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Ruiz v. Berryhill

United States District Court, S.D. Texas, Brownsville Division

March 4, 2019

PRISCILLA ALEJANDRA RUIZ, Plaintiff,
v.
NANCY A. BERRYHILL, COMMISSIONER OF SOCIAL SECURITY, Defendant.

          REPORT AND RECOMMENDATION OF THE MAGISTRATE JUDGE

          Ronald G. Morgan, United States Magistrate Judge

         Pending before the Magistrate Judge is the petition for review of the denial of Disability Insurance Benefits filed by Priscilla Alejandra Ruiz (“Ruiz”). Dkt. No. 1.

         Having reviewed the record and the pleadings, the Court recommends that the petition be denied. This recommendation follows from the fact that there is substantial evidence to support the findings of the Administrative Law Judge (“ALJ”).

         I. Background

         A. Procedural History

         On September 24, 2013, Ruiz applied to receive Disability Insurance Benefits and Supplemental Security Income. Dkt. No. 21-1, p. 15.[1] Ruiz claimed that her disability effective date was April 1, 2006. Id.

         On April 30, 2014, Ruiz's claim was denied. Id. On May 22, 2015, after reconsideration, Ruiz's claim was again denied. Id. On October 24, 2016, a hearing was held before an ALJ. Id. On April 24, 2017, the ALJ decided that Ruiz was not entitled to benefits. Id, p. 34. On January 23, 2018, the Appeals Council denied Ruiz's timely request for review. Id, p. 6. Ruiz has sought timely review of the Commissioner's decision in this Court.

         B. Factual Context

         Ruiz was born in August 1983 and was 23 years old at the time of her claimed disability onset date. Dkt. No. 21-1, p. 35.

         Ruiz had previously worked as a retail sales clerk, a receptionist, and as a medical provider for a rehabilitation facility. Dkt. No. 21-1, pp. 18-20. She graduated from cosmetology school. Id. She is a single mother to two children, including one child who has battled cancer. Dkt. No. 27. At some unspecified date, she began receiving Supplemental Security Income (“SSI”). On April 30, 2014, her SSI was discontinued after the Social Security Administration determined that she was “now able to work.” Dkt. No. 21-1, p. 47.

         The ALJ found that Ruiz suffered from “generalized anxiety disorder and affective disorder.” Dkt. No. 21-1, p. 20. These findings, generally, are undisputed. Instead, Ruiz disputes the ALJ's finding that Ruiz has the residual functional capacity (or “RFC”) to still perform work.[2]

         C. Ruiz's Medical History

         During her treatment and the disability process, Ruiz was examined by multiple doctors. A summary of their observations and findings follows.

         On April 20, 2004, Dr. Bert Levine conducted a “full battery” psychological report on Ruiz. Dkt. No. 21-6, p. 299. Dr. Levine concluded that Ruiz “presented a history of depression that is documented by medical records” and that “[r]ecords, observations and test results” were consistent with that diagnosis. Id., p. 302. Dr. Levine also noted that Ruiz “has a documented diagnosis of a panic disorder without agoraphobia, ” and that test records revealed “anxiety with a phobic quality.” Id.

         On July 25, 2012, Ruiz went to the emergency room at Valley Baptist Medical Center in Brownsville, complaining of headache, facial cramping, insomnia, dizziness and anxiety. Dkt. No. 21-9, p. 499. The examination showed that she was “oriented to person, place, time and situation” with “normal memory” and that her “motor functions [were] normal.” Id, p. 500. Ruiz was discharged after her symptoms improved and she was given a Xanax prescription to use as needed. Id., p. 501.

         On September 18, 2013, Ruiz was seen by Dr. Francisco Torres for a psychiatric evaluation. Dkt. No. 21-11, p. 557. Dr. Torres diagnosed Ruiz with “persistent depressive disorder, ” anxiety and “adjustment disorder with mixed anxiety and depressed mood.” Id., p. 560. Dr. Torres also noted that Ruiz had a Global Assessment of Function (“GAF”)[3] Score of 55. Id. This score “is indicative of moderate difficulty in social, occupational or school functioning.” Dkt. No. 21-1, p. 26.

