Patrick Mutz v. Commissioner of Social Security

          STEVEN J. MURPHY, III DISTRICT JUDGE.

          REPORT AND RECOMMENDATION

          R. STEVEN WHALEN UNITED STATES MAGISTRATE JUDGE.

         Plaintiff Steven Edward Patrick Mutz (“Plaintiff”) brings this action under 42 U.S.C. §405(g) challenging a final decision of Defendant Commissioner (“Defendant”) denying his application for Supplemental Security Income (“SSI”) under the Social Security Act. The parties have filed cross-motions for summary judgment. Both motions have been referred for a Report and Recommendation pursuant to 28 U.S.C. §636(b)(1)(B). For the reasons discussed below, I recommend that Defendant's Motion for Summary Judgment [Docket #12] be GRANTED and that Plaintiff's Motion for Summary Judgment [Docket #11] be DENIED.

         PROCEDURAL HISTORY

         On February 4, 2016, Plaintiff applied for SSI, alleging disability as of December 1, 2015 (Tr. 16). Following the initial denial of benefits, Plaintiff requested an administrative hearing, held on September 25, 2017 in Oak Park, Michigan (Tr. 31). Patricia S. McKay, Administrative Law Judge (“ALJ”) presided. Plaintiff, represented attorney Michael J. White, testified (Tr. 36-46), as did Vocational Expert (“VE”) Judith Findora (Tr. 46-51). On April 4, 2018, ALJ McKay found Plaintiff not disabled (Tr. 16-26). On October 23, 2018, the Appeals Council denied review (Tr. 1-3). Plaintiff filed suit in this Court on November 28, 2018.

         BACKGROUND FACTS

         Plaintiff, born November 30, 1990, was 27 when ALJ McKay issued her decision (Tr. 16, 26). He completed 12^th grade and worked formerly as a dishwasher, receiver at a grocery store, and sales associate (Tr. 144). He alleges disability as a result of anxiety, depression, and autism spectrum disorder (Tr. 143).

         A. Plaintiff's Testimony

         Plaintiff offered the following testimony:

         He was “very uncomfortable” around others, adding that his discomfort increased in larger groups causing him to “withdraw into [him]self” (Tr. 36). He perceived that as a “quiet, reserved” person others were “judging” him (Tr. 37). He felt that he was in control of his life when he was by himself watching television or reading books (Tr. 37). He interacted with his mother and half-sister at home but was more comfortable when he was in his own room (Tr. 37). His discomfort with others was characterized by fidgeting, sweats, hyperventilation, and headaches (Tr. 38-39). He sometimes put off caring for personal hygiene until being reminded by his mother (Tr. 38). He was “extremely uncomfortable” in work situations with “extreme” anxiety about performing his job correctly (Tr. 38). His work-related anxiety lasted from the time he attempted to find work until he ended up leaving the job (Tr. 39).

         Since graduating from high school, Plaintiff was unable hold a job for any meaningful length of time due to anxiety (Tr. 40). He experienced anxiety during his school years, noting that he missed around two days of school each month (Tr. 40). He was not in special education during his school years, and attended Baker College “very briefly” (Tr. 41). His attempts to find work through a job placement program were not successful (Tr. 41). He stood around 5' 10" and weighed 230 pounds (Tr. 42). He did not have a driver's license (Tr. 42). He used a bike for local errands but otherwise relied on his mother for transportation (Tr. 43). He spent most of his days reading, watching television, or playing video games (Tr. 43). He enjoyed reading science fiction novels and mysteries (Tr. 44). He did not keep in touch with high school classmates (Tr. 44). He was able to do laundry (Tr. 43).

         Plaintiff had changed mental health treatment several times due to insurance issues or because he wasn't “connecting with the therapist” (Tr. 44). He took psychotropic medication and did not experience side effects (Tr. 45-46). He did not smoke, drink, or use illicit drugs (Tr. 46). He was unable to work due to job environment anxiety that was so bad that he could “barely keep control of [him]self” (Tr. 46).

