Mitchell v. Astrue

Filing 23

MEMORANDUM AND ORDER - IT IS HEREBY ORDERED that the decision of the Commissioner is affirmed, and Mitchell's Complaint is dismissed with prejudice. A separate Judgment in accordance with this Memorandum and Order is entered this same date. Signed by District Judge Catherine D. Perry on January 8, 2014. (MCB)

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
EASTERN DIVISION

KELSEY P. MITCHELL,
Plaintiff,
v.
CAROLYN W. COLVIN, Acting
Commissioner of Social Security,1
Defendant.

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No. 4:13CV131 CDP

MEMORANDUM AND ORDER
This is an action under 42 U.S.C. §§ 405(g) and 1383(c)(3) for judicial
review of the Commissioner‟s final decision denying Kelsey P. Mitchell‟s
application for supplemental security income under Title XVI of the Social
Security Act, 42 U.S.C. §§ 1381, et seq, in which she claimed she was disabled
because of bipolar disorder, oppositional defiant disorder (ODD), and attention
deficit hyperactivity disorder (ADHD). After a hearing, an Administrative Law
Judge (ALJ) concluded that Mitchell was not disabled. Because I find that the ALJ
committed no legal error and his decision was based on substantial evidence on the
record as a whole, I affirm.

1

Carolyn W. Colvin became the Acting Commissioner of Social Security on February 14, 2013.
As such, she is substituted for Michael J. Astrue as the defendant in this cause of action. Fed. R.
Civ. P. 25(d).

I. Procedural History
Mitchell filed her application for supplemental security income on March 1,
2010, alleging a disability onset date of December 1, 2004. (Tr. 105-08.)2 On May
26, 2010, the Social Security Administration denied her claim for benefits. (Tr. 48,
49, 50-53.) Upon Mitchell‟s request, an administrative hearing was held before an
ALJ on October 18, 2011, at which Mitchell and a vocational expert testified. (Tr.
27-47.) On November 21, 2011, the ALJ issued a decision denying Mitchell‟s
claim for benefits, finding Mitchell able to perform work in the national economy
such as housekeeper/cleaner and hand presser. (Tr. 6-26.) On November 27,
2012, the Appeals Council denied Mitchell‟s request for review of the ALJ's
decision. (Tr. 1-5.) The ALJ's determination thus stands as the final decision of
the Commissioner. 42 U.S.C. § 405(g).
In the instant action for judicial review,3 Mitchell contends that the ALJ
committed legal error by failing to properly acknowledge the Commissioner‟s
regulations on substance abuse and assess disability thereunder, and by failing to
consider the circumstances underlying Mitchell‟s purported failure to follow
prescribed treatment. Mitchell further argues that the ALJ‟s decision is not

2

The ALJ determined that the application was protectively filed on February 16, 2010. (Tr. 9.)

3

In her Complaint, Mitchell claims she is disabled because she suffers from depression, anxiety,
a learning disability, cannabis dependence, ADHD, obsessive compulsive disorder (OCD), and
obesity.
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supported by substantial evidence on the record as a whole inasmuch as the ALJ
failed to properly consider the medical opinion evidence of record. Mitchell
requests that the final decision be reversed and that she be awarded benefits, or that
the matter be remanded for further consideration. For the following reasons, the
decision of the Commissioner will be affirmed.
II. Testimonial Evidence Before the ALJ
A.

Mitchell‟s Testimony
At the hearing on October 18, 2011, Mitchell testified in response to

questions posed by the ALJ and counsel.
At the time of the hearing, Mitchell was twenty-two years of age and
currently attended Meramec Community College. (Tr. 29-30.) Mitchell stood five
feet, five inches tall and weighed 192 pounds. (Tr. 37.)
Mitchell testified that she previously worked at restaurants and at Johnnie
Brock‟s but worked at each location for less than a week because of her inability to
cope with people and the public. (Tr. 31.) Mitchell also testified that she
withdrew from a number of classes at the community college because she felt she
was being judged and therefore did not go to class. Mitchell also testified that she
had difficulty following directions and with reading because of dyslexia and that
she received special services at the community college, including untimed tests and
use of a calculator. (Tr. 38-40.)
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Mitchell testified that she currently sees a doctor for depression, anxiety, and
ADHD and that these conditions cause her to be afraid in public and feel suicidal
and homicidal. (Tr. 34-35.) Mitchell testified that she sees her doctor every two
weeks but that he had recently been out of town. Mitchell testified that medication
for her condition causes muscle cramps, slurred speech, and a dry mouth. (Tr. 41,
43.) Mitchell testified that she underwent six electroconvulsive therapy (ECT)
treatments but did not return for additional treatments because she thought she was
going to die. Mitchell testified that her doctor recommended that she undergo
additional treatments, but she declined. (Tr. 33-34.)
Mitchell testified that she has difficulty concentrating and cannot follow
directions and that she becomes angry in such situations and starts hitting and
punching things. Mitchell testified that she often does not finish a task, such as
cleaning her room or loading the dishwasher. Mitchell testified that she becomes
upset when people are rude to her. Mitchell testified that she is easily
overwhelmed and cries and becomes upset when she is stressed. (Tr. 41-42.)
Mitchell testified that she currently smokes marijuana up to three times a
week to calm her when she is agitated, but that she does not smoke as much as she
did in the past. Mitchell testified that her doctor recommended that she stop
smoking marijuana. (Tr. 32, 34.)
As to her daily activities, Mitchell testified that she has had a boyfriend for
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three years and that they “just hang out.” Mitchell testified that they recently went
to a pumpkin patch. Mitchell testified that she listens to music. Mitchell testified
that she reads for school and attends classes three days a week for fifty minutes
each day. Mitchell testified that she has a driver‟s license but does not drive often.
(Tr. 35-37, 43-44.)
B.

Testimony of Vocational Expert
Ms. Gonzalez, a vocational expert, testified at the hearing in response to

questions posed by the ALJ.
The ALJ asked Ms. Gonzalez to assume an individual twenty years of age
with twelve years of education and no past relevant work at the level of substantial
gainful activity. The ALJ asked Ms. Gonzalez to further assume that the individual
could perform the full range of light work and was
able to understand, remember, and carry out at least simple
instructions on non-detailed tasks; can maintain regular . . . attendance
and work presence without special supervision; should not work in a
setting, which includes constant, or regular contact with the general
public; should not perform work, which includes more than infrequent
handling of customer complaints.
(Tr. 44-45.)
Ms. Gonzalez testified that such a person could perform work as a housekeeper/
cleaner, of which 21,660 such jobs existed in the State of Missouri and 887,890
nationally; and hand presser, of which 1210 such jobs existed in the State of
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Missouri and 60,440 nationally. (Tr. 45.)
The ALJ then asked Ms. Gonzalez to assume an individual who was limited
as Dr. Robinson opined in his October 2011 Assessment,4 to which Ms. Gonzalez
testified that such a person could not work. (Tr. 45-46.)
III. Medical Evidence Before the ALJ
On February 15, 2007, Mitchell visited Dr. Bryan Sewing who noted that
Mitchell was diagnosed with ADHD at three years of age. Dr. Sewing also noted
that Mitchell had previously been “labeled” with ODD, anxiety, bipolar affective
disorder, and learning disabled; and that Mitchell‟s past medications included
Ritalin, Adderall, Dexedrine, Concerta, Effexor, Zoloft, Strattera, Risperdal,
Trileptal, and Abilify. Mitchell reported that she currently felt depressed, had poor
self-esteem, and was failing school. Mitchell also reported that she used marijuana
on a daily basis. Mental status examination showed Mitchell to be friendly,
engaged, and to have good eye contact. Mitchell‟s speech was fluent with normal
amount and volume. Mitchell‟s mood was “okay” and her affect was euthymic.
Mitchell denied any auditory or visual hallucinations, suicidal or homicidal
ideations, paranoia, obsessions, or feelings of hopelessness. Dr. Sewing noted
Mitchell‟s flow of thought to be logical, sequential, and goal directed. Dr. Sewing

4

See summary of medical evidence infra at pp. 46-47.
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diagnosed Mitchell with ADHD, mood disorder not otherwise specified, learning
disorder not otherwise specified, and anxiety not otherwise specified. Dr. Sewing
instructed Mitchell to increase her dosage of Zoloft. (Tr. 296.)
Mitchell returned to Dr. Sewing on March 12, 2007, who noted reports to
show Mitchell to have an above-average IQ. Mitchell‟s father reported that
Mitchell experienced rapid and unpredictable mood swings. Dr. Sewing noted
Mitchell to be compliant with her medication and to have improved sleep, appetite,
energy, and concentration. Mitchell denied any substance abuse. Mental status
examination was unchanged. Dr. Sewing instructed Mitchell to continue with her
current regimen. (Tr. 295.)
Mitchell visited Dr. Sewing on April 18, 2007, who noted Mitchell to be
doing relatively well. Mitchell was compliant with her medication. Mitchell
reported that she was finishing school, earning fair grades, and was looking
forward to community college the following year. Mitchell denied substance
abuse and reported continued improvement in sleep, appetite, energy, and
concentration. Dr. Sewing continued in his diagnoses and prescribed Abilify,
Zoloft, Concerta, Topamax, and Melatonin. (Tr. 294.)
From June through October 2007, Mitchell visited Dr. Sewing on three
occasions with noted improvement on each occasion. Mitchell was noted to be
compliant with her medication, and the medication was adjusted for continued
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improvement. (Tr. 291-93.)
On January 9, 2008, Mitchell visited Dr. Sewing who noted Mitchell to be
noncompliant with her medication. Mitchell denied any substance abuse. Dr.
Sewing noted Mitchell to not be in school. Mitchell was slightly agitated.
Mitchell‟s mood was okay, and her affect was tearful. Dr. Sewing continued in his
diagnoses and instructed Mitchell to restart Abilify and Cymbalta. (Tr. 290.)
On April 3, 2008, Dr. Sewing noted Mitchell to have been compliant with
her medications for one week. Mitchell reported that she felt more stable, and Dr.
Sewing observed Mitchell to be much improved since her last visit. Mitchell
denied any substance abuse. Dr. Sewing instructed Mitchell to continue with
Abilify and Cymbalta. (Tr. 289.)
Mitchell returned to Dr. Sewing on May 15, 2008, who noted Mitchell to be
noncompliant with her medication and to currently be abusing marijuana and
alcohol. Mental status examination was unremarkable. Dr. Sewing diagnosed
Mitchell with bipolar affective disorder and prescribed Abilify, Cymbalta, and
Lamictal. (Tr. 288.)
On May 20, 2008, Mitchell visited Dr. Gordon H. Robinson, a psychiatrist,
and reported a history of bipolar disorder, ADHD, and OCD. Mitchell reported
that “they” thought she was “crazy” and indicated that she did not know why she
was visiting a psychiatrist. Mitchell was eighteen years of age at the time and was
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accompanied by her parents. Mitchell reported being explosive and violent with
her mother with threats to hit her and with episodes of actually striking her on five
occasions in the previous two years. Mitchell reported that her manic episodes
lasted up to a few hours, but that she was depressed fifty percent of the time.
Mitchell reported having negative feelings and that she never felt happy. Mitchell
reported having thoughts of suicide but had no intention to act on her thoughts.
Mitchell reported that she began smoking marijuana when she was sixteen years of
age and developed a habit such that she no longer got “high” despite smoking large
quantities of the drug. Mitchell reported that she stopped smoking marijuana on
May 11, 2008. Dr. Robinson noted Mitchell‟s past medications to include Ritalin,
Dexedrine, Adderall, Cylert, Concerta, Strattera, Effexor, Zoloft, Celexa, Lexapro,
Paxil, Risperdal, Seroquel, and Depakote, but that Mitchell was never hospitalized
psychiatrically. Mitchell reported feeling better with her current medications,
Abilify and Cymbalta. Dr. Robinson noted that Mitchell stopped taking her
medication in December and that her parents noticed in January that she engaged
in rapid cycling and manic behavior. Mitchell reported that she attended
community college for one semester but failed all of her classes because she
skipped classes and got high using marijuana. Mitchell‟s parents reported that
Mitchell was involved in six automobile accidents within the previous year, and
Dr. Robinson indicated that ADHD and bipolar disorder could cause an individual
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to drive carelessly and have difficulty paying attention to driving. Mental status
examination showed Mitchell to be clean and well groomed and to have good eye
contact. Dr. Robinson noted no tics, tremors, psychomotor retardation, or
agitation. Mitchell showed anger toward her parents. Dr. Robinson observed
Mitchell to be tearful at times, as well as calmer at times. Mitchell was irritable
toward her mother but pleasant toward Dr. Robinson. Dr. Robinson noted Mitchell
to be logical and sequential and to speak with regular rate and rhythm. Mitchell
denied having any hallucinations, delusions, or suicidal and homicidal ideas. Dr.
Robinson noted Mitchell‟s judgment and insight to be fair. Upon conclusion of the
evaluation, Dr. Robinson diagnosed Mitchell with ADHD; bipolar disorder, most
recent episode depressed; OCD; and cannabis dependence. Dr. Robinson assigned
a Global Assessment of Functioning (GAF) score of 60, and opined that Mitchell‟s
highest GAF score within the past year was 60.5 At Mitchell‟s request, Dr.
Robinson instructed Mitchell to continue with Abilify. Dr. Robinson prescribed
Fluoxetine and instructed Mitchell to discontinue Cymbalta. Dr. Robinson also
prescribed Lamictal for bipolar disorder. Dr. Robinson instructed Mitchell to
return in two weeks. (Tr. 203-09.)
A GAF score considers “psychological, social, and occupational functioning on a hypothetical
continuum of mental health/illness.” Diagnostic and Statistical Manual of Mental Disorders,
Text Revision 34 (4th ed. 2000). A GAF score of 51 to 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 co-workers).
5

