Rundle v. Saul

          ORDER AFFIRMING DENIAL OF BENEFITS

          R. BROOKE JACKSON, UNITED STATES DISTRICT JUDGE

         This matter is before the Court on review of the Social Security Administration (“SSA”) Commissioner's decision denying claimant Wendy J. Rundle's application for disability insurance benefits (“DIB”) and supplemental security income (“SSI”). Jurisdiction is proper under 42 U.S.C. § 405(g). For the reasons explained below, the Court affirms the Commissioner's decision.

         I. STANDARD OF REVIEW

         A person is disabled within the meaning of the Social Security Act only if her physical and/or mental impairments preclude her from performing both her previous work and any other “substantial gainful work which exists in the national economy.” 42 U.S.C. §423(d)(2). To be disabling, a claimant's conditions must be so limiting as to preclude any substantial gainful work for at least twelve consecutive months. See Kelley v. Chater, 62 F.3d 335, 338 (10th Cir. 1995).

         This appeal is based upon the administrative record and the parties' briefs. In reviewing a final decision by the Commissioner, the District Court examines the record and determines whether it contains substantial evidence to support the Commissioner's decision and whether the Commissioner applied correct legal standards. Winfrey v. Chater, 92 F.3d 1017, 1019 (10th Cir. 1996). The District Court's determination of whether the ruling by the Administrative Law Judge (“ALJ”) is supported by substantial evidence “must be based upon the record taken as a whole.” Washington v. Shalala, 37 F.3d 1437, 1439 (10th Cir. 1994). A decision is not based on substantial evidence if it is “overwhelmed by other evidence in the record.” Bernal v. Bowen, 851 F.2d 297, 299 (10th Cir. 1988). Evidence is not substantial if it “constitutes mere conclusion.” Musgrave v. Sullivan, 966 F.2d 1371, 1374 (10th Cir. 1992). Reversal may be appropriate if the Commissioner applies an incorrect legal standard or fails to demonstrate that the correct legal standards have been followed. Winfrey, 92 F.3d at 1019.

         II. BACKGROUND

         A. Factual Background.

         Ms. Rundle was born on November 17, 1972 and was 44 years old at the time of the ALJ's ruling. R. 129. Ms. Rundle alleges that her disability began on May 15, 2013. Id. Two significant events contributed to plaintiff's alleged disability - an automobile accident in January 2012 and an armed robbery at plaintiff's place of employment in August 2012. R. 293, 499-502.

         In January 2012 plaintiff was involved in a serious automobile accident causing plaintiff to suffer from daily headaches and short-term memory loss. Plaintiff sought treatment for these symptoms and continued working. R. 499-502. Medical examinations subsequent to this accident note plaintiff had normal insight and judgment, appropriate mood and affect, and did not show signs of anxiety. R. 499-505. A computerized tomography (“CT”) scan taken at the time of the accident was normal. R. 500. Plaintiff was eventually diagnosed with post-concussion syndrome, a traumatic brain injury (“TBI”), due to this accident. R. 455.

         In August 2012 plaintiff was the victim of an armed robbery at her place of employment, Smoker Friendly, during which a robber pointed a gun at her chest. R. 293. Thereafter, plaintiff sought medical treatment for agoraphobia, trouble sleeping, nightmares, and anxiety, all of which resulted from the robbery. Id. Plaintiff was treated by Dr. David Hopkins, Ph.D., who found that she was suffering from “significant anxiety and depression related to her attempted robbery.” R. 294. Dr. Hopkins diagnosed plaintiff with acute stress disorder and recommended psychotherapy. R. 294-95. Treatment notes show that plaintiff responded well to relaxation exercises and experienced waxing and waning of her acute stress symptoms through the end of 2012. Id. During this time plaintiff was also treated by Dr. Daniel Peterson, M.D., who found plaintiff anxious but not experiencing acute distress. R. 455. Dr. Peterson opined that plaintiff was suffering from post-traumatic stress disorder (“PTSD”), anxiety, and depression. He prescribed several medications to address these issues. R. 451, 456. Plaintiff was wary of taking all of her medications, fearing that she would become dependent on them. R. 451. She chose not to refill some of these prescriptions when they ran out. Id. Dr. Peterson ultimately discharged plaintiff from his care in January 2013 due to non-compliance. R. 450.

