Patton v. Commissioner of Social Security

Filing 19

MEMORANDUM AND ORDER: IT IS HEREBY ORDERED that the decision of the Commissioner is REVERSED, and this cause is REMANDED for further proceedings.A separate Judgment in accordance with this Memorandum and Order is entered this same date. Signed by Magistrate Judge Abbie Crites-Leoni on 6/8/2015. (JMC)

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
NORTHERN DIVISION
CECELIA J. PATTON,
Plaintiff,
v.
CAROLYN W. COLVIN, Acting
Commissioner of Social Security,
Defendant.

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No. 2:14CV47 ACL

MEMORANDUM AND ORDER
Plaintiff Cecelia J. Patton brings this action pursuant to 42 U.S.C. §§ 405(g)
and 1383(c)(3) seeking judicial review of the Commissioner’s final decision
denying her applications for disability insurance benefits (DIB) under Title II of
the Social Security Act, 42 U.S.C. §§ 401, et seq.; and for supplemental security
income (SSI) under Title XVI of the Act, 42 U.S.C. §§ 1381, et seq. All matters
are pending before the undersigned United States Magistrate Judge, with consent
of the parties, pursuant to 28 U.S.C. § 636(c). Because the Commissioner’s final
decision is not supported by substantial evidence on the record as a whole, it is
reversed.
I. Procedural History
Plaintiff applied for DIB and SSI on December 30, 3010, claiming disability
because of bipolar disorder, anxiety, diabetes, and hypertension. She alleges a

disability onset date of June 30, 2010. The Social Security Administration initially
denied plaintiff’s applications on March 18, 2011. After a hearing on August 30,
2012, at which plaintiff and a vocational expert testified, an Administrative Law
Judge (ALJ) entered a written decision on September 28, 2012, finding plaintiff
not disabled because of her ability to perform her past relevant work as well as
other work as it exists in significant numbers in the national economy. On March
22, 2014, after review of additional evidence, the Appeals Council denied
plaintiff’s request to review the ALJ’s adverse decision. The ALJ’s decision thus
became the final decision of the Commissioner. 42 U.S.C. § 405(g).
Plaintiff now requests this Court to review the ALJ’s decision, arguing that
the ALJ erred by failing to accord controlling weight to the opinion of plaintiff’s
treating psychiatrist, Dr. Clark. Plaintiff further argues that by discounting Dr.
Clark’s opinion, the record was devoid of opinion evidence, and the ALJ should
have ordered a consultative examination in order to fully develop the record.
Plaintiff also contends that the ALJ’s assessment of her residual functional
capacity (RFC) failed to include the effects of her severe mental impairments,
arguing that the ALJ erred by relying on her work history and her role as a mother
to find her able to perform work-related activities. Plaintiff requests that the final
decision be reversed and the matter remanded for an award of benefits or,
alternatively, for further proceedings. For the reasons that follow, the matter is
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remanded for further proceedings.1
II. Testimonial Evidence Before the ALJ
A.

Plaintiff’s Testimony
At the hearing on August 30, 2012, plaintiff testified in response to

questions posed by the ALJ and counsel.
At the time of the hearing, plaintiff was thirty-eight years of age. (Tr. 34.)
Plaintiff is married but has been separated from her spouse for two and a half
years. Plaintiff has four children, ages twenty, eighteen, thirteen, and five. She
lives in her in-laws’ house with her five-year-old daughter. (Tr. 35-36.) Plaintiff
completed high school and went to college for one semester. (Tr. 37.)
Plaintiff’s Work History Report shows plaintiff to have worked as a health
aide from the summer of 2008 to June 2010. (Tr. 212.) The care facility at which
plaintiff last worked was owned by a family member. Plaintiff was laid off from
this job because of missed time from work. Plaintiff testified that she spent a lot of
time in the bathroom during working hours because she was sick. (Tr. 38.)
Plaintiff testified that she also previously worked as a waitress. (Tr. 39-40.)
Plaintiff testified that she receives treatment for bipolar disorder, anxiety,
1

Plaintiff challenges the ALJ’s decision only to the extent it addresses her mental impairments.
Plaintiff raises no challenge to the ALJ’s treatment of her physical impairments. While the
undersigned has reviewed the entirety of the administrative record in determining whether the
Commissioner’s adverse decision is supported by substantial evidence, the recitation of specific
evidence in this Memorandum and Order is limited to only that relating to the issues raised by
plaintiff on this appeal.
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depression, post-traumatic stress disorder (PTSD), and for nighttime and daytime
terrors. Plaintiff testified that her depression affects her about three weeks a month
at which time she cannot function and stays in bed. Plaintiff testified that she is
unable to take care of household chores such as cooking and cleaning, and is
unable to attend to her personal hygiene. Plaintiff’s in-laws and twenty-year-old
daughter shop for her during these periods. (Tr. 41-42.)
Plaintiff testified that her five-year-old daughter is cared for by the child’s
father, sister, or grandmother three or four days a week because plaintiff is in bed.
Plaintiff testified that she calls to have someone pick up her daughter because she
wants to make sure she is taken care of. Plaintiff testified that she worries about
her child’s safety if she is with someone other than her father or grandmother, and
she experiences symptoms of anxiety because of such worry. Plaintiff testified that
she has difficulty giving her daughter a bath because of memories of her own
childhood experiences. Plaintiff takes a thirty-minute “timeout” after her
daughter’s bath in order to “get [herself] together.” (Tr. 43-44.)
Plaintiff testified that she has nightmares at least three times a week for
which she takes medication. Plaintiff testified that she wakes up in a sweat and is
usually yelling. Plaintiff often becomes sick when she has a nightmare and usually
experiences an upset stomach and crying spells the following day. She experiences
nausea, pain, and vomiting six days a week and takes medication to soothe her
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stomach. Plaintiff has seen specialists regarding her upset stomach. (Tr. 45-46.)
Plaintiff testified that she also experiences flashbacks on a daily basis and
remembers things that happened to her, which causes her to feel paranoid and that
people are out to get her. During severe episodes, plaintiff goes into the
bathroom, turns off the light, and spends time alone crying. Plaintiff feels as
though someone is hurting her. (Tr. 47.)
With respect to her bipolar disorder, plaintiff testified that she experiences
manic episodes about twice a year that last four or five days. Plaintiff testified that
she gets really excited during these episodes, exercises poor judgment, talks in a
strange manner, and hears voices. Plaintiff testified that she usually “crash[es] and
burn[s] into depression” after such episodes, at which time she experiences severe
depression, stays in bed, and has suicidal thoughts. (Tr. 46-47.)
Plaintiff takes medications for her conditions, including Prozac, Geodon,
Lamictal, Minipress, Ambien, and Promethazine. Plaintiff testified that she is
compliant with her medications. Plaintiff previously took Seroquel but stopped
because of weight gain, eye problems, and its lack of effectiveness. (Tr. 51, 54.)
Plaintiff testified that she was able to successfully work in the past with her mental
impairments because her medications were effective at the time. Plaintiff testified
that her depression became more severe after the birth of her daughter, and she was
without medication for a year or two afterward. (Tr. 58-60.) Plaintiff then sought
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treatment with Mark Twain Behavioral Health to restart her medication, but she
stopped treatment shortly after starting because of overwhelming depression and
her inability to keep up with her appointments. (Tr. 52, 58-59.) Plaintiff testified
that she thereafter was hospitalized because of increased depression and thoughts
of suicide. At the time of her hospitalization, plaintiff had been without
medication for two or three months. (Tr. 57-58.) Plaintiff began mental health
care with another facility after her hospitalization. (Tr. 52.)
Plaintiff does not drive. She rides in cars, but only when necessary because
she feels a lot of anxiety when in a car – with feelings of paranoia and tightening in
her chest. Plaintiff also has difficulty being around people. She becomes anxious
and has panic attacks, with tightening in her chest and crying. She hurries and tries
to get away from people and locks herself in a bathroom. Plaintiff testified to
being presently uncomfortable in the hearing room. (Tr. 49-50.)
Plaintiff testified to previous marijuana use and that she had been charged in
the past with marijuana possession. Plaintiff testified that she had smoked
marijuana to help calm her stomach, but was told that such use would lead to other
problems. Plaintiff had not smoked marijuana for the two months prior to the
hearing. (Tr. 54-55.)
B.

