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Mendoza v. Saul

United States District Court, E.D. California

September 4, 2019

JENNIFER ADRIANA MENDOZA, Plaintiff,
v.
ANDREW SAUL, Commissioner of Social Security,[1] Defendant.

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

          SHEILA K. OBERTO, UNITED STATES MAGISTRATE JUDGE

         I. INTRODUCTION

         Plaintiff Jennifer Adriana Mendoza (“Plaintiff) seeks judicial review of a final decision of the Commissioner of Social Security (the “Commissioner” or “Defendant”) denying her application for Child's Insurance Benefits under Title II of the Social Security Act, 42 U.S.C. § 402(d), and for Supplemental Security Income (SSI) under Title XVI of the Social Security Act (the “Act”), 42 U.S.C. §§ 1381-1383f.[2] (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.[3]

         II. BACKGROUND

         On June 11, 2013, Plaintiff applied for child's insurance benefits and for SSI, alleging disability due to chronic depression, generalized anxiety disorder, bipolar disorder, and personality disorder. (Administrative Record (“AR”) 71-72, 77-78, 85-86, 94-95, 176-77, 182-83, 195.) The disability onset date for both applications was alleged to be April 1, 2003. (AR 71-72, 77-78, 85-86, 94-95, 176-77, 182-83, 195.)

         Plaintiff was born in April 15, 1985, and was 17 years old on the alleged disability onset date, making her a “younger person” under the regulations. (AR 25, 43, 71-72, 77-78, 85-86, 94-95); see 20 C.F.R §§ 404.1563(c), 416.963(c) (same). Plaintiff has a ninth-grade education and can communicate in English. (AR 23, 43-44, 194-96.)

         A. Relevant Medical Evidence[4]

         1. Community Regional Medical Center

         In December 2011, Plaintiff presented with chest pain and nausea and was hospitalized for four days. (AR 337, 339, 354.) A history of depression, bipolar disorder, and anxiety was noted. (AR 337.) Upon physical examination, Plaintiff had normal mood and affect. (AR 338, 344.) She was assessed with generalized anxiety. (AR 345.) She reported feeling “disgusting” since her mother passed away in November and was in the process of divorcing her husband. (AR 350-52.)

         Plaintiff previously used methamphetamine and marijuana but quit “a long time ago.” (AR 350.) She was observed appearing depressed with flat affect. (AR 352.) Plaintiff had good insight and judgment and denied suicidal ideation, homicidal ideation, auditory hallucinations, and delusional thoughts. (AR 350, 352.) She was found to “meet[] the criteria for Major Depression” and was continued on medication. (AR 352.) Plaintiff was also prescribed medication for her anxiety. (AR 352.)

         2. Fresno County Department of Behavioral Health

         Plaintiff was diagnosed with anxiety, bipolar disorder, and depression in April 2012, while two months pregnant. (AR 241.) In September 2012, while seven months pregnant, Plaintiff reported feeling depressed and “doesn't feel like doing anything.” (AR 244, 253.) She stated she was diagnosed with bipolar disorder as a teenager and had been taking medication. (AR 244, 253.)

         Licensed Clinical Social Worker (LCSW) Scheree Lau performed a comprehensive assessment of Plaintiff in September 2012 and noted she had impaired memory, poor insight and judgment, and exhibited impulsive, violent, and assaultive behavior. (AR 265-72.) According to LCSW Lau, Plaintiffs prognosis was “guarded.” (AR 271.) Plaintiff reported using cocaine, PCP, and methamphetamines in the past, and LCSW Lau noted that Plaintiff uses drugs to self-medicate. (AR 267-68.) Plaintiff reported using marijuana the night before. (AR 272.) She reported insomnia, decreased appetite, temper outbursts, and feelings of lack of control, anger, and grief due to her mother's death. (AR 272.) LCSW Lau diagnosed Plaintiff with “Bipolar I, MRE, mixed, recurrent, ” “Cannabis Abuse, ” and “Bereavement.” (AR 272.)

         In February 2013, Plaintiff reported that she had not taken medication since the birth of her daughter in November. (AR 259.) She presented with a calm mood, organized thought process, and thought content devoid of psychotic or delusional function. (AR 259.) Plaintiff “emphatically denied” all suicidal and homicidal ideation. (AR 259.) She expressed a desire to get back on her medication due to her depression and anger. (AR 259.) Plaintiff reported that “if anyone looks sideways at her she will spontaneously pick a fight with them.” (AR 259.)

