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Rogers v. Commissioner of Social Security

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

April 24, 2018




         Plaintiff Billie Rogers (“Rogers”) seeks judicial review of the final decision of Defendant Commissioner of Social Security (“Commissioner”) denying her application for Disability Insurance Benefits (“DIB”). Doc. 1. This Court has jurisdiction pursuant to 42 U.S.C. § 405(g). This case is before the undersigned Magistrate Judge pursuant to the consent of the parties. Doc. 13.

         As set forth more fully below, the Administrative Law Judge (“ALJ”) did not sufficiently explain his reasons for concluding that Rogers' statements concerning her symptoms were not fully credible. Thus, the Court cannot ascertain whether substantial evidence supports the ALJ's credibility determination or his evaluation of the opinion evidence because the ALJ relied, in part, on his credibility determination when evaluating the opinion evidence. For the reasons stated below, the decision of the Commissioner is REVERSED and REMANDED for further proceedings consistent with this opinion.

         I. Procedural History

         Rogers protectively filed her application for DIB on August 30, 2014, alleging a disability onset date of March 4, 2014. Tr. 12, 143. She alleged disability based on the following: post-traumatic stress disorder, anxiety, severe mood swings, and depression. Tr. 191. After denials by the state agency initially (Tr. 77) and on reconsideration (Tr. 87), Rogers requested an administrative hearing (Tr. 101), and to amend her onset date to August 30, 2014 (Tr. 164). A hearing was held before Administrative Law Judge (“ALJ”) Charles Shinn on June 2, 2016. Tr. 27-63. In his June 17, 2016, decision (Tr. 12-22), the ALJ determined that there are jobs that exist in significant numbers in the national economy that Rogers can perform, i.e. she is not disabled. Tr. 21. Rogers requested review of the ALJ's decision by the Appeals Council (Tr. 140) and, on May 11, 2017, the Appeals Council denied review, making the ALJ's decision the final decision of the Commissioner. Tr. 1-4.

         II. Evidence

         A. Personal and Vocational Evidence

         Rogers was born in 1969 and was 44 years old on the date her application was filed. Tr. 28. She graduated from high school and last worked in August 2014 as a latex inspector/packer. Tr. 33, 36-37.

         B. Relevant Medical Evidence

         On August 4, 2014, Rogers saw nurse practitioner Judith Corcelli at Portage Path Behavioral Health for medication management and mood/behavior problems. Tr. 280-281. She requested a different anxiety medication because the previous medication had caused headaches. Tr. 280. Her Prazosin helped her sleep through the night and she wasn't having nightmares. Tr. 280. She was still working. Tr. 280. Upon exam, her activity was average, she was adequately groomed, had average eye contact, clear speech, a constricted/blunted affect, cooperative behavior, a depressed mood, fair judgment and insight, and logical thoughts. Tr. 280. Corcelli adjusted Roger's medications and recommended a follow-up appointment in 10 to 12 weeks. Tr. 281.

