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Jeffers v. Berryhill

United States District Court, N.D. Alabama, Middle Division

August 23, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Plaintiff Mandi Renee Jeffers (“Plaintiff” or “Jeffers”) brings this action pursuant to Section 205(g) of the Social Security Act (the “Act”), seeking review of the decision of the Commissioner of Social Security (the “Commissioner”) denying her claims for a period of disability and disability insurance benefits (“DIB”). See 42 U.S.C. § 405(g). Based on the court's review of the record and the briefs submitted by the parties, the court finds that the decision of the Commissioner is due to be reversed and remanded under Sentence Four of 42 U.S.C. § 405(g).

         I. Proceedings Below

         Plaintiff applied for DIB on July 23, 2013, alleging a disability beginning on or about June 30, 2012. (Tr. 79, 135). The Social Security Administration (“SSA”) initially denied Plaintiff's application on October 28, 2013. (Tr. 89). Plaintiff then requested a hearing by an Administrative Law Judge. (Tr. 103). Administrative Law Judge Walter V. Lassiter (“the ALJ”) heard the case on October 24, 2014 in Montgomery, Alabama. (Tr. 30-75). On May 22, 2015, the ALJ found Plaintiff was not disabled under sections 216(i) and 223(d) of the Act. (Tr. 9-26).

         Plaintiff requested review of that decision on July 8, 2015. (Tr. 5). On September 22, 2016, the Appeals Council denied Plaintiff's request. (Tr. 1). The ALJ's decision then became the final decision of the Commissioner and therefore a proper subject of this court's appellate review. Chester v. Bowen, 792 F.2d 129, 131 (11th Cir. 1986).

         II. Facts

         Plaintiff, age 31 at the time of the hearing, alleges she has been disabled since age 28. (Tr. 25, 135). She completed a cosmetology degree in 2003 while working as a grocery-store cashier. (Tr. 40, 174). She never used her cosmetology degree, however, other than to cut her father's hair every six weeks. (Tr. 62-63).

         Plaintiff worked as a telephone operator from 2004 to 2007 and as a packager from 2007 to 2008. (Tr. 24, 40-42, 68-69, 156, 174, 176-78). She graduated with an associate's degree in health-information management in May 2012 while working as a convenience-store cashier. (Tr. 16, 37-39, 68, 174-75). Soon after graduation, on May 10, 2012, Plaintiff suffered a nervous breakdown and was treated for both the breakdown and a migraine headache at Oxford Family Practice. (Tr. 16, 39, 42-43, 260). When, in June 2012, Plaintiff was not paid after returning to work from having been out with her migraine and anxiety, she left her convenience-store job. (Tr. 11, 24, 38-40, 43, 174-175, 192).

         After her May 2012 hospitalization, Plaintiff began treatment for anxiety, depression, and migraines. (Tr. 47). She was told that her migraines were caused by her anxiety and depression. (Id.). Drs. Anthony Esposito and Chandra Gehi saw and/or treated Plaintiff nine times for migraines and tremors at Anniston Neurology Clinic. (Tr. 20-21, 50, 271-295). Drs. Esposito and Gehi typically reported that Plaintiff was alert, oriented, cooperative, and non-suicidal, with normal judgment and appropriate mood and affect, though they often noted her anxiety and depression. (Tr. 271, 273-74, 279-285, 288-91, 294). Plaintiff last saw them in November 2013 presenting mild tremor and decreasing migraine episodes of one time per month or less. (Tr. 20-21, 269, 270-72).

         From May 2013 through August 2014, Dr. Glenn Archibald of Grandview Behavioral Health Centers was Plaintiff's treating physician. (Tr. 211-17, 222-43, 296-304). At his initial assessment on May 6, 2013, Dr. Archibald noted that Plaintiff was well-groomed yet her affect was inappropriate and her mood was anxious and depressed. (Tr. 216). Plaintiff reported losing sleep and hearing voices “for years” with command hallucinations. (Tr. 216-17). Dr. Archibald reported that Plaintiff's “reaction appears geared to impress me with how severely ill she is, ” and that “all her responses are extreme.” (Tr. 217). He diagnosed her with social phobia and noted that she was isolated from everyone, more than she typically was in the past. (Id.).

         In July, August, and September 2013, treatment notes that are part of the record indicate that Plaintiff continued to struggle with depression, anxiety, hallucinations, and hypersomnia. (Tr. 214-15). In August 2013, Dr. Archibald noted that Plaintiff was “worse, ” and in September 2013 he noted that her progress was “partial.” (Tr. 212-13). In November 2013, progress notes indicate that Plaintiff's symptoms were “much better, ” affecting her 1-2 times per week, yet the therapist noted that Plaintiff's affect was flat, “behavior lethargic, verbal content shallow, verbal flow severely inhibited, poor eye contact.” (Tr. 237). Though Plaintiff had “good days and bad days, ” the bad days were “severe, a 10 out of 10.” (Tr. 236). Plaintiff continued to have social phobia and problems with hearing voices. (Id.). In early December 2013 Plaintiff was back to experiencing symptoms 3 to 4 times per week with the therapist noting “flat affect, low mood, poor eye contact, lethargic, regressed verbal behavior.” (Tr. 235). Later in December Plaintiff's symptoms were rated as “much better” at 1-2 times per week but Dr. Archibald noted that Plaintiff “had a panic attack at the mall (crowded).” (Tr. 234).

         Therapy notes from 2014 continued to track the ups and downs of Plaintiff's treatment, with notes in late March and early April 2014 stating Plaintiff was “functioning at her peak level” with severe symptoms 1-4 times per week. (Tr. 228-29). Other notes from 2014 have Plaintiff experiencing symptoms nearly every day with flat affect and continued auditory hallucinations (Tr. 232), hypersomnia (Tr. 227, 231), crying all of the time with symptoms every day and “really bad depressed” (Tr. 230), depressed mood, poor eye contact, lethargic behavior, and scarcity of verbal elaboration (Tr. 226), and sleeping all day and inactivity (Tr. 225). The final recorded visit in August 2014 indicates that Plaintiff enjoyed a trip to Gulf Shores and that her medications were helping, except for the side effect of sleepiness during the day.[1] (Tr. 19, 225).

         Dr. Archibald completed a Mental Residual Functional Capacity Assessment (“MRFC”) on October 23, 2014 concluding:

Plaintiff constantly exhibits a baseline of severe impairment due to mental illness. Her symptoms are severe enough to be readily observable by non-professionals. . . . [S]he is isolative and significantly uncomfortable in any social situation. . . . This patient is completely incapable of working and struggles with personal hygiene and minimal self-maintenance.

(Tr. 21-22, 304).

         While seeing Dr. Archibald for mental health, Plaintiff also saw cardiologist Dr. Osita Onyekwere for physical health. (Tr. 22-23, 306-15). Plaintiff complained, in June 2014, of “palpitations, leg and ankle swelling, and fatigue.” (Tr. 22, 312). Noting Plaintiff's “[p]oorly balanced diet, ” Dr. Onyekwere prescribed additional medications and encouraged her to improve her diet. (Tr. 314). Dr. Onyekwere reported at every visit between June and October 2014 that Patient was alert, oriented to time, place, and person, and had appropriate mood and affect. (Tr. 305-15). Plaintiff also saw ...

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