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On May 23, 2008, Mitchell was admitted to St. John‟s Mercy Medical
Center for stabilization after a severe episode of aggressive behavior toward her
mother. Dr. Steven A. Harvey noted Mitchell to have a long history of mood
instability with problematic use of alcohol and marijuana, but that this was her first
psychiatric hospitalization. Although Mitchell reported that she did not engage in
activities because of depression, Dr. Harvey noted that she seemed to spend a lot of
time socializing with friends. Mental status examination showed no extreme
symptoms. Dr. Harvey noted Mitchell‟s insight and judgment to be poor. Lithium
was added to Mitchell‟s treatment regimen during her admission, and Mitchell did
very well. Upon discharge on May 27, 2008, Mitchell was diagnosed with bipolar
disorder, mixed episode, in remission; alcohol dependence; and marijuana abuse.
Mitchell‟s discharge medications were Lithium carbonate, Lamictal, Prozac, and
Abilify. Dr. Harvey instructed Mitchell to participate in outpatient therapy. (Tr.
307-21.)
Mitchell visited Dr. Harvey on May 29, 2008, and reported that she was
doing well and was happy. Mitchell reported abstention from alcohol and
marijuana. Mental status examination showed Mitchell to be pleasant and
cooperative with no psychosis. Dr. Harvey noted Mitchell‟s mood to be euthymic
and her affect stable. Mitchell‟s insight and judgment were fair. Dr. Harvey noted
Mitchell to show some signs of withdrawal from marijuana. A goal was set for
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Mitchell to get a job. Mitchell was instructed to continue with her current
medications. (Tr. 305.)
On June 13, 2008, Mitchell reported to Dr. Harvey that she was doing quite
well but was irritable after having gotten drunk. Mitchell also reported a one-time
use of marijuana. Mitchell reported that she obtained a job but left after three
hours because she had a meltdown. Mitchell reported that she swam and was
going out a lot. Mental status was unchanged. Mitchell was instructed to continue
with her medications and to make arrangements for therapy. (Tr. 304.)
Mitchell returned to Dr. Harvey on June 26, 2008, and reported that she had
regressed. Mitchell admitted to drinking and smoking marijuana and reported not
taking her medications on a couple of occasions. Mitchell‟s parents reported
Mitchell to be verbally aggressive at times. Dr. Harvey noted Mitchell‟s current
medications to be Abilify, Lamictal, Lithium, and Prozac. Dr. Harvey instructed
Mitchell to continue with her current medications and to continue to visit with her
therapist. (Tr. 303.)
On July 24, 2008, Mitchell reported to Dr. Harvey that she was doing well
and had no problems. Dr. Harvey noted Mitchell to have abstained from alcohol
and to have not smoked marijuana for two weeks. Mitchell reported that therapy
was going well. Mental status examination was unchanged. Dr. Harvey
questioned whether Mitchell was bipolar and noted that Mitchell‟s mood problems
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associated with alcohol and marijuana had worsened. Dr. Harvey instructed
Mitchell to continue with her current medications and with therapy. Mitchell was
instructed to return in four weeks for follow up. (Tr. 302.)
On October 21, 2008, Mitchell‟s father called Dr. Harvey and reported that
Mitchell was not doing well, was drinking again, and recently had a temper
outburst. Dr. Harvey noted Mitchell not to have appeared for her most recently
scheduled appointment and invited her to return for treatment. (Tr. 301.)
Mitchell returned to Dr. Harvey on October 28, 2008, and reported that she
had not been well for five or six weeks. Mitchell reported that she was not
compliant with her medication and had not seen her therapist. Mitchell reported
having recently consumed alcohol and having had a little marijuana. Dr. Harvey
noted Mitchell to be very irritable. Mitchell reported that she bit her mother and
punched a hole in a door. Mental status examination showed Mitchell to be
pleasant and cooperative with normal speech and flow of thought. Mitchell
reported having no psychosis or suicidal/homicidal ideations. She was alert and
fully oriented. Mitchell‟s mood was euthymic and her affect stable. Dr. Harvey
noted Mitchell‟s insight and judgment to be fair. Dr. Harvey diagnosed Mitchell
with bipolar disorder. Dr. Harvey instructed Mitchell to abstain from substance
abuse, take her medication faithfully, and attend her upcoming appointment with
her therapist. Dr. Harvey told Mitchell that she could feel better by the weekend if
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she complied with her treatment. (Tr. 299.)
Mitchell visited Dr. Harvey on November 4, 2008, who noted Mitchell to be
doing better in that she was less irritable and not violent. Dr. Harvey observed
Mitchell to be overly irritable toward her parents but nice to him. Mitchell
admitted to snorting Adderall three or four times a week. Dr. Harvey instructed
Mitchell to continue with her medications and to abstain from substance abuse,
including Adderall abuse. Dr. Harvey also instructed Mitchell to continue with
therapy. (Tr. 298.)
Mitchell returned to Dr. Robinson on December 4, 2008, and reported being
a “bad kid.” Mitchell reported that she argued with her mother every day, with
such episodes usually ending in a physical altercation. Mitchell reported that she
lied a lot. Mitchell reported that she smoked marijuana every day, beginning
shortly after waking up in the afternoon. Mitchell reported that she sleeps seven to
eight hours a night, but usually goes to sleep around 5:30 a.m. after being with
friends. Mitchell reported not going to school and not having a job. Dr. Robinson
noted Mitchell to remain depressed. Mitchell reported not feeling happy and that
she continued to have mood swings. Dr. Robinson noted Mitchell‟s current
medications to include Lithium, Lamictal, Abilify, and Prozac, but Mitchell
believed that medication did not help her. Mental status examination showed
Mitchell to be clean and well groomed. She was not restless or tremulous.
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Mitchell‟s eye contact was noted to be okay, but she had a restricted and somewhat
angry affect. Mitchell denied having suicidal or homicidal thoughts. Dr. Robinson
noted Mitchell‟s insight and judgment to be poor. Dr. Robinson diagnosed
Mitchell with ADHD; bipolar disorder, most recent episode depressed; OCD; and
cannabis dependence. Dr. Robinson assigned a GAF score of 60. Dr. Robinson
discontinued Fluoxetine because of its ineffectiveness and instructed Mitchell to
increase her dosages of Lithium and Lamictal. (Tr. 209-12.)
Mitchell returned to Dr. Robinson on December 18, 2008, and reported that
she did not want to change her behavior and did not want to talk to doctors.
Mitchell‟s father reported that she had become more violent and disrespectful
toward her mother, with two episodes resulting in calls to the police. Mitchell‟s
mother reported that Mitchell was calmer while taking medication, and both
parents reported that Mitchell was better until she stopped taking her medication
for three days. Mitchell reported that she forgot to take her medication. Mental
status examination showed Mitchell‟s eye contact to be fair. Mitchell was not
restless or tremulous. Her affect was dysphoric and somewhat agitated. Dr.
Robinson noted Mitchell to be logical and sequential, and Mitchell spoke with a
regular rate and rhythm. Mitchell continued to deny having suicidal or homicidal
thoughts. Dr. Robinson noted Mitchell‟s insight and judgment to be poor. Dr.
Robinson continued in his diagnoses and continued to assign a GAF score of 60.
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Dr. Robinson provided Mitchell with strategies to help her remember to take her
medication. Dr. Robinson prescribed Haloperidol and Lorazepam for agitated
episodes. (Tr. 212-14.)
On January 12, 2009, Dr. Robinson noted Mitchell‟s behavior to improve
since she began taking her medication regularly. Mitchell reported feeling better
and that the medication helped. Dr. Robinson noted Mitchell to remain quite
symptomatic, however. Mental status examination was unchanged from the last
visit. Dr. Robinson continued in his diagnoses and GAF score. Dr. Robinson
instructed Mitchell to increase her dosage of Lamictal and set a goal of finding a
job within the month. Dr. Robinson instructed Mitchell to return in two weeks.
(Tr. 214-16.)
On February 23, 2009, Mitchell reported to Dr. Robinson that she was very
emotional and felt good one moment and angry the next. Mitchell reported that
she no longer threatened her mother but instead punched holes in the wall when
frustrated. Mitchell reported having looked for a job with no success. Mitchell
reported taking her medication every day but that she also smoked marijuana every
day. Mitchell reported being afraid of the dark and of being alone. Mental status
examination showed Mitchell to have a fine, bilateral tremor and to have a labile
affect. Dr. Robinson noted Mitchell to move from anxious and angry to silly and
playful in a very short amount of time. Given that Mitchell was so symptomatic,
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Dr. Robinson determined to increase her dosage of Lithium. Dr. Robinson
encouraged Mitchell to engage in reasonable exercise and referred her for a sleep
study to rule out obstructive sleep apnea. Dr. Robinson instructed Mitchell to
return in two weeks. (Tr. 217-18.)
On March 6, 2009, Mitchell telephoned Dr. Robinson‟s office to cancel her
scheduled appointment. Dr. Robinson noted that Mitchell refused to come. (Tr.
218.)
Mitchell returned to Dr. Robinson on April 3, 2009, and reported that she
had no recent break downs, had not threatened or stolen from her mother, and was
compliant with her mother‟s instructions. Mitchell reported that she changed her
behavior because her boyfriend and friends did not think it was okay for her to
threaten her mother. Mitchell reported that she was looking for a job. Mitchell
continued to report mood swings and disruptive sleep. Dr. Robinson noted
Mitchell to sleep from 10:00 p.m. until noon. Mental status examination was
unchanged from the last visit. Dr. Robinson continued in his diagnoses and GAF
score, noting Mitchell to have improved. Dr. Robinson instructed Mitchell to
remain on her current medications. (Tr. 219-20.)
On April 25, 2009, Mitchell reported to Dr. Robinson that she had no rage
attacks, was not belligerent or irritable, and that she and her boyfriend were doing
well. Mitchell reported feeling angry that she had gained weight. Mitchell
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reported having recently had an anxiety attack that lasted for twenty minutes, and
further reported that she experienced such attacks about every six months.
Mitchell continued to report disrupted sleep, but Dr. Robinson noted that she had
not yet made an appointment with a sleep doctor. Mitchell reported that she
planned to take one class at a community college during the summer but was
anxious about it. Mental status examination showed Mitchell to have good eye
contact but a restricted affect. Mitchell was logical and sequential and spoke with
a regular rate and rhythm. Mitchell denied having suicidal or homicidal thoughts.
Dr. Robinson noted Mitchell‟s insight and judgment to be better. Dr. Robinson
continued in his diagnoses and GAF score, noting Mitchell to be making slow but
steady progress. Mitchell‟s current medications were Abilify, Lithobid, Lamictal,
Haloperidol, and Lorazepam. (Tr. 221-22.)
On April 30, 2009, Dr. Robinson determined to increase Mitchell‟s dosage
of Lithobid, noting Mitchell to continue to be symptomatic. (Tr. 222.)
Mitchell returned to Dr. Robinson on May 9, 2009, and reported continued
mood swings between angry and sad emotions. Mitchell‟s parents reported that
Mitchell was “a lot better” than she was before in that she was no longer
threatening and defused from her angry outbursts more quickly. Mitchell reported
that she fatigued easily, did not exercise, and smoked marijuana every day.
Mitchell was lethargic and slept through part of her appointment. Mental status
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examination showed Mitchell to have poor eye contact and a restricted affect.
Mitchell was logical and sequential and spoke with a regular rate and rhythm.
Mitchell denied having suicidal or homicidal thoughts. Dr. Robinson noted
Mitchell‟s insight and judgment to be better. Dr. Robinson continued in his
diagnoses and GAF score, noting Mitchell to be doing better than before. Dr.
Robinson provided Provigil to help with sleepiness and ADHD symptoms. (Tr.
223-24.)
Mitchell returned to Dr. Robinson on June 8, 2009, and reported feeling
more depressed and irritable. Mitchell expressed feelings of hopelessness.
Mitchell reported sleeping twelve to fourteen hours a day and that she forgets
things very quickly. A recent sleep study failed to show sleep apnea or narcolepsy.
Mitchell reported having thoughts of suicide but no plan. Mitchell reported that
she never tried Provigil because she did not want to take more medication. Mental
status examination showed Mitchell to have poor eye contact with a dysphoric and
tearful affect. Dr. Robinson noted Mitchell‟s insight and judgment to be poor. Dr.
Robinson continued in his diagnoses and assigned a current GAF score of 50.6 Dr.
Robinson instructed Mitchell to increase her dosage of Lamictal. (Tr. 225-26.)

