United States District Court, W.D. Pennsylvania
MAGISTRATE JUDGE'S REPORT AND RECOMMENDATION
SUSAN PARADISE BAXTER, Magistrate Judge.
It is respectfully recommended that the Court deny Plaintiff's Motion for Summary Judgment (ECF No. 9), grant Defendant's Motion for Summary Judgment (ECF No. 11), and affirm the decision of the administrative law judge ("ALJ").
1. Procedural History
Ashley Marie Tirpak ("Plaintiff") brings this action pursuant to 42 U.S.C. § 405(g), seeking review of the final determination of the Commissioner of Social Security ("Defendant" or "Commissioner") denying her applications for Disability Insurance Benefits ("DIB") and supplemental security income ("SSI") under Titles II and XVI of the Social Security Act, 42 U.S.C. § 401, et seq. and § 1381 et seq. ("Act"). Plaintiff filed for benefits, claiming a complete inability to work as of January 1, 2010, due to depression, anxiety, post-traumatic stress disorder ("PTSD"), attention deficit disorder ("ADD"), a learning disability, personality disorder, and a left elbow impairment. (R. at 20, 234). Her applications were denied (R. at 104-109), and having exhausted all administrative remedies, this matter now comes before the Court on cross motions for summary judgment. (ECF Nos. 9, 11).
2. General Background
Plaintiff was twenty seven years old on the date of the ALJ's decision and has a high school education. (R. at 25). She received special education support while in high school in the area of mathematics and to address symptoms of ADHD. (R. at 317). Plaintiff's IQ scores fell within the average range of intellectual functioning. (R. at 315). Following high school, Plaintiff's job history included employment as cashier, food prep worker, and day care worker. (R. at 25, 235, 255).
3. Treatment History
Plaintiff was evaluated by Rose Ann Flick, CRNP on March 20, 2009 at St. Vincent Health Center for complaints of anxiety and depression. (R. at 461-463). Plaintiff reported suffering from anxiety, which she described as "mood swing[s], " and further reported marital difficulties, trouble focusing, and trouble sleeping. (R. at 461). She denied any psychotic symptoms or suicidal thoughts. (R. at 461). She stated that Adderall and Strattera made her feel liked a "zombie." (R. at 461). Ms. Flick reported that Plaintiff presented as fidgety with an incongruent mood when talking about past physical abuse. (R. at 462). She found Plaintiff alert, well-oriented, and able to decipher the glass house proverb. (R. at 462). Plaintiff could perform simple math problems, but was unable to perform serial seven subtraction. (R. at 462). Ms. Flick was of the view that Plaintiff was "street smart" rather than "book smart." (R. at 462). Ms. Flick's diagnostic impressions were rule out PTSD; rule out organic brain disorder due to a fractured skull as an infant; most likely a history of reactive attachment disorder; learning disabilities; and adjustment disorder with mixed features of depression and anxiety. (R. at 462-463). Ms. Flick assigned her a Global Assessment of Functioning ("GAF") score of 55,  and started her on Seroquel. (R. at 463). Plaintiff refused recommended supportive psychotherapy. (R. at 463).
On May 13, 2009, Plaintiff reported that she worked at the Country Fair. (R. at 460). She stated she was agitated, but had no psychotic symptoms or delusions. (R. at 460). Her Risperdal dosage was increased and she was started on Klonopin for agitation. (R. at 460). Plaintiff was assessed with a GAF score of 65. (R. at 460). On August 14, 2009 Plaintiff complained of increased depression and irritability. (R. at 458). She was started on Celexa and assigned a GAF score of 50. (R. at 458).
