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Edward W. v. Saul

United States District Court, D. Minnesota

September 6, 2019

Edward W., Plaintiff,
v.
Andrew Saul,[1] Commissioner of Social Security, Defendant.

          ORDER

          ELIZABETH COWAN WRIGHT UNITED STATES MAGISTRATE JUDGE.

         This matter is before the Court on Plaintiff Edward W.'s (“Plaintiff”) Motion for Summary Judgment (Dkt. 17) and Defendant Commissioner of Social Security Andrew Saul's (“Defendant”) Motion for Summary Judgment (Dkt. 20). Plaintiff filed this case seeking judicial review of a final decision by Defendant denying his application for disability insurance benefits. For the reasons stated below, Plaintiff's Motion is denied, and Defendant's Motion is granted.

         I. BACKGROUND

         On February 18, 2015, Plaintiff filed an application for disability insurance benefits. (R. 215-221.) Plaintiff also filed an application for supplemental security income on February 11, 2015. (R. 209-214.) In both applications, the alleged disability began on November 7, 2012. (R. 66-67, 209, 215.) Plaintiff applied for benefits, alleging disability due to mental disability, post-traumatic stress disorder (“PTSD”), hallucinations, depression, anxiety, anger issues, and schizophrenia. (R. 66-67.) His application was denied initially and on reconsideration. (R. 140-44, 152-54, 156-58.) Plaintiff requested a hearing before an administrative law judge (“ALJ”), which was held on August 17, 2017 before ALJ David Washington. (R. 15-36.) The ALJ issued an unfavorable decision on October 17, 2017, finding that Plaintiff was not disabled through the date of the ALJ's decision. (R. 36.) Plaintiff was 40 years old at the time of the ALJ's decision. (R. 35.) While Plaintiff represented to the Commissioner that he had never received his GED (R. 47) and that he only completed the eighth grade (R. 242), the record shows that he completed his GED in 2007, represented that he graduated high school, and went on to receive an Auto Body Shop certificate from St. Paul College (R. 242, 354, 741).

         Following the five-step sequential evaluation process under 20 C.F.R. § 404.1520(a), [2] the ALJ first determined at step one that Plaintiff had not engaged in substantial gainful activity since November 7, 2012. (R. 17.)

         At step two, the ALJ determined that Plaintiff had the following severe impairments: major depressive disorder (recurrent, severe, without psychotic features); schizoaffective disorder; posttraumatic stress disorder (chronic); cannabis abuse; learning disorder by history; borderline intellectual functioning; and antisocial personality disorder versus borderline personality disorder. (R. 17.)

         At the third step, the ALJ determined that Plaintiff did not have an impairment that meets or medically equals the severity of one of the listed impairments in 20 C.F.R. part 404, subpart P, appendix 1. (R. 18-19.)

         At step four, after reviewing the entire record, the ALJ concluded that Plaintiff had the following residual functional capacity (“RFC”):

After careful consideration of the entire record, the undersigned finds the claimant has the residual functional capacity to perform a full range of work at all exertional levels but with the following nonexertional limitations: limited to brief, infrequent and superficial contact with the public, coworkers, and supervisors; limited to unskilled work activity, routine, repetitive, work.

(R. 23.)

         The ALJ concluded that Plaintiff was able to perform his past relevant work as an auto order picker and automobile detailer. (R. 34.) In addition, at the fifth step of the sequential analysis, and based on the testimony of the vocational expert (“VE”), the ALJ found that through the date last insured, considering the Plaintiff's age, education, work adjustment to other work that existed in significant numbers in the national economy, including the occupation of dryer attendant. (R. 35.) Accordingly, the ALJ deemed Plaintiff not disabled. (R. 36.)

         Plaintiff requested review of the decision. (R. 4.) The Appeals Council denied Plaintiff's request for review, which made the ALJ's decision the final decision of the Commissioner. (R. 1-3.) Plaintiff then commenced this action for judicial review. The Court has reviewed the entire administrative record, giving 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.

