United States District Court, N.D. Ohio, Eastern Division
MEMORANDUM OPINION AND ORDER
R. Knepp II United States Magistrate Judge.
Cynthia Cremens (“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.
filed for DIB and SSI in September 2014, alleging a
disability onset date of August 5, 2010. (Tr. 210-11). Her
claims were denied initially and upon reconsideration. (Tr.
126-43). Plaintiff then requested a hearing before an
administrative law judge (“ALJ”). (Tr. 145).
Plaintiff (represented by counsel), and a vocational expert
(“VE”) testified at a hearing before the ALJ on
February 22, 2017. (Tr. 27-55). On June 20, 2017, the ALJ
found Plaintiff not disabled in a written decision. (Tr.
11-21). 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 May 1, 2018. (Doc. 1).
Background and Testimony
1970, Plaintiff was 40 years old on her alleged onset date.
See Tr. 20, 210. Plaintiff had an eighth-grade
education, and stated she could do basic math and read. (Tr.
45). She also reported past work at a radio station. (Tr.
31-32). Plaintiff lost her job after an August 2010
involuntary inpatient psychiatric hospital stay. (Tr. 33-34).
Plaintiff also had another psychiatric inpatient admission in
the 1990s. (Tr. 35).
time of the hearing, Plaintiff received mental health
treatment from the CharakTreatment Center for depression,
insomnia, mood swings, rage, “[e]pisodes where [she]
tear[s] stuff up”, and blackouts. (Tr. 34-35).
Plaintiff testified to feeling “down” more than
“up”. (Tr. 35). During a down cycle - which could
last “from a couple of days to over a month.”
(Tr. 35), Plaintiff did not get out of bed, and ate less (Tr.
36). Plaintiff also testified to rage episodes where she
would “get so mad [she] can't remember what [she]
do[es]”. (Tr. 36). During such episodes, she had hit
her kids, torn up things in her house, and poured a gallon of
paint over “everything in [her] house.” (Tr.
36-37). Plaintiff was arrested based on her behavior in the
past. (Tr. 37-38).
had auditory hallucinations of music, talking, or people
calling her name. (Tr. 38). Plaintiff testified she had been
on psychiatric medication “[o]n and off since the early
90s”. (Tr. 39). She saw Dr. Ranjan “[o]n and
off” for about two and a half years. (Tr. 40). She
believed that her mental condition was “a lot
worse” the past couple of years. Id. She had a
“hard time concentrating and remembering”. (Tr.
August 2010, Plaintiff was involuntarily admitted to River
Point Behavioral Health for three days after making
statements about suicide. (Tr. 309). On discharge, Plaintiff
was assessed with bipolar disorder (“seemingly Type II,
most recent episode Hypomanic without Psychotic Features in
acute exacerbation, now in discrete remission”),
alcohol abuse, not otherwise specified, and “[n]ormal
grieving (?)”. (Tr. 498). Treatment notes reference the
unexpected death of Plaintiff's father. (Tr. 499).
Plaintiff was discharged into her family's custody to
attend her father's funeral and was noted to be
“normally grieving her father's unexpected
death”, and at that time manifested no suicidal
November 2014, Plaintiff underwent an intake evaluation with
psychologist Charel Khol, with Affiliates in Behavioral
Health. (Tr. 398-401). Plaintiff reported having moved to
Cleveland in June 2014 after living in Florida. (Tr. 398).
She reported past diagnoses of bipolar disorder, panic
attacks, and agoraphobia. Id. Plaintiff reported no
psychiatric medication for the prior three years.
Id. On mental status examination, Plaintiff's
general appearance/behavior was appropriate, cooperative,
open, alert, oriented, and confused, with good eye contact.
