United States District Court, N.D. Indiana, Hammond Division
OPINION AND ORDER
case, plaintiff Thomas Alan Sergent appeals the denial of his
claim for Social Security Disability Insurance Benefits. For
the following reasons, the Court remands this matter to the
Commissioner for further proceedings consistent with this
sought disability insurance benefits on October 15, 2014,
alleging an onset date of February 12, 2013, which was
amended to April 17, 2013. (Tr. 195, 210). Sergent indicated
that he was unable to work due to bilateral upper extremity
radiculopathy, tinnitus, degenerative disc disease of the
cervical spine, headaches, and post-traumatic stress disorder
(“PTSD”). Sergent's application was denied
initially and on reconsideration. (Tr. 102, 132-38). An
Administrative Law Judge (“ALJ”) held a hearing,
during which Sergent appeared with counsel and testified,
along with a vocational expert (“VE”) who
testified. (Tr. 34-88). The ALJ decided that even though
Sergent suffered from the severe impairments of spinal
disorder, headache disorder, and anxiety disorder or PTSD, he
could still perform light work in a quiet environment that
was limited (in relevant part) to simple routine repetitive
tasks that were not performed at a production rate pace and
involved no more than occasional decision making, few changes
in the work setting, occasional interaction with coworkers
and supervisors, and no tandem tasks or interaction with the
general public. (Tr. 15-28). One of the hypotheticals posed
to the VE considered these same limitations (which were
ultimately contained in Sergent's assigned residual
functional capacity (“RFC”)), and the VE
testified that such a restricted individual could still
perform work as a cleaner, packager, and marker. Thus, the
ALJ determined that Sergent was not disabled since he could
perform these other jobs. The Appeals Council denied review,
making the ALJ's decision the final decision of the
agency. (Tr. 1-3). Sergent filed a timely complaint seeking
judicial review of that decision, and this Court has
jurisdiction pursuant to 42 U.S.C. § 405(g).
was born on November 28, 1963 and is currently 53 years old.
(Tr. 89). Over his lifetime, he has had three main skilled
careers ranging from medium to very heavy exertional levels.
Initially, he worked in building maintenance. (Tr. 82).
Sergent was later a combat engineer and heavy equipment
horizontal engineer while serving in Iraq and Afghanistan.
(Tr. 44). Following his service overseas, Sergent worked as a
firefighter/security officer. (Tr. 44-46).
the subject of Sergent's appeal concerns his mental
limitations, it was Sergent's physical limitations that
prevented him from continuing work as a firefighter and
security officer. (Tr. 45). In March 2012, diagnostic imaging
of Sergent's spine documented mild disc disease and early
osteopenic changes of the cervical spine. (Tr. 320). Sergent
underwent a consultative medical examination in November
2014, which reflected that he had a tender cervical spine
with decreased range of motion. (Tr. 869-70). In addition to
noting his mental and emotional conditions, this report noted
that Sergent suffered from neck pain and a history of
degenerative joint disease of the cervical spine. In December
2014, J.V. Corcoran, M.D., conducted a physical RFC
assessment and found that Sergent could perform restricted
light work. (Tr. 95-100). Dr. Corcoran's assessment was
affirmed by B. Whitley, M.D., in February 2015. (Tr. 116).
However, Sergent does not challenge the ALJ's assessment
of his physical limitations, and therefore, the Court turns
to his documented mental limitations.
undisputed that Sergent suffers from PTSD. Sergent testified
that his PTSD bothers him the most, and he was medically
retired from the National Guard primarily on account of his
PTSD. (Tr. 43, 53). Because he doesn't handle
uncontrolled environments or unfamiliar people well, he
rarely leaves his house. (Tr. 53, 55, 57, 65-67, 76, 79).
Sergent wasn't even comfortable during his disability
hearing because it was held in a government building that he
described as a “high-value target.” (Tr. 55).
Sergent described being in public as “nerve-racking,
” and explained that loud noises or situations that
remind him of combat or his war enemies “trigger”
his PTSD symptoms. (Tr. 67, 71-73). Sergent indicated that
once he becomes anxious from a triggering event, it can take
him several hours to recover to a normal controlled state.