6

A GAF score of 41-50 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).
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On June 22, 2009, Mitchell reported to Dr. Robinson that she no longer felt
depressed. Mitchell reported continued irritability but with no threatening or
violent behavior. Mitchell reported feeling less anxious but with continued
paranoia. Mitchell reported taking a math class at the community college for the
fourth time and having scored ninety percent on a recent test. Mitchell reported
doing her homework as assigned but that she had difficulty staying in class or
paying attention for any length of time. Mitchell reported smoking less marijuana
than in the past. Mental status examination showed Mitchell to have poor eye
contact with a dysphoric affect. Mitchell denied having suicidal or homicidal
thoughts. Dr. Robinson noted Mitchell‟s insight and judgment to be limited. Dr.
Robinson continued in his diagnoses and GAF score of 50, noting Mitchell‟s
prominent problems to be anxiety, fear, and paranoia. Dr. Robinson prescribed a
trial dose of Nuvigil for sleep disorder. Dr. Robinson also discussed with Mitchell
the possibility of ECT because of her lack of response to medication. (Tr. 227-28.)
Mitchell‟s mother called Dr. Robinson on June 26, 2009, to report an
increase in Mitchell‟s agitation, weepiness, and fear of driving. Dr. Robinson
adjusted Mitchell‟s dosage of Abilify. ( Tr. 228.)
Mitchell returned to Dr. Robinson on July 7, 2009, and reported feeling
better after her medication adjustment. Dr. Robinson noted that Mitchell never
took Nuvigil. Mitchell reported that she earned mostly B‟s in her math class and
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was doing well. Mental status examination was unchanged from Mitchell‟s last
visit. Dr. Robinson assigned a current GAF score of 55, noting apparent
improvement. (Tr. 229-30.)
On July 24, 2009, Mitchell visited Dr. Robinson and reported that she had a
job as a cashier at a restaurant. Mitchell reported doing well but feeling
overwhelmed during the lunchtime rush. Mitchell‟s parents reported that things
were going well overall. Dr. Robinson noted that Mitchell had not yet begun
Nuvigil. Mental status examination showed Mitchell to have poor eye contact with
a euthymic affect. Dr. Robinson noted Mitchell‟s insight and judgment to be
better. Dr. Robinson continued in his diagnoses and GAF score, noting Mitchell to
be doing well. (Tr. 231-32.)
Mitchell returned to Dr. Robinson on August 6, 2009, and reported having
good self-esteem and not feeling depressed. Mitchell earned a C+ in her math
class and enrolled in three classes for the upcoming fall semester. Mitchell
reported that she was fired from her job after two days. Mental status examination
showed Mitchell to have good eye contact with a euthymic affect. Dr. Robinson
observed Mitchell to be mildly restless. Dr. Robinson noted Mitchell‟s insight and
judgment to be better. Dr. Robinson encouraged Mitchell to take Nuvigil to help
with energy, attention, and concentration. (Tr. 233-34.)
On August 20, 2009, Mitchell reported to Dr. Robinson that her boyfriend
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had moved out after she hit him. Mitchell reported that she briefly lived at a house
where a lot of drug use occurred and that she stopped taking her medication, after
which she did poorly. She reported having only recently recovered. Dr. Robinson
noted Mitchell to remain somewhat irritable and impatient. Mitchell reported her
mood to generally be better but that she continued to have some mood swings.
Mitchell had not yet started Nuvigil. Mental status examination remained largely
unchanged. Dr. Robinson noted Mitchell‟s frequent noncompliance with her
medication and opined that such circumstance may account for her mood
instability. Dr. Robinson discussed counseling with Mitchell for help with anger.
(Tr. 235-36.)
Mitchell returned to Dr. Robinson on September 3, 2009, and reported
recent depression and being tired most of the time. Mitchell expressed her desire
to reconcile with her boyfriend. Mitchell reported that Nuvigil helped her focus at
school, and Mitchell‟s mother reported that Mitchell was more organized and
helpful at home. Mental status examination showed Mitchell to have fair eye
contact with a dysphoric and teary affect. Dr. Robinson noted Mitchell‟s insight
and judgment to be better. Dr. Robinson continued in his diagnoses and GAF
score and instructed Mitchell to continue with her current medications. (Tr. 23637.)
On September 17, 2009, Mitchell reported to Dr. Robinson that she was a
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“bad kid” and that she smoked marijuana every day, which caused her to become
sleepy and sometimes unable to stay awake. Mitchell‟s mother stopped giving
Nuvigil because of manic symptoms, but Mitchell continued to be irritable.
Mitchell reported missing a lot of classes because she often overslept. Dr.
Robinson noted Mitchell‟s self-esteem to be extremely low. Mental status
examination was essentially unchanged, but Mitchell was noted to be extremely
negativistic. Dr. Robinson continued in his diagnoses and assigned a current GAF
score of 50. Dr. Robinson instructed Mitchell to restart Nuvigil at a lower dose
and encouraged Mitchell to abstain from marijuana. Dr. Robinson also discussed
the possibility of ECT. (Tr. 239-40.)
On October 1, 2009, Mitchell reported to Dr. Robinson that she was
depressed, irritable, belligerent, and having rapid mood swings. Mitchell reported
throwing and hitting things on a daily basis. Mitchell reported missing class
because of difficulty waking up in the morning. Mitchell reported that she had an
upcoming job interview. Mitchell reported that she decreased her use of marijuana
and was currently smoking only three bowls a day. Dr. Robinson noted Mitchell
not to be taking medication regularly, having missed all of her morning
medications for two weeks. Mental status examination showed Mitchell to have
good eye contact with a euphoric affect. Mitchell was noted to be outgoing, very
pleasant, and somewhat silly – smiling continuously. Mitchell was logical and
- 23 -

sequential and spoke with a regular rhythm and rate. Mitchell continued to be
extremely negativistic. Mitchell‟s insight and judgment were better. Dr. Robinson
continued in his GAF score of 50, noting Mitchell to continue to be quite
symptomatic with depression and irritability. Dr. Robinson again recommended
ECT. Dr. Robinson adjusted Mitchell‟s current medications and prescribed
Topamax for headaches. (Tr. 241-42.)
On October 12, 2009, Mitchell visited Dr. Robinson who noted Mitchell to
be working about twenty hours a week. Mitchell reported that she had not missed
work but continued to miss a lot of classes because of her difficulty waking up in
the morning. Mitchell reported taking her medications every day and feeling less
irritable, depressed, and agitated. Mitchell also reported having less severe mood
swings. Mental status examination showed Mitchell to have good eye contact with
a euthymic affect. Mitchell was noted to be minimally tremulous and easily
distracted. Mitchell was logical and sequential and spoke with a regular rhythm
and rate. She denied having any suicidal or homicidal thoughts, and her insight
and judgment were better. Dr. Robinson continued in his diagnoses and assigned a
GAF score of 52, noting Mitchell to be a bit better after adjusting her medication.
Dr. Robinson instructed Mitchell to discontinue Nuvigil and to increase Topamax.
(Tr. 243-44.)
On October 29, 2009, Dr. Robinson noted Mitchell to be feeling better but to
- 24 -

have mood instability and paranoia. Mitchell reported that she attended classes
every day that week and was currently passing the two classes in which she was
enrolled. Mental status examination was unchanged. Dr. Robinson assigned a
current GAF score of 55 and continued to discuss ECT. (Tr. 245-46.)
On November 12, 2009, Mitchell reported to Dr. Robinson that she was fired
from her job because she missed work and was anxious. Mitchell reported that she
forgot to take her medication. Mitchell requested Adderall inasmuch as she noted
improvement after she took a friend‟s medication. Mental status examination
remained unchanged. Dr. Robinson prescribed Vyvanse. (Tr. 247-48.)
On November 25, 2009, Mitchell visited Dr. Robinson and reported having
temper outbursts, rapid mood swings, irritability, and frequent crying spells.
Mitchell reported being too anxious and agitated to go to school. Mitchell reported
that she stopped taking Haloperidal and Lorazepam because she did not want to be
“knocked out.” Mitchell‟s mother reported that she did not permit Mitchell to start
Vyvanse. Mental status examination showed Mitchell to have good eye contact
with a restricted affect. Mitchell denied having any suicidal or homicidal thoughts.
Dr. Robinson noted Mitchell‟s insight and judgment to be limited. Dr. Robinson
assigned a current GAF score of 48, noting Mitchell to be more anxious and
agitated with noncompliance being a significant problem. Dr. Robinson adjusted
Mitchell‟s current medications and added Saphris to her medication regimen. (Tr.
- 25 -

