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Baxla v. Colvin

United States District Court, D. Arizona

September 9, 2014

Stacee Kensler Baxla, Plaintiff,
v.
Carolyn W. Colvin, Defendant

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[Copyrighted Material Omitted]

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For Stacee Kensler Baxla, Plaintiff: Eric Glenn Slepian, LEAD ATTORNEY, Slepian Law Office, Phoenix, AZ.

For Carolyn W Colvin, named as: Carolyn Colvin - Acting Commissioner of Social Security, Defendant: Michael Howard, LEAD ATTORNEY, Social Security Administration - Denver, CO, Office of the General Counsel Region VIII, Denver, CO; Michael A Johns, LEAD ATTORNEY, U.S. Attorney's Office, Phoenix, AZ.

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ORDER

Bridget S. Bade, United States District Judge.

Plaintiff Stacee Kensler Baxla seeks judicial review of the final decision of the Commissioner of Social Security (the Commissioner) denying her application for disability insurance benefits under the Social Security Act (the Act). The parties have consented to proceed before a United States Magistrate Judge pursuant to 28 U.S.C. § 636(b) and have filed briefs in accordance with Local Rule of Civil Procedure 16.1.[1] For the following reasons, the Court affirms the Commissioner's decision.

I. Procedural History

On May 19, 2009, Plaintiff applied for disability insurance benefits under Title II of the Act alleging a disability beginning on October 27, 2007. (Tr.13.)[2] After the Social Security Administration (SSA) denied

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Plaintiff's initial application and her request for reconsideration, Plaintiff requested a hearing before an administrative law judge (ALJ). After conducting a hearing, the ALJ issued a decision finding Plaintiff not disabled under the Act. (Tr. 13-22.) This decision became the final decision of the Commissioner when the Social Security Administration Appeals Council denied Plaintiff's request for review. (Tr. 1); see 20 C.F.R. § 404.981 (explaining the effect of a disposition by the Appeals Council.) Plaintiff now seeks judicial review of this decision pursuant to 42 U.S.C. § 405(g).

II. Medical Record

The record before the Court establishes the following history of examination, diagnosis, and treatment. The record also include opinions from medical sources who either examined Plaintiff or reviewed the record, but who did not provide treatment.

A. Treatment Related to Mental Health

In October 2006, Plaintiff sought treatment at Value Options and was diagnosed with bipolar disorder, depressive disorder, obsessive compulsive disorder, post-traumatic stress disorder, and schizoaffective traits. (Tr. 929.) She continued treatment at Value Options throughout 2006. (Tr. 904-42.)

In March 2007, Plaintiff attempted suicide and was hospitalized for several days. (Tr. 262.) The emergency room report noted Plaintiff's diagnoses as bipolar disorder, depression, obsessive-compulsive disorder, and thoughts of self-destructive behavior. (Tr. 262-64.) In June 2007, Plaintiff continued receiving care at Value Options for anxiety, paranoia, increased sleep, auditory hallucinations, and thoughts of self-harm. (Tr. 877-78.)

Plaintiff then sought treatment at Magellan Health Services (Magellan). On November 29, 2007, Plaintiff was treated at Magellan for bipolar disorder. (Tr. 859.) She was instructed to contact the crisis line if she experienced an increase in auditory hallucinations (hearing voices), anxiety, a desire to mutilate herself, or suicidal ideation. (Tr. 859-860.) Magellan's records include a July 30, 2008 annual assessment of Plaintiff's care, which noted that Plaintiff received treatment for irritability and mood cycling. (Tr. 298.) Plaintiff also reported some depression due to headaches, pain issues, and trouble sleeping. (Tr. 298-99.) She reported that she was on " medical leave" from her job and stated that she would probably be unable to return to work " due to the physical demands." (Tr. 298.) On examination, Plaintiff's mood was euthymic and sad, her affect was appropriate, her thought process was goal directed and coherent, she had good insight and judgment, and she denied having thoughts of self-harm. (Tr. 299.) Plaintiff continued treatment at Magellan throughout 2008. (Tr. 727-42.)

