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Ford v. Berryhill

United States District Court, D. Massachusetts

September 28, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         This is an appeal of the final decision of the Commissioner of the Social Security Administration (“SSA”) denying an application for social security disability insurance (“SSDI”) and supplemental security income (“SSI”) benefits. Plaintiff Thomas Ezekiel Ford, IV, alleges disability based on post-traumatic stress disorder, depression, anxiety, and obesity. The Administrative Law Judge determined that Ford retained a sufficient residual functional capacity to perform work existing in the national economy, and thus was not disabled under the Social Security Act, 42 U.S.C. §§ 416(i) and 423(d).

         Ford has moved for judgment on the pleadings seeking an order reversing the ALJ's decision. He contends that the ALJ (1) failed to give proper weight to certain medical opinion evidence; (2) made an improper credibility determination that is not supported by substantial evidence; and (3) failed to properly account for his moderate mental limitations when presenting a hypothetical question concerning residual functional capacity (“RFC”) to the vocational expert. Defendant has cross-moved for an order affirming the ALJ's decision.

         For the reasons set forth below, plaintiff's motion for judgment on the pleadings will be denied, and defendant's motion to affirm the ALJ's decision will be granted.

         I. Background

         A. Educational and Occupational History

         Thomas Ezekiel Ford, IV, was born on February 23, 1974, and was 37 years old at the alleged onset of his disability. (A.R. 46; see A.R. 49). He received a bachelor's degree in sociology and comparative international development from Johns Hopkins University and a master's degree in political science from American University in Cairo, Egypt. (A.R. 47-48).

         From November 2009 to March 2011, Ford worked for the United States Agency for International Development as a General Development Officer. (A.R. 250, 271, 458). While he was embedded with the U.S. military in Afghanistan, Ford endured several life-threatening events, including witnessing enemy explosives cause the death of one soldier and another soldier's loss of three limbs. (A.R. 458). Ford then requested a transfer to a different base in Afghanistan because of job-related stress. (Id.).

         Upon his return to the United States in April 2011, Ford worked as a curriculum development and pre-deployment trainer for International Development Systems (“IDS”), a defense contractor based in Alexandria, Virginia. (A.R. 271-73). Ford left that job in June 2011, and then worked as a consulting expert until December 2012. (A.R. 65, 271). He has not worked since. (Id.).

         B. Medical Evidence

         1. November 2012-November 2013

         Ford contends that he suffers from PTSD, depression, anxiety, and obesity. On November 19, 2012, Ford saw Mark Gorman, Ph.D., for an initial mental-health consultation at the Weight Center at Massachusetts General Hospital (“MGH”). (A.R. 367). According to the doctor's report, Ford's mental status examination (“MSE”) was normal except for diminished concentration, some guilt, and reports of sleep problems. (A.R. 371). Ford reported that his stressors were his “work/travel schedule” and “caretaking for parents.” (A.R. 368). He reported that his current job at IDS required relocation every two to four weeks, so he had avoided making close, personal connections with his co-workers. (A.R. 370).

         Dr. Gorman assessed a Global Assessment of Functioning (“GAF”) score of 71-80 and diagnosed a major depressive disorder in remission and emotionally-triggered eating in remission. (A.R. 372).[1] He also found that Ford demonstrated active symptoms of post-traumatic stress disorder, such as avoidance and numbing; insomnia, diminished concentration; and hypervigilance. (A.R. 370). However, Dr. Gorman opined that Ford did not meet the full diagnostic criteria of PTSD, because he was no longer experiencing flashbacks or intrusive memories. (A.R. 372). Dr. Gorman supported a referral for psychotherapy if Ford was interested. (Id.).

         Ford saw Elizabeth Goetter, Ph.D., at MGH for a psychiatric intake on December 19, 2012. (A.R. 348). Ford described the multiple traumatic experiences he faced as a civilian aid worker in Afghanistan. (Id.). Ford's chief complaint was “sleep issues.” (Id.). Dr. Goetter noted that Ford experienced emotional and physical reactivity to trauma cues, such as anxiety, tachycardia, and flushing. (Id.). He reported increased irritability, hypervigilance, and diminished interest in socializing. (Id.). He stated that his mood had been “fine . . . more stable, less angry, ” but reported depressive episodes in the past, most recently in March through August 2012, that included decreased energy, loss of focus, and passive suicidal ideation. (A.R. 348-49). His MSE was within normal limits, apart from a blunted emotional affect. (A.R. 351-52). Dr. Goetter diagnosed major depressive disorder, recurrent and in remission, generalized anxiety disorder, and PTSD, assessing a GAF of 55. (A.R. 352).[2] She opined that his psychiatric symptoms were likely exacerbated by numerous psychosocial stressors, including job dissatisfaction, limited social support, his parents' failing health, and his own medical concerns. (A.R. 353).

