United States District Court, N.D. Indiana, Fort Wayne Division
RYAN A. DOTSON, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
OPINION AND ORDER
P. Rodovich United States Magistrate Judge
matter is before the court on the petition for judicial
review of the decision of the Commissioner filed by the
plaintiff, Ryan A. Dotson, on February 5, 2015. For the following
reasons, the decision of the Commissioner is REMANDED.
plaintiff, Ryan A. Dotson, filed an application for
Disability Insurance Benefits and Supplemental Security
Income on July 5, 2012, alleging a disability onset date of
June 30, 2012. (Tr. 17). The Disability Determination Bureau
denied Dotson's application on September 13, 2012, and
again upon reconsideration on November 19, 2012. (Tr. 17).
Dotson subsequently filed a timely request for a hearing on
November 30, 2012. (Tr. 17). A hearing was held on August 6,
2013, before Administrative Law Judge (ALJ) Maryann S.
Bright, and the ALJ issued an unfavorable decision on
September 13, 2013. (Tr. 17-29). Vocational Expert (VE) Dale
A. Thomas, Dotson, and Dotson's ex-wife, Melissa Dotson,
testified at the hearing. (Tr. 17, 23). The Appeals Council
denied review, making the ALJ's decision the final
decision of the Commissioner. (Tr. 1-13).
found that Dotson met the insured status requirements of the
Social Security Act through December 30, 2016. (Tr. 19). At
step one of the five step sequential analysis for determining
whether an individual is disabled, the ALJ found that Dotson
had not engaged in substantial gainful activity since June
30, 2012, the alleged onset date. (Tr. 19). At step two, the
ALJ determined that Dotson had the following severe
impairments: bipolar II disorder, panic disorder without
agoraphobia with mild panic attacks, posttraumatic stress
syndrome (PTSD), and obesity. (Tr. 20). At step three, the
ALJ concluded that Dotson did not have an impairment or
combination of impairments that met or medically equaled the
severity of one of the listed impairments. (Tr. 20).
Specifically, she found that he did not meet Listings 12.04
or 12.06. (Tr. 20).
finding that Dotson did not meet the above listings, the ALJ
considered the paragraph B criteria for mental impairments,
which required at least two of the following:
marked restriction of activities of daily living; marked
difficulties in maintaining social functioning; marked
difficulties in maintaining concentration, persistence, or
pace; or repeated episodes of decompensation, each of
21-22). The ALJ defined a marked limitation as more than
moderate but less than extreme and repeated and extended
episodes of decompensation as three episodes within one year
or once every four months with each episode lasting at least
two weeks. (Tr. 21). The ALJ found that Dotson had moderate
restrictions in daily living activities. (Tr. 21). She noted
that Dotson was independent in his personal care but
neglected his hygiene at times. (Tr. 21). Dotson testified
that he received reminders from his mother-in-law to shower
and that he relied on his ex-wife to clean and grocery shop.
(Tr. 21). However, the ALJ reported that Dotson was the
primary caretaker of his infant son. (Tr. 21).
found that Dotson had moderate difficulties in social
functioning. (Tr. 21). When asked if he had ever been fired
for problems getting along with others, Dotson testified at
the hearing that he was fired for having a sexual
relationship with a coworker. (Tr. 21). Dotson's ex-wife
testified that Dotson could not maintain a job for more than
six months because he did not get along well with others.
(Tr. 21). However, the ALJ noted that Dotson left home alone,
worked part-time after the alleged onset date caring for
adults with mental disabilities, and interacted without issue
with clients. (Tr. 21).
concluded that Dotson had moderate difficulties in
concentration, persistence, or pace. (Tr. 21). Dotson
testified to memory problems, but the ALJ indicated his
memory issues were moderate because he could handle a
checkbook and he remembered pertinent information about his
past employment. (Tr. 21). Moreover, the ALJ found that
Dotson had not experienced any extended episodes of
decompensation. (Tr. 21).
concluded that Dotson did not satisfy the paragraph B
criteria because his mental impairments did not cause at
least two marked limitations or one marked limitation and
repeated episodes of decompensation. (Tr. 22). Additionally,
she concluded that Dotson did not satisfy the paragraph C
criteria because the record was devoid of evidence of
episodes of decompensation, potential episodes of
decompensation, or an inability to function outside a highly
supportive living arrangement or his home. (Tr. 22).
