Frederick v. Social Security Administration
MEMORANDUM AND ORDER: For the reasons discussed above, the Commissioner's decision is not based upon substantial evidence on the record as a whole and the cause is therefore remanded to the Commissioner for further consideration in accordance with this Memorandum and Order. Upon remand, the ALJ shall properly consider the opinion evidence, and formulate a new mental RFCbased on the record as a whole. Signed by Magistrate Judge Abbie Crites-Leoni on 3/27/2017. (JMC)
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
NANCY A. BERRYHILL,1
Acting Commissioner of Social Security,
) Case No. 4:15 CV1149 ACL
MEMORANDUM AND ORDER
Plaintiff Michael Frederick brings this action pursuant to 42 U.S.C. ' 405(g), seeking
judicial review of the Social Security Administration Commissioner’s denial of his application for
Disability Insurance Benefits (“DIB”) under Title II of the Social Security Act and Supplemental
Security Income (“SSI”) under Title XVI of the Act.
An Administrative Law Judge (“ALJ”) found that, despite Frederick’s severe mental
impairments, he was not disabled as he had the residual functional capacity (“RFC”) to perform
jobs that exist in significant numbers in the national economy.
This matter is pending before the undersigned United States Magistrate Judge, with
consent of the parties, pursuant to 28 U.S.C. § 636(c). A summary of the entire record is
presented in the parties’ briefs and is repeated here only to the extent necessary.
For the following reasons, the matter is reversed and remanded for further proceedings.
Nancy A. Berryhill is now the Acting Commissioner of Social Security. Pursuant to Rule 25(d)
of the Federal Rules of Civil Procedure, Nancy A. Berryhill is substituted for Acting
Commissioner Carolyn W. Colvin as the defendant in this suit.
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I. Procedural History
Frederick protectively filed his applications for DIB and SSI on November 21, 2011, and
November 18, 2013, respectively. (Tr. 122-28, 1593B-H.) He alleged that he became disabled
on May 1, 2010, due to schizophrenia and depression. (Tr. 170.) Frederick’s claims were denied
initially. (Tr. 42-46.) Following an administrative hearing, Frederick’s claims were denied in a
written opinion by an ALJ, dated May 27, 2014. (Tr. 14-26.) Frederick then filed a request for
review of the ALJ’s decision with the Appeals Council of the Social Security Administration
(SSA), which was denied on June 11, 2015. (Tr. 27, 7-10.) Thus, the decision of the ALJ stands
as the final decision of the Commissioner. See 20 C.F.R. '' 404.981, 416.1481.
In the instant action, Frederick claims that the ALJ failed to properly evaluate Frederick’s
RFC. Frederick also argues that the ALJ failed to properly evaluate the opinion evidence.
II. The ALJ=s Determination
The ALJ stated that Frederick met the insured status requirements of the Social Security
Act through September 30, 2011.2 (Tr. 16.) The ALJ found that Frederick had not engaged in
substantial gainful activity since his alleged onset date of May 1, 2010. Id.
In addition, the ALJ concluded that Frederick had the following severe impairments:
schizophrenia and depression. (Tr. 17.) The ALJ found that Frederick did not have an
impairment or combination of impairments that meets or equals in severity the requirements of any
impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. Id.
To be entitled to DIB under Title II, Frederick must establish that he was disabled prior to the
expiration of his insured status on September 30, 2011. See 20 C.F.R. 404.130. To be entitled to
SSI under Title XVI, he must show that he was disabled while his application was pending. See
42 U.S.C. 1382c; 20 C.F.R. '' 416.330 and 416.335. Thus, the relevant time period in this case is
from May 1, 2010 through May 27, 2014.
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As to Frederick’s RFC, the ALJ stated:
After careful consideration of the entire record, I find that the
claimant has the residual functional capacity to perform a full range
of work at all exertional levels but with the following nonexertional
limitations: he can only understand, remember, and carry out
simple, repetitive tasks. He can have occasional interaction with
supervisors, co-workers, and the public. He can have no
transactional interactions with the public, and he is limited to
performing in low stress jobs, defined as requiring only occasional
decision-making, and having occasional change in work setting.
The ALJ found that Frederick’s allegations regarding his limitations were not entirely
credible. (Tr. 19.) In determining Frederick’s RFC, the ALJ indicated that she was assigning
“strongest weight” to the opinion of treating psychiatrist Adarsh S. Reddy, M.D. (Tr. 24.) The
ALJ discredited the opinions of treating psychiatrists Angela Reiersen, M.D., and Marie Gebara,
M.D.; and of treating counselor, Brooke Justis, MSW, LCSW. (Tr. 21-23.)
The ALJ further found that Frederick is unable to perform any past relevant work. (Tr.
24.) The ALJ noted that a vocational expert testified that Frederick could perform jobs existing in
significant numbers in the national economy, such as addresser, collator operator, or housekeeper.
(Tr. 25.) The ALJ therefore concluded that Frederick has not been under a disability, as defined
in the Social Security Act, from May 1, 2010, through the date of the decision. (Tr. 26.)
The ALJ’s final decision reads as follows:
Based on the application for a period of disability and disability
insurance benefits protectively filed on November 21, 2011, the
claimant is not disabled as defined in sections 216(i) and 223(d) of
the Social Security Act prior to September 30, 2011.
Based on the application for supplemental security income
protectively filed on November 18, 2013, the claimant is not
disabled under section 1614(a)(3)(A) of the Social Security Act.
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III. Applicable Law
III.A. Standard of Review
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 of the evidence, 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 administrative record and consider:
The credibility findings made by the ALJ.
The plaintiff’s vocational factors.
The medical evidence from treating and consulting physicians.
The plaintiff’s subjective complaints relating to exertional and
non-exertional activities and impairments.
Any corroboration by third parties of the plaintiff’s
The testimony of vocational experts when required which is
based upon a proper hypothetical question which sets forth the
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Stewart v. Secretary of Health & Human Servs., 957 F.2d 581, 585-86 (8th Cir. 1992) (internal
citations omitted). The Court must also consider any evidence which fairly detracts from the
Commissioner’s decision. Coleman, 498 F.3d at 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 v. Massanari, 274 F.3d 1211, 1217 (8th Cir. 2001) (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 quotation
marks and citation omitted). See also Jones ex rel. Morris v. Barnhart, 315 F.3d 974, 977 (8th
III.B. Determination of Disability
A disability is defined 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 that has lasted or can be expected to last for a continuous period of not less than
twelve months. 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A); 20 C.F.R. § 416.905. A claimant
has a disability when the claimant is “not only unable to do his previous work but cannot,
considering his age, education and work experience engage in any other kind of substantial gainful
work which exists … in significant numbers either in the region where such individual lives or in
several regions of the country.” 42 U.S.C. § 1382c(a)(3)(B).
To determine whether a claimant has a disability within the meaning of the Social Security
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Act, the Commissioner follows a five-step sequential evaluation process outlined in the
regulations. 20 C.F.R. § 416.920; see Kirby v. Astrue, 500 F.3d 705, 707 (8th Cir. 2007). First,
the Commissioner will consider a claimant’s work activity. If the claimant is engaged in
substantial gainful activity, then the claimant is not disabled. 20 C.F.R. § 416.920(a)(4)(i).
