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Greenhalgh v. Colvin

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

December 21, 2016

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



         This action is before the court for judicial review of the final decision of the defendant Commissioner of Social Security denying the application of plaintiff Rebecca Greenhalgh for supplemental security income (SSI) benefits under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381-1385. The parties have consented to the exercise of plenary authority by the undersigned United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons set forth below, the decision of the Administrative Law Judge (ALJ) is reversed and remanded.

         I. BACKGROUND

         Plaintiff was born in 1984 and was 28 years old at the time of her first hearing. (Tr. 38, 303). She protectively filed her application on May 30, 2011, ultimately alleging a May 30, 2011 onset date of disability due to “polycythemia vera, degenerative disk disease in back and neck, narrowing of spinal canal, diabetes, depression, anxiety disorder, panic attacks, COPD, sleep apnea, [and] methylenetetrahydrofolate reductase (blood disorder).” (Tr. 331, 338). Her application was denied in August 2011, and she requested a hearing before an ALJ. (Tr. 73, 81-82). The first hearing was held in October 2012. (Tr. 38-63).

         In November 2012, following this hearing, the ALJ issued a decision, concluding that plaintiff was not disabled under the Act. (Tr. 140-54). The Appeals Council reviewed this decision and remanded it for failing to adequately evaluate certain medical opinions and account for certain impairments, and to allow the ALJ to consider newly submitted evidence. (Tr. 160-63). After two additional hearings, held in August 2013 and February 2014, the ALJ issued a second decision on April 24, 2014, again concluding that plaintiff was not disabled under the Act. (Tr. 8-29, 64, 101). The Appeals Council denied plaintiff's second request for review. (Tr. 1-7). Thus, the April 2014 decision of the ALJ stands as the final decision of the Commissioner.


         On July 7, 2010, plaintiff saw Dr. Thomas Spencer, Psy.D., for a psychological evaluation. (Tr. 1131-35). She reported that she was depressed most of the time, isolated from friends and family, snapped at those around her, thought about suicide, and had panic attacks. (Tr. 1132). Dr. Spencer noted her affect was bland, but noted no obvious grooming or hygiene impairments, physical distress, or abnormal motor behavior. (Tr. 1133). He opined that her insight, judgment, and flow of thought were intact. He diagnosed her with major depressive disorder, panic disorder, and borderline personality traits, assigning her a GAF score of 60-65. (Tr. 1135).

         On January 14, 2011, plaintiff established care with Dr. Tawnyia Jerome, M.D., at Capital Region Medical Clinic and reported no anxiety or irritability. (Tr. 500-503). She was observed to have appropriate mood and affect, normal speech, and good eye contact, and she was cooperative and interacted appropriately. (Tr. 503). At a January 24, 2011 appointment, Dr. Jerome made the same observations, and plaintiff again reported that she was not experiencing anxiety or irritability. (Tr. 494-98).

         On February 14 and 22, 2011, plaintiff reported anxiety and depression, among other physical ailments, to Indumathi Baskar, M.D., of Jefferson City Medical Group. (Tr. 537-539). She was referred to a psychiatrist for her anxiety. (Tr. 538). On April 4, 2011, plaintiff went to Pathways Community Behavioral Health for a psychological examination. (Tr. 735). She reported a long history of depression, anxiety, personality disorder, and paranoia, and that the symptoms were worsening. Id. She reported limited social interaction because of her paranoia and not wanting to leave her house. Id. Wayne Brown, M.S., provisionally diagnosed plaintiff with schizoaffective disorder, bipolar type, and assessed a GAF score of 48. Id.

         On May 23, 2011, plaintiff returned to Pathways and reported her issues were not so much with isolation, but more with irritability when interacting with other people. (Tr. 737). She agreed to receive counseling on Mondays, because on Mondays she played darts with her husband after he got out of work. She was next seen on July 29, 2011, when she reported she was depressed and irritable because she might have leukemia. (Tr. 779). She reported she wanted to hurt people when her hormones got high. Id. However, as of August 25, 2011, plaintiff was discharged from the Pathways program because she did not meet with her caseworker on a consistent basis, and she did not consistently take her medications. (Tr. 777-78).

