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Couch v. Berryhill

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

May 6, 2019

ASHLEY COUCH, Plaintiff,
v.
NANCY A. BERRYHILL, Deputy Commissioner of Operations, Social Security Administration, Defendant.

          MEMORANDUM OPINION

          DAVID D. NOCE K UNITED STATES MAGISTRATE JUDGE

         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 Ashley Couch for supplemental security income (SSI) benefits under Title XVI of the Social Security Act, 42 U.S.C. § 1381, 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 Ashley Couch, born October 4, 1986, applied for SSI benefits on January 11, 2015. (Tr. 10, 177). She later alleged a disability onset date of January 28, 2015, due to depression, anxiety, post-traumatic stress disorder (PTSD), Wernicke-Korsakoff syndrome, [1] Wernicke's encephalopathy, [2] vision related impairments, and vertigo. (Tr. 10, 30, 181).

         On August 26, 2015, plaintiff requested a hearing before an ALJ. (Tr. 10). On February 1, 2017, the ALJ heard testimony from plaintiff and Vocational Expert (VE) Denise Weaver. (Tr. 27-48). On August 23, 2017, the ALJ found that plaintiff was not disabled. (Tr. 7-20). On April 20, 2018, the Appeals Council denied plaintiff's request for review. (Tr. 1-4). Thus, the decision of the ALJ stands as the final decision of the Commissioner.

         II. MEDICAL HISTORY

         Plaintiff was born on October 4, 1986. (Tr. 177). Plaintiff visited Dr. Syed Imam of Arthur Center Community Health regularly for treatment from May 2014 to September 2016, with two to three month intervals on average between each visit. (Tr. 275-96, 325-61).

         Plaintiff made her first visit to Dr. Imam on May 6, 2014. At the initial meeting, plaintiff said she was hospitalized for six days in 2008 for suicidal thoughts, anorexia and bulimia, severe malnutrition, and related brain damage. She complained of her anxiousness, especially in a crowd, and her mood swings. She shared her history of post-partum depression after her son's birth, nervous breakdowns, and three years of sexual abuse by her stepfather from the ages of 9 to 12. Dr. Imam diagnosed her with PTSD, anxiety, eating disorder, and depression. Dr. Imam noted anxious and depressed mood, anxious affect, fair eye contact, and slurred speech. (Tr. 297-301).

         She visited Dr. Imam again on July 8, 2014, with symptoms and diagnosis mostly similar to the May 6, 2014 initial visit, except that Dr. Imam recorded, “She has [a] major [a]nger problem.” Dr. Imam also noted she had an irritable mood and only fair eye contact, but appropriate affect, normal speech, logical flow of thought, and concrete thought content. (Tr. 275-79). Plaintiff's next visit was on October 14, 2014, and her symptoms and mental status determinations were identical to those of May 6, 2014. (Tr. 283-90).

         Plaintiff visited Dr. Imam again on January 13, 2015. This visit marked some changes in plaintiff's symptoms, because plaintiff described herself as: “[o]verall I am stable.” While Dr. Imam noted evident irritability and fair eye contact, plaintiff's affect, speech, and thought were in the normal range. At the same time, plaintiff complained of feeling sad, loss of interest, a sense of guilt, choking, and heart racing. (Tr. 291-96).

         On March 28, 2015, consultative examiner Kathrina Alexander, M.D., examined plaintiff. Dr. Alexander observed that plaintiff was able to sit, stand, walk, and bear light burdens, and that she was able to touch her toes, squat, rise from a chair, and mount and dismount the examination table without assistance. Also, Dr. Alexander observed that plaintiff had poor balance. (Tr. 315).

         On April 6, 2015, plaintiff was seen by consultative examiner Thomas J. Spencer, Psy.D. Dr. Spencer concluded that plaintiff appeared to be capable of understanding and remembering simple instructions and engaging in and persisting with simple tasks. However, he found she was moderately to markedly impaired in her ability to interact socially and adapt to the environment. In his opinion, plaintiff “did not appear capable of managing her benefits without assistance.” (Tr. 324).

         Shortly thereafter, plaintiff visited Dr. Imam on April 14, 2015, stating that overall, she was “not doing good.” (Tr. 355). She asked for adjustment in her medication. This time, Dr. Imam diagnosed plaintiff's mood differently than in previous visits. In addition to anxious mood and fair eye contact, he found her to have depressed and labile mood, labile and anxious affect, pushed speech, flow of thought marked with loose associations, and anxieties and somatic concerns in thought contents. (Tr. 355, 359-60). Dr. Imam's notes from plaintiff's visit on July 14, 2015, are almost identical to those of April 14, 2015. (Tr. 349-54, 355-60).

         At her October 6, 2015 visit, plaintiff started by saying that “I got a [sic] bad news.” Her mother was diagnosed with stage III breast cancer. Dr. Imam noted plaintiff “was improving and has less anxiety but now it is rough and emotional” and she was very anxious and her emotions were “all over the place.” Dr. Imam's diagnosis of her mental status added “worthless” to her thought content. (Tr. 343-48).

         On March 8, 2016, Dr. Imam's description and diagnosis of plaintiff's symptoms were almost identical to that of the October 6, 2015 visit. (Tr. 337-42). On June 28, 2016, plaintiff claimed to be a “support crew” to her grandfather and her mother, both of whom were suffering from cancer. Also, she stated her medications mostly help her, but sometimes she thinks “her body is adjusting or immune to the doses and it can happen.” (Tr. 331). Her last visit to Dr. Imam took place on September 13, 2016, when she said she continued to act as a “support crew” to her mother and grandfather. (Tr. 325).

         In addition to Dr. Imam's treatment, plaintiff received counseling services and training sessions to develop coping mechanisms, which she initiated on her own on September 30, 2014, at Family Circle Therapeutic Services. She attended 21 sessions from September 30, 2014, to September 23, 2015. According to the Treating Source Statement from the institution, she successfully worked through her relationship issues with her mother, utilized identified strategies to assist in managing her anxiety attacks, set firmer boundaries in regard to her son's father, and found herself in a position of being able to help both her mother and grandfather in a caregiver role when they were struggling with cancer. Her affect was good when she was in her sessions and she denied any ideation of harm to others. Plaintiff ceased counseling on her own, because she felt that her anxiety and depression were in a manageable range and that she had to take care of her mother and grandfather. (Tr. 362-63).

         On July 19, 2017, ten months after plaintiff's last visit with him, Dr. Imam submitted a medical source statement in a check-box format. According to the statement, plaintiff is diagnosed with PTSD, eating disorder, bulimia, obesity, and Wernicke- Korsakoff syndrome. In Dr. Imam's opinion, plaintiff would be “off-task” for 25% or more to perform even simple tasks. He marked that she is more than mildly limited (either moderately limited, markedly limited, or extremely limited) on 14 out of the 20 tasks listed, except for short and simple ones. There were some that were marked as extremely limited, such as the ability to perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances; the ability to complete a normal workday and workweek without interruption from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods; the ability to accept instructions and respond appropriately to criticism from supervisors; and the ability to travel in unfamiliar places or use public transportation. Dr. Imam summarily noted his diagnoses and conclusions were drawn based on medical history, clinical findings, diagnosis, and treatment. (Tr. 373-74).

         III. ALJ HEARING EVIDENCE

         A. ...


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