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Willis v. U.S. Commissioner, Social Security Administration

United States District Court, W.D. Louisiana, Lafayette Division

January 10, 2019




         Before the Court is an appeal of the Commissioner's finding of non-disability. In accordance with the provisions of 28 U.S.C. § 636(c) and Fed.R.Civ.P. 73, the parties consented to have this matter resolved by the undersigned Magistrate Judge (Rec. Doc. 8-1), and the matter was referred to this Court for resolution (Rec. Doc. 9). Considering the administrative record, the briefs of the parties, and the applicable law, the Commissioner's decision is reversed and remanded for further administrative action.

         Administrative Proceedings

          The claimant, Karen Marie Willis, fully exhausted her administrative remedies before filing this action in federal court. She filed applications for disability insurance benefits (“DIB”) and supplemental security income benefits (“SSI”), alleging disability beginning on August 1, 2012.[1] Her alleged disability onset date was later changed to June 7, 2014 to coincide with the denial of a previous application for benefits.[2] After her applications were denied, [3] she requested a hearing, which was held on December 15, 2016 before Administrative Law Judge Robert Grant.[4] The ALJ issued a decision on January 3, 2107, concluding that the claimant was not disabled within the meaning of the Social Security Act from July 7, 2014 through the date of the decision.[5] The claimant requested review of that decision, but the Appeals Council concluded that there was no basis for review.[6]Therefore, the ALJ's decision became the final decision of the Commissioner for the purpose of the Court's review pursuant to 42 U.S.C. § 405(g).

         The claimant then filed this action seeking review of the Commissioner's decision.

         Summary of Pertinent Facts

         The claimant was born on July 7, 1969, [7] and was forty-seven years old at the time of the ALJ's decision. She graduated from high school but has no further relevant education, having failed to complete a cosmetology course and online classes through the University of Phoenix.[8] She has relevant work experience as a caregiver or in-home nursing attendant.[9] She alleged that she has been disabled since June 7, 2014[10] due to high blood pressure, allergies, nerve problems, kidney problems, migraine headaches, mental problems, learning disabilities, acid reflux, depression, anxiety, and hot flashes.[11] Although the record contains documentation of physical ailments and medical treatment, the ALJ found that the claimant's only severe impairments were depression and anxiety, and the claimant's briefing solely addressed her mental impairments. Accordingly, the medical evidence related to the claimant's physical impairments will not be summarized or considered in this memorandum ruling.

         The claimant stopped working in 2012 after her client, who was also her aunt, passed away. The death of her client allegedly exacerbated the claimant's mental health symptoms and led to an increase in crying spells, isolation, and difficulty controlling her anger. In 2012, the claimant began receiving mental health treatment for depression and anxiety at the Dr. Joseph Henry Tyler Mental Health Center in Lafayette, Louisiana, from psychiatrist George W. Diggs, Jr., M.D. She treated with Dr. Diggs consistently thereafter and also consistently received mental health counseling from social workers at the Tyler Center.

         On August 27, 2012, the claimant was evaluated at the Tyler Center.[12] That same day, Dr. Diggs performed a psychiatric evaluation, [13] during which the claimant reported that she felt worthless, depressed, and anxious. She stated that her father abandoned her when she was a child and that she witnessed her mother being abused. She reported hearing voices that others do not hear as well as seeing her deceased grandmother. She reported crying a lot, headaches, overeating, nervousness, and poor concentration. She told Dr. Diggs that she was scared of everyone and wanted to be by herself. Additionally, she reported poor sleep, isolating behavior, panic attacks, and anger. She stated that she saw a psychiatrist when she was five years old. She claimed that her family members do not speak to her. She reported suicidal thoughts but stated that she would not harm herself. She stated that she does not drive and depends on her mother for transportation. Dr. Diggs noted that the claimant was depressed and anxious, had persecutory delusions, and auditory and visual hallucinations. He found her insight to be impaired and her judgment to be fair. His clinical summary was that the claimant experienced depression, feelings of worthlessness and hopelessness, anhedonia, lethargy, and isolation. He also noted that she had a history of an abusive family. He diagnosed a major depressive episode with psychosis, panic without agoraphobia, and impulse control disorder. He rated her current GAF score at 48, which indicates serious symptoms, [14] and he replaced the Paxil she had been taking with Sertraline, Buspirone, and Vistaril.

