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Evans v. Berryhill

United States District Court, D. Minnesota

August 31, 2017

Cheryl Ann Evans, Plaintiff,
Nancy A. Berryhill, Acting Commissioner of Social Security, [1] Defendant.

          Jyotsna Asha Sharma, Esq., Disability Partners PLLC, counsel for Plaintiff.

          Gregory G. Brooker, Esq., United States Attorney's Office, counsel for Defendant.


          BECKY R. THORSON United States Magistrate Judge

         Pursuant to 42 U.S.C. § 405(g), Plaintiff Cheryl Ann Evans seeks judicial review of the final decision of Defendant Commissioner of Social Security denying her applications for disability insurance benefits and supplemental security income. This matter is before the Court on the parties' cross-motions for summary judgment, in accordance with D. Minn. LR 7.2(c)(1). (Doc. Nos. 13, 16.) For the reasons stated below, the Commissioner's denial of benefits is not supported by substantial evidence in the record, and the record convincingly establishes that Plaintiff is disabled within the meaning of the Social Security Act. Therefore, Plaintiff's motion for summary judgment is granted, Defendant's motion for summary judgment is denied, and this matter is remanded for calculation and an award of benefits.


         I. Procedural History

         Plaintiff applied for Title II disability insurance benefits (“DIB”) on May 21, 2013, and for Title XVI supplemental security income (“SSI”) on June 30, 2014. (Tr. 17.)[2] For both applications, Plaintiff alleged a disability onset date of October 1, 2008. (Tr. 17, 167.) The Social Security Administration denied Plaintiff's claims initially and upon reconsideration. (Tr. 108-12, 116-18.) Plaintiff then appealed to an Administrative Law Judge (“ALJ”). (Tr. 119-20.) At Plaintiff's request, an ALJ held an in-person hearing on April 15, 2015. (Tr. 39-82.) On April 23, 2015, the ALJ denied Plaintiff's applications. (Tr. 14-38.) The SSA Appeals Council then denied Plaintiff's request for review on May 31, 2016, making the ALJ's decision the final decision of the Commissioner. (Tr. 1-4); see 20 C.F.R. § 404.981.

         On August 3, 2016, Plaintiff filed this action seeking judicial review pursuant to 42 U.S.C. § 405(g). (Doc. No. 1.) Defendant filed an answer on October 12, 2016. (Doc. No. 10.) The parties have filed cross-motions for summary judgment pursuant to the Local Rules. (Doc. No. 14, Pl.'s Mem. Supp. Mot. Summ. J. (“Pl.'s Mem.”); Doc. No. 17, Def.'s Mem. Supp. Mot. Summ. J. (“Def.'s Mem.”).)[3] Plaintiff argues that the Commissioner's denial of benefits should be reversed, and this matter should be remanded for an immediate award of benefits, because the evidence in the record overwhelmingly supports the conclusion that she is disabled due to her agoraphobia. (See Pl.'s Mem.) Plaintiff also argues that she cannot work because she cannot leave her home by herself due to her agoraphobia. (See id.)

         II. Factual Background

         Plaintiff is a high school graduate who was born on January 9, 1968. (Tr. 49, 190.) Before her alleged onset date, Plaintiff worked as a fabric care aide at a nursing home, an administrative assistant for a collection agency, and most recently, from January 2002 until December 2005, as a tutor/education assistant at an elementary school. (Tr. 196.) In this job, Plaintiff tutored students in math and science and supervised children on the playground and in the lunch room. (Tr. 197.) From January 2002 until October 2009, Plaintiff also worked as a caretaker/leasing agent at her apartment building. (Tr. 196.) Plaintiff did not receive a paycheck for this work because it was a rent reduction job. (Tr. 203.)[4] She has not worked since she lost her tutoring job and stopped working as a leasing agent. Plaintiff currently lives with her longtime boyfriend of thirteen years, and she has a daughter from a previous marriage who is in college. (Tr. 49.)

