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Andrew H. v. Social Security Administration Commissioner

United States District Court, D. Maine

July 8, 2019

ANDREW H., Plaintiff


          Lance E. Walker U.S. District Judge.

         Plaintiff Andrew H. requests judicial review of the Social Security Administration Commissioner's final administrative decision, wherein the Commissioner found Plaintiff not disabled and denied his claim for benefits under Title II of the Social Security Act. Following a review conducted pursuant to 42 U.S.C. § 405(g), for reasons set forth below, the final administrative decision is vacated.

         Standard of Review

         My review is limited to “determining whether the ALJ deployed the proper legal standards and found facts upon the proper quantum of evidence.” Nguyen v. Chater, 172 F.3d 31, 35 (1st Cir. 1999). Provided the final administrative decision is supported by “substantial evidence” and was not “derived by ignoring evidence, misapplying the law, or judging matters entrusted to experts, ” it will stand. Id.; Manso-Pizarro v. Sec'y of HHS, 76 F.3d 15, 16 (1st Cir. 1996). Substantial evidence is “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971). “In applying the “substantial evidence” standard, [I must] bear in mind that it is the province of the ALJ, not the courts, to find facts, decide issues of credibility, draw inferences from the record, and resolve conflicts of evidence.” Applebee v. Berryhill, 744 Fed.Appx. 6 (1st Cir. 2018).


         The administrative law judge (ALJ) found that Plaintiff, during the relevant period, retained the residual functional capacity (RFC) “to perform a range of sedentary work” involving simple, routine, repetitive tasks not performed at a production pace, simple decisions and changes in a routine setting, and only occasional interaction with the public, supervisors, and coworkers, including specific jobs existing in the national economy in significant numbers. ALJ Decision, R. 15, 21.

         Plaintiff argues the ALJ erred when he (A) failed to explicitly state whether Plaintiff's post-traumatic stress disorder (PTSD) was a “severe impairment” at step 2, and then failed to give greater weight to certain expert assessments related to Plaintiff's mental capacity for work activity, including an assessment offered after the Disability Determination Services consultants conducted their review; (B) failed to substantiate the finding that Plaintiff can persist at sedentary work activity provided he can stand for five minutes every hour, particularly given the progression of Plaintiff's hip-joint impairment; and (C) failed to account for Plaintiff's obesity in the RFC discussion.[1]

         A. Post-Traumatic Stress Disorder

         Plaintiff's challenge concerning his mental capacity to perform substantial gainful activity is based on the ALJ's treatment of the medically determinable impairment of post-traumatic stress disorder (PTSD) and certain evaluations concerning Plaintiff's mental capabilities. The question for the Court is whether the ALJ's discussion of the material evidence of record, in particular the assessments offered by Dr. Wesley, Dr. Suyeishi, and Dr. Cotgageorge, is such that a reasonable mind could accept it as adequate to support the ALJ's mental RFC findings.

         At step 2, the ALJ did not itemize post-traumatic stress disorder as a severe mental impairment, but rather found the severe mental impairments to be affective disorder and “anxiety-related” disorder.[2] R. 13. However, at step 3, the ALJ identified Listing 12.15 (trauma- and stressor-related disorders) as applicable to Plaintiff's claim, demonstrating the ALJ's understanding that Plaintiff's alleged mental impairment is due, in part, to a traumatic experience. At step 3, the ALJ found moderate limitation in all of the paragraph B criteria of the mental listings. While the moderate findings precluded a disability decision based on listing-level impairment, they also adequately communicated the ALJ's appreciation that Plaintiff experiences significant mental impairment due to trauma-related anxiety. R. 14.[3] A remand based on the omission of PTSD at step 2 is, on this record, not warranted. Nor is it apparent that the ALJ erred in his mental RFC finding.

