Pate v. Saul

CourtDistrict Court, D. Massachusetts
DecidedJune 11, 2020
Docket1:19-cv-11594
StatusUnknown

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Bluebook
Pate v. Saul, (D. Mass. 2020).

Opinion

UNITED STATES DISTRICT COURT DISTRICT OF MASSACHUSETTS ___________________________________ ) ALISA S. PATE, ) ) Plaintiff, ) ) Civil Action v. ) No. 19-cv-11594-PBS ) ANDREW M. SAUL, ) ) Commissioner of the ) Social Security Administration,1 ) ) Defendant. ) ___________________________________)

MEMORANDUM AND ORDER June 11, 2020 Saris, D.J. Plaintiff Alisa Pate brings this action under 42 U.S.C. §§ 405(g) for judicial review of a final decision denying her applications for Supplemental Security Income. She claims that the Administrative Law Judge (“ALJ”) erred by basing his conclusions on a lay interpretation of the medical record and by failing to consider vocational expert testimony submitted by the Plaintiff.

1Andrew M. Saul has been substituted pursuant to Fed. R. Civ. P. 25(d) for Nancy A. Berryhill, the former Acting Commissioner of the Social Security Administration. For the following reasons, the Court ALLOWS Plaintiff’s motion for an order remanding the decision of the Commissioner (Dkt. No. 14) and DENIES Defendant’s motion for an order affirming the Commissioner’s decision (Dkt. No. 19). FACTUAL BACKGROUND The following facts are taken from the administrative

record. (Dkt. No. 12). I. Medical History Plaintiff suffered a head injury in or around 1985 at the age of twenty-three when she was thrown from a vehicle. She spent the following year in a rehabilitation facility. Following the accident, her memory declined and she began having seizures. Physicians at Southcoast Health System’s Brain and Spine Center (“Southcoast Brain and Spine”) believe Plaintiff’s head injury caused her seizures, which were managed with medication. Around September 2012, Plaintiff

received a brain MRI scan at Southcoast Brain and Spine which showed posttraumatic brain changes. From November 2012 to September 2014, Plaintiff was seen by Randy Caplan, DO at Southcoast Physicians Network (“Southcoast Physicians”) primarily for anxiety, depression, and seizure disorder. Dr. Caplan prescribed Plaintiff several medications for anxiety and depression. On November 13, 2012, Dr. Caplan described that Plaintiff’s depression and anxiety were “under good control with medication.” Dkt. No. 12-7 at 71. In 2013, Plaintiff experienced increased anxiety and depression. In April 2013, Dr. Caplan noted she “feels more anxious lately,” and she complained of anxiety attacks. Id. at 69. In June 2013, Plaintiff was “[s]till

anxious.” Id. at 63. In August 2013, Dr. Caplan assessed Plaintiff for anxiety and depression and noted her symptoms had improved with medication. In November 2013, Dr. Caplan described Plaintiff as experiencing “[c]hronic anxiety and depression,” and wrote that with daily use of Paxil, the Plaintiff’s “relat[ed] anxiety decreased but mood [was] often depressed.” Id. at 53. Her cognitive exam was “grossly normal.” Id. On December 2, 2013, a physician at Southcoast Brain and Spine noted that Plaintiff experienced some increased “fatigue/forgetfulness” but did not report weakness. Id. at 84.

On December 17, 2013, Plaintiff saw Dr. Caplan, who noted Plaintiff was taking Trileptal to prevent seizures was feeling “well transitioning from Paxil to Zoloft for anxiety & depression.” Id. at 51. Plaintiff stated she suffered from depression but denied feeling weakness, dizziness, or recent seizures. Dr. Caplan described the Plaintiff’s psychiatric state as follows: “Chronic excessive worry for [greater than] 6 months. Chronic fear of being unable to cope. Restless. Nervous. Chronic sleep disturbance; controlled with use of medication. Chronically poor concentration ... Less participation in hobbies & social activities (enjoyment) than in the past. Low or depressed mood.” Id. Dr. Caplan described the Plaintiff’s examination as “gait normal,

alert and oriented, cognitive exam grossly normal . . . speech clear,” yet Plaintiff also was “anxious appearing, [with] poor concentration” and Plaintiff’s recollection was “poor.” Id. at 52. Plaintiff described improved symptoms from January 2014 through the beginning of June 2014. On January 16, 2014, Dr. Caplan determined Plaintiff had an “improved mood and less anxiety on sertraline. Denies side effects. Sleeping better.” Id. at 47. Dr. Caplan also noted that Plaintiff “ha[d] res[p]onded nicely” to her treatment for depression. Id. The general examination showed Plaintiff