         On September 21, 2012, licensed clinical social worker Debra J. Milson prepared a treatment plan for the six-month period from September 21, 2012 to March 21, 2013, which was also signed by Dr. Diggs.[15] In addition to medication therapy prescribed by Dr. Diggs, the claimant was to engage in individual mental health therapy with Ms. Milson. That same day, Dr. Diggs adjusted the claimant's medications.[16]

         The claimant saw Ms. Milson for counseling on December 5, 2012[17] and on January 4, 2013.[18] On January 23, 2013, [19] she again saw Dr. Diggs, who noted that she was no longer working, had had a death in the family, was logical and goal oriented, and was continuing with medication management and cognitive therapy. He again adjusted her medication. He discontinued Zoloft, Buspar, and Vistaril, and Trazodone and started her on Paxil and Benadryl.

         When Dr. Diggs saw the claimant again on February 28, 2013, [20] he noted that she continued to be sad and angry and stated that her memory was impaired. She reported that she was not getting enough sleep, denied suicidal and homicidal ideation, but admitted anger and irritability. Dr. Diggs added Nexium and Wellbutrin to her medications.

         The claimant was evaluated by clinical psychologist Sandra B. Durdin, Ph.D., at the request of Disability Determination Services on April 10, 2013.[21] Dr. Durdin's evaluation of the claimant occurred before the alleged onset date of the claimant's disability, and Dr. Durdin had reviewed the Independent Behavioral Health Assessment completed at the claimant's initial visit to the Tyler Center on August 27, 2012 but no other records related to the services provided to the claimant by the professionals at the Tyler Center. More importantly, Dr. Durdin's findings were not referenced in the ALJ's decision. Accordingly, Dr. Durdin's findings are of no value and will not be discussed further in this memorandum ruling.

         The claimant returned to Dr. Diggs on April 12, 2013.[22] She denied suicidal and homicidal ideation but reported some depressive symptoms, hearing voices, and being suspicious. He diagnosed Lexapro and Wellbutrin.

         On June 11, 2013, the claimant saw Ms. Milson for psychotherapy.[23] The claimant reported that she felt some responsibility for her aunt's death, stating that she heard a voice telling her she did not do all she could, although she could not articulate what more she might have done to help extend her aunt's life. She reported being shocked by a nephew's recent accidental death. She also reported that she was no longer trying to interact with her family. She reported bad headaches, she denied suicidal and homicidal ideation, and she reported taking her medication as prescribed. She was reportedly trying to increase her level of functioning by going out and doing more things.

         The claimant followed up with Dr. Diggs on August 7, 2013.[24] She reported continued gastrointestinal problems, stated that she was sleeping OK and her appetite was fair, but her energy level was poor, she was easily fatigued, her concentration was fair, and she rated her depression at 7 and her anxiety at 10. She denied hopelessness, helplessness, or worthlessness; she denied suicidal and homicidal ideation; and she denied hallucinations and delusions. She reported worrying about money and about putting her home in her name. Dr. Diggs increased her Lexapro dosage and continued her Wellbutrin and Benadryl.

         The claimant saw Ms. Milson again on September 20, 2013.[25] She was seeking employment options and reported improvements in her relationship with her family members.

         On December 2, 2013, the claimant again saw Dr. Diggs.[26] She reported depression; sleep problems; decreased fatigue; poor concentration; impaired memory; feelings of hopelessness, worthlessness, or helplessness; and panic symptoms associated with severe depression. She reported that she was unable to find work and unable to complete a certification that would allow her to work in the future. She complained of headaches, and she complained that antihistamines make her drowsy. She also complained that she was unable to afford her medications and unable to get help through Medicaid or the Affordable Care Act. Her medications were continued.

         The claimant again met with Ms. Milson on January 6, 2014, February 4, 2014, March 5, 2014, and April 30, 2014.[27] She continued to complain of depression, anxiety, and negative thoughts. She was continuing to explore options for employment in the face of financial difficulties and dependence on her mother.

