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Chapman v. Commissioner of Social Security

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

July 2, 2019

BEVERLY CHAPMAN, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          Pamela A. Barker, Judge.

          REPORT AND RECOMMENDATION

          James R. Knepp, II United States Magistrate Judge

         Introduction

         Plaintiff Beverly Chapman (“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”). (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 July 13, 2018). Following review, and for the reasons stated below, the undersigned recommends the decision of the Commissioner be affirmed.

         Procedural Background

         Plaintiff filed for DIB in May 2015, alleging a disability onset date of July 3, 2012. (Tr. 173). Her claims were denied initially and upon reconsideration. (Tr. 121-24, 127-29). Plaintiff then requested a hearing before an administrative law judge (“ALJ”). (Tr. 134-35). Plaintiff (represented by counsel), and a vocational expert (“VE”) testified at a hearing before the ALJ on May 17, 2017. (Tr. 34-85). On October 4, 2017, the ALJ found Plaintiff not disabled in a written decision. (Tr. 15-25). The Appeals Council denied Plaintiff's request for review, making the hearing decision the final decision of the Commissioner. (Tr. 1-3); see 20 C.F.R. §§ 404.955, 404.981. Plaintiff timely filed the instant action on July 13, 2018. (Doc. 1).

         Factual Background

         Personal Background and Testimony

         Plaintiff was born in 1962, making her 54 years old at the hearing. See Tr. 40. She had a bachelor's degree in communications (Tr. 46), and past work in the corporate training industry (Tr. 48-49).

         Plaintiff was terminated from her last job due to “erratic behavior” in the workplace. (Tr. 46). She was not “dealing with clients and colleagues well”, and experienced auditory and visual hallucinations, “sobbing episodes”, and mood swings. Id. She noted her behavioral and mental health problems had “progressed a lot” since 2012. (Tr. 55). Plaintiff denied that a single traumatic event caused a decline, but instead she gradually “started having reactions that [she] knew weren't normal”. Id.

         Plaintiff experienced visual hallucinations, seeing and conversing with people who “look as real to me as you look to me right now.” (Tr. 56). She had become familiar with certain people by voice and appearance, describing them as “motorcycle people”. (Tr. 57). Plaintiff noted the people were supportive, offered consolation, and provided positive affirmations. (Tr. 58). Sometimes Plaintiff only heard voices and did not see faces. Id. These hallucinations mostly occurred at home, but sometimes in public. (Tr. 59). Since she started treatment, Plaintiff's hallucinations were less frequent. Id.

         Plaintiff also described mood swings. (Tr. 59-60). Occasionally she woke in the morning feeling depressed - a feeling which sometimes lasted a week and sometimes lasted only the day. (Tr. 60). She had “blow-up episodes” where she overreacted, or otherwise reacted inappropriately, to something that made her angry. Id. Plaintiff also experienced panic attacks where she felt sweaty, shook, had weak legs, and fled whatever setting she was in. (Tr. 60-61). She had approximately three panic attacks per week which lasted fifteen to twenty minutes each. (Tr. 62).

         Plaintiff lived with her elderly mother (Tr. 41), who she testified was the only person with whom she got along. (Tr. 66). She was estranged from her father and only sibling. Id. Plaintiff did not grocery shop and did not participate in household chores due to concentration problems. (Tr. 66-67). She did not have any hobbies and slept most of the day. (Tr. 67-68). Plaintiff was afraid to leave her home due to “agoraphobic tendencies”. (Tr. 69).

         Relevant Medical Evidence

         Plaintiff treated with her primary care physician Richard McBurney, M.D., and a nurse practitioner within his office, a total of three times between 2013 and 2015. See Tr. 266-79, 289-92. Dr. McBurney treated Plaintiff for panic disorder without agoraphobia and generalized anxiety disorder. (Tr. 269-70, 272-73, 289-90). He prescribed Lexapro and clonazepam (Tr. 271, 273, 290), noted her symptoms were “well controlled” on the medications (Tr. 269), and helped her symptoms “considerably” (Tr. 289). Dr. McBurney also found Plaintiff's affect appropriate to her mood. See Tr. 271, 291.

