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Camarillo v. Berryhill

United States District Court, N.D. Texas, Dallas Division

March 2, 2018

TERRY DENICE CAMARILLO, Plaintiff,
v.
NANCY A. BERRYHILL, ACTING COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION, Defendant.

          FINDINGS, CONCLUSIONS, AND RECOMMENDATION

          IRMA CARRILLO RAMIREZ UNITED STATES MAGISTRATE JUDGE

         By Special Order No. 3-251, this case was automatically referred for proposed findings of fact and recommendation for disposition. Before the Court is Plaintiff's Opening Brief, filed May 30, 2017 (doc. 18), Defendant's Response Brief, filed June 29, 2017 (doc. 19), and Plaintiff's Reply Brief, filed July 19, 2017 (doc. 20). Based on the relevant findings, evidence, and applicable law, the Commissioner's decision should be AFFIRMED.

         I. BACKGROUND[1]

A. Procedural History

         Terry Denice Camarillo (Plaintiff) seeks judicial review of a final decision by the Commissioner of Social Security (Commissioner) denying her claims for disability insurance benefits (DIB) under Title II of the Social Security Act (Act) and for supplemental security income (SSI) under Title XVI of the Act. (doc. 18 at 6.) On April 9, 2013, Plaintiff filed her applications for DIB and SSI, alleging disability beginning on November 30, 2012. (R. at 26, 50, 141-42.) Her claims were denied initially on June 27, 2013, and upon reconsideration on September 4, 2013. (R. at 175, 183.) On September 27, 2013, Plaintiff requested a hearing before an Administrative Law Judge (ALJ). (R. at 189.) She appeared and testified at a hearing on August 7, 2014, and at a supplemental hearing on April 6, 2015. (R. at 48-117.) On May 29, 2015, the ALJ issued a decision finding Plaintiff not disabled and denying her claims for benefits. (R. at 23-41.)

         Plaintiff timely appealed the ALJ's decision to the Appeals Council on June 9, 2015. (R. at 22.) The Appeals Council denied her request for review on August 2, 2016, making the ALJ's decision the final decision of the Commissioner. (R. at 14-17.) Plaintiff timely appealed the Commissioner's decision under 42 U.S.C. § 405(g). (See doc. 1.)

         B. Factual History

         1. Age, Education, and Work Experience

         Plaintiff was born on February 1, 1974, and was 40 years old at the time of the initial hearing. (R. at 39, 54.) She had a high school education and could speak English fluently. (R. at 39, 54-55.) She had past relevant work experience as a data entry clerk, lab aid, information clerk, and medical records clerk. (R. at 39.)

         2. Medical Evidence

         On March 3, 2012, Plaintiff arrived at Medical City Dallas Hospital by ambulance reporting chest pain and depression. (R. at 383, 386.) She reported that she felt like hurting herself but she did not act on that feeling and had no plan to do so. (R. at 386.) She stated that she arrived home after spending the day with her daughter and thought she had a panic attack because she “became very sad and started crying and breathing fast.” (R. at 386.) She had experienced problems related to her daughter, work, and personal finances. (R. at 387.) Her exam was normal and it was recommended that she stay for more testing, but she refused and was discharged. (R. at 386, 388.) Plaintiff stated that “she was not actually wanting to hurt herself and [did] not have plans to and was just feeling down earlier.” (R. at 386.) She was oriented to person, place, and time, and rational and coherent; her abstract thinking was intact; and she showed no signs of psychosis, auditory or visual hallucinations, delusional thinking, suicidal or homicidal ideations, slurred speech, or tangential thinking. (R. at 386.)

         From August 26, 2012 to August 29, 2012, Plaintiff was treated at Timberlawn Mental Health System (Timberlawn) for depression and thoughts of harming herself. (R. at 742.) After losing her job, insurance, and apartment, she had an increase in depressed thoughts and no hope for living. (R. at 742.) She admitted to “suicidal thoughts of harming herself or driving her truck off a bridge.” (R. at 742.) While in treatment, she participated in group therapy and milieu, and she stated that “what she did was foolish and she wanted to be discharged to her family.” (R. at 742.) Plaintiff was prescribed Zoloft 100mg and Risperdal 1mg, her suicidal thoughts abated, and she was discharged without suicidal thoughts or homicidal ideations. (R. at 742.) At discharge, she was diagnosed with major depressive disorder that was recurrent and severe with psychotic features. (R. at 743.)

