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Ibrahim v. Berryhill

United States District Court, D. Nebraska

May 21, 2019

NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration; Defendant.


          Laurie Smith Camp, Senior United States District Judge.

         This matter is before the Court on the Motion for an Order Reversing Commissioner's Decision, ECF No. 22, filed by Plaintiff Hamo Murad Ibrahim, and the Motion to Affirm Commissioner's Decision, ECF No. 27, filed by Defendant Nancy A. Berryhill (“Commissioner”). For the reasons stated below, the Motion for an Order Reversing Commissioner's Decision will be denied and the Motion to Affirm Commissioner's Decision will be granted.


         Ibrahim filed for supplemental security income on October 22, 2015. Tr. 11.[1] His claim was denied initially on February 12, 2016, and again on reconsideration on April 4, 2016. Id. He requested a hearing, which was held on November 8, 2017. Id. At the hearing, Ibrahim amended the alleged onset date of disability to October 22, 2015, the application date. Id. The Administrative Law Judge (ALJ) issued a written opinion denying benefits on January 25, 2018. Tr. 8-22.

         An ALJ follows a five-step sequential analysis to determine whether a claimant is disabled. See 20 C.F.R. § 416.920(a). The ALJ must continue the analysis until the claimant is found to be “not disabled” at steps one, two, four or five, or is found to be “disabled” at step three or step five. See Id. Step one requires the ALJ to determine whether the claimant is currently engaged in substantial gainful activity. See 20 C.F.R. § 416.920(a)(4)(i), (b). The ALJ found that Ibrahim had not engaged in substantial gainful activity since the application date. Tr. 13.

         Step two requires the ALJ to determine whether the claimant has a “severe impairment.” 20 C.F.R. § 416.920(a)(4)(ii) & (c). A “severe impairment” is an impairment or combination of impairments that significantly limits the claimant's ability to do “basic work activities, ” 20 C.F.R. § 416.920(a)(4)(ii) & (c), and satisfies the “duration requirement.” 20 C.F.R. § 416.909 (“Unless your impairment is expected to result in death, it must have lasted or must be expected to last for a continuous period of at least 12 months.”). Basic work activities include “[p]hysical functions such as walking, standing, sitting, lifting, pushing, pulling, reaching, carrying, or handling;” “[c]apacities for seeing, hearing, and speaking;” “[u]nderstanding, carrying out, and remembering simple instructions;” “[u]se of judgment”; “[r]esponding appropriately to supervision, co-workers and usual work situations;” and “[d]ealing with changes in a routine work setting.” 20 C.F.R. § 416.922(b). If the claimant cannot prove such an impairment, the ALJ will find that the claimant is not disabled. See 20 C.F.R. § 416.920(a)(4)(ii), (c). The ALJ found that Ibrahim had the following severe impairments: hypothyroidism; major depressive disorder; post-traumatic stress disorder (PTSD); and generalized anxiety disorder (GAD). Tr. 13.

         Step three requires the ALJ to compare the claimant's impairment or impairments to a list of impairments. See 20 C.F.R. § 416.920(a)(4)(iii), (d); see also 20 C.F.R. Part 404, Subpart P, App'x 1 (20 C.F.R. §§ 416.920(d), 416.925 and 416.926). If the claimant has an impairment “that meets or equals one of [the] listings, ” the analysis ends and the claimant is found to be “disabled.” See 20 C.F.R. § 416.920(a)(4)(iii), (d). If a claimant does not suffer from a listed impairment or its equivalent, then the analysis proceeds to steps four and five. See 20 C.F.R. § 416.920(a). The ALJ found that Ibrahim did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments. Tr. 14.

         Step four requires the ALJ to consider the claimant's residual functional capacity[2](“RFC”) to determine whether the impairment or impairments prevent the claimant from engaging in “past relevant work.” See 20 C.F.R. § 416.920(a)(4)(iv), (e), (f). If the claimant can perform any past relevant work, the ALJ will find that the claimant is not disabled. See 20 C.F.R. § 416.920(a)(4)(iv), (f). The ALJ found that Ibrahim had the RFC to perform a full range of work at all exertional levels but with the following nonexertional limitations: Ibrahim was limited to occasional exposure to extreme cold, extreme heat, humidity, hazardous machinery, and unprotected heights. Tr. 14. The ALJ also found that Ibrahim could understand, remember, and carryout simple routine instructions, Tr. 14, and he had no past relevant work. Tr. 21.

         At step five, the ALJ must determine whether the claimant is able to do any other work considering the claimant's RFC, age, education, and work experience. 20 C.F.R. § 416.920(a)(4)(v). If the claimant can do other work, the claimant is not disabled. Id. The ALJ determined that there are jobs that exist in significant numbers in the national economy that Ibrahim could perform, and, therefore, Ibrahim was not disabled from the application date, October 22, 2015, through the date of the decision, January 25, 2018. Tr. 21-22.

         On July 2, 2018, the Appeals Council denied review, and the ALJ's decision stands as the Commissioner's final decision. Tr. 1. On August 8, 2018, Ibrahim filed a Complaint with this Court for judicial review of the agency decision. Compl., ECF No. 1.


         Ibrahim was born in 1966.[4] Tr. 118. He had 5 years of formal education and can read or write little in English.[5] Tr. 119. He suffers from multiple physical issues, but his most severe problems involve his mental health. Tr. 218.

         On October 8, 2015, Ibrahim's primary care provider, John Grandgenett, APRN, concluded Ibrahim had situational depression/anxiety and prescribed Effexor. Tr. 299. On October 22, 2015, Ibrahim filed an application for social security benefits.

         On December 04, 2015, Grandgenett noted Ibrahim had headaches, dizziness, presyncope, chest pains and palpations. Tr. 297. Grandgenett diagnosed anxiety and prescribed Lorazepam. Tr. 450.