Vocational Expert Testimony
Jeffrey F. Magrowski, a vocational expert (VE), testified at the hearing in
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response to questions posed by the ALJ and counsel.
The VE classified plaintiff’s past work as a caregiver as medium and semiskilled; as a waitress as light and semi-skilled; and as a cook helper as medium and
unskilled. (Tr. 62.)
The ALJ asked the VE to assume an individual of plaintiff’s age, education,
and work experience and to further assume the person could perform work at any
exertional level but could not perform any fast-paced production work or tasks
requiring more than superficial contact with the public. The VE testified that such
a person could not perform any of plaintiff’s past relevant work, but could perform
light, unskilled work as a cleaner in housekeeping, of which 2,000 such jobs exist
in the State of Missouri and 200,000 nationally; as an apparel stocker or checker,
of which 1,000 such jobs exist in the State of Missouri and 100,000 nationally; and
as a laundry or garment bagger, of which 1,000 such jobs exist in the State of
Missouri and 50,000 nationally. (Tr. 62-63.) The VE testified that the person
could perform these same jobs if she were restricted to routine, simple, and
repetitive tasks. The VE further testified that a person could perform only parttime work if she was prevented from regularly engaging in sustained work activity
for a full eight-hour day. (Tr. 64.)
In response to counsel’s questions, the VE testified that a person who was
chronically absent from work one or two days a month would likely be terminated
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if the absences continued. The VE also testified that he was unaware of any
“regular jobs” for a person who, in addition to normal customary breaks, would be
off task greater than fifteen percent of the day. (Tr. 65-66.)
III. Medical Evidence
Upon referral, plaintiff went to Mark Twain Area Counseling Center on
August 11, 2008, for evaluation for psychotropic medication. It was noted that
plaintiff had been diagnosed six years prior with PTSD, bipolar disorder, anxiety,
and obsessive compulsive disorder and had difficulty remaining on psychotropic
medication at that time because of her parents not wanting her to be on medication.
Plaintiff was currently taking no psychotropic medication and reported having
increased anxiety with worsening mood swings and tearfulness. Plaintiff reported
a history of sexual molestation as a child and sexual assault as a teenager. Mental
status examination showed plaintiff to be anxious, tearful, sad, and depressed.
Plaintiff had good eye contact and demonstrated fair insight and judgment.
Plaintiff denied any current intent to harm herself or others. Plaintiff reported
having decreased memory and concentration as well as depressed mood. Plaintiff
also reported her mood to fluctuate and that she has had racing and obsessive
thoughts. Plaintiff reported having panic attacks relating to her thoughts of past
abuse and being paranoid about the safety of her daughter. Plaintiff denied any
recent use of illicit substances. Dr. Ronald St. Hill diagnosed plaintiff with bipolar
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disorder, and alcohol and cannabis dependence in sustained remission. A Global
Assessment of Functioning (GAF) score of 45 was assigned.2 Dr. St. Hill
prescribed Seroquel and Prozac and referred plaintiff for individual counseling.
Plaintiff was instructed to return in two to three weeks for medication
management. (Tr. 284-86.) On August 25, plaintiff was noted to be more relaxed.
Although plaintiff complained of headaches, she was continued on her
medications. A GAF score of 52 was assigned.3 (Tr. 283.)
Plaintiff visited Mark Twain Behavioral Health (Mark Twain) on December
29, 2008, and reported an increase in depressive symptoms and anxiety. Mental
status examination showed decreased activity with a depressed affect and slowed
thought process. Plaintiff’s insight and judgment were noted to be fair. Plaintiff
was diagnosed with PTSD, was prescribed Prozac and Trazodone, and was
instructed to hold off on Seroquel. A GAF score of 52 was assigned. (Tr. 282.)
Plaintiff returned to Mark Twain on July 13, 2009, and reported that she had
2

According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed. Text Rev.
2000) (DSM-TR-IV), the GAF scale is used to report the clinician's judgment of the individual's
overall level of functioning and consists of a number between zero and 100 to reflect that
judgment. See Hurd v. Astrue, 621 F.3d 734, 737 (8th Cir. 2010); Hudson ex rel. Jones v.
Barnhart, 345 F.3d 661, 663 n.2 (8th Cir. 2003). A GAF score between 41 and 50 indicates
serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any
serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep
a job). DSM-TR-IV at 34.

