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Monica v. Astrue

September 15, 2010




In May of 2004, Plaintiff Robert Monica ("Plaintiff") protectively filed an application for Supplemental Security Income ("SSI") benefits under the Social Security Act ("the Act"). Plaintiff asserts an onset date for his disability as the date on which he protectively applied for SSI benefits at the beginning of his hearing. The Commissioner of Social Security ("the Commissioner") denied Plaintiff's application for lack of disability.

Plaintiff, through his attorney, commenced this action on November 22, 2006. (Dkt. No. 1). Plaintiff seeks judicial review of the Commissioner's denial of benefits pursuant to 42 U.S.C. §§ 405 (g) and 1383 (c)(3).


A. Plaintiff's History

Plaintiff was born on December 24, 1967; he was thirty-seven years old at the time of the ALJ's determination. R. 50.*fn1 He has a tenth grade education and did not obtain a GED. R. 378. He has worked as a delivery person, auto technician, and a laborer for a construction company. R. 73, 81.

Plaintiff alleges that he has suffered depressive disorder, intermittent explosive disorder, and borderline mental retardation since birth, and that he is further limited by disc herniations and degenerative disc disease in his back. R. 72, 372-73. Plaintiff testified that these impairments, and particularly his inability to control his anger, prevent him from doing all work. R. 385-86, 397. Plaintiff has attempted to address his explosive temper, seeing a psychiatrist every three weeks, but has not been able to control his outbursts and is constantly depressed. R. 399.

Plaintiff claims that his back pain makes him unable to participate in activities of daily life or perform work. R. 386-407. He admits, however, that he has not been treated for his back pain for approximately five years, is able to lift up to twenty pounds, and can perform many tasks such as yard work, cooking, etc., as well as drive in a car for short trips. R. 86-92, 386-407. Plaintiff has a history of alcohol and marijuana abuse, but testified that he had not drank alcohol in over a year prior to his hearing. R. 137-138, 144, 156, 167, 181-182, 190, 197, 393. Plaintiff has submitted various medical records in support of his claims.

Plaintiff was admitted to the Samaritan Medical Center ("SMC") Emergency Room ("ER") on December 25, 1997, for a mental health examination due to a severe bout of anger and depression. R. 103. This episode followed a violent outburst during which Plaintiff, after losing his job allegedly as a result of his mental impairments, became intoxicated and punched holes in the walls of his apartment, resulting in his eviction. R. 103.

Plaintiff returned to the SMC ER on February 4, 1998, with complaints of lower back pain.

R. 108. His pain was diagnosed as stemming from a strain or sprain of the lower back muscles. R. 109. On September 13, 1998, an x-ray at SMC confirmed degenerative changes at L4-L5. R. 112. A CT scan showed a moderately large right-sided disc herniation. R. 113. Plaintiff was admitted to the SMC ER for lower back pain again on March 17, 1999. R. 122.

On April 23, 2000, Plaintiff again returned to the SMC ER complaining of depression, stemming from frustration with his back pain. R. 123-29. He was diagnosed with depressive disorder and chronic back pain. R. 128.

Plaintiff received no treatment for his mental health or back pain until March 31, 2004, when he was admitted to the SMC ER for anger issues and appetite and sleeping difficulties. R. 130-39. This visit followed an incident in which Plaintiff became angry over breaking up with his girlfriend, punched holes in the walls of his apartment, and damaged his possessions. R. 132. Recent alcohol use was noted, and his demeanor was described as angry and hostile. R. 132. Plaintiff told the attending physician, Dr. Phillip Chafe, that he had a prior history of depression, suicide attempts, involvement with the criminal justice system, and drug and alcohol abuse. R. 137. Dr. Chafe diagnosed Plaintiff as suffering from an adjustment disorder with mixed mood/conduct. R. 134. Plaintiff was directed to follow up with outpatient mental health; the next day he returned to the ER seeking medication to help him sleep. R. 132, 134.

Plaintiff was admitted to SMC under the care of Dr. Jose Alfano from April 5, 2004 through April 8, 2004 for treatment of "mood disorder, anger and loss of control." R. 144-56. Dr. Alfano described Plaintiff as "loud, agitated, angry." R. 147. He noted Plaintiff was alert, with good orientation, but displaying limited concentration, attention, and abstract thinking ability. R. 148.

