United States District Court, E.D. Missouri, Eastern Division
MEMORANDUM AND ORDER
M. BODENHAUSEN UNITED STATES MAGISTRATE JUDGE
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.
& SUMMARY OF DECISION
December 2012, Plaintiff filed an application for Disability
Insurance Benefits (“DIB”), alleging that he
became disabled beginning December 7, 2012. (Tr.
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.
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.
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.
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.
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) 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)
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.
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.
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
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.
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)
to completing step four, the ALJ concluded that Plaintiff
retained the residual functional ...