United States District Court, E.D. Missouri, Eastern Division
MEMORANDUM AND ORDER
THOMAS C. MUMMERT, III, Magistrate Judge.
This action under 42 U.S.C. §§ 405(g) and 1383(c)(3) for judicial review of the final decision of Carolyn W. Colvin, the Acting Commissioner of Social Security (Commissioner), denying the applications of Vickie Buchanan for disability insurance benefits ("DIB") under Title II of the Social Security Act ("the Act"), 42 U.S.C. § 401-433, and for supplemental security income ("SSI") under Title XVI of the Act, 42 U.S.C. § 1381-1383b, is before the undersigned by written consent of the parties. See 28 U.S.C § 636(c).
In May 2009, Vickie Buchanan (Plaintiff) applied for DIB and SSI alleging that she became disabled on June 1, 2000, because of anxiety, depression, and headaches. (R. at 220-22, 223-31, 288.) Plaintiff subsequently amended her alleged onset date to January 16, 2008. (Id. at 258.) Her applications were denied initially and after a March 2010 administrative hearing before Administrative Law Judge ("ALJ") J. Pappenfus. (Id. at 43-57, 69, 70, 95-100.) Two months later, the ALJ issued a decision denying Plaintiff's applications. (Id. at 71-85.) The Appeals Council granted Plaintiff's request for review of the ALJ's decision and remanded the matter to the ALJ, finding the ALJ's assessment of Plaintiff's residual functional capacity ("RFC") to be inconsistent with the performance of Plaintiff's past relevant work as a healthcare provider, as well as inconsistent with the ALJ's findings relating to the severity of Plaintiff's mental impairment. The Appeals Council ordered the ALJ to, inter alia, give further consideration to Plaintiff's maximum RFC and to obtain vocational expert testimony to address the issue of whether Plaintiff could perform her past relevant work or other work as it exists in the national economy. (Id. at 89-93.)
Pursuant to the Appeals Council's directive, the ALJ conducted supplemental hearings in December 2011. (Id. at 58-68, 26-42.) The ALJ then issued a decision again denying Plaintiff's applications. (Id. at 7-19.) The Appeals Council denied Plaintiff's request for review of the ALJ's decision, effectively adopting that decision as the final decision of the Commissioner. (Id. at 1-5.)
Testimony Before the ALJ
Plaintiff, represented by counsel, was the only witness to testify at the March 2010 hearing.
At the time of the hearing, Plaintiff lived in a home with two of her children, ages twenty and twenty-one. She had attended college for two years, received computer training at a community college, and received training as a nurse's aide and in hotel hospitality. (Id. at 46-47, 51-52.)
Plaintiff testified that she was currently depressed, had no energy, and cried all of the time. She stays in bed, does not go anywhere, and does not want to be bothered. She has difficulty remembering things and sometimes questions why she is here. Plaintiff currently sees Dr. Byrd, a psychiatrist at the Crider Health Center, once a month and visits a case manager/social worker three or more times a week. (Id. at 49-50, 55.)
As to her daily activities, Plaintiff testified that she wakes up at 10:00 a.m., gets up to go the bathroom, and then lies back down for the remainder of the day unless she has an appointment. She spends most of the day in bed. She sometimes does the dishes but she does not straighten up around the house or do any heavy cleaning, laundry, grocery shopping, or cooking. Her oldest daughter performs such chores. Plaintiff has no friends and is not visited by any family members. She recently began attending church, but she does not engage in any other activities with the exception of going to clinic appointments. (Id. at 53-54.)
At the first December 2011 supplemental hearing,  Delores E. Gonzalez, M.Ed., V.R.C.,  testified as a vocational expert ("VE").
Ms. Gonzalez classified Plaintiff's past work as a cashier as light and semi-skilled; as an office cleaner as heavy and unskilled; as a psychiatric aide as medium and semi-skilled; as a hotel housekeeper and convenience store clerk as light and unskilled; and as an order picker and prep cook as medium and unskilled. (Id. at 63.)
The ALJ asked Ms. Gonzalez to assume that Plaintiff was limited to medium and unskilled work, to which Ms. Gonzalez responded that Plaintiff could perform her past work as a convenience store clerk, hotel housekeeper, order picker, and prep cook. The ALJ then asked Ms. Gonzalez to assume that Plaintiff was limited to light and unskilled work. She responded that Plaintiff could perform her past work as a convenience store clerk and housekeeper. (Id. at 63-64.)
