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Scott Reel v. Michael J. Astrue

January 26, 2011

SCOTT REEL, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Catherine D. Perry United States District Judge

MEMORANDUM AND ORDER

This is an action for judicial review of the Commissioner's decision denying Scott Reel's applications for benefits under the Social Security Act. The first application is for disability insurance benefits (DIB) under Title II of the Act, 42 U.S.C. §§ 401, et seq. The second application is for supplemental security income (SSI) benefits based on disability under Title XVI of the Act, 42 U.S.C. §§ 1381, et seq. Section 205(g) of the Act, 42 U.S.C. §§ 405(g), provides for judicial review of a final decision of the Commissioner under Title II, and Section 1631(c)(3) of the Act, 42 U.S.C. § 1383(c)(3), provides for judicial review of a final decision under Title XVI. Reel claims he is disabled due to a psychotic disorder, a bipolar disorder, a liver disorder, and epilepsy. The relevant time period for consideration of Reel's DIB claim is from July 1, 2002, the alleged onset date, through September 30, 2006, the date his insured status expired.*fn1 The relevant time period for his SSI claim is from April 29, 2005, through the date of the ALJ's decision. Because I find that the decision denying benefits was supported by substantial evidence, I will affirm the decision of the Commissioner.

Procedural History

Reel filed his applications for disability benefits on April 29, 2005. Reel's applications were denied initially.*fn2 On September 12, 2007, following a hearing, the ALJ issued a decision that Reel was not disabled. The ALJ found that Reel's alcohol abuse was a material factor in his disability. The Appeals Council of the Social Security Administration (SSA) denied his request for review on July 8, 2009. Therefore, the decision of the ALJ stands as the final decision of the Commissioner.

Evidence Before the Administrative Law Judge

Medical Records

In March 2002, Reel was hospitalized due to hepatic failure, thrombocytopenia, an infected tooth, and hypokalemia. Reel reported having a sore tooth for the previous two weeks for which he took aspirin. Tests revealed an abnormal liver function and the enzymes suggested a combination of an alcohol injury or ischemic changes with a therapeutic aspirin level. Reel appeared alert, oriented, in no acute distress, and neurologically intact. Reel received treatment with significant improvement and was advised not to take aspirin, use alcohol, or smoke. Peter Mackercher, M.D., indicated that a liver transplant would be "considered." Dr. Mackercher released Reel to return to work on April 9, 2002, but told him that he might be exhausted for awhile.

Reel returned to Dr. Mackercher on January 7, 2003, for complaints of a rash. It was noted that Reel continues to smoke and drink, including a "couple of beers" that day. On February 23, 2003, Dr. Mackercher saw Reel for alcohol intoxication. He had abdominal pain and vomited blood. Reel's blood alcohol content level was above a potentially lethal level. Dr. Mackercher advised Reel to avoid pain medication and alcohol because of his liver damage.

On June 5, 2003, John Black, M.D., treated Reel for being drunk. Reel admitted that he was still smoking and drinking, and tests again revealed a high blood alcohol content level. Two days later, Reel was taken to Dr. Phillip Bufford because he had a seizure while in jail. Reel was assessed with an alcohol withdrawal seizure, and he was admitted by Dr. Mackercher for "acute detoxification" later that day. At that time, Reel appeared tremulous with a tonic clonic seizure. Dr. Mackercher diagnosed alcoholism with alcohol withdrawal seizures. Reel left the detoxification against medical advice.

On June 22, 2003, Mark Williams, M.D., saw Reel following a seizure. He diagnosed Reel with alcohol withdrawal and ordered Reel hospitalized after Reel experienced delirium tremens. Lance Lincoln, M.D., started Reel on alcohol withdrawal protocol after diagnosing Reel with alcohol withdrawal. Although Reel was responding well to the treatment, he again decided to leave the treatment early against medical advice.

