United States District Court, E.D. Missouri, Northern Division
JOHN D. SCHMELZLE, Plaintiff,
NANCY A. BERRYHILL, Deputy Commissioner of Operations, Social Security Administration, Defendant.
MEMORANDUM AND ORDER
M. BODENHAUSEN UNITED STATES MAGISTRATE JUDGE
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).
October 17, 2014, plaintiff John D. Schmelzle protectively
filed applications for disability insurance benefits, Title
II, 42 U.S.C. §§ 401 et seq., and
supplemental security income, Title XVI, 42 U.S.C.
§§ 1381 et seq., with an alleged onset
date of May 3, 2013. (Tr. 207-08, 209-14; see also Tr.
141, 142). Plaintiff subsequently amended his alleged onset
date to October 8, 2014. (Tr. 293). After plaintiff's
applications were denied on initial consideration (Tr.
145-50), he requested a hearing before an Administrative Law
Judge (ALJ). (Tr. 151-52).
and counsel appeared for a hearing on May 19, 2016. (Tr.
45-63). Plaintiff testified concerning his disability, daily
activities, functional limitations, and past work. The ALJ
also received testimony from vocational expert Jacqueline R.
Bethell, MS. The ALJ issued a decision denying
plaintiff's applications on July 14, 2016. (Tr. 22-36).
The Appeals Council denied plaintiff's request for review
on June 23, 2017. (Tr. 1-6). Accordingly, the ALJ's
decision stands as the Commissioner's final decision.
Evidence Before the ALJ
Disability and Function Reports and Hearing
who was born on November 12, 1968, was 45 years old on the
amended alleged onset date. He completed high school with
some special education classes and received training in
building trades while in prison. (Tr. 236, 45). Between 2000
and 2009, plaintiff worked as a custom cabinet builder. (Tr.
244). He was incarcerated from May 2010 to June 2011. (Tr.
85). He worked for an auto parts business in 2012 and 2013,
cleaning and fueling trucks and loading salvaged auto parts
for shipment. (Tr. 246). He returned to custom woodworking in
early 2013. (Tr. 45-46). That job ended on May 3, 2013 when
he was incarcerated “due to [a] bipolar episode.”
Disability Report; but see Function Report (stating
he was fired from job after being arrested following an
altercation with his wife) (Tr. 236, 254).
listed his impairments as bipolar disorder, attention deficit
hyperactivity disorder (ADHD), anxiety disorder, obsessive
compulsive disorder, antisocial personality, a gunshot wound
to his left hand, carpal tunnel, rotator cuff problems, and
dyslexia. (Tr. 235). He was prescribed medications for the
treatment of bipolar disorder, mood disorder, depression,
ADHD, poor sleep, and high cholesterol, in addition to an
anti-inflammatory for musculoskeletal pain. (Tr. 239).
stated in his December 2014 function report that he lived
with his sister and brother-in-law. (Tr. 249-56). His daily
activities consisted of smoking, drinking coffee, and
sitting. He did laundry, washed dishes, and mowed grass. He
did not prepare his own meals and ate only one meal a day. He
no longer cared about his appearance, leaving it to others to
remind him to take care of his grooming and personal hygiene.
He slept about two hours a night. He was capable of managing
his finances. He had pain in his shoulders and lacked
strength and feeling in his left hand and thus could no
longer participate in his former hobbies of hunting, fishing,
and woodwork. He was able to walk without restriction. He
stated that he was always aware of his surroundings but did
not pay attention. He could concentrate for 15 to 30 minutes
at a time, but had difficulty finishing what he started and
could follow spoken instructions more easily than written
instructions. He did not like being around other people and
did not get along with authority figures or handle changes in
routine well. Plaintiff had difficulties with lifting,
reaching, memory, completing tasks, concentrating, following
instructions, and getting along with others. The Field Office
interviewer did not note any unusual behaviors. (Tr. 233).
Schmelzle, plaintiff's estranged wife, completed a
third-party function report in December 2014. (Tr. 260-67).
She had known plaintiff since 2011. She described him as
“not social” and “not motivated for any
activity;” indeed, she said, he spent his days looking
out the window, watching television, and drinking coffee. She
reported that he only slept two hours a night and was
depressed to the point that he did not care about eating or
his appearance. According to his wife, plaintiff could not
lift more than 10 pounds without shoulder pain. He had no
grip or dexterity in his hands and could no longer do things
like cook. In addition, he could not control his temper and
so was unable to tolerate being around others. He argued with
others “all the time because he thinks he's always
right” and became angry if someone told him how to do
something. (Tr. 264-65). He needed reminders to go places and
was unable to concentrate for more than a few minutes. He
misread written instructions and forgot half of any verbal
instructions. In response to stress, he became angry, caused
arguments, and threw things. She also described some
idiosyncrasies; for example, he was a hoarder and would not
use the washer and dryer for fear that they would break. He
also believed that there was always someone out to get him
and he was “afraid to get old.” In a narrative
section, Ms. Schmelzle wrote that plaintiff had suffered
abuse as a child and “cause[s] problems with everyone
around him.” (Tr. 267).
testified at the May 2016 hearing that he moved to his
sister's house after separating from his wife in 2013.