On January 8, 2009, Plaintiff sought treatment at Southwest Network Direct Care Clinic (Southwest) for obsessive compulsive disorder (OCD) tendencies. (Tr. 724.) A mental status examination indicated that she was appropriately dressed, had a cooperative attitude, a euthymic mood, an appropriate affect, goal directed thought, no delusions or hallucinations, and no self-injury. (Tr. 724-25.) In addition, she was alert, had good concentration, grossly intact memory, but poor insight and judgment. (Tr. 725.) She was diagnosed with OCD, major depressive disorder, and panic. (Tr. 724-25.)

On January 12, 2009, Plaintiff received treatment at Magellan for bipolar disorder. (Tr. 303.) She reported experiencing " a lot of anxiety." ( Id.) On examination,

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Plaintiff's mood was appropriate, she had a logical thought process, and was cooperative. (Tr. 303-04.) She denied visualizations and hallucinations. (Tr. 304.) She reported that when she felt well she liked going places and spending time with her children or visiting her mother. (Tr. 303.) When Plaintiff was not doing well, she was tearful, slept a lot, and experienced an increase in hearing voices and anxiety. (Tr. 304.)

On March 11, 2009, Plaintiff was treated at Southwest for " depressive symptoms of anxiety, isolation, fear of leaving home, [and] anhedonia." (Tr. 719.) A mental status examination indicated that her mood was depressed with a tearful affect. ( Id.) Additionally, her appearance was appropriate, she was cooperative, her speech and motor activity were within normal limits, and she had a goal-directed thought process. (Tr. 719.) Plaintiff was also alert, had good concentration, grossly intact memory, good insight and judgment, and no hallucinations or delusions. (Tr. 720.) She was diagnosed with bipolar disorder and unspecified personality disorder. (Tr. 719-20.)

On May 6, 2009, Plaintiff continued treatment at Southwest for " affective reactivity anxiety, depression, [and] chronic low self-esteem." (Tr. 717.) A mental status examination reflected that her mood was depressed and her affect was neutral. ( Id.) She exhibited some paranoia, believing everyone was talking about her. ( Id.) She was prescribed Abilify to augment the Effexor that she was already taking. ( Id.) She was diagnosed with bipolar disorder and unspecified personality disorder. (Tr. 717-18.)

Plaintiff was next treated at Southwest on June 3, 2009. Plaintiff reported that her depression seemed " a little better with the Abilify." (Tr. 715.) Plaintiff continued to report having anxiety with panic attacks when she " had to leave home." ( Id.) Plaintiff also worried about others and had poor sleep. ( Id.) A mental status examination reflected that Plaintiff's appearance was appropriate, her mood was depressed with a neutral affect. (Tr. 715.) She was alert, her memory was grossly intact, and she had good insight and judgment. (Tr. 716.) Plaintiff continued to struggle with panic and motivation. She was diagnosed with bipolar disorder, panic disorder, and unspecified personality disorder. (Tr. 715-16.)

On July 29, 2009, Plaintiff reported to treatment providers at Southwest that the increase in Abilify had helped " a little" with her depression, her anxiety " was better" with Klonopin, and her sleep was improved with Ambien. (Tr. 713.) She still reported some social anxiety. ( Id.) She exhibited a neutral mood with appropriate affect. ( Id.) She had normal speech and motor activity, goal directed thought, no delusions or hallucinations, no thoughts of self-injury, she was alert, had good concentration, grossly intact memory, and good insight and judgment. (Tr. 713-14.) Plaintiff's depression was " somewhat better," but she continued to struggle with motivation and panic. ( Id.)

