United States District Court, E.D. Arkansas, Northern Division
LEANNA S. MARTIN PLAINTIFF
v.
NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration DEFENDANT
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 ...