United States District Court, D. Connecticut
JULIANNE E. TOOKER
v.
NANCY A. BERRYHILL[1], ACTING COMMISSIONER OF SOCIAL SECURITY
RULING ON PLAINTIFF'S MOTION TO REVERSE THE
DECISION OF THE COMMISSIONER AND ON DEFENDANT'S MOTION
FOR AN ORDER AFFIRMING THE DECISION OF THE
COMMISSIONER
Robert
M. Spector United States Magistrate Judge.
This
action, filed under § 205(g) of the Social Security Act,
42 U.S.C. § 405(g), seeks review of a final decision by
the Commissioner of Social Security [“SSA”]
denying plaintiff Supplemental Security Income
[“SSI”] and Social Security Disability Insurance
[“SSDI”] benefits.
I.
ADMINISTRATIVE PROCEEDINGS
On or
about April 13, 2012, the plaintiff filed applications for
SSI and SSDI benefits claiming that she has been disabled
since October 17, 2009, due to “[c]hronic kidney
issues, chronic pain, [post-traumatic stress disorder],
anxiety, ” and “shoulder, neck, back and leg
issues from numerous car [accidents].” (Certified
Transcript of Administrative Proceedings, dated May 19, 2016
[“Tr.”] 253; see Tr. 224-39, 249-62).
The plaintiff's applications were denied initially and
upon reconsideration. (Tr. 66-89, 92-120, 144-51, 159-65;
see generally Tr. 152-58, 271-84). On December 16,
2013, the plaintiff requested a hearing before an
Administrative Law Judge [“ALJ”] (Tr. 166-67;
see Tr. 168-69, 188), and on April 17, 2015, a
hearing was held before ALJ Brian Curley, [2] at which the
plaintiff and a vocational expert, Larry Takki, testified.
(Tr. 36-89; see Tr.189-223). On May 20, 2015, the
ALJ issued an unfavorable decision denying the
plaintiff's claim for benefits. (Tr. 123-43). On May 27,
2015, the plaintiff requested review of the hearing decision
(Tr. 12-13), and on January 13, 2016, the Appeals Council
denied the plaintiff's request for review, thereby
rendering the ALJ's decision the final decision of the
Commissioner. (Tr. 1-3; see Tr. 4-8).
On
March 15, 2016, the plaintiff filed her complaint in this
pending action (Doc. No. 1), and on May 25, 2016, the
defendant filed her answer and certified administrative
transcript, dated May 19, 2016. (Doc. No. 11). On June 13,
2016, this case was transferred to United States District
Judge Robert N. Chatigny, absent consent to a Magistrate
Judge. (Doc. No. 13). On August 25, 2016, the plaintiff filed
the pending Motion to Reverse the Decision of the
Commissioner, with brief in support (Doc. Nos. 16, 16-2
[“Pl.'s Mem.”]; see Doc. Nos.
14-15), along with a Joint Statement of Material Facts (Doc.
No. 16-1). On August 31, 2016, the defendant filed her Motion
for Judgment on the Pleadings, with brief in support. (Doc.
Nos. 17, 17-1 [“Def.'s Mem.”]).
On
March 31, 2017, this case was transferred to Senior United
States District Judge Alfred V. Covello (Doc. No. 18), and on
December 15, 2017, the parties consented to jurisdiction by a
United States Magistrate Judge; the case was transferred to
Magistrate Judge Sarah A. L. Merriam. (Doc. No. 33;
see Doc. Nos. 19-21). Fourteen days later, on
December 29, 2017, this case was transferred to Magistrate
Judge Joan G. Margolis (Doc. No. 23), and on May 1, 2018,
this case was transferred to this Magistrate Judge. (Doc. No.
24).
For the
reasons stated below, the plaintiff's Motion to Reverse
the Decision of the Commissioner (Doc. No. 16) is DENIED, and
the defendant's Motion to Affirm (Doc. No. 17) is
GRANTED.
II.
FACTUAL BACKGROUND
As of
her alleged onset date of disability, October 17, 2009, the
plaintiff was thirty-two years old. (See Tr. 66).
