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Rodriguez v. Berryhill

United States District Court, E.D. California

March 6, 2017

BELINDA RODRIGUEZ, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, [1]Defendant.

          ORDER ON PLAINTIFF'S SOCIAL SECURITY COMPLAINT (DOC. 1)

         I. INTRODUCTION

         On November 24, 2015, Plaintiff Belinda Rodriguez (“Plaintiff) filed a complaint under 42 U.S.C. §§405(g) and 1383(c) seeking judicial review of a final decision of the Commissioner of Social Security (the “Commissioner” or “Defendant”) denying her applications for disability insurance benefits (“DIB”) and Supplemental Security Income (SSI). (Doc. 1.) 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.[2]

         II. BACKGROUND

         On January 5, 2012, Plaintiff filed a claim for DIB and SSI payments, alleging she became disabled on August 30, 2008, due to “Ptsd-mood disorder-depression-social isolation-suicidal, ” “PTSD, ” “Mood Disorder, ” “Hepatitis C, ” “Social Isolation, ” “Severe Depression, ” “Suicidal thoughts, ” “Anxiety Disorder, ” “Paranoid thoughts, ” and “Visual Hallucinations.” (Administrative Record (“AR”) 9, 14, 123-25, 139, 256, 262.) Plaintiff was born on April 4, 1964, and was 44 years old on the alleged disability onset date. (AR 17, 262.) From 2000 to 2008, Plaintiff was an in-home care provider. (AR 254, 261.)

         A. Relevant Medical Evidence[3]

         On November 9, 2010, David Hill, MFT, completed a pre-printed form provided by the Employment and Temporary Assistance Department of the County of Fresno. (AR 396.) When asked whether Plaintiff has “a physical or mental incapacity that prevents or substantially reduces their ability to engage in work, training, and/or provide necessary care for their child(ren), ” Mr. Hill checked the “Yes” box and commented that Plaintiff “appears to be suffering from PTSD and a mood disorder which impairs her emotional stability, attention, judgement [sic], memory, and ability to be around people.” (AR 396-97.) When asked whether Plaintiff is able to work, Mr. Hill checked the “No” box, but then proceeded to indicate that the only limitation or work restriction was that Plaintiff perform a job with “[n]o more than 4th grade reading, writing and/or mathematical skills required.” (AR 396.) Mr. Hill indicated that the expected duration of Plaintiffs inability to work was “[t]emporary, ” and Plaintiff was expected to be released to work in six months. (AR 397.)

         On October 18, 2011, Plaintiff was seen “through triage” at the Fresno County Department of Behavioral Health. (AR 347.) The Progress Note from that visit indicated that Plaintiff “has never received [mental health treatment] other than as a child, reportedly.” (AR 347.) Plaintiff had “significant psychotic symptoms” and reported “significant [auditory and visual hallucinations].” (AR 347.) The Note indicated that Plaintiffs “current symptoms appear to have been chronic and ongoing for some time which lowers the risk [she] will act on her thoughts now.” (AR 347.) Plaintiff rents a room from a man who “wants to kick her out for being ‘crazy.'” (AR 347.) Her “primary motivation for treatment now appears to be fear that she will lose her housing ‘if she doesn't get help and start acting normal.'” (AR 347.)

         That same day, October 18, 2011, an undecipherable provider completed another preprinted form provided by the County. (AR 394-95.) The provider indicated that Plaintiff had “a physical or mental incapacity that prevents or substantially reduces their ability to engage in work, training, and/or provide necessary care for their child(ren), ” and commented that Plaintiff “has a history of trauma as a child. Social isolation, paranoid thoughts, severe depression, thoughts of death, worthlessness, anxiety attacks.” (AR 394.) The provider indicated Plaintiff is not able to work (AR 394), but such inability to work was temporary and Plaintiff was expected to be released for work in six months. (AR 394-95.)

