United States District Court, E.D. Missouri, Southeastern Division
BILLY JOE. T., Plaintiff,
ANDREW M. SAUL,  Commissioner of the 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).
September 30, 2015, plaintiff Billy Joe T. protectively filed
applications for a period of disability and 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 January 1, 2007. (Tr. 171-72, 173-79,
15). After plaintiff's applications were denied on
initial consideration (Tr. 77-82, 83-88), he requested a
hearing from an Administrative Law Judge (ALJ). (Tr. 98-99).
and counsel appeared for a hearing on June 14, 2017. (Tr.
33-59). Plaintiff testified concerning his disability, daily
activities, functional limitations, and past work. The ALJ
also received testimony from plaintiff's case worker,
Rebecca Murrah, and vocational expert Janice S. Hastert, M.S.
The ALJ issued a decision denying plaintiff's
applications on October 19, 2017. (Tr. 15-27). The Appeals
Council denied plaintiff's request for review on June 30,
2018. (Tr. 1-6). Accordingly, the ALJ's decision stands
as the Commissioner's final decision.
Evidence Before the ALJ
Disability Reports and Hearing Testimony
who was born in April 1982, was 24 years old on the alleged
onset date. He lived with his mother and brother and his
mother's two grandchildren in his mother's home. (Tr.
38, 45-46). He had two children, ages 11 and 7, who lived
with their mother. (Tr. 38). He received special education
services until he left school during the 9th grade. (Tr. 37).
He did not have a general education diploma. He testified
that he had previously worked for a construction company, for
fast food restaurants, and at Wal-Mart. His mother helped
him complete job applications. With the exception of the
construction job, he only stayed with an employer for a month
or two because he was unable to remember what he was supposed
to do. (Tr. 43-44, 49). At the time of the hearing, he mowed
lawns once or twice a month in exchange for an offset on his
family's rent. (Tr. 39).
plaintiff applied for disability benefits in 2015, he listed
his impairments as schizoaffective disorder, borderline
intellectual functioning, Stevens-Johnson syndrome,
neuropathy, hypertension, indigestion, and
headaches. (Tr. 77). In March 2017, his medications included
Prazosin to treat schizophrenia; Trazodone for anxiety and
sleep; Zoloft, Cymbalta, and Abilify for depression;
benztropine to control medication side effects; gabapentin
for neuropathy; and medications for acid reflux and blood
pressure. (Tr. 269).
Field Office interviewer noted that plaintiff had difficulty
with understanding and answering questions until they were
simplified. He also had difficulty remembering dates and job
duties. (Tr. 210). The Disability Report he completed with
the help of the interviewer lists four jobs: a job in fast
food from January 2010 through March 2011 for 30 hours a
week; an unspecified restaurant in 2009 for 40 hours a week;
work on a farm for two months in 2015; and work for a waste
removal company from 2102 to 2014. (Tr. 214). This
information is not consistent with earnings reports, which
show that in any given year plaintiff typically worked for a
number of different employers, with earnings ranging from
$165 to nearly $10, 000. (Tr. 164-170, 183). Plaintiff's
highest earnings occurred in 2010, when he earned $16, 500
from a total of five employers. (Tr. 165).
testified that he was unable to work due to pain and tingling
in his legs, his moods, his memory, and poor reading skills.
His household chores included washing the dishes, which he
did while sitting down, and mowing a lawn he described as
“not real big.” Both tasks took him at least an
hour to complete. His mother helped him do his laundry. (Tr.
46-47). He was able to prepare simple meals such as ramen
noodles and Vienna sausages. He did not socialize with
others, preferring to stay home. He did not attend his
children's school functions because there were “too
many people.” (Tr. 50). He did not attend religious
services or go shopping because he was afraid “somebody
will say something.” (Tr. 51). Although he had a
driver's license, he limited his driving because it
caused pain in his legs. (Tr. 48). He had a smart phone that
he used to watch YouTube videos through an app. He did not
use the internet or social media. (Tr. 49). He denied having
a history of drug or alcohol use. He received treatment for
his psychiatric conditions from professionals at Bootheel
worker Rebecca Murrah, of Bootheel Counseling Services,
testified that she had been providing mental health
monitoring to plaintiff for about 6 months. Depending on her
schedule, she saw him once a week or every other week. She
made sure he took his medications, helped him with his
medical appointments, made sure he took care of his personal
hygiene, and assisted him with completing paperwork. Ms.
