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Shegstad v. Saul

United States District Court, W.D. Wisconsin

January 2, 2020

ANDREW M. SAUL, Commissioner of Social Security, Defendant.



         Pursuant to 42 U.S.C. § 405(g), plaintiff James Shegstad seeks judicial review of a final determination that he was not disabled within the meaning of the Social Security Act. Shegstad contends that remand is warranted because the administrative law judge (“ALJ”) failed to consider the effects of Shegstad's mental impairments on his ability to work. Because the ALJ's finding that Shegstad's anxiety and depression caused no more than mild limitations in any of the functional areas was supported by substantial evidence, the court will affirm the denial of benefits.

         BACKGROUND [1]

         A. Overview of Claim

         Plaintiff James Shegstad applied for social security disability benefits on November 6, 2014, claiming an alleged onset date of October 15, 2012. With a birth date of July 16, 1964, Shegstad was at the very top range of “a younger person” at his alleged onset date, and he moved into “closely approaching advanced age” during the course of the administrative process. (AR 84.) Shegstad served in the United States Air Force for 26 years, retiring in 2011. After his retirement, he worked as a human resources assistant or clerk with the United States Customs and Border Control for approximately ten months, with his employment ending shortly before his alleged disability onset date. (AR 31.) He claimed disability based on sleep apnea, tendinitis in his hands, herniated discs in lumbar, hypertension, depression, testicular cancer in remission, hypothyroidism and plantar fasciitis. (AR 84-85.)

         B. ALJ's Decision

         ALJ Corey Ayling held a video hearing on November 27, 2017, at which Shegstad appeared personally and by counsel. As of the alleged onset date, the ALJ found that Shegstad suffered from a variety of physical impairments, including degenerative joint disease and degenerative changes of the lumbar spine with low back pain, among others. (AR 18.) However, the ALJ determined that Shegstad's “medically determinable mental impairments of depressive disorder and anxiety (Exhibit 6F, p. 89), considered singly and in combination, do not cause more than minimal limitation in the claimant's ability to perform basic mental work activities and therefore [are] nonsevere.” (AR 20.) In so finding, the ALJ relied on: (1) neuropsychological testing in August 2017, finding a “normal cognitive profile”; (2) a note by his psychologist Elizabeth Possis, Ph.D., L.P., that Shegstad's “mental status” was “fully intact” and her rating of his GAF as 64-68, “which is consistent with only ‘mild' symptoms or difficulties in functioning”; and (3) the psychological evaluation completed in September 2015 by Travis Hinze, Ph.D., in which Dr. Hinze determined that Shegstad would have no major problems in understanding, remembering and carrying out simple instructions and in maintaining concentration, attention and work pace, and only “mild to moderate” impairments in responding appropriately to supervisors and coworkers and in withstanding routine work stressors. (AR 19-21.)

         The ALJ also conducted his own assessment of the four functional areas, see 20 C.F.R. § 404.1520a(c)(4), finding that Shegstad had no more than mild limitations for each. (AR 21-22.) In this latter analysis, Shegstad again relied on Dr. Hinze's report, as well as on the opinions of the state agency mental health consultants, who similarly found that Shegstad's mental health impairments were non-severe. (Id.)

         In formulating a residual functional capacity (“RFC”), the ALJ limited Shegstad to light work and included a number of additional, exertional limitations, but the ALJ did not include any nonexertional limitations, in light of his finding that Shegstad had no more than mild limitations in the four functional areas. Relying on the testimony of the vocational expert, the ALJ then found that Shegstad could perform his past relevant as a human resources clerk and, therefore, was not disabled.

         C. Mental Health Medical Record

         Plaintiff sought mental health treatment through the Minneapolis VA. Shegstad saw Dr. Possis on October 16, 2012, for a behavioral health provider evaluation and treatment recommendations regarding anxiety. (AR 545-59.) He complained of stress and anxiety, stated that he previously engaged in psychotherapy, and reported that he was taking venlafaxine, which he reported was working. (AR 546.) At that time, Possis's assessment of various mental status indicators were “normal, ” “calm, ” and “good.” (AR 547.) Possis's diagnostic impression was “Anxiety NOS” and “Major Depressive Disorder, Recurrent, in full remission.” (AR 549.) As noted by the ALJ, Dr. Possi also determined that Shegstad's current global assessment of functioning (“GAF”) score was 64.[2] Shegstad was further interested in therapy, which Possis agreed to provide, indicating that she expected improvement in three to eight sessions. (AR 549.) Shegstad proceeded to participate in therapy on a roughly weekly basis from November 1, 2012 to December 12, 2012. (AR 533-545.)[3] Shegstad also attended therapy with other psychologists for various periods of time over the next several years. (See, e.g., AR 726, 1063, 1089, 1132.)

         Material to plaintiff's appeal, Dr. Hinze also conducted a mental status evaluation on September 15, 2015. (AR 624.) Shegstad was referred to Dr. Hinze by the Social Security Determination Bureau. After reviewing his medical record and interviewing Shegstad, Hinze concluded that he suffers from “major depressive disorder, recurrent, mild-to-moderate” and “generalized anxiety disorder, by history.” (AR 627.) Hinze then assessed Shegstad's functional areas, finding:

• Capacity to understand, remember and carry out simple instructions: I doubt he would have any major problems in this areas.
• Capacity to respond appropriately to supervisors and coworkers: He may have mild-to-moderate ...

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