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Robinson v. Berryhill

United States District Court, S.D. Alabama, Southern Division

February 8, 2018

FLETCHER K. ROBINSON, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION AND ORDER

          P. BRADLEY MURRAY UNITED STATES MAGISTRATE JUDGE

         Plaintiff Fletcher K. Robinson brings this action, pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), seeking judicial review of a final decision of the Commissioner of Social Security (“the Commissioner”) denying his claim for Disability Insurance Benefits (“DIB”), and Supplemental Security Income (“SSI”), based on disability. The parties have consented to the exercise of jurisdiction by the Magistrate Judge, pursuant to 28 U.S.C. § 636(c), for all proceedings in this Court. (Doc. 19 (“In accordance with the provisions of 28 U.S.C. 636(c) and Fed.R.Civ.P. 73, the parties in this case consent to have a United States Magistrate Judge conduct any and all proceedings in this case, … order the entry of a final judgment, and conduct all post-judgment proceedings.”)). See also Doc. 21. Upon consideration of the administrative record, Robinson's brief, the Commissioner's brief, all other documents of record, and oral argument, it is determined that the Commissioner's decision denying benefits should be affirmed.[1]

         I. PROCEDURAL HISTORY

         On April 24, 2014, Robinson applied for a Period of Disability and DIB, under Title II of the Social Security Act, and for SSI, based on disability, under Title XVI of the Social Security Act (“the Act”), 42 U.S.C. §§ 1381-1383d, alleging disability beginning on March 25, 2014. (Tr. 235-46). After his application was denied at the initial level of administrative review on August 1, 2014, Robinson requested a hearing by an Administrative Law Judge (ALJ). (Tr. 136-42). After an initial hearing was held on October 16, 2015, and a supplemental hearing was held on February 24, 2016, the ALJ issued an unfavorable decision finding that Robinson was not under a disability from the date the application was filed through the date of the decision, April 21, 2016. (Tr. 33-107). Robinson appealed the ALJ's decision to the Appeals Council, which denied his request for review on March 13, 2017. (Tr. 1-6).

         After exhausting his administrative remedies, Robinson sought judicial review in this Court, pursuant to 42 U.S.C. §§ 405(g) and 1383(c). (Doc. 1). The Commissioner filed an answer and the social security transcript on July 20, 2017. (Docs. 7, 8). On August 18, 2017, Robinson filed a brief in support of his claim. (Doc. 9). The Commissioner filed her brief on December 4, 2017. (Doc. 16). Oral argument was held before the undersigned Magistrate Judge on January 30, 2018. (Doc. 20). The case is now ripe for decision.

         II. CLAIM ON APPEAL

         Robinson alleges that the ALJ's decision to deny him benefits is in error because the ALJ's Residual Functional Capacity (RFC) assessment was not supported by substantial evidence. (Doc. 9 at pp. 1- 2).

         III. BACKGROUND FACTS

         Robinson was born on July 27, 1965, making him 48 years old at the time he filed his claim for benefits. (Tr. 296). Robinson alleged disability due to PTSD, prostate cancer, diabetes, depression, high blood pressure, and back pain. (Tr. 279). He graduated from high school on June 3, 1983, attending regular education classes. (Tr. 280). After high school he joined the Army and served for almost ten years, including a deployment in the Gulf War. (Tr. 94). He worked from 1994 to 2014 as a parts manager for the Mobile County sheriff's garage. (Tr. 280-81). He takes care of his own personal care, although his wife does remind him to take his medicine because he has focus issues. (Tr. 289-90). He is able to iron, do laundry, and some minor cleaning chores. (Tr. 290). He can pay bills, count change, handle a savings account, and use a checkbook/money orders with his wife's help. (Tr. 291). He only drives short distances with someone with him because he does not know when his PTSD will be triggered. (Tr. 291). He goes outside at his home on a daily basis. (Tr. 291). He spends his time at home with his family or at church, going to PTSD therapy, and going to doctor's appointments. (Tr. 292). He enjoys watching television and fishing, but says he cannot fish alone anymore. (Tr. 292). He testified at the first hearing that he had to retire from his employment due to the symptoms caused by his PTSD and having to miss work to attend sessions for treatment of his PTSD. (Tr. 98-100). After conducting the hearings, the ALJ made a determination that Robinson had not been under a disability during the relevant time period, and thus, was not entitled to benefits. (Tr. 36-65).

