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Holt v. Colvin

United States District Court, E.D. California

March 19, 2015

JAMES D. HOLT, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

ORDER DIRECTING ENTRY OF JUDGMENT IN FAVOR OF DEFENDANT CAROLYN W. COLVIN, ACTING COMMISSIONER OF SOCIAL SECURITY, AND AGAINST PLAINTIFF JAMES HOLT

JENNIFER L. THURSTON, Magistrate Judge.

Plaintiff James D. Holt asserts he is entitled to supplemental security income under Title XVI of the Social Security Act. Plaintiff argues the administrative law judge ("ALJ") erred in assessing the credibility of his subjective complaints and in evaluating the medical evidence related to his social functioning. For the reasons set forth below, the ALJ's decision is AFFIRMED.

PROCEDURAL HISTORY

Plaintiff filed his application for supplemental security income on March 19, 2008 and alleged his disability began on January 7, 2007. (Doc. 8-4 at 7.) The Social Security Administration denied Plaintiff's claim initially on June 5, 2008, and upon reconsideration on October 9, 2008. ( Id.; see also Doc. 8-5 at 2-9.) After requesting a hearing, Plaintiff testified before an ALJ on December 7, 2009. (Doc. 8-5 at 7.) The ALJ determined Plaintiff was not disabled under the Social Security Act, and issued an order denying benefits on December 17, 2009. (Doc. 8-4 at 7-15.)

Plaintiff requested the Appeals Council review the decision, and his request was granted on November 10, 2011. (Doc. 8-4 at 20.) The Council found the ALJ "did not properly assess the claimant's mental impairments." (Id. at 20.) The Council observed, "The hearing decision found the claimant to have severe impairments of attention deficit disorder and bipolar disorder, but then states only that the record does not show probative difficulties in daily living, social functioning, concentration or episodes of decompensation." (Id. ) As a result, the ALJ failed to "evaluate all of the claimant's mental impairments in accordance with the special technique defined within the regulation (20 CFR 416.920a)." (Id. ) Further, the Appeals Council observed:

The consultative evaluation in Exhibit 8F found the claimant to have opioid dependence, amphetamine dependence, attention deficit hyperactivity disorder and rule out cognitive disorder not otherwise specified. It found limitations in social functioning and concentration. Internally, the decision on page 6 of 9 gave the global assessment score of forty-five found by the consultative evaluation no weight, but then gave significant weight to this opinion. A state agency reviewer in Exhibit 7F and affirmed in Exhibit 10F found the claimant to have moderate limitations in social functioning and concentration with one or two episodes of decompensation. In Exhibit 6F, the state agency reviewer found the claimant's concentration variable. He can have superficial public and co-worker contact. He would benefit from supportive supervision and vocational counseling. He may adapt slowly to changes.

(Doc. 8-4 at 20.) Therefore, the Appeals Council found that the record "indicate[d] limitations in social functioning that [were] not reflected in the residual functional capacity." (Id. )

The Appeals Council remanded the decision to the ALJ, instructing him to "[f]urther evaluate the claimant's mental impairments..., documenting application of the technique in the decision by providing specific findings and appropriate rationale for each of the functional areas described in 20 CFR 416.920a(c)." (Doc. 8-4 at 21.) Also, the ALJ was directed to "[g]ive further consideration to the claimant's maximum functional capacity and provide appropriate rationale with specific references to evidence of record in support of the assessed limitations." ( Id., citing 20 CFR 461.945 and Social Security Rulings 85-16 and 96-8p.) Finally, the Appeals Council noted that while Plaintiff's request for review was pending, Plaintiff filed a second claim for supplemental security benefits. (Id. ) Accordingly, the ALJ was directed to "associate the claim files and issue a new decision on the associated claims." (Id. )

Plaintiff testified at a second hearing on March 20, 2012. (Doc. 8-3 at 19, 42.) The ALJ found Plaintiff was able to perform the full range of physical exertion levels, but was mentally limited to unskilled work. (Id. at 27.) As a result, the ALJ determined Plaintiff was not disabled under the Social Security Act, and issued an order denying his applications for benefits on April 19, 2012. (Id. at 19-35.) The Appeals Council denied review of the second decision on June 19, 2013. (Id. at 2-4.) Thus, the ALJ's were adopted the Commissioner of Social Security ("Commissioner"), and became the final decision in the action.

