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Camacho v. Commissioner of Social Security

United States District Court, N.D. Ohio, Eastern Division

December 17, 2017


          Sara Lioi Judge.


          James R. Knepp II United States Magistrate Judge.


         Plaintiff Emely Camacho (“Plaintiff”) filed a Complaint against the Commissioner of Social Security (“Commissioner”) seeking judicial review of the Commissioner's decision to deny supplemental security income (“SSI”). (Doc. 1). The district court has jurisdiction under 42 U.S.C. §§ 1383(c) and 405(g). This matter has been referred to the undersigned for preparation of a report and recommendation pursuant to Local Rule 72.2. (Non-document entry dated February 3, 2017). Following review, and for the reasons stated below, the undersigned recommends the decision of the Commissioner be reversed and remanded.

         Procedural Background

         Plaintiff filed for SSI in January 2014, alleging a disability onset date of August 1, 2009. (Tr. 127-37). Her claims were denied initially and upon reconsideration. (Tr. 91-93, 99-100). Plaintiff then requested a hearing before an administrative law judge (“ALJ”). (Tr. 104). Plaintiff (represented by counsel), and a vocational expert (“VE”) testified at a hearing before the ALJ on December 8, 2015. (Tr. 29-66). On February 3, 2016, the ALJ found Plaintiff not disabled in a written decision. (Tr. 13-24). The Appeals Council denied Plaintiff's request for review, making the hearing decision the final decision of the Commissioner. (Tr. 1-7); see 20 C.F.R. §§ 416.1455, 416.1481. Plaintiff timely filed the instant action on February 3, 2017. (Doc. 1).

         Factual Background

         Personal Background and Testimony

         Plaintiff was born in January 1982 and was 31 years old on her application date. (Tr. 22). Plaintiff's mother drove her to the hearing. (Tr. 38). Plaintiff lived with her five children, aged 17, 15, 14, 12, and 9. (Tr. 41). Her oldest daughter and her mother, who lives nearby, helped her care for her other children. Id. Plaintiff testified to past work as a house cleaner. (Tr. 46).

         Plaintiff described the reasons she believed she was unable to work:

It's very hard for me . . . to focus and to concentrate on doing any type of work or any type of pay. . . . I feel like everybody's, like, looking at me while I'm . . . when I'm doing things. . . . I have severe tics, and it's just . . . a problem. . . ., I distract everybody from too much tics that I do.

(Tr. 38-39). Plaintiff had tics in her face, neck, arms, and legs, “every day, like constantly.” (Tr. 39). The tics increased in severity when Plaintiff was “more stressed out.” Id. When questioned about an inconsistency in the record where a provider observed no tics until tics were mentioned, Plaintiff explained:

I always - - like, my tics are always - - I always have tics. There's time periods where I could, like not have tics, like for a time period, but not like - - like, for long time periods. Like, it's just like - - I could - - like if I'm relaxed, I could [have] tics but not as major. But I always tend to have tics, like severely all the time every day.

(Tr. 40-41). Plaintiff testified the longest she could go without having a tic was “a couple minutes” and talking or thinking about tics made them worse. (Tr. 47).

         At the time of the hearing, Plaintiff took Lamictal and Topamax. (Tr. 41-42). The medications caused drowsiness and Plaintiff slept a lot. (Tr. 44); see also Tr. 45 (“I just sleep . . . almost . . . all day. Like, I'm constantly tired all the time.”).

         Plaintiff testified her mother and oldest daughter helped with house cleaning. (Tr. 47-48). Plaintiff stated she could sweep or mop, but “it just takes me more time to do it.” (Tr. 48). Plaintiff testified it took her longer to do these things than it used to, but acknowledged she had always had tics. (Tr. 48-49). Plaintiff washed dishes, but worried she might drop things, and had broken dishes before. (Tr. 50-51). Once while cooking, Plaintiff dropped a pot on the floor. (Tr. 51).

         Plaintiff testified to having obsessive compulsive disorder symptoms including repeatedly checking her door locks, her stove, and whether her children were breathing. Id. She would check the door and the stove three or four times a day, and check her children's breathing whenever they were sleeping. (Tr. 52). She also arranged her children's shoes from smallest to biggest. (Tr. 51-52).