Murrah testified that plaintiff needed regular reminders to
take his medications, about which he had
“constant” questions. She opined that he would
need assistance to complete a job application and would not
be able to work without assistance. (Tr. 52-54).
expert Janice Hastert was asked to testify about the
employment opportunities for a hypothetical person of
plaintiff's age, education, and work experience who had
no exertional limitations, but was limited to simple,
routine, repetitive tasks with occasional interaction with
co-workers and no interaction with the general public, and
who could accept supervision and adapt to changes in the work
place “on a basic level.” (Tr. 56). According to
Ms. Hastert, such an individual would be able to perform
plaintiff's past work as a garbage collector, dishwasher,
and sandwich maker. Other work available in the national
economy the individual could perform included tumbler
operator, shuttle spotter, and casting machine tender. All
work would be precluded if the individual was unable remember
and perform simple, routine, repetitive tasks and was unable
to interact with co-workers, the public, or supervisors. (Tr.
57). In response to questions from plaintiff's counsel,
Ms. Hastert testified that employment would also be precluded
if the individual required repeated training every two or
was identified as having speech and language delays in
kindergarten. (Tr. 723-24). An individualized education plan
(IEP) completed when plaintiff was in second grade identified
him as “educable mentally handicapped” and in
need of special education services for 50 percent of his
school hours with additional speech and language services.
(Tr. 703). In third grade, he was described as likeable and
willing to work hard if given an incentive. He had a
wonderful sense of humor and got along well with everyone. He
had difficulty staying awake and staying on task. (Tr. 706).
Plaintiff's scores on a test of cognitive functioning
administered in the fourth grade yielded a verbal IQ of 74, a
performance IQ of 67, and a full scale IQ of 69, placing him
in the “mentally deficient” range. In the
classroom, he had great difficulty with letter and number
recognition and short-term and long-term memory. (Tr. 729).
In fifth grade, he was described as likeable with a pleasant
personality. (Tr. 716). His scores on the Peabody Individual
Achievement Test showed weaknesses in math computation and
reasoning, spelling, reading comprehension, and sight
vocabulary. He showed strength in general information and,
because he had an interest in science, was able to remember
“some” science facts when he heard them. In
seventh grade, the percentage of time plaintiff received
special education services increased. (Tr. 718). He was again
described as very likable, but it was noted that he was lazy
and it was hard to get work out of him. (Tr. 70). He had
strengths in spelling and reading recognition; he had
difficulties with applying math skills, reading
comprehension, basic science, and social studies facts. (Tr.
720). His scores on the Weschler Intelligence Scale for
Children - III yielded a verbal IQ of 76, performance IQ of
70, and a full scale IQ of 71. (Tr. 733). His good sense of
humor was noted again in eighth grade, but he was very hard
to motivate and preferred to socialize or sleep than to work.
(Tr. 740). He had roughly equal hours of regular and special
education classes. (Tr. 739). By ninth grade, his special
education hours were sharply reduced. (Tr. 744). It was noted
that he was working as a roofer on a part-time basis and
planned to continue in that work when he graduated. (Tr.
755). According to counsel's prehearing memorandum,
plaintiff worked for one construction company for 9 years,
starting at age 16. He was given simple tasks such as
removing nails from wood frames, carrying lumber, and
assisting other workers. (Tr. 282-83).
Treatment for Physical Complaints
the period under consideration, plaintiff received his
primary medical care through SEMO Health Network, where he
was treated by family nurse practitioners Tina Moore and
Danielle E. Jansen.
October 2012, Ms. Moore gave plaintiff a prescription for
Cipro to treat bronchitis, sinusitis, and an ear infection.
(Tr. 682). He had a bad reaction to the Cipro and went to the
emergency room. It was noted that he had a history of Stevens
Johnson Syndrome in response to penicillin. (Tr. 681-82). In
December 2012, Ms. Moore diagnosed plaintiff with thoracic
and sciatic neuritis. (Tr. 680-81). In June 2013, plaintiff
presented with anxiety, high irritability, emotional
liability, depression, and sleep disturbance. (Tr. 678-80).
His affect was angry and anxious. His diagnoses included
dysthymic disorder and panic disorder without agoraphobia, in
addition to obesity. Plaintiff was prescribed the
antidepressant Cymbalta. A week later, Ms. Moore noted that
plaintiff had a depressed mood with sad affect and added a
diagnosis of dysthymic disorder. (Tr. 380-81). She
discontinued the Cymbalta and started the antidepressant
Pristiq. Throughout the remainder of 2013, Ms. Moore treated
plaintiff for elevated blood pressure, pain in his low back,
knees and feet, swelling in his legs, sleep disturbance,
dysthymia, and panic disorder. (Tr. 377-80, 376-77, 374-76,
371-74, 369-71, 368-69, 366-68, 363-65).
