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Pinilla v. Berryhill

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

April 23, 2018

ROBIN L. PINILLA, 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 defendant Commissioner of Social Security denying the application of plaintiff Robin L. Pinilla for disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. § 401, et seq. The parties have consented to the exercise of plenary authority by a United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons set forth below, the decision of the Administrative Law Judge (ALJ) is affirmed.

         I. BACKGROUND

         Plaintiff Robin L. Pinilla, born September 3, 1963, applied for Title II benefits on November 18, 2013. (Tr. 14, 76). She alleged a disability onset date of January 1, 2010, due to bipolar disorder, depression, and anxiety. (Tr. 76). Plaintiff's application was initially denied on February 4, 2014. (Tr. 76-87).

         On February 27, 2014, plaintiff requested a hearing before an ALJ. (Tr. 96-97). On October 1, 2015, the ALJ heard testimony from plaintiff and Vocational Expert (VE) Teresa McLean. (Tr. 32-75). On March 23, 2016, the ALJ found that plaintiff was not disabled. (Tr. 11-31). On March 24, 2017, the Appeals Council denied plaintiff's request for review. (Tr. 1-5). Thus, the decision of the ALJ stands as the final decision of the Commissioner.


         The following is a summary of plaintiff's medical history relevant to this appeal. On November 25, 2009, plaintiff was admitted to Mercy Hospital St. Louis' intensive care unit for intentional overdose of nortriptyline. Plaintiff presented with slurred speech, depression, and suicidal ideation. Plaintiff reported she had swallowed the remainder of an old prescription of nortriptyline and written a suicide note before going to bed. Plaintiff reported one prior suicide attempt by means of Ativan overdose roughly four to five years prior. Plaintiff reported emotional instability associated with her recent decision to stop taking medication for bipolar disorder, including lithium and Lamictal. Plaintiff mentioned drinking about six cans of beer each night but denied previous problematic alcohol or drug use. Treating physician Frederick G. Hicks, M.D., prescribed Trileptal and recommended plaintiff resume taking lithium and Seroquel. (Tr. 260-66).

         On November 27, 2009, plaintiff was transferred to Mercy's psychiatric division. Discharging physician Steven A. Harvey, M.D., noted that plaintiff had successfully completed individual and group therapy while denying suicidal ideation throughout. Dr. Harvey reported that plaintiff took appropriate steps to make her home safe, including removing alcohol and old medications. Dr. Harvey reported that plaintiff was cooperative and stable on the day of discharge with no suicidal ideations or evidence of psychosis. Dr. Harvey changed plaintiff's prescription for lithium to Lithobid to alleviate gastrointestinal side effects. Dr. Harvey recommended that plaintiff follow up with her treating psychiatrist, Dr. Bhat, as soon as possible. (Tr. 288-90).

         On December 1, 2009, plaintiff saw Savita S. Bhat, M.D., to treat issues related to plaintiff's suicide attempt. Dr. Bhat continued prescriptions for lithium and Seroquel and added a prescription for Depakote. On February 16, 2010, Dr. Bhat increased the Seroquel dosage but lowered it after two months. On April 20, 2011, Dr. Bhat again raised the Seroquel dosage after plaintiff reported spending a week in bed. On July 26, 2012, Dr. Bhat prescribed clonazepam to help relieve restless leg syndrome at bedtime. (Tr. 447-59).

         On August 1, 2012, plaintiff met with Don R. Snodgrass, M.D., for a physical exam. Dr. Snodgrass reported that plaintiff had been managing her bipolar disorder by taking lithium and Seroquel and that plaintiff had not had a psychotic episode for several years. Plaintiff reported a recent mixed episode, during which she experienced extreme distress without any precipitating event. Yet, Dr. Snodgrass noted that plaintiff was “doing very well on lithium and Seroquel.” (Tr. 553-56).

         On October 1, 2013, Dr. Bhat diagnosed plaintiff with moderate bipolar 1 disorder after plaintiff underwent a general psychiatric examination. Dr. Bhat reported that plaintiff demonstrated a depressed mood and affect but also a calm and cooperative attitude, an intact memory, a logical thought process, and fair judgment. Dr. Bhat prescribed Lamictal and continued the lithium. Dr. Bhat also recommended cognitive behavioral therapy (CBT) to address anxiety and avoidance and encouraged increased physical activity. (Tr. 446).

         On December 16, 2013, plaintiff reported an ability to accomplish a number of daily activities, including: cleaning and doing laundry, playing memory games, taking her medication, preparing meals, and taking care of her dog. Plaintiff also reported a limited ability to shop for groceries, handle money, and go out in public alone. (Tr. 202-12).

         On January 18, 2014, plaintiff met with Christi Moore, Ph.D., for a consultative psychological evaluation. Plaintiff reported feeling a varying sense of hopelessness, lack of interest or pleasure in activities, challenges with sleep, and feelings of guilt. Plaintiff also reported being more likely to seek immediate assistance from her psychiatrist for medication adjustments. Plaintiff reported she does not require assistance with personal activities of daily living; however, plaintiff stated she relied on memory aids and that she needed a caregiver to help with activities outside the home. Plaintiff reported spending time with family and close friends but said she does not engage in other social activities. (Tr. 471-75).

