Ryan v. Colvin

Filing 22

MEMORANDUM AND ORDER: IT IS HEREBY ORDERED that the decision of the Commissioner is affirmed. A separate judgment in accordance with this Memorandum and Order will be entered this same date. Signed by District Judge Carol E. Jackson on 3/31/2017. (CLO)

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
EASTERN DIVISION
DONALD R. RYAN,
Plaintiff,
vs.
NANCY A. BERRYHILL1,
Acting Commissioner of Social Security,
Defendant.

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Case No. 4:15-CV-1545 (CEJ)

MEMORANDUM AND ORDER
This matter is before the Court for review of an adverse ruling by the Social
Security Administration . The Court has reviewed the parties' briefs and the entire
administrative record.
I.

Procedural History
On February 9, 2011, plaintiff filed an application for Supplementary Security

Income (SSI) under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381-1385
with an alleged onset date of September 30, 1994. (Tr. 86-91).

The claim was

denied initially on April 11, 2011; thereafter the plaintiff timely filed a written
request for a hearing on May 4, 2011. (Tr. 415).
The SSA granted plaintiff’s request for review and an Administrative Law
Judge (ALJ) conducted a hearing on January 12, 2012.

(Tr. 10).

In a decision

dated February 6, 2012, the ALJ found that plaintiff was not disabled. (Tr. 7). On
June 14, 2012, the Social Security Administration Appeals Council (Appeals Council)
1

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.

denied plaintiff’s request for review. (Tr. 424). On August 3, 2012, plaintiff filed a
complaint with this Court alleging: (1) the ALJ decision was incorrect because there
was no substantial evidence on the record to substantiate the ALJ’s findings and (2)
the decision was contrary to the provisions of the Social Security Act. (4:12-cv1380-CEJ, Doc. #1, pg. 2). On February 11, 2013, this Court granted defendant’s
motion to reverse the decision of the ALJ and remanded the case for further
evaluation of plaintiff’s claim. (Tr. 429).

On April 25, 2013, the Appeals Council

vacated the February 6, 2012, ALJ order and remanded the case to an ALJ to
further evaluate vocational evidence in support of its finding. (Tr. 432).
A second hearing was conducted on October 13, 2013, pursuant to the
Appeals Council order. (Tr. 429). In a decision dated January 30, 2014, the ALJ
found that plaintiff was not disabled. (Tr. 435). The ALJ subsequently vacated the
decision on February 12, 2014, to allow the plaintiff to submit additional
information.

(Tr. 460).

On February 28, 2014, after receiving the additional

information, the ALJ again found that plaintiff was not disabled.

(Tr. 316).

On

August 10, 2015, the Appeals Council reviewed the ALJ decision and concluded their
final decision complied with the order of this Court. (Tr. 297). The Appeals Council
noted that the decision was consistent with Social Security Administration
regulations and supported by substantial evidence.

(Tr. 297).

Accordingly, the

ALJ’s decision stands as the Commissioner’s final decision.
II.

Evidence Before the ALJ
A. Disability Application Documents
On February 11, 2011, plaintiff applied for Supplemental Security Income

under Title XVI of the Social Security Act, benefits under other programs

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administered by the Social Security Administration, and medical assistance under
Title XIX of the Social Security Act. (Tr. 86). Plaintiff claimed a disability onset date
of September 30, 1994. (Tr. 86).
1.

February 11, 2011 – Disability Report

In a Disability Report dated February 11, 2011, (Tr. 127-130) plaintiff
described his prior disability filings and how he felt wronged by the ALJ who had
denied his previous application. (Tr. 129).
2.

February 18, 2011 – Function Report

In a Function Report dated February 18, 2011, (Tr. 139-149), plaintiff stated
that he had no permanent residence. (Tr. 139). In terms of relationships, plaintiff
claimed that he had trouble getting along with family, friends, and neighbors
because he lacks social skills, has a third grade education2, and suffers from a
learning disability, anxiety, and depression. (Tr. 144).

