Opinion ID: 3066184
Heading Depth: 3
Heading Rank: 2

Heading: Mental Health Issues

Text: Throughout the relevant time period, Garrison struggled with a variety of diagnosed mental impairments, including bipolar disorder, anxiety, bouts of insomnia, auditory and visual hallucinations, and paranoia. Her treating medical caretakers also came to view her “seizures” (sometimes called “pseudo-seizures” in her treatment records) as the result of psychiatric issues. In September 2007, Garrison visited Nurse Practitioner Susan Anderson for the first time. Anderson, who would become Garrison’s primary psychiatric care giver, noted that Garrison suffered from insomnia, anxiety, depressive symptoms, nightmares, and flashbacks. Anderson diagnosed post-traumatic stress disorder and possible bipolar disorder. She also recorded a Global Assessment of Function (GAF) score of 50.4 Later that month, Anderson noted that Garrison 4 “A GAF score is a rough estimate of an individual’s psychological, social, and occupational functioning used to reflect the individual’s need for treatment.” Vargas v. Lambert, 159 F.3d 1161, 1164 n.2 (9th Cir. 12 GARRISON V. COLVIN had recently suffered another “seizure” and, more important, that Garrison was having trouble with her medication. Garrison stated that she felt electric shocks going through her body, and added that she alternated between feeling very depressed and feeling like she had superpowers that would let her lift piles of wood in the heat. Two months later, in November 2007, Dr. Wayne General examined Garrison at the behest of a state agency. He concluded that her full scale IQ was 77, placing her in the 6th percentile, and observed that “Karen is currently functioning in the range of borderline intelligence.” General then noted that Garrison’s “overall short-term memory is in the borderline range” and that her “concentration is in the low average range.” When subjected to further tests, Garrison performed in “the lower average range” on simple tasks and “very poorly” on more complex tasks requiring concentration. 1998). According to the DSM-IV, a GAF score between 41 and 50 describes “serious symptoms” or “any serious impairment in social, occupational, or school functioning.” A GAF score between 51 to 60 describes “moderate symptoms” or any moderate difficulty in social, occupational, or school functioning.” Although GAF scores, standing alone, do not control determinations of whether a person’s mental impairments rise to the level of a disability (or interact with physical impairments to create a disability), they may be a useful measurement. We note, however, that GAF scores are typically assessed in controlled, clinical settings that may differ from work environments in important respects. See, e.g., Titles II & XVI: Capability to Do Other WorkThemedical-Vocational Rules As A Framework for Evaluating Solely Nonexertional Impairments, SSR 85-15, 1983-1991 Soc. Sec. Rep. Serv. 343 (S.S.A 1985) (“The mentally impaired may cease to function effectively when facing such demands as getting to work regularly, having their performance supervised, and remaining in the workplace for a full day.”). GARRISON V. COLVIN 13 Assessing Garrison’s overall mental well-being, General made a number of diagnoses: Axis I: 296.52 Bipolar I Disorder, Most Recent Episode Depressed, Moderate 995.50 Victim of Physical or Sexual Abuse as a Child 995.81 Victim of Physical or Sexual Abuse as an Adult 309.81 Posttraumatic Stress Disorder, Acute, Chronic, Delayed Onset 304.80 Polysubstance Dependence, Alcohol, Amphetamines, Cannabis and Cocaine in Full, Sustained Remission by self-report Axis II: V62.89 Borderline Intellectual Functioning, by examination Axis III: Overweight, joint disease (neck and back) and arthritis, by referral history; migraine cephalgia by self-report General concluded that Garrison’s “prognosis for returning to work is currently poor, as she had difficulty maintaining concentration and manifested a borderline short-term 14 GARRISON V. COLVIN memory. She did not have sufficient emotional control, and broke into tears three times during test administration. Her ability to perform work-related tasks is currently inadequate based on cognitive functions such as attention, concentration, processing speed and short-term memory.” In December 2007, Anderson noted that Garrison’s mood was “unstable,” that Garrison was dealing with several family issues, and that Garrison was experiencing intense anxiety and severe racing thoughts. Anderson assessed a GAF score of 55, with a continued diagnosis of Bipolar Disorder II and PTSD. Garrison’s attention and concentration, as well as her insight and judgment, were only “fair.” Garrison’s condition did not materially change over the next few months. In January 2008, despite slight improvement due to use of Abilify, Anderson’s records show that Garrison remained anxious and deeply paranoid, with a GAF score of 55–60. That month, Dr. Adrianne Gallucci, Psy.D., a state agency consultant, reviewed some of Anderson’s medical records and filled out a check-box form to state her conclusions. Gallucci opined that Garrison’s impairments were “severe but not expected to last 12 months,” and identified “[c]oexisting [n]onmental [i]mpairment(s) that require referral to another medical specialty.” Gallucci checked off the boxes for affective disorders, mental retardation, and anxiety-related disorders. Under affective disorders, Gallucci marked bipolar disorder. In a summary section, Gallucci checked boxes for “mild” degree of limitation of function in “restriction of activities of daily living” and “difficulties in maintaining social functioning.” Gallucci checked boxes for “moderate” degree of difficulties in “maintaining concentration, persistence, or pace.” In a brief explanation section, Gallucci remarked that Garrison had experienced a good initial GARRISON V. COLVIN 15 response to some medication and had started mental health treatment, and for these reasons was not likely to suffer an impairment lasting more than 12 months. Anderson’s records show that, in February 2008, Garrison’s GAF dropped to 55. In her visit, Garrison reported hearing ghosts and spirits calling her name, a variety of other auditory and visual hallucinations, nightmares, severe anxiety, obsessive preoccupations, and persistent insomnia. Her attention and concentration, as well as her insight and judgment, remained only “fair.” That month, Anderson completed a “Medical Assessment of the Patient’s Ability to Perform Work Related Activity” (“the 2008 Assessment”). In it, Anderson reported a moderate impairment in Garrison’s ability to relate to other people; to perform daily activities; to understand, carry out, and remember instructions; to respond appropriately to supervision; to respond appropriately to co-workers; and to perform varied tasks. Anderson reported moderately severe constriction of interests, including in Garrison’s ability to respond to customary work pressures; ability to perform complex tasks; ability to complete a normal workday/workweek without interruptions from psychologically based symptoms; and ability to perform at a consistent pace without an unreasonable number/length of rest periods. Anderson checked “Yes” when asked, “Have the above limitations lasted or can they be expected to last for 12 months or longer?” Anderson also filled out the comment section of the form, writing as follows: “Client has poor coping skills, auditory hallucinations, unstable moods, and severe anxiety. These psychiatric symptoms are complicated by multiple medical problems.” 16 GARRISON V. COLVIN In July 2008, after a short respite from some of her more severe mental health problems—though she did experience at least one “seizure” during that respite5—Garrison again returned to Anderson with hallucinations, panic attacks, insomnia, racing thoughts, blackouts, unstable mood, and paranoia. Anderson assessed GAF scores of 45–50 and determined that Garrison’s attention and concentration, as well as her insight and judgment, were “limited.” One month later, Garrison collapsed and then fainted in the middle of a counseling session, and continued to report auditory hallucinations, anxiety, and racing thoughts. Anderson’s records show that Garrison’s attention and concentration, as well as her insight and judgment, remained “limited.” Garrison’s GAF score dropped again in September 2008, this time to 50, and Anderson again recorded issues including hallucinations, insomnia, anxiety, and racing thoughts. By late September, Garrison’s issues expanded to include overwhelming depression and paranoia. Throughout this period, her attention and concentration, as well as her insight and judgment, remained “limited.” Then, from November 2008 to February 2009, Garrison’s mental health improved somewhat. Anderson recorded GAF scores ranging from 55 to 61 in this period, noting that, although Garrison remained anxious and was at times tearful, treatment was helping to alleviate Garrison’s more severe symptoms, including her panic attacks, paranoia, and hallucinations. 5 From February 2008 to June 2008, while on a break from some of her medications, Garrison worked four to five times as an “on call” teacher’s aide and also worked a few hours per day as a bus monitor. She was fired by the school district after having a “seizure” on the bus. GARRISON V. COLVIN 17 As before, though, this short-lived and limited uptick in Garrison’s mental health soon ended. By April 2009, Garrison was suicidal and panicked, again reported racing thoughts and pseudo-seizures, and again stated that she was having trouble with—and had stopped some of—her medications. Late in April 2009, Anderson assessed a GAF score of 50 and noted that Garrison was displaying hypomanic symptoms, sleeping less, and had only “partial” insight and judgment. Garrison’s GAF score remained 50 in May 2009. That month, Anderson observed that Garrison had fainted on several occasions when upset, was still experiencing insomnia and racing thoughts, and still had only partial insight and judgment. In June 2009, Garrison felt a bit better, but was still “up and down.” Her GAF score remained 50, an indication of “serious symptoms” or “serious impairment in social, occupational, or school functioning,” she was still troubled by bouts of racing thoughts and anxiety, and Anderson was still trying, apparently with only mixed success, to adjust her medications.