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Willoughby v. Commissioner, SSA

United States District Court, E.D. Texas, Sherman Division

March 29, 2019




         Plaintiff brings this appeal under 42 U.S.C. § 405(g) for judicial review of the final decision of the Commissioner of Social Security (“Commissioner”) denying his claim for supplemental security income and child's insurance benefits. After reviewing the Briefs submitted by the Parties, as well as the evidence contained in the Administrative Record, the Court finds that the Commissioner's decision should be AFFIRMED.



         On May 9, 2014, Matthew Willoughby (“Plaintiff”)[1] filed an application for supplemental security income benefits (“SSI”) under Title XVI of the Social Security Act (“Act”) [TR 277-282]. On October 6, 2014, Plaintiff filed an application for child's insurance benefits (“CIB”) under Title II of the Act [TR 284-290]. Plaintiff alleged an onset-of-disability date of August 1, 1999 in both applications [TR 277, 284]. Plaintiff's applications were initially denied by notice on March 17, 2015 [TR 205-212], and upon reconsideration on August 7, 2015 [TR 216-221]. Plaintiff requested a hearing before an Administrative Law Judge (“ALJ”) on October 6, 2015 [TR 222-225], and the ALJ conducted the hearing (“Hearing”) on September 9, 2016 [TR 33-82, 239]. At Hearing, Plaintiff was represented by counsel, and the ALJ heard testimony from Plaintiff, his mother, and a vocational expert (“VE”).

         On October 13, 2016, the ALJ issued an unfavorable decision denying Plaintiff's application at step five, finding that Plaintiff is capable of performing the requirements of unskilled sedentary occupations [TR 7-32]. Plaintiff requested review of the ALJ's decision by the Appeals Council [TR 275]; the Appeals Council denied Plaintiff's request on December 8, 2017, making the decision of the ALJ the final decision of the Commissioner [TR 1-6].

         On March 6, 2018, Plaintiff filed the instant suit [Dkt. 1]. On May 18, 2018, the Administrative Record was received from the SSA [Dkt. 12]. Plaintiff filed his Brief on June 17, 2018 [Dkt. 17]. The Commissioner filed its Brief in Support of the Commissioner's Decision on August 16, 2018 [Dkt. 19]. Plaintiff did not file a reply.


         1. Age, Education, and Work Experience

          Plaintiff was born on March 16, 1989, making him ten (10) years of age at the time of alleged onset, and twenty-eight (28) on the date of the ALJ's decision [TR 141, 277]. Plaintiff's age classification was defined as “younger person” at all relevant times. See 20 C.F.R. § 404.1563. Plaintiff had at least a high school education and could communicate in English [TR 41, 310]. Plaintiff had no prior work experience [TR 43, 310].

         2. Plaintiff's Relevant Medical Records

         In his application, Plaintiff asserted that he is disabled as a result of fibromyalgia, anxiety, depression, poly arthritis, back pain, obesity, fatigue, myalgia, low testosterone, fatty liver (nonalcoholic), panic attacks, and social anxiety [TR 309]. In connection with his impairments, Plaintiff has seen a multitude of doctors. Plaintiff attended psychotherapy with LPC-S Jeffrey Fletcher, M.A. from July 30, 2013 through September 5, 2016 [TR 678-688]. Plaintiff also received mental health treatment from psychiatrist Dr. J. Michael Brennan [TR 437, 448-52, 666-67]. Plaintiff received treatment at Dallas Diagnostic Association by Drs. Pablo Zeballos and Krishnan Nair from October 2, 2014 through August 26, 2015 [TR 503-525, 531-49, 616-24] where he was diagnosed with chronic pain syndrome, lumbosacral radiculitis, degeneration of the lumbar intervertebral disc, GERD, morbid obesity, anxiety, and depression [TR 505, 536]. Plaintiff also sought treatment for digestive health issues in the fall of 2013 [TR 425-27, 440-46].

