United States District Court, N.D. Ohio, Eastern Division
MEMORANDUM OPINION AND ORDER
R. Knepp II United States Magistrate Judge
Culvesta Ann Pruitt (“Plaintiff”) filed a
Complaint against the Commissioner of Social Security
(“Commissioner”) seeking judicial review of the
Commissioner's decision to deny disability insurance
benefits (“DIB”) and supplemental security income
(“SSI”). (Doc. 1). The district court has
jurisdiction under 42 U.S.C. §§ 1383(c) and 405(g).
The parties consented to the undersigned's exercise of
jurisdiction in accordance with 28 U.S.C. § 636(c) and
Civil Rule 73. (Doc. 11). For the reasons stated below, the
undersigned affirms the decision of the Commissioner.
filed for DIB and SSI in December 2013, alleging a disability
onset date of April 15, 2010. (Tr. 130-31, 218-23). Her
claims were denied initially and upon reconsideration. (Tr.
104-31, 132-63). Plaintiff then requested a hearing before an
administrative law judge (“ALJ”). See
Tr. 96. Plaintiff (represented by counsel), and a vocational
expert (“VE”) testified at a hearing before the
ALJ on December 1, 2015. (Tr. 45-85). On January 27, 2016,
the ALJ found Plaintiff not disabled in a written decision.
(Tr. 29-40). The Appeals Council denied Plaintiff's
request for review, making the hearing decision the final
decision of the Commissioner. (Tr. 1-6); see 20
C.F.R. §§ 404.955, 404.981, 416.1455, 416.1481.
Plaintiff timely filed the instant action on December 6,
2016. (Doc. 1).
April 2013, Plaintiff underwent a consultative examination
with Richard Halas, M.A. (Tr. 353-57). Plaintiff reported she
had graduated from high school in “special
classes” and had maintained average grades. (Tr. 353).
Plaintiff reported a past history of drug abuse treatment,
but no mental health treatment. (Tr. 354). Mr. Halas observed
Plaintiff was cooperative, but tense and anxious.
Id. Her speech was “reasonably fluent and
articulate”. (Tr. 355). Plaintiff had a flat affect and
a depressed mood, as well as low energy levels. Id.
Mr. Halas observed Plaintiff had “some mild symptoms of
anxiety”. Id. Plaintiff reported activities of
daily living including making breakfast, cooking, cleaning,
shopping and laundry. (Tr. 356). She also reported her
children “help her when she needs it.”
Id. Mr. Halas assessed depressive disorder, not
otherwise specified, anxiety disorder, not otherwise
specified, polysubstance abuse, and borderline personality
disorder with paranoid traits and schizoid features.
Id. He assigned a Global Assessment of Functioning
(“GAF”) score of 55, indicating moderate
symptoms. (Tr. 357). For his functional assessment,
Mr. Halas noted Plaintiff would have “little or no
difficulty” in understanding, remembering, and carrying
out instructions; he noted Plaintiff was “estimated to
have low/average intellect”. Id. He also
opined Plaintiff would have “little or no
difficulty” in maintaining attention and concentration,
and maintaining persistence and pace to perform simple or
multi-step tasks. Id. He opined Plaintiff's
“[p]ersonality issues, depression, and anxiety”
were likely to cause “significant problems” in
responding appropriately to supervisors and coworkers in a
work setting. Id. She would also have “some
problems” in responding appropriately to work
September 28, 2013 through October 1, 2013, Plaintiff was
admitted to Lutheran Hospital for suicidal ideation. (Tr.
362-74). On admission, Plaintiff also reported hearing
voices. (Tr. 365). Plaintiff's discharge summary stated
her hospital course was “[u]neventful with improving
symptomology” and she was “started on Zoloft and
Seroquel.” (Tr. 362). Her “affect was markedly
improved” on discharge. Id. Her discharge
diagnosis was major depressive disorder, single episode,
severe without psychotic symptoms. (Tr. 363).
October 2013, Plaintiff started counseling at Connections.
following month, in November 2013, Plaintiff underwent an
initial psychiatric evaluation at Connections with Grace
Herwig, MSN, RN, CS, LCDC III. (Tr. 378-82). Plaintiff
reported a ten year history of auditory hallucinations, as
well as depression. (Tr. 378). Plaintiff reported hearing
voices “whispering and talking”, paranoia, and
not going outside. (Tr. 378). She had a history of physical
and verbal abuse by her father. Id. On examination,
Ms. Herwig noted Plaintiff was moderately disheveled,
severely mistrustful and withdrawn, but had average eye
contact and activity, and clear speech. (Tr. 379). She had
moderate persecutory and suicidal thoughts. Id. She
had severe auditory, and moderate visual hallucinations, but
a logical thought process. Id. Her mood was
depressed, angry, and irritable, and she had a labile affect.
