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Denial is shown to be a constant element of all types of mechanisms of defense and not only an isolated defense mechanism. It functions in the hallucinatory gratifications of the newborn baby, in isolation, projection, introjection, identification with the aggressor, reaction-formation, etc. Chiefly, denial plays a role in physiological processes, such as sleep. Sleep is not only a protection against physical and mental fatigue but is also a defense against specific situations, internal or external, which become unpleasurable. One example is wanting to go to sleep 'out of boredom', which involves deeper anxieties connected with hostility. The author sees sleep not as a passive phenomenon but eminently active, depending frequently on conscious factors which permit the withdrawal of interest and libido from the external world and thereby regression to narcissism. Fainting is an extreme form of the same process of denial. Dreams can thus be a vehicle through which denial operates.
Denial also plays a role in psychotic processes, differing in the various clinical syndromes. Consideration must be given to the content and the effects on the ego of the psychotic as distinct from neurotic denial. Normally, by way of denial we can eliminate external stimuli and thereby concentrate on the task at hand. Accordingly, the author postulates a normal and a pathological form of denial. The working of denial is related essentially to how much it is in the service of the death instinct. At the beginning of life, and later in psychotics, denial is linked for the most part to the death instinct. In the infant it may be in the service of libidinal impulses, aiding the weak ego so that it will not be overwhelmed by all types of anxieties. In the higher stages of development, when the ego is much better integrated, denial as a rule depends on libidinal factors.