United States District Court, N.D. Ohio, Eastern Division
MEMORANDUM OF OPINION AND ORDER
JONATHAN D. GREENBERG UNITED STATES MAGISTRATE.
Laura LT Windsor (“Plaintiff” or
“Windsor”), challenges the final decision of
Defendant, Andrew Saul,  Commissioner of Social Security
(“Commissioner”), denying her applications for a
Period of Disability (“POD”) and Disability
Insurance Benefits (“DIB”), under Titles II of
the Social Security Act, 42 U.S.C. §§ 416(i), 423,
and 1381 et seq. (“Act”). This Court has
jurisdiction pursuant to 42 U.S.C. § 405(g) and the
consent of the parties, pursuant to 28 U.S.C. §
636(c)(2). For the reasons set forth below, the
Commissioner's final decision is AFFIRMED.
2015, Windsor filed an application for POD and DIB alleging a
disability onset date of June 11, 2014 and claiming she was
disabled due to a hysterectomy, anxiety, extreme bleeding
prior to her hysterectomy, joint pain, celiac disease,
parotid swelling, anemia, polyarthralgia, myofascial pain,
dysfunction of eustachian tube, and tenosynovitis.
(Transcript (“Tr.”) at 165, 194.) The
applications were denied initially and upon reconsideration,
and Windsor requested a hearing before an administrative law
judge (“ALJ”). (Tr. 105, 112, 119.)
11, 2017, an ALJ held a hearing, during which Windsor,
represented by counsel, and an impartial vocational expert
(“VE”) testified. (Tr. 36.) On August 30, 2017,
the ALJ issued a written decision finding Plaintiff was not
disabled. (Tr. 8-30.) The ALJ's decision became final on
May 8, 2018, when the Appeals Council declined further
review. (Tr. 1.)
6, 2018, Windsor filed her Complaint to challenge the
Commissioner's final decision. (Doc. No. 1.) The parties
have completed briefing in this case. (Doc. Nos. 20, 21, 22.)
Windsor asserts the following assignments of error:
(1) Whether the ALJ's analysis of treating physician Dr.
Factor's medical opinion violated the treating physician
(2) Whether the ALJ's RFC finding is supported by
(Doc. No. 20.)
Personal and Vocational Evidence
was born in October 1976 and was forty years-old at the time
of her administrative hearing, making her a
“younger” person under social security
regulations. (Tr. 22.) See 20 C.F.R. §§
404.1563. She has a high school education and is able to
communicate in English. (Id.) She has past relevant
work as a cook and electronics assembler. (Id.)
Relevant Medical Evidence
23, 2015, Windsor underwent a psychiatric evaluation with
psychiatrist Thomas M. Robb, M.D. (Tr. 477.) She reported
anxiety, excessive worry, and insomnia. (Id.) Dr.
Robb diagnosed her with generalized anxiety disorder. (Tr.
478.) He prescribed Gabapentin and Klonopin and referred
Windsor for psychotherapy. (Id.)
underwent a diagnostic assessment with counselor Diane
Maytas, LPCC, on July 28, 2015. (Tr. 525.) She indicated she
was struggling with anxiety, worry, low motivation, and
exhaustion. (Id.) She also described paranoia
surrounding eating gluten. (Id.) On examination,
Windsor appeared disheveled, had a flat and depressed affect,
displayed a flight of ideas, with normal thought content, and
no suicidal ideation. (Tr. 528.) She was oriented to person,
place, and time, and her long term memory was intact.
(Id.) Ms. Maytas noted Windsor's concentration
was impaired and her judgment and insight were fair. (Tr.
subsequently began to see Ms. Maytas on a weekly basis for
counseling. (Tr. 523, 522, 521.) She reported “keeping
herself busy, ” by watching friend's pets,
kayaking, bowling, and bike riding. (Tr. 523, 522.) She
described being exhausted after performing small tasks. (Tr.
521.) Windsor displayed anxiety on examination. (Tr. 522.)
returned to Dr. Robb on August 21, 2015, reporting mild
depression and anxiety. (Tr. 485.) On examination, she had
adequate judgment, insight, memory, and concentration. (Tr.
486.) She displayed no signs of depression or suicidal
continued to visit Ms. Maytas on a weekly basis in August and
September 2015. (Tr. 519, 517.) She displayed some anxiety,
but also reported she was staying active by riding her bike,
planning for a vacation, and playing cards with friends. (Tr.
519, 518, 569.) On September 9, 2015, she reported short term
memory deficits, but her concentration was adequate on
examination. (Tr. 649.) On September 15, 2015, she relayed a
recent vacation was “awesome” and she was able to
relax and enjoy herself. (Tr. 517.) On September 22, 2015,
she described several “bad days” the prior week,
during which she felt overwhelmed and anxious. (Tr. 516.)
October 6, 2015, Windsor reported to Ms. Maytas she recently
attended a concert with her sister and husband. (Tr. 568.)