         Plaintiff underwent a consultative examination with psychologist Charles Misja, Ph.D., in June 2014. (Tr. 255-61). Plaintiff reported living in a “continual state of dread expecting the worst”, and that worrying “overwhelm[ed]” her. (Tr. 256). She expressed difficulty maintaining personal relationships and dealing with workplace stress. Id. Plaintiff told Dr. Misja she was terminated from a job as a software applications trainer because she walked out of meetings, hungup on conference calls, and could not get along with supervisors or coworkers. (Tr. 257). She did not belong to any social groups or organizations and did not have any hobbies or interests. (Tr. 258). Plaintiff had a “close” relationship to her brother. Id. She showered every two to three days, managed her own finances, cooked for herself, and did her laundry once per month. Id. On a typical day, Plaintiff woke at noon, had coffee, took her medication, and watched television most of the day. Id.

         On examination, Dr. Misja found Plaintiff dressed appropriately, was adequately groomed, made good eye contact, and did not appear to exaggerate her symptoms. Id. He found she was direct in her conversation with good flow and was verbose and articulate. Id. Plaintiff had a constricted affect and depressed and stable mood. Id. She rated her depression as a “six”, but added it recently was “as high as eight”. Id. She did not have any suicidal thoughts. Id. Plaintiff reported that her depression “never stopped her from functioning and even now [] has no difficulty getting out of bed for the day.” Id. She reported a “drastic” change in her quality of life because she lived with her parents, including her father who was “difficult to cope with.” Id. Plaintiff had no anger towards herself, but was angry with others due to “anticipated mistreatment”. (Tr. 259). She rated her anxiety as a “ten” but stated, “I'm able to function”. Id. Plaintiff was fine by herself, but did not have interest in social settings. Id. Dr. Misja found no evidence of visual or auditory hallucinations or delusions. Id. She was oriented with no sign of grandiosity, religious or sexual preoccupations, suspiciousness, or aggression. Id. Dr. Misja found Plaintiff functioned in the average range of intelligence. Id. She had good insight and fair judgment. (Tr. 260). He diagnosed major depression (moderate), generalized anxiety disorder, and personality disorder (not otherwise specified). Id.

         In August 2015, Plaintiff underwent a second consultative examination with psychologist Alison Flowers, Psy.D. (Tr. 294-301). Plaintiff reported losing three jobs due to psychological problems. (Tr. 294-96). She noted that she was easily annoyed, could not focus, and could not get along with her coworkers. (Tr. 296). Plaintiff reported that she took her prescribed medications (Lexapro and clonazepam) daily (Tr. 295), and they helped “somewhat” (Tr. 296). Plaintiff described her typical mood as “sad and depressed”. (Tr. 297). She further reported panic attacks, difficulty concentrating, dysphoric moods, loss of usual interests, a diminished sense of pleasure, irritability, and social withdrawal. Id. Plaintiff reported that she could dress, bathe, and groom independently. Id. She could not cook or prepare food due to an inability to concentrate. Id. She did “a little” cleaning and shopped for herself in “small stores” such as Walgreens. Id. Plaintiff reported that she was unable to manage her own finances, and was going through bankruptcy. Id. She drove independently. Id.

         On examination, Dr. Flowers found Plaintiff had an open demeanor with appropriate social skills. (Tr. 298). She was appropriately dressed, well-groomed, and had appropriate eye contact. Id. Plaintiff had fluent speech, a clear voice, coherent thought process, and goal-directed thoughts with no evidence of hallucinations, delusions, or paranoia. Id. She had a restricted affect and appeared anxious throughout the appointment. Id. Plaintiff had a neutral mood and euthymic affect. Id. She was oriented to person, place, and time and had “mildly impaired” attention and concentration. Id. Plaintiff had good insight, fair judgment, and was in the average range of intelligence. (Tr. 299). Dr. Flowers diagnosed generalized anxiety disorder, panic disorder, and unspecific depressive disorder. Id. Further, Dr. Flowers offered a “guarded” prognosis because Plaintiff reported problems related to anxiety and depression and she was not receiving mental health treatment for those symptoms. Id. She opined that Plaintiff's prognosis might improve with treatment. Id.

         Plaintiff began treating with counselor Andrea Brown, LPC, in December 2015. See Tr. 305. At her initial visit, Plaintiff reported anxiety symptoms and mood changes. (Tr. 306). On examination, Plaintiff's mood and affect were within normal limits; she made steady eye contact, was oriented, had normal speech, intact memory, average intellect, fair judgment, and a normal thought process. (Tr. 305). Ms. Brown diagnosed major depressive disorder, single episode. (Tr. 308).

         Plaintiff attended several counseling visits with Ms. Brown in January and February 2016. (Tr. 323-65). During the visits Plaintiff reported anxiety symptoms (Tr. 323, 332, 336, 340, 348, 356, 364-65), depression symptoms (Tr. 336, 344), and difficulties with social situations (Tr. 323, 332, 364-65). On examination, Ms. Brown consistently found Plaintiff had an anxious mood, appropriate affect, good concentration, and good or fair judgment. (Tr. 330, 334, 338, 342, 346, 350, 354, 358, 362).

