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Michael L. Dominguez v. Michael J. Astrue

August 14, 2012


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



Michael L. Dominguez, ("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 January 3, 2007,*fn1 alleging disability since March 8, 2004*fn2 due to bipolar disorder and diabetes (AR 82-95; 119 ).*fn3 His applications were denied (AR 60-68), and following a hearing held on October 27, 2008 (AR 21-42), the administrative law judge ("ALJ") issued his decision denying benefits to Plaintiff on November 14, 2008 (AR 11-20). His request for review by the Appeals Council was denied (AR 1-5), rendering the Commissioner's decision final under 42 U.S.C. § 405(g). Plaintiff filed his complaint challenging the ALJ's decision, and presently pending before the Court are the parties' cross-motions for summary judgment. For the following reasons, both motions will be denied and the matter will be remanded to the Commissioner for further proceedings.


Plaintiff was 41 years old on the date of the ALJ's decision and has a limited education (AR 19; 125). He has past relevant work experience as a laborer, mechanic and wheel barrow specialist (AR 120). Plaintiff claims disability based on his alleged mental and physical impairments.

Medical History

A. Mental impairments

Plaintiff was treated at Corry Counseling Center for his mental impairments (AR 174-219). Treatment records reveal that Plaintiff has been diagnosed, at various times, with the following conditions: depression, bipolar disorder, ADHD, alcohol abuse, alcohol abuse in remission, impulse control disorder, and/or partner relational problems, for which he has been prescribed medication (AR 174-213). On June 13, 2006, Plaintiff was seen by Carolyn Eastman, R.N. and reported no significant change in his mood swings (AR 213). Plaintiff stated that he continued to experience occasional irritability, but was able to control his impulses to act out (AR 213). He denied suffering from any suicidal or homicidal ideations (AR 213). He requested an adjustment in his medication regimen due to some daytime sleepiness, and Ms. Eastman noted that progress had been made in his treatment (AR 213). On June 19, 2006, Ms. Eastman noted that Plaintiff's therapy was complete and he was transferred to medication management (AR 214).

Plaintiff continued to complain of daytime sleepiness on July 19, 2006 and his medications were decreased (AR 215). On July 26, 2006, Plaintiff was seen by Asha Prabhu, M.D., and reported that he had stopped taking his medication because it made him tired (AR 217). It was noted that Plaintiff had tried numerous mood stabilizers, including Depakote, Lithium, Seroquel and Geodon (AR 217). Plaintiff stated that he was very irritable and angry, but denied suicidal or homicidal thoughts (AR 217). Topamax was prescribed for his symptoms (AR 217).

Plaintiff underwent a psychiatric evaluation at Stairways Behavioral Health performed by Robin Bailey, M.D. on December 21, 2006 (282-286). Plaintiff complained of lifelong symptoms of anger and volatile moods, and impulsive and reckless behavior (AR 282). Plaintiff claimed that his symptoms worsened with age (AR 282). It was noted that Plaintiff was in a fairly stable relationship for ten years, had avoided the criminal justice system, (except for a remote DUI), had been able to maintain a stable job for seven years, and had not been involved in any physical altercations in recent years (AR 282). At the evaluation, Plaintiff complained of sleep disturbances, "little patience", energy fluctuations, and problems with concentration (AR 283). His mood was primarily euthymic, with episodes of irritability (AR 283). He acknowledged some suicidal thoughts, but had no plan or intent (AR 283). He denied any symptoms of anxiety, panic, obsessive-compulsiveness and paranoia (AR 283). Plaintiff stated he had ongoing problems with "hearing a crowd" and experienced mania symptoms, including impulsiveness and self-endangering behavior (AR 283). Plaintiff was not on any medications for his symptoms (AR 283). Plaintiff reported he had been diabetic since age 21 and it was uncontrolled (AR 283).

