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Brookshire v. Saul

United States District Court, D. New Mexico

December 26, 2019

ANDREW SAUL, Commissioner of the Social Security Administration, Defendant.



         THIS MATTER is before the Court on Plaintiff Cindy M. Brookshire's (“Ms. Brookshire”) Motion to Reverse and Remand for Rehearing with Supporting Memorandum (Doc. 27) (“Motion”), filed August 8, 2019, seeking review of the unfavorable decision of Defendant Andrew Saul, Commissioner of the Social Security Administration (“Commissioner”), on Ms. Brookshire's claim for Title II disability insurance benefits under 42 U.S.C. §§ 405(g) and 1383(c)(3). The Commissioner filed a response in opposition to the Motion on October 8, 2019, (Doc. 29), and Ms. Brookshire filed a reply in support of the Motion on October 15, 2019. (Doc. 30.) Having meticulously reviewed the entire record and the applicable law and being otherwise fully advised in the premises, the Court FINDS that Ms. Brookshire's Motion is well taken and should be GRANTED.

         I. BACKGROUND

         Ms. Brookshire is a 60-year-old, college-educated woman who filed for disability insurance benefits on June 30, 2015, alleging a disability onset date of March 1, 2011. (Administrative Record (“AR”) 041, 159.) From 1999 through February 2011, she worked as a medical records clerk at the Center for Orthopedics. (AR 042-44, 171-73.) She stopped working in February 2011 after her position was “eliminated, ” although Ms. Brookshire suspects that her employer eliminated her position to avoid firing her outright. (AR 043.) According to Ms. Brookshire, she “frightened people” that she worked with by frequently talking out loud to herself and saying “outrageous” and “inappropriate” things. (AR 046-47.)

         Ms. Brookshire first started receiving “mental health services” at age nineteen after suffering “several losses.” (AR 276.) In the Disability Report she completed when she applied for benefits, Ms. Brookshire reported that beginning in 1997, she received treatment for “Depression/Anxiety Situational Bi-polar PTSD [sic]” from various providers while living in Connecticut.[2] (See AR 195-97.) Upon relocating to New Mexico in 2013, Ms. Brookshire established care at Rio Rancho Medical Center, where she received refills for the different medications she was on at the time, including Celexa (citalopram), which was used to treat her dysthymic disorder (depression). (AR 287-289.)

         In April 2015, Ms. Brookshire began treating with psychiatrist Yvonne Hall, M.D.[3] (AR 392-94.) Dr. Hall diagnosed Ms. Brookshire with posttraumatic stress disorder (“PTSD”), depressive disorder, and autism disorder, noting that Ms. Brookshire “is struggling with interpersonal deficits” and that the “course is expected to be chronic[] because of the patient's autistic component.” (AR 393-94.) She continued Ms. Brookshire on her then-current treatment of citalopram for depression and PTSD (AR 394) and later augmented and modified Ms. Brookshire's medication regimen to include prazosin to treat Ms. Brookshire's nightmares (AR 390), aripiprazole to treat her increased depression, which was later switched to Latuda and then lamotrigine (AR 360-61, 367-68, 371, 381), and lorazepam for anxiety (AR 366, 371). Dr. Hall treated Ms. Brookshire on a monthly basis from April 2015 through at least March 2017, titrating her medications throughout that time depending on whether Ms. Brookshire reported improvement in her condition or increased symptoms. (AR 354, 355-94.) As early as September 2015, Dr. Hall encouraged Ms. Brookshire to consider seeing a psychotherapist, which Ms. Brookshire declined at that time because she felt it would be “overwhelming to try to talk to one.” (AR 387-88.) However, Ms. Brookshire eventually agreed to see a psychotherapist and established with Elizabeth Penland, Ph.D., in December 2016. (AR 357, 420-22.)

         Ms. Brookshire saw Dr. Penland eleven times between December 2016 and April 2017, or approximately every week. (AR 401-422.) In March 2017, Dr. Penland opined that Ms. Brookshire suffers from social anxiety disorder, not Asperger's Syndrome or autism. (AR 406, 407.) In April 2017, Dr. Penland diagnosed Ms. Brookshire with (1) dysthymic disorder (seasonal component and pervasive depressive disorder), (2) social anxiety disorder, (3) PTSD, (4) other specified personality disorder (mixed personality features, schizoid, avoidant, dependent personality features), and (5) specific learning disability (dyslexia) by history. (AR 402.) Also in April 2017, Dr. Penland completed a Medical Source Statement of Ability to do Work-Related Activities (Mental) (“medical source statement”) (AR 423-27) in which she indicated her opinion that Ms. Brookshire has either no or mild limitations in most areas of work-related functioning but moderate and marked limitations as follows: moderate limitations in the ability to (1) maintain attention and concentration for extended periods, (2) perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances, and (3) get along with co-worker or peers without unduly distracting them or exhibiting behavioral extremes; marked limitations in the ability to (1) interact appropriately with the general public or customers, and (2) accept instructions and respond appropriately to criticism from supervisors. (AR 424-25.) At the end of her medical source statement where asked to identify the “[d]ate of onset of the foregoing limitations[, ]” Dr. Penland indicated: “Probably going back to childhood. I have not known this patient for very long. I just met her in December of 2016.” (AR 427.)

