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Rodriguez v. Beeryhill

United States District Court, D. Connecticut

April 5, 2018



          Hon. Vanessa L. Bryant United States District Judge.

         This is an administrative appeal following the denial of the Plaintiff, Karen Rodriguez's, application for Title II Social Security Disability benefits, and a Title XVI application for Supplemental Security Income.[1] It is brought pursuant to 42 U.S.C. §§ 405(g). Karen Rodriguez (“Plaintiff” or “Rodriguez”) has moved for an order reversing the decision of the Commissioner of the Social Security Administration (“Commissioner”), or remanding the case for rehearing. [Dkt. No. 16]. The Commissioner opposes this motion. [Dkt. No. 20]. On July 13, 2017, the case was fully briefed. For the following reasons, Rodriguez's Motion for an Order Reversing or Remanding the Commissioner's Decision [Dkt. No. 16] is DENIED.

         I. Background

         A. Administrative Proceedings

         Plaintiff applied for disability insurance benefits and supplemental security income in June 2013. [AR 222-32]. She alleged that she became disabled on January 1, 2011, at age 33, due to panic attacks, insomnia, anxiety, depression, agoraphobia, a personality disorder, and asthma. [AR 279]. Her applications were denied initially and on reconsideration. [AR 126-29, 131-33]. She then requested a hearing before an ALJ. [AR 144-45]. After a hearing, at which Plaintiff was represented by counsel, Administrative Law Judge (“ALJ”) John Noel issued a decision on August 20, 2015, finding that Plaintiff was not disabled under the Social Security Act (the “Act”). [AR 19-29]. The Appeals Council denied Plaintiff's request for review, and this action followed. [AR 1-3].

         B. Medical History

         On appeal before this Court, Plaintiff highlights the following medical conditions: (1) anxiety and depression; (2) right knee impairment; (3) cognitive deficiencies; and (4) obesity.

         1. Anxiety and Depression

         Plaintiff received mental health treatment from therapists and a psychiatrist at Franciscan Life Center from October 2011 through December 2014. Specifically, Plaintiff received mental health care from psychiatrist Dr. Joanna Jakubowska, MD, and from mental health counselors Sister Sophia Peters, MF-T, and Sister John Mary Sullivan, LMFT. [AR 389-411, 436-447, 480-82]. In notes from an October 24, 2011 visit, Peters noted that Plaintiff had moved from the Bronx, NY to Connecticut, and that she had previously been diagnosed with anxiety and depression. Peters stated that Plaintiff was taking 60mg of Cymbalta every day. Peters' notes also stated “ER often for anxiety.” Peters found that Plaintiff had a Global Assessment of Function of 55 and recommended weekly therapy sessions with medication management. [AR 389-92]. Peters also observed that Plaintiff was well-groomed and calm, that she had an appropriate affect and a normal mood, that her thought process was intact and she had no hallucinations, and that she was fully oriented and her memory, cognitive functioning, capacity for abstract thought, judgment, and insight were intact. [AR at 390]. Peters recommended weekly therapy and medication management. [AR 392].

         On November 7, 2011, approximately two weeks after Peters' notations, Plaintiff presented to Dr. Jacubowska for a psychiatric evaluation. Dr. Jacubowska noted symptoms associated with plaintiff's diagnoses, including anxiety, panic attacks, poor concentration, poor sleep, and fear of social situations. Dr. Jacubowska diagnosed Plaintiff with panic disorder with agoraphobia and entertained possible diagnoses or “ruling out” of major depressive disorder and bipolar disorder. [AR 393-94]. Plaintiff noted that her energy and motivation were good, and Dr. Jacubowska observed that Plaintiff was well-groomed and alert and oriented to person, time and place. [AR 394]. Plaintiff's speech was normal in rate, volume, and tone, and her affect was constructed with no lability and her mood was euthymic. [AR 394]. Plaintiff's memory was intact, but her concentration was poor, and Plaintiff denied hallucinations. Plaintiff's thought process was logical and goal directed, and Plaintiff had fair insight and good judgment. [AR 394]. Dr. Jacubowska advised Plaintiff to continue her current medication regimen, which included Trazodone and Cymbalta. [AR 393-94]. In a follow-up appointment on November 28, 2011, Dr. Jacubowska noted that despite treatment, Plaintiff experienced no changes in her symptoms. [AR 395].

         Plaintiff saw Peters weekly from November 28, 2011 to January 6, 2012. [AR 396-97]. On January 6, 2012, Plaintiff reported that she felt “stronger.” [AR 396]. The session focused on Plaintiff's goals and the possibility of getting a general education diploma (“GED”). Peters also explained that she was leaving the Franciscan Center and that Plaintiff would be transferred to a different therapist. [AR 396].