(Tr. 400). Her speech was clear, coherent, relevant, and
spontaneous. Id. Her cognitive functioning was noted
to be within normal limits, but she had immediate memory
problems. Id. She had below average intellect and
fair insight/judgment. Id. Dr. Khol offered
diagnoses of 296.80 (bipolar disorder) and 300.01 (panic
disorder). (Tr. 401). He assigned a
“[c]urrent” Global Assessment of Functioning
(“GAF”) score of 52, and a “[p]ast
[y]ear” score of 57. Id. Dr. Khol commented that
Plaintiff had a history of mood swings and agoraphobia and
had “[n]ever had treatment that is required to manage
week later, Plaintiff underwent a psychological consultative
examination with Amber L. Hill, Ph.D. (Tr. 341-51). Plaintiff
reported she was “off [her] medication” and was
applying for disability in part because she was
“bipolar, manic depress[ive], borderline
suicidal.” (Tr. 341). On examination, Dr. Hill noted
Plaintiff was dressed appropriately and was well-groomed.
(Tr. 346). She had normal motor behavior and maintained
appropriate eye contact. Id. Plaintiff had a
coherent thought process and fluent, clear speech.
Id. There was no evidence of hallucinations,
delusions, or paranoia. Id. Plaintiff's affect
was full and appropriate, and mood was “only slightly
dysthymic.” (Tr. 347). Dr. Hill did not observe any
anxiety in the interview, or in the waiting room.
Id. Plaintiff was oriented and her attention,
concentration, and recent/remote memory “appeared
intact”. Id. Dr. Hill opined Plaintiff's
overall intellectual functioning to be “within a below
average range”. Id. Dr. Hill assessed
persistent depressive disorder (early onset, mild),
agoraphobia, and alcohol use disorder (moderate).
Id. Dr. Hill opined Plaintiff's prognosis was
“guarded” because she was “not currently
engaged in any mental health treatment related to her
reported mental health concerns and states that she has not
had treatment for the past one to two years.” (Tr.
following month - December 2014 - Shura Hegde, M.D. (also at
Affiliates in Behavioral Health), completed an intake
evaluation of Plaintiff. (Tr. 395-96). Plaintiff reported
taking Lamictal, for one month, but “ha[d] not been
taking it on a regular basis”. (Tr. 395). Plaintiff had
mood swings, fatigue, depression, and decreased motivation;
she also reported financial stress and not wanting to be
around people. Id. Dr. Hegde observed Plaintiff was
“in no apparent distress” and reported her mood
“was fine”. (Tr. 396). She had an appropriate
affect, normal speech, linear thought process, and normal
thought content. Id. She denied hallucinations, had
intact memory, and limited judgment. Id. Dr. Hegde
assessed a history of type two bipolar disorder, severe
alcohol use disorder in remission, marijuana use disorder,
rule out substance abuse, mood disorder. Id. She
assessed a GAF score of “[a]bout 52 to 55”.
Id. Dr. Hegde prescribed Seroquel and Brintellix and
instructed Plaintiff to follow up with counseling.
February 2015, Dr. Khol completed a brief mental status
examination form. (Tr. 394). In it, she noted Plaintiff was
disheveled, with dirty clothes. Id. Plaintiff had a
calm and cooperative attitude, normal speech, and behavior.
Id. Her affect was flat and blunted, and her mood
was irritable, anxious, and depressed. Id. Her
thought processes were disorganized; she did not have
suicidal or homicidal ideations, but had fears of leaving
home and being around others. Id. She had no
perceptual disturbances, and was oriented. Id. She
had “some disruption in thoughts”. Id.
At the same time, Dr. Khol completed a daily activities
questionnaire. (Tr. 392-93). In it, she noted Plaintiff lived
with her disabled spouse, and children (ages 22 and 15). (Tr.
392). She noted Plaintiff had difficulty getting along with
family and neighbors, but her sister-in-law drove her to
appointments. Id. She noted Plaintiff reported that
she did not get along with former employers, supervisors, and
coworkers because “she's always argumentative and
some[times] aggressive.” Id. When asked for
examples that might prevent work activities, Dr. Khol noted
Plaintiff was easily stressed out, had blacked out at times,
had poor concentration and restlessness, did not get out of
bed some days, had mood swings, depression, and anxiety, and
would not be able to be safe around equipment. Id.
She also noted Plaintiff rarely engaged in food preparation
(“doesn't pay attention [and] burns meal”) or
shopping (“can ‘run in' for a few things
w[ith] someone with her”). Id. She observed
Plaintiff's personal hygiene was poor. Id. She
did not drive and was afraid of public transportation.
