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Sanborn v. Commissioner of Social Security

United States District Court, D. New Jersey

October 25, 2017


          Michael Joseph Brown, Esq. WOLF & BROWN, LLC Attorney for Plaintiff

          Heather Anne Benderson, Special Assistant U.S. Attorney Social Security Administration Attorney for Defendant


          JEROME B. SIMANDLE U.S. District Judge


         This matter comes before this Court pursuant to 42 U.S.C. § 405(g) for review of the final decision of the Commissioner of the Social Security Administration (“SSA”) denying Plaintiff Adam Sanborn's (“Plaintiff”) application for disability benefits under Title XVI of the Social Security Act, 42 U.S.C. § 401, et seq. Plaintiff, who suffers from a gunshot wound to his right shoulder, upper extremity radiculopathy as a result of his gunshot wound, tinnitus, post-traumatic stress disorder (“PTSD”), and major depressive disorder, was denied benefits for the period beginning on November 26, 2013, the alleged onset date of disability, to November 4, 2015, the date on which the Administrative Law Judge (“ALJ”) issued a written decision.

         In the pending appeal, Plaintiff argues that the ALJ erred by: (1) failing to provide substantial evidence in support of the ALJ's decision to assign little weight to the medical opinion of Plaintiff's treating physicians; (2) failing to provide substantial evidence to support the ALJ's decision to assign little weight to the fact that Plaintiff was found to be disabled by the Veteran's Administration (“VA”); (3)relying solely on the subjective statements of Plaintiff in arriving at the conclusion that Plaintiff's mental impairments do not meet and/or equal the Listings in 12.04 and 12.06; and (4)failing to comply with SSR 96-8 in assessing Plaintiff's Residual Functional Capacity. For the reasons that follow, and after careful review of the entire record, the parties' submissions, and the applicable law, this Court will remand the case for further adjudication consistent with this Opinion.


         A. Procedural Background

         Plaintiff filed his application for Social Security disability benefits on January 4, 2014, alleging an onset of disability from November 26, 2013, when he was age 29. (R. at 197.) His claim was denied by the Social Security Administration on April 24, 2014. (Id. at 21.) His claim was again denied upon reconsideration on August 18, 2014. (Id.) Plaintiff next testified in person in front of the ALJ on June 2, 2015. (Id.) The ALJ issued an opinion on November 4, 2015, denying benefits. (Id. at 39.) On May 18, 2016, the Appeals Council denied Plaintiff's request for review. (Id. at 1.) This appeal follows.

         B. Medical History

         The following facts are relevant to the present motion. Plaintiff was born on December 13, 1984, and is currently thirty-two years old. (Id. at 54.) Plaintiff graduated from high school and then served in the United States Marine Corp from 2004 to 2007. (Id. at 61.) While serving in Iraq, Plaintiff suffered a gunshot wound to the right shoulder. (Id. at 55.) After being honorably discharged, Plaintiff worked at a grocery warehouse in 2008, and then as a corrections officer from 2018 to 2013. (Id. at 63, 206-07.) Plaintiff had to leave his work at the correctional facility when his anxiety and anger became too much. (Id. at 64.) Plaintiff testified that his anger would cause him to have “real mood swings” while at work. (Id.) He also feared that the inmates would attack him. (Id. at 66.) One day at work, his anxiety became so strong that it led to a panic attack. (Id. at 64.) Another day, he got into an altercation with a prisoner and blacked out. (Id. at 65.) After the incident, he and his supervisor argued on how to “handle the incident.” (Id.) This led to Plaintiff feeling tightness in his chest and “sort of hyperventilating”, he radioed for help and passed out. (Id.) When he woke up he was taken to the emergency room. (Id.) While working from 2012 to 2013, Plaintiff completed a year of community college. (Id. at 59.) At his hearing before the ALJ, Plaintiff testified that he continued to take classes and had earned forty-eight credits. (Id. at 61.)

         1. Treatment before Plaintiff's Disability Onset Date (November 21, 2007-August 31, 2013)

         On November 21, 2007, Dr. Rago diagnosed Plaintiff with PTSD and assigned him a Global Assessment of Functioning (“GAF”)[1] Score of 61-70. (Id. at 343.) Dr. Rago wrote in his objective findings that there was no evidence of any major concentration or memory disturbances, and he suspected Plaintiff would get better and his PTSD would resolve. (Id.)

