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Wray v. Berryhill

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

January 10, 2018

TRINA WRAY, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          PATRICIA A. GAUGHAN JUDGE

          REPORT AND RECOMMENDATION

          JONATHAN D. GREEUBERG UNITED STATES MAGISTRATE JUDGE

         Plaintiff, Trina Wray, (“Plaintiff” or “Wray”), challenges the final decision of Defendant, Nancy A. Berryhill, [1] Acting Commissioner of Social Security (“Commissioner”), denying her applications for Period of Disability (“POD”), Disability Insurance Benefits (“DIB”), and Supplemental Security Income (“SSI”) under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 416(i), 423, 1381 et seq. (“Act”). This Court has jurisdiction pursuant to 42 U.S.C. § 405(g). This case is before the undersigned United States Magistrate Judge pursuant to an automatic referral under Local Rule 72.2(b) for a Report and Recommendation. For the reasons set forth below, the Magistrate Judge recommends that the Commissioner's final decision be AFFIRMED.

         I. PROCEDURAL HISTORY

         In March 2013 and April 2013, Wray filed applications for POD, DIB, and SSI, alleging a disability onset date of September 11, 2012 and claiming she was disabled due to chronic pancreatitis, a congenital heart defect, depression, anxiety neurosis, and high blood pressure. (Transcript (“Tr.”) 287, 289, 360.) The applications were denied initially and upon reconsideration, and Wray requested a hearing before an administrative law judge (“ALJ”). (Tr. 196, 200, 205, 208, 212.)

         On July 1, 2015, an ALJ held a hearing, during which Wray, represented by counsel, testified.[2] (Tr. 37-61.) A supplemental hearing was held on October 6, 2015, during which Wray and a VE testified. (Tr. 62-126.) On January 27, 2016, the ALJ issued a written decision finding Wray was not disabled. (Tr. 17-36.) The ALJ's decision became final on February 10, 2017, when the Appeals Council declined further review. (Tr. 1.)

         On March 21, 2017, Wray filed her Complaint to challenge the Commissioner's final decision. (Doc. No. 1.) The parties have completed briefing in this case. (Doc. Nos. 12 & 13.) Wray asserts the following assignments of error:

(1) The ALJ failed to fully consider and give appropriate weight to the opinion of Social Security's consultative psychological examiner, resulting in a mental residual functional capacity assessment that is not supported by substantial evidence.
(2) The ALJ failed to use appropriate standards in the evaluation of Ms. Wray's episodic impairment, necessitating remand to evaluate her intermittent medical limitations and their impact upon sustained work activity.

(Doc. No. 12.)

         II. EVIDENCE

         A. Personal and Vocational Evidence

         Wray was born in January 1973 and was 42 years-old at the time of her administrative hearing, making her a “younger” person under social security regulations. (Tr. 30.) See 20 C.F.R. §§ 404.1563(c) & 416.963(c). She has a high school education and is able to communicate in English. (Id.) She has past relevant work as a receptionist, administrative assistant, collections clerk, and flight attendant. (Tr. 29.)

         B. Medical Evidence[3]

         On April 20, 2012, [4] Wray underwent a celiac plexus block procedure for her chronic pancreatitis. (Tr. 532.) Endosonographic imaging taken during the procedure revealed sonographic changes suggestive of moderate to severe chronic pancreatitis. (Tr. 533.)

         Wray thereafter presented to the emergency room on April 29, 2012, reporting epigastric pain and vomiting. (Tr. 559.) Wray was in moderate distress and had tenderness in her abdomen upon examination. (Tr. 560.) She was admitted to the hospital for symptom control. (Tr. 561.) The hospital physicians assessed Wray as having “acute on chronic pancreatitis” and she was discharged the next day. (Id.)

         Wray visited the emergency room again on May 3, 2012, after intentionally overdosing on Tylenol PM and ultram. (Tr. 417, 425, 436.) She denied suicidal ideation, and explained she was attempting to obtain “peace from all of this pain.” (Tr. 436.) The emergency room physicians noted she had been on Paxil in the past, but was not currently following with any psychiatrist. (Tr. 437.) She reported feeling overwhelmed, and she exhibited poor insight and judgment. (Id.) She denied any death wishes, and made good eye contact. (Id.) The emergency room physicians determined she did not require inpatient care, and referred her for outpatient treatment. (Id.)

