United States District Court, D. Massachusetts
AMY L. COOK, Plaintiff,
NANCY BERRYHILL, Acting Commissioner, Social Security Administration, Defendant.
H. Hennessy, UNITED STATES MAGISTRATE JUDGE
Plaintiff, Amy L. Cook, seeks reversal of the decision by the
Defendant, the Commissioner of the Social Security
Administration (“the Commissioner”), denying her
Disability Insurance Benefits (“DIB”) and
Supplemental Security Income (“SSI”), or, in the
alternative, remand to the Administrative Law Judge
(“ALJ”). (Docket #11). The Commissioner seeks an
order affirming her decision. (Docket #21).
reasons that follow, Cook's Motion to Remand (Docket #11)
is DENIED and Defendant's Motion for Order Affirming the
Decision of the Commissioner (Docket #21) is ALLOWED.
filed an application for DIB on July 9, 2009, and an
application for SSI on August 5, 2009, alleging in both that
she had been disabled since August 8, 2008. (Tr. 324-37). The
applications were denied initially and upon reconsideration.
(Tr. 159-62). Cook requested a hearing on October 1, 2010
(Tr. 210-11), and a hearing was held before an Administrative
Law Judge (“ALJ”) on December 5, 2011, (Tr.
80-120). On January 27, 2012, the ALJ issued a decision
finding that Cook was not disabled. (Tr. 163-82). Cook
requested a review of the decision by the Appeals Council.
order dated April 23, 2013, the Appeals Council vacated the
ALJ's decision and remanded Cook's claim for further
consideration. (Tr. 183-86). Specifically, the Appeals
Council asked the ALJ to resolve two issues. First, the
Appeals Council noted that the ALJ found that Cook had severe
impairments of depression and post-traumatic stress disorder,
resulting in mild to moderate difficulties in maintaining
social functioning; however, the RFC contained no description
of the mental functions that Cook could still perform despite
these social limitations. (Tr. 184). The Appeals Council
stated that such findings required an accompanying mental
limitation. (Id.). Secondly, the Appeals Council
stated that, in light of the ALJ's finding that
Cook's cataracts, status-post-repair, were a severe
impairment, the decision required the ALJ to discuss what, if
any, visual limitations Cook continued to suffer as a result
of her cataracts after surgical repair. (Id.). The
ALJ failed to include this in his decision. (Id.).
November 13, 2013, the ALJ held another hearing. (Tr. 41-79).
In a decision dated November 15, 2013, the ALJ again found
Cook not disabled. (Tr. 22-40). Cook requested review of this
decision on December 6, 2013. (Tr. 19-21). On June 30, 2014,
the Appeals Council denied her request for review, making the
ALJ's November 13, 2013 decision final and ripe for
judicial review. (Tr. 1-3). Having timely pursued and
exhausted her administrative remedies before the
Commissioner, Cook filed a complaint in this Court on August
15, 2014, pursuant to 42 U.S.C. § 405(g). (Docket #1).
Cook filed the motion for reversal or remand on January 30,
2015, (Docket #11), and the Commissioner filed a cross-motion
on May 14, 2015, (Docket #21).
time she claims she became disabled, Cook was forty-four
years old. (Tr. 324). Cook is a high school graduate and
completed two years of college, graduating with an
Associate's Degree in Science. (Tr. 84-85). She has no
past relevant work. (Tr. 56). Cook has a driver's license
and lives in an apartment with her boyfriend. (Tr. 47, 94,
December 22, 2008, Cook was seen by Dr. Trister for
complaints related to hypothyroidism, shortness of breath,
coughing, fatigue, wheezing, and tobacco
dependence. (Tr. 544). Trister noted that Cook had
diabetes and was depressed. (Id.). Trister stated
that Cook's behavior was adequate and she was emotionally
stable. (Id.). Trister diagnosed Cook with
hypothyroidism and chronic obstructive pulmonary disease
(“COPD”) and counseled Cook regarding her tobacco
use and diet. (Tr. 545). At a follow-up visit on May 1,
2009, Cook complained of episodes of blurred vision lasting
twenty to thirty minutes. (Tr. 538). Physical examination
revealed painful joints and bilateral expiratory wheezes.
(Id.). Dr. Trister again noted that Cook's
behavior was adequate and she was emotionally stable.
(Id.). Cook returned for a follow-up on June 15,
2009, where Dr. Trister noted poor compliance with medical
recommendations. (Tr. 533). At a July 7, 2009 follow-up
visit, Cook complained of pain in multiple joints, stiffness,
myalgia, limited range of motion, blurred vision, depressed
mood, anhedonia, poor appetite and sleep, fatigue,
restlessness, irritability, difficulty in concentrating, poor
memory and an inability to make decisions. (Tr. 531). Dr.
