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Christopher v. Berryhill

United States District Court, N.D. Texas, Dallas Division

April 22, 2019

CHRISTOPHER S., Plaintiff,



         By Special Order No. 3-251, this social security appeal was automatically referred for full case management. Based on the relevant filings, evidence, and applicable law, the Commissioner's decision should be REVERSED in part, and the case should be REMANDED for further proceedings.

         I. BACKGROUND [1]

         Christopher S. (Plaintiff) seeks judicial review of a final decision by the Commissioner of Social Security (Commissioner) denying his claim for disability insurance benefits (DIB) under Title II of the Social Security Act, and dismissing his request for hearing on his claim for supplemental security income (SSI) under Title XVI of the Social Security Act. (doc. 1 at 1-2.)

         A. Procedural History

         On February 28, 2015, Plaintiff applied for DIB, alleging disability beginning on December 1, 2007. (R. at 19, 142-43.) His DIB claim was denied on May 28, 2015, and upon reconsideration on August 7, 2015. (R. at 76; 83.) On May 28, 2015, Plaintiff applied for SSI, alleging disability beginning on his protected application date.[2] (R. at 19-20.) On September 29, 2015, he requested a hearing before an Administrative Law Judge (ALJ). (R. at 106-07.) He appeared and testified at a hearing on September 20, 2016. (R. at 34-75.) On December 13, 2016, the ALJ issued a decision finding Plaintiff was not under a disability from December 1, 2007 through December 31, 2012, and denying his claim for DIB benefits. (R. at 19-28.) He also dismissed Plaintiff's request for hearing on his SSI claim, finding no common issue with his DIB claim. (R. at 19-20.)

         Plaintiff appealed the ALJ's decision to the Appeals Council on December 14, 2016. (R. at 141.) The Appeals Council denied his request for review on November 3, 2017. (R. at 1-7.) He timely appealed the Commissioner's decision under 42 U.S.C. § 405(g). (See doc. 1.)

         B. Factual History

         1. Age, Education, and Work Experience

         Plaintiff was born on August 17, 1988, and was 28 years old at the time of the hearing. (R. at 43-44.) He graduated from high school, attended college, and could communicate in English. (R. at 44, 167.) He had past relevant work experience as a fast food worker. (R. at 71.)

         2. Medical Evidence

         Accompanied by his parents, Plaintiff presented to the Holiner Psychiatric Group (Holiner) with anxiety and depression on January 2, 2008, and was seen by Robert Feele, M.D. (R. at 236-38.) He was nineteen years old and attending college full-time but was home for the winter break. (R. at 236.) He reported hearing telepathic messages from the neighbors for three months, but was doing “better” because he was being accepted by others. (Id.) He reported having suicidal thoughts three weeks before, but denied having those thoughts at the time of examination. (Id.) He also reported smoking marijuana daily. (Id.)

         Dr. Feele reported Plaintiff's mood as dysphoric/irritable, anxious, and guilty/worthless, his concentration as “poor, ” and his motivation, energy, socialization, and interest levels as “fair.” (Id.) Plaintiff did not want to quit smoking marijuana because “[i]t expands [his] mind, ” but expressed a willingness to stop. (R. at 237.) During a mental examination, he was observed as having blunted affect, circumstantial thought process, grandiose delusions, dysphoric mood, and fair judgment and insight. (R. at 238.) Dr. Feele diagnosed Plaintiff with Schizophreniform, calculated a Global Assessment of Functioning (GAF) score of 50, [3] and prescribed 20mg of Zyprexa. (Id.)

         Plaintiff visited Dr. Feele on multiple occasions throughout 2008. (R. at 222-35.) During each visit, Plaintiff reported hearing others' thoughts about him and expressed concern that they could hear his thoughts. (Id.) On January 22, 2008, he reported no real improvement in his symptoms, and his “telepathy [was] just getting further away from home.” (R. at 235.) He was sober and leaving school. (Id.) His concentration ability had improved from “poor” to “fair, ” but his motivation, energy, and activity levels had declined to “poor.” (Id.) Dr. Feele's impression of Plaintiff was that he was “psychotic” and had a GAF score of 40. (Id.)

