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Schmidt v. Commissioner of Social Security

December 23, 2009


The opinion of the court was delivered by: Terrence F. McVerry United States District Court Judge


I. Introduction

Pending before the court are cross-motions for summary judgment based on the administrative record: DEFENDANT'S MOTION FOR SUMMARY JUDGMENT (Document No. 10) and PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT (Document No. 8). The motions have been fully briefed and are ripe for resolution.

Plaintiff, Nathan Schmidt, brought this action pursuant to 42 U.S.C. § 405(g) and §1383(c)(3) for judicial review of the final determination of the Commissioner of Social Security ("Commissioner") which denied his application for supplemental security income ("SSI") under title XVI of the Social Security Act ("Act"), 42 U.S.C. §§ 1381-1383f.

II. Background

A. Facts

Plaintiff was granted SSI benefits as a child. At the age of eighteen years old, the agency redetermined Plaintiff's eligibility for SSI. R. 13. Plaintiff was born on January 9, 1988, and was 20 years old at the time of the hearing, and therefore was defined as a "younger individual," age 18-44, pursuant to 20 C.F.R. §416.963. R. 40. Plaintiff has at least a high school education and is able to communicate in English. R. 23. Plaintiff worked for very brief periods of time as a food preparer in fast food restaurants, as a cashier at a gas station, and as a laborer at an aluminum company. R. 366, 460-466.

In November 1994, at the age of six, Plaintiff was tested by his school psychologist and was determined to have an IQ Performance Scale of 66, Verbal Scale of 61, and Full Scale of 61 with a diagnosis of mild mental retardation. R. 260. Plaintiff was placed in special education classes. R. 471. On November 19, 2001, Plaintiff underwent a psychiatric evaluation at Wesley Acute Partial Hospitalization Program for depression and increasingly oppositional behavior. R. 186. The psychologist reported that plaintiff had periods when he was suicidal and would run away from home and run out in front of cars and jump from windows impulsively.

R. 187. Plaintiff would also see ghosts and hear voices from the attic. Id. Plaintiff was diagnosed with major depressive disorder, adjustment disorder with disturbance conduct, rule out ADHD, and rule out oppositional defiant disorder. R. 188. He was placed on psychotropic medications. R. 189.

From February 24, 2002 through March 9, 2002, Plaintiff was hospitalized at Western Psychiatric Institute and Clinic (WPIC)for suicidal and aggressive ideation with auditory hallucinations. R. 194-201. At discharge, it was noted that his mood was good and had significantly improved since admission. R. 196. Plaintiff was hospitalized again from March 15, 2002 through April 8, 2002 for suicidal ideations. R. 324. In late April 2002, he was voluntarily committed for suicidal ideations and was discharged on May 6, 2002. R. 205. Plaintiff was placed in a partial outpatient hospitalization program at WPIC from May 10, 2002 through June 19, 2002. R. 213. Ten hour a week wrap around services were also ordered during this period. R. 213. Plaintiff was diagnosed with schizoaffective disorder, ADHD combined, and ODD with his IQ noted as 59. R. 213. During this period, plaintiff ran away from home and attempted to jump from a bridge on June 4, 2002. R. 232.

Through July 2002, Plaintiff remained in the partial hospitalization program with a reduced number of wrap around hours. R. 327. His standing diagnosis was major depressive disorder, severe, without psychotic features. R. 334. On October 16, 2002, Plaintiff was involuntarily committed for his suicidal intention to jump from a bridge. R. 441. He was subsequently discharged on October 29, 2002. R. 203. Plaintiff had several group and individual therapy sessions from November through February 2003. R. 203, 210, 239, 437. On February 11, 2003, Plaintiff reported suicidal ideations during a group session and was assessed with a GAF of 25. R. 362. He was subsequently hospitalized from February 11, 2003 through February 20, 2003. R. 432. His diagnosis was noted as mood disorder, NOS; rule out schizoaffective disorder, ADHD combined type, ODD, and borderline intellectual functioning.

R. 432.

Plaintiff was seen for individual therapy once a month from February 26, 2003 through April 2003 with reports of an okay mood throughout. R. 426, 427, 428. On May 7, 2003, Plaintiff was evaluated for admission to WPIC due to repeatedly running away from home and refusing to take his medication for four months. R. 423-424. He was not hospitalized at that time. Id. He was seen again for individual therapy on May 12, 2003 and it was reported that there was a continued failure to take his medications. R. 422. Plaintiff reported that his mood was good or "fine" on both May 22 and June 17, 2003, but his mother reported that he had not been taking his medications, had trouble with the law, and possible dependency issues.

R. 419, 421.

Plaintiff had individual therapy sessions on July 3, 2003 and July 9, 2003 wherein his mood was reported as "fine" or "bored." R. 417-418. Plaintiff was evaluated for additional wrap around services on July 29, 2003. The psychologist reported that Plaintiff displayed extremely disruptive behavior in the school environment coupled with suicidal ideations and suicide attempts. He further reported that no treatment had been effective for his mood disorder, NOS; ODD, ADHD combined; and schizoaffective disorder. He recommended that Plaintiff be placed in a residential treatment facility. R. 416. By September 17, 2003, Plaintiff was doing better and consistently taking his medications. He was taking an emergency responder class because he wanted to become a fire fighter. His mood was good with neutral reactive affect. R. 412. At his October 7, 2003 individual therapy session, Plaintiff reported that he was doing well but was quiet and guarded during the interview. R. 407.