         II. MEDICAL RECORD

         On January 10, 2013, Plaintiff presented to the Dorothy Day Center for a mental health assessment before licensed social worker Lindsay Anderson. (R. 499.) Plaintiff had no history of hospitalizations for mental health and no history of medication management for mental health. (Id.) Plaintiff professed experiencing depression since he was a child and that the depression had been ongoing since the day of its onset. (Id.) Plaintiff denied feeling that his life was not worth living. (Id.) Plaintiff was homeless and staying at the Dorothy Day Center. (Id.) Plaintiff was using marijuana five times a day to deal with his pain and muscle spasms. (R. 500.) Plaintiff professed thoughts of self-harm with no plan for suicide. (Id.) Plaintiff had thoughts about harming others, but denied ever harming anyone. (Id.) The mental health assessment showed that Plaintiff's appearance was appropriate; his attitude was cooperative; he was calm; had a broad-range affect; had an up-and-down mood; expressed auditory and visual hallucinations, including talking to himself in his head in a different voice, which told him to be angry and look mean, and he claimed to see bad spirits (including the devil); he was fully oriented; had an intact memory; and experienced flashbacks, nightmare, and terrors. (R. 500-01.) Plaintiff was diagnosed with major depression psychotic behavior, cannabis abuse, and PTSD. (R. 501.) Anderson characterized Plaintiff's major depression as severe based on a PHQ-9 depression assessment, in which Plaintiff claimed that over the past two-week period he had: several days of having little interest or pleasure in doing things; he was depressed or feeling down more than half of the time; he had daily trouble related to sleeping; had little energy, a poor appetite, and concentration problems every day; and had several days of feeling like he was better off dead. (R. 502.) According to Plaintiff, these problems had made it somewhat difficult for Plaintiff to work, take care of things at home, or get along with other people. (Id.)

         On January 15, 2013, Plaintiff saw psychiatrist John Rauenhorst, M.D., for a mental health visit. (R. 493.) Plaintiff represented that he last worked the previous year in a warehouse, but the job had ended, and he could not go back to work because of old leg injuries. (Id.) Plaintiff presented with symptoms of depression which had been present for greater than two weeks. (Id.) Plaintiff denied any thoughts of self-harm. (R. 494.) Plaintiff's appearance was appropriate and disheveled; he was cooperative and calm; he had an appropriate affect; he displayed a depressed and anxious mood; showed a circumstantial thought process; denied hallucinations; he was fully oriented; and had an intact memory. (R. 495.) Plaintiff was diagnosed with major depression, and a rule-out diagnosis for PTSD. (R. 495-96.) Plaintiff was prescribed with Sertraline (Zoloft). (R. 496-97.)

         On February 14, 2013, Plaintiff had a follow-up visit with Dr. Rauenhorst. (R. 489.) Plaintiff noted that the Zoloft previously prescribed had been helping him with no side effects and he needed a refill. (Id.) Plaintiff denied any intention of harming himself. (Id.) Plaintiff's mood had improved with less anxiety. (Id.) His mental assessment remained unchanged, except that his mood was improved, and his thought process was more organized. (R. 490.) Plaintiff was diagnosed with major depression with psychotic behavior, cannabis abuse, and a rule-out diagnosis for PTSD. (R. 490-91.)

         Plaintiff again saw Dr. Rauenhorst on February 26, 2013. (R. 485.) Plaintiff asserted that he thought his medications were working, but that he still felt negative. (Id.) Plaintiff's mood was relaxed, and he was less anxious. (Id.) Plaintiff was diagnosed with major depression with psychotic behavior, cannabis abuse, and a rule-out diagnosis for PTSD. (R. 486-87.) The depression was characterized as better or improved, and Plaintiff did not want any additional medications. (R. 487.)

