Beck v. Astrue

• Decision Date: 07 September 2012
• Docket Number: Case No.: 3:11-cv-00711
• Court: U.S. District Court — Southern District of West Virginia
• Parties: NORMAN BRUCE BECK, Plaintiff, v. MICHAEL J. ASTRUE, Commissioner of the Social Security Administration, Defendant.

NORMAN BRUCE BECK, Plaintiff,

v. MICHAEL J. ASTRUE, Commissioner of the SocialSecurity Administration, Defendant.

Case No.: 3:11-cv-00711

UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF WEST VIRGINIA HUNTINGTON DIVISION

ENTERED: September 7, 2012

MEMORANDUM OPINION

This is an action seeking review of the decision of the Commissioner of the Social Security Administration (hereinafter the "Commissioner") denying plaintiff's application for a period of disability and disability insurance benefits ("DIB") and supplemental security income ("SSI") under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 401-433, 1381-1383f. The case is presently before the Court on the parties' Motions for Judgment on the Pleadings. (ECF Nos. 14 and 17). Both parties have consented in writing to a decision by the United States Magistrate Judge. (ECF Nos. 7 and 9). The Court has fully considered the evidence and the arguments of counsel. For the reasons that follow, the Court finds that the decision of the Commissioner is supported by substantial evidence and should be affirmed.

I. Procedural History

Plaintiff, Norman Bruce Beck (hereinafter referred to as "Claimant"), filed for DIB and SSI on May 7, 2007, (Tr. at 140, 148), alleging disability due to prior stroke, use of apace maker, high blood pressure, high cholesterol, diabetes, knee pain, and back pain.¹ (Tr. at 162). The Social Security Administration ("SSA") denied the application initially and upon reconsideration. (Tr. at 93, 104). On May 19, 2008, Claimant filed a written request for a hearing before an Administrative Law Judge ("ALJ"). (Tr. at 111). The administrative hearing was held on July 23, 2009 before the Honorable Roseanne M. Dummer. (Tr. at 35-88). By decision dated November 27, 2009, the ALJ determined that Claimant was not entitled to benefits. (Tr. at 13-28).

The ALJ's decision became the final decision of the Commissioner on August 25, 2011 when the Appeals Council denied Claimant's request for review. (Tr. at 1-4). On October 7, 2011, Claimant brought the present civil action seeking judicial review of the administrative decision pursuant to 42 U.S.C. § 405(g). (ECF No. 2). The Commissioner filed his Answer and a Transcript of the Proceedings on December 12, 2011. (ECF Nos. 10 and 11). Thereafter, the parties filed their briefs in support of judgment on the pleadings. (ECF Nos. 14 and 17). Therefore, this matter is ripe for resolution.

II. Claimant's Background

Claimant was 44 years old at the time of his alleged disability onset. (Tr. at 39, 42). He attended school to 12th grade, but did not graduate, and later obtained a GED. (Tr. at 40). Claimant previously worked as a night maintenance person at McDonald's. (Id.). He communicates in English.

On January 27, 2007, Claimant suffered from a stroke (transient ischemic attack), for which he sought immediate treatment. (Tr. at 289-90). During hospitalization, he was diagnosed with diabetes, high blood pressure (hypertension),high blood cholesterol (hyperlipidemia), and a complete heart block, which was discovered after Claimant was asystole for over five seconds. (Tr. at 286, 290). Claimant alleged that he became unable to work because of his disabling condition on February 28, 2007, stating that "[a]fter I got out of the hospital, I wasn't very much good at all. (Tr. at 140, 148). Since then, Claimant has undergone a myriad of medical examinations and assessments related to his cardiovascular status and other physical ailments. In 2007, Claimant and his family lost their home and moved into his wife's parents' home. (Tr. at 406). In December of 2007, Claimant commenced mental health treatment at Prestera Center for depression and anxiety. (Tr. at 411-12). Claimant continued his mental health treatment at least through the date of his administrative hearing.² (Tr. at 682).

III. Relevant Medical Records

The Court has reviewed the Transcript of Proceedings in its entirety including the medical records in evidence. Given that Claimant's challenges primarily involve his mental health impairments, the undersigned summarizes below Claimant's mental health treatment and evaluations to the extent that they are relevant to the issues in dispute.

A. Prestera Mental Health Center Records

1. Treatment Notes and Mental Status Evaluations

On December 11, 2007, Claimant sought mental health treatment from Prestera Mental Health Centers ("Prestera"). (Tr. at 406). His chief complaints were depression and anxiety, which had "bec[o]me prominent after becoming injured, out of work, and losing his home." (Tr. at 406). Claimant also "report[ed] experiencing paranoid anddelusional thoughts when in public." (Tr. at 406). In his initial mental status evaluation, Claimant reported insomnia, diminished appetite, no suicidal or homicidal ideation, some delusions/paranoia, and difficulty remembering day-to-day activities. (Tr. at 409-10). The access center clinician described Claimant as "within normal limits" or otherwise unexceptional in his appearance (hygiene, posture, gait, dress), sensorium, attitude, eye contact, attention span, impulse control, mood, affect, intellectual functioning, insight, and judgment. (Tr. at 409-10).