         Ford returned to MGH and saw Heather Kapson, Ph.D. on October 2, 2013. (A.R. 343). Dr. Kapson noted that Ford's primary complaint was that his role as his “parents' primary caregiver over the last 2 years” had been triggering, and living with them had prevented him “from working and from engaging in life with [his] spouse, ” who lived in Baltimore. (Id.). Ford again recounted the difficulties of his time in Afghanistan, and noted that his “tour ended by him visiting his parents and not returning when he saw their health significantly declining.” (Id.). Dr. Kapson noted that Ford still met the symptoms for PTSD, but his symptoms, as reported by him, had decreased as compared with his first one-and-a-half years after his return from Afghanistan. (Id.). His PTSD Checklist score, or PCL score, had improved significantly from his intake in December 2012. (Id.; A.R. 352).[3] Dr. Kapson assessed a GAF score of 55. (A.R. 345). She also diagnosed major depressive disorder, recurrent and mild; generalized anxiety disorder; and adjustment disorder. (Id.). She also noted economic, occupational, and social support problems. (Id.).

         On October 30, 2013, Ford met with Ann R. Stewart, MSW, LICSW, to follow up on his psychosocial needs. He informed her that his mother had passed away on October 11, 2013. (A.R. 391). On November 12, 2013, Ford again saw Dr. Kapson and notified her of his recent decision to move to Baltimore to be with his husband. (A.R. 385). Dr. Kapson noted that he “appeared visibly relieved, ” and expressed “looking forward to being in one place where he can establish roots, refocus on his career, and build a life with his husband.” (Id.). Ford reported that he generally felt more stable, but continued to struggle with sleep disturbances, fatigue, motivation, and difficulty with change overall. (Id.). Ford's MSE was normal, his PCL score further improved to 31, and his GAF score was 60. (A.R. 385-86).

         2. State Agency Consultant Disability Determination - Dr. Walcutt

         On November 13, 2013, Ford underwent a consultative psychiatric evaluation with Olga Rossello, M.D., for his SSDI application. (A.R. 397). Ford recounted his experiences in Afghanistan and reported sleeping problems, an “up and down” mood, irritability, and concentration problems. (Id.). He reported that he stopped working because it exacerbated his problems and caused him to be on edge and lose his patience. (A.R. 398). Dr. Rossello noted that his MSE was normal and that he presented a cooperative attitude, a reactive affect, good remote memory, and fair insight and judgment. (Id.). Ford reported that his typical day includes “watch[ing] news, science, history stuff, ” and that he could cook, clean, and shop independently. (A.R. at 398). He stated that his hobbies were “cars [and] working out” and that he enjoyed reading books about fishing and, for example, works by William Faulkner. (Id.). He explained that when he goes to the market or mall, “he is comfortable with crowds if he gets in and out, ” and socially he “get[s] along with others . . . okay.” (Id.). Dr. Rosello assessed a GAF score of 50[4] and diagnosed PTSD. (A.R. at 399). She noted that his capability appeared fair and that his condition could be improved by treatment. (Id.).

         On November 25, 2013, Dr. Diana Walcutt, Ph.D., a state agency psychological consultant, completed a Disability Determination Explanation form after reviewing Ford's medical records and Dr. Rosello's evaluation. (A.R. 84-85, 88). Dr. Walcutt summarized and cited to Ford's treatment notes, and noted that Ford “suffers from extreme PTSD symptoms, violent mood swings [and] insomnia.” (A.R. 86-88). She diagnosed severe anxiety disorder and severe affective disorders that resulted in mild restriction of activities of daily living, moderate difficulties in maintaining social functioning, moderate difficulties in maintaining concentration, persistence, or pace, and one or two repeated episodes of decompensation of extended duration. (A.R. 87-88). She further determined that despite Ford's insomnia and moderate difficulty with sustained concentration, he was able to understand and follow simple and complex instructions, and he could read, shop, and prepare meals. (A.R. 91). Dr. Walcutt found that Ford experienced mild to moderate limitations in areas dealing with continuity of performance and social interactions. (A.R. 92). Ultimately, Dr. Walcutt determined that because Ford had “the ability to interact and relate with others socially, ” could “adequately negotiate in the general community, ” and retained “the capacity to perform simple tasks from a mental health perspective, ” he was not disabled. (A.R. 93).

