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Mays v. Colvin

United States District Court, N.D. California

June 27, 2016

PHILLIP MAYS, Plaintiff,
v.
CAROLYN W. COLVIN, Defendant.

          ORDER RE: CROSS-MOTIONS FOR SUMMARY JUDGMENT, RE: DKT. NOS. 17, 29

          MARIA-ELENA JAMES United States Magistrate Judge.

         INTRODUCTION

         Plaintiff Phillip Mays ("Plaintiff") brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of a final decision of Defendant Carolyn W. Colvin ("Defendant"), the Acting Commissioner of Social Security, denying Plaintiff's claim for disability benefits. Pending before the Court are the parties' cross-motions for summary judgment. Dkt. Nos. 17, 29. Pursuant to Civil Local Rule 16-5, the motions have been submitted on the papers without oral argument. Having carefully reviewed the parties' positions, the Administrative Record ("AR"), and relevant legal authority, the Court hereby DENIES Plaintiff's Motion and GRANTS the Commissioner's Cross-Motion for the reasons set forth below.

         BACKGROUND

         Plaintiff was born on July 16, 1975. AR 104. He attended Castlemont Community High School from 1989 to 1993, where he received grades ranging from A to F. AR 171-72. The record indicates Plaintiff attended classes through the spring semester of his twelfth grade year, but he did not graduate or get a GED. AR 171, 266, 322, 353. Although Plaintiff reported he attended special education classes for "slow learners" (AR 219, 322, 353), the transcript in the Administrative Record reflects that he was also enrolled in college preparatory classes, including World Culture, Algebra, U.S. History, English, and Economics. AR 171. Plaintiff has previous work experience as a security guard and warehouse worker. AR 145.

         Plaintiff reported that his father was violent and abused him as a child, and that he witnessed abuse between his parents. AR 255, 266. He also reported that he sustained an injury to his skull in a fight around 2005 (AR 219), he was stabbed about 20 times in various locations, including his head and right hand (AR 266), and was stabbed in the head 20 times by a jealous girlfriend (AR 353).[1] Plaintiff frequently reported being homeless or staying with family or friends. AR 266, 322, 326, 341, 346, 354, 361, 369. He was incarcerated at Alameda County Jail between May 12, 2010 and October 24, 2011 (AR 173-86, 251-61), and at Santa Rita Jail between February 5, 2013 and May 21, 2013 (AR 355-67).

         On May 12, 2010, Plaintiff was initially screened for treatment at the Alameda County Behavioral Health Care Services, Criminal Justice Mental Health Program (Alameda County Behavioral Health). AR 186, 213. At his initial screening, Plaintiff reported hearing voices, having depression, paranoia, and violent moods, and difficulties with impulse control. AR 184, 186, 212-13. He denied suicidal or homicidal ideation, or planning a suicide attempt. AR 186, 213. On evaluation, F. Rosenthal, M.D., noted that Plaintiff is "not always consistent in his complaints" and "tends to change focus - [be] evasive, " and that Plaintiff "decided depression more of an issue [yet] refuses antidepressant medication." AR 184, 212. Dr. Rosenthal also noted that Plaintiff "is pressurred [sic], obsessive, and delusional, has paranoid concerns c/o AH's and depression", and "tends to be rambling, poorly organized - and somewhat challenging." Id.

         On May 19, 2010, Plaintiff visited Alameda County Behavioral Health and reported that he had never received psychiatric treatment in the past, that he was not suicidal, and denied attempting suicide in the past. AR 183, 210. The clinician at Alameda County Behavioral Health reported that on mental status examination, Plaintiff was evasive and reported hearing a male voice tell him to harm others; the clinician referred Plaintiff to a medical doctor for a medication evaluation. Id.

         On June 11, 2010, Plaintiff went to Alameda County Behavioral Health and requested medication to treat his auditory hallucination; Dr. Rosenthal reported that Plaintiff appeared to be "somewhat drug seeking and tends to be somewhat vague when asked about details." AR 181, 207.

         On June 15, 2010, Sarah Ulloa, MFTI at Alameda County Behavioral Health, reported that on mental status examination, Plaintiff was well-groomed, anxious, had good eye contact, was clear and coherent, and walked on crutches due to his leg being broken in two places; Plaintiff reported that medications were "helpful" and that he had problems sleeping. AR 180, 206. On July 14, 2010, Ms. Ulloa reported that on mental status examination, Plaintiff had good eye contact and clear and coherent speech, was cooperative, well-groomed, talkative, and "doing well" on psychiatric medication, and his mood was "good." AR 178, 203.

