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In the proposed hierarchy by Vaillant, there are four levels of adaptivity namely psychotic, immature, neurotic and mature. Psychotic defenses are characterized by their extreme degree of distorting reality wherein patients may need to take in psychotic medications to alter such defenses. Psychotic defenses include psychotic denial, delusional projection and schizoid fantasy. Immature defenses may be irritating and are often observed in patients with personality disorders. The immature defenses include the following: splitting, idealization, devaluation, projection, projective identification, acting-out, passive aggression and intermediate denial. Neurotic defenses are privately experienced or less interpersonal which often involve mental inhibitions. The list of neurotic defenses includes repression, control, displacement, reaction formation, intellectualization, rationalization, isolation of affect, and undoing. Mature defenses when observed in patients are appreciated by health care providers; it enables the individual to express himself/herself without negative consequences. Mature defenses include suppression, altruism, humor, sublimation, and anticipation. Each kind of defense has its own unique qualities that distinguish them from each other. For the psychiatrists or nurses to detect what defense mechanisms the patients are using they need to interact with their patients and observe keenly so that they may employ the appropriate interventions needed.