United States District Court, D. Arizona
Alissa L. Allen, Plaintiff,
v.
Commissioner of Social Security, Defendant.
ORDER
Bridget S. Bade, United States Magistrate Judge
Plaintiff
Alissa L. Allen (“Plaintiff”) seeks judicial
review of the final decision of the Commissioner of Social
Security (the “Commissioner”) denying her
application for 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 Rule
16.1 of the Local Rules of Civil Procedure. As discussed
below, the Court affirms the Commissioner's decision.
I.
Procedural Background
On
August 6, 2013, Plaintiff applied for a period of disability
and disability insurance benefits alleging a disability onset
date of July 24, 2012. (R. 20.)[1] After Plaintiff's application
was denied on initial review and on reconsideration, she
requested a hearing before an administrative law judge
(“ALJ”). (Id.) Following a hearing, the
ALJ issued a decision finding Plaintiff not disabled under
the Act. (R. 20-35.) Plaintiff requested review of the
ALJ's decision. (R. 7-10, 15.) The Social Security
Appeals Council denied Plaintiff's request for review and
Plaintiff now seeks judicial review of the Commissioner's
decision pursuant to 42 U.S.C. § 405(g).
II.
Administrative Record
The
administrative record includes medical records pertaining to
the history of diagnoses and treatment of Plaintiff's
alleged impairments. The record also includes several medical
opinions. The Court discusses the relevant records and
opinions below.
A.
Treatment Records related to Mental Impairments
1.
LPC Hillary Shluker and Dr. S. David Hoffman
In July
2012, Licensed Professional Counselor (“LPC”)
Hillary Shluker (R. 606- 15, 679-81) and Dr. S. David Hoffman
(R. 606-17, 679-81) examined Plaintiff and evaluated her for
a Seriously Mentally Ill. (“SMI”) Determination.
(R. 606-16.) As part of that determination, LPC Shluker
completed an “Assessment for Level of Care.” (R.
606-13.) LPC Shluker noted that Plaintiff was hospitalized
several times between 2002 and 2004 for psychiatric issues,
including a suicide attempt. (R. 607.) LPC Shluker noted that
Plaintiff's reported depression “as evidenced by
feeling tired most of the day, not want[ing] to get out of
bed, ” daily migraines, frequent isolation, and
thoughts of wanting to die. (R. 608.) Plaintiff also reported
“mania as evidenced by losing her temper easily, rapid
pressured speech, [being] easily frustrated, [having]
aggressive tendencies, cheating on her husband, sexually
acting out, hyperactivity, impulsivity, excessive and
compulsive spending, difficulty sleeping, [and] excessive
cleaning.” (Id.) Plaintiff reported symptoms
of psychosis including hearing voices and seeing ghosts.
(Id.) Plaintiff also reported instances of
self-harm, including tearing “the skin off [her] hands
constantly” to the point where she “had an
exorcism” because Plaintiff's husband thought she
was “possessed.” (Id.)
On
examination LPC Shluker observed that Plaintiff had a labile
affect, was tearful, had pressured speech, concrete thought
content, circumstantial thought process, and partial
judgment. (R. 610-11.) LPC Shluker concluded that Plaintiff
appeared “to be suffering from a mood disorder as
evidenced by periods of severe depression that occur[ed] for
one week 4-5 times per year, ” and that caused
Plaintiff to sleep “most of day and night, ” have
suicidal ideations, frequent crying spells, and resentment
that her 2004 suicide attempt was unsuccessful. (R. 612.) LPC
Shluker further noted that Plaintiff's mania and
depression symptoms had persisted since her adolescence and
Plaintiff reported that her symptoms were “getting
worse despite two hospitalizations and ongoing psychiatric
medication monitoring.” (Id.) LPC Shluker
concluded that Plaintiff presented with symptoms of
borderline personality disorder including “impulsivity
in at least two self-damaging areas (compulsive spending and
sexually acting out), recurrent self-mutilating behavior,
affective instability due to irritability, unstable
interpersonal relationships, chronic feeling of emptiness,
and frequent displays of temper.” (Id.)