         On July 21, 2011, plaintiff met with Krishna Mettu, M.D., for problems related to her sleep apnea. (Tr. 868-72). Dr. Mettu observed that plaintiff was alert, cooperative, able to follow multi-step commands, able to give details of past medical history, and able to recall remote events. (Tr. 870). Dr. Mettu noted that plaintiff had normal attention and concentration, that her mood and affect seemed appropriate, and that her judgment and insight were intact. Id.

         On July 18, 2011, Paula Kresser, Ph.D., reviewed plaintiff's file and completed a Mental RFC assessment for a state disability determination service (DDS) evaluation. (Tr. 759-73). Dr. Kresser noted that the reported severity of plaintiff's limitations was inconsistent with her behavior, activities, and observations. (Tr. 769). She further noted that plaintiff's complaints and her visits to professionals were inconsistent. Id. Notwithstanding these inconsistencies, Dr. Kresser opined that the file substantiated the presence of major depressive disorder, panic disorder, borderline personality disorder, and avoidant personality disorder. (Tr. 762- 64). She opined that these impairments caused moderate limitations in plaintiff's activities of daily living and ability to maintain social functioning, concentration, persistence, or pace. (Tr. 767).

         Specifically, in her Mental RFC assessment, Dr. Kresser opined that plaintiff had moderate limitations in her ability to understand, remember, and carry out detailed instructions; maintain attention and concentration for extended periods; perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances; complete a normal workweek without interruptions from psychologically-based symptoms; set realistic goals or make plans independently of others; respond appropriately to changes in the work setting; and interact appropriately with the general public. Id. Dr. Kresser opined that plaintiff was not significantly limited in all other areas. (Tr. 771-73). She concluded that plaintiff retained the ability to engage in simple one or two-step tasks under ordinary supervision, as long as her duties were routine and did not involve adaptation to change. (Tr. 773). She opined that plaintiff would perform best in a setting with minimal or superficial contact with others due to her personality traits. Id.

         On October 17, 2011, plaintiff visited a licensed psychologist, Paul Rexroat, Ph.D., for a psychological consultative examination. (Tr. 1137-40). Plaintiff reported concentration deficits, hearing the voice of her dead mother, mood swings around crowds, and occasional suicidal ideation. Id. Dr. Rexroat observed plaintiff's noticeable body odor and flat affect, but noted that she exhibited good social skills in his office and that she said she usually gets along with people if she has to be around them. Id. He observed that plaintiff was not suspicious, anxious, tense, or weepy during the examination. Id. Dr. Rexroat noted that plaintiff was able to understand and remember simple instructions and sustain concentration, persistence, and pace with simple tasks, though she was functioning below the average range of intelligence. (Tr. 1139-40). He diagnosed plaintiff with major depressive disorder and panic disorder with agoraphobia. (Tr. 1140). He assessed her GAF at 61. Id.

         Plaintiff met with Dr. Syed Huq of the Rolla Mercy Clinic on August 10, 2012, for physical complaints. (Tr. 1088-93). Dr. Huq noted that plaintiff had normal mood and affect and that she appeared to possess good judgment and insight. (Tr. 1092).

         On May 15, 2013, plaintiff visited the Mercy Clinic again and was observed by Korshie Dumor, M.D., to have no confusion or decreased concentration. (Tr. 1322). Her behavior was normal, and she had a normal mood and affect. Id.

         Between May and December 2013, plaintiff saw Narismha Muddasani, M.D., of the Sullivan Specialty Clinic, for her anxiety and fear of storms. (Tr. 1284, 92). In May, Dr. Muddasani diagnosed plaintiff with bipolar disorder and depression. (Tr. 1293). She noted that plaintiff was seeking multiple pain medications. (Tr. 1292-93). Plaintiff returned to Dr. Muddasani in June, August, September, and December. In September, Dr. Muddasani noted plaintiff was doing a little better. (Tr. 1284-91). The next day, plaintiff met with Youssef Assioun, M.D., of the PCRMC Medical Group, and reported, among other things, anxiety, and depression. (Tr. 1356). Dr. Assioun observed that plaintiff had an appropriate affect and ...

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