On mental status examination, Dr. Bailey found Plaintiff had poor hygiene with dirty hands and numerous cuts on his right hand (AR 285). Dr. Bailey found Plaintiff was cooperative, maintained good eye contact and had an appropriate affect (AR 285). Dr. Bailey noted that his speech was normal in rate and production, and that his thoughts were logical and goal directed (AR 285). Plaintiff was unable to perform serial 7's but was able to spell "earth" backwards and remember three out of three objects at two minutes (AR 285).

Dr. Bailey formed an impression that Plaintiff had lifelong symptoms of impulsivity and irritability, and, indirectly, self-destructive behavior (AR 285). She noted that years of pharmacotherapy had not produced a significant benefit (AR 285). Dr. Bailey diagnosed Plaintiff with, inter alia, bipolar disorder not otherwise specified, rule out attention deficit disorder, and alcohol dependency history (AR 286). She assigned him a Global Assessment of Functioning ("GAF") score of 51-53 (AR 286). *fn4 Plaintiff declined counseling, and Dr. Bailey prescribed Neurontin (AR 286).

When seen by Dr. Bailey on January 11, 2007, Plaintiff reported sleeping better (AR 287). Plaintiff reported being "stressed" over events the previous day involving his children and multiple arguments with his spouse (AR 287). On mental status examination, Dr. Bailey found Plaintiff displayed adequate grooming and hygiene, and his thoughts were logical and goal directed (AR 287). Plaintiff denied any suicidal or homicidal thoughts (AR 287). His diagnosis remained unchanged, and Dr. Bailey increased his Neurontin dosage (AR 287).

On January 29, 2007, Dr. Bailey completed a Medical Source Statement of Plaintiff's ability to perform mental work related activities (AR 288-290). Dr. Bailey found that Plaintiff had no limitations in his ability to understand, remember, and carry out short, simple instructions (AR 289). She further found that Plaintiff was moderately*fn5 limited in his ability to understand, remember and carry out detailed instructions; make simple work-related decisions; interact appropriately with the public, supervisors and co-workers; and respond appropriately to changes in a routine work setting (AR 289). Dr. Bailey found that Plaintiff was markedly*fn6 limited in his ability to respond appropriately to work pressures in a usual work setting (AR 289). Dr. Bailey noted that her assessment was based upon her clinical interview with the Plaintiff, and the Plaintiff's "self report" (AR 289).

On February 23, 2007, Edward Jonas, Ph.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; moderate difficulties in maintaining concentration, persistence or pace; and moderate difficulties in maintaining social functioning (AR 311). Dr. Jonas completed a mental residual functional capacity assessment form, and opined that Plaintiff was not significantly limited or only moderately limited in a number of work-related areas (AR 297-298). He found that Plaintiff could understand, retain and follow simple job instructions involving one and two step tasks, and make simple decisions (AR 299). Dr. Jonas concluded that Plaintiff remained capable of meeting the basic mental demands of competitive work on a sustained basis despite the limitations resulting from his impairment (AR 299).

On March 29, 2007, Stairways progress notes indicated that Plaintiff was compliant with his medications (AR 382). He reported moderate feelings of depression and occasional feelings of anxiety (AR 382).

On April 16, 2007, Plaintiff reported to Dr. Bailey that Neurontin helped his symptoms but slowed his "reactivity" (AR 379). Plaintiff continued to complain of becoming "highly angry" and volatile, stating that he had become physically aggressive towards his wife (AR 379). He described his mood as "bad" (AR 379). On mental status examination, Dr. Bailey reported Plaintiff's mood was irritable and dysphoric*fn7 (AR 379). He had suicidal thoughts, but no active plan (AR 379). He was diagnosed with a mood disorder and Celexa was added to his medications (AR 379).