LPC
Shluker concluded that Plaintiff's persistent mood
disorder was getting worse and that “outpatient
psychiatric care and medication management [had] done little
to improve her stability so far.” (R. 615.) She further
found that Plaintiff had difficulty with activities of daily
living and was “not functioning well at home and [was]
having difficulties functioning at work . . . .”
(Id.) LPC Shluker opined that Plaintiff “would
greatly benefit by the services offered from the SMI
program.” (Id.)
On July
30, 2012, Dr. Hoffman reviewed LPC Shluker's
“clinical summary” and concluded that Plaintiff
met “the criteria for SMI-A with a qualifying diagnosis
and functional impairment of severe disruption of daily life
with frequent thoughts of death, suicide, or
self-harm.” (R. 617.)
2.
Winona Belmonte, M.D.
Psychiatrist
Dr. Belmonte began treating Plaintiff on August 22, 2012. (R.
601- 05.) On examination, Dr. Belmonte observed that
Plaintiff had a cooperative attitude, depressed and sad mood,
an appropriate and tearful affect, a goal directed thought
process, good attention and concentration, grossly intact
memory, and good insight and judgment. (R. 603-04.) Dr.
Belmonte assessed Plaintiff as having “chronic suicidal
thoughts” and diagnosed Plaintiff with bipolar I
disorder. (R. 604.) Dr. Belmonte prescribed various
medications. (Id.)
During
an October 25, 2012 appointment with Dr. Belmonte, Plaintiff
reported that she was “not as depressed, ” but
that she slept a lot. (R. 594.) On examination, Dr. Belmonte
observed that Plaintiff had an appropriate affect, a euthymic
mood, a cooperative attitude, logical thought process, good
concentration and intact memory, good insight and judgment,
and a good fund of knowledge. (Id.) Dr. Belmonte
assessed that Plaintiff's depression was slightly
improved, but she had “significant daytime sedation
from her meds.” (R. 595.) Dr. Belmonte adjusted
Plaintiff's medications. (Id.)
Dr.
Belmonte saw Plaintiff again on November 15, 2012. (R.
591-93.) Plaintiff reported that overall she was “not
doing so well” since Seroquel was discontinued, but her
sleep had improved. (R. 591.) Plaintiff reported increased
anger and irritability and stated that she could not tolerate
stress. (Id.) Plaintiff was also “getting to a
point of suicidality.” (Id.) Plaintiff
reported the medication side effects caused “increased
daytime sedation” that “[s]ignificantly
interfered with function.” (Id.) On
examination, Dr. Belmonte observed that Plaintiff was alert,
had an appropriate affect and tearful affect, had an angry,
irritable, depressed mood, was cooperative, had a logical and
non-psychotic thought process, had good concentration and
intact memory, and good insight and judgment. (R. 592.)
Dr.
Belmonte assessed that “[o]verall, [Plaintiff] ha[d an]
increase in symptoms.” (Id.) Dr. Belmonte
restarted Seroquel, decreased the dosage of Depakote, and
prescribed Clonazepam to counteract Plaintiff's increased
irritability, anger, and anxiety. (Id.) Dr. Belmonte
noted that plaintiff should return in one week and that
Plaintiff should have more frequent appointments until her
symptoms were “more under control.”
(Id.)
Dr.
Belmonte saw Plaintiff again on November 27, 2012. (R.
588-90.) Plaintiff reported she was sleeping much less than
at the time of her last appointment and that she was waking
up happier. (R. 588.) Plaintiff reported that she felt
“like her normal self . . . [and] was currently
comfortable with [h]ow her meds [were] working for
her.” (Id.) Additionally, Plaintiff stated
that she was able to enjoy time with her family, better
tolerate frustrating situations, and had reconnected with old
friends that she had not seen for about a year.
