United States District Court, N.D. Indiana, Fort Wayne Division
KIBBY L. GROSJEAN, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
OPINION AND ORDER
RUDY LOZANO, District Judge.
This matter is before the Court for review of the Commissioner of Social Security's decision denying Disability Insurance Benefits and Supplemental Security Income to Plaintiff, Kibby L. Grosjean.For the reasons set forth below, the Commissioner of Social Security's final decision is REVERSED and this case is REMANDED to the Social Security Administration for further proceedings consistent with this opinion pursuant to sentence four of 42 U.S.C. section 405(g).
On July 13, 2009, Plaintiff, Kibby L. Grosjean ("Grosjean"), applied for Social Security Disability Insurance Benefits ("DIB") under Title II of the Social Security Act, 42 U.S.C. section 401 et seq. She also applied for Supplemental Security Income ("SSI") under Title XVI of the Social Security Act, 42 U.S.C. section 1381 et. seq.
Grosjean alleged her disability began on May 17, 2003. The Social Security Administration denied her initial applications and also denied her claims on reconsideration. On July 28, 2011, Grosjean appeared with her attorney and testified at an administrative hearing before Administrative Law Judge ("ALJ") Warnecke Miller ("Miller"). In addition, Georgette Gunther testified as a vocational expert ("VE"). On September 15, 2011, ALJ Miller denied Grosjean's claims, finding that Grosjean had not been under a disability as defined in the Social Security Act.
Grosjean requested that the Appeals Council review the ALJ's decision. This request was denied. Accordingly, the ALJ's decision became the Commissioner's final decision. See 20 C.F.R. § 422.210(a)(2005). Grosjean has initiated the instant action for judicial review of the Commissioner's final decision pursuant to 42 U.S.C. section 405(g).
Grosjean was born on January 6, 1959, and was 44 years old on the alleged disability onset date. (Tr. 212). Grosjean's alleged impairments include fibromyalgia, non-insulin dependent diabetes mellitus, headaches, hypertension, chronic fatigue, diverticulitis, obesity with basal metabolic indicator of 33.7, osteoarthritis, GERD, minor spondylosis of the C4-C6 level, mild degenerative changes of the lumbar spine, carpal tunnel syndrome, depression, post traumatic stress disorder ("PTSD"), asthma, alcohol abuse (now in recovery), history of diagnosis of borderline intellectual functioning, and "neuropathy of the heart." (Tr. 17-18). She has a high school education. (Tr. 258). Her past relevant work includes work as an assembler, cashier, and stock clerk. (Tr. 26-27). The medical evidence can be summarized as follows:
Grosjean first treated at Park Center in 1990. (Tr. 493). After a break in treatment, Grosjean presented in July of 2007 requesting services for outpatient therapy. (Tr. 405-11). She had previously been involved with Dialectic Behavioral Therapy ("DBT"), but that did not go well for her. (Tr. 405-11, 676). On mental status exam she had the following significant positive findings: excessive worry; aches and pains; anxiety; fearfulness, and helpless thought content. (Tr. 405). She appeared disheveled, overweight, withdrawn, and with limited insight and judgment. ( Id. ). Her problems included psychiatric instability, anger issues, abuse issues, relationship deficits, alteration in mood/depression, health maintenance deficit, and anxiety. (Tr. 408). She was diagnosed with Post Traumatic Stress Syndrome; major depressive disorder, recurrent unspecified; and borderline personality disorder. ( Id. ).
In November of 2007, Grosjean saw Viann Ellsworth ("Ellsworth"), a psychiatric nurse with Park Center. (Tr. 412). On mental status exam she had the following positive signs: depressed mood; blunted affect; helpless, worthless, and hopeless thought content; and recent memory problems. (Tr. 412-13). Ellsworth found that her treatment response was "worse." (Tr. 213). Ellsworth noted that her medications were not completely addressing her symptoms, but Grosjean did not want to change medications before the holidays. (Tr. 414).
Grosjean was seen again in January of 2008. (Tr. 416). On mental status exam she had the following positive signs: depressed and anxious mood; helpless and hopeless thought content; suicidal ideation without plan or intent; and homicidal ideation without plan or intent. (Tr. 416-17). Her treatment response was noted as "worse." (Tr. 418). Grosjean reported agitation, mood swings, depression, suicidal and homicidal thoughts at times, hypersomnia, isolation, and anxiety. ( Id. )
In May of 2008, Grosjean saw Ellsworth again. (Tr. 420-23). The mental status exam shows the following positive findings: depressed mood, blunted affect, and helpless and hopeless thought content. ( Id. ). Her treatment response was noted as "worse." (Tr. 422).
