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Paschal v. Commissioner of Social Security

United States District Court, N.D. California, Eureka Division

September 25, 2019

KAJUAN PASCHAL, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          ORDER ON CROSS MOTIONS FOR SUMMARY JUDGMENT RE: DKT. NOS. 18, 23

          ROBERT M. ILLMAN UNITED STATES MAGISTRATE JUDGE

         Plaintiff, Kajuan Paschal, received supplemental security income (“SSI”) disability payments under Title XVI of the Social Security Act as a child; and, upon reevaluation of his eligibility when he turned 18, a finding was entered that he was no longer disabled as of July 1, 2014. Plaintiff now seeks judicial review of the administrative law judge (“ALJ”) decision that denied him continuing SSI benefits. Plaintiff’s request for review of the ALJ’s unfavorable decision was denied by the Appeals Council, thus, the ALJ’s decision is the “final decision” of the Commissioner of Social Security which this court may review. See 42 U.S.C. §§ 405(g), 1383(c)(3). Both parties have consented to the jurisdiction of a magistrate judge (dkts. 9, 11), and both parties have moved for summary judgment (dkts. 18, 23). For the reasons stated below, the court will grant Plaintiff’s motion for summary judgment, and will deny Defendant’s motion for summary judgment.

         LEGAL STANDARDS

         The Commissioner’s findings “as to any fact, if supported by substantial evidence, shall be conclusive.” 42 U.S.C. § 405(g). A district court has a limited scope of review and can only set aside a denial of benefits if it is not supported by substantial evidence or if it is based on legal error. Flaten v. Sec’y of Health & Human Servs., 44 F.3d 1453, 1457 (9th Cir. 1995). Substantial evidence is “more than a mere scintilla but less than a preponderance; it is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Sandgathe v. Chater, 108 F.3d 978, 979 (9th Cir. 1997). “In determining whether the Commissioner’s findings are supported by substantial evidence, ” a district court must review the administrative record as a whole, considering “both the evidence that supports and the evidence that detracts from the Commissioner’s conclusion.” Reddick v. Chater, 157 F.3d 715, 720 (9th Cir. 1998). The Commissioner’s conclusion is upheld where evidence is susceptible to more than one rational interpretation. Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005).

         SUMMARY OF THE RELEVANT EVIDENCE

         Plaintiff raises five issues, four of which are interrelated. Plaintiff’s related issues argue that the ALJ committed reversible legal error by improperly rejecting the opinions of treating and examining sources; by improperly rejecting Plaintiff’s symptom testimony; by formulating a residual functioning capacity (“RFC”) not based on substantial evidence; and by relying on vocational expert (“VE”) testimony based on an incomplete hypothetical. See Pl.’s Mot. (dkt. 18) at 5 11-21. Accordingly, the following is a summary of the evidence relevant to the disposition of those claims.

         Evidence from Treating and Examining Doctors

         By way of background, Plaintiff was approximately 21 years old at the time of the hearing before the ALJ, and was living with his grandmother in Alameda County, California. Id. at 6. Growing up, Plaintiff received intermittent psychiatric treatment and special education services for a number of years due to cognitive and behavioral problems; further, he attended an alternative high school due to his inability to function in the standard high school setting. Id.; see also AR at 384, 386, 519-20. As an adult, Plaintiff has been assessed with PTSD, mood disorder not otherwise specified, disruptive disorder, adjustment disorder, and learning disability. Id.; see also AR at 78, 380, 383, 385, 449-53, 519, 526, 621-36. As discussed in detail below, Plaintiff’s mental impairments have been found to result in marked difficulties in his ability to understand, remember, or apply information, and as well as his ability to concentrate, persist, or maintain pace. See AR at 629.

         Plaintiff submits that he was treated by Micheline Beam, Ph.D., for a three-month period between October of 2014 and January of 2015, and that “Dr. Beam noted Plaintiff’s depression, anxiety, aggression, and conflict with his family . . . [and] his depressed mood [which] is present most of time, [] causes him to withdraw, isolate, and if triggered, become angry.” Pl.’s Mot. (dkt. 18) at 7 (citing AR at 518-19, 526-30). Plaintiff adds in this regard that Dr. Beam diagnosed him with a mood disorder not otherwise specified and a learning disorder not otherwise specified. Id. at 16 (citing AR at 518, 526). This appears to have been the sum of the evidence related to this witness, as Plaintiff makes no other references to Dr. Beam.