         On December 30, 2015, Immaculate Wesley, Psy.D., performed a psychological evaluation of Plaintiff. At the evaluation, Plaintiff indicated that his mental health impairment involved memory, comprehension, and lack of organization. Ex. 6F, R. 580. Of note, Plaintiff was involved in motor vehicle accidents in 2001 and 2002 and suffered head trauma in both accidents. Id. Concerning Plaintiff's psychiatric condition, Dr. Wesley noted that Plaintiff, at the time, had “no history of mental health treatment or hospitalization.” R. 581. Plaintiff nevertheless described an inability to function two or three days per week due to pain and depression. R. 582. Based on the treatment history and a mental status examination, Dr. Wesley provided his diagnostic impression that Plaintiff has PTSD, pain disorder, social phobia, and narcissistic traits. R. 582. Dr. Wesley indicated that Plaintiff's report of short-term memory problems was not substantiated by Dr. Wesley's observation and that understanding, memory, and sustained concentration appeared to be adequate; but Dr. Wesley suspected Plaintiff experiences marked limitation secondary to chronic pain and social phobia, and that traumatic brain injury and PTSD would cause a marked difficulty dealing with normal pressure in a work setting. R. 583.

         On January 1, 2016, Mark Suyeishi, Psy.D., performed the psychiatric review technique and provided a mental RFC assessment. Dr. Suyeishi considered not only Dr. Wesley's report but also the evidence contained in Plaintiff's treatment records. Ex. 4A, R. 108. Dr. Suyeishi assessed a moderate impairment in the areas of social functioning and maintaining concentration, persistence, and pace. R. 109. Dr. Suyeishi observed the absence of any history of depression and anxiety and the remote character of Plaintiff's traumatic brain injury. He also observed that Plaintiff's records reflected repeated entries indicating normal memory and orientation, with appropriate mood and affect. Based on these considerations and Dr. Wesley's observation of Plaintiff, Dr. Suyeishi opined that Plaintiff appeared suited for “some types of work.” R. 110. He did not give weight to Dr. Wesley's statement concerning the limiting effect of chronic pain and observed that Dr. Wesley had not performed a physical exam. He also indicated that the pain-related assessment appeared to be beyond Dr. Wesley's expertise. According to Dr. Suyeishi, Plaintiff should be “capable of less complex tasks.” Id.

         Turning to his mental RFC assessment, Dr. Suyeishi did not find persuasive Dr. Wesley's suggestion of marked impairment in social functioning. Dr. Suyeishi observed that Plaintiff walked his child to school and that there was no evidence of agoraphobia. R. 114-15. He did, however, regard Plaintiff as “capable of less interpersonal, ” which he described as precluding close work with supervisors and coworkers, as well as “frequent or prolonged” contact. R. 115. Otherwise, Dr. Suyeishi opined that Plaintiff would be capable of simple tasks, R. 114, including “work of limited complexity but which requires accuracy and attention to detail.” R. 115.

         In October 2016, Plaintiff received a neuropsychological assessment. Plaintiff reported to Ed Cotgageorge, Ph.D., that he experienced, among other things, “constant panic, ” avoidance of people, irritability, and “other anxiety symptoms.” Ex. 13F, R. 722. In a summary of findings, Dr. Cotgageorge assessed “mild to moderate” impairment of attention and concentration and indicated the results reflected a person who “likely experiences at least some mild cognitive difficulties secondary to anxiety.” Id. Overall cognitive functioning was characterized as “within normal functioning limits, ” but “sufficient to interfere with the performance of work.” Id. Dr. Cotgageorge gave his diagnostic impression as traumatic brain injury cognitive disorder and chronic PTSD. R. 723. Describing Plaintiff's mental health history, Dr. Cotgageorge wrote that Plaintiff “denied any mental health problems or treatments until recently, ” and a recent start of medication to address “mood swings.” Id. Dr. Cotgageorge's mental status assessment does not stand out as suggestive of mental disability.[4] Nor do his entries related to thought disorder screening or depression screening, though symptoms were appreciated. R. 725. Concerning social capacity, Dr. ...

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