United States District Court, D. Arizona
ORDER
BRUCE
G. MaCDONALD, UNITED STATES MAGISTRATE JUDGE
Currently
pending before the Court is Plaintiff Daniel Longale's
Opening Brief (Doc. 13). Defendant filed his Brief
(âResponseâ) (Doc. 14), and Plaintiff filed his Reply Brief
(âReplyâ) (Doc. 15). Plaintiff brings this cause of action
for review of the final decision of the Commissioner for
Social Security pursuant to 42 U.S.C. § 405(g).
Pursuant
to Rules 72.1 and 72.2 of the Local Rules of Civil Procedure,
[2]
this matter was referred to Magistrate Judge Macdonald for
Report and Recommendation. Based upon the pleadings of the
parties and the administrative record submitted to the Court,
the Magistrate Judge recommends that the District Court grant
Plaintiff's Opening Brief (Doc. 13) and remand this
matter to the Administrative Law Judge (“ALJ”)
for further proceedings.
I.
BACKGROUND
A.
Procedural History
On
January 9, 2014, Plaintiff filed a Title XVI application for
Supplemental Security Income (“SSI”) alleging
disability as of October 15, 2012 due to depression, anxiety,
antisocial disorder, Attention-Deficit/Hyperactivity Disorder
(“ADHD”), learning disability in reading and
writing, fractured lower arm, fractured shoulder, fractured
hand-surgically repaired, alcohol use, and
Methicillin-resistant Staphylococcus aureus
(“MRSA”). See Administrative Record
(“AR”) at 53, 121-22, 135-38, 248-53, 261, 304,
329. The Social Security Administration (“SSA”)
denied this application on June 9, 2014.[3] Id. at
53, 121-35, 151-54. On August 13, 2014, Plaintiff filed a
request for reconsideration, and on December 17, 2014, SSA
denied Plaintiff's application upon reconsideration.
Id. at 53, 136-50, 160-63. On March 4, 2015,
Plaintiff filed his request for hearing. Id. at 53,
164. On December 1, 2016, a hearing was held before
Administrative Law Judge (“ALJ”) George W. Reyes.
Id. at 53, 70-120. On May 24, 2017, the ALJ issued
an unfavorable decision. AR at 50-65. On May 30, 2017,
Plaintiff requested review of the ALJ's decision by the
Appeals Council, and on December 21, 2017, review was denied.
Id. at 2-7, 37-49, 247, 363-73. On January 17, 2018,
Plaintiff filed this cause of action. Compl. (Doc. 1).
B.
Factual History
Plaintiff
was thirty-two (32) years old at the time of the
administrative hearing, and twenty-eight (28) at the time of
the alleged onset of his disability. AR at 53, 63, 70, 75,
121-22, 135-38, 248, 261, 304, 329. Plaintiff finished his
freshman year, and part of his sophomore year, of high school
but did not obtain a degree. Id. at 75, 135-36, 266.
Prior to his alleged disability, Plaintiff worked in
plumbing; heating and air conditioning; and fast food.
Id. at 76-77, 257-59, 267. Plaintiff also worked as
a delivery driver and dishwasher. Id. at 257-59,
267.
1.
Plaintiff's Testimony
a.
Administrative Hearing
At the
administrative hearing, Plaintiff testified that he completed
the ninth grade, but was kicked out for fighting during 10th
grade. AR at 75. Plaintiff further testified that he had
previously worked in heating and cooling and plumbing, but
neither job lasted for more than three (3) months.
Id. at 76-77. Plaintiff confirmed that he claims
disability as of October 15, 2012, and has not worked since
that date. Id. at 78-79.
Plaintiff
testified that he walks his dog approximately ten (10)
minutes, a couple of times per week. Id. at 79.
Plaintiff further testified that he used to walk his dog for
hours approximately two (2) years prior; however, he does not
enjoy doing it any more. Id. at 79-80. Plaintiff
also testified that he does woodworking, making items such as
jewelry boxes or little pots for plants, approximately once
per week. AR at 81. Plaintiff noted that he uses the
woodworking supplies and equipment that his grandfather had
and does not make any money from it, but does it for a hobby.
Id. at 95-96. Plaintiff also indicated that he
occasionally rides a skateboard, just for something to do.
