James B. v. Berryhill
| Decision Date | 20 March 2019 |
| Docket Number | Case No. 17-cv-06794-TSH |
| Court | U.S. District Court — Northern District of California |
| Parties | JAMES B., Plaintiff, v. NANCY A. BERRYHILL, Defendant. |
Plaintiff James B. brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of a final decision of Defendant Nancy A. Berryhill, the Acting Commissioner of Social Security, denying his claim for disability benefits. Pending before the Court are the parties' cross-motions for summary judgment. ECF Nos. 27 (Pl.'s Mot.), 32 (Def.'s Mot.). Pursuant to Civil Local Rule 16-5, the motions have been submitted on the papers without oral argument. Having reviewed the parties' positions, the Administrative Record ("AR"), and relevant legal authority, the Court hereby DENIES Plaintiff's motion and GRANTS Defendant's cross-motion for the following reasons.
Plaintiff is a 37-year old resident of Alameda County, California with a history of learning and conduct problems. AR 854. As a child, he was beaten with belts and switches but "was wildand careless and laughed when he was beaten." Id. Plaintiff attended special education classes for dyslexia and briefly attended Laney College's culinary program. AR 82, 809, 855. He has had jobs in construction, painting and warehouse work. AR 855. Plaintiff also worked for a brief time as a line bagger at Revolution Foods, "tak[ing] stuff from one spot and put[ting] it on the line." AR 83-84.
Plaintiff has been incarcerated multiple times for violence, including assault and rape, both as a youth in the juvenile justice system and later in state prison as an adult. AR 809, 854-55. His parole was repeatedly extended "due to his short temper and inappropriate behaviors with the parole officer and judges" and he "reportedly cursed his parole officer out and threatened to throw things in the court room." AR 855.
Exhibit 1F consists of records from Alameda County Sheriff's Department, Prison Health Services, dated September 25-30, 2006. AR 350-68. The records primarily consist of Plaintiff being treated for various conditions, including anxiety. AR 351-55. His symptoms included chest pain, facial numbness, vomiting and shortness of breath. AR 359.
Exhibit 2F consists of additional records from Alameda County Sheriff's Department, Prison Health Services, dated September 26, 2006 to January 8, 2008. AR 369-412. These records begin with medication lists from August 2007 through March 2008, indicating Plaintiff was diagnosed with asthma and hypertension and prescribed various medications. AR 370-83. An intake form dated July 15, 2007 indicates Plaintiff did not appear agitated, depressed, confused, or developmentally delayed. AR 411. The records also contain results of a blood test, an X-ray for a hand injury that was negative for acute findings, as well as medical request forms completed by Plaintiff between August 2007 and January 2008. AR 385-408.
Exhibit 3F consists of records from the California Department of Corrections and Rehabilitation, San Quentin State Prison, dated from March 13, 2008 to October 15, 2009. AR 413-74. The records include mental health evaluation notes, psychiatrist progress notes, and case manager progress notes. AR 441-74. On March 13, 2008, Plaintiff reported being diagnosed with Attention Deficit Disorder and leaving school prior to graduating in the 12th grade. AR 442. Healso reported daily use of marijuana, "as much as I can buy," and ecstasy "3x week and all weekend till now." Id. He reported situational depression and sleep disturbance. AR 444. Plaintiff was diagnosed with polysubstance dependence and assessed a GAF2 of 69, but the provider found he did not meet the criteria for mental health inclusion. Id. A September 17, 2008 note indicates a provisional diagnosis of Anxiety Disorder, but also indicates Plaintiff had no complaints or medication side effects, his sleep and appetite were okay, his grooming and hygiene were average, he was goal directed, his judgment and insight were average, and that he was assessed a GAF score of 65. AR 455. A note from October 15, 2009 indicates Plaintiff was experiencing nightmares about being shot and killed. AR 447. The note refers to Plaintiff's depression as an antecedent to substance dependence. Id. The treatment note also indicates Plaintiffs' mood and affect were sad but his depression was stable, he was alert and oriented, his hygiene and grooming were good, his thought process was clear and linear, his judgment and insight were fair, his memory and concentration were intact, he denied any medical concerns, he did not exhibit psychosis, and he was goal directed and isolated himself to avoid trouble and get released on time. Id. Other notes indicate suicidal ideation, dysphoric mood, flat affect (AR 454), "slightly slovenly, and somewhat malodorous' (AR 461), and a prescription for Remeron to treat depression (AR 470).
