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Lowe v. Berryhill

United States District Court, E.D. California

May 4, 2018

LAVELLE EARL LOWE, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, [1] Defendant.

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

          SHEILA K. OBERTO, UNITED STATES MAGISTRATE JUDGE.

         I. INTRODUCTION

         On March 9, 2017, Plaintiff Lavelle Earl Lowe (“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”) benefits. (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 5, 2012, an application for SSI was filed on behalf of Plaintiff, who was then a child under the age of 18. (Administrative Record (“AR”) 169 (Plaintiff was born on April 11, 1996).) The application alleged that Plaintiff became disabled on October 28, 1999, due to seizures, asthma, problems with comprehension and short term memory, depression, self-abuse, and general behavior and learning disabilities. (AR 200.) Plaintiff turned 18 prior to the date of the decision issued by the Administrative Law Judge (“ALJ”) on September 18, 2015. (AR 11.)

         A. Relevant Medical Evidence[3]

         1.Valley Children's Hospital

         On September 4 and October 27, 1998, Plaintiff, who was then two years old, and Plaintiff's mother, Tiffany Wright, presented at Valley Children's Hospital for a psychological evaluation. (AR 284.) Plaintiff was exhibiting aggressive and oppositional behavior, and had attempted to stab a four-year-old with a knife. (AR 284.) Plaintiff's mother reported that Plaintiff was able to form two and three word sentences, feed himself, had “fine” motor coordination, and played well by himself. (AR 285.) However, Plaintiff tended to be hyperactive, had a short attention span, had difficulty interacting with others, and was easily frustrated. (AR 285.) Clinical psychologist Lisa Miller, Ph.D. diagnosed Plaintiff with Attention Deficit Hyperactivity Disorder (“ADHD”). (AR 284.)

         On December 31, 1998, Dr. Miller noted that Plaintiff was “a bright child, ” and “[t]herefore . . . is well aware with whom he can get away with behaviors and with whom he cannot.” (AR 282.) Dr. Miller diagnosed Plaintiff with ADHD and Oppositional Defiant Disorder, and she suggested that Plaintiff be enrolled in Head Start. (AR 282-83.)

         On March 11, 1999, Plaintiff's mother returned to Dr. Miller, complaining that Plaintiff was engaging in aggressive and regressive behavior after she had taken away his pacifier. (AR 278.) Dr. Miller was hopeful that Plaintiff's behavior would improve once he had his scheduled tonsillectomy and had tubes placed in his ears. (AR 278.) Dr. Miller referred Plaintiff to a psychiatrist to determine whether Ritalin should be added to his medication regime. (AR 279.) Dr. Miller continued to provide parenting counseling to Plaintiff's mother and to assist Plaintiff with “self-control issues” through July 1999. (AR 275-78.)

         2. Clinica Sierra Vista

         The medical evidence in the record picks up several years later. On July 8, 2011, Plaintiff, who was then fifteen years old, presented at Clinica Sierra Vista, complaining of lack of appetite. (AR 300.) Plaintiff denied trying to lose weight, and reported that he sleeps at 11 p.m., wakes up at 11 a.m., and plays video games all day. (AR 300.) Kami Jow, M.D. noted that Plaintiff gets irritated easily. (AR 300.)

         On October 5, 2011, Plaintiff underwent a physical examination by Dr. Jow. (AR 294.) The examination revealed that Plaintiff had been prescribed albuterol and advair, but that he had been off his medications since the beginning of the year. (AR 294.) Dr. Jow noted that all of Plaintiff's functions were normal, but assessed Plaintiff with asthma, psychosis, a learning disorder and a history of ADHD, which had been resolved. (AR 294.)

         Two years later, on May 30, 2013, Plaintiff, then 17 years old, returned to Clinica Sierra Vista for a check-up. (AR 391-95.) Plaintiff complained sleep difficulty. (AR 391.) Sudhakar Nadipally, M.D., diagnosed mood changes and referred Plaintiff for a psychiatric consultation. (AR 394.)

         On August 21, 2013, Plaintiff presented at Clinica Sierra Vista with a fracture of his right hand. (AR 382-84.) Plaintiff reported that he had been upset after a classmate touched him, and he had punched doors and walls at school. (AR 384.) Plaintiff was treated with an arm splint and referred to a psychiatrist. (AR 384.)

         3. Nirmal S. Brar, M.D.

         On September 7, 2013, Plaintiff underwent a psychological evaluation with Nirmal Brar, M.D., who had previously seen Plaintiff in 2008. (AR 410-12.) Plaintiff's mother reported that Plaintiff fights, destroys property, is emotional and nervous, and suffers severe mood swings, anger, and memory loss. (AR 410.) Plaintiff previously fractured his hand twice by hitting walls. (AR 410.) He suffers variable sleep patterns, staying awake for two to three days followed by sleeping for nine hours. (AR 410.) Plaintiff reported that he experiences visual hallucinations of people being killed and hears voices commanding him to break things and hurt people. (AR 410.) Plaintiff experiences these hallucinations more during periods of sleeplessness. (AR 410.) Dr. Brar assessed Plaintiff's insight, attention, and concentration as poor. (AR 411.) Dr. Brar diagnosed Plaintiff with a reading learning disorder and psychosis, not otherwise specified but ruling out bipolar disorder, and prescribed Risperdal. (AR 411-12.)

