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
September 20, 2018, Plaintiff Pamela Green
(“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.[2]
II.
FACTUAL BACKGROUND
On
April 2, 2014, Plaintiff protectively filed an application
for DIB payments, [3] alleging she became disabled on January
28, 2013, due to depression, bipolar disorder, arthritis, and
cervical injury. (Administrative Record (“AR”)
16, 19-20, 65, 100, 116, 221-22, 241.) Plaintiff was born on
August 14, 1959 and was 54 years old as of the alleged onset
date. (AR 63-64, 80, 192, 226, 247.) She has a GED and
completed some college, has past work experience as an
accounting clerk, and last worked full-time in 2013. (AR
64-65.)
A.
Relevant Medical Evidence[4]
1.
Charles Douglass, LCSW
On
August 1, 2012, Plaintiff established care with social worker
Charles Douglass for treatment of her depression. (AR
695-700.) Plaintiff reported that she had suffered from
depression for more than thirty years was prescribed Cymbalta
and other medications, had seen therapists in the past, and
had suicidal thoughts but never acted on them. (AR 695.)
Plaintiff completed a depression survey in which he stated
she had significant difficulty concentrating, “fears of
cracking up or going crazy”, and fears of criticism or
disapproval, and had significant feelings of sadness,
discouragement, low self-esteem, inferiority, guilt,
indecisiveness, irritability, loss of interest in life, loss
of motivation, poor self-image, and suicidal impulses. (AR
696-699.)
Plaintiff
returned to Mr. Douglass on August 10, 2012 and August 24,
2012. (AR 693-94.) At those visits, Plaintiff reported she
was “feeling better.” (AR 693-94.) On September
7, 2012, Plaintiff reported her boyfriend had been arrested
and she expected him to go to prison. (AR 692.) On September
27, 2012, Plaintiff stated she talked on the phone and wrote
to her ex-boyfriend and sent him some books on recovery from
addiction. (AR 692.) On October 10, 2012, she reported she
was applying for new jobs and had been on vacation that week.
(AR 692.)
On
October 24, 2012, Plaintiff stated she was “feeling
down, ” was prescribed a new depression medication and
had increased her dosage of Cymbalta to 60 milligrams. (AR
690.) On November 9, 2012, Plaintiff reported she did not get
interviews for the jobs she applied for, and was
“disappointed and hurt, ” but that she did not
feel ready to return to work anyway because she was
“still feeling down and [was] unable to cope with
work.” (AR 690.)
2.
Mark Tetz, M.D.
The
record also contains treatment notes from 2012-2013 from
Plaintiff's primary care physician Mark
Tetz.[5] (AR 375-409, 503-510.) On June 6, 2012,
Dr. Tetz noted that Plaintiff was diagnosed with depression
and bipolar disorder and was prescribed Lamotrigine and
Cymbalta. (AR 389.) Dr. Tetz noted that Plaintiff was
“alert and oriented, cooperative, non-ill appearing,
” and “pleasant.” (AR 390.) On July 26,
2012, Dr. Tetz observed that Plaintiff had no anxiety or
sleep disturbances but did have depression and some suicidal
ideation. (AR 387.) On October 23, 2012, Dr. Tetz noted that
Plaintiff had no anxiety, no sleep disturbances, and no
suicidal ideation. (AR 384.) On November 15, 2012, Dr. Tetz
noted Plaintiff was “alert and oriented, cooperative,
non-ill appearing, ” and “pleasant, ” but
was “[t]earful discussing going back to work.”
(AR 382.)
On
January 28, 2013, Plaintiff reported that she had a problem
“with irritability and anger” and “got into
trouble last week at work.” (AR 509.) Plaintiff
reported she “thought she was doing better, until last
week, ” and felt “like she can't go back . .
. to work now.” (AR 509.) Dr. Tetz noted, however, that
Plaintiff was “alert and oriented, cooperative, non-ill
appearing, pleasant, ” made “good eye contact,
normal speech, alert, ” and exhibited
“appropriate mood and affect.” (AR 509.) Dr. Tetz
refilled Plaintiff's Lamotrigine and Cymbalta. (AR 509.)
On
February 25, 2013, Plaintiff reported she felt “better
since off work, less irritable now, ” but was
“[n]ot able to go back to work yet” because she
was “[w]orried about anger outbursts.” (AR 507.)
