From Intrusion to Hallucination: An Integrative Psychological Model of Traumatic Memory Transformation in PTSD

Context and relevance. PTSD involves not only intrusions and flashbacks but also multimodal hallucinations, previously read as a manifestation of comorbid psychosis, which hindered the development of a unified model linking hallucinations to traumatic memory mechanisms. Objective. To formulate an integrative model of the intrusion-to-hallucination transition in PTSD and its specificity in combat trauma. Methods and Materials. A theoretical synthesis of research on traumatic memory and neuro-metacognitive correlates of perceptual decompensation. Results. A cascade model is proposed: the intrusion-to-hallucination pathway as phase transitions driven by traumatic memory disintegration, dissociation, metacognitive dysregulation, and dominance of traumatic priors over sensory input; combat trauma catalyzes multimodality via cumulative exposure and moral dissonance. Conclusions. Hallucinations are the peak of the re-experiencing continuum, transitioning into a discontinuum (a dissociative register). The cascade model integrates neurocognitive and psychological levels of analysis of hallucinatory experience and provides a phase-specific map of therapeutic targets.

1. Рубинштейн, С.Я. (2016). О рефлекторной природе галлюцинаций. В: Н.В. Зверева, И.Ф. Рощина (Ред.), Диагностика в медицинской (клинической) психологии: традиции и перспективы (к 105-летию С.Я. Рубинштейн) (с. 17—25). М.: Сам Полиграфист. (Впервые опубликовано в 1957 г.).
   Rubinstein, S.Ya. (2016). On the reflex nature of hallucinations. In: N.V. Zvereva, I.F. Roshchina (Eds.), Diagnostics in medical (clinical) psychology: Traditions and outlook (pp. 17—25). Moscow: Sam Poligrafist. (In Russ.). (Original work published 1957).
2. Сагалакова, О.А., Труевцев, Д.В., Жирнова, О.В., Сагалаков, А.М. (2024). Негативность, связанная с ошибкой: динамика нейрокогнитивного маркера чувствительности к несоответствию в решениях при психических расстройствах. Вестник Санкт-Петербургского университета. Психология, 14(3), 485—497. https://doi.org/10.21638/spbu16.2024.305
   Sagalakova, O.A., Truevtsev, D.V., Zhirnova, O.V., Sagalakov, A.M. (2024). Error-related negativity: Dynamics of the neurocognitive marker of sensitivity to mismatch in decisions in mental disorders. Vestnik of Saint Petersburg University. Psychology, 14(3), 485—497. (In Russ.). https://doi.org/10.21638/spbu16.2024.305
3. Сагалакова, О.А., Труевцев, Д.В. (2026). Мультимодальные образы и «голос» межличностной травмы: диссоциативно-когнитивные механизмы в динамике формирования галлюцинаций и суицидального риска. Неврологический вестник, 58(2), 154—168. https://doi.org/10.17816/nb696961
   Sagalakova, O.A., Truevtsev, D.V. (2026). Multimodal imagery and the «voice» of interpersonal trauma: Dissociative-cognitive mechanisms in the dynamics of hallucinations and suicide risk. Neurology Bulletin, 58(2), 154—168. (In Russ.). https://doi.org/10.17816/nb696961
4. Холмогорова, А.Б. (2015). Роль идей Л.С. Выготского для становления парадигмы социального познания в современной психологии: обзор зарубежных исследований и обсуждение перспектив. Культурно-историческая психология, 11(3), 25—43. https://doi.org/10.17759/chp.2015110304
   Kholmogorova, A.B. (2015). The role of L.S. Vygotsky's ideas in the development of the social cognition paradigm in contemporary psychology: A review of international research and discussion of prospects. Cultural-Historical Psychology, 11(3), 25—43. (In Russ.). https://doi.org/10.17759/chp.2015110304
5. Adams, R.A., Stephan, K.E., Brown, H.R., Frith, C.D., Friston, K.J. (2013). The computational anatomy of psychosis. Frontiers in Psychiatry, 4, Аrticle 47. https://doi.org/10.3389/fpsyt.2013.00047
6. Ben-Ezra, M., Bachem, R., Hamama-Raz, Y., Levin, Y. (2024). The relationship between specific auditory hallucinations and acute PTSD vs. complex PTSD following direct and indirect exposure to the October 7 events in Israel. Journal of Psychiatric Research, 179, 21—25. https://doi.org/10.1016/j.jpsychires.2024.08.039
7. Benight, C.C., Shoji, K., Delahanty, D.L. (2017). Self-Regulation Shift Theory: A dynamic systems approach to traumatic stress. Journal of Traumatic Stress, 30(4), 333—342. https://doi.org/10.1002/jts.22208
