Braden v. Commissioner of Social Security

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF INDIANA

SOUTH BEND DIVISION

LAURA D. BRADEN, )

Plaintiff, )

)

v. ) Case No. 1:20-CV-056-JD

)

ANDREW M. SAUL, Commissioner of )

Social Security )

)

Defendant. )

OPINION AND ORDER

Laura D. Braden applied for supplementary security income, alleging that she is unable to

work primarily due to anxiety, post-traumatic stress disorder, depression, an auto immune

disease, fibromyalgia, chronic pain and fatigue, erythema, annulare, centrifugum, general anxiety

disorder, and panic disorder with agoraphobia. Ms. Braden was found to be not disabled in a

December 2018 decision. Ms. Braden filed this appeal, asking the Court to reverse the ALJ’s

decision and remand for further proceedings based on alleged errors with the residual functional

capacity assessment. The Commissioner filed a response in opposition, and Ms. Braden filed a

reply. As explained below, the Court remands the Commissioner’s decision.

I. Factual Background

Until she stopped working, Ms. Braden worked as a secretary. Ms. Braden suffers from

fibromyalgia, arthritic right foot, depression, anxiety, and post-traumatic stress disorder. (R. 18).

Ms. Braden applied for benefits in 2017. The ALJ issued an unfavorable decision on

December 13, 2018. In that decision, the ALJ recognized the following residual functional

capacity:

[T]he claimant has the residual functional capacity to perform light work as defined

in 20 CFR 416.967(b) except the claimant can occasionally climb ramps and stairs.

The claimant can never climb ladders, ropes, or scaffolds. The claimant can

occasionally balance. The claimant can occasionally stoop and kneel. The claimant

cannot crouch or crawl. The claimant must avoid concentrated exposure to

unprotected heights. The claimant can understand, remember, and carry out simple

instructions. The claimant can perform work that can be done at a flexible and goal

oriented pace. The claimant is limited to work within a low stress job requiring only

occasional decision-making and only occasional changes in a work setting. The

claimant can occasionally interact with the general public and can occasionally

interact with co-workers and supervisors other than what is necessary for

instruction and task completion.

(R. 20). Finding that Ms. Braden can perform other work in the economy, the ALJ found that she

is not disabled. The Appeals Council declined review, and Ms. Braden filed this action seeking

judicial review of the Commissioner’s decision.

II. Standard of Review

Because the Appeals Council denied review, the Court evaluates the ALJ’s decision as

the final word of the Commissioner of Social Security. Schomas v. Colvin, 732 F.3d 702, 707

(7th Cir. 2013). This Court will affirm the Commissioner’s findings of fact and denial of benefits

if they are supported by substantial evidence. Craft v. Astrue, 539 F.3d 668, 673 (7th Cir. 2008).

Substantial evidence consists of “such relevant evidence as a reasonable mind might accept as

adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 91 S. Ct. 1420, 28

L. Ed. 2d 842 (1971). This evidence must be “more than a scintilla but may be less than a

preponderance.” Skinner v. Astrue, 478 F.3d 836, 841 (7th Cir. 2007). Even if “reasonable minds

could differ” about the disability status of the claimant, the Court must affirm the

Commissioner’s decision as long as it is adequately supported. Elder v. Astrue, 529 F.3d 408,

413 (7th Cir. 2008).

The ALJ has the duty to weigh the evidence, resolve material conflicts, make

independent findings of fact, and dispose of the case accordingly. Perales, 402 U.S. at 399–400.

In evaluating the ALJ’s decision, the Court considers the entire administrative record but does

not reweigh evidence, resolve conflicts, decide questions of credibility, or substitute the Court’s

own judgment for that of the Commissioner. Lopez ex rel. Lopez v. Barnhart, 336 F.3d 535, 539

(7th Cir. 2003). Nevertheless, the Court conducts a “critical review of the evidence” before

affirming the Commissioner’s decision. Id. An ALJ must evaluate both the evidence favoring the

claimant as well as the evidence favoring the claim’s rejection and may not ignore an entire line

of evidence that is contrary to his or her findings. Zurawski v. Halter, 245 F.3d 881, 887 (7th Cir.