         Less than three months later, on March 3, 2008, Plaintiff was seen by Dr. Dale for a fifty-minute psychotherapy session. (Id. at 353.) During the session Dr. Dale noted that Plaintiff was experiencing anxiety, but was able to leave the house if he had a plan, was still maintaining relationships with friends, especially fellow Marines, and was not experiencing symptoms of depression. (Id.)

         Eight months later, on November 30, 2009, Plaintiff was seen by Physician Assistant Knepp who noted Plaintiff had “new (interval) diagnosis” of worsening PTSD symptoms, insomnia, and sleepwalking. (Id. at 324.)

         On March 4, 2010, Plaintiff was seen by Dr. Aksu who noted that Plaintiff stated he had been having more panic attacks in public so he was isolating himself. (Id. at 314.) Plaintiff also said he was experiencing restlessness, pacing, irritability, nightmares, and continued sleepwalking. (Id.) Plaintiff was diagnosed with alcohol dependence, PTSD, and was prescribed Abilify for his anger, irritability, and agitation. (Id. at 318.)

         On July 15, 2013, Plaintiff was evaluated by Dr. Vangala. (Id. at 406.) Plaintiff's chief complaints were feelings of stress and anxiety, and that his PTSD symptoms were worsening. (Id. at 403.) The doctor conducted a mental status examination and noted that Plaintiff was dressed appropriately, alert, calm and cooperative, well-oriented, had good personal hygiene, maintained eye contact well, had regular speech, was goal-oriented, and had a logical thought process and fair memory (Id.) Dr. Vangala diagnosed Plaintiff with PTSD, work and relocation stress, and a GAF score of 55. (Id. at 405.)

         On August 31, 2013, Dr. Nwachukwa saw Plaintiff for a follow-up appointment. (Id. at 416.) The doctor noted that Plaintiff's PTSD screening test was positive. (Id. at 417.) Dr. Nwachuwka assessed that Plaintiff was acutely suicidal, but did not find him to have suicidal plans or a history of suicide attempts. (Id. at 415.) The doctor noted that Plaintiff already had a follow up appointment scheduled with his behavioral health provider, but reminded the patient of a 24 hours emergency service number. (Id.)

         2. Medical Treatment After Plaintiff's Disability Onset Date (November 26, 2013)

         On November 29, 2013, three days after Plaintiff's alleged onset date, Dr. Baker conducted a mental health clinic intake exam on Plaintiff. (Id. at 397.) Plaintiff's chief complaint was that he was sent home from work because they said he was “unfit for duty.” (Id.) He also complained of feeling angry and irritable, both at work and at home. (Id. at 398.) Plaintiff also reported feeling guilty, disconnected, worthless, and having nightmares. (Id.) The doctor noted that Plaintiff was well-groomed, cooperative, and friendly, and had normal speech and a linear, logical thought process. (Id.) However, he also noted that Plaintiff was distraught, anxious, and depressed. (Id.) Dr. Baker's diagnostic impression was PTSD with co-occurring symptoms of major depression, without psychosis or suicidal ideation. (Id. at 400.)

         On January 24, 2014, Plaintiff was seen for a follow up appointment by Dr. Yocum, a clinical psychologist. (Id. at 387.) Dr. Yocum assessed Plaintiff and found, among other things, that Plaintiff had difficulty with attention, concentration, and employment. (Id. at 395.) In assessing Plaintiff, Dr. Yocum utilized the PTSD Diagnostic Criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).[2] (Id. at 383.) After marking the indicator under each Criterion that were attributable, the doctor diagnosed Plaintiff with PTSD. (Id. at 383.)

         Dr. Yocum next assessed Plaintiff's mental status. (Id. at 385.) The doctor noted that Plaintiff was neatly and casually dressed, well-groomed, and oriented to person, place, and thing. (Id.) The doctor further opined that Plaintiff's thought process was logical and goal-directed, appropriate, and there was no evidence of hallucinations. (Id. at 386.) However, the doctor also noted that Plaintiff's mood was depressed, his judgement was impaired, and he had suicidal ideation without a plan or intent. (Id.)