Id. at 98-99.
Plaintiff
testified that he was in Las Vegas, approximately eight (8)
months prior to the administrative hearing, working for his
uncle, moving kitchen equipment. Id. at 82-83.
Plaintiff further testified that he left the job, because he
got angry with some of his coworkers. Id. at 82.
Plaintiff's subsequent testimony indicated that perhaps
he had a falling out with his uncle during the job and
won't be able to work for him in the future. AR at 90,
95.
Plaintiff
testified that the longest he was able to take the
medications prescribed for his mental health issues was
approximately five (5) days. Id. at 83-84. Plaintiff
also reported that his providers would then change his
medication the following visit. Id. at 84-85. When
asked about his latest diagnosis, Plaintiff was dismissive,
and he complained that prescriptions have yet to be effective
for him. Id. at 86, 102-03. Plaintiff testified that
he smokes cigarettes and estimated that he smokes a little
more than one (1) pack per day. Id. at 77. Plaintiff
further testified that he smokes marijuana approximately
twice per week, when he cannot sleep. AR at 77-78. Plaintiff
also testified that he drinks alcohol; however, this is not
on a consistent basis. Id. at 85-86. Plaintiff
testified that he had been a binge drinker from high school
until approximately five (5) years previously. Id.
at 87. Plaintiff also noted that when he was younger, he had
received a citation for driving under the influence
(“DUI”). Id. Plaintiff testified that as
a result, he has not driven a car since then. Id.
Plaintiff also testified that he has previously used cocaine
and methamphetamines; however, he had not used either
substance in over a year. AR at 90-92. Plaintiff testified
that he does not have a regular social life, but occasionally
sees friends. Id. at 98.
Plaintiff
indicated that he was hostile to the idea of group therapy.
Id. at 86-87. Plaintiff testified that he has racing
thoughts, but does not share them with anyone. Id.
at 97. Plaintiff further testified that he had been paranoid
during the previous six (6) months and that his energy swings
between excessive to depressed. Id. at 97-98.
Plaintiff
also testified that although he is open to the possibility of
job training, he does not know when he is going to have a
good day or bad day with his mental health. AR at 88-89.
Plaintiff testified that in an ideal world he would be able
to live alone, outside the city limits, and not have to
interact with people. Id. at 88. When the ALJ asked
Plaintiff about the difference between the times he could
function and his current situation, Plaintiff responded that
he had “more stuff, ” including money and a car,
but was now stuck, pointing to his paranoia as the main issue
health-wise. Id. at 99-100.
b.
Administrative Forms
On
April 24, 2014 and October 27, 2014, Plaintiff completed a
Function Report- Adult in this matter. AR 279-87, 306-14.
Plaintiff reported that he lived in a house with family.
Id. at 279, 306. Plaintiff described his medical
conditions as follows:
I can't be around more than one or two people at a time
without anxiety and if I don't know people I get very
frustrated and need to move around. I don't read well and
can follow something if it is shown to me but I can't
handle people talking to me when I am doing something. I like
to do physical labor but my head and shoulder injuries limit
my ability to lift or hold things for long or with
regularity.
Id. at 279. Plaintiff also indicated that his
anxiety and aggression keep him from sustaining employment.
Id. at 306. Plaintiff reported that his typical day
involves interacting with his dog, showering, eating
something, looking on Facebook, walking in the neighborhood,
and listening to music. Id. at 280, 307. Plaintiff
indicated that he is also able to go to the store to buy food
for himself and his dog, visit with his friend and their
children, and occasionally have a beer at a local bar. AR at
280.
Plaintiff
reported that he cares for his dog including feeding,
walking, playing, and occasionally bathing him. Id.
at 280, 307. Plaintiff also reported that his grandmother
helps him care for his dog by feeding the dog and letting him
out into the yard. Id. Plaintiff indicated that
prior to his illness he was able to work, drive, see friends,
go to family gatherings, date, and cook. Id.
Plaintiff reported that his illness cause him to have trouble
falling and staying asleep. Id. Plaintiff does not
report any problems with performing personal care tasks;
however, he indicates that he has to shave his head because
hair bothers him and that he has no interest in personal
hygiene when he is depressed or anxious. AR at 281, 308.
