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Preston v. Berryhill

United States District Court, N.D. Florida, Gainesville Division

February 7, 2018

JOANN MARIA PRESTON, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          REPORT AND RECOMMENDATION

          GARY R. JONES UNITED STATES MAGISTRATE JUDGE.

         Plaintiff appeals to this Court from a final decision of the Acting Commissioner of Social Security (the “Commissioner”) denying Plaintiff's application for supplemental security income (“SSI”) pursuant to Title XVI of the Social Security Act (“the Act”). (ECF No. 1.) The Commissioner has answered, (ECF No. 12), and both parties have filed briefs outlining their respective positions. (ECF Nos. 26, 29.) For the reasons discussed below, it is recommended that the Commissioner's decision should be affirmed.

         I. PROCEDURAL HISTORY

         Plaintiff filed her application for Title XVI benefits on July 25, 2013, alleging a disability onset date of June 1, 2004, due to anxiety and depression. (R. 20, 184, 208.) Her application was denied initially on October 25, 2013, and upon reconsideration on January 13, 2014. (R. 20, 110, 117.) An Administrative Law Judge (“ALJ”) held a hearing on October 15, 2015. (R. 38-78.) The ALJ then issued a written decision on December 11, 2015, finding Plaintiff not disabled. (R. 20-32.) The Appeals Council thereafter denied Plaintiff's request for review. (R. 1-5.) Plaintiff subsequently appealed the ALJ's decision to this Court. (ECF No. 1.)

         II. STANDARD OF REVIEW

         The Commissioner's findings of fact are conclusive if supported by substantial evidence. See 42 U.S.C. § 405(g) (2012). Substantial evidence is more than a scintilla, i.e., the evidence must do more than merely create a suspicion of the existence of a fact, and must include such relevant evidence as a reasonable person would accept as adequate to support the conclusion. Foote v. Chater, 67 F.3d 1553, 1560 (11th Cir. 1995) (citing Walden v. Schweiker, 672 F.2d 835, 838 (11th Cir. 1982), Richardson v. Perales, 402 U.S. 389, 401 (1971)); accord Edwards v. Sullivan, 937 F.2d 580, 584 n.3 (11th Cir. 1991).

         Where the Commissioner's decision is supported by substantial evidence, the district court will affirm, even if the reviewer would have reached a contrary result as finder of fact, and even if the reviewer finds that the evidence preponderates against the Commissioner's decision. Edwards, 937 F.2d at 584 n.3; Barnes v. Sullivan, 932 F.2d 1356, 1358 (11th Cir. 1991). The district court must view the evidence as a whole, taking into account evidence favorable as well as unfavorable to the decision. Foote, 67 F.3d at 1560; accord Lowery v. Sullivan, 979 F.2d 835, 837 (11th Cir. 1992) (holding that the court must scrutinize the entire record to determine reasonableness of factual findings); Parker v. Bowen, 793 F.2d 1177 (11th Cir. 1986) (finding that the court must also consider evidence detracting from evidence on which the Commissioner relied). However, the district court will reverse the Commissioner's decision on plenary review if the decision applies incorrect law, or if the decision fails to provide the district court with sufficient reasoning to determine that the Commissioner properly applied the law. Keeton v. Dep't Health & Human Servs., 21 F.3d 1064, 1066 (11th Cir. 1994).

         The law defines disability as the inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death, or has lasted or can be expected to last for a continuous period of not less than twelve months. 42 U.S.C. §§ 416(I), 423(d)(1) (2012); 20 C.F.R. § 416.905 (2015).[1] The impairment must be severe, making Plaintiff unable to do her previous work, or any other substantial gainful activity which exists in the national economy. § 423(d)(2); 20 C.F.R. §§ 416.905-416.911.

         The ALJ must follow five steps in evaluating a claim of disability. 20 C.F.R. § 416.920. The claimant has the burden of proving the existence of a disability as defined by the Social Security Act. Carnes v. Sullivan, 936 F.2d 1215, 1218 (11th Cir. 1991). First, if a claimant is working at a substantial gainful activity, she is not disabled. § 416.920(b). Second, if a claimant does not have any impairment or combination of impairments which significantly limit her physical or mental ability to do basic work activities, then she does not have a severe impairment and is not disabled. § 416.920(c). Third, if a claimant's impairments meet or equal an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1, she is disabled. § 416.920(d). Fourth, if a claimant's impairments do not prevent her from doing past relevant work, she is not disabled. §§ 416.920(e)-(f). Fifth, if a claimant's impairments (considering her residual functional capacity (“RFC”), age, education, and past work) prevent her from doing other work that exists in the national economy, then she is disabled. § 416.920(g).

