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Steppi v. Colvin

United States District Court, D. Delaware

February 27, 2014

JAMES STEPPI, Plaintiff,
v.
CAROLYN W. COLVIN, Commissioner of Social Security, Defendant.

REPORT AND RECOMMENDATION

SHERRY R. FALLON, Magistrate Judge.

I. INTRODUCTION

Plaintiff James Steppi ("Plaintiff') appeals from a decision of Carolyn W. Colvin, the Commissioner of the Social Security Administration (the "Commissioner" or "Defendant"), [1] denying his claim for disability insurance benefits under Sections 216(i) and 223(d) of the Social Security Act. This court has jurisdiction pursuant to 42 U.S.C. ยง 405(g).

Presently before the court are cross-motions for summary judgment filed by Plaintiff (D.I. 9) and the Commissioner (D.I. 14). Plaintiff asks the court to enter an award of benefits or, alternatively, to remand this case for further administrative proceedings. (D.I. 10 at 19) The Commissioner requests that the decision of the administrative law judge ("ALJ") be affirmed. (D.I. 15 at 3) For the reasons set forth below, I recommend that the court DENY Plaintiff's motion for summary judgment and GRANT the Commissioner's cross-motion for summary judgment.

II. BACKGROUND

A. Procedural History

On June 20, 2007, Plaintiff filed an application for disability insurance benefits alleging that he has been disabled since December 11, 2006. (D.I. 5 at 112-19) Plaintiff's claim for benefits was denied initially on February 3, 2008 ( id. at 87-91), and on reconsideration on December 11, 2008 ( id. at 95-98). On January 28, 2009, Plaintiff filed a written request for a hearing. ( Id. at 104-05)

On November 19, 2009, ALJ Melvin D. Benitz held an administrative hearing, by video, at which Plaintiff and a vocational expert ("VE") appeared and testified. ( Id. at 35-82) On December 22, 2009, the ALJ issued a decision finding that Plaintiff was not disabled and could perform a limited range of simple, routine, unskilled, medium work. ( Id. at 16, 24-25) The Appeals Council denied Plaintiff's request for review. ( Id. at 1-3, 83-84)

B. Factual Background

1. Medical History

Plaintiff has four severe impairments: possible toxic exposure to hydrogen sulfide, degenerative disc disease, anxiety/panic disorder, and somatoform disorder.[2] ( Id. at 9)

a. Possible Toxic Exposure to Hydrogen Sulfide

Plaintiff last worked as an electrician for Conti Electric at Valero Oil Refinery. ( Id. at 41, 275, 284, 343) Plaintiff reported that he was working 7 days a week, 12 hours a day. ( Id. at 398)

On December 11, 2006, while at work, Plaintiff thought he was having a stroke. ( Id. at 40-44, 265, 274) Plaintiff reportedly felt nauseous, and experienced chest tightness and tingling in his fingers. ( Id. at 265, 274, 298) He was taken by ambulance to Christiana Hospital. ( Id. ) Paramedics recorded that Plaintiff had a near fainting episode associated with flushing, followed by pallor. ( Id. at 274) Plaintiff was examined at the hospital and diagnosed with back pain and near syncope (fainting), and he was subsequently discharged. ( Id. at 252, 255, 274, 298)

Following the incident, Plaintiff claimed that he had been exposed to hazardous chemicals, namely, hydrogen sulfide and benzene.[3] ( Id. at 52, 284-85, 298, 327, 329, 397) Plaintiff complained of excessive sleepiness, blurry and double vision, poor short-term memory, decreased exercise tolerance, shortness of breath, and anxiety/panic sensation, all of which, he claimed, prevented him from returning to work. ( Id. at 275, 298)

On January 10, 2007, imaging studies of Plaintiff's brain were normal. ( Id. at 308)

On January 15, 2007, William Sommers, D.O., examined Plaintiff. ( Id. at 275) Dr. Sommers noted that Plaintiff expressed concern about potential chemical exposure he suffered while working as an electrician. ( Id. ) Plaintiff reported to Dr. Sommers that he was experiencing symptoms including excessive sleepiness, a feeling that his brain was like "Jello sloshing around in his skull, " blurry and double vision, short-term memory loss, anxiety, and panic attacks. ( Id. ) Plaintiff had a follow-up appointment with Dr. Sommers on February 6, 2007. ( Id. at 274) Dr. Sommers found no organic explanation for Plaintiff's symptoms. ( Id. )

On May 7, 2007, Orn Eliasson, M.D., examined Plaintiff. ( Id. at 284) Plaintiff stated to Dr. Eliasson that since the incident on December 11, 2006, he had trouble writing his name and could not add up a check. ( Id. ) Plaintiff further explained that he tried to walk every day but still felt dizzy and had difficulty breathing. ( Id. ) Dr. Eliasson concluded that Plaintiff experienced a textbook case of hydrogen sulfide exposure. ( Id. at 287) Dr. Eliasson acknowledged that Plaintiff was recovering, but had not recovered completely. ( Id. )