Counsel asked Ms. Gonzalez to consider the person to also be limited to only occasional contact with coworkers, supervisors, and the general public. Ms. Gonzalez testified that such a person could perform Plaintiff's past work as a hotel housekeeper. Ms. Gonzalez further testified that the person could continue to perform such work if she was limited to less than occasional contact with others, even if such limited contact consisted of less than ten percent per day. (Tr. 64-65.)
Counsel then asked if work was available for a person who would "in a fit of anger berate or go off on a fellow employee or supervisor, " to which Ms. Gonzalez testified that such behavior is usually not tolerated and is a reason for dismissal. (Tr. 65.)
As noted above, Plaintiff testified at the second supplemental hearing.
Plaintiff testified that her eighteen-year-old daughter currently lived at home with her. (Id. at 29.)
Plaintiff further testified that she has difficulty being around people in that she is quickly agitated and gets angry and frustrated. (Id. at 37.) She "gets mad to the point where [she] shake[s]" and urinates on herself. She has not yet told a doctor of these occurrences. (Id. at 40.) She takes medication as prescribed through Crider Center, she has been compliant with her treatment regimen, and continues to see a psychiatrist. (Id. at 33, 39.) She does not see any other counselors. (Id. at 39.)
Also, Plaintiff experiences headaches that awaken her from her sleep. She has not yet told a doctor about the headaches, but had an upcoming appointment regarding the condition. (Id. at 39-41.)
Describing her daily activities, Plaintiff testified that she gets up at 11:00 a.m. and does nothing throughout the day. She does not cook, go grocery shopping, straighten up the house, or do yard work. Sometimes, she does the dishes. Sometimes, she sweeps, mops, or vacuums. She usually lies in bed during the day and either sleeps or stares out into space. (Id. at 34-35.) She used to take a nap once or twice a day, but that she has been napping constantly during the previous two months. (Id. at 35-36.) Her mother occasionally calls, but, with the exception of her daughters, Plaintiff is not in contact with other family members. She has no friends. Approximately one year earlier, she stopped attending church. (Id. at 36-37.)
Medical and Other Records Before the ALJ
When applying for DIB and SSI, Plaintiff completed a Work History Report, disclosing that, on unspecified dates, she worked as a home healthcare provider, a hotel housekeeper, a temporary prep cook at a hospital, an order picker at a warehouse, and a cashier at The Dollar Store. (Id. at 307.)
Her medical records are summarized below in chronological order.
In January 2008, Plaintiff, then thirty-nine years old, was taken to the emergency room at St. Joseph Health Center by her daughter's counselor with reports that Plaintiff was "emotionally stressed." Her admitting diagnosis was depression with psychosis. She also complained of anxiety. Plaintiff explained that her current state was caused by caring for three children and looking for a job. She was very disturbed about her financial issues, and complained of increased insomnia and hopelessness. It was reported that Plaintiff was angry and hostile. On examination, Plaintiff was depressed, anxious, tearful, and in mild distress. She was noted to be cooperative and to maintain good eye contact. She had normal speech and appropriate affect. She denied any suicidal or homicidal ideation. Plaintiff was diagnosed with depressive disorder, not otherwise specified and was assigned a Global Assessment of Functioning ("GAF") score of 35. Plaintiff was given Ativan and Motrin and was discharged that same date in improved and stable condition. She was referred to the Crider Health Center (Crider) for further treatment. (Id. at 415-31.)
In February, Plaintiff saw Dr. James Byrd at Crider, reporting having had depressive symptoms for the past seven to eight years and a history of anxiety. She complained of decreased energy and anhedonia. A mental status examination showed her to have a low mood, flat affect, and limited insight and judgment. She was cooperative and nonthreatening. She put forth poor effort with memory examination. Dr. Byrd diagnosed Plaintiff with major depression with symptoms of anxiety and assigned her a GAF score of 60. He prescribed Celexa, trazodone, and Ativan. (Id. at 566-67.) The next month, Plaintiff reported to Dr. Byrd that the medication had initially helped but she currently felt more depressed. He instructed her to increase her dosage of Celexa and trazodone. (Id. at 565.)
