological Medicine, 49(14), 2370–2378. https://doi.org/10.1017/S0033291718003264 Gonzalez, J. S., Safren, S. A., Delahanty, L. M., Cagliero, E., Wexler, D. J., Meigs, J. B., & Grant, R. W. (2008). Symptoms of depression prospectively predict poorer self-care in patients with Type 2 diabetes. Diabetic Medicine, 25(9), 1102–1107. https://doi.org/10.1111/j.1464-5491.2008.02535.x Gupta, M. A. (2013). Review of somatic symptoms in post-traumatic stress disorder. International Review of Psychiatry, 25(1), 86–99. https://doi.org/10.3109/09540261.2012.736367 Hardt, J., Egle, U. T., Kappis, B., Hessel, A., & Brähler, E. (2004). Die Symptom-Checkliste SCL-27 [The Symptom Checklist SCL-27]. Psychotherapie, Psychosomatik, Medizinische Psychologie, 54(5), 214–223. https://doi.org/10.1055/s-2003-814786 Haug, T. T., Mykletun, A., & Dahl, A. A. (2004). The association between anxiety, depression, and somatic symptoms in a large population: The HUNT-II study. Psychosomatic Medicine, 66(6), 845–851. https://doi.org/10.1097/01.psy.0000145823.85658.0c Hays, R. D., & Morales, L. S. (2001). The RAND-36 measure of health-related quality of life. Annals of Medicine, 33(5), 350–357. https://doi.org/10.3109/07853890109002089 *Hennemann, S., Killikelly, C., Hyland, P., Maercker, A., & Witthöft, M. (2023). Somatic symptom distress and ICD-11 prolonged grief in a large intercultural sample. European Journal of Psychotraumatology, 14(2), Article 2254584. https://doi.org/10.1080/20008066.2023.2254584 Prolonged Grief, Physical and Somatic Health: Review 20 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://doi.org/10.1080/07481180590923689 https://doi.org/10.1002/jts.20035 https://doi.org/10.1207/s15402010bsm0403_2 https://doi.org/10.1001/jamainternmed.2013.12179 https://doi.org/10.1016/j.genhosppsych.2010.01.013 https://doi.org/10.1002/nur.4770150406 https://doi.org/10.1017/S0033291718003264 https://doi.org/10.1111/j.1464-5491.2008.02535.x https://doi.org/10.3109/09540261.2012.736367 https://doi.org/10.1055/s-2003-814786 https://doi.org/10.1097/01.psy.0000145823.85658.0c https://doi.org/10.3109/07853890109002089 https://doi.org/10.1080/20008066.2023.2254584 https://www.psychopen.eu/ Horowitz, M. J. (1986). Stress-response syndromes: A review of posttraumatic and adjustment disorders. Psychiatric Services, 37(3), 241–249. https://doi.org/10.1176/ps.37.3.241 James, S. L., Abate, D., Abate, K. H., Abay, S. M., Abbafati, C., Abbasi, N., Abbastabar, H., Abd‐Allah, F., Abdela, J., Abdelalim, A., Abdollahpour, I., Abdulkader, R. S., Abebe, Z., Abera, S. F., Abil, O. Z., Abraha, H. N., Abu-Raddad, L. J., Abu-Rmeileh, N. M. E., Accrombessi, M., . . . Murray, C. J. L. (2018). Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet, 392(10159), 1789–1858. https://doi.org/10.1016/S0140-6736(18)32279-7 Joanna Briggs Institute. (2017a). Checklist for analytical cross sectional studies. https://jbi.global/sites/default/files/2019-05/JBI_Critical_Appraisal- Checklist_for_Analytical_Cross_Sectional_Studies2017_0.pdf Joanna Briggs Institute. (2017b). Checklist for cohort studies. https://jbi.global/sites/default/files/2020-08/Checklist_for_Cohort_Studies.pdf Joiner, T. E., Jr., Steer, R. A., Beck, A. T., Schmidt, N. B., Rudd, M. D., & Catanzaro, S. J. (1999). Physiological hyperarousal: Construct validity of a central aspect of