Juana Moore v. Commissioner of Social Security Administration

District Court, D. Arizona·Decided November 16, 2023·No. 4:22-cv-00550·Unknown

Opinion

Juana Moore, No. CV-22-00550-TUC-RM (JR)

Plaintiff, REPORT AND RECOMMENDATION

v.

Commissioner of Social Security Administration, Defendant. Plaintiff Juana Moore (“Moore”) brings this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), seeking judicial review of a final decision by the Commissioner of the Social Security Administration (“Commissioner”). (Doc. 1.) This matter, on referral to the undersigned United States Magistrate Judge for Report and Recommendation, is ripe for decision.1 (Doc. 15, 24, 26.) As more fully set forth below, the Magistrate Judge recommends that the district court reverse the Administrative Law Judge’s (“ALJ”) decision and remand the matter to the agency for further proceedings. BACKGROUND Procedural History On March 16, 2020, Moore protectively filed a Title II application for disability and 1 Moore did not file a reply brief and the time for filing a reply brief has elapsed. disability insurance benefits alleging a disability onset date of March 4, 2017. (Administrative Record “AR” 24.) More’s claim was denied initially on May 18, 2020, and denied on reconsideration on August 17, 2020. (AR 102-114 (initial denial); AR 116-128 (reconsideration denial).) A hearing was held before an ALJ on May 6, 2021. (AR 43-67.) In a decision dated November 8, 2021, the ALJ determined Moore was not disabled. (AR 24-36.) On November 8, 2022, the Appeals Council denied review thus making the ALJ’s decision final for judicial review. (AR 1-6.) See 42 U.S.C. §§ 405(g), 1383(c)(3). Brief Relevant Factual Background Moore was born in 1967 and holds a GED. (AR 268, 67-68.) She stopped working in January 2015. (AR 67-68.) She has past work as an assembler, custodian and office worker. (AR 268.) Moore was referred by her primary care provider to Amany Hararah, Psy. D., for evaluation and treatment. (AR 625.) On June 7, 2017, Dr. Hararah recorded Moore as stating, “I need to get myself into some counseling. I need [to] start dealing with my pas[t]. It has gotten to the point, where it’s getting to be to[o] much for me to handle . . .[.]” Id. (emphasis omitted.) Dr. Hararah recorded Moore’s complaints as depression including depressed mood, crying spells, insomnia, irritability, decreased concentration[,] trauma including recurrent memories/thoughts, distressing dreams, flashbacks, hyperviligence, avoidance and exaggerated startle response. (AR 625-626.) On June 21, 2017, Moore is recorded by Dr. Hararah as “seeking services to address depression.” (AR 668-669.) Dr. Hararah recorded Moore’s symptoms as “anxiety including excessive worry, restlessness, muscle tension, hypervigilance [and] depression including depressed mood, anhedonia, crying spells, insomnia, decreased energy, guilt, decreased concentration.” (AR 669.) Dr. Hararah noted “sleep issues[,] including difficulty falling asleep, difficulty staying asleep and non-restorative sleep.” Id. Dr. Hararah recorded that Moore has a history of outpatient individual therapy. Id. On mental status exam, Moore is recorded as alert, well groomed, tearful, pleasant and cooperative and guarded, with depressed mood and fair insight. (AR 671.) Dr. Hararah diagnosed Moore with post- traumatic stress disorder (“PTSD”) and referred her to “the acute PTSD group.” (AR 671- 672.) On August 2, 2017, Dr. Hararah saw Moore for a psychiatric follow-up visit. (AR 643-647.) Dr. Hararah recorded that “pt reported that her symptoms have slightly improved.” (AR 643.) Dr. Harrah recorded that Moore continues to experience anxiety and flashbacks and that she also has dreams of getting into a car accident with her daughter and ex-husband chasing them. Id. Dr. Hararah referred Moore to “the anxiety group as a start” with an intent to transition her to the trauma group and eventually to the PTSD group. Id. On August 9, 2017, Dr. Hararah saw Moore via telehealth. (AR 1306-1310.) Dr. Hararah recorded that Moore reported “taking Effexor 75 mg since Monday and has not noticed a positive difference.” (AR 1306.) Moore is recorded as having more difficulties with sleep and middle of the night awakenings due to nightmares surrounding a history of trauma. Id. Dr. Hararah assessed Moore as, inter alia, scoring 51-60 on the DSM Axis V.2 2 Axis V is for reporting the clinician's judgment of the individual's overall level of functioning. A score of 51-60 indicates “Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers).” See https://www.edwardpierce.net/super/Axis5.htm (last visited Nov. 14, 2023). (AR 1307.) On October 6, 2017, Nathan Edmundson, Psy. D., conducted a consultative examination. (AR 1284-1289.) Moore’s chief complaint is recorded as, “PTSD, fear of being alone . . . Claimant reported symptoms of frequent sadness, nightmares, and increased anxiety associated with past traumas.” (AR 1284.) Dr. Edmundson recorded that Moore reported “having to deal with ‘so many things all my life, since a child.’” Id. Dr. Edmundson recorded that Moore reported crying frequently and “seeing a doctor at Kaiser for her mood.” Id. Dr. Edmunson recorded that Moore reported being abandoned by her mother and sent to live with her grandparents as a child, after her half-brother died, due to the emotional impact that her half-brother’s death had on her mother. (AR 1284-1285.) She also reported suffering physical abuse by her previous husband. (AR 1284.) Her mood is recorded by Dr. Edmundson as being “up and down” and the record reflects that Moore suffered suicidal ideation in the past. (AR 1285.) Dr. Edmunson recorded Moore’s diagnoses as PTSD and major depressive disorder, moderate. (AR 1287.) He also opined, inter alia, that Moore is moderately limited in her ability to complete a normal workday or workweek without interruptions resulting from her psychiatric conditions “as [her] depression occurs regularly.” (AR 1288.) Dr. Edmunson opined that Moore is mildly to moderately limited in her ability to interact with coworkers and with the public due to her “PTSD, anxiety, and depressive symptoms.” Id. Dr. Edmunson opined that Moore is moderately limited in her ability to “deal with the usual stresses encountered in [a] competitive work environment” due to her “PTSD, anxiety, and depression.” Id. Dr. Edmunson also opined that Moore is mildly limited in her ability to perform work activities on a consistent basis reasoning that “depression contributes to some distractibility evident by [Moore’s] difficulty with attention and concentration tasks.” (AR 1288.) Dr. Edmunson opined that Moore’s “memory difficulties may require a supervisor to repeat instructions or provide prompts periodically throughout the day.” Id. Dr. Edmunson provided a narrative opinion as follows: Given the claimant’s psychiatric and treatment history and results of this evaluation, it appears that the mental health symptoms may be chronic in nature. Given the current diagnosis, it appears that the claimant’s current mental health condition may not abate on its own within a one-year period. The claimant presented as polite and cooperative, but moderately depressed and anxious. She has long standing depressive symptoms along with anxiety and nightmares related to her PTSD symptoms. She is likely to have difficulty tolerating stressful work environments due to her mental health symptoms, have difficulty making regular and consistent work attendance due to depression, and she is lily (sic) to have some difficulty interacting with [the] general public due to anxiety, social avoidance, and her PTSD symptoms. It appe

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