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West v. Berryhill

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

March 22, 2019

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



         This action is before the Court for judicial review of the final decision of the Commissioner of Social Security finding that Plaintiff Christopher West is not disabled and thus not entitled to disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. §§ 401-434. For the reasons set forth below, Commissioner's decision is affirmed.


         The Court adopts the facts set forth in Plaintiff's Statement of Uncontroverted Facts (ECF No. 21) and Defendant's Statement of Additional Facts (ECF No. 26-2), which Plaintiff has not opposed. Together, these statements provide a fair description of the record before the Court. Specific facts will be discussed as needed to address the parties' arguments.

         Plaintiff, a veteran born November 9, 1978, was diagnosed with post-traumatic stress disorder (PTSD) after serving in Iraq in 2008 and 2009. He was most recently employed by the Parks Department of University City until August 31, 2012, when he was terminated due to aggressive behavior. In September 2013, Plaintiff underwent a compensation and pension (C&P) examination conducted by a psychologist, Dr. Martina Ritchhart, through the Veterans' Administration (VA). After reviewing Plaintiff's medical records and interviewing Plaintiff, Dr. Ritchhart gave Plaintiff a global assessment of functioning (GAF)[2] of 52 and concluded that, although Plaintiff's PTSD symptoms impaired his ability to cope with life stressors, those symptoms did not render him incapable of working. Dr. Ritchhart suggested that, given Plaintiff's “difficulty in forming and maintaining alliances with co-workers, ” he may be suited for independent, autonomous work with adequate leadership. In January 2016, Plaintiff received a VA rating entitling him to VA benefits on the basis of unemployability due to service-connected disability as of October 13, 2015. In January 2017, a VA psychologist, Dr. Joseph Daus, issued a treating source statement indicating that Plaintiff had been enrolled in a VA mental health intensive case management program since February 2016 and was meeting “near-weekly” with a social worker.

         Citing the date of termination of his last employment (August 31, 2012) as the date of onset of his disability, Plaintiff applied for disability benefits on March 28, 2016. His application was denied at the initial administrative level, and he thereafter requested a hearing before an Administrative Law Judge (ALJ). On February 15, 2017, the ALJ heard the testimony of Plaintiff, who was represented by counsel, and of vocational expert (VE) Jennifer Smidt.

         Evidentiary Hearing and ALJ's Decision

         At the administrative hearing, Plaintiff testified that he attended community college briefly but dropped out. He shops and cooks for himself, takes care of his daughter on weekends, is able to concentrate and focus his attention “if it's something [he's] truly interested in, ” and gets anxious in public and is easily angered. He further testified that he was fired from his last job because his co-workers were afraid of him, and he had been charged with assault after holding a gun to his sister's head and threatening to kill her.

         By decision dated April 6, 2017, the ALJ determined that Plaintiff had the severe impairments of PTSD, mood disorder (referenced as major depressive disorder and adjustment disorder in the medical records), alcohol abuse, a history of a gunshot wound to the abdomen, small bi-malleolar spurs of the ankle, and mild concussion symptoms.[3] The ALJ found that the severity of Plaintiff's mental impairments, considered singly and in combination, did not meet or medically equal the criteria of listings 12.02 (neurocognitive disorders), 12.04 (depressive, bipolar, and related disorders), and 12.15 (trauma- and stressor-related disorders). These conditions are not deemed disabling unless functional limitations known as “Paragraph B criteria” are present, meaning a claimant has one extreme or two marked functional limitations in his ability to: (1) understand, remember, or apply information; (2) interact with others; (3) concentrate, persist, or maintain pace; and (4) adapt or manage oneself. 20 C.F.R. § 404.1520a(c)(3).[4] Here, the ALJ found that Plaintiff had only: (1) mild limitations in understanding, remembering, or applying information; (2) moderate limitations in interacting with others; (3) mild limitations in concentrating, persisting, and maintaining pace; and (4) moderate limitations in adapting and managing himself. Thus the ALJ concluded that Paragraph B criteria were not satisfied.

         When Paragraph B criteria are not satisfied, the relevant listings also have additional functional criteria known as “Paragraph C criteria, ” used to evaluate “serious and persistent” mental disorders. Paragraph C criteria require a medically documented history of the existence of the disorder for at least two years, with evidence of (1) medical treatment, mental health therapy, psychosocial support, or a highly structured setting that is ongoing and that diminishes the symptoms and signs of the claimant's disorder and (2) marginal adjustment, meaning a minimal capacity to adapt to changes in one's environment or to demands that are not already part of one's daily life. Here, the ALJ concluded that Paragraph C criteria were not satisfied.

         The ALJ further determined that Plaintiff had the residual functional capacity (RFC) to perform medium work as defined in 20 C.F.R 404.1567(c) in that he (1) can lift, carry, push, or pull 50 pounds occasionally and 25 pounds frequently and (2) can sit, stand, or walk for six hours in an eight-hour work day; but Plaintiff (3) is limited to simple, routine tasks with minimal changes in job setting and duties and (4) can do no handling of customer complaints, no fast-paced production work, no contact with the public, and only occasional contact with co-workers and supervisors. In support of this determination, the ALJ noted the following from Plaintiff's medical and psychological records.[5]

         In May and June 2011, Plaintiff experienced stress due to a divorce but was working and keeping busy, spending time with friends, and denied suicidal ideations. Tr. 1202-1210. In December 2011, Dr. Kurtis, a VA psychiatrist, noted that Plaintiff was stable psychiatrically and not taking any medications. Tr. 1165. In July 2012, Plaintiff spoke with LCSW Jane Tomory and denied any mental health problems. Tr. 1156. In September 2013, Plaintiff spoke with LMSW Laura Riegler and reported that he did not want to take any psychiatric medications but was drinking as a coping method. He denied thoughts of suicide and declined an appointment at the VA PTSD clinic. Tr. 1154.

         At his C&P exam with Dr. Ritchhart in September 2013, he reported that he spent his time working on cars, doing chores, fishing, taking care of his daughter, and going to bars with friends. Tr. 1147. In July 2014, Plaintiff spoke again with Ms. Riegler and reported that he was “doing okay, ” working in the yard, and enrolled in college classes. Tr.1127. In June 2015, after the altercation with his sister, police accompanied him to the SSM Health DePaul emergency room (Dr. William Suk), where he stated that his sister and girlfriend had confronted him about his drinking. He denied suicidal or homicidal ideations or plans. Tr. 1256.

         VA records (Dr. Atthar Naeem) indicate that Plaintiff overdosed on Vicodin on October 15, 2015, after his girlfriend broke up with him (Tr. 951), but he reestablished outpatient therapy with Ms. Rieger shortly thereafter and discussed coping strategies; Plaintiff denied suicidal plans. Tr. 942-943. On October 21, 2015, he spoke with LMSW Meghan Voorhees and reported that he had been hunting with a friend. Tr. 928. On October 29, 2015, he reported to Ms. Voorhees that he spent the weekend with his daughter, watched her cheer at a school game, and carved a pumpkin with her. Tr. 920. On November 5, 2015, Plaintiff was examined by a psychiatrist, Dr. Thena Poteat, after his ex-girlfriend called 911 due to a perceived suicide risk. Dr. Poteat noted that Plaintiff was anxious, irritable, and angry but that Plaintiff explicitly denied aggressive or suicidal thoughts. Tr. 887. On November 16, 2015, he was “doing great” on sertraline. Tr. 764. On December 6, ...

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