then assessed Dotson's residual functional capacity (RFC)
the claimant has the residual functional capacity to perform
medium work as defined in 20 CFR 404.1567(c) and 416.967(c)
except he is unable to engage in complex or detailed tasks,
but can perform simple, routine, and repetitive tasks
consistent with unskilled work; and is able to sustain and
attend to task throughout the workday. He is limited to work
in a low stress job, defined as having only occasional
decision making required and only occasional changes in the
work setting. The claimant is further limited from fast-paced
work such as assembly line production work with strict
productivity requirements. He is limited to superficial
interaction with coworkers, supervisors and the public, with
superficial interaction defined as occasional and casual
contact not involving prolonged conversation or discussion of
involved issues. Contact with supervisors still involves
22). The ALJ explained that in considering Dotson's
symptoms she followed a two-step process. (Tr. 22). First,
she determined whether there was an underlying medically
determinable physical or mental impairment that was shown by
a medically acceptable clinical or laboratory diagnostic
technique that reasonably could be expected to produce
Dotson's pain or other symptoms. (Tr. 22). Then she
evaluated the intensity, persistence, and limiting effects of
the symptoms to determine the extent to which they limited
Dotson's functioning. (Tr. 22-23).
application for disability benefits alleged that his bipolar
disorder, borderline personality disorder, PTSD, and
obsessive-compulsive disorder rendered him disabled. (Tr.
23). He reported on his Function Report that his anxiety
caused memory and concentration problems, difficulty
completing tasks, and getting along with others. (Tr. 23).
Specifically, he indicated due to his anxiety at work he
would cry in the parking lot and hide to call his wife. (Tr.
23). He reported that his medications caused several side
effects. (Tr. 23). Dotson testified that he was the primary
caretaker for his sixteen-month-old son with the help of his
mother-in-law but that she worked during the day. (Tr. 23).
Also, he reported that he attempted suicide after an
altercation with his ex-wife but that he did not seek
emergency treatment. (Tr. 23). He stated that he relied on
his ex-wife to care for the home, mow the lawn, and grocery
shop. (Tr. 23).
ex-wife testified that they divorced because she could not
afford the copays for Dotson's therapy, but that they
continued to live as husband and wife. (Tr. 23). She stated
that Dotson would continuously call her from work because of
his anxiety and occasionally his anxiety caused him to miss
work because he would not get out of bed. (Tr. 23). She
indicated that he was head-butted at work on August 14, 2011,
and that his PTSD worsened after the incident, which led to
his termination. (Tr. 23). Additionally, she testified that
Dotson cared for their son, but that he required her
assistance. (Tr. 23).
found that Dotson's impairments could cause some of his
alleged symptoms, but that he was not entirely credible
regarding the intensity, persistence, and limiting effects of
the symptoms. (Tr. 23). Specifically, she gave Dotson's
testimony limited weight because there were many
inconsistencies between it and the record. (Tr. 23-24). For
example, she found that his work history, daily living
activities, and the medical evidence was inconsistent with
his claim of disabling anxiety. (Tr. 23-24). The ALJ noted
that Dotson worked part-time, including skilled work after
his alleged onset date, therefore, she found that his anxiety
did not significantly interfere with his ability to work.
(Tr. 23-24). Also, despite receiving assistance from his
ex-wife and mother-in-law, the ALJ noted that Dotson was the
primary caretaker for his infant son. (Tr. 24).
indicated that Dotson did not report any medication side
effects at several medication management visits despite
claiming that all his medications caused side effects. (Tr.
24). Additionally, Dotson reported problems with hygiene, yet
he appeared well-groomed and reported taking four showers a
day. (Tr. 24). The ALJ assigned little weight to Dotson's
ex-wife's testimony because it lacked support from the
medical records and she had a financial interest in Dotson
receiving benefits. (Tr. 24).
then reviewed the medical evidence. (Tr. 24-26). She found
that the record did not demonstrate a long history of mental
health treatment. (Tr. 24). She indicated that Dotson first
sought counseling in 2010 when his family experienced a
traumatic event and that he began taking depression
medication in early 2011. (Tr. 24). On July 15, 2011, Dr.