3

A GAF score between 51 and 60 indicates moderate symptoms (e.g., flat affect and
circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or
school functioning (e.g., few friends, conflicts with peers or coworkers). DSM-TR-IV at 34.
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been out of medication for one week. Plaintiff was noted to be depressed and
stressed and to have decreased activity level. Plaintiff reported being forgetful and
losing things. Plaintiff was instructed to increase her Prozac and to continue with
Trazodone. Plaintiff was instructed to return in three to six months. (Tr. 281.)
On January 27, 2010, plaintiff reported to Mark Twain that she was
compliant with her medications but felt sorry for herself because of her emotional
issues. Plaintiff was noted to be calm and pleasant, but she was depressed and had
decreased motivation. Plaintiff reported having mood swings and seeing shadows.
Plaintiff reported drinking at night and that she was quick to get mad. Plaintiff
reported that Trazodone caused bad dreams, and she was instructed to discontinue
its use. Plaintiff was restarted on Seroquel and continued on Prozac. Plaintiff was
instructed to return in four to six weeks. (Tr. 280.)
Plaintiff returned to Mark Twain on March 4, 2010, and reported having
nausea and multiple physical issues. Plaintiff was noted to be depressed and
anxious, and she felt helpless, hopeless, and worthless. Celexa and Prozac were
prescribed, and plaintiff was continued in her GAF score of 52. (Tr. 279.)
The record is silent with respect to mental health treatment for a period of
nineteen months, between March 4, 2010 and October 2011, at which time plaintiff
visited Mark Twain. During this lengthy period of no documented mental health
treatment, the record shows that plaintiff sought and received treatment for
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physical complaints such as nausea and vomiting; and plaintiff’s health care
providers continually noted plaintiff to be taking Prozac and Seroquel. (See Tr.
289, 291-92, 348-49.) Also within this period, and specifically on March 18,
2011, Mark Altomari, Ph.D., a psychological consultant with disability
determinations, reported in a Psychiatric Review Technique Form that there was
insufficient evidence from which to determine the severity of plaintiff’s medically
determinable mental impairments of bipolar disorder, PTSD, and alcohol and
marijuana dependence in sustained remission. Specifically, Dr. Altomari reported
that there was insufficient evidence to determine the effect of such impairments on
plaintiff’s activities of daily living; on her ability to maintain social functioning;
and on her ability to maintain concentration, persistence, or pace; or whether her
impairments caused repeated episodes of decompensation of extended duration.
(Tr. 299-10.)
As noted above, plaintiff returned to Mark Twain in October 2011. She
reported being out of her medication – Prozac and Seroquel – for seven days.
Plaintiff was noted to be polite and cooperative and to have good eye contact and
no eccentricities of speech. Plaintiff reported having occasional nausea and
vomiting caused by anxiety. Plaintiff denied any alcohol use and admitted to past
marijuana use. Plaintiff reported her previous psychiatric treatment to be “hit or
miss.” Mental status examination showed plaintiff to be oriented times four.
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Plaintiff described her sleep as poor and reported having vivid nightmares.
Plaintiff likewise reported her appetite to be poor. Plaintiff reported poor memory,
but recall testing showed her memory to be intact. Plaintiff reported having
difficulty completing tasks and that she had little energy. Plaintiff denied having
any hallucinations. Plaintiff reported having thoughts of suicide but no plan.
Plaintiff also reported having fluctuating moods with periods of occasional highs
and racing thoughts and episodes of depression. Plaintiff reported not being as
happy as she was before, and she wanted to try something different from her
current medications. Dr. David E. Goldman diagnosed plaintiff with bipolar
disorder and attention deficit hyperactivity disorder (ADHD), as well as stomach
upset secondary to stress. Dr. Goldman assigned a GAF score of 45. Plaintiff was
provided samples of Saphris and was instructed to return for follow up in three to
four weeks. (Tr. 320-22.)
Plaintiff visited Dr. Goldman and Mark Twain counselors on November 2,
2011, who noted plaintiff to be somewhat depressed and tearful. Plaintiff was not
doing well and reported not being able to function. Plaintiff reported that she was
compliant with her medication and felt a little better with it but that she continued
to experience symptoms, including night terrors, night sweats, and nightmares.
Plaintiff reported that she also felt hopeless and worthless and would like to just
stay in bed. Plaintiff reported sleeping late and going days without bathing.
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Plaintiff also reported that worsening anxiety caused her not to want to be around a
lot of people. She did not like to leave the house, but was able to shop
independently for groceries and other needed items. Plaintiff also reported
continued manic symptoms in that she had two- or three-day periods when she
cannot sleep; talks excessively and has rapid speech; has racing thoughts, anger,
and increased energy; and has problems with concentration. Plaintiff reported
being obsessive during these periods, especially with housecleaning. Plaintiff
reported occasional suicidal ideations but no intent. Plaintiff admitted to selfmedicating with alcohol and marijuana years prior, but reported that she had not
used alcohol for ten years and last smoked marijuana three years ago. Plaintiff
reported currently receiving unemployment benefits, food stamps, and Medicaid
benefits. Plaintiff reported having poor follow through with appointments, but
expressed a desire to get her mental health under control, continue with treatment,
and participate in therapy. Plaintiff was diagnosed with bipolar disorder, PTSD,
ADHD, and alcohol and cannabis dependence in sustained full remission. Plaintiff
was assigned a current GAF score of 48, with an opinion that her highest GAF
score within the past year was 48. Plaintiff was approved for participation in the
Community Psychiatric Rehabilitation (CPR) Program. (Tr. 336-44.) A treatment
plan was established for plaintiff to receive counseling and medication
management with Dr. Goldman and CPR counselors. Plaintiff’s symptoms and
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limited resources were noted to be significant obstacles that could prevent
achievement of her treatment goals. (Tr. 323-27.)
Attempts to reach plaintiff by telephone on November 8, 16, and 28 to
establish an initial visit for mental health services were unsuccessful. (Tr. 332,
333, 334.) Attempts to contact plaintiff in December and January were likewise
unsuccessful. (Tr. 329, 330, 331.) Effective January 31, 2012, plaintiff was
discharged from Mark Twain for her failure to appear for services. (Tr. 328, 335.)
Plaintiff was admitted to Blessing Hospital on March 26, 2012, with
depression and suicidal ideas with plans to overdose.4 Plaintiff reported having
been off of her prescription medication for three months and that her depression
had become unbearable. Plaintiff reported being sad, down, and depressed and that
she had feelings of hopelessness, helplessness, and worthlessness. Plaintiff
reported being very tearful and having irrational feelings of guilt, an inability to
focus or concentrate, anhedonia, and no energy. Plaintiff also reported being
unable to sleep at night because of bad dreams. Plaintiff reported that she last
drank alcohol about ten years prior and that she smoked cannabis to calm herself
down. Urine screening was positive for the presence of cannabis. Plaintiff’s
4

The records from Blessing Hospital were not before the ALJ at the time of his decision but
were submitted to and considered by the Appeals Council in determining whether to review the
ALJ’s adverse decision. The Court must consider this evidence in determining whether the
ALJ's decision was supported by substantial evidence. Frankl v. Shalala, 47 F.3d 935, 939 (8th
Cir. 1995); Richmond v. Shalala, 23 F.3d 1441, 1444 (8th Cir. 1994).
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mental history was noted, including her most recent discharge from Mark Twain
because of missed appointments. Plaintiff reported that taking Prozac, Seroquel,
and Saphris was effective. Plaintiff reported her childhood history of sexual
trauma and that she continued to have intrusive thoughts, painful memories, bad
dreams, and nightmares about the abuse. Plaintiff reported that raising her
daughter reminds her of the trauma. Mental status examination showed plaintiff to
be tearful and passively cooperative. Plaintiff was dysphoric and had a depressed
mood and affect. Memory, attention, and concentration appeared to be intact.
Plaintiff denied any hallucinations or delusions. Plaintiff’s insight and judgment
were limited. Plaintiff was diagnosed with major depressive disorder, severe,
recurrent, without psychotic features; chronic PTSD; cannabis abuse; and alcohol
dependence in sustained remission. Upon admission, plaintiff was assigned a GAF
score of 30.5 (Tr. 435-36.)
During her admission at Blessing, plaintiff was given Prozac and Geodon
and participated in group therapy. Plaintiff experienced stomach upset possibly
related to her medication, but she was able to tolerate the discomfort. Plaintiff
became more hopeful and positive during her admission. Plaintiff was discharged
on March 30 with a GAF score of 50 and was referred for outpatient counseling at
5