         On August 31, 2012, Plaintiff had a follow-up appointment at Dallas Metrocare Services (Metrocare). (R. at 440-42.) She underwent a psychiatric diagnostic interview exam with Natasha Gultery, APN, in which she reported sadness, depressed mood, anhedonia, crying episodes, difficulty falling asleep, irritability, and low energy that occurred most days of the week, starting in February 2012. (R. at 440.) She denied having suicidal or homicidal thoughts and reported a decrease in auditory hallucinations. (R. at 440.) She reported that she was having visual hallucinations of “a man and woman after [her].” (R. at 440.) She also denied having paranoia, periods of persistent elevated mood, hyperactivity, and decreased need for sleep. (R. at 440.) She reported that on her current medication regiment of Zoloft 100 mg and Risperdal 1mg, she had a stable mood, and a decrease in hallucinations and depressive symptoms, although her symptoms became worse with stress. (R. at 440-41.) Plaintiff was adequately groomed, alert, and oriented times four. (R. at 441.) She exhibited withdrawn behavior, normal psychomotor activity, normal speech, psychosis, organized thought process, intact memory, normal attention, and a good mood with euthymic affect. (R. at 441.) She also had fair insight, judgment, and impulse control, and denied command hallucinations. (R. at 441.) Plaintiff was continued on her medications and started on Benadryl to help with her insomnia. (R. at 441.)

         On September 11, 2012, Plaintiff met with Maria Luna-Wolfe, RN. (R. at 444-45.) She was not suicidal or homicidal, and did not exhibit any signs of paranoia, psychosis, or abnormal thought content. (R. at 444.) She was cooperative and friendly, but dysphoric, sad, and depressed. (R. at 444.) She also reported that she was sleeping adequately and taking her medications. (R. at 445.)

         Plaintiff met with Nurse Gultery on September 28, 2012, and November 9, 2012. (R. at 446, 450.) She reported that she was feeling better and denied having suicidal or homicidal thoughts, paranoia, or auditory or visual hallucinations. (R. at 447, 451.) In September, she reported being stable on Zoloft 150mg and sleeping about five hours per night. (R. at 447.) In November, she reported difficulty staying asleep and reported sleeping about six hours per night. (R. at 451.) Nurse Gultery increased her Zoloft prescription, discontinued Risperdal and Benadryl at Plaintiff's request, and started her on Trazodone to treat her insomnia. (R. at 447, 451.)

         On November 28, 2012, Plaintiff began behavioral therapy with Ana Trueba, Paraprofessional. (R. at 453-54.) The objectives of the therapy were to: (1) get her “back up on [her] feet”; (2) help her “be able to control the voices and impulses that come to her mind”; and (3) decrease her isolation and withdrawal. (R. at 453.) Plaintiff reported that she understood how therapy worked and agreed to start therapy. (R. at 454.)

         Plaintiff had several follow-up appointments with Nurse Gultery from January 4, 2013 to June 28, 2013. (R. at 456-57, 461-62, 465-66, 486-87, 491-92.) She routinely reported auditory hallucinations but denied having paranoia, suicidal or homicidal thoughts, or command hallucinations. (R. at 457, 462, 465, 487, 492.) She stated that she lost her job because one day at work, she heard voices that “told [her] to steal a cell[]phone.” (R. at 457.) She mostly reported that she was feeling better but she still continued to have depressive symptoms. (R. at 457, 462, 465, 487, 492.) She also reported feelings of psychosis and fatigue. (R. at 456-57, 461-62, 465-66, 486-87, 491-92.) In January, she reported visual hallucinations of “stuff crawling on th[e] floor” but denied experiencing visual hallucinations at her later appointments. (R. at 457, 487, 492.) Nurse Gultery initially resumed Plaintiff on Risperdal to treat her intermittent thought confusion, and continued her on Trazodone and Zoloft, but later increased Risperdal and Zoloft to decrease her psychosis and depressive symptoms. (R. at 457, 462.) Plaintiff reported that she was only sleeping four hours per night in April. (R. at 446.) Nurse Gultery discontinued Trazodone and started her on Remeron as adjunct to Zoloft for her depressive symptoms. (R. at 466.) She subsequently increased Remeron to further treat her depression. (R. at 487, 492.)