STANDARD OF REVIEW

District courts have a limited scope of judicial review for disability claims after a decision by the Commissioner to deny benefits under the Social Security Act. When reviewing findings of fact, such as whether a claimant was disabled, the Court must determine whether the Commissioner's decision is supported by substantial evidence or is based on legal error. 42 U.S.C. § 405(g). The ALJ's determination that the claimant is not disabled must be upheld by the Court if the proper legal standards were applied and the findings are supported by substantial evidence. See Sanchez v. Sec'y of Health & Human Serv., 812 F.2d 509, 510 (9th Cir. 1987).

Substantial evidence is "more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson v. Perales, 402 U.S. 389, 401 (1971) (quoting Consol. Edison Co. v. NLRB, 305 U.S. 197 (1938)). The record as a whole must be considered, because "[t]he court must consider both evidence that supports and evidence that detracts from the ALJ's conclusion." Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985).

DISABILITY BENEFITS

To qualify for benefits under the Social Security Act, Plaintiff must establish he is unable to engage in substantial gainful activity due to a medically determinable physical or mental impairment that has lasted or can be expected to last for a continuous period of not less than 12 months. 42 U.S.C. § 1382c(a)(3)(A). An individual shall be considered to have a disability only if:

his physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work, but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy, regardless of whether such work exists in the immediate area in which he lives, or whether a specific job vacancy exists for him, or whether he would be hired if he applied for work.

42 U.S.C. § 1382c(a)(3)(B). The burden of proof is on a claimant to establish disability. Terry v. Sullivan, 903 F.2d 1273, 1275 (9th Cir. 1990). Once a claimant establishes a prima facie case of disability, the burden shifts to the Commissioner to show the claimant is able to engage in substantial gainful employment. Maounis v. Heckler, 738 F.2d 1032, 1034 (9th Cir. 1984).

ADMINISTRATIVE DETERMINATION

To achieve uniform decisions, the Commissioner established a sequential five-step process for evaluating a claimant's alleged disability. 20 C.F.R. § 416.920(a)-(f). The process requires the ALJ to determine whether Plaintiff (1) engaged in substantial gainful activity during the period of alleged disability, (2) had medically determinable severe impairments (3) that met or equaled one of the listed impairments set forth in 20 C.F.R. § 404, Subpart P, Appendix 1; and whether Plaintiff (4) had the residual functional capacity to perform to past relevant work or (5) the ability to perform other work existing in significant numbers at the state and national level. Id. The ALJ must consider objective medical evidence and hearing testimony. 20 C.F.R. § 416.927.

A. Relevant Medical Evidence[1]

On December 27, 2007, Plaintiff underwent an initial assessment at Central Washington Comprehensive Health Center with Tracy Molina, MSW. (Doc. 8-9 at 4-9.) Plaintiff reported he was currently on probation, which "was recently violated for failure to report and a positive UA." (Id. at 4.) He told Molina that he was "seeking services as a mandate from his probation officer." (Id. at 7-8.) Plaintiff reported "he was diagnosed ADHD as a child, but was "not ADHD anymore." (Id. at 4.) In addition, Plaintiff reported he was "diagnosed with bipolar disorder" and had been hospitalized once in the last year. (Id. at 8.) He "complain[ed] of extreme difficulty quitting heroin" and admitted "to being chemically dependent." (Id. at 4, 8.) Plaintiff expressed an interest in a methadone program, and Molina recommended "a psychiatric evaluation for medication management." (Id. at 8.) Molina believed Plaintiff had an antisocial personality disorder, had "an inflated self esteem and grandiosity, " appeared "highly distractible, " and exhibited "[p]roblems related to interacting with [the] legal system." (Id. at 4, 7.) On the other hand, Plaintiff acted in a cooperative manner and "seem[ed] to be helpful toward others." (Id. at 4-5.) Molina believed Plaintiff exhibited "[l]ess severe mental disorder and more severe substance disorder." (Id. at 8.) Molina gave Plaintiff a current GAF score of 40.[2] (Id. at 7.)

On April 1, 2008, Plaintiff was admitted to an American Behavior Health Services facility for a 28-day treatment. (Doc. 8-9 at 11.) Plaintiff was diagnosed with chemical dependency, including alcohol, opioids, and cannabis. (Id. ) He reported that he last consumed alcohol on the day he was admitted, and last used heroin on February 25, 2008. (Id. at 12.) While at the facility, Plaintiff "experienced no issues of acute withdrawal or intoxication." (Id. ) Plaintiff's counselor and clinical supervisor noted that Plaintiff "made good progress" with dealing with his "mental health issues, " and "appeared [to be] coping fairly well with his ADHD and impulse control." (Id. at 13.) Further, the counselor and clinical supervisor believed Plaintiff "made good progress in all treatment areas." (Id. at 14.) Plaintiff was discharged from the facility on April 29, 2008. (Id. at 11.)

