Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Sachs v. Colvin

United States District Court, M.D. Pennsylvania

March 26, 2017

CRISTAL A. SACHS, Plaintiff
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant

          MEMORANDUM

          William J. Nealon United States District Judge.

         On September 2, 2016, Plaintiff, Cristal A. Sachs, filed this instant appeal[1]under 42 U.S.C. § 405(g) for review of the decision of the Commissioner of the Social Security Administration (“SSA”) denying her applications for disability insurance benefits (“DIB”) and supplemental security income (“SSI”)[2] under Titles II and XVI of the Social Security Act, 42 U.S.C. § 1461 et seq. and 42 U.S.C. § 1381 et seq., respectively. (Doc. 1). The parties have fully briefed the appeal. For the reasons set forth below, the decision of the Commissioner denying Plaintiff's applications for DIB and SSI will be affirmed.

         BACKGROUND

         Plaintiff protectively filed[3] her application for DIB on November 9, 2012, and her application for SSI on December 19, 2012, alleging disability beginning on April 15, 2012, due to a combination of Asthma, Chronic Obstructive Pulmonary Disease (“COPD”), high blood pressure, depression, anxiety, and Post-Traumatic Stress Disorder (“PTSD”). (Tr. 19, 173).[4] The claim was initially denied by the Bureau of Disability Determination (“BDD”)[5] on March 15, 2013. (Tr. 19). On March 19, 2013, Plaintiff filed a written request for a hearing before an administrative law judge. (Tr. 19). An oral hearing was held on March 6, 2014, before administrative law judge Therese Hardiman, (“ALJ”), at which Plaintiff and an impartial vocational expert, Nadine Henzes, (“VE”), testified. (Tr. 19). On May 16, 2014, the ALJ issued a decision denying Plaintiff's claims because, as will be explained in more detail infra, Plaintiff was capable of performing full range of light work. (Tr. 16).

         On June 30, 2014, Plaintiff filed a request for review with the Appeals Council. (Tr. 13-14). On July 2, 2015, the Appeals Council concluded that there was no basis upon which to grant Plaintiff's request for review. (Tr. 1-6). Thus, the ALJ's decision stood as the final decision of the Commissioner.

         Plaintiff filed the instant complaint on September 2, 2015. (Doc. 1). On November 18, 2015, Defendant filed an answer and transcript from the SSA proceedings. (Docs. 10 and 11). Plaintiff filed a brief in support of her complaint on February 25, 2016. (Doc. 15). Defendant filed a brief in opposition on March 28, 2016. (Doc. 17). Plaintiff filed a reply brief on April 15, 2016. (Doc. 18).

         Plaintiff was born in the United States on September 2, 1969, and at all times relevant to this matter was considered a “younger individual.”[6] (Tr. 161). Plaintiff obtained her GED, and can communicate in English. (Tr. 41, 172). Her employment records indicate that she previously worked as a clerk in the post office, a customer service representative, and a switchboard operator. (Tr. 163).

         In a document entitled “Function Report - Adult” filed with the SSA on December 2, 2012, Plaintiff indicated that she lived in a house with her children. (Tr. 198). When asked to describe how her illnesses, injuries or conditions limited her ability to work, Plaintiff stated:

Can't do basic activities like walking, cooking, most of the time taking care of myself. I have constant, chronic worry that causes significant distress, it disturbs my life with any and everyone. I have random panic attacks and persistent worry of another panic attack and also I have feelings of terror. I have ongoing and recurring nightmares, flashbacks, or emotional numbing relating to traumatic events that happened in my life. Childhood physical, emotional, and sexual abuse. Flashbacks, hallucinations and nightmares. I was molested by 4 of my uncles over and over and over and over and over from the age of 8 to 16. At 16 my cousin raped me. I watched my father beat my mother for years. I seen so much blood. I then became a victim of domestic violence for nearly 20 years. In and out of domestic violence shelters. I then watched and became involved with my daughter's abusive relationship. All of this led me to have extreme homicidal thoughts which I was hospitalized for. Soon after I was discharged from the hospital, my Don started abusing me. So, I am now at the age of 43, mentally and physically suffering which prevents me from working. Wheezing and shortness of breath, I feel like I'm trying to breath through a straw and always trying to catch my breath.