         On September 10, 2010, Dr. Rosenthal reported that Plaintiff "seems [to be] in [a] fairly good mood, " and that he was not taking Risperdal but had continued with the medication Paxil and was "apparently not troubled by AH [auditory hallucinations] at this time - and may not have a psychotic disorder - [he] feels he does well just w[ith] Paxil and [his] mood is controlled." AR 202.

         On October 6, 2010, Plaintiff complained of continued insomnia and decreasing appetite to a clinician at Alameda County Behavioral Health. AR 200. He presented as "unsure of AH[, ] as he first answered that he continues to have AH but less than originally reported" and then "he said he did not have AH at all." Id. Plaintiff's appearance was within normal limits; he was in a wheelchair but was able to step over to the office chair without difficulty. Id. He was calm and cooperative, and there was no evidence of psychosis or distress. Id. Plaintiff denied having any suicidal and homicidal ideation. Id.

         Also on October 6, 2010, Dr. Rosenthal noted that Plaintiff reported "doing well on current med[ications]" without side effects, and that Plaintiff had a good mood, was calm and appropriate, and had been taking Risperdal and agreed to continue taking his medication. AR 199. Dr. Rosenthal completed a Treatment Continuity Plan for Plaintiff's anticipated jail release date of October 28, 2010 for Plaintiff to continue taking the medication Paxil and contact mental agencies on a list to continue treatment. AR 195. He continued Plaintiff's Paxil prescription. AR 201. On October 15, 2010, Dr. Rosenthal reported that Plaintiff was not compliant with his prescribed medication treatment and that his prescription was extended. AR 196, 260.

         On October 21, 2010, Peter Slaubaugh, M.D., at Alameda County Medical Center Highland Outpatient reported that Plaintiff had decreased flexion in the right knee but had an overall normal examination of the knee. AR 188.

         On November 9, 2010, licensed psychologist Patricia Spivey, Psy.D., examined Plaintiff. AR 219-22. Dr. Spivey reported that Plaintiff had taken public transportation to the appointment and that he could shower, dress, and feed himself. AR 220. On mental status examination, Dr. Spivey reported Plaintiff was oriented to person, place, time, and purpose, his thought processes and content included evidence of poor reality testing, Plaintiff did not respond to internal stimuli or any loose associations, and Plaintiff presented a flat affect and had fair mood, good attention, and poor insight and judgment. Id. Dr. Spivey reported Plaintiff had a full scale IQ score of 79, which was consistent with his presentation and history of being in special education, Plaintiff performed fairly well on the memory subtests, and Bender drawing tests revealed no severe deficits. AR 219, 221. Dr. Spivey opined that Plaintiff had no impairment in his abilities to follow simple and complex instructions and communicate effectively in writing. AR 221. Dr. Spivey commented that Plaintiff had mild impairment in his abilities to maintain adequate pace or persistence to complete 1-2 step simple repetitive tasks or to maintain adequate pace or persistence to complete complex tasks, maintain adequate attention or concentration, and verbally communicate effectively with others. Id. Dr. Spivey also stated that Plaintiff had moderate impairment in his abilities to adapt to changes in job routine and withstand the stress of a routine workday, and moderate to marked impairment in his abilities to maintain emotional stability or predictability and interact appropriately with coworkers, supervisors, and the public on a daily basis. Id.

         On November 17, 2010, State agency reviewing psychiatrist D. Lucila, M.D., reviewed the record evidence and found that Plaintiff had an affective disorder and a personality disorder (AR 223) that caused mild restriction of activities of daily living, and moderate difficulties in maintaining social functioning, concentration, persistence, or pace (AR 231). Dr. Lucila also found that there was insufficient evidence of any repeated episodes of decompensation. AR 231. Also on November 17, Dr. Lucila completed a Mental Residual Functional Capacity Assessment form. AR 234-35. On this form, Dr. Lucila opined that Plaintiff was moderately limited in his abilities to understand, remember, and carry out detailed instructions, complete a normal workday and workweek without interruptions from psychologically-based symptoms, interact appropriately with the general public, accept instructions and respond appropriately to criticism from supervisors, get along with coworkers or peers without distracting them or exhibiting behavioral extremes, and maintain socially appropriate behavior and adhere to basic standards of neatness and cleanliness. Id. Dr. Lucila stated that otherwise, Plaintiff was not significantly limited in most areas of mental functioning, including in the abilities to understand, remember, and carry out very short instructions, maintain attention and concentration for extended periods, sustain an ordinary routine without special supervision, work in coordination with or in proximity to others without being distracted by them, and respond appropriately to changes in the work setting. Id.