249-50.)
Mitchell returned to Dr. Robinson on December 10, 2009, and reported
being much less depressed. Dr. Robinson noted Mitchell not to have taken any
Saphris at her mother‟s suggestion but otherwise had not missed any dose of
medication. Mitchell reported continued temper outbursts and occasional
symptoms suggestive of panic attacks. Mental status examination was unchanged.
Dr. Robinson assigned a current GAF score of 52, noting Mitchell to be doing
better since restarting her medication. Dr. Robinson prescribed Diazepam and
referred Mitchell for counseling. (Tr. 251-52.)
On December 22, 2009, Mitchell‟s parents reported to Dr. Robinson that
Mitchell had extremely rapid mood swings and was extremely demanding. They
reported that Mitchell earned a C in her English class but expressed concern that
Mitchell may have reached maximum improvement. Dr. Robinson discussed the
possibility of Mitchell applying for disability, noting that she was quite resistant to
treatment despite years of aggressive medication treatment. Dr. Robinson opined
that Mitchell was “totally and permanently disabled.” (Tr. 253-54.)
Mitchell visited Dr. Robinson on January 11, 2010, and reported feeling less
depressed, having less severe mood swings, and being less irritable. Mitchell
reported disturbed sleep and continued paranoia. Dr. Robinson noted Mitchell to
be taking her medication as prescribed. Mitchell reported that she planned to quit
- 26 -

smoking tobacco and marijuana as a new year‟s resolution. Mental status
remained unchanged. Dr. Robinson assigned a GAF score of 54, noting Mitchell
to be better but still psychotic and quite symptomatic. Dr. Robinson prescribed
Geodon and discussed the possibility of psychotherapy. (Tr. 255-56.)
Mitchell visited Dr. Robinson on January 25, 2010, and reported feeling
ambivalent about filing for disability. Dr. Robinson noted that Mitchell had been
fired from every minimum wage job within a week of starting. Mitchell reported
improved symptoms upon starting Geodon but that she worsened during the
previous week. Mitchell also reported recent issues with her boyfriend. Mental
status examination showed Mitchell to have good eye contact with a dysphoric and
teary affect. She was mildly restless. Dr. Robinson noted Mitchell to be logical
and sequential and to speak with regular rate and rhythm. Dr. Robinson noted
Mitchell‟s insight and judgment to be poor. Dr. Robinson continued in his
diagnoses and assigned Mitchell a GAF score of 52. Dr. Robinson shared with
Mitchell his opinion that she was totally and permanently disabled because of her
“extremely serious psychiatric disorder.” Dr. Robinson increased Mitchell‟s
dosage of Geodon. (Tr. 257-58.)
On February 10, 2010, Mitchell reported to Dr. Robinson that she felt
Geodon was working because she did not feel depressed and did not have mood
swings. Mitchell reported continued symptoms of paranoia. Mental status
- 27 -

examination was unchanged. Dr. Robinson assigned a GAF score of 53, noting
Mitchell to continue to slowly improve. Dr. Robinson instructed Mitchell to
increase her dosage of Geodon. (Tr. 259-60.)
On February 24, 2010, Mitchell returned to Dr. Robinson and reported that
her mood was more stable than it had been for years and that she felt more
confident. Dr. Robinson noted that Mitchell regularly attended classes but that she
complained of poor memory with poor recall. Mitchell reported that she had little
difficulty focusing. Mitchell also reported a marked decrease in her marijuana use.
Mental status examination showed Mitchell to have good eye contact with a calm
and euthymic affect. Dr. Robinson noted Mitchell‟s insight and judgment to be
poor. Dr. Robinson assigned a current GAF score of 60, noting Mitchell to be
doing quite well. Dr. Robinson observed Mitchell to be the “most calm and stable
that [he‟d] ever seen her” but opined that she remained disabled because of her
psychiatric disorder. Dr. Robinson instructed Mitchell to decrease her dosage of
Topamax. Dr. Robinson prescribed Benztropine for possible EPS symptoms. (Tr.
261-62.)
On March 8, 2010, Mitchell reported to Dr. Robinson that she felt depressed
and angry. Mitchell‟s parents reported that Mitchell was more agitated during the
previous week to ten days and was slurring her words. Mitchell continued to
complain of paranoid thoughts. Dr. Robinson noted that Mitchell had not yet taken
- 28 -

Benztropine but continued to smoke marijuana every day. Mental status
examination showed Mitchell to have fair eye contact with a calm and euthymic
affect. Dr. Robinson noted Mitchell to slur her words and appear very sleepy. Dr.
Robinson also noted, however, that Mitchell was logical and sequential and spoke
with a regular rate and rhythm. Mitchell denied any thoughts of suicide or
homicide. Dr. Robinson noted Mitchell‟s insight and judgment to be poor. Dr.
Robinson assigned a current GAF score of 50. Dr. Robinson noted that Mitchell‟s
symptoms of drooling, slurred speech, sleepiness, impaired memory, and
incontinence may be related to medication side effects and opined that Mitchell
may be overmedicated. Medication adjustments were considered. (Tr. 263-64.)
Mitchell returned to Dr. Robinson on March 22, 2010, and reported having
mood swings, irritability, continued paranoia, and occasional anxiety. Mitchell‟s
mother reported her belief that Mitchell was “taking leaps backwards.” Mental
status examination was unchanged. Dr. Robinson assigned a GAF score of 45,
noting that Mitchell was “definitely worse” than one week before. Dr. Robinson
adjusted Mitchell‟s dosages of Geodon and Abilify. Mitchell‟s additional
medications at that time included Lithobid, Topamax, Lamictal, Diazepam, and
Benztropine. (Tr. 265-66.)
Mitchell returned to Dr. Robinson on April 5, 2010, and reported rapid mood
swings occurring daily. Mitchell reported having impulsively threatened suicide so
- 29 -

that others would feel bad for her, but that she intended never to follow through
with her threats. Mitchell continued to complain of interrupted sleep. Mental
status examination showed poor eye contact with a dysphoric and teary affect. Dr.
Robinson noted Mitchell‟s insight and judgment to be poor. Dr. Robinson
continued in his diagnoses of ADHD; bipolar disorder, most recent episode
depressed; OCD; and cannabis dependence. Dr. Robinson continued to assign a
GAF score of 45. Dr. Robinson adjusted Mitchell‟s dosage of Geodon and
determined to return to the regimen previously prescribed that helped Mitchell to
feel better. (Tr. 267-68.)
On April 19, 2010, Mitchell reported to Dr. Robinson that she felt good and
was in a good mood. Mitchell reported that she smoked marijuana almost every
night and ate fast food most nights with her friends. Mitchell continued to report
mood swings and irritability and that she had difficulty remembering things when
she “goes off.” Mitchell‟s mother reported that Mitchell heard voices and
footsteps, and Mitchell expressed reluctance to discuss the matter fearing it would
increase the frequency of these episodes. Dr. Robinson noted that Mitchell was
taking one course at the community college. Mental status examination showed
Mitchell to have good eye contact with a euthymic affect. Dr. Robinson noted
Mitchell‟s insight and judgment to be limited. Dr. Robinson assigned a GAF score
of 45, noting Mitchell to be manic with prominent paranoia and episodes of
- 30 -

irritability. Dr. Robinson adjusted Mitchell‟s dosage of Geodon and instructed
Mitchell to discontinue Topamax. (Tr. 269-70.)]
On May 3, 2010, Mitchell reported to Dr. Robinson that she continued to be
paranoid and have unreasonable fears. Mitchell reported that she could not sit still
and focus while in class but that she was productive while taking Vyvanse.
Mitchell reported that she continued to smoke marijuana every day. Mental status
examination showed Mitchell to have good eye contact with a restricted affect.
Mitchell was noted to be calm. Dr. Robinson noted Mitchell‟s insight and
judgment to be limited. Dr. Robinson continued in his diagnoses and GAF score,
noting that Mitchell was doing better than before with continued paranoia but
resolved hallucinations. (Tr. 271-72.)
On May 15, 2010, Mitchell underwent a consultative psychological
evaluation for disability determinations. Mitchell reported to Dr. Rosemarie
Kugler that she had bipolar disorder, ODD, and ADHD. Dr. Kugler noted
Mitchell‟s history to include one psychiatric hospitalization and threats to kill
others, including her mother. Dr. Kugler noted Mitchell‟s current medications to
be Lithium, Abilify, Lamictal, Geodon, Diazepam, and Benztropine. Mitchell
reported that she currently felt anxious, irritable, useless, and fearful. Mitchell also
reported that she had no energy, had difficulty controlling her temper, had no
ambition, and had difficulty concentrating. Mitchell reported feeling sad most of
- 31 -

the time. Mitchell reported that she had been fired from all of her previous jobs
within hours or weeks of being hired. Mitchell reported that she smoked marijuana
every other day to calm her and that she began smoking marijuana when she was a
senior in high school. Mitchell reported that she no longer got “high” from
marijuana. Mental status examination showed Mitchell to appear drowsy and
lethargic. Mitchell was oriented times three, and Dr. Kugler noted no apparent
disturbances in attention and concentration. Mitchell had good eye contact, and
her affect was constricted. Mitchell‟s mood was apathetic. Mitchell was
cooperative and forthcoming during the evaluation. Dr. Kugler noted no apparent
disturbances in memory. Dr. Kugler estimated that Mitchell had average
intellectual ability. Dr. Kugler noted Mitchell‟s thought processes to be intact and
goal directed; and Mitchell‟s judgment, insight, and reasoning were adequate.
Mitchell described her daily functioning as “lazy.” Mitchell reported that she
sometimes performed household chores but was unwilling to do so. As to her
social functioning, Mitchell reported getting mad quickly but that she socialized
with two friends. Dr. Kugler noted that Mitchell had the capacity to interact
independently but that her moods and irritability could interfere with this. Dr.
Kugler noted Mitchell to be able to attend to tasks and concentrate despite
appearing drowsy. Mitchell reported to Dr. Kugler that she had an average of four
major episodes of decompensation each year that interfered with her adaptive
- 32 -

functioning. Upon conclusion of the evaluation, Dr. Kugler diagnosed Mitchell
with bipolar-I disorder, most recent episode depressed; and cannabis dependence.
Dr. Kugler assigned a current GAF score of 55 and opined that Mitchell‟s highest
GAF score in the past year was 55. Dr. Kugler determined Mitchell‟s prognosis to
be guarded and opined that she could not manage her own funds. (Tr. 176-80.)
Mitchell returned to Dr. Robinson on May 17, 2010, and reported being
happy, having fun, going to class, and being able to study. She reported that she
was passing her reading class. Mitchell reported being up late and feeling tired
every day. Mitchell reported that taking Vyvanse four times a week was effective
for her. Mitchell reported, however, that her parents were recently away for a
weekend, and she was unable to handle any small crisis. Mitchell reported that she
called and texted her parents almost continuously during that time. Mental status
examination was unchanged. Dr. Robinson continued in his diagnoses and current
GAF score of 45, noting that Mitchell continued to be quite symptomatic and
extremely dependent upon her parents. (Tr. 273-74.)
On May 26, 2010, Dr. James W. Morgan, a medical consultant for disability
determinations, completed a Mental Residual Functional Capacity (RFC)
Assessment wherein he opined that, in the domain of Understanding and Memory,
Mitchell was moderately limited in her ability to understand and remember
detailed instructions, but was not otherwise limited. In the domain of Sustained
- 33 -