         Later in January 2016, Plaintiff underwent a third consultative examination with psychologist Amber Hill, Ph.D. (Tr. 310-19). Plaintiff reported a family history of psychiatric concerns, describing her father as having “rages”. (Tr. 311). She got along with her mother, but had a strained relationship with her father, and was estranged from her brother. Id. Plaintiff had no other socialization and no hobbies or interests. Id. She spent the majority of her day watching television and attending doctor's appointments. Id. If she arrived at an appointment early, she would stop and get a cup of coffee close to the building. Id. Plaintiff reported taking Lexapro and clonazepam, id., and described the medication as “helpful” (Tr. 312). She was terminated from her last job because she had difficulty getting along with her coworkers. Id. Plaintiff reported feeling “very, very sad” most days. (Tr. 313). Plaintiff suggested that she had symptoms of mania, detailing “spending binges” during periods of happiness. Id. She reported three panic attacks per week and that she only left the house to attend appointments. (Tr. 314). Plaintiff was able to dress, bathe, and groom herself but did so infrequently. Id. She did not cook or prepare simple meals, instead relying on her mother's friend to bring over take-out meals. (Tr. 314-15). She reported that she was able to manage her own finances. (Tr. 315).

         On examination, Dr. Hill found Plaintiff appropriately dressed and well groomed. Id. She noted Plaintiff demonstrated normal posture and motor behavior with appropriate eye contact, but visibly shook during most of the session. Id. Plaintiff had fluent speech and a clear voice with coherent goal-directed thoughts. Id. There was no evidence of hallucinations, delusions, or paranoia. Id. Dr. Hill found Plaintiff had a restricted and flat affect with a dysthymic mood. Id. Plaintiff was anxious throughout the session. Id. Her concentration and attention appeared mildly impaired, as did her recent and remote memory skills. (Tr. 315-16). Dr. Hill found Plaintiff's intellectual functioning to be normal. (Tr. 316). She diagnosed panic disorder, generalized anxiety disorder, and persistent depressive disorder and offered a “guarded” prognosis due to Plaintiff's lack of full symptom control or relief. (Tr. 316-17) (“Although the claimant suggests that she has some good benefit from her mental health medication prescribed by her primary care provider for the past seven years, the claimant does not have full symptom control or relief.”).

         Plaintiff began treating with psychiatrist Thomas Thysseril, M.D., in April 2016. See 385-90. At her initial visit, Plaintiff reported a variety of symptoms including: nocturnal sleep habits, rapid speech, road rage, trust issues, fluctuating mood, and distractibility. (Tr. 385). She reported staying at home most of the day; she did not participate in chores or cooking, and showered approximately once per week. Id. Plaintiff also noted that she angered easily. Id. Dr. Thysseril noted Plaintiff had no active hallucinations. Id. On examination, Plaintiff was cooperative, made good eye contact, and appeared casually dressed with “improved” hygiene. (Tr. 388). She had a mixed mood and a labile, guarded, affect. Id. Plaintiff had fair impulse control, judgment, and insight. Id. Dr. Thysseril diagnosed bipolar disorder (mixed, moderate), anxiety disorder, and assigned a Global Assessment of Functioning (“GAF”) score of 60[1]. (Tr. 389). He adjusted Plaintiff's medications. Id.

         Plaintiff saw Dr. Thysseril from April to November 2016. (Tr. 391-425, 454-77). Throughout this period, Plaintiff's reported symptoms included anger (Tr. 391, 396), anxiety (Tr. 454, 464), depression (Tr. 411), and paranoia (Tr. 401, 459). Plaintiff reported a visual hallucination of a man on a bicycle in September 2016 (Tr. 459), and auditory hallucinations in November 2016 (Tr. 474). On a few occasions, Dr. Thysseril described Plaintiff as being “calmer” than usual (Tr. 406, 464, 469) or less paranoid (Tr. 406, 416, 421). On examination, Plaintiff's mood varied from “mixed” (Tr. 393, 398), “expansive” (Tr. 418, 461, 476), and depressed (Tr. 413) to “calmer” (Tr. 408, 423, 456, 471) and “less depressed” (Tr. 403). Plaintiff's affect also varied from “guarded” (Tr. 393, 398), “restricted” (Tr. 418, 423, 456, 471), “tearful” (Tr. 413), and “labile” (Tr. 461, 466, 476) to “less guarded” (Tr. 403, 408). Dr. Thysseril consistently described Plaintiff as “cooperative” with good eye contact, but noted psychomotor retardation was also present. (Tr. 393, 398, 403, 408, 413, 423, 456, 461, 476). He found Plaintiff's recent and remote memory intact and consistently noted Plaintiff had fair impulse control, insight, and judgment; he maintained a diagnosis of bipolar disorder, anxiety disorder, and consistently assigned a GAF score of 60 or 65. (Tr. 394, 399, 404, 409, 414, 418-19, 424, 457, 462, 467, 472, 477).

