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Eralte v. Colvin

United States District Court, S.D. New York

December 23, 2014

ANDERSON ERALTE, Plaintiff,
v.
ACTING COMMISSIONER CAROLYN W. COLVIN of Social Security, Defendant.

MEMORANDUM AND ORDER

JAMES C. FRANCIS, IV, Magistrate Judge.

The plaintiff, Anderson Eralte, brings this action under section 205(g) of the Social Security Act (the "Act"), 42 U.S.C. § 405(g), seeking review of a determination by the Commissioner of Social Security ("the Commissioner") denying his application for disability insurance benefits. The parties have consented to my exercising authority for all purposes pursuant to 28 U.S.C. § 636(c), and each party has submitted a motion for judgment on the pleadings under Rule 12(c) of the Federal Rules of Civil Procedure. Because the Commissioner's decision is supported by substantial evidence, the plaintiff's motion is denied and the defendant's motion is granted.

Background

A. Personal and Vocational History

Mr. Eralte was born on February 18, 1982, in New York, New York. (R. at 31).[1] He has some college education and served in the U.S. Navy for eight years as a petty officer. (R. at 21, 32). He also has prior work experience as a customer service representative. (R. at 32).

While in the Navy, Mr. Eralte twice suffered a torn anterior cruciate ligament ("ACL") in his right knee, each injury requiring reconstructive surgery and physical therapy. (R. at 33-34). The initial ACL tear occurred during the plaintiff's first year in the Navy, and while the injury somewhat limited his physical activity, it did not render Mr. Eralte unfit for service. (R. at 33). The plaintiff remained in the Navy following his second ACL injury in 2010. (R. at 38-39). Mr. Eralte left the Navy in March 2011 and was not discharged for any medical reasons or as a result of any inability to perform his duties. (R. at 39).

Upon leaving the Navy, the plaintiff reported experiencing depression and post-traumatic stress disorder ("PTSD"), including symptoms of intrusive thoughts and memories, hyper-vigilance, aggressiveness, and poor sleep, which, he asserts, have impeded his ability to gain employment. (R. at 42-44). Mr. Eralte's last date of employment was March 8, 2011, when he was discharged from the service. (R. at 32-33, 112). He asserts that he is entitled to disability benefits due to PTSD, depression, the ACL tear with resulting arthritis, lower back pain, and plantar fasciitis. (R. at 33, 122).

B. Medical History

1. Psychiatric Evaluations

i. Dr. Jeffrey S. Fine

On July 19, 2011, the plaintiff presented to Dr. Jeffrey S. Fine for a psychiatric evaluation. (R. at 187, 368). Mr. Eralte reported symptoms of poor sleep, depression, increased vigilance, anxiety, traumatic memories, decreased motivation, and loss of appetite. (R. at 188). Dr. Fine observed that the plaintiff was alert, his speech was coherent and goal-directed, and his affect was normal. (R. at 189). Mr. Eralte described a number of traumatic experiences relating to his childhood, his service in the Navy, and his father's death.[2] (R. at 188-89). Dr. Fine diagnosed depression, not otherwise specified, or, potentially, a prolonged grief reaction related to his father's death. (R. at 187, 189). Dr. Fine noted the possibility that the plaintiff suffered from PTSD as a result of traumatic experiences in the Navy and childhood sexual abuse. (R. at 187, 189-90). He prescribed Paxil and recommended that Mr. Eralte attend psychotherapy with a social worker. (R. at 190).

Mr. Eralte returned to Dr. Fine on August 10, 2011. (R. at 171). The plaintiff reported a decrease in intrusive memories and nightmares, but complained of stress, depression, internalized anger, and anxiety. (R. at 172). Dr. Fine conducted a mental status evaluation and concluded that the plaintiff was alert, cooperative, and generally normal, with the exception of a depressed mood. (R. at 172). Dr. Fine increased the dosage of the plaintiff's medication, and again suggested individual therapy. (R. at 172).

On October 14, 2011, the plaintiff again met with Dr. Fine, complaining of worsening depression, poor appetite, lack of concentration and motivation, anxiety attacks, and intrusive memories two or three times per week. (R. at 505). He had stopped taking Paxil six weeks prior, and was prescribed Wellbutrin. (R. at 504). Dr. Fine advised the plaintiff to return within one month or sooner. (R. at 504).