the tripartite model of depression and anxiety. Journal of Abnormal Psychology, 108(2), 290–298. https://doi.org/10.1037/0021-843X.108.2.290 *Kaiser, J., Nagl, M., Hoffmann, R., Linde, K., & Kersting, A. (2022). Therapist-assisted web-based intervention for prolonged grief disorder after cancer bereavement: Randomized controlled trial. JMIR Mental Health, 9(2), Article e27642. https://doi.org/10.2196/27642 Killikelly, C., & Maercker, A. (2017). Prolonged grief disorder for ICD-11: The primacy of clinical utility and international applicability. European Journal of Psychotraumatology, 8(Suppl 6), Article 1476441. https://doi.org/10.1080/20008198.2018.1476441 *Killikelly, C., Zhou, N., Merzhvynska, M., Stelzer, E.-M., Dotschung, T., Rohner, S., Sun, L. H., & Maercker, A. (2020). Development of the International Prolonged Grief Disorder Scale for the ICD-11: Measurement of core symptoms and culture items adapted for Chinese and German- speaking samples. Journal of Affective Disorders, 277, 568–576. https://doi.org/10.1016/j.jad.2020.08.057 King, L. C., & Werner, P. D. (2012). Attachment, social support, and responses following the death of a companion animal. OMEGA – Journal of Death and Dying, 64(2), 119–141. https://doi.org/10.2190/OM.64.2.b Kolappa, K., Henderson, D. C., & Kishore, S. P. (2013). No physical health without mental health: Lessons unlearned? Bulletin of the World Health Organization, 91(1), 3–3A. https://doi.org/10.2471/BLT.12.115063 Lancel, M., Stroebe, M., & Eisma, M. C. (2020). Sleep disturbances in bereavement: A systematic review. Sleep Medicine Reviews, 53, Article 101331. https://doi.org/10.1016/j.smrv.2020.101331 Lando, H. A. (2006). Reflections on 30+ years of smoking cessation research: From the individual to the world. Drug and Alcohol Review, 25(1), 5–14. https://doi.org/10.1080/09595230500459461 Cunningham, Shevlin, Cerda, & McElroy 21 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://doi.org/10.1176/ps.37.3.241 https://doi.org/10.1016/S0140-6736(18)32279-7 https://jbi.global/sites/default/files/2019-05/JBI_Critical_Appraisal-Checklist_for_Analytical_Cross_Sectional_Studies2017_0.pdf https://jbi.global/sites/default/files/2019-05/JBI_Critical_Appraisal-Checklist_for_Analytical_Cross_Sectional_Studies2017_0.pdf https://jbi.global/sites/default/files/2020-08/Checklist_for_Cohort_Studies.pdf https://doi.org/10.1037/0021-843X.108.2.290 https://doi.org/10.2196/27642 https://doi.org/10.1080/20008198.2018.1476441 https://doi.org/10.1016/j.jad.2020.08.057 https://doi.org/10.2190/OM.64.2.b https://doi.org/10.2471/BLT.12.115063 https://doi.org/10.1016/j.smrv.2020.101331 https://doi.org/10.1080/09595230500459461 https://www.psychopen.eu/ Layne, C. M., Kaplow, J. B., Oosterhoff, B., Hill, R. M., & Pynoos, R. S. (2018). The interplay between posttraumatic stress and grief reactions in traumatically bereaved adolescents: When trauma, bereavement, and adolescence converge. Adolescent Psychiatry, 7(4), 266–285. https://doi.org/10.2174/2210676608666180306162544 *Lenger, M. K., Neergaard, M. A., Guldin, M.