         3. April 2014-November 2014

         After relocating to Maryland, Ford began treatment on April 9, 2014, with Julie Eastin, Ph.D. (A.R. 420-25). Ford reported feeling “helpless, ” “trapped, ” withdrawn from people, and unable to be proactive. (A.R. 420). He said he felt some anger and had scared himself after punching a wall during an argument in January 2014. (Id.). He denied any thoughts of suicide, but expressed that he “accomplished the goals [he] wanted to, and now there[']s no reason left to stay here.” (A.R. 423-24). He reported a stressful past few months because of his partner's “neediness” and feeling as though “he is a psychologist more than a husband.” (A.R. 421). He noted that he used to enjoy music, reading, and writing, and that his recent efforts to write again had been difficult because of his lack of concentration. (A.R. 422). Dr. Easton noted that his MSE was normal. (A.R. 423). She assessed a PCL score of 70 and diagnosed PTSD. (A.R. 424).

         Ford first saw Heather Chase, LCSW, on May 14, 2014. (A.R. 413). She noted that his MSE presented a neutral affect and low mood, but was otherwise normal. (A.R. 413). Ford reported difficulty concentrating, intrusive thoughts, guilt, insomnia, grief and loss, and relational challenges. (Id.). He described thoughts of “not being here anymore, ” but denied any suicidal ideations. (Id.). Ford next met with Chase on May 29, 2014, and appeared “slightly dysphoric” and “tired, ” and became “tearful” in response to Chase's discussion about coping skills. (A.R. 412). At his next session on June 5, 2014, Ford presented with a neutral affect at first, but overall displayed a dysphoric mood and affect. (A.R. 415). Chase performed no MSE. (Id.). Ford stated that he recently experienced panic when expressing his needs to his husband and described the grounding coping technique he used in response to that panic. (Id.). At his fourth session with Chase on June 12, 2014, she noted no significant changes to Ford's presentation. (A.R. 417). She discussed more distress-tolerance skills with Ford. (Id.). There are no treatment notes in the record from Chase after the June 12 appointment, but a behavioral health summary indicates Ford saw her 19 more times through November 25, 2014. (A.R. 478).

         4. State Agency Consultant Disability Determination, Dr. Nunez

         On June 24, 2014, Jeannie Nunez, Psy.D., a state agency psychological consultant, reconsidered Ford's disability determination by reviewing Dr. Walcutt's DDE and Ford's updated medical records. (A.R. 126-38). Dr. Nunez reaffirmed Dr. Walcutt's conclusion. (A.R. 137-38).

         5. August 2014-January 2015 and Medical Opinions

         On August 8, 2014, Ford saw Dr. Douglas Gartrell, M.D., and reported panic symptoms, poor sleep, feeling unsafe when someone is behind him, some depression, anhedonia, and poor appetite, energy, concentration, memory, and motivation. (A.R. 505). He reported flashbacks and being triggered by sound because of his work trauma. (Id.). Dr. Gartrell noted that his MSE reflected good hygiene; a cooperative attitude; clear speech; good eye contact; normal behavior; a constricted, sad, and anxious affect; a dysphoric and anxious mood; an organized thought process with thought content within normal limits; good insight and judgment; and no suicidal risk. (A.R. 507-08). Dr. Gartrell diagnosed depressive disorder and PTSD, assessed a GAF score of 60, and prescribed mirtazapine and Xanax. (A.R. 508-09). At an August 29, 2014 follow-up, Ford reported depression (“7/10”), sleeping a lot, anxiety, and isolation. (A.R. 495). Ford's MSE remained mostly unchanged, except for the addition of an irritable mood. (Id.).

         On September 17, 2014, Chase wrote a letter to Ford's representative discussing her work with him since May 2014. (A.R. 432). She opined that Ford's current symptoms of anxiety and depression were “significant barriers to his ability to work, ” and thus qualified him as disabled. (Id.). She stated that Ford was working to gradually increase his exposure to crowds and social settings, but found it “unlikely that [Ford] would be able to tolerate the continued social interaction that comes with a full-time job” and that his challenges with focus and concentration would render him unable to perform work reliably. (Id.). To support her opinion that Ford's “challenges with sleep and fatigue” would make it “difficult for [him] to attend a job on ...

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