Concentration and Persistence, Dr. Morgan opined that Mitchell was moderately
limited except that she experienced no limitations in her ability to carry out very
short and simple instructions and make simple work-related decisions. In the
domain of Social Interaction, Dr. Morgan opined that Mitchell was moderately
limited in her ability to interact appropriately with the general public and get along
with coworkers or peers without distracting them or exhibiting behavioral
extremes, but was not otherwise limited. In the domain of Adaptation, Dr. Morgan
determined Mitchell to be moderately limited in her ability to respond
appropriately to changes in the work setting and in her ability to set realistic goals
or make plans independently of others, but was not otherwise limited. (Tr. 18183.)
In a Psychiatric Review Technique Form completed May 26, 2010, Dr.
Morgan opined that Mitchell‟s ADHD, learning disability, depression, anxiety,
bipolar disorder, and cannabis dependence caused mild restrictions in Mitchell‟s
activities of daily living; moderate restrictions in maintaining social functioning
and with maintaining concentration, persistence, or pace; and did not result in any
repeated, extended episodes of decompensation. (Tr. 184-95.)
On June 1, 2010, Mitchell reported to Dr. Robinson that she felt better when
she worked out with her personal trainer and that she was more stable on the higher
dose of Geodon. Mitchell reported feeling happier and shared her excitement
- 34 -

about going to a casino that night with her friends to celebrate her birthday.
Mitchell reported that her paranoia and sleep habits had improved, but she felt she
was obsessing about things. Mental status examination showed Mitchell to have
good eye contact and a more euthymic affect. Mitchell was calm and more
optimistic. Dr. Robinson noted Mitchell to have limited insight and judgment. Dr.
Robinson assigned a current GAF score of 50, noting Mitchell to continue to be
symptomatic but with noted improvement. Dr. Robinson noted Mitchell to remain
psychotic and paranoid and completely unable to live independently. Mitchell was
instructed to continue with her current medications. (Tr. 275-76.)
Mitchell returned to Dr. Robinson on June 29, 2010, and reported being tired
despite getting seven to twelve hours of sleep at night. Mitchell reported regular
exercise by working with a personal trainer twice a week. Mitchell reported
continued mood swings and periods of irritability, albeit improved. Mitchell
reported having “rage attacks” that lasted from fifteen to sixty minutes and that
anything could “set her off” during these periods. Mitchell stopped taking daytime
doses of her medication for over a week but recently returned to taking her
medication as prescribed. Mitchell reported continued use of marijuana. Mental
status examination was unchanged. Dr. Robinson continued with his diagnoses
and GAF score, noting Mitchell to be stable because she resumed taking her
medications. Dr. Robinson noted Mitchell to be unstable during those periods
- 35 -

when she was noncompliant with her medication. (Tr. 277-78.)
On July 12, 2010, Mitchell reported to Dr. Robinson that her mood was
more stable and that things were “going okay.” Mitchell reported going to the
casino once or twice a week and that she liked to spend money. Mitchell‟s mother
reported that Mitchell had temper outbursts two or three times a day but not with
most of her friends. Mental status examination showed Mitchell‟s eye contact to
be fair with a restricted affect. Dr. Robinson noted Mitchell to be lethargic and
appear sleepy. Mitchell‟s insight and judgment were noted to be limited. Dr.
Robinson continued in his diagnoses and GAF score. Dr. Robinson encouraged
Mitchell to find an enjoyable activity to help with boredom. Dr. Robinson
instructed Mitchell to restart Vyvanse. (Tr. 279-80.)
Mitchell visited Dr. Robinson on July 26, 2010, and reported continued fear
of death and of other people dying. Mitchell‟s mother reported that the mood
swings were terrible the previous week. Dr. Robinson noted Mitchell to work with
her trainer three times a week and was somewhat less tired. Mental status
examination was unchanged. Dr. Robinson continued in his diagnoses and GAF
score, noting Mitchell to remain paranoid and obsessional. Dr. Robinson
recommended counseling. Mitchell expressed concern regarding memory loss if
she were to undergo ECT. (Tr. 281-82.)
On August 9, 2010, Mitchell reported to Dr. Robinson that she was good but
- 36 -

felt depressed. Mitchell also reported being paranoid and fearful all of the time.
Mitchell reported that she often avoided sleep for fear of being killed. Mitchell
also reported that she enjoyed gambling but did not excessively engage in the
activity. Mitchell‟s mother reported that Mitchell experienced cycling moods
which included being “hyper-happy” and hearing voices. Mental status
examination showed Mitchell to have good eye contact with a calm and restricted
affect. Mitchell was not lethargic. Dr. Robinson noted Mitchell‟s insight and
judgment to be limited. Dr. Robinson continued in his diagnoses of ADHD,
bipolar disorder, OCD, and cannabis dependence. Dr. Robinson also continued to
assign a GAF score of 50. Dr. Robinson noted Mitchell‟s condition to essentially
be unchanged. ECT procedures were discussed. (Tr. 378.)
Mitchell returned to Dr. Robinson on August 26, 2010, and reported
continued irritability but that she felt happier. Mitchell reported that she stopped
smoking marijuana three days prior and was exercising regularly. Mitchell‟s
mother reported continued mood changes and paranoia. Mental status examination
showed Mitchell to have good eye contact with an animated and cheerful affect.
Dr. Robinson noted Mitchell to listen to her mother without getting angry.
Mitchell‟s insight and judgment were limited. Dr. Robinson continued in his
diagnoses and GAF score, noting Mitchell to be more irritable given her recent
attempt to stop smoking marijuana and cigarettes. (Tr. 379.)
- 37 -

From September 1 to September 17, 2010, Mitchell underwent six outpatient
ECT treatments at St. John‟s Mercy Medical Center. (Tr. 322-72.) In the interim,
on September 9, 2010, Dr. Robinson noted Mitchell to be doing better since
starting ECT, with less agitation and anxiousness. Mitchell also reported having
fewer paranoid thoughts and auditory hallucinations, as well as improved memory.
Mitchell reported continued use of marijuana. Inasmuch as ECT was effective, Dr.
Robinson ordered that Mitchell undergo such treatments three times a week. (Tr.
380-81.)
Mitchell returned to Dr. Robinson on September 23, 2010, who noted that
Mitchell refused to undergo two ECT treatments that week. Mitchell reported that
she felt like she was going to die. Mitchell reported having a severe headache with
one of the treatments. Dr. Robinson noted Mitchell to be less paranoid and
anxious and to be much less agitated. Mitchell reported improved memory. Dr.
Robinson continued in his diagnoses of Mitchell and assigned a current GAF score
of 60, noting Mitchell to have clearly improved. Dr. Robinson encouraged
Mitchell to continue with ECT treatments in order to consolidate the gains and
minimize the risk of relapse, but Mitchell declined. Dr. Robinson noted Mitchell‟s
current medications to be Vyvanse, Abilify, Geodon, Lamotrigine, Diazepam, and
Benztropine. (Tr. 383-84.)
On October 7, 2010, Mitchell reported to Dr. Robinson that she was not
- 38 -

depressed and was happier. Mitchell reported having less aggressive or severe
mood swings as well as decreased paranoia. Mitchell reported that she recently
went to a bar and had a good time. Mental status examination showed Mitchell to
have good eye contact and a euthymic affect. Dr. Robinson noted Mitchell‟s
insight and judgment to be better. Dr. Robinson continued in his diagnoses and
assigned a current GAF score of 65,7 noting the difference in Mitchell to be
“striking.” Dr. Robinson discussed with Mitchell the possibility of adjusting
medication to help with anxiety on days that Mitchell was scheduled to undergo
ECT treatment. (Tr. 385-86.)
On October 28, 2010, Mitchell reported to Dr. Robinson that she felt
unhappy much of the time and that her friends told her that she had regressed.
Mitchell acknowledged that she should undergo more ECT treatments but stated
that she did not want to. Mitchell reported that she smoked all day, had difficulty
falling asleep at night, and was experiencing increased paranoia. Dr. Robinson
continued in his current diagnoses and GAF score of 65, but noted Mitchell to have
relapsed. Mitchell refused continued ECT treatments as well as suggested
treatment with Vyvanse and Lithium. Dr. Robinson increased Mitchell‟s dosage of

7

A GAF score of 61 to 70 indicates some mild symptoms (e.g., depressed mood and mild
insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional
truancy, or theft within the household), but generally functioning pretty well, has some
meaningful interpersonal relationships.
- 39 -

Geodon. (Tr. 387-88.)
On November 11, 2010, Mitchell reported to Dr. Robinson that she was not
irritable, had no racing thoughts, and felt good. Mitchell reported going out to
clubs with friends and that she enrolled in a reading class for the spring. Dr.
Robinson continued in his diagnoses and assigned a current GAF score of 60,
noting Mitchell to be mildly manic but not psychotic and much less paranoid.
Mitchell continued to decline ECT treatment. (Tr. 389-90.)
On November 23, 2010, Dr. Robinson noted Mitchell to be doing extremely
well overall. Mitchell reported that she no longer drank or consumed drugs.
Mitchell also reported that her temper had improved and that she did not feel
anxious or worried. Mitchell reported staying up until 4:00 a.m. playing or
watching friends play video games but that she did not feel tired during the day.
Mental status examination showed good eye contact and a euthymic affect. Dr.
Robinson noted Mitchell‟s insight and judgment to be better. Dr. Robinson
continued in his diagnoses and GAF score. (Tr. 391-92.)
Mitchell returned to Dr. Robinson on December 7, 2010, and reported recent
irritability, disturbed sleep, and negative thoughts. Mitchell denied having any
suicidal thoughts. Mitchell reported that she wanted to restart her exercise
program. Mitchell‟s parents reported that she was doing better. Dr. Robinson
continued in his diagnoses and GAF score, noting Mitchell to continue to do well
- 40 -

