United States District Court, M.D. Tennessee, Nashville Division
REPORT AND RECOMMENDATION
JULIET GRIFFIN, Magistrate Judge.
To: The Honorable Aleta A. Trauger, District Judge.
The plaintiff filed this action pursuant to 42 U.S.C. § 405(g) to obtain judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying the plaintiff's claim for Supplemental Security Income benefits ("SSI"), as provided by the Social Security Act.
Upon review of the Administrative Record as a whole, the Court finds that the Commissioner's determination that the plaintiff is not disabled under the Act is supported by substantial evidence in the record as required by 42 U.S.C. § 405(g), and that the plaintiff's motion for judgment on the administrative record (Docket Entry No. 23) should be DENIED.
On June 22, 2010, the plaintiff protectively filed for SSI, alleging a disability onset date of September 16, 2007, due to "a broken spine, left leg numbness, thyroid problems, and anxiety." (Tr. 44, 83, 110-18, 126, 130, 146.) Her application was denied initially and upon reconsideration. (Tr. 59-60, 75-78, 81-83.) The plaintiff testified at a hearing before Administrative Law Judge Linda Gail Roberts ("ALJ") on February 17, 2013, and the ALJ subsequently entered an unfavorable decision. (Tr. 8-38, 44-54.) On June 25, 2013, the Appeals Council denied the plaintiff's request for review of the ALJ's decision, thereby making the ALJ's decision the final decision of the Commissioner. (Tr. 1-7.)
The plaintiff was born on November 14, 1975, and she was 34 years old as of her application date. (Tr. 13-14.) She is an Iraqi refugee who graduated from college and worked as an elementary school teacher in Iraq. (Tr. 14, 16, 26-27, 138.) The plaintiff alleged a number of physical impairments that were the primary focus of the ALJ's decision. However, in this Court, the plaintiff only raises issues pertaining to her alleged mental impairments. See Docket Entry No. 24, at 15-22. Consequently, the Court will focus its review of the medical evidence and hearing testimony on the plaintiff's alleged mental impairments.
A. Chronological Background: Procedural Developments and Medical Records
On November 16, 2010, the plaintiff presented for mental health treatment to Centerstone Community Mental Health Center ("Centerstone") where she was seen by Meryl Taylor, a certified master social worker. (Tr. 260-63.) At her initial intake assessment, the plaintiff complained of having nightmares, trouble sleeping, depression, and symptoms of post-traumatic stress disorder ("PTSD"). (Tr. 262.) She related that she had moved to the United States one and a half years earlier and that Arabic was her first language. (Tr. 260.) She said that she taught English in Iraq but "had to sign a loyalty' paper to the government" and was "[n]ot allowed to keep anything from" the government. (Tr. 262.) She said that her brother was imprisoned for political reasons, which caused her to be fired from her job. Id. She explained that she "witnessed a lot of violence in Iraq" and that she and her husband were injured when their car "was bombed with family in it because [her] husband was working for an American company." Id.
The plaintiff complained of "appetite disruption, eating too much or too little, sadness, crying, fatigue, loss of pleasure, difficulty with concentration, constant intrusive thoughts, flashbacks, re-experiencing trauma, ... rapid heartbeat, difficulty breathing, fearful[ness], isolative behavior, little socializing, feelings of hopelessness, loss of future expectations, [and] difficulty trusting people." Id. She denied experiencing anger, suicidal or homicidal ideation, or hallucinations. Id. During a mental status examination, she had appropriate behavior, appearance, and mood; was well-oriented; and had normal thought content and process. Id. Her judgment, insight, and motivation for treatment were described as "unclear, " and she demonstrated "vegetative disturbance[s]" of appetite, crying, energy, interest, pleasure, and sleep. Id.
