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Jennings v. Berryhill

United States District Court, E.D. Arkansas, Northern Division

October 2, 2017

NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration DEFENDANT


         Plaintiff Samuel C. Jennings ("Jennings") began this case by filing a complaint pursuant to 42 U.S.C. 405(g). In the complaint, he challenged the final decision of the Acting Commissioner of the Social Security Administration ("Commissioner"), a decision based upon the findings of an Administrative Law Judge ("ALJ").

         Jennings maintains that the ALJ's findings are not supported by substantial evidence on the record as a whole and offers two reasons why.[1] Jennings first maintains that his mental impairment meets or equals a listed impairment, and the ALJ failed to so find at step three of the sequential evaluation process. Jennings also maintains that his residual functional capacity was erroneously assessed. He so maintains because his failure to take his medication as prescribed was excusable given his mental impairment and because the opinions of his treating sources were never obtained.

         The record reflects that Jennings was born on December 12, 1995, and was seventeen years old when he allegedly became disabled beginning on October 23, 2013. He filed an application for child's disability benefits on March 15, 2014, and alleged that he became disabled as a result of symptoms associated with paranoid schizophrenia. See Docket Entry 169.[2]

         A summary of the medical evidence reflects that Jennings has sought medical attention for the symptoms associated with his mental impairment on multiple occasions. On October 24, 2013, he was admitted to the Pinnacle Pointe Hospital ("Pinnacle Pointe") after he was expelled from school for attacking and injuring another student and for threatening to kill several other students. See Transcript at 300-310. A mental status examination was performed after his arrival at Pinnacle Pointe, and the following observations were recorded:

The patient is an average build, neatly dressed and groomed Caucasian boy who is alert and cooperative, relates in a quiet, subdued manner. Speech is logical, relevant, and fluent without articulation or processing difficulties. He admits to explosive, out of control temper, and violent, aggressive behaviors, and having made threats to peers at school, but denied any current homicidal ideation. He continues to feel paranoid that the school is trying to poison him and that people are out to get him. Cognitively, he presents as intact and oriented. He is able to recall address, birthday, phone number, spell "house" forward and backwards, and do serial-3 subtractions quickly and easily. Intellectually, he presents as average by vocabulary and fund [sic] of knowledge. Judgment and insight are impaired as evidenced by the violent, aggressive behaviors, homicidal threats, and paranoia.

See Transcript at 305. Jennings was diagnosed with, inter alia, mood and psychotic disorders and prescribed Abilify. When he was discharged on November 4, 2013, he was observed to be medically stable and no longer exhibiting aggressive symptoms. He was referred to Families, Inc., ("Families") for individual and family therapy.

         Jennings and/or members of his family thereafter saw the mental health professionals at Families in excess of forty-five times between November of 2013 and January of 2015.[3] The initial progress notes reflect that he reported difficulties controlling his anger and getting along with others. Following an April 3, 2014, examination, Dr. Richard Lucas, M.D., diagnosed Jennings' primary impairment as paranoid type schizophrenia. See Transcript at 456. Jennings reported difficulties with his medication on several occasions, and it was repeatedly adjusted. He was prescribed, at times, Risperdal, Invega, Trazodone, Remeron, Topamax, and Zyprexa. See Transcript at 447. Generally, as his medication was adjusted, and he took it as prescribed, his condition improved. For instance, in a May 6, 2014, progress note, Jennings was noted to be compliant with his medication and reported feeling better. He was observed to be "more open and responsive" and "more relaxed." See Transcript at 440. In a June 3, 2014, progress note, the following observations were made:

[Jennings] explained he is getting along with family members. He expressed he has decreased his hand gestures and loud talking out in public while with family members. ... He showed no signs of paranoid behaviors during the sessions. He explained he has helped his father with some tasks at work so that he was able to get out of the house. He reported he may continue to help [his] father with work.