Dr. Philip Johnson completed a consultative psychological evaluation on May 19, 2008. (Doc. 8-9 at 43.) Plaintiff told Dr. Johnson that he had "ADHD and bipolar disorder, " and "his main problem is that everybody thinks [he's] moving way too fast and they think [he's] on drugs.'" (Id. at 43.) Dr. Johnson noted:

James reported using "weed and acid" as a kid (he first used marijuana at age 17). He reported that from '81 til recently he had a "non-stop problem with drugs." He used cocaine in the '80's, heroin in the '90's and early '00's. He used meth from '96 til '07 or '08. Opiates he's used included heroin, oxycontin, and fentanyl. His last use of cocaine was in the '90's. His last use of marijuana was in December '07. His last use of meth and heroin was in March '08. He admitted to "doctor shopping."...
He admitted that chemical dependency has been a life-long battle for him. His longest stretch of sobriety (outside of prison) has been 30 days. He indicated a continuous craving for opiates currently. He says meth gets him animated. Asked what he sees the future being for him in the substance abuse area, he said he didn't know.

(Id. at 44.) In addition, Plaintiff told Dr. Johnson that he was able to take care of own grooming, cook simple foods, do his own laundry, and "get[]around by taking a bus." (Id. at 47.) Plaintiff said he shopped "at small stores because he doesn't like large stores, " and he was "pretty distrusting' of the general public." (Id. ) Plaintiff explained that "[h]is only friends are drug addicts or drunks... so he is kind of a hermit. (Id. ) Further, Plaintiff reported he had difficulty "keeping jobs because of lack of enthusiasm or motivation.'" (Id. at 49.)

Upon mental status examination, Dr. Johnson observed Plaintiff was cooperative and "oriented to person, place and time." (Doc. 8-9 at 46.) Dr. Johnson found Plaintiff's memory was adequate; "he was able to recall 2/3 objects after an interval of 5 minutes (3/3 with cuing)" and "was able to recall 7 digits forward and 4 digits backward." (Id. ) In addition, Plaintiff was "able to do a 3-step command, and he was mostly able to follow the conversation." (Id. at 47.) Dr. Johnson administered the Wechsler Adult Intelligence Scale- 3rd Edition (WAIS-III), and found "a lot of variability between subtests, reflecting cognitive inefficiency and unevenness of performance." (Id. at 48.) Based upon the testing, Dr. Johnson opined:

James' ability to understand and reason falls in the low average range overall. His ability to remember is adequate. There are some limitations in the area of social interaction, but whatever skills he has are probably adequate for a lot of jobs. Ability to sustain concentration, persistence, and pace is variable in the short term, and in the long term he has not sustained a job past three or four months due to "lack of enthusiasm or motivation." In the area of stress coping, he said his biggest downfall is that "it's easier to get high than to cope with stress."

(Id. at 49.) According to Dr. Johnson, Plaintiff met the "criteria for antisocial personality disorder as well as ADHD." (Id. at 48.) He believed Plaintiff's prognosis was poor and explained, "The pattern of antisocial behavior is unlikely to change, and a drug relapse seems quite likely outside of a structured, controlled environment." (Id. at 49.) He gave Plaintiff a current GAF score of 45.[3] (Id. )

Dr. James Bailey completed a psychiatric review technique and mental residual functional capacity assessment on June 5, 2008. (Doc. 8-9 at 25-42.) Dr. Bailey opined Plaintiff was "not significantly limited" with his ability to understand, remember, and carry out both simple and complex instructions. (Id. at 25.) He believed Plaintiff was "moderately limited" with his ability to interact appropriately with the general public, accept instructions and respond appropriately to criticism from supervisors, and get along with coworkers or pears without distracting them or exhibiting behavioral extremes. (Id. ) On the other hand, Plaintiff was "not significantly limited" with the ability to maintain socially appropriate behavior. (Id. ) According to Dr. Bailey, Plaintiff's ability to sustain concentration, persistence and pace was "variable, " and his "job retention appears to be impacted by lack of enthusiasm or motivation." (Id. at 41.) Dr. Bailey opined Plaintiff had "the ability to perform simple and complex tasks, " and could "have superficial public and co-worker contact." (Id. at 27.) This assessment was affirmed by Dr. Sharon Underwood on October 7, 2008. (Id. at 50.)

