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Lucas v. Berryhill

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

July 18, 2017

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



         This action is before the Court, pursuant to the Social Security Act (“the Act”), 42 U.S.C. §§ 401, et seq. The Act authorizes judicial review of the final decision of the Commissioner of Social Security (the “Commissioner”) denying Plaintiff William Lucas's application for Disability Insurance Benefits. All matters are pending before the undersigned United States Magistrate Judge with consent of the parties, pursuant to 28 U.S.C. § 636(c). The matter is fully briefed, and for the reasons discussed below, the Commissioner's decision will be reversed and remanded.


         In December 2012, Plaintiff filed an application for Disability Insurance Benefits (“DIB”), alleging that he became disabled beginning December 7, 2012. (Tr. 13)[2] The Commissioner initially denied Plaintiff's claims on August 8, 2013. (Id.) Thereafter, Plaintiff requested a hearing before an Administrative Law Judge (“ALJ”), which was held on December 2, 2014. (Tr. at 13, 51) Plaintiff and Delores Gonzalez, an impartial Vocational Expert (“VE”), testified at the hearing. On March 26, 2015, the ALJ issued a decision concluding that Plaintiff was not disabled under the Act. (Tr. 13-21) The Social Security Administration Appeals Council denied Plaintiff's request for review, leaving the ALJ's decision as the final decision of the Commissioner in this matter. (Tr. 1-4) Plaintiff filed the instant action on June 24, 2016. (ECF No. 1) Plaintiff has exhausted his administrative remedies and the matter is properly before this Court. Plaintiff has been represented throughout all relevant proceedings.

         Although the ultimate issue before the Court is whether substantial evidence supports the Commissioner's decision, Plaintiff presents several specific and related issues for this Court's review: (1) whether, the ALJ erred in according only limited weight to the opinion of Plaintiff's treating psychiatrist, Dr. Kulsoom Junaid, M.D.; (2) whether the evidence supports the ALJ's conclusion that Plaintiff's symptoms are generally well controlled; (3) whether the ALJ's Residual Functional Capacity assessment adequately accounts for Plaintiff's obsessive compulsive disorder symptoms; and (4) whether the ALJ erred in her consideration of the opinion of State Agency psychologist Dr. Robert Cottone, Ph.D.

         The ALJ's decision in this matter is generally thorough, thoughtful, organized and well-reasoned. On the basis of the existing record, however, the undersigned cannot say that the ALJ's decision accurately characterized Plaintiff's history and treatment for obsessive compulsive syndrome symptoms. This error does not reflect a harmless error. Hence, the matter must be remanded.


         Plaintiff is currently 37 years old. In his Disability Report - Adult form, Plaintiff listed the following mental conditions that impaired his ability to work: (1) bi-polar disorder, (2) depression; (3) anxiety; and (4) obsessive compulsive disorder (“OCD”). (Tr. 190-96) In a third party Function Report - Adult, dated June 9, 2013, Plaintiff's mother listed numerous limitations regarding his ability to work. (Tr. 212-19) Plaintiff's mother indicated that his impairments affected the following abilities: lifting, completing tasks, concentration, and getting along with others. (Tr. 217) Prior to his alleged disability onset, Plaintiff worked for his father's asphalt business.

         All of Plaintiff's relevant impairments are psychological /psychiatric in nature. The record before the Court indicates that Plaintiff received regular and consistent treatment for his symptoms from Dr. Kulsoom Junaid, M.D., from 2007 up to and beyond the date of the ALJ's decision in this matter. (Tr. 25-50, 241-302)[4] Dr. Junaid's treatment notes show consistent diagnoses of bipolar disorder and OCD, along with regular references to anxiety and depression-related symptoms. The treatment notes indicate that Plaintiff's OCD symptoms included fear of contamination (and repetitive handwashing) and checking rituals. Dr. Junaid's treatment notes show that he treated and attempted to treat Plaintiff's various symptoms with a variety of techniques and medications. Dr. Junaid made periodic adjustments and changes to Plaintiff's medications. Dr. Junaid's notes consistently indicate that Plaintiff was cooperative, logical, appropriately dressed, did not suffer from psychosis, with his memory intact, but he also continued to suffer from a variety of psychological problems. Likewise, Dr. Junaid's notes indicate that, although Plaintiff sometimes suffered side effects of his medications (e.g., drowsiness), he generally tolerated his medications well. Importantly, however, beginning no later than January 2013, and continuing until at least March 2015, Dr. Junaid's notes often indicated that Plaintiff's OCD symptoms were treatment resistant, medication resistant, and/or difficult to control. (Tr. 252, 253, 295, 297, 301, 345)