-B., & Nielsen, M. K. (2020). Poor physical and mental health predicts prolonged grief disorder: A prospective, population-based cohort study on caregivers of patients at the end of life. Palliative Medicine, 34(10), 1416–1424. https://doi.org/10.1177/0269216320948007 Lenferink, L. I. M., Eisma, M. C., Smid, G. E., De Keijser, J., & Boelen, P. A. (2022). Valid measurement of DSM-5 persistent complex bereavement disorder and DSM-5-TR and ICD-11 prolonged grief disorder: The traumatic grief inventory-self report plus (TGI-SR+). Comprehensive Psychiatry, 112, Article 152281. https://doi.org/10.1016/j.comppsych.2021.152281 Lobb, E. A., Kristjanson, L. J., Aoun, S. M., Monterosso, L., Halkett, G. K. B., & Davies, A. (2010). Predictors of complicated grief: A systematic review of empirical studies. Death Studies, 34(8), 673–698. https://doi.org/10.1080/07481187.2010.496686 Linden, W., Phillips, M. J., & Leclerc, J. (2007). Psychological treatment of cardiac patients: A meta- analysis. European Heart Journal, 28(24), 2972–2984. https://doi.org/10.1093/eurheartj/ehm504 Linn, B. S., Linn, M. W., & Gurel, L. (1968). Cumulative Illness Rating Scale. Journal of the American Geriatrics Society, 16(5), 622–626. https://doi.org/10.1111/j.1532-5415.1968.tb02103.x Liu, Y.-Z., Wang, Y.-X., & Jiang, C.-L. (2017). Inflammation: The common pathway of stress-related diseases. Frontiers in Human Neuroscience, 11, Article 316. https://doi.org/10.3389/fnhum.2017.00316 Lu, W., Mueser, K. T., Rosenberg, S. D., & Jankowski, M. K. (2008). Correlates of adverse childhood experiences among adults with severe mood disorders. Psychiatric Services, 59(9), 1018–1026. https://doi.org/10.1176/ps.2008.59.9.1018 *Lundorff, M., Bonanno, G. A., Johannsen, M., & O’Connor, M. (2020). Are there gender differences in prolonged grief trajectories? A registry-sampled cohort study. Journal of Psychiatric Research, 129, 168–175. https://doi.org/10.1016/j.jpsychires.2020.06.030 Maccallum, F., & Bryant, R. A. (2018). Prolonged grief and attachment security: A latent class analysis. Psychiatry Research, 268, 297–302. https://doi.org/10.1016/j.psychres.2018.07.038 *Maccallum, F., & Bryant, R. A. (2020). A network approach to understanding quality of life impairments in prolonged grief disorder. Journal of Traumatic Stress, 33(1), 106–115. https://doi.org/10.1002/jts.22383 *Marcussen, J., Hounsgaard, L., O’Connor, M., Möller, S., Wilson, R., & Thuen, F. (2021). Parental death in young adults with divorced compared to non-divorced parents: The effect on prolonged grief and mental health. Death Studies, 45(6), 437–450. https://doi.org/10.1080/07481187.2019.1648337 Mason, T. M., & Duffy, A. (2019). Complicated grief and cortisol response: An integrative review of the literature. Journal of the American Psychiatric Nurses Association, 25(3), 181–188. https://doi.org/10.1177/1078390318807966 Prolonged Grief, Physical and Somatic Health: Review 22 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://doi.org/10.2174/2210676608666180306162544 https://doi.org/10.1177/0269216320948007 https://doi.org/10.1016/j.comppsych.2021.152281 https://doi.org/10.1080/07481187.2010.496686 https://doi.org/10.1093/eurheartj/ehm504 https://doi.org/10.1111/j.1532-5415.1968.tb02103.x https://doi.org/10.3389/fnhum.2017.00316 https://doi.org/10.1176/ps.2008.59.9.1018 https://doi.org/10.1016/j.jpsychires.2020.06.030 https://doi.org/10.1016/j.psychres.2018.07.038 https://doi.org/10.1002/jts.22383 https://doi.org/10.1080/07481187.2019.1648337 https://doi.org/10.1177/1078390318807966 https://www.psychopen.eu/ Massetti, G. M., Thomas, C. C., King, J., Ragan, K., & Lunsford, N. B. (2017). Mental health problems and cancer risk factors among young adults. American Journal of Preventive Medicine, 53(3, Suppl. 