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Camden v. Berryhill

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

February 1, 2018

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



         This matter is before the Court for review of an adverse ruling by the Social Security Administration. The parties have consented to the jurisdiction of the undersigned United States Magistrate Judge pursuant to 28 U.S.C. § 636(c).

         I. Procedural History

         In April 2013, plaintiff Valerie Camden filed an application for disability insurance benefits, Title II, 42 U.S.C. §§ 401 et seq. (Tr. 200-01), with an alleged onset date of January 10, 2013. In May 2014, she filed an application for supplemental security income, Title XVI, 42 U.S.C. §§ 1381 et seq., with an alleged onset date of March 1, 2011.[2] (Tr. 236-41). After plaintiff's application for Title II benefits was denied on initial consideration (Tr. 115-19), she requested a hearing from an Administrative Law Judge (ALJ).[3] (Tr. 122-23, 124-25).

         Plaintiff and counsel appeared for a hearing on December 18, 2014. (Tr. 74-100). At plaintiff's request, the ALJ held the record open and conducted a supplemental hearing on July 17, 2015. (Tr. 21, 37-72). Plaintiff testified concerning her disability, daily activities, functional limitations, and past work. The ALJ also received testimony from medical expert Janet Telford-Tyler, Ph.D., and vocational expert Delores Gonzalez, M.Ed. The ALJ issued a decision denying plaintiff's applications on September 4, 2015. (Tr. 18-36). The Appeals Council denied plaintiff's request for review on September 1, 2016. (Tr. 1-7). Accordingly, the ALJ's decision stands as the Commissioner's final decision.

         II. Evidence Before the ALJ

         A. Disability and Function Reports and Hearing Testimony

         Plaintiff was born on June 16, 1970, and was 42 on the alleged onset date. She completed the tenth grade. She did not obtain a GED but did receive vocational training as a medical assistant. (Tr. 81). She previously worked as an administrative assistant, a waitress, a receptionist, and a truck dispatcher. (Tr. 82-88). As a truck dispatcher, plaintiff supervised, hired and fired drivers, made their schedules, and ensured they met annual licensing and drug testing requirements. (Tr. 58, 257). In September 2014, she worked as a cashier at a gas station for one month; the owner complained that she had erratic behavior because she would start to cry and leave her register. In 2015, she worked as a cashier for 15 to 20 hours a week for about two months, but she was unable to continue due to panic attacks and crying spells. (Tr. 52-53). Plaintiff next worked as a “perma sealer” in a plastics factory and continued to experience panic attacks.[4] (Tr. 54-57, 60, 221-22).

         Plaintiff listed her impairments as depression, anxiety, panic attack, and tremors. She stopped working due to her short-term memory, anxiety, panic attacks, and manic depression.[5](Tr. 278). She testified that she was unable to work due to her depression, crying, and self-isolation. (Tr. 89). Between January 2013 and June 2015 - the time period encompassed by the ALJ's decision - plaintiff was prescribed a number of medications for the treatment of anxiety, depression, and insomnia, and to reduce cravings for alcohol or substances. She took levothyroxine and Zantac for medical conditions. (Tr. 89-90, 254, 281, 287-94, 329-33).

         Plaintiff stated in her May 2013 function report (Tr. 230-38) that she attended group therapy at Community Treatment, Inc., (Comtrea) three afternoons a week and AA meetings “6-8 nights a week.” Her husband and daughter prepared dinner. She stated that she had “lost” her short-term memory and needed help remembering to take her medication. She was not able to prepare meals or complete chores without help due to her distraction and poor memory. Her medications caused shaking and blurred vision which, in combination with her poor memory, prevented her from driving. She was unable to pay bills, count change, or handle bank accounts. Plaintiff had difficulties with talking, seeing, memory, completing tasks, concentrating, understanding, following instructions, and using her hands. The Field Office interviewer noted that plaintiff's short-term memory seemed poor, and that she appeared confused and had difficulty answering questions. (Tr. 242-43).

         Plaintiff testified at the December 2014 hearing that she and her 16-year old daughter lived with her parents. (Tr. 91). On good days, she was able to do her laundry and handle some household chores. She used to golf and hunt, but no longer had any interest in doing so. She did not spend time on a computer and generally did not go anywhere other than to medical appointments. (Tr. 92-93). Her recent attempt to work as a cashier failed because she had crying spells and panic attacks when the store got crowded. (Tr. 94). From 2011 to 2013, she was dependent on alcohol and illegal drugs. She had been clean since April 5, 2013, when she admitted herself to Center Pointe Hospital. (Tr. 95). After her release, she received psychiatric treatment from Dr. Rohatgi at Comtrea until July 2014, when she asked her primary care physician, Dr. Kenneth Ross, M.D., to take over her medications.[6] (Tr. 96-97). Despite ceasing all substance use, she experienced four or five “bad days” a week due to her psychiatric symptoms and she and Dr. Ross were going to discuss electric shock treatment at her next appointment. (Tr. 98). At the July 17, 2015 hearing (Tr. 37-72), there was testimony that plaintiff was hospitalized in February 2015 following an overdose of Xanax and alcohol. (Tr. 43-44). A few days before the hearing, she had an episode of crying and shaking at work and was sent home. She contemplated admitting herself for inpatient care, but did not want to miss the hearing. (Tr. 56-57).

