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Becker v. Berryhill

United States District Court, S.D. Iowa, Western Division

November 20, 2017

MATTHEW BECKER, Plaintiff(s),
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, [1] Defendant(s).

          REPORT AND RECOMMENDATION

          Helen C. Adams Chief U.S. Magistrate Judge.

         Plaintiff Matthew Becker seeks review of a final decision of the Commissioner of the Social Security administration ("Commissioner") denying his claim for Supplemental Security Income Benefits ("SSI") under Title XVI of the Social Security Act 42 U.S.C. § 1381-1385. This Court reviews the Commissioner's final decision pursuant to 42 U.S.C. § 1383(c)(3). The case is before the undersigned for report and recommendation pursuant to 28 U.S.C. § 636(b)(1)(B). The Court considers the matter fully submitted on the briefs.

         I.

         PRIOR PROCEEDINGS

         Becker protectively filed his SSI benefits claim on February 1, 2014 alleging disability since January 4, 2010. (AR at32, 180).[2] He alleged oppositional defiant disorder, "social disorder, " anxiety disorder and depression limited his ability to work. (AR at 73, 184). The Social Security Administration denied Becker's claim initially and on reconsideration. (AR at 72-83, 84-96). On July 21, 2014, Becker requested an administrative hearing. Administrative Law Judge ("ALJ") David Buell conducted an administrative hearing on November 9, 2015. Becker appeared with his attorney Gregory Peterson; Becker's mother, Christine Becker, and vocational expert Stephen Schill also testified. At hearing, counsel amended the alleged onset date to February 1, 2014. (AR at 13, 32). The ALJ issued an unfavorable decision on December 18, 2015, finding Becker was not disabled. (AR at 10-26). Becker requested a review of the ALJ's decision. (AR at 8-9). The Appeals Council denied the request for review and the ALJ's decision became a final decision on November 4, 2016. (AR at 1-3). The Complaint [1] in this case was timely filed on December 23, 2016.

         A. Educational and Vocational Factors

         Becker was 18 years old when he filed for benefits. (AR at 166). He had limited past work as cook/counter attendant at a fast food restaurant and housekeeping at a hotel. (AR at 34-37). Becker completed the eleventh grade in high school. (AR at185).

         B. Medical Evidence

         Becker's mental health medical history begins with an admission to Mercy Hospital in Council Bluffs, Iowa on May 27, 2010, when he became suicidal after breaking up with his girlfriend. He told his counselor[3] he was thinking about killing himself and would not contract for safety. (AR at 279, 283). He was hospitalized until May 30, 2010. (AR at 279) Attending physician Dr. S. Ravipati stated that Becker participated in individual and group therapy on the unit, followed rules and regulations, learned some coping skills and denied any suicidal or homicidal ideation on discharge. Dr. Ravipati diagnosed Becker with major depressive disorder current episode and a GAF of 50. The hospital discharged Becker to the custody of his parents with a prescription for Prozac. (Id.)

         Becker was readmitted to Mercy Hospital on July 24, 2011, after an episode at home during which he became "very violent, very aggressive, very demanding." (AR at 295). On intake, his parents reported he had been forcing them to give him money so he could buy cigarettes. (Id. at 299). Becker admitted he had been buying drugs, using marijuana and alcohol, and reported a history of burning and cutting himself. (Id.) On mental status exam Becker was appropriately dressed and groomed, was compliant, cooperative and responsive to the interview process. (Id. at 300). His mood was irritable, affect "very testy, very demanding" and threatening. (Id.) He denied auditory or visual hallucinations and delusions, but admitted he was "explosive and very impulsive." (Id.) Becker's "stream of mental activity" was "goal directed" and appropriate; he was alert and oriented to time, place and person, but his impulse control relatively poor and insight and judgment fair to poor. His medications on admission included Prozac and Abilify which Dr. Ravipati discontinued. (Id.) During his hospitalization, which lasted until July 29, 2011, Becker was started on Trileptal and Risperidone. (Id. at 295). Becker had a court hearing during his hospitalization and it was recommended that he be committed and follow through with outpatient psychiatric care and treatment. (Id.) At discharge Dr. Ravipati diagnosed him with attention deficient hyperactivity disorder (ADHD), mood disorder not otherwise specified, oppositional defiant disorder, and marijuana dependency with a GAF at 50. (Id.)

