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Lockhart v. Berryhill

United States District Court, D. Minnesota

March 23, 2018

Dangelo L. Lockhart, Plaintiff,
Nancy A. Berryhill, Acting Commissioner of Social Security, Defendant.

          James H. Greeman, Esq., Greeman Toomey, counsel for Plaintiff.

          Ann M. Bildsten, Esq., United States Attorney's Office, counsel for Defendant.



         Pursuant to 42 U.S.C. § 405(g), Plaintiff Dangelo L. Lockhart seeks judicial review of the final decision of the Commissioner of Social Security (“the Commissioner”) denying his application for disability insurance benefits. 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. 11, 15.) For the reasons stated below, the Court concludes that the Administrative Law Judge's (“ALJ”) decision is supported by substantial evidence in the record. Therefore, Plaintiff's motion is denied and Defendant's motion is granted.


         I. Procedural History

         Plaintiff filed an application for disability insurance benefits (“DIB”) on April 4, 2013, alleging a disability onset date of November 6, 2012. (Tr. 18, 37.)[1] The Social Security Administration (“SSA”) denied his claim initially on November 19, 2013, and on reconsideration on April 21, 2014. (Tr. 18, 109-10, 118.) A video hearing was then held by an ALJ on May 28, 2015. (Tr. 18, 35, 37.) After the video hearing, Plaintiff submitted additional medical evidence, which was reviewed and added to the record. (Tr. 18, 609-19.) The ALJ issued a decision denying benefits on October 8, 2015 (Tr. 18-29), and Plaintiff sought review. The SSA Appeals Council denied Plaintiff's request for review on August 26, 2016, making the ALJ's decision the final decision of the Commissioner. (Tr. 1-5); 20 C.F.R. § 404.981.

         On October 25, 2016, Plaintiff filed this action seeking judicial review pursuant to 42 U.S.C. § 405(g). (Doc. No. 1, Compl.) The parties then filed cross-motions for summary judgment, pursuant to the Local Rules. (Doc. Nos. 11, 15.) In Plaintiff's motion, he argues that the ALJ erred at step three of the disability evaluation analysis by finding that Plaintiff's assessed full scale IQ score of 48 given by a consultative examiner was invalid; instead, Plaintiff asserts that the score was valid and he is presumptively disabled pursuant to 20 C.F.R. Pt. 404, Subpt. P, App. 1, Listing 12.05(b) - Intellectual Disability. (Doc. No. 13, Pl.'s Mem. Supp. Mot. Summ. J. (“Pl.'s Mem.”) 11-12, 18-19.) Plaintiff also argues that the ALJ erred at step two of the analysis by failing to identify four additional severe impairments diagnosed during the same consultative examination. (Pl.'s Mem. 12, 26-27.) Defendant argues that the ALJ properly assigned little weight to the opinion of the consultative examiner, which included the assessed full scale IQ score, because the opinion was based on a one-time evaluation and was inconsistent with the record as a whole. (Doc. No. 16, Def.'s Mem. Supp. Mot. Summ. J (“Def.'s Mem.”) 5-8, 14.)

         II. Factual Background

         Plaintiff grew up in Mississippi where he attended school until the ninth or tenth grade. (Tr. 55, 464-65, 610.) Plaintiff reported that he was an A, B, and C student while in school (Tr. 389), and he testified at his video hearing that he did not receive any special help in school. (Tr. 55.) The record, however, references that he attended special education classes from 2000 to 2002. (Tr. 209.) He admitted to his medical provider that he had “learning problems.” (Tr. 465.) But at his video hearing, Plaintiff reported that he stopped attending school because he “knew everything.” (Tr. 55.)

         Plaintiff's work history is varied. (Tr. 39-40, 47, 209, 217.) In 2006, he worked as a dishwasher in a restaurant. (Tr. 209, 217.) Between 2007 and 2012, he worked as an automotive detailer at a car wash. (Tr. 47, 209, 217.) Plaintiff moved to Minnesota in 2012. (Tr. 464.) After he moved, there is no record of his employment until 2014, when he worked as a physical therapist assistant and as a cleaner at a baseball stadium. (Tr. 39- 40.)

         Plaintiff was twenty-six years old on November 6, 2012, his alleged disability onset date. (Tr. 39, 71, 204.) Initially, Plaintiff alleged that he was disabled due to sickle cell anemia. (Tr. 71, 90-91, 208.) Later, however, he testified at his video hearing that sickle cell anemia does not preclude him from work. (Tr. 56.) On appeal, he argues that severe mental and intellectual impairments preclude him from work. (Pl.'s Mem. 11-12, 27.)

