United States District Court, E.D. Missouri, Eastern Division
AARON J. BULLIS, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
MEMORANDUM AND ORDER
E. JACKSON UNITED STATES DISTRICT JUDGE
matter is before the Court for review of an adverse ruling by
the Social Security Administration.
Aaron J. Bullis filed applications for disability insurance
benefits, Title II, 42 U.S.C. §§ 401 et
seq., on November 26, 2012, and supplemental security
income, Title XVI, 42 U.S.C. §§ 1381 et
seq., on December 14, 2012, with an alleged onset date
of August 12, 2011. (Tr. 217-29). After plaintiff's
applications were denied on initial consideration (Tr.
145-51), he requested a hearing from an Administrative Law
Judge (ALJ). (Tr. 152-56).
and counsel appeared for a hearing on January 15, 2014. (Tr.
44- 81). The ALJ issued a decision denying plaintiff's
applications on February 6, 2014. (Tr. 25-43). The Appeals
Council denied plaintiff's request for review on April 3,
2015. (Tr. 1-7). Accordingly, the ALJ's decision stands
as the Commissioner's final decision.
Evidence Before the ALJ
Disability Application Documents
Disability Report he completed on June 23, 2008 (Tr. 243-52),
plaintiff listed his conditions as anxiety, depression, and
schizophrenia, which he stated caused him to be an alcoholic
and see or hear things. He had been employed as a restaurant
manager for almost four years, working 14 hours a day, six
days a week. This was his longest period of employment. His
medications included Lexapro,  Rozerem,  Trazodone,  and
Vistaril. Plaintiff had completed three years of
college as his highest level of education.
Function Report dated July 7, 2008 (Tr. 256-63), plaintiff
wrote that his daily activities included taking medications,
watching television, helping with yard work, laundry, and
house cleaning, eating meals, sleeping, exercise, and going
to bed. He was not responsible for taking care of anyone else
or any pets, although he lived in a house with his family.
Before the onset of his conditions, plaintiff wrote that he
could maintain a job and form relationships with others. His
conditions affected his sleep patterns, causing him to either
have insomnia or oversleep. His personal care was not
affected by his conditions, except that he needed reminders
to bathe and brush his teeth.
prepared his own breakfast and lunch meals, including cereal,
toast, grit, soup, and sandwiches. His parents usually cooked
dinner. Prior to the onset of his conditions, plaintiff
enjoyed cooking and preparing meals for others. His household
chores included mowing the lawn, doing the laundry, and
washing dishes, which he did not need reminders to do. Mowing
took him fifteen minutes to an hour. When going out,
plaintiff either walked or rode in a vehicle with family. He
could not drive since his license had been revoked for
driving while intoxicated. He also could not go out alone
because of his anxiety. Plaintiff infrequently went shopping
to buy clothes. Plaintiff reported that he could not pay
bills, but he could count change and use a checkbook. Since
the onset of his conditions, plaintiff's ability to
handle money had changed in that he made impulsive purchases.
hobbies and interests included fishing, drawing, and reading.
He now generally did everything less often, however. Socially
he attended twelve-step meetings a few times a week by
himself. Plaintiff wrote that his conditions had affected his
memory, concentration, and ability to get along with others.
He often forgot things, was distracted easily, and felt he
could not trust people. Plaintiff could walk a mile before
needing a 10 to 15 minute rest. He could pay attention for 30
minutes to one hour. Plaintiff finished what he started and
followed written instructions fairly well. He did not follow
spoken instructions very well and avoided authority figures.
Plaintiff had never been fired or laid off from a job because
of problems getting along with other people. Plaintiff wrote
that he handled stress very poorly and experienced a
substantial amount of anxiety regarding changes in routine.
He feared unfamiliar places and people, which caused him
nervousness and anxiety. Even after becoming sober, plaintiff
continued to suffer from depression.
Background Reports, plaintiff wrote that he had been
unemployed since November 2008. (Tr. 265-68). Prior to that,
he had worked as a customer service representative for a
marketing company from March 2007 to November 2008. From
January 2005 to September 2006, plaintiff worked in the
kitchen and as front management for a catering company. From
November 1995 to January 2005, plaintiff worked in food
preparation, inventory control, and staff management at
several restaurants or cafes.