Plaintiff next saw Dr. Byrd on June 4. She was irritable because she had run out of her medications. Plaintiff reported that her main worries were about her finances. Dr. Byrd noted that her sleep and appetite were fair; her mood was sad and low with a congruent affect; her insight and judgment were fair. She was alert and oriented to time, place, and person. She had no hallucinations, delusions, or suicidal or homicidal ideations. She was nonthreatening. Dr. Byrd diagnosed Plaintiff with major depression and anxiety disorder and prescribed Celexa, trazodone, and hydroxyzine. He instructed Plaintiff to discontinue Ativan and to return in four weeks. (Id. at 480.)
One week later, Plaintiff underwent an assessment at Crider for Community Support Services ("CSS"). She reported that she needed help. She was stressed, depressed, had a poor memory, had poor sleep, and had a poor appetite. She did not have any disruptive behaviors such as physical aggression or property damage, but admitted to recently flipping over a glass table because of frustration. Plaintiff further reported that she wanted to work because she needed to pay her bills but was currently unemployed because of too much stress. She did her own shopping and, when she wanted to, prepared her own meals. She enjoyed going to movies and sitting at the park. She read the Bible and watched television on Sundays, but did not attend church because she had not found one that she liked. She had no energy. She cleaned her home when she was angry so that she would not fuss at her children. No perceptual disturbances were noted. Plaintiff was noted to have a good ability to think abstractly and to have fair judgment, but her insight into understanding her mental illness seemed poor. She was diagnosed with major depressive disorder, severe, without psychotic features; and anxiety disorder, not otherwise specified. Her current GAF was assessed as being 45. Multiple recommendations were made, including that Plaintiff apply for social security and Medicaid as well as seek employment. Dr. Byrd reviewed this evaluation and consulted with the treatment team regarding Plaintiff's need for services. (Id. at 483-87.) On June 18, Dr. Byrd noted that disability forms had been prepared for Plaintiff. (Id. at 479.)
On July 2, Plaintiff reported to Dr. Byrd that she was frustrated over situations involving her son and daughter and that her appetite and sleep were off because of stress. She had received her Medicaid card but some of her utilities had been shut off. On examination, Plaintiff was cooperative and alert and oriented to time, place, and person. She was tearful because of her stress. Anhedonia was noted. Her mood was better; her affect was blunted; her insight and judgment were fair. Her diagnosis was unchanged. Plaintiff was instructed to continue with her medications and to follow up with her case worker. (Id. at 478.)
Plaintiff returned to Dr. Byrd on July 30, reporting that she had been hired at Dollar Tree. He noted that she was more positive. Plaintiff reported that was not as depressed and that was not "stay[ing] mad as long." She felt the medications were helping her, and Dr. Byrd noted that she was compliant with her medication regimen. She had a better mood and a brighter affect on examination. She was instructed to continue with her medications. (Id. at 475.)
In September, Plaintiff reported to Dr. Byrd that her car had broken down and that she might quit her job because she would have to walk to work. Also, having a job "cost her the Medicaid." She had missed several doses of medication, but the medications worked when she took them. On examination, she was sad, tearful, frustrated and had limited insight and judgment. She was alert and oriented to time, place, and person. Dr. Byrd noted that Plaintiff would not cooperate. He diagnosed her with major depression, moderate, and anxiety disorder and continued her on her medications. (Id. at 470.) Later that month, Dr. Byrd noted that Plaintiff was in a better mood and euthymic, but she continued to have limited insight and judgment. (Id. at 467.) That same day, her case worker noted that Plaintiff's mood appeared to be a bit unstable during the month with some references to depression. Plaintiff reported being compliant with her medications, but also admitted that she sometimes forgot to take her medications. (Id. at 466.)
Plaintiff returned to Dr. Byrd in October, reporting that the medications were helping. She was compliant with her medications. She also reported that her sleep and mood were better. She wanted to return to her old job. On examination, Plaintiff had a bright affect but continued to have limited insight and judgment. Her diagnoses were unchanged. She was to continue with her medications. (Id. at 462.) On that same date, Plaintiff met with a new case worker, Diane Appal, and was upset regarding the change and "expressed such [with] vulgarity." It was noted that ...