Second, if the claimant is not engaged in substantial gainful activity, the Commissioner
looks to see “whether the claimant has a severe impairment that significantly limits the claimant’s
physical or mental ability to perform basic work activities.” Dixon v. Barnhart, 343 F.3d 602,
605 (8th Cir. 2003). “An impairment is not severe if it amounts only to a slight abnormality that
would not significantly limit the claimant’s physical or mental ability to do basic work activities.”
Kirby, 500 F.3d at 707; see 20 C.F.R. §§ 416.920(c), 416.921(a).
The ability to do basic work activities is defined as “the abilities and aptitudes necessary to
do most jobs.” 20 C.F.R. § 416.921(b). These abilities and aptitudes include (1) physical
functions such as walking, standing, sitting, lifting, pushing, pulling, reaching, carrying, or
handling; (2) capacities for seeing, hearing, and speaking; (3) understanding, carrying out, and
remembering simple instructions; (4) use of judgment; (5) responding appropriately to
supervision, co-workers, and usual work situations; and (6) dealing with changes in a routine work
setting. Id. § 416.921(b)(1)-(6); see Bowen v. Yuckert, 482 U.S. 137, 141, 107 S.Ct. 2287, 2291
(1987). “The sequential evaluation process may be terminated at step two only when the
claimant’s impairment or combination of impairments would have no more than a minimal impact
on her ability to work.” Page v. Astrue, 484 F.3d 1040, 1043 (8th Cir. 2007) (internal quotation
Third, if the claimant has a severe impairment, then the Commissioner will consider the
medical severity of the impairment. If the impairment meets or equals one of the presumptively
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disabling impairments listed in the regulations, then the claimant is considered disabled, regardless
of age, education, and work experience. 20 C.F.R. §§ 416.920(a)(4)(iii), 416.920(d); see Kelley
v. Callahan, 133 F.3d 583, 588 (8th Cir. 1998).
Fourth, if the claimant’s impairment is severe, but it does not meet or equal one of the
presumptively disabling impairments, then the Commissioner will assess the claimant’s RFC to
determine the claimant’s “ability to meet the physical, mental, sensory, and other requirements” of
the claimant’s past relevant work. 20 C.F.R. §§ 416.920(a)(4)(iv), 416.945(a)(4). “RFC is a
medical question defined wholly in terms of the claimant’s physical ability to perform exertional
tasks or, in other words, what the claimant can still do despite his or her physical or mental
limitations.” Lewis v. Barnhart, 353 F.3d 642, 646 (8th Cir. 2003) (internal quotation marks
omitted); see 20 C.F.R. § 416.945(a)(1). The claimant is responsible for providing evidence the
Commissioner will use to make a finding as to the claimant’s RFC, but the Commissioner is
responsible for developing the claimant’s “complete medical history, including arranging for a
consultative examination(s) if necessary, and making every reasonable effort to help [the claimant]
get medical reports from [the claimant’s] own medical sources.” 20 C.F.R. § 416.945(a)(3).
The Commissioner also will consider certain non-medical evidence and other evidence listed in
the regulations. See id. If a claimant retains the RFC to perform past relevant work, then the
claimant is not disabled. Id. § 416.920(a)(4)(iv).
Fifth, if the claimant’s RFC as determined in Step Four will not allow the claimant to
perform past relevant work, then the burden shifts to the Commissioner to prove that there is other
work that the claimant can do, given the claimant’s RFC as determined at Step Four, and his or her
age, education, and work experience. See Bladow v. Apfel, 205 F.3d 356, 358-59 n.5 (8th Cir.
2000). The Commissioner must prove not only that the claimant’s RFC will allow the claimant to
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make an adjustment to other work, but also that the other work exists in significant numbers in the
national economy. Eichelberger v. Barnhart, 390 F.3d 584, 591 (8th Cir. 2004); 20 C.F.R. §
416.920(a)(4)(v). If the claimant can make an adjustment to other work that exists in significant
numbers in the national economy, then the Commissioner will find the claimant is not disabled. If
the claimant cannot make an adjustment to other work, then the Commissioner will find that the
claimant is disabled. 20 C.F.R. §416.920(a)(4)(v). At Step Five, even though the burden of
production shifts to the Commissioner, the burden of persuasion to prove disability remains on the
claimant. Stormo v. Barnhart, 377 F.3d 801, 806 (8th Cir. 2004).
The evaluation process for mental impairments is set forth in 20 C.F.R. '' 404.1520a,
416.920a. The first step requires the Commissioner to Arecord the pertinent signs, symptoms,
findings, functional limitations, and effects of treatment@ in the case record to assist in the
determination of whether a mental impairment exists. See 20 C.F.R. '' 404.1520a(b)(1),
416.920a(b)(1). If it is determined that a mental impairment exists, the Commissioner must
indicate whether medical findings Aespecially relevant to the ability to work are present or absent.@
20 C.F.R. '' 404.1520a(b)(2), 416.920a(b)(2). The Commissioner must then rate the degree of
functional loss resulting from the impairments in four areas deemed essential to work: activities
of daily living, social functioning, concentration, and persistence or pace. See 20 C.F.R. ''
404.1520a(b)(3), 416.920a(b)(3). Functional loss is rated on a scale that ranges from no
limitation to a level of severity which is incompatible with the ability to perform work-related
activities. See id. Next, the Commissioner must determine the severity of the impairment based
on those ratings. See 20 C.F.R. '' 404.1520a(c), 416.920a(c). If the impairment is severe, the
Commissioner must determine if it meets or equals a listed mental disorder. See 20 C.F.R. ''
404.1520a(c)(2), 416.920a(c)(2). This is completed by comparing the presence of medical
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findings and the rating of functional loss against the paragraph A and B criteria of the Listing of the
appropriate mental disorders. See id. If there is a severe impairment, but the impairment does
not meet or equal the listings, then the Commissioner must prepare an RFC assessment. See 20
C.F.R. '' 404.1520a(c)(3), 416.920a(c)(3).
Frederick argues that the ALJ erred in evaluating his RFC, and in evaluating the medical
Residual functional capacity is defined as that which a person remains able to do despite
her limitations. 20 C.F.R. § 404.1545(a), Lauer v. Apfel, 245 F.3d 700, 703 (8th Cir. 2001). The
ALJ must assess a claimant’s RFC based upon all relevant, credible evidence in the record,
including medical records, the observations of treating physicians and others, and the claimant’s
own description of her symptoms and limitations. 20 C.F.R. § 404.1545(a); Anderson v. Shalala,
51 F.3d 777, 779 (8th Cir. 1995); Goff v. Barnhart, 421 F.3d 785, 793 (8th Cir. 2005). A
claimant’s RFC is a medical question, and there must be some medical evidence, along with other
relevant, credible evidence in the record, to support the ALJ’s RFC determination. Id.; Hutsell v.
Massanari, 259 F.3d 707, 711–12 (8th Cir. 2001); Lauer, 245 F.3d at 703–04; McKinney v. Apfel,
228 F.3d 860, 863 (8th Cir. 2000). An ALJ’s RFC assessment which is not properly informed and
supported by some medical evidence in the record cannot stand. Hutsell, 259 F.3d at 712.