Dr. Alfano diagnosed Plaintiff with depressive disorder, alcohol and marijuana abuse, and personality disorder. R. 144. Upon admission, Plaintiff's Global Assessment of Functioning ("GAF") score was 30, and rose to 55 before he was discharged. R. 144. Overall, his various social skills and levels of intellectual functioning were noted as limited, fair, impaired, and, with respect to his understanding of interpersonal relations and emotional issues, "very unsophisticated." R. 144-145. Dr. Jose Alfano noted that the medication he prescribed appeared to stabilize Plaintiff. R. 144-45. In his discharge summary, Dr. Alfano noted that Plaintiff "was ambulatory and able to return to work." R. 145. Plaintiff was asked to refrain from all drug and alcohol use and resume a regular diet. R. 145. He was prescribed medication and referred to Mercy Center for Behavioral Health and Wellness ("Mercy Behavioral"). R. 145-46.

On April 15, 2004, Plaintiff followed up with Mercy Behavioral. R. 156. Carol Strahm noted he was threatening suicide. R. 156. Strahm also noted Plaintiff was "very depressed-very angry . . . . [d]ifficult to engage - [followed] no steady diet - eat[ing] every few days." R. 156. Plaintiff reported that he never drank alcohol but used marijuana "as much as [he] can." R. 158. Plaintiff was diagnosed with depressive disorder. R. 158. Upon examination, he was described as disheveled, angry, tearful, distractable, slow, impoverished, and possessing a "fair" capacity for concentration. R. 159. His prognosis was "fair." R. 159.

Five days later, Plaintiff returned to Mercy Behavioral. He was directed to reschedule his appointment because he was "rude," "belligerent," "posturing," "threatening," and cursed throughout his appointment. R. 294. Plaintiff angrily left, saying he would never return and did not need help. R. 295. On April 27, 2004, however, Plaintiff returned to Mercy Behavioral for a psychological assessment. R. 165. He told Dr. Lisa Littell, the prescribing therapist, that he felt like crying all the time and was abused by his parents as a child. R. 165-68. Dr. Littell found Plaintiff's concentration, judgment, insight, and impulse control to be poor, and his mood irritable, angry, and labile. R. 166. Dr. Littell diagnosed Plaintiff with intermittent explosive disorder, cannabis abuse, dysthymic disorder, personality disorder, antisocial personality disorder, and a herniated disc. R. 167. He was prescribed additional medication.

Plaintiff returned for a follow up visit at Mercy Behavioral on May 4, 2004. R. 291. Plaintiff related to Sara Cramer, his counselor, that the prescribed medication had not helped any of Plaintiff's symptoms and he was "very negative." R. 292. Plaintiff's prescription was changes and apparently the new medication helped him sleep. R. 289.

On May 5, 2004, Dr. Littell wrote that, due to his intermittent explosive disorder, Plaintiff was "unable to work at this time." R. 169. She advised Plaintiff that he should apply for SSI; Plaintiff filed his application for SSI benefits on May 7, 2004. R. 61.

Dr. Littell completed a medical questionnaire about Plaintiff on June 23, 2004. R. 172-78. Dr. Littell reasserted her diagnosis of intermittent explosive and dysthymic disorders, and she noted Plaintiff's symptoms of getting angry very easily, irritability, and sadness. R. 172. She also documented Plaintiff's suicide attempts in the past (before the medical record in this case), and his problems in getting along with supervisors and co-workers; she further noted Plaintiff had no difficulty with job performance and was able to perform certain daily activities. R. 175. Dr. Littell related that Plaintiff tended to avoid crowds and did not like being around people. R. 175-76. Additionally, Dr. Littell noted that Plaintiff told him he could only sit for 30-45 minutes at a time due to his lower back pain. R. 175.

On July 6, 2004, a consultative psychological examination was performed at the request of the State agency by Jeanne Shapiro, Ph.D. R. 179-83. Plaintiff related his problems with depression, anger, and how twice a year he "flies off the deep end" and punches his vehicles. R. 180. Additionally, he stated he was arrested for assault on multiple occasions between the time he was seventeen years old and the year 2004, but later admitted his last assault arrest occurred "quite a few years ago." R. 181. Dr. Shapiro described his presentation, manner of relating, and social skills as "marginally adequate." R. 181. He was able to count, perform simple calculations, serial 3s, and his recent and remote memory skills were intact. R. 181. Dr. Shapiro also reported Plaintiff was capable of understanding and following directions for simple and some complex tasks. R. 181. Additionally, Dr. Shapiro observed Plaintiff was capable of "maintaining concentration for tasks . . . regularly attend a routine and maintain a schedule if he so desires . . . capable of learning new tasks . . . capable of making some appropriate decisions . . . appears to have difficulty adequately dealing with stress." R. 182.

Plaintiff told Dr. Shapiro that he was unable to work because he was receiving mental health services and had difficulty getting along with people. R. 179. Plaintiff admitted, however, that he believed that he could work in a job which did not involve him being around other people. R. 182. Plaintiff reported that his treatment had improved his symptoms, though they still persist, and that he experiences significant anger problems approximately twice per year. R. 180. Dr. ...

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