         Karen Rodriguez, LISW, LCSW, conducted a Diagnostic Clinical Interview with Becker on August 18, 2011. (AR at 306-309). Becker admitted he was self-medicating with marijuana and had started stealing to support his habit. (Id. at 307). On mental status exam, Becker was unkempt, but alert and oriented x4. (Id.) His attitude was irritable and eye contact poor. (Id. at 308). His motor behavior was normal and his speech minimally responsive with average vocabulary. (Id.) Becker's thought process was logical and goal-directed, his thought content age-appropriate. (Id.) His perception was normal; he denied suicidal or homicidal intent. (Id.) Becker's mood was depressed and irritable, but his affect appropriate, with poor insight and judgment. (Id.) Ms. Rodriguez diagnosed mood disorder NOS, oppositional defiant disorder and ADHD by history and wanted to rule out borderline personality disorder. (Id.) She assessed his GAF at 50. (Id.) Ms. Rodriguez believed Becker was in need of "extensive therapy" and he agreed to participate in outpatient therapy. He feared being removed from home and placed at Orchard Place. (Id. at 309).

         Ms. Rodriguez noted in her prognosis/discharge criteria and aftercare plan:

Matt is a very troubled young man and has a great deal of anger. He appears to be an over-indulged child, as evidenced by the fact that his mother answered many questions for him and did not appear to be interested in pushing Matt for fear of him becoming angry. Matt has agreed to participate in the therapeutic process, however; it appears to be coheresed [sic]. If Matt is not engaged in therapy for the sake of improving his level of functioning, his prognosis is guarded at best.

(Id.)

         Becker treated for a time with Alegent Health Psychiatric Associates, starting on August 18, 2011. (AR at 313-318). The notes are handwritten but it appears Becker was seen on five occasions through May 10, 2012, during which his mood/affect remained consistently irritable and angry, although he reported on occasion he was doing well. (Id. at 314, 317).

         There is a gap in Becker's treatment history until October 30, 2013, when he began seeing Patrick Pucelik, ARNP, at Myrtue Medical Center. (AR at 323). On that occasion he was brought in by his mother to discuss anxiety, which he reported occurred a few times a week. (Id.) Mr. Pucelik noted Becker's mother answered most of the questions because Becker said he was not comfortable answering them. Mr. Pucelik could not get him to engage. Becker had dropped out of high school and was working on his GED. He was not employed. He could not describe his typical day to Mr. Pucelik. (Id.) He had seen a Dr. Armbruster and been started on Clonazepam, which he thought was helping. He admitted smoking marijuana. (Id.) Mr. Pucelik was told Becker had been admitted two times for psychiatric issues. They discussed seeing a psychiatrist and doing labs but Becker was not interested in either, just wanted to take Clonazepam. A prescription was given and he was to follow up in a few weeks. (Id.)

         On November 13, 2013, Becker returned to see Mr. Pucelik. (AR at 324). His mother was not present. Becker told Mr. Pucelik he did not think the Clonazepam worked and never did, just agreed with his mother. (Id.) Mr. Pucelik spent 45 minutes talking with Becker, who was noted to be "very withdrawn and hard to get information from." (Id.) He told Mr. Pucelik none of the medication he had been on ever helped and he just wanted to be left alone, stating "nobody listens to me" during the visit. Becker was not working on his GED anymore and had been doing it to please his mother. (Id.) Becker reported that his mother had left him a note to ask Mr. Pucelik about Lexapro but Becker did not want the medication. (Id.) Becker cried a few times during their interview, recognized he was withdrawn, and wanted people to leave him alone. He wanted to take Xanax instead of Clonazepam as one of his mother's friends had given him a few. Mr. Pucelik had reservations about changing Becker's medications and wanted to refer him to someone else, but Becker did not want to see any more therapists or psychiatrists. (Id.) His prescription for Clonazepam was continued. (Id.)

         At his one month follow-up on December 11, 2013, Becker reported he thought his medication was helping and he was a little more interactive. (AR at 325). Mr. Pucelik observed him to be calmer. (Id.)

         On January 9, 2014, at a monthly check Becker reported he was doing well and had a good Christmas. (AR at 326). He was taking his medications although he said he was not sure he noticed a difference. Becker smiled and laughed during the visit and said his anger was day by day. Mr. Pucelik planned to continue his medications and follow up in a month. (Id.)

