From trigger to response: an ecological momentary study of intrusive memory sequences in PTSD and complex PTSD

Background: Intrusive trauma memories are a hallmark symptom of post-traumatic stress disorder (PTSD) and contribute substantially to its persistence. However, the sequential unfolding of intrusions, from pre-intrusion states to post-intrusion responses, remains insufficiently understood.Method: In a pre-registered Ecological Momentary Assessment study, we examined 553 intrusions reported by 51 individuals diagnosed with PTSD or complex PTSD (cPTSD), capturing key features of the intrusion sequence, including content, modality, triggers, and responses.Results: Results showed high within-person variability across intrusion features, underscoring the dynamic and context-sensitive nature of intrusions and the fluctuating regulatory demands imposed on patients in daily life. Further, emotions demonstrated a pivotal role in the intrusion sequence, functioning as trigger, sensory modality or response. Multilevel analyses revealed that anger prior to an intrusion predicted greater subsequent distress (B = 0.11, p = .041) and heightened perceived loss of control (B = 0.20, p = .001). PTSD and cPTSD subgroups did not differ in terms of trigger types, modalities, or response patterns.Discussion: Together, these findings highlight the real-world burden of intrusive memories and the central role of emotions, such as anger, in intrusion-related distress. This emphasizes the need for interventions targeting not only intrusions themselves, but also their emotional and physiological precursors and consequences, through strategies that promote adaptive regulation in both PTSD and cPTSD.