Plaintiff reported that his grandmother reminds him to keep a
schedule for his medication, but he finds it difficult and
later reported that he was no longer taking medication.
Id. Plaintiff makes simple meals approximately twice
per week. Id. Plaintiff further reports that he does
not have an interest in food since his conditions began.
Id.
Plaintiff
reported that because he cannot do things correctly around
the house, according to his grandmother, he has stopped doing
them. Id. at 282, 309. Plaintiff further reported
that his shoulder and arm hurt “for days” because
he is too aggressive with housework. AR at 282. Plaintiff
noted that he goes outside daily unless he is depressed, in
which case he will stay in his room for several days at a
time without coming out. Id. at 282, 309. Plaintiff
reported that when he goes out he either walks or rides in a
car, although the later makes him anxious. Id.
Plaintiff further reported that he cannot ride the bus,
because there are too many people and he gets into fights,
although he later indicated that he uses public
transportation. Id. Plaintiff does not drive,
because he does not have a license or a car. Id.
Plaintiff
reported that he shops for food and snacks, but he cannot
stay in the store long and lines at the checkout cause
anxiety. AR at 282, 309. Plaintiff further reported that
although he can count change, he is unable to pay bills,
handle a savings account, or use a checkbook/money orders.
Id. at 283, 310. Plaintiff noted that he finds money
management frustrating because he cannot concentrate
sufficiently, and as a result Plaintiff uses cash until it is
gone. Id. Plaintiff described his hobbies and
interests as including watching movies on television or video
and making wooden boxes out of salvaged wood. Id.
Plaintiff further noted that he is anxious and has to move
around a lot. Id. at 283. Plaintiff reported that he
posts on Facebook, but does not have many friends. AR at 283.
Plaintiff further reported that he does not like to visit or
talk in person for long periods of time. Id.
Plaintiff also stated that goes out regularly with his dog or
to the store, and sometimes to visit a friend. Id.
Plaintiff noted that he has difficulty getting along with
people because he is anxious and uncomfortable around
everyone. Id. at 284. Plaintiff reported that he
cannot socialize with more than one or two people at a time.
Id.
Plaintiff
indicated that his condition affects his ability to lift,
squat, bend, reach, kneel, talk, climb stairs, remember,
complete tasks, concentrate, understand, follow instructions,
use hands, and get along with others. AR at 284, 311.
Plaintiff reported that physical activity for more than a
short time causes him to hurt for days. Id.
Plaintiff further reported that he can walk a long way before
requiring a rest, but his ability to pay attention varies
from minutes to approximately one (1) hour. Id.
Plaintiff also reported that he does not follow written
instructions well, needs to be shown how to do things, and
can only remember uncomplicated instructions. Id.
Plaintiff indicated that he does not do well with authority
figures, and he cannot get a job because he is too intense
and cannot deal with people, noting that they always pick
fights with him. Id. at 285, 312. Plaintiff further
reported that he does not handle stress or changes in routine
well. AR at 285, 312.
Plaintiff
reported that he no longer takes any medications, because
after two years of trying to find the right medication he
just gave up. Id. at 286, 313. Plaintiff reiterated
his anger issues and inability to be around people.
Id. at 286.
Plaintiff
completed a Disability Report-Appeal indicating that his
depression had gotten worse and increased his isolation.
Id. at 324. Plaintiff reported vacillating between
aimlessness and volatility. Id. Plaintiff also noted
that he was no longer able to ride the bus due to intense
anxiety. Id. at 326. Plaintiff indicated that he was
hoping to be evaluated by a psychiatrist and is vehemently
opposed to medication. Id. at 327.
2.
Plaintiff's Medical Records
a.
Treatment records
On
January 6, 2012, Plaintiff established care COPE Community
Services (“COPE”). AR at 374-79. Plaintiff
reported his medical history as including a persistent cough
due to smoking, back pain, headaches, hand surgery
approximately one (1) year prior, and problems with sleeping.
Id. at 374-78. Plaintiff further reported smoking
approximately one (1) pack of cigarettes per day.
Id. at 378. Plaintiff also indicated that he had a
psychiatric evaluation when he was approximately nine (9)
years of age and that the prescribed ADHD medication was not
helpful. Id.