A GAF score between 21 and 30 indicates behavior considerably influenced by delusions or
hallucinations, or serious impairment in communication or judgment (e.g., sometimes
incoherent, acts grossly inappropriately, suicidal preoccupation), or inability to function in
almost all areas (e.g., stays in bed all day; no job, home, or friends). DSM-TR-IV at 34.
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Comprehensive Health Systems. Plaintiff’s discharge medications included Prozac
and Geodon. (Tr. 437-39.)
In April 2012, Comprehensive Health Systems completed an evaluation for
intake assessment and treatment plan development. The initial assessment took
place at plaintiff’s home on April 18, and plaintiff underwent a psychiatric
evaluation with Dr. Jason Cafer on April 23. During this assessment, plaintiff
reported that she was recently hospitalized at Blessing because she was “ready to
end it” and knew she needed help. Plaintiff reported that she had been isolating
herself due to anxiety, was sleeping too much, and was unable to complete tasks.
Plaintiff reported needing support as she proceeded through the disability process.
Plaintiff’s current medications were noted to include Geodon and Prozac.
Plaintiff’s hygiene was poor and her hair was disheveled. Her home was noted to
be cluttered and did not appear to be clean. Plaintiff reported that she lacked
energy and had no motivation to complete household tasks. Plaintiff was also
noted not to be motivated to complete personal care tasks. She struggled with
good hygiene because of her depressive symptoms. Plaintiff reported that she
cooks only because she needs to feed her five-year-old daughter. As to her social
relationships, plaintiff reported that she was close to her mother. Plaintiff reported
that her two older children were taken away from her and adopted and that she
maintained a relationship with her fourteen-year-old daughter, who lived in Iowa
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with her father. Plaintiff also maintained contact with her current spouse, from
whom she was separated. Plaintiff admitted to limited coping skills. Plaintiff was
oriented times five, cooperative, and maintained good eye contact. Her intellect
was determined to be average and she was able to stay on topic. No psychotic
symptoms were noted, but plaintiff reported having delusions and hallucinations in
the past. Plaintiff denied any suicidal or homicidal thoughts. She described her
mood as okay. It was noted that plaintiff had been discharged from previous
mental health services because of missed appointments, and plaintiff reported that
she tried to function without medication but realized that she was unable to do so.
It was noted that plaintiff had a history of poor judgment. Plaintiff reported her
current mood symptoms to include sleeping too much, mood changes, crying
spells, isolation, memory and concentration problems, decreased self-esteem,
excessive guilt, irritability, and feelings of hopelessness, helplessness, and
worthlessness. Plaintiff reported that she was sometimes unable to awaken in the
morning and goes days without bathing because she lacks energy. Plaintiff
reported her manic symptoms to include pressured speech, grandiosity, racing
thoughts, increased energy, decreased need for sleep, and euphoric mood. Plaintiff
also reported symptoms of anxiety – including fear of panic attacks – and that she
has night terrors and problems with intrusive memories from the past. Plaintiff
reported a suicide attempt ten years prior. Plaintiff reported that medication has
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helped but she wanted something that would manage her symptoms more
effectively. Plaintiff reported not being troubled by any side effects. Plaintiff
reported past use of alcohol and marijuana and that marijuana helped with anxiety
and to settle her stomach. Plaintiff denied any current use of marijuana, but it was
noted that she tested positive for the substance during her recent hospitalization in
March. Plaintiff reported that she had not used the substance since being
hospitalized. Plaintiff reported drugs and alcohol not to be a problem but
expressed a willingness to attend individual counseling in Integrated Dual Disorder
Treatment (IDDT). Dr. Cafer diagnosed plaintiff with bipolar disorder with
psychotic features, PTSD, cannabis dependence with physiological dependence,
alcohol dependence with physiological dependence in sustained full remission, and
panic disorder. Plaintiff was assigned a GAF score of 35.6 It was noted that
plaintiff continued to receive unemployment benefits and food stamps. Dr. Cafer
determined plaintiff’s mental illness to be chronic and opined that she would need
psychiatric services on a long-term basis. A critical intervention plan was
established for plaintiff to receive medical, psychiatric, and supportive care,
including an assessment for substance abuse counseling. Dr. Cafer determined to
6

