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Jones v. Berryhill

United States District Court, D. Colorado

December 21, 2018

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Plaintiff Scott Tyler Jones appeals from the Social Security Administration (“SSA”) Commissioner's final decision denying his application for disability insurance benefits, filed pursuant to Title II of the Social Security Act, 42 U.S.C. §§ 401-433. 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 AFFIRM the Commissioner's final order.

         I. Statement of the Case

         Plaintiff is a 49 year-old man with a master's degree in counseling and an associate's degree in applied electronic technology. [Administrative Record (“AR”) 66, 262, 319] He seeks judicial review of SSA's decision denying his application for disability insurance benefits. Pl.'s Br., ECF No. 13 at 5. Plaintiff filed his application in July 2015 alleging that his disability began in August 2014. [AR 262]

         The application was initially denied on November 5, 2015. [AR 138] After Plaintiff's request for review, the Administrative Law Judge (“ALJ”) conducted an evidentiary hearing and issued a written ruling on July 5, 2016. [AR 62-100, 116- 28, 144] In that ruling, the ALJ denied Plaintiff's application on the basis that he was not disabled because, considering his age, education, and work experience, he had acquired skills from past relevant work that were transferrable to jobs that existed in significant numbers in the national economy. [AR 127] After a request to review this decision from Plaintiff, the SSA Appeals Council remanded the case back to the ALJ. [AR 132-35] The ALJ held another hearing and issued a written ruling on April 5, 2017. [AR 9-23, 32-58] The ALJ again found that there are jobs that exist in significant numbers in the national economy that Plaintiff could perform. [AR 22]

         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 1-3]; see 20 C.F.R. §404.981. Plaintiff timely filed his Complaint with this court seeking review of SSA's final decision. ECF No. 1.

         II. Relevant Medical History

         Plaintiff's claims on appeal relate to his mental health. In September 2013, Plaintiff, living in Arizona, saw Sami Victor, M.D. for a mental health follow up. [AR 522] Dr. Victor explained that Plaintiff had a “past psychiatric history of [traumatic brain injury], mood disorder and anxiety . . . .” [Id.] His current problem list included bipolar disorder. [AR 523] Plaintiff had an unremarkable mental status exam, with Dr. Victor noting that Plaintiff: appeared appropriately dressed; was awake and alert, cooperative, and euthymic; had appropriate affect, speech, thought content, thought process, perception, orientation, memory, and had no judgment impairment. [AR 522-23] Plaintiff denied anxiety and had an improved mood with no stressors noted. [AR 522] Plaintiff was instructed to continue a medication regime that included Cymbalta and Lamictal. [AR 523]

         A month later, Plaintiff presented to Timothy Baker, M.D. as depressed, tired, and lacking motivation. [AR 598] Four days later, Plaintiff saw Dr. Victor who noted an unremarkable mental status exam. [AR 525-27] A few weeks later, Plaintiff reported to Dr. Victor increased anxiety and appeared anxious, but otherwise had an unremarkable mental status exam. [AR 528-29] Dr. Victor prescribed Klonopin and added an anxiety disorder to Plaintiff's current problem list. [AR 529-30] Dr. Baker noted Plaintiff was doing better in a follow up after his appointment with Dr. Victor. [AR 593-94]

         Dr. Victor did not note anything remarkable in the next appointments in November 2013 and February, June, and September 2014. [AR 532-45] In the September appointment, Dr. Victor noted that Plaintiff lost his job three days prior. [AR 542] In January 2015, Dr. Victor noted that Plaintiff had bouts of anxiety, but was doing well on his medication regimen. [AR 546]

         In May, Plaintiff's wife was present with Plaintiff at his appointment with Dr. Victor. [AR 552] His wife reported that Plaintiff had slight paranoid delusions regarding the September 11 attacks and the illuminati. [Id.] Dr. Victor increased Plaintiff's dosage of Lamictal and added Seroquel to stabilize his mood. [Id.] Dr. Victor noted that Plaintiff was irritable and had paranoid ideation, but otherwise had an unremarkable mental status exam. [AR 554] A few weeks later, Plaintiff returned with his wife and Dr. Victor noted “drastic improvement” with the increased medication and “[l]ess discussion about delusions.” [AR 559] Dr. Victor added insomnia to Plaintiff's problem list and noted Plaintiff would begin seeing a therapist. [AR 559-60]