         B. Medical Evidence

         1. Treating Sources

         March, 2014 psychological records note Plaintiff's report of social anxiety (Tr. 190). The same records note that Plaintiff was a “bright student in high school, ” had never been treated for psychiatric problems, and had helped take care of his grandmother (Tr. 190). Plaintiff was cooperative with normal thought processes, orientation, and memory (Tr. 191). Plaintiff reported that his social anxiety had increased since graduating from high school due to not having a routine (Tr. 193). He reported that he went to the grocery store with his mother “when needed” (Tr. 197). He reported a good relationship with his mother and younger sister and enjoyed writing and reading (Tr. 197-198). He reported that he had worked at Target over the holidays but “became frustrated and quit” after two weeks (Tr. 199). He was assigned a GAF of 50 based on social anxiety and his report of headaches^[1] (Tr. 192).

         June, 2015 records note that Plaintiff had never taken medication for anxiety (Tr. 205). He appeared anxious (Tr. 208). He reported migraines lasting a few hours which were resolved with over-the-counter pain relievers (Tr. 209). Counseling records from the same month note that Plaintiff was eager to prepare himself for employment (Tr. 215). He demonstrated a normal affect and stable mood (Tr. 215). He received a good prognosis (Tr. 215). August, 2015 records note that Plaintiff was preparing to start a job as a receiver at Meijer (Tr. 213, 287). The same month, Lauren Blenman, D.O. noted Plaintiff's report that the prescribed medication of Celexa caused sleep disturbances (Tr. 251). Dr. Blenman's records from the next month note Plaintiff's report that he experienced ergophobia^[2] (Tr. 247). October, 2015 records note that Plaintiff's counseling goals were “partially achieved” with a good prognosis (Tr. 211, 284). December, 2015 records note that Klonopin reduced Plaintiff's worry/anxiety (Tr. 227).

         Dr. Blenman's February, 2016 records note that Plaintiff felt that “he may be transgender” (Tr. 235). May, 2016 counseling records note the conditions of social anxiety, depression, and gender dysphoria (Tr. 281). July, 2016 counseling records note Plaintiff's report of reduced anxiety with “self-calming skills” introduced at an earlier session (Tr. 276). Plaintiff reported that his anxiety, at worst, did not go higher than a “six” on a one-to-ten scale (Tr. 276). Plaintiff reported continued improvement in anxiety levels the following month (Tr. 275).

         Dr. Blenman's September, 2016 records note that Plaintiff was changing counselors to “hopefully find someone he connects with more” (Tr. 304). She noted Plaintiff's report that he had been riding his bike more frequently but had not tried to find a job and was not interested in online classes (Tr. 304).

         In January, 2017 Dr. Blenman noted that Plaintiff had a stationary exercise bike and read and played video games for fun (Tr. 302). In April, 2017, Dr. Blenman encouraged Plaintiff to look for a part time job “for [a] sense of purpose” and to “increase activity” (Tr. 300). A May, 2017 assessment notes that Plaintiff was “dependent, ” “depressed, ” “emotional, ” “fearful, ” “immature, ” “nervous, ” “quiet, ” “resistant to change, ” and “unmotivated” (Tr. 260). Results of a self evaluation reflected “mild anxiety” and “moderate depression” (Tr. 261). Test results also showed “schizoid, avoidant, and dependent traits” (Tr. 266). Arthur Lewandowski, Ph.D. recommended medication and regular therapy with the goals of developing a daily routine and increasing self esteem and coping skills (Tr. 269). The following month, Dr. Blenman noted that Plaintiff had undergone neuropsychological testing the previous month and was “hoping having established diagnoses will help him get disability” (Tr. 298). She noted Plaintiff's report of “feeling less down” since increasing his dose of Effexor (Tr. 292).

         2. Non-Treating Sources

         In May, 2016, Robert Newhouse, M.D. performed a non-examining review of the treating and examining records on behalf of the SSA, finding that as a result of an affective disorder, anxiety-related disorders, and autistic disorder, Plaintiff experienced mild restriction in activities of daily living, marked limitation in social functioning, and moderate limitation in concentration, persistence and pace (Tr. 57). Dr. Newhouse concluded that Plaintiff “appear[ed] able to do simple tasks on [a] sustained basis however would need to be in [a] position with little contact with others” (Tr. 60).

         C. Vocational Expert Testimony

         ALJ McKay found that none of Plaintiff's work activity rose to the level of “past relevant work” (Tr. 47). She then posed the following question to VE Findora, describing a hypothetical individual of Plaintiff's age, education, and work experience who was capable of ...