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Dotson v. Berryhill

United States District Court, N.D. Indiana, Fort Wayne Division

March 22, 2017

RYAN A. DOTSON, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, [1]Defendant.

          OPINION AND ORDER

          Andrew P. Rodovich United States Magistrate Judge

         This 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.[2] For the following reasons, the decision of the Commissioner is REMANDED.

         Background

         The 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).

         The ALJ 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).

         In 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 extended duration.

         (Tr. 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).

         The ALJ 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).

         The ALJ 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).

         The ALJ 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).

         The ALJ then assessed Dotson's residual functional capacity (RFC) as follows:

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 necessary instruction.

         (Tr. 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).

         Dotson 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).

         Dotson's 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).

         The ALJ 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).

         The ALJ 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).

         The ALJ 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).

         In 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).

         After 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).

         Dr. 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).

         Dotson 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).

         Dr. 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). ...


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