Table 1

Hierarchy of Defense Mechanisms–Adapted from Vaillant6

Level I (pathological)
  1. Delusional projection: delusions about external reality, usually of a persecutory type; includes the perception of one's own feelings in others and then acting on the perception

  2. Denial: denial of external reality

  3. Distortion: reshaping external reality to accommodate inner needs

Level II (immature)
  1. Projection: attributing one's own feelings to others

  2. Schizoid fantasy: tendency to use fantasy to resolve conflict; may be associated with global avoidance of interpersonal intimacy

  3. Hypochondriasis: transformation of reproach or aggressive impulses toward others into complaints of pain and somatic illness

  4. Passive-aggressive behavior: indirect expression of aggression toward others through passivity and masochism

  5. Acting out: direct expression of an unconscious impulse or wish in order to avoid awareness of affect that accompanies it

Level III (neurotic)
  1. Intellectualization: thinking about instinctual wishes in affectively bland terms, paying attention to irrelevant detail to avoid expression of inner feelings

  2. Repression: an unconscious process in which the expression and perception of instincts and feelings are prevented

  3. Displacement: redirection of feelings toward a less cared for person or situation than those arousing feelings

  4. Reaction formation: enacting behavior or exhibiting affect that opposes an impulse

  5. Dissociation: temporary, drastic modification of personal identity to avoid emotional distress

Level IV (mature)
  1. Altruism: vicarious gratification of impulses through service to others

  2. Humor: expression of feelings without personal discomfort and unpleasant effect on others

  3. Suppression: conscious diversion of attention from conflict

  4. Anticipation: goal-directed planning for future inner discomfort

  5. Sublimation: modification and direction of acknowledged impulses toward more appropriate activities