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Young v. Berryhill

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

May 2, 2017

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



         This action is before this court for judicial review of the final decision of the defendant Commissioner of Social Security finding that plaintiff Renee Young is not disabled, and, thus, not entitled to Disability Insurance Benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq., or to Supplemental Security Income under Title XVI of the Act, 42 U.S.C. §§ 1381 et seq. The parties 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.


         Plaintiff, who was born on February 18, 1971, filed her applications for SSI and DIB on May 14, 2013 and May 23, 2013, respectively. (Tr. 156-70). She alleged the disabling conditions of agoraphobia, panic attacks, auto-immune disorder, arthritis pain, chronic pain, and post-traumatic stress disorder (“PTSD”), with an alleged onset date of December 21, 2012. (Tr. 185, 201). The agency initially denied her claims, and she requested a hearing before an administrative law judge (“ALJ”). (Tr. 95-110). After an administrative hearing and careful consideration of the entire record, the ALJ found that plaintiff was not disabled under the Act. (Tr. 27).

         Plaintiff filed a timely request for review of this decision with the Social Security Appeals Council and was denied on October 9, 2015. (Tr. 12-15). Accordingly, plaintiff has exhausted all administrative remedies and the ALJ's decision stands as the final decision of the Commissioner subject to judicial review.

         Medical Record and Evidentiary Hearing

         Plaintiff began to see M. Sameer Arain, M.D., approximately every four weeks from January 16, 2012 to July 19, 2013, after which she visited him approximately every eight weeks. (Tr. 299-313, 352-63). Plaintiff's last visit with Dr. Arain on record was March 7, 2014. (Tr. 363). During this time, Dr. Arain's record shows that plaintiff displayed good eye contact, normal psychomotor activities, and appropriate and cooperative behavior. Id. Plaintiff's speech was spontaneous and coherent, both the rate and the volume of which were normal. Id. Her affect was reported as generally restrictive until May 24, 2013, after which it was reported as generally reactive, except on March 7, 2014. Id. Plaintiff displayed linear and logical thought processing and fair insight and judgment. Id. She also consistently appeared alert and oriented and did not display manic behavior or any episode of psychosis. Id. Dr. Arain's notes documented relatively mild mood fluctuations and limitations, where plaintiff reported feeling “[a] little better, ” “fair, ” “okay, ” “so-so, ” “better, ” and sometimes somewhat anxious or depressed. (Tr. 25, 300, 302-09, 311-12, 357-58, 362-63).

         On May 7, 2012, plaintiff reported having anxiety and having cut her wrist superficially a few weeks prior, but she reported better sleep and her affect was reactive. (Tr. 313). She had counseling in June, September, and October 2012. (Tr. 303, 305-06). Plaintiff reported having problems going into public and going out in September and October 2012. (Tr. 305-06). She reported severe headaches and erratic sleep in October 2012. (Tr. 306).

         In June and July 2013, plaintiff reported a high spend-down on her Medicaid and could not pay her copayment. (Tr. 357-58). She had no money to see her primary care provider. Id. She described her mood as fair and reported anxiety in crowds or public places. Id. In July, she reported feeling exhausted and reported her dog was dying. (Tr. 358). She reported having a panic attack when she had to take the dog to the emergency room, but her mood was described as stable with no manic behaviors or psychosis. Id.

         An internal medicine consultative examination (“CE”) was performed at the request of the Social Security Administration on July 13, 2013, with Dr. Heather Cha. (Tr. 314). Based on the Dr. Cha's observations and physical exam findings, as well as the plaintiff's statements and medical history, Dr. Cha opined plaintiff was likely to have agoraphobia, panic attacks, PTSD, abdominal pain and presumed iron deficiency anemia. (Tr. 318). The doctor opined that plaintiff was likely able to perform and sustain work-related functions such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling despite any functional limitations. Id. Dr. Cha determined that approximately half of plaintiff's allegations were not supported by evidence, and the doctor found that plaintiff was not believable in terms of the degree of pain and distress she expressed during the visit. (Tr. 318-22).

         Plaintiff had nine one-hour sessions of counseling therapy with Kay Morrison, LCSW, from September 29, 2013, to June 9, 2014. (Tr. 385-93). Ms. Morrison conducted an initial assessment of plaintiff on September 29, 2013, and came up with a treatment plan on October 7, 2013. (Tr. 372-84). Ms. Morrison noted that at the initial assessment, plaintiff was unable to have any eye contact during the session; her hands trembled; and she had pressured speech, loose associations and flat affect. Id. Ms. Morrison also noted that plaintiff's memory appeared good and she was cooperative. Id.

         After initial assessment, Ms. Morrison issued plaintiff a provisional diagnosis of panic disorder, agoraphobia, major depressive disorder, PTSD by history, and social anxiety disorder. (Tr. 382). Two problems were addressed in the treatment plan. (Tr. 372- 377). The first was plaintiff's fear of being in an environment that plaintiff believed might trigger intense anxiety symptoms (panic), such as leaving home or being in a crowd of people in a restaurant or enclosed environment. (Tr. 372). The second problem included different aspects and levels of sadness, irritability, restlessness, and agitation. (Tr. 375).

         Ms. Morrison's notes show that, during the counseling sessions, Ms. Morrison instructed plaintiff on deep breathing techniques, processing her feelings, and journaling and encouraged her to participate more in household chores and make social plans with her partner outside of the house. (Tr. 385, 387-90). By October and November 2013, plaintiff showed improvement in her eye contact and affect, reported improvement in her mood, and reported having hope about her future. (Tr. 387-89). By April 2014, plaintiff reported going to a store and appeared to feel better, viewing her outing as successful although she didn't stay at the store long. (Tr. 391). In May 2014, plaintiff attended a street celebration and went to a bar and restaurant, and relayed that she was proud of herself that she was able to socialize in public although she did not enjoy it. (Tr. 392).

         Ms. Morrison filled out a mental residual functional capacity questionnaire (“MRFC”) on May 20, 2014, after eight sessions. (Tr. 366-71). She diagnosed plaintiff with major depression, panic disorder with agoraphobia, and PTSD. Id. While Ms. Morrison noted that plaintiff had taken some small steps in getting better, she observed that plaintiff appeared to regress at times when anxiety worsened and observed generally that plaintiff still appeared overwhelmed with daily anxiety and mood disturbance. Id.

         Approximately one month later, on June 14, 2014, psychologist Marva Robinson performed a consultative examination and noted that plaintiff appeared appropriately dressed and groomed. (Tr. 398-403). Plaintiff displayed average intelligence and normal insight, judgment, speech, thought process, and concentration. (Tr. 398-99). (Tr. 26, 394-403). Dr. Robinson noted that plaintiff was cooperative; she had unremarkable motor activity; she maintained fair eye contact; she sat appropriately in her chair and gave coherent, spontaneous reports; and her memory was intact. Id. Dr. Robinson opined that plaintiff could understand, remember, and carry out instructions. (Tr. 401). Dr. Robinson opined that plaintiff had no limitations in interacting with supervisors, but was moderately limited in interacting with ...

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