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Trifiletti v. Saul

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

July 31, 2019

BRIAN TRIFILETTI, Plaintiff,
v.
ANDREW M. SAUL[1], COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant.

          MEMORANDUM OPINION & ORDER

          GEORGE J. LIMBERT, UNITED STATES MAGISTRATE JUDGE

         Plaintiff Brian Trifiletti (“Plaintiff”) requests judicial review of the final decision of the Commissioner of Social Security Administration (“Defendant”) denying his application for Supplemental Security Income (“DIB”). ECF Dkt. #1. In his brief on the merits, Plaintiff asserts that the administrative law judge (“ALJ”): (1) failed to properly evaluate the opinion of his treating psychiatrist Dr. Seng; and (2) erred in evaluating the opinion of state agency sources where he rejected the most limiting aspects of the opinions and failed to consider whether those limitations were consistent with the treating psychiatrist opinion or the record as a whole. ECF Dkt. #14. For the following reasons, the Court AFFIRMS the decision of the ALJ and DISMISSES Plaintiff's case in its entirety WITH PREJUDICE.

         I. FACTUAL AND PROCEDURAL HISTORY

         Plaintiff protectively filed an application for SSI on April 2, 2015 alleging disability beginning January 1, 2013 due to anxiety, agoraphobia, panic attacks, and paruresis. ECF Dkt. #11 (“Tr.”) at 128-133, 150.[2] The Social Security Administration (“SSA”) denied his application initially and upon reconsideration. Id. at 62-72. Plaintiff requested a hearing before an ALJ, and the ALJ held a hearing on December 19, 2016, where Plaintiff was represented by counsel and testified. Id. at 33, 123-126.. A vocational expert (“VE”) also testified. Id. at 33.

         On April 28, 2017, the ALJ issued a decision denying Plaintiff's application for SSI. Tr. at 19-29. Plaintiff requested that the Appeals Council review the ALJ's decision and the Appeals Council denied his request for review on September 24, 2018. Id. at 1-5.

         On March 26, 2018, Plaintiff filed the instant suit seeking review of the ALJ's decision. ECF Dkt. #1. He filed a merits brief on July 9, 2018 and Defendant filed a merits brief on September 27, 2018. ECF Dkt. #s 14, 17. Plaintiff filed a reply brief on October 11, 2018. ECF Dkt. #18.

         II. RELEVANT MEDICAL AND TESTIMONIAL EVIDENCE

         Notes in the record beginning January 4, 2006 from Plaintiff's treating physician indicate that Plaintiff had a phobia of voiding in public, as well as possible agoraphobia,, which was greatly improved with Lexapro, and anxiety/stress, which was also greatly improved with Lexapro. Tr. at 226. Plaintiff presented to his primary care doctor on that date and indicated that he was doing well and his symptoms were under good control, but he was not yet “totally back to normal life style.” Id. The doctor further noted that Plaintiff “straight casts[sic] himself on a prn basis when he is problems voiding in public” and Plaintiff was treating with a counselor for his phobias. Id. Notes from the same physician dated April 6, 2006, May 6, 2006, June 13, 2006, June 20, 2006, September 29, 2006, December 12, 2006, January 2, 2007, April 4, 2007, May 7, 2007, and May 24, 2007 indicated that Plaintiff reported feeling well and his phobia for using public restrooms was “greatly improved.” Id. at 208, 210, 212, 216, 218, 220, 221, 223, 224. Primary care doctor notes also indicated that on May 6, 2006, June 13, 2006, January 2, 2007, April 4, 2007, May 7, 2007, May 24, 2007, and that Plaintiff's possible agoraphobia and anxiety/stress were “greatly improved with Cymbalta.” Id. at 210, 212, 214, 221, 223.

         On June 27, 2013, Plaintiff presented to Dr. Seng, a psychiatrist, for his complaints of anxiety, depression and urinary problems. Tr. at 236. Dr. Seng conducted an evaluation, indicating that Plaintiff first noticed having a shy bladder at the age of six at a baseball game and he began feeling nervous in junior high school. Id. Plaintiff reported that after graduating from high school, he struggled with having a shy bladder and would have to go to the bathroom only at home. Id. He attended a computer school and did really well and really liked it, but he began suffering from panic attacks. Id. at 237. He indicated that he took Lexapro in the past and it did not help. Id. He also indicated that he took Xanax, which helped with his panic attacks, and he took Cymbalta, which helped for anxiety and depression, but he only took it for a year or two as it caused constipation and maybe sexual problems. Id. Plaintiff also reported that he had a girlfriend for the past seven years, he still lived at home, and he could only work part-time because of his urinary issues. Tr. at 238.