Dr. Eliasson examined Plaintiff again on February 20, 2008, and June 24, 2009. ( Id. at 425-27, 571-74) On both occasions, Dr. Eliasson reiterated his diagnosis of hydrogen sulfide exposure and noted that Plaintiff had significant neurological sequelae, such as short-term memory loss, and lack of equilibrium, which caused him to fall and suffer injury. ( Id. )

On October 30, 2007, Plaintiff underwent a forensic psychiatric evaluation with Neil Kaye, M.D. ( Id. at 324-32) Dr. Kaye determined that Plaintiff had not been exposed to hydrogen sulfide. ( Id. at 332) Dr. Kaye based his conclusion on a number of factors: Plaintiff wore a monitor for toxins and it did not alarm; the individuals standing near Plaintiff during the alleged incident were not affected; Plaintiff's examinations performed shortly after the incident, at Christiana Hospital and by Dr. Sommers, revealed no organic explanation for Plaintiff's symptoms. ( Id. )

On January 22, 2008, Yong Kim, M.D., performed a consultative examination. ( Id. at 382-87) Plaintiff complained of fatigue, shortness of breath, balance problems, intermittent involuntary facial movements, arrhythmia, and sleep problems. ( Id. at 382) Plaintiff's grip strength on the right measured 34 kg, below the normal range of 40 kg. ( Id. at 383) His Romberg test was mildly to moderately positive. ( Id. ) Plaintiff's cervical, thoracic, and lumbar spine examinations were within normal limits. ( Id. at 383-87) Dr. Kim diagnosed Plaintiff with a history of possible toxic exposure with symptoms of fatigue and balance problems. ( Id. at 383)

On January 31, 2008, Margit Bleecker, M.D., Ph.D., examined Plaintiff. ( Id. at 397-403) Plaintiff's examination was within normal limits, aside from an odor test, which revealed diminished smell ability and residuals of bilateral carpal tunnel syndrome. ( Id. at 401) Dr. Bleecker noted that chronic exposure to hydrogen sulfide was associated with fatigue, headache, irritability, poor memory, dizziness, disturbed equilibrium, and loss of appetite. ( Id. ) She further stated that cardiac arrhythmias and hemodynamic instability can occur with hydrogen sulfide exposure, which could explain Plaintiff's acute episode since no other etiology was found during his medical evaluation. ( Id. )

b. Degenerative Disc Disease

During Plaintiff's May 7, 2007 examination, Dr. Eliasson noted the presence of osteoarthritis in Plaintiff's past medical history. ( Id. at 6) Although Plaintiff complained that he was not as flexible as he had been in the past, his musculoskeletal examination was within normal limits. ( Id. ) Dr. Eliasson saw Plaintiff again on June 24, 2009, and noted that Plaintiff's musculoskeletal examination was normal. ( Id. at 573)

An imaging study of Plaintiff's cervical spinal cord was performed on September 7, 2007. ( Id. at 310-11) The study revealed a small central disc herniation at C4-C5 without cord compression, multiple neural foraminal narrowing related to facet enlargement and uncovertebral spurs, and a broad disc bulge at C5-C6 and to a lesser extent at C6-C7 without focal disc herniation or cord compression. ( Id. )

Carlos Reyes, M.D., examined Plaintiff on September 19, 2007. ( Id. at 338) Plaintiff denied any cervical pain or radicular symptoms, despite experiencing back problems previously. ( Id. ) Dr. Reyes planned to refer Plaintiff to Bikash Bose, M.D., for evaluation of Plaintiff's herniated disk and neuroforaminal stenosis. ( Id. ) Plaintiff saw Dr. Reyes again on October 26, 2007, after falling, twisting his neck and hitting his head. ( Id. at 337) Plaintiff did not want any pain medication. ( Id. ) Dr. Reyes planned additional imaging studies. ( Id. ) Plaintiff followed up with Dr. Reyes on November 2, 2007 and reported that he was feeling better. ( Id at 336) Dr. Reyes noted that Plaintiff's neck CT showed no significant abnormalities. ( Id. )

An imaging study performed on September 24, 2009 revealed extruded disc herniation and osteophyte occupying the right lateral recess at L3-L4 and broad based disc protrusion and osteophyte at L4-L5 indenting on dural sac. ( Id. at 579-80)

