United States District Court, E.D. Missouri, Eastern Division
KAREN L. HENSON, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
DAVID D. NOCE, District 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 Karen L. Henson under Title II of the Social Security Act (the Act), 42 U.S.C. §§ 401. The parties have consented to the exercise of plenary authority by the undersigned United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). Because the Commissioner's decision is not supported by substantial evidence on the record as a whole, it is reversed.
Plaintiff was born on October 19, 1960. (Tr. 15.) On October 1, 2008, she filed her application for child's disability insurance benefits on October 1, 2008, under Title II of the Act, on the wage earner account of decedent Allen Lang. (Tr. 217.) She initially alleged an onset date of her disability of October 19, 1968 (id.), but amended it to March 7, 1979. (Tr. 148-49). She alleges that prior to the time she attained 22 years of age she was unable to work due to schizophrenia, mood swings, depression, anxiety ("schizoaffective disorder"), trouble with reading and writing, and problems learning ("borderline intellectual functioning"). (Tr. 13, 92, 270.) Plaintiff's application was denied and she requested a hearing before an Administrative Law Judge (ALJ). (Tr. 113-14.)
The ALJ held a hearing on December 21, 2009, and issued a decision unfavorable to plaintiff on March 4, 2010. (Tr. 70-81, 90-94.) The Appeals Council granted the plaintiff's request for review on April 29, 2011 and remanded the case to the ALJ with instructions to: 1) address claimant's amended onset date; 2) address claimant's request to retrieve her 1992 SSI approval file; 3) evaluate claimant's mental health impairments in accordance with the special technique, and document this application with specific findings and an appropriate rationale for each of the function areas; and, 4) evaluate claimant's impairments according to the prescribed sequential process. (Tr. 99-100.)
The ALJ held a second hearing on October 9, 2012 and issued a second decision unfavorable to plaintiff on December 27, 2012. (Tr. 13-22, 29-67.) The Appeals Council denied review on February 4, 2014, and therefore the second decision of the ALJ is the final decision of the Commissioner. 20 C.F.R § 404.984(d).
II. MEDICAL AND EDUCATIONAL HISTORY
An intelligence test was conducted when plaintiff was 14 years old and indicated an overall score of 77. Her educational records from 1975-1978, while she was attending Saint Charles High School, indicated satisfactory or very satisfactory for almost all classes, except math and typing, which were always Cs. She transferred to Wentzville High School where she earned her high school diploma, earning As and Bs. Three credits at Wentzville were labeled as "work study". (Tr. 296-98.)
On March 7, 1979, plaintiff was assessed at Malcolm Bliss Hospital for social services. Plaintiff reported being hospitalized as an alternative living arrangement whenever something does not work out at her current home. She reported being hospitalized several times, the last time being in 1975. (Tr. 322-24.)
Between March 3 and April 4, 1979, plaintiff missed three appointments with her mental health provider at Malcolm Bliss Hospital. On May 9, 1979, plaintiff reported to William Riedesel, M.D., that she wanted to check into a hospital, although she denied having suicidal or homicidal thoughts and she was not decompensating at the time. She was referred to social services for temporary shelter in St. Charles. (Tr. 323.)
On May 18, 1979, plaintiff was diagnosed with depression and saw Dr. Riedesel at Malcolm Bliss Hospital in St. Charles, Missouri, four times through February 11, 1980. On February 18, 1980, plaintiff was diagnosed with adjustment disorder with a depressive mood. Plaintiff missed her appointment on February 25, 1980. (Tr. 316-21.)
On August 18, 1980, the last records from Dr. Riedesel indicate she cannot take medications due to her pregnancy. She was still diagnosed with an adjustment disorder with depressed mood. Plaintiff's records were then transferred to the Crider Mental Health Center. (Tr. 315.)