In September of 2008, she saw Ellsworth, and on mental status exam she had the following positive findings: withdrawn behaviors and anxious mood. (Tr. 424). Ellsworth found that Grosjean's treatment response was "worse." (Tr. 425). Grosjean reported that she was having increased flashbacks, felt on edge, and felt like crying but could not, and was always tired. ( Id. ). Her fibromyalgia was bothering her, but her doctor would not give her adequate pain medications. ( Id. ). In March of 2009, she was seen again by Ellsworth, and she reported sleep problems. (Tr. 428). She reported that the medications helped her, but she had quite a few stressors. ( Id. ). On mental status exam she had the following positive signs: fluctuating mood; paranoid and helpless thought content; impaired recent memory; and blunted affect. (Tr. 428-30). She found that her patient was "symptomatic but stable." (Tr. 430). She was seen again in May of 2009, and she reported that she had been depressed and stressed off and on. (Tr. 433). She wanted to sleep a great deal, but she could not. ( Id. ). On mental status exam she had the following positive findings: depressed mood; hopeless and helpless thought content; impaired recent memory; and blunted affect. (Tr. 433-35). In regard to medication compliance she found that she had missed doses a couple of times, and she was slightly worse from a treatment standpoint. (Tr. 435). Remeron 15 mg was added. (Tr. 436). She was seen again in December of 2009, and she was having more flashbacks since her ex-husband tried to force her to have sex. (Tr. 512). Her sister also called which triggered flashbacks about sexual abuse that her sister perpetrated on her when she was a child. ( Id. ) For two weeks she had problems getting to sleep even though she was taking Cymbalta and Seroquel. ( Id. ). On mental status exam she had the following positive signs: anxious mood; paranoid and helpless thought content; impaired recent memory; and impaired remote memory. (Tr. 513). Ellsworth found that her patient's condition was "slightly worse." ( Id. ). She was told to take Cymbalta in the a.m. (Tr. 515). In May of 2010, she reported to Ellsworth that she was starting to get a little edgy and irritable. (Tr. 507). On mental status exam she had the following positive signs: hopeless, helpless, and worthless thought content and impaired recent memory. (Tr. 508). She reported that she had not been coping well with her brother's death, and she was angry. ( Id. ). Her son had been in trouble, and he had been beating up on Grosjean. ( Id. ). Her house was a "total disaster." ( Id. ). Grosjean was, according to Ellsworth, "much worse." (Tr. 510).
In June of 2010, Grosjean saw Ellsworth and reported that she was still grouchy and uptight as well as crying. (Tr. 502). Grosjean had noticed a little improvement with the addition of Remeron but not a great deal. ( Id. ). She reported that she had a therapist who would come to her house and work with her. ( Id. ). She had sleep problems that involved awakening in the middle of the night. ( Id. ). On mental status exam she had the following positive signs: tearful behavior; paranoid, hopeless, helpless, and worthless thought content; and impaired recent memory. (Tr. 502-04). She was fully compliant with treatment, and she was slightly better. (Tr. 504). Her Remeron was increased to 30 mg. ( Id. ).