Plaintiff
sought help From COPE for his anxiety and insomnia, and noted
that he had trouble falling and staying asleep. Id.
at 381. Plaintiff indicated that he lacks motivation and is
uncomfortable without a routine. AR at 381. Plaintiff's
mother reported that when Plaintiff's anxiety is high, he
becomes short-tempered and aggressive. Id. Plaintiff
reported that he drinks beer to help him socialize with
others. Id. Plaintiff responded that he will know if
things are improving if he can go out and try to get a job.
Id. Plaintiff's mother indicated that she
thought Plaintiff would benefit from skills building,
self-esteem improvement, and possibly anxiety medication.
Id. at 382. Plaintiff reported that he had been
involved with the legal system as a juvenile and was cited
for driving under the influence (“DUI”) when he
was twenty-one (21). AR at 382. Plaintiff reported that her
he drinks to excess a few times per week, uses marijuana, and
his medication history suggested abusing prescription drugs.
Id. at 382-83, 387.
Regarding
Plaintiff's drinking and marijuana use, COPE staff
assessed that Plaintiff needed encouragement not to use, but
had fair self-management and relapse coping skills.
Id. at 385. The assessment also noted that
Plaintiff's environment contained triggers that exposed
him to continued use. Id. Plaintiff's risk
assessment noted that he had thoughts of hurting others and
was known to fight when angry. Id. at 387-89. COPE
notes indicated that Plaintiff suffered some isolation. AR at
388. Plaintiff exhibited a calm and appropriate demeanor, was
polite, and answered questions openly. Id. at 390.
COPE notes further indicated Plaintiff had poor judgment and
impulse control and fair insight. Id. at 392.
Plaintiff Axis I diagnosis included anxiety disorder not
otherwise specified and alcohol abuse. Id. at 393.
Plaintiff's Axis II diagnosis included antisocial
personality disorder. Id. Plaintiff's Global
Assessment of Functioning (“GAF”) score was 62,
indicating moderate symptoms. AR at 395.
Plaintiff
reported to COPE that he lived with his grandmother, but did
not have friends and felt disconnected from his family.
Id. at 399-400. Plaintiff also indicated that he
felt working would take away his negative feelings.
Id. at 400. Plaintiff further reported his negative
school experience and dropping out of high school in the
tenth grade. Id. at 401. Plaintiff noted he had not
work for six (6) years and his previous employment included
electronics, carpentry, and plumbing. Id. at 402.
Plaintiff also indicated a history of arrests, primarily do
to fighting, plus a DUI. AR at 405-06.
On
January 13, 2012, Plaintiff was seen by Dale Hawkins, N.P. at
COPE. Id. at 426-28. Plaintiff complained of
difficulty sleeping. Id. at 426. Treatment records
indicate that Plaintiff's appearance, affect, and mood
were appropriate; concentration, insight, and judgment were
fair; speech was normal; and he denied hallucinations,
homicidal ideation/target/plan, and suicidal
ideation/intent/plan. Id. NP Hawkins prescribed
Trazadone. Id.
On
February 6, 2012, Plaintiff was seen by Dale Hawkins, N.P. at
COPE. Id. at 425-26. Plaintiff reported that he was
taking medication as prescribed. Id. at 425. NP
Hawkins had prescribed trazadone and added Zoloft. Treatment
records indicated that Plaintiff's appearance, affect,
and mood were appropriate. Id. Treatment records
further indicated that Plaintiff's concentration,
insight, and judgment were fair; his speech normal; and
Plaintiff denied hallucinations, homicidal
ideation/target/plan, and suicidal ideation/intent/plan.
Id. Plaintiff's continuing diagnoses included
anxiety disorder not otherwise specified, alcohol abuse, and
antisocial personality disorder. AR at 425.
On
April 13, 2012, Plaintiff was seen by Dale Hawkins, N.P. at
COPE. Id. at 423-24. NP Hawkins noted that Plaintiff
reported Zoloft made him feel like a “zombie” and
was not effective. Id. at 423. As a result NP
Hawkins discontinued Zoloft and prescribed Wellbutrin.
Id. Treatment records indicated that Plaintiff's
appearance, affect, and mood were appropriate; concentration,
insight, and judgment were fair; speech was normal; ...