         On February 4, 2013, Plaintiff met with Nurse Luna-Wolfe and reported that she was still hearing voices telling her that she was “not good enough to go to work, ” and she was seeing “rats run[] across the floor.” (R. at 459.) She was adequately groomed, cooperative, friendly, alert, and euthymic, reported psychosis, and exhibited fair insight and judgment. (R. at 459.)

         On April 13, 2013, Plaintiff was admitted to the emergency department of Parkland Hospital (Parkland) complaining of back pain, auditory hallucinations, and depression. (R. at 409, 411, 413.) Her mother reported that Plaintiff slept too much, and Fuad Khan, MD, noted that she could be experiencing daytime somnolence with poor nighttime sleep. (R. at 410.) Plaintiff was alert, oriented times three, cooperative, behaved appropriately, and had a good mood with no delusions, obsessions, overvalued ideas, or thoughts to harm herself or others. (R. at 416.) She reported voices, but Dr. Khan noted that the “voices” did not classically fit into the true description of auditory hallucinations and were more like loud thoughts. (R. at 416.) Her medications at the time included Risperidone, Sertraline, Mirtazapine, Hydrocodone-Acetaminophen, and Naproxen. (R. at 415.) The Mirtazapine was discontinued because it did not help with her insomnia and she was started on Melatonin. (R. at 410.) She was not found to be a danger to herself or others and discharged to her mother's home. (R. at 410.) That same day, Plaintiff underwent x-rays, which revealed a slight anterior compression deformity of the L3 vertebral body, of uncertain chronicity, and moderate degenerative disc disease at ¶ 5-S1. (R. at 417.) She returned to the emergency department on May 2, 2013, complaining of back pain with shooting pain down her right leg and associated numbness and weakness. (R. at 433.) She stated that she had been given a shot for her back pain that had helped in the past. (R. at 433.)

         On April 16, 2013 and April 18, 2013, Plaintiff went to the Parkland Urgent Care Center (Urgent Care) complaining of back pain. (R. at 424, 429.) She reported severe pain at her first visit and was prescribed medication. (R. at 424, 426.) On her second visit, she reported back pain and requested more powerful medications because the medications she got at her previous visit did not work. (R. at 429.) Her plan of care upon release consisted of taking NSAIDs, muscle relaxers, and Prednisone, and following-up with her primary care provider. (R. at 431.)

         On April 29, 2013, Plaintiff met with Stephanie Exum, a qualified mental health professional, for psychosocial rehabilitation. (R. at 473.) She reported that she had some depression at times, a history of manic symptoms leading to impulsive behaviors, loneliness, and anger, but no issues with sleep or appetite. (R. at 473.) She stated that her symptoms made it hard for her to keep a job and maintain relationships. (R. at 473.) She also reported that she was taking her medications but was not sure if they were helping; she wanted to try therapy. (R. at 473.) She was scheduled to begin weekly psychosocial rehabilitation, along with counseling, in order to help her learn to better manage her symptoms and improve her functionality. (R. at 473.)

         On May 3, 2013, Plaintiff met with Ket Davis, APN, and stated that she was doing “better than yesterday.” (R. at 475-77.) She reported sadness, depressed mood, anhedonia, difficulty concentrating, difficulty falling asleep, and changes in appetite. (R. at 476.) Nurse Davis continued her on her medications but added Hydroxyzine 25mg to treat her anxiety. (R. at 476.)

