United States District Court, E.D. California
ORDER RE PLAINTIFF’S SOCIAL SECURITY
APPEAL
SHEILA
K. OBERTO UNITED STATES MAGISTRATE JUDGE
I.
INTRODUCTION
Plaintiff,
Michael Ontiveros-Yarbrough (“Plaintiff”), seeks
judicial review of a final decision of the Commissioner of
Social Security (the “Commissioner”) denying his
application for Supplement Security Income
(“SSI”) Benefits pursuant to Title XVI of the
Social Security Act. 42 U.S.C. § 1381-83. 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.[1]
II.
FACTUAL BACKGROUND
Plaintiff
was born on March 15, 1993, and alleges disability beginning
on January 19, 2009. (Administrative Record
(“AR”) 13; 208-09.) Plaintiff claims he is
disabled due to paranoid schizophrenia and auditory
halluciantions. (See AR 223.)
A.
Relevant Medical Evidence [2]
On July
15, 2009, Dr. Sugnaykumar P. Patel, M.D., examined Plaintiff
after referral from his primary care provider. (AR 285-92;
422-26.) Dr. Patel noted a history of substance abuse,
including marijuana, hashish, and “club drugs”
such as ecstasy, “poppers, ” and GHB and reported
Plaintiff had used these drugs a “few times” in
the preceding weeks. (AR 286; 291.) Plaintiff’s
description of his symptoms was “vague, confused and
circumstantial” and Plaintiff’s mother reported
he was acting “strange, ” mumbling to himself,
and had put towels over the blinds on the windows. (AR 286.)
On
examination, Plaintiff had “psychomotor retardation,
” a guarded, aloof and withdrawn manner, rambling
speech, anxious mood, restricted and blunted affect,
disorganized thought process, paranoid ideation, audio
hallucinations, distractible attention, and impaired
concentration. (AR 287.) Plaintiff’s impulse control,
insight and judgment, however, were all fair, his fund of
knowledge was normal, his memory was intact, he was fully
oriented, and he was healthy and appropriately dressed (AR
287). Dr. Patel diagnosed Plaintiff with psychotic disorder
and substance induced psychotic disorder. (AR 285.) Plaintiff
was prescribed Seroquel, a drug used to treat schizophrenia.
(AR 288.) Dr. Patel assessed Plaintiff with a
GAF[3]
score of 51-60, reflecting only “moderate”
symptoms. (AR 288.)
On
January 4, 2010, Plaintiff was examined by licensed social
worker Susan Seruby, LCSW, for sleep medication. (AR
296-301.) Plaintiff reported sleeping poorly for
“several days” and experiencing audio and visual
hallucinations, reporting that had not taken his prescribed
Seroquel out of fear of how the medicine would interact with
marijuana. (AR 296.) Plaintiff reported using marijuana two
days prior, but claimed his use of marijuana and alcohol was
“to deal with the voices and hallucinations” and
that he “wants to stop the use.” (AR 296.)
Plaintiff’s mother told Ms. Seruby that Plaintiff was
“a good boy” who “just need[ed] medication
to help him manage.” (AR 296.) Plaintiff denied
suicidal or homicidal intent and did not qualify for
hospitalization. (AR 296.) Plaintiff’s mental status
improved somewhat, with no “psychomotor retardation,
” normal behavior, cooperative demeanor, normal speech,
stable mood, full range and appropriate affect, logical
thought processes and content, and was fully oriented, with
normal memory, attention and concentration, age-appropriate
fund of knowledge, excellent impulse control, good insight,
and fair judgment. (AR 297.) Ms. Seruby opined Plaintiff had
historical and current psychosis, mild paranoia, and a
history of non-compliance with medication but did not opine
to any particular diagnosis. (AR 297-98.) She assigned
Plaintiff a GAF score of 51-60, reflecting only moderate
symptoms. (AR 298.) Plaintiff stated he was willing to follow
her recommended treatment plan, including regularly taking
his prescribed medications and ceasing cannabis and alcohol
use. (AR 297.)