         Plaintiff was diagnosed with schizoaffective disorder on January 4, 2012. (AR 357.) Later that same month, Plaintiff was diagnosed with “major depressive disorder, recurrent, severe with psychotic features.” (AR 374.) At that visit, she was prescribed Paxil for depressive symptoms and Risperdal for psychosis. (AR 374.) On February 7, 2012, an undecipherable PhD and licensed marriage and family therapist completed a form provided by the Employment and Temporary Assistance Department of the County of Fresno. (AR 392-93.) The provider indicated that Plaintiff had “a physical or mental incapacity that prevents or substantially reduces their ability to engage in work, training, and/or provide necessary care for their child(ren), ” and noted that Plaintiff “is suffering with a psychotic disorder which impairs her reality testing, concentration, judgement [sic], leaving home, [and] being around others.” (AR 392.) The provider indicated Plaintiff is not able to work (AR 392), but such inability to work was temporary and Plaintiff was expected to be released for work in one year. (AR 393.)

         A “Medication Progress Note” dated February 27, 2012, indicated Plaintiff “has been doing well on Paxil and Risperdal, ” with “no side effects and feeling improved.” (AR 370.) Another “Medication Progress Note” dated April 5, 2012, indicated that Plaintiff is “taking both Paxil and Risperdal, ” is “doing well and feels less depressed, ” and reported a “good response” to those medications. (AR 368-69.)

         On April 27, 2012, a Disability Determinations Service psychology consultant, Heather Barrons, Psy.D, reviewed the record and analyzed the case. (AR 123-30) Dr. Barrons observed that Plaintiff had an affective disorder that was “severe, ” but that Plaintiffs difficulties in maintaining social functioning, concentration, persistence, and pace were “[m]ild.” (AR 127-28.) Dr. Barrons noted that, per the medical evidence of record, Plaintiff had no treatment until January 2012, when she presented with depression and reported psychosis. (AR 128.) Dr. Barron observed that Plaintiff was started on Risperdal and Paxil “with good response, ” and a follow up mental status exam in February 2012 was within normal limits. (AR 128.) Dr. Barrons concluded:

In consideration of all evidence, [Plaintiff] has only recently begun [treatment] and previously was able to work for a number of years in [the In-Home Supportive Services program]. She showed quick and positive response to medications and had a normal [mental status exam] ¶ 2/12. Given the absence of longitudinal [history] and positive response to [treatment], [Plaintiff] is not expected to meet durational requirements. [Modified onset date] ¶ 1/1/12 is supported by the [medical evidence of record]. IE from [alleged onset date]-12/31/11 given lack of medical evidence of record. Expected to be non-severe by 1/1/13.

(AR 128.)

         In May 2012, Plaintiff reported that she “has been unable to afford [P]axil and therefore has not taken it for at least 3 weeks, ” and she reported “feeling worse and more depressed since April.” (AR 366.) In July 2012, Plaintiff indicated she “stopped taking the [Risperdal] because it was not helping, ” and was prescribed Seroquel instead. (AR 365.) A “Medication Progress Note” dated August 14, 2012, reported that Plaintiff “is feeling better” with Seroquel and “tolerating [it] well so far.” (AR 362.) The Note indicated that Plaintiff “complained that no one is helping her, ” yet “she did not know why she has not signed up for [Medicare, ]” which was “extensively discussed last session.” (AR 362.)

         On November 30, 2012, a Disability Determinations Service psychiatric consultant, A. Garcia, M.D., reviewed the record and analyzed the case. (AR 145-51.) Dr. Garcia noted that Plaintiffs “[m]ost recent clinic note date[d] 8/14/12 shows continued improvement in [symptoms]” and “[s]uggest[s] [Plaintiff] is capable of perform[ing] sustained unskilled work.” (AR 146.) Dr. Garcia found that Plaintiffs ability “to understand and remember detailed instructions” was “[m]oderately limited, ” but that Plaintiffs ability to “remember locations and work-like procedures, ” and “to understand and remember very short and simple instructions, ” were “[n]ot significantly limited.” (AR 148.) Dr. Garcia noted that Plaintiffs ability “to carry out detailed instructions” was “[m]oderately limited, ” but that Plaintiffs ability “to carry out very short and simple instructions”; “to maintain attention and concentration for extended periods”; “to perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances”; “to sustain an ordinary routine without special supervision”; “to work in coordination with or in proximity to others without being distracted by them”; “to make simple work-related decisions”; and “to complete a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a constant pace without an unreasonable number and length of rest periods” were “[n]ot significantly limited.” (AR 148.) Dr. Garcia found that Plaintiff had no “social interaction limitations” and no “adaptive limitations.” (AR 149.) He concluded that Plaintiff was “[a]ble to perform 1-2 step job instructions, moderate limitations in performing detailed/complex instructions”; “[a]ble to concentrate and attend while perform [sic] unskilled work activities”; “[a]ble to relate with co-workers, supervisors, and the public”; and “[a]ble to adapt to common stressors and changes associated with an unskilled work environment.” (AR 149.)