         Plaintiff had trouble concentrating, and worried about others making fun of her or being distracted by her. (Tr. 53). Plaintiff testified she did not go anywhere, and did not like being around people. Id. She clarified that she takes her children to school with her oldest daughter, and goes grocery shopping with her mother. (Tr. 54). She was teased due to her tics, and had pain in her face and neck from the tics. (Tr. 57).

         Plaintiff testified she had been seeing Dr. Pandya for “maybe a year or so”. (Tr. 42). Plaintiff testified that she saw Dr. Pandya on the day she gave him a mental impairment questionnaire in November 2015. (Tr. 43-44). Plaintiff did not feel like she was getting better under Dr. Pandya's treatment and she was “going to be seeing a new doctor because Dr. Pandya is leaving”. (Tr. 55).

         Relevant Medical Evidence[1]

         In March 2011, Plaintiff saw Erick Kauffman, M.D., at Neighborhood Family Practice, for bipolar disorder and Tourette's disorder. (Tr. 264). She reported being off all medications, but that Lamictal had previously helped make her calmer, and Clonidine “helped [T]ourette[‘]s a bit”. Id. On examination, Dr. Kauffman noted normal: mood and affect, behavior, and thought content. (Tr. 265). He prescribed Lamictal and Klonopin for Plaintiff's bipolar disorder and Clonidine for her Tourette's. Id.

         In April 2011, Plaintiff complained of aching epigastric pain with nausea and vomiting. (Tr. 262). Plaintiff reported stopping the Lamictal, but it “was helping mood and reactivity” and she wanted to restart it. Id. Dr. Kauffman again noted normal: mood and affect, behavior, and thought content. Id.

         In June and August 2011, Plaintiff called to request a refill of, inter alia, Klonopin (clonazepam). (Tr. 261). In September 2011, Plaintiff called to request a psychiatric referral, which Dr. Kauffman approved. (Tr. 260).

         At an October 2011 visit with Dr. Kauffman, Plaintiff reported anxiety, panic attacks, and poor sleep. (Tr. 258-59). Dr. Kauffman noted plaintiff was nervous and anxious and had insomnia. (Tr. 259). Dr. Kauffman prescribed Klonopin, and citalopram (Celexa), and instructed Plaintiff to follow up “with psych or me in one month”. Id.

         In December 2011, Plaintiff called requesting refills of Lamictal and Klonopin. (Tr. 258). Plaintiff also reported she had previously taken Seroquel and requested a refill. Id. Plaintiff was informed Dr. Kauffman would address these refills at her next office visit. Id.

         Plaintiff next saw Julia Garcia, MA (in the same office as Dr. Kauffman) later that month. (Tr. 257). Plaintiff reported “[f]unctioning well when she is on lamictal”, but she had “been off it for 2 weeks.” Id. Plaintiff was prescribed Klonopin (clonazepam) and quetiapine (Seroquel), and notes indicate “[w]ill work on psych meds until she is seen by psych”. (Tr. 258). In January, Plaintiff again called Dr. Kauffman for a refill of Klonopin. (Tr. 256).

         In February 2012, Plaintiff saw psychiatrist Sara Stein, M.D. (Tr. 255-56). Plaintiff reported she had been diagnosed with bipolar disorder ten years prior, and had occasional suicidal feeling and panic attacks. (Tr. 255). Plaintiff also reported a previous diagnosis of Tourette's. Id. Plaintiff reported she was taking Lamictal, never started citalopram, and took clonazepam for anxiety. Id. On examination, Plaintiff was anxious, had “obvious motor tics” and her speech was pressured. (Tr. 256). Dr. Stein assessed bipolar disorder, and Tourette's, and assessed a Global Assessment of Functioning (“GAF”) score of 60.[2] Id. Dr. Stein adjusted Plaintiff's medications (increasing her Lamictal dosage, and adding trazodone). Id.

         In May 2012, Plaintiff returned to Dr. Kauffman for a “medication review”. (Tr. 252). Plaintiff reported she was pregnant, and had stopped taking her Klonopin and Lamictal two weeks prior. Id. Dr. Kauffman again noted normal: mood and affect, behavior, and thought content. Id. Dr. Kauffman referred Plaintiff to behavioral health. (Tr. 252-53). Later that month, Plaintiff told Dr. Stein she had stopped all her medications three weeks prior, and that she had racing thoughts and could not sleep. (Tr. 251). Dr. Stein prescribed a low dose of Haloperidol, noting it was safest for pregnancy. Id.