         Dr. Seng's mental status examination indicated that Plaintiff was friendly, attentive, communicative and relaxed. Tr. at 239. Plaintiff's mood presented as normal, with no signs of depression or mood elevation, and an appropriate affect, no hallucinations, delusions, bizarre behaviors, or suicidal ideations. Id. Dr. Seng found that Plaintiff had intact associations, logical thinking, and logical thought content, with normal range cognitive functioning and normal insight and social judgment. Id. He diagnosed Plaintiff with panic disorder, major depressive disorder, recurrent and unspecified, and attention deficit hyperactivity disorder (“ADHD”), combined presentation. Id. He acknowledged Plaintiff's medical diagnoses of paruresis and spondylolythesis and his prescribed medication of Xanax. Id. at 239-240. Dr. Seng rated Plaintiff's global assessment of functioning (“GAF”) at 60, indicative of moderate symptoms. Id. at 240. He increased Plaintiff's Xanax dosage, and he prescribed Zyprexa. Id.

         Dr. Seng's July 16, 2013 treatment notes indicate that Plaintiff presented to him and reported that he was feeling better. Tr. at 242. Plaintiff reported that his anxiety symptoms were less frequent, less intense, and were improved. Id. Mental status examination indicated that Plaintiff was wary, attentive, fully communicative, and he appeared anxious. Id. He had normal speech, a normal mood with no signs of depression or mood elevation, an appropriate affect, and no hallucinations, delusions, bizarre behaviors, or suicidal ideations. Id. Dr. Seng found that Plaintiff had intact associations, logical thinking, and logical thought content, with normal range cognitive functioning and normal insight and fair social judgment. Id. He diagnosed Plaintiff with panic disorder, major depressive disorder, recurrent and unspecified, and ADHD, combined presentation. Id. at 243. He acknowledged Plaintiff's medical diagnoses of paruresis and spondylolythesis and his prescribed medication of Xanax. Id. Dr. Seng rated Plaintiff's GAF at 60, indicative of moderate symptoms. Id. at 240. He counseled Plaintiff and continued his medications. Id.

         On August 17, 2013, Dr. Seng indicated that improvement was occurring and Plaintiff indicated that he was slowly getting better, although his anxiety and agoraphobia continued, but were improving. Tr. at 245. Plaintiff reported being able to go to his girlfriend's house, but his relationships with his family and friends were noted as decreased. Id. Dr. Seng's mental status examination indicated that no abnormalities were found and there was intact recent and remote memory, normal attention span, no signs of hyperactivity, no signs of anxiety, and intact judgment and insight. Id. The same previous diagnoses and GAF were made, and Plaintiff received counseling. Id. at 246.

         Plaintiff continued to treat with Dr. Seng in September, October, November and December of 2013. Dr. Seng's mental status examinations during this time found that Plaintiff presented with no serious mental status abnormalities, an intact memory, and a normal attention span, he appeared wary, attentive, and anxious, and he had normal speech, appropriate affect, no hallucinations, delusions, or suicidal ideations, logical thinking and content, normal cognitive functioning, and fair insight and judgment. Tr. at 248, 251, 254, 257. Dr. Seng's diagnoses remained the same and his GAF scores were rated at 60 each time. Id. at 249, 252, 255, 257.

         Dr. Seng continued to treat Plaintiff in 2014, noting improvement, with some continuing panic attacks, but no mental status examination abnormalities. Tr. at 260, 263. Due to the continuing panic attacks, anxiety, and agoraphobia, Dr. Seng tried additional medications, including Zoloft, Brintellix, Wellbutrin, Latuda, Zyprexa and Klonopin during the year. Id. at 264, 267, 273, 280, 287, 292. His mental status examination findings remained the same as those reported prior. Id. at 264, 268, 270. In July of 2014, Dr. Seng noted that Plaintiff showed an inadequate treatment response as his anxiety symptoms continued unchanged. Id. at 273. The mental status examination findings remained relatively the same at this session, and Wellbutrin was prescribed. Id. at 274-275. In August of 2014, Plaintiff's symptoms were partially improved as the panic attacks were less frequent and intense. Id. at 277.

         September 2014 treatment notes from Dr. Seng indicated that Plaintiff showed inadequate treatment response as his anxiety symptoms continued and had increased. Tr. at 280. Dr. Seng noted that Plaintiff had reported that he had gotten out more than any time in the past, as he had gone to Cedar Point, Put-in-Bay, Riverfest, and bars. Id. Plaintiff reported that he could not go to a store or gas station as he would get short of breath, had poor focus, and was impatient. Id. Mental status examination findings remained essentially the same. Id. Dr. Seng added Latuda. Id. Plaintiff reported feeling better in early October of 2014 with the Latuda. Id. at 284. In late October of 2014, however, Plaintiff reported a setback and was feeling worse. Id. at 287. The mental status examination findings remained the same, however, as well as Plaintiff's diagnoses and GAF of 60. Id. at 288. Plaintiff's dosage of Zyprexa was changed. Id. at 289. Improvement was noted in November of 2014, although Plaintiff reported continuing social anxiety. Id. at 291. Klonopin was added to his medications. Id. at 292.

