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Jim S. v. Saul

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

September 25, 2019

JIM S., Plaintiff,
v.
ANDREW SAUL, COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant.

         Consent Case[1]

          MEMORANDUM OPINION AND ORDER

         Jim S. (Plaintiff) seeks judicial review of a final decision by the Commissioner of Social Security (Commissioner)[2] denying his claim for disability insurance benefits (DIB) under Title II of the Social Security Act. (See docs. 1; 13.) Based on the relevant filings, evidence, and applicable law, the Commissioner’s decision is REVERSED, and the case is REMANDED for reconsideration.

         I. BACKGROUND

         On August 25, 2015, Plaintiff filed his application for DIB, alleging disability beginning on January 1, 2011. (doc. 10-1 at 206.)[3] His claim was denied initially on September 28, 2015 (Id. at 95), and upon reconsideration on November 16, 2015 (id. at 102). On February 23, 2016, Plaintiff requested a hearing before an Administrative Law Judge (ALJ). (Id. at 108.) He appeared and testified at a hearing on April 21, 2017. (Id. at 30.) On July 27, 2017, the ALJ issued a decision finding him not disabled. (Id. at 11.)

         Plaintiff timely appealed the ALJ’s decision to the Appeals Council on September 25, 2017. (Id. at 204-05.) The Appeals Council denied his request for review on July 9, 2018, making the ALJ’s decision the final decision of the Commissioner. (Id. at 5-7.) He timely appealed the Commissioner’s decision under 42 U.S.C. § 405(g). (See doc. 1.)

         A. Age, Education, and Work Experience

          Plaintiff was born on August 15, 1969, and was 47 years old at the time of the hearing. (doc. 10-1 at 206.) He had completed two years of college and could communicate in English. (Id. at 235.) He had past relevant work as a semi-conductor wafer-etcher and as a semi-conductor processor. (Id. at 73-74.)

         B. Medical, Psychological, and Psychiatric Evidence[4]

         On November 23, 2010, Plaintiff presented to the Veterans Affairs Medical Center (VAMC) with complaints of worsening anxiety. (doc. 10-1 at 283.) He reported that his upbringing made him anxious around others, and his anxiety had worsened during military service because he lived around a lot of people in the barracks. (Id.) He also reported feeling tense “all the time even at home, ” and had to quit his job in a silicon manufacturing company due to his worsening anxiety. (Id.) He stated that in 2005, a doctor prescribed him Wellbutrin for his anxiety disorder, but he stopped taking the medication in 2006. (Id.)

         Plaintiff joined an anxiety support group and attended three therapy sessions in January 2011. (Id. at 1103-05.) Clinical notes from those sessions noted that he participated and had some interactions with other group members. (Id.)

         On January 24, 2011, Plaintiff presented to the VAMC and was seen by Anadhi Sethupathi, M.D. (Id. at 1102-03.) He reported that when having a panic attack, he experienced chest tightness and a racing heart. (Id. at 1102.) His anxiety continued to worsen when around other people, and he was having several anxiety episodes every day. (Id.) Plaintiff lived alone and admitted to having mild depression, but he denied suicidal or homicidal ideation. (Id.) Dr. Sethupathi noted that Plaintiff had fair insight and judgment; his speech was normal; his thought process was coherent and goal directed; he appeared alert, oriented, and fair groomed; and he showed no delusions. (Id.) He assessed Plaintiff with mildly depressed mood but continued anxiety, and updated his antidepressant regimen to include Effexor, Buspar, Clonazepam, and Lexapro. (Id. at 1103.)

         On February 16, 2011, Plaintiff returned to the VAMC for a drop-in appointment with staff psychologist, Amy Anthony, Ph.D. (Id. at 1093.) He reported not benefitting from group therapy and felt that others in the group were “judging” him. (Id.) He requested a referral for individual cognitive-behavioral therapy (CBT) sessions. (Id.) Dr. Anthony opined that Plaintiff’s Minnesota Multiphasic Personality Inventory-2 (MMPI-2) profile was “very elevated” and showed possible “exaggeration of symptoms, ” but it also suggested that he was experiencing a high level of emotional distress, self-criticism, depression, pessimism, anger and resentment, feelings of being mistreated, anxiety, social alienation, and insecurity in social situations. (Id. at 1092.) She also opined that Plaintiff’s severe anxiety, insecurity about his adequacy as a person, and rigid beliefs about himself and how others perceived him, had hindered him from having satisfying relationships, and individual CBT would likely correct some of his cognitive distortions and negative core beliefs. (Id. at 1092.)