         Plaintiff continued to suffer from depression and anxiety throughout 2013 but began to complain of worsening symptoms after stopping some of her medications. R. 297. A CT scan taken in July 2013 was once again normal. R. 408. Plaintiff resumed treatment with Dr. Peterson in May 2013 and began slowly improving. R. 444-48. Dr. Peterson noted that plaintiff was still reluctant to take her medication, though she claimed that the medication caused no side effects. Id. He also noted that plaintiff was involved in physical therapy, feeling better, and responding well to Cognitive Behavioral Therapy with Dr. Hopkins. Id. Though plaintiff could not sit still and jiggled her leg through a few appointments, Dr. Peterson determined that plaintiff was not in acute distress. R. 440-44. During this time Dr. Hopkins opined that plaintiff's acute stress disorder had progressed to PTSD. R. 292. He recommended that plaintiff reevaluate the efficacy of her medications with a psychiatrist and continue psychotherapy. Id.

         Plaintiff also began seeing Dr. Robert Kleinman, M.D., for anxiety in 2013. R. 302. Dr. Kleinman noted plaintiff was depressed, anxious, and fidgety. R. 305. He also noted that plaintiff had intact remote and recent memory; intact concentration and attention; good judgment; and a cooperative attitude. Id. He opined that plaintiff's symptoms were moderate and that plaintiff had moderate difficulty with “social/occupational functioning.” R. 306.

         In 2014 plaintiff had consistently normal physical evaluations demonstrating normal coordination and gait; she was also consistently found to have normal mood, affect, behavior, and speech. R. 467, 471, 474. During this time CT scans of plaintiff's head were normal, though a Magnetic Resonance Imaging (“MRI”) scan showed some white matter changes. R. 487, 490. Plaintiff also continued treatment with Dr. Peterson who found plaintiff's symptoms were improving with prescribed medication, and that she was “overall much better.” R. 438. Plaintiff stated that she was experiencing no side effects from medications and only rarely experiencing nightmares. Id. Importantly, plaintiff also stated that she had “not been working because she chose not to work.” Id. During this time plaintiff missed several appointments with Dr. Kleinman and Dr. Hopkins which she attributed to forgetfulness caused by her TBI. Id. Dr. Peterson recommended that plaintiff continue her prescribed medication and psychotherapy, but ultimately opined that plaintiff had achieved maximum medical improvement. Id. He released plaintiff from his care with “no permanent impairment.” Id.

         A 2014 neuropsychological evaluation with Dr. Michael Nunley, Ph.D., showed plaintiff was cooperative, fairly well-focused, and not easily distracted. R. 336. Dr. Nunley recommended physical therapy for plaintiff's headaches and disequilibrium issues, an evaluation by a Speech Language Pathologist (“SLP”) for her language and memory issues, and a neuro-optometric evaluation for her visual disturbances. R. 337-38. Plaintiff then attended physical therapy from July to August 2014. R. 351-59, 387-91. Plaintiff's August 2014 SLP evaluation found that she had cognitive-linguistic deficits in the areas of attention, memory, problem-solving, and word finding. R. 355. After a few weeks of therapy with the SLP plaintiff had “demonstrated improvement” and had made “qualitative gains.” R. 364. Additionally, in September 2014 plaintiff saw Dr. Thomas Wilson, O.D., for an ophthalmologic examination; Dr. Wilson diagnosed plaintiff with hyperopia (farsightedness), astigmatism (a common condition in which the eye is not completely round), visual ...