On
January 5, 2010, Dr. Sreekanth Chava, M.D., examined
Plaintiff after he referral by Ms. Seruby. (AR 302-07;
427-32.) Plaintiff displayed good social skills, reported
having many friends, and told Dr. Chava that he had not
undergone psychological testing. (AR 304.) Plaintiff reported
smoking cigarettes and consuming alcohol regularly, and
smoking one to two “blunts” of marijuana daily a
year and a half. (AR 304.) On examination, Plaintiff was
appropriately dressed but disheveled; had psychomotor
agitation; talked and laughed to himself; was hyperverbal,
disorganized, and anxious with blunted affect; had paranoid
ideation with ideas of reference and hallucinations,
distractible attention, and poor impulse control, insight,
and judgment; was aloof and fully oriented; and had normal
concentration, intact memory, and an age-appropriate fund of
knowledge. (AR 305.) Dr. Chava diagnosed psychosis not
otherwise specified (NOS) with “polysubstance abuse vs.
dependence” and ruled out substance-induced psychotic
disorder. (AR 305.) Dr. Chava assigned Plaintiff a GAF score
of 41-50, reflecting “serious symptoms.” (AR
305.) Plaintiff agreed to take his Seroquel and enrolled in
outpatient group therapy. (AR 306.)
On
January 8, 11, and 12, 2010, Plaintiff participated in
intensive outpatient group therapy with Drs. Shoujie Zhang,
M.D., and Diane Kawagoe, Ph.D. (AR 308- 17; 318-22; 323-31;
433- 41.) Plaintiff had “good response to
medication” (AR 320) and his condition
“significantly improved” with treatment (AR 320).
(See AR 305 (GAF score of 41-50 on January 5th); 321
(GAF score of 51-60 on January 11th); 326 (GAF score of 61-70
on January 12th). On January 12, 2010, Plaintiff denied
hallucinations but was observed to be “very
guarded” and “appeared to be responding to
internal stimuli throughout interview, often smiling, but
unwilling to share thoughts or feelings fueling
smile[.]” (AR 326.) On January 15, 2010, Dr. Zhang
increased Plaintiff’s Seroquel’s dosage after
Plaintiff’s mother reported he was talking to himself
more and more easily irritable and angry. (AR 332.)
On
January 26, 2010, Plaintiff reported becoming “sedated
and verbally aggressive” and seeing “eye
particles” on Seroquel so Dr. Chava changed his
prescription to Risperdal, another anti-psychotic medication.
(AR 334-37; 442-45.) Plaintiff’s mother reported
Plaintiff “paced back and forth” and
“continue[d] to talk and smile to himself, stare at the
walls, [and got] distracted easily during conversation”
but was now sleeping for up to 10 hours. (AR 335).
Plaintiff’s academic functioning, family relations, and
peer relations were all “impaired.” (AR 335.)
On
examination, Plaintiff talked and laughed to himself a few
times; expressed anxious mood, halting speech, disorganized
thought process, paranoid ideation and hallucinations; and
was noted to have distractible attention and poor insight.
(AR 335.) Plaintiff was, however, also observed to be
well-groomed and appropriately dressed, exhibited normal
behavior, had congruent mood, was fully oriented, and had
normal concentration, intact memory, age appropriate fund of
knowledge, and “improving” impulse control and
judgment. (AR 335.) Dr. Chava again assigned a GAF score of
41-50. (AR 336.)
Plaintiff
cancelled his follow-up appointments and was not seen again
until April 16, 2010. (AR 340; 345; 446-47.) Plaintiff and
his mother both reported partial improvement with Risperdal,
and Dr. Chava assessed an improved GAF score of 51-60. (AR
345-48; 448-51.) Plaintiff refused a urinary drug screen
(UDS), though he denied substance abuse. (AR 346.)
Plaintiff
was next seen on January 20, 2011, reported smoking five to
six cigarettes each day and smoking marijuana once a week,
and denied abusing other substances. (AR 355.)