         On September 10, 2013, Plaintiff returned to Dr. Brar. (AR 408.) Dr. Brar observed that Plaintiff was properly oriented, denied hallucinations, and exhibited good judgment, an appropriate attitude, and normal psychomotor activity and speech. (AR 408.)

         On September 17, 2013, Plaintiff reported severe mood swings and hallucinations. (AR 406.) Dr. Brar examined Plaintiff and observed again that Plaintiff was properly oriented, denied hallucinations, and exhibited good judgment, an appropriate attitude, and normal psychomotor activity and speech. (AR 406.) However, Dr. Brar increased Plaintiff's dosage of Risperdal. (AR 406.)

         On September 24, 2013, Plaintiff complained that the medication was not working. (AR 404.) Plaintiff was still hearing voices commanding him to hurt people, visually hallucinating, and sleeping “too much.” (AR 404.) Dr. Brar observed that Plaintiff was properly oriented, exhibited good judgment, an appropriate attitude, and normal psychomotor activity and speech, but that he had poor attention and concentration. (AR 405.) Dr. Brar increased Plaintiff's dosage of Risperdal. (AR 405.)

         On October 8, 2013, Plaintiff complained that he continued to feel “sleepy, ” but reported that he had been sleeping nine hours a night. (AR 402.) Plaintiff further reported that he had not fought anyone recently, had been playing football seven days a week, and heard voices only when he fails to take his medication. (AR 402.) Plaintiff's mother reported that Plaintiff was less agitated and had not been hearing voices. (AR 402.) Dr. Brar observed that Plaintiff was properly oriented, denied hallucinations, exhibited fair to good judgment, an appropriate attitude, and normal psychomotor activity and speech, but that he had poor attention and concentration. (AR 403.)

         On November 12, 2013, Plaintiff complained that he was sleeping only three to four hours a night and continued hearing command voices at night. (AR 453.) He gets angry around people his age, and, in those moments, he feels suicidal and punches holes in the wall. (AR 453.) However, Plaintiff reported that he was on his school's track team, and his mother reported that Plaintiff was doing better than before. (AR 453.)

         On November 26, 2013, Plaintiff reported that he was having fewer hallucinations, and he was less angry because the medication was making him so sleepy. (AR 451.)

         On February 5, 2014, Plaintiff reported hearing command voices and having suicidal ideation. (AR 448.) He had written on Facebook that he no longer feels like living. (AR 448.) Plaintiff was also having difficulty complying with his medication. (AR 448.) Plaintiff's mental health examination revealed auditory hallucinations, poor insight, and poor attention. (AR 449.) On February 11, 2014, after Plaintiff again reported hearing command voices, Dr. Brar increased Plaintiff's dosage of Risperdal. (AR 445.)

         On March 11, 2014, Plaintiff reported that he was not taking his medications, and that he continued hearing voices. (AR 433.) Plaintiff also reported that he was fighting less. (AR 433.) Dr. Brar noted that Plaintiff was properly oriented, had an appropriate attitude and fair to good judgment, exhibited normal psychomotor activity and speech, denied hallucinations, and had poor attention or concentration. (AR 444.)

         On April 16, 2014, Plaintiff reported recently trying to cut himself with a knife after an argument with his mother. (AR 440.) Although Plaintiff had been compliant with his medication, he continued to hear voices intermittently, get mad at others, and “get off” on people who upset him. (AR 440.)

         On July 14, 2014, Plaintiff requested an increase of his medication. (AR 436.) Plaintiff stated that the voices he hears were “getting grouchy and irritated, ” and that he was almost violent with his girlfriend. (AR 437.) Dr. Brar prescribed Lamictal. (AR 438.)

         Between September and December 2014, Plaintiff reported increased anger and auditory hallucinations commanding him to hurt people, but that he was able to distract himself from acting on the commands. (AR 427, 431, 433.) Plaintiff also reported visual hallucinations and suicidal ideation. (AR 427-28.) Plaintiff had not been consistent with his medications and his sleep suffered as a result. (AR 433.) Dr. Brar increased Plaintiff's dosage of Lamictal. (AR 429-30.)

         In February 2015, Plaintiff reported continued auditory hallucinations commanding him to hurt himself and occasionally others. (AR 423, 425.) Plaintiff also reported experiencing suicidal ideation approximately five times a month, poor sleep, and visual hallucinations. (AR 423, 426.) A mental status examination revealed that Plaintiff exhibited normal psychomotor activity and speech, experienced auditory hallucinations, was properly oriented, and had an appropriate attitude, fair to good judgment, good attention and concentration, and poor insight. (AR 424.) Plaintiff's dosages of Lactimal and Risperdal were increased. (AR 424, 426.)

         Between March and May 2015, Plaintiff reported being “angry” and hearing command voices to hurt others. (AR 421.) By April, Plaintiff's auditory hallucinations had lessened to about an hour each episode. (AR 419.) By May, Plaintiff reported that the medicine was working, he was rarely having visual hallucinations, and was hearing command voices two to three times a week. (AR 417.) Dr. Brar noted that Plaintiff was properly oriented, exhibited normal psychomotor ...


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