Trister noted that Cook was obese and diagnosed her with
hypothyroidism, COPD, vision change, and depression. (Tr.
October 7, 2009, Dr. Moss, Cook's ophthalmologist, stated
that Cook had a cataract first diagnosed on June 17, 2009,
and that he expected a good prognosis for restoring vision
with a planned cataract surgery. (Tr. 557-59).
November 4, 2009, Cook returned to Dr. Trister complaining of
chronic fatigue, weakness, lack of energy, poor concentration
and motivation, weight gain, hair loss, frequent colds,
depressed mood, insomnia, and an unstable appetite. (Tr.
603). Her diagnoses remained unchanged. (Tr. 604).
November 29, 2009, Cook fell as she was coming out of her
bedroom; however, she was able to get up. (Tr. 624). After
twenty-four hours, she noted some unsteadiness.
(Id.). By December 1, 2009, she noted a feeling of
weakness involving the left arm and leg with dragging of her
left foot and some numbness over the left side of her face.
(Id.). She was then seen at UMass Medical Center and
sent home after examination. (Id.). Dr. Trister
later characterized this episode as a transient ischemic
attack (“TIA”). (Tr. 649). On that date, a CT of
her head was taken revealing a normal exam. (Tr. 594). A CT
angiography of her neck and head also taken on that date was
unremarkable. (Tr. 595).
December 2, 2009, an MRI of Cook's brain was performed
due to her complaints of left-sided weakness, right-sided
sensory loss, headaches, and gait instability. (Tr. 590). The
MRI revealed no acute intracranial abnormality but mild
nonspecific increased T2 signal foci in the cerebral white
matter and a possible small posterior fossa arachnoid cyst in
the retrocerebellar location. (Tr. 591). Differential
diagnoses included migraine headaches, chronic small vessel
ischemic change, and mild demyelinating or inflammatory
process. (Id.). A cervical MRI was also performed on
the same day due to Cook's gait instability. (Tr. 592).
The imaging revealed no acute abnormality or evidence of cord
compression. (Tr. 593). The imaging did show mild spondylotic
changes, most prominent at the C4-C5 and C5-C6 levels with
mild to moderate left neural foraminal stenosis.
December 8, 2009, Dr. Och, a psychiatrist, composed a
narrative report stating that Cook suffered from major
depressive disorder with psychotic features. (Tr. 702). Cook
had been under Dr. Och's care since August 11,
2009. (Tr. 826). Dr. Och stated that Cook had a
sad mood, depressed affect, poor energy, experienced
hallucinations, and suffered from poor sleep. (Tr. 702). Dr.
Och opined that these symptoms interfered with Cook's
functioning and rendered her unable to do any type of work
for at least one year. (Id.).
to orders by Dr. Trister, a brain/head MRI was performed on
December 11, 2009. (Tr. 583, 650). The results were normal.
(Tr. 585, 647). At her follow-up appointment with Dr. Trister
on that date, Cook complained of no improvement in her
dizziness and continued left side weakness and numbness. (Tr.
December 16, 2009, Dr. Savla, a neurologist, examined Cook.
(Tr. 588). Physical examination revealed mild left pronator
drift, slightly slurred speech, slow gait, and some
circumduction of the left leg. (Id.). Cook could
extend her leg up to thirty degrees and had upgoing toes on
the left side. (Id.). Dr. Savla diagnosed right
cerebro-vascular accident (“CVA”) (stroke) with
left hemiparesis. (Tr. 588). Dr. Savla opined that the
etiology of the stroke was hypertension and prescribed one
baby aspirin daily. (Tr. 599).
February 16, 2010, Cook reported to Dr. Och that she was
“not too bad, ” reporting that she had woken up
twice with hallucinations and nightmares of childhood
events. (Tr. 793).
followed up with Dr. Trister on February 25, 2010 complaining
of continued dizziness, occipital headache, fatigue, and poor
concentration. (Tr. 632). An occipital nerve block was
administered using Lidocaine and Kenalog. (Tr. 632-33).
April 6, 2010, Dr. Och composed a subsequent narrative
report. (Tr. 826). Dr. Och stated that he had treated Cook
since August 11, 2009 for depression and anxiety as well as
hallucinations. (Id.). Dr. Och reported that
Cook's mood had improved with medication but psychotic
symptoms continued. (Id.). He opined that Cook was
“totally and permanently disabled” at this time.
followed-up with Dr. Och on April 7, 2010. (Tr. 792). Dr. Och
noted that Cook's hallucinations were improved overall
and that her depression was “under good control.”