         At her next visit with Corcelli on October 17, 2014, Rogers reported that she was taking her medications as prescribed and that they were helping and she had less problems with anger, although the medications were not lasting all day. Tr. 276. She stated that when things aggravate her she is now more easily able to let them go. Tr. 276. She was still having problems with anxiety, anger, and nightmares and reported breaking out in hives when she saw the consultative examiner in connection with her disability application. Tr. 276. She had to wait two hours for the doctor and it was too much for her. Tr. 276. She reported panic attacks a couple of times a month that made her feel like she was having a heart attack. Tr. 276. She was fired from her job due to attitude problems. Tr. 276. She rated her anxiety and depression 8/10 and stated that she does not want to leave the house. Tr. 276. Her mental exam findings were the same as her prior visit, although her mood was also irritable. Tr. 276. After seeing Corcelli, Rogers saw licensed social worker Cynthia Ball, M.S. Tr. 278. Rogers explained that she was fired because she threatened her boss after he got in her face “again” and had gotten very angry when work changed her shift time by a half an hour, stating, “I don't like change.” Tr. 278. She has problems keeping jobs due to her refusal to let people talk to her “like that.” Tr. 278. The day after she was fired her friend was also fired for standing up for herself when the supervisor got nasty. Tr. 278. Her co-workers told her that she is too angry and she agrees. Tr. 278. She is angry with her husband, who, now that she is unemployed, expects her to wait on him. Tr. 278. She is pretty happy until someone “pisses her off, ” which is very easy to do. Tr. 278. She is “always on the edge of being angry” and she does not like to be around many people because she is afraid someone will do something to make her angry. Tr. 278. Her attitude has gotten worse since her grandmother died 15 months ago and her kids moved out of state. Tr. 278. She gets mad at other drivers and she feels like other people are always doing things to make her mad. Tr. 278. Upon exam, Rogers was angry, anxious, and depressed with a dichotomous thought process; her other findings were unchanged. Tr. 278. Ball suggested that Rogers' anger would be “a normal response to a lot that has happened to her.” Tr. 278.

         On November 11, 2014, Rogers reported to Ball that her increase in Zoloft had been helpful and that she could “see that a lot of things are not as bad as she would have once thought.” Tr. 274. She was sleeping less and had more interest in performing her daily activities. Tr. 274. Her main stressor that day was that her cat might be pregnant, although her veterinarian had previously stated that her cat could not get pregnant; she planned to take her cat to the veterinarian for a correct diagnosis. Tr. 274. Her mental status exam findings were unchanged. Tr. 274. Ball joined Rogers in “chuckling about the ‘miracle kittens' that she may have when she comes in next time.” Tr. 274.

         On December 4, 2014, Rogers saw Corcelli for medication management. Tr. 271-271. Her nightmares were improving and she was still depressed, did not want to go anywhere, was “very edgy” and irritable. Tr. 271. She experienced stress from visits from family and friends, including children, who had visited her and she noted that her house was not baby-proof. Tr. 271. Her cat had had kittens. Tr. 271. She reported having a little more energy during the day but stated that she was not getting continued improvement with irritability. Tr. 271. Upon exam, she had a full affect, cooperative behavior, an anxious mood, fair insight and judgment and a logical thought process. Tr. 271. Corcelli adjusted her medication. Tr. 272.

         On December 9, 2014, Rogers saw Ball, reporting an “ok” Thanksgiving holiday until her mother-in-law dropped by and started making “critical remarks.” Tr. 269. Rogers allowed that her mother-in-law's behavior had gotten worse since a severe head injury and that she did not know whether that was the cause of her behavior. Tr. 269. Ball discussed reasonable expectations regarding Roger's mother-in-law's behavior and reminded her that she had the ability to choose how much time she spent thinking about it. Tr. 269. Upon exam, her mood was angry and her thought process was dichotomous. Tr. 269.

         On January 14, 2015, Rogers saw Ball and reported that she had found homes for all the kittens. Tr. 306. Her son and his girlfriend had moved back from West Virginia and into her home and were looking for work. Tr. 306. Her husband continued to annoy her despite her requesting he stop; this caused her to break out in hives and she had threatened to punch him, but knows that she would get into trouble if she did. Tr. 306. Upon exam, her mood was angry and anxious and Ball counseled her on reflective techniques and encouraged her to have her cats fixed. Tr. 306.

         On February 6, 2015, Rogers saw Ball again and complained of continuing irritation with her husband concerning things he did and said that she found annoying despite the fact that she has asked him to stop. Tr. 304. She believed that, if he cared about her, he would stop. Tr. 304. To her, this was a very big deal. Tr. 304. Upon exam, her affect was appropriate, she was cooperative, her mood was depressed and angry, and her thought process was dichotomous. Tr. 304. Ball “normalized her annoyance” with her husband's behavior and counseled her on how to rate problems, 10 being life-threatening, and commented, “Client kept insisting that her annoyance is a 10, even though it is not life threatening.” Tr. 304. Rogers was “resistant” to reconsidering the level of her response but was willing to think about it as well as gender differences and her expectations. Tr. 304.

