United States District Court, N.D. Ohio, Western Division
MEMORANDUM OPINION & ORDER
J. LIMBERT, UNITED STATES MAGISTRATE JUDGE
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.
FACTUAL AND PROCEDURAL HISTORY
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. 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.
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.
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.
RELEVANT MEDICAL AND TESTIMONIAL EVIDENCE
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.
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.
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.
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.
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
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,
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.
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
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.
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.
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.
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.
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 ...