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Proctor v. Berryhill

United States District Court, W.D. Missouri, St. Joseph Division

October 10, 2017

TINA PROCTOR, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner Of Social Security, Defendant.



         Plaintiff Tina Proctor appeals the Commissioner of Social Security's final decision denying her application for supplemental security income. The decision is affirmed.

         I. Background

         Proctor was born in 1971, completed the eleventh grade, and obtained a G.E.D. She has worked as a cashier and a nurse's aide. She was struck by a car in September 2011 and spent a month in the hospital. At the time of filing her application for benefits, Proctor alleged that she became disabled on September 1, 2011. However, at the hearing before the Administrative Law Judge, Proctor, through her attorney, amended the alleged date of onset to January 21, 2014.

         The ALJ denied Proctor's application on December 4, 2015. The Appeals Council denied her request for review on November 29, 2016. Proctor's appeal to this Court concerns mental limitations.

         A. Psychological history

         Proctor suffered several fractures and traumatic brain injury after being struck by a car in September 2011. She showed “mild” impairments in cognition and behavior when she began rehabilitation. Tr. 419. At the time of discharge in October 2011, she had met all of her rehabilitation goals with respect to the TBI. Tr. 452. She could follow multi-step and nonsequential instructions, solve simple and complex problems, track basic and complex conversation, and read multi-paragraph text without assistance. Tr. 452-53. She had some deficit in attention to detail in reading, “as she gets off topic.” Tr. 453. She had decreased verbal organization and was verbose at times, and had deficits in terminating conversations and getting off topic. Tr. 454-55. She was “Not impaired” in the areas of short- or long-term memory, numerical reasoning, situational problem solving, awareness of problems, goal setting, initiation, planning, or carry over. Tr. 455. She was “Impaired” in attention/concentration (described as “mild-self distracted”), abstract reasoning (described as “mild for multi-component situations”), and organization, self-monitoring and time management (all described as “mild”). Id.

         From March 2013 through December 2013, Proctor saw Samuel Fadare, M.D., a psychiatrist, a total of eight times, or about once a month. Tr. 205-230. She reported anxiety, depression, and feelings of anger. Throughout the year, Dr. Fadare prescribed Remeron, Paxil, Viibryd, or Seroquel. In September and November 2013, Proctor reported stable symptoms on her medication, and said she felt happier. In December 2013, she reported anxiety and feelings of anger in dealing with her teenaged children, and the doctor wrote that Proctor needed “to see a therapist to help with” her children. Tr. 205. The results of her mental status exam were normal, except for “some problems with short term memory.” Tr. 208. Dr. Fadare renewed Proctor's Seroquel. Dr. Fadare never ordered in-patient treatment and Proctor was never hospitalized for mental-health related issues from March 2013 through December 2013.

         From March 2014 through July 2015, Proctor saw Dr. Fadare a total of six times, or about once every three months. At the visits, Proctor was alert, oriented, calm, and cheerful. Tr. 270, 277-78, 285-86, 293-94, 301-02, and 310. She had normal psychomotor activity, an unremarkable appearance, unremarkable speech, logical flow of thought, unremarkable thought processes, normal intellect, good insight, intact judgment, and no delusions or hallucinations. Tr. 269-70, 277-78, 285-86, 293-94, 301- 02, and 310. She was not suicidal or threating to others. Tr. 270, 277-78, 285-86, 293-94, 301-02, and 310. Her mental status exam showed “some problems with short term memory” in March 2014, June 2014, October 2014, January 2015, April 2015, and July 2015. Tr.270, 278, 286, 294, 302, and 310. Except for the March 2014 visit, however, Dr. Fadare recorded “Memory intact” on every exam. Tr. 270, 278, 286, 294, 302. The only medication that he prescribed from March 2014 through July 2015 was Seroquel, although he decreased the dosage in January 2015. Tr. 286. In October 2014, the doctor found that Proctor's symptoms were responding to the antidepressant medication, Tr. 296, and made the same finding in April 2015, Tr. 275. Dr. Fadare never ordered in-patient treatment during that time period, nor was Proctor hospitalized for mental-health related issues.