         Wray returned to the emergency room on May 30, 2012 for abdominal pain and constipation. (Tr. 429.) Her symptoms improved while in the emergency room, and she was discharged with antibiotics for a urinary tract infection. (Tr. 430.)

         On June 6, 2012, Wray visited Sumit Katyal, M.D., a pain management physician, for evaluation of her abdominal pain. (Tr. 571.) She indicated she had suffered from abdominal pain for the past four years. (Id.) She described her symptoms as worsening, and relayed she was on several pain medications. (Id.) On examination, Wray had a normal gait, and her joint range of motion was full and pain free in all four extremities. (Tr. 575.) Dr. Katyal recommended a bilateral celiac plexus block, which Wray subsequently underwent on June 15, 2012. (Tr. 575, 578.)

         Wray returned to Dr. Katyal for another celiac plexus block on July 17, 2012. (Tr. 582.) She indicated she had 25% pain relief following her last procedure. (Id.) She underwent a third celiac plexus block on August 14, 2012. (Tr. 586.) She reported 25-50% pain relief following her second block, and also indicated she had no additional “pain attacks.” (Id.)

         Wray was then hospitalized from September 11 - 14, 2012 for “acute on chronic pancreatitis.” (Tr. 483.) She reported abdominal pain, nausea, and vomiting. (Id.) During her hospital stay, her pain medications were adjusted and she was placed on a special diet. (Tr. 484.) At the time of discharge, her pain had improved and she was able to tolerate a regular diet. (Id.)

         On October 2, 2012, Wray returned to Dr. Katyal. (Tr. 455.) She indicated her abdominal pain had improved about 50% since her last visit. (Id.) Dr. Katyal also noted she “has not required any hospital visits since the block for acute pain ‘episodes, ' which is a significant change for her.” (Id.) She reported appetite loss, nausea, and vomiting, and a 10-15 pound weight loss. (Id.) Dr. Katyal noted Wray had fewer acute pain episodes, but still was experiencing baseline pain and daily Percocet. (Tr. 457.) Dr. Katyal adjusted Wray's pain medications, switching Percocet to Vicodin due to nausea. (Id.)

         On January 2, 2013, Wray visited Dr. Katyal's pain management practice, and treated with nurse practitioner Stacy Mathews, CNP. (Tr. 461.) Wray described her symptoms as a “sharp, stabbing pain in her mid-epigastric area, ” which “worsens during bowel movements and at night.” (Id.) She rated her pain as 9/10 and was tearful during the evaluation. (Id.) She indicated she had lost employment after missing work for hospitalizations and abdominal pain. (Id.) On examination, she was well appearing and in no acute distress. (Tr. 462.) Her abdomen was soft and tender to touch in the mid-epigastric area. (Id.) Ms. Mathews refilled Wray's medications and referred her to a Chronic Pain Rehabilitation Program (“CPRP”), for a “multifocal team approach for treating pain.” (Tr. 463.)

         Wray saw Dr. Katyal again on February 13, 2013. (Tr. 465.) She indicated her pain had been stable, but sharp and stabbing in nature. (Id.) She rated her pain as 3-4/10. (Id.) On examination, she was well appearing and in no acute distress. (Tr. 466.) Her abdomen was soft and tender to touch in the mid-epigastric area. (Id.) Dr. Katyal noted Wray's pancreatitis was “well controlled after proceeding with bilateral celiac plexus block last year.” (Id.) Wray indicated her “opiate regimen is controlling pain well, ” and requested another celiac block for her symptoms. (Id.) On March 5, 2013, Wray underwent another bilateral celiac plexus block. (Tr. 471.) At that time, Dr. Kaytal noted Wray had “obtained 75% relief. . . for months” after her last procedure. (Id.)

         On May 10, 2013, Wray visited Walter Clark, M.D., a primary care doctor at Northeast Ohio Neighborhood Health Service (“NEON”). (Tr. 624.) Dr. Clark checked her blood pressure and treated her for a urinary tract infection. (Id.) Wray reported she had been experiencing insomnia and depression, which was improved with Paxil. (Id.) Dr. Clark refilled Wray's medications, and also prescribed her Trazadone for insomnia. (Tr. 626.)