(Tr. 198-199). From the time she woke up to the time she went to bed, Plaintiff took her medicine and took care of her children. (Tr. 200). She was able to make meals with the aid of a chair with wheels, could take care of her personal needs while experiencing shortness of breath, iron, and perform household chores with the help of her children. (Tr. 201). She was able to walk for up to six (6) steps before needing to rest for up to a half hour. (Tr. 204). When asked to check items which her “illnesses, injuries, or conditions affect, ” Plaintiff did not check hearing, seeing, or using hands. (Tr. 204).

         Regarding her concentration and memory, Plaintiff did not need special reminders to take care of her personal needs, take her medicine, and attend appointments. (Tr. 203, 205). She could count change, use a checkbook, pay bills, and handle a savings account. (Tr. 202). She could pay attention for “not long at all, ” she did not follow written or spoken instructions well, and she was not able to finish what she started. (Tr. 204). She could not handle stress or changes in routine at all. (Tr. 205).

         Socially, Plaintiff did not go outside often, but when she did, she could do so unaccompanied, but did not prefer to due to anxiety and the fear of shortness of breath. (Tr. 202). Her hobbies included reading the Bible and listening to Gospel music. (Tr. 203). In response to the question regarding whether she had problems getting along with family, friends, neighbors, or others, Plaintiff responded, “I seem to be self-conscious in the face of an uncomfortable social situation. Fear and anxieties arise.” (Tr. 204). When asked how she got along with authority figures, she responded, “I stay to myself so I don't come in contact with them or anyone else.” (Tr. 205).

         At her hearing on March 6, 2014, Plaintiff testified that, regarding her mental health impairments, including Major Depressive Disorder, anxiety, and PTSD, she saw a psychiatrist every four (4) or five (5) months and a therapist every Friday. (Tr. 43-44, 51). She also attends group therapy once a week. (Tr. 44). She testified that television aggravated her psychological symptoms. (Tr. 51). She stated that she experienced psychological symptoms such as depression, anxiety, panic attacks, crying, flashbacks, and hallucinations very frequently every day, sometimes all day, and that the symptoms made it hard for her to concentrate or focus. (Tr. 51-52). She stated that these symptoms made it difficult for her to hold a job and get along with others because she had difficulty trusting anyone. (Tr. 54).

         Regarding pulmonary issues, Plaintiff testified that she was hospitalized for five days for asthma and COPD two (2) to three (3) weeks before the hearing. (Tr. 45). She stated that allergies, extreme temperatures, perfume, and dust triggered her asthma. (Tr. 50-51).

         In regards to activities of daily living, Plaintiff stated that she did not perform personal care tasks; did not do household chores such as cooking, cleaning, or laundry; was able to pay her bills; and had no hobbies whatsoever. (Tr. 46). She stated that she was in bed until her children came home, at which point she would help the with homework and spend time with them talking and sitting. (Tr. 46).

         In terms of physical limitations, Plaintiff stated that the heaviest thing she could pickup was her shoe; that from a seated position, she could raise her leg straight out and then put them down; that she could extend her arms forward and bring them back and reach overhead; that she could stand for about a minute, sit for long periods of time, and walk from her bed to her bathroom. (Tr. 46-47). She was able to sleep for ten (10) hours on average, but stated that her sleep was interrupted by dreams and anxiety. (Tr. 47).

         In terms of medications, Plaintiff testified that, at the time of the hearing, she was taking Fluoxetine, Prozac, Neurontin, Risperdal, Singulair, Advair, Norvasc, Hydrochlothyazide, Trazadone, Lisinopril, Meloxicam, and Albuterol. (Tr. 48-49). She stated that her medications helped, but that they caused side effects. (Tr. 50).