(Id.) On examination, Dr. Belmonte observed that
Plaintiff was alert, had an appropriate affect, had a
euthymic, angry, and irritable mood, was cooperative, had a
logical and non-psychotic thought process, had good
concentration and intact memory, and good insight and
judgment. (R. 588.) Dr. Belmonte assessed that
Plaintiff's mood had “improved to [where] she was
her usual self” and she was stable on her medication.
(Id.) Dr. Belmonte advised Plaintiff to return in
eight weeks. (R. 589.)
Dr.
Belmonte's treatment notes from a February 7, 2013
appointment record that Plaintiff was “clinically
stable” and that her only complaints were “anger
issues” and anxiety that was “manifested by
[Plaintiff's] increased picking [of her skin].” (R.
586.)
During
a June 27, 2013 appointment, Plaintiff reported that her mood
was stable and she denied any “aggressive behavior or
uncontrollable anger.” (R. 578.) Plaintiff reported
that her medications “were working quite well.”
(Id.) Plaintiff reported that she still had anxiety
and continued to pick her skin. (Id.) Plaintiff was
“tolerating” the Clonazepam “well.”
(Id.) Plaintiff also reported that her depression
was “stable” on Wellbutrin and Lexapro.
(Id.) She reported having felt down for a few days,
but she was able to “manage her symptoms
appropriately” and “was able to tolerate stress
better.” (Id.)
On
examination, Dr. Belmonte observed that Plaintiff was alert,
had an appropriate affect, had a euthymic, angry, and
irritable mood, was cooperative, had a logical and
non-psychotic thought process, had good concentration and
intact memory, and good insight and judgment. (R. 579.) Dr.
Belmonte assessed that Plaintiff was “clinically
stable, ” “comfortable with how her current
medication regimen [was] working, ” had “much
decreased crying spells, decreased depressive symptoms, . . .
no psychotic symptoms, [and was] able to tolerate her job
better.” (R. 580.) Dr. Belmonte advised Plaintiff to
return in twelve weeks. (Id.)
3.
Nurse Practitioner Jessica Dery
Nurse
Practitioner (“NP”) Dery also treated Plaintiff
for ongoing symptoms of bipolar I disorder. (R. 648-51, 666,
691-96, 698-702, 714-16, 885-88, 894-98, 899-902, 903-05.) On
October 18, 2013, NP Dery saw Plaintiff for a “routine
medication check.” (R. 691-94.) Plaintiff reported
memory loss and migraines. (R. 691.) On examination, NP Dery
found that Plaintiff exhibited a euthymic mood, did not
appear to be an imminent risk to herself or others, had a
cooperative attitude, had a logical and unremarkable thought
process, that her thought-content was non-psychotic, her
concentration was good, her memory intact, and her memory,
intellect, insight, and judgment were all “fair.”
(R. 692.) NP Dery advised Plaintiff to return in four weeks.
(R. 693.) Plaintiff continued treatment with NP Dery. (R.
698-702 (November 2013), 714-16 (January 2014, noting
increased suicidal ideation), 903-05 (April 2014), 899-902
(June 2014, noting dysphoric mood, increased suicidal
thoughts, increased “intrusive” (homicidal)
thoughts), 894-98 (June 2014), R. 889-93 (August 2014, noting
recent suicidal ideation, dysphoric mood), R. 885-88 (October
2014).)
B.
Treatment Records related to Physical Impairments
1.
Marisa Sosinsky, M.D.