P. Samant ("Samant"), MSED. Parke Center evaluated Grosjean in June of 2010. (Tr. 493-500). She had been referred to Samant by her son's caseworker. (Tr. 493). She was re-experiencing her symptoms when she was around her two sons who were aggressive towards each other and towards Grosjean. ( Id. ). She was recommended for home-based services. ( Id. ). She reported experiencing severe anxieties related to her past trauma of physical and emotional abuse from her childhood. ( Id. ). She was also having difficulty with parenting her children due to limitations of her mental health conditions. ( Id. ). She reported that she had had children removed from her care in the past. ( Id. ). She had a 25-year-old daughter and two younger sons. ( Id. ). She reported an extensive history of mental disorder and treatment. (Tr. 494). She was having significant problems such as flashbacks, unwanted thoughts, and/or constant anxiety related to past trauma. (Tr. 495). She had post traumatic stress difficulties, and she had experienced one episode of sexual abuse. ( Id. ). She had experienced intrusive thoughts that interfere with the ability to function in some life domains. ( Id. ). She also reported that she worried excessively, and she had poor grooming and hygiene. ( Id. ). She had minimal insight, and she was anxious and fearful. ( Id. ). She reported significant periods of time in which she did not remember what she had done or where she had been. ( Id. ). She was unable to stay on task. ( Id. ). She had trouble shifting from one activity to another. ( Id. ). She would become agitated when confronted with a problem, and she had difficulty thinking through problems and consequences. (Tr. 496). She had a debilitating level of anxiety as well as trouble sleeping. ( Id. ). She was frequently irritable or others complained that she was irritable. ( Id. ). She had a loss of interest and pleasure, and she was experiencing pervasive sadness. ( Id. ). She had a moderate level of depression. ( Id. ). Her diagnosis was PTSD; major depressive disorder, recurrent unspecified; and borderline personality disorder. (Tr. 498). Her Global Assessment of Functioning ("GAF") was rated at 45. (Tr. 499). Grosjean was seen by Ellsworth again in September of 2010, and she reported that her medications were working "pretty good." (Tr. 572). She was a little more irritable, and she was forgetting her morning medications until afternoon. ( Id. ). She continued to have problems sleeping due to pain, and she was also sleepy during the day. ( Id. ). On mental status exam she had the following positive findings: fluctuating and irritable mood; worthless thought content; and impaired recent memory. (Tr. 572-73). Her condition was described as slightly worse, and her Remeron was increased to 45 mg. (Tr. 575).
In February of 2011 she was seen again, and she reported having nightmares of past abuse. (Tr. 549). She was acting these out in her sleep, and she was afraid that someone would get hurt. ( Id. ). She had been under a great deal of stress. ( Id. ). She had sleep problems because of trauma based on nightmares as well as appetite problems. ( Id. ). On mental status exam she had the following positive signs: depressed, anxious, and irritable moods; paranoid, helpless, worthless, and hopeless thought content; suicidal ideation without plan or intent; homicidal ideation without plan or intent; and overactive and tearful behavior. (Tr. 549-51). Ellsworth found that Grosjean was "much worse." (Tr. 552). She added Periactin. ( Id. ).
In March of 2011, she told Ellsworth that her medication was working, but she had a tough time getting them. (Tr. 711). On mental status exam she had the following positive signs: a fluctuating mood and paranoid, helpless, worthless, and hopeless thought content. (Tr. 712). She was found to be fully compliant, and the assessment of her treatment was that she was "much better." (Tr. 713-14).
In May of 2011, Grosjean reported that the medications were working "pretty good, " and she was doing better. (Tr. 682). She was still having problems with sleep because she did not have pain medications. ( Id. ) On mental status exam she had the following positive signs: fluctuating mood; hopeless, helpless, and worthless thought content; and impaired recent memory. (Tr. 682-83). The sassessment was that she was "much better." (Tr. 684).