         On March 28, 2013, Plaintiff saw Dr. Rauenhorst for a mental health follow-up. (R. 481.) Plaintiff requested a medication change. (Id.) Plaintiff asserted that he was not sleeping well and felt that the medications did not work. (Id.) Dr. Rauenhorst believed that Plaintiff was not regularly taking his medications. (R. 481-82.) Dr. Rauenhorst noted that Plaintiff was relaxed, depressed, and more negative. (Id.) Plaintiff was diagnosed with major depression (moderate), cannabis abuse, and a rule-out diagnosis for PTSD. (R. 482-83.) Plaintiff continued to smoke marijuana daily. (R. 483.)

         On April 9, 2013, Plaintiff saw Dr. Rauenhorst for another mental health follow-up. (R. 477.) Plaintiff reported running out of medications three days earlier. (Id.) Plaintiff represented that he felt that his medications were helping him feel less irritable and anxious. (Id.) Plaintiff had lost more weight and had been thinking about jumping off a bridge, without any intention to carry out such a plan. (Id.) Plaintiff's appearance was appropriate, he was cooperative but irritable, he was agitated, his affect was appropriate, his mood was depressed and more negative, his thought process was intact and more organized with no hallucinations, he was fully oriented, and had an intact memory. (R. 477-78.) Dr. Rauenhorst noted that Plaintiff's depression was still a problem and was worse when he did not have medications. (R. 479.) Plaintiff was prescribed with Zoloft and Seroquel. (Id.)

         On April 18, 2013, Plaintiff underwent a consultative examination conducted by Reena Pathak, Psy.D., L.P., at South Metro Human Services. (R. 352.). Dr. Pathak conducted a clinical interview. (Id.) In addition, the following testing was performed: a Montreal cognitive assessment test, a Wechsler adult intelligence scale test, a Weschler test of adult reasoning, a repeatable battery for the assessment of neuropsychological status, and a Delis Kaplan Executive Function System Trail Making Test. (R. 353.) Dr. Pathak diagnosed Plaintiff with major depressive disorder recurrent (severe), PTSD, cannabis abuse, borderline intellectual functioning, and learning disorder by history. (Id.) While Plaintiff reported using marijuana to deal with anxiety, Dr. Pathak explained that “while cannabis appears to have been a contributing factor to affective and behavioral disturbance, it does not appear to have been the main precipitant.” (Id.) According to Dr. Pathak, Plaintiff identified the following signs and symptoms: sleep disturbance, mood disturbance (depression, anxiety), emotional lability, substance dependence, anhedonia or pervasive loss of interests, psychomotor agitation or retardation, feelings of guilt/worthlessness, social withdrawal or isolation, an inappropriate affect, decreased energy, generalized persistent anxiety, difficulty thinking or concentrating, hostility and irritability, and suicidal ideation. (R. 353-54.)

         During Plaintiff's mental status examination with Dr. Pathak, Plaintiff presented as being alert and oriented to all spheres. (R. 354.) His eye contact was appropriate. (Id.) Grooming and hygiene were appropriate. (Id.) He was pleasant and cooperative with an anxious mood and constricted affect. (Id.) His speech was generally goal directed but his responses tended to be vague. (Id.) There were no apparent difficulties regarding comprehension of interview questions or assessment instructions, and Plaintiff was a fair historian. (Id.) Plaintiff acknowledged passive suicidal ideations, but denied any intent or plan. (Id.)

         As part of the assessment, Plaintiff completed the Montreal Cognitive Assessment (“MOCA”), a mini-mental status examination. (Id.) He attained a score of 18 out of 30, which fell below the normal range. (Id.) Areas of difficulty included visuospatial construction (copy of a figure, clock drawing), executive functioning (trail making), language repetition, verbal abstract reasoning, and delayed recall. (Id.) In addition, Plaintiff was unable to recall any of the five random words after a five-minute delay. (Id.)

         Plaintiff reported that he had been previously incarcerated 9 to 10 years for felony charges related to selling drugs and assault, but reported he had no further involvement in the legal system since 1995. (R. 355.) Plaintiff also reported that he was last employed in 2011. (Id.) Plaintiff represented having no history of difficulties getting along with bosses and coworkers. (Id.) He did identify difficulty managing stress, causing him to walk off the job at times. (Id.) Plaintiff had never been fired from a job. (Id.)