8. Bere, M., Rossell, S.L., Meyer, D., Nicholls, J.D., Halperin, S., Toh, W.L. (2026). Trauma and hallucinations across the sensory modalities: The importance of considering experiences in childhood and adulthood. Schizophrenia Research, 289, 71—78. https://doi.org/10.1016/j.schres.2026.01.009
9. Brewin, C.R. (2011). The nature and significance of memory disturbance in PTSD. Annual Review of Clinical Psychology, 7, 203—227. https://doi.org/10.1146/annurev-clinpsy-032210-104544
10. Cheung, C.T.Y., Huang, C.H.O., Geng, F., Chau, A.K.C., Yuan, G.F., Liu, C., Wong, J.Y., Fung, H.W. (2025). Auditory verbal hallucinations among intervention seekers with and without complex PTSD: Prevalence and relationship with dissociative symptoms. Journal of Psychiatric Research, 184, 405—410. https://doi.org/10.1016/j.jpsychires.2025.03.021
11. Cioroboiu, N., Whittingham, K., Dodgson, G., Fernyhough, C., Alderson-Day, B. (2025). Auditory verbal hallucinations: The ins and outs of subtypes. Psychiatry Research, 352, e116696. https://doi.org/10.1016/j.psychres.2025.116696
12. Collerton, D., Barnes, J., Diederich, N.J., Dudley, R., Ffytche, D., Friston, K., Goetz, C.G., Goldman, J.G., Jardri, R., Kulisevsky, J., Lewis, S.J.G., Nara, S., O'Callaghan, C., Onofrj, M., Pagonabarraga, J., Parr, T., Shine, J.M., Stebbins, G., Taylor, J.P., Tsuda, I., Weil, R.S. (2023). Understanding visual hallucinations: A new synthesis. Neuroscience & Biobehavioral Reviews, 150, e105208. https://doi.org/10.1016/j.neubiorev.2023.105208
13. Crompton, L., Lahav, Y., Solomon, Z. (2017). Auditory hallucinations and PTSD in ex-POWS. Journal of Trauma & Dissociation, 18(5), 663—678. https://doi.org/10.1080/15299732.2016.1267682
14. Dudley, R., White, S., Miskin, R., Oakes, L., Longden, E., Steel, C., Swan, S., Underwood, R., Peters, E. (2024). Hallucinations across sensory domains in people with post-traumatic stress disorder and psychosis. Psychiatry Research, 342, Аrticle 116229. https://doi.org/10.1016/j.psychres.2024.116229
15. Ehlers, A., Clark, D.M. (2000). A cognitive model of PTSD. Behaviour Research and Therapy, 38(4), 319—345. https://doi.org/10.1016/s0005-7967(99)00123-0
16. Evans, T.C., Rodriguez Alonso, M., Jagger-Rickels, A., Rothlein, D., Zuberer, A., Bernstein, J., Fortier, C.B., Fonda, J.R., Villalon, A., Jorge, R., Milberg, W., McGlinchey, R., DeGutis, J., Esterman, M. (2022). PTSD symptomatology is selectively associated with impaired sustained attention ability and dorsal attention network synchronization. NeuroImage: Clinical, 36, Аrticle 103146. https://doi.org/10.1016/j.nicl.2022.103146
17. Eysenck, M.W., Moser, J.S., Derakshan, N., Hepsomali, P., Allen, P. (2023). A neurocognitive account of attentional control theory: How does trait anxiety affect the brain’s attentional networks? Cognition and Emotion, 37(2), 220—237. https://doi.org/10.1080/02699931.2022.2159936
18. Fenster, R.J., Lebois, L.A.M., Ressler, K.J., Suh, J. (2018). Brain circuit dysfunction in post-traumatic stress disorder: From mouse to man. Nature Reviews Neuroscience, 19(9), 535—551. https://doi.org/10.1038/s41583-018-0039-7
19. Fernyhough, C. (2019). Modality-general and modality-specific processes in hallucinations. Psychological Medicine, 49(16), 2639—2645. https://doi.org/10.1017/S0033291719002496
20. Hayward, M., Bibby-Jones, A.M., Thomas, N., Paulik, G., Mutanda, D., Berry, C. (2024). Multi-modal hallucinations across diagnoses: What relationships do they have with voice-related distress? Schizophrenia Research, 265, 58—65. https://doi.org/10.1016/j.schres.2023.04.005
21. Hugdahl, K., Aleman, A. (2025). Role of prefrontal cortex in auditory-verbal hallucinations: Actor or passive bystander? Neuroscience & Biobehavioral Reviews, 176, Аrticle 106306. https://doi.org/10.1016/j.neubiorev.2025.106306
22. Lanius, R.A., Vermetten, E., Loewenstein, R.J., Brand, B., Schmahl, C., Bremner, J.D., Spiegel, D. (2010). Emotion modulation in PTSD: Clinical and neurobiological evidence for a dissociative subtype. American Journal of Psychiatry, 167(6), 640—647. https://doi.org/10.1176/appi.ajp.2009.09081168