Id. Her behavior was hyperactive, agitated, and
cooperative. Id. She was oriented, able to abstract,
and had moderate limitations in attention, concentration, and
memory. Id. She was estimated to have average
intelligence. Id. Ms. Herwig continued Plaintiff on
Seroquel and Zoloft. (Tr. 381).
returned to Ms. Herwig in December 2013. (Tr. 376-77). Ms.
Herwig noted Plaintiff was sleeping in the waiting room, and
that she reported thoughts of suicide and a sense of
hopelessness. (Tr. 376). Plaintiff was tearful, paranoid, and
had a depressed mood. Id. Ms. Herwig increased
Plaintiff's Seroquel dosage. Id.
January 2014, Plaintiff's daughter reported
Plaintiff's mood was “improved, with less crying
and less anger and irritability.” (Tr. 404). Plaintiff
“acknowledge[d] she [was] crying less but otherwise
seem[ed] unaware of any improvement.” Id. At
Plaintiff's next visit in February 2014, Plaintiff
reported one episode of crying for half a day. (Tr. 401).
Plaintiff's daughter reported Plaintiff was sleeping more
than twelve hours per day, and performing tasks and speaking
more slowly. Id. Plaintiff also described paranoid
March 2014, Plaintiff “look[ed] brighter” and
reported her mood had been better for the prior two weeks.
(Tr. 399). She still reported being “fearful”
around people, and worrying that people talk about or would
harm her. (Tr. 399). Plaintiff requested Abilify for her
mood, and Ms. Herwig prescribed it. (Tr. 399-400).
April 2014, Plaintiff was admitted to the hospital after
attempting suicide by overdosing on her prescribed Seroquel.
(Tr. 439-40). Plaintiff was “a little paranoid about
being in the hospital” and reported continuing, though
lessened, depression on her current medications. (Tr. 440).
She also reported “the last time she heard a voice was
in November.” Id. On examination, Plaintiff
was pleasant, interactive, oriented, with appropriate speech
and mood. (Tr. 441). Her insight was limited, judgment was
lacking, and memory was mildly impaired. Id. Her
thought form was circumstantial and evasive, and she had
auditory hallucinations, but no suicidal ideations.
Id. Plaintiff was assessed with major depressive
disorder, recurrent, severe with psychotic symptoms, rule out
bipolar disorder with psychotic symptoms. (Tr. 439). She was
continued on her medications. Id.
in April, Plaintiff reported she as doing well “in
terms of not withdrawing to her room”, attending
church, and visiting with family. (Tr. 579). Plaintiff also
told Ms. Herwig about her hospitalization. Id. Ms.
Herwig noted “Her pattern is that she takes care of
everyone and sets no limits until she is so frustrated that
she either verbally explodes or in this case impulsively
overdosed.” Id. Plaintiff agreed to counseling
and to continue her medications. Id. In May,
Plaintiff reported she “continue[d] to improve”
and was getting out of the house most days. (Tr. 577).
2014, Plaintiff began counseling with Brenda Dillane, LPCC.
(Tr. 649-50). She reported depressive symptoms with auditory
hallucinations and suicidal ideations at times. (Tr. 649).
Ms. Dillane noted Plaintiff was “pleasant, cooperative,
and engaged in [the] therapeutic process.” (Tr. 650).
She reported suicidal ideations “at times” but
was “able to overcome them with phone calls to friends,
prayer, and church attendance.” Id.
July 2014 counseling session with Ms. Dillane, Plaintiff
reported she was “not so depressed” and had been
deliberately taking actions to avoid staying in her room such
as going to the movies, and going to the park with a friend.
(Tr. 641). Later that month, she reported to Ms. Herwig that
she believed medications and counseling were helping her.
(Tr. 575). Plaintiff was “out of her room more, out of
doors in her yard”; she was crying less, but still
fairly often. Id. Ms. Herwig increased
Plaintiff's Abilify dosage. Id.
August 2014 counseling session, Plaintiff reported: “I
think if it weren't for you and my kids, I woulda done
taken my life . . . now I just turned it around, changed my
thoughts.” (Tr. 634). Plaintiff was also “[v]ery
pleased with her ability to take bus and her literacy
September 2014, Plaintiff reported mood improvement with
Abilify, but weight gain. (Tr. 573). She had also had a
recurrence of hearing voices and seeing someone in her room
at night. Id. Ms. Herwig increased Plaintiff's
Seroquel dosage, and instructed her to take Abilify before
bedtime to help with weight gain. (Tr. 573-74). At a
counseling session that month, Ms. Dillane noted Plaintiff
was able to acknowledge her significant progress in the past
year. (Tr. 630).