         Plaintiff reported a history of depression, general anxiety, and PTSD that included frequent suicidal ideation as a child and significant difficulties managing his temper. (Id.) As it relates to depression, Plaintiff identified experiencing low motivation, loss of interest, anhedonia (“there's nothing to live for”), low energy/fatigue, impaired sleep, irritability, negative and intrusive thoughts, feelings of helplessness/hopelessness, feelings of worthlessness, and loss of appetite. (Id.) Plaintiff also identified experiencing high reactivity, poor anger management, racing intrusive thoughts, flashbacks (gunshots, being chased, and being beaten up), vivid nightmares, intrusive memories, and thoughts, avoidance of triggers (crowds, violent shows/movies), hypervigilance (carrying a gun for protection, frequent fighting), and an exaggerated startle response. (Id.) Further, Plaintiff claimed experiencing auditory perceptual disturbances of voices or “strong thoughts” telling him to do things, such as hurting others. (Id.) He also claimed that he saw “spirits.” (Id.)

         The Wechsler adult intelligence scale test results showed that Plaintiff's full-scale IQ fell in the extremely low range. (R. 356-57.) Within the various subtests, Plaintiff scored an 80 (low average to borderline) in verbal comprehension, 65 (extremely low) in perceptual reasoning, 77 (borderline) in working memory, and 76 (borderline) in processing speed. (Id.) Based on the testing, Dr. Pathak opined that Plaintiff's “[o]verall intellectual functioning is consistent with mild cognitive impairment with perceptual reasoning as an area of relative weakness.” (R. 358 (emphasis added).) Plaintiff's testing also showed that his immediate recall and delayed recall were both severely impaired. (Id.) Dr. Pathak also opined as follows regarding the implications of the testing:

In terms of the neurocognitive findings, the primary areas of dysfunction surround processing speed, immediate memory, working memory, visual memory, visual motor organization and speed, aspects of executive functioning, and auditory and visual attention. Involvement of the frontal lobes, right parietal lobes, and related temporal areas are implicated. The most likely etiologies appear to be related to developmental learning difficulties, effects of multiple untreated head injuries and psychiatric symptoms surrounding affective dysregulation and inability to manage stress. The effects from head injury are likely stable, thus variability in cognitive and behavioral functioning is likely due to variability in psychiatric symptoms. As [Plaintiff] is not involved in consistent psychiatric or therapeutic supportive services, this is unlikely to abate within 12 months, even with sobriety. Additionally, assessment results suggest that repetition and rehearsal do not aid in learning and memory. It is likely that slowed and inefficient processing speed is a contributing factor. Namely, when processing speed is slowed information does not get into short-term memory effectively and then will fade before it can be consolidated into long term memory storage.

(Id.) Dr. Pathak ultimately opined that “[i]t does not appear likely that [he] would be able to establish and maintain employment at this time without stabilization, therapeutic supports, and vocational supports.” (R. 358-59.) As to Plaintiff's mental abilities and aptitude to do unskilled work, Dr. Pathak opined that Plaintiff had a “Fair” ability to: understand and remember very short and simple instructions; carry out very short and simple instructions; maintain attention for two-hour segments; maintain regular attendance and be punctual within customary, usually strict tolerances; make simple work-related decisions; perform at a consistent pace without an unreasonable number and lengths of rest periods; ask simple questions or request assistance; respond appropriately in a routine work setting; and be aware of normal hazards and take appropriate precautions. (R. 360.) Dr. Pathak also found that Plaintiff had a “poor” or no ability to: remember work-like procedures; sustain an ordinary routine without special supervision; complete a normal workday and workweek without interruptions from psychologically based symptoms; accept instructions and respond appropriately to criticism from supervisors; get along with coworkers or peers without unduly distracting them or exhibiting behavioral extremes; and deal with normal work stress. (Id.) Dr. Pathak did not specifically identify any particular medical or clinical findings which supported her opinion regarding these limitations in the portion allotted in her report. (Id.)