Ms. Taylor diagnosed the plaintiff with chronic PTSD and noted that she was "willing to participate in recommended treatment of therapy and medication" and had an expected length of treatment of "approximately 12-18 months." (Tr. 262-63.) Ms. Taylor also observed that her "[p]rognosis is good, although ongoing problems in Iraq are likely to exacerbate current symptoms at times." (Tr. 263.) A Tennessee Clinically Related Group ("CRG") form completed by Ms. Taylor assessed the plaintiff as having moderate limitations in the areas of activities of daily living, interpersonal functioning, adaptation to change, and concentration, task performance, and pace, and she was assigned a Global Assessment of Functioning ("GAF") score of 55. (Tr. 257-59.)
At a therapy session on December 2, 2010, the plaintiff reported that she had difficulty trusting people (tr. 268), and Ms. Taylor added an Axis-IV diagnosis, noting that the plaintiff's recent move to the United States had caused her some social problems. (Tr. 271.) On December 30, 2010, the plaintiff reported that she was "about the same" but that her "sleep [was] worse." (Tr. 265.) She also reported that she was "fearful of speaking English due to trauma in Iraq" and did not like being around other people. Id. She failed to show up for a January 24, 2011 appointment. (Tr. 266-67.)
From February to December 2011, the plaintiff received medication, but not counseling, at the Precision Pain Center for anxiety and depression. (Tr. 47, 343-70.) She was prescribed Cymbalta for depression, but it was discontinued because the plaintiff could not tolerate it. (Tr. 360, 364.)
In disability function reports, the plaintiff indicated that she had a "constant feeling of anxiety and frustration" (tr. 164) and that she "became nervous" and sometimes could not "do anything, " could not "contact with people" and felt "tired" and "stress[ed]." (Tr. 146.) She reported that she went grocery shopping once a week with her husband for "about one hour" (tr. 149) and that she went to the "gardens" once a week with her husband and children. (Tr. 150.) In one report she indicated that she took care of her children with her husband's help (tr. 147), but in another report she indicated that her husband took care of the children without her help. (Tr. 165.) She related that she could make sandwiches and frozen dinners but could not cook or make meals. (Tr. 148, 166.)
At a psychiatric evaluation at Centerstone on February 18, 2011, the plaintiff arrived with a friend who translated for her. (Tr. 316-20.) The plaintiff explained that she spoke English and had a degree in English, but was afraid to speak the language because, while in Iraq, she "was accused of hiding info about her brother." (Tr. 316.) She complained of symptoms of anxiety, depression, poor sleep, decreased appetite, poor concentration, low motivation, anhedonia, history of trauma, flashbacks, and nightmares. Id. She said that she had never taken mental health medication or received in-patient psychiatric care. Id. She reported that she did not work and did not have any hobbies or activities but that she got along well with her family. (Tr. 316, 318.) The psychiatric evaluator noted that she was "easily engaged" and "smiled at times" and prescribed Zoloft. (Tr. 319-20.)
At a therapy session on February 18, 2011, the plaintiff demonstrated no improvement towards goals and reported that she was "afraid to go anywhere, " "afraid the police will arrest her and... afraid of the future." (Tr. 332.) She said that she "like[d] to stay home because she feels safe" but acknowledged feeling "bored and lonely." Id. On March 18, 2011, the plaintiff reported that she was experiencing paranoia, headaches, and nausea and had stopped taking Zoloft after three days on the medication, and she was prescribed Remeron as an alternative. (Tr. 328-29.) In March and April, the plaintiff cancelled three scheduled appointments. (Tr. 324-27.)
