United States District Court, N.D. Texas, Dallas Division
FINDINGS, CONCLUSIONS AND RECOMMENDATION OF THE
UNITED STATES MAGISTRATE JUDGE
HARRIS TOLIVER UNITED STATES MAGISTRATE JUDGE.
to Special Order 3 and 28 U.S.C. §
636(b)(1)(B), this case has been referred to the undersigned
for pretrial management. The Court now considers the
parties' cross-motions for summary judgment. For the
reasons that follow, Plaintiff's Motion for Summary
Judgment, Doc. 12, should be
GRANTED, Defendant's Motion for
Summary Judgment, Doc. 14, should be
DENIED, the Commissioner's decision
should be REVERSED, and this case should be
REMANDED for further proceedings.
seeks judicial review of a final decision by the Commissioner
denying his claim for disability insurance benefits and
supplemental security income under the Social Security Act
(“the Act”). Plaintiff originally filed for
benefits in August 2013, claiming that he became disabled in
December 2007. Doc. 7-7 at 2-8. Plaintiff's
application was denied at all administrative levels, and he
now appeals to this Court pursuant to 42 U.S.C. §
405(g). Doc. 7-3 at 2-4; Doc. 7-3 at 16-32;
Doc. 7-4 at 22-34; Doc. 7-5 at 4-6,
was born in 1976 and was 31 years old on his alleged date of
disability onset. Doc. 7-7 at 2, 4. He had
a high school education, some college, attended the police
academy, and past relevant work as a systems administrator
and cashier. Doc. 7-3 at 43, 72-74.
Plaintiff served in the Gulf War as a paratrooper for more
than three years and, in 1998, was determined to be disabled
due to combat-related injury. Doc. 7-12 at 30-37;
Doc. 7-18 at 8. Specifically, in 1997, he injured
his lower back when his parachute failed to deploy, and he
fractured his left femur and knee along with other
service-related injuries. Doc. 7-18 at 6-7.
relevant here, Plaintiff was hospitalized for four days in
October 2006 for suicidal ideation, depression, and severe
chronic pain lasting over ten years. Doc. 7-17 at 3,
6. He was diagnosed with major depressive disorder,
moderate, without psychotic features. Doc. 7-17 at
7. In December 2007, Plaintiff reported that he was
taking his prescribed anti-depressant, but his anxiety had
increased to the point that he rarely left home. Doc.
7-16 at 68. Additionally, he reported suicidal ideation
with no plan, pain, and depression. Doc. 7-16 at 69.
In May 2008, Plaintiff reported that he always felt tired, an
increase in his anti-depressant dosage did not help, and he
struggled with concentration, focus, and motivation. Doc.
7-16 at 65.
2010, Plaintiff reported anhedonia (inability to experience
pleasure from activities usually found enjoyable), lack of
motivation, depression, difficulty sleeping, and an inability
to get out of bed. Doc. 7-18 at 17. In October 2011,
Dr. Victoria Menold, M.D., noted that Plaintiff had an
abnormal gait, motor weakness on one of his left-hand
fingers, a positive straight leg raise test on the left, left
side abnormal weakness, left thigh atrophy, paraspinal
tenderness, and muscle tightness. Doc. 7-17 at
59-60. Dr. Menold diagnosed Plaintiff with chronic pain
secondary to cervical spine degenerative disc disease with
radiculopathy on the left and degenerative joint disease of
the knees that was worsening. Doc. 7-17 at 60.
November 2011, Plaintiff again reported lack of motivation
and anhedonia and became tearful during his medical
examination. Doc. 7-16 at 54-55. The treating nurse
practitioner determined that Plaintiff's status was
worsening and added an additional anti-depressant to his
regimen. Doc. 7-16 at 55-56. By April 2012,
Plaintiff's appearance had changed, he could not remember
the last time he shaved, he was gaining weight, and he was
disheveled. Doc. 7-16 at 51-52. From March to July
2013, Plaintiff underwent six pain-coping skills sessions,
during which the clinical psychologist, Dr. Stacey Sandusky,
Ph.D., noted that Plaintiff's mood and affect were
dysphoric, he was tearful when discussing his quality of life
and pain, and he had “no desire to do anything.”
Doc. 7-9 at 47, 64-65; Doc. 7-10 at
2013, Dr. Nazimuddin Qazi, M.D., noted that Plaintiff's
“mental health issues” had to take precedence
because they were not conducive to a more active lifestyle
and participation in pain management plans. Doc. 7-9 at
50. In July 2013, Dr. Qazi noted that Plaintiff was
non-compliant with treatment for his neck and back pain.
Doc. 7-14 at 39. That same month, Plaintiff's
cognitive status was assessed, and he demonstrated poor eye
contact and positioned his head on a cane, sometimes nodding
off. Doc. 7-14 at 37. He stated that he was not
engaging in physical activity as recommended, did not bring
his exercise logs to the treatment session, was minimally
motivated, and did not see any benefit to pain management or
outpatient treatment. Doc. 7-14 at 37. The following
month, he complained of anhedonia and low motivation despite
taking his antidepressants, and he admitted to less frequent
personal hygiene as evidenced by his beard and long hair.
Doc. 7-9 at 33. Plaintiff made only intermittent eye
contact, his insight was fair, and his status was worsening.
Doc. 7-9 at 33-34.
October 2013, a non-examining psychiatrist from Disability
Services concluded that Plaintiff's mental impairments
were non-severe, he had only mild difficulties in social
functioning and in maintaining concentration, persistence, or
pace, and he had the capacity to perform light work. Doc.
7-4 at 32-33, 37. In January 2014, a
non-examining psychologist concurred with this assessment.
Doc. 7-4 at 67-68.
December 2013, Plaintiff reported that his depressed mood
continued, and he was anxious, not sleeping well, and had
chronic pain. Doc. 7-11 at 48-49. The following
month, Dr. Qazi reported that Plaintiff lacked the motivation
to attempt to cope with his pain, and that his depression and
mental health issues possibly worsened his pain perception.
Doc. 7-11 at 40. The doctor noted that Plaintiff was
able to perform his activities of daily living without
assistance. Doc. 7-11 at 41. It was also documented
in the record that Plaintiff had either cancelled or not
shown up for numerous doctors' appointments in late 2013.
Doc. 7-11 at 40.
November 2014, Plaintiff was examined by clinical
psychologist Dr. Eric Mariano, Ph.D., who noted that
Plaintiff reported feeling restless, had low energy and
motivation, had anxiety, would barely leave his apartment,
and was having sudden panic attacks that Plaintiff thought
were heart attacks. Doc. 7-12 at 63. Dr. Mariano
diagnosed Plaintiff with “unspecified depression vs.
due to [general medical condition] pain vs. [major depressive