Ball v. Colvin

RONALD E. BALL, Plaintiff, v. CAROLYN W. COLVIN,¹ Acting Commissioner of Social Security, Defendant.

CAUSE NO. 1:12-CV-00369

UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF INDIANA FORT WAYNE DIVISION

February 28, 2014

OPINION AND ORDER

Plaintiff Ronald Ball appeals to the district court from a final decision of the Commissioner of Social Security ("Commissioner") denying his application under the Social Security Act (the "Act") for a period of disability and Disability Insurance Benefits ("DIB").² (Docket # 1.) For the following reasons, the Commissioner's decision will be REVERSED, and the case will be REMANDED to the Commissioner for further proceedings in accordance with this Opinion and Order.

I. PROCEDURAL HISTORY

Ball applied for DIB in October 2009, alleging disability as of June 24, 2008. (Tr. 16271.) The Commissioner denied his application initially and upon reconsideration, and Ball requested an administrative hearing. (Tr. 90-93, 125-30.) On April 7, 2011, a hearing was conducted by Administrative Law Judge ("ALJ") John Pope, at which Ball, who was representedby counsel, and a vocational expert ("VE") testified. (Tr. 34-78.) On July 14, 2011, the ALJ rendered an unfavorable decision to Ball, concluding that he was not disabled because he could perform a significant number of jobs in the economy despite the limitations caused by his impairments. (Tr. 16-29.) The Appeals Council denied his request for review, at which point the ALJ's decision became the final decision of the Commissioner. (Tr. 1-12, 79-86, 264-81.)

Ball filed a complaint with this Court on October 22, 2012, seeking relief from the Commissioner's final decision. (Docket # 1.) In this appeal, Ball argues that the ALJ: (1) improperly discounted the credibility of Ball's mental health symptom testimony; and (2) failed to adequately incorporate Ball's moderate difficulties in concentration, persistence, and pace into the RFC and the hypothetical posed to the VE. (Opening Br. of Pl. in Social Security Appeal Pursuant to L.R. 7.3 ("Opening Br.") 6-11.)

II. FACTUAL BACKGROUND³

A. Background

At the time of the ALJ's decision, Ball was forty-seven years old, had a high school education, and had worked as an automobile assembler for Chrysler Corporation from 1997 to June 2008; he also had past work experience as a surgical support health aide. (Tr. 41, 164, 262, 399.) Ball alleges that he is disabled due to degenerative disc disease, sleep apnea, post traumatic stress disorder ("PTSD"), attention deficit hyperactivity disorder ("ADHD"), and depression. (Opening Br. 2.) Because he challenges only the ALJ's findings concerning his mental impairments (Opening Br. 2 n.1), the Court will focus on the evidence pertaining to Ball's mental, rather than physical, limitations.

At the hearing, Ball stated that he lived with his girlfriend in a mobile home. (Tr. 40.) He was laid off from his assembler job at Chrysler in 2008; he applied for other jobs but was unsuccessful. (Tr. 42-45.) Ball is independent with his self care and goes shopping alone if needed; he also visits his mother each week. (Tr. 53-54, 58.) In his spare time, Ball enjoys going to the shooting range; riding his motorcycle; and serving as the quartermaster of the local VFW, which involves financial management. (Tr. 54, 59, 69.) In a typical day, Ball rises early and packs his girlfriend's lunch, but then usually lies back down. (Tr. 50-51.) By mid-morning, he performs household chores, including laundry, vacuuming, and unloading the dishwasher; and watches television. (Tr. 51-52, 54.) Once his girlfriend returns home, they fix dinner or go out to eat and then watch television. (Tr. 52-53.)

When asked about how his psychological conditions affect his ability to work, Ball stated that he used to feel anxious just getting out of the car at work, as well as "hyper," which others mistook for anger. (Tr. 55-56, 70.) He added that he would have an absenteeism problem and difficulties with concentration, but no problem getting along with others. (Tr. 59, 70-71.) He had been receiving treatment for his psychological conditions through the Veterans' Administration ("VA") since 2005. (Tr. 56.) Currently, he was seeing a VA psychologist two to three times a month and a psychiatrist once a month, and participating in a PTSD group. (Tr. 56-57.)

B. Summary of the Relevant Medical Evidence

In March 2007, Ball underwent a mental status exam by Dr. Elizabeth Martin, a psychiatrist, at the VA. (Tr. 833-34.) His mood, insight, and judgment were fair, and his thought process ruminative. (Tr. 834.) He reported a suicidal thought from the night before, but otherwise none in the past several weeks. (Tr. 834.) No psychosis or suicidal plan or intent werenoted. (Tr. 834.) He admitted that he drinks beer, but was adamant that he would not return to hard liquor, fearing it would lead to a black-out or hurting someone. (Tr. 834.) Dr. Martin assessed that Ball had depression and possible PTSD and ADHD, and adjusted his medications. (Tr. 834.) Dr. Martin, or another VA psychiatrist, saw Ball approximately twenty-five times from January 2007 to December 2010. (Tr. 517, 607, 630, 633, 666, 677, 758, 768, 904, 907, 924, 940, 979, 1000, 1025, 1044, 1049, 1057, 1062, 1070, 1077-79.) He was assigned Global Assessment of Functioning ("GAF") scores ranging from 55 to 65, reflecting moderate or mild mental health symptoms, in 2008 to 2010.⁴ (Tr. 383-85, 666, 758, 768.)

