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Hamilton v. Berryhill

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

March 21, 2019

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         This matter is before the Court on Angela Hamilton's appeal regarding the denial of disability insurance benefits and supplemental security income under the Social Security Act. The Court has jurisdiction over the subject matter of this action under 42 U.S.C. § 405(g). The parties have consented to the exercise of authority by the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). [Doc. 9.] The Court has reviewed the parties' briefs and the entire administrative record, including the transcript and medical evidence. Based on the following, the Court will reverse and remand the Commissioner's decision.

         Issue for Review

          Hamilton presents one issue for review. She asserts that the ALJ failed to properly evaluate her treating physicians' medical opinions and the agency psychologist's opinion. The Commissioner contends that the ALJ's decision is supported by substantial evidence in the record as a whole and should be affirmed.

         Standard of Review

         The Social Security Act defines disability as an “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. §§ 416(i)(1)(A), 423(d)(1)(A).

         The standard of review is narrow. Pearsall v. Massanari, 274 F.3d 1211, 1217 (8th Cir. 2001). This Court reviews the decision of the ALJ to determine whether the decision is supported by substantial evidence in the record as a whole. 42 U.S.C. § 405(g). Substantial evidence is less than a preponderance, but enough that a reasonable mind would find adequate support for the ALJ's decision. Smith v. Shalala, 31 F.3d 715, 717 (8th Cir. 1994). The Court determines whether evidence is substantial by considering evidence that detracts from the Commissioner's decision as well as evidence that supports it. Cox v. Barnhart, 471 F.3d 902, 906 (8th Cir. 2006). The Court may not reverse just because substantial evidence exists that would support a contrary outcome or because the Court would have decided the case differently. Id. If, after reviewing the record as a whole, the Court finds it possible to draw two inconsistent positions from the evidence and one of those positions represents the Commissioner's finding, the Commissioner's decision must be affirmed. Masterson v. Barnhart, 363 F.3d 731, 736 (8th Cir. 2004). The Court must affirm the Commissioner's decision so long as it conforms to the law and is supported by substantial evidence on the record as a whole. Collins ex rel. Williams v. Barnhart, 335 F.3d 726, 729 (8th Cir. 2003).


         Hamilton contends that the ALJ improperly weighed the medical opinions in this case. There were four medical opinions in the record authored by Hamilton's treating psychiatrists Dr. Julio Bernardi and Dr. Michael Wenzinger, state agency psychologist Dr. Raphael Smith, and consultative examiner Dr. Amy J. Marty, a psychologist. Hamilton asserts that the ALJ failed to properly evaluate the opinion evidence provided by Dr. Bernardi, Dr. Wenzinger, and Dr. Smith.

         Hamilton's Medical Record

         The medical record in this case is small. The first treatment record concerns Hamilton's hospital admission from February 25, 2014 to March 3, 2014. (Tr. 309-20.) At the time of her admission, Hamilton was disheveled and unkempt with increased psychomotor activity. (Tr. 319.) She was experiencing auditory hallucinations, as well as persecutory, somatic, religious, and bizarre delusions. (Tr. 319.) Her flow of thought was described as disorganized and illogical with derailment. (Tr. 319.) At discharge, the number of auditory hallucinations had decreased, but she still reported grandiose delusions of being married to a prominent religious figure. (Tr. 311.) Her discharge diagnosis was psychosis and she was started on Risperidone. (Tr. 312.)

         Hamilton was treated by Dr. Julio Bernardi between July 2014 and June 2015. There are four visits with Dr. Bernardi in the record between July 2014 and June 2015. (Tr. 253-57, 277-78, 283-84.) Dr. Bernardi diagnosed Hamilton with schizophrenia. Hamilton's mental status examinations were within normal limits and her symptoms were noted as stable or in remission. (Tr. 253-54, 283-84.) During the last visit in the record, Hamilton reported that she had not had psychotic symptoms in over a year. (Tr. 277.) Hamilton also noted, however, that since her mother's death seven months before, she experienced low mood, poor energy, some anhedonia, social isolation, frequent crying, and decreased concentration. (Tr. 277.)

         On August 14, 2015, Dr. Andrea Giedinghagen, psychiatrist, conducted an annual clinic psychiatric intake assessment. (Tr. 273-76.) During the assessment, Hamilton reported that she had not had any psychotic symptoms, persecutory or grandiose delusions, or auditory hallucinations for several months. (Tr. 274.) She also responded that she was experiencing bouts of low mood, low energy, crying spells, and decrease in self-care. (Tr. 274.) Although her mood was described as anxious, the mental status examination was within normal limits. (Tr. 275.) Hamilton testified that she received treatment from Dr. Giedinghagen for a year. (Tr. 49.)

         Dr. Michael Wenzinger began treating Hamilton in July 2016, but there are no medical records from Dr. Wenzinger, except Hamilton's annual psychiatric clinic intake assessment on July 28, 2016. (Tr. 296-300.) At the assessment, Hamilton reported that she continued to experience episodes of low mood despite initiation of Zoloft medication, onsets of low energy, crying spells, decreased levels of self-care, decreased mood, and anhedonia. (Tr. 297.) She also reported that the Zoloft decreased the number of days that she experienced these symptoms. Hamilton's mental status examination was normal. (Tr. 298-99.) Dr. Wenzinger opined that there was “notably and confoundingly a history of depressive symptoms that do not appear to quite meet full ...

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