23. Leptourgos, P., Bouttier, V., Denève, S., Jardri, R. (2022). From hallucinations to synaesthesia: A circular inference account of unimodal and multimodal erroneous percepts in clinical and drug-induced psychosis. Neuroscience & Biobehavioral Reviews, 135, Аrticle 104593. https://doi.org/10.1016/j.neubiorev.2022.104593
24. Li, L., Xu, Z., Chen, L., Suo, X., Fu, S., Wang, S., Lui, S., Huang, X., Li, L., Li, S.-J., Biswal, B.B., Gong, Q. (2021). Dysconnectivity of the amygdala and dorsal anterior cingulate cortex in drug-naive post-traumatic stress disorder. European Neuropsychopharmacology, 52, 84—93. https://doi.org/10.1016/j.euroneuro.2021.06.010
25. Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W.P., Silva, C., Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695—706. https://doi.org/10.1016/j.cpr.2009.07.003
26. Liu, J., Tan, C.M., Ho, J.C., Tang, C., Verma, S., Subramaniam, M. (2025). Dissociation as transdiagnostic mediator between trauma exposure and the post-traumatic stress disorder-psychosis symptom spectrum: A structural equation modelling meta-analysis. Journal of Affective Disorders, 381, 592—634. https://doi.org/10.1016/j.jad.2025.03.192
27. Longden, E., Madill, A. (2010). Why hearing voices is dissociative in origin, not psychotic in kind. Schizophrenia Research, 117(2—3), 185—186. https://doi.org/10.1016/j.schres.2010.02.234
28. Lyndon, S., Corlett, P.R. (2020). Hallucinations in posttraumatic stress disorder: Insights from predictive coding. Journal of Abnormal Psychology, 129(6), 534—543. https://doi.org/10.1037/abn0000531
29. McGovern, H.T., De Foe, A., Biddell, H., Leptourgos, P., Corlett, P., Bandara, K., Hutchinson, B.T. (2022). Learned uncertainty: The free energy principle in anxiety. Frontiers in Psychology, 13, Аrticle 943785. https://doi.org/10.3389/fpsyg.2022.943785
30. Montagnese, M., Leptourgos, P., Fernyhough, C., Waters, F., Larøi, F., Jardri, R., McCarthy-Jones, S., Thomas, N., Dudley, R., Taylor, J. P., Collerton, D., Urwyler, P. (2021). A review of multimodal hallucinations: Categorization, assessment, theoretical perspectives, and clinical recommendations. Schizophrenia Bulletin, 47(1), 237—248. https://doi.org/10.1093/schbul/sbaa101
31. Morrison, A.P., Frame, L., Larkin, W. (2003). Relationships between trauma and psychosis: A review and integration. British Journal of Clinical Psychology, 42(4), 331—353. https://doi.org/10.1348/014466503322528892
32. O'Connell, J., Lim, M.H., Kamitsis, I., Peters, W., Bendall, S. (2026). Hallucinations as sensory-perceptual intrusions from traumatic memory: Empirical investigation of a phenomenologically important subgroup. Psychological Trauma: Theory, Research, Practice, and Policy, 18(3), 485—496. https://doi.org/10.1037/tra0001902
33. Ostojic, D., Quilligan, F., Cannon, D.M., Madden, M.G., Donohoe, G., Morris, D.W. (2026). Machine learning identifies traumatic experiences as being associated with auditory verbal hallucinations in both a non-clinical population and individuals diagnosed with psychosis. Psychiatry Research, 356, Аrticle 116854. https://doi.org/10.1016/j.psychres.2025.116854
34. Perona-Garcelán, S., Bellido-Zanin, G., Rodríguez-Testal, J.F., López-Jiménez, A.M., García-Montes, J.M., Ruiz-Veguilla, M. (2016). The relationship of depersonalization and absorption to hallucinations in psychotic and non-clinical participants. Psychiatry Research, 244, 357—362. https://doi.org/10.1016/j.psychres.2016.08.015
35. Pierce, Z.P., Black, J.M. (2024). The hierarchical predictive coding framework of post-traumatic stress disorder. Medical Hypotheses, 188, Аrticle 111365. https://doi.org/10.1016/j.mehy.2024.111365
36. Toh, W.L., Richards, S., Fernyhough, C., Longden, E., Moseley, P., Ramachandran, P., Thomas, N., Rossell, S.L. (2025). Hearing voices and other altered perceptual experiences across psychotic, mood, and anxiety disorders: From phenomenology and mechanisms to future directions. Schizophrenia, 11(1), Аrticle 121. https://doi.org/10.1038/s41537-025-00673-3
37. Wells, A. (2019). Breaking the cybernetic code: Understanding and treating the human metacognitive control system to enhance mental health. Frontiers in Psychology, 10, Article 2621. https://doi.org/10.3389/fpsyg.2019.02621