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Hinderhan v. Colvin

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

September 14, 2016

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



         Christopher Hinderhan (“Plaintiff”) seeks review of the decision of the Social Security Commissioner, Carolyn Colvin, denying his applications for Social Security Income and Disability Insurance Benefits under the Social Security Act. The parties consented to the exercise of authority by the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). (ECF No. 9). Because the Court finds that substantial evidence supports the decision to deny benefits, the Court affirms the denial of Plaintiff's applications.

         I. Background and Procedural History

         In January 2012, Plaintiff filed applications for Social Security Income and Disability Insurance Benefits.[1] (Tr. 178-84, 187-94). The Social Security Administration (SSA) denied Plaintiff's claims, and he filed a timely request for a hearing before an administrative law judge. (Tr. 88-89, 98-99). The SSA granted Plaintiff's request for review and conducted a hearing on September 6, 2013. (Tr. 35-59). In a decision dated December 13, 2013, the ALJ found that Plaintiff “has not been under a disability, as defined in the Social Security Act, from July 27, 2011, through the date of this decision.” (Tr. 27). The SSA Appeals Council denied Plaintiff's subsequent request for review of the ALJ's decision. (Tr. 1-3). Plaintiff has exhausted all administrative remedies, and the ALJ's decision stands as the Commissioner's final decision. Sims v. Apfel, 530 U.S. 103, 106-07 (2000).

         II. Evidence Before the ALJ

         A. ALJ Hearing

         Plaintiff appeared with counsel, via video conference, at the administrative hearing on September 6, 2013. (Tr. 35). Plaintiff testified that he completed school through the eighth grade and did not earn a GED. (Tr. 38). Since his most recent employment ended in July 2011, Plaintiff had applied for two part-time dishwasher positions for which he was not hired. (Tr. 38).

         In regard to his medical care, Plaintiff stated that he had begun treatment for his depression, bipolar disorder, and anxiety at Pathways the previous month, and he had an appointment to see a physical therapist in two weeks. (Tr. 39-40). Plaintiff explained that he experienced frequent mood swings and angered easily. (Tr. 41-42). On his bad days, which occurred about four days per week, he slept all day and, on better days, he loaded the dishwasher and cleaned the house. (Tr. 42-43, 52). Plaintiff did not have any friends and did not attend family gatherings. (Tr. 53). Plaintiff also watched movies and played “brain games” on the computer, which are “kind of like chess.” (Tr. 53, 55). He was taking Seroquel and Prozac, which helped with the depression, but “keep me pretty close to almost down. Like a zombie almost[.]” (Tr. 43).

         Plaintiff testified that his bipolar disorder manifested itself in anger and caused “difficulty getting along with other people[.]” (Tr. 44). Plaintiff explained that his most recent job was as a meat clerk at Kroger's where his boss “mess[ed] with” and “antagonize[d]” him. (Tr. 44). According to Plaintiff, two days after he and his boss had an argument about Plaintiff's health benefits, Plaintiff's boss “told me that I had to start doing things differently and I had to clean more and help [with] other people's jobs.” (Tr. 45). Plaintiff felt that his boss was “picking on” him, so he “told him it was unfair and he wasn't going to treat me like crap.” (Id.). Shortly thereafter, Plaintiff's boss summoned him to a meeting with the assistant manager and union representative, who were “just sitting there talking crap to me.” (Id.). Plaintiff stated that he “started shaking and [] turned red” and he “was ready to hurt [his boss].” (Tr. 46). Plaintiff told his boss to get out of his way, threatened to “put his head through the glass door, ” and stormed out, slamming the door and breaking the glass. (Tr. 45-46). Plaintiff testified that he quit later that day. (Tr. 46).

         In regard to his anxiety, Plaintiff testified that he suffered anxiety attacks that felt “like I'm having a heart attack.” (Tr. 47). “Negative drama” and “[i]nteracting with other people” triggered the attacks. (Tr. 47). Plaintiff avoided crowds, shopping, and leaving the house. (Tr. 48).