         Plaintiff's medical history shows a history various mental health issues, including Posttraumatic Stress Disorder (“PTSD”)[2], depression, and anxiety. On September 26, 2013, Plaintiff presented to Family Life Mental Health Center (“Family Life”) and was urged to “come into the hospital.” (Tr. 388.) Plaintiff took that advice and sought treatment for depression, suicidal ideation, and hallucinations at the Mercy Hospital Emergency Department. (Tr. 371, 397.) He reported a long history of depression that had worsened in severity. (Tr. 371.) He was transferred to United Hospital Behavioral Health Service Unit (“United”) and placed on a 72-hour hold because he had reported auditory hallucinations telling him to harm himself or others. (Tr. 371, 373, 380, 397.)[3]

         During the 72-hour hold at United, Plaintiff reported symptoms of PTSD, depression, and anxiety. (Tr. 385.) In addition, he reported that he had been diagnosed with (1) PTSD; (2) bipolar disorder; and (3) Attention Deficit Hyperactivity Disorder (“ADHD”). (Tr. 387.) Medical notes made during his hospital stay indicate that Plaintiff did “not describe any true bipolar symptoms other than having extensive mood swings.” (Tr. 388.) His discharge record notes, however, that he appeared to be “somewhat psychotic.” (Tr. 386.) Plaintiff denied any panic attack symptoms. (Id.) A mental status examination during his 72-hour hold indicated that Plaintiff had “average intelligence.” (Tr. 385, 389.) Plaintiff was discharged on September 30, 2013, with a diagnosis of “mood disorder, not otherwise specified, ” “Cannabis abuse, ” “Seizure disorder, ” “[s]tressors of moving to the Minneapolis-St. Paul area with poor social support, ” and a GAF score of 50. (Tr. 384.) During his discharge examination, “[h]e was motivated to continue follow-up with outpatient therapy and psychiatry at Family Life, and thus . . . was able to be discharged to follow up with these recommendations.” (Tr. 386.)

         Plaintiff continued treatment at Family Life from October 2013 to March 2014. In October 2013, the diagnosis summary listed several issues including: posttraumatic stress disorder; schizophrenia; chronic undifferentiated-provisions; borderline level intellectual functioning-rule out; and seizure disorder-unspecified. (Tr. 416.) Medications kept his seizures under control. (Tr. 434.) The goal in October, and throughout his treatment, was to assist Plaintiff in managing his PTSD symptoms. (Tr. 445, 447, 449, 451, 453, 455, 457, 459.) Treatment included psychotropic medications, such as Zoloft, Prazosin, and Vistaril. (Tr. 466.) From October 2, 2013 through November 20, 2013, Plaintiff sought weekly treatment for his depression and anxiety. (Tr. 332, 416, 418, 420, 445, 447, 449.) His treatment for depression and anxiety was then sporadic from December 5, 2013 through March 21, 2014. (Tr. 451, 453, 455, 457, 459, 461, 463.) Plaintiff's treatment providers maintained that Plaintiff had PTSD throughout his treatment. (Tr. 416, 418, 420, 445, 447, 449, 453, 455, 457, 459, 461, 463.)

         On January 24, 2014, Plaintiff had an initial office visit with Dr. M. Orhan Ucer at Health Partners Regions Hospital (“Health Partners”) for depression, anxiety, and PTSD treatment. (Tr. 589-90.) Dr. Ucer indicated that the PTSD diagnosis was “related to previous abuse” (Tr. 598), and stated that for “his depression/anxiety/stress issues [the plan will be] he will continue to follow with his psychiatrist” (Tr. 599), which he did with Family Life until March 21, 2014. (Tr. 461.) Meanwhile, Plaintiff received a Psychiatric Evaluation at Family Life on February 20, 2014. (Tr. 463.) The report limits his diagnosis to PTSD and depression. (Id.) This report states that Plaintiff's “[i]ntelligence seems to lie in the low range, based on fund of knowledge, use of language and educational achievements.” (Id.) This evaluation, however, did not include the reference to “borderline level intellectual functioning-rule out” as part of the diagnosis. (Id.) Plaintiff's treatment plan, following this visit, was to continue to “target PTSD, depression and anxiety.” (Tr. 466.)

