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Hernandez v. Saul

United States District Court, E.D. California

June 28, 2019

ANDREW SAUL, Commissioner of Social Security, [1]Defendant.




         On June 29, 2018, Plaintiff Nicholas R. Hernandez (“Plaintiff”) filed a complaint under 42 U.S.C. § 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) under Title XVI of the Social Security Act (the “Act”). (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]


         Plaintiff was born on June 19, 1995 and obtained a General Educational Development (GED) certificate. (Administrative Record (“AR”) 22, 106, 120, 684.) Plaintiff previously received SSI benefits based on disability as a child. (AR 16.) On October 18, 2012, Plaintiff filed claim for SSI payments as an adult, alleging disability beginning on July 16, 2012 due to mental health symptoms, including schizophrenia, depression, and anxiety. (AR 21, 120-21, 246-55, 279-80, 328.)

         A. Relevant Medical Evidence[3]

         1. Treating Physician Veena Doddakashi, M.D.

         From ages 4 to 15, Plaintiff lived with his father, stepmother, and six other children. Plaintiff witnessed domestic violence between his father and stepmother, was exposed to sexual content, and was reportedly raped by his stepbrother. (AR 481, 574.) He returned to his mother's care in 2011. (AR 481, 574.) In 2012, Plaintiff was hospitalized several times for severe depression, severe paranoia, anger, and mood lability. (AR 552, 554, 567, 568-69, 586.) While hospitalized, he was diagnosed with schizophrenia. (AR 554.)

         In February 2013, Plaintiff presented Dr. Doddakashi for evaluation following a recent hospitalization. (AR 542-43.) Plaintiff reported having been hospitalized for wanting to hurt his mother because she was “messing with [his] head.” (AR 542.) At the hospital, Plaintiff's medications were changed. (AR 542.) Plaintiff's mother reported that he was “doing better” since his change in medications. (AR 542.) Plaintiff stated he was calmer and felt no aggression toward his mother or others. (AR 542.) He denied suicidal or homicidal ideations. (AR 542.) Dr. Doddakashi noted Plaintiff's mental status examination was normal. (AR 542.) Plaintiff received individual and group therapy from February to August 2013. (AR 489-519.)

         2. Kern County Mental Health Department

         In August 2013, Plaintiff presented to Kern County Mental Health Department for an assessment. (AR 574-85.) He reported last having suicidal ideations in December 2012, which was “due to the wrong antidepressant.” (AR 578.) Once his medication was change he reported no longer having those thoughts. (AR 578.) Plaintiff's mental status examination showed guarded attitude and depressed, anxious, hopeless, and worried mood. (AR 579.) The rest of the exam was normal/unremarkable. (AR 580.) Plaintiff was diagnosed with posttraumatic stress disorder (PTSD) and major depression. (AR 582.)

         Plaintiff attended a follow up appointment in October 2013. (AR 601.) He reported being stable on his current medications and denied side effects, hallucinations, and paranoid delusions. (AR 596.) Plaintiff was noted to have “much improved” in response to treatment. (AR 599.) In November 2013, Plaintiff stated that his “mood and anxiety got better on medication” but that he still has difficulty trusting people and “got suspicious sometimes.” (AR 601.) He denied side effects, hallucinations, delusions, and suicidal and homicidal ideations. (AR 601.) Plaintiff was noted to be in “partial remission on medication.” (AR 605.) His mental status examination was normal/unremarkable. (AR 602-03.)

         In January 2014, Plaintiff established care with a new provider at Kern County Mental Health Department. (AR 608-15.) He reported taking all of his medications and experiencing no adverse effects from them. (AR 608.) Plaintiff denied hallucinations and suicidal and homicidal ideations. (AR 608.) The treatment provider noted that Plaintiff “seems to be doing not so bad as to the combination of psychotropic medications he is on, ” he “doesn't sound irritable or despondent about the whole situation” but “may be anxious a bit, ” and he “[o]verall . . . seems to be doing fine.” (AR 610.) From March to June 2014, Plaintiff “seem[ed] to be doing fine” and exhibited a “[f]air to [g]ood response to [p]sychopharmacology and [p]sychotherapy.” (AR 558, 660, 665, 667, 672, 674, 679, 681.)

