Summary: this case involved a PTSD disability claim by a 43 year old female whose PTSD arose from her service in the army in the early 1990’s. This case resulted in a favorable decision.
Claimant: 43 year old female with college education and post-graduate degree
Past work: supply chain logistics in U.S. Army; logistics manager for stateside contractor to military; retail furniture sales; foreclosed house cleaner (work attempt)
Hearing background: this was a hearing scheduled before a very reasonable and compassionate judge in the late summer of 2011. My client had developed PTSD while serving overseas, when she saw war casualties (dead bodies and severely injured soldiers) over an extended period of time. My client sought treatment at the local VA hospital and had treated there continuously since returning home. In addition to her PTSD and depression, my client had a number of physical injuries associated with her military service, including a torn rotator cuff, bilateral carpal tunnel, ankle injuries (requiring surgery) and degenerative disc disease in her spine.
Medical background: most of the medical record consisted of VA records – close to 1,000 pages. There was a supportive psychological consultative evaluation and a minimally supportive physical consultative evaluation. One area of concern – the VA records and the psych evaluation referred to cocaine and alcohol abuse and treatment during the early 2000’s. Although the record suggested that my client was no longer actively abusing drugs and/or alcohol (and she was prepared to testify as such), any reference to substance abuse raises a red flag.
My strategy: I felt that the strongest argument in this case would be to argue that my client’s functional capacity for work has been so eroded by the symptoms of her PTSD and side effects of associated medication that she would not be a reliable employee at any type of job.
Hearing report: the judge opened the hearing by introducing himself, the hearing reporter and the vocational expert witness (who was appearing telephonically). The judge then read an opening statement setting out the issues and accepted the evidence into the record. He then asked me for an opening statement – I focused mainly on the PTSD mental health component of the case. I stressed that my client had a long and consistent work history, that she had been consistent and compliant with her psychiatric and psychological treatment at the VA and that she had tried to return to work unsuccessfully. I noted that she was taking numerous medications both for her mental health condition and for her physical ailments and that these medications caused drowsiness. Finally, I pointed out that the consultative psychological evaluation identified several significant work activity limitations including the “inability to maintain a work schedule” which would appear to preclude all regular employment.
The judge then turned to question the claimant. He began by asking her about her physical issues and about her capacity to perform various physical activities. Interestingly the judge basically reviewed Social Security’s residual functional capacity form (Form SSA-4734-BK) and asked my client for her responses to each of these questions. He did the same thing on the mental health questions (Form SSA-4734-F4).
As the hearing wore on, I got the sense that my client was becoming somewhat agitated and confused with some of the questions. For example, the judge asked a series of questions like these:
Q: how long can you sit before you have to stand up and walk around?
A: 30 minutes
Q: when you take a break, how long do you walk around?
A: 10 to 15 minutes
Q: what is the total number of minutes you can sit during the course of a day?
A: I don’t know – I usually lie down during the day; I have not tried to sit up all day
I felt that some of the answers that my client was giving were not fully responsive to the judge’s questions, so when the judge turned the questioning over to me, I revisited some of these questions to clarify the answers.
Also on my direct, I focused more on the mental health issues, which the judge did not explore fully on his direct examination. Specifically I asked her to describe what it was like to have PTSD and what it was like to be depressed. We also discussed occasional audio hallucinations and her medication side effects.
After my direct, the judge the turned to the vocational witness and asked him to describe and classify my client’s past work. He then asked two hypothetical questions. The first question tracked my client’s responses to the judge’s questions about her physical problems (i.e. the physical functional capacity questions) and the second question tracked the limitations set out in the psychological consultative evaluation:
Question I:
Assume an individual between the ages of 41 and 43, with a high school education and a masters degree.
- she can lift 25 lbs. occasionally and 10 lbs. frequently
- she should avoid overhead lifting over 10 lbs. with her right upper extremity
- she should avoid overhead reaching
- she can walk up to 1/4 mile, then needs to rest 1 – 2 hours
- she can walk a maximum of 1/2 to 1 mile in a day
- she can stand for 10 minutes, then needs to rest for 10 to 15 minutes
- she can stand for a maximum of 2 hours in a day
- she can sit for 1 hour continuously, then needs to stand and walk for 10 to 15 minutes
- she can sit for a maximum of 3 1/2 hours in a day
- she cannot push or pull items over 25 lbs.
- she should avoid repetitive fingering, handling and jobs that require bilateral hand controls
- she should avoid repetitive bending and twisting at the waist
- she should avoid climbing ladders, ropes & scaffolds
- she should use stairs and ramps only occasionally
- she should avoid all hazards in the workplace including dangerous machinery and unprotected heights because of drowsiness, a side effect of her medications
- she should avoid crouching
Q: Could such a person perform the claimant’s past relevant work?
A: No
Q: Could such a person perform any work in the regional or national economy?
A: No, because her total sitting, standing and walking is less than 8 hours
Question II
Assume an individual between the ages of 41 and 43, with a high school education and a masters degree.
- she can sit for 6 out of 8 hours in a day
- she can stand for 5 out of 8 hours in a day
- she can perform occasional fingering and handling
- she can occasionally crouch
- she can lift and carry 20 lbs. occasionally and 10 lbs. frequently
- she cannot manage a rescue or work routines due to her emotional state
Q: Could such a person perform the claimant’s past relevant work?
A: No
Q: Could such a person perform any work in the regional or national economy?
A: No, because work routines and schedules are necessary for every job
Conclusions: I believe that the judge was predisposed to find my client credible because of her long work history and extensive medical record. Her testimony was believable and she came across as sincere and honest. The judge essentially accepted her testimony in full regarding her physical impairments and he accepted the consultative psych evaluation in full regarding her mental impairments. He will issue a favorable decision.