There are no additional medical records from the time in question, 1978-1982. Plaintiff has provided documentation from Barnes Jewish Hospital, St. Joseph Health Center-St. Charles, Missouri Division of Vocational Rehab, Crider Health Center, and St. Louis Children's Hospital showing an attempt to recover her records, but that these institutions did not retain records for this amount of time. (Tr. 327, 332, 345-49, 352.) Any medical records that were a part of her 1992 SSI approval proceeding appear to have been lost (Tr. 233, 302.)
Plaintiff's records restart on October 9, 2008, when she applied for the Title II benefits at issue in the present case and completed an adult function report. Plaintiff reported not being able to stand easily, and having numbness and weakness in legs and left arm. She asserts she can only take basic care of herself and must have her home health aide assist her on all things. She cannot lift, walk, climb stairs, stand, squat, bend, kneel, use her hands, or reach. (Tr. 255-65.)
On February 4, 2009, Sonjay Fonn, M.D., of Midwest Neurosurgeons reported plaintiff complained of back pain with paresthesias, or a pins and needle sensation, in her legs. He diagnosed her with degenerative disk disease at L5/S1 with a small disc herniation, an abnormal bulge in the lower section of the back. Plaintiff's diabetes is a significant factor in her back problems. Physical therapy was recommended, but she declined, and surgery was not recommended at that time. (Tr. 338.)
On February 12, 2009, plaintiff underwent an annual evaluation of her mental health status. Social worker Deborah Cole and licensed counselor Kristi Peirce reported plaintiff's depression continued, she heard voices, and saw other people "watching over her." She has anxiety and avoids leaving her house and does not like groups. Plaintiff was taking Lorazepam (for anxiety), Invega (for mood disorders), Cymbalta (for fibromyalgia), and Ativan (for anxiety). Plaintiff was diagnosed with schizoaffective disorder, borderline intellectual functioning, and a GAF score of 41. (Tr. 338.)
On February 27, 2009, Dinu P. Gangure, M.D., at Barnes Jewish Behavioral Health-Southeast completed an employment ability assessment and listed plaintiff's diagnosed illnesses as schizoaffective disorder, borderline intellectual functioning, and having a GAF of 41. Over the past year her highest GAF was 45. Plaintiff would be absent from work at least three times each month and would only have fair or poor abilities in all job and personal-social adjustment factors. (Tr. 340-44.)
From February 28, 2010 through August 15, 2012, ten mental health plans were completed by plaintiff. The Barnes Jewish Mental Health department detailed her mental and physical health goals and ways to achieve them. (Tr. 395-402.)
On October 27, 2010, the Barnes Jewish Mental Health department assessed plaintiff's GAF as 50. (Tr. 393.)
On October 3, 2011, Christina Gesmundo, M.D., completed a social security mental health assessment. Plaintiff was diagnosed with schizoaffective disorder. Plaintiff's current and highest GAF score for the past year was 55. Dr. Gesmundo assessed that plaintiff had refractory psychosis with difficulty in reality based thinking. Plaintiff would miss at least three days of work every month and have marked and frequent problems involving daily living, social functioning, concentration, persistence or pace, and repeated decompensations. Plaintiff had only a fair or poor ability in most occupational, performance, or personal-social adjustments. (Tr. 357-61.)
On January 11, 2012, Dr. Gesmundo saw plaintiff for supportive psychotherapy. She continued plaintiff on Haldol (for mania and bipolar disorder), Benadryl (to counteract muscle spasms resulting from the side-effects of her other prescription medications), and Lexapro (for depression). (Tr. 369-70.)
On March 4, 2012, Dr. Gesmundo added Xanax (for depression) to plaintiff's medications.
On April 5, 2012, Dr. Gesmundo increased plaintiff's Lexapro prescription beyond the recommended dosage, because her depressive symptoms without psychosis were continuing. (Tr. 375-76.)
On May 3, 2012, during her psychotherapy appointment, Dr. Gesmundo changed her depression medication from Lexapro to a trial of ...