         On June 22, 2013, at the request of Disability Determination Services (DDS), Plaintiff met with Barbara Susanne Fletcher, Psy. D., for a psychological consultive examination. (R. at 479-84.) Dr. Fletcher noted that Plaintiff's mother drove her to the appointment, and she reported living with her mother, having contact with family, and having a best friend. (R. at 481-82.) She reported symptoms of depression including tearfulness, sleep disturbance, decreased energy, decreased motivation, appetite disturbance, loss of interest in pleasurable activities, social withdrawal, irritability, and problems with concentration and memory. (R. at 481.) She stated that she heard voices that told her people were out to get her, she lost her job because the voices told her to steal a telephone, and she sees “bugs and things” out of the side of her eye. (R. at 481.) She also reported feeling calm when she worked because she worked nights, when there were not too many people around. (R. at 482.) She stated that she could not handle visits by her sister and sister's five children to their mother. (R. at 482.) She also could not handle going to the store without her mother. (R. at 482.) Her symptoms were reportedly worse when she was without her medications, which included Risperidone, Hydroxyzine, Mirtazapine, and Sertraline. (R. at 482.) Plaintiff reported being able to care for her personal hygiene but lacking motivation to do so, and stated that her mother did the cooking, cleaning, and shopping. (R. at 482.) She indicated that she spent her time sleeping. (R. at 482.) She also reported that she had not used alcohol in about a month, but the last time she drank, she was so drunk that she pulled her car over and fell asleep. (R. at 482.) She was able to state the month, day, and year, knew where she was, and could state the similarities between a piano and a drum as well as a banana and an orange. (R. at 483.) Dr. Fletcher estimated that her intelligence and knowledge were average. (R. at 483.) Dr. Fletcher diagnosed her with major depressive disorder that was recurrent and severe without psychotic features, anxiety disorder, and alcohol abuse, as well as a Global Assessment of Functioning[2] (GAF) of 48. (R. at 484.)

         On June 24, 2013, Susan Posey, Psy. D., a state agency medical consultant (SAMC), completed a mental residual functional capacity (MRFC) assessment of Plaintiff based on the medical evidence. (R. at 125-27.) She opined that Plaintiff was markedly limited in her ability to understand, remember, and carry out detailed instructions, but was not significantly limited in any other areas of understanding, memory, sustained concentration, or persistence, and no more than moderately limited in the areas of social interaction and adaptation. (R. at 125-27.) Plaintiff could understand, remember, and carry out only simple instructions; make simple decisions; attend and concentrate for extended periods; interact adequately with coworkers and supervisors; and respond appropriately to changes in a routine work setting. (R. at 127.)

         On August 30, 2013, Veena Ghai, M.D., an SAMC, completed an MRFC assessment of Plaintiff based on the medical evidence. (R. at 151-53.) Dr. Ghai opined that Plaintiff was markedly limited in her ability to understand, remember, and carry out detailed instructions, but no more than moderately limited in her other abilities in the areas of understanding, memory, sustained concentration, persistence, social interaction, and adaptation. (R. at 152-53.) Plaintiff could understand, remember, and carry out only simple instructions; make simple decisions; attend and concentrate for extended periods; interact adequately with coworkers and supervisors; and respond appropriately to changes in a routine work setting. (R. at 153.)

         Plaintiff met with Laura Settlage, APN, multiple times from September 18, 2013 to May 7, 2015. (R. at 495-97, 581-83, 596-98, 618-20, 627-29, 637-39, 642-44, 646-48, 712-14, 725-27, 810-12, 815, 820-22, 827, 847-49, 912-14, 943-45, 953-55, 962-64, 969-71, 976-78.) Throughout her visits, Plaintiff reported that her depressive symptoms decreased and denied having suicidal or homicidal thoughts, but she continuously experienced demeaning auditory hallucinations. (R. at 496, 582, 597, 619, 628, 638, 643, 647, 827, 963, 970, 977.) She reported that she was still suffering from depressive symptoms at several of the appointments. (R. at 628, 638, 643, 827.) Nurse Settlage routinely noted that Plaintiff reported experiencing initial and middle insomnia, sleeping only a few hours at night, or not sleeping at all. (R. at 496, 638, 643, 811, 821, 827.) On other occasions, however, Plaintiff reported sleeping well. (R. at 582, 619, 848, 944.) On December 3, 2013, she reported that she was going to bed at 10:00 p.m., waking up at 9:30 a.m., and not taking naps during the day because she had a lot to do. (R. at 619.) On February 25, 2014, her mother reported that she was not telling Nurse Settlage everything about her sleep, to which Plaintiff agreed, because she would actually sleep all the time and only get out of bed at 12:50 p.m. to watch General Hospital. (R. at 628.)