See Transcript at 399. The mental health professionals at Families made similar observations during the approximately six month period that followed, again, as long as Jennings took his medication as prescribed. In an October 7, 2014, progress note, the following observations were made:

[Jennings] explained he went on a trip with his [u]ncle over the weekend. [Jennings] expressed they went to a powwow with different tribes. He explained during the trip he did not have any paranoid thoughts or behaviors. He expressed that he had a "good time." [The mental health professional] and [Jennings] discussed ways to remain productive in his life. [Jennings] explained he feels as if he is in "a rut." He and [the mental health professional] explored ways to break the time up during the day. [They] discussed "jobs, volunteering, working around the home, playing drums."

See Transcript at 485. In a November 4, 2014, progress note, the following observations were made: "... [Jennings] expressed he enjoys the drums and music. He explained he got a part time job [raking leaves] and helping out an elderly lady around her home. He expressed several times he would like more out of life and become something of himself." See Transcript at 481.

         Jennings' condition became less stable, though, when he did not take his medication as prescribed. For instance, Jennings' grandmother visited with a mental health professional from Families on January 5, 2015, and provided the following report concerning Jennings' mental health:

Nancy [i.e., Jennings' grandmother] reports "[Jennings] has not been taking his medicine. He acts like a Wildman. He comes to my house and wants money. He told me last night that if I did not give him what he wanted that he was going to break my legs. I told him to get out. He did. My son was here and my boyfriend last night when [Jennings] said that so I was not afraid of him. He left." ...

See Transcript at 664. The mental health professional opined that Jennings was "regressing due to not taking his medication." See Transcript at 664.

         On April 19, 2014, or during the period Jennings was seeing the mental health professionals at Families, he was arrested on charges of criminal trespass and public intoxication. He was referred by the Izard County Sheriff's Department to the BridgeWay ("BridgeWay"), a psychiatric hospital, where he was hospitalized for nine days. See Transcript at 343-361. At the time of his admission, the following observations were recorded: "... [Jennings] has had disorganized thoughts with an inappropriate affect and was uncooperative with the initial evaluation. He is noncompliant with medication. He reports being easily agitated with significant paranoia. No suicidal or homicidal ideations at this time." See Transcript at 345. He was prescribed Zyprexa, and it appears to have been of some benefit. Dr. Victor McNemey, M.D., noted the following in a discharge summary:

... [Jennings] had no episodes of agitated or combative behavior. He was easily redirected by nursing staff. He was calm. He interacted appropriately with peers. His encounters with me were relatively brief. He had notable negative symptoms of schizophrenia including hypoverbal speech, poor inner social relatedness, and in general a lack of interest in socialization. However, he did not exhibit any significant positive symptoms of schizophrenia. His schizophrenia appeared consistent with undifferentiated type of possibly disorganized type. ...

See Transcript at 343.

         On August 6, 2014, Jennings was seen by Dr. Nancy Bunting, Ph.D., ("Bunting") for a mental status examination and an evaluation of adaptive functioning. See Transcript at 465-470. Her observations included the following:

[Jennings] was alert, attentive, and superficially cooperative. Once this patient stated early in the interview that he had had NO psychiatric hospitalizations, the examiner became very careful and validated information later with the father in a separate session. In no way nor at any time did this patient appear to be psychotic, out of touch with reality, or delusional. On the contrary he appeared to be quite competent, and once he denied any hospitalizations the examiner had to seriously consider the possibility that he is a liar.

See Transcript at 467. Bunting observed that Jennings' thought processes were logical, relevant, and goal-directed. She diagnosed, inter alia, an antisocial personality disorder. With respect to his symptoms, she opined, in part, the following:

While [Jennings] had one stilted sentence, this seemed to be a function of his disdain for the evaluation and NOT any indication of psychosis. ...
This patient is not a reliable informant. ...
[Jennings'] father's remark about "milking" the system for sympathy since grade school would be consistent with an antisocial personality disorder. His father was quite distraught as he cannot afford to support this young man and he knows that he has access to the $10, 000. The patient's almost immediate question about what the examiner was writing suggest he was very aware of the nature of the interview and he was careful about what he revealed. His answers ...

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