A GAF score between 31 and 40 indicates some impairment in reality testing or
communication (e.g., some speech is at times illogical, obscure, or irrelevant); or major
impairment in several areas, such as work or school, family relations, judgment, thinking, or
mood (e.g., depressed person avoid friends, neglects family, and is unable to work). DSM-TRIV at 34.
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increase plaintiff’s Prozac, and Minipress was added to plaintiff’s medication
regimen for nightmares. (Tr. 359-67, 389-91.)
Plaintiff reported to Dr. Cafer on May 7, 2012, that Minipress was not
helping with nightmares and that she was irritable and snapping at everyone.
Plaintiff was instructed to increase her dosage of Minipress. (Tr. 387.) On May
24, plaintiff reported to Dr. Cafer that she had difficulty with sleep. Plaintiff
reported her racing thoughts to worsen at night. On a scale of one to ten, plaintiff
rated her depression as a three, her anxiety as a seven, her irritability as a six, and
her insomnia as a nine. Plaintiff reported having nightmares less frequently and
less severe than before increasing Minipress, but she continued to have them twice
a week. Plaintiff’s current medications were noted to be Geodon, Prozac, and
Minipress. Mental status examination showed plaintiff’s grooming to be fair. Her
mood was mildly to moderately depressed, and her affect was within normal limits.
Plaintiff’s mental status examination was normal in all other respects. Dr. Cafer
continued in his diagnoses of plaintiff and assigned a GAF score of 42. Plaintiff
was instructed to further increase her dosage of Minipress for nightmares as well as
her dosage of Geodon for mood, anxiety, and irritability. Ambien was prescribed
for insomnia. Plaintiff was instructed to return in one month at which time she
would see Dr. Clark. (Tr. 385.)
On June 4, Dr. Cafer again instructed plaintiff to increase her dosage of
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Minipress in response to plaintiff’s complaints of worsening nightmares. (Tr.
383.)
Plaintiff underwent evaluation for substance abuse treatment on June 11,
2012, and reported having used cannabis four times within the past thirty days to
ease her stomach pains. Plaintiff reported having no alcohol or drug problems
within the past thirty days. It was recommended that plaintiff be admitted to the
IDDT program given that she met the criteria for cannabis and alcohol dependence,
but plaintiff indicated that she was not presently interested in participating. (Tr.
379-80.)
Plaintiff went to Hannibal Regional Hospital on June 19, 2012, for reasons
not stated in the records. Plaintiff left against medical advice prior to receiving
treatment because of the delay in being seen. (Tr. 356.)
On July 12, 2012, plaintiff underwent a psychiatric evaluation with Dr. Lyle
Clark at Comprehensive Health Systems. Dr. Clark noted plaintiff’s current
medications to be Geodon, Minipress, Ambien, and Prozac. Plaintiff reported that
she felt her medication was working “pretty good,” but her symptoms were noted
to be only partially controlled. Dr. Clark noted plaintiff’s history of mental
impairments, and plaintiff reported that she currently experienced problems with
being tired, very irritable, and becoming angry with people. Plaintiff also reported
having psychotic symptoms for more than one year, including an altered
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perception of reality with auditory hallucinations, disorganization of thought, and
persecutory delusions. Plaintiff reported having a depressed mood almost every
day, anhedonia, increased sleep, loss of energy, inappropriate guilt, problems with
thinking and concentration, and thoughts of death. Plaintiff also described
experiencing manic episodes that included talkativeness, racing thoughts,
distractibility, restlessness, increased socialization, and spending sprees. Plaintiff
reported experiencing mood swings several times a week. Plaintiff also reported
having symptoms of panic attacks several times a week, with feelings of intense
fear or discomfort, palpitations, sweating, shortness of breath, shaking, chest pain,
and fear of losing control. Plaintiff also described agoraphobic symptoms and
symptoms of social phobia, which were considered by Dr. Clark to be excessive
and to interfere with normal functioning. Plaintiff also reported symptoms of
compulsions, such as arranging things, repeating words, and performing tasks in a
certain order. Plaintiff reported having intrusive thoughts, repeated nightmares,
flashbacks, and intense bad feelings about her abuse as a child. Dr. Clark observed
plaintiff to have problems consistent with serious impairments in thinking and
mood as well as serious impairments due to anxiety. Dr. Clark determined plaintiff
to be in sustained full remission with regard to her alcohol and cannabis
dependence. Mental status examination showed plaintiff to be oriented times four.
Plaintiff’s hygiene was adequate. She was cooperative and pleasant, and her
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speech was within normal limits. Plaintiff’s intellect was considered to be average,
and her memory was noted to be fair. Plaintiff’s thoughts demonstrated logical
associations. Plaintiff reported occasional auditory hallucinations, but no delusions
were detected. Plaintiff reported having depressive ideation but no suicidal
ideation. Dr. Clark noted plaintiff’s mood to be depressed and her affect
appropriate. Plaintiff’s insight and judgment were adequate. Dr. Clark determined
that plaintiff’s symptoms caused significant distress and interference with
functioning. Dr. Clark diagnosed plaintiff with chronic bipolar disorder, severe,
with psychotic features and rapid cycling; panic disorder with agoraphobia; social
phobia; obsessive compulsive disorder; chronic PTSD; and alcohol and cannabis
dependence, without physiologic dependence, in sustained full remission. Dr.
Clark assigned a GAF score of 43. Lamictal was added to plaintiff’s medication
regimen, and she was instructed to return in four weeks. (Tr. 375-78.)
On August 16, 2012, Dr. Clark completed a Mental Medical Source
Statement of Ability to Do Work-Related Activities (Mental MSS). Dr. Clark
opined that plaintiff was moderately limited in her ability to make judgments on
complex work-related decisions and to understand, remember, and carry out
complex instructions, but was only mildly limited with respect to simple work
decisions and instructions. Dr. Clark further opined that plaintiff was markedly
limited in her ability to interact appropriately with the public and supervisors, and
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moderately limited in her ability to interact appropriately with coworkers and
respond appropriately to usual work situations and to changes in a routine work
setting. Dr. Clark explained that plaintiff had social phobia and had difficulty in
public situations. Dr. Clark reported that plaintiff’s dysfunction worsens when she
is being closely supervised. Dr. Clark also explained that plaintiff had problems
with irritability that made it difficult for her to function in frustrating situations.
Dr. Clark reported that, to his knowledge, alcohol or substance abuse did not
contribute to any of plaintiff’s limitations. (Tr. 393-95.)
IV. The ALJ's Decision
The ALJ found that plaintiff met the insured status requirements of the
Social Security Act through March 31, 2014, and had not engaged in substantial
gainful activity since June 30, 2010, the alleged onset date of disability. The ALJ
found plaintiff’s bipolar disorder, anxiety disorder, and PTSD to be severe
impairments, but that plaintiff did not have an impairment or combination of
impairments that met or medically equaled the severity of an impairment listed in
20 C.F.R. Part 404, Subpart P, Appendix. 1. The ALJ found that plaintiff had the
RFC to perform a full range of work at all exertional levels, but was limited to jobs
requiring no more than superficial interaction with the public and no fast-paced
production work. The ALJ found plaintiff’s RFC not to preclude the performance
of her past relevant work as a kitchen prep worker. Alternatively, the ALJ found
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vocational expert testimony to support a finding that, with her age, education, work
experience, and RFC, plaintiff could perform other work as it exists in significant
numbers in the national economy, and specifically, cleaner, stocking work –
apparel, and garment bagger. The ALJ thus found plaintiff not to be under a
disability from June 30, 2010, through the date of the decision. (Tr. 11-24.)
V. Discussion
To be eligible for DIB and SSI under the Social Security Act, plaintiff must
prove that she is disabled. Pearsall v. Massanari, 274 F.3d 1211, 1217 (8th Cir.
2001); Baker v. Secretary of Health & Human Servs., 955 F.2d 552, 555 (8th Cir.
1992). The Social Security Act defines disability as the "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 which has lasted or
can be expected to last for a continuous period of not less than 12 months." 42
U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A). An individual will be declared disabled
"only if [her] physical or mental impairment or impairments are of such severity
that [she] is not only unable to do [her] previous work but cannot, considering [her]
age, education, and work experience, engage in any other kind of substantial
gainful work which exists in the national economy." 42 U.S.C. §§ 423(d)(2)(A),
1382c(a)(3)(B).
To determine whether a claimant is disabled, the Commissioner engages in a
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five-step evaluation process. See 20 C.F.R. §§ 404.1520, 416.920; Bowen v.
Yuckert, 482 U.S. 137, 140-42 (1987). The Commissioner begins by deciding
whether the claimant is engaged in substantial gainful activity. If the claimant is
working, disability benefits are denied. Next, the Commissioner decides whether
the claimant has a “severe” impairment or combination of impairments, meaning
that which significantly limits her ability to do basic work activities. If the
claimant's impairment(s) is not severe, then she is not disabled. The Commissioner
then determines whether claimant's impairment(s) meets or equals one of the
impairments listed in 20 C.F.R., Part 404, Subpart P, Appendix 1. If claimant's
impairment(s) is equivalent to one of the listed impairments, she is conclusively
disabled. At the fourth step, the Commissioner establishes whether the claimant
can perform her past relevant work. If so, the claimant is not disabled. Finally, the
Commissioner evaluates various factors to determine whether the claimant is
capable of performing any other work in the economy. If not, the claimant is
declared disabled and becomes entitled to disability benefits.
The decision of the Commissioner must be affirmed if it is supported by
substantial evidence on the record as a whole. 42 U.S.C. § 405(g); Richardson v.
Perales, 402 U.S. 389, 401 (1971); Estes v. Barnhart, 275 F.3d 722, 724 (8th Cir.
2002). Substantial evidence is less than a preponderance but enough that a
reasonable person would find it adequate to support the conclusion. Johnson v.
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Apfel, 240 F.3d 1145, 1147 (8th Cir. 2001). This “substantial evidence test,”
however, is “more than a mere search of the record for evidence supporting the
Commissioner’s findings.” Coleman v. Astrue, 498 F.3d 767, 770 (8th Cir. 2007)
(internal quotation marks and citation omitted). “Substantial evidence on the
record as a whole . . . requires a more scrutinizing analysis.” Id. (internal quotation
marks and citations omitted).
To determine whether the Commissioner's decision is supported by
substantial evidence on the record as a whole, the Court must review the entire
administrative record and consider:
1.

The credibility findings made by the ALJ.

2.

The plaintiff's vocational factors.

3.

The medical evidence from treating and consulting physicians.

4.

The plaintiff's subjective complaints relating to exertional and
non-exertional activities and impairments.

5.

Any corroboration by third parties of the plaintiff's
impairments.

6.

The testimony of vocational experts when required which is
based upon a proper hypothetical question which sets forth the
claimant's impairment.

