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Jerry Garcia, Sr v. Michael J. Astrue

June 5, 2012


The opinion of the court was delivered by: McLAUGHLIN, Sean J., District Judge.



Jerry Garcia, Sr. ("Plaintiff"), commenced the instant action pursuant to 42 U.S.C. § 405(g), seeking judicial review of the final decision of the Commissioner of Social Security ("Commissioner"), denying his claims for disability insurance benefits ("DIB") and supplemental security income ("SSI) under Titles II and XVI of the Social Security Act, 42 U.S.C. § 401, et seq. and § 1381 et seq. Plaintiff filed his applications on September 26, 2008, alleging disability since April 2, 2008 due to depression and anxiety (AR 111-116; 125).*fn1 His applications were denied (AR 54-63), and following a hearing held on April 27, 2010 (AR 29-50), the administrative law judge ("ALJ") issued his decision denying benefits to Plaintiff on June 4, 2010 (AR 16-23).

Plaintiff's request for review by the Appeals Council was subsequently denied (AR 1-8), rendering the Commissioner's decision final under 42 U.S.C. § 405(g). The instant action challenges the ALJ's decision. Presently pending before the Court are the parties' cross-motions for summary judgment. For the reasons that follow, the Plaintiff's motion will be denied and the Commissioner's motion will be granted.


Plaintiff was 36 years old on the date of the ALJ's decision and has a general equivalency diploma (AR 132). He has past work experience as a taxi driver, security guard, laborer and telemarketer (AR 126).

On August 18, 2008, Plaintiff underwent a psychosocial evaluation at Safe Harbor Behavioral Health performed by Katherine Goodiel LSW (AR 202-205). Plaintiff reported a four year history of depression and anxiety, with recent suicidal thoughts that caused him to seek help (AR 202). He relayed a history of aggressive behavior, which included cutting himself and engaging in fights with others (AR 202). Plaintiff stated that he experienced difficulty breathing and his thoughts "raced" (AR 202). He reported hearing "whispering" sounds during the previous six months, and also reported sleep and appetite disturbances, a decreased energy level, attention and concentration difficulties, and a depressed mood (AR 202). In addition, he stated that his alcohol usage had increased (AR 202). His medications consisted of Paxil and Xanex prescribed by his primary care physician, but he claimed they were ineffectual in combating his symptoms (AR 202).

On mental status examination, Ms. Goodiel found Plaintiff was fully oriented, cooperative, exhibited adequate eye contact, displayed adequate hygiene and was appropriately dressed (AR 205). His speech was slow and underproductive, his thought processes were organized and relevant, but he demonstrated low self-esteem and hopelessness for the future (AR 205). Ms. Goodiel also found Plaintiff exhibited an anxious, sad and flat affect, and his judgment and insight were poor (AR 205). He was diagnosed with major depressive disorder, recurrent episode; alcohol abuse; and rule out borderline personality disorder (AR 205). She assigned Plaintiff a global assessment of functioning*fn2 ("GAF") score of 45 and recommended he undergo a psychiatric evaluation (AR 205).

Plaintiff was psychiatrically evaluated by Liberty Eberly, D.O. on August 20, 2008 (AR 207-209). On mental status examination, Dr. Eberly found Plaintiff was fully oriented, friendly, and cooperative (AR 208). He displayed good grooming and hygiene (AR 208). Plaintiff admitted to some mild suspiciousness but did not exhibit any paranoid delusions (AR 208). He denied suffering from visual hallucinations but reported auditory hallucinations (AR 208). His cognition and memory were unimpaired (AR 208). Dr. Eberly found him to be depressed and anxious, but also concluded that he had "fair" judgment and insight (AR 208). Plaintiff was diagnosed with major depressive disorder with psychotic features; generalized anxiety disorder; and alcohol abuse, and was assigned a GAF score of 49 (AR 208). Dr. Eberly increased Plaintiff's Paxil dosage for his symptoms of depression and anxiety, decreased his Xanax dosage, and prescribed Seroquel for his symptoms of anxiety, irritability and hallucinations (AR 208). She further recommended that he cut back on his alcohol usage and contact a therapist (AR 208).

Plaintiff returned to Dr. Eberly on September 9, 2008 and reported that he continued to experience hallucinations and felt depressed (AR 215). Dr. Eberly, once again, found Plaintiff to be cooperative and friendly (AR 215). Plaintiff had fleeting suicidal thoughts but no suicidal intention (AR 215). Dr. Eberly assigned him a GAF score of 49, and added Risperdal to his medication regimen (AR 216).