Neurologist
Dr. Sosinsky treated Plaintiff for several physical
impairments. (R. 793-94) (May 6, 2014), R. 795-96 (July 28,
2014), R. 797-98 (August 12, 2014), R. 799-803 (November 4,
2014), R. 804 (January 20, 2015), R. 936-40 (April 7, 2015),
R. 931-34 (April 28, 2015).) She diagnosed Plaintiff with
cervical and lumbrosacral radiculopathy at all of her
appointments. (Id.) She also diagnosed Plaintiff
with carpal tunnel syndrome and skin sensation disturbance
(R. 797-800, 802, 804, 931-34, 936-40), and with migraines
without aura. (R. 799-800, 802, 804. 931-34, 936-40.) In
2015, Dr. Sosinsky noted that Plaintiff had a history of
migraine headaches and that she was having daily headaches,
“many of which” were “migraine quality . .
. at least half the days of the month.” (R. 933, 939.)
Dr. Sosinsky noted that Plaintiff's headaches had
“significantly decreased” her quality of life.
(Id.) Dr. Sosinsky noted that due to Plaintiff's
“severe history of mental health issues” certain
medications for treating migraines were contraindicated.
(Id.) She concluded that Botox was the most
appropriate treatment. (Id.)
In
January 2015, Dr. Sosinsky administered a Botox injection for
Plaintiff's migraines and indicated that Plaintiff should
receive injections every 90 days. (R. 804.) On April 7, 2015,
Dr. Sosinsky again assessed migraine without aura, and noted
that Plaintiff's migraines had decreased. (R. 938.) She
diagnosed Plaintiff with chronic migraines and directed
Plaintiff to return on April 28, 2015 for another injection.
(R. 939.) On April 28, 2015, Dr. Sosinsky noted that the
Botox injection was “dramatically effective” but
had worn off during the past couple of weeks before
Plaintiff's appointment. (R. 932.) Dr. Sosinsky
administered another Botox injection and directed Plaintiff
to repeat the procedure in three months. (R. 932, 933.)
2.
Treatment at Central Mesa Medical
Beginning
in June 2014, Plaintiff received treatment from several
providers at Central Mesa Medical, including Travis Steigler,
M.D., for migraines, joint pain, neck pain, low back pain,
skin picking, and fatigue. (R. 973-1060.) During a June 23,
2014 appointment, Dr. Steigler diagnosed neck pain, low back
pain, migraines, and bipolar disorder. (R. 1041.) Dr.
Steigler noted that Plaintiff was in a car accident on June
2, 2014. (R. 1045.) Plaintiff reported waking up at night due
to pain and complained of “constant migraines.”
(Id.) Dr. Steigler observed that Plaintiff had a
reduced range of motion in the “cervical region [with]
rotation, side bending, flexion, and extension.” (R.
1046.) Dr. Steigler prescribed Gabapentin, Percocet, and
Imitrex. (R. 1041.)
During
a July 21, 2014 appointment, Dr. Steigler treated Plaintiff
for low back pain and neck pain. (R. 1035.) Plaintiff
described the pain as sharp and radiating. (R. 1036.)
Plaintiff reported that pain caused her difficulty dressing
and sleeping. (R. 1037.) Dr. Steigler diagnosed cervical
bulging discs, neck pain, migraines, and lower extremity
edema. (R. 1034.) He prescribed Oxycontin, Perocet, and
Imitrex. (Id.) Dr. Steigler continued these
prescriptions at Plaintiff's subsequent appointments. (R.
1037, 1039.) In July 2015, Plaintiff had right upper
extremity carpal tunnel decompression surgery. (R. 967.)
C.
Opinion Evidence
1.
Jonna L. Krabbenhoft-Examining Physician
On
November 20, 2012, Psychologist Dr. Jonna L. Krabbenhoft
examined Plaintiff related to her mental impairments. (R.
571-76.) She also reviewed Plaintiff's medical records
from May 2011 to July 2012 and reviewed two “Function
Reports” that Plaintiff completed as part of her
application for disability benefits. (R. 571.) Plaintiff
reported that she could not work because she could not
“get along with people and [had] nervous breakdowns,
and [was] depressed a lot.” (Id.) Plaintiff
reported that she had been “suicidal since age
ten” and she received treatment for suicidal ideations,
including a hospital stay sometime between 2000 and 2002. (R.
