Martin v. Berryhill

          FINDINGS AND RECOMMENDATION

         INSTRUCTIONS

         The following proposed Findings and Recommendation have been sent to United States District Judge James M. Moody Jr. You may file written objections to all or part of this Recommendation. If you do so, those objections must: (1) specifically explain the factual and/or legal basis for your objection, and (2) be received by the Clerk of this Court within fourteen (14) days of this Recommendation. By not objecting, you may waive the right to appeal questions of fact.

         DISPOSITION

         Plaintiff Leanna S. Martin (“Martin”) began this case by filing a complaint pursuant to 42 U.S.C. 405(g). In the complaint, she challenged the final decision of the Acting Commissioner of the Social Security Administration (“Commissioner”), a decision based upon the findings of an Administrative Law Judge (“ALJ”).

         Martin maintains that the ALJ's findings are not supported by substantial evidence on the record as a whole.^[1] Specifically, Martin maintains that her residual functional capacity was erroneously assessed and offers two reasons why: 1) the ALJ gave insufficient reasons for discounting a consulting physician's opinions, and 2) the ALJ did not consider the possibility that Martin's failure to consistently keep her mental health treatment appointments was itself due to her mental impairments.

         The record reflects that Martin was born on September 12, 1979, and was thirty-five years old on November 1, 2014, the alleged onset date. She filed applications for disability insurance benefits and supplemental security income payments on January 5, 2015, and alleged that she was disabled as a result of, inter alia, mental impairments.

         The medical evidence relevant to Martin's mental impairments reflects that she sought medical attention for them prior to the alleged onset date. For instance, Martin saw Dr. Donald Wright, M.D., (“Wright”) on January 13, 2014, complaining of worsening depression/anxiety and reported being easily upset by trivial events. See Transcript at 484-488. Wright discontinued Martin on citalopram and began her on sertraline.

         Martin saw Wright again on June 16, 2014. See Transcript at 492-496. Martin continued to report problems with depression and anxiety. Wright discontinued Martin on sertraline and began her on fluoxetine.

         On September 23, 2014, Martin was seen by Dr. Tammy Berke, Ph.D., (“Berke”) for a mental health evaluation. See Transcript at 459-466. Berke recorded Martin's presenting problems to be as follow:

I have a big problem being around big crowds. I have a problem with anger. I don't have any drug problems. I have real bad panic attacks. They can hit me when I am driving or just sitting. I think I have some depress[ion]. I just don't want to be around anyone or go any [where], even family. I have never been like this before and I don't know why it hit me. I have gained weight and it affects my self esteem. She states that she obsesses alot. Her husband is 50. She has always felt threatened by his previous wife, who died from a homicidal suicidal event her BF. She died 7-8 [years] ago. She states that she still obsesses over her, afraid that her husband still loves her. She [has] always been worried that he could have been seeing his ex wife while they were married.

...

She states remembering panic attacks starting about 4 yrs. The first panic attack she had[, ] she had to go to the emergency room. She found out at age 12 that her father was not her real father. He drank a lot and was mean. She may have a real issue of not knowing of her bio father. She started having anxiety around people about 4 years. Went through a period of drinking around 21-30. She has 2 children, daughters age 14 and 9. She has been married 13 years. Depression started about 3 years ago.

See Transcript at 461. Martin's mood/affect was appropriate but sad, and her thought process was within normal limits. She was not a risk of harm to herself or others, and she expressed no homicidal ideations. Berke diagnosed a panic disorder and a major depressive disorder. Although Berke assigned Martin a Global Assessment of Functioning (“GAF”) of fifty, Berke believed Martin's condition could respond favorably to therapy.