         In any event, Plaintiff was referred for consultative psychological examinations on two occasions. The first evaluation was performed by Jodi D. Snyder, Psy.D., in May of 2014, at the request of the state agency for disability determination and review, and which Dr. Snyder described as an “evaluation [that] was limited in scope and based on a single, time-limited session.” AR at 449-50. Initially, Dr. Snyder noted that Plaintiff presents as a slow learner, and as someone with difficulties with comprehension, focus, attention, and following written and spoken instructions. Id. at 449. Dr. Snyder added that Plaintiff had never worked and that he reportedly received $876.00 per month in SSI payments, which were managed by his grandmother on his behalf. Id. at 450. As part of this evaluation, Dr. Snyder completed an independent psychological examination and administered a series of diagnostic tests including the Folstein Mini Mental Status Exam (“MMSE”), the Wechsler Adult Intelligence Scale (4th Ed.) (“WAIS-IV”), the Wechsler Memory Scale (4th Ed.) (“WMS-IV”), as well as both parts of the trail making tests. Id. Following the administration of these tests, Dr. Snyder reported that Plaintiff’s full-scale IQ score was 70, placing him in the borderline range of intellectual functioning. Id. at 451. Specifically, Plaintiff’s WAIS-IV processing speed was measured at 68, or in the extremely low range, where he was measured at the borderline range in verbal comprehension, perceptual reasoning, and working memory. Id. As to his memory, Plaintiff’s WMS-IV scores showed that his auditory memory operated in the extremely low range of functioning. Id. Dr. Snyder then opined that Plaintiff was moderately to severely impaired in his ability to follow complex instruction or complete complex tasks, but that he was moderately impaired in his ability to adapt to changes in job routine. Id. at 452. By way of prognosis, Dr. Snyder cautioned that “Claimant appears to have difficulty with his cognition [which] appears primarily medical therefore [I] will defer to [a] medical opinion.” Id. Lastly, Dr. Snyder opined that Plaintiff does not have the ability to manage funds. Id. at 453.

         Plaintiff’s second evaluation, performed as a result of a referral from his counsel, was undertaken by Elizabeth Pearce, Psy.D. and Sonia Reyes-Tena, M.A., over the course of three days at the Hume Behavioral Health and Training Center in December of 2016. Id. at 621. Dr. Pearce’s assessment procedures were thorough, resulting in a 16-page report. Id. at 621-36. Plaintiff appeared for testing and evaluation on December 13th, 20th, and 27th of 2016, such as to allow Dr. Pearce time for separate clinical interviews with Plaintiff and his grandmother, as well as a review of Plaintiff’s school records and the administering of the following diagnostic tests: the WAIS-IV, the Dot Counting Test, the Montreal Cognitive Assessment (“MoCa”), the California Verbal Learning Test (2nd Ed.) (“CVLT-II”), the Personality Assessment Inventory (“PAI”), the Rey Complex Figure Test (“RCFT”), the Ruff 2 and 7 Selective Attention test, the Test of Memory Malingering (“TOMM”), and the Wide Ranging Achievement Test (4th Ed.) (“WRAT-4”). Id. at 621.

         Dr. Pearce described Plaintiff’s psychological history as being shaped in large part by the fact that Plaintiff had experienced the loss of “several friends and family [members] being shot or dying.” Id. at 622. This started when Plaintiff “was younger [and] saw one of his close friends in the hospital after he sustained a bullet wound, ” after which Plaintiff would be perpetually preoccupied with his safety. Id. Dr. Pearce also noted that Plaintiff was admitted to special education services from the 8th grade onwards due to his deficits in auditory processing. Id. After eventually finishing high school, Plaintiff briefly worked as a “store courtesy clerk, ” and while Plaintiff reported that “he left the job because he did not like the pace of the job, ” his grandmother reported that he was in fact fired because he could not keep up with the pace of the job. Id. Dr. Pearce also noted that her review of Plaintiff’s medical records reflected diagnoses of various mental health disorders including generalized anxiety disorder, disruptive behavior disorder not otherwise specified, and mood disorder not otherwise specified. Id. When she asked Plaintiff about how he was affected by the violence of which his friends and family had been victims, Plaintiff reported to Dr. Pearce that he constantly wondered why he was still alive. Id. at 623. Dr. Pearce noted that, as a result, Plaintiff “showed an increase of anxious thoughts and behaviors . . . [and] that while he is out of his home he looks over his shoulder frequently, he also ruminates on bad things happening to him or his loved ones.” Id. Plaintiff’s grandmother, Ms. Watson, reported to Dr. Pearce that Plaintiff had largely withdrawn himself from the society of his peers, and that Plaintiff would generally avoid leaving the home alone, “unless someone comes and takes him out.” Id. (internal quotation marks omitted). Regarding his daily functioning, Ms. Watson reported to Dr. Pearce that Plaintiff occasionally forgets having put a pot on the stove, and only remembers when the house becomes filled with smoke. Id. Consequently, Ms. Watson “encourages him to mak[e] quick and easy meals (e.g., sandwiches) . . . [beause] his attention span is limited and varies between 2 or 3 minutes for most tasks.” Id. Ms. Watson also reported to Dr. Pearce that Plaintiff can be forgetful to the point that “his grandmother typically needs to remind him of appointments.” Id. 623-24.