Plaintiff
reported good response to medication, and Dr. Chava noted a
pleasant demeanor, lack of psychomotor abnormalities,
positive (euthymic) mood, no evidence of hallucinations, full
orientation, attention and concentration within normal
limits, and fair impulse control, insight and judgment on
examination. (AR 356.) Dr. Chava assigned Plaintiff a GAF
score of 71-80 for “transient symptoms, ”
assessed psychosis and cannabis abuse, and ruled out
substance-induced psychotic disorder. (AR 356.)
Plaintiff
was next seen on September 13, 2011, and reported he had not
taken his anti-psychotic medication for five to six months
but had continued smoking cannabis on a daily basis. (AR
364.) Plaintiff’s mother claimed he was talking to
himself and throwing things “randomly” in his
room while unmedicated. (AR 364.) His mother reported
experiencing psychotic symptoms including paranoid delusions,
auditory hallucinations, auditory “command”
hallucinations, thought blocking, and disorganized behavior.
(AR 364.) Plaintiff had stopped smoking cannabis two weeks
prior and had resumed taking his medication three days before
the visit, and his mother reported a slight improvement in
his symptoms. (AR 364.)
Plaintiff
“report[ed] multiple voices, talking between
themselves, at time single voice ‘doing running
commentary, ’ worried that people are reading his mind
and trying to do ‘mean things.’” (AR 364.)
Plaintiff reported “psychosis including hallucinations,
delusions, disorganized speech, inappropriate affect,
paranoia, thought blocking, thought insertion, and thought
broadcasting, and “denied suicidality, homicidality,
current substance use, command auditory hallucinations, or
access to weapons.” (AR 364-65.) Plaintiff appeared
“fidgety, ” guarded and distracted, with halting
speech, anxious mood, disorganized thought process, paranoid
ideation, delusions, and hallucinations, and was seen talking
to himself. (AR 364.) Plaintiff had a congruent affect; was
fully oriented; had normal concentration, intact memory,
age-appropriate fund of knowledge; and had fair impulse
control, insight and judgment. (AR 364.) Dr. Chava assigned a
GAF score of 41-50 reflecting “serious symptoms,
” assessed psychosis and cannabis abuse, ruled out
substance induced psychotic disorder, and ruled out paranoid
type schizophrenia. (AR 365.) Dr. Chava further opined
Plaintiff “present[ed] with ongoing psychotic
sym[ptoms] in the setting of treatment noncompliance and
substance abuse” and increased Plaintiff’s
Risperdal to treat psychosis. (AR 365.)
Plaintiff
participated in intensive outpatient group therapy in
September through October 2011. (See AR 368- 417.)
Plaintiff’s first therapy session, led by Dr. Firoz
Bashirahmed Munshi, M.D., took place on September 14, 2011.
(AR 368-77.) Plaintiff initially reported “extreme
paranoia, ” felt uncomfortable, and refused to talk
with Dr. Munshi, insisting that he could only talk with Dr.
Chava. (AR 368.) Plaintiff reported ceasing smoking
marijuana, but Dr. Munshi considered this report
“debatable.” (AR 368.) Plaintiff’s mother
reported he had flushed his medications down the toilet three
months earlier and was not sleeping well and suspected
Plaintiff’s friends were supplying him with marijuana.
(AR 369.)
Plaintiff
was not talkative and Dr. Munshi suspected “underlying
paranoid thinking, ” but he was observed to be alert
and oriented; dressed appropriately though disheveled; had
normal concentration, normal speech rate, volume and tone,
and fair mood with restricted affect; linear, logical, and
goal-directed though “blocked” thought processes;
and had intact memory and cognition, average fund of
knowledge, and fair judgment, insight and impulse control.
(AR 369.) Dr. Munshi updated Plaintiff’s risk
assessment with “significant psychotic symptoms --
suspected drug abuse” and assessed him with
“severe psychotic symptom co-morbid with cannabis abuse
as well as medication non-compliance issues.” (AR 369.)
