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Guilford v. Berryhill

United States District Court, D. Connecticut

September 24, 2018



          Donna F. Martinez United States Magistrate Judge

         The plaintiff, Guilda Guilford, seeks judicial review pursuant to 42 U.S.C. § 405(g) of a final decision by the Commissioner of Social Security ("Commissioner") denying her application for disability insurance benefits. The plaintiff asks the court to reverse the Commissioner's decision or, alternatively, remand for a rehearing. (Doc. #23.) The Commissioner, in turn, seeks an order affirming the decision. (Doc. #24.) For the reasons set forth below, the plaintiff's motion is denied and the defendant's motion is granted.[1]

         I. Administrative Proceedings

         In May 2014, the plaintiff applied for disability insurance benefits alleging that she was disabled as of September 24, 2012 due to "menorhagia[2], anemia, 4 uterine fibroid tumors, 20 breast adenomas, tachycardia, [3] high blood pressure, severe depression and anxiety." (R. at 183.) Her last date insured is December 31, 2017. Her application was denied initially and upon reconsideration. She requested a hearing before an Administrative Law Judge ("ALJ"). On May 23, 2016, the plaintiff, represented by counsel, testified at the hearing. A vocational expert also testified. On June 20, 2016, the ALJ issued a decision finding that the plaintiff "was not under a disability, as defined in the Social Security Act, from September 24, 2012 through the date of this decision." (R. at 26.) On June 15, 2017, the Appeals Counsel denied review, making the ALJ's decision final. This action followed. On February 2, 2018, the plaintiff filed a motion for reversal or remand and on March 8, 2018, the defendant filed a motion to affirm.

         II. Factual Background

         The plaintiff, born in 1968, was 44 years old at the time of her alleged onset[4] date of September 24, 2012. She graduated high school and completed two years of college. (R. at 184.) Last employed as a customer service representative, the plaintiff states that she lost this job in September 2012 after she left work to "go to the hospital and get a blood transfusion." (R. at 44.)

         A. Medical Evidence

         In February 2009, the plaintiff saw Dr. Klein of Shoreline Medical for complaints of fatigue and chest pains on exertion. (R. at 445.) The plaintiff had a history of anemia. Dr. Klein noted that the plaintiff had "normal" menses. Dr. Klein assessed her with hypertension. She was next seen in April 2010 by Dr. Nina Inamdar for ear pain. (R. at 446.) 2012 On September 26, 2012, the plaintiff was seen for complaints of backache, bodyache and fatigue. (R. at 272.) Blood work indicated that her hemoglobin was 4.7.[5] The next day, the plaintiff presented to the Bridgeport Hospital with complaints of feeling lightheaded for the past week, requiring time off from work. (R. at 366.) She also reported sinus congestion, headaches, and increased urinary frequency. Notes states that the plaintiff has a "long history of iron deficient anemia initially secondary to heavy menses and now in combination with a vegetarian diet." (R. at 367.) She did not take recommended "iron treatments" because she was concerned about side effects of constipation and/or diarrhea. (R. at 366.) The plaintiff reported that her menses were regular, occurring every 28 days and lasting approximately 4 days. She had had heavy menses in the past but this "changed after she lost weight." (R. at 366.) The plaintiff explained that she had followed a strict diet to lose 60 pounds and stopped eating meat. The plaintiff was given a transfusion. She was assessed with severe symptomatic anemia with reactive thrombosis. (R. at 367.) She also was noted as tachycardic which was thought to be due to her anemia. (R. at 367.)

         On September 29, 2012, the plaintiff had a hematology consultation. (R. at 292.) She explained that she discontinued iron therapy because of her concern regarding side effects. She also stated that although physicians had recommended she take birth control medication to address her heavy menses, she elected not do so. The plaintiff was given intravenous iron. (R. at 294.)

         On October 11, 2012, the plaintiff was seen by internist Dr. Nina Inamdar of Shoreline Medical. The plaintiff reported that she was anxious and stressed over losing her job but declined treatment for anxiety. Dr. Inamdar prescribed Atenolol, a beta blocker, for the plaintiff's hypertension.

         The next medical record is dated more than a year later.


         On October 31, 2013, the plaintiff went to the emergency room after hitting her head. (R. at 337.) She denied loss of consciousness. She reported a history of anemia. She stated that her menses "usually lasts 5 days with the heaviest day [being] day 2." (R. at 361.) She was alert, oriented, and had normal strength. Her hemoglobin was 3.2. Her anemia was thought to be due to menses and diet. The plaintiff was admitted to the hospital and given blood transfusions and an iron infusion. After the treatments, she reported "feeling much better" and denied any fatigue. Hormonal therapy was recommended to address her menorrhagia. (R. at 362.) She left the hospital against medical advice. (R. at 365.)

         A CAT scan of the plaintiff's abdomen showed "multiple uterine masses which may represent large necrotic fibroids," ovarian cysts, multiple large gallstones, splenomegaly, [6] multiple breast nodules, and a small right pleural effusion." (R. at 416.)