Mr. Eralte presented to Dr. Fine on November 10, 2011, describing his depression level as 4 out of 10, and stating that his intrusive memories and nightmares had decreased. (R. at 484). In light of Dr. Fine's conclusion that "some ptsd and depression" symptoms persisted, albeit "somewhat less, " the plaintiff was prescribed a new antidepressant, Venalafaxine, and was advised to return again in one month. (R. at 484).

The plaintiff returned to Dr. Fine on December 28, 2011, reporting that the medications were helpful, describing his mood overall as "medium down." (R. at 459). Although the plaintiff reported fewer intrusive memories, his nightmares and symptoms of hyper-vigilance and anxiety persisted. (R. at 459).

On February 9, 2012, Mr. Eralte presented to Dr. Fine for medication management. (R. at 436). The plaintiff described his symptoms as being "reasonably stable, " but reported that he continued to experience migraine headaches and intrusive memories several times per week. (R. at 436). In response, Dr. Fine increased the plaintiff's prescription. (R. at 436). On March 15, 2012, Mr. Eralte again met with Dr. Fine for medication management, continuing to complain of hyper-vigilance. (R. at 563). Mr. Eralte described his mood as "up and down" and "mildly depressed, " but stated that he was "calm and in control" of his anger when he took his medication. (R. at 563).

One month later, the plaintiff continued to display symptoms of anxiety, lack of motivation and concentration, and intrusive traumatic memories, and rated his depression at a severity level of 8 out of 10. (R. at 537). A medical status examination was normal, but in light of the plaintiff's "high level of depression, " Dr. Fine doubled the plaintiff's existing medication and prescribed Klonopin. (R. at 537).

Dr. Fine completed a psychiatric disability questionnaire on May 4, 2012, diagnosing Mr. Eralte with PTSD and depression, not otherwise specified. (R. at 525). He found Mr. Eralte markedly limited in his ability to understand and carry out detailed instructions, maintain concentration for extended periods, complete a normal workweek, and interact appropriately with the general public. (R. at 528-30). The plaintiff possessed moderate limitations in his ability to remember work-like procedures, and to work with peers and supervisors, but Dr. Fine assessed no limitations in the plaintiff's ability to understand, remember, and carry out simple instructions. (R. at 528-30). Dr. Fine assigned the plaintiff a Global Assessment of Function ("GAF") score of 50.[3] (R. at 525).

ii. Dr. Joshua Hooberman

The plaintiff visited Dr. Joshua Hooberman, a clinical psychologist, on July 28, 2011, reporting symptoms of depression, anxiety, and posttraumatic stress. (R. at 206, 212). Following an assessment of the plaintiff, Dr. Hooberman assigned a GAF score of 58, indicating moderate symptoms.[4] (R. at 211). While the plaintiff exhibited some symptoms of PTSD, he did not meet the criteria for a diagnosis. (R. at 210-11). Dr. Hooberman found that Mr. Eralte's symptoms limited his occupational and educational functioning, noting that the plaintiff complained of significant difficulty concentrating on his school assignments. (R. at 211). Dr. Hooberman diagnosed adjustment disorder with mixed depression and anxiety. (R. at 211).

iii. Dr. Fairweather

On October 31, 2011, another clinical psychologist, Dr. Angela Fairweather, met with Mr. Eralte, and conducted a mental status examination. (R. at 391). Dr. Fairweather noted a depressed affect and dysthymic mood, [5] but found that the plaintiff was able to follow and understand simple instructions, perform simple tasks independently, learn new tasks, and make appropriate decisions. (R. at 392-93). The plaintiff exhibited mild difficulty maintaining concentration and performing complex tasks independently, as well as moderate difficulty maintaining a regular schedule and dealing appropriately with stress. (R. at 393). Dr. Fairweather diagnosed the plaintiff with major depressive disorder, without psychotic features, and anxiety disorder not otherwise specified, noting that his symptoms may cause "moderate impairments" with respect to his daily functioning. (R. at 393-94).

iv. Linda Blackwell, State Agency Psychologist

On November 10, 2011, Linda Blackwell, a State agency psychologist, performed a Psychiatric Review and found that Mr. Eralte possessed mild difficulties in maintaining social functioning and moderate difficulties in maintaining concentration, but had no restrictions on daily living activities. (R. at 395, 405). A functional capacity assessment indicated that the plaintiff possessed mild to moderate limitation ...


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