Id. Dr. Khol described Plaintiff's current
treatment as once per month for psychotherapy, and noted
Plaintiff saw Dr. Hegde for psychiatric medication.
saw Rakesh Ranjan, M.D., and Michelle Steele, L.P.N., at the
Charak Center for Health and Wellness for a medication review
visit in January 2016. (Tr. 447-52). Plaintiff rated her
depression as 8/10 and attributed this to the “extra
stress” of the holidays, and being off her medication.
(Tr. 447). She reported missing an appointment and running
out of medication. Id. She reported her symptoms had
worsened, with daily panic attacks, poor sleep, and no
appetite. Id. She also, however, reported bathing
regularly and keeping up with her activities of daily living.
Id. She wanted to get back on medication to help
with her anxiety, depression, and sleep. Id. On
mental status examination, she was noted to be well-groomed,
with average eye contact and motor activity. (Tr. 449). Her
demeanor was cooperative, and her speech was normal.
Id. Her thought content contained no delusions, but
she reported auditory and visual hallucinations. Id.
Her mood was euthymic and her affect constricted. (Tr. 450).
She was oriented, her reasoning ability was intact, and her
memory was normal. Id. She was noted to have average
insight, fair judgment, normal impulse control, and
moderately impaired energy and concentration. Id.
Dr. Ranjan continued Plaintiff's medications (Seroquel
XR, Lamotrigine, Abilify, and Klonopin). (Tr. 451). She was
instructed to continue individual therapy sessions to
identify coping mechanisms and stress reduction techniques.
November 2014 consultative examination, Dr. Hill offered an
opinion regarding Plaintiff's limitations. (Tr. 349-51).
She opined Plaintiff appeared able to understand, remember,
and carry out instructions and that there “does not
appear to be any significant limitation in this area.”
(Tr. 349). She noted Plaintiff appeared able to maintain
attention and concentration and perform simple and multi-step
tasks “as evidenced by her presentation within the
clinical interview setting, her performance on the mental
status exam tasks, and her reported daily functioning, in
which she completes numerous multi-step tasks
independently[.]” Id. She noted Plaintiff
“may have some limitation in maintaining persistence
and pace” due to her depression symptoms, but noted
that she “might have improvements in this area if she
were to engage in mental health treatment, such as counseling
and therapy or medical for possibly symptom control or
relief.” Id. Dr. Hill also opined Plaintiff
appeared able to respond appropriately to supervisors and
coworkers in a work setting based on her conduct during the
interview, and her “report of positive socialization in
her life”. (Tr. 350). She acknowledged Plaintiff's
self-reported agoraphobia, “which could possibly cause
difficulty in this area”, but noted she had not
observed such symptoms in the interview or the waiting area,
and that it was “difficult to determine” whether
mental health treatment” would help with this.
Id. Finally, Dr. Hill opined Plaintiff “may
have some difficulty” responding appropriately to work
pressures in a work setting based on her reported agoraphobia
and alcohol use. Id. Dr. Hill continued:
Having said that, the claimant's reported concerns with
anxiety related symptomatology of agoraphobia were not
observed within the clinical interview setting. Further, the
claimant did not report any difficulty in this area in her
reported work history. It is possible if the claimant were to
engage in mental health treatment, such as counseling and
therapy or medication, that she could have positive benefit,
including symptom control or relief in this area.
February 2015, Dr. Khol completed a mental status
questionnaire. (Tr. 389-91). Dr. Khol noted she first saw
Plaintiff on November 18, 2014, and had last seen her on
February 16, 2015 (the date on the questionnaire). (Tr. 389).
Dr. Khol observed Plaintiff was disheveled, with a depressed,
anxious, and irritated mood, and a flat and blunted affect.
(Tr. 389). She noted Plaintiff cried when anxious and did not
like to be around others or leave her home. Id. Dr.
Khol observed Plaintiff's concentration was very poor and
it was difficult for her to focus on one topic. Id.
(“mind wanders during sessions”). Further, Dr.
