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Cagle v. Colvin

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

September 8, 2016

CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.



         Plaintiff Charles Alan Cagle brings this action under 42 U.S.C. § 405(g) seeking judicial review of the Commissioner's denial of his application for disability insurance benefits (DIB) under Title II of the Social Security Act, 42 U.S.C. §§ 401, et seq. Because the Commissioner's final decision is supported by substantial evidence on the record as a whole, I will affirm the decision.

         I. Procedural History

         On June 4, 2012, the Social Security Administration denied Cagle's March 2012 application for DIB, in which he claimed he became disabled on April 15, 2008, because of brain injury, social anxiety, lack of concentration and focus, depression, and short term memory loss. After Cagle's application was initially denied, a hearing was held before an administrative law judge (ALJ) on November 6, 2013, at which Cagle and a vocational expert testified. On January 21, 2014, the ALJ denied Cagle's claim for benefits, finding that Cagle could perform work as it exists in significant numbers in the national economy. On May 14, 2015, the Appeals Council denied Cagle's request for review of the ALJ's decision. The ALJ's decision is thus the final decision of the Commissioner. 42 U.S.C. § 405(g).

         In this action for judicial review, Cagle claims that the ALJ's decision is not supported by substantial evidence on the record as a whole. Cagle specifically challenges the ALJ's determination of his residual functional capacity (RFC), arguing that the ALJ improperly weighed the medical opinion evidence of record and failed to include all of his limitations in the RFC. Cagle also contends that the ALJ failed to cite medical evidence supporting the RFC determination and, indeed, that no medical evidence supports the ALJ's RFC findings. Cagle also claims that the ALJ improperly found his subjective complaints not to be credible. Cagle requests that the decision of the Commissioner be reversed and that the matter be remanded for an award of benefits or, alternatively, for further evaluation.

         For the reasons that follow, the ALJ did not err in his decision.

         II. Testimonial Evidence Before the ALJ

         At the hearing on November 6, 2013, Cagle testified in response to questions posed by the ALJ and counsel.

         Cagle was fifty-one years old at the time of the hearing. He is a high school graduate and received no other formal education. (Tr. 33.) He lives in a house with his wife and two-year-old son and is the primary caregiver for his son. (Tr. 44.)

         Cagle worked at Target from June 1995 through April 2008 and was store manager when his employment ended. He has a pension with Target and negotiated a severance package when he ended his employment. After leaving Target, Cagle worked for six months in a temporary position as a small parts assembler. (Tr. 34-36.) He stopped working in January 2010 because of his impairments and because of the inconsistent nature of the work. (Tr. 155.) Cagle testified that he can no longer work because of anxiety and depression. (Tr. 36, 46-47.)

         In 2003, Cagle underwent emergency surgery to relieve pressure on the brain caused by hydrocephalus. An artery was nicked during the surgery. (Tr. 35.) Cagle testified that he experienced problems with concentration, motivation, and exhaustion immediately after his surgery, which caused difficulties with his job; but these problems neither improved nor worsened over time. (Tr. 41.)

         Cagle testified that he currently experiences constant low-grade headaches for which he takes over-the-counter medication. He has not had a serious headache for six or seven months. His physician will not prescribe narcotic medication for his headaches. (Tr. 37, 43.)

         Cagle testified that he experiences problems with anxiety on a daily basis and that his brain “goes extremely fast.” He constantly feels on edge, has no tolerance for the public, does not go out in public, and does not talk on the telephone. He has difficulty with daily activities and with hobbies because his mind races and he cannot maintain focus. (Tr. 41-42.) Cagle testified that his headaches make his anxiety worse. (Tr. 44.) He testified that he also experiences depression, which is manifested through lack of motivation, avoiding family and friends, and general uncertainty. He testified that he also experiences short-term memory problems, especially with schedules, conversations, and daily activities. (Tr. 42-43.)

         Cagle testified that has not seen his psychiatrist for months and was not scheduled to see him until the following year. He testified that he does not need to see his psychiatrist as often as he used to because he was doing better. He takes psychotropic medications, including Seroquel and Cymbalta, but he testified that they make him lightheaded or cause him to faint. (Tr. 39-40, 46.) Cagle testified that his lightheadedness creates difficulty with stooping, kneeling, and crouching. Extreme heat causes him to feel dizzy, disoriented, and weak. (Tr. 48.)

         Cagle testified that he passes out with no warning three or four times a month. He continues to drive. (Tr. 38.)