In July of 2003, Charles Smith, M.D., treated Reel for "passing out." Dr. Smith assessed alcohol abuse and noncompliance. Reel was told not to drive and was prescribed Dilantin. Smith presented to Jamie Pritchard, M.D., on November 22, 2003, stating that he had a history of "stress seizures." Dr. Pritchard noted that Reel smelled of alcohol. Reel appeared neurologically intact and admitted to being out of Dilantin for some time.

Reel did not seek medical treatment again until August 4, 2004. Reel saw Dr. Bufford again after he had a seizure in jail. Reel had stopped taking his Dilantin two weeks prior to his seizure and was advised not to drive for six months. On November 18, 2004, Reel underwent a psychological screening in jail. During the screening, Reel assaulted a guard. Reel exhibited an anxious mood, an inappropriate affect, agitated behavior, and impaired judgment and insight. Reel had no history of any mental health treatment. Donald Vinke, R.N., assessed Reel as acutely psychotic, delusional, and "possible detox." Mr. Vinke assigned a Global Assessment of Functioning (GAF) score of 45.*fn3 On the same day, Reel was admitted to St. Vincent Health System with an exacerbation of psychosis with auditory hallucinations and paranoia, and appeared very irritable and agitated. He exhibited moderate psychomotor retardation, and tests showed that his Dilantin level was subtherapeutic. While there, Reel also had a sonogram of his liver, which revealed a moderate fatty infiltration of the liver. After six days of treatment, Reel was discharged.

On January 17, 2005, Reel was referred to Steve Gaut, M.D., for evaluation.

Reel stated that he was having panic attacks, and that he could not concentrate or sleep. Reel told Dr. Gaut that he had not had a drink for 54 days. He appeared well groomed, with average demeanor, eye contact, psychomotor activity, and speech. Gaut noted that Reel demonstrated logical thought process, full affect, and cooperative behavior. Gaut assigned Reel a GAF score of 48.

R. Stephen Austin, M.D., examined Reel on March 18, 2005. Reel told Dr. Austin that his seizures prevented him from doing his past work setting up mobile homes. Reel complained of anxiety but admitted that he did not take his medications as prescribed. Dr. Austin noted that Reel's attention span remained adequate to read, and Reel appeared alert, oriented, in no acute distress, pleasant, cooperative, and polite, with appropriate behavior and normal psychomotor activity. Reel's memory was normal. Dr. Austin assigned Reel a GAF score of 48 and diagnosed him with psychotic disorder, major depressive disorder, panic disorder, and seizure disorder. Austin prescribed Klonopin and Risperdal and noted that Reel should return in two months, or sooner if needed. On April 7, 2005, Reel reported that was already out of his medications so he was prescribed more. Dr. Austin renewed Reel's prescription for a generic brand of Dilantin on April 29, 2005.

In August of 2005, Reel, with the assistance of friends and family members, completed Social Security Agency forms in connection with his applications for benefits. Reel's wife stated that Reel had six seizures over a two to three year period, and his cousin indicated that Reel had 3 seizures over a 24-month period.

On August 23, 2005, Robert Hudson, Ph.D., a consultative examiner, examined Reel in connection with his applications for benefits. Dr. Hudson reported that Reel appeared cleanly dressed, pleasant, and totally relaxed. Reel walked to the examination by himself. Reel had just been released from jail and reported no behaviors similar to those from November of 2004 since that time, but Reel expressed fear that it could happen again "at random." Dr. Hudson believed that Reel's medication should effectively control any thought disorder symptoms that he experienced, "which presumably he never had much anyway." Reel spoke in either "vague or overly direct terms" and demonstrated a somewhat blunt affect with "unknown mood." Reel's concentration, persistence, and pace were found to be "within normal limits" (WNL).

On August 30, 2005, Stephen Waley, M.D., one of the defendant's medical consultants, reviewed Reel's medical records and concluded that Reel did not suffer from a severe physical impairment, including seizures.