         On July 29, 2013, Wray visited Connections for a mental health diagnostic assessment with Michelle Javorek, PCC-S. (Tr. 654, 663.) Wray indicated increased depression over losing jobs due to her medical problems. (Tr. 654.) She relayed she was currently in the midst of a divorce. (Id.) She reported volunteering “a lot for the county or planning events.” (Id.) She indicated she enjoyed volunteering, but did not “like the pressures of deadlines.” (Id.) She also reported she often read the bible, and had recently started a bible study group in her apartment building. (Id.)

         During the assessment, Wray denied any consistent mental health treatment, but reported a suicide attempt in April 2012. (Tr. 656.) She indicated she was currently taking Zoloft and Paxil. (Id.) Wray reported she had trouble concentrating, which interfered with her volunteer work. (Tr. 658.) She also indicated trouble controlling her emotions, poor sleep, depression, and worry. (Id.) She denied suicidal ideation. (Id.) Wray described weekly episodes where she would have increased energy, as well as anger issues stemming from childhood sexual abuse. (Tr. 654, 659.)

         Ms. Javorek diagnosed Wray with major depressive disorder, recurrent, moderate; generalized anxiety disorder; and alcohol abuse unspecified. (Tr. 661.) She assessed a Global Assessment of Functioning (“GAF”)[5] score of 41, indicating serious symptoms. (Id.) Ms. Javorek referred Wray for a psychiatric evaluation. (Id.)

         On October 8, 2013, Wray visited Dr. Carl Robson, M.D., a primary care doctor at NEON. (Tr. 715.) She indicated her current dosage of Oxycodone was not “quite enough” to control her abdominal pain. (Id.) Wray's physical examination was overall normal, though she did exhibit abdominal tenderness. (Tr. 716, 717.) Dr. Robson ordered labwork and prescribed Wray a two-month supply of pain medications. (Tr. 717.) He also renewed her Paxil and Trazodone prescriptions. (Id.)

         Wray returned to Dr. Katyal on October 21, 2013, indicating her pain had worsened since her last visit. (Tr. 670.) Dr. Katyal recommended another celiac plexus block, “as it has been over 6 months and she states she does get greater than 75% benefit for a few months with the procedure.” (Tr. 672.) Wray subsequently underwent a bilateral celiac plexus block on October 22, 2013. (Tr. 676.)

         On November 5, 2013, Wray visited the emergency room with a headache. (Tr. 680.) She indicated she took Percocet for the pain, which made the headache worse. (Id.) She admitted she also drank some wine earlier in the day. (Id.) On examination, she was anxious and tearful. (Tr. 682.) The emergency room physicians ordered a head CT and administered IV fluids. (Id.) Her head CT was normal, with no evidence of an acute intracranial process. (Tr. 706.)

         Wray returned to Dr. Robson at NEON on February 24, 2014. (Tr. 722.) She indicated she had a flare of pancreatitis over the holidays, and resumed Oxycodone in January due to painful pancreatitis. (Id.) Her pancreatitis was “now improved.” (Id.) Dr. Robson refilled Wray's medications, including Prozac, Trazodone, Pancrelipase, blood pressure medication, and Oxycodone. (Tr. 724.)

         On March 11, 2014, Wray had a chronic pain management evaluation with physician assistant Carrie Knaus, PA-C. (Tr. 684.) She indicated her pain had been gradually worsening, though her recent celiac plexus block provided 50% pain relief for about three months. (Id.) She indicated she was having intermittent episodes of sharp, stabbing pain. (Id.) Ms. Knaus noted Wray “used to have blocks monthly which gave her better and longer pain control.” (Id.) Wray requested a functional capacity evaluation for her disability application. (Id.) Ms. Knaus then scheduled Wray for another bilateral celiac plexus block and a functional capacity evaluation. (Tr. 686.) Wray underwent a bilateral celiac plexus block on March 18, 2014. (Tr. 689.)