In March of 2011, she underwent an extensive psychological evaluation by Dr. Danielle Wardell and Dr. Kimberly Harrison at the request of her home-based caseworker. (Tr. 675). The testing was done to clarify diagnosis, determine her overall IQ, and assess parenting needs. ( Id. ). The caseworker made the referral upon the recommendation of the court system which Grosjean was involved with due to her son not getting to school on a regular basis. ( Id. ). IQ testing showed that she was in the average range. (Tr. 676-77). She was administered the PAI to assess her personality functioning. (Tr. 677). The results were valid and considered an accurate reflection of her personality functioning at that time. ( Id. ). There were two clinical scales that were significantly elevated, the somatization and anxiety-related disorders. ( Id. ). It was noted that individuals who have significant elevations on these scales typically report functional impairment due to symptoms associated with sensory or motor dysfunction, typically they are preoccupied with physical health status and physical health problems, have multiple anxiety disorders associated with psychological turmoil, faced with constant rumination, and are often guilt-ridden and prone to past transgressions, real or imagined. ( Id. ). It was also found that she likely engages in a number of maladaptive behavioral patterns aimed at controlling anxiety, but that they were probably ineffective in preventing intrusive experiences such as nightmares and flashbacks. ( Id. ). On the MCMI-III her personality functioning was also assessed, and it was considered valid and accurate. ( Id. ). The results indicated that she was experiencing a considerable amount of post-traumatic stress such as nightmares, flashbacks, foreshortened sense of future, as well as general anxiety such as restlessness, being prone to worry, and feeling out of control due to her worry. ( Id. ). She also appeared to have a personality trait of compulsiveness - she has difficulty being flexible, adhering to rigid routines, and expects perfection. ( Id. ). She was also experiencing a significant amount of depressive symptoms such as depressed mood, loss of interest, loss of energy, and sleep difficulties. ( Id. ). She was administered the TSI in order to assess the presence of post-traumatic stress symptoms at that time. ( Id. ). The results were considered valid. ( Id. ). Three scales were significantly elevated. (Tr. 678). The first one was depression which reflected frequent feelings of sadness and unhappiness and a general sense of being depressed, feeling worthless and inadequate, having hopeless views of the future, a tendency at times to have thoughts of death and dying, tearfulness, and isolating herself from others. ( Id. ). She also appeared to be experiencing some significant amount of intrusive experiences such as nightmares, flashbacks, and intrusive ideation that can be quite upsetting. ( Id. ). She engaged in a significant amount of defensive avoidance where she is repeatedly seeking to eliminate painful thoughts or memories from her consciousness. ( Id. ). One conclusion was that the depressive symptoms impact her parenting role in that she likely cannot generate the emotional and/or physical energy it takes to parent her children, particularly her two sons who were having considerable behavioral difficulties at that time. (Tr. 679). Her diagnosis was major depressive disorder, recurrent, moderate and PTSD, chronic; rule out traits of obsessive-compulsive personality disorder. (Tr. 680). Her GAF was rated at 51. ( Id. ).
Her progress was tracked through her Treatment Plan. In September of 2010 her diagnosis was PTSD; major depressive disorder, recurrent unspecified; and borderline personality disorder. (Tr. 577). According to the treatment plan, her GAF was rated at 45. ( Id. ).She reported that she continued to have mood swings and thinks about her past physical and sexual abuse, and then stated that she feels "sad and frustrated sometimes."(Tr. 581). She is currently working with her therapist on past abuse, but the therapist had reported that she missed the last two appointments. ( Id. ). She had the same diagnosis and GAF listed in her December 2010 treatment plan. (Tr. 556). She continued in the home-based services program and she was willing to work on her treatment goals. (Tr. 559). She continued to exhibit stress related to her sons, had difficulties communicating her feelings, and stated that her "PTSD feelings come and go." ( Id. ). Her caseworker was working with her to improve her parenting and communication skills, and she was getting along better with others. ( Id. ). In March of 2011 her diagnoses were the same, but her GAF was 51. (Tr. 705). She continued to exhibit occasional flashbacks, sad affect, mood swings, and difficulties in getting her children to follow directions. (Tr. 709). Grosjean appeared unmotivated at times in keeping her house clean and following through with the consequences she gives her children. ( Id. ).
The records demonstrate that Grosjean received extensive counseling, follow-up, and home-based treatment. (Tr. 491, 554, 562, 564, 566, 568, 570, 583, 587, 589, 593, 595, 597, 663, 665, 673, 687, 689, 691, 692, 695, 697, 699, 701, 703, 716, 718, 720, 722, 724, 726, 728, 730, 732, 735, 736, 738, 740, 742, 744, 746, 748, 750, 752, 754, 756, 758, and 760). Grosjean was not paying her bills, and had been scammed out of money. (Tr. 745). Her home was eventually condemned. (Tr. 752, 756).Her two boys were taken from her care and placed in a shelter. (Tr. 748).