         The burden of proof regarding the plaintiff's inability to perform past relevant work initially lies with the plaintiff. Walker v. Bowen, 826 F.2d 996, 1002 (11th Cir. 1987); see also Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001). The burden then temporarily shifts to the Commissioner to demonstrate that “other work” which the claimant can perform currently exists in the national economy. Doughty, 245 F.3d at 1278 n.2.[2]

         III. SUMMARY OF THE RECORD

         A. Medical Records

         1. Mental

         Plaintiff had an individual education plan throughout school. (R. 305-19.) She graduated from high school in 2004 with a special diploma. (R. 308.)

         In June 2013, at the age of twenty-seven, Plaintiff presented to New Horizons of the Treasure Coast (“New Horizons”) for a psychological evaluation. (R. 323-40.) Plaintiff said she did not know why she was there. Plaintiff's mother reported that Plaintiff had developmental delays since birth and that she therefore wanted disability for Plaintiff. Plaintiff admitted to some pervasive sadness, apathy, anxiety about being away from her mother, anhedonia, [3] and helplessness. She denied having any auditory or visual hallucinations. She was not on any psychotropic medications at the time. Plaintiff reported spending her adult life with her mother, having no significant adult relationship, and never having a job. She could, however, perform activities of daily living and cook for herself. She had a pet dog and enjoyed art and nail art.

         On examination Plaintiff was oriented to person, place, and time. Her appearance, motor activity, flow of thought, affect, and behavior were within normal limits. There was no evidence of psychosis. She demonstrated, however, a reduced amount of speech, stuttering, and a depressed mood. Natalie Keegan, ARNP, assessed Plaintiff with depressive disorder not otherwise specified, assigned a Global Assessment of Functioning (“GAF”) score of 50, and prescribed Prozac.

         Plaintiff returned to New Horizons in July 2013 for a follow up with Bassem El-Bahtity, M.D. (R. 328-29.) Plaintiff reported anhedonia, anxiety, decreased concentration and mood, and feelings of isolation. She denied having any auditory or visual hallucinations. Plaintiff's mother reported that the Prozac had helped “somewhat, ” and that Plaintiff was “more social.” Plaintiff appeared casual but disheveled, with a constricted, depressed, dysphoric affect and guarded attitude. Her speech was decreased in production, slow in rate, and soft in volume. Plaintiff's thought process, however, was congruent and there was no evidence of hallucinations. Dr. El-Bahtity assessed Plaintiff with a GAF score of 45 and increased Plaintiff's Prozac prescription to help alleviate her depression and anxiety.

         By September 2013 the Prozac was helping Plaintiff. (R. 370-71.) Although she still had occasional crying spells and irritability, she was able to redirect her thinking during those occasions to positive thoughts. She nonetheless continued to report anhedonia, depressed mood, and irritability. Plaintiff denied perceptual disturbances and appeared casual and well-groomed. She was communicative, cooperative, and demonstrated congruent thought content and thought process. Peter Sanchez, M.D., assessed Plaintiff with a GAF score of 55 and continued her Prozac prescription.

         In October 2013 Plaintiff presented to Shanlis Counseling and Assessment (“Shanlis”) for a psychological assessment by Christopher J. Beltran, PsyD. (R. 343-46.) Plaintiff reported feeling sad, that she felt like she was not contributing because no one wanted to hire her for “simple stuff” like labor, and that employers would have to be patient with her. She also claimed to forget things that her mother would ask her to do. Plaintiff's typical day included cleaning the house, watching television, and laying on the bed. She claimed to socialize only with her mother, and enjoyed drawing, making key chains, and nail art.

         On examination, Plaintiff's vision, speech, hearing, and language were adequate. Her activity level was normal and her affect appropriate. There was no evidence of psychosis and Plaintiff denied suicidal ideation. Plaintiff was oriented, demonstrated good attention, concentration, and judgment, and demonstrated fair reasoning. Her recent and remote memory, however, were poor.

         Plaintiff underwent an intelligence assessment, which revealed a perceptual reasoning score of 88, which was in the low average range. She obtained scores of 74, 71, and 71 in verbal comprehension, working memory, and processing speed, respectively, all of which were in the borderline range. Her full scale IQ of 72 was also in the borderline range. Dr. Beltran assessed Plaintiff with unspecified anxiety disorder and unspecified depressive disorder. Dr. Beltran recommended that Plaintiff undergo therapy to address her mood and anxiety and also receive a vocational evaluation.

