United States District Court, Southern District of Indiana, Indianapolis Division
REPORT AND RECOMMENDATION
Mark J. Dinsmore, United States Magistrate Judge, Southern District of Indiana
Plaintiff Ivan Allen Willoughby (“Willoughby”) requests judicial review of the final decision of the Commissioner of the Social Security Administration (“Commissioner”) denying his application for Supplemental Security Income (“SSI”) under Title XVI of the Social Security Act (“SSA”). See 42 U.S.C. § 416. For the reasons set forth below, the Magistrate Judge recommends that the matter be AFFIRMED.
I. Procedural History
Willoughby filed an application for SSI on October 26, 2010, alleging an onset of disability as of September 2, 2010. Willoughby’s application was denied initially on December 27, 2010 and denied on reconsideration on April 8, 2011. Willoughby timely requested a hearing, which was held before Administrative Law Judge Joseph L. Brinkley (“ALJ”) by videoconference on May 15, 2012. The ALJ’s July 10, 2012 decision also denied Willoughby’s application SSI, and on July 16, 2013 the Appeals Council denied Willoughby’s request for review, making the ALJ’s decision the final decision for purposes of judicial review. Willoughby timely filed his Complaint with this Court on August 5, 2013.
II. Factual Background and Medical History
Willoughby, now forty-eight years old, applied for SSI due to his schizoaffective disorder, high blood pressure, high cholesterol, lower back pain, arthritis, mental conditions, and learning disabilities. [R. at 152.] In order to manage these conditions, Willoughby takes several medications, including perphenazine, an anti-psychotic; citalopram, an anti-depressant; doxepin, for depression and anxiety; and benztropine, to cope with the side effects of his psychiatric medications. [R. at 155.] In his disability report, Willoughby reported that, although his medication “keeps him worn out and prevents him from doing the things he would like to do, ” without taking his medication he would hear voices that tell him to do things and he becomes paranoid that people with come up behind him, making him susceptible to “acting out violently towards others.” [R. at 158.] Although Willoughby reported an inability to be outside for prolonged periods of time due to the side effects of his medications, he reported being able to prepare some of his own meals, perform basic household chores, and take his scooter to run errands. [R. at 173-74.] Willoughby’s limitations are mental and social, as he reported having trouble with memory, completing tasks, concentration, understanding, following instructions, and getting along with others—no physical limitations were checked. [R. at 176.]
In September of 2010, Willoughby began treatment at Centerstone for his psychological impairments. [R. at 237.] At his initial intake, Willoughby reported a history of drug and alcohol abuse in order to self-medicate, but he has been clean since 2003. [R. at 168 (clean), 237 (history).] Also at Willoughby’s initial intake, the clinician observed that, while Willoughby is in a safe and well structured environment with supportive family and is motivated and recognizes the needs of his mental illness, he needs to develop better coping strategies, to learn to control his anger, and to secure a steady income. [R. at 237-38.] Willoughby was diagnosed with schizoaffective disorder, bipolar type, with a GAF of 42 and given a care plan to spend more time with his family and friends or support group, to walk away from stressful situations, and to take medications as prescribed. [R, at 240-41, 248-49.] At his initial appointments, Willoughby was very concerned about running out of medication, as he had not yet applied for Medicaid and had difficulty finding work due to his criminal history, medication side effects like fatigue, and anger issues. [See, e.g., R. at 262, 266.] After receiving a steady supply of medication and making efforts to take it regularly, Willoughby reported that the medications were working well, and he only suffers from his auditory hallucinations when in “highly stressful situations, ” such as crowded stores. [R. at 281.] At a following session the clinician observed that Willoughby was “hypervigilant” in the waiting room but seemed to relax upon entering the interview room, noting that Willoughby is not defensive or drug-seeking, instead reporting that Willoughby “seems to be a reliable historian” who does not exhibit delusional symptoms and is “future oriented and happy.” [R. at 282.]
