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Darrell B. v. Saul

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

December 12, 2019

DARRELL B., Plaintiff,
ANDREW M. SAUL, [1]Commissioner of the Social Security Administration, Defendant.



         This 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).

         I. Procedural History

         On September 10, 2015, plaintiff Darrell B. 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 December 5, 2014.[2] (Tr. 186, 189-90, 191-94). Plaintiff subsequently amended the alleged onset date to May 25, 2015. (Tr. 209). After plaintiff's applications were denied on initial consideration (Tr. 117-21), he requested a hearing from an Administrative Law Judge (ALJ). (Tr. 124-25).

         Plaintiff and counsel appeared for a hearing on October 12, 2017. (Tr. 32-71). Plaintiff testified concerning his disability, daily activities, functional limitations, and past work. The ALJ also received testimony from vocational expert Anne H. Darnell, M.Ed. The ALJ issued a decision denying plaintiff's applications on January 19, 2018. (Tr. 15-26). The Appeals Council denied plaintiff's request for review on August 18, 2018. (Tr. 1-6). Accordingly, the ALJ's decision stands as the Commissioner's final decision.

         II. Evidence Before the ALJ

         A. Disability and Function Reports and Hearing Testimony

         Plaintiff, who was born in May 1965, was 50 years old on the amended alleged onset date. In September 2015, when he filed his applications, he lived with his parents on their farm. (Tr. 251). He had a high school diploma and worked for 21 years as a union welder before retraining as an HVAC technician. He also worked as a welding instructor and at an auto parts store. (Tr. 215, 440, 61). Plaintiff listed his impairments as severe back pain, back problems, arthritis, nerve damage, muscle spasms, bipolar, manic depression, and migraines. (Tr. 214). His medications included baclofen and hydrocodone for pain, trazodone for sleep, Depakote to stabilize moods, Topamax for bipolar disorder, medication to treat high blood pressure, and injections for migraines. (Tr. 217).

         In his October 2015 Function Report (Tr. 250-58), plaintiff stated that he was unable to work due to back pain and bipolar disorder. His pain interfered with his sleep and kept him from doing farm work or other labor. He did other household chores to assist his parents, including laundry, mowing, and repairs. He was able to drive and go to the grocery store, where he used a motorized cart. He was able to manage financial accounts. His attention was limited to three to five minutes and he had short-term memory problems.

         Plaintiff described his activities with others as watching movies, playing board games or cards, and having conversations, including on the telephone. He was no longer able to hike, camp, ride motorcycles, restore cars, bowl, or spend time with kids. He had a short temper, which he attributed to his extreme pain and mental illness. He had been fired from his auto parts job due to his inability to relate to other employees. Plaintiff had difficulties with lifting, squatting, bending, standing, reaching, walking, sitting, kneeling, hearing, climbing stairs, remembering, completing tasks, concentrating, understanding, using his hands, and getting along with others. His ability to follow instructions was limited by his ADHD and short-term memory loss. He could walk on level ground for 50 to 100 feet before needing to rest. He used a cane on occasion.

         Plaintiff's mother Pamela completed a Third Party Function Report. (Tr. 234-41). She stated that plaintiff was no longer able to work, lift, stretch, bend, or control his emotions. He was only able to handle small jobs and had to rest after doing household chores. Although plaintiff was able to go out on his own, she did not think he should do so because he had trouble with concentration and memory. He went shopping for food twice a month. Her son's pain and mental disorders had completely changed his personality, causing a lot of stress with his family and friends. She described him as short-tempered and occasionally unreasonable. His pain and migraines caused his emotions to “roller coaster” and his unpredictable behavior made it impossible for him to find employment and support himself. She opined that he could lift no more than 3 to 5 pounds and stated that he used a cane. The ALJ gave limited weight to Ms. B.'s description of plaintiff's physical limitations as inconsistent with plaintiff's medical examinations. The ALJ gave greater weight to her description of plaintiff's daily activities, including the ability to do occasional yard work, clean his room, do laundry, drive, shop for groceries, spend time with others, and manage finances. (Tr. 24)

         By the time of the October 2017 hearing, plaintiff's parents had sold the family farm and moved to Florida. Plaintiff and his girlfriend lived in a trailer on a piece of property he owned with his sister, who lived in an adjacent trailer with her son. (Tr. 49-51).

         Plaintiff testified that he sustained nerve damage during back surgery in 2012, causing numbness in his right leg and foot. The outside edge of his right foot was numb all the time, altering his balance. (Tr. 38-39). If he twisted or sat the wrong way, his leg went numb and he collapsed. He had shooting pains down the back of his right leg and suffered back spasms if he stood for any length of time. (Tr. 39-40). Sitting hurt more than standing and the only position in which he could comfortably sit was in a recliner with his feet elevated. (Tr. 40, 68). When he went grocery shopping, he leaned on the cart and used it like a walker. At the time of the hearing, he had reapplied for Medicaid. He managed his musculoskeletal pain with nonnarcotic muscle relaxers and Advil. (Tr. 46). Twice a week, plaintiff got debilitating migraine headaches that lasted between one and three days. He sat in a quiet dark room with a cool cloth on his head and took medication that helped him sleep but caused him to feel hungover. He used to receive injections for migraines but found them too painful. (Tr. 45-47). Plaintiff also took medication to treat high blood pressure, which he stated was caused by his 2012 back surgery.[3] (Tr. 56). Finally, he had a lifelong 75% loss of hearing in his right ear. (Tr. 58). Plaintiff's physical impairments caused him some difficulty with self-care. In particular, he used a shower chair to avoid slipping and he had trouble putting on shoes and socks. The heaviest weight he could lift was a gallon of milk.