On August 31, 2005, Jay Rankin, another medical consultant for defendant, completed a form called the Psychiatric Review Technique form, to assess Reel's residual functional capacity (RFC) in connection with Reel's application for benefits. Rankin did not examine Reel. Rankin found that Reel suffered from schizophrenic, paranoid, and other psychotic disorders, affective disorder, anxiety-related disorder, and personality disorder. Rankin found Reel had mild restrictions of activities of daily living and mild difficulties in maintaining concentration, persistence, and pace. Rankin found that Reel suffered from moderate difficulties in maintaining social functioning and had no episodes of decompensation. In the Mental RFC assessment, Rankin noted that Reel was only moderately limited in the following areas: the ability to work in coordination with or proximity to others without distraction; the ability to complete a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a persistent pace and without an unreasonable number and length of rest periods; the ability to interact appropriately with the general public; the ability to accept instructions and respond appropriately to criticism from supervisors; and the ability to set realistic goals or make plans independently of others. In all other categories, Reel was rated as not significantly limited. Rankin concluded that Reel was "able to perform work where interpersonal contact is incidental to work performed, e.g. assembly work; complexity of task is learned and performed by rote, few variables, little judgment; supervision required is simple direct and concrete."

Reel went to Dr. Austin on September 26, 2005. He stated that he was not on any medication because he "could not really afford" it. Reel told Dr. Austin that he took Xanax to sleep and had "a lot of bad days" and panic attacks. Dr. Austin noted that Reel's affect and mood were anxious, but Reel appeared alert and oriented and denied having hallucinations. Dr. Austin's diagnosis remained the same except he added "problems with social environment/ occupational/ economic/ access to health care/ legal/ other psychosocial and environmental problems." Dr. Austin assigned Reel a GAF score of 50 and prescribed him Xanax. He also noted that he should consider putting Reel back on Risperdal for his psychotic disorder.

Reel's medical files were reviewed by two SSA medical consultants in connection with his applications for benefits. On December 19, 2005, Alice Davidson, M.D., completed the SSA forms for disability determination. She noted that Reel's impairments were liver disease and alcohol abuse and concluded that his physical impairments "would be rated not severe." On December 28, 2005, Dan Donahue, Ph.D., stated that he reviewed all the evidence in the file and affirmed Rankin's assessment of August 31, 2005.

On December 30, 2005, Reel saw Lauri Patterson, a registered nurse in Dr.

Austin's office, for medication management. Reel told her that he was taking his prescribed Lexapro and Alprazolam, but he could not afford to pick up his Risperdal medication. He also reported six seizures a month, at least one of which was a grand mal seizure. Reel told Patterson that he continued to see things that "are not part of reality," but denied auditory hallucinations. He reported an increase in stress levels and erratic appetite. Patterson described Reel's mood as euthymic and noted that he was alert and oriented with fair eye contact. When told that he needed to see his therapist to comply with his treatment plan, Reel claimed that she had been unavailable.

Reel saw Dr. Austin again on March 3, 2006. Reel reported feeling anxious and stated that he needed to take more than the prescribed amount of medication to control his anxiety. Reel mentioned that he got angry at his wife, so Dr. Austin increased his dosage of Risperdal to control the anger and anxiety. Austin's diagnosis remained the same as before, except that he added "rule out antisocial personality disorder." He assigned Reel a GAF score of 50 and noted that he should continue to see Dr. Gaut.

On July 7, 2006, Reel went to emergency services at Baxter Regional Medical Center and was admitted because of a seizure, alcohol withdrawal, and delirium tremens. Reel was successfully treated with Valium, along with a Haldol and Allopurinal infusion for "vegetation and psychosis." A liver test confirmed alcohol abuse. While in the hospital, Reel was evaluated by a physical therapist and was found to be ambulatory and able to perform all functions of daily living. After a six day stay, Reel was discharged and advised that if he continued his behavior that his likelihood of survival over the next 5 years was less than five ...


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