Khol noted Plaintiff reported throwing things at home, or
sometimes “black[ed]” out (not from alcohol) and
did not remember her actions. Id. Dr. Khol opined
Plaintiff could remember, understand, and follow directions
“[i]f written down” due to memory problems. (Tr.
390). She opined Plaintiff had a “poor” ability
to maintain attention because she “tends to jump to
other areas” or “turn off if a problem or
conflict” arises. Id. Dr. Khol also opined
Plaintiff could not sustain concentration, persist at tasks,
or complete them in a timely fashion, observing: “takes
long time to complete tasks - problems with organizing
thoughts and plan[ning] ahead.” Id. Dr. Khol
also observed Plaintiff had “great difficulty” in
social interaction and stayed away from others, noting by way
of example that she did not shop for many things, but sent
family members instead. Id. Dr. Khol also opined
Plaintiff would not be able to make adjustments to work
pressures because she is “extremely anxious in
situations that she perceives as unknown and trapped”.
February 2015, state agency reviewing psychologist Juliette
Savitscus, Ph.D., reviewed Plaintiff's records and opined
Plaintiff was moderately limited in social functioning and
maintaining concentration, persistence or pace, and mildly
limited in activities of daily living. (Tr. 64). Dr.
Savitscus opined Plaintiff was moderately limited in her
ability to work in coordination with or in proximity to
others without being distracted and moderately limited in her
ability to complete a normal workday and workweek without
interruptions from psychologically based symptoms and to
perform at a consistent pace. (Tr. 67-68). She opined
Plaintiff could “perform simple and moderately complex
tasks (1-4 steps) in a work environment without fast-paced
production standards.” (Tr. 68). Dr. Savitscus also
opined Plaintiff was moderately limited in her ability to
interact with the general public, but “retain[ed] the
ability to work in a setting requiring infrequent and
superficial interactions with the public.” (Tr. 68-69).
Finally, she opined Plaintiff was moderately limited in her
ability to respond appropriately to changes in the work
setting, but “retain[ed] the ability to function in an
environment with infrequent changes that can be explained in
advance.” (Tr. 69).Within her opinion, Dr. Savitscus
noted where her opinion diverged from Dr. Khol's opinion.
See Tr. 65, 67-69.
2015, the State agency sent Affiliates in Behavioral Health a
Mental Status Questionnaire and Daily Activities
Questionnaire forms. (Tr. 404-09). The forms were returned
with a handwritten note: “Was seen by physician only 1
time this year. Dr. will not fill out!!!” (Tr. 405).
August 2015, Paul Tangeman, Ph.D., affirmed Dr.
Savitscus's opinion. (Tr. 102-04).
September 2015, Dr. Ranjan and Kelly Stevenson, LISW,
completed a form entitled “Medical Source Statement:
Patient's Mental Capacity”. (Tr. 440-41). In it,
they opined Plaintiff could rarely: use judgment, maintain
attention and concentration for extended periods of 2 hour
segments, maintain regular attendance and be punctual, deal
with the public, interact with supervisors, function
independently without redirection, work in coordination with
or proximity to others without being distracted, complete a
normal workday and workweek without interruption from
psychologically based symptoms and perform at a consistent
pace without an unreasonable number and length of rest
periods, understand, remember, and carry out complex job
instructions, relate predictably in social situations, and
manage funds/schedules. Id. Plaintiff could
occasionally: follow work rules, respond appropriately to
changes in routine settings, relate to coworkers, work in
coordination with or proximity to others without being
distracted, deal with work stress, understand, remember and
carry out simple or complex job instructions, socialize,
behave in an emotionally stable manner, and leave home on her
own. Id. She could frequently maintain her
appearance. (Tr. 441). As the diagnoses and symptoms to
support the assessment, they noted:
(1) bipolar [disorder] 1, mixed, severe with psychotic
features - sad mood, anhedonia, low energy, low self-esteem,
poor focus, sleep disturbance, auditory hallucinations,
impulsive spending, psychomotor agitation, racing thoughts,
pressured speech, (2) panic [disorder] [with] agoraphobia.
Severe panic attacks every 2 mo[nths] or so, minor ...