         Plaintiff testified that he was constantly angry as a result of his mental impairments. (Tr. 42). He took medication that reduced his temper outbursts but made him “wander around like a mindless little drone.” (Tr. 43). As discussed below, plaintiff was admitted to a psychiatric unit in December 2014 after texting suicidal and homicidal statements to a friend who then called 911. At his hearing, plaintiff testified that he was asleep when the police came to his home in tactical gear.[4] They used physical force to restrain him and transport him to the emergency room, where he remained in restraints on the floor wearing only his underwear. (Tr. 53-55). He testified that he continued to have nightmares and paranoid feelings arising from this incident. Plaintiff also testified that he had heard muffled voices and music since he was a child. (Tr. 59). He told treatment providers that he was uncertain whether these occurrences were due to his hearing loss or were truly auditory hallucinations.

         Plaintiff testified that he did not enjoy watching television and only talked on the phone when someone called him. He usually sat and listened to music. (Tr. 43). He stated that, in the past, he drank beer to increase the effect of his nonnarcotic pain medication, but he quit because he was not “a drinker” and “never really drank.” At the time of the hearing, he was taking a muscle relaxer that relieved his back pain and had not been drinking for about six months.[5] (Tr. 43-44). Plaintiff described repairs he was making on his trailer. He approached these repairs slowly, both to protect his back and because his medication made it difficult for him to concentrate. (Tr. 45).

         Vocational expert Ann Darnell, M.Ed., was asked to testify about the employment opportunities for a hypothetical person who was closely approaching advanced age, with a high school education and plaintiff's work history, who was limited to light work. Ms. Darnell was asked to assume that the individual could never climb ladders, ropes, and scaffolds; could occasionally climb ramps and stairs, balance, stoop, kneel, crouch, and crawl; should avoid exposure to environmental hazards, including vibration; and was limited to simple, routine, repetitive tasks, involving only simple decisions. Ms. Darnell was also asked to assume that the individual was limited to occasional interaction with supervisors and co-workers and no interaction with the general public. (Tr. 66-67). According to Ms. Darnell, such an individual would not be able to perform plaintiff's past work as a welder, HVAC technician, auto parts sales person, or welding instructor. Other work available in the national economy the individual could perform included warehouse checker, hand bander, and mail clerk. The individual would not be able to perform these jobs if he were limited to sedentary work. All work would be precluded if the individual were off-task 20 percent of the day due to psychological issues or medication side effects. (Tr. 67-68).

         B. Medical Evidence

         Plaintiff begins his discussion of the medical record in May 2015 and the Court will do the same, with a brief synopsis of the earlier records included in the administrative transcript.

         On October 16, 2012, Theodore J. Choma, M.D., performed a microdiscectomy to treat plaintiff's “massive” and “severely debilitating” disc herniation at L4-L5. (Tr. 288). Starting shortly after the surgery and continuing throughout the period under review, plaintiff complained of headaches and numbness in the toes of his right foot. (Tr. 522). A postoperative MRI disclosed moderate central canal and moderate-to-severe bilateral recess, mild-to-moderate stenosis at the L4-L5 level, and mild lumbar spondylosis. (Tr. 524). He continued to have back pain, which Dr. Choma attributed to multilevel lumbar spondylosis that was not amenable to surgical intervention. (Tr. 525-26). Records from 2014 show that plaintiff was prescribed tramadol and hydrocodone for pain and Flexeril for muscle spasms. He was also started on medication to address hypertension. (Tr. 436, 426-31).

         In December 2014, plaintiff was hospitalized on a 96-hour hold after he made threatening statements in text messages to a friend. (Tr. 316-59). He blamed his outbursts on intractable pain and numbness in his right leg which interfered with his sleep. He was also using alcohol and marijuana regularly. He was discharged with diagnoses of Adjustment Disorder with Depressed Mood, rule out Bipolar Disorder; and Pain Disorder, rule out Malingering Component. (Tr. 344). He was directed to enter pain management services and outpatient mental health treatment.

         In January 2015, plaintiff sought emergency care for a headache with photophobia. (Tr. 365-72). A CT scan of his brain was negative. He was prescribed a beta blocker to address hypertension and migraines and an increased dose of hydrocodone for back pain. (Tr. 420-25). Also in January 2015, plaintiff entered into mental health treatment at Burrell Behavioral Health. (Tr. 458-61). He reported having mood swings, auditory hallucinations, poor sleep, and violent dreams; he also wished that he had not woken up from surgery. He received medication monitoring from Kristin Parkinson, M.D., who diagnosed plaintiff with Bipolar Affective ...

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