“in no acute distress” and a “good mood.” Id. In March 2014, Dr. Caplan noted “no recent seizures.” Id. at 45. On May 19, 2014, Dr. Caplan noted that Plaintiff “[d]enies any seizures.” Id. at 43. The physician also noted Plaintiff’s depression was “improved,” anxiety “improved” and seizure disorder was “currently stable.” Id. at 43-44. On June 11, 2014, Dr. Caplan stated Plaintiff “currently feels well. Denies complaints.” Id. at 39. On June 30, 2014, Dr. Caplan described “an episode where [Plaintiff] was driving to the grocery store and she forgot where she was and how to get there.” Id. at 37. Dr. Caplan reasoned it was “possible she may have had some seizure

activity.” Id. She was asked not to drive. Id. In July 2014, Plaintiff received an EEG to assess seizure- like activity after the driving incident. The EEG revealed “normal waking, drowsing, and sleeping,” but the test provider noted that it did “not exclude the clinical diagnosis of seizures or epilepsy.” Id. On August 16, 2014, Plaintiff was admitted to the hospital after experiencing “abnormal gait” and “falling over without provocation.” Id. at 33. Plaintiff experienced a “[n]ew onset unsteady gait [and] weakness.” Id. at 7. A CT scan of Plaintiff’s head showed a white matter disease possibly related

to her prior traumatic injury. On August 18, 2014, Plaintiff received a brain MRI at Southcoast Health System, and Dr. Gregory Hurlock noted a history of unsteady gait, dizziness, and frequent falls. Dr. Hurlock concluded the MRI showed “[n]onspecific white matter changes, likely represent[ing] sequela of chronic microangiopathy, similar to” results seen a test performed on Plaintiff in 2012. Id. at 6. Upon discharge, on August 18, 2014, Dr. Caplan diagnosed Plaintiff with chronic “[g]ait disorder, likely due to alcohol use in the past with Dilantin use as well.” Id. at 115.

In September 2014, Plaintiff saw Dr. Caplan for a follow up. Dr. Caplan noted Plaintiff was “in no acute distress,” with “good mood.” Id. at 33-34. Her gait abnormality had “resolved” and her seizure disorder was “stable.” Id. at 34. Between 2014 and 2018, Plaintiff’s condition devolved, though Plaintiff occasionally reported improved symptoms. In April 2016, Plaintiff’s EEG test results were abnormal. In October 2016, a nurse practitioner described Plaintiff as “manic” during a physical exam. Dkt. No. 12-14 at 16. In January 2017, the same nurse practitioner described

Plaintiff’s mood and behavior as normal. However, in July 2017, Dr. Anna Somerto wrote Plaintiff’s memory was “worsening over time” and that “difficulty concentrating.” Id. at 27. Plaintiff was advised multiple times to seek treatment for alcohol abuse. In April 2018, Plaintiff denied having anxiety, depression, or memory loss. In May and September 2018, John Dorn, Psy.D., examined the Plaintiff to produce a diagnostic testing report. Dr. Dorn administered the psychological testing, including the Wechsler Adult Intelligence Scale. Dr. Dorn diagnosed Plaintiff with major depression, generalized anxiety disorder, history of traumatic brain injury, mild neurocognitive disorder, seizure

disorder, alcohol use disorder, unspecified dementia, and unspecified attention deficit hyperactivity disorder. II. Medical Opinions A. Dr. Roland Einhorn On September 22, 2014, Dr.

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