         On June 13, 2014, the claimant was seen by Dr. Karen Bates in the internal medicine clinic at University Hospital & Clinics (“UHC”) in Lafayette, Louisiana, [28]in follow up with regard to hypertension, cough, and chest congestion. She was diagnosed with hypertension and allergic rhinitis. She was prescribed hydrochlorothiazide-lisinopril, cetirizine, and propranolol.

         She saw Dr. Diggs again on August 4, 2014, and he adjusted her medications.[29]

         The claimant returned to see Ms. Milson on January 16, 2015[30] after not having seen her since November 2014. Ms. Milson noted that four appointments had been scheduled and cancelled during the interim. The claimant reported increased depression, crying, anxiety, agitation, and decreased appetite. She denied suicidal and homicidal ideation and denied paranoid thinking but she admitted seeing her deceased grandmother from time to time. She reported being upset because family members wanted her to relinquish family-owned property. She was taking medications but stated that she found the Wellbutrin and Lexapro to be less effective than before. She agreed to monthly counseling.

         The claimant also saw Dr. Diggs again on that same day.[31] She admitted depression and anger but denied thoughts of suicide or self-harm. She reported that she felt bad about herself daily, slept poorly some nights, had a poor appetite, had poor concentration and energy, and felt hopeless some days. Dr. Diggs noted that she had severe depression, diagnosed a major depressive episode, and prescribed Buspar, increased her Trazodone dosage, and continued Lexapro, Wellbutrin, and Benadryl.

         On February 16, 2015, the claimant saw Ms. Milson again.[32] She reported a low energy level, continued depression, increased agitation, and anxiety with diarrhea when she gets extremely upset. She denied suicidal ideation, homicidal ideation, and hallucinations. She reported thinking that others are out to harm her and thinking that people are talking about her. She reported taking her medication as prescribed without side effects. She agreed to increase her level of activity by walking daily.

         The claimant saw Dr. Diggs on April 27, 2015.[33] He noted that her affect was appropriate, her mood was anxious, dysphoric, irritable, and depressed, and her attitude was cooperative. She had no thoughts of harm to herself or others. Her thought content contained delusions, was paranoid and fearful, and expressed helplessness and hopelessness. Her concentration was fair, and her memory was intact. He continued her medications, including Wellbutrin, Lexapro, Benadryl, Trazodone, and Buspar. She reported continued headaches, and she reported becoming upset during interactions with family members, particularly with regard to her living in her deceased aunt's house. She reported continued panic attacks without agoraphobia and breaking things because of difficulty controlling impulses. She explained that she had missed a recent mental health appointment because she thought that she would be hospitalized if she presented for the appointment. Dr. Diggs noted that her symptoms were moderate and that there had been no change in their severity from the previous appointment. Dr. Diggs diagnosed major depressive disorder - recurrent episode - psychotic as well as panic disorder without agoraphobia and impulsive control disorder, unspecified. Dr. Diggs also noted that she had hypertension and obesity. She was to return in twelve weeks.

         The claimant saw Ms. Milson on May 22, 2015.[34] She again discussed missing an appointment at the Tyler Center because she was so upset that she feared being hospitalized if she went to the appointment. She had been upset with family members but the situation was resolved. She reported limiting her interactions with others and indicated that she spent most of her time alone at home.

         On July 30, 2015, the claimant returned to Ms. Milson.[35] She reported being anxious, suspicious, and fearful that someone would start shooting when she was in a store.

         The claimant again saw Ms. Milson on August 27, 2015.[36] She reported feeling depressed, staying in the dark, crying sometimes, being anxious at times, having problems with her memory, and feeling hopeless at times. She also reported that she was attempting a business administration course through an online college but was having trouble keeping up with assignments and feeling frustrated.