The record shows that Claimant met with a Prestera therapist roughly once a month for discussion-based therapy sessions, while a physician's assistant managed Claimant's medication with appointments occurring every few months: Claimant met with Prestera therapist Nicole Wilson on January 8, January 23, March 4, March 26, April 16, June 3, July 3, August 1, September 5, October 1, November 14, and December 18 of 2008, and January 16 or 2009. (Tr. at 404, 405, 493, 527, 540, 542, 545, 645, 647, 650-51 652, 655, at 657). He met with Prestera therapist Marybeth Smith on February 11, May 13, July 8, August 4, and August 18 of 2009, (Tr. at 659, 673-74, 676, 678, and 680), and with Prestera Physician's Assistant (PA) Sarah Rodes on February 9, March 7, May 2, July 3, October 1, and December 10 of 2008, and March 20, June 30, August 29 of 2009. (Tr. at 402-03, 491, 541, 544, 649, 654, 672, 675, and 682).

In all of therapist Wilson's session notes, she described Claimant's mental status as "within normal limits" or as showing "no significant change from last visit." (Tr. at 404, 405, 493, 527, 54, 542, 645, 647, 650, 652, 655, and 657). Similarly, therapist Smith initially reported all of Claimant's mental status attributes as "unremarkable," describing him as "oriented x4" and a danger to none. (Tr. at 659). In all subsequent session notes, Smith described Claimant's mental status as simply "alert and orientedx4." (Tr. at 659, 673-74, 676, 678, and 680). Likewise, aside from periodically presenting as anxious or depressed in mood, PA Rodes's assessments of Claimant's mental status were wholly unexceptional. (Tr. at 402-03, 491, 541, 544, 649, 654, 672, 675, and 682).

Notes from therapist Wilson's first meeting with Claimant on January 8, 2008 reflect that his primary difficulty was in coping with recent changes in his life, including chronic pain, loss of his home, moving in with parents-in-law, and having no income. (Tr. at 405). These concerns, as well as several deaths in the family, turned out to be recurring themes throughout the course of Claimant's treatment at Prestera as documented in the following treatment records:

• Claimant "has low self esteem and his pride has been injured by his inability to work and provide for his family." (Tr. at 404)

• Claimant "is doing fair but continues to have some problem areas to discuss, most are related to his physical health and relational problems." (Tr. at 450)

• Claimant reports that he "had been doing ok" and had not had any major episodes with his father-in-law. (Tr. at 542)

• Claimant's "physical health plays a major role in the continuation of his depression" and "the family also struggles a great deal financially." (Tr. at 545)

• Claimant has "been supportive of his wife" whose mother had recently become terminally ill. (Tr. at 645)

• Claimant reports that he had been "spending most of his time taking care of his children and helping his wife" handle the grief of losing her mother. (Tr. at 647)

• Claimant "feels like he should be doing more to support his family and becomes depressed when he realizes that he may never be able to work again." (Tr. at 650)

• Claimant explores coping options for the unexpected loss of his mother. (Tr. at 652)• Claimant reports feeling "moody" and "like a failure." (Tr. at 655)

• Claimant reports that he and his wife were mostly "doing okay," though he still grieves for his mother. (Tr. at 657)

• Claimant reports that not being able to work has been a difficult transition for him. (Tr. at 659)

• Claimant reports "frustration with not being able to work and provide for the family" and about frequent arguments with his wife. (Tr. at 676)

• Claimant reports frequent arguments with his wife and feelings of helplessness due to not being able to work and not bringing in any income. (Tr. at 678)

• Claimant reports feeling emasculated. (Tr. at 680)

However, the use of medication and the development of coping strategies appeared to have had some positive effect on Claimant's depression and anxiety as documented below:

• Claimant "discussed options for change and coping." (Tr. at 404-05)

• Claimant reports improvement since taking Cymbalta. (Tr. at 491)

• Claimant "feels that Cymbalta has helped his depression and he is starting to feel less anger." (Tr. at 493)

• Claimant had "shown some minor improvements with the regimen he is taking." (Tr. at 540)

• Claimant "enjoys taking walks and often goes and sits outside when he needs to calm down." (Tr. at 542)

• Claimant reports that "his medication has been helping him," and the therapist observes that Claimant had "learned some good coping skills including walking that have helped him stay calmer." (Tr. at 645)

• Claimant reports that he is "much better at handling stress when he has Ativan to help

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