         Nurse Practitioner (NP) Elisa Salazar conducted a psychiatric evaluation of Plaintiff in May 2013. (AR 250-52, 400-02.) Plaintiff appeared well-groomed and engaged/responded appropriately with her six-month-old daughter. (AR 251, 401.) Her motor activity, cognition, speech, affective range, and orientation were all normal, with organized and linear thought processes. (AR 251-52, 401-402.) Plaintiff endorsed auditory hallucinations and passive suicidal ideation but denied intent. (AR 252, 402.) Her mood was listed as depressed and irritable and her insight was fair. (AR 252, 402.) NP Salazar diagnosed bipolar disorder, post-traumatic stress disorder (PTSD) (rule-out), and polysubstance dependence. (AR 252, 402.) She prescribed Abilify for “mood stabilization.” (AR 252, 402.)

         In July 2013, Plaintiff reported to NP Salazar that she got into a fight with her aunt that resulted in the police and child protective services being called. (AR 246, 396.) She stated that she felt “more calm” on Abilify but was tired. (AR 246, 396.) Plaintiff denied suicidal or homicidal ideation but reported that she experiences auditory hallucinations when she is alone. (AR 246, 396.) Plaintiffs mood was “angry” but her behavior cooperative, and her motor activity, sensorium, speech, orientation, affective range, and thought processes were all normal. (AR 246, 396.) NP Salazar noted Plaintiff displayed “borderline traits: fear of abandonment, intense relationships, mood instability, [and] difficulty controlling anger.” (AR 247, 397.) NP Salazar assessed Plaintiff with borderline personality disorder and referred her to individual therapy. (AR 247, 397.)

         Plaintiff presented for a follow-up visit with NP Salazar in October 2013. (AR 393-94.) She reported having stopped taking Abilify because she was tired. (AR 393.) According to Plaintiff, she “[h]ears voices calling her name, sounded like her mom.” (AR 393.) She reported getting irritated and agitated easily, getting into “fights with random people, ” and superficial cutting of her arm to “take[] the inside pain away.” (AR 393.) Upon examination, NP Salazar found Plaintiff cooperative, with alert sensorium, organized thought processes, and normal motor activity, cognition, speech, orientation, and affective range. (AR 393.) Plaintiff denied suicidal and homicidal ideation. (AR 393.) Her mood was listed as irritable and “angry.” (AR 393.) NP Salazar noted Plaintiff had poor to fair insight, had not followed up with treatment in the past, and was not honest about substance abuse. (AR 393.) Borderline personality disorder was once against assessed. (AR 394.) NP Salazar recommended that Plaintiff discontinue Abilify and try Lamictal (Lamotrigine) instead. (AR 394.)

         At a follow up appointment in December 2013, Plaintiff reported continued irritability and anger, but she had stopped cutting. (AR 390.) She had also run out of Lamictal. (AR 390.) Upon examination, NP Salazar found Plaintiff cooperative, with alert sensorium, organized thought processes, and normal motor activity, cognition, speech, orientation, and affective range. (AR 390.) Plaintiff experienced hallucinations and passive suicidal ideation. (AR 390.) She denied homicidal ideation. (AR 390.) Her mood was listed as depressed and irritable. (AR 390.) NP Salazar noted Plaintiff had poor to fair insight, had not followed up with treatment in the past, and was not honest about substance abuse. (AR 390.) Borderline personality disorder was once against assessed. (AR 391.) NP Salazar recommended Plaintiff re-start Lamictal. (AR 391.)

         Plaintiff failed to show for follow up appointments in February and March 2014. (AR 388-89.) In August 2014, Plaintiff was seen via telemedicine by John F. Balog, M.D. (AR 412-17, .) She reported feeling better on Lamictal. (AR 416.) Plaintiff reported living in a “place for women” that is “not safe” and where there is “fighting constantly.” (AR 412, 414, 416.) According to Plaintiff, her anxiety is overwhelming due to her living situation. (AR 416.) Dr. Balog noted Plaintiffs motor activity, cognition, speech, orientation, sensorium, affective range, and thought processes were all normal. (AR 412, 414, 416.) Her mood was listed as depressed and irritable. (AR 412, 414, 416.) Dr. Balog noted Plaintiff had poor to fair insight, had not followed up with treatment in the past, and was not honest about substance abuse. (AR 412, 414, 416.) Bipolar disorder, PTSD (rule-out), and borderline personality disorder were once against assessed. (AR 413, 415, 417.)