Dr. Tetz also stated that Plaintiff was “[no]t able to
go back to” work and that her “disability”
leave should “continue . . . until start of
5/2013.” (AR 507.) However, Dr. Tetz also noted that
Plaintiff was “alert and oriented, cooperative, non-ill
appearing, pleasant, ” made “good eye contact,
normal speech, alert, ” and exhibited
“appropriate mood and affect.” (AR 507.) On April
24, 2013, Dr. Tetz noted Plaintiff had normal affect, normal
speech, appropriate mood, appropriate affect, and no thought
disorder. (AR 376.)
3.
Family Healthcare Network
In
December 2013, Plaintiff established care with the Family
Healthcare Network. (See AR 705-803.) On December
19, 2013, Plaintiff saw physician assistant Christian
Wigfall, and reported a history of depression and bipolar
disorder, and requested prescription refills of Cymbalta and
Lamotrigine. (AR 708.) Plaintiff returned on January 8, 2014,
to meet with social worker Meredith Casares, MSW, and
reported loss of interest in activities, low energy,
difficulty concentrating and remembering, feeling hopeless,
irritable, guilty, sad, and fatigued, and difficulty
maintaining a job. (AR 710.) Ms. Casares assessed Plaintiff
as suffering from Bipolar I disorder, depressive disorder,
nondependent cannabis abuse, and major depressive disorder.
(AR 712.)
Plaintiff
returned to see Ms. Casares on March 19, 2014. (See
AR 717.) Plaintiff reported that she was having negative
thoughts about how people view her and “has been more
paranoid about how people are viewing her and interacting
with her.” (AR 717.) On April 18, 2014, Plaintiff
stated to Ms. Casares that “overall things have been
‘good'” but she had fears about her ability
to concentrate and learn, had very high expectations for
herself, and “links things that are out of her control
to her worth.” (AR 719.) Plaintiff returned on May 29,
2014, and reported that “she feels suicidal many
times” and had “thought about veering off the
road.” (AR 723.) Plaintiff reported she had been called
back for interviews for jobs she applied for but she decided
not to go to the interviews. (AR 723.) Plaintiff stated she
took a competency test for a job placement agency but did
“so poorly, ” and contacted a lawyer about
applying for disability. (AR 723.) Ms. Casares gave Plaintiff
the number for the suicide prevention hotline and confirmed
that Plaintiff would go to the emergency room if she had
suicidal thoughts. (AR 723.)
Plaintiff
saw Mr. Wigfall on June 5, 2014 and reported increased
depression and memory loss. (AR 725.) Mr. Wigfall noted that
Plaintiff was “pleasant, alert, in no acute distress,
well developed, [and] well nourished.” (AR 726.) Mr.
Wigfall also noted that Plaintiff was “emotionally
upset” and “crying when discussing current
situation.” (AR 726.) Plaintiff returned to see
physician assistant Dustin Wetmore on December 30, 2014. (AR
730.) Plaintiff reported worsened depression and occasional
suicidal thoughts, and said her “lack of money [was]
her biggest source of anxiety and depression.” (AR
730.) Plaintiff's depression medications were also
re-filled. (AR 731.)
On
April 22, 2015, Plaintiff reported “severe”
depression, “mood swings every day, ” and
intermittent suicidal ideation. (AR 732.) Plaintiff reported
that before she stopped working in January 2013, she
“had mood swings at work, had difficulty working with
others, ” and had gone on “stress leave”
once in 2012 and again in January 2013. (AR 732.) On May 27,
2015, Plaintiff reported she had been sexually assaulted by
her boyfriend on February 22, 2015, and did not want to
report it because she feared retaliation. (AR 738.) Plaintiff
was reluctant to discuss what happened but generally reported
“anxiety about the incident.” (AR 739.)
On July
15, 2015, Plaintiff reported she had been “struggling
with her stress and depression, ” and was going to see
a rape counselor about her sexual assault. (See AR
742.) On September 2, 2015, Plaintiff reported her depression
was “not well-controlled” and she had been on
medications for “a long time for bipolar and
depression.” (AR 744.) Plaintiff reported
“feeling very sad sometimes” and “had some
suicidal thoughts recently, but . . . no intention of acting
on them.” (AR 744.) Plaintiff stated she also had
intermittent “crying episodes” and reported
“feeling tired frequently.” (AR 744.) On
September 9, 2015, Plaintiff reported she will “stay in
bed for a few days and cry” and on those days she is
“unable to get out of bed and complete anything.”