         Dr. Pearce also made a series of behavioral and mental status observations; initially, she found confirmation of Ms. Watson’s statements about her grandson’s need to be reminded about appointments by observing that Plaintiff arrived approximately an hour late for two of the three evaluation sessions. Id. at 624. Observing that Plaintiff “exhibited a flat affect, ” Dr. Pearce added that “[t]hroughout the sessions he tapped his feet, shifted in his chair, and tapped his hands (or pencil) while completing different tasks.” Id. Regarding the results of the diagnostic testing, Dr. Pearce found that Plaintiff’s performance on the Dot Counting Test, which measures response effort, fell outside the range of normal effort even when compared to a group of individuals with learning disability. Id. at 625. Plaintiff’s full-scale IQ was measured by Dr. Pearce as 81, suggesting overall intellectual functioning in the low-average range. Id. In this regard, Dr. Pearce found that Plaintiff showed impairment in the executive functioning aspects of language. Id.

         Plaintiff’s short-term memory was evaluated as “significantly impaired with his immediate visual memory score falling below the 1st percentile, ” while his delayed memory appeared to be mildly impaired, placing him in the 4th percentile. Id. at 626. Dr. Pearce noted that on the MoCA, Plaintiff’s “performance was severely impaired on a memory task [when] [h]e recalled [only] one of the five words on the list during the free recall.” Id. Likewise, as a result of his performance on the CVLT-II, a measure of auditory learning, Plaintiff’s “performance was in the significantly impaired range” on short and long delayed free recall conditions, “where he was asked to state as many of the words he could remember from the list spontaneously.” Id. Dr. Pearce’s overall conclusion as to Plaintiff’s memory deficits was that he “has moderate to severe impairment in retrieval of verbal information . . . [which] appear to be consistent with the report of both Mr. Pascal and his grandmother about his inability to remember appointments and remember what he has been working on at that point of time.” Id. at 627. In areas of executive functioning, Dr. Pearce found that Plaintiff had “significant difficulties completing a clock drawing task on the MoCA, ” and that his performance was impaired on another portion of the MoCA, the Alternating Trail Making section, due to his inability to shift between numbers and letters. Id. Further, as to Plaintiff’s ability for visual scanning, discrimination, and motor skills, Dr. Pearce found that his performance on the Ruff 2 and 7 Tests of Selective Attention showed mild to moderate impairment. Id.

         Dr. Pearce then discussed Plaintiff’s performance on the emotional and personality tests administered. In this regard, Dr. Pearce began by noting that Plaintiff’s “[e]valuations on somatic symptoms scales appear to be consistent with [Plaintiff]’s documented medical history . . . reflect[ing] anxiety, stress, and feelings of persecution . . . [coupled with] an elevation on the traumatic stress scale, which seem consistent with his report of witnessing violence and deaths in proximal social groups.” Id. Dr. Pearce added that Plaintiff’s responses on the Personality Assessment Inventory “also indicated that he has difficulty sleeping, is unable to manage time effectively, and has difficulty maintaining patience and attention, ” further opining that “[a]ll these factors may be related to his repeated exposure to violence and death.” Id. at 627-28. Accordingly, Dr. Pearce diagnosed Plaintiff with PTSD and noted his “recurrent intrusive thoughts and memories about the violent deaths and injuries of his friends and family members, and about the manner in which they died ...


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