October, Plaintiff reported increased depression over the
past five days with an increase in suicidal thoughts. (Tr.
570). She also reported her auditory hallucinations
“are down to a whisper but they do speak about
suicide.” Id. She continued to report spending
more time with her family than she had in the past, and was
able to take the bus to her appointment. Id. Ms.
Herwig increased Plaintiff's Abilify dosage. (Tr.
November, Plaintiff reported “she felt better within a
few days of increasing the dosage of [A]bilify” and her
mood was “much improved.” (Tr. 568). She
continued to hear whispers, and her children said she talked
to herself. Id. Ms. Herwig increased Plaintiff's
Seroquel dosage. (Tr. 568-69).
February 2015 counseling session, Plaintiff reported her
medications “seem[ed] like they're working
better”. (Tr. 613). She still heard voices, but
“they are really low and [she could] talk over
them.” Id. Plaintiff also reported fewer bouts
of tearfulness. Id. Plaintiff's mother had
praised her for taking the bus by herself; Plaintiff was
excited about the prospect of living alone and looking
forward to working in the garden. Id.
March 2015, Plaintiff reported continued improvement to Ms.
Herwig. (Tr. 566). She had taken the bus alone, and was still
hearing whispering, “but it is very low”.
Id. She believed her family was talking about her,
but her mother reassured her they were not, and she was
“trying to learn to ignore this”. Id.
Plaintiff was still experiencing weight gain as a side
effect, but she was working to buy more healthy foods and her
daughter was taking her to exercise because she wished to
stay on her current medications. Id. At a March 2015
session with a different provider, Plaintiff reported she was
“currently going to community college and loves to
cook.” (Tr. 651).
2015, Plaintiff requested to change her medication to Abilify
Maintaina because she was living alone, and had missed doses.
(Tr. 564). Ms. Herwig noted Plaintiff's “thinking
seem[ed] clear and organized” but that “she
seem[ed] to need supervision to fulfill basic
responsibilities of self care.” Id. Ms. Herwig
prescribed Abilify Maintaina. (Tr. 565). At a counseling
session the same day, Plaintiff reported attending college
and that it was “going ok”. (Tr. 604). She was
“getting help for math at the culture center and
culinary classes”, and planned to start cooking the
following month. Id. Plaintiff reported some stress
from family moving away, but that her classes were
“going well”, and that she had been volunteering
at the library. Id.
counseling session in June 2015, Ms. Dillane noted
Plaintiff's mood “appeared bright” and she
was alert and oriented. (Tr. 601). She was no longer
attending reading at the library, but was still visiting.
Id. She also went to the culture center Mondays and
Wednesdays for math, language, and reading, and had culinary
classes on Tuesday, Thursday, and Friday. Id. Ms.
Dillane noted Plaintiff was “pleasant, cooperative, and
engaged in [the] therapeutic process” as well as
reported benefits from medications. Id.
2015, Ms. Dillane noted progress made toward Plaintiff's
goals and objectives. (Tr. 680). Ms. Dillane observed
Plaintiff was alert and oriented and her mood was stable.
Id. Plaintiff was continuing to “get help with
reading” and taking culinary classes. Id.
Notes from that same month with a different provider indicate
Plaintiff was “friendly and actively participated in
discussion” and denied hallucinations. (Tr. 670);
see also Tr. 672 (“alert and friendly”).
August 2015, Plaintiff reported improvement, stating she was
“fine”. (Tr. 698). She was “uneasy”
about a plan to live independently, but described her plan to
live within walking distance of her daughter. (Tr. 698). She
reported her auditory hallucinations were down to a whisper,
and her mood was good. Id. At an appointment with a
different provider in August 2015, Plaintiff was observed to
be “alert and friendly”, “actively
participated in discussion” and denied hallucinations.
(Tr. 674-75, 676-77). Later in August 2015, Ms. Dillane
observed Plaintiff was “pleasant, cooperative, and
engaged the therapeutic process”, alert and oriented,
with a stable appearing mood. (Tr. 686). She was similarly
alert and oriented with a stable, but “subdued mood,
which she attributed to very poor sleep” toward the end
of the month. (Tr. 688). Plaintiff noted she “realized
she did not take her meds” the night before.