         On June 1, 2015, three days after his video hearing with the ALJ, Plaintiff underwent a consultative examination at Nystrom & Associates, Ltd. (Tr. 26, 609.) Plaintiff was referred by his attorney for an assessment relating to Plaintiff's application for DIB. (Id.) Doctoral Intern, Kristen Lane, MA, (“Lane”) conducted the examination, which was also adopted and signed by Dr. Heather Bodurtha. (Tr. 26, 619.) The purpose of the assessment was to evaluate Plaintiff's “cognitive functioning, obtain clarification on his mental health diagnosis, and evaluate his adaptive functioning.” (Tr. 609.) Lane administered (1) a clinical interview; (2) the Wechsler Adult Intelligence Scale, Fourth Edition (“WAIS-IV”) test; (3) the Beck Depression Index, Second Edition (“BDI-II”) test; (4) the Beck Anxiety Index (“BAI”) test; and (5) the Adaptive Behavior Assessment System, Second Edition (“ABAS-II”). (Tr. 26, 613.) The record appears to indicate that the assessments were administered on June 1, 2015, and the results of the WAIS-IV, BDI-II, BAI, and ABAS-II were obtained on June 22, 2015. (Tr. 609, 613.)

         During the clinical interview, Plaintiff relayed that he had been diagnosed with PTSD, anxiety, borderline IQ, and ADHD. (Tr. 609.)[4] In addition, he reported that he had been physically and verbally abused as a child by his mother. (Tr. 610, 612.) He also reported “mania/hypomania symptoms, ” such as manic episodes lasting 2-3 weeks, “feeling on top of the world, ” “engaging in risky behavior, ” and feeling “either really high or really low.” (Tr. 612.) He also “reported symptoms that are consistent with posttraumatic stress disorder, ” such as talking about his alleged childhood abuse “all the time” that he cannot control, having flashbacks and nightmares, and “feeling like the thoughts and memories of his abuse will be in his head forever.” (Tr. 612.)

         Based on the clinical interview and reviewing testing data, Lane concluded that Plaintiff met the “criteria for Schizoaffective Disorder Bipolar Type, Panic Disorder, Posttraumatic Stress Disorder and Intellectual Disability, Moderate, Provisions.” (Tr. 616.) Her assessment of schizoaffective disorder was based on (1) Plaintiff's reports of “depressive symptoms, ” such as “feeling down” and being irritated; (2) a BDI-II rating of 42, which suggested a severe level of depression; (3) his reports of mania symptoms; and (4) Plaintiff's descriptions of auditory hallucinations and paranoia. (Tr. 616-17.) In Lane's view, Plaintiff also met the criteria for panic disorder based on (1) his reports of anxiety, such as irritability, “poor sleep, ” being “jittery, ” and having “racing thoughts”; and (2) a BAI rating of 29, which suggested a moderate level of anxiety. (Tr. 617.) And, Lane offered diagnostic impressions of Plaintiff's PTSD, based on childhood abuse.” (Tr. 612.) Lane did not refer to any historical medical records.

         Lane also diagnosed Plaintiff with “intellectual disability, moderate, provisional” based on (1) WAIS-IV results “in the extremely low range”; and (2) ABAS-II[5] results indicating that Plaintiff was significantly more dependent on the other adults in his environment to meet daily needs than most other adults his age. (Id.)[6] Lane recognized that the validity of her conclusions was limited by the “quantity and quality of the available information and the impossibility of absolute predictions.” (Tr. 619.)[7] Plaintiff relies on his assessed full scale IQ score of 48 (“IQ Score”) to support his disability claim. (Pl.'s Mem. 11-12, 13-14; see also Tr. 613.) This IQ Score is the only IQ score in the record. (Tr. 613.)

         III. The ALJ's Findings and Decision

         In his decision dated October 8, 2015, the ALJ denied Plaintiff's application for DIB, finding that Plaintiff was not disabled as defined by the Social Security Act. (Tr. 29.) The ALJ proceeded through the five-step evaluation process provided in the social security regulations. See 20 C.F.R. § 404.1520(a)(4). These steps are as follows: (1) whether the claimant is presently engaged in “substantial gainful activity”; (2) whether the claimant is severely impaired; (3) whether the impairment meets or equals a presumptively disabling impairment listed in the regulations; (4) whether the claimant can perform past relevant work; and, if not, (5) whether the claimant can perform other jobs available in sufficient numbers in the national economy. 20 C.F.R. § 404.1520(a)(4)(i)-(v).

         At step one, the ALJ found that Plaintiff had not engaged in substantial gainful activity since April 4, 2013, the DIB application date. (Tr. 20.) Although Plaintiff worked in 2014, the ALJ found that this work activity did not rise to the level of substantial gainful activity because it did not meet the minimum income threshold requirements. (Id.)

         At step two, the ALJ found that Plaintiff's severe impairments were affective disorder and seizure disorder. (Id.)[8] The ALJ found that all other impairments, alleged and found in the record, are either non-severe or not medically determinable. (Tr. 20.) Since the ALJ determined that Plaintiff had severe impairments, he continued to step three of the analysis, where a claimant must show that his 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. ยง 404.1520(a)(iii). In examining Plaintiff's impairments, the ALJ reviewed the Listing of Impairments, specifically Sections 11.02 and ...

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