In November of 2010, Willoughby’s treatment team at Centerstone completed a Report of Psychiatric Status. [R. at 291-96.] When asked about Willoughby’s “current specific manifestations of the mental disorder, ” the team noted that Willoughby “endorses experiencing auditory hallucinations” and “exhibits symptoms of paranoia and becomes anxious when in situations around others, ” though he reports that taking his medication “helps with symptom control.” [R. at 293-94.] When discussing Willoughby’s functional capacity, the team noted that he tries not to leave home “because he gets aggravated by people, ” he is “somewhat defensive regarding criticism and could be easily angered due to paranoia around others, ” and his auditory hallucinations “make it difficult to concentrate and complete tasks.” [R. at 295.] Additionally, the team noted that Willoughby’s medication makes him groggy, “making it difficult for him to perform tasks, ” and that he “becomes anxious in social environment [sic]” and can become “increasingly anxious and may become agitated” due to “paranoid symptoms.” [Id.] However, the team also reported that they were “unable to determine” a current prognosis “due to chronicity of illness, ” adding that Willoughby “has been compliant with all treatment recommendations to date.” [R. at 296.]
Several State Agency medical consultants have also submitted reports regarding Willoughby’s mental impairments. First, in December of 2010 Dr. Pressner found that Willoughby has mild restrictions of activities of daily living, moderate difficulties in maintaining social functioning and in maintaining concentration, persistence, or pace, and no episodes of decompensation. [R. at 315.] Without finding any marked limitations of Willoughby’s scizoaffective disorder, Dr. Pressner checked that an RFC assessment was necessary. [R. at 305, 308.] In his comments, Dr. Pressner relied heavily on the Report of Psychiatric Status from Centerstone, writing that Willoughby “tends to isolate himself and stay at home, ” that he is “somewhat defensive regarding criticism and could be easily angered due to paranoia around others, ” that Willoughby’s auditory hallucinations “make it difficult to concentrate, ” that his medications make him groggy, “making it difficult for him to perform tasks.” [R. at 317.] Dr. Pressner further writes “give [treating source] controlling weight” and that Willoughby’s “statements are credible.” [Id.] In his mental RFC assessment, Dr. Pressner then found that Willoughby was only “markedly limited” in two out of twenty summary conclusions: (1) his “ability to interact appropriately with the general public” and (2) his “ability to travel to unfamiliar places or use public transportation.” [R. at 333-34.] In conclusion Dr. Pressner writes in depth:
[Willoughby] is capable of understanding, remembering, and carrying out simple instructions. The information in [sic] file suggests that [he] has the intellectual wherewithal to make simple work related decisions, to remember locations, and to remember simple work-like procedures. [Willoughby] seems to have the cognitive abilities, and attention necessary to anticipate usual hazards in the work place.
[Willoughby] seems to relate adequately to other people. Therefore it appears that [he] would be able to relate adequately to co-workers, and to work supervisors. Interpersonal conflicts on the job would probably be within normal limits for the population at large. However, [he] appears to be anxious around groups of strangers. Thus [Willoughby] could not work with the general public or in jobs which require intensive, interpersonal contact with others. [Willoughby] would appear to work best alone, in semi-isolation from others or as part of a small group. [Willoughby] could work with a supervisor who was normally considerate and positive, but would have problems with a supervisor who was often negative, critical, or quarrelsome.
[Willoughby’s] pace would be within normal limits except as limited by [his] physical problems. [Willoughby] should be able to attend to task [sic] for a two hour period of time although there may be problems with prolonged or intensive concentration. It appears that [he] is capable of maintaining a schedule. Any problems with tardiness or absenteeism would seem to be a matter of choice rather than the effects of [Willoughby’s] mental disorder.
The evidence suggests that [Willoughby] can understand, remember, and carry-out simple tasks. [Willoughby] can relate on at least a superficial basis on an ongoing basis with co-workers and supervisors. [Willoughby] can attend to task [sic] for sufficient periods of time to complete tasks. [Willoughby] can manage the stresses involved with simple work.
[R. at 335.] In April of 2011, State Agency medical consultant Dr. Kaldder reviewed and affirmed Dr. Pressner’s mental RFC assessment, noting that Willoughby ...