However, although an ALJ must determine the claimant’s RFC based upon all relevant evidence,
the ALJ is not required to produce evidence and affirmatively prove that a claimant is able to
perform certain functions. Pearsall, 274 F.3d at 1217 (8th Cir. 2001); McKinney, 228 F.3d at
863. The claimant bears the burden of establishing her RFC. Goff, 421 F.3d at 790.
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The ALJ provided the following explanation for her RFC determination:
In sum, the above residual functional capacity assessment is supported by the
objective medical evidence in the record that clearly and repeatedly shows that the
claimant has compliance and coping issues that are the primary cause of his mental
issues. The persuasive and consistent findings and other logical and objective
evidence shows the claimant’s condition is clearly controlled well on medications
if and when he is compliant with them. I see no persuasive evidence the claimant
is more limited than set out in this finding despite having reviewed every page of
every exhibit in this file. The most persuasive longitudinal evidence of record
most fully supports the residual functional capacity I have recited herein. Despite
many duplicative exhibits having been removed, many exhibits have reports of the
same periods of hospital visits and hospitalizations each consistently stating the
claimant was noncompliant, and always responded well to medication with little or
no side effects through years of records from Barnes-Jewish Hospital, Washington
University School of Medicine, and other providers. As a result of reviewing all
of this evidence, the residual functional capacity is the best reflection of the
claimant’s ability to function day in and day out, and will allow him to work on a
regular and continuing basis without being overwhelmed by his coping issues and
other emotional problems.
Frederick argues that the ALJ erred in attributing all of his symptoms from schizophrenia
and depression to non-compliance and issues unrelated to the ability to work. He further contends
that the ALJ’s findings are inconsistent with the very nature of schizophrenia, which includes
periods of remission and relapse. The undersigned agrees.
The Court notes that recognition must be given to the instability of mental impairments and
their waxing and waning nature after manifestation. See Rowland v. Astrue, 673 F. Supp.2d 902,
920–21 (D.S.D. 2009) (citing Jones v. Chater, 65 F.3d 102, 103 (8th Cir. 1995)). As stated by the
Eighth Circuit, “[i]t is inherent in psychotic illnesses that periods of remission will occur [.] ...
Indeed, one characteristic of mental illness is the presence of occasional symptom-free periods.”
Andler v. Chater, 100 F.3d 1389, 1393 (8th Cir. 1996) (internal quotation marks and citations
omitted). Given that a claimant’s level of mental functioning may seem relatively adequate at a
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specific time, proper evaluation of the impairment must take into account a claimant’s level of
functioning “over time.” 20 C.F.R., Pt. 404, Subpt. P, App. 1, § 12.00(D)(2).
The relevant objective medical evidence is summarized below.
Frederick saw Angela Reiersen, M.D., Assistant Professor of Psychiatry, Washington
University School of Medicine, from October 2002 to April 2012, for treatment of his mental
impairments. (Tr. 656.) In an Assessment for Social Security Disability Claim dated September
21, 2012, Dr. Reiersen summarized Frederick’s psychiatric history. She stated that Frederick was
first treated at the Washington University Child and Adolescent Psychiatry Clinic in March 1999,
at the age of twelve. Id. Dr. Reiersen evaluated him in October 2002 in the emergency room
when he had a disorganized psychotic episode, which required hospitalization. Id. During that
episode, Frederick showed very disorganized speech and unusual behaviors such as removing his
braces with a screwdriver. Id. Dr. Reiersen stated that, once stabilized, on medication,
Frederick had a period of “several years where he functioned relatively well most of the time.”
Id. In spring of 2010, Frederick stopped his antipsychotic medication “due to losing insurance
and difficulty in paying for the medication.” Id. This resulted in recurrence of psychotic
symptoms. Id. Since that time, Frederick has had “frequent exacerbations of his symptoms,”
which has interfered with his performance at school and employment settings, and resulted in
additional hospitalizations and medication changes. Id. Dr. Reiersen last saw Frederick on
April 3, 2012, at which time she discussed a plan for Frederick to transition to an adult psychiatry
Records from Barnes-Jewish Hospital and Dr. Reiersen reveal that Frederick was
hospitalized from May 4, 2010, through May 6, 2010, with symptoms of perceptual disturbances,
visual hallucinations, and suicidal ideation. (Tr. 270, 284, 458.) Frederick’s father had lost his
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job, which resulted in Frederick losing his health insurance. Id. Consequently, Frederick was
unable to afford his Abilify3 and relapsed. Id. Frederick was restarted on his medications. Id.
Frederick saw Dr. Reiersen for follow-up on May 17, 2010, at which time he was back on
his medications and was feeling better. (Tr. 459.) He had no suicidal thoughts or overt
psychotic symptoms, although he was still somewhat nervous in crowds. Id. Dr. Reiersen
diagnosed Frederick with schizophrenia, disorganized type;4 and a GAF score of 65.5 Id. She
continued his medications. Id.
Frederick was hospitalized again from November 30, 2010, through December 1, 2010,
after reporting suicidal thoughts and a return of psychotic symptoms. (Tr. 366, 378.) Frederick
reported that he had run out of medications one week prior because he was unable to afford them.
(Tr. 284, 366, 383.) Frederick was described by an examining psychiatrist as “completely
reliable.” (Tr. 381.) Frederick was diagnosed with re-emergence of psychosis and depressive
symptoms in the setting of medical noncompliance due to financial stressors. (Tr. 389.) He was
switched from Abilify to Haldol6 for financial reasons. Id. At the time of his discharge, he was
Abilify is an anti-psychotic drug indicated for the treatment of disorders such as schizophrenia.
See WebMD, http:// www.webmd.com/drugs (last visited February 2, 2017).
A severe type of schizophrenia characterized by the predominance of incoherence; blunted,
inappropriate or silly affect; and the absence of systematized delusions. Stedman’s Medical
Dictionary 1729 (27th ed. 2000).
A GAF score of 61 to 70 denotes “[s]ome 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.” See American Psychiatric Ass'n., Diagnostic and Statistical Manual
of Mental Disorders 34 (Text Revision 4th ed. 2000) (“DSM IV–TR”).
Haldol is an anti-psychotic drug indicated for the treatments of disorders such as schizophrenia.
See WebMD, http:// www.webmd.com/drugs (last visited February 2, 2017).
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assessed a GAF score of 40 to 50.7 (Tr. 378.)
At Frederick’s December 7, 2010 follow-up with Dr. Reiersen, he reported that he had to
drop out of school that semester because he was not doing well cognitively. (Tr. 455.) He had
no psychotic symptoms or suicidal ideations at that time. Id. Dr. Reiersen diagnosed Frederick
with schizophrenia, disorganized type; and assessed a GAF score of 65. (Tr. 456.)
Frederick presented to the emergency room at Barnes-Jewish Hospital on April 20, 2011,
with complaints of hearing voices, and experiencing suicidal ideations. (Tr. 278.) He reported
that he was failing school, he had lost his job due to distraction, and he had problems with his
fiancée’s family. (Tr. 282.) Emergency room physician Christopher S. Sampson, M.D., noted
that Dr. Reiersen reported that Frederick and his fiancée have “very good insight into his illness
and do not make unreasonable requests for admission. Dr. Reiersen also notes that when the
patient decompensates, his decompensation is very rapid.” (Tr. 284.) Frederick was diagnosed
with paranoid schizophrenia, and acute depression. (Tr. 290.) His dosage of Haldol was
increased, and he was excused from school for a week. Id.