         On July 21, 2011, L. Crumpler, M.D., at LifeLong Medical Care, reported that Plaintiff was cooperative and pleasant, was alert and oriented times three, and had an antalgic gait. AR 257-58. Dr. Crumpler ordered x-rays after Plaintiff's complaints of leg pain, reported that Plaintiff's asthma was controlled and that Plaintiff was given an inhaler, and stated that Plaintiff would start Paxil for his depression. AR 258. Plaintiff denied having any current suicidal or homicidal ideation, reported sleeping too much, and reported that his appetite was okay. AR 257.

         On August 25, 2011, Plaintiff's clinician at Alameda County Behavioral Health noted that his last dose of Paxil was on July 20, 2011. AR 255. The clinician reported that on mental status examination, Plaintiff was cooperative, had behavior, orientation, thought content, and thought processes within normal limits, and had depressed and dysthymic mood, flat affect, fair insight, fair impulse control, fair judgment, and no hallucinations. AR 255-56.

         On August 29, 2011, a doctor at Alameda County Behavioral Health reported that Plaintiff was "clear" and cooperative, had no observed abnormal movements, had speech within normal limits, and found the change in medication to Remeron "helpful" and asked for medication "to control his anxiety." AR 254.

         On October 28, 2011, Dr. Crumpler saw Plaintiff for his asthma, mental health, and sores on his penis. AR 335. Dr. Crumpler assessed Plaintiff's asthma as mild and intermittent, found Plaintiff's depression controlled by his taking Remeron and Buspar, and found that the sores had healed. Id.

         On November 7, 2011, registered psychological assistant Katherine Wiebe, Ph.D., examined Plaintiff upon referral by the Homeless Action Center. AR 265-80. Dr. Wiebe reported that Plaintiff was well-groomed and casually dressed, had an anhedonic mood, was mildly dysphoric, was generally dissociated, had normal affect, was cooperative during the interview, had normally flowing thoughts, appeared to have "slow[]" thinking with delayed responses, had vague speech, expressed suicidal ideation without intent, denied current auditory or visual hallucinations while stating he had them "in the past, " and was oriented to person, place, and time. AR 268. She also noted that Plaintiff did not have a cane with him though he usually did. AR 267.

         Dr. Wiebe found that Plaintiff had severe impairment in memory, visual and spatial fields, executive areas, and attention, concentration, and persistence, as well as moderate sensory, motor, and language impairments, and mildly to moderately impaired intellectual functioning. AR 276. She also stated that Plaintiff's symptoms made him unlikely to be able to complete tasks assigned to him in a work setting; he was easily fatigued; he required reminders to accomplish tasks; had difficulty leaving his home due to paranoia, anxiety, and depression; was limited in his ability to manage daily tasks and affairs; and had trouble with interpersonal relationships because of his personality disorder symptoms. Id. Dr. Wiebe diagnosed Plaintiff with major depressive disorder - recurrent, chronic, severe, and with psychotic features. Id. She reported that Plaintiff was in the <0.1 to 4 percentile for the RBANS tests. AR 278. Dr. Wiebe opined that Plaintiff had mild impairment in intellectual functioning, minimal impairment in orientation, moderate impairment in language and motor and praxis skills, severe impairment in attention and concentration, short-term memory, long-term memory, visual and spatial organization, judgment and insight, executive functioning, and social functioning, marked impairment in the ability to understand, remember, and carry out very short and simple instructions, get along and work with others, and accept instructions and respond appropriately to criticism from supervisors, and extreme limitation in the rest of the abilities, including the ability to maintain attention and concentration for two hour segments, perform at a consistent pace without an unreasonable number and length of rest periods, interact appropriately with the general public, respond appropriately to changes in a routine work setting and deal with normal work stressors, complete a normal workday and workweek without interruptions from psychologically-based symptoms, and maintain regular attendance and be punctual within customary, usually strict tolerances. AR 279-80.