         Plaintiff returned to New Horizons in November 2013 reporting anhedonia, depressed mood, feelings of isolation, interrupted sleep with bad dreams, and low volition/energy. (R. 372-73.) She also expressed frustration about being denied disability. She denied having hallucinations. Plaintiff appeared casual and well-groomed, communicative, and cooperative. Although she demonstrated a constricted affect and underproductive speech, her speech was clear and coherent with no evidence of psychosis. Plaintiff's cognition was grossly intact, and her memory, insight, reasoning, and judgment were all good. Dr. Sanchez assessed Plaintiff with a GAF score of 55, increased Plaintiff's Prozac prescription, and prescribed Seroquel to help with Plaintiff's sleep.

         By December 2013 Plaintiff appeared more spontaneous and with a brighter affect. (R. 374-75.) She was uncertain, however, about her mood and reported poor sleep with occasional nightmares. Plaintiff reported being unable to purchase Seroquel. On examination, Plaintiff's cognition appeared to be grossly intact, with good recent and remote memory, and there was no evidence of hallucinations. Dr. Sanchez assessed Plaintiff with a GAF score of 60, provided samples of Seroquel, and continued Plaintiff's Prozac prescription.

         Plaintiff next presented to Meridian Behavioral Healthcare (“Meridian”) in June 2014 to continue with the mental healthcare she had previously been receiving at New Horizons. (R. 400-03.) Plaintiff reported taking Risperdal and Prozac, that she was compliant with her medications, and that the medications worked. She also reported, however, having auditory hallucinations upon waking or falling asleep, but that she had no hallucinations in at least one week.

         On examination Plaintiff demonstrated good eye contact, appropriate demeanor, clear speech, and goal directed and logical thought process. Her affect was broad, normal, and congruent with her reported mood. Plaintiff's behavior was cooperative, her memory appeared grossly intact, and she was oriented in four spheres. Plaintiff demonstrated appropriate insight and judgment. Plaintiff appeared to be future oriented, as she reported being interested in day to day activities and events, that she found pleasure in daily life, and that she was hopeful about the future. Plaintiff also admitted to having close friends and denied awkwardness in interactions with others. Sanford Kaufman, M.D., noted that Plaintiff's auditory hallucinations were “not considered to be clinically significant.” (R. 401.) Dr. Kaufman therefore assessed Plaintiff with depressive disorder not otherwise specified and renewed Plaintiff's Risperdal and Prozac prescriptions. (R. 402.)

         By July 2014 Plaintiff was maintaining a stable level of functioning and had made fair progress toward decreasing the occurrence of auditory hallucinations. (R. 404-06.) Accordingly, Dr. Kaufman increased Plaintiff's Risperdal prescription.

         In August 2014 Plaintiff reported that her medication was helping with her symptoms but that she was sleeping too much. (R. 410-12.) She had no visual hallucinations and she did not remember the last time she had any auditory hallucinations. Plaintiff demonstrated appropriate eye contact and demeanor, clear speech, goal directed and logical thought process, euthymic mood, normal affect, and intact insight and judgment. She was cooperative, oriented in four spheres, and displayed grossly intact memory. Dr. Kaufman noted that Plaintiff was maintaining a stable level of functioning for a chronic condition, but decreased Plaintiff's Prozac dosage to decrease daytime sleeping.

         At her follow-up with Dr. Kaufman in October 2014, Plaintiff reported coping well, that her mood was good, and that she had no auditory or visual hallucinations. (R. 413-15.) Plaintiff demonstrated appropriate eye contact and demeanor, clear speech, goal directed and logical thought process, euthymic mood, normal affect, and intact insight and judgment. She was cooperative, oriented in four spheres, and displayed grossly intact memory. Dr. Kaufman noted that Plaintiff was maintaining a stable level of functioning for a chronic condition and assessed Plaintiff as “doing well.”

         In December 2014, Plaintiff reported having some crying spells and depression after having run out of her medications two days prior. (R. 416-18.) Plaintiff also said she still had auditory hallucinations even when taking her medications. She admitted, however, that her medications were helping with symptoms. Plaintiff demonstrated appropriate eye contact and demeanor, clear speech, goal directed and logical thought process, euthymic mood, normal affect, and intact insight and judgment. She was cooperative, oriented in four spheres, and displayed grossly intact memory. Dr. Kaufman assessed Plaintiff as maintaining a stable level of functioning for a chronic condition. He also changed Plaintiff's medications to Latuda and Celexa to comply with the patient financial assistance program.

         When Plaintiff returned to Meridian in February 2015 she admitted that she had not taken her new medications for two months because she did not like the way they made her feel. (R. 379-81.) She was frustrated, depressed, and withdrawn with crying spells. On examination Plaintiff's eye contact and demeanor were appropriate, she had clear speech, and demonstrated goal directed and logical thought process. Her mood was euthymic and her affect within normal limits. Plaintiff was cooperative and oriented. She also demonstrated grossly intact memory and appropriate insight and judgment. Dr. Kaufman ...


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