Frederick returned to the emergency room on April 27, 2011, with complaints of hearing
voices, and wanting to hurt himself. (Tr. 298.) He had a plan to take a knife and slit his wrist.
Id. Frederick reported increased stress, difficulty sleeping at night, sleeping during the day, and
missing school. (Tr. 303.) It was noted that Frederick was taking his medications. Id. Dr.
Reiersen had reduced the dosage of Haldol secondary to Frederick’s reports of sedation two days
prior. Id. Dr. Reiersen agreed with the emergency room physician’s plan to increase Frederick’s
A GAF score of 31–40 indicates some impairment in reality testing or communication (e.g.,
speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as
work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends,
neglects family, and is unable to work). DSM IV–TR at 34. A GAF score of 41 to 50 indicates
“serious symptoms” or “any serious impairment in social, occupational, or school functioning
(e.g., no friends, unable to keep a job).” Id.
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dosage of Haldol. Id.
Frederick was hospitalized from June 22, 2011, through June 27, 2011, due to complaints
of hearing voices and experiencing suicidal thoughts. (Tr. 401.) Dr. Sampson noted that
Frederick was “actually quite compliant and self aware,” and was in need of admission. (Tr. 402.)
Frederick reported the he had had a “bad interview” for a job. (Tr. 403.) He complained of
symptoms including worsening low mood with disrupted sleep, inability to enjoy activities,
inability to maintain concentration, and suicidal ideation with plan to overdose on his medications.
Id. He had attempted to use coping skills but these strategies were ineffective in helping either the
hallucinations or the low mood. Id. Frederick’s dosages of Haldol and Paxil8 were increased,
and his mood improved. (Tr. 414.) At the time of discharge, he was not completely at baseline
but was stable for discharge. Id. Dr. Sampson diagnosed Frederick with paranoid schizophrenia
and depression not otherwise specified, with a GAF score of 51 to 60. (Tr. 413-14.)
On July 19, 2011, Frederick reported that he had not experienced any psychotic symptoms
or suicidal ideation since his discharge. (Tr. 443.) He continued to experience poor
concentration, which had been long-standing since the initiation of Haldol; and excessive sedation.
Id. His mood had improved since his medications were increased. Id. Dr. Reiersen diagnosed
Frederick with schizophrenia, disorganized type; and depression not otherwise specified; and
assessed a GAF score of 70. (Tr. 44.) In September 2011, Dr. Reiersen stated that Frederick had
shown reasonable control of his positive9 symptoms but continued to struggle with low
Paxil is indicated for the treatment of depression. See WebMD, http:// www.webmd.com/drugs
(last visited February 2, 2017).
One of the acute symptoms of schizophrenia, including hallucinations, delusions, thought
disorder, loose associations, ambivalence, or affective lability. Stedman’s at 1885. “Negative”
symptoms are deficit symptoms of schizophrenia that follow from diminished volition and
executive function including inertia, lack of involvement with the environment, poverty of
thought, social withdrawal, and blunted affect. Id.
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concentration, and low motivation which were significantly interfering in his social and
occupational functioning. (Tr. 441.) Frederick was a senior in college, but struggled to focus
and keep up his grades. (Tr. 440.) Dr. Reiersen’s diagnoses remained unchanged. (Tr. 441.)
Dr. Reiersen started Frederick on a trial of Risperdal10 because it was a generic medication. Id.
On April 3, 2012, Frederick’s last visit with Dr. Reiersen, Frederick reported he was doing well
and was taking classes part-time. (Tr. 437.) He was seeing a therapist weekly, and reported
compliance with his medications. Id. Dr. Reiersen found that Frederick had good control of his
symptoms overall with Risperdal. (Tr. 438.) She noted a mild concern that Frederick’s had
more disorganization of thought process, and noted this increased tendency to make cynical
comments. (Tr. 439.)
Frederick was hospitalized from June 3, 2012, through June 6, 2012, due to a worsening of
psychotic and depressive symptoms. (Tr. 471.) Frederick reported increasing stresses including
financial stressors; a stressful relationship with his parents; problems with maintaining his grades
in college, for which he was recently suspended; and employment problems. Id. Frederick
complained of auditory hallucinations of voices telling him derogatory things, increased paranoia
regarding his girlfriend’s father, and depressive symptoms. Id. Frederick’s outpatient treating
psychiatrist confirmed that an increase in Frederick’s psychotic symptoms caused a concurrent
worsening of depressive symptoms. Id. Frederick was assessed a GAF score of 31 to 40. (Tr.
475.) He reported that he had been compliant with his medications. (Tr. 476.) Frederick’s
dosage of Risperdal was increased during his hospital stay, and his suicidal ideations resolved.
Frederick was hospitalized again from June 28, 2012, through July 2, 2012, with suicidal
Risperdal is an anti-psychotic drug indicated for the treatment of disorders such as
schizophrenia. See WebMD, http:// www.webmd.com/drugs (last visited February 2, 2017).
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ideations and worsening auditory hallucinations. (Tr. 490.) He was found to be reliable. Id.
Frederick reported three weeks of worsening symptoms, including: poor appetite, poor sleep,
increased thoughts of guilt about eating, increased thoughts of worthlessness, low energy and
anhedonia with loss of interest in watching sports and watching television. (Tr. 495.) The
worsening symptoms developed in the context of increased financial stressors and family
problems. Id. The examining physician found that Frederick had an intent to die because of all
of his social stressors. (Tr. 497.)
Frederick presented to the emergency room on September 12, 2012, with complaints of
increased hallucinations and difficulty telling what was real and what was not. (Tr. 748.) It was
noted that Frederick had been following closely with Dr. Marie Anne Gebara since his last
admission, and that Dr. Gebara planned to change his medications from Risperdal to Abilify. (Tr.
750.) He was not suicidal, and later reported that he was ready to go home. Id. Frederick was
discharged with instructions to continue his medication regimen and follow-up with Dr. Gebara.
(Tr. 752.) Frederick saw Dr. Gebara on September 14, 2012, at which time she found Frederick
was stable for outpatient care. (Tr. 752.) She recommended continued therapy with Kirk
Frederick returned to the emergency room on September 18, 2012, with complaints of
suicidal ideations and auditory hallucinations. (Tr. 1108.) He reported hearing voices telling
him to kill himself. Id. Frederick reported that he did not believe the Risperdal was working so
he did not take it that night. (Tr. 1111.) Frederick was discharged to home, with instructions to
take his antipsychotic medications and follow-up with Dr. Gebara the next day. (Tr. 1115.)
Frederick was admitted at the St. Louis Regional Psychiatric Stabilization Center from
October 1, 2012, through October 8, 2012, due to complaints of suicidal ideations with some
Page 16 of 32
anxiety and hallucinations. (Tr. 1146.) Frederick reported that he had been taking his
medications, and attributed his increased stress resulting from losing his job to his current
symptoms. (Tr. 1127.) Frederick was extremely agitated, paranoid, and suspicious. (Tr. 1131.)
Upon his discharge, Narsimha Muddasani, M.D., noted that staff was unable to completely control
his oppositional behavior, as “this is his baseline social functioning.” (Tr. 1147.) He diagnosed
Frederick with bipolar disorder, and personality disorder. (Tr. 114.)
On November 27, 2012, Frederick presented to the emergency room at Barnes-Jewish
Hospital, with complaints of being suicidal for the past couple weeks with a plan to slit his wrists.