         In June 2012, Plaintiff called Dr. Kauffman to request a Lamictal refill. (Tr. 250). Plaintiff also reported she was no longer pregnant and had an appointment with Dr. Stein the following day. (Tr. 250-51). Plaintiff did not show up for her appointment with Dr. Stein, and Dr. Stein requested a staff member call her to request she come into the office. (Tr. 251).

         In October 2012, Plaintiff saw Dr. Stein, reporting a lost pregnancy, difficulty sleeping, “[b]ad tics”, and racing thoughts. (Tr. 248). Dr. Stein adjusted Plaintiff's medications (restarting Lamictal, increasing haloperidol, and adding vitamin B6). Id.

         Records reflect prescription refills from both Dr. Stein and Dr. Kauffman from January through June 2013. (Tr. 247). In June 2013, Plaintiff called Dr. Kauffman requesting a Klonopin refill, and was instructed to make an appointment. Id. Plaintiff saw Dr. Kauffman later that month, reporting stress from relationship issues, caring for her children alone, and wanting to get back on medications. (Tr. 245-46). Dr. Kauffman noted Plaintiff was depressed, nervous, and anxious. (Tr. 246). Dr. Kauffman restarted Plaintiff's medications (adding Doxepin), and referred Plaintiff to counseling. Id.

         Plaintiff called Dr. Kauffman later in June and again in July, reporting the Doxepin dosage was too strong and made her sleepy. (Tr. 244-45). Plaintiff was instructed to take half a tablet, and later given a prescription for a lower dose. (Tr. 245).

         In December 2013, Plaintiff called Dr. Kauffman's office requesting refills of Lamictal and Klonopin until her appointment in January. (Tr. 244).

         In January 2014, Plaintiff saw Dr. Kauffman for a physical, and reported she continued to suffer from depression and insomnia. (Tr. 242). She also reported the Doxepin “makes her too drowsy.” Id. On examination, Dr. Kauffman noted Plaintiff was “[p]ositive for depression”, and was “nervous/anxious and ha[d] insomnia.” Id. She was, however, noted to have a normal mood and affect. (Tr. 243). Dr. Kauffman prescribed Elavil. (Tr. 240-41). She called two weeks later, requesting a refill of Doxepin, and stating the Elavil was not helping with sleep. Id. The following day, Plaintiff called back, stating the prescribed Doxepin dose was too strong. (Tr. 240). Dr. Kauffman's office also recommended Plaintiff “set up an intake time with behavioral health”. Id.

         Also in January 2014, Plaintiff began treatment with Jane Harris, L.I.S.W. (Tr. 287). Plaintiff reported suffering from Tourette's since age 12, anxiety, depression, and OCD. Id. She reported symptoms of aggressive behavior, agitation/irritability, crying spells, distressed mood, distractibility, hypervigilance, general anxiety, hyperactivity, impaired memory, lack of interest in activities, low energy, nightmares, obsessions/compulsions, paranoia, phobias, poor concentration, poor impulse control, racing thoughts, sleep disturbances, and thoughts of death. (Tr. 287-93). Plaintiff reported previously taking several medications for her mental health problems, but had discontinued several due to ineffectiveness or side effects. (Tr. 296-304). She was currently taking Doxepin for sleep and depression (though it made her sleepy during the day) (Tr. 297), Klonopin for anxiety, and Lamictal for depression (Tr. 299). Ms. Harris noted Plaintiff had trouble concentrating, and was “not prepared to spend the time required”, but “was cooperative and engaged.” (Tr. 313). Ms. Harris noted Plaintiff yawned throughout the session, and had facial tics. Id. Plaintiff failed to attend two sessions in February, and cancelled one. (Tr. 314-16).

         Plaintiff saw Ms. Harris three times in March 2014. (Tr. 318-20). Plaintiff reported anxiety and depression increasing after the death of a family member, and Ms. Harris noted Plaintiff was doing “[w]orse.” (Tr. 318). Ms. Harris noted Plaintiff reported medication compliance, but “then admitted she was partially med compliant off and on.” Id. Ms. Harris encouraged Plaintiff to address her diet, medication compliance, and caffeine and nicotine intake. (Tr. 320). In April 2014, Plaintiff saw Ms. Harris to discuss anxiety and ...

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