         On May 7, 2013, Plaintiff had a mental health visit with Dr. Rauenhorst. (R. 472.) Plaintiff had trouble sleeping and complained that he could not sleep with others around. (Id.) Plaintiff believed he needed additional Seroquel in order for him to sleep better. (Id.) He also professed that he thought about shooting himself, but did not own a gun. (Id.) Plaintiff remained significantly depressed and felt that this was in part because he was not sleeping well. (R. 474.) As a result, Plaintiff wanted to increase the dosage of Seroquel. (R. 474.) Dr. Rauenhorst agreed to increase the dosage of Seroquel. (Id.) Plaintiff was diagnosed with PTSD and prescribed with sertraline. (R. 475.) Dr. Rauenhorst filled out a medical opinion diagnosing Plaintiff with major depression and cannabis abuse, which was expected to last at least 60 days during which he was unable to work at least until July 7, 2013. (R. 819.)

         During a May 23, 2013 preoperative appointment related to his foot, Plaintiff professed wanting to seek a new psychiatrist, as he was not happy with his medications due to weight loss. (R. 700.) Plaintiff claimed he was irritated a lot, staying away from people, sometimes having thoughts of hurting people, “visions of people drowning in the water - dreaming about being in jail and hurting people.” (R. 701.) Plaintiff asserted that he did not want to hurt anyone in particular. (Id.) He contracted for safety despite telling the doctor that he did have thoughts about hurting people. (Id.) He was highly motivated to have his surgery and stated that he would never hurt a doctor, nurse, or anyone in the hospital helping him. (Id.) Plaintiff's negative thoughts revolved around people he knew from the Dorothy Day Center, or in the neighborhood who he felt bullied him. (Id.) In a post-operative note, Plaintiff asserted that he had been finding ways of addressing his frustrations with a roommate. (R. 707.)

         On June 6, 2013, Plaintiff saw Dr. Rauenhorst. (R. 466.) Plaintiff had been regularly taking his medications, but was still depressed. (Id.)

         On June 13, 2013, Plaintiff saw Dr. Rauenhorst related to his inability to sleep and his use of marijuana. (R. 459.) Plaintiff did note that his depression was better, but that he could not sleep. (Id.) Plaintiff was diagnosed with major depression, moderate, and a rule-out diagnosis for PTSD. (R. 460-61.) Plaintiff was prescribed with Remeron (mitrazapine) given that his other medications were not working for him. (R. 461.)

         During a July 8, 2013 mental health visit, Dr. Rauenhorst diagnosed Plaintiff with improved major/moderate depression. (R. 452, 454.) Plaintiff described a depressive mood, and in some ways was better, but he remained very irritable and negative. (R. 454.) Plaintiff's appearance was appropriate; he was agitated; his affect was appropriate; he was depressed; his thought process was intact and more organized; he had no hallucinations; he was fully oriented; and had an intact memory. (R. 453.) Plaintiff was diagnosed with major depression, cannabis abuse, and a rule-out diagnosis for PSTD. (Id.) Plaintiff was smoking synthetic marijuana, instead of marijuana. (R. 452.)

         On July 22, 2013, Plaintiff showed no signs or symptoms from depression, his mood had been stable, but he was feeling frustrated. (R. 712.)

         On August 5, 2013, Plaintiff saw Dr. Rauenhorst related to his mental health. Plaintiff complained of nightmares, with no relief from medications. (R. 448.) He noted he would wake up and not be able to fall asleep for two hours after a nightmare. (Id.) Plaintiff admitted to using marijuana daily. (Id.) Plaintiff's appearance was appropriate; he was cooperative, but irritable; his affect was appropriate; he was depressed; his thought process was intact and more organized; he had no hallucinations; he was fully oriented; and had an intact memory. (R. 449.) Plaintiff was diagnosed with major depression, which was improved, cannabis abuse, and a rule-out diagnosis for PTSD. (R. 449-50.)

         On August 15, 2013, Plaintiff saw Dr. Laurel Gamm for a respite check. (R. 445.) According to Dr. Gamm, Plaintiff was not in any acute distress, he was alert and oriented, his thought content and affect appeared normal, and he maintained good eye contact. (R. 445-46.)