but to exhibit some explosiveness as well as anxiousness. Dr. Robinson opined
that Mitchell may be somewhat more depressed. Mitchell continued to decline
ECT treatments. Dr. Robinson prescribed Trileptal as a mood stabilizer. (Tr. 39394.)
On December 21, 2010, Dr. Robinson noted that Mitchell remained
improved and was more stable. Mitchell reported feeling no different but being
less irritable. Mitchell reported less fearfulness but continued to have intermittent
paranoia. Mitchell also reported having mood swings throughout the day. Dr.
Robinson noted Mitchell to be compliant with her medication but that her Trileptal
was never filled because of potential adverse drug interactions. Mitchell indicated
her desire to continue with her current medications and to undergo ECT treatments
if her condition deteriorated. (Tr. 395-96.)
On January 18, 2011, Dr. Robinson noted Mitchell to continue to improve.
Mitchell continued to report having mood swings but that she felt pretty good and
was not too depressed. Dr. Robinson noted her to be “hypertalkative.” Dr.
Robinson added Vyvanse to Mitchell‟s medication regimen. (Tr. 397-98.)
On February 15, 2011, Mitchell reported to Dr. Robinson that she was able
to focus at school and study while taking Vyvanse but that she became more
irritable. Mitchell described a recent episode whereby she chased her boyfriend
through a parking lot, and the police came. Dr. Robinson noted Mitchell to have
- 41 -

stopped taking Vyvanse and that she returned to baseline, but that she remained
paranoid at baseline. Dr. Robinson instructed Mitchell to take a decreased dose of
Vyvanse and only on school days. (Tr. 399-400.)
Mitchell returned to Dr. Robinson on March 1, 2011, and reported being
anxious, very angry, and having mood swings and negative thoughts. Mitchell
reported having recently lost $40.00 at a casino. Mitchell reported that she argued
with her mother and believed that she had no friends. Dr. Robinson noted
Mitchell‟s self-esteem to be low. Mental status examination showed Mitchell to be
somewhat agitated and anxious with a dysphoric and teary affect. Mitchell was not
hypertalkative or circumstantial, and Dr. Robinson noted her insight and judgment
to be better. Dr. Robinson noted Mitchell not to have taken any Vyvanse since her
last visit. Dr. Robinson determined to prescribe Trileptal. Dr. Robinson assigned a
current GAF score of 55. (Tr. 401-02.)
On March 11, 2011, Dr. Robinson completed a Mental Assessment Of
Ability To Do Work-Related Activities in which he opined that Mitchell had poor
or no ability to make occupational adjustments, which included following work
rules, relating to co-workers, dealing with the public, using judgment, interacting
with supervisors, dealing with work stresses, functioning independently, and
concentration. Dr. Robinson further opined that Mitchell had poor or no ability to
make performance adjustments, which included the ability to understand,
- 42 -

remember and carry out complex, detailed, or simple job instructions. Finally, Dr.
Robinson opined that Mitchell had poor or no ability to make personal-social
adjustments, including maintaining personal appearance, behaving in an
emotionally stable manner, relating predictably in social situations, and
demonstrating reliability. (Tr. 377.)
Mitchell returned to Dr. Robinson on March 17, 2011, and reported feeling
depressed and having continued feelings of paranoia, albeit to a lesser extent.
Mitchell reported being demanding but not irritable. Dr. Robinson noted Mitchell
to be regularly attending school. Mitchell reported occasional marijuana use. Dr.
Robinson noted Mitchell not to have taken the Trileptal. Dr. Robinson adjusted
Mitchell‟s dose of Lamotrigine and Abilify. (Tr. 407.)
On March 31, 2011, Mitchell reported to Dr. Robinson that she had not been
emotional and was having good days. Mitchel reported having daytime sleepiness
and missing some classes because of this. Dr. Robinson assigned a GAF score of
60, noting Mitchell to be doing well overall and to be more calm and stable than
the last visit. Dr. Robinson instructed Mitchell to continue with her current
medications as prescribed. (Tr. 408-09.)
On April 14, 2011, Dr. Robinson prescribed Zaleplon for insomnia in
response to complaints that Mitchell experienced rapid mood cycles triggered by
lack of sleep. During a visit on April 28, 2011, Dr. Robinson noted that Mitchell
- 43 -

never filled the prescription. Mitchell reported at that time that she smoked
marijuana to help her sleep. Mitchell reported feeling goofy and “high on life.”
Mitchell reported having difficulty attending class regularly and paying attention in
class. Mental status examination showed Mitchell to be energetic and talkative.
Mitchell denied having hallucinations. Dr. Robinson noted Mitchell‟s insight and
judgment to be fair. Dr. Robinson continued in his diagnoses and GAF score,
noting Mitchell to continue to cycle between manic and depressive moods. Dr.
Robinson prescribed Vyvanse. On May 12, 2011, Dr. Robinson noted Mitchell to
be about the same. (Tr. 411-16.)
On May 26, 2011, Mitchell reported to Dr. Robinson that her mood was
stable and that her mood swings had decreased. Mitchell reported that she was
travelling out of state the following week with a friend and their family. Dr.
Robinson assigned a GAF score of 65 and instructed Mitchell to continue with her
current medications. (Tr. 417-18.)
On June 6, 2011, Mitchell reported to Dr. Robinson that she was depressed
and had poor motivation. Dr. Robinson noted Mitchell to be upset with her body
image. Dr. Robinson advised Mitchell that smoking marijuana may stimulate her
appetite. (Tr. 419-20.) On June 23, 2011, Dr. Robinson noted Mitchell to be
generally doing well. Mitchell reported that she was enrolling in more classes at
the community college. Dr. Robinson added reading comprehension learning
- 44 -

disability as a diagnosis. Dr. Robinson noted that Mitchell never increased her
dosage of Abilify as previously planned. Dr. Robinson instructed Mitchell to
continue with her current medications. (Tr. 421.)
Mitchell returned to Dr. Robinson on July 21, 2011, and reported that she
was somewhat frustrated. Mitchell‟s mother reported that Mitchell was more
argumentative and negative. Dr. Robinson noted Mitchell to be unchanged and
continued in his diagnoses and GAF score of 65. (Tr. 422-23).
On August 4, 2011, Mitchell reported to Dr. Robinson that she was
exercising and felt good. Dr. Robinson continued in his diagnoses and GAF score.
(Tr. 424-25.) On August 18, 2011, Mitchell reported to Dr. Robinson that she
stopped smoking marijuana but has since had difficulty sleeping. Mitchell
reported playing card games with her friends but continued to feel intolerant of
others. Mitchell reported that she was taking Vyvanse and was not as irritable as
before. Dr. Robinson determined that Mitchell was doing reasonably well and
continued in his diagnoses and GAF score. (Tr. 427-28.)
Mitchell returned to Dr. Robinson on September 1, 2011, and reported that
her temper had worsened but that she occasionally smoked marijuana to calm her.
Mitchell reported that taking Vyvanse before school helped, but that she continued
to have a problem with dyslexia. Dr. Robinson continued in his diagnoses and
GAF score. (Tr. 430-31.) On September 8, 2011, Mitchell reported to Dr.
- 45 -

Robinson that she continued to be paranoid, feeling that someone was going to
shoot or attack her. Mitchell reported that she smoked marijuana to calm her. Dr.
Robinson noted Mitchell to be more stable than in the past but continued to be
paranoid and psychotic, which regularly affected her behavior. Dr. Robinson
suggested that Mitchell begin taking Clozapine given the severity of symptoms,
but Mitchell declined. (Tr. 433-34.)
Mitchell visited Dr. Robinson on October 17, 2011, and reported that she
was less agitated but continued to be paranoid. Mitchell reported that she
continued to smoke marijuana two or three times a week because it calmed her.
Dr. Robinson continued in his diagnoses and assigned a GAF score of 65. (Tr.
440-41.)
On that same date, October 17, 2011, Dr. Robinson completed an
Assessment for Social Security Disability Claim in which he reported that Mitchell
had a history of frequent and severe mood swings, impaired cognition, paranoia,
fatigue, low energy, poor frustration tolerance, and severe anxiety. Dr. Robinson
reported Mitchell‟s diagnoses to be ADHD, bipolar disorder – current episode
depressed, OCD, and reading comprehension learning disability; and that her
medications were Vyvanse, Lamotrigine, Benztropine, Abilify, Geodon, and
Diazepam. Dr. Robinson opined that Mitchell‟s mental impairment affected her
ability to work in that she “remains psychotic [and] paranoid which affects her
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behavior on a regular basis. She remains intolerant of others. She is very restless
[and] continues to move almost constantly.” (Tr. 438.)
In a Mental Assessment Of Ability To Do Work-Related Activities
completed October 17, 2011, Dr. Robinson continued to opine that Mitchell had
poor or no ability to make occupational adjustments or performance adjustments.
Dr. Robinson further opined that Mitchell had poor or no ability to make personalsocial adjustments, except that Mitchell had a fair ability to maintain personal
appearance. (Tr. 439.)
IV. School Records Before the ALJ
In May 2004, at fifteen years of age, Mitchell underwent the WoodcockJohnson Psycho-Educational Battery Revised Tests of Achievement and scored in
the average range for broad reading and broad written language, and in the low
average range for broad mathematics. (Tr. 150-52.)
Mitchell graduated from high school in May 2007 with a cumulative grade
point average of 1.645. During Mitchell‟s senior year in high school, she earned
grades ranging from a B in physical education, to D‟s and F‟s in economics, math,
and reading. (Tr. 136.) Mitchell participated in an Individual Education Program
because of her educational diagnoses of ADHD, learning disability – math
reasoning, adjustment disorder with mixed anxiety and depression, and bipolar
disorder. Mitchell was placed in the regular classroom 100 percent of the time.
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(Tr. 139-49.)
Mitchell‟s transcript from St. Louis Community College dated September
15, 2011, shows Mitchell to have earned twelve credit hours and to have a
cumulative GPA of 2.50. During the Fall 2009 semester, Mitchell withdrew from
two classes, earned a C in Introduction to College Writing, and earned F‟s in
Developmental Reading and Reading Lab. During the Spring 2010 semester,
Mitchell withdrew from three classes and earned B‟s in Developmental Reading
and Reading Lab. During the Spring 2011 semester, Mitchell earned a B in
Reading Improvement. (Tr. 173.)
V. The ALJ's Decision
The ALJ found that Mitchell had not engaged in substantial gainful activity
since February 16, 2010, the protected filing date of her application for benefits.
The ALJ found Mitchell‟s depression, anxiety, learning disability, cannabis
dependence, ADHD, OCD, and obesity to be severe impairments, but that Mitchell
did not have an impairment or combination of impairments that met or medically
equaled an impairment listed in 20 CFR Part 404, Subpart P, Appendix 1. The
ALJ determined that Mitchell had the RFC to perform the exertional demands of
light work and could understand, remember, and carry out at least simple
instructions and non-detailed tasks, and maintain regular attendance and work
presence without special supervision. The ALJ determined Mitchell to be limited
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in her RFC in that she should not work in a setting that included constant/regular
contact with the general public, and should not perform work that required more
than infrequent handling of customer complaints. The ALJ found Mitchell to have
no past relevant work. Considering Mitchell‟s age, education, work experience,
and RFC, the ALJ determined that Mitchell was able to perform jobs that exist in
significant numbers in the national economy, and specifically, housekeeper/cleaner
and hand presser. The ALJ thus found Mitchell not to be under a disability since
February 16, 2010. (Tr. 9-23.)
VI. Discussion
To be eligible for supplemental security income under the Social Security
Act, Mitchell 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. § 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
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substantial gainful work which exists in the national economy." 42 U.S.C. §
1382c(a)(3)(B).
To determine whether a claimant is disabled, the Commissioner engages in a
five-step evaluation process. See 20 C.F.R. § 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.
impairment is not severe, then she is not disabled.