         In connection with his application for disability benefits, Plaintiff also underwent two consultative examinations. On December 9, 2014, Dr. Linda Ludden completed a mental status examination of Plaintiff [TR 470-75] and on December 17, 2014, Dr. S. Katkuri completed a physical examination [TR 481-88]. Further, on March 9, 2015 non-examining State Agency Medical Consultants (“SAMCs”) Dr. Tina Ward and Dr. Jean Germain assisted in an initial-level agency determination of Plaintiff's medical conditions and functional limitations finding Plaintiff could sit, stand, and/or walk for six hours in an eight-hour workday and “understand, remember, and carry out detailed but not complex instructions, make decisions, attend and concentrate for extended periods, accept instructions and respond appropriately to carry out detailed changes in routine work setting” [TR 150, 154]. On reconsideration, SAMCs Dr. Scott Spoor and Dr. Thomas Geary confirmed the assessments of Drs. Ward and Germain [TR 181, 184].

         3. Hearing Testimony

         a. Plaintiff and Plaintiff's Mother's Testimony

         At Hearing, counsel for Plaintiff asserted that Plaintiff satisfied listings 12.04 (“Depressive, bipolar and related disorders”) and 12.06 (“Anxiety and obsessive-compulsive disorders”) [TR 39]. Plaintiff thereafter testified that pain and fatigue owing to fibromyalgia, headaches, low testosterone, hypothyroidism, depression, anxiety, and panic attacks, prevented him from holding employment [TR 44-45]. Plaintiff explained that he first became impaired in fifth grade when he was diagnosed with fibromyalgia [TR 41-42]. Plaintiff stated that this condition spread pain throughout his body, but most acutely to his hands, lower back, and right leg [TR 44-49]. Plaintiff elaborated that on a scale of one to ten, he experienced an average level of hand discomfort of four, but that on some days this rose to nine [TR 46]. Plaintiff explained that remedies such as heat packs, ice packs, and over-the-counter medication had not relieved this pain [TR 47]. Plaintiff described his lower back pain as “[c]onstant[ ]” and estimated its average level of discomfort at seven out of ten [TR 48-49]. He noted that this pain traveled to his right hip, knee, leg, and heel [TR 49]. Plaintiff summarized that overall, the fibromyalgia caused him great pain and fatigue, and that standing, walking, and sitting all exacerbated his discomfort [TR 48-49]. Plaintiff added that he could only walk and stand for approximately five minutes at a time, and that he could not remain in a normal seated position for more than one hour [TR 58-59]. He related that “[r]eclining or lying down in [his] bed” and elevating his feet above his waist were the only ways that that he could find relief, and that he spent most of each day in these positions [TR 49, 51].

         Plaintiff stated that he took a host of prescription medications to address the fibromyalgia-induced pain and fatigue, including Gabapentin, Oxycodone, Morphine, and Skelaxin [TR 47-48, 50]. Regarding the efficacy of these medications, Plaintiff remarked, “They help. Yes. But even with them I'm still in terrible pain.” [TR 50]. Plaintiff noted, for example, that the Skelaxin caused both of his legs to swell [TR 50-51]. Plaintiff explained that no one was treating him for his fibromyalgia, but that Dr. Krishnan Nair was his primary care physician and that Dr. Amir Alavi was his pain management doctor [TR 47-48].

         Plaintiff went on to describe his other physical impairments [TR 45, 52-54]. He explained that he experienced moderate headaches a few times per week, but that sometimes he endured “terrible headaches” that lasted up to a month [TR 52]. Plaintiff testified, however, that he did not see a doctor for this problem [TR 52]. Plaintiff also discussed his low testosterone, and explained that he previously received regular treatment from an endocrinologist [TR 53]. Plaintiff recalled that the doctor provided him supplies with which to inject himself on a regular basis, and that while his testosterone increased, he “did not notice a physical difference.” [TR 53]. Plaintiff added that the endocrinologist also provided him with steroid injections, but that Plaintiff stopped receiving these because they made him gain weight [TR 45, 54]. Finally, Plaintiff related that this doctor treated his hypothyroidism by prescribing Anastrozole, but that Plaintiff had stopped taking these pills as well.