On September 25, 2009, an MRI was performed on Plaintiff's cervical and thoracic spine. ( Id. at 576-68) The MRI of Plaintiff's cervical spine demonstrated multilevel moderate cervical spondylotic changes with degenerative disc disease. ( Id. at 577-78) Focal disc protrusions were seen at C4-C5 and a broad based disc osteophyte protrusion was noted at C5-C6 and C6-C7 with mild canal stenosis and bilateral foraminal narrowing. ( Id. ) Mild cord abutment was seen at C5-C6 and C6-C7. ( Id. ) The MRI of Plaintiff's thoracic spine revealed mild spondylotic changes with degenerative disc disease. ( Id. at 576) A small focal posterior central disc protrusion was noted at T7-T8 level with a broad based disc protrusion at T8-T9 and disc osteophyte extended toward the left neuroforamen at T9-T10 level with left neuroforaminal stenosis. ( Id. )

Plaintiff followed up with Dr. Reyes on October 15, 2009. ( Id. at 795) Plaintiff complained of mild back pain. ( Id. ) Dr. Reyes noted his intention to refer Plaintiff to Dr. Bose for further treatment. ( Id. )

c. Somatoform Disorder

On June 27, 2007, Marilyn Howarth, M.D., an Occupational Medicine Specialist, examined Plaintiff. ( Id. at 298) Plaintiff described the December 11, 2006 incident involving alleged toxic substance exposure. ( Id. ) All of Plaintiff's testing to date was negative, aside from an exercise stress test that Plaintiff was unable to complete. ( Id. ) Dr. Howarth observed that Plaintiff was agitated with pressured speech, but had no apparent thinking difficulty and responded to questions rapidly. ( Id. ) Dr. Howarth noted that the lack of initial irritative features combined with no real loss of consciousness suggested modest exposure at best, and follow-up testing revealed no objective findings. ( Id. ) Dr. Howarth concluded that Plaintiff's current symptoms were consistent with adjustment reaction, and she recommended a psychiatric evaluation. ( Id. )

Samuel Romirowsky, Ph.D., a licensed psychologist, evaluated Plaintiff on August 20, 2007 and September 6, 2007. ( Id. at 313-17) Dr. Romirowsky noted that Plaintiff's speech was rapid, pressured, digressive and tangential. ( Id. at 314) Plaintiff had difficulty staying focused. ( Id. ) Dr. Romirowsky observed that Plaintiff had memory problems and was easily frustrated by his inability to recall details of his history. ( Id. ) Plaintiff complained that after his work-related incident he was suddenly overcome with excessive fatigue, dizziness, pain in the back of his head, loss of equilibrium and panic attacks. ( Id. )

Dr. Romirowsky performed a number of psychological tests on Plaintiff. ( Id. at 315) Dr. Romirowsky noted Plaintiff's Personality Assessment Inventory test took twice as long to complete than average. ( Id. at 317) Plaintiff appeared crippled with indecision and exhibited an excessive need to weigh alternatives before selecting an answer. ( Id. ) Plaintiff also expressed a degree of concern about his physical functioning and health matters. ( Id. ) Plaintiff described his thought process as marked by confusion, distractibility, and poor concentration. ( Id. ) Dr. Romirowsky recommended a diagnosis of conversion disorder, assuming there was no further evidence to support a medical basis for Plaintiff's symptoms. ( Id. ) Dr. Romirowsky also stated that Plaintiff had adjustment disorder with mixed emotional features and obsessive, compulsive personality traits. ( Id. )

On November 26, 2007, Richard Ivins, Ph.D., a licensed psychologist, performed psychological testing on Plaintiff. ( Id. at 318-23) Plaintiff indicated that his symptoms were severe for five to six months following the work-related incident, and he continued to experience dizziness and extreme vertigo. ( Id. at 319) Plaintiff performed an exercise stress test, but was unable to complete it because he could not tolerate the treadmill. ( Id. ) Plaintiff's blood pressure was elevated following the test. ( Id. ) Plaintiff reported that he has not had a good day since the incident. ( Id. ) He described his difficulty with attention, concentration, short-term memory and following conversations with people. ( Id. ) Initially, he had difficulty driving and would get lost, but that problem had improved. ( Id. ) Plaintiff expressed that he was mad, upset, and somewhat depressed. ( Id. ) Plaintiff confirmed that he was not taking any medication nor undergoing psychiatric treatment. ( Id. )

Dr. Ivins administered comprehensive neuropsychological testing on Plaintiff ( Id. at 320-23) Plaintiff tested in the average range of general intelligence on the Wechsler Adult Intelligence Scale. ( Id. at 320) Dr. Ivins noted that on tests where time, speed, and concentration were factors, Plaintiff had difficulty and on several occasions could not finish that item on the test. ( Id. ) Plaintiff's arithmetic reasoning scores were the highest one could earn. ( Id. ) His Wide Range Achievement Test-4 scores were consistent with his level of academic achievement (i.e., high school diploma). ( Id. ) A Memory Assessment Scales test yielded a score of 104, indicating that Plaintiff was in the average range of overall memory functioning when compared to other individuals of his age and education level. ( Id. at 321) Plaintiff's overall memory function was not significantly lower than his other cognitive functions. ( Id. ) The Verbal Summary Scale test reflected that Plaintiff's ability to learn and retain orally transmitted information was in the low average range. ( Id. ) Plaintiff's Visual Summary Scale results were in the high average range, which indicated that he was able to learn and retain visual-spatial information. ( Id. )

