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Kayla Marie Lockwood v. Carolyn W. Colvin

May 10, 2013


The opinion of the court was delivered by: United States Magistrate Judge Nandor J. Vadas



Kayla Lockwood seeks judicial review of an administrative law judge decision denying her further Supplemental Security Income (Title XVI) benefits. Doc. No. 19. Lockwood‟s request for 16 review of the administrative law judge‟s decision was denied by the Appeals Council. See 17

Administrative Record ("AR") 6-9. The decision thus is the "final decision" of the Commissioner 18 of Social Security, which this court may review. See 42 U.S.C. §§ 405(g), 1383(c)(3). Both 19 parties have consented to the jurisdiction of a magistrate judge. Doc. Nos. 4 & 5. The court 20 therefore may review the parties‟ cross-motions for summary judgment. For the reasons stated 21 below, the court will grant Lockwood‟s motion for summary judgment, deny Defendant‟s motion 22 for summary judgment, and remand the case for further proceedings consistent with this order. 23


A.Procedural History.

The Social Security Administration (the "SSA") found Lockwood disabled as of April 1, 2001, due to a history of bipolar disorder and post-traumatic stress disorder. AR 27, 40. She was 27

13 years old. Specifically, the SSA found that Lockwood‟s symptoms met the mental disorder(s) 28 described in Childhood Listing 112.04 (Mood Disorders) and awarded Lockwood Supplemental Security Income ("SSI") benefits. AR 17, 40. By law, the SSA was required to re-determine 2

Lockwood‟s eligibility for SSI benefits under the adult rules when Lockwood became 18 years 3 old. AR 17, 28. To make that determination, the SSA needed current medical evidence and 4 therefore attempted to schedule a consultative mental health evaluation for Lockwood. AR 28.

The SSA sent two notices to Lockwood, and although Lockwood acknowledged receiving at least 6 one of the notices, she never scheduled the examination. Id.; see also AR 144-158. Because the 7

SSA had "insufficient evidence to determine the continuing severity of [Lockwood‟s] conditions 8 under the adult rules," in April 2007 it "cease[d] her benefits for insufficient evidence and failure 9 to cooperate." Id. 10

Lockwood sought reconsideration of the cessation of benefits. In May 2009, Lockwood 11 attended a hearing before a disability hearing officer, who again concluded that there was 12 insufficient medical evidence with which to find that Lockwood was disabled. AR 37-45.


Lockwood then requested a hearing before an administrative law judge ("ALJ") and appeared for that hearing on March 31, 2010. AR 476-522. The ALJ found that although Lockwood suffered from severe impairments, she would not be disabled if she discontinued her 16 use of marijuana, and therefore was not eligible for SSI benefits. AR 14-25. The Appeals Council 17 denied Lockwood‟s request for review without comment. AR 6-8. Lockwood thereafter filed the 18 instant action. 19

B.Medical History.

Lockwood was born in 1988, and was physically and sexually abused throughout her childhood. AR 500-502. The earliest medical records in the AR establish that she was diagnosed 22 by her treating physician, Dr. Robert Soper, with Major Depression, Dissociative Disorder and 23 Borderline Traits as early as 2001. AR 383-386. 24 In 2003, Lockwood began outpatient mental health treatment for her depression. AR 395. At intake, a social worker diagnosed Lockwood with Bipolar Affective Disorder and PTSD. AR 26 25 398. Her global assessment of functioning ("GAF") *fn1 score was 35. AR 396. Lockwood 27voluntarily entered a day treatment program in early 2004. AR 404, 408. At intake, another social 2 worker diagnosed Lockwood with Major Depressive Disorder and Anxiety Disorder. AR 408-3409.

Her GAF (indicated as "Axis V") was noted to be 40 currently, with 45 as her highest. AR 4 409. She was discharged on February 25, 2004. AR 417. At a scheduled follow-up appointment, Lockwood was diagnosed by Dr. Christopher Lang as having Bipolar Affective Disorder and 6

PTSD. AR 418. At that time, she was taking Lithium to stabilize her mood. Id. Lang observed 7 that Lockwood experienced "a high degree of interpersonal sensitivity to feeling that adults in her 8 immediate environment are treating other age peers differently than they are treating [her]." AR 9

419. Lockwood was prescribed Prozac in May 2004. AR 422. 10

On November 24, 2004, Lockwood stopped using methamphetamines when she

Northern District of United States District Court

11 discovered she was pregnant. AR 288. 12

In 2005, Lockwood ceased taking Lithium and Prozac because of concerns about her


pregnancy. Lockwood also for the first time revealed to Dr. Lang that she had been using 14 methamphetamines regularly before her pregnancy. AR 429. Dr. Lang noted that "[t]he mood

instability that was attributed to Bipolar Disorder now appears much more likely to correlate with 16 the substance abuse, although the family history is strong for bipolar disorder and the Lithium 17 appeared to be significantly helpful with mood stability." AR 429; see also 430-432 (Lockwood 18 ceased taking crystal meth upon discovering pregnancy, but continued using marijuana "on a daily 19 basis"). Based on Lockwood‟s methamphetamine use, Dr. Lang revised Lockwood‟s diagnosis to 20

