(SS) Trevino v. Commissioner of Social Security

District Court, E.D. California·Decided September 21, 2020·No. 1:19-cv-00870·Unknown

Opinion

2 3 4 5 6 7 UNITED STATES DISTRICT COURT 8 EASTERN DISTRICT OF CALIFORNIA 9

10 ERNESTO TREVINO, Case No. 1:19–cv–00870–SKO 11 Plaintiff,

12 v. ORDER ON PLAINTIFF’S SOCIAL 13 SECURITY COMPLAINT ANDREW SAUL, 14 Commissioner of Social Security, 15 Defendant. (Doc. 1)

16 _____________________________________/ 17 18 I. INTRODUCTION 19 On June 24, 2019, Plaintiff Ernesto Trevino (“Plaintiff”) filed a complaint under 42 U.S.C. 20 § 1383(c) seeking judicial review of a final decision of the Commissioner of Social Security (the 21 “Commissioner” or “Defendant”) denying his application for Supplemental Security Income (SSI) 22 under the Social Security Act (the “Act”). (Doc. 1.) The matter is currently before the Court on 23 the parties’ briefs, which were submitted, without oral argument, to the Honorable Sheila K. 24 Oberto, United States Magistrate Judge.1 25 II. BACKGROUND 26 Plaintiff was born on December 28, 1967, passed a GED test, and has no past relevant work. 27 (Administrative Record (“AR”) 26, 83, 51, 52, 201, 206, 238, 273.) He has been in and out of 28 1 prison since he was 15 years old. (AR 76–77, 95, 202.) 2 Plaintiff filed a claim for SSI payments on February 28, 2015, alleging he became disabled 3 on February 1, 2014, due to post-traumatic stress disorder (PTSD), depression, high blood pressure, 4 and “knee lock.” (AR 17, 22, 72, 84, 201, 205, 238, 241, 273, 368, 375.) 5 A. Relevant Medical Evidence2 6 1. Merced County Department of Mental Health 7 Plaintiff presented for mental health services on January 7, 2015, having been referred by 8 his primary care provider after experiencing symptoms of depression, paranoia, and frustration. 9 (AR 343.) He reported serving 17 years in prison and having “witnessed many murders” there. 10 (AR 343.) According to Plaintiff, he hears voices and “sees shadows” in the night time. (AR 343.) 11 He is the oldest of seven children and stated that he has a “good relationship” with his siblings. 12 (AR 344.) Plaintiff reported having a strained relationship with his 24-year-old daughter, but a 13 “good relationship” with his two 29-year-old sons. (AR 656.) 14 Upon mental status examination, Plaintiff was cooperative with good eye contact and was 15 oriented to time, place, person, and situation. (AR 349, 661.) His motor activity, cognitive 16 performance and abstraction were all normal, with good insight but impaired judgment. (AR 349, 17 661.) Plaintiff was assessed with auditory and visual hallucinations, but with clear speech, full 18 affect, and “unremarkable” mood. (AR 349–50, 661–62.) He was diagnosed with PTSD. (AR 19 314, 653, 668.) 20 On April 30, 2015, Plaintiff presented to Edward Benton, M.D. requesting medications for 21 depression, auditory hallucinations, and symptoms of PTSD. Plaintiff’s physical examination 22 showed “[n]o overt psychopathology.” (AR 356.) Plaintiff was pleasant, cooperative, neat, and 23 well-groomed, with good hygiene. (AR 356.) His intellect was within normal limits and his insight 24 and judgment “acceptable.” (AR 356.) Plaintiff’s affect was full range. (AR 356.) Dr. Benton 25 noted no overt psychosis, but Plaintiff complained of frequent and mostly unintelligible auditory 26 hallucination of male voices that are “internal and ego dystonic.” (AR 356.) Plaintiff reported that 27