(Tr. 704.) He indicated that his suicidal thoughts were precipitated by an argument with his
brother, and that he heard voices the previous day telling him to kill himself. (Tr. 707.)
Frederick reported that he took his medications regularly. Id. He was admitted to the psychiatric
unit. Id. Frederick was discharged the next day, at which time he was diagnosed with
schizophrenia, disorganized; depression not otherwise specified; and was assessed a GAF score of
45 to 50. (Tr. 719.) The attending physician stated that Frederick’s symptoms were most
consistent with “negativism” found in schizophrenia. (Tr. 720.) Frederick had had a number of
emergency room visits when his stressors “result in exacerbation of psychosis and suicidal
ideation.” Id. His medications were continued. Id.
Frederick was admitted from December 23, 2012, through December 25, 2012. (Tr. 670.)
Frederick had called “911” because he was hearing voices telling him to jump into traffic in the
context of psychosocial stressors and threatened eviction. Id. The emergency room physician
noted that Frederick was well known to the hospital, and had “poor coping skills.” Id. Frederick
had presented to the emergency room just three days prior for similar complaints and was
discharged with instructions to follow-up with his psychiatrist. Id. Examining physician Brian
Page 17 of 32
R. Froelke, M.D., stated that Frederick had a long-standing history of schizophrenia and also
reported depressive symptoms that were in response to stressors or could be secondary to
schizophrenia. (Tr. 672.) Dr. Froelke discussed with Frederick the need to develop coping
skills. Id. Frederick continued to be non-redirectable and preoccupied with trying to kill
himself. Id. He displayed poor future planning. Id. Upon discharge, his mood symptoms
improved. (Tr. 684.)
Frederick presented to the emergency room three times in February 2013, and one time in
March 2013, due to symptoms of schizophrenia and depression. (Tr. 940, 909, 880, 838.) On
February 15, 2013, Dr. Gebara stated that Frederick’s psychotic symptoms have included thought
and speech disorganization, auditory hallucinations, and persecutory delusions that have affected
his social functioning, with some residual symptoms when he is not psychotic. (Tr. 797.) He
also had depressive symptoms including low mood, anhedonia, and poor sleep and appetite. Id.
Dr. Gebara indicated that Frederick seemed to be doing much better after switching from Risperdal
to Abilify, and that he was working on coping skills to avoid repeated emergency room visits. Id.
She assessed a GAF score of 51 to 60. Id. On February 26, 2013, Frederick reported that he quit
his job because it was “very stressful and too mentally taxing for him.” (Tr. 790.) He reported
paranoid ideation and auditory hallucinations. Id. Frederick continued to work on coping skills
for managing stress and psychotic symptoms. Id.
Frederick was hospitalized from April 29, 2013, to May 1, 2013, due to complaints that his
medications were bugs and he felt like his wrists were bleeding. (Tr. 1363.) He had not taken
his Seroquel the night of admission due to his belief that it was a bug. (Tr. 1364.) Frederick also
reported hearing voices, including a voice telling him to jump into traffic. Id. He reported a
recent stressor of getting fired from a janitorial job because he had “not been able to go to
Page 18 of 32
bathroom due to Seroquel.” (Tr. 1369.) The emergency room physician noted that Frederick
kept picking at his wrist and stating “it’s bleeding look.” Id. Frederick was admitted due to
depressive symptoms and psychotic symptoms. (Tr. 1370.) He was noted to have features
indicating “possible decompensation from schizophrenia all in context of depressive symptoms x
1 week.” Id. Frederick’s “outpatient psychiatrist” noted that Frederick “begins having
hallucinations with life stressors, and that going to the Emergency Department may represent a
coping mechanism.” (Tr. 1388.) Upon discharge, Frederick was diagnosed with disorganized
schizophrenia and depression NOS, and was continued on his medications. (Tr. 1388.)
Frederick was hospitalized again from May 8, 2013, through May 13, 2013, with
complaints of hearing voices again telling him to kill himself. (Tr. 1316.) He stated he felt like
he was going to jump out of his skin. Id. Frederick reported that he did not remember if he took
his medications. Id. Upon discharge, it was stated that Frederick had a history of disorganized
schizophrenia and presented with “visual, auditory and tactile hallucinations, and depressive mood
in the setting of possible medication non-compliance.” (Tr. 1339.) Frederick was given an
injection of Invega11 and his auditory and visual hallucinations subsided two days later. Id.
Frederick started seeing Adarsh Reddy, M.D., at the Barnes-Jewish Hospital Outpatient
Psychiatry Clinic, on July 16, 2013. (Tr. 1532.) Frederick had last been seen on an outpatient
basis by Dr. Gebara in June 2013. Id. Frederick reported that he had been doing better since his
discharge. (Tr. 1533.) He started seeing a new therapist, Brooke Justis, and was working on
cognitive behavior therapy techniques. Id. Dr. Reddy found that Frederick was stable on Invega
Invega is an anti-psychotic drug indicated for the treatment of conditions such as schizophrenia.
The medication is injected into a muscle. See WebMD, http:// www.webmd.com/drugs (last
visited February 2, 2017).
Page 19 of 32
and Cymbalta,12 and that his mood was “good for the most part.” (Tr. 1535.) Dr. Reddy
diagnosed Frederick with schizophrenia, disorganized type; depression, not otherwise specified;
and assessed a GAF score of 50 to 60. (Tr. 1532.) Dr. Reddy noted that Frederick had a “history
of decompensation with psychosis and suicidal ideations but at this time he appears to be relatively
stable and as such, is under moderate risk of self-harm or harm to others.” Id. She continued
Frederick’s medications, and praised him for being compliant with his medications. (Tr. 1535.)
Dr. Reddy also encouraged Frederick to continue to go to the Independent Center to socialize and
be active. Id.
Frederick presented to the emergency room on July 21, 2013, with complaints of
hallucinations. (Tr. 1509.) He heard voices telling him to jump into traffic and was visualizing
his wrists bleeding. Id. Frederick later reported feeling better and was discharged. (Tr. 1510.)
Frederick returned to the emergency room on July 30, 2013, with the same complaints.
(Tr. 1480.) He was transferred to the Psychiatric Stabilization Center on July 31, 2013.13 Id.
Frederick saw Dr. Reddy for follow-up on August 26, 2013. (Tr. 1446-47.) Frederick
had just been discharged the previous day from the Neurology department after complaints of
dizziness, nausea, blurring of vision, and vertigo. (Tr. 1446.) Frederick reported a good mood,
but his girlfriend indicated that he was quite irritable and gets upset about trivial things. Id. He
had been seeing his therapist, Ms. Justis, almost on a weekly basis and they were working on
improving coping strategies. Id. Dr. Reddy’s diagnoses remained unchanged. (Tr. 1447.) Dr.
Reddy continued the monthly Invega injection and daily Cymbalta. Id.
On September 23, 2013, Frederick reported that he had been doing better, and had not had
Cymbalta is indicated for the treatment of depression. See WebMD, http://
www.webmd.com/drugs (last visited February 2, 2017).
These records are illegible due to the poor quality of the photocopies.
Page 20 of 32
to call the crisis line for over two months. (Tr. 1407.) Frederick reported experiencing auditory
hallucinations briefly and visual hallucinations a few nights prior where he felt that his wrist was
bleeding. Id. He was able to successfully use coping mechanisms that he learned in therapy.