         MEDICAL RECORDS

         A. Mental Health Impairments

         Before the relevant time period for the ALJ's decision, which was from April 15, 2012 through May 16, 2014, on the dates of March 29 to April 4, 2012, Plaintiff was voluntarily admitted to the Wilkes-Barre Behavioral Hospital due to complaints of PTSD, hallucinations, and homicidal ideations. (Tr. 530-31). At discharge, after being placed of medication undergoing therapy, “all of her problems [were] adequately resolved, ” and her global assessment of functioning (“GAF”) increased to fifty (50) to fifty-five (55). 530-31, 534). Her last examination revealed she was alert, had an appropriate mood and affect, was fully oriented, had an intact memory with no intellectual limitations, and had no hallucinations, delusions, or ideations of suicide or homicide. (Tr. 531-534).

         In May and July of 2012, Plaintiff failed to attend scheduled therapy session. (Tr. 381-382). Psychiatric examinations during two separate, unrelated Emergency Room (“ER”) visits in 2012 showed normal affect, judgment, insight, recent memory, concentration, and mentation. (Tr. 252, 265, 395, 397).

         On January 8, 2013, Plaintiff began treatment with Community Counseling Services of Northeastern Pennsylvania (“CCS”) due to increased depression and anxiety related to medical issues. (Tr. 487, 490). Her mental status examination revealed she had: a neat appearance; good hygiene; appropriate psychomotor activity; normal speech; good eye contact; a logical thought process; a cooperative manner; good memory, insight, and judgment; and an average intellectual ability. (Tr. 490-492). She was diagnosed with recurrent Major Depressive Disorder. (Tr. 494).

         On January 22, 2013, Plaintiff had another appointment at CCS, and reported she was “doing better” with medication. (Tr. 487). It was noted that she: was calm, cooperative, and fully oriented; displayed normal motor activity; was in a better mood; and had a linear thought process, good memory, average intellectual functioning, intact insight, and improving judgment. (Tr. 487).

         On January 30, 2013, Plaintiff presented to Stephen Timchak, Psy.D., for a consultative psychological examination. (Tr. 463-68). She described a history of anxiety, depression, and sexual abuse by family members. (Tr. 463-65). Plaintiff was noted as being anxious, hyper-vigilant, and fidgety. (Tr. 466). Her examination revealed she: was alert and oriented; had intact memory; had logical and goal-directed speech; denied any hallucinations; had impaired attention and concentration; had a hypervigilant mental trend; had fair insight; and had an average to low average IQ. (Tr. 466-467). Her diagnoses included PTSD and Depressive Disorder, NOS, and Dr. Timchack opined that Plaintiff's prognosis was poor. (Tr. 467).

         On February 11, 2013, Plaintiff had an appointment at CCS. (Tr. 475). Her mental status examination revealed she had a: neatly groomed appearance; good rapport; a depressed mood; a related affect; controlled, cooperative, and tearful behavior; normal speech; average intellect; a normal thought process and thought content; intact memory; fair insight, judgment, and motivation for treatment; and no homicidal or suicidal ideations. (Tr. 482-483). Her diagnosis was Major Depressive Disorder, recurrent and unspecified. (Tr. 475, 483). Her medications included Seroquel, Ambien, Neurontin, and Celexa. (Tr. 484).

         On March 8, 2013, Dr. Timchak completed a check-box form, where he checked boxes to indicate that Plaintiff had no impairment in handling simple instructions; a slight impairment in remembering details instructions; a moderate impairment in carrying out detailed instructions; a marked impairment in making judgments on simple work-related decisions; and marked restrictions in every category relating to social interaction and workplace adaptation. (Tr. 461-462).

