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Rose Marie Hall v. Michael J. Astrue

August 10, 2011


The opinion of the court was delivered by: Sheila K. Oberto United States Magistrate Judge

(Doc. 1)



Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security (the "Commissioner" or "Defendant") denying her application for disability insurance benefits ("DIB") and supplemental security income ("SSI") pursuant to Titles II and XVI of the Social Security Act (the "Act"). 42 U.S.C. §§ 405(g), 1383(c)(3). The matter is currently before the Court on the parties' briefs which were submitted, without oral argument, to the Honorable Sheila K. Oberto, United States Magistrate Judge.


Plaintiff was born in 1958, has an eleventh-grade education, earned her GED, and previously worked as a factory production line worker. (Administrative Record ("AR") 22, 130, 133, 136.) On December 21, 2005, Plaintiff filed an application for SSI and DIB, alleging disability beginning April 1, 2004, due to knee and back pain, joint and disc disease, and psychotic disorder. (AR 13, 15.)

A. Medical Evidence

1. Physical Ailments

Plaintiff visited Community Medical Center in Fresno a number of times from January 2004 to October 2006, for treatment of different physical injuries, including dental problems and injuries to the hip, ankle, head, knee, and back. (AR 289-320.) In January 2005, Plaintiff was assaulted and received non-urgent care for injuries to her neck and tailbone. (AR 320.) On December 15, 2005, Plaintiff was treated in the emergency room for chemical burns on her hands and feet that she sustained while cleaning with bleach and ammonia. (AR 313.) A few days later on December 18, 2005, Plaintiff received treatment for head injuries inflicted during an altercation. (AR 298.)

On April 3, 2006, Juliane Tran, M.D. conducted an orthopedic evaluation. (AR 171.) Dr. Tran noted generally that Plaintiff did not have any difficulty walking into the exam room, sitting, or getting on and off the exam table. (AR 172.) Dr. Tran determined a diagnostic impression of bilateral knee pain, neck and back pain, and mild right carpal tunnel syndrome. (AR 174.) Dr. Tran provided a functional assessment that Plaintiff should be restricted from work involving frequent right wrist movements, activities involving frequent overhead reaching, and lifting more than fifty pounds occasionally and more than twenty-five pounds frequently. (AR 174.) Plaintiff had no restrictions on sitting, standing, walking, bending, stooping, crouching, climbing, or balancing. (AR 174.) There were also no restrictions on Plaintiff in terms of height, visual, environmental, fingering, or grasping conditions. (AR 174.)

2. Mental Ailments

Plaintiff's earliest treatment record regarding mental conditions is dated November 15, 2004, from Fresno County Human Services System, Mental Health Services ("Fresno County Mental Health"). (AR 268.) Plaintiff had previously been prescribed Perphenazine*fn1 before that time. (AR235.) Progress notes from December 28, 2004, indicate that Plaintiff had not taken the medication since June of that year. (AR 235.) On that date, Plaintiff was additionally prescribed Vistaril*fn2 for her anxiety. (AR 235.) In January and February of 2005, Plaintiff's treatment notes indicate that she was preoccupied with finding a service that would provide her with a place to live, and often visited the staff at Fresno County Mental Health to seek help in securing housing. (AR 242-49, 264-67.)

On January 5, 2005, Plaintiff saw Frederick Reinfurt, M.D. of Fresno County Mental Health for a refill of Perphenazine and Vistaril. (AR 233-34.) Plaintiff reported that the medications helped with her anxiety and sleeping habits, and denied that these medicines had any side effects. (AR 234.) On January 19, 2005, Plaintiff attempted to have Dr. Reinfurt refill a prescription for Trazadone, a medication that had been intentionally discontinued.*fn3 (AR 233.) Plaintiff "accept[ed] that [Dr. Reinfurt would] not refill [the] medication," and the doctor noted that Plaintiff had an adequate amount of her other medications at the time. (AR 233.) On February 14, 2005, Plaintiff visited Dr. Reinfurt for a premature refill on her medications because she had been using them too frequently. (AR 232.) Dr. Reinfurt told Plaintiff that she needed "to make the bottle last a total of a month," but authorized a refill on that one occasion. (AR 232.) Plaintiff consulted with Dr. Reinfurt on February 22, 2005, and Plaintiff stated the medication helped "keep the voices down." (AR 231.) Plaintiff continued to intermittently receive treatment from Fresno County Mental Health through the remainder of 2005. (AR 222-31.)