         On February 19, Rogers saw Corcelli for medication management. Tr. 301. She reported that her mood was bad and that she became angry in the evenings when her husband came home and threw his clothes on the floor instead of the laundry basket. Tr. 301. She liked to be home in the quiet. Tr. 301. She reported getting angry when sitting in a physician's office for a long period of time. Tr. 301. Upon exam, her affect was blunted/constricted, she was cooperative, and her mood was anxious and irritable. Tr. 301. She indicated that the benefits of her mood stabilization medication (Lamotrigine) had started to wane and Corcelli increased her dosage. Tr. 302.

         On March 18, Rogers saw Ball, stating that she was less irritable and her husband's annoying behavior did not “get to her” as much anymore. Tr. 298. Her increased dosage had helped her, but not when her 14-year old dog died suddenly in the back yard and she had to take him to the veterinarian to be cremated. Tr. 298. She was bothered by her husband and wanted to leave him but could not because she did not have any money. Tr. 298. She believed her husband could kick her out because she was not sure if the house belonged to her too. Tr. 298. She did not think she could tolerate a workplace because “the last one was so bad” and she could not handle a supervisor who “gets in my place.” Tr. 298. She believes that she has to yell back or strike out physically because that is what she has always done. Tr. 298. Upon exam, she was cooperative, her affect was appropriate, her mood was angry and depressed, and she had a dichotomous thought process. Tr. 298. Ball emphasized that it was normal Rogers should feel bad when her dog died and challenged her conclusions about workplaces in general based on her experience in one exceptionally bad workplace. Tr. 298-299. She assured Rogers that no one likes people “getting in their face” and encouraged Rogers to walk away rather than fight, although Rogers was skeptical that walking away would prevent people from staying out of her face. Tr. 299.

         On April 2, 2015, Rogers told Corcelli that she continued to have problems with anxiety and irritability. Tr. 295. She gets itchy when she is around other people and she is having problems with road rage. Tr. 295. Upon exam, her affect was constricted/blunted and her mood was depressed. Tr. 295. On May 1, Rogers told Ball that she remains very irritable and that her increased Lamotrigine has not helped. Tr. 292. She was almost in a road rage incident when a car almost rear ended her and she jumped out of her car and yelled at the offending driver. Tr. 292. She stated that she feels like there is always someone following her or watching her, which is why she stays in her house as much as possible. Tr. 292. She is afraid that someone may be trying to kill her and expressed a fear of dying and being unhappy with bugs crawling on her in her grave. Tr. 292. Upon exam, her affect was appropriate, her behavior agitated/restless, her mood anxious, angry and depressed, and her thought process irrational and dichotomous. Tr. 292.

         On June 22, Rogers told Ball that she was recovering from a visit with her in-laws, whose children, she believed, stole her GERD medication. Tr. 290. Her cat was pregnant again; Rogers had not had her cats fixed. Tr. 290. Her husband had gotten her a new puppy but was not helping her housebreak it. Tr. 290. She continued to avoid others, stayed home as much as possible, and believed others were out to hurt her due to her history of abuses from her mother, partners, and a former friend. Tr. 290. She reported getting very irritated when others do not do things the way they should, such as when people know she is behind them and they hold her up. Tr. 290. She does not think that she should have to speak up to ask them to let her by. Tr. 290. She reported that she had been accused of having a “bad attitude” which has contributed to all of her job losses. Tr. 290. Upon exam, her mood was angry, her thought process dichotomous, her insight and judgment fair, her affect appropriate and her behavior cooperative. Tr. 290.