         After the alleged onset date, Martin continued to seek medical attention for her mental impairments. For instance, Martin continued to see Berke for individual therapy and saw her on December 3, 2014. See Transcript at 457-458. Berke recorded Martin's presenting problems to be as follow: “She has increased stressors, taking care of [her] mother and grandmother. Panic attacks have been 2-3X a day. She went to work parttime as a cashier. ‘I am ready to [quit]. It is non stop, gets off task, can't remember things, can't focus on the job.'” See Transcript at 457. Martin was oriented as to person, place, and time. Her affect was concurrent with her mood, her appearance was clean and groomed, and she was medication compliant. Berke encouraged Martin to utilize, inter alia, relaxation skills, muscular relaxation, deep breathing, self-calming, and cognitive self-talk to help lessen the severity of her symptoms.

         The following day, Jennie Dawson, A.N.P, (“Dawson”) prepared a mental health evaluation of Martin. See Transcript at 453-456. Martin's appearance was neat/clean; her affect was appropriate, although her mood was depressed; her thought process was intact; and she reported no suicidal or homicidal ideations. A panic disorder and a major depressive disorder were diagnosed, and she was assigned a GAF of fifty. The following assessment of Martin's mental state was offered:

Pt endorse sx past 4 yrs and receiving tx per pcp for panic without warning several times daily; depression with social isolation, lack of motivation, mood lability, racing thoughts nightly that affect sleeping-getting about 4 hrs nightly average, rates depression and anxiety 8:10 daily average with 10 severe, mood swings daily and becomes angered and then self isolates. She feels most of this is coming from not know[ing] who her father is. She is motivated to get past this and hopes this will resolv[e].

See Transcript at 455.

         Martin saw Berke again on December 18, 2014. See Transcript at 451-452. Martin reported sleeping well with trazodone. She also reported that her other medications have helped reduced her panic attacks and anxiety. Berke additionally noted that Martin reported the following:

She is still emotionally [haunted] by the fact that when she was 11-12, she found out that [her] father was not her bio father. She has 2 sisters from her bio mother [and her father] is now [her] step father. She is not recovered from the fact that he used to beat her and treated her different than her 2 sisters. They were never abused. She witness[ed] alot of domestic violence with her step father beating her mother.

See Transcript at 451. Martin was oriented as to person, place, time, and situation. Her affect was concurrent with her mood, and she was medication compliant. She reported two to three panic attacks a day and noted that the Christmas season had brought about an increase in her level of stress. Berke continued to encourage Martin to utilize non-medical techniques to help lessen the severity of her symptoms.

         Martin saw Berke again on February 3, 2015. See Transcript at 449-450. Martin reported that her grandmother had died since the last time Martin saw Berke. Martin reported that she was with her grandmother at the time of death, and Martin's father was with them, acting inappropriately and saying rude things. Martin was oriented as to person, place, time, and situation. Her affect was concurrent with her mood, and she was medication compliant. Martin reported having three to four panic attacks a day. She reported that the attacks hit her “hard and quick, ” and she could sometime feel them coming on because her hands would start to sweat, and her heart would begin racing. See Transcript at 449. Berke continued to recommend the use of non-medical techniques to help lessen the severity of the symptoms.

         Martin continued to see Berke and/or Dawson throughout 2015 and on into 2016. See Transcript at 596-597 (04/30/2015), 594-595 (04/30/2015), 592-593 (05/18/2015), 590-591 (05/28/2015), 588-589 (09/17/2015), 586-587 (12/16/2015), 584-585 (12/16/2015), 580-583 (12/16/2015), 578-579 (03/31/2016), 576-577 (03/31/2016), 572-575 (04/18/2016). The progress notes from the presentations are generally consistent with the progress notes from the earlier presentations. Specifically, Martin continued to complain of panic attacks and problems stemming from her family and other relationships. She was nevertheless oriented as to person, place, time, and situation; and her affect continued to be concurrent with her mood. Although Martin had been medication compliant, Berke observed in a December 16, 2015, progress note that Martin had stopped taking her medication during an approximately two to three month period “due to interfering with her heart [arrhythmia].” See Transcript at 584. Berke also observed the following in the progress ...