United States District Court, W.D. Missouri, Southwestern Division
NANETTE K. LAUGHREY, District Judge.
Before the Court is Plaintiff Paula Cornell's appeal of the Commissioner of Social Security's final decision denying her application for disability insurance benefits and supplemental security income under Titles II and XVI of the Social Security Act. [Doc. 8]. For the following reasons, the Commissioner's decision is reversed and remanded for further consideration consistent with this Order.
Plaintiff was born in June 1963 and has a high school education. Plaintiff alleges she became disabled on June 1, 2010, due to degenerative disc disease in her back, chronic obstructive pulmonary disease (COPD), bilateral shoulder pain with particular pain in her right shoulder, diverticulosis, bipolar disorder, anxiety, panic attacks, and depression. [Tr. 33, 173].
A. Medical History
Plaintiff has numerous medical records documenting complaints of back pain and symptoms related to COPD, but because the focus of Plaintiff's appeal relates to the ALJ's assessment of Plaintiff's mental impairments, the Court will only summarize Plaintiff's mental health history.
Plaintiff stated that she has been anxious all her life. [Tr. 435]. In September 2009, Plaintiff reported no desire to do anything and insomnia, but denied that she was bipolar or suicidal. [Tr. 242]. She was diagnosed with depression and anxiety and prescribed Depakote. Id. In April 2011, Plaintiff complained of being very emotional and having bad thoughts, but not thoughts of self-harm or harming others. [Tr. 393]. Plaintiff requested Cymbalta to help her sleep at night because she couldn't "turn off [her] head to get any sleep." Id. She was diagnosed with depressive disorder. Id. In June and September 2011, Plaintiff reported increased insomnia and feelings of anxiety, and was diagnosed with anxiety. [Tr. 397, 557].
In November 2011, Plaintiff began mental health treatment with Vera Vitt, APRN. Plaintiff reported nervousness, crying spells, negativity, insomnia, poor concentration and memory, loss of appetite, distractibility, hopelessness, racing thoughts, and fear of death. [Tr. 421]. Nurse Vitt observed that Plaintiff was on time for her appointment, had an unremarkable appearance, and was cooperative and oriented. Her affective reactions were generally flat, she had depressed mood with flat affect, and her thought processes were tangential and required some redirection and control. Id. Nurse Vitt diagnosed Plaintiff with bipolar disorder, dysthymic disorder, health-related stress, and anxiety and prescribed Ambien, Neurontin, Elavil, and Xanax. [Tr. 422]. At a later appointment in November, Plaintiff reported that her medications were helping. In December 2011, she felt moody and Nurse Vitt adjusted her medications. Nurse Vitt observed that Plaintiff had a neat appearance, was pleasant, had a flat, blunted affect, and had circumstantial thought content. [Tr. 419].
In January 2012, Plaintiff was treated by Scott Gordon, M.S., a licensed psychologist. From January to September 2012, Mr. Gordon treated Plaintiff fourteen times. [Tr. 424-37]. Throughout this time, Plaintiff's primary documented complaints related to getting along with her parents - who she lived with - her daughter, and siblings. She did not feel they appreciated or needed her. Id. She also stated that her back pain made her irritable and anxious. During multiple sessions, Plaintiff reported difficulty sleeping [Tr. 426, 431, 437]. She also felt stressed and questioned why she was "still here."
In January 2012, Plaintiff requested an emergency appointment with Mr. Gordon. She was having a panic attack. [Tr. 436]. Dr. Gordon wrote that Plaintiff had "some irrational depressive thoughts and anxiety regarding not feeling needed." Id. In January 2012, during an appointment with Nurse Vitt, Plaintiff reported difficulty with her parents and that she was babysitting two small children. She stated that she felt irritable and anxious. [Tr. 18]. Nurse Vitt observed that Plaintiff was neatly dressed, pleasant, had a flat and blunted affect and circumstantial thought content. Id. In April 2012, Plaintiff babysat her grandchildren, but said the situation was stressful. [Tr. 433]. In May 2012, Mr. Gordon noted that Plaintiff "very depressed asked, Why am I here?" [Tr. 432]. Nurse Vitt noted that she was disheveled and disorganized, had a flat affect, and circumstantial thought. [Tr. 417]. In June 2012, Plaintiff reported to Mr. Gordon that she continued to have problems with her family and tension with her boyfriend. [Tr. 431]. In July 2012, Plaintiff reported feeling anxious because her mother was in the hospital with heart complications and feeling "smothered, trapped" because her parents required her to do too many chores. [Tr. 428-29]. Nurse Vitt observed that Plaintiff was positive and happy, had a neat appearance, appropriate affect, and circumstantial thought content. [Tr. 416]. In August 2012, Plaintiff told Mr. Gordon that she joined the YMCA. [Tr. 426]. She reported problems with her friend and with her sister. Id. She broke up with her boyfriend. [Tr. 425]. In September 2012, Plaintiff told Nurse Vitt that she was "not doing well" because she was upset with her mother. She was babysitting the neighbor's children and exercising at the YMCA. [Tr. 415]. She reported sleeping well. Nurse Vitt observed that Plaintiff had good communication and eye contact, was neatly dressed, pleasant, had an appropriate affect, had logical and coherent thought content, good energy, and a stable mental status. Id.
On November 7, 2012, Mr. Gordon completed a Medical Source Statement-Mental. Mr. Gordon opined that Plaintiff was not significantly limited in four areas, moderately limited in six areas, markedly limited in eight areas, and extremely limited in one area. [Tr. 439-40]. On November 9, 2012, Nurse Vitt completed a Medical Source Statement-Mental. Nurse Vitt opined that Plaintiff was not significantly limited in any areas of mental functioning except the ability to travel in unfamiliar places or use public transportations, for which she was moderately limited. [Tr. 496-97]. Nurse Vitt stated that Plaintiff "is able to do general work. Job training should be necessary. Mood and depression... controlled by medication." [Tr. 497].
B. ALJ's Decision
After a hearing, the Administrative Law Judge (ALJ) found that Plaintiff suffered from the following severe impairments: degenerative disc disease of the lumbar spine, non-displaced fracture humeral head right shoulder, COPD, obesity, bipolar disorder, dysthymic disorder, and anxiety. [Tr. 13]. The ALJ determined Plaintiff had the residual functional capacity (RFC) to perform light work. She can lift and carry twenty pounds occasionally and ten pounds frequently. She can stand, walk and sit for six hours in an eight-hour workday if she is allowed to change positions at will every thirty minutes. She cannot climb ladders, ropes, or scaffolds. She can occasionally stoop, kneel, crouch, crawl, and push and pull with her right arm. She should avoid dusts, fumes, odors, and gases. She is capable of simple, routine, repetitive, unskilled work tasks with occasional contact with the public, coworkers, and supervisors. [Tr. 15].
In making this conclusion, the ALJ gave "great weight" to the opinion of Nurse Vitt because it was consistent with the evidence of the record. [Tr. 21]. The ALJ gave Mr. Gordon's opinion "some weight" because he was not an "acceptable medical ...