Chris Shelton v. Michael J. Astrue, No. 2:2009cv06316 - Document 16 (C.D. Cal. 2010)
Court Description: MEMORANDUM AND OPINION by Magistrate Judge Victor B. Kenton re social security claim. The Court finds no error with regard to Plaintiff's second issue. The decision of the ALJ will be affirmed. The Complaint will be dismissed with prejudice. (rh)
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1 2 3 4 5 6 UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA WESTERN DIVISION 7 8 9 10 11 CHRIS SHELTON, 12 13 14 15 Plaintiff, v. MICHAEL J. ASTRUE, Commissioner of Social Security, 16 Defendant. ) ) ) ) ) ) ) ) ) ) ) ) No. CV 09-06316-VBK MEMORANDUM OPINION AND ORDER (Social Security Case) 17 18 This matter is before the Court for review of the decision by the 19 Commissioner of Social Security denying Plaintiff s application for 20 disability benefits. 21 consented that the case may be handled by the Magistrate Judge. 22 action arises under 42 U.S.C. §405(g), which authorizes the Court to 23 enter judgment upon the pleadings and transcript of the record before 24 the Commissioner. 25 ( JS ), and the Commissioner has filed the certified Administrative 26 Record ( AR ). Pursuant to 28 U.S.C. §636(c), the parties have The The parties have filed the Joint Stipulation 27 Plaintiff raises the following issues: 28 1. Whether the Administrative Law Judge ( ALJ ) properly 1 considered the evaluating physician s initial assessment; 2 and 3 2. Whether the ALJ properly developed the record. 4 5 This Memorandum Opinion will constitute the Court s findings of 6 fact and conclusions of law. After reviewing the matter, the Court 7 concludes that the decision of the Commissioner must be affirmed. 8 9 I 10 THE ALJ PROPERLY EVALUATED PLAINTIFF S 11 MENTAL STATUS AND FUNCTIONAL LIMITATIONS 12 In Plaintiff s first issue, he asserts that the ALJ failed to 13 properly consider the evaluation of his treating physician, Dr. 14 Hernandez, of the Los Angeles County Department of Mental Health, 15 Compton Mental Health Unit. (JS at 3, et seq., AR at 299-310, 16 hereinafter Compton Mental Health. ) 17 of schizoaffective disorder, bipolar type, major depression, alcohol 18 dependence, and a Global Assessment of Function ( GAF ) score of 55. 19 (JS at 3, citing AR at 307. 20 should have considered the Adult Initial Assessment of Compton 21 Mental 22 dysphoric and irritable mood with blunted affect, and exhibited 23 command and persecutory auditory hallucinations, known to begin at age 24 13. 25 blocking, excessive worry, apathy, and displayed inappropriate crying. 26 (AR 306.) 27 // 28 // Health, which Plaintiff notes his diagnosis Further, Plaintiff notes that the ALJ indicated, in part, that Plaintiff has a Plaintiff was found to have impaired concentration and thought 2 1 A. 2 The ALJ summed up his analysis of Plaintiff s mental impairments 3 The ALJ s Decision. in the following portion of his opinion: 4 Regarding [Plaintiff s] mental impairments, about a 5 year ago, as per [Plaintiff s] testimony and as evidenced by 6 the record, [Plaintiff] was abusing drugs. 7 suicidal and homicidal ideation which led to [Plaintiff s] 8 hospitalization due to psychotic symptoms occurred primarily 9 because he was abusing drugs. The evidence of Absent substance abuse and 10 under treatment however, the record shows [Plaintiff] is 11 stable and functional, with few if any restrictions. Indeed 12 some treatment notes indicate no work restrictions were 13 recommended, while others indicate [Plaintiff] was stable 14 and doing well, without any medication side effects. 15 (AR 15, exhibit citations omitted.) 16 17 Dr. Hernandez report is dated April 19, 2005. (AR 307.) The ALJ 18 relied upon evidence developed later in time. 19 report of consultative examining psychiatrist Dr. Yang (AR 275-78), 20 and State Agency psychiatrist Dr. McDowell (AR 279-92). 21 performed a consultative examination on August 29, 2007, in which he 22 diagnosed 23 disorder. (AR 277.) 24 perceptual disturbances, or delusional disorders. (AR 278.) Plaintiff 25 was able to focus his attention adequately. (AR 278.) 26 that Plaintiff indicated he has had problems with an addiction to 27 alcohol, cocaine, PCP and marijuana, but that he has been clean for 28 over eight months, having attended a 12-step program. (AR 276.) Plaintiff with polysubstance This included the dependence and Dr. Yang anxiety There was no evidence of any cognitive deficits, 3 It was noted 1 After reviewing the record, Dr. McDowell completed a Psychiatric 2 Review Technique Form ( PRTF ) on September 17, 2007. (AR 279-289.) 