28 2 Because the parties are familiar with the medical evidence, it is summarized here only to the extent relevant to the 1 his sleep was “plagued by nightmares,” yet appeared well rested and nourished, with normal motor 2 function. (AR 356.) Dr. Benton assessed Plaintiff with “psychosis [not otherwise specified],” 3 cannabis use, “[rule out] ptsd due to prison experiences,” and “[rule out] antisocial [personality 4 disorder]” (AR 356.) He was prescribed a trial of medications targeting his hallucinations and his 5 mood. (AR 356.) 6 Plaintiff presented for a medication review appointment with Dr. Benton on May 29, 2015. 7 (AR 358.) He reported experiencing depression and auditory hallucinations despite taking 8 medication. (AR 358.) Plaintiff’s mental status examination showed that he was alert and oriented, 9 neat and calm, and in no overt distress. (AR 358.) No overt psychosis was noted, and Plaintiff 10 appeared well-rested and nourished. (AR 358.) Dr. Benton recommended Plaintiff to continue his 11 medications and to “taper[] up on med[ications]s to improve efficacy.” (AR 358.) 12 On July 23, 2015, Plaintiff complained to Dr. Benton that the increased dosage of Abilify 13 made his auditory hallucinations worse. (AR 360.) He was observed to have a frustrated affect 14 but no overt psychosis. (AR 360.) Dr. Benton recommended Plaintiff to stop taking Abilify and 15 Zoloft and start a trial of Seroquel and Cymbalta. (AR 360.) 16 Plaintiff presented for another medication review appointment with Dr. Benton on 17 September 22, 2015. (AR 361.) He reported stopping taking his medication because they made 18 him feel worse, not better. (AR 361.) Dr. Benton noted Plaintiff was irritable, with no overt 19 psychosis, and good hygiene and grooming. (AR 361.) He recommended Plaintiff begin a dose of 20 Risperdal. (AR 361.) 21 On October 21, 2015, Plaintiff complained to Dr. Benton that he felt worse with Risperdal, 22 so he stopped taking it. (AR 363.) He reported having moved into an apartment and “feeling 23 [somewhat] better overall.” (AR 363.) Upon examination, Plaintiff was irritable but much less 24 than the previous visit. (AR 363.) Dr. Benton found no overt psychosis. (AR 363.) Plaintiff was 25 started on a trial of Zyprexa. (AR 363.) 26 Plaintiff presented for another medication review appointment with Dr. Benton on 27 November 19, 2015. (AR 365.) He reported no benefit from Zyprexa and that it caused him to 28 itch. (AR 365.) Plaintiff’s mental status examination showed he was alert, oriented, and calm, 1 with level affect and no overt psychosis. (AR 365.) Dr. Benton noted Plaintiff appeared well rested 2 and nourished. (AR 365.) He was recommended to start a trial of Geodon. (AR 365.) 3 On December 14, 2015, Plaintiff reported poor compliance with medication, having 4 experienced feeling suicidal after taking it for two weeks. (AR 366.) He thereafter stopped taking 5 it. (AR 366.) Plaintiff also reported hearing voices and seeing shadows. (AR 366.) Upon mental 6 status examination, no psychosis was noted or reported, with Plaintiff appearing clean and neatly 7 groomed with good hygiene. (AR 366.) He had good eye contact, with regular speech, a calm and 8 cooperative demeanor, and appropriate affect. (AR 366.) Plaintiff denied any depressive feelings. 9 (AR 366.) With respect to medication, Plaintiff stated that he did not want to try anything else. 10 (AR 366.) 11 2. Conrad Castellino, M.D. 12 On March 2, 2015, Plaintiff presented to Dr. Castellino for a new patient consultation. (AR 13 386.) He complained of depression as a result of his incarceration, occasional bizarre thoughts, 14 and poor sleep. (AR 386.) Dr. Castellino observed Plaintiff had a “slightly anxious sad affect,” 15 and diagnosed him with depression and “mixed disor[der] reaction to stress.” (AR 388.) He 16 advised Plaintiff to see a psychiatrist. (AR 388.) 17 Plaintiff presented to Dr. Castellino for a routine check-up on May 4, 2015. (AR 384.) He 18 complained of hearing voices, depressed affect, and PTSD. (AR 384.) Plaintiff stated he had been 19 taking Abilify and Zoloft for a few days and felt they were not helping. (AR 384.) Upon 20 examination, Dr. Castellino noted Plaintiff’s pleasant affect and that he was “not worried or 21 depressed,” but indicated “some” anxiety. (AR 384.) He diagnosed Plaintiff with depression, 22 history of schizophrenia, and psychological stress. (AR 384.) 23 3. Steven Swanson, Ph.D. 24 Dr. Swanson conducted a psychological assessment of Plaintiff on September 23, 2015.

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