Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Broers v. Berryhill

United States District Court, E.D. California

April 21, 2017

EDWARD T. BROERS, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security,[1] Defendant.

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

         I. INTRODUCTION

         On February 12, 2016, Plaintiff Edward T. Broers ("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 his application for 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 December 28, 2012, Plaintiff filed a claim for SSI payments, alleging he became disabled on October 1, 2012, due to "Mental illness and physical inabilities, " "Severe Depression, " "Anxiety, " "Social Anxiety, " "PTSD, " "Specific Learning Disability, " "Obesity, " "Coordination deficiency, " "Seizures (non-epileptic), " "abnormal growth, " and "drug addiction." (Administrative Record ("AR") 12, 17, 163, 178, 182.) Plaintiff was born on June 22, 1991, and was 21 years old on the alleged disability onset date. (AR 25, 163.) Plaintiff has a high school education. (AR 37.)

         A. Relevant Medical Evidence[3]

         On December 14, 2012, Plaintiff presented at the Fresno County Urgent Care Wellness Center requesting mental health services. (AR 414.) Plaintiff was "alert and oriented, " "calm, coherent, and cooperative, " "had good eye contact, " "dressed appropriately, " his "hygiene was good, " and his "thought process was intact." (AR 414.) Plaintiff reported symptoms of "low energy, lack of motivation, sad[ness], hopeless[ness], helpless[ness], over or poor sleep, and feeling all that [sic] time." (AR 414.) Plaintiff also stated that he had been experiencing anxiety." (AR 414.) Plaintiff reported that about six months prior to the visit his depression had gotten worse. (AR 414.) Plaintiff denied auditory and visual hallucinations, but stated that when he used "bad [sic] salt and spice" he experienced hallucinations. (AR 414.) Plaintiff stated that he had a "long history of alcohol and substance abuse, e.g., meth, opium, ecstasy, " but that he had stopped using all substances as of October 1, 2012. (AR 414.)

         Plaintiff was evaluated by a Fresno County licensed clinical social worker on December 17, 2012, who noted that "the symptoms [Plaintiff] reports are usually associated with drug use [and] the adjustment to not using." (AR 412.) The social worker's assessment notes diagnoses of "[a]djustment disorder with anxiety and depressed mood[, ] [rule-out] substance induced mood disorder" and "[p]olysub stance [d]ependence." (AR 412.)

         On January 3, 2013, Juan Carlos Ruvalcaba, M.D. saw Plaintiff during an office visit and completed a mental capacity assessment form. (AR 390, 397-99, 447.) At the visit, Plaintiff was "[n]egative for confusion, " was "oriented to time, place, person and situation, " and "demonstrate[d] the appropriate mood and affect." (AR 399.) Dr. Ruvalcaba noted that Plaintiff was to "follow up with substance abuse program." (AR 399.) On the mental capacity form, Dr. Ruvalcaba stated that "[b]ecause of recent drug abuse, [Plaintiff] has sustained emotional/mental instability and depression/anxiety/panic attacks." (AR 390, 447.) Plaintiff was noted as "unable to perform in large groups" and having "developed severe social anxiety." (AR 390, 447.) Dr. Plaintiff is "unable to focus, has developed deficit disorder" and has a history of learning disability since childhood. (AR 390, 447.) Dr. Ruvalcaba opined that Plaintiff is "unable to work or perform under stressful situation[s] [due] to emotional/mental instability." (AR 390, 447.)

         On April 5, 2013, Plaintiff visited the Fresno County Urgent Care Wellness Center and requested to start services "due to depression, anxiety, and having panic attacks." (AR 416, 444.) Plaintiff reported "increased anxiety, paranoia that others are after or are watching him, " "increased depression" for the past six months, feeling worthless and helpless, "having mood swings, [and] lacking energy, motivation or interest." (AR 416, 444.) Plaintiff is noted as having had an "assessment last year but was not optioned for services." (AR 416.) Plaintiff reported he was told that he "needed to be clean and sober for six months in order to be seen for mental health, " and had completed a "New Connections" program two days prior. (AR 416.)

         Plaintiff attended a group meeting on April 16, 2013, in which he was observed to be "alert and oriented" and "calm and coherent." (AR 421.) Plaintiff "had good eye contact, " was "groomed well, " his speech was within normal limits, and his "thought process was intact." (AR 421.) Plaintiff participated in the group meeting for the first time, introduced himself, and was "attentively listening [to] other participants' experiences and their pre-crisis plan ideas." (AR 421.) During the meeting, Plaintiff "shared struggles with his depression and anxiety." (AR 421.)