2014, plaintiff was prescribed the antidepressants Pristiq,
followed by paroxetine, Celexa, and finally Brintellix. (Tr.
360-62, 664, 352-53). He quit smoking cigarettes and began
using e-cigarettes. (Tr. 362, 354-56). With respect to
physical complaints, plaintiff continued to present with
elevated blood pressure, swelling in his legs after exercise,
leg pain at night, spasm of the back muscles, and thoracic
and sciatic neuritis. (Tr. 664, 358-59, 357, 352-53, 349-51). He
had his gall bladder removed in May 2014. (Tr. 664-66).
of plaintiff's lumbar spine completed in March 2015
disclosed mild multilevel arthropathy and mild degenerative
disc disease at ¶ 5-S1, without stenosis. (Tr. 415). In
June 2015, Ms. Jansen noted that plaintiff had begun
receiving mental health treatment at Bootheel. He had
excessive thirst and nonpitting edema. (Tr. 382-84). She
discontinued Brintellix and gabapentin and directed him to
lower his sodium intake, increase his water intake, increase
activity, and elevate his legs when possible.
February 2016, an ankle brachial index test was completed in
response to plaintiff's complaints of swelling in his
legs, numbness in the right leg, and a sensation of heat at
the top of his legs. (Tr. 413). No. interpretation of the
results was provided. Later in the month, plaintiff underwent
a sleep study. (430-47). The study found that plaintiff
experienced a few respiratory events and snoring, but he did
not qualify for positive pressure therapy. He was advised to
achieve a normal body mass index. Imaging studies of
plaintiff's left knee in May 2016 disclosed moderate
partial thickness of the chondrosis and a small Baker's
cyst without evidence of rupture. (Tr. 461, 463, 465). In
September 2016, plaintiff sought emergency treatment for low
back pain, which he rated at level 7, and an abrasion on his
shoulder. (Tr. 449-55, 482-90).
Treatment of Mental Health Complaints
in March 2015, plaintiff began receiving psychiatric services
from Bootheel Counseling Services, where Linda Kohler, M.D.,
provided medication management and psychiatric treatment. In
August 2015, Bootheel began providing community support
services to plaintiff as well.
March 25, 2015, plaintiff had a crisis counseling session at
Bootheel. (Tr. 546-49). He had been hospitalized at Southeast
Hospital in Cape Girardeau seven days earlier on reports that
he was hearing voices, and experiencing memory loss,
depression, and anxiety. On April 21, 2015, Dr. Kohler
completed an evaluation. (Tr. 399-400). Plaintiff described
episodes in which he heard his mother calling him or thought
that someone was there. These experiences kept him awake at
night and he slept during the day. He described himself as
aggravated and irritable. He had two prior hospitalizations
for self-harm. He dropped out of school in ninth grade
because other students made fun of him. He reported that he
had worked on chicken farms, built grain bins, and in fast
food. Others told him that he just “can't
comprehend” and “can't get it.” He
stated that he did not know how to read. On mental status
examination, Dr. Kohler noted that plaintiff was cooperative,
had “much” yawning, was a little fidgety, was
goal-directed in his thinking but had paucity of thought. He
denied experiencing hallucinations and suicidal and homicidal
ideation, and was not delusional. He was alert, but oriented
only to name, and not date, day or season. His insight was
“nil” and his judgment was poor. Dr. Kohler
diagnosed plaintiff with schizoaffective disorder and
borderline intellectual functioning. She assigned a Global
Assessment of Functioning (GAF) score of 45. She discontinued
his prescription for Brintellix due to its cost, and started
fluoxetine and haloperidol. For the purposes of treatment
planning, Dr. Kohler identified plaintiff's strength as
“seeking treatment” and his weaknesses as
“mood instability” and “symptoms that
interfere with daily living.” (Tr. 492).
6, 2015, Dr. Kohler noted that plaintiff had stopped taking
the fluoxetine because it caused somnolence and that the
haloperidol had not addressed his auditory hallucinations. He
was taking gabapentin for leg pain. (Tr. 397). On mental
status evaluation, plaintiff had appropriate grooming,
unremarkable psychomotor activity, made good eye contact, had
normal word fluency and goal-directed thoughts. His judgment
and insight were poor, but he was alert and oriented. Dr.
Kohler discontinued fluoxetine, started Sertraline, and
increased the haloperidol. His GAF remained at 45. On May 14,
2015, plaintiff reported that the sertraline helped him to
“mellow” but he could not afford to fill the
haloperidol prescription. (Tr. 395). His mood was improved.
His mental status was unremarkable with the exception of
occasional auditory hallucinations and ...