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De La Rosa v. Berryhill

United States District Court, E.D. California

June 27, 2019

REGINA DE LA ROSA, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

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

          SHEILA K. OBERTO UNITED STATES MAGISTRATE JUDGE

         I. INTRODUCTION

         On July 11, 2018, Plaintiff Regina De La Rosa (“Plaintiff) filed a complaint under 42 U.S.C. § 405(g) seeking judicial review of a final decision of the Commissioner of Social Security (the “Commissioner” or “Defendant”) denying her application for disability insurance benefits (“DIB”) under Title II of the Social Security Act (the “Act”). 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

         On July 23, 2014, Plaintiff protectively filed an application for DIB payments, alleging she became disabled on November 15, 2013 due to bipolar disorder, anxiety, and drug and alcohol abuse. (Administrative Record (“AR”) 16, 18-19, 40, 56, 144-50, 163.) Plaintiff was born on October 3, 1978 and was 35 years old as of the alleged onset date. (AR 25, 40, 56, 144, 163.) Plaintiff has a high school education and past work experience as a cashier and an elections clerk, and last worked full-time in 2013. (AR 12, 25, 35-36, 193.)

         A. Relevant Medical Evidence[2]

         1. Ravi Goklaney, M.D.

         On November 1, 2013, Plaintiff established care with psychiatrist Dr. Ravi Goklaney to treat her bipolar disorder and symptoms of depression and anxiety. (AR 249-50.) During her initial evaluation, Dr. Goklaney noted Plaintiff had been manic-depressive since her teenage years and based on her description of the symptoms, her disorder appeared severe. (AR 249.) Plaintiff reported feelings of sadness, worthlessness, mood elevation, insomnia, agitation, and racing thoughts. (AR 249-50.) Dr. Goklaney also noted that Plaintiff had been treated for bipolar disorder starting some time in 2010 and had been taking multiple medications since then. (AR 249.) Dr. Goklaney diagnosed Plaintiff with “Bipolar I, severe, ” and started her on Seroquel and Trileptal. (AR 250.)

         In a progress note dated November 18, 2013, Dr. Goklaney noted that Plaintiff's sadness, social difficulties, feelings of worthlessness, manic and depressive episodes, racing thoughts and agitation had all worsened. (AR 252.) Dr. Goklaney also noted Plaintiff was fully oriented and her cognitive functioning was in the normal range, social judgment was intact, and she was cooperative and attentive during the session. (AR 252.) Dr. Goklaney started Plaintiff on 20 milligrams of Prozac following the appointment. (AR 252.)

         On December 19, 2013, Dr. Goklaney noted that Plaintiff's sadness, worrying, social isolation, sleep difficulty, racing thoughts, and functioning at work had worsened, but her cognitive functioning, memory, orientation, social judgment, and behavior all appeared normal. (AR 254.) Dr. Goklaney recommended Plaintiff take a leave of absence from work until January 20, 2014 “to gain stability[, ]” and increased her Seroquel dosage, continued her Trileptal and Prozac, and started her on Klonopin. (AR 254-55.) On January 15, 2014, Dr. Goklaney noted Plaintiff exhibited symptoms of mania and her mood irritability had worsened, but her energy level had increased and her sleep patterns had improved. (AR 256.) Plaintiff returned to Dr. Goklaney on February 6, 2014, and reported she was improving and her symptoms had lessened in frequency and intensity. (AR 257.) Plaintiff reported further improvement on April 17, 2014, although she still exhibited symptoms. (AR 262.) Dr. Goklaney's treatment notes from Plaintiff's visits in April 2014 stated that Plaintiff had recently gone back to work and continued taking her medications. (AR 260-65.)