Disability Reports plaintiff completed on July 19, 2012 and
November 28, 2012 (Tr. 272-94), he listed his disabling
conditions as “back, ” bipolar disorder,
borderline personality disorder, “knees, ” and
post-traumatic stress disorder. Plaintiff was
5'11'' and weighed 300 pounds. He listed his last
day of employment as January 15, 2009. In a Field Office
Disability Report dated November 26, 2012 (Tr. 282-84), the
interviewer noted that plaintiff talked very slowly and in a
low voice that made it difficult to hear him.
Function Report dated December 4, 2012 (Tr. 295-305),
plaintiff wrote that he lived alone in an apartment. His
daily activities consisted of preparing meals for himself,
attending counseling and doctor's appointments, visiting
family and friends, trying to keep himself and his
surroundings clean, and occasionally grocery shopping. Before
the onset of his conditions, plaintiff wrote that he used to
be able to do many physical and mental activities, including
walking long distances, bending easily at the knees and
waist, attending school, making complex decisions, and paying
attention for long periods of time. Pain affected the quality
and duration of his sleep. He had no problems with personal
care, aside from slight wobbliness getting in and out of the
bathtub. Plaintiff wrote that he needed special reminders to
clean his apartment, shave, and use injections in his back
and knees. The food he prepared daily included sandwiches,
eggs, and potatoes. Since the onset of his conditions, he
wrote that he had become less able to prepare complex or
creative multicourse meals.
regard to house work, plaintiff did his own laundry and
dishes, although he found it difficult to stay motivated to
do these tasks. He went outside daily, drove a car, and could
go out alone. He shopped for fishing gear online, in-person,
and over the phone. It took him longer than average to make
shopping decisions, however. Plaintiff shared a banking
account with his father, who paid plaintiff's bills for
him. Plaintiff's hobbies included collecting knives,
watching television, and spending time with friends. He spoke
with friends on the phone and over the computer on a weekly
basis and took them to the store with him. Plaintiff
regularly went to medical and counseling appointments alone.
He had difficulty maintaining his temper and concentrating on
others' needs. Travel was difficult for him due to
anxiety and fear.
affected plaintiff's ability to lift, squat, bend, stand,
walk, sit, kneel, and climb stairs. He could walk 100 yards
before needing a 5 to 10 minute rest. Plaintiff's mental
difficulties gave him a limited attention span, making it
difficult to remember, complete tasks, concentrate, follow
instructions, and get along with others. He could only pay
attention for 15 to 45 minutes at a time and could not finish
what he started. Plaintiff did not follow written
instructions well and repeatedly needed to refer back to
instructions. He also had difficulty following oral
instructions. In this report, plaintiff wrote that he had
been fired or laid off from a job because of problems getting
along with others-“too many [times] to count, over and
over again, ” citing his library job, his catering
company position, and a security job.
wrote that he handled stress “okay, ” but handled
changes in routine poorly. Night driving scared him. He
indicated that he used a cane, brace or splint, and glasses.
In a supplemental questionnaire, plaintiff wrote that he
could use a computer and listen to music for a few hours at a
time. He stated that his condition had not improved since his
first application for benefits.
Function Report dated December 14, 2012 (Tr. 306-16),
plaintiff listed his daily activities as grooming, preparing
quick and simple meals, picking up groceries, doing the
dishes and laundry, ordering medications, going to counseling
appointments, and watching television. Prior to the onset of
his conditions, plaintiff wrote that he was able to stand,
walk, run, pay attention, and engage in complex tasks for a
period of time. His conditions affected the duration and
quality of his sleep. He did not have problems with his
personal care, except for getting in and out of the shower.
Plaintiff needed repeated, verbal reminders to shave, unload
the dryer and dishwasher, and take or reorder his
wrote that he formerly was a confident chef, but now was
afraid to use a knife. He would “get lost in a
task” and forget what step he was on with house work.
