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Hart v. Commissioner of Social Security

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

March 31, 2017

DANIEL L. HART, III, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          OPINION AND ORDER

          Susan Collins, United States Magistrate Judge

         Plaintiff Daniel L. Hart, III, appeals to the district court from a final decision of the Commissioner of Social Security ("Commissioner") denying his application under the Social Security Act (the "Act") for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI").[1] (DE 1). For the following reasons, the Commissioner's decision will be AFFIRMED.

         I. PROCEDURAL HISTORY

         Hart applied for DIB and SSI in September 2014, alleging disability as of January 1, 2011.[2] (DE 11 Administrative Record ("AR") 233-46). The Commissioner denied Hart's application initially and upon reconsideration. (AR 122-23, 146-57). On May 26, 2015, a hearing was held before the ALJ, at which Hart, who was represented by counsel, and a vocational expert, Sharon Ringenberg (the "VE"), testified. (AR 41-83). On July 17, 2015, the ALJ rendered an unfavorable decision to Hart, concluding that he was not disabled because he was capable of performing a significant number of jobs in the economy despite the limitations caused by his impairments. (AR 18-34). The Appeals Council denied Hart's request for review (AR 1-14), at which point the ALJ's decision became the final decision of the Commissioner. See 20 C.F.R §§ 404.981, 416.1481.

         Hart filed a complaint with this Court on December 14, 2015, seeking relief from the Commissioner's final decision. (DE 1). In this appeal, Hart advances just one argument-that the ALJ improperly assessed the credibility of his symptom testimony. (DE 17 at 6-14).

         II. FACTUAL BACKGROUND [3]

         At the time of the ALJ's decision, Hart was 25 years old (AR 34, 233); had a high school education (AR 302) with some special education classes (AR 569-70); and had work experience as a forklift operator, a loader and unloader, and a production worker (AR 363). Because Hart does not challenge the ALJ's findings concerning his physical impairments, the Court will focus on the evidence pertaining to his mental impairments.

         A. Hart's Testimony at the Hearing

         At the hearing, Hart testified that he has full custody of his three children, who all under the age of four, and that he and his children live with his mother and grandmother. (AR 47-48). He was receiving food stamps and had just been approved for Medicaid. (AR 48, 50, 62). He lost his license in December 2013 after an accident, and he no longer drives, stating that it causes him anxiety. (AR 49-50). His mother helps him care for his children, and his mother does all of the cooking. (AR 59-61). He has two or three bad days a month where he does not get out of bed and his mother and grandmother care for his children. (AR 64). He has a restraining order against his ex-wife, and she is not involved in the children's care. (AR 63).

         Hart had worked after his alleged onset date. (AR 50-51). Most notably, from May 2011 to May 2012, he worked up to 35 hours a week unloading trucks and stocking shelves at Walmart. (AR 51). During his employment with Walmart, Hart was taking medications "on and off' and was not participating in any mental health treatment. (AR 67). Although Walmart disciplined him for missing "a lot" of days, which he estimated was "an average of four days a month, " it did not terminate his employment. (AR 52-54, 65-66, 286). Rather, he left Walmart because he got what he thought was a "better job" at Family Dollar. (AR 52). Hart, however, lost his job at Family Dollar within three weeks due to missing too many days. (AR 52-53). Hart then worked at AZZ for a few months, but stated that he lost that job, too, for missing too many days. (AR 54-55). After AZZ, he worked at Menards for a few months, again stating that he had lost that job due to absenteeism. (AR 54-56). Several days before the hearing, Hart had lost a job at a service station due to absenteeism. (AR 69). When asked why he missed so many days at these jobs, Hart testified that his absences were all due to his anxiety and depression. (AR 55-56, 69).

         When asked why he thought he cannot work, Hart stated that he gets very anxious around large groups of people, in that his chest starts hurting and he finds it hard to breathe. (AR 61, 64-65). He stated that he has hallucinations on occasion, indicating that they increase in frequency the longer he is off his medications. (AR 61). He also indicated that he suffers from delusions randomly throughout the day, in that he can be walking down the street and a person pops up beside him and then the person is gone two seconds later. (AR 63).

         Hart stated that his medications help control these symptoms, reporting that when he takes his medications, the voices and hallucinations "were cut down to almost non-existent" or about a half-hour per week. (AR 58-59). He had not taken any medications for the past six months because he could not afford them, but he planned to resume his medications now that he had Medicaid again. (AR 61-63).

         B. Summary of the Relevant Medical Evidence

         Hart first received mental health treatment in the third grade when he was prescribed medications. (AR 667). Hart stopped treatment in 1996 at the age of 16 because he thought he had "everything under control." (AR 667).

         In January 2011, Hart had an initial visit with Dr. Sylvia Rutten, a psychiatrist at the Northeastern Center, telling her that he "has papers he needs filled out for disability and that's why he's here." (AR 667). He stated that his mental health had been worsening for the past three or four years and that he had very little control over his temper. (AR 667). He complained of insomnia, low energy, decreased concentration, feeling restless, paranoia, and worrying. (AR 667-68). He stated that he had suicidal ideation in the past and had attempted suicide twice; he did not have any psychiatric hospitalizations. (AR 668). On exam, he demonstrated intact memory; average intellect; and fair, but somewhat limited, judgment. (AR 668). Dr. Rutten diagnosed Hart with major depressive disorder, recurrent; no psychosis, but rule out history of psychosis; generalized anxiety disorder; history of ODD, possible conduct disorder; family relational issues; and rule out antisocial personality disorder. (AR 669). She assigned him a current Global Assessment of Functioning ("GAF") score of 50.[4] (AR 669). She prescribed Inderal, stated that she would consider adding additional medications in the future, and recommended that he continue therapy. (AR 669). Hart, however, failed to follow through with treatment at the Northeastern Center. (AR 648, 666).

