David Attias’ defense team began to lay out their case Monday with testimony from Matthew State, a psychiatrist who treated the defendant when he was 13.

State was in his residency at the UCLA adolescent in-patient ward during Attias’ treatment, from early December 1995 until Jan. 26, 1996.

Attias has pleaded not guilty by reason of insanity to the nine felony counts against him, including four counts of second degree murder, for the Feb. 23 2001 collision on Sabado Tarde Road that left four pedestrians dead and a fifth seriously injured.

Much of State’s testimony focused on general questions regarding mental illness, in particular psychotic breaks -which he defined as simply a break with reality – as well as Attias’ stay at the clinic. State said Attias’ month-long committal was considered long by psychiatric standards, and was a drastic step for such a young person.

State said Attias entered the clinic soon after an altercation with his sister, in which he tried to strangle her. He said the defendant was having trouble getting along with his parents, was apt to become angry quickly and was impulsive.

“David was a very difficult case for various reasons. He was difficult diagnostically – we were challenged to understand what was going wrong at the time. The second thing: They were a lovely family, David was a very nice boy struggling mightily against … very difficult issues,” he said. “He had a very serious problem with acting before he thought, he was impulsive. He would say something before he thought about it and then he would be remorseful.”

Attias left the clinic after a little over a month there, with a diagnosis of bipolar disorder not otherwise specified. State said Attias’ “laundry list” of syndromes led to the semi-vague diagnosis – which was given in order to allow for some sort of treatment and to alert future doctors of his past problems.

“If you had asked me to bet whether he would have bipolar, I wouldn’t have bet too much – but if you had asked me if he had strong psychiatric problems … I would have said I was worried that was the case,” he said.

State said it is difficult to diagnose children and adolescents because the brain is still developing and many disorders may change or develop as a person ages.

“Kids are moving pictures. … Many of the medications that work on adults don’t work on kids until they’re a certain age,” he said. “Often the beginning of an illness doesn’t look like what it’s going to look like down the line.”

Defense attorney Jack Earley also questioned the psychiatrist about the difficulty of evaluating a person’s mental state. The prosecution previously asked many of their witnesses if Attias appeared “crazy” around the time of the incident.

State said that even a psychiatrist would have trouble differentiating between a normal person and one having a psychotic break “unless they ask the right questions.”

“It’s not necessarily the case you can tell someone’s psychotic by looking at them,” he said

State also said it is important to differentiate between a mental exam, which Attias was given at Cottage Hospital after the collision, and a psychiatric exam. A mental exam, according to State, is mostly to check orientation: the patient is asked questions about the time and place.

On April 29, the registered nurse and emergency room physician who treated Attias on Feb. 23, testified for the prosecution that the defendant was orientated. Cynthia Watt, the nurse, said Attias “seemed to be acting like a normal patient.”

During cross examination, assistant district attorney Pat McKinley read comments from Attias’ UCLA chart in an attempt to convey the severity of the defendant’s anger. McKinley brought up a situation that happened immediately before Attias was committed to the psychiatric ward in which the defendant was accused of spreading sexual rumors about a 6th-grade girl at his school.

“The record says that the patient made homicidal statements. What does that mean?” McKinley said.

“He said he was going to kill [the girl’s] parents, said he was going to kill his parents, and I think at one point he said he was going to kill me,” State said. “I hope I didn’t give the impression in my previous testimony that David didn’t have problems striking out at people – he did. That’s why he was in the hospital.”

McKinley also asked State if a person suffering from a psychotic break still has the ability to make plans, including homicidal plans.

“There’s nothing that contradicts being psychotic and carrying out daily activities,” he said. “You retain your ability to plan … even if you’re psychotic.”