         IV. ALJ'S DECISION

         The ALJ made the following relevant findings in her April 26, 2016 decision:

3. The claimant has the following severe impairments: Prostate cancer, obesity, diabetes mellitus, osteoarthrosis, essential hypertension, anxiety disorders, and affective disorders. (20 CFR 404.1520(c) and 416.920(c)).
The medical evidence of record documents that the claimant has received mental health treatment through the Veteran's Administration Health Care System (VA) since at least May 2010. A document dated May 5, 2010 indicates that the claimant was scheduled for admission to the Psychosocial Rehabilitation Residential Treatment Program (PRRTP) at the VA Gulf Coast Veterans Health Care System in Biloxi, Mississippi on May 17, 2010. (Exhibit 1F). The evidentiary record contains no other documentation regarding this admission. (Exhibit 18E).The record does contain a “Certificate of Completion” dated July 9, 2010, signed by a psychologist, two social workers, a recreation therapist, and a chaplain, indicating that the claimant successfully completed the “PTSD Intensive Outpatient program” through the PRRTP. (Exhibit 2F).
The evidentiary record further documents that, since January 2011, the claimant has received mental health treatment through the Gulf Coast VA Health Care System for diagnoses of post-traumatic stress disorder (PTSD), Chronic Depression, and OCD. (Exhibits 3F, 4F, 7F, and 10F). The treatment records reflect Global Assessment of Functioning (GAF) scores of 45 to 50 since 2012. (Exhibits 4F at pages 123 and 232, 10F at pages 64, 69, 71, and 109, and 21F at page 6). The claimant has been followed medically at the VA by staff psychiatrist Douglas Ewing, M.D., since February 2011. A treatment note from Dr. Ewing dated February 6, 2014, approximately one month prior to the claimant's alleged onset date, reflects that the claimant presented with worries about the responsiveness of his prostate cancer to treatment. The claimant reported having no medication side effects, and his mental status examination (MSE) revealed that he reported his mood was “down” and that his affect was subdued, but appropriate to topic. Dr. Ewing further noted at that time that the claimant was oriented to person, place, time, and situation, that he denied current suicidal or homicidal ideation, plan, or intent, that his thoughts were logical and goal-directed without evidence of thought disorder or delusion, that feelings of hopelessness were not elicited, and that the claimant did not appear to be responding to auditory/visual hallucinations. Dr. Ewing diagnosed the claimant with PTSD. A psychiatric outpatient note a little over six weeks later, on the claimant's alleged onset date, March 25, 2014, indicates that the claimant complained to Dr. Ewing of symptoms of weekly intrusive thoughts, weekly dreams/nightmares, weekly flashbacks, psychological distress, psychological reactivity, efforts to avoid thoughts, feelings, people, places, and events, markedly diminished interest in activities, social isolation from others, loss of ability to feel emotions, sleep disturbances, anger outbursts, poor concentration, hypervigilance, and exaggerated startle response. The claimant further reported having “chronic persistent dysphoria and anxiety and social and interpersonal restriction.” The claimant denied current suicidal ideation, plan, or intent and he denied persistent morbid thoughts. However, Dr. Ewing noted that the claimant's MSE on March 25, 2014 was remarkable only for “low” mood and “mild to moderately glum” affect. All other aspects of the claimant's MSE on that date were within normal limits. The claimant's diagnosis on that date was chronic PTSD. (Exhibit 3F at pages 1-11).
A review of the claimant's mental health treatment records from the VA Medical Center from 2014 and 2015 reflects Dr. Ewing, and VA staff psychologist Susan K. Rhodes, Ph.D., treated the claimant for PTSD and depression with psychotropic medications and individual therapy on a regular basis. The records indicate that, although the claimant continued to complain of symptoms of “self-injurious thoughts, ” recurrent, involuntary, and intrusive distressing memories of events that occurred during his military service, psychological distress, and avoidance of distressing memories, thoughts, or feelings associated with events that occurred during his military service, he consistently denied having active suicidal intent, and he also consistently denied having feelings of hopelessness. The treatment records do not reflect that the claimant's mental health treatment providers, Dr. Ewing and Dr. Rhodes, documented any significantly abnormal mental status examination findings during their office visits with the claimant. For example, at the claimant's July 2014 visit with Dr. Ewing, the claimant's MSE appeared normal, and the claimant's mood was reported as “IT'S GOOD” and his affect was subdued but appropriate to topic. Dr. Ewing further noted that the claimant “smiled broadly at times.” (Exhibit 7F at page 37). On October 22, 2014, Dr. Ewing recorded very similar MSE findings, and noted that the claimant reported that his mood was “ALRIGHT” and that his affect was subdued but appropriate to topic. Dr. Ewing again observed that the claimant “smiled broadly.” (Exhibit 10F at page 79). At his visit with the claimant on May 20, 2015, Dr. Ewing again noted no abnormalities in the claimant's MSE and he noted that the claimant reported that his mood was “GOOD, ” and he observed that the claimant's affect was “ smiling, friendly and engaging” and appropriate to topic. (Exhibit 10F at page 116).