         On December 14, 2011, William Spivey, Ph.D., filled out a Mental Impairment Questionnaire. AR 283-87. Dr. Spivey indicated that Plaintiff had mild impairments in understanding and remembering very short and simple instructions, making simple work-related decisions, asking simple questions or requesting assistance, maintaining socially appropriate behavior, and adhering to basic standards of neatness and cleanliness, and moderate impairment in carrying out very short and simple instructions, sustaining an ordinary routine without special supervision, accepting instructions and responding appropriately to criticism from supervisors, being aware of normal hazards and taking appropriate precautions, interacting appropriately with the general public, traveling in unfamiliar places, and using public transportation. AR 285-86. He also indicated that Plaintiff otherwise had marked or extreme limitations in the rest of the mental abilities and aptitudes needed to do unskilled, semiskilled, and skilled work, and to do particular jobs. Id. Such abilities and aptitudes include remembering work-like procedures, maintaining attention for two hour segments, maintaining regular attendance and being punctual within customary, usually strict tolerances, working in coordination with or in proximity to others without being unduly distracted, and completing a normal workday and workweek without interruptions from psychologically-based symptoms. Id. They also include performing at a consistent pace without an unreasonable number of and lengths of rest periods, getting along with coworkers or peers without unduly distracting them or exhibiting behavioral extremes, responding appropriately to changes in a routine work setting, and dealing with normal work stress. Id. Dr. Spivey opined that Plaintiff had marked restriction of activities of daily living, difficulties in maintaining social functioning, deficiencies in concentration, persistence, or pace, and three repeated episodes of decompensation within a twelve-month period, each of at least two weeks duration. AR 286.

         On March 20, 2012, Board certified internist Jenna Brimmer, M.D., conducted a consultative internal medicine examination, as Plaintiff complained of a leg injury. AR 291-95. Dr. Brimmer reported that Plaintiff suffered a right leg fracture around late 2010 when he fell off a second story balcony and subsequently underwent surgery with hardware placed. AR 291. Dr. Brimmer reported that Plaintiff was pleasant and cooperative, spoke in full sentences and used hand gestures while talking, and was casually dressed with adequate grooming and hygiene. AR 292. Plaintiff reported to Dr. Brimmer that he could dress himself but needed help with putting on his pants and washing his feet due to his leg pain, he could heat food in the microwave, do dishes, and vacuum, and that he fed birds during the day as a hobby. AR 291-92. Dr. Brimmer reported that Plaintiff came with a cane and walked with a limp, but that he had no difficulty moving about the exam room, getting onto the exam table, manipulating his clothing and personal items, opening the door, and writing his name independently. AR 292.

         Dr. Brimmer reported that on physical examination, Plaintiff had full 5/5 strength in the lower extremities, had no evidence of muscle atrophy, was able to stand on his tiptoes and heels, and could walk heel-to-toe in a straight line. AR 293-94. She opined Plaintiff could stand or walk for six hours in an eight-hour workday, could sit without limitation, could walk with a cane, could lift up to 50 pounds occasionally and 25 pounds frequently, could occasionally take part in climbing, balancing, stooping, kneeling, crouching, and crawling, could perform manipulative activities without limitation, and could perform workplace environmental activities without limitation. AR 294-95.

         On April 19, 2012, State agency reviewing physician L. Pancho, M.D., reviewed the medical evidence in the record. AR 301-02. Dr. Pancho opined that Plaintiff was able to lift and carry 50 pounds occasionally and 25 pounds frequently, stand or walk for a total of about six hours in an eight-hour workday, and sit for a total of about six hours in an eight-hour workday. Id. Dr. Pancho also determined that Plaintiff was unlimited in pushing or pulling, and could occasionally climb ramps and ladders, balance, stoop, kneel, crouch, and crawl. Id.