         On June 25, 2015, Rogers saw Corcelli for medication management. Tr. 287. Her problems with nightmares and itching had improved, but she still had problems with irritability and anxiety and had a panic attack “[e]very once in a while, ” for instance at the grocery store or where there was a lot of people. Tr. 287. She mentioned her road rage incident when she confronted a driver she thought was following her. Tr. 287. She rated her depression 10/10 and stated that she tries to stay home and that she tends to sleep a lot. Tr. 287. Her new puppy was keeping her very busy. Tr. 287. Upon exam, she had average activity, was adequately groomed, had average eye contact, clear speech, a constricted affect, cooperative behavior, logical thoughts, and fair insight and judgment. Tr. 287. Corcelli indicated that her status was “improving.” Tr. 289.

         On July 14, 2015, Rogers saw Ball and reported that she found her previously missing and presumed stolen GERD medication under a table. Tr. 332. Her puppy was now completely housebroken and her cat had had her kittens. Tr. 332. Her son and his girlfriend had moved out and her husband's friend who had been staying in the house was told to leave after he came home inebriated and urinated all over the bathroom. Tr. 332. She was angry most of the time and “just figures she has to be that way.” Tr. 332. She referenced abuse from her mother and her mother favoring her sister over her. Tr. 332. She continued to report dissatisfaction with her husband and was waiting to be approved for disability benefits so that she would have the money to leave him. Tr. 332. Ball reminded her that her irritable response is caused by her own outlook and attitude and that she could change. Tr. 332.

         On August 7, Rogers saw Corcelli for medication management and reported that her anger issues have improved since her medication dosage was increased. Tr. 329. She still had anger “at times, ” part of which had to do with her husband. Tr. 329. She moved out and in with her son for a day but moved back home because she did not want to burden her son. Tr. 329. She was still self-isolating and cannot be around people because she gets rude if she has any problems. Tr. 329. She was in a traffic jam for a half-hour the day before, screamed at the police officer directing traffic, and was angry for 10-15 minutes after that. Tr. 330. Corcelli noted that Rogers' status was improving. Tr. 331.

         On August 14, 2015, Rogers told Ball that she still wanted to leave her husband and hoped to get disability benefits. Tr. 327. She relayed that when she had left him he had already changed the locks before she returned, his abuse had worsened, and she regretted that she had returned. Tr. 327. She went back because of her animals. Tr. 327. Ball counseled her on planning a leave so that the next time she left she had what she needed with her and would not need to return; she also advised Rogers to speak to legal aid. Tr. 327.

         On September 10, Rogers told Ball that she had recently traveled to West Virginia for her uncle's funeral and was reminded how much better she felt in the mountains. Tr. 325. She slept for 8 hours straight, which she rarely does. Tr. 325. She stated that she was slowly putting together a stash of things she will need for when she leaves her husband and would like to move to West Virginia. Tr. 325. She hoped to leave once she got money from disability benefits. Tr. 325. Upon exam, she was cooperative, had an appropriate affect, was angry and depressed, and had dichotomous thoughts. Tr. 325.

         On October 30, 2015, Rogers told Ball that she is making minimal progress, if any, after having learned that her husband was going to lose his job and would be home more. Tr. 322.

         She is upset with her mother-in-law, who expected Rogers to run errands for her promptly and at any time, and she “doesn't want to go to the store because the people there ‘make me mad…they don't do what they are supposed to do....Stay out of my way, or get out of my way when I say excuse me.'” Tr. 322. Ball wrote, “[Rogers] pretty sure that others are responsible for all her feelings.” Tr. 322. Her exam findings were similar to her prior visit. Tr. 322. Ball invited Rogers to look for one good thing in each day to show that the whole day was not bad. Tr. 323.

         On November 3, Rogers relayed to Corcelli how much she enjoyed going to West Virginia and staying with relatives and she considered whether this might be a better place for her to live because people there were so nice. Tr. 318. She again expressed dread that her husband would be off work soon and home more and how he expected her to wait on him and constantly told her to do things. Tr. 318. Corcelli observed that it seemed Rogers' mood was better when she was away from her husband and listed her condition as stable. Tr. 318, 320.