         On February 12, 2008, Plaintiff reported concern that his thoughts were being broadcast, but he was not as concerned about hearing other people's thoughts. (R. at 234.) He also reported “definite progress, ” but his mood was low, and he remained isolated. (Id.) No. significant changes were noted. (Id.) Dr. Feele added Haldol 5mg to his medication regimen. (Id.) On June 10, 2008, Plaintiff reported experiencing much better mood and more energy but was still isolated. (R. at 228.) His GAF score was 50. (Id.) Dr. Feele “reluctantly agreed” to reduce the dosage of Plaintiff's psychotrophic medication. (Id.)

         On September 12, 2008, Plaintiff and his mother both reported that he was doing “much better.” (Id.) He was going back to school, getting out of the house, and being more social, and he denied experiencing delusions. (Id.) Dr. Feele noted that he still appeared “blunt and suspicious, ” however. (Id.) His GAF had improved to 60. (Id.) On November 7, 2008, he noted as being “a bit guarded, ” but he reported doing well, going to school and work, and being compliant with his medication, and he denied any psychosis. (Id.) His mother was worried that he was not taking his medication daily because he had been “more oppositional” and was sleeping irregularly. (Id.)

         On November 28, 2008, Plaintiff's parents took him to the emergency room (ER) because he was vomiting after excessive drinking of alcohol. (R. at 336-39.) Plaintiff admitted to some marijuana abuse, and his parents reported him having “some minor hallucinations. (R. at 337.)

         On December 7, 2008, Plaintiff was involuntarily committed for four days at Green Oaks Hospital (Green Oaks) after his parents filed a mental inquest warrant due to his aggressive behavior, suicidal thoughts, and noncompliance with prescription medication. (R. at 239-40.) He reported having “general life issues” and would pound his fist on a desk when experiencing episodes of aggression. (R. at 239.) He was initially diagnosed with psychosis, depression, alcohol and cannabis abuse, and had a GAF score of 20. (Id.) It was noted that Plaintiff was not improving and would need to be transferred to another hospital for further medication management. (Id.)

         On December 11, 2008, Plaintiff was transferred to Terrell State Hospital (Terrell) for extended psychiatric inpatient treatment. (R. at 248-91). He was seen by Erik Blois, M.D., for a psychiatric evaluation. (R. at 257-62.) Plaintiff stated that he started having troubles with telepathy and mental voices back in 2007. (R. at 257.) He denied any neurovegetative symptoms of depression, but admitted to purchasing a gun with thoughts of suicide. (Id.) He used marijuana daily but was unwilling to take any of his medication. (R. at 258.) School and work stressed him out, and considered his boss intolerable and his main stressor. (Id.) Dr. Blois assessed Plaintiff as a mild risk for suicide. (R. at 260.) His presumptive diagnoses was paranoid-type Schizophrenia, cannabis abuse, and chronic mental illness with a current GAF of 25-30. (R. at 262.) Dr. Blois recommended that Plaintiff remain hospitalized for two weeks. (Id.)

         Dr. Blois also conducted Plaintiff's mental status examination. (R. at 512-13.) Plaintiff was anxious, somewhat fidgety, and talkative, and he had a euthymic mood and flat affect. (R. at 512.) His thought process was circumstantial and he was positive for auditory hallucinations. (Id.) Plaintiff had intact concentration and intact immediate, recent, and remote memory. (Id.) D r . B l o i s also noted that Plaintiff had impaired abstractions, poor judgment, and fair insight, and he estimated that Plaintiff had average intellectual functioning. (R. at 512-13.)

         Plaintiff was discharged from Terrell on December 19, 2008. (R. at 285.) He reported being free of auditory hallucinations and acknowledged that they were symptoms and not instances of mental telepathy. (R. at 287.) He was observed as being calmer and having well-contained anxiety. (Id.) His discharge diagnoses were Bipolar I disorder with hallucinations, cannabis abuse, Schizophreniform psychosis, and problems with substance abuse and treatment non-compliance with a GAF of 45. (R. at 285.)

         On December 29, 2008, Plaintiff established outpatient psychiatric treatment with Alcohol and Drug Abuse Prevention Training (ADAPT). (R. at -329.) His diagnoses were bipolar type, schizophrenia disorder, and cannabis abuse. (R. at 329.) His parents reported that he was doing better since his hospitalization, but he would become irritable and talk about suicide “when off his medications.” (Id.)