         In addition to his PTSD diagnosis, Dr. Yocum remarked that Plaintiff met the diagnostic criterion for Major Depressive Disorder, which is secondary to his PTSD. (Id. at 386.) The doctor also noted that Plaintiff's symptoms had slightly worsened since his evaluation by Dr. Baker on December 27, 2013. (Id. at 386.) Under “Current Diagnosis, ” Dr. Yocum stated that “Veteran is diagnosed with PTSD and depression. These diagnoses result in symptoms that are active and independent. All symptoms work in conjunction to impact social and occupational functioning. It is impossible to fully differentiae what portion of impairments are attributable to each diagnosis.” (Id. at 389.) In regard to Plaintiff's unemployment, Dr. Yocum stated:

Veteran's irritability and outbursts of anger alienates others. His panic abruptly removes him from others and causes him to withdraw and avoid social interactions. His feeling “on guard” with others can impede his ability to form good working relationships. The overall effects of these symptoms are impairments in his ability to work cooperatively with peers, management and with the public.

(Id. at 395.) In regard to Plaintiff's attention and concentration, Dr. Yocum stated:

Veteran has many symptoms that interfere with attention, concentration, memory and problem-solving. He has intense internal and external cues which cause his psychological distress. His hypervigilance and his flashbacks all impede his attention and concentrations. These symptoms impair his ability to understand and follow instructions, retain instructions, and communicate effectively.

(Id.) Finally, in regard to motivation and drive, Dr. Yocum wrote “[Plaintiff's] flashbacks and lack of energy impair [his] ability to maintain task persistence, to arrive at work on time, and to work a regular schedule without excessive absences to a severe extent.” (Id.)

         On March 20, 2015, [3] Plaintiff was examined by Dr. Guttin. (Id. at 481.) Plaintiff informed the doctor that he had not worked in fifteen months and had not been leaving the house. (Id.) Despite his lack of work and his poor sleep quality, Plaintiff did note that his wife was a good support for him and their relationship was doing well. (Id.) The nursing note for the visit stated that Plaintiff took a PHQ-2 and screened positive for depression. (Id. at 484.) The note also indicated that Plaintiff took little interest or pleasure in doing things and felt down, depressed, or hopeless nearly every day. (Id.)

         Five days later, on Match 25, 2015, Plaintiff was seen by a licensed clinical social worker, Ms. Sarsingh. (Id. at 475.) During the examination Plaintiff was administered assessments. (Id.) The first assessment, a PHQ-9 for Patient Health, resulted in a score of 24, which indicates severe depressive symptoms, including, but not limited to, hopelessness, low energy, and trouble concentrating. (Id. at 476.) The second assessment, a GAD-7 for Generalized Anxiety Disorder, resulted in a score of 21, which indicates severe symptoms of anxiety. (Id. at 478.) Finally, a PCL-F assessment to measure PTSD symptoms was conducted and Plaintiff scored 58/80. (Id. at 477.)

         On April 27, 2015, Dr. Baye examined Plaintiff. (Id. at 469.) Plaintiff explained that he was feeling overwhelmed and having anger management issues. (Id. at 470.) Plaintiff described an incident with his neighbor where the neighbor banged on the floor while Plaintiff was walking across it causing Plaintiff to bang on her apartment door and scream at her. (Id.) Dr. Baye noted Plaintiff's mood to be “depressed and stressed out, ” but also noted that his thought process was linear, goal directed, and future oriented. (Id. at 470.) The doctor assed plaintiff with PTSD and insomnia. (Id.)

         On April 29, 2015, Dr. Nola, a clinical psychologist and one of Plaintiff's treating physicians at the VA, conducted a mental health examination. (Id. at 461.) According to the medical records, Plaintiff's “symptoms were addressed and his diagnosis was reported utilizing the DSM-5.” (Id. at 469.) Dr. Nola diagnosed Plaintiff with PTSD and Major Depressive Disorder recurrent with anxious distress (secondary to PTSD.) (Id.) The doctor reported that the following symptoms actively applied to Plaintiff's diagnosis: depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective ...

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