United States District Court, W.D. Wisconsin
SARAH P. ZAY, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
OPINION AND ORDER
BARBARA B. CRABB District Judge
Sarah P. Zay is seeking review of a final decision denying
her claim for disability insurance benefits under the Social
Security Act. 42 U.S.C. § 405(g). Plaintiff contends
that she has been disabled since March 3, 2011 because of
narcolepsy, anxiety disorder and panic disorder. An
administrative law judge concluded that even though plaintiff
has severe impairments, she is not disabled because she can
perform full-time work at all exertional levels, with some
restrictions. The Appeals Council accepted review and also
concluded that plaintiff is not disabled. As explained below,
I agree with plaintiff that the commissioner did not give an
adequate explanation in her decision for discounting the
medical opinions in the record. Therefore, I will reverse the
commissioner's decision and remand this case for further
following facts are drawn from the administrative record
Social Security Application and Background
Sarah Zay was born in 1983. She filed for disability
insurance benefits in November 2012, contending that she was
disabled by anxiety, panic attacks and narcolepsy. AR 24,
218-24. Her application was denied initially and on
reconsideration. AR 136-44, 146-54. Plaintiff requested a
hearing, and appeared without representation at a hearing
before an administrative law judge in March 2016. AR 78-105.
In November 2016, plaintiff testified at a supplemental
hearing in front of a different administrative law judge and
with the assistance of counsel. AR 42-75. A medical expert
and vocational expert also testified at the second hearing.
The administrative law judge issued a written decision in
December 2016, concluding that plaintiff was not disabled. AR
24-36. In January 2017, plaintiff sought review of the
administrative law judge's decision from the Appeals
Council, AR 209, and in March 2018, the appeals council
granted review. AR 210-17.
2018, the Appeals Council issued an unfavorable decision. AR
1-6. The Appeals Council amended the date that plaintiff was
last insured to September 2021, but adopted many of the
administrative law judge's findings regarding whether
plaintiff was disabled.
Overview of Medical Problems and Treatment
2011, plaintiff has reported symptoms of anxiety, depression
and narcolepsy and has been treated with various medications
for those impairments, including Klonopin, Adderall,
Trazadone and Ativan. In March 2011, a psychologist gave
plaintiff a diagnosis of social anxiety and narcolepsy and
assessed her global assessment of functioning score as 70. AR
316. At follow up appointments that same year, she seemed
engaged during the visit and reported that she was doing
well. She was working two jobs and had a vacation planned for
Cancun. (It is not clear from the record whether plaintiff
went on the vacation.) By July 2011, however plaintiff
reported that her anxiety had increased and was making it
difficult for her to engage in daily activities. She also
reported that she had recently had a panic attack, and stated
that she had had 10 panic attacks in her life. AR 368. In
October 2011, plaintiff reported that she was working more
than 32 hours a week at a nursing home, but that her
exhaustion was making her frustrated and that she was
considering applying for disability benefits. AR 366. By
November 2011, she reported that she was having daily panic
attacks before going to work and before any medical
appointment. AR 363.
2012, plaintiff continued to report difficulty sleeping,
anxiety and panic attacks. In March 2012, she reported that
her panic attacks were worsening and that she had difficulty
leaving the house and answering her phone or door. AR 361.
She quit her job because it was too stressful for her.
Id. In April 2012, she reported that her panic
attacks were difficult to control and that her medications
were not helping. AR 359. Her doctor recommended on several
occasions that plaintiff meet with a psychiatrist regarding
her anxiety, but she responded that contacting psychiatry was
too stressful for her. AR 351, 357, 361. Plaintiff continued
to seek treatment for her anxiety, panic attacks and sleep
difficulties from her primary care provider in 2013. Her
symptoms were generally the same as they were during 2012,
and she experienced severe anxiety with social interactions
and car rides. AR 344.
2014, plaintiff participated in a consultative examination
with Charles Moore, a psychologist. AR 415-21. Moore noted
that plaintiff was cooperative and made fair eye contact, but
her mood and affect were anxious. Moore gave plaintiff a
diagnosis of generalized anxiety disorder, AR 420, and
concluded that plaintiff would have problems understanding,
remembering and carrying out even simple instructions, would
not be able to respond satisfactorily in a basic social
context and would be “less able” to withstand
routine stressors. AR 421.
August 2015, plaintiff was still working part-time for home
health care and reported that her narcolepsy was
well-controlled, but that she had problems with anxiety. AR
434. She still had not made an appointment with psychiatry
for her anxiety. Id.
2016, plaintiff participated in a second consultative
examination with Rebecca Angle, a psychologist. AR 450. She
was anxious at the appointment and cried through most of it.
AR 451. She reported having frequent panic attacks,
especially when she had to drive or ride in a car. AR 450.
Angle gave plaintiff a diagnosis of unspecified anxiety
disorder. AR 454. As for plaintiff's ability to work,
Angle concluded that plaintiff had the ability to understand,
remember and carry out simply instructions, but would be
significantly limited in her ability to get along with
supervisors and coworkers, manage day-to-day work stress and
maintain her concentration and work pace. Id.
medical progress notes from 2016 show that plaintiff
continued to report symptoms from anxiety and narcolepsy and
continued to take Klonopin and Adderall, in addition to other
medications. AR 461-42, 475. She also reported suffering
panic attacks multiple times a day. AR 475. She continued to
refuse to make appointments with behavioral health
specialists because she thought making appointments with a
new provider was too stressful. Id.