In January 2007, Ball began seeing Birgette Miller, a psychologist, for fifty-minute sessions of psychotherapy. (Tr. 854.) He saw her approximately 120 times from January 2007 to March 2011. (Tr. 426, 441, 448, 464, 467, 469, 471, 477, 485-86, 488, 507, 510, 514, 520, 530, 532, 534, 598, 604, 609, 612-13, 616, 621, 625, 644, 647, 653, 658, 661-62, 664, 670-71, 673, 675, 680, 682, 687, 690, 741-42, 745, 750, 754, 761, 773, 779, 783, 786, 789, 793, 797, 805, 827, 829-30, 840-42, 846, 850, 854, 891, 893-94, 900, 902, 908-09, 914, 925, 933, 935-39, 942, 965, 970, 978, 986, 988, 990, 992, 995, 997-99, 1002, 1004, 1011, 1022, 1024, 1028, 1031, 1033, 1035, 1038-39, 1043, 1045, 1047, 1056, 1059, 1060, 1066, 1068-69, 1076, 1079.)

Dr. Miller assigned Ball GAF scores ranging from 56 to 64, reflecting moderate or mild symptoms, in 2007 to 2009. (Tr. 383-85.) During several visits from February 2010 through March 2011, she administered the Beck Depression and Beck Anxiety tests to Ball, and heconsistently scored in the "severe" category. (Tr. 599, 645, 648, 651, 656, 774, 783, 794.) Dr. Miller periodically encouraged Ball to pursue work, vocational rehabilitation, and volunteer opportunities. (See, e.g., Tr. 491, 516, 521, 806, 937.)

In June 2007, Ball was hospitalized in the psychiatric unit at the VA for two weeks after having suicidal ideation. (Tr. 1102-04.) During his hospitalization, he complained of symptoms of depression, hypomania, mood swings, and anxiety. (Tr. 1103.) By discharge, Ball's mood, insight, and judgment were good; his affect appropriate; and his thought processes logical and sequential. (Tr. 1103.) He denied suicidal ideation. (Tr. 1103.)

In January 2009, Gerald Vasily, Ph.D., performed a mental status examination on Ball at the VA. (Tr. 391-409.) After reviewing Ball's mental health history, including alcohol dependence, Dr. Vasily concluded that Ball's mental health problems appeared to be of "mild to moderate severity." (Tr. 400-01.) During the session, Ball appeared relaxed and in no distress, but became tearful when talking of relationships; his mood was depressed with congruent affect. (Tr. 406.) His insight, judgment, and comprehension appeared intact and in the average range; his speech patterns were logical, relevant, coherent, and goal directed. (Tr. 406.) Ball denied any hallucinations, delusions, thought disorders, or suicidal or homicidal ideations. (Tr. 406-07.)

Dr. Vasily diagnosed Ball with depressive order, not otherwise specified; alcohol dependence (in early remission); ADHD (by history); and dysfunctional personality traits with dependent features. (Tr. 408.) He concluded that Ball did not meet the criteria for bipolar disorder, and also disputed Dr. Martin's diagnosis of PTSD because he "could not find any discussion of the rationale in [her] progress notes." (Tr. 408.) Dr. Vasily thought that Ball's depressive disorder "affected his functioning in the workplace to a mild degree." (Tr. 408.)

On December 8, 2009, Ball underwent a mental status examination by Candace Martin, Psy.D., at the request of Social Security. (Tr. 562-66.) His mood strongly reflected anxiety and depression with notable discouragement, and he cried and fidgeted frequently. (Tr. 564.) His performance on the mental status examination and his cognitive skills were generally within normal limits; he did, however, exhibit relative weakness in verbal concept formation and short term memory, which seemed to be related to difficulty with concentration, possibly related to ADHD. (Tr. 565.) She concluded that "his ability to function independently seems to be disturbed generally only in terms of his physical complaints." (Tr. 565.) Dr. Martin further opined:

His [PTSD] does not appear to be a significant limiting factor in his ability to engage in tasks during the day. His sleep problems would certainly have a notable affect upon his ability to drive or handle dangerous machinery. He does not report specific symptoms of ADHD, which would negatively affect his ability to work, although there are likely to be some symptoms of ADHD which may be more apparent to others that he is not identifying to. He does not show any significant cognitive factors that would affect his ability to function in most jobs.

(Tr. 565-66.) Dr. Martin assigned Ball a GAF score of 55 and diagnosed ADHD, combined type; depressive disorder, not otherwise specified; specific phobia-claustrophobia; generalized anxiety disorder; and alcohol abuse, in remission. (Tr. 566.)

On January 27, 2010, F....