Ontiveros-Yarbrough v. Colvin

          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         On examination, Plaintiff had “psychomotor retardation, ” a guarded, aloof and withdrawn manner, rambling speech, anxious mood, restricted and blunted affect, disorganized thought process, paranoid ideation, audio hallucinations, distractible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. ...