2001). The ALJ must provide a “logical bridge” between the evidence and the conclusions. Terry

v. Astrue, 580 F.3d 471, 475 (7th Cir. 2009).

III. Standard for Disability

Disability benefits are available only to those individuals who can establish disability

under the terms of the Social Security Act. Estok v. Apfel, 152 F.3d 636, 638 (7th Cir. 1998).

Specifically, the claimant must be unable “to engage in any substantial gainful activity by reason

of any medically determinable physical or mental impairment which can be expected to result in

death or which has lasted or can be expected to last for a continuous period of not less than 12

months.” 42 U.S. C. § 423(d)(1)(A). The Social Security regulations create a five-step process to

determine whether the claimant qualifies as disabled. 20 C.F.R. §§ 404.1520(a)(4)(i)–(v);

416.920(a)(4)(i)–(v). The steps are to be used in the following order:

1. Whether the claimant is currently engaged in substantial gainful activity;

2. Whether the claimant has a medically severe impairment;

3. Whether the claimant’s impairment meets or equals one listed in the regulations;

4. Whether the claimant can still perform past relevant work; and

5. Whether the claimant can perform other work in the community.

See Dixon v. Massanari, 270 F.3d 1171, 1176 (7th Cir. 2001).

At step two, an impairment is severe if it significantly limits a claimant’s ability to do

basic work activities. 20 C.F.R. §§ 404.1522(a), 416.922(a). At step three, a claimant is deemed

disabled if the ALJ determines that the claimant’s impairment or combination of impairments

meets or equals an impairment listed in the regulations. 20 C.F.R. §§ 404.1520(a)(4)(iii),

416.920(a)(4)(iii). If not, the ALJ must then assess the claimant’s residual functional capacity,

which is defined as the most a person can do despite any physical and mental limitations that

may affect what can be done in a work setting. 20 C.F.R. §§ 404.1545, 416.945. The ALJ uses

the residual functional capacity to determine whether the claimant can perform his or her past

work under step four and whether the claimant can perform other work in society at step five. 20

C.F.R. §§404.1520(e), 416.920(e). A claimant qualifies as disabled if he or she cannot perform

such work. The claimant has the initial burden of proof at steps one through four, while the

burden shifts to the Commissioner at step five to show that there are a significant number of jobs

in the national economy that the claimant can perform. Young v. Barnhart, 362 F.3d 995, 1000

(7th Cir. 2004).

IV. Discussion

Ms. Braden offers three arguments, in support of reversal. She argues that the ALJ erred

at step two in finding many of her impairments to be non-severe; that the ALJ erred at step three

in considering the listings; and the ALJ erred in assessing Ms. Braden’s RFC. The Court finds

that the ALJ erred in finding her Sjögren’s syndrome was not severe at step two and failing to

consider relevant medical evidence in the RFC discussion.

Ms. Braden asserts that the ALJ erred at step two in finding multiple of her impairments

non-severe, and then failing to include symptoms related to those impairments in the RFC. At

step two, the ALJ must determine the severity of the claimant’s impairments. 20 C.F.R.

§404.1520(a)(4)(ii). An impairment is severe if it significantly limits the claimant’s physical or

mental ability to perform basic work activities. 20 C.F.R. §§416.920(c); 416.921(a). According

to 20 C.F.R. § 416.921(b), “basic work activities” means:

The abilities and aptitudes necessary to do most jobs. Examples of these include—

(1) Physical functions such as walking, standing, sitting, lifting, pushing, pulling,

reaching, carrying, or handling;

(2) Capacities for seeing, hearing, and speaking;

(3) Understanding, carrying out, and remembering simple instructions;

(4) Use of judgment;

(5) Responding appropriately to supervision, co-workers and usual work situations; and

(6) Dealing with changes in a routine work setting.