         Plaintiff's medications were continuously altered throughout her visits with Nurse Settlage. (R. at 496, 582, 619, 628, 638, 643, 726, 811, 815.) Nurse Settlage first changed Plaintiff's Risperdal to Geodon to target her psychosis, increased Gabapentin for anxiety, and added Benadryl for insomnia. (R. at 496.) Plaintiff reported “sleeping [six] hours with the Benadryl” but still had initial and middle insomnia. (R. at 582.) She was then taken off Geodon and Risperdal, and prescribed Olanzapine for psychosis. (R. at 582.) Nurse Settlage increased the Olanzapine, began Plaintiff on Topamax for her depressive symptoms and Doxepin for insomnia, and discontinued Diphenhydramine and Benadryl. (R. at 619, 622.) Plaintiff was also prescribed Wellbutrin to help target her depressive symptoms, and subsequently prescribed Ambien to help with her insomnia. (R. at 628, 638.) She then started a trial of Geodon to treat the auditory hallucinations. (R. at 643.) Plaintiff had also been taking Thorazine, but it was discontinued after she reported that it was “too much” and made her “dopey all day.” (R. at 726.) Nurse Settlage added Gabapentin to treat her anxiety and Temazepam for insomnia, but she reported vivid nightmares with Temazepam and was instructed to quit taking it. (R. at 811, 815.) Plaintiff reported sleeping twelve hours at night on Doxepin, and her dosage was increased. (R. at 944.) Nurse Settlage also extensively discussed the importance of sleep hygiene with Plaintiff and the need to discontinue her day time napping in order to get into a normal sleep pattern. (R. at 638, 821.) On October 7, 2014, however, her mother reported that sleep hygiene remained a problem. (R. at 847-48.)

         On March 18, 2014 and April 2, 2014, Plaintiff attended individual counseling during which she noted that she was ready to get a job. (R. at 635, 640.) During the March session, she reported that she had been awake for four days with only a one-hour nap, her mind raced and would not stop, and she was experiencing paranoid delusions and thought people were out to get her. (R. at 635.) She had auditory hallucinations that occurred mostly at night, telling her that she was “stupid” and did not need a job, and commanding her to hurt herself. (R. at 635.) She also reported that she had a depressed mood most days, anxiety when around others, changes in appetite, feelings of worthlessness and hopelessness, anhedonia, suicidal thoughts twice a day, problems with family, and difficulties in activities of daily life. (R. at 635.) During the April session, Plaintiff presented with appropriate affect, hygiene, and appearance and reported she was sleeping better on her medication, but was still having auditory hallucinations and paranoid delusions. (R. at 640.) She reported a decreased depression level from her prior visit. (R. at 640.)

         On May 16, 2014, Plaintiff was admitted to Baylor Hospital (Baylor) after taking a large quantity of prescription medications in an attempt to harm herself. (R. at 653, 664.) She was deemed to be a moderate to high suicide risk after affirming that in the past week, she wanted to sleep and not wake up, had a plan to commit suicide, and intended to carry it out. (R. at 654.) She stated that she attempted to harm herself after she did not receive a call back from her psychiatric doctor. (R. at 664.) She later reported to Nurse Settlage that she was previously having a good day but the “voices told [her] to take all [her] medications.” (R. at 713.)