Stewart v. Secretary of Health & Human Servs., 957 F.2d 581, 585-86 (8th Cir.
1992) (internal citations omitted). The Court must also consider any evidence
which fairly detracts from the Commissioner’s decision. Coleman, 498 F.3d at
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770; Warburton v. Apfel, 188 F.3d 1047, 1050 (8th Cir. 1999). “If, after reviewing
the entire record, it is possible to draw two inconsistent positions, and the
Commissioner has adopted one of those positions,” the Commissioner’s decision
must be affirmed. Anderson v. Astrue, 696 F.3d 790, 793 (8th Cir. 2012). The
decision may not be reversed merely because substantial evidence could also
support a contrary outcome. Young v. Apfel, 221 F.3d 1065, 1068 (8th Cir. 2000).
Plaintiff’s challenges to the ALJ’s decision involve the manner and method
by which the ALJ determined plaintiff’s RFC. Specifically, plaintiff challenges the
weight accorded by the ALJ to Dr. Clark’s August 2012 opinion, the failure of the
ALJ to include relevant mental limitations in the RFC, the ALJ’s improper reliance
on plaintiff’s work history and role as a mother to find her able to work, and the
lack of relevant medical evidence to support the RFC determination. The matter
will be remanded for further proceedings for the reasons set out below, because it
cannot be said that the ALJ’s decision is supported by substantial evidence on the
record as a whole.
Plaintiff’s Credibility
Residual functional capacity is the most a claimant can do despite her
physical or mental limitations. Masterson v. Barnhart, 363 F.3d 731, 737 (8th Cir.
2004). The ALJ bears the primary responsibility for assessing a claimant’s RFC
based on all relevant, credible evidence in the record, including medical records,
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the observations of treating physicians and others, and the claimant’s own
description of her symptoms and limitations. Goff v. Barnhart, 421 F.3d 785, 793
(8th Cir. 2005); Eichelberger v. Barnhart, 390 F.3d 584, 591 (8th Cir. 2004); 20
C.F.R. §§ 404.1545(a), 416.945(a). Because a claimant’s RFC is a medical
question, some medical evidence must support the ALJ’s RFC assessment. Vossen
v. Astrue, 612 F.3d 1011, 1016 (8th Cir. 2010); Eichelberger, 390 F.3d at 591;
Hutsell v. Massanari, 259 F.3d 707, 711-12 (8th Cir. 2001). As such, the ALJ
must “consider at least some supporting evidence from a [medical professional]”
and should obtain medical evidence that addresses the claimant’s ability to
function in the workplace. Hutsell, 259 F.3d at 712 (internal quotation marks and
citation omitted). An ALJ’s RFC assessment which is not properly informed and
supported by some medical evidence in the record cannot stand. Id.
When determining a claimant’s RFC, the ALJ must evaluate the credibility
of the claimant’s subjective complaints. Wagner v. Astrue, 499 F.3d 842, 851 (8th
Cir. 2007); Tellez v. Barnhart, 403 F.3d 953, 957 (8th Cir. 2005). In so doing, the
ALJ must consider all evidence relating thereto, including the claimant’s prior
work record and third party observations as to the claimant's daily activities; the
duration, frequency and intensity of the symptoms; any precipitating and
aggravating factors; the dosage, effectiveness and side effects of medication; and
any functional restrictions. Halverson v. Astrue, 600 F.3d 922, 931 (8th Cir.
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2010); Polaski v. Heckler, 739 F.2d 1320, 1322 (8th Cir. 1984) (subsequent history
omitted). When rejecting a claimant's subjective complaints, the ALJ must make
an express credibility determination detailing the reasons for discrediting the
testimony. Renstrom v. Astrue, 680 F.3d 1057, 1066 (8th Cir. 2012); Cline v.
Sullivan, 939 F.2d 560, 565 (8th Cir. 1991). An ALJ must do more than merely
invoke Polaski to insure "safe passage for his or her decision through the course of
appellate review." Harris v. Shalala, 45 F.3d 1190, 1193 (8th Cir. 1995). Instead,
“the ALJ must set forth the inconsistencies in the evidence presented and discuss
the factors set forth in Polaski[.]” Cline, 939 F.2d at 565; see also Renstrom, 680
F.3d at 1066; Beckley v. Apfel, 152 F.3d 1056, 1059-60 (8th Cir. 1998). It is not
enough to merely state that inconsistencies are said to exist. Cline, 939 F.2d at
565. While an ALJ need not explicitly discuss each Polaski factor, he nevertheless
must acknowledge and consider these factors before discounting a claimant’s
subjective complaints. Wildman v. Astrue, 596 F.3d 959, 968 (8th Cir. 2010). If
the ALJ’s credibility determination is supported by good reasons and substantial
evidence, the Court must defer to this determination. Renstrom, 680 F.3d at 1064.
Here, the ALJ cited various inconsistencies in the record to find plaintiff’s
credibility to be “severely undermine[d].” (Tr. 21.) Specifically, the ALJ noted
that plaintiff’s compliance with her treatment regimen was questionable, observing
that plaintiff failed to appear for mental health services in late 2011 and early 2012
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and had stopped taking her medication in early 2012. A claimant’s noncompliance with prescribed treatment is a basis upon which to find her subjective
complaints not credible. Wildman, 596 F.3d at 968-69; Brown v. Barnhart, 390
F.3d 535, 542 (8th Cir. 2004). To the extent plaintiff claims that the effects of her
depression caused her failure to keep her appointments, the undersigned notes the
ALJ to have acknowledged this possibility but to have observed that plaintiff kept
her appointments regarding her physical health during this time, including
participating in a sleep study and getting routine treatment for diabetes. (See Tr.
21.) As such, while an adverse determination may be flawed by an ALJ’s failure
to recognize that a claimant’s non-compliance with treatment may be a
manifestation of her mental impairment, Pate-Fires v. Astrue, 564 F.3d 935, 945
(8th Cir. 2009), the ALJ here acknowledged such circumstance and properly
considered evidence of record that showed plaintiff’s mental impairment not to
interfere with her ability to keep and maintain appointments. The ALJ therefore
did not err in considering plaintiff’s non-compliance with treatment to find her
claims not credible.
The ALJ also noted plaintiff to have given inconsistent reports regarding her
substance abuse and continued use of marijuana and that, while being eligible for
substance abuse treatment, she declined services. See Gulliams v. Barnhart, 393
F.3d 798, 802 (8th Cir. 2005) (failure to follow recommended course of treatment
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weighs against claimant’s credibility); Ply v. Massanari, 251 F.3d 777, 779 (8th
Cir. 2001) (inconsistency in claimant’s statements valid reason to discredit
subjective complaints). The ALJ also noted the record to show plaintiff’s
continued receipt of unemployment benefits during the period she claimed she was
disabled. A claimant’s application for unemployment benefits adversely affects
her credibility inasmuch as an unemployment applicant must hold herself out as
available, willing, and able to work. Smith v. Colvin, 756 F.3d 621, 625 (8th Cir.
2014).
The ALJ also looked to plaintiff’s work record and found the evidence to
show that plaintiff was able to work with her mental impairments prior to June 30,
2010, her alleged onset date of disability, and that the record showed no
“worsening symptoms around that time.” (Tr. 21.) Although it is reasonable to
conclude that an impairment is not disabling where a claimant effectively works
with her impairment over a period of time and there is no indication that her
condition significantly deteriorated on or after the alleged onset date of disability,
see Goff, 421 F.3d at 793, the record here shows that plaintiff’s symptoms indeed
worsened after the alleged onset date, see discussion infra at pp. 38-39, and no
evidence shows that plaintiff worked or engaged in work-related activities with
these worsening symptoms.
The ALJ also determined to discredit plaintiff’s complaints because of her
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ability to manage her own household and care for her daughter. To support his
finding that plaintiff experienced only mild difficulty with such activities of daily
living, the ALJ specifically recited plaintiff’s ability to perform household chores –
albeit without motivation – as well as her ability to help her daughter with
grooming and hygiene and prepare meals for her. Although the ALJ
acknowledged in other portions of his written decision that plaintiff claimed an
onset of PTSD symptoms while bathing her daughter and that other family
members actually care for her daughter three or four days a week because of
plaintiff’s claimed inability to do so, it appears that he failed to consider these
adverse circumstances when determining that plaintiff’s daily activities discredited
her claims of disabling symptoms. Nor did the ALJ consider plaintiff’s report to
her healthcare providers that she obsessively performs chores during manic phases
of her bipolar disorder and, further, that plaintiff’s home appeared unclean and
cluttered during her initial assessment for mental health services. When
considered in context, therefore, plaintiff’s daily activities as recited by the ALJ
are not so inconsistent with plaintiff’s claims of limited daily activities such that
her credibility should be generally discounted. See Cline, 939 F.2d at 565-66 (ALJ
must clarify the basis on which daily activities are inconsistent with allegations of
pain; evaluation of extent to which claimant actually performed activities did not
support adverse credibility determination). See also Wagner, 499 F.3d at 851 (ALJ
- 32 -