On mental status examination of the claimant on October 20, 2014, Dr. Rhodes observed that the claimant demonstrated agitated psychomotor behavior and stated that his mood was depressed (with congruent affect), but she further noted that the claimant was alert and oriented to person, place, time, and purpose, that his grooming and hygiene were properly maintained, that his speech was average in rate and tone, that his thoughts were logical and goal-directed, that there was no evidence of psychosis, and that his attention, concentration, and memory appeared adequate. The claimant reported having suicidal thoughts, but he denied any intent to act upon it. Dr. Rhodes diagnosed the claimant with PTSD and Depression NOS. (Exhibit 10F at pages 83-84).
The claimant was admitted to the PTSD Intensive Outpatient Program, PRRTP, in the Gulf Coast Veterans Health Care System, from March 31, 2015 to May 19, 2015. The record indicates that the claimant successfully completed the program. (Exhibit 10F at pages 112; Exhibit 11F).
On June 11, 2015, Dr. Rhodes observed that the claimant's mood appeared depressed with congruent flat affect, but he was alert and fully oriented, that he was well-groomed with good hygiene, that his speech was normal, that his thoughts were logical and goal-directed, that there was no evidence of psychosis, and that he denied suicidal or homicidal ideation and did not endorse any factors interfering with continued maintenance of safety from harm to self or others. Dr. Rhodes noted very similar findings at her visit with the claimant on June 30, 2015. Dr. Rhodes diagnosed the claimant with PTSD and Depressive Disorder, NOS. (Exhibit 10F at page 109). On September 2, 2015, Dr. Ewing noted that the claimant reported that he was less anxious/irritable/reactive and that his sleep and mood were improved. The claimant's mental status examination on that date was essentially normal, with no suicidal or homicidal ideation, plan, or intent, and no feelings of hopelessness. (Exhibit 14F at pages 8-9).
Dr. Ewing wrote a letter on April 9, 2014 in support of the claimant 's VA compensation and pension claim based on PTSD. In that letter, Dr. Ewing indicated that the claimant continued to experience “significant distress related to his PTSD, ” despite treatment with psychotropic medications and individual psychotherapy. Dr. Ewing listed the claimant's daily to weekly symptoms and he stated that the claimant's symptoms were significant and, in his opinion, the claimant was not “cognitively, interpersonally or affectively capable of functioning in the workplace” at that time due to his PTSD. (Exhibit 4F at pages 94-95). Dr. Ewing also completed disability forms on the claimant's behalf for the Retirement Systems of Alabama (RSA) on April 28, 2014 and July 8, 2015. (Exhibits 12E, 5F, and 9F). In both forms, Dr. Ewing opined that the claimant was “totally incapacitated” from duty due to PTSD, depressed mood, chronic anxiety, low frustration tolerance, and emotional reactivity, and that his employer could not make any accommodations which would allow the claimant to be capable of employability. In the April 28, 2014 form, Dr. Ewing also noted that the claimant's “anxiety/agitation” precluded tolerance of the workplace, and in the July 8, 2015 form, he stated that the claimant was “intolerant of social demands of workplace settings.”
The record documents that the claimant was granted disability retirement from The Retirement Systems of Alabama effective June 1, 2014. (Exhibit 5D).
On June 19, 2014, clinical psychologist Jennifer M. Jackson, Psy. D., completed an Initial PTSD Disability Benefits Questionnaire on the claimant for “internal VA or DoD use only.” Dr. Jackson indicated that the claimant 's diagnoses were PTSD and Unspecified Depressive Disorder, and that he had overlapping symptoms with one condition exacerbating the other. Dr. Jackson opined that the claimant had “occupational and social impairment with reduced reliability and productivity.” (Exhibit 7F at pages 39-46).
The claimant received a VA rating decision on July 25, 2014 which found that he had a 50 percent disability rating effective August 24, 2009 due to PTSD with unspecified depressive disorder based on the claimant's difficulty in adapting to a work like setting, disturbance of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, occupational and social impairment with reduced reliability and productivity, chronic sleep impairment, weekly panic attacks, anxiety, and depressed mood. (Exhibit 10D).
In the most recent VA rating decision dated May 16, 2015, the claimant received a temporary 100 percent disability rating from the VA based on his admission to the PTSD Intensive Outpatient Program, PRRTP from March 31, 2015 through May 19, 2015 for PTSD. The rating decision explained that an evaluation of 50 percent was assigned from August 1, 2010; an evaluation of 100 percent was assigned from March 31, 2015; and an evaluation of 50 percent was assigned from June 1, 2015. The claimant's overall combined rating was 50 percent for occupational and social impairment with reduced reliability and productivity due to specific symptom [sic] such as flattened affect, circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of ...

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