On April 11, 2011, Dr. Celine Payne-Gair, Ph.D., a Tennessee Disability Determination Services ("DDS") nonexamining psychiatric consultant, completed a Psychiatric Review Technique ("PRT") and mental Residual Functional Capacity assessment ("RFC"). (Tr. 283-96; 371-74.) In the PRT, Dr. Payne-Gair found that the plaintiff had PTSD (tr. 288) and opined that she had mild restrictions of the activities of daily living; moderate difficulties maintaining social functioning; moderate difficulties maintaining concentration, persistence, or pace; and no episodes of decompensation. (Tr. 297.) In the mental RFC assessment, Dr. Payne-Gair opined that the plaintiff was moderately limited in her abilities to maintain attention and concentration for extended periods, interact appropriately with the general public, and respond appropriately to changes in the work setting. (Tr. 371-74.) At the end of the assessment, Dr. Payne-Gair further explained that the plaintiff: (1) "can remember locations and simple work-like procedures and can understand and remember simple and detailed instructions;" (2) "can complete simple and detailed tasks, maintain attention and concentration for periods of at least two hours, adequately maintain workday/workweek and pace, and make simple decisions;" (3) "can relate appropriately to peers and supervisors;" and (4) "can adapt to routine workplace changes." (Tr. 373.)
The plaintiff was discharged from Centerstone on June 20, 2011, after she "stopped coming for appointments." (Tr. 309-10.) She returned on January 4, 2012, reporting an "[i]ncrease in anxiety symptoms... [and a] continuation of depression and PTSD." (Tr. 383.) She indicated that she "[s]topped services previously in part due to stigma attached to getting mental health [treatment]." Id. Ms. Taylor noted that the plaintiff's "[p]rognosis [was] fair given cultural issues that may interfere with treatment, including stigma attached to getting mental health treatment." (Tr. 384.) Ms. Taylor continued to diagnose her with PTSD, and her assigned GAF score remained at 55. (Tr. 385.)
The plaintiff underwent a psychiatric evaluation on January 20, 2012, and, through an interpreter, reported that Cymbalta caused "severe nausea" and Zoloft was "ineffective" but that Remeron was "helpful." (Tr. 386.) She reported that her symptoms included "sad mood, [irratibility] at times, poor sleep, nightmares, flashbacks, anxiety and worry all the time, hypervigilance, low energy, [and a] sense of fear and impending doom." Id. During a mental status examination, she had normal mood and speech, appropriate affect, good insight, intact judgment, and organized and logical thinking. (Tr. 388.) Her intelligence was described as "above average, " and she denied hallucinations as well as suicidal or homicidal ideation. Id. She was prescribed Remeron for depression and anxiety due to her "past positive experience." (Tr. 389.)
The plaintiff cancelled an appointment on January 30, 2012. (Tr. 420.) At a therapy session on February 9, 2012, Ms. Taylor noted the plaintiff's reports that "it was very hard for her to come to Centerstone" for the appointment and that "she thought about the appointment for three days with increasing anxiety due to the need to leave home (not because of coming to Centerstone itself)." (Tr. 418.) At a follow-up appointment on February 16, 2012, the plaintiff reported that she was taking Remeron as prescribed but that it was causing nausea and headaches. (Tr. 417.) She described the side effects as "tolerable, " and her prescribed dosage of Remeron was increased. (Tr. 409-10, 417.) Ms. Taylor observed that the plaintiff was having "difficulty engaging in [the] therapy process." (Tr. 415.)
The plaintiff cancelled her next scheduled appointment and later cancelled appointments scheduled for February 28, and March 1, 2012. (Tr. 411-14.) She returned on March 14, 2012, and reported that the side effects from medication, including nausea, constipation, and headaches, had become "intolerable" and that she was continuing to have "nightmares, anxiety, flashbacks, feeling[s] of doom, [and] hypervigilance." (Tr. 409.) She was taken off Remeron and prescribed Celexa. (Tr. 410.) At a therapy session the same day, she demonstrated slight improvement towards goals and reported her belief that she was "taking a small step forward by going places with her husband." (Tr. 407.) Ms. Taylor noted that her obstacles included "extreme fear" and "poor motivation." Id.
