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Bindner v. Berryhill

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

February 21, 2018

PAUL BINDNER, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         This action is before the court for judicial review of the final decision of the Commissioner of Social Security finding that plaintiff Paul D. Bindner is not disabled and, thus, not entitled to Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act, 42 U.S.C. §§ 401-434. The parties have 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 affirmed.

         I. BACKGROUND

         Plaintiff was born on March 14, 1989. (Tr. 65). Plaintiff filed an application for DIB on November 7, 2015, when he was 26 years old, alleging an onset date of August II, 2015.[1] (Tr. 129-31, 211). Plaintiff alleges that he suffers from major depressive disorder with residuals of a traumatic brain injury, sleep apnea, left shoulder strain, lumbar spine strain, right knee strain with bursitis and tendonitis, and tinnitus. (Tr. 202). Plaintiff's application was denied on December 28, 2015, and he requested a hearing before an administrative law judge (“ALJ”). (Tr. 78-85). A hearing was held in June 2016, where plaintiff, a vocational expert (“VE”), and a witness testified. (Tr. 28-64). By decision dated July 29, 2016, the ALJ found that plaintiff was not disabled under the Social Security Act. (Tr. 14-23). The ALJ determined that plaintiff retained the residual functional capacity (“RFC”) to perform jobs available in significant numbers in the national economy. Id.

         On February 15, 2017, the Appeals Council of the Social Security Administration denied plaintiff's request for review of the ALJ's decision, making the ALJ's decision the final decision of the Commissioner to be reviewed in this case. (Tr. 1-5). Plaintiff argues that the ALJ's decision is not supported by substantial evidence. (Doc. 18). He asks that the ALJ's decision be reversed and an award of benefits entered or that the case be remanded for further proceedings.

         A. Medical Record and Evidentiary Hearing

         Relevant to the issues before the court are the following facts. Plaintiff served on active duty with the United States Air Force from 2009 through November 2015, when he was medically discharged. (Tr. 202-03). Plaintiff underwent counseling from October 2014 through August 2015, at which time the Air Force placed him on convalescence leave, and then again from January through June 2016. (Tr. 36, 501, 911, 916, 924, 941, 944). The majority of his treatment records predate his alleged onset date of August 11, 2015.

         On October 8, 2014, plaintiff self-referred to an Air Force medical clinic “for depression associated with high job dissatisfaction.” (Tr. 951). He met with Joseph C. Stankus, Ph.D., a licensed clinical psychologist, and stated he was unhappy at his job in finance and preferred to work with his hands in “wide-open spaces.” (Tr. 951). Dr. Stankus observed that plaintiff had a limited affect, but was otherwise normal with a good prognosis. (Tr. 951-57). Dr. Stankus diagnosed plaintiff with problems related to employment and ruled out adjustment disorder with depressed mood. (Tr. 954). He determined that plaintiff did not need any alterations to duty status and was fit for continued military service. (Tr. 957).

         At subsequent sessions, from October 2014 to March 2015, then again in July and August 2015, plaintiff repeated his discouragement at having to do a job “he basically hates, ” low morale about his job, and his desire to get out of the Air Force. (Tr. 958, 971, 976, 980, 996, 1007, 1011, 1017, 1026, 1033, 1039, 1064, 1214, 1226).

         On November 17, 2014, plaintiff informed Wenjing Cao, PMHAPN-BC, a psychiatric nurse practitioner, that he only took medication to help him cope with work and he planned to stop taking it when he went on vacation to visit his farm. (Tr. 992). On December 8, 2014, he reported to Nurse Cao that he stopped his medications during his two week vacation and “had a good time during his visit, worked outdoors, fixed his jeep, cut firewood, shot some targets, did pretty much the things he planned.” (Tr. 1002). When he returned, he reported he would try medication again to cope with his job stressors. (Tr. 1002).

         In March 2015, plaintiff reported trouble keeping his continuous positive airway pressure (“CPAP”) mask on, and he was “strongly urged” to keep trying anyway, because he could not become accustomed to it unless he wore it consistently. (Tr. 695).

         On June 3, 2015, plaintiff met with Dr. Stankus and reported that once he left the service, he wanted to spend 6 to 12 months on his farm doing various repairs on fences, the barn, and the house. (Tr. 616).

