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Corley v. Berryhill

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

March 27, 2017

BILLY CORLEY, [1]Plaintiff,
v.
NANCY A. BERRYHILL, [2]Acting Commissioner of Social Security, Defendant.

          MEMORANDUM

          DAVID D. NOCE UNITED STATES MAGISTRATE JUDGE

         This action is before this court for judicial review of the final decision of the Commissioner of Social Security finding that plaintiff Billy Corley was not disabled, and, thus, not entitled to Supplemental Security Income (“SSI”) under Title XVI of the Social Security Act (“the Act”), 42 U.S.C. § 1381, et seq. 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 Commissioner is affirmed.

         BACKGROUND

         Plaintiff, born February 23, 1978, filed his application for SSI on May 17, 2012, alleging a disability onset date of February 1, 2008 due to mental problems, and neck and back pain.[3] (Tr. 200-20). On November 9, 2012, his application was denied; thereafter, plaintiff requested a hearing before an Administrative Law Judge (“ALJ”). (Tr. 88, 95). The hearing was held on March 25, 2014.[4] (Tr. 38, 171). Delores Gonzalez, a vocational expert (“VE”), and plaintiff testified at the hearing. (Tr. 20, 38, 189-92). The ALJ decided on July 1, 2014, that plaintiff had the Residual Functional Capacity (“RFC”) to perform light work as defined in 20 CFR 416.967(b), with some exceptions. (Tr. 24). Considering plaintiff's age, education, work experience, and RFC, the ALJ determined there are jobs that exist in significant numbers in the national economy that plaintiff could perform, and therefore found that plaintiff was not disabled under the Act. (Tr. 29). Plaintiff requested review by the Appeals Council of the Social Security Administration on August 30, 2014. (Tr. 20). The Appeals Council denied the request. (Tr. 1). Plaintiff has exhausted all administrative remedies and the ALJ's decision stands as the final agency action now under review.

         Plaintiff argues the ALJ's decision contained inaccuracies, incomplete analysis, and unresolved conflicts of evidence that demonstrate the ALJ's decision was not based on substantial evidence. Specifically, he asserts the ALJ erred in determining plaintiff's credibility by improperly considering some factors and failing to cite to the record. Plaintiff asks that the ALJ's decision be reversed and the case be remanded for further evaluation of the record.

         MEDICAL RECORD AND OTHER ADMINISTRATIVE RECORD

         On May 9, 2008, Karen Hampton, Ph.D., a licensed psychologist, prepared a psychological evaluation of plaintiff. (Tr. 306-20). Plaintiff had reported concerns of mental problems, anxiety, panic attacks, and memory problems.[5] (Tr. 316). Plaintiff stated anxiety made it difficult to be around people; however, he continued to do his own basic shopping. (Tr. 316). Plaintiff had placed job applications since his discharge from the Army in December 2006, but had not worked since the discharge. (Tr. 317).[6]Plaintiff had previous employment at a bowling alley, the Dollar Tree, and, immediately prior to his enlistment in the Army, at a pizza place where he worked for over two years. (Tr. 318). Plaintiff had not attended outpatient counseling or psychotherapy, nor had he been psychiatrically hospitalized at any time. (Tr. 319). Dr. Hampton found plaintiff expressed signs of physiological anxiety. (Tr. 317). Dr. Hampton diagnosed plaintiff with bipolar disorder (type unspecified), learning disorder, and dependent and avoidant personality traits. (Tr. 320). Dr. Hampton listed plaintiff's GAF score at 53, consistent with moderate limitations of functioning.[7] (Id.). She concluded:

Based on the results of the current evaluation, Billy is able to understand and recall simple instructions. Concentration is mildly impaired, and pace is adequate compared to other same-age adults. Ability to adapt to social situations and work-like settings is moderately impaired, in what sounds like fairly chronic anxiety and paranoid thoughts, in what may be a bipolar mood disorder or psychotic thought disorder, Billy appears likely to decompensate in the face of increased stressors. He is considered capable of managing funds independently in his own best interest.

(Tr. 320).

         On July 15, 2009, plaintiff reported feeling less depressed at a meeting with Ginger Nicol, M.D., a psychiatrist at BJC Behavioral Health Services. (Tr. 347). On July 29, 2009, plaintiff told Dr. Nicol he denied feeling depressed or anxious, and denied problems with sleep. (Tr. 346). Plaintiff demonstrated the ability to consistently take oral medication with assistance from his social worker and a pill box. (Tr. 346).

         On August 19, 2009, Dr. Nicol noted improved hygiene, improved social interactions (e.g., riding the bus on his own and attending the Independence Center (“IC”)), and a significant decrease in paranoia, anxiety, and depressive symptoms. (Tr. 345). Dr. Nicol noted since taking prescribed medication, psychiatric symptoms improved dramatically. (Tr. 345).

         On September 9, 2009, Dr. Nicol noted the social worker checked pill boxes during a home visit and verified plaintiff had been taking prescribed medication; however, it was unclear whether plaintiff took the medication consistently. (Tr. 343). Dr. Nicol found plaintiff's symptoms improved somewhat since changing medication. (Tr. 344).

         On October 7, 2009, Dr. Nicol noted plaintiff took medications, attended the IC regularly, and used public transportation without problems. Plaintiff's symptoms were stabilized under medication. (Tr. 342).

         On November 11, 2009, plaintiff reported tolerating medication without problems and reported he had not missed any doses since setting up a pillbox and alarm system for reminders. Dr. Nicol noted plaintiff's psychotic and mood symptoms were under good control and plaintiff participated well in the psychosocial rehabilitation programming. (Tr. 341).