         At the 2015 hearing, Dr. Telford-Tyler offered her opinion about the limitations on plaintiff's mental ability to perform work-related functions, based on interrogatories and a medical source statement she completed in February 2015 (see Tr. 890-98) and plaintiff's more recent medical treatment. (Tr. 41-50). Dr. Telford-Tyler found that plaintiff's medically determinable impairments were major depressive disorder (Listing 12.04) and alcohol and cocaine dependence (Listing 12.09). Her opinion is discussed in greater detail below but, in summary, Dr. Telford-Tyler opined that plaintiff would have moderate difficulties in maintaining concentration, persistence, and pace, but was able to understand and complete simple and detailed work, with some occasional problems with more complex tasks. She was likely to miss work one or two times a month.

         Vocational expert Delores E. Gonzalez was asked to testify about the employment opportunities for a hypothetical person of plaintiff's age, education, and work experience who was able to perform work at all exertional levels but who was limited to understanding, remembering, and carrying out simple instructions. (Tr. 67). In addition, the hypothetical individual was limited to only occasional interaction with the public, coworkers, and supervisors, and could tolerate only occasional changes in work location, and could make only simple work-related decisions. According to Ms. Gonzalez, such an individual would be able to perform plaintiff's past work as a sealer. In addition, the individual could perform other work that was available in the regional and national economy, including cleaner, lab equipment cleaner, and marker. (Tr. 67-68). An individual who was absent from work, late for work or needed to leave work early one to two times a week would be unable to perform any work in the national economy. (Tr. 68). For a person working at the unskilled level, absences of more than one day a month would preclude employment. (Tr. 69-70).

         B. Medical Evidence

         The administrative record in this case includes records of plaintiff's medical care beginning in May 2010. Plaintiff confines her discussion of the medical evidence to the treatment she received beginning in March 2013. The Court briefly summarizes the earlier records.

         1. Treatment records: 2010 through 2012

         Between May 2010 and September 2012, plaintiff was treated at St. Anthony's Medical Center on seven occasions after an overdose of medication or other suicidal gesture made while intoxicated. (Tr. 369, 388, 401, 417, 442, 457, 455-56). In February 2012, plaintiff had an initial assessment at Comtrea, at the urging of a DFS caseworker. (Tr. 617). Plaintiff reported that she wanted inpatient treatment for alcohol and cocaine use, and it appears that she entered the program at Southeast Missouri Behavioral Health. (Tr. 534); (see also Tr. 442) (noting that plaintiff was allowed to sign out from St. Anthony's Hyland Center against medical advice to enter treatment program). In June 2012, plaintiff reported to psychiatrist Gautam Rohatgi, D.O., at Comtrea that she had been off all medication and sober for two months and was attending AA meetings. (Tr. 530-31). She was diagnosed with major depressive disorder, recurrent; generalized anxiety disorder; cocaine dependence in early sustained remission; and alcohol dependence in early sustained remission. Dr. Rohatgi prescribed the antidepressant amoxapine, and antipsychotic Haldol. Although plaintiff reported improvement in her symptoms on July 28, 2012, she was treated in the emergency department on July 29, 2012, and again on September 3, 2012, after being found unresponsive as a result of mixing alcohol and medication. (Tr. 528, 455, 457). In October 2012, plaintiff reported that she had been drinking and requested a support group. (Tr. 579). She was referred to Comtrea's substance treatment program and, in November 2012, began attending education and support groups and receiving services from a community support specialist and a substance abuse counselor. (Tr. 581, 574-75, 576-77, 558-59).