         On November 30, Rogers saw Ball and reported problems with her husband and “insist[ed] that ‘everybody' should know how she wants them to behave, and [it] make[s] her angry when they don't.” Tr. 316. She explained that she used to be happy and outgoing but that she turned angry and now wants to be alone most of the time. Tr. 316. She reported that this began after she experienced several losses, including her maternal grandmother who was her true nurturer and protected her from her abusive mother. Tr. 316.

         On December 18, Rogers returned to Ball and said she was excited for Christmas because her elder son, who lives in Indiana, is coming to visit. Tr. 314. She applied for food stamps at the Jobs and Family Services Center and got angry with the problems in the parking lot and with all the commotion in the room. Tr. 314. She was also angry because her sister told her that she, her sister, had been made the executor of their father's will and also that her stepbrother is a beneficiary. Tr. 314. Rogers believed her sister told her this just to make her angry. Tr. 314. She also relayed a history of her mother and step-mother treating Rogers' children worse than they had treated her sister's children. Ball counseled Rogers on controlling her responses to things and told her that she has the power to change her life. Tr. 315. Rogers' exam findings were similar to past findings. Tr. 314.

         On January 14, 2016, Rogers saw Corcelli and reported that the holidays had not gone well, that her husband is home and was “agitating, ” they were having financial difficulty since her husband lost his job, she had gone to get food stamps and was having panic attacks when she goes out, and stated, “they are ‘hitting me harder.'” Tr. 310. Corcelli adjusted her medication and rated her condition as “baseline.” Tr. 312.

         On January 27, Rogers reported several panic attacks a day due to her husband's constant attempts to get her upset. Tr. 335. She is grateful that he is starting a new temporary job soon and will be out of the house. Tr. 335. She was disappointed because her son could not come from Indiana for Christmas and her mother-in-law came over and this automatically made the day unpleasant. Tr. 335. She had waited too long to get her cats fixed and she now had 5 new kittens. Tr. 335. She was not sure that she could do anything about her anger. Tr. 335. Ball provided her with information explaining how a panic attack feels so that Rogers did not worry that she was having a heart attack and counseled her on having realistic expectations and to “disconnect the buttons” to decrease her responses to her husband's behavior. Tr. 336. Upon exam, she was cooperative, appropriate and angry. Tr. 335.

         On February 19, Rogers repeated that she planned to leave her husband when she started receiving disability benefits, had started researching the housing market in West Virginia where she would like to live, and was looking forward to her husband returning to work. Tr. 354. She enjoyed watching the kittens grow and play. Tr. 354.

         On March 18, 2016, Rogers told Ball hat her husband does all kinds of things to annoy or “torture” her and she spends a lot of time stewing about “what a jerk he is.” Tr. 351. Rogers had sold all her kittens but was now concerned that her dog was pregnant. Tr. 351. Her food stamp assistance was reduced based on an income level that, she stated, was incorrect. Tr. 351. She was annoyed that her dogs appeared to like her husband more than her and thought that they should like her better because she feeds them and cleans up after them. Tr. 351. She expressed annoyance again that her mother-in-law and husband ask her to run errands for them even though they could do it themselves. Tr. 351.

         On March 24, Rogers told Corcelli that she was under significant stress due to her husband being home; he is constantly harping on her and he and his mother continued to ask her to run errands for them. Tr. 347. She reported that her medications were helping except that her husband has told her that they are not because at some point during the day she gets fed up and threatens to punch him. Tr. 347. She spoke about some of the abuse she suffered from her mother when she was a child, stated that she does not feel safe in public, and shared that she recently had an “ugly exchange” with a stranger when she had to step aside to let him pass and he “gave her a look.” Tr. 348. Upon exam, she had a constricted/blunted affect, an ...

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