         On December 30, 2009, Dr. Nicol noted plaintiff went to the grocery store and to primary care physician appointments alone, remembered to fill his pill boxes weekly, denied any mood or psychotic symptoms, attended the IC daily, and expressed interest in the IC's temporary work program. Dr. Nicol noted plaintiff did well on his current medication without side effects, engaged in self-care activities, and was fully engaged in psychosocial rehabilitation programming. (Tr. 339).

         From January 2 through 9, 2010, plaintiff was admitted to the DePaul Health Center because of self-harming behavior, unsafe behavior, suicidality symptoms, and mood symptoms. Plaintiff stated when he thought about the past he wanted to hurt his siblings. (Tr. 547). Plaintiff presented signs of homicidal ideation towards his brother, whom he would like to shoot, although plaintiff did not own a gun but stated guns are for sale at a local store. Plaintiff also claimed he would like to throw acid into his sister's face. (Tr. 547). At the time of admittance, plaintiff had aggressive and self-mutilating behaviors, suicidal symptoms, and homicidal ideas. (Tr. 548). Plaintiff was provided inpatient psychiatric treatment. At the time of discharge, plaintiff had no suicidal ideas, no homicidal ideas, no aggressive thoughts, no endangering behavior, and no debilitating adverse effects. (Tr. 548).

         On January 13, 2010, Dr. Nicol found plaintiff suffers from schizoaffective disorder. (Tr. 323). Dr. Nicol found a Global Assessment of Functioning (“GAF”) of 65, consistent with only “mild” impairment. (Tr. 323).

         On January 18, 2010, Alyssa Trimble, M.A., C.M., prepared a clinical psychological assessment of plaintiff. (Tr. 324-29). Plaintiff reported his current goal was “to get a job.” (Tr. 324). Plaintiff attended the IC five days a week, helped out on the third-floor, and communicated with acquaintances at the center. (Tr. 327). Plaintiff was compliant with treatment. (Tr. 328). Plaintiff was to continue community support services from Barnes-Jewish/Christian Behavioral Health (“BJCBH”), continue to see Dr. Nicol every two months, and attend the IC five days a week to increase socialization and to obtain employment. The assessment referred plaintiff to the BJCBH employment specialist should he be unable to obtain employment thorough the IC. (Tr. 328).

         On February 3, 2010, plaintiff reported not sleeping for days. Dr. Nicol noticed plaintiff did not look as if he was sleep deprived. (Tr. 337).

         On March 3, 2010, plaintiff reported doing custodial work through the IC work program for approximately 4 hours per day, five days a week. Plaintiff went to the IC and worked out and did well on his current medications. Dr. Nicol recommended he attend social outlets, such as book clubs, to meet people. (Tr. 336).

         On November 2, 2010, Aqeeb Ahmad, M.D. of Jennings Medical Center Inc. prepared a consultative psychiatric evaluation of plaintiff. (Tr. 352). Plaintiff complained he was unable to work because of anxiety and his schizoaffective disorder. (Tr. 352). Dr. Ahmad noted plaintiff was never psychiatrically hospitalized. (Tr. 353). Dr. Ahmad gave plaintiff a GAF of about 50, consistent with serious limitations of functioning. (Tr. 354). Dr. Ahmad stated plaintiff would probably not be able to hold a job on a consistent basis because of anxiety, paranoia, social isolation, difficulty getting along with people, and suspiciousness. (Tr. 354).

         From December 2 to 9, 2010, plaintiff was hospitalized for suicidal and homicidal thoughts, self-harming behavior, unsafe behavior, suicidality, and mood symptoms. (Tr. 544-60). At admission, he made specific statements of harming his brother and his sister, who he said abused him when he was growing up. (Tr. 547). Plaintiff received therapeutic care. His discharge diagnoses were schizoaffective disorder, unspecified schizophrenia, generalized anxiety disorder, depressive disorder, and unspecified psychosis. (Tr. 548). The discharge summary stated in part:

The patient's depression, anxiety, stress management skill, impulse/anger control, motivation, understanding of disease and compliance to treatment are improved. The patient continued to have difficulty in motivation. At the time of discharge, the patient had no suicidal ideas, no homicidal ideas, no aggressive thoughts, no endangering behavior and no debilitating adverse effects. The patient agreed on the treatment plan, understood the risk, benefit, alternative treatment, potential consequence of no treatment, and gave informed consent.

(Tr. 548).

         On February 3, 2011, Dr. Nicol noted plaintiff, while still dating his girlfriend, began having sexual relations with a man he met at a metro station a few weeks ago. (Tr. 391). Dr. Nicol referred plaintiff for regular psychotherapy. (Tr. 393).

         In March through June of 2011, Dr. Nicol noted plaintiff tolerated medications with some residual anxiety and needed assistance linking to alternate psychosocial rehabilitative resources and therapy. (Tr. 396). Dr. Nicol found no acute evidence of psychosis or mood symptoms, found symptom stability with respect to mood and psychotic symptoms, and found plaintiff had ongoing issues with sexual identity. (Tr. 400, 403, 415). Dr. Nicol encouraged plaintiff to schedule an intake for trauma-focused therapy, to do dialectical behavior therapy, [8] and to work with his case manager on identifying appropriate social outlets such as a book club or joining the local YMCA. (Tr. 400, 409, 415). Dr. Nicol stated plaintiff was on the waitlist to receive a dialectical behavior therapist assignment. (Tr. 409).

         During plaintiff's visits in July and August 2011, Dr. Nicol noted plaintiff tolerated medications well, had no frank psychotic symptoms, and was stable overall, but continued to struggle with wanting social interaction and had ongoing issues with cognitive function. (Tr. 422, 425). Dr. Nicol suggested plaintiff join the local YMCA for exercise and social engagement and continue attendance at the IC. (Tr. 422). Plaintiff was ...


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