         On June 7, 2012, Plaintiff completed an Adult Medical History form for LifeLong Medical Care. AR 330-33. On the form, he indicated that he had a history of asthma, that he took the medications Remeron and Burspuren [sic] and used an asthma pump, and that he had a history of problems involving dizziness, forgetfulness, headaches, sinus problems, tooth pain, pain or loss of strength or feeling in the hips and legs and knees, depression, and biting his skin. AR 330-31. Plaintiff indicated that he did not feel threatened by anyone, that he felt safe in his home, and that he had a gun and smoke detector in his home. AR 332.

         On July 5, 2012, a medical provider at LifeLong Medical Care continued Plaintiff on Ibuprofen, asthma inhaler treatment, and Remeron and Buspar treatment for his leg pain, asthma, and depression. AR 324, 326.

         On July 26, 2012, Rene Thomas, M.D., conducted a psychiatric evaluation. AR 322-23. Plaintiff denied, to Dr. Thomas, having any prior psychiatric treatment or hospitalizations prior to his being in Santa Rita Jail starting in 2010. AR 322-23. Plaintiff reported to Dr. Thomas that the antidepressant Remeron had been effective in controlling his depressive symptoms and helped him sleep better, but the symptoms returned when he had not taken Remeron in three months. Id.

         On mental status examination, Dr. Thomas noted that Plaintiff was alert, neatly dressed, calm, and appropriate, and had a normal speech rate and rhythm. AR 323. Dr. Thomas also stated that Plaintiff had a depressed mood, had a positive affect within the normal range, did not appear depressed, had logical and coherent thought processes, had no suicidal or homicidal ideation, had no auditory or visual hallucination, did not exhibit any evidence of delusions or paranoid ideation, and appeared to have normal cognition. Id. Dr. Thomas diagnosed Plaintiff with a recurrent major depressive disorder, as borderline intellectual functioning by history, and as taking part in marijuana use. AR 323. Dr. Thomas recommended that Plaintiff restart Remeron and another medication, Buspar, for Plaintiff's nail biting, and that Plaintiff follow up in one month. Id. Dr. Thomas continued Plaintiff on asthma inhaler treatment. AR 321.

         Between August 30, 2012 and January 14, 2013, Plaintiff periodically received treatment from Health Care for the Homeless via the TRUST Clinic. AR 339-46. On August 30, 2012, he reported to Nurse Practitioner Laurel Barber that he was currently taking the medications Remeron and Risperdal, that Remeron was the only reason he could sleep, that he took Risperdal to make the voices go away, and that his last auditory hallucination was about a year prior. AR 345. Ms. Barber reported that on mental status examination, Plaintiff was casually dressed, had poor eye contact, was "very cooperative, " had slow and soft speech, described his mood as depressed and affect as sad, had linear and logical thought process, denied auditory and visual hallucination, denied paranoia and delusions, was fully alert and oriented, and had fair insight and poor judgment. AR 346.

         On September 6, 2012, Dr. Thomas at Lifelong Medical Care reported that Plaintiff was alert, calm, engageable, neatly dressed, and exhibited a flat affect. AR 320. Plaintiff reported sleeping well on Remeron but had a poor appetite. Id. He reported having no side effects from taking Remeron and Buspar, denied having any suicidal ideation, homicidal ideation, or feelings of hopelessness, and complained of being irritable with his brother for "little things." Id. Dr. Thomas assessed Plaintiff as having a recurrent major depressive disorder, with no improvement yet. Id. Dr. Thomas increased Plaintiff's prescriptions for Remeron and Buspar, and discussed counseling referrals with Plaintiff. Id.

         On September 24, 2012, Adisa Wilmer, M.D., at Lifelong Medical Care, reported that Plaintiff had right leg pain and strain, reduced strength in his right hamstring, and that his asthma and depression were stable. AR 318.

         On September 26, 2012, Plaintiff received treatment at LifeLong Medical Care for his complaints of leg pain and a cold. AR 316. Plaintiff continued using an asthma inhaler. AR 374.

         On October 22, 2012, Plaintiff visited LifeLong Medical Care, complaining of leg pain and requesting an asthma pump; also, the doctor, Dr. Wilmer, reported that Plaintiff's depression was "stable." AR 315. Dr. Wilmer referred Plaintiff for x-rays of his right knee. AR 317.

