Baskin v. Colvin
| Decision Date | 19 March 2013 |
| Docket Number | No. 3:11-0948,3:11-0948 |
| Parties | WILLIAM N. BASKIN Plaintiff v. CAROLYN W. COLVIN, Acting Commissioner of Social Security |
| Court | U.S. District Court — Middle District of Tennessee |
The plaintiff filed this action pursuant to 42 U.S.C. § 405(g) to obtain judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying the plaintiff's claim for Supplemental Security Income ("SSI") and Disability Insurance Benefits ("DIB"), as provided by the Social Security Act ("Act").
Upon review of the Administrative Record as a whole, the Court finds that the Commissioner's determination that the plaintiff is not disabled under the Act is not supported by substantial evidence in the record as required by 42 U.S.C. § 405(g), and that the plaintiff's motionfor judgment on the administrative record (Docket Entry No. 15) should be GRANTED to the extent that the case should be remanded as provided herein.
On June 12, 2008, the plaintiff protectively filed applications for SSI and DIB, alleging a disability onset date of April 14, 2006. (Tr. 16, 127-37.) His claim was denied initially and upon reconsideration. (Tr. 16, 61-67, 73-76.) A hearing was held before Administrative Law Judge ("ALJ") William B. Churchill on June 2, 2010 (tr. 29-56), and the plaintiff amended his alleged disability onset date to April 13, 2009, at the hearing. (Tr. 16, 32). On July 26, 2010, the ALJ issued an unfavorable decision. (Tr. 16-24.) On August 5, 2011, the Appeals Council denied the plaintiff's request for review, rendering the ALJ's decision the final decision of the Commissioner. (Tr. 1-7.)
The plaintiff was born on August 31, 1979 (tr. 129, 134), and he was thirty years old at the time of the hearing. He is married, has a tenth grade education, and has previously worked as a plumber's helper and as a forklift operator. (Tr. 33-35.)
The plaintiff presented to Volunteer Behavioral Health Care System ("Volunteer") in Lebanon, Tennessee, on March 23, 2007, for alcohol and drug assessment, depression, and sleep disturbance. (Tr. 290.) He reported using opiates "heavily" for about twelve years and having suicidal thoughts in the past. Id. He also reported being "in an altercation in which he was hit witha baseball bat" and that this incident had "been bothering [him] every single day." Id. A mental status examination showed that the plaintiff's appearance was casual, his speech normal, and he had no problem with orientation. (Tr. 292.) His affect and behavior were appropriate; however, he was anxious, agitated, and depressed, and he exhibited evidence of delusions and hallucinations. Id. His memory was good, concentration fair, insight level fair, and insight rating poor. Id. His judgment level was limited, and his judgment rating was poor. (Tr. 293.) His impulse level was impaired, and his impulse rating was poor. Id. He was assessed to be a moderate suicide risk. Id. He was diagnosed with "polysubstance dependence; bipolar I disorder, most recent episode depressed with psychotic features; posttraumatic stress disorder, chronic;" and borderline hypertension, and he was prescribed Tegretol.2 Id. He was assigned a GAF score of 56.3 Id.
The plaintiff began seeing Dr. Wayne Swilley in Goodlettsville, Tennessee, for addiction treatment on April 2, 2007, and reported that he had taken Oxycontin, morphine, and Percocet for the past thirteen years.4 (Tr. 336-37.) The plaintiff reported that he had been "clean" for fifteen days. (Tr. 336.) Dr. Swilley prescribed Suboxone.5 Id. The plaintiff regularly visited Dr. Swilley foraddiction treatment from April 2007, through May 20, 2010.6 (Tr. 335-72, 546-95.) During this time, the plaintiff reported feeling anxious and depressed and not sleeping well. (Tr. 335, 339, 356, 364.) The plaintiff reported occasional relapses with Lortab and morphine to Dr. Swilley and to his mental health care providers at Volunteer. (Tr. 346, 356, 359, 491, 493, 580.) He also reported various maladies including left wrist pain (tr. 348, 359); sore throat, congestion, and coughing (tr. 349, 557, 573, 577, 581); and back pain (tr. 350, 354). Dr. Swilley treated these minor medical issues and prescribed the anti-hypertensive atenolol to treat the plaintiff's high-blood pressure. (Tr. 547-48.)
On September 24, 2007, the plaintiff returned to Volunteer for a followup. (Tr. 295.) He reported that he had not slept in three days due to "racing thoughts" and that he had a depressed mood, flashbacks, nightmares, occasional irritability and crying spells. Id. He also reported that he had stopped taking Tegretol two months earlier because it had not helped. Id. He was diagnosed with polysubstance dependence, "bipolar I disorder, most recent episode depressed, severe with psychotic features," chronic posttraumatic stress disorder, and borderline hypertension. (Tr. 296.) He was assigned a GAF score of 52. Id. He was referred to therapy and prescribed trazodone and valproic acid.7 Id. His prescribed dosage of trazodone was increased at his request on October 10, 2007.(Tr. 502.) On December 11, 2007, the plaintiff reported that trazodone was not working for him, and he was prescribed Seroquel.8 (Tr. 487.)