         Plaintiff testified that he began experiencing back problems when he was eighteen years old. (Tr. 48). In the last twelve years, the pain had intensified to the point that Plaintiff had “gotten on my knees and cried…[a]nd like prayed to God…to make the pain go away[.]” (Tr. 49). Plaintiff stated that “it's been that extreme for about 12 years now” and he “would wolf down Ibuprofen and Aspirin, Motrin, Tylenol…like it's candy just to take the pain away.” (Id.). Plaintiff recently started taking Voltaren, which helped. (Tr. 50).

         Additionally, Plaintiff stated that he suffered memory problems that prohibited him from working. (Tr. 51). Plaintiff had an appointment to see a neurologist the following month. (Id.). He explained, “I can't tell you what I ate for dinner last night. . . . It's like I have the memory of an 80-year-old man with whatever that memory thing is called[.]” (Tr. 52). Plaintiff's caseworker at Pathways assisted him with keeping his appointments. (Id.).

         Because the vocational expert, Susan Hullender, was not present at the hearing, the ALJ issued her interrogatories. (Tr. 58). The ALJ asked Ms. Hullender to consider a hypothetical individual with Plaintiff's age (thirty-six years), education, and work history, and the residual functional capacity (RFC) to perform work at all exertional levels “except is able to perform work at up to General Education Development reasoning level of two in the OT.”[2] (Tr. 320). Ms. Hullender opined that such individual could perform all of Plaintiff's past work, except that of a cashier, which required interaction with the public. (Tr. 320-21). Ms. Hullender stated that Plaintiff could also work as a racker, bottling line attendant, or egg washer. (Id.).

         B. Relevant Medical Records

         On December 11, 2011, the day after his wife left him for another man, Plaintiff presented to the emergency room at Phelps County Regional Medical Center with suicidal ideations. (Tr. 223-35). Doctors transferred Plaintiff to Jefferson Regional Medical Center, where Plaintiff was admitted for treatment. (Tr. 342-55). On December 12, 2011, Dr. Ahmad Ardekani completed a psychiatric evaluation for Plaintiff, noting that Plaintiff's insight and judgment were impaired, but his general knowledge and intellectual function were “okay.” (Tr. 342). Dr. Ardekani diagnosed Plaintiff with bipolar affective disorder, mixed; panic anxiety; and possible dependent personality. (Tr. 343). Dr. Ardekani stated that Plaintiff required “some medicine” and “extensive psychotherapy.” (Tr. 346). Dr. Ardekani observed on December 14, 2011 that Plaintiff's mood had improved such that he was no longer suicidal, and the following day, Plaintiff was “smiling, interacting.” (Tr. 348, 349). Nurses' notes from Plaintiff's hospitalization state that, on December 13, 2011, Plaintiff was “interacting with peers and has spent a great deal of time with one select female peer.” (Tr. 353). Dr. Ardekani assessed a GAF score of 40, [3] indicating serious symptoms, and discharged Plaintiff on December 16, 2011 with prescriptions for Seroquel and Clonazepam. (Tr. 350).

         On January 17, 2012, Plaintiff went to Mercy St. John's clinic and requested a refill on his medications. (Tr. 361). Plaintiff received a refill and a referral to a psychiatrist at Pathways. (Id.).

         On April 12, 2012, Dr. Heather Derix, Psy.D., completed a consultative psychological evaluation for Plaintiff at the request of the SSA. (Tr. 380-88). Plaintiff informed Dr. Derix that he received Social Security as a child, but he lost coverage when he married at age twenty-three. (Tr. 380). He stated that he received some special education and dropped out of school in tenth grade. (Tr. 382-83). Plaintiff explained that he participated in individual and family therapy when he “used to get social security” but “can't afford therapy now.” (Tr. 383). He was currently taking Citalopram, which “used to work” and Klonopin, which “works great.” (Id.).