         At a followup visit on November 14, 2013, Dr. Torres noted that Ruiz “hasn't been consistent with her followup appointments, but lately she wanted to continue the treatment as she has been struggling with anxiety and depression.” Dkt. No. 21-11, p. 563. Ruiz was prescribed “Lexapro for anxiety and depression and Trazodone for insomnia.” Id., p. 564.

         On December 11, 2013, Ruiz saw Dr. Torres for another followup visit. Dkt. No. 21-11, p. 566. Ruiz reported that she had been improving after taking her meds, “but she wasn't able to tolerate the Lexapro because it was making her feel weird and dizzy.” Id. (internal quotations omitted). Ruiz discontinued the Lexapro prescription and did not wish “to try any other antidepressant at this time as she feels her moods are better.” Id., p. 567.

         On March 5, 2014, Ruiz had another followup visit with Dr. Torres. Dkt. No. 21-11, p. 570. At that time, Ruiz was unable to take any “psychiatric medications as she is on her first trimester of pregnancy.” Id., p. 571. Ruiz “agreed to rely more on psychotherapy for the time being.” Id.

         On April 2, 2014, Ruiz had another follow up visit with Dr. Torres, reporting that her mood was better and that she was “not as depressed as before.” Dkt. No. 21-11, p. 573.

         On May 14, 2014, at her next follow up visit with Dr. Torres, Ruiz reported that she was no longer seeing a counselor and was “in low spirits” and “feels desperate and pressured.” Dkt. No. 21-11, p. 576. She was prescribed Prozac for her depression. Id, p. 577-78.

         On May 29, 2014, Ruiz reported to Dr. Torres that Prozac was helping, but she was anxious “after learning that her baby might have Down's Syndrome.” Dkt. No. 21-11, p. 579. Ruiz continued with her Prozac prescription. Id., p. 581.

         On October 8, 2014, Ruiz reported to Dr. Torres that she “hasn't taken her medications as prescribed as her moods have been consistently better, ” and she hadn't felt anxious or depressed. Dkt. No. 21-12, p. 621. Ruiz agreed to go off her medications temporarily because she was scheduled to give birth within the next two weeks and did not want the medications to impact her child. Id.[4]

         On January 20, 2015, Ruiz had a follow up visit with Dr. Torres, where she reported that she was in a good mood and did not feel anxious or depressed, because she felt “the medication is working.” Dkt. No. 21-12, p. 618. Again, Ruiz was prescribed Lexapro for depression and Trazodone for insomnia. Id, p. 620.

         On April 2, 2015, Ruiz was seen by Dr. Torres, informing him that she was feeling depressed, anxious and had trouble sleeping. Dkt. No. 21-12, p. 613. Ruiz felt that her medications were not helping and she was “doing some sort of counseling with a Scientologist.” Id. Ruiz continued her prescriptions for Lexapro and Trazodone. Id, p. 617. At this appointment, Ruiz's GAF score was 63. Id.

         On June 10, 2015, Ruiz had another follow up visit with Dr. Torres, where she reported that she continued to feel depressed and suffered from “crying spells” and anxiety. Dkt. No. 21-12, p. 608. Ruiz continued her prescriptions for Lexapro and Trazodone. Id, p. 610-11. Her GAF score was noted as 50.[5] Id.

         D. Disability Evaluations

         Two state agency consultants - Dr. Charles Lankford and Dr. Robert Gilliland - reviewed Ruiz's medical records regarding her mental abilities as part of the SSD process. Furthermore, she was also personally interviewed by Dr. G. Alan Trimble and Dr. Shelia Bailey as part of the process.

         1. Dr. ...


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