When seen by Dr. Bailey on May 17, 2007, Plaintiff reported increased stress (AR 378). He stated that Celexa made him tired (AR 378). Plaintiff claimed his main issue was his "temperament" and irritability (AR 378). On mental status examination, Dr. Bailey found he was cooperative and his thoughts were logical, but he was pervasively irritable (AR 378). He denied any suicidal or homicidal thoughts (AR 378). Dr. Bailey increased his Neurontin dosage, stopped the Celexa and started Plaintiff on Effexor (AR 378).

Plaintiff complained of depression, irritability, lack of motivation, anxiety and stress at his visit on August 1, 2007 (AR 377). Dr. Bailey found his mood and affect to be irritable and rude, and he was verbally abusive when talking about his pharmacy (AR 377). He was cooperative during the visit and denied any suicidal or homicidal thoughts (AR 377). Generic Effexor was prescribed and he was continued on Neurontin (AR 377).

On September 24, 2007, Plaintiff reported that he stopped taking Effexor because it caused an upset stomach (AR 374). Plaintiff complained of irritability, and his mood and affect were reported as irritable (AR 374). Plaintiff had passive suicidal thoughts (AR 374). He was continued on Neurontin for his bipolar disorder, Effexor was discontinued, and he was started on a trial of Lamictal (AR 374).

On October 8, 2007, Plaintiff reported that Neurontin made him tired (AR 373). On mental status examination, Dr. Bailey reported that Plaintiff's speech was spontaneous, but he was preoccupied with his neck and back pain (AR 373). Plaintiff denied suicidal thoughts, stating that he "always want[ed] to hurt someone else," and avoided contact with others (AR 373). His medications were continued (AR 373).

Plaintiff also received mental health treatment at Safe Harbor Behavioral Health (AR 401-413). On March 28, 2008, Plaintiff was evaluated by Melissa Olivett, M.S., Ph.D. Intern (AR 401-406). Plaintiff complained of anger problems, rapid mood changes, sleep disturbances, a decreased energy level, attention and concentration problems, and isolating behavior (AR 401). On mental status examination, Ms. Olivett found Plaintiff fully oriented, cooperative and alert (AR 404). He had adequate hygiene and was appropriately dressed (AR 404). Plaintiff's speech was spontaneous; his thought processes were organized, relevant and circumstantial; and his affect was anxious but appropriate (AR 404). She further found his judgment to be poor and his insight fair (AR 404). She diagnosed Plaintiff with bipolar disorder and assigned him a GAF score of 45 (AR 405).

A psychiatric evaluation was performed by Ralph Walton, M.D. on June 3, 2008 (AR 407-408). Plaintiff reported that he was "full of hate" (AR 407). He stated that he had a tendency to be either very depressed or very high (AR 407). Plaintiff reported that his "high" periods could last up to one week at a time, causing him to be extremely reckless, irritable and aggressive (AR 407). On mental status examination, Dr. Walton found Plaintiff fully oriented and capable of presenting his history in an organized fashion (AR 407). He described hearing "constant chatter" from multiple voices but was unable to discern what was being said (AR 408). Dr. Walton found no obvious delusional processes (AR 408). He was diagnosed with bipolar disorder and assigned a GAF score of 48 (AR 408). He was prescribed Abilify (AR 408).

On July 15, 2008 Plaintiff was seen by Matthew Behan, D.O. and complained that he was "in a bad mood," was irritable, and had conflicts with those around him (AR 410). Dr. Behan found no obvious signs or symptoms of psychosis or mania, and Plaintiff denied any suicidal or homicidal thoughts (AR 410). He was diagnosed with bipolar disorder and assigned a GAF score of 52, and his Abilify dosage was increased (AR 410).

Plaintiff returned to Safe Harbor on September 19, 2008 and treatment notes reflect that he was depressed and unmotivated, and "somewhat anhedonic"*fn8 (AR 409). He claimed he had difficulty "sitting still" (AR 409). On mental status examination, a registered nurse reported that Plaintiff was sarcastic and somewhat irritable, although he answered questions appropriately and became more pleasant as the interview progressed (AR 409). He was diagnosed with ...

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