United States District Court, D. Delaware
Leona Teel, Newark, Delaware. Pro se Plaintiff.
Charles M. Oberly III, United States Attorney, Wilmington, Delaware, and Heather Benderson and Patricia A. Stewart, Special Assistant United States Attorneys, Office of the General Counsel Social Security Administration, Counsel for Defendant.
RICHARD G. ANDREWS, District Judge.
Plaintiff Leona Teel appeals the denial of her applications for disability insurance benefits under Title II, and supplemental security income benefits under Title XVI, of the Social Security Act. See 42 U.S.C. §§ 401-434, 1381-1383f. Jurisdiction exists pursuant to 42 U.S.C. § 405(g). Pending before the Court are cross-motions for summary judgment filed by Teel and Carolyn W. Colvin, Acting Commissioner of Social Security. (D.I. 15, 17). For the reasons set forth below, the Court will grant Teel's motion for summary judgment, will deny the Commissioner's motion for summary judgment, and will remand the matter for further proceedings.
I. Procedural History
Teel filed applications for DIB and SSI on November 3, 2009, alleging disability as of August 21, 2008 due to right knee arthritis, back pain, post traumatic stress disorder, and depression. Her claim was denied initially and upon reconsideration. A hearing was held on October 14, 2011, before an Administrative Law Judge who denied Teel's application for benefits. The Appeals Council declined to overturn that decision, and it became the final order of the agency. Teel filed the instant complaint seeking judicial review of the ALJ's decision. (D.I. 2). Teel seeks a finding of disability, and the Acting Commissioner asks that the Court affirm the decision to deny benefits.
Teel had counsel during the October 14, 2011 hearing. She does not have counsel now, and therefore proceeds pro se in this Court.
II. Medical Evidence
Teel received treatment from Dr. Joanne Lundholm for a depressive disorder beginning in October 2007. Dr. Lundholm prescribed various medications including Paxil, Xanax, and Buspar, and referred Teel for counseling in February 2008. (D.I. 12 at 404-06, 419, 435-42). As of August 8, 2008, Teel was doing well and taking only one Xanax per day. ( Id. at 404). On examination, Teel was cooperative and well groomed, oriented with appropriate mood and affect, able to articulate well with normal speech/language, rate, volume, and coherence, with no evidence of hallucinations. ( Id. ).
When Teel was seen by certified registered nurse practitioner Stacey Graves on September 16, 2008, she stated that she was depressed, and that she was seeing a counselor for posttraumatic stress disorder related to the recent death of her son. ( Id. at 408). Teel was taking Buspar with some relief, but was still frequently sad and tearful. ( Id. ). Teel was appropriate, but tearful, when speaking about the death of her son. ( Id. ). On examination, Teel was oriented with appropriate mood and affect and able to articulate well with normal speech/language, rate, volume, and coherence. ( Id. at 410). Her thought content was normal with the ability to perform basic computations and apply abstract reasoning. ( Id. ). There was no evidence of hallucinations, delusions, obsessions, or homicidal/suicidal ideation. ( Id. ). Teel demonstrated appropriate judgment and insight, intact memory, and her attention span and ability to concentrate were normal. ( Id. ) Teel was prescribed Clonazepam. ( Id. )
When Teel saw Dr. Muhammed A. Niaz from February 2009 through November 2009, he made diagnoses of bipolar affective disorder, depressive disorder, and anxiety/panic disorder. ( Id. at 503-15). Dr. Niaz prescribed Klonopin and Buspar. In January 2010, Dr. Niaz referred Teel to a psychiatrist for her unresolved grief. ( Id. at 546). In April 2010, Teel began treatment at Harmonious Mind Psychiatric and Counseling Services. ( Id. at 549).
On April 13, 2010, Teel underwent a psychological functional capacities evaluation by Brian Simon, Psy.D. ( Id. at 526-32). His diagnostic impression was major depressive disorder, recurrent, severe with psychotic features; rule out personality disorder, not otherwise specified; numerous medical problems by self-report; occupational problems, problems with primary support group; and a GAF of 50. ( Id. at 531). The prognosis was guarded, with Dr. Simon stating that much ofTeel's prognosis was dependent on how well she was able to continue to cope with her psychiatric and medical problems. ( Id. )
Dr. Simon opined that Teel had a mild impairment in her ability to relate to other people, a moderate restriction in her activities of daily living, a moderately severe deterioration in her personal habits, and a moderately severe constriction of interests. ( Id. at 526). He found that Teel had a moderate impairment in her ability to understand simple, oral instructions, and a moderately severe impairment in her ability to carry out instructions under ordinary supervision, sustain work performance and attendance, cope with pressures of ordinary work, and perform routine, repetitive tasks under ordinary supervision. ( Id. at 527).
Dr. Simon reported that Teel appeared to be a poor historian, and he found her minimally disheveled, quite frantic, and hysterical during the evaluation. ( Id. at 528, 530). Teel informed Dr. Simon that she was applying for disability benefits due to depression resulting from the death of her sixteen year old son, who had died two years earlier from a staph infection. ( Id. at 28). She cried incessantly and looked around the room a lot, reported being uncomfortable in public, but was able to make good eye contact. ( Id. at 530). Teel's attention and concentration were fair to poor; her speech was normal in rate and volume but was limited to brief responses; and she did not show articulation problems. ( Id. ). Teel was oriented with good immediate memory, but poor short-term memory. ( Id. ). Her mood was depressed and her affect was labile. (Id.). Teel reported having nightmares, but denied feeling suicidal or homicidal. ( Id. ). Dr. Simon considered Teel's judgment and insight fair to poor. ( Id. ). Dr. Simon concluded that Teel's presentation suggested that her psychiatric problems would adversely affect her ability to make decisions, adapt to different circumstances, and exercise judgment, insight, and common sense at work. ( Id. ). He opined that she may have problems interacting appropriately with others and performing simple tasks and avoiding hazards. ( Id. ).