         On December 18, 2012, a “Medication Progress Note” signed by Michael Thao, M.D., indicated that Plaintiff was taking both Risperdal and Seroquel. (AR 495.) Plaintiff reported “her overall mood has been good, she has not been hearing voices, ” is “living independently and functioning better.” (AR 495.) Plaintiff was sleeping well, her appetite was good, and she was tolerating all of the medications well.” (AR 495.) Dr. Thao reported that Plaintiff had a normal mood, affective range, insight and judgment, cognition, and sensorium, and her thought processes were “organized.” (AR 495.) Plaintiff was advised to stop taking Risperdal and to continue Seroquel. (AR 496.) “Medication Progress Notes” from February and April 2013 stated that Plaintiffs response to medication and lab results were “[i]mproved” and that she “has responded well” to taking Seroquel. (AR 491-94.)

         On August 15, 2013, Ramon Raypon, M.D., saw Plaintiff and noted that “she has not been taking medications for several months.” (AR 489.) Plaintiff reported “feeling depressed, nervous, episodes of agitation, irritability, sleeping problems” and hearing voices “every day.” (AR 489.) Plaintiff stated she “was doing alright when I was taking medications, feeling less depressed and hearing voices, ” and wanted to resume medications. (AR 489.) Dr. Raypon noted that Plaintiff appeared “anxious, tense, guarded” and had “poor compliance resulting in more depression, psychosis.” (AR 489-90.) Plaintiff was instructed to restart Seroquel. (AR 490.)

         Dr. Raypon saw Plaintiff again on October 14, 2013, who was brought in by her mother for a “medication visit.” (AR 487.) Plaintiff reported that she still experienced “episodes of depression, ‘feeling alone, sad helpless hopeless, low energy, '” and that she is still hearing voices. (AR 487.) Dr. Raypon observed that Plaintiff appeared “relatively calm” and had normal motor activity, cognition, speech, and orientation, and that her thought processes were “organized, ” “relevant, ” and “coherent.” (AR 487.) Dr. Raypon increased Plaintiffs Seroquel dosage and prescribed an antidepressant. (AR 488.)

         Plaintiff was seen by Dr. Raypon a third and final time on December 11, 2013, and reported still experiencing “episodes of depression, ” with low energy, poor concentration, lack of interests, and withdrawal. (AR 482, 485.) She reported hearing voices and seeing visions at times. (AR 485.) Plaintiff “ran out of medications a few weeks” prior to the visit. (AR 485.) Plaintiff stated that she was living with a roommate and that she “maintained frequent contract with her mother.” (AR 485.) Dr. Raypon observed that Plaintiffs motor activity, cognition, speech, and orientation were all normal, and her thought processes were organized, relevant, and coherent. (AR 485.) Plaintiff was “alert” and “responsive, ” and that she “reported benefits” from the antidepressant. (AR 485-86.) Dr. Raypon's plan was to increase the Seroquel to “control hallucinations and mood.” (AR 486.)

         On December 16, 2013, Dr. Raypon completed a “Mental Disorder Questionnaire for Evaluation of Ability to Work.” (AR 481-82.) The questionnaire asked the following question:

Are there abnormalities in any of the following areas to a degree that it would impair this individual's ability to work? (YES or NO) If yes, would any of these impair the individual's ability to perform simple work for two hours at a time or for eight hours per day? (If so, then check Significant Impairment box)

(AR 481.) Dr. Raypon checked the “YES” and “Significant Impairment” boxes for memory, concentration, and judgment. (AR 481.) When asked whether Plaintiffs “mood and affect [are] affected to a degree that it would impair [Plaintiffs] ability to work, ” Dr. Raypon checked “Yes, ” and commented “episodes of depression, poor concentration, and delusions.” (AR 481.) Dr. Raypon noted Plaintiffs diagnosis of “major depressive disorder with psychotic features.” (AR 481.) The questionnaire also asked:

Are there abnormalities in any of the following areas to a degree that it would impair this patient's ability to work? (YES or NO) Would any of these impair the patient's ability to perform full-time work, week after ...

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