(Tr. 308). When cooking, he repeatedly needed to look back at
recipes. His girlfriend reminded him to finish the laundry
and rinse dishes. Plaintiff went outside daily, drove a car,
and could go out alone. He shopped for camping and fishing
gear, knives, clothes, and groceries in-stores and online.
Plaintiff shared a joint banking account with his father, and
only independently paid for gasoline for his car and
cigarettes. He felt overwhelmed by his bills. Reading, short
walks, television, and spending time with his friends were
his hobbies. He was successful with most relationships. Long
distance travel was “out of the question” for
him. (Tr. 310). Plaintiff interacted with caseworkers and
close friends in-person and on the computer. He regularly met
his parents for Sunday dinner. If family members began
fighting and yelling, he would leave.
stated that he did not get along with his siblings and he had
“no close friends other than doctors, therapists, and
counselors.” (Tr. 311). He was less independent and
more lethargic since the onset of his conditions. Severe
arthritis limited plaintiff physically, and he became
frustrated easily. He could walk 100 to 200 yards before
needing a ten minute rest, and could pay attention for 30 to
45 minutes. Plaintiff did not have any problems with
authority figures, but wrote that he did not
“click” with other employees or managers at
restaurants at which he had worked. (Tr. 312). He used
different coping skills to handle different, stressful
situations. He needed to follow a routine to feel safe and
comfortable. Plaintiff feared driving or riding in a vehicle
for long distances and had “some OCD type
behaviors.” (Tr. 312). He used a cane, but it was not
prescribed by a doctor. He used a brace when his knee
swelled. His arthritis and mental illnesses in combination
made life difficult.
list of medications included Risperidone as an antipsychotic,
Clonazepam and Hydroxyzine for anxiety, Meloxicam for
arthritis pain, Gemfibrozil for cholesterol, Glimepiride and
Metformin for diabetes, Ranitidine for GERD, Amlodipine,
Hydrochlorothiazide, Lisinopril, and Metoprolol for high
blood pressure, Clonidine for both high blood pressure and
anxiety, Divalproex Sodium as a mood stabilizer, Gabapentin
and Hydrocodone for pain, Benadryl for sleep, Trazodone for
sleep and depression, and a multivitamin as a supplement.
Testimony at the Hearing
was 39 years old on the date of the hearing and lived alone
in an apartment. (Tr. 52). Plaintiff's father also
attended the hearing. (Tr. 48-49). In an opening statement,
plaintiff's counsel stated that plaintiff lacked the
mental residual functional capacity for work activity as a
result of his mood and personality disorders. Drugs and
alcohol were not material to plaintiff's condition.
Despite plaintiff's sobriety, he struggled on and off
with auditory hallucinations, mood fluctuations, anxiety
attacks, panic attacks, mania, and difficulty sleeping. (Tr.
rent was paid by a grant from the Department of Mental Health
and Barnes-Jewish Hospital. (Tr. 52). Prior to moving into
the apartment, plaintiff had lived at Maple Ridge Residential
Care, because his psychiatrist thought he needed more
structure. He weighed 270 pounds, but had weighed 306 pounds
on the date of the onset of his conditions. (Tr. 53). He
gained weight when he was depressed, not eating well, and not
exercising. Plaintiff had recently undergone lap-band surgery
to lose weight.
had a driver's license, but only drove short distances.
(Tr. 54). He was too anxious and nervous to be in a vehicle
for very long. His father drove him to the hearing. Plaintiff
had an associate's degree. He did not complete his
bachelor's degree due to low self-esteem. (Tr. 55).
Plaintiff testified that he last worked as a cook at a
restaurant in 2008. He worked there for six months before he
was fired. (Tr. 56). His previous job at a marketing company
had ended due to a combination of alcoholism and frustration.