1), S30–S39. https://doi.org/10.1016/j.amepre.2017.04.023 Massie, M. J. (2004). Prevalence of depression in patients with cancer. Journal of the National Cancer Institute Monographs, 2004(32), 57–71. https://doi.org/10.1093/jncimonographs/lgh014 McFarlane, A. C. (2010). The long-term costs of traumatic stress: Intertwined physical and psychological consequences. World Psychiatry, 9(1), 3–10. https://doi.org/10.1002/j.2051-5545.2010.tb00254.x *Miller, L. M., Utz, R. L., Supiano, K., Lund, D. A., & Caserta, M. S. (2020). Health profiles of spouse caregivers: The role of active coping and the risk for developing prolonged grief symptoms. Social Science & Medicine, 266, Article 113455. https://doi.org/10.1016/j.socscimed.2020.113455 Morin, C. M. (1993). Insomnia Severity Index. PsycTESTS. https://doi.org/10.1037/t07115-000 Pacella, M. L., Hruska, B., & Delahanty, D. L. (2013). The physical health consequences of PTSD and PTSD symptoms: A meta-analytic review. Journal of Anxiety Disorders, 27(1), 33–46. https://doi.org/10.1016/j.janxdis.2012.08.004 Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T., Mulrow, C. D., Shamseer, L., Tetzlaff, J., Akl, E. A., Brennan, S., Chou, R., Glanville, J., Grimshaw, J., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E., Mayo‐Wilson, E., McDonald, S., . . . Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ (Clinical Research Ed.), 372, Article 71. https://doi.org/10.1136/bmj.n71 *Palitsky, R., Wilson, D., Friedman, S. E., Ruiz, J. M., Sullivan, D., & O’Connor, M.-F. (2023). The relationship of prolonged grief disorder symptoms with hemodynamic response to grief recall among bereaved adults. Psychosomatic Medicine, 85(6), 545–550. https://doi.org/10.1097/PSY.0000000000001223 Parkes, C. M. (1964). Effects of bereavement on physical and mental health—A study of the medical records of widows. British Medical Journal, 2(5404), 274–279. https://doi.org/10.1136/bmj.2.5404.274 *Pohlkamp, L., Kreicbergs, U., & Sveen, J. (2019). Bereaved mothers’ and fathers’ prolonged grief and psychological health 1 to 5 years after loss—A nationwide study. Psycho-Oncology, 28(7), 1530–1536. https://doi.org/10.1002/pon.5112 Power, M., Bullinger, M., & Harper, A. E. (1999). The World Health Organization WHOQOL-100: Tests of the universality of quality of life in 15 different cultural groups worldwide. Health Psychology, 18(5), 495–505. https://doi.org/10.1037/0278-6133.18.5.495 Prigerson, H. G., Horowitz, M. J., Jacobs, S., Parkes, C. M., Aslan, M., Goodkin, K., Raphael, B., Marwit, S. J., Wortman, C. B., Neimeyer, R. A., Bonanno, G. A., Block, S. D., Kissane, D. W., Boelen, P. A., Maercker, A., Litz, B. T., Johnson, J. G., First, M. B., & Maciejewski, P. K. (2009). Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Medicine, 6(8), Article e1000121. https://doi.org/10.1371/journal.pmed.1000121 Prigerson, H. O., & Jacobs, S. C. (2001). Traumatic grief as a distinct disorder: A rationale, consensus criteria, and a preliminary empirical test. In M. S. Stroebe, R. O. Hansson, W. Cunningham, Shevlin, Cerda, & McElroy 23 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://doi.org/10.1016/j.amepre.2017.04.023 https://doi.org/10.1093/jncimonographs/lgh014 https://doi.org/10.1002/j.2051-5545.2010.tb00254.x https://doi.org/10.1016/j.socscimed.2020.113455 https://doi.org/10.1037/t07115-000 https://doi.org/10.1016/j.janxdis.2012.08.004 https://doi.org/10.1136/bmj.n71 https://doi.org/10.1097/PSY.0000000000001223 https://doi.org/10.1136/bmj.2.5404.274 https://doi.org/10.1002/pon.5112 https://doi.org/10.1037/0278-6133.18.5.495 https://doi.org/10.1371/journal.pmed.1000121 https://www.psychopen.eu/ Stroebe, & H. Schut (Eds.), Handbook of bereavement research: Consequences, coping, and care (pp. 613–645). American Psychological Association. https://doi.org/10.1037/10436-026 Prigerson, H. G., Maciejewski, P. K., Reynolds, C. F., Bierhals, A. J., Newsom, J. T., Fasiczka, A. L., Frank, E., Doman, J., & Miller, M. W. (1995). Inventory of Complicated Grief: A scale to measure maladaptive symptoms of loss. Psychiatry Research, 59(1–2), 65–79. https://doi.org/10.1016/0165-1781(95)02757-2 Qureshi, S. U., Pyne, J. M., Magruder, K. M., Schulz, P. E., & Kunik, M. E. (2009). The link between post-traumatic stress disorder and physical comorbidities: A systematic review. The Psychiatric Quarterly, 80(2), 87–97. https://doi.org/10.1007/s11126-009-9096-4 Rief, W., & Hiller, W. (2003). A new approach to the assessment of the treatment effects of somatoform disorders. Psychosomatics, 44(6), 492–498. https://doi.org/10.1176/appi.psy.44.6.492 Riemann, D., Spiegelhalder, K., Feige, B., Voderholzer, U., Berger, T., Perlis, M. L., & Nissen, C. (2010). The hyperarousal model of insomnia: A review of the concept and its evidence. Sleep Medicine Reviews, 14(1), 19–31. https://doi.org/10.1016/j.smrv.2009.04.002 Ryder, A. L., Azcarate, P. M., & Cohen, B. E. (2018). PTSD and physical health. Current Psychiatry Reports, 20(12), Article 116. https://doi.org/10.1007/s11920-018-0977-9 Sillis, L., Claes, L., & Andriessen, K. (2022). Association between grief and somatic complaints in bereaved university and college students. International Journal of Environmental Research and Public Health, 19(19), Article 12108. https://doi.org/10.3390/ijerph191912108 Slavich, G. M., & Irwin, M. R. (2014). From stress to inflammation and major depressive disorder: A social signal transduction theory of depression. Psychological Bulletin, 140(3), 774–815. https://doi.org/10.1037/a0035302 Stroebe, M., & Schut, H. (1999). The dual process model of coping with bereavement: Rationale and description. Death Studies, 23(3), 197–224. https://doi.org/10.1080/074811899201046 Stroebe, M., Schut, H., & Stroebe, W. (2007). Health outcomes of bereavement. Lancet, 370(9603), 1960–1973. https://doi.org/10.1016/S0140-6736(07)61816-9 *Sveen, J., Bondjers, K., Heinsoo, J., & Arnberg, F. K. (2020). Psychometric evaluation of the Swedish version of the Prolonged Grief Disorder-13 (PG-13) in a bereaved mixed trauma sample. Frontiers in Psychiatry, 11, Article 541789. https://doi.org/10.3389/fpsyt.2020.541789 Szuhany, K. L., Malgaroli, M., Miron, C. D., & Simon, N. M. (2021). Prolonged grief disorder: Course, diagnosis, assessment, and treatment. Focus – American Psychiatric Publishing, 19(2), 161–172. https://doi.org/10.1176/appi.focus.20200052 Tebeka, S., Hoertel, N., Dubertret, C., & Le Strat, Y. (2016). Parental divorce or death during childhood and adolescence