Id. Frederick reported compliance with his medications. Id. He requested that Dr. Reddy
complete paperwork for his upcoming Social Security Disability hearing. Id. Upon mental
status examination, Dr. Reddy noted that Frederick occasionally made mildly condescending
statements like “are residents supposed to get vacation?” and “maybe you don’t know, but in this
country every state has its own licensing procedure.” Id. Dr. Reddy diagnosed Frederick with
schizophrenia, cluster b traits,14 and a GAF score of 70. (Tr. 1408.) He stated that Frederick
reports continuing auditory hallucinations and visual hallucinations, but his symptoms are stable
and he is at baseline. Id. Dr. Reddy stated that Frederick is “high functioning at baseline,” and
that he “has not been able to work and it is likely related to his poor coping strategies rather than
his primary illness.” Id. Dr. Reddy encouraged Frederick to “consider going back to school and
try to obtain a job as it may give him a better chance of leading a life that he wants.” Id.
The medical evidence summarized above does not support the ALJ’s determination that
Frederick’s “condition is clearly controlled well on medications if and when he is compliant with
them.” (Tr. 24.) It is true Frederick was noncompliant with his medications for a period in 2010
due to losing his insurance and being unable to afford his medications. (Tr. 458, 366.) This led
to two hospitalizations, in May 2010 and November 2010. Id. Frederick was switched from
Abilify to Haldol for financial reasons after his November 2010 hospitalization. (Tr. 389.)
There are no instances of noncompliance with medication noted again until September 18, 2012, at
Cluster B personality disorders include Antisocial, Borderline, Narcissistic, and Histrionic
Personality Disorders. See American Psychiatric Ass’n., Diagnostic and Statistical Manual of
Mental Disorders 659–72 (5th ed. 2013) (“DSM V”).
Page 21 of 32
which time Frederick reported he did not take his medication that day he presented to the
emergency room because he did not believe the Risperdal was working. (Tr. 1111.) When
Frederick was hospitalized on April 29, 2013, he reported that he had not taken his Seroquel that
night due to his belief it was a bug. (Tr. 1364.) Approximately a week later, during Frederick’s
May 8, 2013 admission, he reported that he did not remember if he had taken his medications.
The record does not demonstrate that Frederick was consistently noncompliant with his
medications. Rather, it shows that Frederick had run out of medications and was financially
unable to refill them for a period during 2010. Cf. Brown v. Barnhart, 390 F.3d 535, 540 (8th Cir.
2004) (lack of sufficient financial resources may justify noncompliance with prescribed
treatment). Frederick’s treating psychiatrist addressed his financial obstacles to compliance by
changing his medication to a more affordable drug.
The other instances of noncompliance were on days when Frederick presented to the
emergency room due to increased symptoms of schizophrenia—September 18, 2012, and April 29,
2013—and reported that the medication was not working or he believed the medication was a bug.
He also stated that he did not remember if he had taken his medications on the day he was admitted
for five-days with complaints of hearing voices telling him to kill himself on May 8, 2013. (Tr.
1316.) The Eighth Circuit has repeatedly recognized that a mentally ill claimant’s
noncompliance with treatment can be, and ordinarily is, the result of the mental impairment itself
and cannot, with nothing more, be deemed willful or unjustifiable to such an extent that the
claimant’s subjective complaints relating thereto should be discredited. See Pate–Fires v. Astrue,
564 F.3d 935, 945-47 (8th Cir. 2009) (and cases cited therein).
Frederick’s isolated instances of medication noncompliance do not support the ALJ’s
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finding of consistent noncompliance. In addition, the incidents of noncompliance appear to be
related to his mental impairments and are an insufficient basis to undermine the credibility of his
complaints of disabling psychiatric symptoms.
Further, the record does not support the ALJ’s conclusion that Frederick’s condition is
well-controlled when he is compliant. After Frederick’s change in medication in December 2010,
he was compliant with his medications for almost two years. In June 2011, Dr. Sampson
remarked that Frederick was “actually quite compliant.” (Tr. 402.) Despite Frederick’s
compliance with his medications, he was hospitalized due to psychotic symptoms and suicidal
thoughts on three occasions during this period: from June 22, 2011, to June 27, 2011; June 3, 2012
to June 6, 2012; and from June 28, 2012, to July 2, 2012. (Tr. 401, 471, 490.) Frederick also
presented to the emergency room with complaints of symptoms of schizophrenia and suicidal
thoughts on three occasions: on April 20, 2011, April 27, 2011, and September 12, 2012. (Tr.
278, 298, 748.) During the period of October 2012 through July 2013, he was hospitalized six
times (Tr. 704, 1146, 670, 1363, 1316, 1480), and presented to the emergency room on four
different occasions (Tr. 940, 909, 880, 1509) due to psychotic and suicidal symptoms.
Frederick’s frequent inpatient admissions and emergency room visits due to psychiatric
symptoms, despite his compliance during the majority of the relevant period, reveal that
Frederick’s mental illness was not well-controlled.
The ALJ also found that “it was not Frederick’s psychosis that caused him to lose his job,
but his job loss that caused his increased symptoms” (Tr. 20), and that Frederick’s coping issues
were the “primary cause of his mental issue” (Tr. 24). Frederick’s difficulty coping with social
stressors are well-documented in the medical record. There is also, however, significant evidence
that Frederick’s difficulty in maintaining employment and attending school was caused by his
Page 23 of 32
psychiatric symptoms. On April 20, 2011, Frederick reported to Dr. Sampson that he had lost his
job due to distraction and he was failing at school. (Tr. 282.) Dr. Reiersen reported to Dr.
Sampson that Frederick had good insight into his illness, and that when he “decompensates, his
decompensation is very rapid.” (Tr. 284.) During Frederick’s June 2011 inpatient admission, it
was noted that Frederick experienced a worsening of psychiatric symptoms after having a “bad
interview,” and that he attempted to use coping strategies he had learned in therapy but the
strategies were ineffective in helping his hallucinations or low mood. (Tr. 403.) In September
2011, Dr. Reiersen stated that Frederick was attending college but struggled to focus and keep up
his grades. (Tr. 440.) Frederick was counseled by an emergency room physician about the need
to develop coping skills during his December 2012 admission, but Frederick could not be
redirected and was preoccupied with trying to kill himself. (Tr. 672.) On February 26, 2013,
Frederick reported to Dr. Gebara that he had quit his job because it was “very stressful and too
mentally taxing.” (Tr. 790.) He reported that he was fired from a janitorial job in April 2013
because he had “not been able to go to the bathroom due to Seroquel.” (Tr. 1369.) In addition,
Frederick testified at the hearing that he had lost a job making coffee in 2012 due to becoming
“symptomatic.” (Tr. 1611.) The ALJ’s finding that Frederick’s coping difficulties and difficulty
maintaining employment were not caused by his mental illness is not supported by the record.
Due to the ALJ’s errors in evaluating Frederick’s mental illness, she failed to incorporate
sufficient limitations in Frederick’s RFC. Notably, the ALJ did not account for the time
Frederick would be expected to miss work due to emergency room visits and hospitalizations
resulting from exacerbations in his psychotic symptoms and depression. Thus, the ALJ’s RFC
determination is not supported by substantial evidence in the record as a whole.