"Major Depression, recurrent, severe, with psychotic features" and PTSD; he ruled out the bipolar 21 disorder diagnosis. AR 432. 22

In May 2005, Dr. Anna Williams diagnosed Lockwood with Major Depressive Disorder 23 and PTSD. AR 438. She prescribed Zoloft and recommended psychotherapy. Id. Lockwood‟s 24

GAF was 55. Id. She represented to Dr. Williams that she had been sober for 6 months. Id.

In July 2006, Lockwood reported that she had not used any substance for two years. AR

443. (This conflicts with her prior report that she had used methamphetamines until November 3

2004. AR 428.) She was taking Zoloft for her depression and identified residual mood-related 4 symptoms, but Dr. Lang felt she was competent to manage her own funds based on his interview. 5

AR 443. 6

October 2007, Lockwood was involuntarily committed for psychiatric treatment after

7 reporting that she was hearing voices, and threatening to harm herself and others. AR 444, 447. 8

At intake, Dr. Rebecca Danforth diagnosed Lockwood with "Schizoaffective Disorder, Bipolar 9

Type;" PTSD; and cannabis dependence; Lockwood‟s GAF was 30. AR 454. Upon discharge 10 four days later, Dr. Jennifer Star diagnosed Lockwood with "Bipolar Affective Disorder, Most 11

Recent Episode Mixed;" marijuana dependence; and PTSD. AR 449. Her GAF upon discharge 12 was 50. AR 450.

In connection with Lockwood‟s request for reconsideration of the SSA‟s denial of benefits,

14 a medical consultant completed a Psychiatric Review of Lockwood based on her medical records

alone. See AR 249-259. In his Medical Summary, Dr. Harrison indicated that an RFC assessment 16 was necessary in connection with Listing 12.04 (Affective Disorders). AR 249, 251. Dr. Harrison 17 did not indicate whether Lockwood met or equaled any of the other listings implicated by the 18 diagnoses Lockwood‟s physicians had made in the past, such as 12.03 (Schizophrenic, Paranoid 19 and other Psychotic Disorders), 12.06 (Anxiety-related Disorders), 12.08 (Personality Disorders), 20 or 12.09 (Substance Addiction Disorders). Dr. Harrison‟s report does not refer to Lockwood‟s 21 substance abuse in any manner. He indicates that Lockwood would have mild restriction of her 22 activities of daily living; mild difficulties in maintaining social functioning, and moderate 23 difficulties in maintaining concentration, persistence or pace. AR 257. He identified no episodes 24 of decompensation of extended duration. Id. The report was signed on February 3, 2009. AR 25 249. 26


On May 5, 2009, Lockwood testified during her disability hearing that she used marijuana 27 regularly. AR 38. 28

In July 2009, Lockwood visited the ER for anxiety. AR 361-62. She denied having hallucination or homicidal ideations; she admitted having suicidal thoughts but denied having a 2 plan. AR 361. At that time, she denied using street drugs, but her urine tested positive for 3 cannabinoids. AR 361-62. The physician‟s impression was "acute anxiety," and Lockwood was 4 released with anti-anxiety medication after meeting with a county mental health worker. AR 362. 5

On a follow-up visit to the Del Norte Mental Health Clinic, social worker Celia Perez added 6

"Toxic Effects of Narcotics" to Lockwood‟s diagnosis form. AR 299. She noted that Lockwood‟s 7

GAF was 45. AR 300. 8

In August 2009, Carol Kays, a social worker at the Del Norte Mental Health Clinic, 9 recorded a prior diagnosis of bipolar disorder and added "Acute Stress Disorder" and "Personality 10

Disorder" to Lockwood‟s diagnosis form. AR 460. Lockwood‟s GAF at the time was 45. AR 11 461.


In March 2010, Lockwood saw Dr. Christian Holland at the Del Norte Community Health Clinic for the first time. Dr. Holland diagnosed Lockwood with Manic Depression. AR 464. 14

conducted by Dr. Paul Butler. AR 467-471.*fn2 After reviewing her records and examining her, Dr. 16

Butler diagnosed Lockwood as suffering from Bipolar Disorder and PTSD. AR 470. Her GAF 17 was 50. Id. She denied using any illicit drugs at that time. AR 469. Dr. Butler opined that 18

Lockwood was "likely to experience problems performing both simple, as well as complex tasks[. 19

. . ;] has problems with authority [and] is likely to need special assistance in order to perform work 20 on a consistent basis." AR 470. 21

On February 5, 2011, Lockwood attended a comprehensive ...

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