The manifest psychiatric symptoms of refugees may be mediated by their dominant defense mechanism. In conclusion, the psychiatric symptoms of North Korean refugees were associated with specific defense mechanism. Although our cross-sectional study design could not confirm the causal relationship between trauma, defenses, and psychiatric symptoms, our study suggests the moderating role of defenses in the development of psychiatric illnesses by refugees who have experienced various traumatic and stressful events and in the type of psychiatric illnesses that are developed by this population.