         Plaintiff reported being “not good” in September 2014. (AR 410.) Her children were removed from her custody due to marijuana use and child endangerment. (AR 410.) Plaintiff reported that she is trying to get her children back. (AR 410.) Dr. Balog's examination findings remained the same as the previous month. (AR 410-11.) He advised Plaintiff to continue Lamictal and prescribed Geodon and Trazodone. (AR 411.) Dr. Balog also recommended that Plaintiff undergo behavioral therapy. (AR 411.)

         In December 2015, Plaintiff presented via telemedicine for a follow-up appointment with Dr. Balog. (AR 408-09.) She reported that she didn't continue treatment and “things got out of hand.” (AR 408.) Plaintiff was “on the streets for a while” but had been in an apartment for five months and living with her boyfriend. (AR 408.) She stated being out of medication and not having taken it for over a year. Plaintiff had a baby five months earlier and all of her children were living with their grandmother. (AR 408.) She reported having completed a four-and-a-half-month in-patient treatment. (AR 408.) Upon examination, Dr. Balog noted she was well-groomed and cooperative, with normal motor activity, sensorium, cognition, speech, orientation, and affective range. (AR 408.) Plaintiff s thought processes were linear and goal-oriented. (AR 408.) She denied suicidal and homicidal ideation but endorsed auditory and visual hallucinations. (AR 408.) Plaintiffs mood was noted to be depressed and irritable, and Dr. Balog noted impaired insight and judgment due to her history of non-compliance. (AR 408.) He prescribed Buproprion, Perphenazine, and Trazodone. (AR 409.)

         3.State Agency Physicians

         On February 20, 2014, Winston Brown, M.D., a Disability Determinations Service medical consultant, reviewed Plaintiffs medical records and found them insufficient to make a determination regarding her mental residual functional capacity (RFC).[5] (AR 74-76, 80-82.) Dr. Brown indicated that a consultative examination was required (AR 74, 80.) A consultative examination was scheduled for May 24, 2014, but Plaintiff failed to show up. (AR 405-06.)

         Upon reconsideration on July 14, 2014, another Disability Determinations Service medical consultant, R. Torigoe, Ph.D., affirmed Dr. Brown's determination of insufficient evidence. (AR 91-92, 100-02.)

         B. Administrative Proceedings

         The Commissioner denied Plaintiffs applications for benefits initially on February 26, 2014, and again on reconsideration on August 5, 2014. (AR 18, 107-12, 116-26.) Consequently, Plaintiff requested a hearing before an Administrative Law Judge (“ALJ ”). (AR 127-35.)

         On September 16, 2016, Plaintiff appeared with counsel and testified before an ALJ as to her alleged disabling conditions. (AR 43-69.) Plaintiff testified that her mood varies between neutral, not mad, and angry. (AR 64.) She also testified she is depressed “[p]retty much daily.” (AR 64.)

         C. The ALJ's Decision

         In a decision dated February 1, 2017, the ALJ found that Plaintiff was not disabled. (AR 18-26.) The ALJ conducted the five-step disability analysis set forth in 20 C.F.R. § 404.1520(a)(4) and § 416.920(a)(4). (AR 20-26.) The ALJ first determined that Plaintiff had not attained age 22 as of April 1, 2003, the alleged onset date. (AR 20.) The ALJ next decided that Plaintiff had not engaged in substantial gainful activity since April 1, 2003, the alleged onset date (step one). (AR 20.) At step two, the ALJ found Plaintiffs following combination of impairments to be severe: depression versus major depression; anxiety versus generalized anxiety disorder; a history of polysubstance abuse, in remission; posttraumatic stress disorder; psoriasis; asthma; gastroesophageal reflux disease; marijuana abuse, in remission; hepatitis; bradycardia; a history of amphetamine dependence; a personality disorder; bipolar disorder; and borderline ...


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