         On May 29, 2013, internist Samuel Rush, M.D., performed a complete internal medical evaluation of Plaintiff at the request of the California Department of Social Services. (AR 429- 433.) Plaintiff reported that he "has had a problem with drug abuse for several years[, ] specifically marijuana and alcohol." (AR 429.) Plaintiff said that "as a consequence of his drug abuse he developed anxiety, panic attacks and depression." At the time of the evaluation, Plaintiff was "stable and untreated." (AR 429.) Dr. Rush noted that Plaintiff had a history of anxiety, panic attacks, and depression, but that Plaintiff presented with a "[n]ormal mental status." (AR432.)

         Clinical psychologist James P. Murphy, Ph.D., performed a psychological evaluation of Plaintiff on July 9, 2013, at the request of the California Department of Social Services. (AR 436-440.) Dr. Murphy observed that Plaintiffs attention was "within normal limits and he was oriented to person, place, time, and purpose for the interview." (AR 437.) Plaintiffs memory "appeared to be intact for short term and remote recall." (AR 437.) Dr. Murphy noted that Plaintiffs eye contact was "appropriate" and his facial expression was "responsive." (AR 437.) Plaintiffs attitude towards Dr. Murphy was "cooperative and friendly" and was "cooperative throughout the tasks asked of him." (AR 437.) Plaintiff described his mood as "sad, " but Dr. Murphy opined that Plaintiffs "emotional expression was not congruent to his reported mood." (AR 437.) Plaintiffs "flow of speech was normal for rate, rhythm, tone, and articulation." (AR 437.) Dr. Murphy observed that Plaintiffs "thoughts were clear, coherent, well organized, goal directed, and relevant to the subject at hand." (AR 437.) Plaintiff was "able to handle ideas well, and could identify basic similarities, differences, and absurdities." (AR 437.) Plaintiff "denied that he experienced any auditory, olfactory, gustatory, or tactile hallucinations and none were observed." (AR 437.) Dr. Murphy noted that Plaintiff "did report experiencing some visual hallucinations[, ] but his description did not meet DSM-IV-TR criteria for a diagnosis" and he "did not appear to be distracted by internal stimuli." (AR 437.) Plaintiff "did not endorse any delusional material during the interview and his insight, judgment and motivation were appropriate as was supported by his ability to keep the appointment in a timely fashion and his performance on the requested testing tasks." (AR 437.)

         Dr. Murphy noted that he "did not observe any abnormal behavior, " but that Plaintiffs "memory scale scores were considerably poorer than would normally be expected from an individual with a Low Average Intelligence Score." (AR 439.) Dr. Murphy opined that Plaintiff has no restrictions concerning daily activities; has no difficulty maintaining social functioning; does not appear to have problems with concentration, persistence, and pace that could jeopardize his ability to work; would not experience episodes of emotional deterioration in work like situations; would not have difficultly understanding, carrying out, and remembering simple instructions; would not have difficulty responding appropriately to co-workers, supervisors, and the public; would not have difficultly responding appropriately to usual work situations; would not have difficulty dealing with changes in routine work settings; and does not have other limitations due to mental impairment. (AR439.) Dr. Murphy continued:

It appeared that the most difficult barrier for this individual to overcome if he were to enter the workforce would be his desire not to work and some memory deficits that appeared during the testing. It is recommended that this individual be given the appropriate neurological tests to determine why his memory is failing. This individual is capable of performing Simple Repetitive Tasks (SRT) on a regular basis but not complex tasks.

(AR 439.) Dr. Murphy concluded that Plaintiff "had no difficulty understanding what was asked of him concerning the various tasks during the mental status examination." (AR 440.) Plaintiff "did not demonstrate difficulties understanding the simple instructions of the various tasks, confidentiality, or the reason for the evaluation." (AR 440.) Dr. Murphy noted "no psychological impairment" but that Plaintiff "did endorse psychological problem [sic] as part of his history." (AR 440.) Plaintiff "appeared to understand and follow simple, basic instructions without difficulty." (AR 440.) Dr. Murphy opined that Plaintiff "does not appear to meet the DSM-IV-TR criteria for a mental disorder." (AR 440.)

         On July 22, 2013, a Disability Determinations Service psychiatric consultant, Jay S. Flocks, M.D., reviewed the record and analyzed the case. (AR 64-75.) Dr. Flocks noted that Plaintiff presented groomed, alert, and cooperative, Plaintiffs presentation was "normal, " and Plaintiff denied auditory or olfactory hallucinations but claimed visual hallucinations that "did not meet diagnostic criteria." (AR 71.) Dr. Flocks found that Plaintiff did not have a severe mental impairment and concluded that the medical evidence "leads to a decision of non-severe polysubstance abuse." (AR 71.)

