Allen v. Commissioner of Social Security

          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, ...