United States District Court, Western District of Missouri, Southern Division
ORDER AND OPINION AFFIRMING COMMISSIONER’S FINAL DECISION DENYING BENEFITS
ORTRIE D. SMITH, SENIOR JUDGE UNITED STATES DISTRICT COURT
Pending is Plaintiff’s appeal of the Commissioner of Social Security’s final decision denying her application for supplemental security income benefits under Title XVI. The Commissioner’s decision is affirmed.
Plaintiff’s arguments focus on (1) the ALJ’s resolution of testimony from Dr. Colby Wang, Dr. Sharol McGehee, and Dr. Joseph Cools, and (2) the content of the ALJ’s written decision. The Court’s discussion will focus on facts relevant to these issues, which means the Court will not exhaustively discuss all of the evidence generally, or all of the medical evidence specifically.
Plaintiff was born in September 1994. Her mother filed an application for benefits in August 2011, before Plaintiff turned eighteen. Upon reaching the age of eighteen, Plaintiff filed an application of her own and at some point the two applications were consolidated.
The analytical framework for a minor’s claim differs from the analytical framework for an adult’s claim, but not in ways that matter to the resolution of this case. The issues presented concern the ALJ’s findings based on the medical evidence and the sufficiency of his findings regarding Plaintiff’s residual functional capacity. Neither of these issues depends on differences between an adult’s and a child’s claim.
Plaintiff’s alleged onset date is August 19, 2011, which is also the date her mother filed the initial claim. Before then, she had dropped out of school (during her ninth grade year); the ALJ described her as a good student in middle school who participated in the gifted program, but she dropped out “because there were large groups of people. She said she had difficulty sitting still all day. After missing school for a month after a surgery, she never recovered academically and decided to drop out.” R. at 19. Plaintiff began, but did not complete, home schooling, and “demonstrates little motivation” to obtain her GED. Id. Around this time period Plaintiff also began using illegal drugs (primarily marijuana); there is no suggestion Plaintiff’s limitations are caused by her drug use, but the issue is relevant because Plaintiff’s inconsistent statements on the matter became a factor in assessing her credibility. Id.
In May 2010 – before her alleged onset date – Plaintiff went to Jordan Valley Community Health (“Jordan Valley”) to establish care. There, it was noted that she had a “long history of migraine headaches” and she reported auditory and visual hallucinations that began one month prior. R. at 273. In June, her report expanded to indicate she had been experiencing hallucinations “year(s) ago.” R. at 269. Medication helped resolve Plaintiff’s migraines but reportedly increased the hallucinations. R. at 262, 264. Imaging studies conducted in August revealed no abnormalities. R. at 277. Subsequent visits to Jordan Valley did not address Plaintiff’s mental issues until April 2011, at which time she reported self-treating her condition with marijuana and LSD. R. at 252.
B. Dr. Colby Wang
Plaintiff began seeing Dr. Colby Wang for treatment in May 2011. At her initial visit Plaintiff reported increasing auditory and visual hallucinations, insomnia, and paranoia. No clear diagnosis or treatment is mentioned, but apparently Plaintiff was already taking medication and Dr. Wang issued prescriptions of his own. R. at 285. In June, Plaintiff still reported hallucinations but her mood swings were less pronounced. Dr. Wang noted Plaintiff was not anxious or depressed and that her “paranoia is 97% better.” He diagnosed her as suffering from a psychotic disorder, not otherwise specified and added Risperdal to her medications (which apparently already included Seroquel and Topamax, among others). R. at 284. In July Plaintiff reported she was not hearing voices as much and she was sleeping well. R. at 448.
In August 2011, Plaintiff reported uneven results regarding paranoia, but her hallucinations appeared only occasionally and she believed she could “do things during the day, instead of feeling bad and staying in bed.” During this visit Plaintiff reported that she had a relative who suffered from schizophrenia, and Dr. Wang noted that a diagnosis of schizophrenia needed to be ruled out. In the meantime, Plaintiff’s medication was not changed except for the addition of Invega – a medication used to treat schizophrenia. R. at 283. The following month Plaintiff was sleeping well and she denied sad or depressed feelings; her mother described her as “indifferent.” Dr. Wang discontinued the Invega and started her on Geodon and Trileptal; the former is used to treat schizophrenia and bipolar disorder and the latter is used to treat seizures. R. at 282. However, Dr. Wang did not – during this visit, or ever after – formally diagnose Plaintiff as suffering from schizophrenia. In fact, the note from this visit indicates no EEG was performed. R. at 282. During a visit later that month, Dr. Wang diagnosed Plaintiff as suffering from moderate ADHD, social anxiety disorder, migraine headaches, and bipolar disorder. R. at 281. In October, Dr. Wang’s diagnoses were ADHD, bipolar disorder, and “infrequent migraines.” He prescribed Vyvanse to help with hyperactivity but Plaintiff refused to take it. R. at 280.
In November 2011 Plaintiff was dealing with some physical issues unrelated to her disability claim. Dr. Wang wrote that Plaintiff reported having more energy and was sleeping better, was not feeling depressed or anxious, and the auditory hallucinations were not present (no mention was made of visual hallucinations). Plaintiff’s paranoia was described as “linger[ing]” and present only when she was in the shower or a dark room. R. at 331. In December, Plaintiff’s irritability, paranoia and discomfort around people had decreased. Her headaches were precipitated by not taking her medication. R. at 333.
In January 2012 Plaintiff discussed with Dr. Wang the need for him to complete a Medical Source Statement (“MSS”). It was also during this meeting that Plaintiff discussed (apparently for the first time) that the “zombie apocalypse is ready to begin” and she was “prepared to survive.” Dr. Wang diagnosed her as suffering from migraine headaches (resolved), mild polysubstance abuse, and disassociative disorder not otherwise specified. The Record does not contain a MSS from Dr. Wang from this visit. In February Plaintiff reported difficulty concentrating at work, and Dr. Wang indicated she was suffering from anxiety, insomnia, and visual (but not auditory) hallucinations, and diagnosed her with Bipolar I disorder and generalized anxiety disorder. R. at 335. The following month, Plaintiff reported she was using LSD, Ecstasy, and marijuana; nonetheless, she was “feeling much better” and Dr. Wang described her as “alert, oriented, well appearing female, in no apparent distress” who was “feeling much better except for her sleep.” The diagnosis of bipolar disorder and generalized anxiety disorder remained unchanged. R. at 337. In April Plaintiff reported her “hallucinations and perceptual problems are slowing returning to some extent, ” but Dr. Wang’s diagnoses did not change. He wrote that Plaintiff’s seizures were controlled with medicine, and that she was not suffering from depression, anxiety, or paranoia. He also added lithium and temazepam to her list of medications (the latter to help her sleep). R. at 339-41. Plaintiff stopped using temazepam on her own in June, R. at 346, and in July Plaintiff confirmed she was still using recreational drugs; Dr. Wang’s diagnosis remained bipolar disorder and generalized anxiety disorder. R. at 347. In September Plaintiff reported leaving her job (she had been working part-time at a Wal-Mart since at least February 2012) “because she was hearing people’s thoughts again. She was being mean to the customers. She said that it is dirty there. Bugs crawl everywhere, and ...