United States District Court, N.D. New York
DENVER A. CHAMBERLAIN, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
DECISION and ORDER
THOMAS J. McAVOY, Sr., District Judge.
Plaintiff Denver A. Chamberlain this suit under § 205(g) of the Social Security Act ("Act"), as amended, 42 U.S.C. § 405(g), to review a final decision of the Commissioner of Social Security ("Commissioner") denying Plaintiff's application for supplemental security benefits. Plaintiff alleges that the decision of the Administrative Law Judge ("ALJ") denying the application for benefits is not supported by substantial evidence and contrary to the applicable legal standards. The Commissioner argues that the decision is supported by substantial evidence and made in accordance with the correct legal standards. Pursuant to Northern District of New York General Order No. 8, the Court proceeds as if both parties had accompanied their briefs with a motion for judgment on the pleadings.
I. PROCEDURAL HISTORY
Plaintiff applied for Supplemental Security Income benefits on September 25, 2006, alleging disability as of July 19, 2006 based upon mental illness. (T. 168, 181, 185) His application was denied on December 8, 2006. (T. 13) On January 29, 2007, Plaintiff filed a written request for a hearing. (T. 13) On July 2, 2008, Plaintiff appeared and testified at a hearing in Norfolk, VA before ALJ William Vest, after which an unfavorable determination was issued, dated October 23, 2008. (T. 88) Upon Plaintiff's Request for Review, the Appeals Counsel vacated the decision and remanded the case to ALJ Thomas P. Tielens. (T. 70, 85)
On March 18, 2010, Plaintiff appeared and testified at a video hearing before ALJ Tielens, after which an unfavorable determination was issued, dated June 24, 2010. (T. 94-103) On February 10, 2011, the Appeals Council vacated the hearing decision for a second time, and remanded the case back to ALJ Tielens for further proceedings. (T. 138)
A second video hearing was held on July 5, 2011, after which an unfavorable determination was issued, dated June 21, 2011. (T. 10, 13-25) Plaintiff timely filed his Request for Review, and the Appeals Council denied review on December 17, 2012. (T. 6-8, 28)
a. Medical Evidence
Plaintiff was born on September 5, 1963. (T. 168) From January 7, 1999 to January 21, 1999, Plaintiff was admitted to the Benjamin Rush Center after his wife called 911. (T. 237) He believed his wife was having an affair and trying to kill him by putting birth control pills and arsenic into his food. (T. 237) He alleged that his wife was programming him and stealing his thoughts away. (T. 239) Plaintiff was placed in the Intensive Care Unit due to "totally psychotic, paranoid, [and] agitated" behavior and was described by Dr. Pradhan as having developed an "elaborate delusional system." (T. 237) Plaintiff was also described as being capable of "saying the right things" to be released from hospitalization. (T. 239) Dr. Pradhan diagnosed bipolar disorder, manic psychotic type, assigned a global assessment of functioning (GAF) score of 20 on admission, and noted that Plaintiff had been unable to hold a job for several years and "appear[ed] to be a danger to himself and others. (T. 240) Plaintiff was started on Depakote, Risperdal, and Haldol, and his dosages were increased until his mood began to stabilize. (T. 237)
In January 2002, Plaintiff was again admitted to the hospital due to increased paranoid thoughts about his girlfriend. (T. 255-256) He was admitted again from February 4, 2003 to February 10, 2003, presenting with thoughts of killing drug dealers who took his cab, which he saw as an easy way to improve society. (T. 252)
From October 2004 until April 2005, Plaintiff treated at the VAMC in Syracuse, NY. (T. 427-434) He complained to Dr. Aliya Hafeez on October 21, 2004, that he felt suicidal, and that he was thinking of overdosing on his Depakote. (T. 432-433) He was described as "very dysphoric, " diagnosed with bipolar depression, and assigned a GAF score of 60. (T. 433-34)
On April 4, 2005, Plaintiff told Dr. Alison Lentz, VAMC, that he was desperate and suicidal. (T. 428) He spoke with himself repeatedly and startled violently when he heard stray noises in the hall. (T. 429) He was described as suspicious and wary and talked about how he thought things had sinister double meanings. (T. 429) Following examination, Plaintiff was escorted in handcuffs to Samaritan Medical Center ("SMC") for emergency involuntary psychiatric care until April 19, 2005. (T. 343) He refused to sign the papers for a voluntary admission due to suspicion about the hospital staff. (T. 343) He believed that the FBI and CIA were following him. (T. 343) Plaintiff was diagnosed with major depressive disorder with psychotic features and assigned a GAF score of 31. (T. 343, 350) He was restricted to his unit as a safety precaution and became more paranoid and aggressive after his admission. (T. 344) He was started on Risperdal, but remained too psychotic to participate in therapy during his first week of admission. (T. 344) Over the course of his stay his GAF improved to a 71,  and he was discharged on Lexapro and Risperdal. (T. 344)