She reported her anxiety had improved, but described some
short term memory issues. (Id.)
October 7, 2015, Ms. Maytas filled out a “Daily
Activities Questionnaire” on behalf of Windsor. (Tr.
532-533.) She noted the following:
• Windsor has good relationships with family and friends
and regularly socializes;
• She displayed difficulty with short term memory
• She has anxiety symptoms in the morning;
• Her finds her dietary needs draining, overwhelming,
and challenging at times;
• She requires additional rest throughout the day;
• She tires easily and becomes overwhelmed with
• She plans shopping throughout the week in order to
avoid feeling overwhelmed;
• She takes public transportation to and from
• Her husband and sister assist her when needed.
October and November 2015 therapy notes from Ms. Maytas
indicated she continued to stay busy by socializing and going
for walks. (Tr. 567, 564, 562.) She expressed worry over Dr.
Robb possibly discontinuing her medications because she felt
they were working well. (Tr. 566, 562.)
December 2015, Windsor continued to feel anxious in the
morning, had short term memory issues, and often felt
exhausted and overwhelmed. (Tr. 558, 559, 557, 556.) She
indicated she was providing a great deal of assistance to her
sister and other individuals in her life, which frustrated
her. (Tr. 557.)
continued to regularly attend counseling sessions Ms. Maytas
in 2016. On January 14, 2016, Windsor reported she was often
worried and her hair was falling out. (Tr. 555.) Windsor
appeared tired on examination. (Id.) On February 3,
2016, Windsor reported she recently went to Detroit for a
trip and attended a concert. (Tr. 624.) She described low
motivation and excessive sleep. (Id.) On February
19, 2016, she described anxiety and difficulty waking in the
morning. (Tr. 623.) However, by March 23, 2016, Windsor
indicated her mood and fatigue improved a decrease to her
Gabapentin dosage and discontinuing her acid reflux
medication. (Tr. 621.) She also reported her morning anxiety
had improved. (Id.)
April 2016, Windsor continued to express frustration and
stress over providing so much support to the people in her
life. (Tr. 619.) Ms. Maytas noted Windsor had trouble setting
boundaries with her family. (Id.) In May 2016,
Windsor attended a gluten free convention in Chicago with her
husband. (Tr. 643, 642.) At that time, Ms. Maytas observed
Windsor had “come to the realization that when she gets
out of the home and does something she feels fine.”
24, 2016, Windsor returned to Dr. Robb for medication
management. (Tr. 647.) Dr. Robb noted Windsor continued to
have anxiety, but it was managed by medication.
(Id.) Windsor denied suicidal ideation and displayed
adequate concentration in conversation. (Id.)
21, 2016, Windsor reported to Ms. Maytas that she did not
feel “too bad” and her motivation had increased.
(Tr. 638.) On August 4, 2016, Ms. Maytas observed Windsor
appeared “to be doing well and progressing when
utilizing coping skills.” (Tr. 637.)
August 18, 2016, Windsor underwent an updated diagnostic
assessment and treatment plan with Ms. Maytas. (Tr. 634.) Ms.
Maytas concluded Windsor had made good progress with episodic
setbacks. (Id.) Windsor reported she was struggling
with short term memory retrieval, reading, and concentration.
(Tr. 635.) She described low motivation in the morning due to
her lack of employment. (Tr. 636.)
then began to see Ms. Maytas every few weeks rather than on a
weekly basis. (Tr. 661, 660.) On September 1, 2016, Windsor
reported she had gone on a weekend camping trip with her
husband and had been walking a great deal in the evenings.
(Tr. 661.) She again described low motivation. (Id.)
On September 15, 2016, Windsor reported increased anxiety and
low motivation. (Tr. 660.) On September 28, 2016, Windsor
indicated that since discontinuing her Gapapentin, she felt
more aware and was able to multi-task. (Tr. 659.) However,
Windsor's anxiety levels increased in October 2016. (Tr.
658.) Her memory had improved. (Id.)
November 2016, Ms. Maytas observed Windsor was learning
coping skills. (Tr. 739.) Windsor reported feeling exhausted
by household chores. (Tr. 738.) Windsor continued to express
frustration and stress with her family in December 2016. (Tr.
December 9, 2016, Windsor followed up with Dr. Robb,
reporting continued anxiety. (Tr. 680.) She indicated she was
able think clearer after discontinuing her Gabapentin and her
stomach felt better as well. (Id.) On examination,
she had adequate concentration and displayed anxiety.
continued to treat with Ms. Maytas and Dr. Robb in 2017. On
January 3, 2017, Windsor indicated she had gone out of town
for New Years and enjoyed herself. (Tr. 735.) She relayed
that while she was doing well, it took a lot of effort.
