United States District Court, D. Colorado
KATHY M. CAYNOR, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
ORDER
LEWIS
T. BABCOCK, JUDGE.
Plaintiff
Kathy M. Caynor appeals from the Social Security
Administration (“SSA”) Commissioner's final
decision denying her application for disability insurance
benefits, filed pursuant to Title II of the Social Security
Act, 42 U.S.C. §§ 401 et seq., and her application
for supplemental security income, 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). Oral argument would not materially assist me in the
determination of this appeal.
After
consideration of the parties' briefs, as well as the
administrative record, I REVERSE and REMAND the
Commissioner's final order for further proceedings.
I.
Statement of the Case
Plaintiff
is a 66 year-old woman who has performed work as an
administrative and personal assistant. [Administrative Record
(“AR”) 166, 171, 204] She seeks judicial review
of SSA's decision denying her application for disability
insurance benefits and supplemental security income.
Pl.'s Br., ECF No. 17 at 2. Plaintiff filed her
applications in June 2014 alleging that her disability began
in January 2014. [AR 140, 147]
The
applications were initially denied in September 2014. [AR
55-65, 83-85] The Administrative Law Judge
(“ALJ”) conducted an evidentiary hearing and
issued a written ruling on June 29, 2016. [AR 17-42, 66-81]
In that ruling, the ALJ denied Plaintiff's applications
on the basis that she was not disabled because she had the
ability to perform her past relevant work. [AR 76-77] The SSA
Appeals Council subsequently denied Plaintiff's
administrative request for review of the ALJ's
determination, making SSA's denial final for the purpose
of judicial review. [AR 1-5]; see 20 C.F.R.
§§ 404.981, 416.1481. Plaintiff timely filed her
Complaint with this court seeking review of SSA's final
decision. ECF No. 1.
II.
Background
A.
Relevant Medical History
The
relevant medical history relates to Plaintiff's mental
ailments. In February 2014, Plaintiff saw Randal Villalovas,
M.D. at Heart of the Rockies Regional Medical Center. [AR
285] Dr. Villalovas explained that Plaintiff's chief
complaint and history of present illness related to a
“significant history of bipolar disorder, treated with
lithium for the past 20 to 30 years.” [Id.]
She complained of increasing symptoms of “weakness,
difficulty walking, and general body pain” and
described shakiness and unsteadiness of gait. [Id.]
Dr. Villanovas noted that Plaintiff reported that “she
has not had her lithium level checked in the past, and their
current symptoms are consistent with lithium toxicity.”
[AR 286] He referred her to a psychiatrist. [Id.]
Shortly
thereafter, Plaintiff saw Amy Ellis, M.D. for an initial
psychiatric evaluation. [AR 357] Dr. Ellis noted that
Plaintiff said her functioning was increasingly poor over the
prior few months. [Id.] Plaintiff arrived in a
wheelchair and said she could not sleep, had nearly all-day
episodes of nausea and vomiting, severe tremors, low energy,
poor concentration, and no appetite. [Id.] Plaintiff
denied suicidal ideation or psychotic symptoms of
hallucinations or paranoia. [Id.] Dr. Ellis noted
that Plaintiff showed symptoms of lithium toxicity and
Plaintiff had to leave the evaluation midway-through because
of a hot flash consistent with a panic attack. [AR 358] In
part, Dr. Ellis diagnosed Plaintiff with “Bipolar I
Disorder; most recent episode depressed, severe without
psychotic features; panic disorder with agoraphobia”,
lithium toxicity, and problems related to limited social
interaction. [AR 359] Dr. Ellis directed Plaintiff to wean
off lithium and prescribed Ativan to ameliorate panic
attacks. [Id.]
Dr.
Ellis saw Plaintiff on a follow-up two weeks later. [AR 354]
Plaintiff noted issues with urination which interfered with
her ability to sleep. [Id.] She stated that her
strength was returning, potentially because of her weaning
off lithium. [Id.] Dr. Ellis noted that
Plaintiff's anxiety and panic attacks were occurring
less, but she was experiencing visual hallucinations in the
form of red and purple color ribbons. [Id.] Dr.
Ellis wrote that Plaintiff was calm initially, but became
easily anxious and began to experience a panic attack.
[Id.] Dr. Ellis suggested discontinuing lithium
completely and trying Seroquel in a low dose to help with
sleep, psychotic symptoms, and mood stabilization. [AR 355]
These general sentiments were echoed by Dr. Villanovas. [AR
284-89]
At a
follow up in April 2014, Dr. Ellis noted Plaintiff was
improving and responding to treatment regarding her bipolar
disorder. [AR 352] Dr. Ellis found Plaintiff to be anxious,
but otherwise noted an unremarkable psychiatric exam. [AR
352-53] This included normal thought processes, normal
thought content, fair insight and judgment, normal
concentration, normal memory, and normal higher cognitive
functioning. [Id.] Dr. Ellis noted similar findings
in additional follow-up appointments in May, June, July,
August, and September. [AR 335-37, 340-50]
In
August 2014, Plaintiff had a consultative exam performed by
Matthew Simpson, M.D. [AR 300-06] Plaintiff stated to Dr.
Simpson that since ceasing lithium, her symptoms had been
improving, though she did not feel completely back to normal.
[AR 300] Dr. Simpson wrote that Plaintiff's switch to
other medications left her feeling in better control of her
bipolar disorder. [Id.] Dr. Simpson noted that
Plaintiff “was pleasant, cooperative, and appeared in
no acute distress, ” and “did not appear
particularly anxious, agitated, or drowsy and responded
appropriately with adequate effort throughout.” [AR
302]
In
November and January of 2015, Dr. Ellis noted similar
findings as in her prior records, except that Plaintiff's
mood was anxious and depressed in relation to her
husband's temperament. [AR 330, 334] In March 2015, Dr.
Ellis again noted Plaintiff's mood as depressed and
anxious because of her home environment and wrote that her
status was worsening. [AR 321-22] The next appointment, Dr.
Ellis noted Plaintiff's mood as euthymic and content, but
that she was mildly anxious due to her husband's back
pain. [AR 318] Similar findings followed in June, July, and
August. [AR 407-423] This irritation from her home life and
her anxious thoughts continued in ...