         Plaintiff informed Dr. Derix that he suffered pain related to “three broken discs in my spine.” (Id.). He also had “titanium in [his] arm” because he shattered it when he “got mad and flipped over a 2, 000 pound soda machine.” (Id.). He explained that he had not “seen a doctor in a good 20 something years, ” and he did not take medications for physical problems. (Id.).

         In regard to his employment history, Plaintiff explained that he had difficulty maintaining employment because “I have a problem getting along with others, I don't play nice, I like to do things on my own. I don't like someone to tell me what to do.” (Tr. 384). His daily routine involved awaking at 7:00 or 8:00 a.m., taking his antidepressant, and going back to sleep until “1 or 3 or 4 if I'm tired.” (Tr. 385). Defendant reported that he did housework when his mother left him a to-do list and stated, “I do like to keep the floors clean, and my laundry clean.” (Id.).

         In her summation, Dr. Derix observed:

The claimant was able to understand and remember simple instructions; had no difficulty with concentration and persistence on simple tasks; demonstrated extreme impairment in his capacity to interact in limited contact situations with the general public; demonstrated extreme impairments in his capacity to interact in limited contact situations with supervisors and coworkers, is likely to struggle with adapting to a simple environment (due to difficulties with socialization and subsequent anxiety); was capable of managing funds independently and appeared to be a generally reliable informant.

(Tr. 387). Dr. Derix diagnosed Plaintiff with: bipolar disorder I, most recent episode depressed; panic disorder with agoraphobia; and nicotine dependence. (Tr. 386). She assessed a GAF score of 40-45. (Id.).

         On March 10, 2012, Plaintiff presented to the emergency room claiming that he “was at the bar last night and then ‘woke up in the dirt at the courthouse' ~ 3 a.m.” after he “was beat up.” (Tr. 416-21). Plaintiff was intoxicated and complained of pain in his face and neck. (Tr. 416).

         On April 16, 2012, Dr. Deborah Doxsee, PhD, a state agency psychological consultant, completed a psychiatric review technique based upon her review of Plaintiff's records and adult function report. (Tr. 65-74). Dr. Doxsee determined that Plaintiff suffered an affective disorder and anxiety disorder, which caused moderate restrictions or difficulties in activities of daily living, social functioning, and concentration, persistence, or pace. (Tr. 69). Dr. Doxsee also noted “one or two” episodes of decompensation of extended duration. (Id.). Dr. Doxsee deemed Plaintiff's reports of limitations “partially credible.” (Tr. 71).

         Dr. Doxsee assessed Plaintiff's mental RFC and found Plaintiff was either “not significantly limited” or “moderately” limited in all four categories of limitations (i.e., understanding and memory, sustained concentration and persistence, social interaction, and adaptation). (Tr. 71-73). Dr. Doxsee noted that Dr. Derix assessed more restrictive limitations, but she believed that Dr. Derix “relie[d] heavily on the subjective reports of symptoms and limitations provided by the individual” and “overestimate[d]…the severity of the individual's restrictions/limitation . . . .” (Tr. 73). Dr. Doxsee concluded that Plaintiff was “limited to unskilled work because of the impairments” but was not disabled. (Tr. 74).

         On April 24, 2012, Plaintiff attempted to establish care with and obtain a mental and physical disability determination from Dr. Bohdan Lebedowicz. (Tr. 471-73). Dr. Lebedowicz declined to complete Plaintiff's disability papers and referred him to a psychiatrist. (Tr. 472). When Dr. Lebedowicz asked Plaintiff “if he needs any help with his back pain, ” Plaintiff “said that he doesn't and he does not want to have any medication for it.” (Id.).

         On August 1, 2012, Plaintiff presented to the emergency room complaining of “mid and lower back pain” and requesting medication. (Tr. 412). Dr. Earl Scott wrote that “[u]pon further investigation, ” he learned that Plaintiff had “received tramadol from his PCP for treatment of chronic back pain.” (Tr. 415). Plaintiff admitted he received a prescription on ...

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