United States District Court, E.D. Missouri, Northern Division
DAVID D. NOCE, Magistrate Judge.
This action is before the court for judicial review of the final decision of the defendant Commissioner of Social Security denying the application of plaintiff Melissa Anne Story Bates for disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. § 401, et seq., and supplemental security income under Title XVI of that Act, 42 U.S.C. § 1381, et seq. For the reasons set forth below, the decision of the Administrative Law Judge (ALJ) is affirmed.
Plaintiff was born on August 28, 1976. (Tr. 127.) She filed her applications on October 21, 2009, alleging an onset date of June 1, 2007 and alleging disability due to bipolar disorder and acid reflux. (Tr. 127, 134, 171-72.) Her applications were denied initially, and she requested a hearing before an ALJ. (Tr. 11, 68-77.)
On August 14, 2012, following a hearing, the ALJ issued an unfavorable decision. (Tr. 11-22.) The Appeals Council denied her request for review. (Tr. 1.) Thus, the decision of the ALJ stands as the final decision of the Commissioner.
II. MEDICAL AND OTHER HISTORY
On July 19, 2007, plaintiff was admitted to Hannibal Regional Hospital for a psychotic episode at which time she had been hallucinating about her deceased grandparents. She had also recently attempted to run in front of a car and was stopped by family members. She had recently experienced the deaths of two family members and had a controlling husband. She was taking Zoloft, an antidepressant, and it was discontinued. She was started on Carbatrol, used to treat bipolar disorder. She was diagnosed with bipolar disorder, depressed, with psychotic features. She was significantly improved upon discharge on July 24, 2007. (Tr. 223-34.)
Plaintiff was seen at the Arthur Center in Mexico, Missouri, from December 2007 to February 19, 2010 for outpatient treatment for her bipolar disorder. During that period she had many situational stressors and was frequently depressed. She was treated with Depakote, for bipolar disorder, and Lexapro, an antidepressant. (Tr. 243-61.)
On March 18, 2010, plaintiff began treatment with Robert A. Parsonson, D.O., a family practitioner, at Preferred Family Healthcare (Preferred Family) in Hannibal, Missouri. A Psychosocial History/Diagnostic Assessment reported that she wanted her medication adjusted because she could not be around her family or go out and do things. She reported being on edge a lot, wanting to "blow up, " and being very angry. She sometimes had hallucinations of her grandparents' voices. She was diagnosed with Schizoaffective, Bipolar Type Disorder. Dr. Parsonson wanted to rule out Borderline Personality Disorder. She was having moderate to severe family, relationship, and budgeting problems at the time. Her GAF score was 50, indicating "serious" symptoms. (Tr. 333-40.)
Plaintiff saw Dr. Parsonson on March 30, 2010 with complaints of depression, anxiety, irritability, racing thoughts, and hypersomnia. She reported sleeping sixteen hours per day and smoking a pack of cigarettes per day. Dr. Parsonson diagnosed schizoaffective disorder, bipolar type, and gastroesophageal reflux disorder (GERD). He prescribed Lithium, for bipolar disorder, Mellaril, an antipsychotic, and Ranitidine, for GERD. He opined her prognosis was guarded. He assigned a GAF score of 50, and instructed her to return in in one week. (Tr. 347-48.)
In April 2010, a detailed Individual Treatment and Rehabilitation Plan was prepared for plaintiff at Preferred Family. She was assigned a GAF score of 50. (Tr. 341-45.)
On July 21, 2010, plaintiff saw her primary care physician for abdominal pain at which time her husband reported that she had not been taking her psychiatric medication for several weeks. (Tr. 293.)
On May 17, 2010, state agency medical consultant Mark Altomari, Ph.D., completed a Psychiatric Review Technique form following review of plaintiff's medical records. He found, among other things, that plaintiff had moderate limitations in social functioning. Based on these limitations, plaintiff retained the ability to perform short and simple instructions, relate appropriately to coworkers and supervisors in small numbers and for brief periods, adapt to most usual changes common to competitive work, and make simple work-related decisions. (Tr. 266-79.)
By September 23, 2010, plaintiff was compliant with her Lithium. During that time, she tried other medications for schizophrenia, including Zyprexa, Seroquel, and Invega, as well as Fluoxetine, an antidepressant.
On March 23, 2011, plaintiff underwent an annual evaluation at Preferred Family. She reported taking her medications as prescribed although a report stated she had been noncompliant with caseworker meetings. The evaluation stated she displayed "personality disorder traits, including antisocial, borderline, dependent and histrionic tendencies, but appears more immature than actually personality disordered" and that the "hallucinations she reported years ago were likely related to bereavement." (Tr. 456.) The report stated she "avoids employment although appears capable and has worked within the past year with a boyfriend "junking." (Id.) She was assigned a current GAF score of 58, and 59 for the past year, indicating "moderate" symptoms. The evaluation concluded she remained eligible for services due to anxious and impulsive symptoms and the need for psychiatric and supportive care. The five professionals who signed the evaluation stated Dr. Parsonson's diagnosis of schizoaffective disorder was an "eligible" diagnosis. (Tr. 453-59.)
On September 14, 2011, Dr. Parsonson wrote on a prescription pad: "[Plaintiff] is in my care for bipolar disorder. Some days she is so depressed she can't get out of bed. Other days she is irritable and should not be around other people." (Tr. 352.) On April 3, 2012, he wrote on a prescription pad: "[Plaintiff] is in my care for bipolar disorder and should be considered permanently disabled." (Tr. 471.)
On April 2, 2012, plaintiff was seen at Preferred Family for her annual evaluation. The Center had been unable to contact her to schedule her evaluation. She was diagnosed with Schizoaffective disorder, bipolar type and borderline personality. Her current GAF score was 52. (Tr. 499-522.)
On April 25, 2012, Dr. Parsonson completed a Mental Medical Source Statement (MSS). He opined that plaintiff had "moderate" limitations in her ability to understand and remember simple instructions; to make judgments on simple work-related decisions; to understand and remember complex instructions, and to carry out simple instructions. She had "marked" limitations in her ability to carry out simple instructions and her ability to make judgments on complex work-related decisions. Dr. Parsonson opined that she had "moderate" limitations in her ability to interact socially with the public, coworkers, and responded appropriately to usual work situations and to changes in routines work settings. She had "moderate" limitation in her ability to interact appropriately with supervisors. He based his statement on plaintiff's subjective report. (Tr. 487-89.)
On May 30, 2012, plaintiff underwent a psychiatric evaluation under Lyle A. Clark, M.D. She reported not doing very well, sleeping a lot, and feeling depressed and agitated. She weighed 264 pounds. She did not think her medications, Zyprexa, Prozac, and Lithium, were working well. She reported having diarrhea from Lithium and feeling sedated since starting Zyprexa. She had psychotic symptoms, including an altered perception of reality with auditory and visual hallucinations. Dr. Clark believed she described symptoms of Major Depressive Episode. She was assigned a GAF score of 40, indicating major impairment in several areas. Dr. Clark diagnosed severe bipolar I disorder, depressed, with psychotic features; panic disorder with ...