United States District Court, E.D. Missouri, Northern Division
CECELIA J. PATTON, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
MEMORANDUM AND ORDER
ABBIE CRITES-LEONI, Magistrate Judge.
Plaintiff Cecelia J. Patton brings this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) seeking judicial review of the Commissioner's final decision denying her applications for disability insurance benefits (DIB) under Title II of the Social Security Act, 42 U.S.C. §§ 401, et seq.; and for supplemental security income (SSI) under Title XVI of the Act, 42 U.S.C. §§ 1381, et seq. All matters are pending before the undersigned United States Magistrate Judge, with consent of the parties, pursuant to 28 U.S.C. § 636(c). Because the Commissioner's final decision is not supported by substantial evidence on the record as a whole, it is reversed.
I. Procedural History
Plaintiff applied for DIB and SSI on December 30, 3010, claiming disability because of bipolar disorder, anxiety, diabetes, and hypertension. She alleges a disability onset date of June 30, 2010. The Social Security Administration initially denied plaintiff's applications on March 18, 2011. After a hearing on August 30, 2012, at which plaintiff and a vocational expert testified, an Administrative Law Judge (ALJ) entered a written decision on September 28, 2012, finding plaintiff not disabled because of her ability to perform her past relevant work as well as other work as it exists in significant numbers in the national economy. On March 22, 2014, after review of additional evidence, the Appeals Council denied plaintiff's request to review the ALJ's adverse decision. The ALJ's decision thus became the final decision of the Commissioner. 42 U.S.C. § 405(g).
Plaintiff now requests this Court to review the ALJ's decision, arguing that the ALJ erred by failing to accord controlling weight to the opinion of plaintiff's treating psychiatrist, Dr. Clark. Plaintiff further argues that by discounting Dr. Clark's opinion, the record was devoid of opinion evidence, and the ALJ should have ordered a consultative examination in order to fully develop the record. Plaintiff also contends that the ALJ's assessment of her residual functional capacity (RFC) failed to include the effects of her severe mental impairments, arguing that the ALJ erred by relying on her work history and her role as a mother to find her able to perform work-related activities. Plaintiff requests that the final decision be reversed and the matter remanded for an award of benefits or, alternatively, for further proceedings. For the reasons that follow, the matter is remanded for further proceedings.
II. Testimonial Evidence Before the ALJ
A. Plaintiff's Testimony
At the hearing on August 30, 2012, plaintiff testified in response to questions posed by the ALJ and counsel.
At the time of the hearing, plaintiff was thirty-eight years of age. (Tr. 34.) Plaintiff is married but has been separated from her spouse for two and a half years. Plaintiff has four children, ages twenty, eighteen, thirteen, and five. She lives in her in-laws' house with her five-year-old daughter. (Tr. 35-36.) Plaintiff completed high school and went to college for one semester. (Tr. 37.)
Plaintiff's Work History Report shows plaintiff to have worked as a health aide from the summer of 2008 to June 2010. (Tr. 212.) The care facility at which plaintiff last worked was owned by a family member. Plaintiff was laid off from this job because of missed time from work. Plaintiff testified that she spent a lot of time in the bathroom during working hours because she was sick. (Tr. 38.) Plaintiff testified that she also previously worked as a waitress. (Tr. 39-40.)
Plaintiff testified that she receives treatment for bipolar disorder, anxiety, depression, post-traumatic stress disorder (PTSD), and for nighttime and daytime terrors. Plaintiff testified that her depression affects her about three weeks a month at which time she cannot function and stays in bed. Plaintiff testified that she is unable to take care of household chores such as cooking and cleaning, and is unable to attend to her personal hygiene. Plaintiff's in-laws and twenty-year-old daughter shop for her during these periods. (Tr. 41-42.)
Plaintiff testified that her five-year-old daughter is cared for by the child's father, sister, or grandmother three or four days a week because plaintiff is in bed. Plaintiff testified that she calls to have someone pick up her daughter because she wants to make sure she is taken care of. Plaintiff testified that she worries about her child's safety if she is with someone other than her father or grandmother, and she experiences symptoms of anxiety because of such worry. Plaintiff testified that she has difficulty giving her daughter a bath because of memories of her own childhood experiences. Plaintiff takes a thirty-minute "timeout" after her daughter's bath in order to "get [herself] together." (Tr. 43-44.)
Plaintiff testified that she has nightmares at least three times a week for which she takes medication. Plaintiff testified that she wakes up in a sweat and is usually yelling. Plaintiff often becomes sick when she has a nightmare and usually experiences an upset stomach and crying spells the following day. She experiences nausea, pain, and vomiting six days a week and takes medication to soothe her stomach. Plaintiff has seen specialists regarding her upset stomach. (Tr. 45-46.)
Plaintiff testified that she also experiences flashbacks on a daily basis and remembers things that happened to her, which causes her to feel paranoid and that people are out to get her. During severe episodes, plaintiff goes into the bathroom, turns off the light, and spends time alone crying. Plaintiff feels as though someone is hurting her. (Tr. 47.)