         On March 17, 2011, Plaintiff returned to Dr. Sethupathi. (Id. at 1077.) He reported having difficulty concentrating, getting easily distracted, and that he “flunked” out of college due to poor concentration. (Id.) He stopped taking Buspar because it made him feel dizzy, but his anxiety continued to get worse when he was around a lot of people. (Id.) Despite his attempts at avoiding “social situations, ” he was still having multiple “anxiety episodes” on a daily basis. (Id.)

         On April 12, 2011, Plaintiff presented to Dr. Spain to discuss his therapy options. (Id. at 1061.) He reported problems interacting with others since childhood, and his inability to engage in “banter” “prohibit[ed] him from developing friendships and other relationships with colleagues or fellow students.” (Id.) He felt that his problems with depression might have manifested as anxiety, but he did not have a history of severe depression or suicidal ideation. (Id.)

         In April and May of 2011, Plaintiff attended five CBT sessions with Dr. Spain. (Id. at 639-41, 647-50, 1057-58.) Dr. Spain reported that Plaintiff presented with symptoms of depression and anxiety, and that his primary treatment goal was to learn how to socialize with others and to eventually return to college. (Id. at 1057-58.) Plaintiff appeared well-groomed, his speech was normal for tone and pace, he made appropriate eye contact, he was polite, and he demonstrated good concentration and attention. (Id. at 639-41, 647-50, 1057-58.) His affect was anxious, but he did not report current suicidal or homicidal thoughts, intentions, or plans. (Id.) At his first three sessions, he rated his mood as a 4 or 5 on a 0-10 scale, but no mood rating was noted from his last two sessions. (Id.) At his last session on May 16, 2011, Plaintiff stated that he was still “working through the experience of leaving his last job . . . realizing that he left because he was uncomfortable with socializing with his co-workers.” (Id. at 639.) He also stated that he was not interested in engaging in behavioral experiment strategies or exploring cognitive patterns, and preferred to be by himself at home “rather than participating in therapy.” (Id.)

         On May 21, 2011, Plaintiff called the Veteran Affair’s (VA) suicide prevention hotline and reported suicidal ideation. (Id. at 636-37.) The hotline responder noted that Plaintiff was “very disorganized” and unclear as to what he wanted from the call. (Id.) He stated that he felt worse than he ever had in the past and needed a psychiatric admission “to sort things out and get some structure back into [his] life.” (Id.) He did not have a suicide plan or current intent, and agreed to call back if his feelings worsened. (Id.)

         On May 27, 2011, Plaintiff saw Dr. Sethupathi to discuss his suicide hotline call. (Id. at 634-35.) He spoke about his anxiety issues and poor social communication, and about how he had not recovered from “the situations” that caused him to leave his job six months ago. (Id. at 634.) Ritalin helped him with his concentration, but he refused to start any antidepressants due to the side-effects. (Id.) Dr. Sethupathi noted that Plaintiff had fair eye contact, normal speech, fair insight and judgment, and no delusions or suicidal ideation; his mood was anxious; and his thought process was coherent and goal directed. (Id. at 635.)

         On June 1, 2011, Plaintiff was transported to the hospital via ambulance after suffering a “nervous breakdown” at a Dallas Area Rapid Transit (DART) rail station. (Id. at 584-629.) He reported that he had confronted a passenger about smoking on the train platform, and DART police handcuffed him after he confronted a DART employee for not enforcing DART’s no smoking rules. (Id. at 607.) DART police released him and dropped him off near his home, but made him sign an agreement to stay off DART for 12 months. (Id. at 584.) He became “so overwhelmed with anger, anxiety, [and] frustration” that he broke down and wept uncontrollably. (Id.)

