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Baum v. Berryhill

United States District Court, N.D. Indiana, South Bend Division

September 19, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         On May 24, 2016, Plaintiff Craig Joseph Baum filed a pro se complaint in this Court seeking review of the final decision of the Defendant Commissioner of Social Security denying his application for social security disability benefits [DE 1]. The matter is fully briefed and ripe for decision [DE 12; DE 17; DE 22]. Because the ALJ's decision was supported by substantial evidence, the Court affirms the Commissioner's decision.

         I. FACTS

         Baum filed an application for disability insurance benefits (“DIB”) and supplemental security income (“SSI”) on June 19, 2014, [1] alleging an onset date of November 11, 2011, at which time he was 53 years old. Baum claimed disability on account of back pain, bilateral leg pain caused by varicose veins, diabetes, attention deficit disorder (“ADD”), and severe depression since age four. R. at 249-59. Baum blames his severe depression for his inability to maintain relationships. Despite these problems, Baum reported that he regularly attends religious activities, cares for himself independently, performs chores at a regular pace (but can't rush), walks one to two miles, and spends a lot of time praying in the park. In the past decade, Baum has lacked insurance, had little to no income, and has been homeless. Prior to that, Baum worked for almost forty years and reported to doctors that he never sought treatment for his severe depression during that time. In fact, there are no medical records in the record predating July of 2014.

         A. Mental Health Records

         With respect to the medical records concerning Baum's mental limitations, the results of a July 2014 psychological consultative examination with Kent A. Hershberger, Ph.D., showed that Baum's grooming and hygiene were good, his mood was mildly depressed, and his affect was slightly restricted in range. R. at 320-35. His stream of thought was documented as “occasionally tangential” with some possible delusional/conspiratorial thoughts being present. However, Baum's attention and concentration were adequate and he was generally cooperative. Baum complained of extreme loneliness. But he also reported to being able to complete chores on a daily basis, such as sweeping and mopping, at the Center for the Homeless. Baum also indicated that he could cook for himself, do his own laundry, shop for groceries, and manage his own affairs. The examiner reported that Baum fostered some ideas that appeared “odd” and sometimes he had speech that was vague and rambling; however, the examiner further indicated that Baum did not appear to be overtly psychotic. The consultative examiner believed that the most appropriate diagnosis for Baum was personality disorder, not otherwise specified, with some depressive features, as well as some antisocial features and borderline tendencies. He assigned Baum a Global Assessment of Functioning (“GAF”) score of 50.[2] Ultimately, it was the examiner's opinion that Baum was oriented, knew what he was doing, and would be able to get along with co-workers and supervisors if he chose to do so. Moreover, he would be capable of taking directions from a supervisor and performing repetitive tasks that did not exacerbate his back pain.

         After a referral from the Center for the Homeless, Baum underwent a psychological examination in January 2015 and an educational assessment in February 2015, by psychologist, Linda Monroe. R. at 392-403. Baum reported feeling socially isolated and being irritated by and having problems with others. The examiner reported that Baum's thought patterns were “quite tangential” and he shared some “very unusual beliefs which border on delusional” (such as, believing that he was one of the most gifted artists in the U.S. and displaying paranoid reactions to others). Despite noting that Baum had never been on any medications for mental health issues up through that time, the examiner diagnosed Baum with major recurrent depression with psychotic features and chronic post-traumatic stress disorder (“PTSD”) with the need to rule out schizoaffective disorder. The plan included seeing if Baum's physician would prescribe antidepressants, which Baum was willing to try. Dr. Monroe opined that with proper treatment for depression, Baum might be able to work at least part-time.

         A Kaufman Brief Intelligence Test revealed an average IQ composite score. Despite Baum's self-reported history of ADD, he had normal results on the Test of Variables of Attention (“TOVA”), a test of attentional functioning. He also scored in the normal range on the Attention Performance Index of the TOVA. Dr. Monroe noted problems with the validity of Baum's results on the Personality Assessment Inventory due to Baum's inconsistent responses, but she noted that his highest scores were for somatic symptoms, symptoms of possible psychosis, PTSD, and borderline personality disorder.

         Baum's educational assessment revealed scores in the average range on the Verbal Comprehension Index, Perceptual Reasoning Index, Processing Speed Index, Full Scale IQ, and General Ability Index, and in the low average range on the Working Memory Index of the Wechsler Adult Intelligence Scale-Fourth Edition. Dr. Monroe concluded that Baum did not have any specific learning disability, but his reported history of ADD may have impacted his learning. Thus, she listed a diagnosis of ADD.

         Given the recommendation for Baum to start antidepressants, Baum saw his primary care physician in early 2015 and reported being depressed. R. at 481-89. He was documented as being in a good general state of health with normal examine findings. He was given samples of viibryd for his depression. One month later, it was reported that Baum was feeling better with the medication, and he was given a refill for viibryd, which was increased at a subsequent appointment.