         On October 31, 2012, Plaintiff saw Michael Boroff, M.D., at the TRUST Clinic and complained of leg pain, anger issues, depression, problems sleeping, auditory hallucinations, fainting spells, and frequent biting of his fingers. AR 343. Dr. Boroff reported that on mental status examination, Plaintiff was cooperative and engaged, struggled to articulate his symptoms and was often vague when questioned. AR 343. Dr. Boroff also stated that Plaintiff denied having any suicidal ideation but self-reported having a severely depressed mood and frequent auditory hallucinations, though he did not appear to be attending to them in the session. Id. Plaintiff also self-reported having feelings of significant paranoia, denied and gave no obvious indications of mania or depersonalization, had apparently impaired memory and focus, and had estimated below-average intelligence. AR 343-44.

         On December 13, 2012, Plaintiff saw Dr. Boroff again and reported experiencing leg pain that kept him from standing or walking for long periods of time. AR 341. Plaintiff also told Dr. Boroff that he was relying on others to help him keep track of things in his life, about his history of being in special education, about dropping out of school to support his wife, and that he had a poor memory, problems focusing, and difficulties with reading comprehension. Id.

         On December 27, 2012, Plaintiff reported to Dr. Boroff that his mood was "down" due to his being out of medication, and that "When on medication, he feels much better, " although "even with medication, he has to avoid people, as they trigger his anger." AR 340. Plaintiff gave vague answers about his psychotic symptoms but denied hearing voices, although he reported that he talks to himself. Id.

         On January 14, 2013, Plaintiff saw Dr. Boroff while in distress, as he was hearing voices again and was out of medication. AR 339.

         Dr. Boroff conducted a psychological evaluation based on meetings with Plaintiff on August 30, 2012, October 31, 2012, December 13, 2012, December 27, 2012, and January 14, 2013. AR 353-54. In his psychological evaluation, Dr. Boroff reported that Plaintiff struggled to make it to his appointments and gave vague answers to questions posed to him, but on mental status examination, Plaintiff was oriented times four, and was cooperative and engaged. AR 354. Dr. Boroff stated that Plaintiff self-reported that his mood was depressed, but his affect was not mood-congruent, and that Plaintiff smiled at inappropriate times. Id. Dr. Boroff also noted that Plaintiff denied having any suicidal or homicidal ideation, though he reported hearing voices that commanded him to hurt himself, and self-reported having intense feelings of paranoia, although neither paranoia nor auditory hallucinations were apparent in sessions. Id. The doctor also mentioned Plaintiff's coherent speech, and that Plaintiff denied experiencing and did not display obvious signs of mania or depersonalization, and had limited insight, had severely impaired judgment, demonstrated clear deficits in memory and focus, and had estimated below-average intelligence. Id.

         On February 5, 2013, intern Sarah Ulloa at Alameda County Behavioral Health Care Services reported that Plaintiff was prescribed the medication Risperdal at Lifelong Clinic and that Plaintiff stated that the medication was helpful. AR 359. Plaintiff denied having any suicidal ideation, and on mental status examination, Plaintiff was alert, had clear speech and "good" grooming, made good eye contact, and was cooperative (though a poor historian). Id.

         On February 14, 2013, Dr. Boroff completed a Mental Impairment Questionnaire. AR 347-51. Dr. Boroff stated that Plaintiff exhibited signs and symptoms included paranoia and suspiciousness, his list of prescribed medications showed Remeron and Risperdal, and he experienced side effects of drowsiness, lethargy, and weight gain. AR 347-48. Dr. Boroff gave a prognosis of "Poor. Permanently disabled" and the list of clinical findings demonstrating the severity of Plaintiff's mental impairment and symptoms shows that Plaintiff has: depressed mood, incongruent affect, impaired memory and focus, below-average intelligence, limited insight, poor judgment, and reports of auditory hallucinations and paranoia. AR 347.

         Dr. Boroff opined that Plaintiff was seriously limited, but not precluded from carrying out very short and simple instructions, making simple work-related decisions, responding appropriately to changes in a routine work setting, and adhering to basic standards of neatness and cleanliness. AR 348-49. Dr. Boroff also noted that Plaintiff had limited but satisfactory ability to ask simple questions, be aware of normal hazards and take appropriate precautions, travel in an unfamiliar place, and use public transportation. AR 349. Dr. Boroff opined that Plaintiff was unable to meet competitive standards or had no useful function in all other mental abilities and aptitudes needed to do unskilled work and semiskilled to skilled work, and to do particular types of jobs. Id. Such abilities and aptitudes include maintaining regular attendance, working in coordination with or proximity to others without being unduly distracted, completing a normal workday and workweek without interruptions from psychologically-based symptoms, getting along with coworkers or peers without unduly distracting them or exhibiting behavioral extremes, dealing with normal stress, interacting appropriately with the general public, and maintaining socially-appropriate behavior. Id.