Page 24 of 32
Frederick also argues that the ALJ erred in assessing the medical opinion evidence when
determining his RFC. Specifically, Frederick contends that the ALJ discredited the opinions of
Drs. Reiersen and Gebara, and Ms. Justis, without indicating the specific weight assigned to the
opinions. Frederick further argues that the ALJ erred in according the most weight to the opinion
of Dr. Reddy.
“‘It is the ALJ’s function to resolve conflicts among the various treating and examining
physicians.” Tindell v. Barnhart, 444 F.3d 1002, 1005 (8th Cir. 2006) (quoting Vandenboom v.
Barnhart, 421 F.3d 745, 749–50 (8th Cir. 2005) (internal marks omitted)). The opinion of a
treating physician will be given “controlling weight” only if it is “well supported by medically
acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other
substantial evidence in [the] record.” Prosch v. Apfel, 201 F.3d 1010, 1012–13 (8th Cir. 2000).
The record, though, should be “evaluated as a whole.” Id. at 1013 (quoting Bentley v. Shalala, 52
F.3d 784, 785–86 (8th Cir. 1997)). The ALJ is not required to rely on one doctor’s opinion
entirely or choose between the opinions. Martise v. Astrue, 641 F.3d 909, 927 (8th Cir. 2011).
Additionally, when a physician’s records provide no elaboration and are “conclusory checkbox”
forms, the opinion can be of little evidentiary value. See Anderson v. Astrue, 696 F.3d 790, 794
(8th Cir. 2012). Regardless of the decision the ALJ must still provide “good reasons” for the
weight assigned the treating physician’s opinion. 20 C.F.R § 404.1527(d)(2).
The ALJ must weigh each opinion by considering the following factors: the examining and
treatment relationship between the claimant and the medical source, the length of the treatment
relationship and the frequency of examination, the nature and extent of the treatment relationship,
whether the physician provides support for his findings, whether other evidence in the record is
Page 25 of 32
consistent with the physician's findings, and the physician’s area of specialty. 20 C.F.R. §§
404.1527(c)(1)-(5), 416 .927(c)(1)-(5).
Dr. Reiersen completed an Assessment for Social Security Disability Claim dated
September 21, 2012, in which she stated that, when Frederick’s illness is most severe, he has
exhibited disorganized thinking/speech and behavior, delusions of persecutions, auditory
hallucinations, reduced ability to concentrate, low mood, sleep disturbances, and/or suicidal
thoughts. (Tr. 656.) She stated Frederick has also had prominent depressive symptoms, which
seem mainly secondary to his psychotic disorder, and led to his diagnosis of Depression-Not
Otherwise Specified. Id. Dr. Reiersen indicated that, on Fredrick’s last visit on April 3, 2012,
she diagnosed him with schizophrenia-disorganized type; and depression-not otherwise specified;
and assessed a GAF score of 70. Id. She stated that Frederick’s GAF score has fluctuated up and
down frequently, and that Frederick can “appear to have quite good functioning during well
periods, but his level of functioning tends to rapidly deteriorate when he is having recurrence of his
As to Frederick’s ability to work, Dr. Reiersen concluded as follows:
Based on my knowledge of this patient, he has had psychotic symptoms off and on,
at least since 2002. There was a period from approximately 2003 to 2010 where
he was functioning relatively well and I believe he was able to function reasonably
well in school and in any employment situations during most of that period.
However, in Spring of 2010 he showed worsening of his symptoms, leading to
substantial disability. He has had increased symptoms and fluctuating ability to
maintain his functioning since that time, which I believe have prevented him from
maintaining sustained, full time employment since the Spring of 2010.
The ALJ acknowledged Dr. Reiersen’s opinion that Frederick was disabled beginning in
2010 but found that it was inconsistent with Dr. Reiersen’s own treatment notes, which “attribute
the claimant’s fluctuating symptoms to noncompliance, financial stress and job losses.” (Tr.
Page 26 of 32
20-21.) The ALJ stated that, even Dr. Reiersen’s medical source statement provided a GAF score
of 70, which indicates mild symptoms. (Tr. 21.) She further stated that Dr. Reiersen’s opinion is
not consistent with “her own reports regarding the cause and effect relationship of the claimant’s
depressive and psychotic episodes.” Id.
The ALJ erred in discrediting Dr. Reiersen’s opinion. Dr. Reiersen was Frederick’s
treating psychiatrist from October 2002, through April 2012, a period of approximately ten years.
(Tr. 657.) As such, Dr. Reiersen was the most qualified source to provide a longitudinal opinion
of psychiatric functioning. Dr. Reiersen’s opinion is supported by her treatment notes. Her
records do reflect periods during which Reiersen was doing well and she assessed high GAF
scores. As Dr. Reiersen reported to Dr. Sampson, however, when Frederick decompensates, his
decompensation is very rapid. (Tr. 284.) In September of 2011, Dr. Reiersen stated that
Frederick had shown reasonable control of his positive symptoms but continued to struggle with
low concentration and motivation, which were “significantly interfering in his social and
occupational functioning.” (Tr. 441.)
Contrary to the ALJ’s finding, Dr. Reiersen provides a reasoned analysis of her opinion
that Frederick is disabled and her statement is not inherently contradictory. She explains in her
statement that, since 2010, Frederick has had “frequent exacerbations of his symptoms,” which
have interfered with his performance at school and employment settings, and resulted in additional
hospitalizations and medication changes. (Tr. 656.) The medical record of Frederick’s many
inpatient admissions and emergency room visits discussed above supports this statement. Dr.
Reiersen does not attribute Frederick’s fluctuating symptoms solely to noncompliance, or stressors
as the ALJ finds. Rather, Dr. Reiersen indicates that Frederick was noncompliant with his
medications only for a period in 2010, and that his psychiatric symptoms interfere with his
Page 27 of 32
occupational functioning. Thus, the ALJ erred in discrediting Dr. Reiersen’s opinion, without
indicating the specific weight assigned to it.
Dr. Gebara completed a Mental Residual Functional Capacity Assessment on July 23,
2012. (Tr. 1150.) Dr. Gebara expressed the opinion that Frederick had marked limitations in his
ability to understand, remember and carry out simple work instructions and procedures;
understand, remember and carry out detailed instructions and procedures; maintain adequate
attention, concentration and focus on work duties through a complete work day; make appropriate
simple work related decisions; complete a normal work week without interruptions from
psychologically based symptoms; work in coordination with, or in close proximity to others;
maintain socially appropriate behavior and adhere to basic standards of neatness and cleanliness;
respond appropriately to routine changes in the work stetting; respond appropriately to routine
work related stressors; maintain acceptable personal appearance and hygiene; and sustain
extended periods of employment (greater than 6 months) without decompensation from periodic
exacerbation of psychiatric symptoms. Id.
Dr. Gebara found that Frederick had moderate
limitations in his ability to maintain a work schedule and be consistently punctual, interact
appropriately with the general public or customers, accept instructions and respond appropriately
to criticism from supervisors or co-workers, and demonstrate reliability in a work setting. Id.
The ALJ found that Dr. Gebara’s opinion was inconsistent with her treatment notes, which
“consistently reported no clinical findings of abnormality and reported the claimant functioned
well when he was on Abilify and Paxil.” (Tr. 22.)
Dr. Gebara treated Frederick from July 2012 through June 2013. (Tr. 501, 1548.)