         Plaintiff underwent an assessment in July 2014, where it was noted he “continues to suffer psychosis believing his father controls his thoughts.” (AR 684.) It was also noted that Plaintiff “has made improvements in his mental health but continued individual therapy will be beneficial.” (AR 684.) Plaintiff reported that he “seldomly has suicidal ideation” and had not had any suicidal thoughts in the past year. (AR 686, 688.) His mental status examination showed a depressed, anxious, and worried mood, but was otherwise normal/unremarkable. (AR 689.)

         Plaintiff presented for a follow up appointment on October 1, 2014, where he admitted he “decided to take himself off medication” and “asked to be placed back on medication” at his mother's insistence. (AR 696.) Plaintiff stated that due to his PTSD he “experiences problematic nightmare[s] at least every other day, that he gets “frustrated upon waking up because of this, ” and that “he tends to ruminate about it the whole day.” (AR 696.) Plaintiff's mood was noted as dysphoric and sad, with intermittent eye contact, constricted affect, and paranoid ideation. (AR 697.) On October 29, 2014, Plaintiff reported that he has been taking his medications and “seems to be helped” by them. (AR 703.) He denied suicidal or homicidal ideations or experiencing hallucinations. (AR 707.)

         Plaintiff's last appointment at Kern County Mental Health Department occurred on January 7, 2015. (AR 717.) He reported that his medications helped and that he suffered no adverse effects from them. (AR 717.) Plaintiff stated there were “occasions when he still feels that irritability brought about by the thought, especially at night, that people around are controlling him.” (AR 717.) His mood was anxious and euthymic, otherwise his mental status examination was unremarkable. (AR 718.) Plaintiff denied suicidal or homicidal ideations or experiencing hallucinations. (AR 721.)

         3.Office of Jagdeep Garewal, M.D.

         On January 21, 2015, Plaintiff established care with Dr. Garewal's office. (AR 750-51, 772-73.) He reported major depressive episodes, panic attacks, flashbacks, nightmares, irritability, and anger. (AR 750.) No psychosis, suicide attempts, or homicidal attempts or ideations were reported. (AR 750.) Plaintiff's mood was noted as “OK” and poor insight and judgment into and about his mental problems were observed. (AR 751.) Plaintiff was diagnosed with major depression, PTSD, and a panic disorder. (AR 751.) He was given a “sequential medication trials” for treatment of his symptoms. (AR 751.)

         In February and March 2015, Plaintiff reported that his symptoms had improved with medication and that they were sporadic and less intense. (AR 752, 754, 774, 776.) His mood was “good, ” and he had no suicidal or homicidal ideations or hallucinations. (AR 752, 754, 774, 776.) Dr. Garewal noted “mild decline” in Plaintiff's attention, concentration, and memory. (AR 754, 776.)

         Plaintiff reported to Dr. Kimberly Hoffman in May 2015 that he was “feeling good” and Plaintiff's mother reported that he had not had any “episodes.” (AR 757, 778.) Dr. Hoffman observed that Plaintiff was taking his medications with “good tolerance” and that he had “improved dramatically.” (AR 757, 778.) Dr. Hoffman deemed Plaintiff's treatment outcome as “GOOD.” (AR 757, 778.) In June 2015, Dr. Hoffman noted that Plaintiff is “feeling very good and is very stabilized” on his medication regimen. (AR 758, 779.) Plaintiff reported in October 2015 that he “does not feel he is depressed anymore” and “no longer has outbursts of anger.” (AR 759, 780.) His medication was decreased. (AR 760, 780.)

         In December 2015, Plaintiff presented to Dr. Hoffman with complaints of explosive anger, irritability, and “being scared he could hurt someone.” (AR 761, 782.) His mood was reported as “sad.” (AR 761.) Plaintiff also stated he does not feel rested. (AR 761, 782.) Dr. Hoffman readjusted Plaintiff's medication. (AR 761, 782.) Later than month, Plaintiff noted improvement and that he was no longer having hallucinations. (AR 783.)

         At a follow up appointment with Dr. Hoffman in February 2016, Plaintiff reported that he was “doing better.” (AR 764, 784.) His mental status examination showed normal cognitive functioning for reasoning and logic, and mild decline in attention, concentration, and memory. (AR 764, 784.) Dr. Hoffman noted Plaintiff “has improved and is stabilized” on his medication regimen. (AR 764, 784.) She further noted that Plaintiff “feels he has stopped worrying about everything.” (AR 764, 784) In April 2016, Plaintiff reported mood swings and anger but that he was no longer anxious. (AR 765, 785.) Dr. Hoffman observed that “ongoing medication monitoring and adjustments are still needed.” (AR 765, 785.)