Heidi Ehrhardt diagnosed Dotson with depression and bipolar
disorder. (Tr. 24). In August of 2011, Dotson began treatment
with Dr. Jay Fawver. (Tr. 24). Dr. Fawver prescribed several
medications and Dotson was treated on a monthly basis at the
Fawver Wellness Clinic through July 2012. (Tr. 24). Dotson
testified that he stopped treatment with Dr. Fawver because
he did not recommend disability. (Tr. 24).
August of 2012, Dotson began treatment with Dr. Samir Ishak
who assessed him with anxiety disorder and prescribed several
medications. (Tr. 25). At Dotson's follow up appointment,
he reported that he stopped using Abilify because it made him
feel manic. (Tr. 25). In October 2012, Dotson saw Dr.
Ehrhardt again and complained of psychological and memory
problems. (Tr. 25). She recommended a neuropsychological
evaluation and noted that Dotson had lost consciousness after
a patient pushed him down at work. (Tr. 25).
Dr. Ehrhardt's recommendation, Dotson saw
neuropsychologist Christina Stemmler, Psy.D. for complaints
of disorientation, short-term memory loss, confusion, and
disorganization. (Tr. 25). Dotson denied having attention
problems despite his history of ADHD. (Tr. 25). He reported
that his daily activities consisted of caring for his
seven-month-old son and his horse. (Tr. 25). Dr. Stemmler
found some memory and attention problems during her mental
status examination and diagnosed Dotson with cognitive
disorder, bipolar II disorder, ADHD, anxiety disorder, and a
learning disorder. (Tr. 25). She concluded that Dotson could
be experiencing residual deficits from a traumatic brain
injury and recommended further testing, more medication
management, and psychiatric monitoring from Dr. Ishak. (Tr.
25). Dr. Ishak treated Dotson and noted that he was not
experiencing any side effects from his medications. (Tr. 25).
Dr. Ishak continued Dotson on his medications. (Tr. 25).
Susan Tielker-Sharpe provided coping techniques during a
counseling session after Dotson discussed his anger issues,
insecurities, belief that he was disabled, grief over his
grandfather's passing, and dependency problems. (Tr. 25).
Stemmler performed a neuropsychological examination and
recommended Dotson receive ongoing monitoring from his
treating physicians and mental health providers. (Tr. 25).
She supported Social Security disability temporarily, but she
indicated that Dotson's head injury did not prevent him
from returning to gainful employment. (Tr. 25). Dotson
reported isolation, neglecting his personal hygiene,
worsening depression and anxiety, and failing to take his
diagnosed Lithium for two weeks. (Tr. 25). Dr. Ishak
requested Dotson be hospitalized due to his worsening
depression symptoms and changes in behavior. (Tr. 25). Dr.
Ishak assessed him with bipolar affective disorder,
posttraumatic stress disorder, and panic attacks without
agoraphobia. (Tr. 25-26). Dotson was hospitalized twice and
discharged both times at his own request. (Tr. 26).
underwent an independent psychological evaluation with
Revathi Bingi, Ed.D. who assessed him with bipolar disorder,
most recent episode depressed, panic disorder with
agoraphobia, PTSD, and OCD. (Tr. 26). Dotson reported
symptoms of panic attacks, feelings of worthlessness, mind
racing, excessive anger, poor focus, mood swings, and
suicidal ideation. (Tr. 26). However, the ALJ noted that he
correctly interpreted proverbs, identified similarities and
differences between objects, recalled digits, and calculated
simple math problems. (Tr. 26).
Ishak opinioned that Dotson was unable to hold employment,
however, Dotson was working at the time. (Tr. 26). Therefore,
the ALJ assigned little weight to his opinion because he had
treated Dotson for only three months and his opinion was
inconsistent with Dotson's current work activity. (Tr.
26). The ALJ assigned little weight to Dr. Fawver's
opinion that Dotson should remain off work because his mood
was unpredictable and unstable. (Tr. 26). ...