Meshetnaglee S. v. Saul

          Dana W. Duncan, Jennifer G. Mrozik, Hoglund, Chwialkowski & Mrozik, PLLC, for Plaintiff Meshetnaglee S.

          Elvi D. Jenkins, Social Security Administration, for Andrew Saul, Commissioner of Social Security.

          AMENDED ORDER ^[1]

          HILDY BOWBEER, UNITED STATES MAGISTRATE JUDGE.^[2]

         Pursuant to 42 U.S.C. § 405(g), Plaintiff Meshetnaglee S. seeks judicial review of a final decision by the Commissioner of Social Security, denying his applications for social security disability insurance benefits (DIB) and supplemental security income (SSI). The matter is before the Court on the parties' cross-motions for summary judgment [Doc. Nos. 13, 15]. For the reasons set forth below, the Court denies Plaintiff's motion for summary judgment and grants the Commissioner's motion for summary judgment.

         I. Procedural Background

         Plaintiff applied for DIB and SSI on July 25, 2016, alleging disability which began on November 10, 2014. (See R. 19.)^[3] The claims were denied on January 19, 2016, and denied again on reconsideration on February 6, 2017. (Id.) Plaintiff requested a hearing to review the denial of his claims on March 1, 2017. (Id.) On August 10, 2017, an administrative law judge (“ALJ”) held a hearing wherein Plaintiff and David Russell, a vocational expert, appeared and testified. (Id.) The ALJ analyzed Plaintiff's claims under the Social Security Administration's five-step sequential evaluation procedure. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4). The ALJ issued a written opinion on October 6, 2017, finding that Plaintiff was not disabled under § 216(i) and 223(d) of the Social Security Act. (R. 21-34.)

         At step one, the ALJ concluded that Plaintiff had not engaged in substantial gainful activity since November 10, 2014, the alleged date of disability onset. (R. 21.) At step two, the ALJ concluded that Plaintiff had the following severe impairments: hearing loss on the right side, headaches, obesity, degenerative disc disease, left hip sclerosis, major depression, borderline personality disorder, posttraumatic stress disorder, and panic disorder. (R. 22.) However, at step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of an impairment listed in 20 C.F.R. part 404, subpart P, appendix 1. (R. 22-25.)

         At step four, the ALJ assessed Plaintiff's residual functional capacity (“RFC”). (R. 25-33.) As part of that assessment, the ALJ analyzed whether the intensity, persistence, and limiting effects of Plaintiff's symptoms were as severe as he claimed. (R. 26-27, 29.) The ALJ also analyzed and assigned evidentiary weight to three medical sources who opined on Plaintiff's RFC. (R. 29-32.) Two of these sources were treating sources (Dr. Kirk Mueller, Ph.D., and Dr. Brandon Dugan, Psy.D), and one opinion was from a non-treating Social Security Administration consultant, Dr. Donald Wiger, Ph.D. (Id.) Ultimately, the ALJ relied on the opinions of two non-examining, non-treating agency physicians, and based his RFC assessment on their opinions, with modifications derived from the ALJ's findings. (R. 32.)

         The ALJ concluded Plaintiff could perform medium work with some excluded tasks, which were enumerated in detail.^[4] The ALJ found that Plaintiff was capable of simple, routine, repetitive tasks with occasional, brief, and superficial contact with coworkers, supervisors, and the public. (R. 25.) The ALJ noted that Plaintiff had no past relevant work and therefore did not determine the transferability of his job skills. (R. 33.)

         At step five, the ALJ considered the limitations impeding Plaintiff's RFC as well as his age, education, and work experience. (R. 33-34.) Turning to the testimony of the vocational expert, the ALJ concluded that Plaintiff could successfully adjust to work including positions such as packager, assembler, and cleaner. (Id.) Because those positions exist in significant numbers in the national economy, the ALJ decided that Plaintiff was not disabled. (Id.) Plaintiff sought review by the Appeals Council, which denied her request. (R. 3.) The ALJ's decision therefore became the final decision of the Commissioner. (See R. 3.)