September 2015, Ms. Dillane again noted Plaintiff was alert
and oriented, and her mood was stable. (Tr. 690). That same
day, Plaintiff again “actively participated in
discussion” with another provider; she was “alert
and attentive” and denied hallucinations. (Tr. 678).
Plaintiff “admit[ted] to having stressors, however,
report[ed] that overall she fe[lt] stable.”
saw Ms. Dillane three times in October 2015. (Tr. 692-97). At
each visit, Plaintiff was alert and oriented, with a stable,
or improved, mood. (Tr. 692, 694, 696). Plaintiff was
“pleasant, cooperative, and engaged in the therapeutic
process.” (Tr. 696).
January 2014, Robyn Hoffman, Ph.D., reviewed Plaintiff's
records at the request of the state agency. (Tr. 111-14;
125-27). She opined Plaintiff was moderately limited in the
ability to understand, remember, and carry out detailed
instructions, as well as maintain attention and concentration
for extended periods, noting that she “appear[ed]
capable of simple 1-3 step tasks which do not involve timed
or speeded activities or large production quantities.”
(Tr. 112, 125). She also opined Plaintiff “appear[ed]
capable of work in an environment w/ only limited superficial
interaction w/ coworkers, supervisors, and the general
public.” (Tr. 113, 126).
February 2014, Ms. Herwig completed a Mental Impairment
Questionnaire. (Tr. 390-93). She noted she had seen Plaintiff
monthly for three months and had assessed major depressive
disorder, severe, and rule out schizoaffective disorder. (Tr.
390). She noted Plaintiff had a “[p]artial response to
treatment so far”. Id. With regard to
understanding and memory limitations, Ms. Herwig opined
Plaintiff was seriously limited, but not precluded from
understanding and remembering short and simple instructions,
but would be unable to meet competitive standards in
remembering locations and work procedures, or detailed
instructions. (Tr. 391). With regard to concentration and
persistence limitations, she opined Plaintiff was unable to
meet competitive standards, or had no useful ability to
function in every category except making “simple
work-related decisions” (for which she found Plaintiff
was seriously limited, but not precluded). Id. With
regard to social interaction, Ms. Herwig opined Plaintiff had
a limited but satisfactory ability to ask simple questions,
or accept instructions and respond appropriately to criticism
from supervisors, but would be unable to interact with the
general public, and unable to meet competitive standards in
getting along with coworkers or peers. (Tr. 392). She also
assessed severe adaptation limitations. Id. Ms
Herwig opined Plaintiff did not have a low IQ or reduced
intellectual functioning. Id. She further opined
Plaintiff would miss more than four days of work per month,
and would be off-task 25% or more of a work day. (Tr. 393).
April 2014, state agency reviewing psychologist Katherine
Fernandez, Psy.D., reviewed Plaintiff's records and
affirmed Dr. Hoffman's conclusions. (Tr. 142-44, 157-59).
Dr. Fernandez noted specifically: “With med adjustments
and ongoing care, she is doing better. Per 4/14 note, mood is
better, she is crying less, seems brighter. The initial level
MRFC is affirmed.” (Tr. 144, 159).
2015, Ms. Herwig completed a second Mental Impairment
Questionnaire. (Tr. 489-90). She again opined Plaintiff had
no useful ability to function or was unable to meet
competitive standards in most listed categories regarding
concentration, social interaction, and adaptation.
Id. the clinical findings in support of her opinion
were: “tiredness, forgetfulness, continues to get
auditory hallucinations that client tries to ignore, poor
concentration.” (Tr. 489).
July 2015, Ms. Dillane completed a Mental Impairment
Questionnaire. (Tr. 487-88). She noted she had seen Plaintiff
approximately twice per month beginning in June 2014. (Tr.
487). She noted Plaintiff's condition was chronic,
Plaintiff was “forgetful” and that
“auditory hallucinations continue despite psychotropic
medications.” Id. She opined Plaintiff had no
useful ability to function, or was unable to meet competitive
standards, in every area of sustained concentration or
persistence limitations. Id. Plaintiff was seriously
limited but not precluded from remembering locations and
work-like procedures, but unable to meet competitive
standards in the ability to understand and member short and
simple instructions, and had no useful ability to function in
understanding and remembering detailed instructions. (Tr.
488). She also found Plaintiff was unable to meet competitive
standards or had no ability to function in adaptation
limitations. Id. Ms. Dillane opined Plaintiff would
be absent form work three days per week, and be off task for
40 to 80 percent of a workday. Id.
Background and Testimony
was born in June 1961, making her 48 years old on her alleged