         The ALJ found that prior to her date last insured of December 31, 2016, Ms. Brookshire had the following severe impairments: “Autistic Disorders; Anxiety Disorders; and Affective Disorders[.]” (AR 024.) Finding that none of Ms. Brookshire's severe impairments, alone or in combination, met a Listing[4], the ALJ proceeded to assess Ms. Brookshire's residual functional capacity (“RFC”) to work. (AR 024-28.) The ALJ found that Ms. Brookshire has the RFC to perform a full range of work at all exertional levels but with the following non-exertional limitations:

[Ms. Brookshire] can understand, carry out, and remember simple 1 to 3 step instructions, and make commensurate work-related decisions. She can respond appropriately to supervision, coworkers, and work situations. She can deal with routine changes in work setting. She can maintain concentration, persistence, and pace for up to and including two hours at a time, with normal breaks throughout a normal workday. She is limited to occasional superficial interaction with the general public.

(AR 026.) In discussing the medical opinion evidence vis-à-vis the RFC he assessed, the ALJ accorded “great weight” to the opinion of non-examining state agency psychologists William Farrell, Ph.D., and Joan Holloway, Ph.D., that Ms. Brookshire “retains the capacity to understand simple, one to three step instructions during an eight-hour workday.” (AR 027.) He did so because he found that Drs. Farrell and Holloway “had an overview of the medical evidence, [are] familiar with Social Security disability standards, and [their] opinion[s are] well-explained.” (Id.) While recognizing Dr. Penland as Ms. Brookshire's “treating psychologist[, ]” the ALJ accorded Dr. Penland's opinions only “some weight.” (Id.) The ALJ explained that Dr. Penland's opinions- specifically as to Ms. Brookshire's areas of marked limitation-were not entitled to “controlling or even great weight” because Dr. Penland had only been treating Ms. Brookshire since December 2016, which the ALJ concluded “is not long enough to establish a treatment history that would” entitle Dr. Penland's opinions to greater weight. (Id.) The other reason the ALJ gave for according only “some weight” to Dr. Penland's opinions was that “most of her treatment notes are not clear.” (Id.) Other than noting that Dr. Penland's treatment notes “mention[] [Ms. Brookshire's] family history, depression and post-traumatic stress disorder” and that Dr. Penland “does not believe that [Ms. Brookshire] had either Asperger's or Autism[, ]” the ALJ's decision contains no further discussion of the evidence supplied by Dr. Penland's records and medical source statement. (Id.)

         Although the ALJ found that Ms. Brookshire was unable to perform past relevant work, he concluded that given her age, education, work experience, and the RFC he assessed, she would be able to perform other jobs that exist in significant numbers in the national economy. (AR 028-29.) He therefore found that Ms. Brookshire was “not disabled.” (AR 029.) Ms. Brookshire sought review by the Appeals Council, which denied her request. (AR 001-6, 157-58.) Ms. Brookshire then appealed to this Court. (Doc. 1.)


         A. Standard of Review

         Judicial review of the Commissioner's denial of disability benefits is limited to whether the final decision is supported by substantial evidence and whether the Commissioner applied the correct legal standards to evaluate the evidence. 42 U.S.C. § 405(g); Hamlin v. Barnhart, 365 F.3d 1208, 1214 (10th Cir. 2004). In making these determinations, the Court must meticulously examine the entire record but may neither reweigh the evidence nor substitute its judgment for that of the Commissioner. Flaherty v. Astrue, 515 F.3d 1067, 1070 (10th Cir. 2007). In other words, the Court does not reexamine the issues de novo. Sisco v. U.S. Dep't of Health & Human Servs., 10 F.3d 739, 741 (10th Cir. 1993). The Court will not disturb the Commissioner's final decision if it correctly applies legal standards and is based on substantial evidence in the record.

         “Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Langley v. Barnhart, 373 F.3d 1116, 1118 (10th Cir. 2004) (quotation marks omitted). Substantial evidence is “more than a scintilla, but less than a preponderance.” Lax v. Astrue, 489 F.3d 1080, 1084 (10th Cir. 2007). A decision “is not based on substantial evidence if it is overwhelmed by other evidence in the record[, ]” Langley, 373 F.3d at 1118 (quotation marks omitted), or “constitutes mere conclusion.” Musgrave v. Sullivan, 966 F.2d 1371, 1374 (10th Cir. 1992). The Court's examination of the record as a whole must include ...

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