         On December 5, 2013, the plaintiff was seen by Dr. Inamdar. (R. at 263.) She denied chest pain, dyspnea, fatigue, and palpitations. Dr. Inamdar's notes state "negative" for depression, syncope, bone pain, joint pain and weakness. (R. at 264.) Dr. Inamdar noted that the plaintiff's hypertension was poorly controlled. She renewed the prescription for Atenolol and prescribed hydrochlorothiazide, a diuretic. When Dr. Inamdar saw the plaintiff a few weeks, the plaintiff's hypertension had improved. (R. at 266.)


         In January 2014, a bilateral breast ultrasound revealed "multiple circumscribed ovoid structures" that appeared benign and "likely represent[ed] fibroadenomas."[7] (R. at 404.) The plaintiff was told to follow up in six months. (R. at 406.)

         On February 20, 2014, the plaintiff had a gynecological appointment with Wilheelmina Thomas-Jackson, a certified nurse midwife ("CRN"). (R. at 611.) The plaintiff reported that she was taking an iron supplement daily as directed and that her last hemoglobin was 9. CRN Thomas-Jackson discussed options for treating the plaintiff's menorrhagia. The plaintiff declined hormonal medication due to weight gain concerns but expressed interest in an embolization treatment. (R. at 611.)

         On March 12, 2014, Dr. Inamdar completed a Medical Source Statement for the State of Connecticut Department of Social Services. (R. at 313.) On the one page form, Dr. Inamdar listed the plaintiff's conditions as severe chronic anemia, menorrhagia, fibroid tumors, and fibroadenomas. (R. at 313.) Dr. Inamdar checked a box on the form indicating that the conditions prevented the plaintiff from working for "6 months or more." Dr. Inamdar also indicated that the plaintiff did not have a mental health problem. (R. at 313.)

         On September 2, 2014, the plaintiff underwent a consultative physical examination by Dr. Joseph Guaranaccia. (R. at 314-17.) The plaintiff told him that her menses lasted 10 days, during which she experienced severe bleeding. She also said that her breast fibroadenomas caused her "severe pain in her chest" and that the medication she took for hypertension caused fatigue and lightheadness. (R. at 314.)

         Upon examination, Dr. Guaranaccia noted that the plaintiff's affect was normal and that she was not anxious. He remarked that she was a "good historian." (R. at 316.) Her physical examination was unremarkable. Under the "Assessment" section of his report, Dr. Guaranaccia stated:

46 year old woman with heavy menses due to fibroid tumors, and discomfort due to breast tumors. Until these issues are resolved she is limited in her ability to be consistent in a work setting.

(R. at 317.)

         State agency physician Dr. Jeanne Kuslis reviewed the plaintiff's medical records and completed a physical residual functional capacity assessment. Dr. Kuslis determined that the plaintiff could frequently lift and/or carry 20 pounds; occasionally lift and/or carry 10 pounds; stand and/or walk 6 hours in an 8 day; and sit 6 hours in an 8 hour day. (R. at 61.)

         On September 17, 2014, the plaintiff underwent a consultative psychological examination by Dr. Dana Martinez. The plaintiff reported difficulty sleeping "due to frequent urination as a result of water pills and a tumor pressing on her bladder." She stated that "when she has her menses she is literally awake for two days straight since it requires so much care due to the heavy bleeding." (R. at 320.) She reported anxiety, panic attacks, and depression.

         Dr. Martinez observed that the plaintiff was well spoken and that her speech was clear and organized. She was oriented to date, time and person. The plaintiff's affect was sad and she disclosed current suicidal ideation due to her financial stressors and illness. She denied auditory and visual hallucinations and Dr. Martinez saw no evidence of delusional ideation. Dr. Martinez assessed the plaintiff's "insight and introspective abilities" as "good." Her attention was good and her "effort and concentration" were "very good." (R. at 320.) Dr. Martinez noted that the plaintiff "appeared to be intently focus[ed] and "attempting to do as well as possible." The plaintiff was able to recall three out of four words after fifteen minutes.

         Dr. Martinez's diagnostic impressions were Major Depressive Disorder, severe, single episode; Generalized Anxiety Disorder; and Panic Disorder. (R. at 320.) According to Dr. Martinez, the plaintiff "will require direction to needed social services and monitoring to ensure attendance." Dr. Martinez stated that the plaintiff "would benefit" from therapy and a "psychiatric evaluation to determine if medication would ameliorate" her symptoms. (R. at 320.)

         On September 30, 2014, State agency physician Dr. Warren Lieb reviewed the plaintiff's medical record. Dr. Lieb found that the plaintiff had no restrictions in the activities of daily living; mild difficulties in maintaining social functioning; mild difficulties in maintaining concentration, persistence or pace; and no repeated episode of decompensation. (R. at 60.)