3 This resulted in an assessment of only mild functional limitations in 4 daily 5 maintaining concentration, persistence, or pace; and insufficient 6 evidence of repeated episodes of decompensation. (AR 287.) 7 adopted Dr. McDowell s analysis regarding the extent of limitations in 8 each of these four areas. (AR 12-13, see infra.) 9 this residual mental functional capacity (see AR at 13, ¶ 4), was 10 supported by Dr. Yang s consultative examination and opinion, and 11 affirmed by two State Agency reviewing medical sources. The ALJ noted 12 that he assigned the greatest weight to Dr. Yang s opinion, and the 13 State Agency psychiatrists. (AR 16.) 14 living and social functioning; moderate limitations in The ALJ The ALJ noted that The ALJ did acknowledge Plaintiff s treatment at the Compton 15 Mental Health Center, by Dr. Hernandez. (See AR at 12, 15.) 16 Plaintiff s specific complaint, however, is that the ALJ failed to 17 provide specific and legitimate reasons to reject Dr. Hernandez 18 opinion. 19 20 B. Applicable Law. 21 In evaluating mental impairments, 20 C.F.R. §404.1520a(c)(3)(4) 22 and §416.920a(c)(3)(4) mandate that consideration be given, among 23 other 24 functioning; concentration, persistence, or pace; and episodes of 25 decompensation. These factors are generally analyzed in a Psychiatric 26 Review Technique Form ( PRTF ). 27 sequential evaluation to determine if a claimant is disabled under the 28 Listing of Impairments; however, the same data must be considered at things, to activities of daily living ( ADLs ), social The PRTF is used at Step Three of the 4 1 subsequent steps unless the mental impairment is found to be not 2 severe at Step Two. 3 20 C.F.R. See SSR 85-16. §§404.1520a(c)(1) and 416.920a(c)(1) require 4 consideration of all relevant and available clinical signs and 5 laboratory findings, the effects of your symptoms, and how your 6 functioning may be affected by factors including, but not limited to, 7 chronic mental disorders, structured settings, medication and other 8 treatment. 1 9 SSR 85-16 suggests the following as relevant evidence: 10 History, findings, and observations from medical 11 sources (including psychological test results), regarding 12 the presence, frequency, and intensity of hallucinations, 13 delusions or paranoid tendencies; depression or elation; 14 confusion or disorientation; conversion symptoms or phobias; 15 psycho-physiological 16 behavior; anxiety or tension. 17 activities of daily living and work activity, as well as 18 testimony 19 performance and behavior. 20 homes, or similar assistive entities. of third symptoms, parties withdrawn or bizarre Reports of the individual s about the individual s Reports from workshops, group 21 22 It is also required under §404.1520a(c)(2) and §416.920a(c)(2) 23 that the ALJ must consider the extent to which the mental impairment 24 25 26 27 28 1 20 C.F.R. §404.1545(c) and §416.945(c) also require consideration of residual functional capacity for work activity on a regular and continuing basis and a limited ability to carry out certain mental activities, such as limitations in understanding, remembering, and carrying out instructions, and in responding appropriately to supervision, co-workers, and work pressures in a work setting. 5 1 interferes with an ability to function independently, appropriately, 2 effectively, and on a sustained basis including such factors as the 3 quality and level of [] overall functional performance, any episodic 4 limitations 5 require[d]. [and] the amount of supervision or assistance [] 6 Pursuant to the September 2000 amendments to the regulations 7 which modify 20 C.F.R. §404.1520a(e)(2) and §416.920a(e)(2), the ALJ 8 is no longer required to complete and attach a PRTF. 9 regulations identify five discrete categories for the first three of 10 four relevant functional areas: activities of daily living; social 11 functioning; concentration, persistence or pace; and episodes of 12 decomposition. These categories are None, Mild, Moderate, Marked, and 13 Extreme. (§404.1520a(c)(3), (4).) In the decision, the ALJ must 14 incorporate pertinent findings and conclusions based on the PRTF 15 technique. §404.1520a(e)(2) mandates that the ALJ s decision must show 16 the 17 findings, and the functional limitations that were considered in 18 reaching a conclusion about the severity of the mental impairment(s). 19 The decision must include a specific finding as to the degree of 20 limitation in each of the functional areas described in paragraph (c) 21 of this section. significant history, including examination and The revised laboratory 22 The Step Two and Three analyses are intended to determine, first, 23 whether a claimant has a severe mental impairment (Step Two), and if 24 so, whether it meets or equals any of the Listings (Step Three). 