         In February 2011, Hart underwent a mental status examination by Michael Scherbinski, Ph.D., for purposes of his disability application. (AR 596-600). He reported having extreme anxiety in social situations; he stated that he blacks out occasionally when in groups of people and wakes up chasing or hitting them. (AR 596). He also complained of mood swings, depression, sleeplessness, and hallucinations. (AR 596). He hears voices in his head up to six times a week and sees himself hurting others when he is angry. (AR 596). He does not want to leave his room when feeling depressed. (AR 596). He indicated that he has difficulty regulating his emotions, being around people, and maintaining employment. (AR 596). He denied any current suicidal ideation or thoughts of self-harm. (AR 596). Upon mental status exam, Hart showed no evidence of a thought disorder; his affect appeared anxious. (AR 598). His performance on a mental status exam revealed average judgment and insight, and he was compliant with all requests. (AR 600). He was able to maintain focus and concentration, and he demonstrated appropriate communication and social skills throughout the examination. (AR 600). Dr. Scherbinski concluded that Hart's abilities "would likely allow him to potentially gain and/or maintain employment, " but that "given his mental health concerns, [he] may have difficulty consistently meeting demands in a work environment." (AR 600). Dr. Scherbinski diagnosed Hart with social phobia (provisional) and assigned him a GAF of 63. (AR 600).

         In March 2011, B. Randal Horton, Psy.D., a state agency psychologist, reviewed Hart's record and concluded that he had mild restrictions in activities of daily living, in maintaining social functioning, and in maintaining concentration, persistence, or pace. (AR 603-15). Dr. Horton concluded that Hart's mental impairments were not severely limiting. (AR 615). J. Gange, Ph.D., another state agency psychologist, affirmed Dr. Horton's opinion in July 2011. (AR617).

         Hart visited the emergency room for various physical ailments in August 2012, November 2012, January 2013, May 2013, June 2013, July 2013, August 2013, and December 2013, and psychiatric review of systems were negative during those visits. (AR 413-14, 418-26, 429-32, 434-47.)

         In July 2013, Hart returned to the Northeastern Center, stating that he needed to get stable so that he could provide for his family. (AR 648-50, 660). He reported a depressed mood, difficulty being around people, anger, fleeting suicidal ideation, broken sleep, racing thoughts, intermittent homicidal ideation, and visual hallucinations. (AR 648, 660). Upon mental status exam in August 2013, the clinician noted a depressed mood, normal psychomotor activity, flat affect, organized thought processes, grossly intact cognition, limited insight and judgment, and no current suicidal or homicidal thoughts. (AR 648-50). He was assigned diagnoses of bipolar disorder, depressed, severe, and post traumatic stress disorder ("PTSD"). (AR 650). He had a current GAF of 50 and a GAF upon admission of 48. (AR 650).

         In September 2013, Hart told a clinician at the Northeastern Center that he was having decreased sleep and increased anxiety. (AR 646). He also reported having auditory and visual hallucinations, as well as suicidal ideation, but he clarified that he did not want to hurt himself due to his children. (AR 646). His mood was depressed and anxious. (AR 647). His memory, attention, concentration, insight, and judgment were all good. (AR 647). His medications were adjusted. (AR647).

         In October 2013, the Northeastern Center noted that there was no increase in Hart's GAF score, "as client is not fully engaged in individual therapy." (AR 661).

         In November 2013, Hart told a clinician at the Northeastern Center that he just wanted to stay in bed all day. (AR 643). He was having trouble sleeping. (AR 643). He reported having visual hallucinations up to four times a week. (AR 643). He had lingering thoughts of self harm, but no thoughts of violence toward others. (AR 644). He had a depressed mood and a blunted affect. (AR 644). The clinician adjusted his medications and indicated diagnoses of bipolar disorder and PTSD. (AR 644).

         In early December 2013, Hart reported to a clinician at the Northeastern Center that he was just staying in bed. (AR 641). He stated that his hallucinations had lessened, but that they increased if he missed a medication dosage. (AR 641). He reported suicidal ideation up to three times a day and thoughts of violence toward others. (AR641). His mood swings varied. (AR 642). His medications were adjusted. (AR 642).

         Later in December 2013, Hart reported to Dr. Teresa Greiner at the Northeastern Center that he continued to have mood swings. (AR 639). His hallucinations decreased since being on Invega, and he had no thoughts of hurting himself or others. (AR 639). His mood was anxious and depressed, and his affect was quite flat. (AR 639). He had normal attention and concentration, insight and judgment, and thought process. (AR 639). She assessed bipolar disorder, mixed, with ongoing symptoms; and PTSD, with ongoing symptoms. (AR 640). She adjusted his medications. (AR 640).

         In January 2014, Hart told Dr. Greiner that his mood was better overall and although he still had mood swings, they were significantly better. (AR 637). His mood was flat, but he had normal thought process and content, intact memory and attention, and intact insight and judgment. (AR637). He had no suicidal or homicidal thoughts. (AR637). Diagnoses included bipolar disorder, depressed with psychotic features, improved with ...


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