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Young v. Berryhill

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

April 21, 2017

NANCY A. BERRYHILL,[1] Acting Commissioner of Social Security, Defendant.



         This matter is before the Court for review of an adverse ruling by the Social Security Administration.

         I. Procedural History

         On June 7, 2013, plaintiff Marjorie Young filed applications for a period of disability, disability insurance benefits, Title II, 42 U.S.C. §§ 401 et seq., and for supplemental security income, Title XVI, 42 U.S.C. §§ 1381 et seq., with an alleged onset date of October 17, 2011. (Tr. 233-38, 239-45). After plaintiff's applications were denied on initial consideration (Tr. 164-68), she requested a hearing from an Administrative Law Judge (ALJ). (Tr. 172-23, 174-76).

         A video hearing was held on September 19, 2014. (Tr. 74-128). The ALJ issued a decision denying plaintiff's applications on December 8, 2014. (Tr. 11-30). The Appeals Council denied plaintiff's request for review on February 16, 2016. (Tr. 1-6). Accordingly, the ALJ's decision stands as the Commissioner's final decision.

         II. Evidence Before the ALJ

         A. Disability Application Documents

         In a Disability Report dated June 7, 2013 (Tr. 275-83), plaintiff reported that she had stopped working on October 7, 2012 and was unable to work due to the following conditions: post-traumatic stress disorder (PTSD), severe depression, panic attacks, bad vision, ulcer in right eye, three concussions in 2006, negative neck curvature, scoliosis, torn sheath of the left chest muscle, lumbar disk displacement, neck and back spasms, “degloving” damage to the left hand and arm, diabetes, high cholesterol, elevated blood pressure during episodes of psychosis, broken teeth, toenail fungus, weak bladder, periodic chest pains, pain and limited movement of the right thumb, plantar wart, sore hip joints, possible sleep apnea, insomnia, and nerve damage in the arch of the left foot. She completed three years of college and was trained as a licensed manicurist. She had worked as a substance abuse technician, a heavy equipment operator, a limousine driver, a pipeline oiler, and a phone clerk. Plaintiff was prescribed the antidepressant citalopram.

         In a Function Report dated June 20, 2013, (Tr. 284-94), plaintiff reported that she lived alone in an apartment. In response to a question about her daily activities, plaintiff stated that she engaged in prayer and meditation, ate meals, attended to her personal hygiene, washed dishes, and took a short walk or tended to errands with family members. Her sleep was disturbed by anxiety and pain in her hips, back, and neck. Each week, she prepared two complete meals which she supplemented with sandwiches, canned soups, and frozen foods. She cleaned her kitchen and bathroom, swept floors, and did laundry. At the time she completed the report, she could read for 15 minutes before her eyes began to hurt. She was able to watch television without limitation. She visited with family at home or while doing errands. She walked to church with a neighbor three times a week.

         Plaintiff stated that she had previously been a heavy equipment operator but was no longer able to climb, sit, stand or lift. She had limited use of her left arm and hand and suffered pain in her right thumb due to overuse. She felt unable to cope with her anxiety and PTSD. She had difficulty communicating and calming herself. She had no energy, her reactions were dulled, and she could not concentrate. She complained of an inability to see clearly. She had difficulty sleeping due to pain, a frequent need to urinate, and disturbing thoughts. She was able to pay bills, count change, and manage a checkbook, money orders, and a savings account. Plaintiff had difficulties with lifting, squatting, bending, standing, reaching, walking, sitting, kneeling, talking, hearing, climbing stairs, seeing, remembering, completing tasks, concentrating, following instructions, using her hands, and getting along with others. She was able to walk about 150 yards before she needed to return home, due to pain. She could generally follow written instructions, but often needed clarification of spoken instructions. She did not always get along with police officers but had never been fired because of conflict with others. She liked to plan things out and sudden changes in routine caused a great deal of tension. She described an extensive history of sexual, physical, and emotional abuse, as well as a pattern of tense interactions in the workplace.

         The record contains a letter from plaintiff's older sister, who reported that plaintiff was sexually and physically abused by their grandfather, between the ages of 4 and 7. (Tr. 312-14). Plaintiff had a lot of conflict with her mother, leading her to move to Missouri to live with her father when she was 14. When she was 18, she was held up at gunpoint while working in a clothing store. When she was 28 years old, she was admitted to a treatment center where she was diagnosed with depression and PTSD. She was unable to maintain employment, due to physical and psychiatric issues, and had married and divorced five times. Plaintiff's sister reported that plaintiff's ability to cope had deteriorated in the preceding four years, leading her to give away her belongings in order to reduce her stress. Participating in a two-way conversation “derailed” plaintiff and caused her great frustration. Her behavior had changed to the extent that her sister wondered if she suffered from schizophrenia.