(Id.) She expressed a desire to possibly work in a
gluten free restaurant. (Id.) On January 17, 2017,
Ms. Maytas noted Windsor had shown progress in
“expanding her comfort zone.” (Tr. 734.) Windsor
denied any issues with her memory on January 31, 2017. (Tr.
February 2017, Windsor was planning a trip to Florida. (Tr.
731.) She continued to struggle with motivation, but
demonstrated progress in setting boundaries with her family
members. (Tr. 731, 732.)
returned to Dr. Robb on March 10, 2017, displaying good
insight, adequate judgment, adequate
concentration in conversation, and no suicidal ideation. (Tr.
789.) On March 14, 2017, Windsor described exhaustion after
completing household tasks, but had made progress in reaching
out to others for support and talking with friends. (Tr.
730.) On March 28, 2017, Windsor indicated to Ms. Maytas she
struggled to pay attention and could not handle stress. (Tr.
April 2017, Windsor reported frustration with her celiac
disease. (Tr. 841, 839.) In May 2017, Windsor's sleep was
improved, but she still felt exhausted most of the time. (Tr.
838, 837.) On June 20, 2017, Windsor reported she had
recently attended a concert and was planning a trip with her
husband. (Tr. 835.) She relayed her anxiety increased when
she felt overwhelmed and had a lot of events to attend.
27, 2014, Windsor visited her gynecologist, Soghra Hornafar,
M.D., for a surgical consultation. (Tr. 380.) She reported
heavy bleeding and requested a hysterectomy. (Id.)
Windsor underwent a hysterectomy on June 11, 2014. (Tr. 419.)
January 8, 2015, Windsor visited primary care physician
Virginia Mateo Factor, D.O., for a new patient visit. (Tr.
361.) She reported anxiety, menopausal symptoms, and joint
pain and stiffness. (Tr. 361-362.) On examination, Windsor
had a full range of motion in her elbows, crepitus in her
right elbow, no obvious swelling in her joints, and a normal
gait and station. (Tr. 364.) Dr. Factor diagnosed generalized
anxiety disorder and polyarthralgia, and referred Windsor to
a rheumatologist. (Tr. 365.)
initially visited rheumatologist Inderprit Singh, M.D., on
February 16, 2015. (Tr. 262.) She reported pain in her left
shoulder, wrists, hands, left ankle, and left foot.
(Id.) On examination, she displayed skin
hyperextensibility and ankle joint hypermobility. (Tr. 265.)
The remainder of her musculoskeletal examination was normal,
with no swelling and a normal range of motion in her
shoulders, elbows, wrists, hands, hips, knees, and ankles.
(Tr. 265, 266.) Her gait and station were normal, with full
strength and no muscle atrophy. (Tr. 267.) Dr. Singh ordered
blood work. (Tr. 269.)
February 24, 2015, gastroenterologist Mehrdad Asgeri, M.D.,
reviewed this labwork and diagnosed Windsor with celiac
disease. (Tr. 307.) Windsor reported fatigue and anemia since
her hysterectomy. (Tr. 305.)
followed up with Dr. Factor on March 2, 2015, reporting her
anxiety medications were effective. (Tr. 366.) On
examination, she had edema in her lower extremities, but a
normal gait and station and normal mood and affect. (Tr.
369.) Dr. Factor noted a “significant
improvement” in Windsor's anxiety. (Id.)
March 19, 2015, Windsor underwent an EGD and had biopsies
taken. (Tr. 303.) She followed up with Dr. Asgeri on March
23, 2015. (Tr. 289.) She reported mild abdominal bloating and
pain, but indicated she felt “a little better”
since starting a gluten-free diet. (Id.) Dr. Asgeri
referred her to a dietician. (Tr. 291.)
visited dietician Margaret Zeller, R.D., on March 31, 2015
for a nutrition consultation. (Tr. 354.) She reported
abdominal pain, bloating, and gas. (Id.) Ms. Zeller
observed Windsor had already made dietary changes and
provided her with nutrition education. (Tr. 355.)
returned to Dr. Factor on June 1, 2015, again reporting her
anxiety medications were working “very well.”
(Tr. 370.) She saw Dr. Singh that same date, reporting her
recent diagnosis of celiac disease. (Tr. 269.) Windsor
indicated she was a “lot better” on her gluten
free diet. (Tr. 270.) On examination, her shoulders, elbows,
hips, knees, and ankles were normal, with no swelling and a
normal range of motion. (Tr. 272, 273.) Dr. Singh did observe
De Quervain's tenosynovitis on the right side, but
Windsor's gait and station were normal. (Tr. 274.)
17, 2015, Windsor visited Dr. Singh, again reporting
improvement on her gluten free diet. (Tr. 277.) She reported
no side effects from her Gabapentin, other than drowsiness.
(Id.) She rated her pain as 2/10, but 5/10 after
activity. (Id.) On examination, her shoulders,
elbows, hips, knees, ankles, and feet displayed no swelling
and a full ...