On October 19, 2009, Plaintiff underwent a consultative psychological evaluation performed by Glenn Bailey, Ph.D. (R. at 384-393). Plaintiff reported she was separated from her husband, and that she and her two minor children lived with her grandparents. (R. at 386). She reported a past history of physical and mental abuse. (R. at 385). Plaintiff stated that she had been treated for anxiety when younger, and that she was being treated at St. Vincent's Behavioral Health for a "mood disorder and post-traumatic stress disorder" at the time of the evaluation. (R. at 385-386). Plaintiff was reportedly "still bothered" by the abuse she experienced as a child. (R. at 387). Plaintiff indicated that she previously worked 40 hours a week at the Country Fair, but that her hours had been cut back to four hours a week. (R. at 385). Plaintiff reported that she took Strattera, Abilify, Celexa and clonazepam, as needed. (R. at 387). Plaintiff stated that she felt "a lot better" on medication, in that she felt normal, was "actually happy, " and slept better. (R. at 387).
On examination, Plaintiff was fully oriented, her immediate and short term memories were intact, she was able to follow simple instructions and write short sentences. (R. at 388). She refused to perform the serial seven memory test. (R. at 388). Dr. Bailey found her thoughts were goal-directed and relevant, with no loose associations, tangentiality or distractibility noted. (R. at 388). Plaintiff was able to speak clearly and concisely, and she denied any thought disturbances. (R. at 389). On abstract thinking testing, Plaintiff was unable to render an interpretation of two proverbs. (R. at 389). Dr. Bailey estimated that Plaintiff had borderline intelligence, possibly in the mentally retarded range, and that her impulse control was minimal. (R. at 389). Dr. Bailey noted no problems with Plaintiff's ability to perform daily activities and noted that her concentration appeared to be "good" during the evaluation. (R. at 391). He recommended that she continue with treatment through St. Vincent. (R. at 391). He diagnosed Plaintiff with impulse control disorder, NOS; major depression, recurrent, by history; PTSD; ADD; generalized anxiety disorder; borderline personality disorder; and possibly mild mental retardation. (R. at 391). Dr. Bailey assigned her a GAF score of 55. (R. at 391).
In connection with his evaluation, Dr. Bailey opined that Plaintiff was slightly limited in her ability to understand, remember, and carry out short, simple instructions, and interact appropriately with the public. (R. at 379). He further opined that she was moderately limited in her ability to understand, remember and carry out detailed instructions; make judgments on simple work-related decisions; interact appropriately with supervisors and co-workers; and respond appropriately to pressures and changes in the work setting. (R. at 379).
On October 28, 2009, Sharon Tarter, Ph.D., a state agency reviewing psychologist, reviewed all the medical evidence of record and completed a Mental Residual Functional Capacity Assessment form. (R. at 398-401). Dr. Tarter found that the Plaintiff was not significantly limited in a number of work-related areas, and was only moderately limited in her ability to carry out detailed instructions; maintain attention and concentration for extended periods; perform activities within a schedule; maintain regular attendance; and be punctual. (R. at 398). She further found Plaintiff was moderately limited in her ability to accept instructions; respond appropriately to criticism from supervisors; get along with co-workers; maintain socially appropriate behavior; and respond appropriately to changes in the work setting. (R. at 399).
Dr. Tarter found that Plaintiff's basic memory processes were intact, and she had the capability of working within a schedule at a consistent pace. (R. at 400). Dr. Tarter further found that Plaintiff could be expected to complete a normal workweek without exacerbation of her psychological symptoms, sustain an ordinary routine and adapt to changes without special supervision, and perform repetitive work activities without constant supervision. (R. at 400). Dr. Tarter found that Plaintiff had no restrictions in her abilities in regards to understanding and memory. (R. at 400). Plaintiff was functional with respect to her activities of daily living and social skills. (R. at 400). She afforded great weight to the assessment of Dr. Bailey, and concluded that Plaintiff could "meet the basic mental demands of competitive work on a sustained basis despite the limitations resulting from her impairment." (R. at 400).
Plaintiff returned to St. Vincent on December 22, 2009 and reported that Celexa had helped her depressive symptoms, but complained that she felt "down a lot" during the holidays. (R. at 457). She was assigned a GAF score of 45 and her Celexa dosage was increased. (R. at 457). By January 26, 2010, ...