With respect to her bipolar disorder, plaintiff testified that she experiences manic episodes about twice a year that last four or five days. Plaintiff testified that she gets really excited during these episodes, exercises poor judgment, talks in a strange manner, and hears voices. Plaintiff testified that she usually "crash[es] and burn[s] into depression" after such episodes, at which time she experiences severe depression, stays in bed, and has suicidal thoughts. (Tr. 46-47.)
Plaintiff takes medications for her conditions, including Prozac, Geodon, Lamictal, Minipress, Ambien, and Promethazine. Plaintiff testified that she is compliant with her medications. Plaintiff previously took Seroquel but stopped because of weight gain, eye problems, and its lack of effectiveness. (Tr. 51, 54.) Plaintiff testified that she was able to successfully work in the past with her mental impairments because her medications were effective at the time. Plaintiff testified that her depression became more severe after the birth of her daughter, and she was without medication for a year or two afterward. (Tr. 58-60.) Plaintiff then sought treatment with Mark Twain Behavioral Health to restart her medication, but she stopped treatment shortly after starting because of overwhelming depression and her inability to keep up with her appointments. (Tr. 52, 58-59.) Plaintiff testified that she thereafter was hospitalized because of increased depression and thoughts of suicide. At the time of her hospitalization, plaintiff had been without medication for two or three months. (Tr. 57-58.) Plaintiff began mental health care with another facility after her hospitalization. (Tr. 52.)
Plaintiff does not drive. She rides in cars, but only when necessary because she feels a lot of anxiety when in a car - with feelings of paranoia and tightening in her chest. Plaintiff also has difficulty being around people. She becomes anxious and has panic attacks, with tightening in her chest and crying. She hurries and tries to get away from people and locks herself in a bathroom. Plaintiff testified to being presently uncomfortable in the hearing room. (Tr. 49-50.)
Plaintiff testified to previous marijuana use and that she had been charged in the past with marijuana possession. Plaintiff testified that she had smoked marijuana to help calm her stomach, but was told that such use would lead to other problems. Plaintiff had not smoked marijuana for the two months prior to the hearing. (Tr. 54-55.)
B. Vocational Expert Testimony
Jeffrey F. Magrowski, a vocational expert (VE), testified at the hearing in response to questions posed by the ALJ and counsel.
The VE classified plaintiff's past work as a caregiver as medium and semiskilled; as a waitress as light and semi-skilled; and as a cook helper as medium and unskilled. (Tr. 62.)
The ALJ asked the VE to assume an individual of plaintiff's age, education, and work experience and to further assume the person could perform work at any exertional level but could not perform any fast-paced production work or tasks requiring more than superficial contact with the public. The VE testified that such a person could not perform any of plaintiff's past relevant work, but could perform light, unskilled work as a cleaner in housekeeping, of which 2, 000 such jobs exist in the State of Missouri and 200, 000 nationally; as an apparel stocker or checker, of which 1, 000 such jobs exist in the State of Missouri and 100, 000 nationally; and as a laundry or garment bagger, of which 1, 000 such jobs exist in the State of Missouri and 50, 000 nationally. (Tr. 62-63.) The VE testified that the person could perform these same jobs if she were restricted to routine, simple, and repetitive tasks. The VE further testified that a person could perform only parttime work if she was prevented from regularly engaging in sustained work activity for a full eight-hour day. (Tr. 64.)
In response to counsel's questions, the VE testified that a person who was chronically absent from work one or two days a month would likely be terminated if the absences continued. The VE also testified that he was unaware of any "regular jobs" for a person who, in addition to normal customary breaks, would be off task greater than fifteen percent of the day. (Tr. 65-66.)
III. Medical Evidence
Upon referral, plaintiff went to Mark Twain Area Counseling Center on August 11, 2008, for evaluation for psychotropic medication. It was noted that plaintiff had been diagnosed six years prior with PTSD, bipolar disorder, anxiety, and obsessive compulsive disorder and had difficulty remaining on psychotropic medication at that time because of her parents not wanting her to be on medication. Plaintiff was currently taking no psychotropic medication and reported having increased anxiety with worsening mood swings and tearfulness. Plaintiff reported a history of sexual molestation as a child and sexual assault as a teenager. Mental status examination showed plaintiff to be anxious, tearful, sad, and depressed. Plaintiff had good eye contact and demonstrated fair insight and judgment. Plaintiff denied any current intent to harm herself or others. Plaintiff reported having decreased memory and concentration as well as depressed mood. Plaintiff also reported her mood to fluctuate and that she has had racing and obsessive thoughts. Plaintiff reported having panic attacks relating to her thoughts of past abuse and being paranoid about the safety of her daughter. Plaintiff denied any recent use of illicit substances. Dr. Ronald St. Hill diagnosed plaintiff with bipolar disorder, and alcohol and cannabis dependence in sustained remission. A Global Assessment of Functioning (GAF) score of 45 was assigned. Dr. St. ...