         At a visit on February 13, 2014, Becker told Mr. Pucelik he was doing well and had no concerns. (AR at 327). Mr. Pucelik observed Becker had better eye contact but was still very nonverbal. He was groomed and well dressed and had his hood down instead of over his head as on previous occasions. (Id.) Becker reported he was taking his medications as prescribed. Mr. Pucelik provided a refill of his prescription. (Id.)

         On March 12, 2014, when Becker reported for a medication check, he told Mr. Pucelik he was doing well and had no concerns. (AR at 328). Mr. Pucelik tried to engage him in conversation but got "[m]any yes no answers. Not as irritable as in the past but still not forthcoming with discussion." (Id.)

         At a visit with Mr. Pucelik on April 9, 2014, Becker was noted to be more "interactive" than he had been. (AR at 350). Becker reported he was looking for a job. He was not interested in restarting his GED studies. He had not done much with making candles and tried selling them locally without much success. They discussed other job options. Becker said he felt the medications were working. (Id.)

         On May 8, 2014, Becker met with Mr. Pucelik for routine medication management. (AR at 351). He said he was doing well and had no concerns. Mr. Pucelik noted Becker had been stable on his current medications. They discussed going to every other month visits, to which Becker agreed. (Id.)

         Becker returned to see Mr. Pucelik on July 9, 2014, for routine medication management. (AR at 379). He reported he was getting along well and Mr. Pucelik observed Becker was interactive with the examination. (Id.) Becker said he was thinking about going to therapy in Council Bluffs and Mr. Pucelik encouraged him in that regard. (Id. at 380).

         At a visit on September 10, 2014, Becker said he was doing good. (AR at 381). Becker reported that his mother wanted him to ask about Lexapro but he was not interested in the medication. Becker again made a comment about seeing a therapist but was no longer interested. (Id.)

         On November 6, 2014, Becker appeared for a medication check. (AR at 382). He was getting along well. At this visit he said he was not interested in seeing a counselor or starting new medications as the current medications were working fine. (Id.) His only concern was night sweats he was experiencing many nights a week. Mr. Pucelik offered lab draws and workup but Becker declined. (Id.)

         At a two-month medication check on January 7, 2015, Becker said he was doing good and had an "ok" Christmas. (AR at 383). He again declined a counselor and did not want to see anyone or try anything different. (Id. at 384).

         On March 6, 2015, Becker told Mr. Pucelik he was doing well, had a new girlfriend, and things were going well. (AR at 385). He was frustrated on this occasion because he had to wait and was going to be late for another appointment. His hood was on but not pulled completely over his head. They again discussed Becker getting counseling but he declined. Mr. Pucelik observed Becker's birthday was approaching and he had a "self imposed deadline of having a job by" that time, which Mr. Pucelik thought was affecting his attitude on this occasion. (Id.)

         At a visit on May 4, 2015, Becker said he was living in Omaha with his girlfriend and the relationship was going well. (AR at 386). Mr. Pucelik observed Becker was more interactive and smiled a few times. Becker needed a letter in support of his application for social security disability. He gave Mr. Pucelik verbal consent to talk with his parents. (Id.)

         On July 6, 2015, Mr. Pucelik observed Becker was pleasant and cooperative during his interview, with good hygiene. (AR at 387). He told Mr. Pucelik he was doing good. His medications were discussed and refilled. (Id.)

         C. Medical Source Opinions/Evaluations

         1. Dr. Jones-Thurman

         Rosanna M. Jones-Thurman, Ph.D., a licensed clinical psychologist, undertook a psychological evaluation of Matthew Becker on April 23, 2014, at the request of the Disability Determination Services Bureau of Iowa. (AR at 336-340). Dr. Jones-Thurman took a complete demographic and family history; asked about Becker's education, family dynamics and employment; asked about medical and addiction issues, and Becker's mental health history. (Id. at 337). At that time Becker reported he had treated with Karen Rodriguez in Avoca, Iowa; Christine Schwery in Harlan, Iowa; and Dr. Matthew Eggers in Harlan, Iowa. (Id. at 338). He described his symptoms as not being happy, he could not be around people and did not talk to people; when he went out in public he got nervous and anxious. He also stated he did leave the house and would go to Walmart or pick up his girlfriend. He did not like to be at home and would leave and drive around. (Id.) Becker did not think his medications were helping and he had lost weight. (Id.) He reported he got angry easily, yelled a lot and would say things in public. (Id.) He said he kept to himself but was argumentative at home. He said he had problems with attention, concentration, and distraction but denied being hyper or fidgety. Becker denied panic attacks but his mother reported he would panic and shake. (Id.) His mother also reported he did not process emotion, worried all the time, liked the same routine, and did not like change. Becker said he did not like loud noises but had no other sensory integration problems. (Id.)