         In June, Plaintiff's mental state had degraded as Dr. Victor wrote that Plaintiff had “[c]ontinued delusional thought disorder[, ] reported that I was trying to trick him into taking more medications and that I was fooled by them (illuminati).” [AR 565] Dr. Victor continued that it was “[u]nknown if patient is adherent to his medications” and Plaintiff would not allow his wife to administer them. [Id.] Dr. Victor noted paranoid ideation and paranoid delusion. [AR 568]

         Soon after, Plaintiff was involuntarily taken to a mental hospital. [AR 408, 412] Plaintiff's wife indicated that Plaintiff had threatened suicide in front of their children; had been forcing his children to watch conspiracy videos; had been physical with her and their children; threatened her; believed he saw a ghost in the house; and that she was concerned for her and their children's safety and had been speaking to a divorce lawyer. [AR 412] Plaintiff was nonresponsive and uncooperative with staff. [AR 411-22] Plaintiff was hospitalized for 12 days. [AR 482]

         Dennis Michael Hughes, M.D. performed Plaintiff's psychiatric discharge summary. [AR 482-90] Dr. Hughes noted that Plaintiff's dose of Seroquel was significantly increased, to which Plaintiff responded well “with resolution of psychotic symptoms and significant reduction of manic symptoms within a few days.” [AR 482] In his interview, Plaintiff presented as pleasant, cooperative, verbose, circumstantial, and over inclusive and was “near his psychiatric baseline, with no overt manic or psychotic symptoms noted currently.” [AR 482-83] The doctor noted that Plaintiff's wife had filed for an order of protection and Plaintiff would be discharged under the care of his mother, brother, and sister-in-law in Colorado. [AR 482-83, 490]

         In July, Plaintiff saw Dana Jean Lahaie, MD in Arizona. Dr. Lahaie noted Plaintiff's constricted affect, circumstantial speech, and anxious mood, but otherwise noted Plaintiff's casual appearance, good concentration, denial of delusions and hallucinations, appropriate orientation, fair insight, and fair judgment. [AR 452] She recommended Plaintiff stay on his medication regimen and that he find mental health care in Colorado. [AR 453]

         In August, Plaintiff saw Dr. Baker to get refills for medication and for a referral to a new primary doctor in Colorado. Plaintiff noted that he felt “like things are stable” and Dr. Baker noted an unremarkable psychological exam. [AR 578-79] A few weeks later, Plaintiff saw Mitchell J. Janasek, M.D. for a preventative exam, where Dr. Janasek referred Plaintiff to a psychiatrist and noted that Plaintiff had a normal psychiatric exam with appropriate mood and affect. [AR 671-75]

         In October, Plaintiff had a consultative exam performed by David A. Fohrman, M.D. [AR 683] Plaintiff noted his level of depression over the last two weeks was an eight and anxiety a nine on a scale of ten. [Id.] This was related to his pending divorce and his lack of a job and a home. [Id.] He noted that he had recent manic episodes and he saw a “shimmering curtain” at night due to him taking Seroquel. [AR 684] He stated he was not as focused on conspiracy theories as before his hospitalization and that he enjoyed bike riding and working on the model rocket kit his brother purchased for him. [Id.] He felt his medication had helped him “for the most part.” [Id.]

         Dr. Fohrman wrote that Plaintiff “was alert and oriented times four. He was overall cooperative for the examination. His mood was subdued, congruent. He had no evidence of audio or visual hallucinations.” [AR 686] Plaintiff knew his Social Security number, could recall three of three unrelated words immediately and two of three in five minutes, could spell “world” backwards, and responded appropriately to questions regarding his fund of general information. [Id.] Plaintiff had issues performing “serial sevens” where he was to count back from 100 by seven. [Id.] Under a section titled “abstract thinking”, Dr. Fohrman wrote that Plaintiff “thought the similarity [between] the words apples and bananas was they are both ...

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