         2. Treatment records: 2013 through 2015

         In February 2013, plaintiff reported to substance abuse counselor Peter Ninneman, M.S.W., that “everything is good.” She was looking for a job and had gone to court and reported to her community service assignment. She reported some side effects of medication. (Tr. 556). Plaintiff resumed medication review with Dr. Rohatgi in January 2013. (Tr. 524-25). On March 1, 2013, Dr. Rohatgi noted that plaintiff was sad and depressed and was sleeping too much. She had multiple psychosocial stressors. On examination, plaintiff was quite guarded and quiet, with fair-to-poor eye contact. She had minimal spontaneous speech. Her insight and judgment were fair to poor. She was diagnosed with major depressive disorder, recurrent, mild to moderate; generalized anxiety disorder; and cocaine dependence and alcohol dependence in early sustained remission. Dr. Rohatgi made changes to plaintiff's antidepressant medications. On March 7, 2013, plaintiff told Mr. Ninneman that her mood had improved with the medication changes and that she wanted to taper off Xanax. She admitted to drinking small quantities of alcohol. (Tr. 547-48). On March 30, 2013, plaintiff was taken to St. Anthony's Medical Center in police custody after an overdose of alcohol and Xanax, which she denied was a suicide attempt. (Tr. 479-80, 482-84, 520). She was variously described as combative, agitated, and labile, and ultimately required physical and chemical restraint. Once sober, she was anxious and worried but not suicidal. She was discharged to continue in outpatient treatment. (Tr. 485). On April 1, 2013, plaintiff told Dr. Rohatgi that she had difficulty controlling the urge to drink. (Tr. 520-21). She denied feeling depressed and, on examination was cooperative, with good eye contact, linear thought processes, and frustrated mood. Her insight and judgment were poor. Dr. Rohatgi directed plaintiff to speak with her primary care physician about discontinuing Xanax and starting gabapentin. He prescribed ReVia.[7] On April 2, 2013, plaintiff told Mr. Ninneman that she was having difficulty handling stress. She was unhappy with the total abstinence requirement and reported that her husband was abusive and enabled her continued drinking. (Tr. 544-45). Mr. Ninneman gave plaintiff referrals for medical detoxification programs at her request.

         Plaintiff was admitted to Center Pointe Hospital's inpatient chemical dependency unit on April 5, 2013. (Tr. 502-06). She reported that she had been drinking a fifth of vodka a day for about three months and using methamphetamine periodically. A physical examination was unremarkable, with the exception of elevated thyroid stimulating hormone levels. She was started on Synthroid. (Tr. 507-09). At discharge on April 19th, it was noted that plaintiff actively participated in all phases of the rehabilitation program. (Tr. 501). She was described as making good progress and motivated to continue a recovery program. She wished to move with her teenaged daughter to her parents' home. At discharge, her diagnoses were polysubstance dependence, rule out bipolar disorder NOS; alcohol dependence; and hypothyroidism. Her discharge medications included Cogentin to address extrapyramidal symptoms, Tegretol as a mood stabilizer, trazadone for insomnia, Vistaril for anxiety, Neurontin, Prilosec, and Synthroid. She was directed, pursuant to a court order, to follow-up with Comtrea. (Tr. 501-02).

         Plaintiff attended regular group meetings at Comtrea. (Tr. 780-89). She met with Dr. Rohatgi for medication management every three or four weeks. In May 2013, she reported that she had detoxed from Xanax while at Center Pointe. (Tr. 796-97). She denied any depression or loss of interest, but was uncomfortable due to medication side effects, including sedation, tiredness, confusion, and fatigue. On examination, she was cooperative, with good eye contact, linear thought processes, and fluent, clear speech. Her affect was “worried due to the side effects of these medications.” Her insight and judgment were fair. Dr. Rohatgi made changes to plaintiff's medication and directed her to contact the clinic if she noticed any deterioration in her mood or behavior. In June 2013, the side effects had dissipated, but she complained of mood swings, frustration, anger, anxiety, and difficulty with short-term memory. She reported that her medications were effective in curbing her desire for alcohol and drugs. On examination, she was cooperative and had good eye contact, linear thought processes, and fluent, clear speech. Her mood was tired and anxious, and her affect was worried. Her insight and judgment were fair. Her diagnoses were major depressive disorder, recurrent; generalized anxiety disorder; and alcohol dependence and cocaine dependence in sustained early remission. Dr. Rohatgi again made medication changes. (Tr. 825-26). In July 2013, plaintiff reported that the mood swings, anger, and irritability had abated and she was maintaining sobriety. Dr. Rohatgi determined that her depression was in full remission and made no changes to her medication. (Tr. 823-24).