Plaintiff had also been fired from another job as an
associate chef at a restaurant. A retail job ended because
the employer did not have any hours available for plaintiff
to work. (Tr. 57). At one point, plaintiff worked as many as
three jobs at the same time. (Tr. 58). At a café he
managed kitchen staff and learned Spanish quickly. (Tr.
stated that he stopped working because he no longer had the
physical abilities or mental capacity. (Tr. 59). Physically,
his ankles, knees, hips and back bothered him. He also had
difficulty sitting or standing for long periods of time. He
could stand for six to ten minutes before he became dizzy. If
he wanted to bend over and pick up something on the floor, he
would need to use the wall as a brace. (Tr. 60). Plaintiff
could not bend his knees past a certain point. When he went
up or down stairs, plaintiff needed to hold on to both sides
of the railing and take one step at a time. With respect to
lifting, plaintiff could lift no more than half a gallon of
milk. He stated that he had lost muscle tone in his arms and
plaintiff experienced depression, anxiety, and feelings of
isolation. He had had problems with alcohol, but had
experienced months-long periods of sobriety in the past two
years. Plaintiff stated that he cried daily, had very low
energy when he was depressed, and took naps during the day
until he had the motivation to do something. (Tr. 63). On a
typical night, plaintiff slept four to six hours. (Tr. 64).
Other times, he slept for 12 hours straight. Once, during an
anxiety attack, plaintiff was awake for 54 hours. He had
anxiety attacks eight to ten times a month. During these
attacks, his heart raced and the palms of his hands became
sweaty. The attacks lasted until he took his medication. He
felt exhausted after the attacks were over.
general, plaintiff's concentration was poor. (Tr. 65). He
found it difficult to focus during a 30-minute television
sitcom. Twice a week plaintiff went to individual dual
diagnosis treatment and dialectical behavioral therapy. (Tr.
66). He saw a psychiatrist every six weeks. A nurse from
Pyramid Home Health came to plaintiff's house to fill his
medications once a week and a home health aide came three
times a week to do plaintiff's dishes, laundry, and clean
his floors. (Tr. 67). Sweeping or mopping floors caused
plaintiff's back to “tie up in knots.” On a
typical day at home, plaintiff watched television and read
magazines. As a hobby, plaintiff collected knives. (Tr. 68).
He used to do woodcarving, but stopped because it was hard on
his fingers and too tedious for him to pay attention.
questioning by the ALJ, plaintiff testified that he believed
the cause of his physical pain was from being injured in
“a couple of serious car accidents, ” playing
football, and being on his feet 16 hours a day six days a
week as a cook. With respect to the medications plaintiff
took, he stated that some worked and others had side effects.
(Tr. 70). His side effects included sleepiness,
sleeplessness, diarrhea, upset stomach, headaches, and
dizziness. (Tr. 71). Plaintiff had had nine or ten epidural
steroid injections and experienced relief for three to six
months from those injections. Difficulties moving around,
squatting, bending, and walking were his biggest obstacles to
working as a cook. (Tr. 72). Plaintiff stated that he could
not do sedentary work due to the side effects of his
medications, which required him to get up and walk around for
the blood to flow in his legs.
mental impairments caused him to not get along well with
others, including his siblings. He got along well with his
parents. In reviewing plaintiff's work history, the ALJ
noted that plaintiff worked in various food industry jobs
where he was oftentimes the manager. His prior work as an
associate chef, a cook, a security guard at a senior housing
unit, and a kitchen manager were done in a standing position,
and most of them were done at the light exertional level with
regard to lifting. (Tr. 74, 76-77).
expert Tyra A. Bernard-Watts, Rh. D., C.R.C., characterized
plaintiff's past relevant work as he performed it and as
it was generally performed. (Tr. 77). Plaintiff's
position as a security guard was semi-skilled at a light
exertional level. His duties as a kitchen manager and cook
were skilled with a light strength level. The ALJ posed a
hypothetical question about the work ability of an individual
who was limited to work at no greater than the light
exertional level, could not climb ladders, ropes, or
scaffolds, could only occasionally climb ramps and stairs,
could only occasionally stoop, crouch, crawl, and kneel, was
limited to simple, routine tasks, must avoid work involving
intense interpersonal interaction, handling complaints of
dissatisfied customers, and close proximity to coworkers.