         On January 11, 2016, consultative examiner Dr. Barbara Eckert conducted Ibrahim's consultative mental health exam ordered by Social Security. Tr. 320-23. Dr. Eckert noted Ibrahim's symptoms of anxiety include worrying, restlessness, and irritability. Tr. 321. Ibrahim described to Dr. Eckert his depression over the two prior weeks as an 8 or 9 out of a ten-point scale and indicated his depression day to day was unpredictable. Tr. 321. Dr. Eckert noted that Ibrahim reported sleeping up to 12 hours or not at all and waking up frequently. Tr. 321. Ibrahim reported having “scary” dreams or nightmares three times a week and re-experiencing trauma and flashbacks. Tr. 321. Ibrahim felt hopeless and worthless. Tr. 321 He was irritable around his family and worried frequently. Tr. 321. Ibrahim described his current mood as “okay, ” yet Dr. Eckert noted: “[H]is mood is not congruent with his self-report. He appears to be in a depressed mood. He makes no eye contact during the evaluation.” Tr. 321.

         Dr. Eckert noted Ibrahim had no disturbance in perception and denied having auditory hallucinations. Tr. 322. Although Ibrahim stated he might have some visual hallucinations, Dr. Eckert concluded he did not appear to respond to internal stimuli. Tr. 322. She addressed his functioning by saying he was able to dress himself and maintain his own hygiene. Tr. 323.

         Ibrahim had memory problems and would forget where items were, such as his glasses when they were in his hand. Tr. 321. Dr. Eckert noted that he might need requests repeated and had trouble with comprehension and memory. Tr. 321. Dr. Eckert found Ibrahim appeared to have moderate difficulty with sustained concentration for the interview. Tr. 323. Dr. Eckert found Ibrahim might need extra time to complete tasks and would be unable to keep up in a fast-paced environment. Tr. 323. Dr. Eckert further found Ibrahim might need additional supervision and time to carry out short and simple instructions under ordinary supervision and, his participation in the interview was indicative of that. Tr. 323.

         Dr. Eckert stated Ibrahim was “oriented times three, ” was able to state the date, and could receive, organize, analyze, remember, and express information appropriately in a conversation. Tr. 322. Dr. Eckert stated Ibrahim was cooperative. Tr. 322. Ibrahim's psychomotor activity was slow, but his thought content was appropriate and adequate; and he had no hallucinations, delusions, or suicidal/homicidal ideations. Tr. 322. Although Ibrahim had difficulty with serial sevens, recalling words, and most tasks, Dr. Eckert estimated Ibrahim had average intelligence. Tr. 322. Dr. Eckert stated Ibrahim's overall cognitive functioning appeared to be in the normal range. Tr. 322.

         On February 10, 2016, at the request of the Social Security Administration, consultative examiner Elizabeth Dayton, D.O., performed a physical examination. Tr. 326-31. Dr. Dayton noted Ibrahim was pleasant and had normal speech and thought content. Tr. 330.

         Ibrahim reported to Dr. Dayton that he was diagnosed with a thyroid disorder in 1992. Tr. 326. He reported that his thyroid condition initially caused him difficulty sleeping, hot flashes, trembling or shaking of his body, and changes in the color of his face and around his eyes. Tr. 326. Ibrahim informed Dr. Dayton that the medications he was taking for his thyroid disorder helped some of his symptoms, but they had not entirely gone away. Tr. 326. Dayton found Ibrahim appeared to be on the correct medicine for his thyroid disease but needed to ensure his medication dosage controlled his symptoms. Tr. 330.

         On March 15, 2016, Ibrahim told Grandgenett that he could not sleep and did not like to be outside if it was sunny. Tr. 446. Grandgenett prescribed Lexapro. Tr. 446.

         On May 21, 2016, Ibrahim's treating therapist, Seth Brown, LIMHP, concluded he had PTSD (diagnosis F43.10). Tr. 364. On the mental status examination, Ibrahim had normal attention, concentration, and memory. Tr. 360. His eye contact was normal, facial expression was responsive, and affect was appropriate. Tr. 361. His speech flow was normal, thought content was appropriate, and organization was logical; he had no preoccupations or hallucinations. Tr. 361. His intelligence was average, and his abstraction, judgment, reality-testing, and insight were all normal. Tr. 361.

         On July 1, 2016, Ibrahim reported being anxious and depressed. Tr. 344. He also reported poor sleep. Tr. 344. Nevertheless, he stated he desired not to take medication for depression or sleep. Tr. 344. Brown instructed Ibrahim to perform relaxation techniques. Tr. 344-47.

         On August 12, 2016, Brown indicated Ibrahim was minimally receptive to relaxation techniques and minimally open to working with a doctor for medication. Tr. 334.

         On October 28, 2016, Ibrahim reported to Grandgenett that he experienced depression, anxiety, and insomnia. Tr. 438. Grandgenett refilled Ibrahim's Lexapro prescription. Tr. 438.

         On January 13, 2017, Brown noted Ibrahim had been somewhat resistant to improving himself physically and appeared to come up with excuses. Tr. 421. Ibrahim agreed to work on relaxation techniques to deal with anxiety. Tr. 421.

         On February 20, 2017, Ibrahim returned to Grandgenett and reported Lexapro helped with his moodiness and anger. Tr. 434. Ibrahim did not report any continued insomnia. Tr. 434.

         On March 3, 2017, Ibrahim told Brown that he was feeling better with medication, although he reported he felt very tired. Tr. 411.

         On March 24, 2017, Ibrahim reported to Brown that he felt better emotionally, but was having difficulty with energy and motivation. Tr. 406. Brown encouraged him to socialize, go ...

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