The plaintiff returned to Volunteer for a followup on February 26, 2008, indicating that he experienced paranoia, mood swings, and anxiety. (Tr. 297, 467.) He reported that his medications were "somewhat beneficial" and that Trazodone had helped him sleep better but that he still had some sleepless nights. Id. He was advised to continue therapy and start taking valproic acid, his dosage of trazodone was increased, and he was also prescribed Haldol.9 (Tr. 298.)
On a Tennessee Clinically Related Group ("CRG") assessment completed by Volunteer staff on March 26, 2008, the plaintiff was rated as having moderate difficulties with interpersonal functioning; adaptation to change; and concentration, task performance, and pace due to reported anxiety. (Tr. 460-462.) He returned to Volunteer for a followup on June 19, 2008, at which time he reported that he had not slept in four days. (Tr. 299, 448.) He reported "poor sleeep [sic] continuity/severe insomnia, anhedonia, reduced appetite, energy, concentration and motivation" as well as "sever [sic] anxiety, irrational fears, difficulty controlling affect, agitation, racing thoughts and anger." Id. He was alert and oriented, cooperative, denied suicidal thoughts, hopelessness or inappropriate guilt, and did not demonstrate delusions or hallucinations. Id.
On August 1, 2008, the plaintiff visited Volunteer, reporting that he had not slept in four days, was out of trazodone, and had stopped taking Haldol because it had not helped him sleep. (Tr. 439.) He was irritable and bouncing his knee, his concentration was impaired, and his mood wasdescribed as "expansive." Id. He was instructed to take his medication as prescribed; however, he was taken off of trazodone, Haldol, and Seroquel, and prescribed Geodon.10 (Tr. 440.) The plaintiff returned for a followup on August 13, 2008, reporting that he had been suicidal for the past week. (Tr. 437.) He reported that he had stopped taking his medication, had not been sleeping, and had been hallucinating. Id. The plaintiff had tics and rocked in his seat. Id. He was taken off Geodon and started back on Seroquel. (Tr. 438.)
On September 16, 2008, Dr. Frank D. Kupstas, a nonexamining consultative DDS psychologist, completed a Psychiatric Review Technique and determined that the plaintiff had bipolar affective disorder, PTSD, and substance addiction disorder. (Tr. 381-390.) Dr. Kupstas rated the plaintiff as mildly limited in the activities of daily living and maintaining social functioning and moderately limited in maintaining concentration, persistence, or pace. (Tr. 391.) Dr. Kupstas also completed a Mental Residual Functional Capacity ("RFC") assessment on September 16, 2008. (Tr. 377-79.) Dr. Kupstas opined that the plaintiff was moderately limited in his ability to maintain attention and concentration for extended periods of time and in his ability to perform activities with a schedule, maintain regular attendance, and be punctual. (Tr. 377-379.) Dr. Kupstas elaborated that the plaintiff was "able to sustain CPP11 over extended periods for simple tasks, detailed [with] some difficulty at times, but still can do so." (Tr. 379.) Dr. Kupstas found no other significant limitations. (Tr. 377-79.) Dr. Andrew Phay, a nonexamining consultative DDS psychologist, "affirmed"Dr. Kupstas' RFC on December 18, 2008, after the plaintiff reported no new allegations, treatment, or worsening. (Tr. 395.)
On September 24, 2008, the plaintiff reported to Volunteer that his mood had stabilized and that he was not as angry or irritable as before. (Tr. 431.) The plaintiff demonstrated "vocal and facial tics constantly" and rocked "throughout" the visit. Id. His concentration, insight, and judgment were unimpaired, he denied suicidal or homicidal ideation or psychotic symptoms, and his speech was normal. Id. The September 24, 2008, progress note included the same diagnoses provided a year earlier and also included Tourette's disorder. (Tr. 432.)
The plaintiff presented to Volunteer on January 7, 2009, for an "extension of medication." (Tr. 426.) He reported that his depression was a 7 on a scale of 1-10 and that he had not slept in four days after running out of medication. Id. He returned to Volunteer on January 19, 2009, reporting that he was not sleeping well and was having some depression, irritability, and racing thoughts. (Tr. 424.) He reported that he lost his job because his company went out of business and that he was having trouble finding employment. Id. He continued to demonstrate "phonic and muscular tics" and "rock[ed] continuously."...
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