Multimodal imagery and the “voice” of interpersonal trauma: dissociative-cognitive mechanisms in the dynamics of hallucinations and suicide risk

Background: Despite the established link between interpersonal violence and hallucinatory experiences, the psychological mechanisms that transform traumatic memory into perceptual disturbances remain understudied. Empirical models explaining the transition from intrusions to multimodal hallucinations and their association with suicide risk outside the psychotic spectrum are lacking.

Aim: To empirically verify a cascade model in which both hallucination formation and suicidal behavior result from a sequential chain: trauma → dissociation → thought suppression.

Methods: This observational cross-sectional study included 103 participants divided into two groups: those with documented interpersonal violence exposure (n = 23) and a comparison group (n = 80). Measures included the Peritraumatic Dissociative Experiences Questionnaire (PDEQ), the Launay-Slade Hallucination Scale (LSHS), the White Bear Suppression Inventory (WBSI), a custom suicide risk questionnaire, and scales assessing social emotions and the phenomenology of “voices.” Data were analyzed using the Mann-Whitney U test and mediation modeling (PROCESS macro) with bootstrapping (10,000 samples).

Results: Interpersonal violence trauma does not directly affect hallucination frequency (U = 575.5, p = 0.033 for daydreaming proneness only) but transforms hallucinations into a multimodal affective complex characterized by distorted dialogicality (short commands, accusations) that conveys alienated affect. The trauma-exposed group showed higher dissociation (U = 505.0, p = 0.007) and active suicidal behavior (U = 562.5, p = 0.022). The dissociative-cognitive cascade model was confirmed, accounting for 48.3% of the variance in hallucinatory experience (F(3,99) = 30.82, p 0.001, R² = 0.483). Three pathways “from intrusions to hallucinations” were identified: a “dual” pathway (dissociation and suppression) for perceptual-dialogic hallucinations; a “cognitive” pathway (primarily suppression) for imaginal-sensory phenomena; and a “somatic” pathway (dissociation) for bodily experiences. Dissociation was a key mediator of the trauma–suicidal behavior link (indirect effects: b = 0.604, 95% CI [0.153, 1.121] for non-suicidal self-injury; b = 0.525, 95% CI [0.128, 0.980] for anti-vital experiences; b = 0.651, 95% CI [0.180, 1.197] for active suicidal behavior), whereas hallucinatory experience mediated the effect of shame on self-aggression (internal shame: b = 0.113, 95% CI [0.008, 0.240], R² = 0.382; external shame: b = 0.146, 95% CI [0.027, 0.279], R² = 0.345).

Conclusion: Hallucinations in interpersonal trauma are a dynamic product of dissociative detachment and dysfunctional metacognitive strategies. Therapeutic targets should include shame processing, restoration of dialogicality, and integration of fragmented multimodal experience.