With those limitations, the vocational expert testified that
such an individual would not be able to perform
plaintiff's past relevant work. However, she opined that
such an individual would be able to perform the duties of a
garment sorter and a slot-tag inserter. (Tr. 78).
second hypothetical question, the ALJ asked Ms. Bernard-Watts
to assume all of the limitations contained in the first
hypothetical, but also to assume that the individual was
limited to sedentary work. Ms. Bernard-Watts testified that
such a person could perform the duties of a weight tester and
a stringing-machine tender. (Tr. 79). In a third
hypothetical, the ALJ asked the vocational expert to assume
that the individual additionally would be off task more than
20 percent of the workday. Ms. Bernard-Watts opined that this
hypothetical individual could not perform any work that
existed in the national economy. On cross-examination,
plaintiff's counsel asked the vocational expert to return
to the first hypothetical, and to add the limitation that,
because of psychologically-based symptoms, the individual
would miss three or more days of work a month. Ms.
Bernard-Watts stated that such an individual would not be
capable of performing any jobs.
December 23, 2006 to July 23, 2007, plaintiff received
alcohol and drug treatment at the Southeast Missouri
Community Treatment Center. (Tr. 331-33). Plaintiff was
admitted to the program after losing his job as a chef due to
drinking. His wife had kicked him out of the house, and he
reported that he was getting a divorce. Plaintiff's
treatment plan focused on his chemical substance dependency
and relapse prevention. Plaintiff agreed to attend six hours
of group therapy weekly. He met three times with a counselor,
but failed to make any follow-up appointments. It was noted
that plaintiff had a “poor prognosis due to him not
keeping his appointments.” (Tr. 333). In an office
treatment record from Advanced Psychiatric Services dated
April 26, 2007, plaintiff stated that he enjoyed work, was
sober, and was doing better. (Tr. 329).
notes from JoAnn Franklin, MSN, RN, CS dated May 3, 2007
indicate that plaintiff was hospitalized in January because
of a suicide attempt. (Tr. 413-14). Plaintiff reported that
he worked two jobs at that time. He admitted to having
alcohol problems and problems with cravings. Nurse Franklin
assessed plaintiff with hypertension, depression with alcohol
abuse, and insomnia. She instructed plaintiff to monitor his
blood pressure periodically. In psychiatric treatment notes
dated May 24, 2007 (Tr. 330), plaintiff stated that he had
nervous anxiety. At his next appointment with nurse Franklin
on June 1, 2007, only one set of plaintiff's blood
pressure records was normal out of all that he recorded. (Tr.
409-11). His mental status exam seemed to be within normal
limits, and he denied drinking any alcohol. Nurse Franklin
again increased plaintiff's hypertension medications.
had a follow-up visit with nurse Franklin on June 14, 2007.
(Tr. 407- 08). Based on lab tests, he was informed that his
liver enzymes were extremely elevated due to his alcohol
problem. The remainder of his labs had some abnormalities on
the high side in the electrolyte category, which nurse
Franklin noted was probably in relation to his drinking as
well. Plaintiff was given a prescription for
Vivitrol at his request, which was expected to help
with his alcohol problem. Plaintiff was given a Vivitrol
injection intramuscular in his right hip at his appointment
on June 28, 2007. (Tr. 405-06). He was also given
Librium for withdrawal symptoms after nurse
Franklin consulted with Dr. Klemm. Plaintiff reported that he
had quit drinking 16 hours ago and was developing the shakes.
He currently had a good support system with his parents.
Plaintiff sought a referral for a new psychiatrist.
follow-up appointment on July 5, 2007, plaintiff stated that
he needed a work note because of withdrawal symptoms he had
had and also needed a refill of Enalapril. (Tr. 403-04). His
blood pressure remained elevated. Nurse Franklin noted that
the Vivitrol was supposed to work for four weeks and
plaintiff was not supposed to drink with it. However, to test
whether the medication worked or not, plaintiff placed a shot
of vodka in eight ounces of water and drank it. He reported
that his legs gave way and he experienced projectile
vomiting. In addition to providing plaintiff a refill of
Enalapril, nurse Franklin added Clonidine 0.1 mg twice a
day in an attempt to lower his blood pressure and also treat
his addiction problems. At his appointment with nurse
Franklin on July 12, 2007, plaintiff stated that he had not
had any drinking episodes recently and denied any depression.
His Enalapril and Effexor prescriptions were refilled.