         On March 28, 2014, Wray visited Dr. Roberto D. Chang, M.D., at the Cleveland Clinic's Pain Management Center for an evaluation. (Tr. 696.) Dr. Daniel J. Leizman was the attending physician overseeing the evaluation. (Tr. 700.) Dr. Chang noted Wray had been receiving periodic celiac plexus blocks, which provided “excellent relief” for 2-3 months at a time. (Tr. 696.) Wray indicated her pain would worsen in intensity and frequency after a few months, and she would need another block. (Id.)

         On examination, Wray had a normal gait, and her upper and lower extremity strength was normal and symmetric. (Tr. 699.) She had mild tenderness to palpitation in her epigastric supraumbilical substernal area. (Id.) Dr. Chang concluded Wray “is capable of performing light duty type work. She may perform light duty type work, though intermittent absence of work may be required due to ongoing medical treatment in the future.” (Tr. 700.)

         Dr. Robson, Wray's primary care doctor at NEON, provided a letter regarding Wray on April 24, 2014. (Tr. 708.) The letter provided:

Trina Wray is currently under my medical care for several medical problems: high blood pressure, chronic pancreatitis, and anxiety neurosis. She requires ongoing medications, which maintain medical stability.

(Id.)

         Wray returned to Dr. Robson on June 27, 2014. (Tr. 726.) She indicated she had been abstinent from alcohol, and was doing well on her medications. (Id.) She indicated she did not always need her pain medications, but she did continue to have daily epigastric pain, with varying intensity. (Id.) She relayed she was taking her pancreatic enzymes regularly to prevent diarrhea. (Id.)

         Wray saw Dr. Robson again on August 18, 2014. She denied drinking alcohol. (Tr. 730.) She indicated she still had nausea and vomiting, despite taking her pancreatic enzymes. (Id.) She returned to Dr. Robson on November 5, 2014, again reporting abstinence from alcohol. (Tr. 734.) Wray also indicated her Prozac and Trazadone was helpful for her depression. (Id.)

         On January 29, 2015, Wray reported to Dr. Robson she was having pain with eating, and felt it was time for another nerve block. (Tr. 738.) She had mild upper abdominal tenderness on examination. (Tr. 739.) Dr. Robson prescribed her Oxycodone and Ensure. (Id.) He also renewed her Prozac prescription. (Tr. 740.)

         Wray returned to Dr. Robson on May 18, 2015, and indicated she had not consumed any alcohol for about a year. (Tr. 741.) She continued to take her pancreatic enzymes, but she was still having chronic epigastric pain. (Id.) She reported her Oxycodone was helpful. (Id.) Her physical examination was overall normal, beyond some upper abdominal tenderness. (Tr. 743.) Dr. Robson renewed Wray's Oxycodone, Ensure, pancreatic enzymes, and Prozac. (Tr. 743, 744.)

         C. State Agency Reports

         1. Mental Impairments

         On October 18, 2011, Wray underwent a consultative psychological examination with David V. House, Ph.D. (Tr. 408-413.) This examination was in connection with a prior application for disability. Wray reported depression and anxiety, and indicated she received counseling back in 2004 or 2005. She indicated her current mental health treatment consisted of medications from her primary care doctor, Dr. Robson. (Tr. 409.) She reported crying spells, a suicide attempt at the age of 19, thoughts of death, mood swings, and insomnia. (Tr. 410.) Dr. House characterized her as “generally talkative” and “somewhat circumstantial.” (Id.) During the examination, Wray did not demonstrate any significant long-term memory deficits, and she was able to perform a serial seven subtraction task. (Tr. 411.)

         Dr. House diagnosed Wray with Depressive Disorder, not otherwise specified, and Post Traumatic Stress Disorder. (Tr. 413.) He assessed a GAF score of 51, indicating moderate symptoms. (Id.) With regard to Wray's functional capabilities, Dr. House made the following conclusions:

1. Describe the claimant's abilities and limitations in understanding and remembering to carry out instructions: She does not demonstrate any significant deficits in either lone[sic] or short-term memory.
2. Describe the claimant's abilities and limitations in maintaining attention and concentration and maintaining persistence and pace to perform simple tasks and to perform multi-step tasks: Her ability to concentrate and attend to task[sic] appears to be fairly stable and broadly within normal limits.
3. Describe the claimant's abilities and limitations in responding appropriately to supervision and to coworkers in a work setting: She seems capable of conducting appropriate adequate relationships. She does not describe the people she hangs out with as friends, but as associates, but it appears that she has no issues to any significant degree of obstructionism or difficulties with authority figures or other employees or coworkers.
4. Describe the claimant's abilities and limitations in appropriately responding to work pressures in a work setting: Her emotional resources are reduced to some degree, but she will continue to maintain some capability for coping. The examiner does not believe at the current levels of stress that she would have any major difficulties or be especially dysfunctional or disruptive.