April 15, 2010, Dr. Och completed a Psychiatric/Psychological
Impairment Questionnaire. (Tr. 838-45). Dr. Och diagnosed
Cook with major depressive disorder with psychotic features
and a global assessment of functioning (“GAF”)
score of 50. (Tr. 838). Dr. Och indicated that
Cook's psychiatric condition would exacerbate her chronic
pain issues. (Tr. 844). Dr. Och stated that Cook's
impairments would last at least twelve months and that she
was not a malingerer. (Id.). Dr. Och opined that
Cook's prognosis was fair. (Tr. 838). Clinical findings
included poor memory; appetite disturbance with weight
change; sleep disturbance; mood disturbance; emotional
liability; hallucinations; recurrent panic attacks; anhedonia
or pervasive loss of interests; psychomotor agitation or
retardation; paranoia or inappropriate suspiciousness;
feelings of guilt/worthlessness; difficulty thinking or
concentrating; suicidal ideation or attempts; social
withdrawal or isolation; blunt, flat, or inappropriate
affect; decreased energy; and generalized persistent anxiety.
(Tr. 839). Dr. Och noted that Cook's primary symptoms
were a depressed mood, visual hallucinations, and anxiety
with her depression and anxiety being the most severe. (Tr.
840). Dr. Och stated that Cook was markedly limited, defined
as effectively precluded, in the following abilities:
remember location and work-like procedures; understand and
remember one or two-step instructions; understand and
remember detailed instructions; carry out detailed
instructions; maintain attention and concentration for
extended periods; perform activities within a schedule,
maintain regular attendance, and be punctual within customary
tolerance; work in coordination with or proximity to others
without being distracted by them; complete a normal workweek
without interruptions from psychologically-based symptoms and
perform at a consistent pace without an unreasonable number
and length of rest periods; accept instructions and respond
appropriately to criticism from supervisors; maintain
socially appropriate behavior and adhere to basic standards
of neatness and cleanliness; respond appropriately to changes
in the work setting; awareness of normal hazards and taking
of appropriate precautions; travel to unfamiliar places or
use public transportation; and set realistic goals or make
plans independently. (Tr. 841-43). Dr. Och stated that Cook
was moderately limited, defined as significantly affected,
but not totally precluded, in the following abilities: carry
out simple one or two-step instructions; sustain ordinary
routine without supervision; make simple work related
decisions; interact appropriately with the general public;
ask simple questions or request assistance; and get along
with co-workers or peers without distracting them or
exhibiting behavioral extremes. (Id.). Dr. Och
concluded that Cook was incapable of even “low
stress” in the workplace, and that she would be absent
from work more than three times a month as a result of her
impairments. (Tr. 844-45).
11, 2010, Dr. Och stated that Cook was “[d]oing
well” and “[s]table with meds.” (Tr. 791).
Cook reported that her sleep was “good” and that
her auditory hallucinations had decreased. (Id.). On
June 7, 2010, Cook stated that she was doing “OK”
except for some visual hallucinations. (Tr. 790). Dr. Och
adjusted her medication in response. (Id.).
8, 2010, Dr. Trister completed a Multiple Impairment
Questionnaire. (Tr. 812-20). Dr. Trister diagnosed Cook
with hypertension, hypothyroidism, depression, anxiety,
hyperlipidemia, dizziness, chronic back and neck pain,
diffuse myalgia, and bilateral cataracts. (Tr. 813). Dr.
Trister rated Cook's prognosis as fair. (Id.).
Dr. Trister stated that Cook was chronically fatigued, weak,
depressed, and anxious, and had intermittent
moderate-to-severe dizziness which affected her activities of
daily living. (Id.). Her primary symptoms were
chronic diffused pain in her shoulders, mid back, lower back,
and legs, depression, anxiety, fatigue, and insomnia due to
pain and depression. (Tr. 814). Dr. Trister observed that
Cook's pain was constant and rated it an eight to nine on
a scale of ten. (Tr. 814-15). Dr. Trister opined that, in an
eight-hour day, Cook could, in total, sit for less than one
hour and stand/walk for less than one hour. (Tr. 815). Dr.
Trister stated that Cook would need to get up and move around
every ten minutes for a five to ten minute period. (Tr.