The plaintiff lives with her partner, and, at times, her
adult son and her grandson. (Tr. 43).[3] The plaintiff has a twelfth
grade education and does not have a driver's license; she
is afraid to drive. (Tr. 24-25). She does not take public
transportation because she panics when she is around other
people; her psychiatrist approved her need for a medical
livery service. (Tr. 46).
At the
time of the hearing, the plaintiff weighed 133 pounds (Tr.
24, 33); previously, she weighed 200 pounds. (See
Tr. 32). She attributed her weight loss to her depression,
suppressed appetite, and medications. (Tr. 24). She has a
history of cutting herself, and she had cut herself two weeks
prior to her hearing. (Tr. 31-32). As discussed below, she
has been treated by Dr. Lori Sobel for depression, her lack
of desire to leave her house, suicidal thoughts, anxiety,
bipolar disorder, and post-traumatic stress disorder
[“PTSD”]. (Tr. 31-32; see also Tr.
154-55).
A.
ACTIVITIES OF DAILY LIVING
The
plaintiff watches some television but has difficulty focusing
on shows lasting an hour. (Tr. 44). She does not have any
hobbies although, in the past, she would ride a motorcycle,
camp, fish, and walk. (Tr. 45). The plaintiff's partner
does their grocery shopping and cooks, and the plaintiff
“tr[ies]” to do some housecleaning, but her
partner helps her with all of their household chores. (Tr.
42-43; see Tr. 153 (the plaintiff wants to shower,
clean her house, and talk to others but her mind tells her
that others are talking about her)). At the time of her
hearing, the plaintiff was attending a weekly women's
support group at her church although sometimes she did not
attend because of her depression or anxiety. (Tr. 45). When
she is depressed, she does not shower for two or three days
in a week. (Tr. 44).
The
plaintiff testified that she has difficulty falling asleep,
she has a lot of nightmares that cause her to wake in a
panic, and she is tired during the day from getting less than
four hours of sleep each night. (Tr. 33). Additionally,
according to the plaintiff, it is very difficult for her to
focus and concentrate on tasks, including on counseling
sessions with Dr. Sobel (Tr. 33-34; see also Tr. 250
(SSA claims representative noted that the plaintiff had
difficulty answering questions, was unable to focus, and was
overly talkative)), and she feels angry when people speak to
her. (Tr. 263, 266).
The
plaintiff testified that she was being treated with Methadone
for opiate dependence at the Connecticut Counseling Center;
she became dependent on OxyContin which had been prescribed
for pain from her kidney surgeries and for her back problems.
(Tr. 38-39). However, the plaintiff has been
“clean” for the past three years, with the
exception of prescribed Benzodiazepines when she had her
kidney surgeries. (Tr. 39-40). According to the plaintiff,
she never felt that she was abusing drugs, but rather, was
using them only as needed. (Tr. 51-52).
The
plaintiff worked as a hostess at the Holiday Inn Express at
the CoCo Key Resort; as a taxi driver; in the seafood
department of Price Chopper; and as a school bus
driver.[4] (Tr. 26-27). At the time of her hearing,
the plaintiff was watching her two-year old nephew for three
to five hours a week (Tr. 36-37), however, she testified that
at times she cannot watch him because she is “very
depressed, very nervous, ” and she does not think it
would be “good for him in that state of mind.”
(Tr. 37).
B.
MEDICAL RECORDS[5]
1.
DR. SOBEL
The
record reflects a long and consistent treatment history with
Dr. Lori Sobel at Connecticut Counseling Centers. The
plaintiff was initially evaluated by Dr. Sobel on December
21, 2010. (Tr. 995-96). The plaintiff's mental status
examination revealed a history of depression and crying for
the past year, decreased sleep, anxiety, panic attacks
(shaking, shortness of breath) lasting a few minutes,
flashbacks and nightmares, decreased concentration,
compulsive behavior, feelings that she would be better off
dead but no plans to harm herself, racing thoughts especially
if she had a flashback, and irritability. (Tr. 996). She
indicated the plaintiff's diagnoses were depression and
PTSD, and she prescribed Vistaril and Zoloft. (Tr. 996).