20 C.F.R. § 416.921(b).

At step two, the ALJ found that Ms. Braden’s autoimmune disease, Sjögren’s syndrome,

was a non-severe impairment. The ALJ based this on finding that Ms. Braden was on medication

to treat her Sjögren’s syndrome, and that the record does not reflect any emergency treatment or

ongoing treatment for flare-ups of her Sjögren’s syndrome. (R. 18). Sjögren’s syndrome is an

autoimmune syndrome that causes dry eyes and a dry mouth. It often accompanies other immune

system disorder, such as rheumatoid arthritis and lupus. Sjögren’s syndrome can also cause joint

pain, swelling, stiffness, swollen salivary glands, skin rashes or dry skin, persistent dry cough,

and prolonged fatigue.1 Ms. Braden argues that the ALJ’s indication that her condition is non-

severe shows a lack of understanding of Sjögren’s syndrome.

As an initial matter, it is improper for the ALJ to rely on a lack of emergency treatment in

finding her Sjögren’s syndrome is not severe. See Myles v. Astrue, 582 F.3d 672, 677 (7th Cir.

2009) (finding that it was improper for the ALJ to infer a claimant was not experiencing

significant problems simply because specific treatment was not prescribed). It is illogical to

assume that an impairment must require emergency treatment in order to be severe. Rather, a

severe impairment is one which significantly limit the claimant’s ability to perform basic work

activities. 20 C.F.R. §§416.920(c); 416.921(a). Nowhere in the regulations does it state that an

impairment must require emergency treatment in order to significantly limit one’s ability to

perform basic work activities. The ALJ erred in finding Ms. Braden’s Sjögren’s syndrome was

nonsevere simply because there was no emergency treatment in the record.

The ALJ also erroneously relied on a lack of treatment “for flare ups” in finding her

Sjögren’s syndrome is nonsevere. This shows a lack of understanding for Sjögren’s syndrome

and its treatment. There is no specific treatment for Sjögren’s flares, and the treatment is

continued medication.2 Ms. Braden was already taking Plaquenil and Prednisone in addition to

Celebrex. (R. 711). Plaquenil is the suggested medication for joint pain for Sjögren’s syndrome

not controlled by other medications. She also took Prednisone, which is a short-term option for

both arthritis and Sjögren’s syndrome3, but she could no longer receive steroid injections due to

her other impairments. (R. 1373).

1 https://www.mayoclinic.org/diseases-conditions/sjogrens-syndrome/symptoms-causes/syc-20353216 (last visited

January 12, 2021).

2 https://www.hopkinssjogrens.org/disease-information/sjogrens-syndrome/joint-pain/ (last visited January 20,

2021); http://info.sjogrens.org/conquering-sjogrens/what-is-a-sjogrens-flare (last visited January 20, 2021).

3 https://www.hopkinssjogrens.org/disease-information/sjogrens-syndrome/joint-pain/

The ALJ also asserts that Ms. Braden’s Sjögren’s syndrome symptoms were controlled

with the medication Pilocarpine. (R. 18). However, the record indicates that she had to start

Plaquenil in 2017 due to continued symptoms. (R. 711-15). While Plaquenil improved her

symptoms, the dosage had to be decreased due to increased anxiety and depression while on

Plaquenil. (R. 711, 715, 789, 807, 810). Even while on Plaquenil and noting that it improved her

symptoms, Ms. Braden continued to complain of tenderness and joint pain. (R. 711, 789, 807).

The ALJ’s finding that Ms. Braden’s Sjögren’s syndrome was controlled, let alone by a single

medication, is in error, as the evidence indicates that her symptoms persisted.

In fact, the ALJ ignored large portions of evidence regarding her symptoms related to her

Sjögren’s syndrome. Ms. Braden reported to her physician in June 2018 that she was having

negative side effects to her medication prescribed for symptom relief, and that she could no

longer receive steroid injections for her pain due to her conditions. (R. 1373). The ALJ relied on

both those injections and Plaquenil, the medication to which she was having negative side

effects, to find that her pain was less limiting than alleged. (R. 21). The ALJ provided very little

discussion about her pain, either with regards to her fibromyalgia, her arthritis, or her Sjögren’s

syndrome (all of which have similar symptoms). The ALJ did not discuss further reports of

recurring pain and discomfort that Ms. Braden attributed to her Sjögren’s syndrome. (R. 1373.).

