United States District Court, E.D. California
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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