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Pupic v. Colvin

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

August 29, 2016

EDIN PUPIC, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM AND ORDER

          AUDREY G. FLEISSIG, UNITED STATES DISTRICT JUDGE

         This action is before the Court for judicial review of the final decision of the Commissioner of Social Security finding that Plaintiff Edin Pupic was not disabled and, thus, not entitled to disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401-434, or supplemental security income under Title XVI of the Act, 42 §§ 1381-1383f. For the reasons set forth below, the decision of the Commissioner will be affirmed.

         BACKGROUND

         Plaintiff, who was born on September 14, 1961, filed applications for disability benefits and supplemental security income on February 27, 2012, alleging a disability onset date of September 27, 2011, due to both mental and physical impairments. His alleged mental impairments included post-traumatic stress disorder (“PTSD”), severe depression, and insomnia.[1] The Social Security Administration denied Plaintiff's claims on April 25, 2012, and Plaintiff filed a request for a hearing before an administrative law judge (“ALJ”). Following a hearing on May 9, 2013, the ALJ issued a written decision on September 4, 2013, denying benefits. Plaintiff requested review of the ALJ's decision by the Appeals Council; the request was denied on February 5, 2015. Thus, the decision of the ALJ stands as the final decision of the Commissioner. See Sims v. Apfel, 530 U.S. 103, 107 (2000).

         Plaintiff argues that the ALJ's decision is not supported by substantial evidence in the record as a whole. Specifically, Plaintiff argues that the ALJ failed to fully describe how medical and other evidence supported the ALJ's determination of Plaintiff's residual functional capacity (“RFC”); failed to consider all of the relevant evidence in determining Plaintiff's RFC; and failed to give proper weight to the opinion of Plaintiff's therapist and licensed clinical social worker, Helen McGlynn, Ph.D., whom Plaintiff admits is not an “acceptable medical source, ” as defined in the Commissioner's regulations.[2]

         Work History and Application Forms

         Plaintiff represented on his application forms that he worked from 1999 to 2006 as a supervisor for a cleaning service, and from 2006 to 2011 as a long-distance truck driver. He indicated that he stopped working on September 27, 2011 because of his conditions. (Tr. 155-56.) Plaintiff also indicated that his primary language was Bosnian and that he could not read or write much in English.[3] (Tr. 161.)

         On a third-party Function Report dated March 16, 2012, and completed by Plaintiff's daughter, with whom Plaintiff lived at the time, Plaintiff's daughter described Plaintiff's typical daily activities as getting up in the morning, taking his medicine, having coffee with his daughter, and otherwise being uninterested in doing anything unless his daughter took him somewhere. (Tr. 162.) Plaintiff's daughter reported that Plaintiff's conditions affected his sleep; that although Plaintiff was able to maintain personal care and complete some yard work, he did not want to do these things alone; and that his conditions affected his concentration, memory, understanding, ability to follow instructions, and ability to get along with others. (Tr. 163-68.)

         Medical Records

         On February 15, 2012, Plaintiff presented to Places for People, a mental health organization, for an initial psychiatric evaluation with licensed psychiatrist Mirela Marcu, M.D. Plaintiff was accompanied by his wife and an interpreter. Plaintiff, a Bosnian war survivor who had been physically beaten and emotionally tortured during the war, reported that he had flashbacks of the war at least two to three times per week, elicited by various triggers from the environment. Plaintiff reported hearing voices, especially the voice of a friend who was killed during the war, and being depressed, with symptoms including decreased pleasure and interest, poor sleep, and intrusive thoughts. (Tr. 214.) In a mental status examination, Dr. Marcu indicated that Plaintiff was cooperative and pleasant, but that he had a depressed mood. Dr. Marcu recorded that Plaintiff had no suicidal or homicidal ideations, but she noted the presence of auditory hallucinations and paranoid delusions. She indicated that Plaintiff had good insight and judgment, and a goal-directed thought process. Dr. Marcu diagnosed Plaintiff with PTSD and severe major depressive disorder. She prescribed Cymbalta and Klonopin, and referred Plaintiff to therapy. Dr. Marcu also assigned Plaintiff a Global Assessment of Functioning (“GAF”) score of 40.[4] (Tr. 218.)

         Plaintiff returned to see Dr. Marcu on March 7, 2012, accompanied again by his wife and an interpreter. He reported improvement; he was less anxious, felt less hopeless and worthless, and had better sleep and an improved mood. However, Plaintiff also reported still feeling isolated, being easily startled, hearing voices, and feeling like someone was “on [his] back.” Dr. Marcu noted that Plaintiff was pleasant and had clean clothes, normal speech, and fair insight and judgment. On this visit, Dr. Marcu diagnosed Plaintiff with PTSD and psychosis, and added Abilify to Plaintiff's prescribed medication. (Tr. 220.)