From September 15 through 17, 2009, Plaintiff was hospitalized at Banner Thunderbird Medical Center for suicidal ideation with a recent attempt. (Tr. 349.) After her release from the hospital, Plaintiff was transferred to Aurora Behavioral Health (Aurora) for inpatient psychiatric care from September 17 through 21, 2009 for severe, recurrent major depression. (Tr. 359.) On discharge, it was noted that Plaintiff had responded well to treatment. ( Id.) She denied depressive symptoms. ( Id.) On examination, Plaintiff was cooperative, alert, her thought was logical and coherent, her speech and motor activity were normal, her affect was full, her cognitive

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functioning was average, and her insight and judgment were fair. (Tr. 359-60.) She denied hallucinations, delusions, and suicidal ideation. ( Id.)

After her discharge from Aurora, Plaintiff continued treatment at Magellan and Southwest. (Tr. 711.) The Magellan records include an October 15, 2009 annual assessment (for the period July 30, 2008 to October 15, 2009), which noted that Plaintiff had received treatment for bipolar disorder and obsessive-compulsive disorder with schizoaffective traits. (Tr. 388.) Her symptoms included irritability and self-abusing behavior such as cutting herself, mood cycling, and isolation. ( Id.) During a home visit the week before the annual assessment, Plaintiff exhibited a dull, blunted affect, poor eye contact, and her voice was low and rambling. ( Id.) She reported that recent neck surgery contributed to her depression. ( Id.) Plaintiff reported that she had low energy and was spending a lot of time in bed. ( Id.) She displayed good information processing and problem solving. She was diagnosed with bipolar disorder. (Tr. 380-90.)

On January 15, 2010, Plaintiff was treated at Southwest. (Tr. 698.) She described her mood as " blah" and her energy as poor. ( Id.) She reported some paranoia and social phobia, and stated that she stayed home most of the time. (Tr. 697.) A mental status examination indicated that Plaintiff was appropriately groomed with good hygiene. She had an appropriate affect, normal speech and motor activity, and goal directed thought. (Tr. 699.) She denied delusions, hallucinations, or self-injury. ( Id.) She was alert and had fair concentration, insight, and memory. ( Id.) She was diagnosed with bipolar disorder, social phobia, and post-traumatic stress disorder (PTSD). (Tr. 698-99.)

On February 16, 2010 Plaintiff was treated at Magellan. (Tr. 691.) Plaintiff's affect was appropriate and her mood was anxious. ( Id.) She reported that she stayed home most of the time. (Tr. 692.) Her symptoms were described as moderate and minimally improved. ( Id.) She was diagnosed with bipolar disorder, PTSD, social phobia, and OCD. (Tr. 697.)

On August 6, 2010, after Plaintiff's girlfriend committed suicide, Petitioner was treated at Magellan for bipolar disorder. (Tr. 682.) Plaintiff was tearful, shocked and upset, and reported that she might pursue inpatient psychological admission to Aurora. (Tr. 681.) Plaintiff's affect was appropriate and tearful, with an anxious and depressed mood. (Tr. 682.) Her symptoms were noted to be moderate and globally minimally worse. ( Id.) She was diagnosed with bipolar disorder, PTSD, social phobia, and obsessive-compulsive disorder. ( Id.)

From August 21 through 26, 2010, Plaintiff received inpatient care at Aurora for suicidal ideation, bipolar disorder, OCD, and PTSD. (Tr. 556-679) Plaintiff " improved rapidly and greatly during her stay." (Tr. 556.) She was " free of any depression and suicidal ideation at the end of her stay." ( Id.) On discharge, Plaintiff was diagnosed with bipolar disorder, PTSD, obsessive-compulsive disorder, and cluster B traits. (Tr. 556-675.)

B. Treatment Related to Physical Health

In addition to mental health issues, Plaintiff had chronic migraine headaches, neck pain, optic neuritis, and syncope. (Tr. 911-15.) In 2006, her treating neurologist, Dr. Shyamala Kumar, M.D., noted that Topamax resulted in a " 35% improvement in headaches." (Tr. 766.) In 2007, Dr. Kumar discontinued Topamax because he thought that it could be contributing to suicidal thoughts. (Tr. 763.)