         In October 2014, State agency consultant Russell Phillips, Ph.D, completed a mental residual functional capacity assessment. Dr. Phillips found that the plaintiff had no significant limitations in her ability to: carry out very short and simple instructions; carry out detailed instructions; and sustain an ordinary routine without special supervision. The plaintiff was "moderately limited" in her ability to: maintain attention and concentration for extended periods; perform activities within a schedule; maintain regular attendance and be punctual within customary tolerances; work in coordination with or in proximity to others without being distracted by them; and make simple work-related decisions. Dr. Phillips opined that the plaintiff could "maintain attention for two hours at a time and persist at simple tasks over eight and forty hour periods with normal supervision." (R. at 78.) He further found that the plaintiff could "tolerate the minimum social demands of simple-task settings" but not "sustained contact with the general public." (R. at 79.) Dr. Phillips stated that the plaintiff was "able to persist at simple, repetitive tasks over time under ordinary conditions." (R. at 79.)

         The plaintiff had a consultation with Dr. Richard Garvey, a surgeon, on October 22, 2014 regarding the "[m]ultiple masses" in her breasts. (R. at 327.) The plaintiff reported that she was taking iron supplements and felt better. Her examination was unremarkable. (R. at 328.)

         In November 2014, the plaintiff began individual therapy with Jennifer Lockshier, a licensed clinical social worker ("LCSW"). She treated with LCSW Lockshier through September 2015.

         On November 20, 2014, the plaintiff was seen by Dr. Dorothy Zachmann, a psychiatrist, at the Bridgeport Hospital Intensive Outpatient Program. (R. at 324.) The plaintiff was noted as having "significant mood instability." Dr. Zachmann observed that the plaintiff's impulse control was impaired; her mood was "discouraged, irritable and depressed"; and her affect was labile. The plaintiff's speech was normal and her thought process was organized and coherent. She was oriented, her attention and concentration were normal, and her judgment was good. She had limited insight into her illness. Dr. Zachmann diagnosed the plaintiff with "bipolar I disorder depressed and panic disorder." (R. at 326.) The plaintiff was prescribed Abilify.[8] (R. at 327.)

         When seen on December 8, 2014, LCSW Lockshier observed that the plaintiff's mood and affect were improved. The plaintiff reported that she was taking medication. On December 11, 2014, the plaintiff reported that she was part of a "paid focus group." (R. at 674.) She said she felt better and wanted to return to work. (R. at 674.) On December 23, 2014, the plaintiff indicated she had stopped taking her medication. She presented with blunted affect and depressed mood. (R. at 672.) The plaintiff "express[ed] difficulty" with Dr. Zachmann's diagnosis of bipolar and felt that "maybe she could use it as an excuse." She indicated she planned on moving to Bridgeport and was "uncertain where to find a job because she does not want a long commute." (R. at 672.)


         On January 8, 2015, the plaintiff told LCSW Lockshier that her living situation was stressful and she planned to move shortly. She expressed uncertainty about getting a job due to her health issues. She "is uncertain and feels that she is an unreliable employee and should maybe not work." LCSW Lockshier noted that despite recommendations, the plaintiff was not seeking treatment for her medical issues. (R. at 670.) The next week, the plaintiff stated that she felt "unprepared to go to work" due to her medical issues. She was concerned that she "will be unreliable and they will fire her so why [should she] even try." (R. at 669.) LCSW Lockshier recommended a higher level of care. In February, the plaintiff continued to present with a blunted affect and depressed mood. In March 2015, the plaintiff expressed anger at her family for their lack of support. She expressed feeling "conflicted" about not being married with children. (R. at 661.)

         In a letter to plaintiff's counsel dated March 31, 2015, LCSW Lockshier stated that she had seen the plaintiff since November 2014. The plaintiff had presented with "symptoms consistent with panic attacks when in public." LCSW Lockshier stated that the plaintiff suffered from uterine fibroids and anemia, which "contribute to her feelings that she will be unsuccessful in the workplace. She was residing with one of her sisters with the hope that she could be able to work soon." LCSW Lockshier further stated that the plaintiff

attend[ed] weekly sessions for psychotherapy to address the issues she has been experiencing. The sessions were increased to twice weekly for several weeks when she reached a critical phase and was more acute. The recommendation has been made to begin a higher level of care with the possibility of psychotropic intervention to address her depression and feelings of suicidality. An appointment to Intensive Outpatient Services (IOP) [at] Bridgeport Hospital REACH was made. Her symptoms and these feelings most certainly inhibited her ability to work. She was unable to commit to the requirements of the IOP due to multiple reasons, including [that she moved]. They had prescribed two medications, however, client felt uncomfortable taking the medication due to side effects and that she was not feeling that they will be effective.
Client remains in a time of transition and has been essentially homeless. She resided with a sister in Bridgeport but moved in with her niece in Darien due to family obligations and an argument with the Bridgeport sister. Her Darien sister has indicated that she will need to move out of the home very soon. Referrals and recommendations have been made to outpatient community resources to assist her in becoming more stable and to address her basic needs.
It is apparent that [the plaintiff] has been declining emotionally over the past few years. She has insight into her mental health but has poor judgment on how to overcome these obstacles and barriers in her life. Her coping skills have worsened since losing her job and she had become more socially isolated. Her social supports have been more limited and certainly less supportive of her now that she is [in] need of [] assistance. Her overall mood is generally depressed with anxious ...

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