         Dr. Hoffman evaluated Plaintiff in July 2016 and noted he had improved. (AR 771.) Plaintiff himself reported “I'm doing good now.” (AR 771.) Dr. Hoffman stated that Plaintiff is “stabilized and no longer agitated or having [visual hallucinations] or [auditory hallucinations].” (AR 771.)

         4. State Agency Physician B. Smith, M.D.

         On April 3, 2014, B. Smith, M.D., a State psychiatric consultant, reviewed Plaintiff's medical records and opined that Plaintiff had mild limitations in activities of daily living and maintaining concentration, persistence or pace. (AR 632.) Dr. Smith further opined that Plaintiff moderate difficulties in social functioning. (AR 632). Dr. Smith found that Plaintiff did not meet any of the “C” criteria for categories 12.04 and 12.06 under 20 C.F.R. Part 404, Subpart P, Appendix 1 (“the Listings”). (AR 624, 633.) Dr. Smith concluded that Plaintiff is capable of performing unskilled tasks with limited public contact. (AR 637.)

         B. Plaintiff's Mother's Statement

         On April 7, 2014, Plaintiff's mother Lydia Vasquez completed a Third-Party Adult Function Report. (AR 316-24.) Ms. Vasquez reported that she spends every day with Plaintiff except when he's at school. (AR 316.) She states that Plaintiff “gets depressed at times off and on, ” has a “hard time trusting others, ” and “thinks people are after him at times.” (AR 316.) According to Ms. Vasquez, Plaintiff “cannot sleep at times” and “thinks a lot [a]bout his past.” (AR 317.) Ms. Vasquez reported that Plaintiff needs reminders to take his medication and needs encouragement to perform household chores due to his depression. (AR 318-19.) Plaintiff “has issues with trust” and “isolates himself at times.” (AR 321.) According to Ms. Vasquez, Plaintiff's “trust issues” affect his ability to talk to people. (AR 321.) Ms. Vasquez reported Plaintiff “forgets a lot, ” “has trouble completing things, ” and his “concentration is interrupted by past thoughts/fears others will get him at times.” (AR 321.) Plaintiff can pay attention “for about [five] minutes” before he sometimes “drifts off.” (AR 321.) According to Ms. Vasquez, Plaintiff is “shaky” on spoken instructions and “[d]oesn't like them.” (AR 321.) Plaintiff “doesn't handle stress well, ” as he “gets agitated and wants to isolate himself.” (AR 322.) Mr. Vasquez stated that he gets medication side effects “often” and experiences mood swings “daily.” (AR 323.) Plaintiff has “anxiety attacks” if his medication is not taken and “needs monitoring.” (AR 323.)

         C. Administrative Proceedings

         The Commissioner reviewed Plaintiff's case and on January 29, 2014, determined he was no longer disabled as of January 1, 2014. (AR 134-37.) Plaintiff requested reconsideration of this determination on February 5, 2014. (AR 138-39.) Following a hearing before a disability hearing officer (AR 140-59), reconsideration was denied on June 2, 2014 (AR 160-62).

         Consequently, Plaintiff requested a hearing before an Administrative Law Judge (“ALJ”). (AR 166-95.) Plaintiff appeared without counsel and testified before the ALJ at hearings held on January 21, 2016, May 27, 2016, and September 15, 2016. (AR 19-119.) Plaintiff's mother also testified at the January and May 2016 hearings. (AR 50-119.)

         1. Testimony at the January 2016 Hearing

         Plaintiff and his mother Ms. Vasquez appeared and testified at the first hearing. (AR 87- 119.) Plaintiff testified that he was currently enrolled in Bakersfield College and that he had taken three classes the previous semester. (AR 104.) Plaintiff stated he received no special accommodations for his studies at Bakersfield College. (AR 105.) He also took classes in the Spring 2015 semester and received his GED from an adult school. (AR 106.) Plaintiff stated that he passed the written examination for a driver's license but had yet to take the road test. (AR 107.)

         Plaintiff could not remember when he moved to his current address. (AR 102-03.) He testified he uses a computer daily, performed household chores, and also goes to the grocery store (AR 108-110.) Plaintiff ...

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