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Hartley v. Commissioner of Social Security

United States District Court, M.D. Florida, Jacksonville Division

September 14, 2017

Keith Hartley, Plaintiff,
v.
Commissioner of Social Security, Defendant.

          ORDER REVERSING COMMISSIONER'S DECISION

          PATRICIA D. BARKSDALE UNITED STATES MAGISTRATE JUDGE.

         This is a case under 42 U.S.C. § 405(g) and 1383(c)(3) to review a final decision of the Commissioner of Social Security denying Keith Hartley's claim for disability insurance benefits and supplemental security income.[1] He seeks reversal, Doc. 11; the Commissioner, affirmance, Doc. 13.

         Background

         Hartley was born in 1962 and last worked in 2011. Tr. 202, 210, 229. He has a high-school education and experience as a local-delivery driver and a long-haul truck driver. Tr. 230. He alleged he had become disabled in September 2011 from asthma, lung problems, heart problems, left eye problems, leg problems, high blood pressure, sleep apnea, sinusitis, and gout. Tr. 224, 229. Later, he added that in October or December 2012, he was diagnosed as bipolar and schizophrenic, could not focus, hallucinated, and started hearing voices. Tr. 256, 264. He is insured through 2016. Tr. 217. He proceeded through the administrative process, failing at each level. Tr. 1-7, 18-39, 133-43, 149-58. This case followed. Doc. 1.

         Issue

         Hartley presents one issue: whether the Appeals Council erred by denying his request for review of the Administrative Law Judge's (“ALJ's”) decision in light of newly submitted evidence.

         Evidence Before the ALJ

         On an August 2012 questionnaire, Hartley reported the following. His condition began bothering him in 2003. Tr. 253. He lost his job as a truck driver because he had an asthma attack, blacked out, and ran off the road into the bushes. Tr. 253. When asked to mark or list his conditions, he indicated he suffers severe fatigue, shortness of breath, chest pain, leg pain, digestion problems, and lung problems. Tr. 253. He sleeps four to eight hours a night but sometimes stays up all night and naps five to six hours during the day. Tr. 253. He can care for his personal needs as long as he does not stand too long. Tr. 254. He lives with his sister and sometimes helps with chores but stops when he gets short of breath and his chest and legs start to hurt. Tr. 254. He “do[es] good” in church but can no longer sing in the choir and likes to bowl but no longer can. Tr. 254.

         Many medical records from Hartley's treatment for breathing problems contain notations of normal psychological status. See, e.g. Tr. 355 (no anxiety, depression, and sleep disturbances), 398 (oriented to time, person, and place; normal speech and content; appropriate mood and affect; interactive and responsive; intact memory, judgment, and insight), 436 (normal mood and affect), 442 (no confusion), 445 (normal mood, affect, behavior, judgment, and thought content), 529 (normal mood, affect, behavior, judgment, and thought content), 687 (normal mood, affect, speech, behavior, judgment, thought content, cognition, and memory), 693 (no signs of anxiety, depression, or suicidal intention), 695 (no signs of anxiety, depression, or suicidal intention), 723 (normal mood, affect, behavior, judgment, and thought content), 729 (no psychosis; good judgment, memory, and behavior), 731 (no psychosis; good judgment, memory, and behavior).

         In October 2012, Hartley was admitted to the hospital for shortness of breath, wheezing, and coughing. Tr. 630. William Hunt, III, M.D., performed a psychiatry consultation to evaluate Hartley's depression and suicidal ideation. Tr. 637. Dr. Hunt noted Hartley's mental status was within normal limits except for a moderately depressed mood, and he displayed a broad range of affect and fair to good judgment and insight. Tr. 637. Hartley reported no current perceptual distortions but a history of hearing voices, symptoms of depression, and post-traumatic stress disorder (“PTSD”). Tr. 637. Dr. Hunt opined Hartley had experienced a single episode of major depression, was not actively suicidal, and had chronic PTSD. Tr. 637. He recommended psychoeducational psychotherapy and involvement in church and prescribed medication for the depression and PTSD. Tr. 637.

         In December 2012, Hartley was admitted to the hospital for exacerbation of his asthma. Tr. 600. Eduardo Sanchez, M.D., performed a psychiatry consultation. Tr. 600-01. Dr. Sanchez noted Hartley had experienced persistent auditory hallucinations telling him to hurt himself and others, including telling him to run over a person in front of him while he was driving a truck. Tr. 600. He observed Hartley was “agreeable and apparently in control of himself” but required antipsychotic medication. Tr. 600. A mental status exam showed Hartley was alert, well-oriented, had no cognitive deficits or memory defects, and displayed no evidence of a formal thinking disorder but was depressed and had suicidal command hallucinations. Tr. 600. Dr. Sanchez diagnosed Hartley with psychotic depression, opined Hartley was a danger to himself, and stated he would initiate a Baker Act to admit Hartley to an inpatient psychiatric facility. Tr. 600; accord Tr. 606.