         In this action for judicial review, Plaintiff contends that the ALJ did not afford appropriate weight to the treating source opinions during step four of the analysis. (Pl.'s Br. Supp. Mot. Summ. J. at 15-34 [Doc. No. 14].)^[5] Plaintiff argues that the ALJ improperly discounted the opinions of Drs. Mueller, Dugan, and Wiger, and afforded disproportionate weight to the opinions of non-examining state agency physicians. (Id. at 15-16.)

         II. Medical Background

         The Court has reviewed the entire administrative record, and given particular attention to the facts and records cited by the parties. The Court will recount the facts of record only to the extent they are helpful for context or necessary for resolution of the specific issues presented in the parties' motions.

         During the relevant time period, Plaintiff received medical care at three locations: the Mayo Clinic in Austin, Minnesota; Sioux Trails Mental Health Center; and Eunoia Family Resource Center in Mankato, Minnesota.

         A. Mayo Clinic

         At the Mayo Clinic, Plaintiff was first seen by Joanne M. McGaffey, a certified nurse practitioner, on November 3 and 17, 2014, for a musculoskeletal injury he claimed to have incurred at work. (R. 419-23.) Initial examination found an abnormal gait and paraspinous tenderness to palpation without signs of radiculopathy. (R. 421-23.) X-ray studies showed “trace” degenerative disc disease, which the radiologist reported to be common in asymptomatic patients. (Id.) On follow up, McGaffey noted Plaintiff reported improvement, and his physical examination showed improvement as well. (R. 419-20.)

         Plaintiff's psychological illness was first noted on January 29, 2016, by Dr. Bryan M. Cairns, M.D., a family practitioner. (R. 415-18.) Dr. Cairns noted Plaintiff engaged in self-harm (“cutting”) in the past year after several fights with his father. (Id.) However, Dr. Cairns reported Plaintiff's mental status examination was largely normal. (Id.) Repeat x-ray studies of his left hip and left knee were unchanged since 2012 and remained within normal limits. (R. 417-18.)

         On February 17, 2016, Plaintiff treated with Dr. Alberto Marcelin, M.D., a family practitioner. (R. 406-08.) Plaintiff discussed many complaints with Dr. Marcelin. (Id.) In addition, Plaintiff's significant other reported odd behavior, specifically, that he had recently been “giggly.” (Id.) Due to Plaintiff's history of cutting and childhood meningitis, Dr. Marcelin ordered consultation with psychiatry and neurology and started him on an antidepressant. (Id.)

         Plaintiff was seen by a psychiatrist, Dr. Fatma Reda, M.D., on March 7, 2016. (R. 398-400.) She noted a past history of “non-serious” suicide attempts prior to 2010, “very superficial” self-injurious behavior, depression, post-traumatic stress disorder, and anxiety. (Id.) Plaintiff's depressive symptoms were improving after three weeks on fluoxetine, however, and his mental status examination was grossly normal. (Id.) Dr. Reda ordered an increased dose of antidepressants and a Millon Clinical Multiaxial Inventory-III (“MCMI-III”) to further assess Plaintiff's psychological condition. (Id.) Dr. Kirk H. Mueller, Ph.D., a psychologist, administered the MCMI-III on April 6, 2016; the results were confounded, however, by exceedingly high scores suggestive of “self-depreciation” and “vulnerability.” (R. 397.) On April 6, 2016, Dr. Reda continued to report a normal mental status examination but noted self-reported agitation that she attributed to an increased antidepressant dose. (R. 395-96.)

