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Wade v. Berryhill

United States District Court, N.D. Indiana, Hammond Division

October 4, 2018

ALICIA J. WADE, Plaintiff,
v.
NANCY A. BERRYHILL, Deputy Commissioner for Operations, Social Security Administration, Defendant.

          OPINION AND ORDER

          Andrew P. Rodovich United States Magistrate Judge.

         This 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 REMANDED.

         Background

         The 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).

         Wade 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).

         At step 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).

         In 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 extended duration.

(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).

         The ALJ 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).

         Next, 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).

         The ALJ 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. 19).

         Wade 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).

         The ALJ 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).

         At step 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 follows:

[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).

         Wade 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, ...


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