I appreciate Ms. Broitman's tact with Otto. He does seem as if he has a great deal of anger and anxiety built up in him, and that a slow approach is indicated early on (including ruling out D & A, etc.).
I might only add to Ms. Broitman's response that I would gently start trying to assess the cognitions associated with Otto's anger and severe anxiety: I would hope to work up to assessing what "having" to be in control means to Otto/what it says to him if he's not in control. (Does he think dichtomously - as I guess he does - that if he surrenders control in one instance that he's completely out of control?)
This is, of course, best done gently. To go too quickly with this (or any) tact with Otto could provoke too strong a level of emotion. This could be too much for somebody whose thoughts/beliefs dictate that he always be in control,
Otto also seems to need some behavioral techniques to help him deal with anger/stress/anxiety. If he's having physical manifestations (itching, sexual problems, etc.) of his emotions, he might benefit from some progressive relaxation, diaphragmatic breathing, etc. (My guess is that Otto would take to these techniques if they were framed as way of giving him more control.)