Plaintiff reported resuming his medications and ceasing
smoking marijuana, denied suicidal or homicidal ideation,
intention or plan, and was not considered a candidate for
involuntary hospitalization. (AR 370.) Dr. Munshi assigned
Plaintiff a GAF score of 51-60, reflecting moderate symptoms.
(AR 370.)
Plaintiff
actively participated in another group therapy session led on
September 14, 2011, by JoAnn Carroll, M.F.T. (AR 370-77;
461-65.) Plaintiff behaved “normally, ” was
pleasant and cooperative, provided good insight and
engagement, was “hopeful about the future, ” and
reported attending adult high school to obtain his GED. (AR
370-74.) Plaintiff admitted smoking marijuana daily for the
past year, and told Ms. Carroll he had quit one week and ten
days prior. (AR 374; see also AR 385 (positive
September 11, 2011, drug test for marijuana use).)
Plaintiff
reported his audio hallucinations had returned after he
flushed his medication down the toilet one month before the
therapy session. (AR 374.) On examination, Ms. Carrol noted
no abnormal findings, observing good impulse control,
insight, and judgment, and a normal range of concentration.
(AR 376.) Ms. Carroll assessed Plaintiff as presenting a
“low” risk and assigned Plaintiff a GAF score of
51-60, reflecting moderate symptoms. (AR 376.)
On
September 16, 2011, Plaintiff attended another group therapy
session led by Dr. Kathleen Friedland, Ph.D. (AR 378-80.)
Plaintiff actively participated, reported feeling better,
measuring himself at “10 on a 10 point scale, ”
and expressed enthusiasm about life, the way “he used
to feel” before the onset of his schizotypal symptoms.
(AR 378-79.) Plaintiff denied auditory hallucinations and on
examination was noted to have good impulse control and
insight, pleasant demeanor, and no abnormal symptoms or
behavior. (AR 378-79.) On September 19, 2011, Plaintiff was
the first to share in the group, reported an improvement in
sleep and mood, and said that the “only thing”
causing distress was quitting smoking cigarettes. (AR 381.)
Plaintiff reported ceasing marijuana use, exhibited increased
focus and attention, smiled, and appeared to be “in a
positive mind set.” (AR 381.) Ms. Carroll assigned
Plaintiff a GAF score of 61-70, reflecting “mild
symptoms” (AR 381.)
On
September 21, 2011, Dr. Chava examined Plaintiff and found
his symptoms “significantly improved.” (AR
384-86.) Plaintiff slept and ate well; denied any audio or
visual hallucinations, paranoia, delusions, other psychotic
symptoms or “any other concerns;” and found
stopping cannabis use and taking his medication helpful. (AR
385.) On examination, Dr. Chava noted no abnormalities and
observed Plaintiff to be “significantly better from the
last visit” and Plaintiff’s impulse control,
insight and judgment to have improved. (AR 385.) Dr. Chava
assigned Plaintiff a GAF score of 51-60, reflecting moderate
symptoms. (AR 385-86).
On
September 27, 2011, Plaintiff was an active participant in
group therapy and reported responding well to treatment,
sleeping well, “optimism, and an above-average
mood.” (AR 389.) On examination, Amany Issa Hararah,
psychologist trainee, noted no abnormalities in
Plaintiff’s mental status and assessed Plaintiff as
“no” risk. (AR 389-90.) On October 7, 2011,
Plaintiff again reported responding well to treatment,
sleeping well, optimism, and an above average mood, endorsing
a “5 signifying great for feeling/thoughts about
oneself, home and work environment on the adult check in
form.” (AR 394-95.) However, during the group session
Plaintiff was also observed to smile to himself and
“appeared distracted by external stimuli.” (AR
395.)