         Dr. Boroff reported that Plaintiff's anger and paranoia severely impaired Plaintiff's social functioning. AR 349. He opined that Plaintiff had moderate restriction of activities of daily living, extreme difficulties in maintaining social functioning, marked deficiencies in concentration, persistence, or pace, and one or two episodes of decompensation within a twelvemonth period, each of at least two weeks duration. AR 350. He also opined that Plaintiff had a "Medically documented history of a chronic organic mental, schizophrenic, etc. or affective disorder of at least [two] years' duration that has caused more than a minimal limitation of ability to do any basic work activity, with symptoms or signs currently attenuated by medication or psychosocial support, " and "A residual disease process that . . . resulted in such marginal adjustment that even a minimal increase in mental demands or change in the environment would be predicted to cause the individual to compensate." AR 350-51. Dr. Boroff noted that the impairments lasted or can be expected to last at least twelve months. AR 351.

         On February 5, 2013, Plaintiff was initially screened for psychiatric treatment at Alameda County Behavioral Health Care Services, but he eventually asked to be rescheduled because he felt it was too long a wait. AR 357-60.

         On February 19, 2013, Neelam Sachdev, M.D., at Alameda County Behavioral Health Care Services reported that Plaintiff was alert, oriented, and cooperative, made fairly good eye contact, and had clear speech, anxious and depressed mood, a somewhat dysthymic affect, linear thought processes, and no suicidal or homicidal ideation or auditory or visual hallucinations. AR 361. Plaintiff reported that the medication Buspar helped him with his problem of biting the skin on his fingers. Id.

         On March 5 and 19, 2013, Dr. Sachdev reported that Plaintiff did not attend his scheduled appointments. AR 363-64.

         On April 9, 2013, Plaintiff informed Dr. Sachdev that he had been to Santa Rita Jail more than twenty-five times since 1998, that he had taken the medications Buspar and Remeron, which had helped him, and that he had received treatment at LifeLong. AR 365. Dr. Sachdev reported that Plaintiff denied experiencing feelings of paranoia, having auditory or visual hallucinations, and having any suicidal or homicidal ideation. Id. Plaintiff told Dr. Sachdev that he was sleeping and eating "good." Id. Dr. Sachdev reported that on mental status examination, Plaintiff appeared to be somewhat guarded but spoke clearly and mostly coherently, described his own mood as "fine, " had a guarded affect, and was a little hypomanic, with what appeared to be some loose and circumstantial thought processing. AR 365-66. Dr. Sachdev described Plaintiff as "grandiose" based on his statements that his uncle is the famous baseball player Willie Mays, that all his incarcerations were a result of being "set up, " and that many women wanted Plaintiff and would say untrue things about him if he tried to leave them. AR 365-66. Dr. Sachdev recommended that Plaintiff continue with the medications Remeron and Buspar and that he follow up with Dr. Sachdev in four months. AR 366. Plaintiff refused to take any anti-psychotic medication, such as Risperdal, Lithium, or Dekapote. Id.

         On May 21, 2013, Dr. Sachdev reported that Plaintiff was a no-show for his appointment, but he was continued on the medications Remeron and Buspar. AR 367.

         On September 5, 2013, Plaintiff visited LifeLong Medical Care after previously seeing Dr.

         Wilmer in 2012; he was returning after his recent incarceration at Santa Rita Jail in order to reestablish care. AR 373. Plaintiff had no changes in medication, denied having any suicidal or homicidal ideation or auditory hallucinations, reported that medication helped his mood, and requested a referral for physical therapy because of a leg injury he suffered in 2011. AR 373.

         On January 13, 2014, Plaintiff visited Serena Wu, M.D., at LifeLong Medical Care because he was experiencing pain in his right knee and he additionally wanted to get his medication refilled. AR 369. Dr. Wu noted that although Plaintiff was previously referred for physical therapy, he never followed-up, and although he was referred to a psychiatrist during his previous ...


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