         Cagle testified that he was examined at Center Pointe Hospital in February 2013 because of his wife's concern regarding his general health and occasional drinking. Cagle testified that he stopped drinking about one year ago. (Tr. 39.)

         As to his daily activities, Cagle testified that his wife leaves for work at 6:00 a.m., after which he and his son awaken. His day is spent caring for his son and trying to take care of household chores such as dishes, laundry, and cleaning. He testified that he sometimes has a short fuse with his son's misbehavior but is fortunate that his son is a “very good boy.” (Tr. 44.) He no longer goes shopping with his wife because he cannot go out in public. He testified that he drives his wife to and from shopping, but stays in the car while she shops. He also drives to his parents' home, which is about thirty-five miles away. Cagle watches a lot of television but does not read because he cannot focus or retain the material. (Tr. 45-46.)

         At the conclusion of Cagle's testimony, the ALJ asked the vocational expert to consider a person of Cagle's age, education, and vocational background, and who had the following limitations:

lift and carry 20 pounds occasionally, 10 pounds frequently; can stand or walk for six hours out of eight, sit for six; can occasionally climb stairs and ramps, never ropes, ladders and scaffolds; should avoid concentrated exposure to extreme heat, all exposure to unprotected heights, and all exposure to moving and dangerous machinery; and he should not operate motorized vehicles as part of his job. . . . [He] is able to understand, remember and carry out at least simple instructions and non-detailed tasks; can demonstrate adequate judgment to make simple work-related decisions; can respond appropriately to supervisors and coworkers in a task-oriented setting where contact with others is casual and infrequent; can adapt to routine, simple work changes; should not work in a setting which includes constant and regular contact with the general public; and should not perform work which includes more than infrequent handling of customer complaints.

(Tr. 50.) The ALJ also instructed the expert to consider that the person required “a sit/stand option where [he] can change position every 30 minutes but would work a total of eight hours sitting, standing and walking with normal customary breaks[.]” (Id.) The expert testified that such a person could not perform Cagle's past relevant work but could perform other work as a mail sorter and as a marker. (Tr. 50-51.)

         III. Medical Evidence Before the ALJ

         Cagle was admitted to the emergency room at Progress West Healthcare Center on January 28, 2008, with complaints of having a headache for forty-eight hours with pain at a level nine out of ten. His history of hydrocephalus, hypertension, and meningitis was noted and his medications were noted to include Inderal, Seroquel, and Klonopin. Physical examination was unremarkable. A CT scan of the brain showed post-cranictomy changes with underlying right frontal tissue loss, and hydrocephalus with similar ventricular size compared to prior studies. Cagle was diagnosed with headache and acute sinusitis and was discharged that same date in stable condition. He was prescribed Vicodin upon discharge. (Tr. 192-212.)

         In May 2008, Cagle was admitted to St. Joseph Hospital West with complaints of chest pain. His history of hydrocephalus was noted, as well as neurosurgical notes indicating that an artery was nicked during related surgery. Cagle reported that he had been reasonably active since that surgery. He reported having no syncopal episodes. It was noted that Cagle had worked at Target for twelve years and was currently looking for another job. He was discharged from the hospital after testing showed that he did not suffer myocardial infarction. (Tr. 219-27, 304.)

         Cagle visited Dr. Matthew Beckerdite on November 13, 2008, who noted that he had not seen Cagle in over one year. Cagle reported having chronic headaches that were gradually worsening. He did not experience any dizziness. He also reported having memory problems. Physical examination was normal. Psychological assessment showed Cagle to have normal mood and affect, as well as normal judgment, thought content, and behavior. No depression was noted. Dr. Beckerdite diagnosed Cagle with anxiety, essential hypertension, hyperlipidemia, and acute sinusitis. Laboratory tests were ordered, and an antibiotic was prescribed. (Tr. 306-07.)

         Cagle went to the emergency room at St. Joseph Hospital West on May 28, 2009, with complaints of recurrent headaches. His current medications were noted to include Dilacor, Tylenol, Seroquel, and Klonopin. A CT scan of the head was unremarkable when compared with previous studies. Cagle was diagnosed with high blood pressure and was discharged. (Tr. 238-59.)