572.) Plaintiff reported that, roughly a year later, she was
hospitalized after she tried to commit suicide.
(Id.)
Plaintiff
also reported that, at the time of her appointment with Dr.
Krabbenhoft, she was taking Depakote, Wellbutrin, Seroquel,
Klonopin, and Lexapro and experienced some side effects.
(Id.) Plaintiff explained that Depakote caused her
to experience increased agitation at night and that when one
of her providers “attempted to discontinue
Seroquel” her anger increased and she “was
extremely mad at everybody.” (Id.) Plaintiff
denied any recent suicide attempts and reported that she
continued to have “extreme nervous breakdowns when
under stress, ” mood swings, excessive tearfulness,
feelings of hopelessness and helplessness, and suicidal
ideation. (Id.)
Dr.
Krabbenhoft diagnosed Plaintiff with mood disorder, not
otherwise specified (“NOS”) with psychotic
features, personality disorder, NOS traits, and migraines.
(R. 574.) Dr. Krabbenhoft opined that Plaintiff's
prognosis was “[g]uarded” due to “reported
ongoing suicidal ideations and ‘breakdowns.'”
(Id.)
2.
NP Dery and Dr. Araashdeep Gill
On
November 4, 2013, NP Dery at Partners in Recovery completed a
“Medical Assessment of Claimant's Ability to
Perform Work Related Activities (Mental).” (R. 695.) NP
Dery opined that Plaintiff had mild “deterioration in
her personal habits” and “constriction of
interests.” (Id.) NP Dery also opined that
Plaintiff had moderately severe limitations in her abilities
to relate to other people, to perform daily activities, to
understand, carry out, and remember instructions, to respond
appropriately to supervisors and co-workers, to respond
appropriately to customary work pressure, and to perform
simple tasks. (Id.) NP Dery indicated that
Plaintiff's limitations had “lasted or [could] be
expected to last twelve months or longer.” (R. 696.)
Beneath that statement she wrote “dependent on findings
from Barrows Neurological [Institute].” (Id.)
In response to whether Plaintiff's “psychiatric
symptoms were exacerbated by a general medical condition,
” NP Dery wrote “memory loss follow up at
Barrows.” (Id.) NP Dery opined that
Plaintiff's psychiatric symptoms moderately limited
“the sustainability of work pace.” (Id.)
NP Dery
indicated that, as of the date of her opinion, she had
treated Plaintiff once and she had considered or reviewed
“records from other providers, mental status
examination, [and Plaintiff's] response to treatment . .
. .” (Id.) NP Dery indicated that the
limitations she assessed “result[ed] from objective,
clinical, or diagnostic findings which [were] documented
either by [her], or elsewhere in [Plaintiff's] medical
records.” (Id.)
In an
undated letter addressed “to whom it may concern,
” Dr. Gill from Partners in Recovery stated that
Plaintiff's “case . . . was reviewed by [NP] Dery
in collaboration with Dr. Araashdeep Gill, Chief
Psychiatrist.” (R. 703.) Dr. Gill stated that the
assessment was based on “past treatment documentation
and most recent assessment.” (Id.) Dr. Gill
agreed with NP Dery's assessment. (Id.)
3.
Dr. Maria Sosinsky
In May
2015, Dr. Sosinsky completed a “Medical Assessment of
Ability to do Work-Related Physical
Activities.”[2] (R. 910-11.) Dr. Sosinsky opined that
Plaintiff's headaches limited her ability to perform work
related activities. (R. 910.) Dr. Sosinsky indicated that,
“without her current Botox treatments, ”
Plaintiff had “severe migraine” headaches four to
five times a week that lasted for three or more hours.
(Id.) Dr. Sosinsky noted that Plaintiff had
“ancillary symptoms” of nausea, fatigue, ...