His sister restricted him to the lower level of her
split-level house because she did not want him around the
children who lived in the home. (Tr. 55, 62-64). He spent the
days walking around in the woods or sitting and staring at
the wall. He did not watch television and denied knowing how
to use the internet or social media, although his wife
previously set up a social media account for him. His sister
bought his groceries and counted his pills to make sure he
was taking his medication. His driver's license was
revoked for unpaid child support and he relied on his mother
and sister to drive him places. (Tr. 60-61). He no longer did
any household chores or yard work. (Tr. 62-63).
testified that the first two fingers of his left hand were
shot off in an accident in 1993. The fingers were reattached
but he said that he had no sensation in the fingers and was
unable to bend them. As a consequence, his left forearm was
atrophied and he could not use his left hand to grip or lift
anything heavier than a shoe or coffee cup. In addition, he
had undergone carpal tunnel surgery on his left wrist. He had
pain in both shoulders, especially when reaching overhead
with his left arm. Despite his impairments, plaintiff had
been employed by a friend to load trucks. He explained to the
ALJ that he used his right arm to pick up the items and then
slid them into the truck. (Tr. 47-49, 57-59).
respect to his mental conditions, plaintiff stated that he
did not like to be in public places because he had anxiety
“all the time.” When he was around other people,
he got headaches, became extremely nervous or irritable, and
was likely to lash out or fight. He stated it was
“safer” for everyone if he avoided interacting
with other people. (Tr. 50-52). He had lost his last job due
to constant arguing with his boss about being given
instructions. His sleep patterns fluctuated between sleeping
“all the time” or not at all. In the three days
before the hearing he had slept only two hours. (Tr. 52-53,
57-58). His weight also fluctuated. (Tr. 57). He took
medications to stabilize his mood and was seeing a counselor.
expert Jacqueline Bethell 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 light work; who could lift or carry 20 pounds
occasionally and 10 pounds frequently; who could sit for six
hours in an eight-hour day, stand or walk for six hours in an
eight-hour day; could frequently reach, handle and finger;
and who was restricted from crawling and climbing ladders,
ropes or scaffolds; and who needed to avoid hazardous
conditions. In addition, this individual was limited to
performing simple and routine tasks, with occasional
interaction with supervisors and coworkers, in an environment
in which the individual would not be around members of the
public or be required to interact with the public on the
employer's behalf. (Tr. 64-65). According to Ms. Bethell,
such an individual would be able to perform work that was
available in the national economy such as office helper,
labeler, or mail clerk. (Tr. 66-67). When asked to assume
that the individual was restricted to only occasional
fingering, in addition to requiring no public contact, Ms.
Bethell testified that these three occupations and, indeed,
all other unskilled light positions would be ruled out. (Tr.
67-68). There were sedentary positions without public contact
that did not require more than occasional fingering, such as
surveillance system monitor and cutter and paster,
they were not widely available. (Tr. 69-70). Furthermore,
these jobs would not be available if, for 20 percent of the
time, the hypothetical individual was unable to accept
instructions or criticism, get along with peers without
distracting them, maintain basic standards of appropriate
behavior and grooming, and get along with the general public.
(Tr. 70). Finally, there would be no work available in the
national economy if the hypothetical individual was absent
from work two or more days per month or made threats of
violence. (Tr. 73).
received mental health treatment from East Central Mo
Behavioral Health Services (BHS) as a condition of
probation. Catherine Browning, DNP, PMHNP, provided
medication management and Dennis Campbell, MSPSY, provided
counseling. He also received primary medical care from
Mark Tucker, DO,  and surgery for carpal tunnel syndrome
from Christopher M. Bieniek, MD.
had eight appointments for medication management with Ms.
Browning between July 17, 2014, and February 10, 2016. (Tr.
315-19, 320-24, 325-29, 358-62, 363-68, 369-73, 374-79,
394-98). The treatment notes state that he had multiple
incarcerations for assault and firearm charges and was barred
by the terms of his probation and an ex parte order from
living with his new wife and her children. (Tr. 315); see
also Tr. 330 (plaintiff reported spending 11 of his
adult years in prison for violence and assault); 397 (noting
history of 300 assault charges). His aggressive tendencies
were exacerbated by alcohol, which he stopped using in
September 2013. (Tr. 316, 85). The treatment notes for each
session state that plaintiff had the following symptoms:
anxiety, compulsive behaviors, depression, hyperactivity,
obsessive thoughts, poor concentration, and racing thoughts.