On January 18, 2004, Plaintiff reported that his mood was "fine" but had a dysphoric and restricted affect and was limitedly cooperative. It was noted that he did not appear to respond to anything. R. 406. On March 17, 2004, Plaintiff admitted that he was not longer taking his medications with no change or new symptoms. He reported feeling better without them and stated that he had found a job bussing tables at a local restaurant. His mood was noted as fine and his affect dysphoric and restricted. It was noted that he was guarded and vague with answers to questions and did not appear to respond to anything. R. 405. On November 29, 2005, it was noted that Plaintiff worked at Steak N' Shake for a period of time but was subsequently released and was training to become a fireman. R. 242.

Plaintiff turned eighteen on January 9, 2006. R. 40. He did not receive further treatment until April 5, 2007 when he voluntarily admitted himself to UPMC McKeesport for depression. Plaintiff indicated at admission that it had been three years since he was involved in outpatient treatment or on psychotropic medications. The psychologist reported that Plaintiff was minimally cooperative during the meeting and possibly withheld information. Plaintiff's intelligence was noted as in the average range with no cognitive deficits present. Upon mental examination, the psychologist reported that Plaintiff's mood was moderately depressed with constricted affect. Plaintiff came across as moderately paranoid. The psychologist diagnosed Plaintiff with bipolar disorder rule out psychotic features and rule out personality disorder not otherwise specified with schizoid features. He assessed a GAF of 25. R. 355. At discharge on April 6, 2007, Plaintiff's final diagnosis was noted as bipolar depression and borderline IQ with a GAF of 50. It was noted that Plaintiff appeared "slow and retarded and was mumbling inaudibly" with limited insight. He was released to his mother for care with medications. R. 351-352.

On May 3, 2007, Plaintiff's mother completed an Adult Function Report for Plaintiff.

R. 142. The report suggested that Plaintiff's days consisted of looking for employment, watching TV, and training on occasion as a volunteer fireman. Id. She reported that his medicine made him sleepy and that she would set his schedule, provide reminders, and make him his food daily. R. 145. Plaintiff shopped in stores for food weekly, but could not pay bills, handle savings, or use a checkbook or money orders. Id. He went to the movies on occasion with his mother, brother, and friends and had fire drills and appointments weekly. R. 146. Problems were reported with memory, completing tasks, concentration, understanding, and following directions. R. 147. It was noted that he became frustrated and depressed with stress.

R. 148. His work history was reported as three days at an aluminum company and three months at Wendy's. R. 150.

Plaintiff underwent a psychological disability evaluation with Dr. Marvin Wheeler on June 25, 2007. R. 360-364. Plaintiff took public transportation to the examination and was cooperative and basically self-sufficient. R. 360. He was to be intaked at Mon Yough Mental Health on the same day with a psychiatrist but missed the appointment. Id. Plaintiff reported being hypertensive in school due to ADHD. Id. Plaintiff presented as a pleasant withdrawn male with responses to a mood disorder questionnaire that were consistent with bipolar disorder. R. 361. Plaintiff reported that he had worked at Wendy's for a few months and was living alone in an apartment where he did daily chores and had his mother take him shopping. Id. Dr. Wheeler noted that Plaintiff's affective expression was flat and thought processes were slow for responding to general questions. His general fund of knowledge was limited and mental arithmetic presented problems and concentration was slow for subtracting. His memory was noted as fair, social judgment as questionable, and insight limited. He was diagnosed with bipolar disorder and borderline intellectual functioning. R. 361. Plaintiff's prognosis was considered fair with continued compliance with treatment with a GAF of 60. R. 362. Dr. Wheeler considered him minimally capable of managing personal funds with mental impairments that have some impact on his ability to complete daily activities on a sustained basis. Id. Plaintiff's concentration was noted as fair, ability to sustain attention to tasks was fair, ability to sustain concentration for simple, repetitive tasks was considered appropriate, and ability to handle stress and pressures of daily work was considered in the fair range. Id.

Dr. Wheeler also completed a residual functional capacity evaluation on the same day. R. 363-364. He opined that Plaintiff had no limitations in remembering, understanding, and carrying out short, simple directions; marked restrictions in remembering, understanding, and carrying out detailed instructions; moderate limitations in making judgments on simple work-related decisions; slight limitations in interacting appropriately with the public; moderate limitations in interacting appropriately with supervisors and co-workers; and marked limitations in responding appropriately to work pressures in the usual work setting and to changes in the usual work setting. Id.

On September 24, 2007, Dr. Wheeler performed an intellectual evaluation for disability. Plaintiff reported that he took public transportation to get there and it was noted that he smelled and was dirty. R. 365. Plaintiff appeared tired and responded only to direct questions in a soft and barely audible voice. He could manage his own monies with the help of his mother. Plaintiff reported that he was being seen regularly, at the time, at Mon Yough. He worked at Wendy's but stated that he "couldn't catch on" and was living in a small apartment where his mother helped him maintain his residency. R. 366. He reported that he was sad at times but denied any major depressive issues. Dr. Wheeler administered the Weschler Adult Intelligence Scale Third Edition which yielded IQ scores of 76 in verbal, 70 in performance, and a full scale score of 71. R. 366. Dr. Wheeler indicated that these scores were indicative of intellectual functioning in the low borderline range and that they were valid. Plaintiff's reading scores indicated a level at the beginning of sixth grade and his spelling scores indicated a level at the beginning of third grade. Dr. Wheeler indicated a fair prognosis suggestive of capability of completing daily activities, but also opined that Plaintiff was not capable of managing his own funds. R. 367.

In a second functional capacity evaluation based on the additional evidence, Dr. Wheeler indicated that Plaintiff had slight limitations in remembering, understanding, and carrying out simple instructions; marked limitations in remembering, understanding, and carrying out detailed instructions; marked limitations in making judgments on simple work related decisions; slight limitations in interacting with the public and co-workers; moderate limitations in interacting with supervisors, and marked ...

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