(AR 747.) On September 24, 2015, Plaintiff reported having
bad days that caused her to be depressed, stay in bed all
day, and consider suicide, and that she “often becomes
overwhelmed and upset when she has her days that are
difficult.” (AR 751.)
On
November 20, 2015, Plaintiff reported to Ms. Casares that
nearly every day, she had little interest or pleasure in
doing things; felt down, depressed or hopeless; had trouble
falling or staying asleep, or slept too much; felt tired or
had little energy; had poor appetite or over-ate; felt bad
about herself; had trouble concentrating on things; moved
very slowly or too quickly; and had thoughts of suicide. (AR
758.) Ms. Casares assessed that Plaintiff had severe
depression. (AR 758.) On December 4, 2015, Ms. Casares again
assessed that Plaintiff was severely depressed. (AR 760.)
On
December 30, 2015, Plaintiff reported that only about half
the time she had little interest or pleasure in doing things;
felt down, depressed or hopeless; had trouble falling or
staying asleep, or slept too much; felt tired or had little
energy; had poor appetite or over-ate; felt bad about
herself; and had trouble concentrating. (AR 762.) Plaintiff
reported that only on several days she moved very slowly or
too quickly, and never had thoughts of suicide. (AR 762.) Ms.
Casares assessed Plaintiff with moderately severe depression.
(AR 762.)
On
February 10, 2016, Plaintiff reported only for several days
she had little interest or pleasure in doing things; felt
down, depressed or hopeless; had trouble falling or staying
asleep, or slept too much; felt tired or had little energy;
had poor appetite or over-ate; felt bad about herself; and
had trouble concentrating. (AR 767.) Ms. Casares assessed
Plaintiff with only mild depression. (AR 767.) On March 9,
2016, April 8, 2016, and May 5, 2019, Ms. Casares again
assessed Plaintiff with mild depression based on
Plaintiff's complaints. (AR 769, 771, 773.) On June 9,
2016, Ms. Casares assessed Plaintiff with moderately severe
depression. (AR 775.) On July 12, 2016, her depression was
still assessed as moderately severe. (AR 882.) On August 5,
2016, Plaintiff's depression had improved to mild. (AR
884.) Finally, on December 16, 2016, Plaintiff's
depression was assessed as moderately severe. (AR 892.)
4.
Family Services of Tulare County
Plaintiff
reported to Family Services of Tulare County for four
sessions to discuss her February 2015 sexual assault and her
mental impairments. (See AR 866.) On July 31, 2015,
the therapist and clinical supervisor diagnosed Plaintiff
with adjustment disorder, mixed anxiety and depressed mood,
spouse or partner violence, sexual, parent-child related
problem, and employment problem. (AR 866.) At the July 15,
2015 session, Plaintiff described the rape by her
ex-boyfriend and stated that she felt “emotionally and
psychologically troubled” but did not report the rape
to police because she feared retaliation from the
ex-boyfriend and “she had no evidence about the rape
incident.” (AR 868-69.) Plaintiff returned for two more
sessions and reported she was “still bothered by the
thought of the shame of rape” and was “afraid
that people would blame her and reject her because of what
had happened.” (AR 871-73.)
5.
Claudia Gonzalez, Psy.D.
In
January 2017, Plaintiff established care with psychologist
Claudia Gonzalez. (AR 894.) On January 31, 2017, Plaintiff
reported to Dr. Gonzalez difficulties managing her symptoms
of anxiety and depression, and stated feeling
“overwhelmed” and an increase in stress lately.
(AR 894.) Plaintiff reported that she tended to
“overthink certain situations” and felt like
others did not like her, which caused her to have anxiety
around other people. (AR 894.) Plaintiff reported she was
still taking multiple medications for her mental impairments,
including Cymbalta. (AR 894.) On March 3, 2017, Dr. Gonzalez
noted that Plaintiff's symptoms of depression and anxiety
had increased, she felt “tense and frustrated, ”
had sleep disturbance, frequent racing thoughts, difficulties
getting out of bed, and was currently taking Cymbalta,
Lamotrigine, and Hydroxyzine. (AR 897.) On March 14, 2017,
Dr. Gonzalez noted Plaintiff's symptoms had decreased
because she was on a “mood stabilizer, ” but she
still had feelings of paranoia, racing thoughts, sleep
disturbance, and difficulty getting out of bed. (AR 900.)