In addition, plaintiff's mental status at every session
was agitated, guarded and cooperative, with a disheveled
appearance. His mood was anxious, depressed, and irritable,
and his affect was anxious and sad. He avoided eye contact.
His speech was pushed and rapid. While his flow of thought
was logical, the content of his thoughts included anxieties,
hopelessness, and worthlessness. He had no delusions or
hallucinations, was well oriented, and had fair insight and
judgment. For each of the first six sessions, plaintiff was
assigned a Global Assessment of Functioning (GAF) score of
thereafter, BHS discontinued using the GAF. (Tr. 376-77,
397). His diagnoses were bipolar disorder, most recent
episode depressed, and history of alcohol dependence.
Throughout the period under review, plaintiff was prescribed
medications for depression,  mood stabilization and
aggression,  and ADHD in addition to trazadone for
sleep, and benztropine for control of extrapyramidal
medical record begins with a session on July 17, 2014. Ms.
Browning noted that plaintiff had reconciled with his wife
and was living in the family home. (Tr. 315-19). He was
trying to spend time outside and looked healthier. He had
completed an application for Medicaid. Ms. Browning directed
plaintiff to continue taking his medications and noted that,
once he had Medicaid, he would be able to resume medications
known to be effective for his ADHD symptoms and mood
underwent a new patient evaluation with Dr. Mark Tucker on
October 8, 2014. (Tr. 305-08). He complained that he had pain
in his right shoulder and was losing feeling in his hands,
with his left hand “going to sleep.” He had a
history of periodic migraine headaches but they had improved
with his mood stabilization medication. On examination, Dr.
Tucker described plaintiff as awake, alert and oriented, with
stable mood, attention and focus. Plaintiff had tenderness
and positive signs of rotator cuff tendinitis in his right
shoulder, while his left wrist was tender over the carpal
ligament and his left hand was visibly swollen. Dr. Tucker
diagnosed plaintiff with rotator cuff tendinitis, for which
he administered a steroid injection, and probable carpal
tunnel syndrome, for which he prescribed a nonsteroidal
anti-inflammatory. Dr. Tucker also agreed to refill
plaintiff's prescriptions for mood stabilization and
sleep, after plaintiff explained that it was difficult to get
refills from Ms. Browning in a reasonable time. Blood tests
revealed that he had very high lipid levels and he was
started on a statin medication. (Tr. 309, 311). Dr. Tucker
urged plaintiff to quit smoking.
October 21, 2014, Ms. Browning noted that plaintiff was
“back with” with his wife. (Tr. 320-24). He
continued to present multiple symptoms of ADHD, including
lack of attention to detail, poor focus, poor follow-through
on tasks, constant fidgeting and restlessness, poor
listening, and interrupting others. He also had some
aggression and needed ongoing assistance with anger
management. Plaintiff agreed to a referral to services from
BHS's Community Psychiatric Rehabilitation Center and
“HCH” nurse. Ms. Browning added Seroquel to his
other medications and noted that she would consider changing
plaintiff's antidepressant medication in the future.
tests completed in October and November 2014 showed that
plaintiff had mild and moderate degenerative joint disease of
the right shoulder, in addition to a configuration that could
contribute to impingement. He also had mild bursitis,
tendinopathy, and a labral tear. (Tr. 300-02). In October,
Dr. Tucker prescribed high doses of aspirin to treat the
shoulder pain, and on November 25, 2014, Dr. Bieniek injected
plaintiff's right shoulder. (Tr. 309-12, 314). Dr.
Bieniek performed carpal tunnel release surgery on
plaintiff's left wrist on December 4, 2014. (Tr. 332-47).
At follow-up on December 9, 2014, Dr. Bieniek found that
plaintiff's numbness was “improving nicely”
and released him from care without restrictions. (Tr. 313).
December 1, 2014, plaintiff began individual counseling with
Dennis Campbell with the goal of developing emotional
regulation skills. (Tr. 330-31). He reported problems with
irritability, racing thoughts, depression, and lack of
restorative sleep. He stated that he slept about 10 hours a
week, but he also acknowledged that he drank three pots of
coffee a day. Although he was living with his wife and her
children, he stated that he did not trust people and
preferred to be alone. In addition, he no longer had any
interest in doing things he used to enjoy, such as woodwork.
He stated that his symptoms worsened when he learned that his
wife was unfaithful. A few days later, Ms. Browning noted
that plaintiff “appear[ed] calmer than ever.”
(Tr. 325-29). He reported that his medications were working
well. He still had quick mood changes which he coped with by
withdrawing from others. Based on the results of an