         The record also includes a letter from a participant in the Piedmont Family Counseling Center day treatment program that plaintiff attended. (Tr. 311). The letter writer reported that plaintiff displayed anxiety in a number of circumstances, such as being instructed by staff members or participating in the weekly trips organized by the counseling center. In addition, plaintiff became “nervous” unless everything “was in its place.”

         Plaintiff received unemployment benefits from the State of Nevada for the third quarter of 2012 through the second quarter of 2013. (Tr. 265-66).

         B. Testimony at September 19, 2014 Hearing

         Plaintiff was 52 years old at the time of the hearing. (Tr. 82). She lived alone in an apartment in what she described as disability housing. (Tr. 106-07). She had a driver's license but did not have a car. She used a scooter to ride to the store near her home and, occasionally, to a grocery store 22 miles away.

         Plaintiff completed three years of college and earned a manicurist's license. She started working as a heavy equipment operator in 1991, driving trucks in the gold mines.[2] The “jarring” she sustained while driving caused compression fractures in her spine. (Tr. 83-84). She stopped working in October 2011 when her depression and PTSD worsened. At first these conditions forced her to leave work early, but ultimately they caused her to be unable to get up to go to work. Plaintiff was exhausted and was not “clear minded.” (Tr. 88).

         Plaintiff attended the Piedmont Family Counseling Center in Kennett, Missouri, four days a week. She was paid to do light cleaning for two hours each week. When asked whether she would be able to perform such work on a fulltime basis, she testified that her physical and psychiatric conditions would prevent her from meeting her commitments. (Tr. 90). She identified her fear of making mistakes - a component of her PTSD - as the most significant barrier to maintaining employment. She also had panic attacks, during which her body felt tense and vibrated, she became choked up, and she was unable to breathe or speak. These panic attacks could be caused by a change in the topic of conversation. Plaintiff met with a case manager once a week to help her stay focused on her treatment plan and cope with her constant fears of making a mistake or getting into trouble. (Tr. 93). She took medication to treat PTSD and severe depression and a sleep aid to deal with nightmares and insomnia. (Tr. 95). The medications had reduced the nightmares, but she continued to experience flashbacks. She testified that she just didn't seem to be able to function anymore and that her family and children could not “handle” her. (Tr. 113).

         Plaintiff testified that she generally slept three or four hours a night. When she was working, she struggled to stay awake and not nod off. A recent sleep study revealed that she had obstructive sleep apnea. She had an appointment for another sleep study and to be fitted for a CPAP mask. (Tr. 111-12).

         In January 2014, plaintiff began taking medication for diabetes. Although her condition had stabilized with medication and an alteration in her diet, she experienced daily episodes of flushing and poor vision. She testified that she had a service dog to alert her when her blood sugar was out of balance. (Tr. 97-99).

         Plaintiff sustained a traumatic injury in 2009 when she fell off a horse. The reins wrapped around her left bicep, causing a violent jerking of her arm and injury to the brachial plexus. The reins then wrapped around her wrist and “degloved” a portion of her left hand. (Tr. 100-101). Her arm was paralyzed for three months. She had physical therapy for 6 months following the accident, but her left arm remained weaker and smaller than her right arm and she had a very weak grip. After a nerve conduction study in early 2014, her primary care physician told her that her “muscles were not getting the communication they need.” (Tr. 102-03). She testified that she had constant back pain due to her prior injuries and muscle spasms. The pain fluctuated in intensity between 3 and 10 on a 10-point scale. Her pain was aggravated by holding her arms out in front, such as when washing dishes, sitting or standing too long, and sleeping. (Tr. 99-100).

         Plaintiff identified other physical pains: She had severe bunions which caused pain if she wore a closed shoe. She also had a growth on one foot that required lancing once a month. (Tr. 103-04). On occasion a rib moved out of place, causing severe pain. (Tr. 105-06). She experienced “big chest pains” that radiated into her shoulders and jaw and which caused her to worry that she was having a heart attack. (Tr. 106). Riding the scooter caused unspecified pain. (Tr. 107).

         Plaintiff testified that when she awoke in the morning, she walked her dog, ate her breakfast, and then got ready for the day. The van from the Family Counseling Center picked her up by 8:30 a.m. four days a week. While there, she attended groups. Over time she had learned to cope with the other people in the groups. (Tr. 110-11).

