United States District Court, D. Colorado
Michael E. Hegarty United States Magistrate Judge
Plaintiff Belma Jazvin appeals from the Social Security Administration ("SSA") Commissioner's final decision denying her application for disability and disability insurance benefits ("DIB"), filed pursuant to Title II of the Social Security Act, 42 U.S.C. §§ 401-433, and her application for supplemental security income benefits ("SSF'), filed pursuant to Title XVI of the Social Security Act, 42 U.S.C. §§ 1381-1383c. Jurisdiction is proper under 42 U.S.C. §405(g). The parties have not requested oral argument, and the Court finds it would not materially assist the Court in its determination of this appeal. After consideration of the parties' briefs and the administrative record, the Court affirms the ALJ's decision.
I. Procedural History
Plaintiff seeks judicial review of the Commissioner's decision denying her applications for DIB and SSI benefits filed on May 18, 2012. [Administrative Record (“AR”) 156-166] After the applications were initially denied on August 20, 2012 [AR 83-86], an Administrative Law Judge (“ALJ”) scheduled a hearing upon the Plaintiff’s request for August 22, 2013 [AR 125-129]. At the hearing, the Plaintiff, her friends, and a vocational expert testified. [AR 33-63] The ALJ issued a written ruling on August 27, 2013 finding Plaintiff was not disabled starting on February 7, 2012 because Plaintiff could perform her past work considering her age, education, work experience and residual functional capacity. [AR 17-28] The SSA Appeals Council subsequently denied Plaintiff’s administrative request for review of the ALJ’s determination on August 4, 2014, making the SSA Commissioner’s denial final for the purpose of judicial review [AR 3-6]. See 20 C.F.R. § 416.1481. Plaintiff timely filed her complaint with this Court seeking review of the Commissioner’s final decision.
II. Plaintiff’s Alleged Conditions
Plaintiff was born on March 9, 1966; she was 46 years old when she filed her applications for DIB and SSI on May 18, 2012. [AR 156] Plaintiff claims she became disabled on February 7, 2012 [id.] and reported that she was limited in her ability to work due to schizophrenia, complications from medications, dizziness, shakes, and vision issues. [AR 195] Plaintiff’s friend (due to language barriers) completed a “Function Report” in tandem with Plaintiff’s application, in which she described Plaintiff as having symptoms of hearing voices intermittently, disorganized thought processes, and side effects from medication including dizziness, shaking, tingling, and vision impairment (her right eye “rolling back in her head”). [AR 212] Plaintiff asserts she came to the United States in 1995 as a refugee from the Bosnian war, during which time she lived in refugee camps and lost her mother; she believes this history is a major cause of her declining mental health, which in turn, contributes to a decline in her physical health. [AR 219]
The record indicates that in July 2002, Plaintiff was admitted to the Denver Health Medical Center Psychiatric Emergency Room for short-term treatment after taking an overdose of Zyprexa; Plaintiff reported that “voices from the roof” told her “bad things” (such as that they killed her mother and grandmother) when she was alone. [AR 249] The reporting physicians concluded that Plaintiff “suffer[ed] from a mental illness that [ ] caused her to be a danger to herself and gravely disabled.” [Id.]
The next record is dated September 13, 2010 from the University of Colorado (“CU”) Hospital which reflects it was the Plaintiff’s “first followup visit since transfer to new resident.” [AR 260] Plaintiff reported to Kurt Humphrey, M.D. that she was doing well overall and her only concern was running out of her “psych” medication, Geoden, because without it, she may have a return of psychotic symptoms. [Id.] The next record from May 25, 2011 reflects Plaintiff’s report to Dr. Humphrey that Geoden still worked well for her, but she was under additional stress since losing her job the previous week. [AR 255] Dr. Humphrey reported that Plaintiff was “fairly high functioning on her medications.” [Id.]