should consider quality of daily activities and ability to engage in such activities
over a period of time).
Although the ALJ’s evaluation of plaintiff’s work record and daily activities
was not the only component of his finding that plaintiff’s subjective complaints
were not consistent with the record evidence, the improper consideration of these
factors weakens the ALJ’s overall conclusion that plaintiff’s credibility was
“severely undermined” by the perceived inconsistencies in the record. See
generally Baumgarten v. Chater, 75 F.3d 366 (8th Cir. 1996). The matter must
therefore be remanded for an appropriate analysis of plaintiff's credibility in the
manner required by and for the reasons discussed in Polaski.
Treating Source Opinion
Upon determining plaintiff not to be credible, the ALJ turned to Dr. Clark’s
August 2012 Mental MSS and determined to give it little weight in assessing
plaintiff’s RFC. (Tr. 21-22.) To support this determination, the ALJ noted that Dr.
Clark had treated plaintiff on only one occasion, gave a poor explanation for his
opinions, failed to acknowledge plaintiff’s improvement with medication, and
appeared to base his opinions on plaintiff’s subjective complaints. Plaintiff claims
that the opinion of this treating source was entitled to controlling weight.
In evaluating opinion evidence, the Regulations require the ALJ to explain
in the decision the weight given to any opinions from treating sources, non-treating
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sources, and non-examining sources. See 20 C.F.R. §§ 404.1527(e)(2)(ii),
416.927(e)(2)(ii). The Regulations require that more weight be given to the
opinions of treating physicians than other sources and, indeed, that a treating
physician's assessment of the nature and severity of a claimant's impairments
should be given controlling weight if the opinion is well supported by medically
acceptable clinical and laboratory diagnostic techniques and is not inconsistent
with other substantial evidence in the record. 20 C.F.R. §§ 404.1527(c)(2),
416.927(c)(2); see also Forehand v. Barnhart, 364 F.3d 984, 986 (8th Cir. 2004).
This is so because a treating physician has the best opportunity to observe and
evaluate a claimant's condition,
since these sources are likely to be the medical professionals most
able to provide a detailed, longitudinal picture of [a claimant's]
medical impairment(s) and may bring a unique perspective to the
medical evidence that cannot be obtained from the objective medical
findings alone or from reports of individual examinations, such as
consultative examinations or brief hospitalizations.
20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2).
When a treating physician's opinion is not given controlling weight, the
Commissioner must look to various factors in determining what weight to accord
the opinion, including the length of the treatment relationship and the frequency of
examination, the nature and extent of the treatment relationship, whether the
treating physician provides support for his findings, whether other evidence in the
record is consistent with the treating physician's findings, and the treating
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physician's area of specialty. 20 C.F.R. §§ 404.1527(c), 416.927(c). The
Regulations further provide that the Commissioner “will always give good reasons
in [the] notice of determination or decision for the weight [given to the] treating
source's opinion.” 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2).
Plaintiff contends that Dr. Clark’s Mental MSS was entitled to controlling
weight inasmuch as Dr. Clark was plaintiff’s treating psychiatrist and because his
opinions were consistent with all the other evidence of record. The Regulations
define a “treating source” as a claimant’s “own physician, psychologist, or other
acceptable medical source who provides you, or has provided you, with medical
treatment or evaluation and who has, or has had, an ongoing treatment relationship
with you.” 20 C.F.R. §§ 404.1502, 416.902 (emphasis added).
The record contains no evidence that, at the time Dr. Clark rendered his
opinion in August 2012, he had an ongoing treatment relationship with plaintiff –
given that he had seen plaintiff on only one occasion in July 2012 – such that he
had sufficient knowledge from which he could form an opinion regarding
plaintiff’s ability to function in the workplace. Randolph v. Barnhart, 386 F.3d
835, 840 (8th Cir. 2004). Because the record does not support plaintiff’s
contention that Dr. Clark was a treating source as defined by the Regulations, the
ALJ did not err in failing to accord controlling weight to his Mental MSS.
Furthermore, the ALJ cited other reasons for providing less than controlling
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weight to Dr. Clark’s opinions. Specifically, the ALJ noted Dr. Clark’s lack of an
ongoing treatment relationship with plaintiff and that Dr. Clark provided little
support for his conclusions. These reasons are supported by substantial evidence
on the record as a whole and constitute good reasons to discount medical opinion
evidence. See C.F.R. §§ 404.1527(c)(2)(i), (c)(3); 416.927(c)(2)(i), (c)(3). The
ALJ also noted that Dr. Clark failed to discuss the effects of plaintiff’s substance
abuse on her ability to function. Although an ALJ’s determination of disability
must first be made without segregating out any effects that might be due to
substance use disorders, see Brueggemann v. Barnhart, 348 F.3d 689, 694 (8th Cir.
2011), the ALJ’s perceived error here in faulting Dr. Clark’s failure to address
plaintiff’s substance abuse was harmless at most given that Dr. Clark indeed
addressed such abuse by stating that alcohol or substance abuse did not appear to
contribute to any of plaintiff’s limitations.
Plaintiff contends, however, that the ALJ should not have discounted Dr.
Clark’s opinion inasmuch as it was consistent with all the other evidence of record,
and specifically, evidence that plaintiff’s medications were continually adjusted
and changed because of their ineffectiveness as well as evidence of plaintiff’s
consistent GAF scores below 50. Although Dr. Clark’s opinions were consistent
with some of the medical evidence of record, said medical evidence was limited
and does not support that Dr. Clark’s opinion should have been accorded greater
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weight. As discussed above, Dr. Clark was not a treating physician as defined by
the Regulations and, as such, his opinions were not entitled to controlling weight.
Additionally, the ALJ cited other good reasons to discount the opinion
evidence from Dr. Clark--his lack of an ongoing treatment relationship and the lack
of support given for the opinions. Nevertheless, given the limited medical
evidence of record after the alleged onset date of disability of June 30, 2010 (i.e.,
the records submitted only consist of roughly a half dozen treatment notes
regarding plaintiff’s mental impairments between October 6, 2011 and July 12,
2012) and the ALJ’s conclusion that Dr. Clark’s opinions should be accorded only
little weight, the ALJ should have more fully developed the record. The ALJ
needed more evidence regarding how plaintiff’s mental impairments affect her
ability to work so that he could properly develop the plaintiff’s RFC. To
accomplish this objective, the parties should have been afforded an opportunity to
provide additional medical evidence.
Plaintiff’s Residual Functional Capacity (RFC)
In his written decision, the ALJ summarized the medical evidence of record
in a very detailed fashion, however, failed to discuss or analyze how such evidence
affected the RFC assessment. Although it was not error for the ALJ to accord little
weight to Dr. Clark’s opinion, a review of the record in toto shows multiple mental
health providers to have consistently observed plaintiff to exhibit serious
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symptoms of mental illness or serious impairments in functioning. To the extent
medical records show plaintiff to exhibit only moderate symptoms, a review of the
record shows such occurrences to have been prior to plaintiff’s alleged onset date
of disability of June 30, 2010. Although the ALJ observed that plaintiff was able
to work with her impairments prior to the alleged onset date and correctly stated
that the record showed no worsening symptoms “around that time,” the record also
shows a significant worsening of symptoms thereafter. By March 2012, the
plaintiff was voluntarily admitted to the hospital for suicidal ideation.
While the record shows plaintiff to have received no specific mental health
treatment from a mental health provider until October 2011, there were continuous
references by her physical health care providers that she was taking Prozac and
Seroquel prior to October 2011, and specifically, in December 2010, January 2011,
and May 2011. Plaintiff sought specific mental health treatment in October 2011
at which time she reported being out of medication for seven days and that she
wanted to try different medication inasmuch as she was not as happy as before.
She had a GAF score of 45 at the time, indicating serious symptoms.
Four weeks later, plaintiff continued to exhibit serious symptoms despite
compliance with medication, as demonstrated by her GAF score of 48 as well as by
Dr. Goldman’s observations. She thereafter failed to keep appointments with her
mental health providers and admittedly stopped taking her medication. As
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previously noted, in March 2012, plaintiff appeared at a hospital with suicidal
ideation and a plan. Her intake GAF score was 30, indicating an inability to
function, but she had been without treatment for some time. After a four-day
period of hospitalization, which included medication management and therapy,
plaintiff was discharged with a GAF score of 50, which, while improved,
nevertheless continued to indicate serious symptoms. Three weeks later, during a
subsequent evaluation for continued outpatient treatment, plaintiff exhibited
symptoms that Dr. Cafer considered to demonstrate major impairments in
functioning, as demonstrated by the GAF score of 35. Significantly, these
observations were made after plaintiff had been on a treatment regimen with
psychotropic medication for at least three weeks.
Despite Dr. Cafer’s prescription for additional medication as well as his
adjustments to plaintiff’s current medications, plaintiff continued to exhibit serious
symptoms with worsening irritability and continued nightmares as recorded in the
treatment notes. Although the ALJ states that plaintiff had shown some
improvement as demonstrated by a GAF score of 42 in May 2012, it cannot be said
that an improvement from major impairments in functioning (GAF 35) to serious
symptoms and impairments in functioning (GAF 42) indicates an improvement so
significant that it renders plaintiff’s impairments amendable to medication – at
least not to the degree that she is able to function in the workplace. Indeed, despite
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continued therapy with psychotropic medication, including additional medications
and increased dosages, plaintiff continued to report serious symptoms and
impairments in functioning that were documented by a number of the treating
sources.
The Commissioner argues that GAF scores alone are not determinative of
the extent to which a claimant’s mental impairment affects her RFC and that
plaintiff’s low GAF scores here bear no direct relation to the severity of her mental
impairments. The Commissioner is correct in that the GAF scale has not been
endorsed by the Social Security Administration for use in the Social Security and
SSI disability programs and “does not have a direct correlation to the severity
requirements in [the] mental disorders listings.” 65 FR 50746-01, 50764, 2000
WL 1173632 (Soc. Sec. Admin. Aug. 21, 2000); see also Halverson, 600 F.3d at
930-31. The GAF scores, however, may still be used to assist the ALJ in assessing
the level of a claimant’s functioning. Halverson, 600 F.3d at 930-31. Here, while
the ALJ acknowledged plaintiff’s GAF scores, he did not discuss the significance
of the consistently low scores nor give any reason why they should not be
considered in assessing plaintiff’s RFC. A “history of GAF scores at 50 or below,
taken as a whole, indicate [that the claimant] has ‘[s]erious symptoms . . . or any
serious impairment in social, occupational or school functioning . . . .’” PateFires, 564 F.3d at 944 (quoting DSM-IV at 32) (emphasis added), and cases cited
- 40 -

