United States District Court, D. Maine
MEMORANDUM OF DECISION AND ORDER
E. Walker U.S. District Judge.
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.
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.
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.
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
Post-Traumatic Stress Disorder
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.
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. 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. 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.
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.
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.”
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.
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. Nor do his entries related to thought
disorder screening or depression screening, though symptoms
were appreciated. R. 725. Concerning social capacity, Dr.