         On August 28, 2013, Plaintiff again saw Dr. Gamm for a respite check. (R. 438.) According to Dr. Gamm, Plaintiff's thought content and affect appeared normal, he had good eye contact, and his normal short-term memory was grossly normal. (R. 439.)

         On September 3, 2013, Plaintiff reported to Dr. Rauenhorst that he was more depressed. (R. 434.) Plaintiff represented that he had a lot of pain with an infection in his foot, and felt like dying to be to be rid of the pain, but he had no plans to harm himself. (R. 434-35.) Plaintiff's appearance was appropriate, he was irritable and very negative, his affect was appropriate, he was relaxed but depressed, his thought process was more organized, he had no hallucinations, he was fully oriented, and had an intact memory. (R. 435.) Plaintiff was diagnosed with major depression. (Id.) Dr. Rauenhorst also filled out a medical opinion diagnosing Plaintiff with major depression, which was expected to last at least 60 days during which he was unable to work at least until December 1, 2013. (R. 820.)

         On September 11, 2013, Plaintiff had a screening with Dr. Gamm at the Dorothy Day Center. (R. 431.) Plaintiff did not appear in acute distress, his thought content appeared normal, and his short-term memory was grossly normal. (R. 431-32.) Plaintiff denied any hallucinations. (R. 432.) Plaintiff complained of anxiety and depression, with fleeting suicidal thoughts, but he had no plan to act on those thoughts. (Id.) Plaintiff was diagnosed with moderate major depression. (Id.)

         On September 17, 2013, Plaintiff reported irritability and increased thoughts of self-harm. (R. 427.) He had been started on sertraline, which made him feel better, but he had run out of the medication. (Id.) Plaintiff complained of no new medical problems. (Id.)

         On October 29, 2013, Plaintiff saw Dr. Rauenhorst for a follow-up related to his mental health and a prescription refill. (R. 423.) Plaintiff's mood was anxious and depressed. (Id.) Plaintiff's appearance was appropriate; he was cooperative and irritable; he had an appropriate affect; he was more organized; was fully oriented; and had an intact memory. (Id.) Plaintiff reported no hallucinations. (Id.) Plaintiff was diagnosed with major depression, cannabis abuse, and rule-out diagnosis for PTSD. (R. 423.) Plaintiff ran out of medications and was getting worse. (R. 424.) Plaintiff was so negative about the other residents that it was difficult to discuss his symptoms. (Id.) Dr. Rauenhorst increased Plaintiff's dosage of sertraline. (R. 425.)

         On December 2, 2013, Plaintiff had a mental health office visit with Dr. Rauenhorst. (R. 419.) Plaintiff had run out of his medications. (Id.) Plaintiff indicated that the medications definitely helped and that he was worse without the medications. (Id.) Plaintiff reported no new problems since his previous visit and admitted that he was still using marijuana. (Id.) Plaintiff reported no hallucinations but believed that he could dream about the future. (R. 420.) Plaintiff was cooperative, but irritable, he was agitated and very negative, had an appropriate affect, was depressed and anxious, was fully oriented, and his memory was intact. (R. 419-20.) Dr. Rauenhorst noted that Plaintiff's depression had deteriorated. (R. 421.) According to Dr. Rauenhorst, Plaintiff was describing odd thoughts, and was borderline delusional if not outright delusional. (R. 421.) Dr. Rauenhorst noted that some of this could have been the marijuana use, but also noted that it could also have been the result of a psychotic disorder. (R. 421.) Plaintiff and Dr. Rauenhorst agreed to start Plaintiff on Seroquel as well as continue the sertraline. (R. 421.)

         On January 7, 2014, Plaintiff saw Dr. Rauenhorst for a mental health office visit. (R. 415.) Plaintiff reported that he was “doing all right” and represented that his medications were helping him. (Id.) Plaintiff did represent that he had trouble getting along with people despite his medications. (Id.) Plaintiff asserted that he ...


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