Plaintiff visited Dr. Reinfurt on February 1, 2006, for a "medication review." (AR 180-81.) Plaintiff discussed her mental condition with the doctor, noting that the Perphenazine helped her hear voices "not as much." (AR 181.) The doctor noted that Plaintiff showed "no overt sign of disordered thought, perception, [or] cognition." (AR 181.) Dr. Reinfurt further opined that Plaintiff was "savvy enough to take advantage [of] (and demand) services." (AR 180.) He then found that Plaintiff did "not appear able to work at [the] time," but also that she did not have any psycho-motorretardation and needed to show effort at treatment. (AR 180.) Dr. Reinfurt spoke with Plaintiff about her plans to begin attending group therapy. (AR 181.)

On March 3, 2006, Richard Mamula, Ph.D. examined Plaintiff and created a treatment plan. (AR 466-69.) Dr. Mamula indicated that Plaintiff's symptoms included delusions, hallucinations, disorganized speech, preoccupation with delusions, and paranoid thoughts. (AR 466.) Plaintiff had a good understanding of her illness and reported compliance with her medication regime. (AR 467.) Dr. Mamula assessed Plaintiff with a Global Assessment of Functioning score ("GAF") of forty-seven.*fn4 The doctor further diagnosed Plaintiff with paranoid type schizophrenia. (AR 469.)

On March 7, 2006, Plaintiff returned to Dr. Reinfurt for another medication review. (AR 178.) The doctor noted that Plaintiff found group therapy helpful. (AR 178.) Plaintiff again reported the effectiveness of her medications, stating that when she took her Perphenazine the voices were "a little quieter," and that her "anxiety pills" were helping. (AR 178.) Dr. Reinfurt found that Plaintiff's anxiety was still problematic and diagnosed Plaintiff with a psychotic disorder not otherwise specified, but opined that Plaintiff "seem[ed] improved." (AR 178.)

Ekram Michiel, M.D. examined Plaintiff on April 2, 2006. (AR 167.) Dr. Michiel noted that Plaintiff showed no abnormal or bizarre behavior. (AR 167.) Plaintiff complained to Dr. Michiel of hearing voices, feeling things touch her, and getting nervous around other people. (AR167.) Plaintiff also told Dr. Michiel that she felt depressed and slept "a lot" or not "at all" when she was on her medication. (AR 167.) The doctor noted that Plaintiff complained of knee and back pain, but also noted that she was on no medications for the pain. (AR 168.) Dr. Michiel conducted a mental status examination and found that Plaintiff performed well on the memory, knowledge, concentration, abstract thinking, similarities and differences, insight, and judgment tests. (AR 168-69.) The doctor observed that Plaintiff's behavior during the interview did not confirm her claim of hallucinations and delusions, and also noted that she did not respond to internal stimuli. (AR168.) Assessing Plaintiff with a GAF between sixty and sixty-five,*fn5 Dr. Michiel opined that Plaintiff was capable of maintaining sufficient attention and concentration to carry out simple job instructions, though not extensively technical or complex instructions. (AR 169.) Further, Plaintiff was "capable of relating appropriately to her co-workers, supervisors, and the public." (AR 169.) Dr. Michiel also noted that Plaintiff could maintain regular workplace attendance and complete a normal workweek without interruptions from her psychiatric condition. (AR 169-70.)

Between April and September 2006, Plaintiff was treated by Maximo A. Parayno, Jr., M.D. (AR 321, 323-29.) On April 25, 2006, Dr. Parayno conducted a psychiatric assessment and examination of Plaintiff. (AR 325-27.) Confusingly, in this assessment Dr. Parayno indicated that Plaintiff was both capable of independent living and incapable of independent living. (AR 327.) Dr. Parayno also found that Plaintiff had poor activities of daily living but was motivated for treatment, had good physical health, and had good communication skills. (AR 327.) The doctor diagnosed Plaintiff with paranoid type schizophrenia and assessed her with a GAF score of forty-five. (AR 327.) Dr. Parayno also saw Plaintiff in May, June, July, and September 2006, as indicated by psychiatric progress notes and medication orders. (AR 321, 323-24.)

On July 25, 2006, state agency psychiatrist Archimedes Garcia, M.D. reviewed Plaintiff's records and opined that Plaintiff would only have moderate limitations on performing detailed tasks, and that she would be able to perform simple repetitive tasks adequately. (AR 274-76.)

Between August 2006 and October 2006, Plaintiff attended group therapy classes at Fresno County Mental Health. On many of these occasions, the department staff reflected positively on Plaintiff, noting things such as good mood, positive behavior, and articulate speech. (AR 188, 189, 194, 201, 202, 209, 213, 217, 218, 219.) Notably, at one point a friend of Plaintiff's was shot and killed, and Plaintiff indicated that her ability to cope with this loss was better than it would have been in earlier times. (AR 205.) During the time between August and October 2006, however, Plaintiff also skipped many of her scheduled classes. (AR 182-87, 190-93, 197-200, 203-04, 206-08, 211-12, 214, 216, 220.)