She has gone through multiple medication changes, yet still complained of significant joint pain.

(R. 1373, 1379). Ms. Braden also started pain management treatment in June 2018, including a

referral to physical therapy. (R. 1006, 1012-13). During her first pain management appointment,

Ms. Braden stated that her pain is at an 8/10 on her best days, and at a 10/10 on her worst days.

(R. 1006). She further stated that her symptoms are aggravated by bending, standing, and

activity. (Id.).

The reported aggravation of symptoms and continued pain is critical, as the worsening of

symptoms occurred after the state agency physicians evaluated her claim. The ALJ provided

those state agency physician opinions “considerable weight” (R. 23), and did not consider

subsequent evidence in determining that Ms. Braden’s Sjögren’s syndrome is nonsevere. While

the ALJ mentioned this evidence as part of a string of citations to support his finding that Ms.

Braden’s fibromyalgia and right foot arthritis are less limiting than alleged, he does not discuss

the evidence showing worsening symptoms and pain. This Court is not determining that Ms.

Braden’s Sjögren’s syndrome is a severe impairment. However, the ALJ improperly found it to

be nonsevere without considering all of the evidence in the record.

The ALJ’s errors in discussing Ms. Braden’s Sjögren’s goes hand in hand with his

dismissal of her subjective symptoms regarding her fibromyalgia and right foot arthritis, which

manifest similar symptoms as Sjögren’s syndrome, including joint pain and discomfort. The ALJ

found that Ms. Braden’s symptoms of pain were less limiting than alleged, finding that pain

medication, psychotropic medication, and physical therapy manage her conditions. (R. 21-22).

The ALJ also found that Ms. Braden retains the ability to sit and read, generally gets along with

others, is able to drive, and can count money, organize her bills, pay her bills on time, and

balance a checking account independently. (R. 22). Ms. Braden asserts that the ALJ erred in

evaluating her subjective symptoms.

An ALJ’s subjective symptoms analysis is given special deference so long as the ALJ

explains his reasoning and it is supported by the record. The Court will not overturn an ALJ’s

subjective symptoms analysis unless it is “patently wrong.” Summers v. Berryhill, 864 F.3d 523,

528 (7th Cir. 2017) (internal quotations omitted); Curvin v. Colvin, 778 F.3d 645, 651 (7th Cir.

2015). The claimant bears the burden of demonstrating that an ALJ’s subjective symptom

evaluation is patently wrong. See Horr v. Berryhill, 743 F. App’x 16, 19-20 (7th Cir. 2018). The

regulations require the ALJ to look at a variety of factors in evaluating a claimant’s symptoms,

including the nature and intensity of pain, the effects of his pain on his ability to function, and

daily activities. 20 C.F.R. § 404.1529(c).

The ALJ relies on normal findings related to her “head, eyes, ears, nose, throat, neck,

back, lungs, breasts, heart, abdomen, extremities, pulses, and skin,” as well as a lack of

“musculoskeletal swelling, redness, tenderness, or joint deformity” to discredit the right foot

arthritis and fibromyalgia symptoms. However, none of these normal findings relate to any

symptoms related to fibromyalgia and arthritis in the right foot. Normal findings related to the

head, eyes, ears, etc., do not disprove joint pain or foot pain. Joint swelling or deformity is not a

symptom of fibromyalgia,4 and therefore it is improper for the ALJ to find that a lack of

swelling or deformity discredits Ms. Braden’s testimony of continued fibromyalgia pain. See