On
March 29, 2017, Plaintiff reported “she was feeling
very angry” and had the same problems as reported at
previous visits-paranoia, racing thoughts, sleep disturbance,
and difficulty getting out of bed. (AR 903.) On April 13,
2017, Plaintiff reported similar symptoms and she
“spoke extensively about overthinking and feeling
nervous about a variety of different things.” (AR 906.)
Plaintiff stated she was not ready to return to work because
of her symptoms. (AR 906.) On April 26, 2017, Plaintiff
stated all her symptoms and stressors had increased, and she
reported problems with her children. (AR 909.)
On
April 13, 2017, Dr. Gonzalez completed a Medical Opinion
Questionnaire regarding Plaintiff's mental impairments.
(AR 860-62.) Dr. Gonzalez diagnosed Plaintiff with mood
disorder with mixed features and borderline personality
disorder. (AR 860.) Dr. Gonzalez opined that Plaintiff had
poor or no ability to accept instructions and respond
appropriately to criticism from supervisors, get along with
co-workers or peers without unduly distracting them or
exhibiting behavioral extremes, and deal with stress of
semiskilled and skilled work. (AR 860-61.) Dr. Gonzalez
opined that Plaintiff had fair ability to interact
appropriately with the general public, maintain socially
appropriate behavior, maintain attention for two hour
segment, complete a normal workday, respond appropriately to
changes in a work setting, and deal with normal work stress.
(AR 860-61.)
Dr.
Gonzalez opined that Plaintiff had good ability to use public
transportation, sustain an ordinary routine without special
supervision, work in coordination with others, make simple
work-related decisions, perform at a consistent pace without
an unreasonable number and length of rest periods, ask simple
questions, and set realistic goals. (AR 860-61.) Dr. Gonzalez
opined that Plaintiff had unlimited or very good ability to
adhere to basic standards of neatness and cleanliness, travel
in unfamiliar places, remember work-like procedures,
understand, remember and carry out very short and simple
instructions, maintain attention for two-hour segments,
maintain regular attendance and be punctual within customary,
usually strict tolerances, be aware of normal hazards and
take appropriate precautions, understand and remember
detailed instructions, and carry out detailed instructions.
(AR 860-61.) Dr. Gonzalez also opined that Plaintiff's
mental impairments would cause her to be absent from work
about twice per month. (AR 861.)
6.Mary
McDonald, Ph.D.
On
September 16, 2014, and September 23, 2014, Plaintiff
underwent a consultative examination with psychologist Mary
McDonald. (AR 683-88.) During the interview portion,
Plaintiff reported suffering from memory loss and
concentration problems. (AR 684.) Plaintiff was
“tearful and sad and cried several times during both
interviews.” (AR 684.) Dr. McDonald observed Plaintiff
was “tearful, irritable, and very slow in responding to
the tests.” (AR 685.) Plaintiff reported feeling
“overwhelmed, irritable, and sad, ” and reported
memory loss. (AR 685.) Dr. McDonald noted Plaintiff was
prescribed to take 60 milligrams of Cymbalta and 150
milligrams of Lamotrigine daily. (AR 685.)
Dr.
McDonald opined that Plaintiff had symptoms of “a
longstanding, long-term depressive disorder, ” and
diagnosed her with unspecified depressive disorder, cannabis
related disorder, and alcohol related disorder. (AR 687.) Dr.
McDonald stated Plaintiff's “prognosis in terms of
her ability to work is fair.” (AR 688.) Dr. McDonald
opined that Plaintiff's ability to perform all
work-related functions was “unimpaired, ” except
for her ability to accept instructions from supervisors and
respond appropriately to criticism, which was rated
“unknown, ” and her social judgment, which was
rated as “mildly unimpaired.” (AR 688.)
7.State
Agency Physicians
State
agency physician Harvey Bilik, Psy.D., reviewed the record
and assessed Plaintiff's mental RFC on October 9, 2014.
(AR 100-09.) Dr. Bilik opined that Plaintiff had affective
disorders and had mild restrictions on activities of daily
living, mild difficulties in maintaining social functioning,
and mild difficulties in maintaining concentration,
persistence or pace. (AR 107.) Upon reconsideration on
January 16, 2015, another state agency physician, Elizabeth
Covey, Psy.D., reviewed the record and affirmed Dr.
Bilik's findings. (AR 111-20.)
B.
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