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Bullis v. Colvin

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

September 9, 2016

AARON J. BULLIS, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.



         This matter is before the Court for review of an adverse ruling by the Social Security Administration.

         I. Procedural History

         Plaintiff 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).[1] 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).

         Plaintiff 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.

         II. Evidence Before the ALJ

         A. Disability Application Documents

         In the 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, [2] Rozerem, [3] Trazodone, [4] and Vistaril.[5] Plaintiff had completed three years of college as his highest level of education.

         In a 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.

         Plaintiff 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.

         Plaintiff's 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.

         In Work 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.

         In the 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.

         In a 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.

         With 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.

         Arthritis 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.

         Plaintiff 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.

         In a 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 medications.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff's 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. (Tr. 327-28).

         B. Testimony at the Hearing

         Plaintiff 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. 49- 50).

         Plaintiff's 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.

         Plaintiff 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. 58-59).

         Plaintiff 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 was weak.

         Psychologically, 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.

         In 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.

         Upon 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.

         Plaintiff's 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).

         Vocational 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).

         In a 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.

         C. Medical Records

         From 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).

         Treatment 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.

         Plaintiff 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[6] 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[7] 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.

         At a 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.[8] (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[9] 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[10] prescriptions were refilled. Chantix[11] 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.

         On July 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.

         At his 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 lie.”

         On 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.

         Plaintiff 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[12] decreased his urge to drink, but Vivitrol had not made a substantial difference. Dr. Klemm provided plaintiff a prescription for Ativan[13] 0.5 mg twice daily to help reduce the anxiety of his alcohol cravings.

         At his 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.

         Plaintiff's 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[14] to take after his emergency room medications wore off. He was instructed to follow up with his psychiatrist, Dr. Klemm, in the morning.

         At a 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[15] 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.

         On 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.[16] 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).

         Plaintiff 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.

         To treat his depression, plaintiff was given Trazodone[17] to improve his sleep and Lexapro to decrease his depression. He also began taking Risperdal.[18] 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.[19] He was given a two-day supply of Vasotec8 20 mg, Norvasc[20] 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 recommended.

         On 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.

         From 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.

         Joan 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.

         Per an 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[21] 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).

         On 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[22] to Lamictal[23] 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 ...

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