Dr. Ivins concluded that Plaintiff's overall memory scores were in the average range with mild difficulties in retaining visual material and borderline impairment in retaining new information presented in oral and written form. ( Id. ) Results of the Symptom Check List-90-R test revealed that Plaintiff's symptomatic distress levels were in the clinical range. ( Id. at 322) His somatization levels were high and in the clinical range. ( Id. ) He had extremely high obsessive compulsive symptoms. ( Id. ) Plaintiff's depression levels were in the clinical range and were consistent with a true depressive disorder. ( Id. ) He manifested extremely high levels of paranoid ideation. ( Id. ) Dr. Ivins concluded that there was not sufficient test evidence to diagnose a cognitive impairment secondary to toxic exposure. ( Id. at 323) Dr. Ivins found significant evidence that Plaintiff was having a severe psychological reaction to the incident and had avoided any suggestion that he should avail himself of psychological treatment. ( Id. )

On January 31, 2008, Daniel Malone, Ph.D., J.D., performed a neurological examination on Plaintiff ( Id. at 404-09) Plaintiff's performance on visual, motor and perceptual testing was above average for his age. ( Id. at 404) Plaintiff's concentration, learning and memory testing measured in the average range, which was consistent with the testing performed by Dr. Ivins. ( Id. ) Plaintiff exhibited an ability to remember information more accurately thirty minutes after it was presented than immediately after it was presented. ( Id. ) Dr. Malone concluded that this was evidence that Plaintiff was not experiencing any abnormal rate of forgetting, which was characteristic of memory impairment associated with neurological disease. ( Id. ) Dr. Malone diagnosed Plaintiff with undifferentiated somatoform disorder. ( Id. )

d. Anxiety Reaction/Panic Attack

On October 30, 2007, Plaintiff underwent a forensic psychiatric evaluation with Neil Kaye, M.D. ( Id. at 324-33) Plaintiff indicated that he was finally able to pass a stress test in July 2007. ( Id. at 329) Plaintiff reported continuing fatigue but rated it at a medium level, "not excessive." ( Id. ) Plaintiff stated that he had "a bounce in his step" and his heart was back to where it was prior to the incident. ( Id. ) Plaintiff stated, "I'm progressing.... If it keeps progressing, in another 6 months, I think I'll be there." ( Id. ) However, Plaintiff noted that his energy level was still not good, his mind was not crisp, his balance was off a bit and he experienced "very[, ] very slight vertigo." ( Id. ) He also reported short-term memory problems and indicated that he had gone from a "memory bank computer" to "instant Alzheimer's." ( Id. )

Dr. Kaye observed that Plaintiff's mood was euthymic and his affect was congruent and appropriate. ( Id. at 331) His attention and concentration were intact and his memory was also intact for immediate, recent, and remote events. ( Id. ) Plaintiff performed serial sevens rapidly but told Dr. Kaye he was slow. ( Id. ) He was able to spell the word "world" forward and backward. ( Id. ) Dr. Kaye noted that Plaintiff had been working long hours and was tired when the incident occurred. ( Id. at 332) Plaintiff's presentation and symptoms were classic for an anxiety reaction/panic attack. ( Id. ) He had a very rigid, obsessive personality with narcissistic and paranoid features. ( Id. ) He was over controlling. ( Id. ) Plaintiff's anxiety and stress manifested through physical symptoms spanning many different organ systems, which pointed to a psychiatric explanation, as very few medical conditions cross organ systems. ( Id. ) Dr. Kaye noted that the somatic presentation was to be expected in a man who would have difficulty admitting any weaknesses. ( Id. ) Dr. Kaye diagnosed Plaintiff with adjustment disorder and personality disorder with obsessive and narcissistic features. ( Id. )

2. Non-Medical Evidence

Gertrude Steppi ("Ms. Steppi"), Plaintiff's mother, completed a Third Party Function Report on November 3, 2008. ( Id. at 193-200) Ms. Steppi noted that Plaintiff was able to take care of his own personal care needs, but he needed to be reminded about personal grooming. ( Id. at 193-95) He could prepare simple meals, clean, do the laundry, take care of the dishes and do light chores. ( Id. at 194-96) He shopped for newspapers, groceries, and personal items once or twice a week. ( Id. ) Ms. Steppi also indicated that Plaintiff could pay bills, handle a savings account, and use a checkbook. ( Id. at 196-98) ...


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