         Hartley received inpatient psychiatric care for three days for depression and suicidal thoughts. Tr. 654-63. Mohammad Farooque, M.D., Ph.D., documented that Hartley had been hearing voices since 1993 but had received only outpatient care. Tr. 659. A mental status examination showed the following. He had good eye contact, poor grooming and hygiene, flat affect, apathetic mood, and limited insight and judgment; was alert and oriented to person, place, time, and situation; reported auditory hallucinations and paranoia; had alogia (inability to speak due to mental deficiency or confusion), [2] and appeared to have bradyphrenia (slowness of thought). Tr. 660. Dr. Farooque diagnosed him with “psychosis, not otherwise specified, rule out schizophrenia, paranoid type, ” assigned a Global Assessment of Functioning (“GAF”) scale rating of around 40, [3] and prescribed antipsychotic medication. Tr. 660. In a discharge summary, Dr. Farooque repeated that diagnosis and GAF scale rating and stated Hartley had improved with treatment, was alert and oriented, and denied suicidal or homicidal ideation. Tr. 654.

         In April 2013, Hartley underwent an initial psychiatric assessment with Julie Ozan, PA-C (a physician's assistant). Tr. 755-58. His chief complaint was hearing voices, and he reported auditory and visual hallucinations “as far back as he can recall, ” cutting his fingertips when pressured by negative voices, sad mood, low energy, crying spells, decreased appetite, worries and anxieties, passive suicidal thoughts, passive thoughts of harming others, a tendency to self-isolate because of hallucinations, and sedation from his medications. Tr. 755. He denied episodes of violence, prolonged periods of sleeplessness, spending sprees, or impulsive risk-taking behaviors. Tr. 755. Ozan noted he had had two psychiatric inpatient hospitalizations, a poor response to Abilify, fair response to Risperidone and Trazadone, and good response to Citalopram. Tr. 755.

         A mental status exam showed he was appropriately dressed and groomed, had a cooperative but initially guarded attitude, and maintained eye contact. Tr. 757. Ozan made the following observations:

Mr. Hartley's speech was initially guarded, but more spontaneous as exam progressed. He was alert and oriented to person, place, month[, ] and year. His stated mood was mildly depressed, and he had a blunted affect, with occasional appropriate smiles.
Thought content was linear and goal directed. He showed no flight of ideas or disorganized thinking. There were some mild paranoid versus overly suspicious thoughts expressed.
Mr. Hartley denied any current [suicidal ideation] or [homicidal ideation], but endorsed past thoughts of harming himself[, ] his family[, ] and strangers, with no intention of doing so. He endorsed current auditory hallucinations of commands and negative commentary, with several voices. He endorsed occasional visions as if daydreaming, sometimes ominous, but mostly random. He was not observed responding to internal stimuli during the interview.
There were no abnormal involuntary movements noted on exam. He had an overweight frame, with decreased muscle tone, but a steady gait. He had no pronator drift with gait and station testing. His psychomotor activity was calm.
He was able to perform serial 7s without error, but was unable to read or spell. He was able to name the current president of the United States and who was president before him. Recent and remote memory were grossly intact, and he was able to register and recall 3/3 items at 0 and 5 minutes.
He was partially able to comprehend the current situation correctly, and demonstrated the ability to orient his behavior appropriately. He was partially able to understand and appreciate the risks, benefits, and alternatives for treatment, the impact of his psychiatric condition, and need for treatment. He had adequate capacity to comply with treatment recommendations. Insight and judgment were present and adequate. Fund of knowledge was average, with some learning challenges of illiteracy.
He was not suicidal or acutely agitated or homicidal and did not require admission to a psychiatric hospital.

Tr. 757.

         Ozan diagnosed Hartley with schizoaffective disorder, depressed type, with “[p]sychotic symptoms consistent with other psychotic disorders but with many years of function inconsistent with typical schizophrenia, ” assigned a GAF scale rating of 41 to 50, [4] adjusted his medication, and opined his prognosis was fair to guarded. Tr. 757-58.

         In October 2013, Hartley attended a psychiatric medication management appointment with Phyliss Taylor, M.D. Tr. 762-63.[5] Dr. Taylor noted he had been hospitalized in January 2013 for psychosis, suicidal ideation, and homicidal ideation toward his family and had been hospitalized again shortly after his appointment with Ozan but had not followed up with treatment. Tr. 762. He reported auditory hallucinations, depression, suicidal ideation, trouble sleeping, two to three panic attacks each month, and PTSD flashbacks and nightmares despite taking medication. Tr. 762.