If the claimant's

The Commissioner then

determines whether the claimant‟s impairment meets or equals one of the
impairments listed in 20 C.F.R., Subpart P, Appendix 1. If so, the claimant is
conclusively disabled. At the fourth step, the Commissioner establishes whether
the claimant can perform her past relevant work. If the claimant can do so, she 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.
In cases involving mental impairments, the Commissioner undergoes an
additional evaluation process to determine the severity of such impairment(s). 20
C.F.R. § 416.920a. Specifically, the Commissioner rates the degree of functional
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loss the claimant suffers as a result of the impairment in the areas of daily living;
social functioning; concentration, persistence or pace; and episodes of
decompensation. 20 C.F.R. § 416.920a(c)(3). If the mental impairment is found to
be severe, the Commissioner then determines if it meets or equals a listed mental
disorder. 20 C.F.R. § 416.920a(d)(2). If the severe impairment does not meet or
equal a listed mental disorder, the Commissioner proceeds to perform an RFC
assessment. 20 C.F.R. § 416.920a(d)(3).
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.
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
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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
impairments.

6.

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

by

third

parties

of

the

plaintiff's

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 that fairly detracts from the
Commissioner‟s decision. Coleman, 498 F.3d at 770; Warburton v. Apfel, 188
F.3d 1047, 1050 (8th Cir. 1999). However, even though two inconsistent
conclusions may be drawn from the evidence, the Commissioner's findings may
still be supported by substantial evidence on the record as a whole. Pearsall, 274
F.3d at 1217 (citing Young v. Apfel, 221 F.3d 1065, 1068 (8th Cir. 2000)). “[I]f
there is substantial evidence on the record as a whole, we must affirm the
administrative decision, even if the record could also have supported an opposite
decision.” Weikert v. Sullivan, 977 F.2d 1249, 1252 (8th Cir. 1992) (internal
- 52 -

quotation marks and citation omitted); see also Jones ex rel. Morris v. Barnhart,
315 F.3d 974, 977 (8th Cir. 2003).
A.

Application of Regulations for Substance Abuse
As her first point on this appeal for judicial review, Mitchell argues that the

ALJ legally erred by failing to analyze her claim for disability under the
appropriate regulatory framework governing substance abuse. Mitchell contends
that the ALJ‟s failure to cite to the relevant Regulations and case law demonstrates
that he wholly failed to undergo the required analysis as required by the
Regulations. For the following reasons, Mitchell‟s argument is misplaced.
In 1996, Congress eliminated alcoholism or drug addiction as a basis for
obtaining social security benefits. See Kluesner v. Astrue, 607 F.3d 533, 537 (8th
Cir. 2010). “An individual shall not be considered disabled for purposes of this
title if alcoholism or drug addiction would (but for this subparagraph) be a
contributing factor material to the Commissioner's determination that the
individual is disabled.” 42 U.S.C. § 1382c(a)(3)(J). The Regulations set out a
two-step process in cases involving evidence of substance abuse. First, the ALJ
must determine if the claimant‟s symptoms, regardless of cause, constitute a
disability. Kluesner, 607 F.3d at 537; 20 C.F.R. § 416.935(a). If the ALJ finds a
disability and evidence of substance abuse, the next step is to determine whether
the disability would exist in the absence of the substance abuse. Kluesner, 607
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F.3d at 537. As such, the ALJ's finding of disability “is, in effect, a „condition
precedent‟ to applying the special rule on alcoholism and drug addiction.” Frank
S. Bloch, Bloch on Social Security § 3.39 (2003), cited approvingly in
Brueggemann v. Barnhart, 348 F.3d 689, 693 (8th Cir. 2003). See also Fastner v.
Barnhart, 324 F.3d 981, 986 (8th Cir. 2003) (“Generally, a determination under . .
. § 416.935(b) is only necessary if the ALJ has found that the sum of that
individual‟s impairments would otherwise amount to a finding of disability.”).
Here, upon consideration of all of the effects of Mitchell‟s symptoms,
regardless of cause and including those attributable to Mitchell‟s marijuana use,
the ALJ determined that Mitchell was not disabled. Absent a finding of disability,
the ALJ was not required to assess the materiality of Mitchell‟s substance abuse or
addiction under § 416.935. Fastner, 324 F.3d at 986. Accordingly, the ALJ did
not err by failing to invoke the Regulations to address Mitchell‟s substance abuse
disorder.
B.

Failure to Follow Prescribed Treatment
Mitchell next argues that the ALJ legally erred by assigning significance to

Mitchell‟s failure to follow prescribed treatment without considering her mental
illness as the reason for such failure. Mitchell further argues that the ALJ failed to
undergo the required analysis when determining that a failure to follow prescribed
treatment would preclude a finding of disability. For the following reasons,
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Mitchell‟s arguments are misplaced.
“Failure to follow a prescribed course of remedial treatment without good
reason is grounds for denying an application for benefits.” Roth v. Shalala, 45
F.3d 279, 282 (8th Cir. 1995). Before a claimant is denied benefits because of a
failure to follow a prescribed course of treatment, the ALJ must examine the
circumstances surrounding such failure and determine on the basis of the evidence
of record whether the prescribed treatment would restore the claimant‟s ability to
work or sufficiently improve her condition. Burnside v. Apfel, 223 F.3d 840, 84344 (8th Cir. 2000); 20 C.F.R. § 416.930(a).
As an initial matter, I note that the ALJ did not base his determination of
non-disability on Mitchell‟s failure to comply with prescribed treatment. Although
Mitchell appears to assert that the ALJ determined that her failure to follow
prescribed treatment precluded a finding of disability, I have reviewed the ALJ‟s
decision in its entirety and find that it does not contain such a determination.
Instead, a review of the decision shows that the ALJ considered all of the medical
evidence of record, which demonstrated that Mitchell‟s impairments were not
disabling. As noted by the ALJ, treatment records from treating and consulting
physicians alike consistently showed normal to near-normal mental status
examinations, mild to moderate symptoms as measured by GAF scores, adequate
concentration, and Mitchell‟s engagement in social and academic activities. The
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ALJ further considered Mitchell‟s subjective complaints and found them not to be
credible to the extent Mitchell claimed her impairments rendered her disabled
during the relevant time.8 To the extent the ALJ considered Mitchell‟s
noncompliance with prescribed treatment as a factor in determining Mitchell‟s
credibility, such consideration is permissible. Wildman v. Astrue, 596 F.3d 959,
968-69 (8th Cir. 2010). Indeed, noncompliance with a doctor‟s instructions to take
medication and abstain from alcohol and drugs is a valid reason to discredit a
claimant‟s subjective complaints. Id. Finally, the ALJ considered the
demonstrated improvement of Mitchell‟s impairments with appropriate treatment.
As noted by the ALJ, multiple instances documented throughout the medical
record demonstrate sufficient medical improvement upon Mitchell‟s compliance
with prescribed treatment. Indeed, the record shows that Dr. Robinson observed
Mitchell to be stable and her psychiatric symptoms to significantly decrease when
she regularly took her medications as prescribed. In addition, Dr. Robinson noted
that Mitchell “clearly improved” with ECT treatments, and he thereafter
Although Mitchell does not challenge the ALJ‟s credibility determination here, a review of the
ALJ‟s decision nevertheless shows that, in a manner consistent with and as required by Polaski
v. Heckler, 739 F.2d 1320 (8th Cir. 1984) (subsequent history omitted), the ALJ thoroughly
considered the subjective allegations of Mitchell‟s disabling symptoms on the basis of the entire
record before him and set out numerous inconsistencies detracting from the credibility of such
allegations. The ALJ may disbelieve subjective complaints where there are inconsistencies on
the record as a whole. Battles v. Sullivan, 902 F.2d 657, 660 (8th Cir. 1990). The ALJ's
credibility determination is supported by substantial evidence on the record as a whole. I am
therefore bound by this determination. Robinson v. Sullivan, 956 F.2d 836, 841 (8th Cir. 1992).
8

- 56 -

consistently assigned GAF scores of 60 or 65 indicating only mild to moderate
symptoms. The record also demonstrates a consistent pattern of relapse when
Mitchell failed to take her medication as prescribed or declined recommendations
for further treatment. Impairments that are controllable or amenable to treatment
do not support a finding of disability. Roth, 45 F.3d at 282. To the extent Dr.
Robinson nevertheless opined that Mitchell‟s psychiatric condition rendered her
disabled, an ALJ need not defer to a treating physician‟s opinion that an applicant
is totally disabled “because it invades the province of the Commissioner to make
the ultimate disability determination.” Renstrom v. Astrue, 680 F.3d 1057, 1065
(8th Cir. 2012) (internal quotation marks and citation omitted).
Mitchell also argues that the ALJ should have considered her mental
impairment as the reason underlying her failure to follow prescribed treatment. A
review of the record, however, shows many occasions on which Mitchell‟s mother
determined for Mitchell to either not take the prescribed medication or to take it at
a different dose. A parent‟s failure to consistently administer effective medication
as prescribed without good reason can be a proper ground for denying disability
benefits. Blake ex rel. Blake v. Barnhart, 28 Fed. Appx. 597, 599 (8th Cir. 2002)
(unpublished) (per curiam) (citing Kelley v. Callahan, 133 F.3d 583, 589 (8th Cir.
1998)). The record also shows Mitchell‟s noncompliance to coincide on many
occasions with her use of marijuana. Mitchell‟s noncompliance with prescribed
- 57 -

treatment appears to be the result of things other than mental illness. Cf. PateFires v. Astrue, 564 F.3d 935, 946 (8th Cir. 2009).
Mitchell argues, however, that the ALJ inadequately considered her
diagnosed impairment of bipolar disorder as a cause for her noncompliance
because he failed to find the impairment to be severe at Step 2 of the sequential
evaluation. I find the ALJ‟s failure to identify this impairment at Step 2 to be
harmless error. Because the ALJ found Mitchell to suffer other severe
impairments, including severe mental impairments such as depression and anxiety,
he was required to consider any non-severe impairments when determining
Mitchell‟s RFC. 20 C.F.R. § 416.945(a)(2). Subsequent to his analysis at Step 2
and indeed throughout the remainder of his decision, the ALJ considered and
discussed Mitchell‟s complaints and symptoms relating to all of her mental
impairments - including bipolar disorder - as well as her providers‟ observations
and the treatment rendered and recommended for her impairments. Given the
ALJ‟s inclusion of Mitchell‟s bipolar disorder in his overall analysis, the failure to
find the condition to be a severe impairment at Step 2 was harmless. See Maziarz
v. Secretary of Health & Human Servs., 837 F.2d 240, 244 (6th Cir. 1987);
Lorence v. Astrue, 691 F. Supp. 2d 1008, 1028 (D. Minn. 2010); see also Chavez v.
Astrue, 699 F. Supp. 2d 1125, 1133 (C.D. Cal. 2009).
Accordingly, I find that the ALJ considered the entirety of the record in
- 58 -

determining whether Mitchell‟s impairments were disabling. Although the ALJ
considered Mitchell‟s noncompliance with prescribed treatment as a factor in
determining her credibility, which he is permitted to do, the ALJ did not base his
adverse determination only on Mitchell‟s noncompliance. The ALJ was therefore
not required to examine the circumstances surrounding such noncompliance and
determine on the basis of the evidence of record whether the prescribed treatment
would restore Mitchell‟s ability to work or sufficiently improve her condition.
C.