Exhibit 4F contains additional records from the California Department of Corrections and Rehabilitation, San Quentin State Prison, dated from January 16, 2009 to January 25, 2010. AR 475-552. These records are chart notes and medication lists, indicating Plaintiff was being treated for asthma, hypertension, hyperlipidemia, a mental health disorder, rhinitis and skin rashes; and medicated with aspirin, Flovent, hydrochlorothiazide, Lisinopril, mirtazapine (Remeron), simvastatin, verapamil, and fluocinolone. AR 474-532. A chart note from October 29, 2009 indicates Plaintiff sought medical treatment because he was experiencing nightmares. AR 533.He denied medication side effects, his appetite was normal, he was alert and oriented, his grooming and hygiene were adequate, his speech was normal and goal directed, his associations were intact, his mood was mildly low with congruent affect, he denied hallucinations, and his judgment and insight appeared average. Id. The provider assessed a GAF score of 65. AR 533.
Exhibit 5F contains additional records from Alameda County Sheriff's Department, Prison Health Services, dated January 2, 2007 to March 10, 2011. AR 553-600. These records are chart notes indicating treatment for hypertension and asthma. AR 570. A November 26, 2007 note also indicates a diagnosis of Attention Deficit Disorder. AR 566. A December 12, 2007 note indicates Plaintiff complained of insomnia. AR 576.
Exhibit 6F contains additional records from Alameda County Sheriff's Department, Prison Health Services, dated February 3, 2011 to August 16, 2012. AR 601-47. The records reflect ongoing treatment and medication for hypertension, hyperlipidemia, asthma, and depression. AR 610. The notes also indicate that although Plaintiff reported a history of mental health disorders, he denied mental health symptoms, denied a history of special education, and denied having a learning disability. AR 613.
Exhibit 7F contains additional records from Alameda County Sheriff's Department, Prison Health Services, dated August 9, 2012 to October 7, 2012. AR 648-710. The records also reflect ongoing treatment and medication for hypertension, hyperlipidemia, asthma, and depression. Id.
Exhibit 8F contains records from the California Department of Corrections and Rehabilitation, Parole Outpatient Clinic, dated February 3, 2010 to April 11, 2013. AR 711-31. These records consist of individual and group therapy progress notes (AR 711-18) and a February 3, 2010 mental health evaluation conducted by Francesca Biffi, LCSW. AR 728-31. Ms. Biffi indicated Plaintiff was alert and oriented to time, person, and place; he was cooperative, attentive, and pleasant; his speech was clear, organized, and had no abnormalities; his thought process and content were normal; he was calm with no unusual behaviors; his concentration was sufficient and he could follow instructions; he had fair long-term memory; his fund of knowledge was average and appropriate for his educational level; and he denied auditory or visual hallucinations. AR 729. Ms. Biffi noted Plaintiff had poor insight and judgment and refused to take responsibility for hiscrime of rape. Id. She also noted he reported starting to drink alcohol at the age of 11 and using marijuana at the age of 12. AR 730. Ms. Biffi diagnosed Plaintiff with Sexual Abuse of Adult; Polysubstance Dependence; Alcohol Abuse; and Antisocial Personality Disorder. AR 728. A November 5, 2012 chart note completed by psychiatrist James Dotson, M.D., indicates Plaintiff was diagnosed with Bipolar Disorder after getting into fights in jail. AR 712. A July 16, 2012 chart note also completed by Dr. Dotson diagnosed Plaintiff with provisional Depressive Disorder NOS. AR 722. Dr. Dotson indicated Plaintiff's medications were effective for depression and he had no side effects aside from increased appetite. Id.
Exhibits 9F and 10F are records from the Emergency Department of Alameda Medical Center, dated October 16, 2005 to May 27, 2013. AR 732-806. The records reflect treatment in the ER for injuries caused by being stabbed in 2005 (AR 772), hematuria and a wrist injury in 2012 (AR 736, 794), and a hand injury, back pain and asthma in 2013 (AR 765, 800).
Exhibit 11F is a psychological evaluation by Jonathan Howard, Psy.D., dated September 16, 2013. AR 808-11. Dr. Howard diagnosed Plaintiff with "Mood Disorder, NOS, with depressed, anxious, and reported angry and labile features, and reported auditory hallucinations; Rule out Psychotic Disorder, NOS; Marijuana dependence, in remission (by claimant's report);" and a GAF of 58-60.3 AR 810. Dr. Howard concluded that Plaintiff demonstrated "mild to moderate impairment in his ability to understand and carry out simple instructions and tasks;" "moderate impairment as the instructions and task become more complex;" "moderate impairment in his ability to attend and concentrate on usual work situations;" "moderate to marked impairment in his ability...
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