Pruitt v. Commissioner of Social Security

          MEMORANDUM OPINION AND ORDER

          James R. Knepp II United States Magistrate Judge

         Introduction

         Plaintiff 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.

         Procedural Background

         Plaintiff 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).

         Factual Background

         Relevant Medical Evidence^[1]

         In 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.^[2] (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 pressures. Id.

         From 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).

         In October 2013, Plaintiff started counseling at Connections. (Tr. 666-67).

         The 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).

         Plaintiff 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.

         In 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 thoughts. Id.

         In 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).

         In 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.

         Later 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).

         In June 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.

         In a 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.

         In an 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 classes.” Id.

         In 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).

         In 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. 570-71).

         In 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).

         At a 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.

         In 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).

         In May 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.

         At a 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.

         In July 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”).

         In 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. Id.

         In 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.” Id.

         Plaintiff 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).

         Opinion Evidence

         In 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).

         In 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).

         In 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).

         In July 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).

         Also in 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.

         Personal Background and Testimony

         Plaintiff was born in June 1961, making her 48 years old on her alleged ...