On October 24, 2008, Plaintiff continued to complain of depression, anxiety, panic attacks and auditory hallucinations when angry (AR 214). Plaintiff stated that he had trouble leaving his house and isolated himself in his room (AR 214). He declined to attend Alcoholics Anonymous meetings "due to anxiety" (AR 214). While he remained friendly and cooperative with appropriate eye contact and grooming, Dr. Eberly noted that he was "very anxious" (AR 214). He was assigned a GAF score of 45 (AR 214).

On November 24, 2008, Michelle Santilli, Psy.D., a state agency reviewing psychologist, reviewed the psychiatric evidence of record and determined that Plaintiff had mild limitations in completing activities of daily living and moderate difficulties in maintaining concentration, persistence or pace, and moderate difficulties in maintaining social functioning (AR 231). Dr. Santilli completed a mental residual functional capacity assessment form, and opined that Plaintiff was not significantly limited in his ability to ask simple questions, request assistance, avoid normal hazards, travel and use public transportation, or set realistic goals (AR 219). She found Plaintiff was markedly limited, however, in his ability to understand, remember, and carry out detailed instructions (AR 218). She further found that Plaintiff was only moderately limited in all other work-related areas (AR 218-219).

Dr. Santilli found that Plaintiff's basic memory processes were intact (AR 220). She opined that he could perform simple, routine, repetitive work in a stable environment (AR 220). She found he was able to understand, retain and follow simple job instructions and make simple decisions (AR 220). Dr. Santilli noted that Plaintiff's activities of daily living and social skills were functional, and he could sustain an ordinary routine without special supervision (AR 220). Finally, Dr. Santilli concluded that Plaintiff had some limitations in dealing with work stresses and public contact, but that he remained capable of meeting the basic mental demands of competitive work on a sustained basis (AR 220).

On December 29, 2008, Plaintiff returned to Dr. Eberly with complaints that his anxiety had worsened and that he had suffered two panic attacks the previous week (AR 310). He also reported visual hallucinations occurring several times per week (AR 310). Although he expressed suicidal thoughts, he indicated he had no plan to carry them out (AR 310). Dr. Eberly found, as in previous visits, that Plaintiff was friendly and cooperative, but depressed and anxious (AR 310). She continued to diagnose him with major depressive disorder, recurrent episode, severe; generalized anxiety disorder; and nondependent alcohol abuse (AR 310). He was assigned a GAF score of 45 (AR 310). His Effexor dosage was increased and Risperdal was restarted for his hallucinations (AR 311).

Plaintiff was evaluated by Paul Shields, D.O. on December 29, 2008 (AR 239-244). Plaintiff stated an inability to work due to depression and anxiety (AR 239). He reported feelings of stress, difficulty concentrating and sadness, but denied any suicidal or homicidal thoughts (AR 239). On mental status examination, Dr. Shields reported his "affect/demeanor" as "anxious, depressed [and] flat" (AR 240). Plaintiff was diagnosed with generalized anxiety disorder and major depression (AR 240).

Plaintiff also received treatment at Great Lakes Family Medicine from February 2009 through July 2009 from James Jageman, M.D. (AR 251-308). On February 25, 2009, Plaintiff was seen for a general check-up and was assessed with, inter alia, depression with anxiety (AR 252). Dr. Jageman reported Plaintiff's mood as normal at this visit (AR 254).

When seen by Dr. Eberly on February 23, 2009, Plaintiff reported suffering from three panic attacks in the prior week (AR 312). He continued to complain of anxiety, depression and hallucinations (AR 312). Plaintiff had switched from individual therapy to group therapy, which he found helpful (AR 312). Her diagnosis was similar to that of December 29, 2008, with the exception that she added "panic disorder without agoraphobia" (AR 312). She also assigned him a GAF score of 49 (AR 312).

On April 8, 2009, Plaintiff reported that he had "good days and bad days," but he continued to suffer from auditory and visual hallucinations (AR 313). Plaintiff claimed he heard voices more frequently, telling him to kill himself (AR 313). He felt that others were "whispering" about him, and believed his brother was "looking for ways to hurt [him]" (AR 313). His anxiety symptoms had decreased with the increase in his medications, and he had only one panic attack the week prior (AR 313). His group therapy had ended and he ...

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