         In May 2015, Baum began mental health treatment at Oaklawn Psychiatric Center. R. at 500-13. Baum reported that he felt depressed for most of his life, but he had never sought treatment or therapy. Baum mentioned that he had been denied disability twice and he was gathering information to support his appeal. It was documented that Baum's speech was well- articulated, his thinking was logical and goal directed (although tangential), his affect was congruent but his mood was depressed, his insight and judgment seemed fair, his level of intelligence appeared to be average, and he denied any past or current suicidal thoughts. Baum received an initial diagnosis of major depression with a need to rule out psychotic disorder, and he was assigned a GAF score of 60.[3] It was recommended that he undergo outpatient group therapy and possibly individual therapy depending on the outcome of a psychiatric evaluation. His treatment records note that despite also being diagnosed with narcissistic personality disorder, he was doing well at the homeless shelter. After three sessions of therapy, it was documented that Baum was stable and wanted to continue his therapy.

         B. Physical Health Records

         With respect to the medical records concerning Baum's physical limitations, in August 2014, Baum underwent an internal medicine consultative examination with R. Gupta, M.D. R. at 327-33. Baum reported several longstanding issues, including a back injury in the 1970s and varicose veins since the 1990s. However, Baum had a normal gait, did not use a cane, and was able to stoop, squat, tandem walk, heel to toe walk, and stand from a seated position. Dr. Gupta reported normal exam findings, including negative straight leg raising test; full range of motion in the lumbar, cervical, and thoracic regions; and full strength in the upper extremities, along with full grip strength and normal coordination. It was noted that Baum's veins were noticeable on both calves which were marked by abnormal sensation; however, Baum appeared comfortable and was in no painful distress. Baum was supposed to wear support hosiery due to his varicose veins, but he reported being unable to afford them. It was Dr. Gupta's impression that Baum suffered from current uncontrolled high blood pressure and a history of untreated and undiagnosed severe depression, with further history of ADD, lower back injury, and varicose veins.

         An examination in September 2014 showed that Baum was in a good general state of health, including normal gait and balance. R. at 355-56. Despite normal exam findings, he was given referrals for his depression, back pain, and varicose veins in the event that he decided to seek follow-up care. A couple of weeks later, he reported “doing well” and his physical examination was normal. R. at 258-59. He was given samples of medicine for hypertension.

         Baum underwent an orthopedic consultation in October 2014 due to complaints of back pain. R. at 334-36. The record indicated that Baum exercised regularly, twenty or more minutes, three or more times per week. Baum's physical examination was normal, including normal ranges of motion without edema and normal strength in the upper and lower extremities. While an x-ray of his back revealed normal alignment, it also showed degenerative changes and total loss of disk space height at ¶ 1. The orthopedic doctor simply told Baum to return as needed.

         Baum also sought treatment in October for the pain, heaviness, and fatigue associated with his varicose veins. R. at 379. The record notes that Baum had previously been prescribed compression stockings many years ago, but he was unable to tolerate them. He was documented as having painful bilateral lower extremity varicose veins, which were to be further assessed with a venus duplex study.

         In December 2014, Baum reported that he was “doing well.” R. at 360-62. He was noted to be in a good general state of health, but he was diagnosed with diabetes and placed on metformin. Later that month, Baum sought treatment from his vascular doctor, Dr. Jeffrey Borders, for the pain caused by his varicose veins. R. at 371. Baum reported attempted use of compression stockings and to now wanting surgical intervention. A venous duplex study showed no deep venous thrombosis (“DVT”) (blood clots in the legs), but revealed severe bilateral greater saphenous vein reflux and bilateral small saphenous vein reflux. R. at 372. Thereafter, Baum underwent a radiofrequency endovenous closure of the left greater saphenous vein in February 2015 and of the right greater saphenous vein in March 2015. R. at 447-48, 465-66. Baum did well after the procedures and venous duplex studies continued to show no DVT and a successful closure of his veins. R. at 421, 427, 445, 462. In April 2015 Dr. Borders reported that Baum was doing very well clinically and a review of Baum's body systems showed negative results. R. at 431-32, 444. In July 2015, Baum reported that his legs felt much better and that the heaviness in his legs had completely resolved. R. at 414-17, 427. Baum told Dr. Borders that he was very happy with the outcome of the procedures. Physical examination showed that Baum's legs were unremarkable with no significant erythema or pitting edema. Baum was told to follow-up with the doctor in one year.

         Baum also performed a stress test in the summer of 2015, which was interpreted as showing a normal myocardial perfusion study and a normal resting gated left ventricular ejection fraction and resting left ventricular wall motion. R. at 407-12. A follow-up for his diabetes in October 2015 indicated that Baum reported neck pain and achiness in his feet and ankles. Documented were a normal balance, gait, and physical exam findings. R. at 468-69. He was diagnosed with controlled hypertension (for which he was to continue his medication), uncontrolled diabetes (for which he was to increase his metformin), and depression (for which he was to continue counseling).

         On December 7, 2015, Baum reported to the emergency room with complaints of cough, shortness of breath, wheezing, congestion, and rhinorrhea. R. at 495-99. On examination, he was reported as having normal ranges of motion and strength. He was alert, cooperative, and displayed an appropriate mood and affect. His chest x-ray was negative for acute pulmonary disease process. ...

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