         Through the rest of 2014, Dr. Goklaney noted Plaintiff was generally improving and that her behavior was cooperative and attentive with no gross behavioral abnormalities. (See AR 266, 292- 319.) For example, on May 19, 2014, Dr. Goklaney noted that despite some issues, Plaintiff's symptoms had “improved as they [were] less frequent or less intense[, ]” Plaintiff was taking her medication as directed, and her “self care skills” were “intact and unimpaired.” (AR 306.) On June 19, 2014, Dr. Goklaney again noted Plaintiff's symptoms had improved and were less intense. (AR 304.) Dr. Goklaney also noted Plaintiff's “work performance [was] impaired” but stated her “school performance [was] normal” and that she was continuing to improve generally. (See AR 304.) On July 17, 2014 and August 7, 2014, Dr. Goklaney stated Plaintiff's symptoms continued to improve and her work performance was “marginal” as opposed to “impaired.” (AR 300, 302.) In a progress note dated September 12, 2014, Dr. Goklaney again stated Plaintiff's “functioning at work [was] marginal.” (AR 298.) On October 9, 2014, Dr. Goklaney noted that Plaintiff was continuing to improve and her school performance was normal, but her work performance had returned to “impaired.” (AR 296.)

         On October 27, 2014, Dr. Goklaney completed a medical source statement that stated Plaintiff suffered from “Bipolar I, severe, ” had slow speech and blunted affect, and was inattentive, tense, soft, glum, downcast, anxious, and easily distracted. (AR 269.) Dr. Goklaney opined Plaintiff had marked limitations in restriction of activities of daily living and difficulties in maintaining social functioning, extreme limitations in difficulties in maintaining concentration, persistence, or pace, and four or more episodes of decompensation within the past 12 months. (AR 273.) Dr. Goklaney opined that Plaintiff was “unable to meet competitive standards” in all applicable mental abilities necessary to perform work activities. (AR 271-72.)

         On March 6, 2015, Plaintiff established care with Omni Family Health in Bakersfield, California, where Dr. Goklaney continued to treat her.[3] (See AR 636-744.) On March 20, 2015, Dr. Goklaney restarted Plaintiff on Seroquel, Benztropine, Lexapro, Depakote, and Klonopin. (AR 694.) During visits in July and September 2015, Plaintiff reported to Dr. Goklaney that her symptoms were controlled by medication. (AR 707-09.) In January 2016, she reported an increase in symptoms but also noted she had been off her medication. (AR 724-26.) Dr. Goklaney submitted mental capacities forms on July 20, 2016, October 28, 2016, and November 2, 2016, each opining that Plaintiff was unable to work due to her mental illness. (AR 478-80.) On January 4, 2017, Dr. Goklaney noted Plaintiff complained of mood swings and feeling irritable, angry, and getting upset easily. (AR 742-44.)

         Dr. Goklaney submitted a second medical source statement on Plaintiff's behalf on January 4, 2017. (AR 481-86.) In the second statement, Dr. Goklaney stated Plaintiff suffered from bipolar disorder, “current episode depressed, ” and “agoraphobia with panic disorder” and her prognosis was severe, chronic and persistent. (AR 481.) He noted Plaintiff's symptoms included depression, mood swings, fatigue, anxiety, panic attacks and racing thoughts. (AR 481.) Dr. Goklaney opined that in Plaintiff's current state she was “unable to effectively complete work-like procedures and interact with others in the workforce.” (AR 484.) Dr. Goklaney also opined Plaintiff had moderate limitations in restriction of activities of daily living and marked limitations in difficulties in maintaining social functioning and difficulties in maintaining concentration, persistence or pace, and had three episodes of decompensation within the last 12 months. (AR 485.)

         Dr. Goklaney opined Plaintiff was “limited but satisfactory” in her ability to remember work-like procedures, understand and remember short and simple instructions, carry out short and simple instructions, and understand and remember detailed instructions; “seriously limited, but not precluded” in her ability to maintain attention for two hour segments, maintain regular attendance and be punctual, sustain an ordinary work routine, ask simple questions or request assistance, deal with normal work stress, be aware of normal hazards, carry out detailed instructions, deal with stress of semiskilled and skilled work, maintain socially appropriate behavior, and adhere to basic standards of neatness and cleanliness; and “unable to meet competitive standards” in her ability to work in coordination with others, make simple work-related decisions, complete a normal workday, perform at a consistent pace, accept instructions and criticism from supervisors, get along with coworkers, respond appropriately to changes in a work setting, set realistic goals or make plans independently, interact appropriately with the general public, travel in an unfamiliar place, and use public transportation. (AR 483-84.)