         Dr. Moore reported that plaintiff displayed the ability to maintain adequate attention during the exam, appeared to comprehend questions, and seemed to have good practical judgment and a good understanding of more complex aspects of situations. Dr. Moore also opined that plaintiff might struggle with functioning in social settings or placements with interpersonal demands due to plaintiff's anxiety and reported memory challenges. Dr. Moore reported that plaintiff did not appear capable of managing her own funds, but concluded that with continued psychiatric and occupational supports, plaintiff could be expected to function with improvement. Dr. Moore diagnosed plaintiff with bipolar 1 disorder, panic disorder without agoraphobia, and alcohol abuse. Dr. Moore assigned a Global Assessment of Functioning (GAF) score of 46. (Tr. 475).

         On March 13, 2014, plaintiff met with Leanne Watson-Ficken, D.O., for a physical exam. Plaintiff stated her bipolar disorder had been under control, but she also reported symptoms of depression, anxiety, and sleep disturbances. Plaintiff reported no confusion or memory loss issues. Plaintiff reported consuming 4-5 drinks of alcohol once or twice per week. (Tr. 505-07).

         On May 13, 2014, plaintiff reported an increased ability to finish errands at home but also continued difficulty with driving and being in public. Plaintiff reported she had quit consuming alcohol. Plaintiff successfully completed memory tasks. Dr. Bhat encouraged plaintiff to continue setting self-care goals. (Tr. 479).

         On May 23, 2014, Dr. Watson-Ficken submitted a Physical Residual Functional Capacity (“RFC”) Assessment. Dr. Watson-Ficken noted that plaintiff was experiencing chronic depression, anxiety, and poor sleep due to bipolar disorder. Dr. Watson-Ficken reported a marked limitation in plaintiff's ability to deal with work stress, and that plaintiff's poor coping skills would make it difficult for her to work full-time on a sustained basis. Dr. Watson-Ficken expected plaintiff would be off-task more than 20 percent of an eight-hour work day and would require redirection one to two times per week. Dr. Watson-Ficken also anticipated plaintiff's impairments would cause about two absences per month. (Tr. 517-18).

         On May 23, 2014, plaintiff reported to Dr. Watson-Ficken that she was experiencing depression, anxiety, and sleep disturbances. Plaintiff reported no confusion or memory loss issues. (Tr. 502-04).

         On May 27, 2014, Dr. Bhat submitted a mental RFC assessment. Dr. Bhat identified the following symptoms: poor memory, sleep disturbance, mood disturbance, and recurrent panic attacks; however, Dr. Bhat reported that plaintiff was responding to medication. Dr. Bhat opined that plaintiff would have difficulty working a full-time job on a sustained basis. She expected plaintiff to be off-task during at least 20 percent of an eight-hour work day and to require redirection one to two times per day. Dr. Bhat was unable to assess how often plaintiff would be absent from work. (Tr. 520-21).

         Dr. Bhat noted the following functional limitations due to plaintiff's impairments: moderate restriction of daily living activities; moderate difficulty in maintaining social functioning; moderate limitation in areas of understanding and memory; frequent difficulty maintaining concentration and persistence; seldom repeated episodes of decompensation of extended duration; and moderate limitation in the ability to complete a normal work day without interruption. (Tr. 521-23).

         On August 4, 2014, plaintiff reported a relatively stable mood but also that she had trouble staying asleep. Plaintiff related an inability to leave her home without someone accompanying her. Plaintiff reported no panic, worrying, or feelings of hopelessness. Dr. Bhat encouraged plaintiff to schedule a sleep study. (Tr. 481-82).

         On four separate occasions from August 22, 2014, through July 27, 2015, Dr. Watson-Ficken conducted depression screenings indicating no need for intervention, finding that plaintiff expressed interest and pleasure in certain activities and had no feelings of depression or hopelessness. During each visit, Dr. Watson also noted that plaintiff appeared alert, oriented, and in no acute distress. (Tr. 491-501).

         On both August 22, 2014, and October 31, 2014, plaintiff reported consuming 4-5 drinks of alcohol once or twice per week. (Tr. 498-501).

         On November 4, 2014, plaintiff reported that she stopped taking Depakote because of weight gain and over-sedation, but plaintiff also stated that she was doing well emotionally. Plaintiff reported improved sleep, which she attributed to Relpax for alleviating restless leg syndrome. Dr. Bhat made a note to check plaintiff's lithium dosage to confirm therapeutic levels. (Tr. 483-84).

         On February 17, 2015, plaintiff reported a continued pattern of avoidance secondary to panic and anxiety, as well as an increased difficulty with social situations or events involving crowds. Plaintiff stated she was working with family to improve her comfort with leaving her home. Plaintiff further stated a desire to find a clerical job to get her out of the house; however, she also reported mood swings and inconsistency in feelings of hope and empowerment to make changes. Plaintiff reported disrupted sleep with 3-4 hours of uninterrupted sleep each night. Plaintiff stated she had completely abstained from alcohol for the previous 41 days. (Tr. 485).

         Dr. Bhat recommended plaintiff use an anxiety workbook after discussing strategies to overcome avoidance patterns. Dr. Bhat noted the need to avoid certain medication due to plaintiff's history of alcohol abuse. Dr. Bhat prescribed Trileptal to address ...

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