         Regarding his mental impairments, Plaintiff described his depression by stating “I feel that there's no form to life. I wish I, that I, could just fall asleep and not wake up.” [TR 55]. Plaintiff further discussed his “terrible anxiety;” he acknowledged that it stemmed from fear of judgment, prevented him from socializing with others, and even made him uncomfortable around his own family [TR 44, 56]. Plaintiff also confirmed that he suffered panic attacks “[m]ultiple times a day” and that these were triggered by “thinking about how messed up [his] life is.” [TR 57-58]. Plaintiff explained that as a result of these conditions he had no desire to interact with people and preferred to “hide” in his room [TR 56-57]. Plaintiff noted that he had been seeing a psychiatrist (Michael Brennan) for the last three or four years, and that except for a gap due to a “falling out, ” they met every three months [TR 77]. Plaintiff added that he had major difficulty sleeping and that he took Ambien with mixed results [TR 55].

         As a result of the above conditions, Plaintiff testified that he spent his days alone in his bedroom watching television and movies [TR 57-58]. Plaintiff stated that he dressed himself daily, but that his back pain prevented him from bathing every day [TR 57]. Plaintiff explained that he did not cook, perform housework, or do laundry [TR 58]. Plaintiff related that he had built a computer earlier in the year, but that while he “used to be a very avid video gamer, ” he no longer played these games because he could not sit in his chair [TR 60]. Plaintiff also stated that in the past he would accompany his family to the gun range on “rare occurrence[s]”, but that he could not do this anymore [TR 61]. He elaborated that he obtained his concealed-carry license in 2012, and that this entailed attending a four-plus hour class-an experience that Plaintiff described as “anxiety-inducing” and “uncomfortable” [TR 80]. Plaintiff testified that he pursued this activity on the advice of his therapist, who thought that this would boost his self-esteem and re-acclimate him to social situations [TR 80]. Plaintiff added that he had just one friend, and that he communicated with this friend via texting and speaking on the phone [TR 55-56].

         Plaintiff's mother also testified at Hearing [TR 68-77, 78-81]. She recalled Plaintiff's fibromyalgia diagnosis when he was in fifth grade and explained that “he never got better” because the doctors did not administer or prescribe medical treatment [TR 68]. She testified that she home-schooled Plaintiff from fifth grade through the end of high school because Plaintiff's pain and fatigue prevented him from attending school in person [TR 69-70]. Plaintiff's mother echoed Plaintiff's testimony regarding his physical and mental ailments, pain, and daily routine; for example, she averred that he remained in his bedroom and did not socialize, sat in his recliner or lay in his bed all day, and experienced regular panic attacks [TR 70-74]. She added that Plaintiff cried “[v]ery frequently” [TR 72]. Plaintiff's mother also provided that Plaintiff had seen many different medical professionals, including a counselor (Jeffrey Fletcher) and a psychiatrist (Michael Brennan) [TR 75]. She opined that Plaintiff's condition had actually worsened over the three years he had seen Mr. Fletcher, stating “He doesn't see that there's any future for him because he feels like the pain and the anxiety will never get better.” [TR 76].

         Finally, Plaintiff's mother answered questions about Plaintiff going to the gun range [TR 79-80]. She explained that he had gone there perhaps once in the last year and “[t]wo or three times” overall [TR 79]. She mentioned that Plaintiff attended a concealed-carry class and obtained his concealed-carry license, but clarified that Plaintiff's condition had progressed so much since then that he could not have completed this class in his present state [TR 80]. Plaintiff's mother also provided that Plaintiff kept a gun and bullets in his room [TR 81].

         b. VE's Testimony

         The VE also offered testimony at Hearing in response to questions about Plaintiff's work history and hypotheticals posed by the ALJ [TR 61-67]. The VE testified that Plaintiff had no prior work experience [TR 62]. The ALJ then presented the following hypothetical to the VE:

Okay, if you can assume a hypothetical individual of the claimant's age, education, with the past jobs you described. And further assume the individual is limited to occasional lift [sic] and carry of 20 pounds; frequently lift and carry 10 pounds. Is able to stand or walk approximately a total of six hours in an eight hour day; and able to sit approximately six hours in an eight hour day. Can occasionally climb ramps and stairs, but no climbing of ladders, ropes or scaffolds. May occasionally balance, stoop, kneel, crouch and crawl. Can understand, remember and carry out detailed but not complex instructions. Can make ...

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