         2. Alexis Valos, Ph.D.

         On March 11, 2015, psychologist Dr. Alexis Valos interviewed Plaintiff for a psychological consultative evaluation. (AR 379-84.) Dr. Valos noted Plaintiff was alert and oriented for the interview and was cooperative and polite throughout. (AR 381.) Plaintiff's affect was “depressed and flat, ” her speech was normal, her thought content was normal and goal-oriented, and she was able to effectively communicate. (AR 381.) Dr. Valos noted that Plaintiff's attention and concentration were below average, memory appeared mildly impaired, and her intelligence was below average. (AR 381.) Dr. Valos found that Plaintiff could “carry out various simple tasks, which require focused attention, concentration, and memory skills” but Plaintiff could not carry out complex tasks. (AR 382.) Dr. Valos opined that Plaintiff suffered from bipolar disorder and anxiety disorder, and her “daily activities and social functioning appear[ed] to be vulnerable to episodes of deterioration in a work-like situation.” (AR 382.) Dr. Valos further opined that Plaintiff's “social or emotional impairments suggest that [Plaintiff would] have difficulty in tolerating the stresses, pressures, and changes in routine that are usually associated with day-to-day work activities.” (AR 382.)

         3. John Murphy, LMFT

         On December 1, 2014, therapist John Murphy completed an evaluation of Plaintiff based on his approximately three meetings with her from 2011 through November 2013. (AR 275-91.) Mr. Murphy noted Plaintiff had been diagnosed with bipolar disorder and that her mood was normal, anxious, depressed, fearful, elated, euphoric, angry and unpredictable, and her affect was appropriate, labile, expansive, blunted, flat and constricted. (AR 275-78, 280.) Based on his evaluation of Plaintiff, Mr. Murphy opined that Plaintiff had fair ability to understand, remember, and carry out complex instructions, and respond appropriately to changes in a work setting; good ability to understand, remember, and carry out simple instructions; and poor ability to maintain concentration, attention and persistence, perform activities within a schedule and maintain regular attendance, and complete a normal workday and workweek without interruptions from psychologically based symptoms. (AR 277.)

         4. Kern Medical Center

         On January 10, 2015, Plaintiff was admitted to the emergency department of Kern Medical Center for a reported overdose on multiple medications, categorized as a suicide attempt. (See AR 330-78.) Paramedics arrived to find Plaintiff alert and oriented but stating she “took 16 pills because she was depressed.” (AR 336.) Plaintiff also had “4 superficial cuts on her arm with bleeding controlled.” (AR 336.) The treating nurse noted Plaintiff suffered from depression and bipolar disorder and stated she took a combination of her psychiatric medications that day including Seroquel, Lexapro, and Klonopin. (AR 349.) Plaintiff was kept overnight in the emergency department and discharged on January 11, 2015, and directed to follow up with her primary care physician within a week. (AR 347-59, 362.)

         5. State Agency Physicians

         On May 27, 2015, D. Funkenstein, M.D., a Disability Determinations Service medical consultant, assessed the severity of Plaintiff's impairments and found that Plaintiff had moderate difficulties in maintaining social functioning and maintaining concentration, persistence or pace, had moderate restriction of activities of daily living, and had the severe impairment of affective disorders. (AR 48.) In assessing Plaintiff's mental residual functional capacity (RFC), [4] Dr. Funkenstein opined that Plaintiff was moderately limited in her ability to understand and remember detailed instructions, carry out detailed instructions, maintain attention and concentration for extended periods, perform activities within a schedule, sustain an ordinary routine, complete a normal workday, interact appropriately with the general public, accept instructions and criticism from supervisors, get along with coworkers, and respond appropriately to changes in the work setting. (AR 49-51.) Dr. Funkenstein further stated that Plaintiff had no limitation in her ability to remember locations and work-like procedures, understand and remember short and simple instructions, carry out short and simple instructions, work in coordination with others, make simple work-related decisions, ask simple questions or request assistance, maintain socially appropriate behavior and adhere to basic standards of neatness and cleanness, be aware of normal hazards, travel in unfamiliar places, and set realistic goals or make plans independently. (AR 49-51.)

         Upon reconsideration, on September 21, 2015, another Disability Determinations Service medical consultant, Joshua Schwartz, Ph.D., affirmed Dr. Funkenstein's findings as to the severity of Plaintiff's impairments and her mental RFC.[5] (AR 64-65, 68-70.)

         B. ...


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