It is an honor to have someone of your stature join the BOL system. As you may realize if you read the "conversation" between Gil Levin (director/publisher of BOL)and me in another part of this system, I represent a realm of psychiatry quite foreign to your world of digital data. One of the reasons we have decided to start this round of case conferences is that there are lots of ways to approach a patient, and those who are interested in learning new systems of thought can get a great deal from watching the evolution of a case in the hands of someone who thinks differently.
In the case of Otto Freund, I am far less interested in diagnosis than in the actions taken to reduce his discomfort and perhaps move him a bit further on the curve of his emotional growth. Many details have been left out simply because there is a limit to the space we want taken up on the system, and there is a limit to the patience of the ordinary browser. Nevertheless, since you find such information of importance, I am happy to report that Otto was hospitalized because he seemed increasingly afraid that the other man was going to come after him and kill him, and that only a fight to the death might resolve the impasse between them. There was no evidence to support his belief that he was in mortal danger; he seemed increasingly afraid to live in his own apartment because of the imminence of mortal combat; medication seemed only to make him more frightened (as if he would be in greater danger were he to lose the fear he thought so reasonable). Remember, too, this took place in 1989, when hospitalization was far less difficult and indeed sanctioned quite easily by the then-normal insurers.
I understand the group of adjustment reactions to include situations in which the stressor is within certain limits of danger (as opposed to the stressors responsible for Acute Stress Disorder and Post Traumatic Stress Disorder)and the intensity of the affect triggered proportional to the stressor. His reaction seemed far out of proportion to the insult, and seemed to be getting worse and worse every day; he asked to be placed in the hospital because he was afraid he was "going crazy." Since I have only found it necessary to hospitalize 11 patients or so in the 30 years I've been in practice, I do not act as the primary hospital phycisican in these rare situations. The diagnosis I cited was that of the staff psychiatrist at The Institute of Pennsylvania Hospital who took care of the patient, and who presented this unusual patient to a staff conference where the official diagnosis was declared.
I place very little importance on diagnosis, preferring to look at the specific affects that have brought a patient to my attention and attempting to decide whether these affects are matters of hardware, firmware, or software; treatment is predicated on my assessment of these factors. Additionally, I am concerned about the number of clinicians who treat people as if they were only part of a statistical cohort and predicate their treatments on that statistical analysis. I teach clinicians to identify the specific affects involved at the time we see the patient, to look for the cause of that affect, to determine the reasons that affect was so intense as to require a visit to a psychotherapist, and to figure out the "scripts" involved in the clinical situation.
You might be interested in reading the first section of my book "Shame and Pride: Affect, Sex, and the Birth of the Self" for a more extensive description of the affect theory of Silvan Tomkins and the way I have attempted to bring it into modern psychopharmacology and psychotherapy. Seems only fair---I've read a great deal of your work over the years. There are lots of ways to think about patients, lots of ways to help people, and lots of new ideas just now gaining momentum in our field. I look forward to your comments after you learn a bit more about the discipline I represent.