         On January 22, 2009, Plaintiff was evaluated by Ehireme Ibazebo, M.D., at ADAPT. (R. at 324-27.) Plaintiff reported “doing alright, ” but continued hearing voices. (R. at 324.) He was still seeing things and felt that his thoughts were being controlled by others. (Id.) He reported having a depressed mood for a few days and experiencing suicidal ideation. (Id.) During a mental status examination, Dr. Ibazebo observed Plaintiff as being calm, cooperative, open, and euthymic; his affect was blunted and his thought process was “sometimes illogical.” (R. at 326.) He had bizarre delusions, including thought broadcasting, thought insertion, and thought control. (Id.) Plaintiff was oriented with intact memory and good concentration, his intelligence was “average, ” and his insight and judgment were “good.” (Id.) Plaintiff had a GAF score of 39. (R. at 327.)

         Clinical notes from Dr. Ibazebo reveal improvements in Plaintiff's mental condition through June 2010. (R. at 300-23.) On March 13, 2009, he reported that his depression had stopped, but he continued hearing voices a few times a day. (R. at 320.) On April 10, 2009, he reported doing well at his job. (R. at 318.) He was doing well overall and his job was going “great” on May 12, 2009. (R. at 316.) Plaintiff continued to report that he was doing fine, good, or great during each of his other sessions with Dr. Ibazebo. (R. at 310-15.) He was noted as experiencing “intermittent” auditory hallucinations throughout this period. (Id.) On June 14, 2010, Plaintiff reported doing “fine” and that he would be starting full-time hours at his job. (R. at 300.) Dr. Ibazebo reported that he was not depressed, and his cannabis abuse was in early remission. (R. at 300-01.)

         On November 16, 2010, Plaintiff presented to clinical psychologist Dale General, Ph.D., for a psychology evaluation. (R. at 330-35.) Plaintiff complained that his medication was affecting his sleep schedule, but stated that “right now everything is pretty good on the meds” and his “hallucinations are pretty rare now.” (R. at 330.) Dr. General noted that Plaintiff had been working as a server, cashier, and bus boy for a pizza restaurant for the past eighteen months. (R. at 331.) Plaintiff worked approximately twenty-five hours per week and the job was going well. (Id.) He stated that a year ago he would smoke marijuana once or twice per week. (Id.) When asked about his daily activities, Plaintiff stated that he would watch television and play video games during his free time and primarily socialized with his family and co-workers. (Id.) Dr. General noted that Plaintiff's ability to handle day-to-day stress appeared generally intact, and he was capable of independently setting goals and making plans. (Id.) He reported that Plaintiff was able to manage his own finances and handle financial transactions. (Id.)

         Plaintiff stated that he had friends but currently preferred to interact with his family and co-workers. (R. at 332.) He did not have difficulty relating to his supervisors or people of authority in job situations. (Id.) Dr. General noted Plaintiff as appearing lucid, and he could read, write, follow instructions, and utilize a telephone. (Id.) Plaintiff's mood was euthymic and his psychomotor behavior was within normal limits. (Id.) Dr. General reported that Plaintiff was able to remain on-task throughout testing without difficulty, and assessed his abstract reasoning at the ninety-fifth percentile. (Id.) He also reported that Plaintiff's memory functioning was at the ninety-first percentile. and he had intact judgment and insight. (R. at 333.)

         Dr. General opined that Plaintiff's history of depressive symptoms and auditory hallucinations was consistent with the diagnostic criteria for Schizoaffective Disorder, Depressed Type. (R. at 333.) His current GAF score was 65, and his “prognosis for continued improvement in symptoms [was] fair given compliance with appropriate treatment.” (Id.) Dr. General concluded that Plaintiff would be capable to handle any funds due to him and would understand the meaning of filing for benefits. (R. at 334-35.)

         On May 26, 2015, State Agency Medical Consultant (SAMC) Thomas Geary, Ph.D., conducted a consultative evaluation of Plaintiff's medical records. (R. at 79-82.) He opined that Plaintiff's schizoaffective disorder and bipolar disorder were medically determinable impairments, but were not severe. (R. at 80-81.) Dr. Geary concluded that the medical evidence did not support Plaintiff's disability claim during the time frame between December 1, 2007 and December 31, 2012. (R. at 81.) On August 6, 2015, SAMC Susan Posey, PsyD., affirmed Dr. Geary's opinion upon ...

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