         Beginning on January 20, 2013, Plaintiff began seeing Sullivan, and she continued see Dr. Jacubowska for medication management. [AR 397]. On March 28, 2012, Sullivan noted that Plaintiff reported she “continue[d] to struggle” with anxiety and depression and had been unable to implement any relaxation techniques. Sullivan reviewed relaxation techniques with Plaintiff and instructed her to utilize these techniques when experiencing symptoms. [AR 395]. On a follow-up appointment on April 24, 2012, Sullivan stated that Plaintiff reported that she was struggling with sleep problems and was “unable to sleep through the night due to anxiety.” [AR 397]. In a treatment note dated April 25, 2012, Jacubowska noted that she was going to discontinue prescribing Buspar to Plaintiff due to lack of benefits but would continue to prescribe Cymbalta. She also noted that Plaintiff had complaints of mood changes, racing thoughts, irritability and fear/paranoia. [AR 398].

         In her May 11, 2012 treatment notes, Dr. Jacubowska stated that Plaintiff continued to complain of racing thoughts and poor sleep, and Dr. Jacubowska prescribed Abilify to treat these symptoms. [AR 398]. In her June 7, 2012 treatment notes, Dr. Jacubowska stated that Plaintiff's dosage of Abilify would be increased and that Plaintiff continued to suffer from anxiety and poor sleep.

         Plaintiff's mental health treaters' notes from December 12, 2012 through November 21, 2013 state that during this period of time, Plaintiff continued to suffer from symptoms of anxiety, depression, agoraphobia, and panic attacks. [AR 401-410]. On October 29, 2013, Sullivan completed a Mental Impairment Questionnaire. This questionnaire is co-signed by Dr. Jacubowska. Sullivan stated that Plaintiff had a diagnosis of panic disorder with agoraphobia and major depressive disorder. Sullivan noted that Plaintiff was taking the following medications: Celexa, Lemictal, Klonopin, and Abilify, all of which are used to treat anxiety and depression. Positive clinical findings included poor concentration, auditory halluciations, paranoia, depressed mood, and constricted affect. Plaintiff's judgment and insight were rated “fair, ” Plaintiff was well groomed, and under “cognitive status, ” Sullivan noted that Plaintiff was oriented to person, place, and time, her memory was intact, her attention was fair, and her concentration was poor. Sullivan noted that Plaintiff had a slight problem in carrying out single-step instructions and changing from one simple task to another. [AR 385]. Sullivan stated that Plaintiff would have an “obvious problem” with respect to: (1) using appropriate coping skills to meet ordinary demands of a work environment; (2) handling frustration appropriately; (3) interacting appropriately with others in a work environment; (4) asking question or requesting assistance; (5) getting along with others without distracting them or exhibiting behavioral extremes; (6) carrying out multi-step instructions; (7) focusing long enough to finish assigned simple activities or tasks; (8) performing basic work activities at a reasonable pace/finishing on time; and (9) performing work activity on a sustained basis. [AR 382-86].

         On November 12, 2013, Plaintiff told Dr. Jacubowska that she was doing well. [AR 409, 436]. Plaintiff's sleep had improved with an increase in Klonopin and she denied having a depressed mood. [AR 409]. Dr. Jacubowska found that Plaintiff was alert and oriented to person, place, and time, that Plaintiff's mood was normal and that Plaintiff's affect was constricted but with no lability. [AR 409, 436]. Plaintiff did not hallucinate, and her judgment and insight were good.

         On January 22, 2014, Dr. Jacubowska completed a Medical Report for Incapacity for the State of Connecticut's Department of Social Services. Dr. Jacubowska states that Plaintiff had been diagnosed with panic disorder with agoraphobia and bipolar I disorder. Dr. Jacubowska opined that Plaintiff experiences panic attacks, poor sleep, inability to focus, high anxiety, and poor concentration. She added that Plaintiff “continues to have a fear of social settings. [AR 411-415]. On the form, Jacubowska marked a box indicating that Plaintiff could not work while she was being treated. [AR 413].

         Plaintiff continued treatment with Sullivan and Dr. Jacubowska throughout 2014. [AR 438-47, 481]. In January 2014, Plaintiff reported that she had more anxiety during the holidays and felt overwhelmed by her responsibilities. [AR 440]. Dr. Jacubowska found that Plaintiff was oriented to person, place, and time, Plaintiff's mood was normal and her affect was constricted, but she exhibited no lability. [AR 440]. Plaintiff did not have hallucinations and her judgment and insight were good. [AR 440]. Dr. Jacubowska noted that Plaintiff's mood was stable and her anxiety had increased in the context of recent stressors. [AR 440]. She recommended that Plaintiff continue therapy and her current medications, and she reported the same findings during subsequent evaluations, except in December 2014.

         On that date, Dr. Jacubowska observed that Plaintiff's affect was bright instead of constricted, and Plaintiff reported that she was doing well. [AR 440-41, 444-47]. Dr. Jacubowska also saw Plaintiff in January, March, and April 2015, at which point Dr. Jacubowska found that Plaintiff was alert and oriented to person, place, and time, her mood was dysphoric, her affect was constricted, she had no lability or hallucinations, and her judgment and insight were good. [AR 481-82].

         2. Right ...

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