Thereafter, Dr. Sobel regularly saw the plaintiff for
medication management.
On
March 11, 2011, the plaintiff reported that she felt no
improvement with Zoloft and Vistaril; Dr. Sobel added
Seroquel. (Tr. 380). The plaintiff described feeling very
frustrated and depressed; she said that she had a panic
attack in a supermarket. (Tr. 380). She also advised that she
had no appetite and had lost twelve pounds. (Tr. 380). A
month later, the plaintiff reported that she felt
“awful[, ]” and that she was moody; she went from
being a raving lunatic to crying, sitting on her bed doing
nothing, and banging her head against the wall. (Tr. 381).
The plaintiff continued to complain of depression with
irritability and racing thoughts; Dr. Sobel felt the
plaintiff was at chronic risk to act impulsively, and she
noted that the plaintiff “likely has Bipolar NOS . .
.[, and] PTSD[.]” (Tr. 381). She discontinued the
plaintiff's Vistaril and Seroquel and added Trazodone and
Abilify. (Tr. 381). By May 20, 2011, the plaintiff had lost
another seven pounds (Tr. 383), and she continued to complain
of depression, decreased motivation, and crying. (Tr. 383).
Dr. Sobel noted that, although the plaintiff continued to be
“symptomatic[, ] she . . . appear[ed] a little
better.” (Tr. 383). She increased her Trazodone and
Zoloft dosages and started to taper her Lamictal
prescription. (Tr. 383).
In July
2011, Dr. Sobel noted that the plaintiff appeared a little
calmer, and she recommended Intensive Outpatient Treatment
[“IOP”], but the plaintiff expressed a concern
over a lack of transportation. (Tr. 384). At that time, the
plaintiff's diagnoses were bipolar NOS (not otherwise
specified), PTSD, and borderline personality traits. (Tr.
384). Dr. Sobel continued to prescribe Trazodone, Zoloft,
Abilify, and Lamictal. (Tr. 384). On September 16, 2011, Dr.
Sobel thought that the plaintiff appeared better emotionally,
although the plaintiff reported that her mood was still up
and down, she had decreased sleep, crying, and racing
thoughts, and she felt depressed. (Tr. 385). Dr. Sobel added
Ambien to the plaintiff's medication regimen. (Tr. 385).
On
November 14, 2011, the plaintiff complained of decreased
sleep, and although Ambien helped her fall asleep, she would
wake because of pain, crying, or racing thoughts. (Tr. 387,
972). Dr. Sobel noted that the plaintiff appeared calmer and
better, but the plaintiff reported that she still would have
periodic thoughts of wishing she would not wake up, and urges
to cut herself. (Tr. 387, 972). According to Dr. Sobel, the
plaintiff was “not a reliable historian” because,
although she filled her medications as prescribed, she did
not pick up the refills, yet told Dr. Sobel that she was
taking her medications compliantly. (Tr. 387, 972). Dr. Sobel
increased the plaintiff's prescription for Trazodone for
sleep and discontinued Lamictal. (Tr. 388, 973).
On
January 23, 2012, the plaintiff returned to Dr. Sobel with
continued complaints of panic attacks, feeling depressed and
stressed, decreased sleep, racing thoughts, urges to cut
herself, and feelings that she would be better off dead. (Tr.
389, 411, 968). Dr. Sobel thought that the plaintiff appeared
“improved and calmer[, ]” and Dr. Sobel noted
again that the plaintiff was “an inconsistent and
unreliable historian[, ]” and that medication
compliance “has been an issue in the past.” (Tr.
389, 411, 968.). Her diagnoses remained bipolar
disorder NOS, PTSD, and borderline personality traits, and
Dr. Sobel added Neurontin to the plaintiff's medication
regimen. (Tr. 389, 411, 968). A month later, the plaintiff
reported ongoing panic attacks, depression, and stress. (Tr.
391, 413). Dr. Sobel increased the plaintiff's Trazodone
dosage and repeated that the plaintiff was “an
inconsistent and unreliable historian” and that
medication compliance had been a problem in the past. (Tr.