         On June 22, 2015, plaintiff reported to Kurt R. Guindon, M.D., that his Klonopin medication was “spot on, ” leaving him relatively anxiety-free, centered, and functional. (Tr. 576). Dr. Guindon urged him to try his CPAP now that he had this medication, as it might help him better tolerate the mask. (Tr. 576). The following day, plaintiff reported to Dr. Stankus that his sleep had improved and he was getting 6 to 7 hours of sleep a night. (Tr. 574). One week later, plaintiff stated his sleep had improved but was still fitful. (Tr. 571). Dr. Guindon noted that plaintiff “bucked” off the CPAP at night, had markedly interrupted sleep, and did not feel rested during the day. (Tr. 507, 521, 547, 556, 578). He diagnosed plaintiff with sleep onset myoclonus and insomnia. (Tr. 508, 522, 535, 557, 579).

         On July 6, 2015, Dr. Guindon noted that plaintiff had a case of severe anxiety that he believed met the threshold for generalized anxiety disorder. (Tr. 554). Dr. Guindon opined that plaintiff's anxiety disorder would require second generation antipsychotics and benzodiazepines. (Tr. 554). Dr. Guindon increased the Klonopin and another drug and discontinued a third drug. (Tr. 554). Dr. Guindon also opined that plaintiff had elements of post-traumatic stress disorder, in that he re-experiences events, has extreme hypervigilance, has arousal and reactivity, and has anger and irritability. (Tr. 557).

         On July 7, 2015, in response to a medical benefits questionnaire, plaintiff reported trouble with his CPAP machine. (Tr. 325). He reported that he had difficulty keeping it in place and had not had a full night of sleep with it in place, so he continued to experience some symptoms of daytime sleepiness associated with his upper airway resistance syndrome/sleep apnea. (Tr. 334).

         On July 9, 2015, plaintiff complained that the Klonopin was now making him feel drowsy and unable to stay alert. (Tr. 552). Dr. Guindon reduced the dosage, stating that they were “struggling to find the window between sedation and reasonable anxiolysis.” (Tr. 552).

         On July 16, 2015, plaintiff reported that his girlfriend had left for two weeks of temporary duty and that he could not stop crying at work that day. (Tr. 542). On July 20, 2015, he reported that he continued to miss his girlfriend, but he was trying to cope by “keeping busy, ” including cleaning the house and repairing and detailing his girlfriend's car. (Tr. 540-42). He reported that he continued to miss his girlfriend, but his crying spells had reduced to one time per day. (Tr. 540). He remained quite depressed at night and sleep remained problematic. (Tr. 540).

         On July 28, 2015, plaintiff called Dr. Guindon to report severe anxiety and that the medication was wearing off in the afternoon, causing agitation. (Tr. 526). Dr. Guindon made some adjustments in his medication plan and instructed him to come in the next day. (Tr. 526).

         On August 10, 2015, plaintiff reported becoming more irritable and “rageful” and that he had difficulty going out in public. (Tr. 514). He stated the only time he felt reasonably calm was at home. (Tr. 514). Dr. Stankus suggested the possibility of inpatient hospitalization, but plaintiff declined because he did not want to be separated from his girlfriend. (Tr. 514).

         Following his alleged onset date, on August 17, 2015, Dr. Guindon confirmed diagnoses of generalized anxiety disorder, major depression, and adjustment disorder with anxiety and depressed mood, and intended to extend plaintiff's convalescence leave. (Tr. 511). He noted plaintiff was experiencing anxiety with profound and detailed worry, panic, some increase in anger and irritability, obsessive-compulsive disorder, some disillusionment, PTSD, and demoralization. (Tr. 507-08). However, Dr. Guindon also opined that Valium was working much better than Klonopin, and that plaintiff's anger had considerably improved. (Tr. 505). Plaintiff reported that he was working from home and “much less tortured by his anxiety.” (Tr. 505). Plaintiff reported feeling a bit tired, but functional, and Dr. Guindon observed that he had a calmer mood with congruent affect. (Tr. 505).

         On August 26, 2015, plaintiff reported to Dr. Stankus that he planned to live on his farm, raise fowl, get an apprenticeship working on airplanes in exchange for free flight time at the local airport, and complete his pilot's license. (Tr. 501). Plaintiff was taking Seroquel and Valium at the time. (Tr. 501). Dr. Stankus noted that plaintiff was very anxious, noticeably agitated, and broke down in tears during the session. (Tr. 502). Plaintiff also reported he could not tolerate the CPAP machine. (Tr. 502).

         Plaintiff cancelled follow-up appointments with Dr. Stankus that were scheduled in September and October 2015. (Tr. 500). After the August 26, 2015 appointment, plaintiff did not receive any additional treatment until January 21, 2016, following his medical discharge form the ...

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