         On September 4, 2015, the claimant again saw Dr. Diggs.[37] Her affect was appropriate, her mood was dysphoric, and her attitude was cooperative. She expressed no thoughts of harm to herself or others. The claimant reported increased forgetfulness, depression, trouble sleeping, daytime drowsiness, anger, irritability, crying, and lethargy. Dr. Diggs noted that her symptoms were markedly severe and minimally worse. Although Dr. Diggs noted that the claimant's thought content was non-psychotic, his diagnosis of major depression disorder - recurrent episode - psychotic plus panic disorder without agoraphobia and impulsive control disorder - unspecified remained the same. He modified her medication by discontinuing Lexapro, Buspar, and Trazodone, adding Brintellix, and decreasing the dosage of her Wellbutrin and Benadryl. She was to return in twelve weeks.

         The claimant again saw Ms. Milson on October 8, 2015.[38] She reported that changes in her medication had helped her symptoms. However, she also reported ongoing problems with depression, anxiety, hearing voices, and impulse control. She admitted getting angry and throwing things as well as having problems interacting with others. She reported that she preferred interacting with elderly people because she found them less judgmental of her. She was continuing to attend school online.

         In an Annual Psychosocial Update dated November 12, 2015, [39] Ms. Milson noted that the claimant had chronic depression and anxiety, occupational problems, economic problems, and psychosocial problems that were being addressed with medication management, individual therapy, and psychiatric assessment. She noted that the claimant was not currently psychotic.

         The claimant saw Ms. Milson again on December 28, 2015.[40] The claimant denied suicidal ideation, homicidal ideation, and hallucinations. She reported continued anger but stated that her medications helped her maintain control. She reported continued financial problems and recent weight loss. Ms. Milson noted that the claimant “follows through minimally with suggested techniques to help her better manage her emotions.”

         The claimant returned to Ms. Milson on February 5, 2016.[41] The claimant reported medical problems including a change in blood pressure medication that resulted in dizziness and upset stomach. She reported worrying a lot and not managing her depression and anxiety effectively. She also reported sleep disturbance but denied thoughts of harm to herself or others.

         On April 20, 2016, the claimant saw licensed clinical social worker Jennifer Bell at the Tyler Center.[42] The claimant was alert and oriented but had a depressed affect. She reported grieving an aunt who had passed away two months previously. Her application for Social Security benefits was causing stress and anxiety. She reported disliking social gatherings, difficulty dealing with stressors, and difficulty engaging in healthful activities.

         The claimant saw Ms. Bell again on May 19, 2016.[43] She was still grieving her aunt, and she reported periodic panic attacks and isolation. It was noted that her depression is a severe and persistent mental illness.

         The claimant again saw Ms. Bell on August 1, 2016.[44] The claimant reported auditory hallucinations in the nature of someone calling her name, but she denied having visual hallucinations or thoughts of harming herself or others. She was still having panic attacks and impulsivity was still an issue, although her anger problems had improved.

         On December 14, 2016, Dr. Diggs filled out a Mental Functional Capacity Assessment, in which he estimated that the claimant had a GAF score of 50, signifying serious symptoms. He noted that she had limitations that were likely to occur more than 50% of the work week in nine categories, including the ability to remember detailed instructions; the ability to maintain attention and concentration for two-hour blocks of time; the ability to perform activities within a schedule, maintain regular attendance, and be punctual; the ability to work in coordination with or in proximity to others without being distracted; the ability to make work-related decisions; the ability to complete a normal work day and work week without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods; the ability to accept instructions and respond appropriately to criticism from supervisors; the ability to get along with coworkers or peers without distracting them; and the ability to respond appropriately to changes in a work setting.

         On December 15, 2016, the claimant testified at a hearing regarding her symptoms and her medical treatment. She explained that she is depressed and spends her time along in the dark crying. She stated that she experiences “horrible” panic attacks about twice a week. She further explained that she had previously worked as a home health aide for her Aunt Mildred, who died in December 2012. She stated that her aunt's death negatively affected her mental state and led her to seek mental health treatment. She admitted having anger control issues. She stated that her depression symptoms are particularly severe about two days out of seven. Although she completed the twelfth grade, she had trouble learning in school and was twenty years old when she graduated from high school. She explained that she failed a cosmetology course and also twice failed online courses through the University of Phoenix. She stated that her mother had helped with her medications and with her finances for the past four years. She stated that she had lost two more aunts in the previous year, which had negatively impacted her mental state. She explained that she had difficulty focusing and concentrating. She said that there are days when she does not get dressed or attend to personal hygiene.