Chantix was also given to plaintiff to encourage
him to stop smoking. He was told that walking half an hour a
day would help with his blood pressure and pulse rate. Nurse
Franklin scheduled plaintiff for a follow up in one week,
because she thought he needed that for a support system.
19, 2007, plaintiff saw nurse Franklin for a follow-up visit
after being on Vivitrol for three weeks. (Tr. 399-400). He
reported that he was still sober, feared drinking because of
his use of Vivitrol, did not enjoy his customer service job
and that he had gotten in trouble for saying things that were
overheard by quality assurance. He enjoyed cooking, had been
fishing with his father, and went walking twice in the
preceding week. Upon a review of plaintiff's systems, the
nurse noted that plaintiff's blood pressure was
well-controlled and he had been more active and social
lately. Plaintiff reported feeling a lack of interest, which
the nurse thought was a symptom of Effexor. Plaintiff was not
interested in making any changes to his medications since he
felt he had progressed. Chantix reportedly had helped him cut
down to approximately eight cigarettes a day. Nurse Franklin
encouraged plaintiff to continue getting Vivitrol injections
every four weeks, continue using Chantix, set goals for job
applications, decrease smoking, and increase exercise.
appointment with nurse Franklin on July 26, 2007, plaintiff
had recorded some elevated blood pressure levels in his log,
but the rest were within normal limits. (Tr. 397-98). He
reported exercising on a regular basis and was not smoking at
work since starting Chantix. Upon a mental status
examination, the nurse noted that plaintiff appeared more
verbal that day and also appeared to have been drinking
alcohol. He was given a Vivitrol injection in his left hip.
At his next appointment on August 2, 2007, plaintiff reported
that he had drunk a small bottle of vodka the week before.
(Tr. 395-96). When his blood alcohol content (BAC) indicated
more recent use, plaintiff was “confronted about the
August 9, 2007, plaintiff reported that he began drinking the
previous Sunday and missed work on Monday and Tuesday. (Tr.
393-94). Because he'd had a Vivtrol injection, he became
ill after ingesting half a pint of vodka. Upon a mental
status examination, nurse Franklin noted that plaintiff
appeared somewhat insecure, had poor self-esteem, and was
concerned about the way he looked.
had a follow-up appointment with Marianne Klemm, D.O. on
August 15, 2007. (Tr. 391-92). Because he had reached his
maximum insurance coverage, his Vivitrol injections were no
longer covered. Plaintiff had missed several days of work and
doubted he still had a job. He planned to look for another.
Plaintiff understood that he should not be drinking. He told
Dr. Klemm that Campral decreased his urge to drink, but
Vivitrol had not made a substantial difference. Dr. Klemm
provided plaintiff a prescription for Ativan 0.5 mg twice
daily to help reduce the anxiety of his alcohol cravings.
appointment with nurse Franklin on August 23, 2007, plaintiff
reported that he had drunk alcohol all last weekend and quit
his job on Monday. (Tr. 389- 90). He experienced nausea and
vomiting for three days and began having visual and auditory
hallucinations. Upon examination, plaintiff was tearful,
apologetic, had very low self-esteem, and felt that his
Vivitrol injection should be given to someone who would
benefit from it. He was not making any plans for his future.
Nurse Franklin gave plaintiff a Vivitrol injection and told
him it would be his last if he continued to drink.
family brought him to the emergency room at Jefferson
Memorial Hospital on August 23, 2007 for substance abuse
issues. (Tr. 334-53). Plaintiff had been detoxing from
alcohol and started having visual and auditory
hallucinations. He had been hospitalized twice since December
for similar issues. It was noted that plaintiff had smoked
1½ packs of cigarettes a day for 17 years. Early in
his hospital admission, plaintiff stated that he saw someone
in his room even though he knew no one was there. Two hours
later, he was not in distress, took fluids without
difficulty, and was calm and cooperative with his parents by
his bedside. An hour later he was not in distress and ate a
lunch box without nausea. Plaintiff was diagnosed with
alcohol withdrawal, bipolar disorder, anxiety, acute
psychosis, and schizophrenia. Plaintiff declined transfer to
another facility. The severity of his symptoms warranted
admission, but plaintiff did not pose a threat of imminent
harm to himself or others. Plaintiff was given 10 mg of
Valium to take after his emergency room
medications wore off. He was instructed to follow up with his
psychiatrist, Dr. Klemm, in the morning.
follow-up appointment with nurse Franklin on August 30, 2007
(Tr. 387- 88), plaintiff stated that he remained depressed.