         With respect to his activities of daily living, Becker reported he got on the computer, read email, took care of his hygiene daily, did cooking, cleaning, laundry, ran errands and drove around. (AR at 338). He did not like being at home but said he was unable to be around other people. (Id. at 339). He liked to make candles and watch movies. He did not know if he could manage money. (Id.)

         On mental status exam, Becker was neat in appearance and well groomed. (AR at 339). His behavior during the interview was appropriate; he was open and cooperative. Becker's speech was within normal range and easily understood; it was normal for volume, rate and tone. He was oriented to time, place and person; could state the date and where he was; his memory, concentration and attention were intact. His thought organization was coherent and logical; he denied thought process distortion and appeared to be of average intellectual ability. (Id.) Dr. Jones-Thurman believed Becker was "possibly demonstrating a mood disturbance" based on his flat mood and report of vegetative signs of depression such as sleep and appetite disturbance. He did not appear to be a risk of danger to himself or others. (Id.)

         Dr. Jones-Thurman concluded that based on her examination Becker "would be able to remember and understand instructions, procedures, and locations and could carry those out and maintain attention, concentration, and pace." (AR at 339-340). She thought he might have "some difficulty using fair judgment and responding to changes in the work place." (Id. at 340). She "imagine[d]" he would have "some difficulty getting along with others." (Id.) Her diagnostic impression was dysthymic disorder, rule out bipolar disorder, attention deficit hyperactivity disorder, combined type, moderate, generalized anxiety disorder, social anxiety disorder, and cannabis dependence (although he alleged remission and sobriety). (Id.) Her Axis II diagnosis was schizoid and avoidant personality traits; she assessed his GAF at 50. (Id.)

         2. Amy Riessland, LISW

         In a statement dated July 3, 2014, Amy Riessland, LISW, at the Center for Healing and Hope stated she evaluated Becker on July 1, 2014. (AR at 356). At that time he was well groomed but had "very poor eye contact" and he was "disengaged in the conversation." (Id.) She observed he appeared "very anxious and agitated" and looked down most of the interview. (Id.) Both Becker and his mother were present and they both reported it was difficult to get Becker to attend the meeting because of his struggle to talk to people and his anxiety. They reported his anxiety often presented in verbal aggression towards others, which occurred at the interview in response to discussion about setting up future appointments and goals. (Id.) Becker and his mother reported he obsessed about his future, was depressed and hopeless. (Id.) Ms. Riessland stated Becker appeared to understand instructions but during the interview his immediate past recall was not good. Ms. Riessland opined that based on the intake information Becker would "struggle to carry out instructions, maintain attention, concentration and pace . . . to interact appropriately with supervisors, co-workers and especially the public due to his extreme social anxiety." (Id.) Based on his report about extreme anxiety in response to any change, Ms. Riessland believed "he would not be able to use good judgment and respond appropriately to change in the workplace." (Id.) He did appear to have average intelligence and she "did not see a reason" why he could not manage any benefits he received. (Id.)

         3. Patrick Pucelik, ARNP

         Mr. Pucelik offered two statements regarding his treatment of Becker. The first was dated May 5, 2015. Mr. Pucelik briefly stated he had been caring for Becker since October 2013 for social anxiety disorder, anxiety and depression. (AR at 362). He seemed to be stable at the time of the statement. (Id.) Mr. Pucelik gave the opinion that Becker would not be "able to hold or maintain a job given the amount of anxiety he has when in a public setting." (Id.)

         In a second statement dated September 29, 2015, Mr. Pucelik stated he had treated Becker for about three years, during which his condition "waxed and waned." (AR at 363). He noted that in the past few months Becker seemed to be in a better place, having met a girl and moved to Omaha with her, as well as living in Pennsylvania with her and another friend. (Id.) Becker told Mr. Pucelik he had some anxiety in both places but was able to manage. (Id.) Mr. Pucelik was hopeful Becker would get out and be more involved but cautioned about "doing too much, too fast." (Id.) He noted Becker had not seen a psychiatrist for a "number of years" and was resistant to seeing one, which Mr. Pucelik related to "past exposure to the mental health community." (Id.) Mr. Pucelik believed it would be "detrimental to force him to see someone now." (Id.) Mr. Pucelik believed Becker was "disabled by his social anxiety, general anxiety and general depression" but hopeful that he could "work with these disabilities and obtain employment, " although not at the time of his report. (Id.)