         On March 8, 2012, Plaintiff underwent an initial assessment with Dr. McGlynn, a therapist at the Center for Survivors of Torture and War Trauma.[5] Plaintiff reported that he had been in a truck accident several months before, when he was driving his truck in the rain. (Tr. 266-69.) Plaintiff reported that he saw his “dead friend” on the seat next to him at the time of the accident. (Tr. 307-08.) Plaintiff indicated he was fired from his job after the accident. Plaintiff also reported hallucinations, such as frequently hearing his deceased friend's voice and seeing white mice. Dr. McGlynn assessed Plaintiff's GAF score as 38. Dr. McGlynn reported that Plaintiff's general appearance, motor activity, affect/mood/attitude, thought content and process, orientation, insight, and judgment, were all within normal limits, and she recorded no suicidal ideation. (Tr. 266-69.)

         Plaintiff engaged in weekly psychotherapy with Dr. McGlynn through the end of March 2012. They discussed improving his poor sleep and reducing the hallucinations of his deceased friend. Dr. McGlynn reported that Plaintiff appeared well-groomed and was cooperative but depressed. (Tr. 303-06.)

         Plaintiff returned to see Dr. Marcu on April 11, 2012, again attending his appointment with a family member and an interpreter. At this time, Plaintiff reported some improvement in his anxiety and depression, but he again reported poor sleep and appetite, stating that he lost 15 pounds in the last two months. On mental status examination, Dr. Marcu observed that Plaintiff appeared disheveled, tired, and unshaven. Dr. Marcu noted that Plaintiff's speech was soft and he exhibited a depressed and constricted affect. Plaintiff still had no suicidal or homicidal ideations, but he continued to talk to his deceased friend, whom he stated died in his arms during the war.

         Plaintiff saw Dr. McGlynn for six more psychotherapy sessions between April 12, 2012 and June 13, 2012. (Tr. 293-300.) On April 17, 2012, Plaintiff reported that Cymbalta was helping him and that Abilify helped to calm him, but that he still could not sleep. Dr. McGlynn observed that Plaintiff appeared disheveled, depressed, and irritable, but she also indicated that he was insightful and she did not indicate that he lacked concentration. (Tr. 299.) On April 25, 2012, Plaintiff stated that he got “panicky when away from home.” (Tr. 298.) Throughout June 2013, Plaintiff continued to report that he saw and spoke with his deceased friend. During these visits, Dr. McGlynn observed that Plaintiff was well-groomed and cooperative but had a depressed mood. (Tr. 293-94.)

         Plaintiff had a follow-up appointment at Places for People on June 27, 2012.[6]During this visit, Plaintiff, accompanied by an interpreter, reported that he was still isolating himself and feeling irritable and pessimistic. However, Plaintiff reported that his anxiety had decreased, and he had no suicidal or homicidal ideations. On mental status examination, Plaintiff's speech, thought process, thought content, insight, and judgment were all within normal limits. Plaintiff was reported to be dysphoric and sarcastic, with poor eye contact and a restricted and irritable affect. Plaintiff was diagnosed with depression and PTSD with psychotic features. His medication prescriptions were continued, and his prescription for Abilify was increased. (Tr. 248.)

         Plaintiff had two more psychotherapy sessions with Dr. McGlynn in July 2012, during which Dr. McGlynn observed that Plaintiff was well-groomed, cooperative, and insightful, but also agitated and depressed. (Tr. 290-92.)

         Dr. Marcu treated Plaintiff again on August 8, 2012. Plaintiff attended the visit with an interpreter, his daughter, a case worker, and a therapist. Plaintiff and his daughter felt that Plaintiff had not made any improvement, but Plaintiff reported that his sleep had improved. Plaintiff also reported continuing to have nightmares, but stated that they occurred less frequently. Plaintiff reported that he was living with his daughter because he could no longer live with his large family. Plaintiff continued to have visual and auditory hallucinations of his deceased friend, and Dr. Marcu observed that Plaintiff was very depressed, was hopeless, and had a constricted affect. Dr. Marcu noted that Plaintiff appeared to be very dysphoric and irritable but that he had fair insight and judgment. Dr. Marcu stated that Plaintiff did not want his medication changed. (Tr. 249.)

         Plaintiff was treated by his general practitioner, Gopy Arumugam, M.D., on August 21, 2012. He reported no feelings of hopelessness and stated that his mood was currently well-controlled with medication. (Tr. 233-35.)

         Plaintiff last saw Dr. Marcu on September 5, 2012. Plaintiff initially stated that he was doing well but later stated that he was ill, did not work, and talked to people that were not there. Dr. Marcu assessed Plaintiff with symptomatic PTSD and continued his medications. (Tr. 250.)

         Plaintiff visited again with Dr. Arumugam on November 9, 2012, at which time he again denied feelings of hopelessness, had a normal appearance and affect, and had a euthymic mood. (Tr. 225-26.)

         Plaintiff continued to engage in regular psychotherapy with Dr. McGlynn from September 2012 to May 2013. (Tr. 273-89.) Plaintiff continued to report seeing his deceased friend and not sleeping well. (Tr. 284, 286, 288.) On February 20, 2013, Dr. McGlynn noted that Plaintiff was “better” and “stable, ” he appeared well-groomed, and was cooperative but had agitated motor activity, had a depressed mood, and still had auditory and visual hallucinations. (Tr. 282.) On March 6, 2013, Dr. McGlynn observed that Plaintiff was well-groomed, relaxed, had a normal mood, and was ...


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