Medical Opinion Evidence
Finally, Mitchell argues that the ALJ erred by according no weight to the

opinion of her treating physician, Dr. Robinson; by according great weight to the
opinion of the state agency consultant, Dr. Morgan; and by failing to define the
weight given to the opinion of the examining consulting physician, Dr. Kruger.
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
sources, and non-examining sources. See 20 C.F.R. § 416.927(f)(2)(ii).9 The
Regulations require that more weight be given to the opinions of treating
physicians than other sources. 20 C.F.R. § 416.927(d)(2). A treating physician's

9

Citations to 20 C.F.R. § 416.927 are to the 2011 version of the Regulations, which were in
effect at the time the ALJ rendered the final decision in this cause. This Regulation‟s most
recent amendment, effective March 26, 2012, reorganizes the subparagraphs relevant to this
discussion but does not otherwise change the substance therein.
- 59 -

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. Id.; 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. § 416.927(d)(2). However, a medical source‟s opinion that an applicant
is “unable to work” involves an issue reserved for the Commissioner and is not the
type of opinion which the Commissioner must credit. Ellis v. Barnhart, 392 F.3d
988, 994-95 (8th Cir. 2005).
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. 20 C.F.R. § 416.927(d)(2). Such factors include 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
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physician's findings, and the treating physician's area of specialty. Id. 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.” Id.
An ALJ does not err in giving less than controlling weight to a treating
physician‟s opinion where substantial evidence on the record shows the claimant to
have been noncompliant with prescribed treatment without good reason. Brown v.
Barnhart, 390 F.3d 535, 540-51 (8th Cir. 2004). In addition, an ALJ may discount
or even disregard a treating physician‟s opinion if the physician renders
inconsistent opinions that undermine their credibility. Goff v. Barnhart, 421 F.3d
785, 790-91 (8th Cir. 2005). Finally, inconsistency with other substantial evidence
alone is sufficient to discount a treating physician‟s opinion. Id.
Here, the ALJ discounted the various opinions of Dr. Robinson and provided
good reasons therefor. First, the ALJ found Dr. Robinson‟s opinion that Mitchell
was disabled to be an issue reserved to the Commissioner and not a medical
opinion entitled to deference. The ALJ did not err in this determination. Ellis, 392
F.3d at 994-95. The ALJ discounted Dr. Robinson‟s March 2011 and October
2011 Assessments – wherein he essentially opined that Mitchell had no useful
ability to function in any area – finding them to be inconsistent with his own
treatment records in that they 1) failed to account for Mitchell‟s noncompliance
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with treatment and her continued substance abuse; 2) were inconsistent with his
GAF scores indicating mild to moderate symptoms; and 3) were based, in part, on
Mitchell‟s subjective complaints, determined by the ALJ not to be credible. For
the following reasons, substantial evidence on the record as a whole supports these
reasons to discount Dr. Robinson‟s opinions.
As discussed above, Dr. Robinson‟s treatment records show that when
Mitchell was compliant with her treatment regimen, she was more stable, actively
and successfully engaged in social and academic activities, and exhibited less
symptomatic behavior. Indeed, throughout most of her treatment with Dr.
Robinson, Mitchell was assigned GAF scores between 51 and 65, indicating mild
to moderate symptoms, and was continually assigned GAF scores of 60 and 65
after undergoing ECT treatment. In his Assessments, Dr. Robinson opined that
Mitchell was functionally unable to perform any work activity, but he did not
account for Mitchell‟s repeated noncompliance with her medication and treatment
regimen – a regimen that proved successful when followed. In light of Mitchell‟s
failure to continue with ECT treatments, stop marijuana use, and follow
instructions regarding her prescribed medications, the ALJ did not err in
considering Dr. Robinson‟s failure to account for Mitchell‟s noncompliance in his
determination to discredit the physician‟s opinions. Owen v. Astrue, 551 F.3d 792,
799-800 (8th Cir. 2008).
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In addition, Dr. Robinson‟s opinions were rendered at the same time he
assigned GAF scores indicating that Mitchell exhibited mild to moderate
symptoms. Indeed, on October 17, 2011, the same date of his opinion that
Mitchell had poor or no ability to engage in essentially any work-related activities,
Dr. Robinson examined Mitchell and assigned a GAF score of 65. This
inconsistency between a treating physician‟s treatment records and his
simultaneous functional assessment provides good reason for an ALJ to discount
the physician‟s opinion. See Halverson v. Astrue, 600 F.3d 922, 930 (8th Cir.
2010); Goff, 421 F.3d at 791 (ALJ not compelled to give controlling weight to
physician‟s opinion where GAF score of 58 was inconsistent with opinion that
claimant suffered from extreme limitations); Hudson ex rel. Jones v. Barnhart, 345
F.3d 661, 666 (8th Cir. 2003).
Finally, the ALJ noted that Mitchell‟s subjective complaints made to Dr.
Robinson were “so extreme” that they were not credible, including Mitchell‟s
reports of violent behavior toward others and her reported hallucinations.10 The
ALJ noted that such extreme behavior would have likely resulted in more frequent
psychiatric hospitalizations or have legal consequences. The ALJ further noted
that Dr. Robinson‟s mental status examinations of Mitchell essentially yielded

10

As noted supra at n. 8, Mitchell does not challenge the ALJ‟s credibility determination.
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normal results despite Mitchell‟s extreme subjective reports of psychotic behavior.
See Halverson, 600 F.3d at 930. Where a treating physician‟s opinions are largely
based on a claimant‟s subjective complaints rather than on objective findings, an
ALJ does not err in giving such opinions less than controlling weight. Renstrom,
680 F.3d at 1064.
With respect to Dr. Kruger‟s May 2010 psychological evaluation, Mitchell
argues that the ALJ committed reversible error by failing to identify what weight
he accorded the opinions therein. As noted above, an ALJ must explain the weight
given to opinions from treating sources, non-treating sources, and non-examining
sources. 20 C.F.R. § 416.927(f)(2)(ii). By explaining the weight given to medical
source opinions, an ALJ both complies with the Regulations and assists the Court
in reviewing the decision. See Willcockson v. Astrue, 540 F.3d 878, 880 (8th Cir.
2008). Substantial evidence does not support an ALJ's decision if it cannot be
determined what, if any, weight the ALJ afforded the opinion of a medical source.
McCadney v. Astrue, 519 F.3d 764, 767 (8th Cir. 2008); see also Woods v. Astrue,
780 F. Supp. 2d 904, 913-14 (E.D. Mo. 2011).
Here, the ALJ thoroughly summarized the results of Dr. Kruger‟s
psychological evaluation of Mitchell and specifically noted Dr. Kruger‟s summary
of Mitchell‟s subjective complaints as well as her own objective findings that
Mitchell was fully oriented with no disturbances in attention and concentration;
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had good eye contact and appropriate grooming and dress; had no deficits in motor
functioning, speech, auditory comprehension, and memory; had appropriate
thought content with intact and goal-directed thought processes; had average
intellectual ability; and had adequate judgment, insight, and reasoning. Although
Dr. Kruger rendered an opinion as to Mitchell‟s diagnoses and prognosis, she gave
no opinion as to the severity of Mitchell‟s impairments, what Mitchell could still
do despite her impairments, or any physical or mental restrictions. See 20 C.F.R. §
416.927(a)(2) (setting out contents of medical opinions). Nevertheless, the ALJ
noted Dr. Kruger‟s objective observations during the mental status examination to
be consistent with the results of such examinations by Dr. Robinson and consistent
with the opinions rendered by Dr. Morgan. As such, when considered in view of
the decision in toto, I am able to determine that the ALJ accorded some weight to
Dr. Kruger‟s observations as demonstrated by his finding that they were consistent
with other substantial evidence on the record that he credited. Accordingly,
although the ALJ did not use specific terms to identify the precise weight he
accorded Dr. Kruger‟s limited opinion or her findings, the failure to do so here
does not require his finding of non-disability to be set aside. See Robinson v.
Sullivan, 956 F.2d 836, 841 (8th Cir. 1992) (administrative finding not required to
be set aside when deficiency in opinion-writing technique has no bearing on
outcome).
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Finally, with respect to Dr. Morgan‟s May 2010 Assessment, the ALJ
determined to accord great weight to the opinions rendered therein, finding them to
be the most consistent with the evidence of record, including the results of the
mental status examinations as reported by Dr. Robinson and the consultative
psychological examination by Dr. Kruger. While opinions of non-treating
practitioners who have attempted to evaluate a claimant without examination do
not normally constitute substantial evidence on the record as a whole, Coleman,
498 F.3d at 772, the ALJ did not rely on Dr. Morgan‟s opinion alone in
determining Mitchell not to be disabled. Instead, as noted above, the ALJ
considered Dr. Robinson‟s treatment notes which showed, more often than not,
that Mitchell had normal mental status examinations and exhibited only mild to
moderate symptoms. The ALJ also considered the results of Dr. Kruger‟s
psychological evaluation which likewise showed a normal mental status
examination and less than disabling symptoms. Because Dr. Morgan‟s Assessment
was consistent with this substantial medical evidence, the ALJ did not err in
considering Dr. Morgan‟s Assessment in determining Mitchell‟s RFC. Casey v.
Astrue, 503 F.3d 687, 694 (8th Cir. 2007) (not error for an ALJ to consider opinion
of state agency consultant rendered upon review of the medical evidence which
was consistent with medical evidence of record).
A review of the ALJ‟s decision shows the ALJ to have evaluated all of the
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opinion evidence of record and to have adequately explained his consideration
thereof such that I can determine what weight the ALJ afforded the medical source
opinions. Where, as here, there are conflicts in the medical opinion evidence, it is
the duty of the Commissioner to resolve such conflicts. Renstrom, 680 F.3d at,
1065; Spradling v. Chater, 126 F.3d 1072, 1075 (8th Cir. 1997); Bentley v.
Shalala, 52 F.3d 784, 787 (8th Cir. 1995). For the reasons set out above,
substantial evidence on the record as whole supports the ALJ‟s determination as to
the weight he accorded the opinion evidence in this cause.
VII. Conclusion
For all of the foregoing reasons, the Commissioner‟s decision that Mitchell
was not under a disability since February 16, 2010, is affirmed. Because the
Commissioner committed no legal error and there is substantial evidence on the
record as a whole to support the Commissioner's decision, I may not reverse the
decision merely because substantial evidence exists in the record that would have
supported a contrary outcome or because another court might have reached a
different conclusion. Gowell v. Apfel, 242 F.3d 793, 796 (8th Cir. 2001); see also
Buckner v. Astrue, 646 F.3d 549, 556 (8th Cir. 2011).
Accordingly,
IT IS HEREBY ORDERED that the decision of the Commissioner is
affirmed, and Mitchell‟s Complaint is dismissed with prejudice.
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A separate Judgment in accordance with this Memorandum and Order is
entered this same date.

____________________________________
CATHERINE D. PERRY
UNITED STATES DISTRICT JUDGE
Dated this 8th day of January, 2014.

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