         She was referred from Baylor to Green Oaks Hospital where she was treated from May 17, 2014, to May 18, 2014. (R. at 689.) She stated that when her psychiatrist did not call her back, two squirrels told her to take the medications. (R. at 694.) She was regretful that the overdose was not successful. (R. at 694.) She noted that she had been depressed for a while, and the medications that were previously helping her sleep were no longer working. (R. at 694.) She also noted that some days she only wanted to sleep. (R. at 690.) Plaintiff started doing better and was discharged from the hospital. (R. at 700.) She was prescribed Thorazine, which was later discontinued because it made her feel “dopey all day.” (R. at 701, 706, 726.)

         Plaintiff underwent psychosocial rehabilitation with Vesha Akao, a qualified mental health professional, multiple times from June 3, 2014 to September 25, 2014. (R. at 723-24, 729-30, 731-32, 636-38, 806-09, 813-14, 817-18, 825-26, 828-29, 836-38, 843-44.) During her first session, she reported that she attempted suicide and went to Baylor and then Green Oaks Hospital. (R. at 724.) She identified depressive symptoms of “not sleeping, feeling down, fatigue[d], thinking about death, and no interest[s].” (R. at 724.) She felt “like sometimes folks [were] out to get [her]” and did not feel safe going outside. (R. at 724.) At her next session, she reported hearing voices telling her to go to Timberlawn. (R. at 730.) During the following session, she was “so sleepy” and stated she was hearing voices telling her “do[ not] go to sleep or someone will break in.” (R. at 731.) She also reported during another session that she just wanted to sleep during the day and could not sleep at night. (R. at 806.) She later reported sleeping better after receiving her medications. (R. at 817.) She began reporting that she was doing better during the final sessions. (R. at 826, 836, 838, 843.)

         On June 20, 2014, Plaintiff went back to Nurse Gultery and stated that she was not sleeping. (R. at 733-35.) She reported difficulty falling asleep, increased paranoia, low energy, and difficulty concentrating. (R. at 734.) She had not slept “[ten] hours in [four] days.” (R. at 734.) She also continued to report auditory hallucinations of voices telling her someone was going to break into the house, as well as visual hallucinations of “shadows and bugs.” (R. at 734.) Nurse Gultery discontinued her Ambien prescription, increased her Doxepin and Zyprexa, and continued her other medications. (R. at 734.)

         On August 27, 2014, A. Mirzatuny, M.D., and Nurse Settlage, completed a “Medical Assessment of Ability to do Work-Related Activities (Mental)” for Plaintiff. (R. at 799-801.) Dr. Mirzatuny diagnosed her with major depressive disorder with recurrent, severe psychotic features. (R. at 800.) Dr. Mirzatuny opined that Plaintiff had “extreme loss of ability to perform” in the following categories: performing at a consistent pace without an unreasonable number and length of rest/break periods; accepting instructions and responding appropriately to criticism from supervisors; getting along with co-workers or peers without unduly distracting them or exhibiting behavioral extremes; responding appropriately to changes in a routine work setting; and finishing a normal work week without interruption from psychologically based symptoms. (R. at 799-800.) Dr. Mirzatuny also opined that Plaintiff had “substantial loss of ability to perform” in the following categories: understanding to carry out detailed but uninvolved written or oral instructions; maintaining concentration, attention, and staying on task for an extended period (being two hours); acting appropriately with the general public; asking simple questions or requesting assistance; maintaining personal appearance; behaving in an emotionally stable manner; and coping with normal work stress without exacerbating pathologically based symptoms.[3] (R. at 799-800.) Plaintiff would be expected to be absent from work more than 4 days a month, and it was unlikely that her mental disorders would exacerbate the degree of disability from her physical impairments. (R. at 801.)

         On November 19, 2014, Plaintiff saw Mahmood Panjwani, M.D., P.A., for a physical examination. (R. at 917-28.) He found that she had chronic low back pain, and imaging studies revealed degenerative disc disease. (R. at 920.) Her weight aggravated and contributed to her back pain. (R. at 920.) He also noted that she suffered from major ...


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