         On September 20, 2013, Plaintiff underwent an initial psychiatric evaluation at Northeast Counseling Services (“NCS”) due to complaints of depression and anxiety. (Tr. 681). Her mental status examination revealed she: was alert, ambulatory, cooperative, tearful, coherent, relevant, and oriented in three (3) spheres; and had speech of normal rate, rhythm, and volume, affect appropriate to content of thought, clear sensorium, intact memory, average intelligence, and good impulse control, judgment, and insight. (Tr. 682). Her Axis I diagnoses were Depressive Disorder, Not Otherwise Specified, and PTSD. (Tr. 682). It was recommended that Plaintiff start Prozac and Trazodone. (Tr. 683).

         On October 7, 2013, Plaintiff had another appointment at NCS. (Tr. 680). Her mental status examination revealed she had: appropriate appearance; good hygiene; cooperative attitude; calm motor activity; spontaneous speech; a euthymic mood; an appropriate affect; relevant thought process; intact judgment; good eye contact; and no delusions, hallucinations, or suicidal or homicidal ideations. (Tr. 680). Plaintiff was instructed to continue taking Trazodone and to increase her Prozac dosage. (Tr. 680).

         On November 1, 2013, Plaintiff had an appointment at NCS. (Tr. 679). She reported that the Prozac was “helping some, ” but that her anxiety continued to be an issue, that she started attending group therapy, and that she continued to have many stressors. (Tr. 679). Her mental status examination revealed she had: appropriate appearance; good hygiene; cooperative attitude; calm motor activity; spontaneous speech; a euthymic mood; an appropriate affect; relevant thought process; intact judgment; good eye contact; and no delusions, hallucinations, or suicidal or homicidal ideations. (Tr. 679). Plaintiff was instructed to continue taking Trazodone and to increase her Prozac dosage. (Tr. 679).

         On December 13, 2013, Plaintiff had an appointment at NCS. (Tr. 678). She reported that she continued to have anxiety when she left her house, but that she did so when she needed to and that she felt group therapy was beneficial. (Tr. 678). Her mental status examination revealed she had: appropriate appearance; good hygiene; cooperative attitude; calm motor activity; spontaneous speech; a euthymic mood; an appropriate affect; relevant thought process; intact judgment; good eye contact; and no delusions, hallucinations, or suicidal or homicidal ideations. (Tr. 678). Plaintiff was instructed to continue taking her medications. (Tr. 678).

         On January 20, 2014, Plaintiff had an appointment at NCS. (Tr. 677). She reported that she had run out of medication, that she was experiencing auditory hallucinations, and that she was having flashbacks and nightmares. (Tr. 677). Her mental status examination revealed she had: appropriate appearance; good hygiene; cooperative attitude; calm motor activity; spontaneous speech; a euthymic mood; an appropriate affect; relevant thought process; intact judgment; good eye contact; and no delusions, hallucinations, or suicidal or homicidal ideations. (Tr. 677). Plaintiff was instructed to decrease her Prozac in substitution of Risperdal. (Tr. 677).

         B. Physical Impairments

         1.Neck Condition

         On August 4, 2012, Plaintiff presented to the ER with complaints of neck and back pain after a motor vehicle accident. (Tr. 422). Plaintiff described her pain as dull and aching in nature and associated it with range of motion. (Tr. 422). On physical examination, Plaintiff' had a normal range of motion in her back and neck with tenderness, and a normal range of motions in her extremities without tenderness, swelling, or deformities. (Tr. 423). Plaintiff was discharged with medication and with a diagnosis of neck strain and muscle spasms. (Tr. 425).

         On October 3, 2012, during a visit to the ER for unrelated shortness of breath, it was noted that Plaintiff denied back or neck injury, pain, and weakness. (Tr. 397). A physical examination revealed a normal range of motion in her neck, no tenderness, and normal motor function. (Tr. 397-398).

         On November 18, 2012, Plaintiff presented to the ER after a fall with complaints of low back and hip pain. (Tr. 437). Plaintiff underwent a CT scan of her cervical spine which revealed moderate to severe narrowing of the C5-C6 intervertebral disc space with disc osteophyte complex with no fracture, subluxation, or prevertebral soft tissue swelling. (Tr. 443, 454). It ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.