391, 413).
The
plaintiff returned on May 8, 2012; she continued to complain
of panic attacks especially when she had to leave her house.
(Tr. 393, 415, 958). Dr. Sobel noted, however, that the
plaintiff appeared “improved and calmer.” (Tr.
393, 415, 958). She continued the plaintiff on her same
medications (Trazodone, Zoloft, Abilify, Ambien, and
Neurontin). (Tr. 393, 415, 958). On July 17, 2012, the
plaintiff reported that she felt about the same although she
was scattered and had problems focusing. (Tr. 941). Dr. Sobel
added attention deficit disorder [“ADD”] to the
plaintiff's diagnoses. (Tr. 941). Her medications
remained the same. (Tr. 941.).
On
September 25, 2012, the plaintiff reported that she felt
about the same, but Dr. Sobel noted that she appeared
“much brighter.” (Tr. 933). The plaintiff had
been able to stop the illicit use of Klonopin (Tr. 933); she
continued to complain of panic attacks and depression, but
did not appear as depressed and did not discuss wanting to
hurt herself. (Tr. 933). According to Dr. Sobel, the
plaintiff was “doing better and [was] less symptomatic
both psychiatrically and physically.” (Tr. 933). The
plaintiff mentioned that she was focused on her
daughter-in-law's baby shower, which helped to
“organize her.” (Tr. 933). Dr. Sobel stated that,
in the past, the plaintiff had been an “inconsistent
and unreliable historian” and that she had issues with
medication compliance, but she appeared “better with
this.” (Tr. 933). A month later, Dr. Sobel noted that
the plaintiff “continues to do about the best I have
seen her.” (Tr. 931). Dr. Sobel also noted that she was
doing better with her medication compliance as well. (Tr.
931). Plaintiff continued to complain of depression,
difficulty leaving the house, and panic attacks, but the
panic attacks occurred less often, and she used behavioral
techniques to lessen their intensity. (Tr. 931). Dr. Sobel
added Concerta to the plaintiff's medication regimen.
(Tr. 931).
On
November 13, 2012, the plaintiff continued to complain of
periodic triggered panic attacks, but they were occurring
less often and were less intense. (Tr. 450, 929). She also
complained of depression, difficulty leaving the house, and
periodically thinking she would be better off dead. (Tr. 450,
929). Dr. Sobel opined that the plaintiff had “been
doing better and [was] less symptomatic both psychiatrically
and physically[, ]” but “[m]edication
compli[a]nce [was] still an issue.” (Tr. 450, 929). She
increased the plaintiff's prescription for Concerta. (Tr.
450, 929). A month later, the plaintiff reported
that she had not noticed a change on Concerta, but she might
have been more irritable and had a bad panic attack with
stress. (Tr. 451, 924). The plaintiff continued to do better,
and Dr. Sobel advised her to monitor her irritability. (Tr.
451, 924).
On
February 25, 2013, the plaintiff reported that the Concerta
helped her to focus and be better organized. (Tr. 917). A
mental status examination revealed the plaintiff's speech
was fluent and her language was coherent, although she
continued to complain of depression and crying, and she had
difficulty leaving the house. (Tr. 917). She had no
psychosis, but she ruminated on negative thoughts and had low
self-esteem. (Tr. 917). Dr. Sobel opined that the plaintiff
was doing better, but she still had “much stress”
and continued to be symptomatic. (Tr. 917). Dr. Sobel
increased her Zoloft prescription and told her to continue to
monitor her irritability. (Tr. 917).
When
the plaintiff returned on April 8, 2013, she reported that
she was seeing her pastor on Sundays for counseling. (Tr.
913). According to the plaintiff, Concerta helped her focus,
but she was more irritable. (Id.). On October 29,
2013, Dr. Sobel noted that she had not seen the plaintiff
since April due to the plaintiff's hospitalizations for
kidney problems and surgery. (Tr. 901; see generally
Tr. 519-55, 611-854, 1034-1141). Following a phone call from
the plaintiff, Dr. Sobel noted that she had not filled her
prescriptions regularly; she ordered refills of prescriptions
for ...