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Valdez v. Astrue

October 25, 2010


The opinion of the court was delivered by: Andrew J. Wistrich United States Magistrate Judge


Plaintiff filed this action seeking reversal of the decision of defendant, the Commissioner of the Social Security Administration (the "Commissioner"), denying plaintiff's application for supplemental security income ("SSI") benefits. The parties have filed a Joint Stipulation ("JS") setting forth their contentions with respect to each disputed issue.

Administrative Proceedings

Plaintiff filed an SSI benefits application on January 24, 2007. He alleged that he had been disabled since August 1, 2004 due to high blood pressure, tiredness, depression, and swollen legs. [JS 2; Administrative Record ("AR") 76-82, 89-93]. In a written hearing decision that constitutes the Commissioner's final decision in this matter, an administrative law judge ("ALJ") concluded that plaintiff was not disabled. [AR 9-16]. The ALJ found that plaintiff had a severe cardiovascular system impairment from morbid obesity, but that he retained the residual functional capacity ("RFC") to perform a range of sedentary work. [AR 13]. The ALJ concluded that plaintiff was not disabled because his RFC did not preclude him from performing work available in significant numbers in the national economy. [AR 13-15].

Standard of Review

The Commissioner's denial of benefits should be disturbed only if it is not supported by substantial evidence or is based on legal error. Stout v. Comm'r, Social Sec. Admin., 454 F.3d 1050, 1054 (9th Cir. 2006); Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002). "Substantial evidence" means "more than a mere scintilla, but less than a preponderance." Bayliss v. Barnhart, 427 F.3d 1211, 1214 n.1 (9th Cir. 2005). "It is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005)(internal quotation marks omitted). The court is required to review the record as a whole and to consider evidence detracting from the decision as well as evidence supporting the decision. Robbins v. Social Sec. Admin, 466 F.3d 880, 882 (9th Cir. 2006); Verduzco v. Apfel, 188 F.3d 1087, 1089 (9th Cir. 1999). "Where the evidence is susceptible to more than one rational interpretation, one of which supports the ALJ's decision, the ALJ's conclusion must be upheld." Thomas, 278 F.3d at 954 (citing Morgan v. Comm'r of Social Sec. Admin., 169 F.3d 595, 599 (9th Cir.1999)).


Severity Finding

Plaintiff contends that the ALJ improperly ignored a diagnosis of schizophrenia and a Global Assessment of Function ("GAF") score of 55 provided by plaintiff's treating psychiatrist in December 2008. [JS 3--9]. Plaintiff further contends that the ALJ erred in finding that plaintiff did not have a severe mental impairment. [JS 13-14].

The ALJ found that plaintiff had no severe mental impairment. [AR 12]. The ALJ based that finding on a February 2007 consultative psychiatric evaluation [AR 142-149], and the opinions of the non-examining state agency psychiatrists, who "noted no current psychiatric treatment, history of psychiatric hospitalization or use of medication." [AR 12; see AR 150-162]. The ALJ completely ignored plaintiff's testimony and medical records indicating that he had been receiving outpatient psychiatric treatment at a Riverside County Department of Mental Health clinic since November 2007. [See AR 164-195, 215-219].

In his testimony and statements to his mental health providers, plaintiff reported that he had experienced psychiatric problems since the age of 13, when an acquaintance drove plaintiff and his best friend, who had lived off and on with plaintiff's family, to the desert with the promise of buying them pizza, shot his friend to death in the head as "payback" for a dispute, and then shot plaintiff several times before running out of bullets. Plaintiff managed to escape and spent hours hiding in the brush before being rescued. His injuries required multiple surgeries. [See AR 181, 184, 216-219]. Plaintiff told the Riverside County intake examiner that his parents "don't believe in mental health" treatment and never supported, assisted, or approved of his getting treatment, but instead "expected him to 'get over it.'" [AR 181].

In November 2007, plaintiff presented to a Riverside County clinic with a history of depression, anxiety, and delusions. Dr. Lu, a treating psychiatrist, diagnosed plaintiff with major depression with psychotic features and post-traumatic stress disorder ("PTSD"). [AR 166, 174]. Dr. Lu also gave plaintiff a GAF score of 55, which signifies moderate symptoms, such as flat affect or occasional panic attacks, or moderate difficulty in social, occupational, or school functioning, such as having few friends or conflicts with peers or co-workers. See American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Multiaxial Assessment, 27-36 (rev. 2000)). [AR 174]. In December 2008, Dr. Lu reassessed plaintiff and gave him diagnoses of schizophrenia, "paranoid type," major depression, and PTSD. Plaintiff's GAF score remained at 55. [AR 169].

Dr. Lu initially prescribed Risperdal for psychosis and Zoloft for depression and anxiety. [See AR 166, 174]. Plaintiff returned for periodic medication checks. His Risperdal dosage was increased; Risperdal subsequently was discontinued and restarted. Zoloft was discontinued, and trials of Paxil, Lexapro, Zyprexa, and Effexor were attempted to treat plaintiff's symptoms and "minimize side effects." [See AR 165-166, 185-186].

During the hearing in December 2008, plaintiff testified that he was currently taking Effexor, Risperdal, Paxil, and Zyprexa. [AR 215]. Plaintiff said that he heard "a voice in my head which is not in my ears," and frequently experienced paranoia, anxiety, panic ...

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