25 is also required under §404.1520a(c)(2) and §416.920a(c)(2) that the 26 ALJ must consider the extent to which the mental impairment interferes 27 with 28 effectively, and on a sustained basis including such factors as the an ability to function 6 independently, It appropriately, 1 quality and level of [] overall functional performance, any episodic 2 limitations 3 require[d]. [and] the amount of supervision or assistance [] 4 The GAF scale is intended to reflect a person s overall level of 5 functioning at or about the time of the examination, not for a period 6 of at least 12 consecutive months, which is required for a finding of 7 impairment or disability. (See 20 C.F.R. §§416.905, 416.920(c)(2006).) 8 GAF scores are intended to be used for clinical diagnosis and 9 treatment, and do not directly correlate to the severity assessment 10 set forth in Social Security regulations. (See Revised Medical 11 Criteria for Evaluating Mental Disorders and Traumatic Brain Injury, 12 65 Fed. Reg. 50746, 50764-65 (Aug. 21, 2000), and American Psychiatric 13 Ass n, Diagnostic and Statistical Manual of Mental Disorders, Text 14 Revision 33 (4th Ed. 2000). 15 16 C. Analysis. 17 The ALJ carefully distinguished the various determinations of 18 Plaintiff s mental functional limitations based upon whether, at the 19 time he was examined or tested, he was experiencing the effects of 20 alcoholism and/or drug dependence. 21 Compton Mental Health, and Dr. Hernandez, in 2005, the ALJ noted that, 22 at that time, Plaintiff was excessively utilizing alcohol and drugs, 23 and that the mental functional limitations which were diagnosed were 24 integrally intertwined with his use of these substances. 25 noted, Plaintiff s excessive use of alcohol and drugs continued into 26 late 2006, when he self-reported to Centinela Hospital Medical Center 27 and toxicology reports were positive for cocaine and marijuana. (AR 28 11, citing AR at 213-16.) With regard to the records of As the ALJ A few days later, at the Penn Mar 7 1 Therapeutic Center, Plaintiff was treated for a diagnosis of psychotic 2 disorder, NOS. 3 alcohol, 4 [Plaintiff s] condition was noted to have steadily improved during 5 admission 6 paranoid, suicidal or homicidal ideation, and he had no side effects 7 from the medication. (AR 11.) He admitted that he had increased his abuse of marijuana, until he and cocaine. was no The longer ALJ observed experiencing that, The hallucinations, 8 Thus, Dr. Yang s psychiatric evaluation on August 29, 2007 can be 9 placed in better perspective vis-a-vis Plaintiff s intake of alcohol 10 and drugs. At that time, Plaintiff reported that he had been clean 11 (presumably, of alcohol and drugs) for over eight months, and had 12 attended a twelve-step program. Plaintiff was working, doing odd jobs 13 such as laying tile and remodeling houses, and was taking psychiatric 14 medications, which Dr. Yang indicated were helpful. 15 church, ran errands, and had a good relationship with friends. (AR 16 278.) 17 deficits, perceptual disturbances or delusional disorders. 18 fairly groomed, and seemed capable of taking care of his own needs. 19 He was able to focus attention adequately, was able to follow one- and 20 two-part instructions, could adequately remember and complete simple 21 and complex tasks, was able to tolerate stress inherent in the work 22 environment, maintain 23 supervision. Further, Dr. Yang assessed that Plaintiff was able to 24 interact appropriately both with himself and staff, and he surmised 25 that Plaintiff would be able to interact in the same manner with 26 supervisors, co-workers, and the public in the workplace. (AR 278.) He attended Dr. Yang concluded that Plaintiff had no evidence of cognitive regular attendances, and work He was without 27 On reviewing this record, the State Agency psychiatrist, Dr. 28 McDowell, completed a PRTF on September 17, 2007 (AR 279-89), and 8 1 observed the level of mental functioning in the four relevant areas 2 which the Court has previously summarized in this decision. 3 relied upon these opinions in finding that Plaintiff did not have a 4 mental disability. (See Thomas v. Barnhart, 278 F.3d 947, 957 (9th Cir. 5 2002)(the opinions of non-treating or non-examining physicians may be 6 relied upon as substantial evidence when they are consistent with 7 independent clinical findings or other evidence in the record)). 