         At some point in 2007, Plaintiff began experiencing increased anxiety and developed agoraphobia. (See Tr. 45, 271-73.) Plaintiff's treating therapist, Dr. Kathleen Wise, MA, LP, diagnosed Plaintiff with panic disorder with agoraphobia and major depression, recurrent severe. (Tr. 326.) Plaintiff's condition left her essentially homebound, except for when she was able to leave with her “safety people”--family members such as her boyfriend, her daughter, and her sister. (Tr. 45.) At the hearing, Plaintiff testified about her condition as follows:

I get dizzy. The world becomes distorted. I don't know how to--visually distorted. Everything seems crooked and I'm wobbly on my feet. I feel that--you know, I always feel like I'm going to fall down or--everything is just loud and distorted.
. . . .
There's no drive or no sunny side that a person sees to make anything worthwhile. It's just bleak . . . . [E]verything is bleak.
. . . .
[I fear] [p]retty much everything sometimes it feels like. I fear people. I feel like they're going to harm me. I fear people. I--and noise, and everything. Going in the car over 30 miles an hour. I just see doom around every corner. It--I'm not sure how else to describe, you know, all of my fears. But it's crowds, it's rooms that are too small, it's rooms that are too big, it's ceilings that are too low, it's lights that are too bright, it's too dark, it's lots of things. It's life basically.

(Tr. 59-60, 62.)

         III. The ALJ's Findings and Decision

          On April 23, 2015, the ALJ issued a decision denying Plaintiff's applications for benefits. (Tr. 17-33.) The ALJ found that Plaintiff was not disabled as defined by the Social Security Act from October 1, 2008, through the date of the decision. (Tr. 18, 33.)

         The ALJ followed the five-step evaluation process dictated by 20 C.F.R. § 404.1520(a)(4), which involves the following determinations: (1) whether Plaintiff is involved in “substantial gainful activity”; (2) whether Plaintiff has a severe impairment that significantly limits her mental or physical ability to work; (3) whether Plaintiff's impairments meet or equal a presumptively disabling impairment listed in the regulations; (4) whether Plaintiff has the residual functional capacity (“RFC”) to perform her past work; and (5) if Plaintiff cannot perform her past work, whether the government has shown that Plaintiff can perform other work, and that there is a sufficient number of those jobs available in the national economy. (Tr. 18-19.)

         At step one of the evaluation, the ALJ found that Plaintiff had not engaged in substantial gainful activity since her alleged onset date of October 1, 2008. (Tr. 19.) At step two, the ALJ determined that Plaintiff had the following severe impairments: depression, not otherwise specified; major depression, recurrent; agoraphobia; panic disorder with agoraphobia; anxiety; and generalized anxiety disorder. (Id.)

         Because the ALJ determined that Plaintiff had severe impairments, he continued to step three of the analysis. At this step, a claimant must show that her impairment or combination of impairments meets or medically equals the severity of one of the listed impairments in 20 C.F.R. § Part 404, Subpart P, Appendix 1. See 20 C.F.R. § 404.1520(a)(iii). The ALJ relied on the objective medical evidence, in addition to the testimony of Dr. Karen Butler, Ph.D, a neutral medical expert who testified at the hearing, in finding that the claimant's mental impairments do not meet or equal the criteria of Listings 12.04 and 12.06. (Tr. 17, 20.) Beginning with the paragraph B criteria, the ALJ credited Dr. Butler's opinion that Plaintiff has moderate restrictions in activities of daily living “evidenced by her fairly intact range of activities which reflect that the claimant has the ability to do activities of daily living but is reduced depending on her level of depression and anxiety in any given day.” (Tr. 20.) The ALJ did note Plaintiff often “did not take baths for days, which was a reflection of the depth of her depression” (Tr. 20), and could only shop in stores “after hours if accompanied by her significant other or her daughter.” (Tr. 21.) Even so, Plaintiff did the laundry, simple cooking, knitted hats, scarves and wash cloths, managed her finances, watched television and did Sudoku puzzles, played computer games, took care of and taught tricks to her dog, and attended to her personal care. (Tr. 20-21.) Plaintiff also cared for her elderly father when he lived independently, exercised, and worked on a deck project with her daughter during the claim period. (Id.)

         Regarding social functioning, the ALJ discussed Dr. Butler's testimony regarding Plaintiff's relationships, which are “confined within her family as opposed to specific friendships, clubs, hobbies or other activities outside of her home.” (Tr. 21.) The ALJ further considered Plaintiff's testimony that “she would have difficulty forming trusting relationships if she became employed, she has fears people are going to harm her, sees doom around every corner and in crowds, and only feels comfortable being around her trusted network of family members and her significant other.” (Id.) The ALJ found no more than moderate social limitations, however, apparently because Plaintiff watched television in her home with her family and talked on the phone with her sister. (Id.)