         The record also includes two relevant opinions. The first opinion is from Dr. Robert Cottone, Ph.D., which was part of a Disability Determination Explanation, dated August 8, 2013. (Tr. 91-99) Dr. Cottone did not examine Plaintiff but reviewed the medical records of Dr. Junaid available as of early June 2013. Dr. Cottone concluded that Plaintiff suffered from both affective and anxiety-related disorders, including OCD. Dr. Cottone completed a mental residual functional capacity assessment, with specific findings relative to Plaintiff's understanding and memory limitations, concentration and persistence limitations, social interaction limitations, and adaptation limitations. Based on his findings, Dr. Cottone concluded that Plaintiff's illness “would be contained more adequately if he worked with decrease[d] interpersonal interaction and less complex work activity.” (Tr. 97) Dr. Cottone opined that Plaintiff should avoid work that involves intense or excessive interpersonal interactions, customer complaints, close proximity to co-workers, and public contact. (Id.) Dr. Cottone further opined that Plaintiff could understand, remember, and carry out simple tasks, make simple work-related adjustments, relate adequately to his co-workers and supervisors, and adjust to ordinary changes in his work routine or setting. (Id.)

         The second relevant opinion was submitted in a Mental Residual Functional Capacity Questionnaire prepared by Dr. Junaid, and dated November 20, 2014. (Tr. 340-44) Dr. Junaid represented that he had been treating Plaintiff since 2007. Dr. Junaid's noted that Plaintiff suffered from bipolar disorder and OCD. Dr. Junaid reported that Plaintiff's response to treatment was only partial because Plaintiff's symptoms were treatment resistant. Regarding Plaintiff's prognosis, Dr. Junaid again noted that Plaintiff suffered from treatment resistant symptoms, and had symptoms including anxiety, fatigue, obsessive intensive thoughts, social anxiety, checking rituals, and a preoccupation with contamination. Dr. Junaid found Plaintiff either seriously limited (but not precluded) or unable to meet competitive standards in each of fifteen listed mental abilities and aptitudes needed to perform unskilled work. Regarding these limitations, Dr. Junaid noted that Plaintiff's situation is complicated by the fact that he suffers from “severe & treatment resistant obsessive compulsive disorder.” (Tr. 342) Finally, in commenting on why Plaintiff would have difficulty working on a full-time and sustained basis, Dr. Junaid again explained that Plaintiff's symptoms are treatment resistant. Dr. Junaid further explained that Plaintiff had only a partial response to medication, had tried several different combinations of medications, and still only achieved a partial response or developed side-effects.

         On December 2, 2014, the ALJ conducted a hearing on Plaintiff's applications. (Tr.51-90) Plaintiff appeared in person, with counsel. The ALJ also received testimony from independent vocational expert (“VE”) Dolores Gonzalez.


         In assessing whether Plaintiff was disabled, the ALJ followed the required five-step process laid out in the Commissioner's regulations. At step one, the ALJ found that Plaintiff had not engaged in substantial gainful activity since December 7, 2012, his alleged onset date. (Tr. 15) At step two, the ALJ found that Plaintiff had severe impairments of obsessive compulsive disorder and bipolar disorder. (Id.) The ALJ found Plaintiff's history of back and neck pain to be nonsevere.

         At step three, the ALJ found that none of Plaintiff's impairments-whether considered alone or in combination-met or equaled a listed impairment under either Listing 12.04 or Listing 12.06. (Tr. 15-17) The ALJ concluded that Plaintiff had mild restrictions in his activities of daily living, moderate difficulties in his social functioning, and mild difficulties with concentration, persistence or pace. The ALJ found Plaintiff had no episodes of decompensation of an extended duration. (Tr. 16)

         Prior to completing step four, the ALJ concluded that Plaintiff retained the residual functional ...

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