Between October 2006 and December 2007, Plaintiff attended treatment classes at Turning Point of Central California. (AR 374-474.) During many of these classes, Plaintiff displayed anxiety, depression, and behavior of isolation. (AR 378-82, 384-87, 390-93, 395-400, 405-07, 411, 423, 433, 435, 481-83, 485-87, 490-91, 493-94, 496-97, 500-02, 504, 507-08, 511, 513-16, 519, 521, 530, 548, 551, 553-55, 558, 561-62, 566-67, 569-71, 573-74, 577, 583-86.) On multiple occasions, though, Plaintiff exhibited a good mood and other positive behaviors. (AR 401, 403, 404, 408, 418, 421-22, 426-27, 430-32, 447, 452, 463, 476-78, 517, 527, 531, 538, 541, 545, 547, 564, 576, 580.) In May 2007, Plaintiff began taking classes at Fresno City College. (AR 374-75.)

State agency psychiatrist Robert Y. Hood, M.D. reviewed Plaintiff's records on April 18, 2007. (AR 337-50.) Dr. Hood opined that Plaintiff could concentrate and sustain pace, deal with the public, adapt to change, and complete a normal workweek without interruptions from her psychologically based symptoms. (AR 349-50.)

The Turning Point program closed in December 2007, and by March 2008, Plaintiff had begun receiving services from the Kings View Housing and Recovery Network ("Kings View"). (AR 21, 372-73, 478, 481-83, 492.) At Kings View, Herbert A. Cruz, M.D. examined Plaintiff on April 4, 2008. (AR 369.) Dr. Cruz noted that Plaintiff was "extremely amicable and interactive, although it is evident through a constrained affect." (AR 369.) Plaintiff reported no medication side effects. (AR 369.) The doctor opined that Plaintiff was cooperative, with normal motor activity, speech, cognition, orientation, thought process, mood, intelligence, insight, and judgment. (AR 369.) Dr. Cruz indicated that Plaintiff's thought content included hallucinations and other voices. (AR 369.) Plaintiff was diagnosed with a GAF of twenty-eight,*fn6 and Dr. Cruz concluded that Plaintiff, "in spite of her recovery[, could] not work due to residual symptoms of her illness." (AR 369.)

B. Administrative Proceedings

The Commissioner denied Plaintiff's application initially and again on reconsideration; consequently, Plaintiff requested a hearing before an Administrative Law Judge ("ALJ"). (AR 77-82, 84-89, 90.)

1. Plaintiff's Testimony

On June 26, 2008, ALJ Christopher Larsen held a hearing where Plaintiff testified that the last time she worked was more than fifteen years prior. (AR 32.) According to Plaintiff, she was unable to work presently because of "health and concentration." (AR 32.) Plaintiff alleged pain in her knees, back, shoulder, arm, hands, and joints, as well as high blood pressure and headaches. (AR 34-36.) After a short bathroom break, Plaintiff stated that she had to use the restroom three to four times per hour as a side effect of her medication. (AR 38-39.) Plaintiff further claimed that she could only be on her feet for half an hour without a break, and that she could only sit for fifteen minutes at a time. (AR 38-39.) Plaintiff also stated that she needed to lie down and rest for twenty minutes to an hour at least five times a day because of constant pain in her knees, arms, and hands. (AR 33-34.)

In addition to these physical complaints, Plaintiff testified about her mental health problems. Plaintiff alleged that she "constantly" had voices in her head and saw shadows, and that her medication did not alleviate these symptoms. (AR 43-44.) Further, Plaintiff stated that she suffered from depression and panic attacks. (AR 42.)

2. Vocational Expert's Testimony

A vocational expert ("VE") testified at the hearing that a hypothetical person with the same age, education, and work experience as Plaintiff could perform several jobs in the regional and national economy if that person could (1) lift fifty pounds occasionally and twenty-five pounds frequently, (2) stand and walk for six out of eight hours a day, (3) never reach above her shoulders, and (4) perform simple repetitive tasks. (AR 46-47.) However, this same hypothetical person with the added limitation of being unable to complete a work day without interruption from psychologically based symptoms would not be able to find work according to the VE, nor would a hypothetical person who was unable to maintain consistent attention and concentration for other reasons. (AR 47-48.)

Pursuant to Plaintiff's counsel's questioning, the VE testified that the same initial hypothetical person with the added limitation of needing to use the restroom approximately three to four times an ...

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