         Plaintiff received psychotherapeutic care from Dr. Mueller on three occasions between May 2, 2016, and July 12, 2016. (R. 385, 388, 392.) Dr. Mueller's mental status examinations noted marginal grooming with body odor, depressed mood with congruent affect, intact insight and judgment, and thoughts of self-harm without suicidal ideation or intent. (Id.) Dr. Mueller opined that Plaintiff's thoughts of self-harm were secondary to family trauma and caring for his significant other who suffered from depression. (R. 388.) Dr. Mueller observed improvement with psychotherapeutic and medical interventions. (R. 386.) Dr. Mueller completed a medical source statement on October 30, 2016. (R. 429-30.)

         On June 8, 2016, Plaintiff saw Dr. Marcelin for worsening symptoms of depression over the prior three to four days that he attributed to a complicated relationship with his significant other. (R. 387.) Dr. Marcelin recommended hospitalization, but Plaintiff refused. (Id.) Shortly thereafter, Plaintiff was seen in the emergency department. Following an argument with his girlfriend he made “superficial” cuts on his right arm and had a panic attack. (R. 376.) The emergency department physician noted “appropriate mood [and] affect, [and] normal judgment.” (R. 379.) He elaborated that Plaintiff “looks ok[ay], he is smiling, has good eye contact . . . [and] does not feel suicidal.” (R. 380.)

         On follow up, Dr. Marcelin noted that Plaintiff had been noncompliant with his Zoloft regimen; therefore, Dr. Marcelin changed his antidepressant course. (R. 386). On August 3, 2016, Plaintiff's girlfriend reported his mood had improved with the new antidepressant. (R. 383-84.)

         On September 7, 2016, Plaintiff saw another family medicine practitioner, Dr. Kristen L. Holland, M.D., to request disability documentation. (R. 441-43.) When asked why he was disabled, Plaintiff answered it is “probably . . . related to his psychiatric diagnoses.” (R. 442.) Dr. Holland declined to provide a medical source opinion given Plaintiff was just establishing care with her. (R. 445.) Dr. Holland reported that Plaintiff's depression began in 2011. (R. 442.) She found his psychological symptoms were related to his living situation with his parents. (Id.) Plaintiff reported being unemployed after August, 2016, when he moved to Saint Peter, Minnesota. (Id.) While living in St. Peter he continued to work at his family's store. (Id.) Dr. Holland's psychiatric examination revealed neutral mood and affect. (Id.) On follow up, Dr. Holland observed a normal affect, and recommended that Plaintiff disentangle himself from his “toxic family” relationships. (R. 434-35.)

         Plaintiff saw Dr. Holland on three more occasions from September 2016 to April 2017 for a variety of complaints including pain and numbness, gastrointestinal symptoms, and a cough. (R. 447-50, 541-44, 545-47.) During this time, he began treating at Sioux Trails Mental Health Center. Plaintiff consistently reported only occasional alcohol use throughout his time at the Mayo Clinic. (See, e.g., R. 443.)

         B. Sioux Trails Mental Health Center

         Plaintiff treated at Sioux Trails Mental Health Center from October 2016 through February 2017. (R. 459-73.) During that time he was seen by psychologist Dr. Mark E. Kleiman, Ph.D., on ten occasions, and psychiatrist Dr. Nora Bammidi, M.D., twice. (Id.) Dr. Kleiman noted that Plaintiff's euthymic mood was incongruent with the severity of his subjective symptoms. (R. 470.) Plaintiff reported binge drinking until he blacked out. (See, e.g., R. 464, 467.) Dr. Kleiman consistently reported improvement with psychotherapy. (R. 463, 468.) He also observed that Plaintiff started seeking mental health care around the time of his DIB application. (See R. 462.)

         Dr. Kleiman repeatedly attributed exacerbations in Plaintiff's anxiety, self-harm, and depression to family stressors including confrontations with his father and his girlfriend. (See R. 463, 466.) Dr. Kleiman noted symptoms of sleep disturbance, hyperactivity, and aggression associated with changes in medication; however, he did not observe any other symptoms of mania. (R. 458, 463.) Plaintiff reported ...