         Beginning in August 2013, plaintiff experienced multiple stressors: her husband was drinking heavily, her daughter was assaulted by a neighbor, and she and her daughter moved into her parents' home. She used alcohol at least once in August. (Tr. 783). On August 29, 2013, she told Dr. Rohatgi that she had been without medication for two weeks. He declined her request for Valium and Xanax, explaining that they were not in her best interest, and restarted her medications. On examination, she was cooperative, with good eye contact and linear thought processes, and fluid, clear speech. Her affect was angry, upset, and sad. Her insight and judgment were fair. (Tr. 819-20). In September 2013, Dr. Rohatgi noted that plaintiff improved once she resumed her medications. (Tr. 821-22). She reported that her anxiety had decreased by 20-30%, but her sleep was disturbed. She continued to experience a number of stressors but was coping as best as could be expected and meeting her responsibilities, despite feeling sad, angry, and frustrated over recent events. She denied all alcohol and drug use. On examination, her affect was calm and appropriate, her mood was frustrated and upset, and her insight and judgment were fair. Dr. Rohatgi made some alterations to her medications and set a follow-up appointment in two weeks.

         On October 4, 2013, plaintiff reported that she was having difficulty sleeping and so had changed her gabapentin dosage and was taking Nyquil. (Tr. 817-18). In addition, she had taken Valium, which was detected in a drug screen administered to her after a car accident. She stated that she was not having mood swings or irritability, but continued to feel sad, angry, and frustrated. She was performing her activities of daily living. Dr. Rohatgi prescribed doxepin for insomnia. On October 31st, plaintiff reported that she still experienced disturbed sleep. (Tr. 815-16). She was otherwise doing well in that her agitation and irritability had decreased and her mood was more calm and relaxed. She did not experience mood swings, mania, depression, loss of interest, or cravings for alcohol or drugs. She was planning to start working in a relative's cleaning business. Dr. Rohatgi diagnosed her with major depressive disorder, recurrent, improved; generalized anxiety disorder; and alcohol dependence and cocaine dependence in sustained early remission.

         Plaintiff's engagement with services at Comtrea dropped off between November 2013 and January 2014, and she faced dismissal from the program. (Tr. 766-80). During a phone call in December, she told Mr. Ninneman that she was moving and had enough medication to last until January. He agreed to send her referrals for treatment providers in her new area. (Tr. 775). In late January 2014, plaintiff called Mr. Ninneman and reported that she was still living with her parents and was home schooling her daughter. She agreed to make an appointment at Comtrea. (Tr. 766).

         On February 4, 2014, plaintiff told Dr. Rohatgi that she was doing well and coping appropriately with various stressors, although she had trouble sleeping. (Tr. 813-16). He made some changes to her medication. He described her as quite guarded and diagnosed her with major depressive disorder, recurrent, in full remission; generalized anxiety disorder; and alcohol dependence and cocaine dependence in sustained early remission. On February 28, 2014, plaintiff reported that she was still struggling with depression, and rated her anxiety level at 10 on a 10-point scale. She continued to struggle with sleep and stated that she had racing thoughts. She was helping her mother take care of her father, who was now disabled. She was informed that she needed to remain alcohol free and have consistent attendance in order to graduate from the substance abuse program. (Tr. 875-76). On March 24, 2014, plaintiff told Mr. Ninneman that she was working and had gotten a car. (Tr. 864-65). She reported that there were days when she did not want to get out of bed and she had used alcohol on two occasions. Her goal was to drink in moderation, rather than “shoot for abstinence.” She understood that abstinence was required to complete the program, however, and stated that she would avoid “happy hour for ten weeks.” In April 2014, she reported that she was working and had a better relationship with her daughter. She said she was maintaining sobriety, even though she was tempted to drink. (Tr. 860-61). She had stopped taking her thorazine “to see if it would make a difference, ” because going off her medications was “the only thing that gives excitement to my life.” (Tr. 861). She agreed not to make any more medication changes without consulting with Dr. Rohatgi first. Plaintiff's urine screens came back positive for alcohol and benzodiazepines on April 17, and May 6, 2014. (Tr. 862, 855). She admitted to taking two sips of wine and taking a prescription cough medicine, but denied taking benzodiazepines. She worried about the impact of the positive test on her probation status. (Tr. 856).

         On June 10, 2014, plaintiff reported to Mr. Ninneman that she was attending AA, staying sober, and enjoying work as a school bus driver. (Tr. 847-48). She was finding it much easier to stay sober “because she is doing the kind of work she wants to.” Unfortunately, her job was terminated a few days later based on her past drug offense. (Tr. 841). By late June, she was working in the family cleaning business again. (Tr. 838). Dr. Rohatgi noted that plaintiff's mood was euthymic as long as she was taking Cymbalta and Haldol. (Tr. 809-10). She agreed to accept a referral to a sleep specialist to address her continuing insomnia. Plaintiff's diagnoses were major depressive disorder, recurrent, in full remission; generalized anxiety disorder; and alcohol dependence and cocaine dependence in sustained early remission. In July 2014, she was preparing for discharge from Comtrea. (Tr. 834-35). She had spoken with the pastor of her church about forming a support group. On August 6, 2014, she successfully completed the alcohol and ...

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