On
October 10, 2011, Dr. Patel observed Plaintiff’s
“symptoms of psychosis have significantly improved over
[the] last several weeks.” (AR 398.) Plaintiff denied
auditory hallucinations, visual hallucinations, paranoia,
delusions, or other psychotic symptoms; denied substance use
for prior several weeks; and reported eating well, sleeping
well, and being “happy with the improvements with
current treatment.” (AR 398-99.) Dr. Patel assessed a
GAF score of 70-80, reflecting “mild symptoms”
(AR 400). That same day, however, Elaine Ingham Schomaker,
LCSW, noted Plaintiff was “very restless” in the
group therapy session, having run out of Ativan a few days
prior, and reported having had a “fantastic”
weekend though his parents “are just glad [he] lived
through the weekend.” (AR 401.) Plaintiff
“admitted when he hears the voices, he responds to them
‘telling me what to do’” and admitted
“he is never sure what he will do and, many times, the
behavior is aggressive with a sense of anger.” (AR
401.) Though the voices never tell him to harm himself,
Plaintiff reported being “‘terrified’
because the voices and images have come back.” (AR
401.)
On
October 21, 2011, Vincenta M. Leigh, R.N., noted Plaintiff
reported feeling “great” with group therapy and
denied having current hallucinations or bad dreams. (AR 407.)
Plaintiff described symptoms as past occurences and said he
“might write a book on all that he has
experienced.” (AR 407.) On examination,
Plaintiff’s mental status was observed to be normal in
each category, and his speech, impulse control and
insight/engagement were all rated “good.” (AR
407; see also AR 410-11 (RN discharge summary);
412-13 (MSW maintenance group note).) Based on his improved
symptoms, RN Leigh discharged Plaintiff from group therapy.
(AR 407.) Plaintiff reported feeling “relieved”
to be discharged, noting he had been required to attend
therapy longer than the originally ordered two weeks. (AR
407.)
On
October 26, 2011, during a follow-up examination with Dr.
Chava, Plaintiff reported his “symptoms of psychosis
have resolved” and denied audial or visual
halluciations, delusions, or other psychotic symptoms. (AR
414-15; 466-67.) Plaintiff’s mother reported Plaintiff
had improved, and Dr. Chava assigned a final GAF score of
71-80, reflecting “transient symptoms.” (AR
415-16; 467-68.)
On
January 4, 2012, agency reviewing psychologist Dr. Celine
Payne-Gair, Ph.D., reviewed Plaintiff’s records and
diagnosed Plaintiff with “schizophrenic, paranoid and
other functional psychotic disorders” and “drug,
substance addiction disorders, ” both
“severe.” (AR 64.) Dr. Payne-Gair
determined[4] Plaintiff did not meet the
“Paragraph B” criteria because he exhibited only
“moderate” difficulties in maintaining social
functioning and concentration, persistence and pace, and had
only “one or two” episodes of decompensation of
extended duration and did not meet the “Paragraph
C” criteria.[5] (AR 65).
Dr.
Payne-Gair opined that before age 18, Plaintiff had psychosis
and “polysubstance abuse vs. dependence, ” and
“substance induced psychosis.” (AR 65.) After age
18, Dr. Payne-Gair opined Plaintiff had psychosis and
cannabis abuse; both resolved as of October 26, 2011, based
upon Plaintiff’s treating record and self-reports of
ceasing cannabis use, and ruled out substance induced
psychosis. (AR 65.) Dr. Payne-Gair concluded that
Plaintiff’s allegations, symptoms and statements
regarding severity of his symptoms were only partially
credible, as the allegations were not fully supported by
Plaintiff’s activities of daily living; the location,
duration, frequency and intensity of his symptoms; and
Plaintiff’s successful treatment with medication. (AR
65-66.)
Dr.
Payne-Gair opined Plaintiff had understanding and memory
limitations, as he was “moderately limited” in
his ability to understand and remember detailed instructions,
but would not have significant limitations in his ability to
remember locations and work-like procedures or understand and
remember short and simple instructions. (AR 66.) She further
opined Plaintiff would have sustained concentration and
persistence limitations because he would be “moderately
limited” in his ability to maintain attention and
concentration for extended periods and carry out detailed
instructions. (AR 66-67.) Dr. Payne-Gair found Plaintiff
moderately limited in his ability to get along with the
general public, accept instructions and respond appropriately
from supervisors, and get along with coworkers and peers
without distracting them or exhibiting behavioral extremes.