(Tr. 56). Dr. Krage, Sergent's long-time psychologist,
prescribed medication to treat Sergent's PTSD, but
Sergent was told that he did not have to take it after
reporting that the medication made him feel
“numb” and “stupid, ” and it
interfered with his needed ability to feel in control and
alert. (Tr. 54, 72). Sergent continues to engage in talk
therapy once a month, and as recommended by Dr. Krage,
Sergent attends “Pets and Vets” on a weekly basis
with his service dog. (Tr. 53-54, 69). Sergent explained that
his service dog really assists with keeping his anxiety down
and he feels comfortable attending a closed meeting designed
only for veterans suffering from PTSD. (Tr. 56, 69).
has routinely been documented by doctors as being oriented,
neatly groomed and dressed, cooperative and pleasant,
coherent as to thought process, good as to insight and
judgment, and without memory issues or suicidal/homicidal
ideations. (Tr. 484, 488-89, 746-47, 763, 884-887). However,
some of these same medical records and various others
demonstrate that Sergent has continued to experience various
serious symptoms of his anxiety and PTSD. (Tr. 458, 484-85,
488, 490-92, 746, 767, 769, 886). In January 2014, Sergent
presented for a PTSD evaluation which indicated that he was
easily distracted, apprehensive, anxious, impaired as to
judgment, had poor insight, and it noted that he suffered
from moderate to severe impairment in psychological, social,
and occupational functioning, and moderate to severe
impairment in judgment and impulsivity. (Tr. 780-82).
December 2014, Amy S. Johnson, Ph.D., conducted a
consultative examination and concluded that Sergent had only
mild restriction in performing activities of daily living and
moderate difficulties in maintaining social functioning and
concentration, persistence or pace. (Tr. 94). Further, Dr.
Johnson found that Sergent could understand, remember, and
follow simple instructions, but he was limited to work that
involved brief, superficial interactions with fellow workers,
supervisors, and the public. (Tr. 99). Additionally, Dr.
Johnson deemed that within these parameters and in the
context of performing simple, routine, repetitive, concrete,
tangible tasks, Sergent was able to sustain the necessary
attention and concentration to perform work with reasonable
pace and persistence. (Tr. 99). B. Randal Horton, Psy.D.,
reviewed Sergent's file and affirmed Dr. Johnson's
assessment in February 2015. (Tr. 109, 114).
Krage completed a mental impairment questionnaire in
September of 2014. (Tr. 337-40). Dr. Krage believed that
Sergent had mild restrictions in his activities of daily
living and moderate difficulties in social functioning and
maintaining concentration, persistence or pace. (Tr. 340).
Dr. Krage also believed that Sergent was moderately limited
in five of seventeen listed areas of mental functioning, as
well as markedly limited in his ability to maintain attention
and concentration for extended periods. (Tr. 339). About a
year later, Dr. Krage reported that Sergent's condition
varied from being “moderately to severely impaired by
PTSD, ” that despite treatment “his PTSD symptoms
have remained constant with little to no improvement, ”
and that his “ability to effectively interact with
others is significantly impacted by his internal distress and
can be further exacerbated due to normal daily
stressors.” (Tr. 888-89).
STANDARD OF REVIEW
the Appeals Council denied review, the Court evaluates the
ALJ's decision as the final word of the Commissioner of
Social Security. Schomas v. Colvin, 732 F.3d 702,
707 (7th Cir. 2013). The Court will affirm the
Commissioner's denial of disability benefits if it is
supported by substantial evidence. Craft v. Astrue,539 F.3d 668, 673 (7th Cir. 2008). Substantial evidence
consists of “such relevant evidence as a reasonable
mind might accept as adequate to support a conclusion.”
Richardson v. Perales,402 U.S. 389, 401 (1971). It
must be “more than a scintilla but may be less than a
preponderance.” Skinner v. Astrue, 478 F.3d
836, 841 (7th Cir. 2007). Thus, even if “reasonable
minds could ...