         The ALJ also found moderate difficulties in concentration, persistence or pace, due in part to her activities of daily living. (Id.) The ALJ pointed to a June 2013 function report, where Plaintiff indicated she did not need reminders or encouragement to attend to her personal needs, take her medications, or do household chores, but had difficulty paying attention, following written and spoken instructions, and handling stress or changes in routine. (Id.) Plaintiff also presented a “constricted affect and dysphoric mood” to her treating providers, but she typically presented as alert and fully oriented with normal speech, thought process, attention, memory, and fund of knowledge, and had no difficulty understanding treatment recommendations, maintaining conversation, or asking appropriate questions. (Id.) Plaintiff also answered questions appropriately at the hearing and there was no evidence that Plaintiff did not understand the content of the hearing. (Id.) “Resolving conflicts in the evidence, ” the ALJ found “no more than moderate difficulties in maintaining concentration, persistence, or pace.” (Tr. 21-22.)

         Finally, the ALJ found no episodes of decompensation, such as psychiatric hospitalization, enrollment in day treatment, or any increase in outpatient psychotherapy for an extended period. (Tr. 22.)

         Regarding the paragraph C criteria, the ALJ stated that the record did not reflect “repeated episodes of decompensation, a residual disease process that has resulted in such marginal adjustment that even a minimal increase in mental demands or change in the environment would be predicted to cause decompensation, or a current history of one or more years' inability to function outside a highly supportive living arrangement.” (Id.)[5]The ALJ therefore found that Plaintiff's impairments did not meet or equal a listing.

         Before step four, the ALJ found that Plaintiff had the RFC to perform a full range of work at all exertional levels, but with the following nonexertional limitations: limited to unskilled to semi-skilled tasks; no more than infrequent contacts and superficial contacts with others in a work setting; and she should not be serving the public as a primary part of her job tasks. (Tr. 22.)

         The ALJ began by outlining the Plaintiff's allegations:

The claimant . . . alleges she is disabled and unable to work due to mental health impairments and symptoms, which interfere with her ability to leave her home without people she trust[s], and which causes her to become dizzy, wobbly on her feet and distorts her world when she does leave her home unaccompanied. In addition, the claimant testified as a result of her psychological symptoms, she is only able to drive for short distances in the radius of her house, she only goes to places she can handle, she is often driven to places by her sister and significant other, her future outlook is bleak and she struggles to get out of her bed five to six days out of the month. Further, she testified she has fears of people harming her, fear of noise and of driving over thirty miles per hour and sees doom everywhere around her. Additionally, the claimant stated she would have difficulty forming a trusting relationship with another person if she became employed, did not have the concentration necessary to work and could only concentrate for a short time. The symptoms of claimant's condition have reportedly affected several of her work-related activities, such as memory, completing tasks, concentration, understanding and following instructions.

(Tr. 23-24.) The ALJ found that Plaintiff's allegations were credible “subject to a degree of functional restriction as a result of her mental impairments and symptoms.” (Tr. 24.) Thus, the RFC was reduced to accommodate Plaintiff's difficulties in performing complex, stressful work with prolonged or intense social contacts. (Id.) However, the ALJ rejected the contention that Plaintiff was completely unable to work “due to significant inconsistencies in the records as a whole and a lack of objective evidence to support her complaints.” (Id.)

         First, the ALJ gave “great weight” to the conclusions of Dr. Butler, an expert in clinical psychology, who “carefully scrutinized the comprehensive, objective, longitudinal records and had the opportunity to observe and question the claimant at the hearing.” (Tr. 25.) Dr. Butler opined that the medical evidence described someone who could perform unskilled or semi-skilled work, but with only brief, superficial and infrequent contacts with others in a job where serving the public is not a primary task. (Id.) This was in spite of Dr. Butler's “concerns” about inconsistencies in the record as to the severity of Plaintiff's mental health symptoms, her daily functioning, and her compliance with prescribed medications. (Tr. 24.) Plaintiff was functioning well and independently, but had difficulty being outside of her home and was not consistently compliant with her treatment medications. (Id.) Additionally, the recommended treatment for Plaintiff's anxiety would be incremental exposure to the things making her anxious, but Plaintiff had never undergone such treatment and was now seeking a new therapist. (Tr. 24-25.)