On December 8, 2008, Russell Anderson, MSW, performed an evaluation at the Washington State Department of Social & Health Services. (Doc. 8-9 at 57-62.) Plaintiff reported he had been sober for six months, and had a history of "ADHD, memory problems, insomnia, mood swings, fatigue, audio hallucinations, anger problems, guilt, [and] manic episodes." (Id. at 59-60.) Anderson observed that Plaintiff's speech was "pressured" and his eye contact was "limited." (Id. at 61.) Plaintiff said he was "really nervous" and he did "not like being around people much." (Id. )

On October 13, 2009, Dr. Jagdeep Garewal examined Plaintiff at Ridgecrest Regional Hospital. (Doc. 8-9 at 55.) Plaintiff reported he had been diagnosed as with a bipolar disorder and ADHD, and he had not taken medication for two months. (Id. ) Also, Plaintiff reported feeling a loss of energy, anger, and a loss of concentration associated with depression. (Id. ) Plaintiff stated that his "sociability ha[d] decreased" and he had "[f]eelings of worthlessness." (Id. ) Dr. Garewal observed that Plaintiff's thought content was depressed, and Plaintiff was "inattentive and not focused." (Id. at 56.) Dr. Garewal believed "[a] short attention span [was] evident." (Id. ) He counseled Plaintiff "regarding the need for compliance with all medical instructions, particularly having to do with medication." (Id. at 66.) Dr. Garewal gave Plaintiff a current GAF score of 50. (Id. at 56, 65.)

Dr. Parsons began treating Plaintiff for pain in his hip and back at the Ridgecrest Community Health Center on October 24, 2009. (Doc. 8-9 at 70.) Plaintiff reported he had "tried a variety of medications for ADD, ADHD, and Bipolar Disorder, " and was currently taking trazadone as prescribed by Dr. Garewal. (Id. ) Plaintiff said he did not have any disability that affected his learning. (Id. )

Dr. H. Skopec completed a psychiatric review technique and mental residual functional capacity assessment on March 17, 2010. (Doc. 8-9 at 73-86.) Dr. Skopec opined Plaintiff had "moderate" limitations with his activities of daily living; maintaining social functioning; and maintaining concentration, persistence, or pace. (Id. at 81.) Dr. Skopec believed Plaintiff was "not significantly limited" with his ability to understand, remember, and carry out simple instructions, but was "moderately limited" with his ability to carry out detailed instructions. (Id. at 84.) Also, Dr. Skopec determined Plaintiff was "moderately limited" with the ability to work in coordination or proximity to others without being distracted by them and being able to interact appropriately with the general public. (Id. at 84-85.) However, Plaintiff was "not significantly limited" with the ability to maintain socially appropriate behavior. (Id. at 85.) Dr. Skopec concluded Plaintiff "can sustain simple repetitive tasks with adequate pace and persistence, can adapt and relate to co-workers and supervisors but likely cannot work with the public." (Id. at 86.)

On June 8, 2010, Plaintiff had a telemedicine consultation with Dr. Garewal, who noted that Plaintiff described a "level of activity to be moderate in extent." (Doc. 8-9 at 92-93.) Dr. Garewal believed Plaintiff's behavior was "stable and uneventful" and "[his] medication compliance is good." (Id. at 93.) Plaintiff "complain[ed] of subjective concentration problems and difficulty focussing" [sic]." (Id. ) Dr. Garewal observed that Plaintiff was "inattentive and... not focused, " and his memory interfered with functioning." (Id. ) Plaintiff exhibited "signs of anxiety" and "fair" social judgment. (Id. ) Dr. Garewal gave Plaintiff a GAF score of 50. (Id. at 94.)

In addition, Dr. Garewal completed a psychiatric/psychological impairment questionnaire on June 8, 2010. (Doc. 8-9 at 108-116.) Dr. Garewal noted he had treated Plaintiff on two occasions, and diagnosed Plaintiff with a moderate Bipolar disorder, and "ADHD, combined type." (Id. at 108.) Further, he noted Plaintiff had agitation and labile mood, both of which were "moderate." (Id. at 110.) According to Dr. Garewal, Plaintiff was "moderately limited" with his ability to remember locations and work-like procedures and the ability to carry out one or two-step instructions. (Id. at 110-11.) He opined Plaintiff was "markedly limited" with his ability to understand and remember one or two step directions, carry out detailed instructions, maintain attention and concentration, and perform activities within a regular schedule. (Id. at 111.) Dr. Garewal indicated Plaintiff's ability to interact appropriately with the general public was "mildly limited, " while his ability to maintain socially appropriate behavior was "moderately ...


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