and its association with mental health. The Journal of Nervous and Mental Disease, 204(9), 678–685. https://doi.org/10.1097/NMD.0000000000000549 Thimm, J. C., Kristoffersen, A. E., & Ringberg, U. (2020). The prevalence of severe grief reactions after bereavement and their associations with mental health, physical health, and health service utilization: A population-based study. European Journal of Psychotraumatology, 11(1), Article 1844440. https://doi.org/10.1080/20008198.2020.1844440 Prolonged Grief, Physical and Somatic Health: Review 24 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://doi.org/10.1037/10436-026 https://doi.org/10.1016/0165-1781(95)02757-2 https://doi.org/10.1007/s11126-009-9096-4 https://doi.org/10.1176/appi.psy.44.6.492 https://doi.org/10.1016/j.smrv.2009.04.002 https://doi.org/10.1007/s11920-018-0977-9 https://doi.org/10.3390/ijerph191912108 https://doi.org/10.1037/a0035302 https://doi.org/10.1080/074811899201046 https://doi.org/10.1016/S0140-6736(07)61816-9 https://doi.org/10.3389/fpsyt.2020.541789 https://doi.org/10.1176/appi.focus.20200052 https://doi.org/10.1097/NMD.0000000000000549 https://doi.org/10.1080/20008198.2020.1844440 https://www.psychopen.eu/ Thom, R., Silbersweig, D. A., & Boland, R. J. (2019). Major depressive disorder in medical illness: A review of assessment, prevalence, and treatment options. Psychosomatic Medicine, 81(3), 246– 255. https://doi.org/10.1097/PSY.0000000000000678 Toblin, R. L., Riviere, L. A., Thomas, J. L., Adler, A. B., Kok, B. C., & Hoge, C. W. (2012). Grief and physical health outcomes in U.S. soldiers returning from combat. Journal of Affective Disorders, 136(3), 469–475. https://doi.org/10.1016/j.jad.2011.10.048 Tur, C., Campos, D., Suso‐Ribera, C., Kazlauskas, E., Castilla, D., Zaragozá, I., García‐Palacios, A., & Quero, S. (2022). An internet-delivered cognitive-behavioral therapy (iCBT) for prolonged grief disorder (PGD) in adults: A multiple-baseline single-case experimental design study. Internet Interventions, 29, Article 100558. https://doi.org/10.1016/j.invent.2022.100558 Utz, R. L., Caserta, M. S., & Lund, D. A. (2012). Grief, depressive symptoms, and physical health among recently bereaved spouses. The Gerontologist, 52(4), 460–471. https://doi.org/10.1093/geront/gnr110 *Vogel, A., Comteße, H., Nocon, A., Kersting, A., Rief, W., Steil, R., & Rosner, R. (2021). Feasibility of present-centered therapy for prolonged grief disorder: Results of a pilot study. Frontiers in Psychiatry, 12, Article 534664. https://doi.org/10.3389/fpsyt.2021.534664 Walsh, F. (2007). Traumatic loss and major disasters: Strengthening family and community resilience. Family Process, 46(2), 207–227. https://doi.org/10.1111/j.1545-5300.2007.00205.x Ware, J. E., Jr. (1999). SF-36 health survey. In M. E. Maruish (Ed.), The use of psychological testing for treatment planning and outcomes assessment (pp. 1227–1246). Lawrence Erlbaum Associates. Ware, J. E., Jr., Kosinski, M., & Keller, S. D. (1996). A 12-Item Short-Form health survey: Construction of scales and preliminary tests of reliability and validity. Medical Care, 34(3), 220– 233. https://doi.org/10.1097/00005650-199603000-00003 Wichmann, S., Kirschbaum, C., Böhme, C., & Petrowski, K. (2017). Cortisol stress response in post- traumatic stress disorder, panic disorder, and major