A state agency consultant - Janet S. Brandon, a psychologist - performed a mental residual functional capacity assessment on April 27, 2010. (D.I. 11 at 150-81). She determined that Teel had mild restrictions of activities in daily living, moderate difficulties in maintaining social functioning, concentration, persistence or pace, and that there were no episodes of decompensation. ( Id. at 158-59). The state agency consultant determined that Teel was not significantly limited in her ability to work in coordination with or in close proximity to others without being distracted, that she did not have any social interaction limitations, and that she did not have any adaptation limitations. ( Id. at 163). She found that Teel's prolonged grief had interfered with focus at times. ( Id. ). The state agency consultant found that Teel was able to perform simple tasks from a mental standpoint. ( Id. ).
Teel was seen at Harmonious Mind on a regular basis from July 2010 through June 2011. (D.I. 12 at 692-727). She was prescribed various medications including Cymbalta and Lamictal. As of June 6, 2011, Teel was well oriented and alert with a dysphoric and tearful affect. ( Id. at 699). She had a depressed mood; fair eye contact; excessive speech; normal memory; normal psychomotor activity; a negligible degree of conceptual disorganization evident; and her thought process was characterized by a preoccupation with illness and grieving. ( Id. ). Teel had no suicidal or homicidal ideations. ( Id. ). On June 30, 2011, Teel reported to Harmonious Mind personnel that she was having a difficult time ( id. at 701), but by July 26, 2011, Teel reported that she was having "more good days than bad" and she was less tearful and better kempt. ( Id. at 702). Diagnoses at that time included major depressive disorder, recurrent, severe with psychotic features, without full interepisode recovery, mood disorder NOS (RIO), panic disorder without agoraphobia, bereavement, and post traumatic stress disorder (principal). ( Id. at 701).
Teel presented to Bert M. Bieler, M.D. on October 12, 2007, with complaints of back pain. ( Id. at 443). Teel stated that she managed her back pain during her recent pregnancy with Percocet, and that she was feeling well and had no symptoms of depression. ( Id. at 443-44). Dr. Bieler prescribed Tramadol and instructed Teel to follow up with Dr. Lundholm. ( Id. at 444). Teel saw Dr. Lundholm from December 2007 through August 2008 for back pain and knee pain. (D.I. 11 at 394; D.I. 12 at 404-06, 431-40). Dr. Lundholm prescribed pain medication including Percocet, diagnostic testing including an MRI of the lumbar spine, and physical therapy. As of June 10, 2008, Teel indicated that her back pain was better, but she had episodes of pain and was looking for a pain doctor. (D.I. 12 at 405). Upon examination, Teel's back had some paraspinous spasm bilaterally, she had a negative straight leg-raising test, and her gait was within normal limits. ( Id. at 406). Teel began physical therapy in August 2008 for low back pain. ( Id. at 404).
Teel was seen by Jie Zhu, M.D. on September 16, 2008, for pain management of her neck and lower back. (D.I. 11 at 395). Teel provided a history of chronic neck and back pain for over five years after falling down stairs, that physical therapy, Motrin and/or Naprosyn failed to relieve the pain, and that she was taking Percocet. ( Id. ). Examination of the neck revealed a normal range of motion, and a negative Spurling's maneuver with mild to moderate tenderness. ( Id. at 396). Examination of the lower back revealed mild, diffuse tenderness. ( Id. ). Examination of the upper and lower extremity indicated that deep tendon reflexes were symmetrical, and manual muscle testing was grossly intact. ( Id. ). Teel had normal range of motion in all extremities, straight leg raising test was negative, there was full muscle strength in the upper and lower extremities, and normal muscle tone. ( Id. at 396-97). Dr. Zhu diagnosed radicular syndrome of lower limbs, chronic pain syndrome, low back pain, neck pain, myalgia, cervical spondyloarthritis, spondylosis, and injury oflumbar nerve roots. ( Id. at 397). He prescribed Neurontin and Darvon, and ordered an MRI of the spine and an EMG of the right lower extremity. ( Id. ).
Teel saw Dr. Niaz in October, November, and December 2008. He diagnosed Teel with backache, fibromyalgia, and ambulatory dysfunction, changed the doses and frequency of some medications and prescribed Oxycodone. ( Id. at 517-20). A January 13, 2009 x-ray of Teel's lumbar spine was normal, and a February 12, 2009 x-ray of Teel's right knee revealed mild osteoarthritic changes, with no acute abnormality. ( Id. at 401, 403, 551). On February 24, 2009, Dr. Niaz diagnosed ambulatory dysfunction, and arthritis, and he ordered an MRI of the right knee. ( Id. at 515). A March 18, 2009 MRI of the right knee revealed no tear in the menisci, ligaments, or tendons, but hypertrophic degenerative changes of the femorotibial and femoropatellar joints and a moderate amount of joint fluid. (D.I. 11 at 399). The March 18, 2009 MRI of the lumbar spine revealed disc desiccation with mild disc bulging, peripheral annular tear at L5-S 1, but no distinct focal disc herniation. ( Id. at 400).
Teel continued to see Dr. Niaz from April 2009 through April 2010. (D.I. 12 at 505-520). He diagnosed arthritis and backache, encouraged Teel to increase her exercise, and make healthy diet choices. He ordered diagnostic testing including an x-ray of the sacroiliac joint. He prescribed several medications including Levaquin, Soma, and Oxycodone. In addition, he ordered a knee brace. In January 2010, Dr. Niaz began the process for Teel to undergo breast reduction. ...