         Dr. Taylor made the following observations. Hartley was appropriately dressed and groomed, cooperative, alert, and oriented to person, place, and time. Tr. 763. He had normal speech, blunted affect, depressed mood, negative mental attitude, non-future-oriented thinking, logical and coherent thought processes, and limited insight and judgment. Tr. 763. He reported auditory and visual hallucinations but no apparent delusions, suicidal or homicidal ideation, or abnormal involuntary movements. Tr. 763. He had retarded psychomotor activity but normal muscle strength and tone and a steady gait. Tr. 763. Dr. Taylor diagnosed him with schizoaffective disorder, depressed type, and PTSD; assigned a GAF scale rating of 41 to 50; adjusted his medications; and opined he was severely ill. Tr. 763.

         On a March 2014 impairments questionnaire, a doctor marked that Hartley has depression, anxiety, schizophrenia, and other psychological factors affecting his physical condition and cannot work in even low-stress jobs. Tr. 773.

         In April 2014, Hartley attended a medication management appointment with Dr. Taylor. Tr. 825-26. His chief complaint was that he was shaking and talking to himself. Tr. 825. He reported depression, fleeting suicidal ideation, nightmares, and sleeping only a couple hours a night. Tr. 825. Dr. Taylor observed he was appropriately dressed and groomed, cooperative, alert, and oriented to person, place, and time. Tr. 825. He had normal speech, blunted affect, depressed mood, logical and coherent thought process, limited insight and judgment, normal muscle strength and tone, steady gait, retarded psychomotor activity, non-future-oriented thinking, and negative mental attitude. Tr. 825. He had no apparent delusions and denied suicidal or homicidal ideation but endorsed auditory and visual hallucinations. Tr. 825.

         Dr. Taylor diagnosed him with schizoaffective disorder, depressed type, and PTSD; assigned a GAF scale rating of 41 to 50; opined he was severely ill, and adjusted his medication. Tr. 825-26.

         In May 2014, Hartley attended a medication management appointment with Dr. Taylor. Tr. 823-24. He denied depression, mania, panic attacks, hallucinations, delusions, nightmares, flashbacks, and sleep problems. Tr. 823. Dr. Taylor noted the following. Hartley was appropriately dressed and groomed, cooperative, alert, and oriented to person, place, and time. Tr. 823. He had normal speech, calm affect, stable mood, logical and coherent thought process, limited insight and judgment, normal muscle strength and tone, steady gait, non-future-oriented thinking, and negative mental attitude. Tr. 823. He had no apparent delusion, no abnormal or involuntary movement, no suicide risk, and no violence risk. Tr. 823. He denied suicidal ideation, homicidal ideation, and auditory and visual hallucinations. Tr. 823.

         Dr. Taylor diagnosed Hartley with schizoaffective disorder, depressed type, and PTSD; assigned a GAF scale rating of 51 to 60;[6] opined he was moderately ill; and continued his medications. Tr. 823-24.

         Hearing Testimony

         At a July 2014 hearing, Hartley testified as follows.

         He lives with his wife and 20-year-old son. Tr. 58. His wife does most of the cooking and cleaning. Tr. 61. Sometimes he tries to help, but when he moves around too much he gets sick and has to use a nebulizer machine. Tr. 61. In a good week, he uses the nebulizer two or three times; in a bad week, he uses it every day. Tr. 61.

         He has ten grandchildren, two of whom (ages 11 and 4) he watches during the day while his daughter is at work. Tr. 58-59. He takes care of them but cannot get up and walk around much because he gets out of breath. Tr. 59-60.

         He used to drive trucks, but his asthma doctor told him he should stop because he “can't do [anything] without Prednisone.” Tr. 53-54. In 2011, he had an asthma attack while driving a truck. Tr. 57-58. He became short of breath and, because he was taking too much Prednisone and was alone, he panicked, passed out at the wheel, and hit a telephone pole. Tr. 63-64. He no longer has his commercial driver's license. Tr. 64. In 2012, he was in the hospital for a week or two every month because of breathing problems. Tr. 55.

         He used to see Ozan for his mental conditions but now sees Dr. Taylor. Tr. 56. It is “hard to say” if his schizophrenia has improved. Tr. 56. He hears voices, talks to himself, and wants to hurt himself, even when he takes his medication. Tr. 56-57. When he told Dr. Taylor he was depressed and hearing voices, she increased his medication. Tr. 57. Sometimes the medications work, and sometimes they do not. Tr. 57.

         The ALJ asked a vocational expert to consider a hypothetical claimant the same age as ...


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