Plaintiff presented to CU Hospital on September 19, 2011 for a follow-up appointment with Sarah Kuykendall, M.D. and reported she was “doing very well” on her medications with no side effects; she experienced “only occasional” auditory hallucinations with stress. [AR 252] Plaintiff was still unemployed and enjoyed relaxing and “time for herself, ” but was “eager to find employment again.” [Id.] Dr. Kuykendall diagnosed Plaintiff with paranoid schizophrenia and assessed a Global Assessment of Functioning (GAF) score of 70. [AR 253] A subsequent record from December 8, 2011 reflects a similar report from Dr. Kuykendall that Plaintiff was “very high functioning” and “remains stable psychiatrically, ” but the doctor adjusted her GAF score to 61-70. [AR 263-265] Dr. Kuykendall made the same findings on February 7, 2012 (Plaintiff’s stated disability onset date), including that Plaintiff’s symptoms were “well controlled, ” but noted a “head tilt” and symptoms of “torticollis, ” so diagnosed Plaintiff with extrapyramidal symptoms and started her on a new medication. [AR 265-267]
On May 14, 2012, Dr. Kuykendall made the same findings as above, but noted Plaintiff’s complaints of diplopia,  torticollis, and dystonia symptoms, which Plaintiff reported as having “for over 3 years.” [AR 268-269] Plaintiff also sought the doctor’s help in applying for disability benefits, as her unemployment benefits were soon ending. [Id.] The following month, Plaintiff reported to Dr. Kuykendall that her dystonia symptoms were improved with medication management; notably, the doctor repeated the same findings as in previous reports regarding Plaintiff’s mental health. [AR 272-274]
Plaintiff presented to a new doctor at CU Hospital, Jeanne Theobald, M.D., on September 10, 2012, and complained of worsening dystonia symptoms, including her eyes rolling back in her head and trouble walking. [AR 303] Dr. Theobald found Plaintiff had been stable on psychotic medications for 10 years, observed no dystonic movements during the appointment, and diagnosed Plaintiff with chronic paranoid schizophrenia and extrapyramidal symptoms, and assessed a GAF score of 41-50. [AR 303-304] At the same time, Dr. Theobald and Brian Rothberg, M.D. completed a Med-9 form for the Plaintiff in which they asserted Plaintiff “has, at times, marked hallucinations as well as delusional and disorganized thoughts that make it difficult to communicate with her. She is also having significant problems w/ dystonias from the anti-psychotic medications which often leave her physically disabled.” [AR 293]
At a visit with Dr. Theobald on November 19, 2012, Plaintiff reported “things are going much better with the new [psychotic] medicine”; in addition, although she still had problems with her eye and a stiff neck, she experienced no “problems using her legs.” [AR 276] However, Plaintiff reported to the doctor on January 4, 2013 that her dystonias were happening “daily” and were “severe”; the doctor also noted “some concerns that she isn’t taking [her medication] correctly.” [AR 279-280] The following month, Plaintiff reported she was hearing voices “less frequently” and, while still having dystonias in her eye and neck, she had no further problems with her legs “cramping up.” [AR 283-284] Then, in March 2013, Plaintiff reported she was “doing well overall, ” her psychotic symptoms were “well controlled with occasional paranoid thought, ” but there was no change in her dystonias. [AR 287-288] In this last medical record, Dr. Theobald assessed the same diagnoses (chronic paranoid schizophrenia and extrapyramidal symptom) and GAF score (41-50).
III. Hearing Testimony
On August 22, 2013, Plaintiff, her friends, Gail and Michael Weiss, and a vocational expert, William Tysdale, testified at the hearing. [AR 34-64] Plaintiff testified that she had a “very hard time” while working full-time and dealing with people; she and her doctor made a decision in February 2012 that she could no longer work; physically, she was able to work but her medication made her dizzy and she may fall down; other side effects of her medication was a stiff neck and her eye rolling up; she heard voices both at night and in the morning; a doctor whose name she could not recall told her she was not able to work because her mental illness was “very heavy”; she was able financially to get the medication she was currently taking; she was told she had a stroke, saw a neurologist “a couple of times” but could not follow up because she did not have insurance; and, she could no longer drive anywhere other than close to her home because of her eye impairment (seeing double). [AR 37-49]
Plaintiff’s friends testified that Plaintiff received mental health treatment at CU Hospital for free due to a program developed specifically for war refugees; Plaintiff’s eye and neck conditions have gotten worse over the years, but she could not afford medical tests; she was recently approved for AND, and was on the waiting list for a physical examination; although Plaintiff tried to find work between her last job and February 2012, she had no offers or interviews; working at the convenience store during the night shift was “very stressful” for Plaintiff; and the doctor was unsure whether Plaintiff’s dystonias were caused by medication or a physical problem. [AR 49-56]
The ALJ then turned to the vocational expert, Mr. Tysdale, who testified that an individual with Plaintiff’s age, experience and education – and the ability to do a full range of work but not required to lift and carry more than 20 pounds occasionally and 10 pounds frequently; not required to climb scaffolds, ladders, and ropes, or balance; not required to work at unguarded heights and near unguarded hazardous mechanical equipment; not required to understand, remember, and carry out more than simple instructions; not required to have more than superficial interaction with the public (“superficial meaning that kind of contact and interaction verbally that doesn’t involve anything of a detailed nature or problem-solving or anything of that sort, nothing that, you know, would amount to stress because of the content of the discussion”) – could perform the Plaintiff’s past job as an assembler, as well as the jobs of “inserting machine operator” and “cleaner/housekeeper.” [AR 60-62]
The ALJ issued an unfavorable decision on August 27, 2013. [AR 17-28]
To qualify for benefits under sections 216(I) and 223 of the SSA, an individual must meet the insured status requirements of these sections, be under age 65, file an application for DIB and/or SSI for a period of disability, and be “disabled” as defined by the SSA. 42 U.S.C. §§ 416(I), 423, 1382. Additionally, SSI requires that an individual meet income, resource, and other relevant requirements. See 42 U.S.C. § 1382.
I. SSA’s Five-Step Process for Determining Disability
Here, the Court will review the ALJ’s application of the five-step sequential evaluation process used to determine whether an adult claimant is “disabled” under Title II and Title XVI of the Social Security Act, which is generally defined as the “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a ...