815-16). Dr. Trister further opined that Cook could only
occasionally lift or carry up to five pounds and had
significant limitations in doing repetitive reaching,
handling, fingering, or lifting. (Tr. 816). He concluded that
Cook had marked limitations in using her upper extremities
that essentially precluding her from using them in a
competitive eight-hour work day. (Tr. 816-17). Dr. Trister
opined that Cook's symptoms would constantly interfere
with her attention and concentration, she was incapable of
even low work stress, and was likely to be absent from work
due to her conditions more than three times a month. (Tr.
818-19). Stating that she was not a malingerer, Dr. Trister
concluded that Cook was unable to work. (Tr. 818).
June 9, 2010 appointment with Dr. Trister, Cook reported a
depressed mood and insomnia, complaining of a lack of
motivation, fatigue, and weakness. (Tr. 725). With respect to
her complaints of depression, Dr. Trister found that
“[o]verall, patient is stable at present.”
(Id.). Cook also reported widespread pain,
stiffness, irritability, and nonrestorative sleep.
(Id.). Physical examination revealed multiple tender
muscular, musculotendinous, capsular, and ligamentous points.
(Id.). Dr. Trister diagnosed hypothyroidism,
depression, and myofascial pain syndrome. (Tr. 726). That
same day, Dr. Trister filled out a form provided by Cook as
part of an application for State welfare benefits in which he
indicated that Cook had multiple joints pain, which he did
not expect would improve, as well as depression, anxiety,
hypothyroidism, hypertension, and cataract. (Tr. 713-21).
With respect to Cook's mental impairments, Dr. Trister
noted that her appearance, attitude, behavior, orientation,
speech, thought process, and cognition were all normal and
that she had not experienced hallucinations. (Tr. 718). Dr.
Trister stated that Cook had a depressed mood and affect.
(Id.). Dr. Trister indicated that Cook's
impairments affected her ability to work. (Tr. 721). Also on
that date, Dr. Trister wrote a letter opining that Cook was
totally disabled. (Tr. 795-96).
follow-up appointment with Dr. Och on July 13, 2010, Cook
stated that she was “OK” but was still
experiencing visual hallucinations. (Tr. 789). Dr. Och again
adjusted Cook's medications. (Id.).
30, 2010, Dr. Trister completed a Neurological Disorder form
in which he observed that Cook used a walker for balance and
had a slow and unsteady gait. (Tr. 724). Dr. Trister stated
that Cook had no persistent motor dysfunction in her upper
extremities and only mild persistent motor dysfunction in her
lower extremities. (Id.). No visual, auditory, or
speech changes were detected. (Id.). Dr. Trister
offered a fair prognosis. (Id.).
August 11, 2010, Dr. Och noted that Cook's mood was
stable and her anxiety was under control although issues
remained with respect to her sleep. (Tr. 788).
followed-up with Dr. Trister on September 1, 2010. (Tr. 805).
Dr. Trister stated that Cook's depression was stable at
present with no complaints and that she was suffering no
adverse effect from her medications. (Id.). Dr.
Trister also noted that Cook's hypothyroidism was stable
at present and that she was tolerating therapy well and that
control of her hypertension was adequate. (Id.).
September 15, 2011, Cook had a visit with Dr. Och after
having moved to Florida and back with her boyfriend. (Tr.
787). Cook reported that she was forgetful and still
experienced auditory hallucinations and nightmares.
(Id.). Dr. Och reported that Cook appeared to be in
a good mood, and was pleasant although she was stressed.
September 20, 2011, Dr. Trister found that Cook's
hypothyroidism was stable and noted that, with respect to her
hypertension, Cook reported feeling well. (Tr. 798). While
Cook complained of a lack of motivation, fatigue, and
weakness, Dr. Trister stated that her depression was stable
and noted that Cook had reported that her medications had
been somewhat effective. (Id.).
follow-up appointment on September 29, 2011, Dr. Och reported
that Cook was “doing well” and had no issues with
her medications. (Tr. 786).
October 25, 2011, Dr. Och stated that Cook “[s]eems
better [w]ith no acute psychosis” and was “less
depressed” but did have one incident of hallucinations.
(Tr. 860). Dr. Och increased Cook's dosage of Prozac and
that day, Cook returned to Dr. Trister complaining of a
cough, sneezing, headache, chills, and myalgia. (Tr. 127).
Dr. Trister again noted, that with respect to her
hypertension, Cook reported feeling well, and that the
current therapy for Cook's hypothyroidism was effective.
(Id.). Dr. Trister observed that Cook's mood was
November 22, 2011, Dr. Och noted that Cook was
“[g]reatly improved, ” okay on her medications,
and was “no longer psychotic.” (Tr. 859). On
December 20, 2011, Dr. Och observed that, except for a cold,