         On the same day, Plaintiff was transferred from the hospital to the VAMC and was examined by Fred Gioia, M.D. (Id. at 592.). Dr. Gioia noted that Plaintiff appeared “extremely anxious” and uncomfortable with any personal interaction, and became distressed when asked to discuss the train incident. (Id.) Plaintiff displayed fair eye contact, anxious mood, psychomotor agitation, and some insight, but was also cooperative, talkative, and showed “improving” judgment. (Id. at 594.) Dr. Gioia opined that Plaintiff was an “extremely anxious and socially award individual” with “strong ruminative tendencies regarding such deficiencies, bordering on obsessive and delusional thinking.” (Id.) He also opined that he did not represent a threat to himself or others. (Id.) Monte Goen, M.D., also examined Plaintiff and noted that he had poor eye contact, unkempt hair, flat facial expressions, logical but somewhat circumstantial thought processes, dysphoric mood, restricted affect, fairly poor insight, and fair judgment. (Id. at 612.) He assessed Plaintiff with pervasive developmental disorder, anxiety disorder, and depression, and calculated a Global Assessment of Functioning (GAF) score of 45-50.[5] (Id.) Plaintiff was discharged the same day. (Id. at 580.)

         On June 6, 2011, Dr. Spain issued a letter as part of Plaintiff’s application to the VA for increased service-connected disability. (Id. at 578-79.) It stated that Plaintiff often presented as anxious and irritable, his thought content was at times tangential, and he demonstrated difficulty in expressing and experiencing emotions other than frustration and anger. (Id. at 579.) It also stated that Plaintiff had “a long history of difficulty maintaining jobs, completing his academic goals, and having close personal relationships due to his perceived difficulties in communication and socialization.” (Id.)

         On September 9, 2011, VA staff psychologist John Esthafer completed a mental disorders Disability Benefits Questionnaire (DBQ) for Plaintiff. (Id. at 363-70). He noted that Plaintiff had been diagnosed with schizoid personality disorder with avoidant traits, social phobia, and generalized anxiety disorder (GAD), and he had a current GAF of 40. (Id. at 363-64.) Dr. Esthafer opined that Plaintiff’s situational social anxiety would make job positions that required contact with the public or collaborative work difficult for him; his lack of desire for social contact, schizoid lifestyle, unusual thinking, lack of interest in activities, and flattened affect would contribute to inefficiency at work, difficulty relating to peers, and self-termination of employment; and his ruminative worry would contribute to overall tension and difficulty adapting to a work or social environment. (Id. at 366.) He concluded that Plaintiff’s GAD was “at most a tertiary diagnosis as his primary ruminative worry [was] in regard to social functioning rather than a global worry about multiple aspects of his life.” (Id. at 370.)

         On September 27, 2011, Plaintiff presented to a nurse practitioner (NP) for a neurosurgery consult for his low back problems. (Id. at 1948-52.) She noted that he had been diagnosed with anxiety disorder and depression and had a service-connected disability rating of 90 percent.[6] (Id. at 1948, 1951.) During his examination, Plaintiff “frequently interrupted [her], became argumentative, and [was] insistent that something needed to be done regarding his cervical spine complaints, ” and he dismissed her answers regarding his parethesia. (Id. at 1952-53.)

         On October 18, 2011, Plaintiff presented to Dr. Sethupathi for a scheduled appointment. (Id. at 712.) He reported not leaving the house because of his anxiety and not having a car. (Id.) He was able to go out with a friend for a game and have a normal conversation, but remained worried about having panic attacks when outside the house, and he was still not interested in attending a social skills group. (Id.) Plaintiff returned to Dr. Sethupathi on January 19, 2012, May 17, 2012, and September 5, 2012; the clinical notes from those visits were generally the same. (Id. at 667-68, 678-79, 691-92, 712-14.)

         On March 21, 2013, another examiner[7] interviewed Plaintiff and completed a second mental disorders DBQ. (Id. at 842-50.) He noted that Plaintiff had been diagnosed with GAD, social phobia, and schizoid personality disorder, and had a current GAF of 48. (Id. at 844.) He opined that Plaintiff’s mental disorder diagnoses were an occupational and social impairment resulting in him having deficiencies in most areas like work, school, family relations, judgment, thinking, and mood. (Id. at 846-47.) Plaintiff stated that if he was not on his psychotropic medication, his mind tended to wander to things that made him anxious, which resulted in him having repeated “run-ins” with supervisors and co-workers, and the same happened with the June 2011 incident at the DART rail station. (Id. at 847.) The examiner opined that Plaintiff’s mental disorders caused the following symptoms: anxiety; suspiciousness; flattened affect; circumstantial, circumlocutory, or stereotyped speech; impaired judgment; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work-like setting; and inability to establish and maintain effective relationships. (Id. at 848-49.) He further opined that given ...


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