Sarchet v. Chater, 78 F.3d 305, 307 (7th Cir. 1996) (“Since swelling of the joints is not a

symptom of fibromyalgia, its absence is no more indicative that the patient’s fibromyalgia is not

disabling than the absence of headache is an indication that a patient’s prostate cancer is not

advanced.”) Joint swelling is also not a necessary symptom of arthritis, as osteoarthritis is non-

inflammatory in nature.5 The ALJ failed to discredit Ms. Braden’s complaints of fibromyalgia

and right foot pain with any medical findings related to either condition. Normal findings related

to her head, eyes, ears, nose, throat, etc., provide no indication that she isn’t suffering from pain

in her right foot or pain related to her fibromyalgia. Moreover, the ALJ improperly found that

Ms. Braden did not have any tender points. (AR 21). In June and August 2016, Ms. Braden was

4 https://www.medicalnewstoday.com/articles/321682#do-i-have-fibromyalgia-or-ra- (last visited January 14, 2021)

(showing that swelling is a symptom of rheumatoid arthritis and not a symptom of fibromyalgia).

5 https://www.pellahealth.org/services/rheumatology/arthritis-non-inflammatory-vs-inflammatory/ (last visited

January 20, 2021).

found to have “multiple fibromyalgia tender points present.” (AR 514, 526). Other medical

records show tenderness in her sternum, lower lumbar spine tenderness, tenderness in multiple

joints, (R. 807, 809). The ALJ erred in discrediting Ms. Braden’s subjective symptoms on the

basis of cherry picked evidence that does not logically relate to her impairments.

Ms. Braden also asserts that the ALJ ignored evidence related to her pain, osteoarthritis,

and gastrointestinal impairments that were added to the medical record after the state agency

medical consultants conducted their review. Ms. Braden began attending pain management,

physical therapy, and began working with a new primary care physician after the state agency

medical consultants reviewed the evidence. (AR 988, 1006-14, 1455-95, 1373-1410). Her pain

management doctor diagnosed her with osteoarthritis in both hips, as well as added chronic pain

syndrome to her already existing diagnosis of fibromyalgia. (AR 1013). The only mention of her

pain management treatment notes in the ALJ’s decision occurs in a citation of multiple medical

exhibits used to support the ALJ’s finding that Ms. Braden’s subjective symptoms were not as

limiting as alleged. (AR 21-22). Yet, after fifteen sessions of physical therapy, she was noted to

have continued pain and tenderness in her lower back, and she had started having new pain and

limited range of motion in her cervical spine. (AR 1461). Her therapist recommended continued

physical therapy and stated that Ms. Braden “requires skilled therapy to reduce signs and

symptoms and improve function.” (AR 1461-62). Moreover, neither the ALJ nor the state agency

physicians discussed Ms. Braden’s gastrointestinal issues as documented by Dr. Brianna Serbus.

Dr. Serbus noted that Ms. Braden’s abdominal and periumbilical pain was worsening, and that

she was experiencing nausea and vomiting. (AR 771-74). Other portions of the medical evidence

showed that Ms. Braden experienced diarrhea, and that her intestinal pain and issues grew worse

when her pain was worse. (AR 44-45, 379, 467-68, 608, 758, 1373). While the exclusion of any

discussion regarding these impairments or limitations on their own may not be enough for

remand, taken all together they indicate that the ALJ did not fully examine all of Ms. Braden’s

impairments or the combined effect they may have on her ability to function.

The ALJ improperly ignored evidence in evaluating Ms. Braden’s Sjögren’s syndrome

and subjective symptoms. On remand, the ALJ must properly weigh the evidence and make a

full and proper analysis of Ms. Braden’s Sjögren’s syndrome and subjective symptoms.

Accordingly, the Court reverses and remands for additional proceedings. The parties are free to

address any remaining issues on remand.

CONCLUSION

For those reasons, the Court REVERSES the Commissioner’s decision and REMANDS

for additional proceedings consistent with this opinion. The Clerk is DIRECTED to prepare a

judgment for the Court’s approval.

SO ORDERED: January 26, 2021

/s/JON E. DEGUILIO

Chief Judge

United States District Court