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In January 2008, Plaintiff had an episode of syncope while she was at work. (Tr. 515.) At Arrowhead Hospital, she was diagnosed with neurocardiogenic syncope and directed to follow-up with her neurologist. ( Id.) On February 1, 2008, Plaintiff followed up with Dr. Kumar for tremors, syncope, migraine headaches, and neck pain. (Tr. 539.) Dr. Kumar noted that Plaintiff had had " few near syncope episodes" since she had such an episode at work the previous week. ( Id.)

On February 18, 2008, Plaintiff saw Dr. Rick Okagawa, M.D. at Cardiovascular Consultants for syncope. (Tr. 547.) Plaintiff reported continued episodes of syncope without warning. ( Id.) She reported that the " total duration of the episodes [was] usually 1 minute." ( Id.) Dr. Okagawa advised Plaintiff to follow-up with his colleague Dr. Deepak Khosla in two weeks. (Tr. 548.) On June 26, 2008, Plaintiff saw Dr. Khosla. (Tr. 543.) He noted that Plaintiff still had " symptoms of lightheadedness and a few episodes of syncope." (Tr. 543.) He advised Plaintiff to ask her psychiatrist to prescribe Paxil in place of Effexor because there was " not much experience with Effexor in neurocardiac syncope." ( Id.)

On August 27, 2009, Plaintiff had an anterior cervical discectomy with fusion and plating. (Tr. 477-79, 480-82.) In October 2009, Plaintiff reported ongoing headaches. (Tr. 388-94.) Plaintiff also reported that her neck pain and radicular symptoms subsided post fusion. (Tr. 470-71.) Approximately ten months later, Plaintiff's migraine headaches returned. (Tr. 530-31, 997.)

In September 2010, Plaintiff was treated for a recurrence of neck pain. On examination, she was tender to palpation and had a markedly decreased range of motion. (Tr. 823, 954, 991-92, 820-22.) In May 2011, Plaintiff continued experiencing headaches, but they were less intense and less frequent than in the past. (Tr. 816-17.) Medical records also show that Plaintiff had optic neuritis, and macular damage to the right eye and blindness in the left. (Tr. 459.) Her right eye exhibited a retinal hole, with severe loss of visual field. (Tr. 979.)

C. Medical Opinion Evidence

1. Akrum Al-Zubaidi, M.D.

In February 2010, Plaintiff was examined by State Agency Physician Dr. Akrum Al-Zubaidi. (Tr. 441.) Plaintiff's " chief complaint" was " vasovagal syncope." ( Id.) Plaintiff reported that she had past cervical neck problems, but after cervical fusion her neck pain was resolved. ( Id.)

She reported that she had " vasovagal syncope two years ago while working at UPS," and that at the time of Dr. Al-Zubaidi's examination, she was passing out twice a week. ( Id.) She stated that " her mental condition is the main reason she that she [was] unable to work, not her physical condition." ( Id.) Plaintiff reported that she could cook, clean, do yard work, and take care of her personal needs. (Tr. 442.) On examination, Dr. Al-Zubaidi noted that Plaintiff was " very polite, well-dressed." ( Id.) She had a normal gait, was able to squat, heel talk, toe walk, tandem walk, and hop on either foot. ( Id.) She had a normal range of motion and full strength in her upper and lower extremities. ( Id.)

Dr. Al-Zubaidi completed a physical functional assessment. (Tr. 444-46.) He opined that Plaintiff could sit and stand or walk six to eight hours in an eight-hour workday. (Tr. 444.) He found that Plaintiff could lift fifty pounds occasionally and twenty-five pounds frequently and that she was unrestricted in all other postural and manipulative activities. (Tr. 444-45.) He

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further found that Plaintiff should avoid working around heights and moving machinery. (Tr. 445.) He explained that Plaintiff " suffer[ed] from vasovagal syncope with two full syncopal episodes per week. This would make it dangerous for her to work ...


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