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Murphy v. Colvin

United States District Court, E.D. Missouri, Southeastern Division

August 5, 2016

CAROLYN COLVIN, Acting Commissioner of Social Security, Defendant.



         This action is before this Court for judicial review of the final decision of the Commissioner of Social Security’s finding that Plaintiff Timmothy Murphy was not disabled, and, thus, not entitled to disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401, et seq., or supplemental security income (“SSI”) under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381, et seq. For the reasons set forth below, the decision of the Commissioner will be reversed and the case remanded for further proceedings consistent with this Memorandum and Order.


         Plaintiff, who was born on November 14, 1979, filed his applications for disability insurance benefits and supplemental security income on May 25, 2011, alleging disability beginning July 1, 2009, at age 29. Plaintiff alleged disability due to a wide range of physical impairments including seizures and pain stemming from a car crash Plaintiff experienced in 2001, and psychological impairments including depression, anxiety, bipolar disorder, and posttraumatic stress disorder. (Tr. 279-291.) After Plaintiff’s application was denied at the initial administrative level, he requested a hearing before an Administrative Law Judge (“ALJ”). Such a hearing was twice postponed while Plaintiff obtained counsel, and was finally held on January 10, 2014. By decision dated January 23, 2014, the ALJ found that Plaintiff suffered from the following severe impairments: seizure disorder, degenerative disc disorder, disc bulges, history of lumbar laminectomies, anxiety, depression, posttraumatic stress disorder, bipolar disorder, and a history of polysubstance abuse. However, the ALJ also determined that Plaintiff had the residual functional capacity (“RFC”) to perform certain jobs that were available in the national economy, and was thus not disabled under the Social Security Act. Plaintiff’s request for review by the Appeals Council of the Social Security Administration was denied on May 21, 2015. Plaintiff has thus exhausted all administrative remedies, and the ALJ’s decision stands as the final agency action now under review. On application for judicial review, Plaintiff makes argument only with regard to his mental and psychological impairments, and alleges that the ALJ erred by failing to find his mental and psychological impairments severe and disabling.

         Medical Evidence

         Plaintiff has an extensive medical history dating back to his motor vehicle accident on July 30, 2001. (Tr. 680.) The Court will summarize Plaintiff’s medical records to the extent they are relevant to his instant action for judicial review, and will focus primarily on Plaintiff’s history of mental and psychological treatment.

         Plaintiff initially began mental health treatment following DUI arrests in 1997 and 1998. (Tr. 683.) Plaintiff’s self-reported medical history suggested he began drinking alcohol at the age of twelve and began drinking daily at the age of twenty-two. However, Plaintiff reported to a psychiatrist that he stopped drinking altogether on October 16, 2005, and he attended Alcoholics Anonymous from 2008 to 2010. Plaintiff also admitted to using heroin from the age of 22 until 2005, when he was arrested on heroin-related charges.

         In 2009, Plaintiff received treatment regularly from primary care physician Dr. Kara Fess at Hygienic Institute Community Health Center (“HICHC”). Plaintiff presented to Dr. Fess on January 23, 2009, complaining of panic attacks sometimes accompanied by fainting spells. Plaintiff reported that one such panic attack was triggered by stress Plaintiff endured at work. Dr. Fess ordered a CT and other neurological exams. Plaintiff returned to the clinic in February 2009 and reported anxiety, tingling, and back pain. (Tr. 769.)

         On May 29, 2009, Plaintiff began treatment at North Central Behavioral Health System for substance abuse, where he attended numerous counseling sessions and participated in group therapy, and completed 75 hours of treatment on September 25, 2009. He again presented at HICHC in September 2009 stating that he “had an anxiety attack back in [February] and now needs clearance stating he is ok to return to work.” (Tr. 757.) Plaintiff also reported being “off Xanax” at that appointment, and stated that he was doing well. Id. He presented again in October 2009 for an updated work release, and again reported not having any problems. (Tr. 755.)

         Thereafter, Plaintiff was sent to Continued Care, but was discharged from North Central Behavioral Health System on December 1, 2009, for failing to follow through with recommended substance abuse treatment. Although Plaintiff presented again to HICHC at various times throughout 2010 and 2011, these visits were related to physical symptoms-in several instances, stemming from physical altercations between Plaintiff and others-and Plaintiff’s psychological symptoms were not significantly addressed.

         Plaintiff was seen by Mark Langgut, Ph.D., for a psychological assessment on July 22, 2011. Dr. Langgut described Plaintiff as “fidgety, and initially emotionally guarded.” (Tr. 681.) At the time of Dr. Langgut’s evaluation, Plaintiff was taking Celexa, an antidepressant, but was not otherwise engaged in ongoing mental health treatment. He was also under a prescription for Valium and Dilantin, which were prescribed “by a neurologist in Peru [Illinois].” (Tr. 683.) Plaintiff reported to Dr. Langgut that these medications helped “reduce his depressive symptoms.” Id. Plaintiff also reported to Dr. Langgut his significant history of substance abuse. Dr. Langgut ultimately diagnosed Plaintiff with dysthymic disorder, generalized anxiety disorder, and alcohol and heroin abuse in remission.

         Plaintiff was subsequently seen by Patricia Russell, M.D., on August 6, 2011. Dr. Russell diagnosed Plaintiff with seizure disorder, anxiety, and depression. On February 15, 2013, Plaintiff was evaluated at Big Springs Medical Clinic (“Big Springs”) following convulsions. The treating doctor diagnosed him with sinusitis, migraines, bipolar disorder, and depression and anxiety. (Tr. 880.) Plaintiff reported anxiety during another visit to Big Springs on March 5, 2013, during which visit he reported he was unable to go to Wal-Mart because he felt like he was being stared at. He also reported a poor appetite. (Tr. 877.) Dr. Georgia Jones diagnosed bipolar disorder. (Tr. 878.)

         Plaintiff saw Dr. Jones again at Big Springs on April 9, 2013, and reported an anger episode that had occurred over the weekend involving his father. Dr. Jones saw Plaintiff again on April 30, 2013, and again diagnosed bipolar disorder and noted Plaintiff’s blunted expression. Dr. Jones also reported that Plaintiff was on Vicodin, Dilantin (for seizures), and Celexa at that time, and that he “push[ed] a little for [benzodiazepines] but not too hard.” (Tr. 876.) Dr. Jones noted Plaintiff’s depressed mood during the visit. Plaintiff was also noted to be anxious during a physical exam on September 18, 2013. (Tr. 825.)

         Plaintiff was seen by Sandra Keeling, LPC, at Family Counseling Center in October 2013. (Tr. 831.) Plaintiff reported his history of posttraumatic stress disorder, bipolar disorder, and depression, and also reported severe anger outbursts, explaining that he has “harmed [people]” in the past as a result of these outbursts. Id.

         Finally, Plaintiff was seen at C&S Family Medical by Casey Dement, a physician’s assistant, on November 25, 2013. Ms. Dement-who, according to Plaintiff’s hearing testimony, saw Plaintiff once a month beginning in 2013 and served as Plaintiff’s primary healthcare provider, and refilled his prescriptions for Celexa, Dilantin, and Klonopin-completed a mental Medical Source Statement for Plaintiff. In it, she opined in a checkbox form that Plaintiff suffered marked limitation in six areas: ability to maintain concentration and attention for extended periods; ability to perform activities regularly and within a schedule; ability to work in coordination with or proximity to others without being distracted by them; ability to complete a normal workday and workweek without interruption from psychologically-based symptoms; ability to interact appropriately with the general public; and finally, ability to travel in unfamiliar places or use public transportation. (Tr. 885-86.)

         Consultative ...

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