8 In sum, while the ALJ s reference to the The ALJ opinions of Dr. 9 Hernandez in 2005, a period when Plaintiff was abusing drugs and 10 alcohol, may not have been accompanied by a specific or lengthy 11 discussion, the Court cannot disagree with the correctness of the 12 ALJ s analysis, which correlated Plaintiff s mental problems with his 13 excessive use of alcohol and drugs, and conversely, correlated his 14 improved 15 substances. 16 considered disabled based on mental health reasons during part of the 17 2005 period covered by the Compton Mental Health Center records, the 18 fact that his mental functioning was integrally related to his abuse 19 of alcohol and drugs would have vitiated any finding of disability, 20 based on applicable regulations. 21 mental status with his cessation of the use of these Even if, hypothetically, Plaintiff might have been For the foregoing reasons, the Court finds no error with regard 22 to the ALJ s 23 determination of Plaintiff s mental status and functioning. 24 25 II 26 THE ALJ DID NOT FAIL TO PROPERLY DEVELOP THE RECORD 27 In Plaintiff s second issue, he asserts that the ALJ failed to 28 properly develop the record with regard to a June 27, 2008 letter from 9 1 Rose Marie Andrews, OTR, from the Los Angeles County Department of 2 Mental 3 denominated a Vocation Services Coordinator (Id.), commented that 4 Plaintiff has been a patient, or client, at Compton Mental Health 5 since February 2005, that he has suffered from mental health problems 6 all his life, and that he remains in dire need of treatment and other 7 support services. 8 permanent mental disorder which requires persistent medical treatment 9 and other living assistance, that he is not able to perform for a 10 compensated job, be productive, concentrate, focus, follow directions, 11 or process multiple step information. 12 Plaintiff is not able to generate enough income to provide for 13 himself. (Id.) Health. In that letter (see AR at 331), Ms. Andrews, Ms. Andrews opined that Plaintiff has a chronic, Finally, she opined that 14 The ALJ rejected Ms. Andrews opinion, noting that she failed to 15 indicate the nature and extent of her relationship with Plaintiff, and 16 that as a Vocational Services Coordinator, she appears to lack any 17 form of specialization to give an opinion regarding the [Plaintiff s] 18 mental health history, his diagnoses, his current ability to function 19 mentally, 20 functions. (AR 16.) and his sustained ability to perform work-related 21 Plaintiff s counsel argues that the ALJ should have developed the 22 record to determine what treatment relationship Ms. Andrews had with 23 Plaintiff. 24 It is apparent that Ms. Andrews did not have an ongoing treatment 25 relationship with Plaintiff, because her descriptions of Plaintiff s 26 mental 27 inability to work, or support himself, are totally at odds with 28 concurrent actual reports of mental health professionals contained in infirmities, along with her 10 opinions about Plaintiff s 1 the AR, which are based upon actual examinations. 2 Plaintiff was examined by Dr. Yang on August 29, 2007, he was working 3 doing odd jobs, was able to eat, dress and bathe independently, was 4 able to manage money, take bus transportation, visit with family and 5 friends, and otherwise function appropriately. (AR 276-77.) 6 addition, Ms. Andrews assessment is entirely inconsistent with the 7 reports 8 rehabilitation centers during 2007. 9 2007, Valerie R. Ramirez, a consultative medical source, reviewed 10 reports of these facilities and providers in 2007, and reported that, 11 [Plaintiff] does not need reminders, cook [sic], cleans, uses public 12 transportation, shops, handles money, goes to church, walks 1/2 mile. 13 (AR 316.) of Plaintiff s functioning at various For example, when therapeutic In and As the ALJ noted, on October 26, 14 Based on the foregoing, the Court does not deem that the ALJ 15 erred by failing to follow up with development of the record to 16 determine what, if any, treatment or professional relationship Ms. 17 Andrews had with Plaintiff. 18 appear to be based upon any professional medical relationship with 19 Plaintiff, and, in any event, it is completely at odds with the 20 uniformly 21 professionals summarized in the ALJ s decision. 22 23 24 25 26 27 28 consistent reports Indeed, Ms. Andrews opinion does not of the other doctors and medical Based on the foregoing, the Court finds no error with regard to Plaintiff s second issue. The decision of the ALJ will be affirmed. The Complaint will be dismissed with prejudice. IT IS SO ORDERED. DATED: May 24, 2010 /s/ VICTOR B. KENTON UNITED STATES MAGISTRATE JUDGE 11
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