         4. Beverly A. Doyle, Ph.D.

         Beverly A. Doyle, Ph.D., licensed psychologist, performed a mental status exam on Becker on October 12, 2015, at the request of Disability Consultants, Becker's attorney. (AR at 392-93). Dr. Doyle noted Becker was driven to the evaluation by his mother. He was cooperative, open and honest, and provided information to the best of his recollection. (Id.) Dr. Doyle reviewed his personal, educational, and work history as reported by Becker. (Id.) She reviewed the history of his present illness with Becker and his mother and referred to records from Mr. Pucelik. (Id. at 392-393). On examination, Becker was orientated and understood why he was being evaluated. He remembered general events in his mental health treatment history but not the exact sequence, who he saw, or what diagnoses were made or medications given. (Id. at 393). Becker reported he was living with his girlfriend in Omaha and tried a move to Pennsylvania. He described his mental health problems as including feeling sad and panic attacks, about twice a week. (Id.) During his panic attacks, Becker said he could not breathe and hyperventilated. He would call his mother to calm down. (Id.) Becker said "[h]is anxiety affected his ability to apply for jobs or go out." (Id.) He told Dr. Doyle he played video games with a few friends and watched TV. (Id.) Dr. Doyle made a diagnosis of major depressive disorder, recurrent-severe and panic disorder. (Id.) She stated his disorder caused "him to be unable to complete his education, work and live independently. He is unable to manage his funds and engage in daily activities including housekeeping, shopping and cooking." She opined that his prognosis was poor. (Id.)

         In a follow-up to this report, Dr. Doyle filled out a Mental Residual Functional Capacity Questionnaire. (AR at 397-404). Dr. Doyle identified Becker's signs and symptoms as including sleep and mood disturbance; emotional lability; recurrent panic attacks; psychomotor agitation or retardation; feelings of guilt/worthlessness; difficulty thinking or concentrating; suicidal ideation or attempts; oddities of thought, perception, speech, or behavior; social withdrawal or isolation; persistent irrational fears; and generalized persistent anxiety. (Id. at 397). Her clinical findings were that Becker had recurrent panic attacks and severe depression. (Id.) Dr. Doyle indicated Becker had been hospitalized, treated with medications and given therapy but had not improved. She did not believe he was a malingerer. (Id. at 398). She expected his impairments to last at least twelve months. With respect to whether his psychiatric condition exacerbated his experience of pain or other physical symptom, Dr. Doyle said he had panic attacks and could not function. (Id.) He did not have a low I.Q. She anticipated his impairment would cause him to be absent from work more than three times a month. (Id.)

         With respect to Becker's mental abilities and aptitudes needed to do unskilled work, Dr. Doyle rated his ability to remember work-like procedures, understand and remember and carry out very short and simple instructions as unlimited or very good; sustain an ordinary routine without special supervision and make simple work-related decisions, perform at a consistent pace without an unreasonable number and length of rest periods, ask simple questions or request assistance, and be aware of normal hazards and take appropriate precautions as good; and his ability to maintain attention for two hour segments as fair; and as poor or none his ability to maintain regular attendance and be punctual within customary, usually strict tolerances or to work in coordination with or proximity to others without being unduly distracted, complete a normal workday and workweek without interruptions from psychologically based symptoms, perform at a consistent pace without an unreasonable number and length of rest periods, accept instructions and respond appropriately to criticism from supervisors, get along with co-workers or peers without unduly distracting them or exhibiting behavior extremes, respond appropriate to changes in a routine work setting, and deal with normal work stress. (AR at 399).

         With respect to Becker's mental abilities and aptitudes needed to do semiskilled and skilled work, Dr. Doyle rated his ability to understand and remember detailed instructions and carry out detailed instructions as good; to set realistic goals or make plans independently of others as fair; and to deal with stress of semiskilled and skilled work as poor or none. (AR at 400). In support of the fair and poor ratings, Dr. ...


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