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Koenig v. Berryhill

United States District Court, W.D. Missouri, Western Division

March 3, 2017

NANCY A. BERRYHILL, Acting Commissioner Of Social Security, Defendant.


          NANETTE K. LAUGHREY, United States District Judge

         Plaintiff Jennifer Koenig appeals the Commissioner of Social Security's final decision denying her application for disability and disability insurance benefits, and supplemental security income. The decision is affirmed.

         I. Background

         Koenig was born in 1985. She alleges she became disabled on April 1, 2010. Her date last insured was June 30, 2013. The Administrative Law Judge held a hearing on January 1, 2015 and denied her application on January 29, 2015. The Appeals Council denied her request for review on April 13, 2016. Koenig's appeal to this Court concerns mental limitations.

         A. Medical history

         On December 23, 2010, Koenig went to the emergency room, stating that her boyfriend told her she had had a seizure. Koenig said she was not taking any medication for seizures but had in the past. After being examined, Koenig told the nurse she wanted to leave, so she was discharged.

         On January 26, 2011, Koenig saw Henry Wisdom, D.O., at North Central Missouri Mental Health Center. She reported that she had been diagnosed with bipolar disorder and had issues with seizures. The doctor prescribed Lamictal and hydroxyzine.

         Koenig saw Dr. Wisdom again on February 23, 2011 for a supportive psychotherapy session. Dr. Wisdom noted that he was not “certain what [Koenig] want[ed]. On the one hand she said she wants to get her kids back, and on the other hand she wants to have the medication she was taking prior to going into a drug and alcohol facility[.]” Tr. 292. The doctor increased Koenig's medication dosages. He instructed her to continue therapy, as it seemed to help.

         At a visit on March 23, 2011, Dr. Wisdom noted that Koenig was “able to concentrate.” Tr. 293. She was well oriented and taking her medication. Dr. Wisdom also noted that Koenig was participating in therapy, “with good results.” Id.

         On April 20, 2011, Koenig saw Dr. Wisdom for another follow-up appointment. Dr. Wisdom suggested involvement in local and church activities and vocational rehabilitation.

         Koenig next saw Dr. Wisdom on May 18, 2011. The doctor did not change Koenig's medications.

         Koenig went to the emergency room on June 19, 2012 with an injury to her left foot. X-rays showed multiple fractures. The next day, Koenig had surgery.

         Koenig went to the emergency room on August 15, 2012, reporting a seizure that had lasted for two minutes. She refused a drug test, but other tests indicated no cardiac event.

         On December 7, 2012, Koenig saw Linda Lock at Truman Medical Center Behavioral Health for a psychological examination and to begin receiving outpatient services. She reported that she was required by Grundy County Family court to participate in mental health services. Koenig said she had stopped taking her psychotropic medication two years earlier and wanted to start them again. She said that since stopping them, she had headaches, anxiety, social anxiety, mood swings, and depression. Her mental status examination was largely normal, although Lock noted that Koenig's “attention and concentration [were] impaired as evidenced by [her] stating that she cannot even watch TV and do something else at the same time.” Tr. 357. Her memory was intact. The therapist recommended Koenig receive individual therapy and work with employment services.

         On December 12, 2012, Koenig saw Trena Willich, a community support specialist, at Truman Medical Center. Koenig said that she did not have any income and wanted to work. Willich noted that Koenig was talkative and polite with a bright affect.

         Koenig had a psychiatric evaluation by Douglas Burgess, M.D., a staff psychiatrist at Truman Medical Center, on December 18, 2012. Koenig reported that her mood was “up and down” and that she was irritable and snapped at people for minor things. Tr. 348. She also stated that her mood was “alright, ” but then said she had been depressed for the past 2 to 3 weeks. Id. Koenig stated that medication had not been effective in the past because she did not take it consistently, but she was interested in resuming. Koenig stated that she had used alcohol and drugs in the past, but had not used alcohol for four months, or drugs since entering treatment in 2009. Koenig's behavior was cooperative, she was well oriented, and she displayed intact memory. Dr. Burgess opined that Koenig's mood lability was largely due to situational stressors and assessed a GAF score of 38. He diagnosed bipolar disorder, major depressive disorder, alcohol dependence under partial remission, and methamphetamine dependence in remission by report. He prescribed sertraline and recommended psychotherapy.

         On January 11, 2013, Koenig was discharged from the outpatient program, having “completed all of her outpatient treatment goals.” Tr. 366. The discharge summary noted that she had a stable transition plan and a stable relapse prevention plan.

         On April 8, 2013, Koenig saw Jean Tadokoro, M.S.W., L.C.S.W., about substance abuse issues and in an effort to regain custody of her son. On April 10, 2013, Koenig began attending group therapy related to addiction recovery skills. Therapy continued several times a week through early June of 2013, when Koenig had a positive drug test. Koenig said she would not comply with her revised treatment plan, so was discharged from the program.

         On April 12, 2013, an x-ray of Koenig's left foot showed an old healed fracture of the left fourth and fifth metatarsal bones and post-operative changes, but was otherwise unremarkable.

         On June 1, 2013, Koenig saw David Whitmer, M.D., at the Truman Medical Center Emergency Department. She described experiencing an episode in which she felt nauseated, sweaty, and like she was going to pass out. A ...

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