During this period, Frederick was hospitalized five times (Tr. 1146, 704, 676, 1363, 1316), and
received emergency room treatment on five occasions (Tr. 748, 1108, 946, 880, 838). In her
Page 28 of 32
treatment notes, Dr. Gebara noted that Frederick’s psychotic symptoms have included thought and
speech disorganization, auditory hallucinations, and persecutory delusions that have affected his
social functioning, with some residual symptoms when he is not psychotic. (Tr. 742, 739, 797,
781.) She stated that Frederick has also had depressive symptoms including low mood,
anhedonia, poor sleep, and appetite. Id. Dr. Gebara noted that Frederick had a blunted or
restricted affect; a disheveled appearance, and was occasionally odorous; and fair insight and
judgment. Id. She assessed a GAF score of 51 to 60. Id.
Dr. Gebara’s opinion that Frederick had marked and moderate limitations was consistent
with her treatment notes, as well as Frederick’s frequent exacerbations resulting in hospitalizations
during this period. Thus, the ALJ did not provide sufficient reasons for discrediting Dr. Gebara’s
Frederick also contends that the ALJ erred in failing to consider the opinion of Frederick’s
treating social worker, Ms. Justis. Ms. Justis authored a letter on October 3, 2013, in which she
stated that she had seen Frederick for counseling services five times since July 11, 2013. (Tr.
1228.) Ms. Justis cited Frederick’s frequent hospitalizations for recurrence of severe psychiatric
symptoms during the time she had been working with him. Id. Ms. Justis expressed the opinion
that Frederick is “an intelligent, thoughtful, contentious young man who continuously works hard
to maintain stability via regularly accessing care from his psychiatrist, therapist and daily support
at Independence Center, but appears to be unable to function consistently in daily activities of
living due to his chronic illness.” Id.
The ALJ acknowledged Ms. Justis’ statement, but found that her “entire basis for making that
statement was the claimant’s report to her about his ongoing impairments and functional
problems.” (Tr. 23.) The ALJ stated that there is no report of clinical signs to support her
Page 29 of 32
The record does not include any treatment notes from Ms. Justis. There is no indication,
however, that Ms. Justis relied on Frederick’s subjective reports only when providing her opinion.
Rather, Ms. Justis specifically referred to Frederick’s frequent hospitalizations due to
exacerbations of symptoms during the time she was treating him. The ALJ’s rationale for
discrediting this opinion is therefore insufficient.
The ALJ indicated that she was according “strongest weight” to the report of Dr. Reddy.
(Tr. 24.) Dr. Reddy completed a Mental Residual Functional Capacity Assessment on October
10, 2013, in which he expressed the opinion that Frederick had only mild limitations in all
functional areas. (Tr. 1231.) The ALJ stated that Frederick is “often not medication compliant
which resulted in his episodes of decompensation.” Id. The ALJ also found that Dr. Reddy’s
opinion was consistent with his records. (Tr. 23.)
Dr. Reddy treated Frederick from July 16, 2013, through September 23, 2013. On July
16, 2013, Dr. Reddy found that Fredrick had a “history of decompensation with psychosis and
suicidal ideations but at this time he appears to be relatively stable and as such, is under moderate
risk of self-harm or harm to others.” (Tr. 1532.) Dr. Reddy praised Frederick for being
compliant with his medications. (Tr. 1535.) Dr. Reddy diagnosed Frederick with schizophrenia,
disorganized type, and depression NOS; and assessed a GAF score of 50 to 60. (Tr. 1532.)
Frederick was admitted at the Psychiatric Stabilization Center on July 31, 2013, with complaints of
hearing voices telling him to jump into traffic and visualizing his wrists bleeding. (Tr. 1480.)
Dr. Reddy saw Fredrick for follow-up in August 2013, at which time his diagnoses remained
unchanged. (Tr. 1446.) Frederick was seeing his therapist, Ms. Justis, almost on a weekly basis
and was working on coping strategies. (Tr. 1446.) On September 23, 2011, Frederick was doing
Page 30 of 32
better, but still reported experiencing auditory and visual hallucinations briefly. (Tr. 1407.) Dr.
Reddy assessed a GAF score of 70, and found that Frederick was at baseline. (Tr. 1408.)
The undersigned finds that Dr. Reddy’s opinion that Frederick has only mild limitations in
all areas of functioning is not supported by the record. Dr. Reddy’s own treatment notes reveal
Frederick continued to experience hallucinations even at baseline. On each visit except his last,
Dr. Reddy assessed a GAF score of 51 to 60, which denotes moderate rather than mild symptoms.
Dr. Reddy also noted that Frederick was compliant with his medications. Despite this
compliance, he was admitted at the Psychiatric Stabilization Center with psychotic and suicidal
symptoms during the short period Dr. Reddy was treating him.
The ALJ cited Frederick’s noncompliance as the cause for his decompensation but, as
previously discussed, this is not supported by the record. There is no question that Frederick was
compliant when he was being treated by Dr. Reddy. The ALJ also pointed out that Dr. Reddy
noted in his records that Frederick did not return calls. (Tr. 23.) The statement to which she
refers, however, was a statement Frederick made to Dr. Reddy. On August 26, 2013, Dr. Reddy
noted that he apologized to Frederick for being unable to reach him during his hospitalization, and
Frederick responded “well you are just starting your third year…you are probably overwhelmed
with all the work.” (Tr. 1446.) To the extent the ALJ considered this statement evidence of
Frederick’s noncompliance, it was error.
The ALJ relied on the opinion of Dr. Reddy, who had treated Frederick for only a
three-month period as “the most persuasive longitudinal evidence of record.” (Tr. 24.) All of
the other opinion evidence, including the opinion of Frederick’s treating psychiatrist for ten years,
supports the presence of much greater limitations due to the fluctuating nature of Frederick’s
Page 31 of 32
The undersigned again notes that recognition must be given to the instability of mental
impairments and their waxing and waning nature after manifestation. See Rowland, 673 F.
Supp.2d at 920-21. Here, the longitudinal picture of Frederick’s mental impairment shows him to
continue to exhibit symptoms of psychotic illness even through periods of regular treatment and
improvement. An “improvement” in a chronic schizophrenic is not inconsistent with a finding of
disability where, as here, a claimant’s treating psychiatrist has not discharged him from treatment
and requires frequent appointments, and other sources have concluded that his work skills are
deficient. See Hutsell, 259 F.3d at 712–13.
Given the ALJ’s improper analysis of Frederick’s mental impairments, discounting of the
medical opinions of Frederick’s treating sources, together with her unsupported determination to
accord the greatest weight to the opinion of Dr. Reddy, the ALJ’s RFC determination is not
supported by substantial evidence in the record as a whole. Significantly, the RFC formulated by
the ALJ fails to consider the absences from work that would be expected as a result of Frederick’s
visits to the emergency room or hospitalizations due to exacerbations.
For the reasons discussed above, the Commissioner’s decision is not based upon
substantial evidence on the record as a whole and the cause is therefore remanded to the
Commissioner for further consideration in accordance with this Memorandum and Order. Upon
remand, the ALJ shall properly consider the opinion evidence, and formulate a new mental RFC
based on the record as a whole.
Dated: March 27, 2017
UNITED STATES MAGISTRATE JUDGE
Page 32 of 32
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