         Plaintiff underwent a battery of cognitive testing in August 2016 with consultative examiners Matthew Liptensky, M.A., P.C. (a counselor) and Deborah Koricke, Ph.D (a psychologist). (Tr. 427-30). Wechsler Adult Intelligence Scale testing revealed Plaintiff fell in the low average range of overall mental abilities. (Tr. 427-28). She was in the low average range in the area of verbal comprehension; borderline in perceptual reasoning; and low average in the area of attention and concentration. (Tr. 428). Plaintiff's processing speed fell within the average range. Id. Plaintiff also underwent Integrated Visual and Auditory Continuous Performance Testing (“IVA-CPT”) to assess her overall attention and concentration. (Tr. 429). Results indicated Plaintiff fell within the “impaired” range in all areas of functioning related to attention consistent with someone suffering from attention deficit hyperactivity disorder (“ADHD”). Id. These providers also administered the Minnesota Multiphasic Personality Inventory -2- Revised Format (“MMPI-2-RF”) to assess psychopathology and maladaptive personality functioning. (Tr. 430). Plaintiff's score was indicative of someone likely exaggerating their symptoms; it was thus likely invalid. Id. Mr. Liptensky and Dr. Koricke noted, however, that Plaintiff “was not perceived to be attempting to feign an illness and appeared to be attempting to put forth a consistent effort.” Id.

         Plaintiff reported to the emergency room in January 2017 for suicidal thoughts (Tr. 582, 588); she was admitted (Tr. 590). On examination, Plaintiff was actively engaged in her interview, was pleasant and courteous, and came across as “open and unguarded”. (Tr. 592). Her speech was somewhat rapid. Id. Plaintiff's mood was mildly hypomanic and her affect congruent. Id. She had fair insight and judgment, was somewhat distracted by racing thoughts, and had “excellent” recent and remote recall. Id. Providers diagnosed bipolar mood disorder, hypomanic. Id.; see also Tr. 594 (discharge summary).

         Opinion Evidence

         Treating Physician

         Dr. Thysseril completed a medical source statement in March 2017. (Tr. 948-53). In it, he listed Plaintiff's diagnosis as bipolar disorder with a GAF score of 65[2]. (Tr. 948). He also listed Plaintiff's symptoms and medications. (Tr. 948-49). Dr. Thysseril opined Plaintiff had unlimited ability to adhere to basic standards of neatness and cleanliness. (Tr. 952). When asked his opinion on Plaintiff's ability to ask simple questions or request assistance, Dr. Thysseril checked two boxes indicating that she was both “unlimited or very good” and “unable to meet competitive standards” in her ability to ask simple questions or request assistance. See Tr. 950. He found she was “limited but satisfactory”[3] in her ability to maintain regular and punctual attendance; make simple work-related decisions; perform at a consistent pace without an unreasonable number of rest periods; and set realistic goals or make plans independently of others. (Tr. 950, 952). Dr. Thysseril found Plaintiff “seriously limited”[4] in her ability to carry out very short and simple instructions; accept instructions and respond appropriately to criticism from supervisors; respond appropriately to changes in a routine work setting, understand, remember, and carry out detailed instructions; interact appropriately with the public; maintain socially appropriate behavior; and travel in unfamiliar places. Id. He found she was “unable to meet competitive standards”[5] in her ability to maintain attention for a two-hour segment; work in coordination with or proximity to others without being distracted; and complete a normal workday (or workweek) without interruptions from psychologically based symptoms. (Tr. 950). When asked to explain these limitations, including the medical/clinical findings in support, Dr. Thysseril left the questions blank. (Tr. 950, 952). Dr. Thysseril opined Plaintiff had a mild limitation in her ability to understand, remember, or apply information. (Tr. 951). He found a moderate limitation in her ability to interact with others and maintain attention, concentration, persistence, or pace. Id. Dr. Thysseril found a marked limitation in Plaintiff's ability to adapt or manage herself. Id. He did not offer an opinion on absenteeism (Tr. 951) and left blank a question which asked “[i]f stress tolerance is an issue, what demands of work does this patient find stressful?” (Tr. 953). Finally, Dr. Thysseril did not answer when asked if Plaintiff impairment lasted (or could be expected to last) at least twelve months. (Tr. 951).