         The claimant's mother Vergie Willis also testified at the hearing. She stated that she visits the claimant every day to assure that she takes her medication, to monitor her eating, and to assure that she gets to her doctor's appointments. She stated that the claimant has no friends, and sometimes is very quiet, spending time in her bedroom in the dark, and crying a lot while at other times, the claimant is very angry and emotional. She testified that, in her opinion, the claimant is incapable of taking care of herself on her own and requires assistance with being pushed to take care of her hygiene, keeping herself occupied, and taking care of her finances. The claimant now seeks reversal of the Commissioner's adverse ruling.


         A. Standard of Review

         Judicial review of the Commissioner's denial of disability benefits is limited to determining whether substantial evidence supports the decision and whether the proper legal standards were used in evaluating the evidence.[45] “Substantial evidence is more than a scintilla, less than a preponderance, and is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”[46] Substantial evidence “must do more than create a suspicion of the existence of the fact to be established, but ‘no substantial evidence' will only be found when there is a ‘conspicuous absence of credible choices' or ‘no contrary medical evidence.'”[47]

         If the Commissioner's findings are supported by substantial evidence, they are conclusive and must be affirmed.[48] In reviewing the Commissioner's findings, a court must carefully examine the entire record, but refrain from re-weighing the evidence or substituting its judgment for that of the Commissioner.[49] Conflicts in the evidence[50] and credibility assessments[51] are for the Commissioner to resolve, not the courts. Courts consider four elements of proof in determining if substantial evidence supports the Commissioner's determination: (1) objective medical facts, (2) diagnoses and opinions of treating and examining physicians, (3) the claimant's subjective evidence of pain and disability, and (4) the claimant's age, education and work experience.[52]

         B. Entitlement to Benefits

         The Disability Insurance Benefit (“DIB”) program provides income to individuals who are forced into involuntary, premature retirement, provided they are both insured and disabled, regardless of indigence, [53] while individuals who meet certain income and resource requirements, have filed an application for benefits, and are determined to be disabled are eligible to receive Supplemental Security Income (“SSI”) benefits.[54]

         A person is disabled “if he is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve months.”[55] A claimant is disabled only if his physical or mental impairment or impairments are so severe that he is unable to not only do his previous work, but cannot, considering his age, education, and work experience, participate in any other kind of substantial gainful work which exists in significant numbers in the national economy, regardless of whether such work exists in the area in which the claimant lives, whether a specific job vacancy exists, or whether the claimant would be hired if he applied for work.[56]

         C. Evaluation Process and Burden of Proof

         The Commissioner uses a sequential five-step inquiry to determine whether a claimant is disabled. This process requires the ALJ to determine whether the claimant (1) is currently working; (2) has a severe impairment; (3) has an impairment listed in or medically equivalent to those in 20 C.F.R. Part 404, Subpart P, Appendix 1; (4) is able to do the kind of work he did in the past; and (5) can perform any other work.[57]

         Before going from step three to step four, the Commissioner assesses the claimant's residual functional capacity[58] by determining the most the claimant can still do despite his physical and mental limitations based on all relevant evidence in the record.[59] The claimant's residual functional capacity is used at the fourth step to determine if he can still do his past relevant work and at the fifth step to determine whether he can adjust to any other type of work.[60]

         The claimant bears the burden of proof on the first four steps; at the fifth step, however, the Commissioner bears the burden of showing that the claimant can perform other substantial work in the national economy.[61] This burden may be satisfied by reference to the Medical-Vocational Guidelines of the regulations, by expert vocational testimony, or by other similar evidence.[62] If the Commissioner makes the necessary showing at step five, the burden shifts back to the claimant to rebut this finding.[63] “A finding that a claimant is disabled or is not disabled at any point in the five-step review is conclusive and terminates the analysis.”[64]

         D. The ALJ's Findings and Conclusions

         In this case, the ALJ determined, at step one, that the claimant has not engaged in substantial gainful activity since June 7, 2014.[65] This finding is ...

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