The plaintiff cancelled a scheduled appointment on April 4, 2012, and failed to show for an appointment on April 19, 2012. (Tr. 403-06.) On May 2, 2012, she presented for a medication follow-up and reported that she was compliant with medications and not experiencing side effects. (Tr. 401.) She also reported "slight improvement in her depression and nightmares" but was still experiencing "hypervigilance, constant worry, and fairly frequent nightmares." Id. She did not want to increase her medication dosage. Id. On May 30, 2012, she reported that she was compliant with medications and not experiencing side effects but had not had a significant decrease in symptoms. (Tr. 399.) She said that she felt better some days but that other days she was "back to her previous self." Id. She did not want to increase her dosage of medications (tr. 399), and, following a therapy session, Ms. Taylor observed that the plaintiff "appear[ed] uncertain regarding her commitment to change." (Tr. 397.)
The plaintiff failed to appear for a scheduled appointment on July 10, 2012 (tr. 395), and Ms. Taylor noted that she "ha[d] not been keeping appointments regularly." (Tr. 392.) She was discharged from Centerstone on October 3, 2012, after she "[d]ropped out of treatment, " having had no contact with Centerstone in over ninety days. (Tr. 378.) Her diagnosis at the time of discharge remained chronic PTSD. Id. Ms. Taylor noted that the plaintiff's status at last contact was "fair, " that she did not achieve progress during treatment, and that she "had difficulty engaging in therapy and was inconsistent in keeping appointments." (Tr. 379.)
B. Hearing Testimony
At the hearing on February 17, 2013, the plaintiff was represented by counsel, and the plaintiff and the vocational expert ("VE"), Rebecca Williams, testified. (Tr. 8-38.) The plaintiff testified that she taught English at an elementary school in Iraq for ten years prior to immigrating to the United States in 2009. (Tr. 14, 16.) She said that, although she studied the English language as her major in college, she had not "practiced English to the point where she can speak it fluently or have a command of it." (Tr. 16.) She testified that she lives with her husband and two children. (Tr. 19.)
The plaintiff testified that she began to have anxiety and depression in Iraq and that she currently receives mental health treatment. (Tr. 22.) She explained that she "[does not] want to leave home at all" because her home "makes her feel safe" and that she feels "insecure" and "scared" and is "anxious and depressed for three days in advance" of a scheduled appointment. (Tr. 23.) She said that she does not go grocery shopping but will "very rare[ly]" go to a mall or park for her children. (Tr. 24.) She said that she gets "stressed" and "scared" in public and "expects that something wrong is going to happen to her children or her husband when they are out." Id. She testified that her treatment at Centerstone has not helped but that "she is still going there in the hope that one day she would get better." Id. She said that her mental health problems affect her ability to work (tr. 22-23) but that she is able to prepare breakfast for her family and uses a computer to communicate with her family in Iraq. (Tr. 24-25.) She said that, if she is unable to get in touch with her family on a particular day, she "expect[s] that something wrong happened to [them] in Iraq." (Tr. 24-25.)
The VE testified that her testimony did not conflict with the Dictionary of Occupational Titles and classified the plaintiff's past work as an elementary school teacher as light and skilled. (Tr. 26-27, 33-34.) The ALJ asked the VE a series of hypothetical questions including only physical impairments (i.e., with no mental impairments), and the VE identified several unskilled jobs that a person with those limitations could perform. (Tr. 27-34.) In response to questioning by the plaintiff's attorney, the VE testified that these jobs would not be available to someone who needed continuous supervision or retraining or who needed to miss at least one day of work per month. (Tr. 34-36.)
III. THE ALJ'S FINDINGS
The ALJ issued an unfavorable ruling in which she made the following findings:
1. The claimant has not engaged in substantial gainful activity since June 22, 2010, the application date (20 CFR 416.971 et seq. ).
2. The claimant has the following severe impairments: lumbar degenerative disc disease; history of closed fracture, dorsal (thoracic) vertebra without mention of spinal cord injury; and hypothyroidism (20 CFR 416.920(c)).
3. The claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, ...