United States District Court, E.D. Missouri, Eastern Division
D. Noce UNITED STATES MAGISTRATE JUDGE
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.
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).
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.
MEDICAL AND OTHER HISTORY
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).
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).
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.
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).
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.
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).
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
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.
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).
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.
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 ...