         Plaintiff testified that she was took Metformin and Victoza for diabetes, cholesterol medication, the muscle relaxer Robaxin, ibuprofen, the antidepressant Zoloft, and Trazadone for sleep. (Tr. 114).

         Vocational expert J. Stephen Dolan testified that plaintiff's past work as a substance abuse service aide was classified as skilled, light work and her work as a heavy equipment operator was classified as unskilled, heavy work. (Tr. 119-20). Mr. Dolan was asked to testify about the employment opportunities for a hypothetical person who was limited to performing work in the light exertional range, with the additional limitation of performing only simple routine tasks that did not involve interaction with the general public. Mr. Dolan testified that such an individual would not be able to perform plaintiff's past relevant work. (Tr. 120). However, other suitable jobs were available in the state and national economy, including small product assembler, housekeeping cleaner, or hand packager. (Tr. 121). These jobs were also suitable if the individual was further limited to working primarily with objects rather than people and only occasional contact with co-workers and supervisors. (Tr. 123). However, an individual whose conditions caused her to be off-task 20 percent of the workday would not be able to perform the assembler and packager jobs, and the number of housekeeping cleaner jobs available in the Missouri economy would decrease from 20, 000 to 5, 000. Limiting the hypothetical individual to sedentary work narrowed the available occupations to sedentary unskilled assemblers. (Tr. 124). Employers would not tolerate more than two unexcused absences in a month or repeated tardiness. (Tr. 122).

         In response to questioning by plaintiff's counsel, Mr. Dolan testified that the identified occupations could be performed with a service animal present to the extent that an employer permitted it. Imposing additional restrictions on the hypothetical individual's ability to walk did not reduce the occupations available; however, a requirement that the individual elevate her legs to waist level, outside normal breaks, would eliminate all light and sedentary work. (Tr. 126-27).

         C. Relevant Medical Records

         In March 2011, plaintiff was admitted to a hospital in Nevada with complaints of chest pain, dyspnea, diarrhea, and dizziness. She reported experiencing three episodes of nondescript chest pain, with vague shortness of breath. Blood tests, x-rays and electrocardiogram were all negative and she was discharged the following day with instructions to follow up with her primary care physician. (Tr. 329-33). Plaintiff was being treated for depression with Lexapro at the time of this admission.

         The next medical record dates from October 17, 2011, when plaintiff presented to the emergency room seeking medication to treat her depression, which she described as mild. (Tr. 320-27). She was not experiencing appetite loss and she had no suicidal or homicidal ideation, no hallucinations, and was not experiencing anxiety, confusion or agitation. On examination, she was unkempt with dirty clothes and matted hair. However, her affect was normal, her speech was within normal limits, and she was not in any apparent distress. She denied having muscle aches or weakness, back or chest pains, or difficulty breathing. She had no difficulty with ambulation and her extremities exhibited normal ranges of motion. She was stable and had good social support. She stated that she wanted medication to improve her sleep. She was provided with 5 Ativan pills and discharged with instructions to follow up with her primary care physician before returning to work. The record contains no evidence of further treatment until May 16, 2012, when she presented to the emergency room in Nevada with an apparent panic attack. (Tr. 318). After waiting 90 minutes, she left without being seen.

         On May 30, 2013, plaintiff made a visit to a social services office in Poplar Bluff, Missouri. In a moment of frustration, she said, “I would be better off if I was suicidal, ' a statement that she later explained was sarcastic. (Tr. 353). Later that day, emergency responders came to her home and transported her to the emergency room, where she was given Vistaril for severe anxiety/agitation. When interviewed, she denied suicidal or homicidal ideation, but reported a long history of depression. She was under a great deal of stress due to poor finances and conflict with family members and requested admission to the behavioral health unit. On examination, she was found to be appropriately groomed, alert and oriented, with good attention and concentration. Her affect was anxious and restricted. She described her mood as “jittery, good, a little agitated.” Her speech was clear, coherent, loud, and pressured. She had no hallucinations or paranoid ideations and denied all suicidal and homicidal thoughts. Her memory was grossly intact; her insight and judgment were borderline. (Tr. 354). She was assessed with substance- induced mood disorder with suicidal ideations and cannabis dependence; PTSD by history, rule out major depressive disorder; anxiety disorder with panic attacks; and nicotine dependence. Her current Global Assessment of Functioning (GAF) was estimated to be 35-40. Plaintiff was admitted to the behavioral health unit, with the ...

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