         Plaintiff underwent a "Medication Evaluation" by Patricia A. Santy, M.D., on August 7, 2013. (AR 451-53.) Dr. Santy noted that Plaintiff "continues to have depression, decreased energy" and hallucinations. (AR 451.) Plaintiffs current symptoms included "sad mood, sleeping all the time, [and] lack of interest in his usual activities." (AR 451.) Dr. Santy observed that Plaintiff was "[n]ot feeling paranoid and no delusions were elicited." (AR 451.) Dr. Santy noted that Plaintiffs behavior was "cooperative, " his sensorium was "alert, " and his cognition was "[n]ormal" and "grossly intact." (AR 452.) Plaintiffs speech was "[n]ormal and "somewhat slowed, " and his thought processes were "[o]rganized" and "slowed." (AR 452.) Plaintiffs thought content entailed auditory and visual hallucinations, his mood was described as "[d]epressed, [a]nxious, " and his affective range was "[b]lunted." (AR 452.) Dr. Santy diagnosed Plaintiff with mood disorder, ruling out schizoaffective disorder, and polysubstance dependence. (AR 453.) Plaintiff was prescribed Prozac "to target depression" and Abilify "to target psychotic [symptoms.]" (AR453.)

         On August 19, 2013, Dr. Ruvalcaba completed a Fresno County Department of Social Services form where he indicated that Plaintiff had "a physical or mental health condition that prevents or substantially reduces [his] ability to engage in work or training." (AR 555-56.) Dr. Ruvalcaba indicated that Plaintiff was permanently unable to work due to being "depressed and having hallucinations." (AR555.)

         Plaintiff saw Daniel Brooks, M.D., via telepsychiatry for medication management on November 7, 2013. (AR 511-12.) Plaintiff reported a "good response to both Abilify and Prozac." (AR 511.) Dr. Brooks observed that Plaintiff was well groomed, with cooperative behavior, alert sensorium, and organized thought processes. (AR 511.) Plaintiffs motor activity, cognition, speech, orientation, mood, and affective range were all indicated as normal. (AR 511.) Dr. Brooks noted Plaintiff was positive for auditory hallucinations, which were improving with Abilify. (AR 511.) Dr. Brooks noted a diagnosis of major depressive disorder, recurrent, severe with psychotic features, but also indicated that his condition was "improving." (AR 511-12.) Dr. Brooks further indicated that Plaintiff had an "[i]mproved" response to medication, and specifically that he was less depressed on medication. (AR 511.)

         On July 24, 2014, Dr. Brooks saw Plaintiff via telepsychiatry. (AR 507-08.) Dr. Brooks observed that Plaintiff was well groomed, with cooperative behavior, alert sensorium, and organized thought processes. (AR 507.) Plaintiffs motor activity, cognition, speech, orientation, and affective range were all indicated as normal. (AR 507.) Dr. Brooks noted Plaintiff was positive for auditory hallucinations, which were improving with Abilify. (AR 507.) Plaintiffs mood was indicated as normal, depressed, and anxious, with Dr. Brooks noting that Plaintiff is "less depressed on meds but still has 'panic attacks' and will begin Zoloft 50mg." (AR 507.) Dr. Brooks observed that Plaintiff had a "good response to Abilify, " and that Plaintiff wishes to discontinue Prozac and begin a trial of Zoloft. (AR 507.) Dr. Brooks noted that Plaintiffs diagnosis of "major depressive disorder, recurrent, severe with psychotic features" was "improving." (AR 508.)

         Plaintiff again saw Dr. Brooks via telepsychiatry on September 25, 2014. (AR 505-06.) Dr. Brooks indicated that no side effects from Plaintiffs medications were noted and that Plaintiff had a "[f]avorable response" and his "symptoms [were] improving." (AR 505.) Dr. Brooks observed that Plaintiff was well groomed, with cooperative behavior, alert sensorium, and organized thought processes. (AR 505.) Plaintiffs motor activity, cognition, speech, orientation, and affective range were all indicated as normal. (AR 505.) Dr. Brooks noted Plaintiff auditory hallucinations were improved with Abilify. (AR 505.) Plaintiffs mood was indicated as normal, depressed, and anxious, with Dr. Brooks noting that Plaintiff is "less depressed on meds but still has 'panic attacks'." (AR 505.) Dr. ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.