therein. The ALJ’s failure to consider this consistent evidence of impaired
functioning in conjunction with the other evidence of record that demonstrated the
same was error. Id. at 944-45.
Notably, the State agency consultant reported in March 2011 that there was
insufficient evidence from which the severity of plaintiff’s mental impairments
could be determined. This report was made seven months prior to plaintiff’s first
documented treatment received from a mental health provider subsequent to the
alleged onset date of disability, and thus prior to all of the evidence of record
demonstrating the extent to which plaintiff’s mental impairments affected her
functional abilities during the relevant period. With the ALJ’s determination to
accord little weight to Dr. Clark’s opinion evidence, his lack of analysis regarding
the consistent medical evidence of record demonstrating plaintiff’s serious
limitations caused by her mental impairments, and the absence of medical evidence
from any other source, it is not clear as to what medical evidence, if any, the ALJ
relied on to conclude that plaintiff was limited only with regard to fast-paced
production work and the degree of her interaction with the public. Because the
ALJ’s decision is unclear as to the medical basis for his assessment of the degree to
which plaintiff’s impairments affect her RFC, the matter must be remanded to the
Commissioner for further proceedings. Lauer v. Apfel, 245 F.3d 700, 704-05 (8th
Cir. 2001). Drawing a conclusion regarding credibility is not equivalent to
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demonstrating by medical evidence that a claimant has the RFC to perform certain
work-related activities. Estabrook v. Apfel, 14 F. Supp. 2d 1115, 1122 (S.D. Iowa
1998), cited approvingly in Graham v. Colvin, No. 4:12-cv-00863-SPM, 2013 WL
3820613, at *7 (E.D. Mo. July 23, 2013) (memorandum opinion).
This cause is therefore remanded to the Commissioner for further
consideration. Upon remand, the ALJ shall further develop the record. The
Commissioner shall obtain and provide the parties an opportunity to submit
additional medical evidence that addresses plaintiff’s ability to function in the
workplace, which may include contacting her treating mental health sources to
clarify her limitations and restrictions in order to ascertain what level of work, if
any, she is able to perform. See Coleman v. Astrue, 498 F.3d 767 (8th Cir. 2007);
Smith v. Barnhart, 435 F.3d 926, 930-31 (8th Cir. 2006). The ALJ is also
permitted to order additional mental examinations and tests in order for him to
make an informed decision as to disability. Dozier v. Heckler, 754 F.2d 274, 276
(8th Cir. 1985); 20 C.F.R. §§ 404.1517, 416.907. Upon receipt of any additional
evidence, the ALJ shall reconsider the record as a whole, reevaluate the credibility
of plaintiff’s own description of her symptoms and limitations, and reassess
plaintiff’s RFC. Such reassessed RFC shall be based on some medical evidence in
the record and shall be accompanied by a discussion and description of how the
evidence supports each RFC conclusion. Cox v. Astrue, 495 F.3d 614, 619 (8th
- 42 -

Cir. 2007).
Therefore, for the reasons stated above,
IT IS HEREBY ORDERED that the decision of the Commissioner is
REVERSED, and this cause is REMANDED for further proceedings.
A separate Judgment in accordance with this Memorandum and Order is
entered this same date.

Dated: June 8, 2015
ABBIE CRITES-LEONI
UNITED STATES MAGISTRATE JUDGE

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