In August of 2011, Ellsworth completed a "Mental Impairment Questionnaire." (Tr. 762-66). Ellsworth reported her current symptoms as fluctuating moods; feelings of helplessness, hopelessness, and worthlessness; and impaired recent memory. (Tr. 762). In regard to depressive episodes she found that Grosjean had never been totally free from depressive symptoms since 2007 when these symptoms had been moderate to severe in intensity and had significantly interfered with her ability to function. ( Id. ). In the last four months they have been moderate to mild and interfere less often. ( Id. ). Ellsworth found that Grosjean had frequent flashbacks and nightmares of abuse that interfere mildly with her ability to function. ( Id. ). She has had at least two severe episodes of flashbacks and nightmares that have interfered significantly with her ability to function for two to four weeks at a time since November of 2007. ( Id. ). At the time of the assessment, Grosjean felt that she had fair control of her moods, but based on her past, this control is easily lost and severely interferes with her ability to function for weeks to months at a time. (Tr. 763). Ellsworth found that Grosjean would have problems with absenteeism because she frequently has difficulty sleeping as a result of depression, flashbacks, and nightmares which make it difficult for her to function the next day. ( Id. ). She found that Grosjean would miss greater than three days of work a month due to these problems. ( Id. ). Ellsworth also found that Grosjean would have difficulty maintaining attention and concentration in unskilled work because depression makes it difficult for her to concentrate and stay on task. ( Id. ). Furthermore, Grosjean could be unexpectedly triggered about memories of past abuse and when triggered, she is unable to focus on work tasks. ( Id. ). Ellsworth opined that Grosjean would be able to concentrate and pay attention for less than 85% of the workday. (Tr. 764).
Dr. Daniel Hauschild
Dr. Daniel Hauschild ("Dr. Hauschild") performed a psychological evaluation at the request of Social Security in October of 2009. (Tr. 447). Grosjean told Dr. Hauschild that she is sometimes too tense, and she cannot stop thinking in order to fall asleep. ( Id. ). She reported bad dreams and a history of severe nightmares. ( Id. ).
She also reported that when she was awake she would have episodes of disassociation and would see her abusers. ( Id. ). She goes blank, and she has to touch something to bring herself back to reality. ( Id. ). She stated that her flashbacks are triggered by sights, smells, and seeing her sons fighting. ( Id. ). She also ruminates about her appointments. ( Id. ). She is sometimes up until two or three a.m. due to being in pain, but she is more able to maintain her sleep since she started taking Lyrica and Vicodin. ( Id. ). On some days she hurts so much that she cannot do anything, and she frequently just sits. ( Id. ). She admitted that sometimes she has trouble getting out of bed, and she can keep hitting the snooze button. ( Id. ). She reported that once she gets up, she can keep going though she still needs to take short breaks. ( Id. ). She also reported problems with concentration at times. ( Id. ). She also acknowledged feelings of worthlessness, and she reported that she makes self-deprecating statements. (Tr. 448). In regard to how she spent most of her time each day, she reported that she cleaned a little, rested, ate, took a nap, and then ate a snack, did more work, and then watched TV for about two hours. ( Id. ). She reported that her ability to do dishes, vacuuming, and laundry depend upon the day and how she was feeling physically. (Tr. at 449). She reported that she needed assistance with shopping. ( Id. ). On mental status exam she repeated five digits forward and three digits backward. (Tr. 449). She could recall two out of four items that had been presented to her five minutes earlier. ( Id. ). In regard to serial 7's she gave up after sixty seconds. (Tr. 450). She appeared mildly depressed. (Tr. 451). She acknowledged some crying spells and irritably. ( Id. ). She also admitted to thinking about suicide. ( Id. ). His diagnostic impression was PTSD and major depressive disorder, recurrent, severe without psychotic features. ( Id. ). He rated her current GAF as 47. (Tr. 452).
Drs. J. Gange and F. Kladder
Dr. Gange completed a psychiatric review technique form on November 08, 2009. (Tr. 466). Dr. Gange noted that Grosjean had affective disorders and anxiety-related disorders. (Tr. 466). Dr. Gange found that she had mild limitations in daily living activities and in maintaining social functioning. (Tr. 476). She had no episodes of decompensation. ( Id. ). She also had a moderate degree of limitation in concentration, persistence, and pace. ( Id. ).
Dr. Gange also completed a "Mental Residual Functional Capacity Assessment" on November 8, 2009. Dr. Gange found that she was "moderately limited" in her mental abilities to maintain attention and concentration for extended periods; to respond appropriately to changes in the work setting; and to set realistic goals or make plans independent of others. (Tr. 480-81). Dr. Gange noted a remote treatment history through Park Center, and that she had not required recent treatment as she obtained medications from her primary care provider. (Tr. 482). Dr. Gange also found that her activities of daily living remain intact within physical parameters. ( Id. ). Dr. Gange concluded that the intensity of the symptoms and their impact on functioning were not ...