United States District Court, D. Colorado
WENDY J. RUNDLE, Plaintiff,
v.
ANDREW SAUL, Commissioner of Social Security, Defendant.
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
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