United States District Court, E.D. Missouri, Eastern Division
D. NOCE UNITED STATES MAGISTRATE JUDGE.
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
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).
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
Record and Evidentiary Hearing
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).
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).
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.
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.
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.
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).
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).
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.
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 ...