Dr. Klemm was consulted and it was noted that Ativan seemed
to help plaintiff through stressful periods and helped him
avoid drinking. As such, he was given a refill of Ativan. On
September 6, 2007, plaintiff reported that he had had 19 days
of sobriety, but nurse Franklin noted that the room smelled
of alcohol. (Tr. 385-86). Plaintiff was very talkative and
had not had any hallucinations as of late. He reported that
he was feeling very depressed. His blood alcohol content was
found to be 0.239. Because of his poor compliance, plaintiff
was denied further Vivitrol injections. At his next
appointment on September 13, 2007, plaintiff reported that he
had greatly improved with the increase in his
Wellbutrin prescription from 75 mg to 150 mg daily.
(Tr. 383). Upon a review of plaintiff's systems, nurse
Franklin noted that he had hypertension, tachycardia and
continued problems with alcohol. Plaintiff appeared to be in
a much better mood, and he reported that his sleep and
concentration were better since he had obtained a job in the
past week. Plaintiff's prescription for Clonidine was
increased, labs were ordered, and Dr. Klemm gave a verbal
order to renew plaintiff's Ativan prescription.
October 11, 2007, plaintiff reported to nurse Franklin that
his blood pressure was elevated. (Tr. 381-82). The nurse
thought it was related to his Effexor being doubled. His
Effexor was switched to Lexapro. It was also recommended
that plaintiff enroll in a 30-day treatment program because
he continued to drink. His most recent drinking episode was
the preceding Tuesday. One week after starting Lexapro,
plaintiff told nurse Franklin that he still felt depressed.
(Tr. 379-80). He also reported drinking one liter of vodka a
day. He was openly intoxicated at the appointment. Plaintiff
reported that he had quit his job as a dishwasher because
“he could not take it anymore.” (Tr. 379).
Plaintiff did not seem motivated to stop drinking and his
parents were frustrated with his behavior. Nurse Franklin
doubled plaintiff's Lexapro dosage and instructed him to
call and report where he was eligible to go for a treatment
program. Plaintiff rejected two treatment facilities. On
October 26, 2007, plaintiff's father reported to Dr.
Klemm that plaintiff had been admitted to Southeast Missouri
Mental Health Center. (Tr. 376).
remained at Southeast from November 8 to November 14, 2007.
(Tr. 354-63). This was his third psychiatric hospitalization
at this facility. Plaintiff requested help for his alcohol
dependence. It was noted that he had spent ten days in
another facility and had been discharged two weeks earlier.
He stayed sober for one week. He was stopped while driving a
vehicle and received a DWI violation. His license was
suspended and he started binge drinking. His blood alcohol
content was 0.231 when he arrived at Southeast. Plaintiff
reported that he had had a long history of alcohol dependence
and excessive drinking to the point of blacking out since he
was 21-years old. Plaintiff also had a history of significant
alcohol withdrawal which included delirium tremens,
hallucinations, shaking, sweating, and confusion. He reported
almost seven delirium tremens episodes in the past year since
he had been trying to detox independently. He also reported
progressive symptoms of depression over the past several
years. Plaintiff reported poor sleep, fluctuations of
appetite, and a sense of helplessness and hopelessness. He
had been to several psychiatrists over the years, but did not
follow up with them because he did not like them.
treat his depression, plaintiff was given
Trazodone to improve his sleep and Lexapro to
decrease his depression. He also began taking
Risperdal. He was encouraged to attend group
therapy sessions. His group therapy attendance, participation
and outcome were fair. He was also complaint with his
medications, and by November 12 he displayed a bright affect.
