United States District Court, N.D. Indiana, Hammond Division
ALICIA J. WADE, Plaintiff,
NANCY A. BERRYHILL, Deputy Commissioner for Operations, Social Security Administration, Defendant.
OPINION AND ORDER
P. Rodovich United States Magistrate Judge.
matter is before the court on petition for judicial review of
the decision of the Commissioner filed by the plaintiff,
Alicia J. Wade, on June 29, 2017. For the following reasons,
the decision of the Commissioner is
plaintiff, Alicia J. Wade, filed an application for
Disability Insurance Benefits on January 7, 2014, alleging a
disability onset date of July 19, 2012. (Tr. 16). The
Disability Determination Bureau denied Wade's application
on May 12, 2014, and again upon reconsideration on August 4,
2014. (Tr. 16). Wade subsequently filed a timely request for
a hearing on September 3, 2014. (Tr. 16). A hearing was held
on May 24, 2016, before Administrative Law Judge (ALJ) Shane
McGovern, and the ALJ issued an unfavorable decision on June
28, 2016. (Tr. 16-30). Wade and Vocational Expert (VE)
Leonard M. Fisher testified at the hearing. (Tr. 16). The
Appeals Council denied review, making the ALJ's decision
the final decision of the Commissioner. (Tr. 1-3).
met the insured status requirements of the Social Security
Act through December 31, 2017. (Tr. 18). The ALJ issued an
unfavorable decision and made findings as to each of the
steps in the five-step sequential analysis. (Tr. 16-30). At
step one of the five-step sequential analysis for determining
whether an individual is disabled, the ALJ found that Wade
had not engaged in substantial gainful activity since July
19, 2012, her alleged onset date. (Tr. 18).
two, the ALJ determined that Wade had the following severe
impairments: complex regional pain syndrome of right upper
extremity; s/p right wrist schapholunate tear; and s/p carpal
and cubital tunnel release with debridement and
reconstruction. (Tr. 18). The ALJ determined that Wade's
medically determinable mental impairments of depressive
disorder and anxiety disorder, considered singly and in
combination, did not cause more than minimal limitation in
Wade's ability to perform mental activities, and
therefore were non-severe. (Tr. 19).
making this determination, 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
(Tr. 19). The ALJ defined a marked limitation as more than
moderate but less than extreme and repeated episodes of
decompensation, each of extended duration, as three episodes
within one year or once every four months with each episode
lasting at least two weeks. (Tr. 19).
found that Wade had a mild limitation in activities of daily
living. (Tr. 19). The ALJ considered Wade's testimony
that she had trouble with personal care and household
activities, but he concluded that these difficulties
primarily were due to her physical impairments rather than
her non-severe mental impairments. (Tr. 19).
the ALJ determined that Wade had a mild limitation in social
functioning. (Tr. 19). Wade indicated that isolating herself
became part of her routine. (Tr. 19). However, she also
stated that she did not have problems getting along with
family, friends, or neighbors; that she got along fine with
authority figures; and that she never had been fired or laid
off from a job because of problems getting along with other
people. (Tr. 19).
determined that Wade had mild limitation in concentration,
persistence, or pace. (Tr. 19). The ALJ concluded that while
Wade alleged difficulty handling stress and changes in her
routine, her treatment records indicated little to no
difficulty with concentration and attention. (Tr. 19).
Finally, the ALJ noted that Wade had experienced no episodes
of decompensation. (Tr. 19). Based on the foregoing analysis,
the ALJ concluded that Wade's mental impairments caused
no more than mild limitations and thus were non-severe. (Tr.
testified that due to her upper right extremity injury and
her resulting inability to do things, she experienced
depression and that this depression was exacerbated when her
husband died in January 2016. (Tr. 20). Wade's records
indicated consistent treatment starting in June of 2013 with
psychiatrist, Robert Reff, M.D. (Tr. 20). Dr. Reff diagnosed
Wade with depression and anxiety and prescribed Venlafaxine,
Diazepam, Amitriptyline, Zolpidem, Tramadol, and Gabapentin.
(Tr. 20). Wade reported that Cymbalta was helpful for
depression, but she continued to report frustration and
anxiety due to ongoing symptoms in her right hand. (Tr. 20).
In October of 2014, Dr. Reff prescribed Zolpidem for
insomnia, and by the next month, she reported that she was
sleeping better. (Tr. 20). In December of 2014, March of
2015, and April of 2015, Dr. Reff noted that Wade was in the
“maintenance phase of treatment” despite ongoing
anxiety. (Tr. 20). As a result, Dr. Reff reduced their
meetings to quarterly rather than monthly basis. (Tr. 20). In
July 2015, Wade reported “being able to hold her own,
” and in late 2015, Dr. Reff found that Wade was calm
with no evidence of active depression. (Tr. 20). In 2016,
Wade's husband committed suicide, but while the ALJ noted
“increased stressors” from the event, he
emphasized that her treatment records from February 2016
“indicate[d] that she tried to stay busy and put a good
face forward.” (Tr. 20).
found that while her treatment records reflected some ups and
downs in her anxiety and depression, longitudinally her
mental health symptoms and functioning improved significantly
with medication and therapy. (Tr. 20). Thus, the ALJ
concluded that her mental health records indicated that her
anxiety and depression had less than a minimal impact on her
ability to perform basic work activities. (Tr. 21).
three, the ALJ concluded that Wade did not have an impairment
or combination of impairments that met or medically equaled
the severity of one of the listed impairments. (Tr. 21).
After consideration of the entire record, the ALJ then
assessed Wade's residual functional capacity (RFC) as
[T]he claimant has the residual functional capacity to
perform light work as defined in 20 CFR 404.1567(b) except
that she has no use of her right dominant upper extremity.
She cannot push or pull with the right dominant upper
extremity. She can never climb ladders, ropes, or scaffolds
and never crawl. She can have no exposure to mechanical
parts, to unprotected heights, or to excessive vibration.
(Tr. 22). The ALJ explained that in considering Wade's
symptoms he followed a two-step process. (Tr. 22). First, he
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
Wade's pain or other symptoms. (Tr. 22). Then, he
evaluated the intensity, persistence, and limiting effects of
the symptoms to determine the extent to which they limited
Wade's functioning. (Tr. 22).
has alleged disability in her right arm due to a work-related
accident where she fell on her right arm. (Tr. 22). Although
she underwent two surgeries, ganglion blocks, Botox
injections, and multiple medications, Wade indicated that she
suffered from complex regional pain syndrome in her right arm
with no functional use of that arm. (Tr. 22). She also stated
that she had tremors in her fingers which made it difficult
to sleep, despite taking medications such as Gabapentin,