(AR 67.) She further found Plaintiff was not significantly
limited in his ability to perform activities within a
schedule, maintain regular attendance and be punctual,
sustain an ordinary routine without supervision, work in
coordination with others without being distracted by them,
make simple work-related decisions, complete a normal workday
and workweek without interruptions from psychologically based
symptoms, and perform at a consistent pace without an
unreasonable number and length of rest periods. (AR 67-68.)
Dr. Payne-Gair opined Plaintiff was “moderately
limited” in his ability to respond to changes in the
work setting, but was not limited in his ability to be aware
of normal hazards and take appropriate precautions, to travel
in unfamiliar places or use public transportation, or to set
realistic goals or make plans independently of others. (AR
67-68.) Dr. Payne-Gair concluded Plaintiff retained the
mental functional capacity to understand and remember simple
instructions, complete simple tasks, maintain attention and
concentration for periods of at least two hours and complete
a normal workday and workweek at a consistent pace, relate
appropriately to peers and supervisors as needed, and adapt
to routine workplace changes. (AR 68.)
On June
14, 2012, Dr. Zhang again examined Plaintiff. (AR 482-87.)
Plaintiff reported that he was “doing better” and
that his auditory hallucinations and delusions were
“well controlled” with Risperdal, his sleep was
“getting better” with Trazodone, and his
“anxiety and worry” were being treated with
Ativan. (AR 483.) Plaintiff denied using cannabis since
November 2011, and reported he was “thinking about
getting a job in the medical field and wanting to have
dat[ing] relationship[s] with others.” (AR 483.) On
examination, Plaintiff appeared well-groomed and healthy,
pleasant and cooperative, with normal speech, restricted
affect, logical thought process and goal directed thought
content, with fair impulse control, excellent insight, and
good judgment. (AR 484.) Dr. Zhang assessed Plaintiff with
“psychotic disorder in remission” and with a GAF
score of 61-70, reflecting “mild symptoms.” (AR
485.)
On
August 3, 2012, agency reviewing physician Dr. F.L. Williams,
M.D., reviewed Plaintiff’s medical records, including
the additional June 2012 records from Dr. Zhang, and
concluded no consultative examination was necessary. (AR 78.)
Dr. Williams noted Plaintiff’s auditory hallucinations
and delusions were well-controlled with Risperdal, his sleep
was improved with Trazodone, his anxiety was treated with
Ativan, and his last use of marijuana was in November 2011.
(AR 79.) Dr. Williams concurred for the most part with Dr.
Payne-Gair’s assessment, opining that Plaintiff can
relate appropriately to peers and supervisors as needed and
can adapt to routine workplace changes. (See AR
80-83.) Dr. Williams concluded Plaintiff fell under Medical
Vocational Guidelines Rule 204.00, for an individual of any
age, education, and skill level, to determine Plaintiff was
capable of performing the requirements of representative
occupations of laundry worker I, Dictionary of Occupational
Titles (“DOT”) 361.684-014, drier operator (can
& preserve), DOT 523.685-062, and kapok/cotton machine
operator (textiles), DOT 689.685-082. (AR 83.)
On
January 4, 2013, Dr. Chava again examined Plaintiff. (AR
495-99.) Plaintiff presented with full remission in psychosis
and cannabis abuse, and rule out substance-induced psychotic
disorder. (AR 497-98.) Plaintiff reported he avoided cannabis
and other substances and had thought about going back to
school and completing his GED. (AR 496.) On examination,
Plaintiff appeared healthy and appropriately dressed,
pleasant and cooperative, with normal speech, mood congruent
affect, logical thought process and normal thought content,
attention and concentration within normal limits, age
appropriate impulse control, and improving insight and
judgment. (AR 496-97.) Dr. Chava assessed Plaintiff with a
GAF score of 71-80, reflecting “transient
symptoms.” (AR 497.)
B.
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