(Tr. 412.)

         On May 7, 2013, Wray underwent another consultative psychological examination with David V. House, Ph.D. (Tr. 629-635.) At the outset, Dr. House noted he had seen her in 2011, and she was an “adequate historian” at that time. (Tr. 629.) He found her to be a “poor historian, ” however, for this examination. (Id.) Wray denied a current problematic use of drugs, but Dr. House felt she tended to “bypass her alcohol use to some degree.” (Tr. 630.) Wray reported a suicide attempt in 2012, but denied any counseling. (Tr. 631.) She indicated she took Paxil, Zolpidem, and Lorazepam. (Id.)

         During the examination, Dr. House noted Wray was “quite circumstantial in manner, but also somewhat hysteroid, labile and tearful. It appears she is quite impulsive, especially regarding use of alcohol.” (Id.) Wray described poor sleep, nightmares, poor appetite, and daily crying. (Tr. 632.) Wray also described monthly panic attacks, as well as flashbacks to past abuse. (Id.) Dr. House felt Wray's mood was “quite disturbed” as she was “crying throughout.” (Id.) Dr. House also noted mood swings during the evaluation. (Id.)

         Wray also described hearing voices on occasion, but denied any visual hallucinations. (Tr. 633.) Dr. House did not think Wray appeared psychotic, but did note she “appear[ed] to be at a lower level of functioning than she was in 2011.” (Id.) Wray's pace was fair, she was able to perform a serial seven subtraction task, and her long and short term memory were intact. (Id.) Dr. House did note “in terms of concentration and attention, her ability to present her narrative was somewhat inconsistent, primarily due to crying.” (Id.)

         Dr. House diagnosed Wray with Mood Disorder, not otherwise specified, Post Traumatic Stress Disorder, and Alcohol Abuse. He noted there was not enough information to “advance a diagnosis of Personality Disorder Not Otherwise Specified, generally either with hysteroid or narcissistic features.” (Tr. 634.) He assessed a GAF score of 41, indicating serious symptoms. (Tr. 635.) With regard to Wray's functional capabilities, Dr. House made the following conclusions:

1. Describe the claimant's abilities and limitations in understanding and remembering to carry out instructions: Memory function remains intact, both long term and short term. She should be able to follow instructions.
2. Describe the claimant's abilities and limitations in maintaining attention and concentration and maintaining persistence and pace to perform simple tasks and to perform multi-step tasks: At least for the most part, concentration and attention are at least broadly intact and, generally, she should be able to follow multi-step directions. There are times when she is a bit more emotional which may interfere with her concentration, but these interruptions appear to be episodic.
3. Describe the claimant's abilities and limitations in responding appropriately to supervision and to coworkers in a work setting: She seems rather socially isolated and does not seem to trust other people to a great degree. That she has had difficulty interacting with supervisors in the past is not clear. Her work history is, at least in a relatively high level as far as what types of jobs she has done, including use of computers, but her persistence on those jobs does not appear to be consistent.
4. Describe the claimant's abilities and limitations in appropriately responding to work pressures in a work setting: She is having more difficulties dealing with stress at this time than she was two years ago. The evaluator would believe that, given her emotional responses currently, she would have a great deal of difficulty responding effectively to increased stress in the workplace. She would likely be ineffective and dysfunctional.

(Tr. 634.)

         On June 18, 2013, state agency physician Leslie Rudy, Ph.D. reviewed Wray's medical records and completed a Psychiatric Review Technique (“PRT”). (Tr. 161.) Dr. Rudy found Wray had mild restrictions in activities of daily living; mild difficulties in maintaining social functioning; moderate difficulties in maintaining concentration, persistence, or pace; and no episodes of decompensation. (Id.) Dr. Rudy also completed a Mental Residual Functional Capacity (“RFC”) Assessment. (Tr. ...


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