On discharge, plaintiff described his mood as good. His
affect was euthymic, form of thought logical and sequential,
insight and judgment were fair, and he denied psychotic
symptoms. Plaintiff was diagnosed with alcohol dependence,
alcohol withdrawal to rule out substance-induced mood
disorder, exogenous obesity, elevated liver enzymes,
substance abuse, legal issues, and occupational problems. He
was assigned a Global Assessment of Functioning (GAF) score
of 60. He was given a two-day supply of
Vasotec8 20 mg, Norvasc 5 mg, Clonidine 0.3 mg, Trazodone 150
mg, Lexapro 10 mg, and was told to decrease Risperdal.
Counseling and Alcoholics Anonymous (AA) meetings were
December 6, 2007, plaintiff reported being sober for 32 days
and working at a restaurant three days a week. (Tr. 373).
Upon objective examination, he was alert, cooperative, in a
better mood, more confident, and had decreased anxiety. On
January 10, 2008, plaintiff reported that he had not drunken
alcohol for eight days. (Tr. 372). He was still working at
the restaurant and was getting more hours. He had had two
anxiety episodes since his last appointment. His Norvasc and
Trazodone dosages were increased. He was also given a
Vistaril injection and told to follow up in two months. On
March 6, 2008 (Tr. 369), plaintiff told Dr. Klemm that he was
sober and had finished his counseling at Southeast Missouri
Mental Health Center. On May 7, 2008, plaintiff requested
Librium from Dr. Klemm for relief from withdrawal symptoms.
(Tr. 367-68). He stated that he had gone back to drinking
multiple times before, but “this is the last
time” he was ever going to drink. Plaintiff stated that
alcohol had messed up his whole life and cost him his job. He
seemed more motivated than the last time Dr. Klemm had seen
him. Dr. Klemm wrote plaintiff a prescription for Librium and
encouraged him to stay sober.
June 11 to 14, 2008, plaintiff was admitted to a detox
program at Gibson Recovery Center, Inc. (Tr. 364-65). He
stated that he had drunk one liter of vodka a day. Plaintiff
was monitored every shift and his tremors began to subside.
He stated that he was eating fine, drinking fluids, and
resting okay. He attended some group therapy sessions and
interacted well with peers and staff. Upon discharge,
plaintiff was referred to AA meetings and other outside
support networks. On June 26, 2008, plaintiff reported to
medical providers that he had moved back in with his parents.
(Tr. 366). He reported poor sleep and anxiety.
Singer, Ph.D. completed a Psychiatric Review Technique for
plaintiff on August 8, 2008. (Tr. 415-25). Dr. Singer
assessed plaintiff with depression, anxiety disorder, and
alcohol dependence, which she opined were not severe.
Plaintiff had mild limitations with respect to his
restriction of daily living activities, difficulties in
maintaining social functioning, and difficulties in
maintaining concentration, persistence, and pace. Plaintiff
had had no repeated episodes of decompensation of an extended
duration. Dr. Singer noted that plaintiff had a long history
of alcohol dependent and noncompliance with treatment. Based
on the evidence in the record, Dr. Singer found that
plaintiff's impairments would be non-severe if he did not
continue to use alcohol. As such, plaintiff's alleged
severity of his conditions was not found credible.
integrated recovery plan from BJC Behavioral Health Center
dated April 12, 2010 (Tr. 629-30), plaintiff was diagnosed
with a mood disorder not otherwise specified, alcohol and
nicotine dependence, personality disorder not otherwise
specified, obesity, hypertension, esophageal reflux,
arthritis, substances use and limited coping skills. He was
assigned a current GAF score of 50 and stated that he had
been sober almost six months. A diagnosis summary report from
BJC Behavioral Health dated June 21, 2010 diagnosed plaintiff
with bipolar I disorder, most recent episode depressed,
moderate, alcohol and nicotine dependence, obesity,
hypertension, and esophageal reflux. (Tr. 577).
August 26, 2010, plaintiff presented himself to the emergency
department at Mineral Area Regional Medical Center with an
anxiety attack. (Tr. 500-02). He was concerned about his
current transition from Valproate to Lamictal for his
bipolar disorder. Valproate had been effective in controlling
his cycles of bipolar, but contributed to significant weight
gain and dyslipidemia. He felt his current symptoms were
consistent with a panic ...