         In 2015, Plaintiff continued to treat with Dr. Seng, and he reported in January of 2015 that he was unable to take Klonopin and his agoraphobia symptoms continued, as well as panic attacks, although the frequency and intensity of the panic attacks had decreased. Tr. at 294. Dr. Seng's mental status examination findings for Plaintiff remained essentially unchanged and his GAF remained at 60. Id. at 294-295. April 9, 2015 treatment notes indicate that Plaintiff was able to go to Cleveland and felt panicky, and the next day he had a panic attack in a gas station. Id. at 297. Mental status examination findings indicated that Plaintiff was wary, inattentive, communicative and anxious, with normal speech and cognitive functioning, fair insight and judgment, but he was mildly depressed, appeared downcast, and his affect was blunted. Id. Dr. Seng added the diagnosis of agoraphobia and removed the ADHD diagnoses. Id. at 298. He assigned Plaintiff a GAF of 55, still indicative of moderate symptoms. Id. Plaintiff reported continuing panic attacks in August of 2015 and Lithium was added to his medications. Id. at 318. In December of 2015, Dr. Seng changed Plaintiff's diagnoses to agoraphobia with panic disorder and major depressive disorder, mild and recurrent. Id. at 325. He assigned Plaintiff a GAF of 50, indicative of serious symptoms, and he added Lamictal to Plaintiff's medication regimen. Id.

         On June 13, 2015, Dr. Seleshi, M.D., an agency reviewing doctor, considered the evidence of record and specifically considered Listings 12.04 for affective disorder, 12.06 for anxiety-related disorders, and 12.07 for somatoform disorders. Tr. at 56. Dr. Seleshi opined that Plaintiff was mildly restricted in his daily living activities and in maintaining concentration, persistence or pace, and he was moderately restricted in maintaining social functioning. Id. He concluded that Plaintiff's anxiety may reduce his work-related efficiency and he could perform a variety of tasks that could be carried out independent of others without expectations to adhere to strict productivity standards or time constraints. Id. at 58. He found that Plaintiff was markedly limited in interacting with the general public and moderately limited in interacting with others, so he should avoid work involving more than an occasional direct contact with the general public or collaborative tasks entailing sustained engagement with others. Id. at 58-59. He further opined that Plaintiff could relate to co-workers and supervisors on a brief, intermittent and superficial basis only. Id. at 59. He also opined that Plaintiff could work in a stable, low-stress environment where he could perform solitary assignments at a relaxed pace. Id. Dr. Waggoner, Psy.D., reviewed the record and affirmed Dr. Seleshi's findings and opinion. Id. at 63-71.

         Dr. Seng continued to treat Plaintiff in 2016 and his anxiety symptoms continued. Tr. at 327. He reported that it was a struggle to go out and mental status examination findings showed that Plaintiff appeared way, inattentive, communicative, anxious, with mild depression symptoms, appropriate affect, no hallucinations, delusions, or bizarre behaviors, logical thinking, and fair insight and judgment. Id. Lamictal added to his medication regimen in January appeared to be helping in April of 2016, with Plaintiff reporting that he was feeling much better. Id. at 330. He indicated that he could occasionally go to a store or other building with his girlfriend and he was participating in adult education. Id. Dr. Seng told him to try to get out daily to see how far he could go. Id. at 331.

         Dr. Seng's June 2016 treatment notes show that Plaintiff reported that he was able to go to Columbus to watch a graduation ceremony, but his agoraphobia symptoms continued, although they had improved. Tr. at 333. July 2016 treatment notes indicate that Plaintiff's condition was stable and he had no psychiatric complaints. Id. at 336. Plaintiff reported that he was going to live with his girlfriend and his behavior was stable and uneventful. Id. September 2016 treatment notes show that Plaintiff appeared to be improving, he moved in with his girlfriend, and he was getting out more. Id. at 339. He was going to a store 1-2 times per week and he was able to use the bathroom when he was out and able to go to a restaurant. Id. He indicated that he enjoyed a past teaching position and he continued to look for anything that would allow him flexibility and the ability to work only part-time as he continued to struggling with “‘having to be'” anywhere. Id.

         On November 29, 2016, Dr. Seng completed a medical assessment of Plaintiff's ability to perform work-related activities with his mental impairments. Tr. at 343. Dr. Seng checked the “Extreme” boxes as to Plaintiff's abilities to follow work rules, relate to co-workers, deal with the public, use judgment, interact with supervisors, deal with work stresses, function independently, and maintain attention and concentration. Id. “Extreme” was defined as “[t]he individual has major limitations in this area with no useful ability to function.” Id. In describing the findings that supported his assessment, Dr. Seng wrote that “[h]is [Plaintiff's] agoraphobia has not allowed him to consistently go anywhere particularly if there is some requirement that he remain at the location. His anxiety becomes debilitating.” Id. Dr. Seng also checked “Extreme” for Plaintiff's abilities to understand and carry out any kind of job instructions, including simple instructions. Id. at 344. In support, he wrote “[a]gain, his agoraphobia would prevent attendance & would cause debilitating anxiety if he tried.” Id. In assessing Plaintiff's abilities to make personal and social adjustments, Dr. Seng checked the “Extreme” boxes for Plaintiff's abilities to maintain his personal appearance, behave in an emotionally stable manner, relate predictably in social situations, and demonstrate reliability. Id. He relied on his prior statements for support. Id. When asked about other work-related activities, Dr. Seng wrote that “[h]is agoraphobia ...


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