On May 4, 2005, Plaintiff was diagnosed with schizoaffective disorder, bipolar type by the Syracuse VAMC. (T. 426) From May 9, 2005 to May 17, 2005, Plaintiff was again involuntarily admitted to SMC, stating he "couldn't handle it anymore" and that his son was too aggressive and could not be trusted. (T. 355) He was sad and depressed, had poor sleep and appetite, and was assigned a GAF score of 31. (T. 355, 358) He was discharged on Lexapro, Risperdal, and Abilify. (T. 356)
From June 27, 2005 to June 29, 2005, Plaintiff was hospitalized due to attempted suicide, presenting with multiple linear lacerations to his wrists bilaterally after drinking a bottle of Nyquil to numb his senses. (T. 368, 370) Dr. James Mead commented that it was unusual Plaintiff had failed to cause more serious injury to himself given the severity of his lacerations, which required 35 sutures. (T. 371) Later notes suggest resultant nerve damage. (T. 525) Plaintiff was diagnosed with bipolar disorder, depression, and borderline personality disorder. (T. 364) His Effexor prescription was restarted. (T. 371)
After his discharge, Plaintiff continued to treat at the Syracuse VAMC through August 2006. (T. 405) Over the course of his care, he attended therapy and had medication management. (T. 405-427) He described panic attacks, constant worry, and feelings of being overwhelmed. (T. 423) He continued to have suicidal thoughts. (T. 418)
On October 31, 2006, Dr. Jeanne Shapiro conducted a consultative psychological examination. She reviewed Plaintiff's subjective allegations and noted that he was relatively stabilized at the time of her examination. (T. 437) Plaintiff discussed his history of paranoid delusions, feeling that his co-workers were undercover CIA agents, and past thoughts that his girlfriend had been hired by his ex-wife's family and had microphones in her rings. (T. 436) When depressed, his symptoms were noted to include dysphoric moods, psychomotor retardation, crying spells, feelings of guilt, fatigue, loss of energy, feelings of worthlessness, diminished self-esteem, problems with memory, problems with concentration, and recurrent thoughts of death or suicide. (T. 436) When manic, his symptoms included inflated self-esteem, grandiosity, talkative and pressured speech, obsessive cleaning, psychomotor agitation, flight of ideas, elevated and expansive mood, decreased need for sleep, and excessive energy. (T. 436) Dr. Shapiro diagnosed bipolar disorder and schizophrenia (paranoid type), and concluded that Plaintiff's capacity for work-related activities depended on him not being in a depressive or manic state. (T. 438) She opined that he could maintain attention and concentration "when he is not feeling too fatigued, " make appropriate decisions "unless he is in a paranoid state, " relate to others unless he was "paranoid or experiencing a manic or depressive episode, " and deal with stress "at the present time, but not when he is experiencing psychiatric symptoms." (T.438)
Plaintiff was hospitalized from November 16, 2006 to November 28, 2006 after attempting suicide by ingesting 20 Ambien pills. (T. 514) Dr. Wendy Armenta noted that Plaintiff's paranoid delusional thinking had been "on and off' over the past two years. (T. 514-515) Plaintiff discussed the sexual abuse he suffered from the age of 8 to 12. (T. 515) During the admission, Plaintiff developed more paranoia and became upset by the notion that the nurses were talking about him and other patients; consequently, his Risperdal was increased. (T. 515)
On December 4, 2006, non-examining medical consultant Dr. Richard Altmansberger opined that Plaintiff had mild limitations in his activities of daily living; moderate limitations in his social functioning; moderate limitations in his concentration, persistence, and pace; and that he has had one to two episodes of decompensation. (T. 457) In the Mental Residual Functional Capacity Assessment, Dr. Altmansberger opined Plaintiff had moderate limitations in his abilities to accept instructions and respond appropriately to criticism from supervisors; respond appropriately to changes in the work setting; maintain attention and concentration for extended periods; and complete a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest period. (T. 443-444)
Plaintiff continued treatment at the Syracuse VAMC from November 2006 through August 2007, including therapy and medication management. During this time, he began treatment with VA psychiatrist Dr. T. Thomas Keller. (T. 523) Following initial assessment on May 8, 2007, which documented decreased concentration and fair to poor insight and judgment, Dr. Keller diagnosed schizoaffective disorder and a GAF score of 60. (T. 523-527). At the time, Plaintiff was driving a cab part time and planned on living in a tent through the month of June before moving to Virginia to be near his girlfriend. (T. 523)
On July 12, 2007, Plaintiff complained to Dr. Keller of increasing feelings of tiredness. (T. 520) He was fearful that something was happening to him and was having "bad thoughts" of putting out a lit cigarette on his arm. (T. 520) He expressed that the thought may have come from Satan, and described telling Satan to get out of his head. (T. 520) Dr. Keller diagnosed bipolar disorder and schizoaffective disorder, added Trazodone to Plaintiff's ...