depressive disorder patients. Psychoneuroendocrinology, 83, 135–141. https://doi.org/10.1016/j.psyneuen.2017.06.005 World Health Organization. (2019). International statistical classification of diseases and related health problems (11th ed.). https://icd.who.int/browse11/l-m/en Wu, Y., Tao, Z., Qiao, Y., Chai, Y., Liu, Q., Lu, Q., Zhou, H., Li, S., Mao, J., Jiang, M., & Pu, J. (2022). Prevalence and characteristics of somatic symptom disorder in the elderly in a community- based population: A large-scale cross-sectional study in China. BMC Psychiatry, 22(1), Article 257. https://doi.org/10.1186/s12888-022-03907-1 *Yıldırım, Y. E. (2023). Prevalence of prolonged grief disorder and related clinical factors among Turkish psychiatric outpatients during the COVID-19 pandemic. OMEGA – Journal of Death and Dying. Advance online publication. https://doi.org/10.1177/00302228231187296 Yin, Q., Shang, Z., Zhou, N., Wu, L., Liu, G., Yu, X., Zhang, H., Xue, H., & Liu, W. (2018). An investigation of physical and mental health consequences among Chinese parents who lost their only child. BMC Psychiatry, 18(1), Article 45. https://doi.org/10.1186/s12888-018-1621-2 *Zhang, H., Shang, Z., Wu, L., Sun, Z., Zhang, F., Sun, L., Zhou, Y., Wang, Y., & Liu, W. (2020). Prolonged grief disorder in Chinese Shidu parents who have lost their only child. European Cunningham, Shevlin, Cerda, & McElroy 25 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://doi.org/10.1097/PSY.0000000000000678 https://doi.org/10.1016/j.jad.2011.10.048 https://doi.org/10.1016/j.invent.2022.100558 https://doi.org/10.1093/geront/gnr110 https://doi.org/10.3389/fpsyt.2021.534664 https://doi.org/10.1111/j.1545-5300.2007.00205.x https://doi.org/10.1097/00005650-199603000-00003 https://doi.org/10.1016/j.psyneuen.2017.06.005 https://icd.who.int/browse11/l-m/en https://doi.org/10.1186/s12888-022-03907-1 https://doi.org/10.1177/00302228231187296 https://doi.org/10.1186/s12888-018-1621-2 https://www.psychopen.eu/ Journal of Psychotraumatology, 11(1), Article 1726071. https://doi.org/10.1080/20008198.2020.1726071 *Zhou, N., Wen, J., Stelzer, E.-M., Killikelly, C., Yu, W., Xu, X., Shi, G., Luo, H., Wang, J., & Maercker, A. (2020). Prevalence and associated factors of prolonged grief disorder in Chinese parents bereaved by losing their only child. Psychiatry Research, 284, Article 112766. https://doi.org/10.1016/j.psychres.2020.112766 Clinical Psychology in Europe (CPE) is the official journal of the European Association of Clinical Psychology and Psychological Treatment (EACLIPT). PsychOpen GOLD is a publishing service by Leibniz Institute for Psychology (ZPID), Germany. Prolonged Grief, Physical and Somatic Health: Review 26 Clinical Psychology in Europe 2025, Vol. 7(1), Article e14351 https://doi.org/10.32872/cpe.14351 https://doi.org/10.1080/20008198.2020.1726071 https://doi.org/10.1016/j.psychres.2020.112766 https://www.psychopen.eu/ Prolonged Grief, Physical and Somatic Health: Review (Introduction) Method Inclusion and Exclusion Criteria Search Strategy Reporting Guidelines Data Collection, Extraction and Quality Assessment Results Discussion (Additional Information) Funding Acknowledgments Competing Interests Ethics Statement Social Media Accounts Preregistration Reporting Guidelines Data Availability Supplementary Materials References