         Examining Physicians

         In June 2014, Dr. Misja opined Plaintiff functioned in the average range of intelligence and would be able to understand and implement ordinary instructions. (Tr. 261). She would have “minimal” problems in her ability to maintain attention and concentration, maintain persistence and pace, and perform simple and multi-step tasks. Id. He opined Plaintiff would have “severe” problems responding appropriately to supervision and coworkers due to a “significant personality disorder”. Id. Dr. Misja also found Plaintiff would have “severe” problems in her ability to respond appropriately to work pressures, depending on the particulars of the job. Id. By way of example, he noted that if Plaintiff traveled for work (as she did in the past) that she may “be able to hide her problem”. Id. Finally, Dr. Misja opined Plaintiff could manage her own finances. (Tr. 260).

         In August 2015, Dr. Flowers opined Plaintiff would have some limits in her ability to understand and carry out instructions based on the observation that Plaintiff required repetition of some instructions during the examination. (Tr. 300). Dr. Flowers opined Plaintiff was likely limited in her ability to perform multi-step tasks. Id. She noted that, although Plaintiff appeared to be able to sustain attention and concentration during the appointment, there were some deficits in this area on examination. Id. She further noted that Plaintiff reported difficulty performing multi-step tasks at work in recent years. Id. She observed Plaintiff appeared anxious during the appointment and noted this might impact Plaintiff's ability to respond appropriately to pressures in a work setting. (Tr. 301). In considering Plaintiff's ability to respond appropriately to supervisors or coworkers in a work setting, Dr. Flowers described Plaintiff's subjective reports of anger and irritability in social settings, but also found that, during the exam, she was able to interact appropriately. Id. Further, she pointed out that Plaintiff's reporting of her socialization abilities was “somewhat inconsistent”, and she drove with a friend to her appointment that day. Id.

         In January 2016, Dr. Hill opined Plaintiff had mild impairment in her ability to understand, remember, and carry out instructions due to her impaired remote memory skills and self-reported difficulties in carrying out instructions. (Tr. 318). She found Plaintiff limited in her ability to maintain attention and concentration and persistence and pace, as well as to perform some multi-step instructions, due to her self-reported distress with her anxiety and depression symptoms. Id. She opined Plaintiff could perform simple tasks, and some multi-step tasks. Id. Dr. Hill further found Plaintiff limited in her ability to respond appropriately to supervision and coworkers. (Tr. 319). In support, she cited of Plaintiff's depression and anxiety related symptoms as well as their interactions within the clinical setting. Id. Finally, Dr. Hill found Plaintiff limited in her ability to respond appropriately to work pressures in a work setting due to her observed and reported symptoms of anxiety and depression. Id.

         VE Testimony

         A VE appeared and testified at the hearing before the ALJ. See Tr. 77-84. The ALJ asked the VE to consider a person with Plaintiff's age, education, and vocational background who was physically and mentally limited in the way in which the ALJ determined Plaintiff to be. See Tr. 78-80. The VE opined such an individual could not perform Plaintiff's past work, but could perform other jobs such as an industrial cleaner, linen room attendant, and a hospital cleaner. (Tr. 78-81). ALJ Decision In a written decision dated October 4, 2017, the ALJ found Plaintiff met the insured status requirements for DIB through September 30, 2019 and had not engaged in substantial gainful activity from since her alleged onset date (July 3, 2012). (Tr. 17). He concluded Plaintiff had severe impairments of: depression, anxiety, personality disorder, ADHD, degenerative disc disease, fibroids, and ovarian cysts, but found these impairments (alone or in combination) did not meet or medically equal the severity of a listed impairment. (Tr. 18). The ALJ then found Plaintiff had the residual functional capacity (“RFC”):

to perform medium work as defined in 20 CFR 404.1567(c) except for the following limitations. The claimant can perform occasional left overhead reaching. The claimant cannot climb ladders, ropes, or scaffolds. The claimant can have no exposure to hazards such as unprotected heights or moving mechanical parts. The claimant must avoid concentrated exposure to dust, odors, fumes, and pulmonary irritants. The claimant cannot perform work involving fast paced or high production quota standards. The claimant can have occasional and superficial interaction with supervisors and coworkers, meaning no arbitration, mediation, confrontation, negotiations, supervising ...

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