         Cagle returned to Dr. Beckerdite on June 26, 2009, who noted him to have had poor follow up and compliance during the previous year. Cagle reported his hypertension not to be well controlled but that he was feeling well. He reported that being out of work for fourteen months caused anxiety and stress, but that he had improved with Klonopin and Seroquel. Cagle was not depressed. Physical examination was normal. Psychological assessment showed Cagle to have normal mood and affect, with normal behavior and thought content. Dr. Beckerdite diagnosed Cagle with essential hypertension, anxiety, and hyperlipidemia. He adjusted Cagle's medications. (Tr. 308-10.)

         Cagle returned to Dr. Beckerdite in August and reported that decreasing Seroquel rendered him unable to sleep. He reported having memory loss but had no signs of depression. He also reported being nervous and anxious and that he had insomnia. Examination was unremarkable. Dr. Beckerdite noted Cagle to have elevated triglycerides secondary to Seroquel, and he instructed Cagle to continue to taper off the medication. (Tr. 311.)

         On November 9, 2009, Cagle reported to Dr. Beckerdite that he stopped taking Abilify because he was having suicidal thoughts.[1] Cagle had stopped Seroquel about one month prior but now had difficulty with insomnia. He reported having low energy but that he also felt wired, nervous, and on edge. Dr. Beckerdite noted that Cagle no longer saw his psychiatrist. Examination was normal, including neurological and psychological assessments. Dr. Beckerdite diagnosed Cagle with bipolar disorder and Zyprexa was prescribed. He referred Cagle to Dr. Anderson for psychiatric consultation. (Tr. 312.) On November 16, Dr. Beckerdite noted Cagle's bipolar disorder to be improving. Cagle was instructed to continue with his medication. (Tr. 313.) On November 30, Dr. Beckerdite noted that Dr. Anderson restarted Seroquel. Cagle continued to report being anxious and nervous, but psychological assessment was normal. Laboratory testing was ordered. (Tr. 314.)

         Cagle next visited Dr. Beckerdite in May 2010 and reported that his hypertension was not well controlled but that he felt well. He reported having memory loss but no longer suffered from insomnia. Cagle denied any depression. Physical and psychological examination was unremarkable. Dr. Beckerdite continued Cagle on his medications, including Seroquel for bipolar disorder. (Tr. 315-16.)

         Cagle's next visit with Dr. Beckerdite was on January 27, 2011. He reported that he felt well despite poor control of his blood pressure. He was fatigued but did not experience dizziness, weakness, or loss of consciousness. Cagle reported that he had had a headache for ten days and that over-the-counter medication did not help. He reported that he has had intermittent headaches since childhood. Cagle also reported feeling anxious and nervous and having memory loss. Physical and psychological examination was normal in all respects. Dr. Beckerdite prescribed Vicodin for headaches. (Tr. 317-18.)

         Four days later, on January 31, plaintiff went to the emergency room at St. Joseph Hospital West with complaints of having a headache for one week. He reported having similar headaches twice a year, with each lasting about one week. His current medications were noted to include Vicodin, Bystolic, Dilacor, Tylenol, Seroquel, and Klonopin. Cagle was diagnosed with headaches and was discharged. (Tr. 260-79.) On February 3, Cagle reported to Dr. Beckerdite that his headaches were mild and that he was able to function. Dr. Beckerdite referred Cagle to Dr. Anderson for Seroquel management. (Tr. 319-20.)

         Cagle visited Dr. Richard Anderson, a psychiatrist, on March 28, 2011, and reported that his anxiety had worsened and that he does not get out of the house. He also reported his memory to be worsening. Cagle's wife was present and reported that Cagle's anxiety increases the longer he is without a job. Cagle reported that he cannot sleep without Seroquel and that an increased dosage helps him to shut off his brain. He also reported that taking Latuda and Celexa helped reduce his anxiety. Upon review of lab reports, Dr. Anderson instructed Cagle to increase his Celexa, decrease his Latuda and Seroquel, and maintain his Klonopin. Cagle was instructed to return in four months. (Tr. 337.)

         Cagle reported to Dr. Beckerdite on April 4 that he felt well despite not exercising and not adhering to his diet. Cagle denied having any headaches or fatigue. Examination was normal in all respects. Dr. Beckerdite noted that Cagle was being weaned from Seroquel. (Tr. 321.)

         Cagle returned to Dr. Beckerdite on July 19 and reported having headaches with associated sensitivity to light. He reported his headaches to come once a month and to last four or five days. He generally takes over-the-counter medication but takes Vicodin for severe headaches. He requested a refill of Vicodin. Cagle reported being depressed, nervous, and anxious but that Seroquel helped his insomnia. Physical ...

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