         The ALJ noted that Plaintiff's treatment had been conservative, primarily individual psychotherapy sessions, and she often failed to follow through with treatment recommendations or consistently comply with prescribed medications. (Tr. 25.) The ALJ also observed that Plaintiff's symptoms are typically related to situational stressors, such as her inability to work outside of her home, finances, her shaky relationship with her boyfriend, her elderly father's living arrangement, who recently suffered a stroke, and her daughter moving away to college. (Id.) The ALJ cited a comment made by Plaintiff's treating therapist, Dr. Wise, who stated that Plaintiff was stressed about finances, yet Plaintiff responded with “shock” when it was suggested that she could eventually return to work. (Id.)

         The ALJ asserted that “overall” the records demonstrate that Plaintiff's symptoms are “generally effectively controlled with medication management and the claimant acknowledged improvements in her mental health symptoms.” (Tr. 26.) The ALJ also cited to the testimony of Dr. Butler, however, who stated that Plaintiff's “symptoms did not respond to some medications while other medications improved or reduced the claimant's symptoms although there is no indication in the medical evidence any single medication completely alleviated her mental health symptoms.” (Id.) The ALJ then discussed in some detail Plaintiff's continuing failure to her take her medications or adhere to suggestions made by various providers such as Dr. Wise, Dr. Steven Clarke, Dr. Dawn Graham, and Dr. Richard Gebhart. (Tr. 25-27.) For example, on January 11, 2011, Dr. Wise noted that Plaintiff had not taken her antidepressant medication, prescribed to her a year earlier by her primary care provider, because she did not like taking medications. (Tr. 27.) In May 2012, Plaintiff reported to Dr. Gebhart that she stopped taking her medication three months prior and had developed a “who cares” attitude. (Id.) Dr. Wise also stated in June 2013 that Plaintiff “has a variety of reasons why she cannot possibly follow through on any treatment suggestions and that everything appears to be an effort which she cannot muster.” (Id.) And in August 2013, Dr. Clarke noted that Plaintiff unilaterally stopped taking one of her medications and determined that her antidepressant was helpful enough, and that she would continue to try making changes in her life but not her medication. (Id.) The ALJ concluded that Plaintiff's “unwillingness to follow prescribed medical treatment seriously reduces the credibility of claimant's allegation that she is disabled.” (Id.)[6]

         In light of the foregoing, the ALJ found that Plaintiff's “comprehensive allegations of disability due to her various mental impairments are not completely credible, ” and the objective medical evidence did not corroborate the alleged level of restrictions. (Tr. 28- 29.) Moreover, Plaintiff's daily activities, discussed above, suggested to the ALJ that Plaintiff is “more active than alleged.” (Tr. 29.)

         Turning to the opinion evidence, the ALJ gave “some weight” to two medical source statements by Dr. Wise, dated March 2011 and June 2013. (Tr. 29.) In the March 2011 statement, Dr. Wise stated that Plaintiff “had several situational stressors in her life, had not been compliant with prescribed medications, did not seem interested in eventually returning to work and that it was Ms. Wise's hope that the claimant could find her way back to employment.” (Id.) In the June 2013 statement, Dr. Wise noted that Plaintiff's symptoms “had worsened despite numerous suggestions and interventions because of the claimant's inability to follow through with treatment recommendations and her noncompliance with prescribed medications.” (Id.) Dr. Wise further stated her belief that Plaintiff “wanted to be taken care of, ” that she had a “variety of excuses” for why “she could not follow through on treatment recommendations and that working with the claimant was a challenge in achieving any treatment goals.” (Tr. 29-30.)

         The ALJ gave “little weight, ” however, to two mental functioning questionnaires completed by Dr. Wise in August 2013 and February 2015. (Tr. 30.) In both questionnaires, Dr. Wise opined that Plaintiff has a number of mental limitations that would affect her work-related abilities, and that she would likely miss more than four days per month due to her mental impairments and symptoms. (Id.) The ALJ gave little weight to these opinions because they are “inconsistent with her own treatment notes and other medical source statements . . . in which she described the claimant as being noncompliant with prescribed medication and reluctant to follow through with treatment recommendations.” (Tr. 31.) In addition, the ALJ rejected Dr. Wise's opinion because it was not consistent with the medical evidence, overall record, conservative course of treatment, mental status examinations and observations, Plaintiff's daily functioning, and the expert opinions of Dr. Butler and the State Agency mental ...

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