         Proctor did complain in March 2014 of feelings of anger toward a former friend who had assaulted her, and Dr. Fadare suggested she see a therapist. Tr. 307. In June 2014, she told Dr. Fadare that she felt anxious, and had difficulty about every other day in controlling her anger with her children. Tr. 304. In October 2014, Proctor reported that she felt anxious and was losing control of her anger with her children. Tr. 296. In January 2015, she reported a stable mood. Tr. 283. In April 2015, she reported that she continued to experience anxiety, anger, and mood swings a few times per week or daily, and it was mostly her “children and change” that set her off. Tr. 280. In July 2015, she reported that she was doing well and her mood was stable. Tr. 267.

         Proctor was seen in the emergency room for migraine in May 2014. The E.R. physician's exam findings included, “Psychiatric: Cooperative, appropriate mood & affect.” Tr. 508.

         At doctor's office visits in November 2014 and June 2015, the providers recorded that Proctor's mood was euthymic. Tr. 513 and 518.

         From December 2103 through September 2015, Proctor received services from a social worker. Tr. 311-401. The social worker's progress notes reflect that Proctor frequently reported improvement in her mood, and with depression and anxiety symptoms. Tr. 314, 322, 332, 336, 360, 364, 367, 370, 374, 377, and 384. Proctor also reported socializing with friends, dating, and otherwise getting out of the house. Tr. 318, 332-33, 336, 353, 360, 364, 368, 375, 377, and 379. Proctor reported having bad days and good days, “especially when it comes to her children but she feels she is doing better.” Tr. 316.

         B. Proctor's adult function report and hearing testimony

         In her adult function report dated February 22, 2014, Tr. 142-149, Proctor stated that she takes care of her children and pet, without help. She has problems falling asleep and said she remembered things better before the car accident. She prepares meals and takes care of house and yard work without help or reminders. She goes outside daily, can go out alone, and shops weekly for groceries and personal items. She is able to pay bills and handle her money. Her hobbies are reading and puzzles, but she reads less than she used to and does not work puzzles at all. She spends time with others daily, whether in person or on the computer, talking, watching television or listening to music. She has fewer friends and dates less than before. She needs reminders to go to doctor appointments and needs someone to accompany her. She said that she has trouble with “memory, concentration and understanding, due to car hitting me.” Tr. 147. Where asked on the form whether she finished what she started, she answered, “No.” Id. Where asked how well she can follow spoken instructions, she answered, “Good.” Id. She gets along with authority figures, has never been fired from a job because of problems getting along with others, is “ok with changes, ” and has no unusual behaviors or fears. Tr. 148.

         Proctor testified at the hearing before the ALJ on November 16, 2015. She has worked in the past as a cashier and as a nurse's aide. She said that she could not work now because she does not get along with others and has difficulty remembering things. Tr. 37. She testified that she tries not to go anywhere and to stay in the house to avoid dealing with people, and has short-and long-term memory problems. Tr. 39-40. She said she could not “remember anything” and had difficulty completing tasks. Tr. 40, 42. She also said that she became angry every day and had crying episodes three or four times per week. Tr. 40-42. She takes Seroquel daily, and when asked whether she had any side effects, testified, “No.” Tr. 38. She testified that she had not worked since 2008 because she had been living with a person who “was paying all [her] bills and taking care of [her].” Tr. 43.

         C. Expert opinions

         In May 2014, Esteban Alejo, M.D., performed a consultative exam. With respect to mental issues, Proctor reported symptoms of difficulty sleeping, crying spells, changes to appetite, lack of motivation, and sleeping all day. Tr. 256. Under Neurological findings, Dr. Alejo wrote, “The claimant was in a good mood. She had normal concentration, good eye contact. Speech was fluent and she had a good memory.” Tr. 258. Under Impressions, the doctor wrote, “Mental issues: Patient in good mood, no emotional distress ...

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