When asked whether his

condition affects his sleep, plaintiff replied in the affirmative and explained that he
cries and is depressed which results in limited sleep. (Tr. 140). When asked about
his daily activities, plaintiff stated that he was depressed emotionally, and does
nothing from the time he wakes up until going to bed. (Tr. 139). Plaintiff stated
that he goes outdoors on a limited basis. (Tr. 142). Plaintiff attributed this to a
lack of social skills and experiencing anxiety around crowds.

(Tr. 142).

When

asked about his shopping habits, plaintiff stated that he goes to the store once a
week and primarily purchases chips and soda. (Tr. 142-143).
In terms of personal care, plaintiff’s ability to dress, bathe, shave, and care
for his hair were all impacted by low self-esteem.
2

(Tr. 140).

Plaintiff did not

Plaintiff’s educational records reflect the plaintiff attending high school until the tenth grade. (Tr.
561)

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prepare his own meals and lacked an appetite. (Tr. 140-141). He had problems
using the bathroom, which he attributed to being stressed and emotionally
depressed. (Tr. 140). Plaintiff needed special reminders to take care of personal
needs and grooming and to take medicine. (Tr. 141).

Plaintiff attributed these

personal care issues to lack of energy, low self-esteem, emotional disturbance, and
memory lapses he suffers due to his learning disability.

(Tr. 141).

Plaintiff also

reported that he does not handle stress or changes in routine well. (Tr. 145).
In terms of personal responsibilities, plaintiff stated that he is unable to do
house or yard work because his balance is not stable, he fears getting hurt, and he
lacks education and confidence.

(Tr. 142).

Plaintiff reported that he has no

hobbies or interests because of anxiety, emotional distress, and loss of balance.
(Tr. 143). Plaintiff’s “limited” activities consisted of “helping with paperwork.” (Tr.
143).

Plaintiff stated that he is unable to pay bills, count change, handle a savings

account, or use a checkbook which he attributes to a learning disability. (Tr. 142).
Plaintiff also stated that he has a low IQ score and lacks of education. (Tr. 142).
When asked how his condition affects him, plaintiff stated that he has
trouble: lifting, squatting, bending, standing, walking, kneeling, talking, hearing,
with memory, stair-climbing, using hands, completing tasks, concentrating,
understanding, following instructions, and getting along with others.

(Tr. 144).

Plaintiff attributed all of these issues to his lack of social skills, lack of balance, hand
injury, hearing loss, and poor education. (Tr. 144).

Plaintiff stated that he could

only walk for one block before needing a rest, but could resume walking within
fifteen minutes. (Tr. 144). Plaintiff stated that he walks with a cane because his
balance is not always stable. (Tr. 145).

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Plaintiff stated that he does not get along well with authority figures because
he lacks social skills and has anger issues. (Tr. 145). Plaintiff stated that he has
been fired or laid off because of problems getting along with people because of his
learning disability, lack of education, and lack of social skills. (Tr. 145). Plaintiff
could not remember the name of the employer who fired or laid him off. (Tr. 145).
Plaintiff also struggles following written instructions. (Tr. 144). When asked about
unusual behavior or fears, plaintiff stated that he also believes he received an
unfavorable decision on his previous disability application because the judge went
out of his way to harm him physically. (Tr. 145).
3.

February 18, 2011 – Third-Party Function Report

A Third-Party Function Report was completed by Linda McMenomy on
February 18, 2011. (Tr. 131-138). McMenomy identified herself as a “lady from
church” in defining her relationship to plaintiff. (Tr. 131). McMenomy stated that
she sees plaintiff “from time to time” to assist with mail.
McMenomy described plaintiff as being depressed and suffering from anxiety
and memory lapses.

Because of depression and anxiety, plaintiff engaged in no

activities during the day and had no hobbies or interests. He went outdoors only on
a limited basis.

McMenomy reported that plaintiff’s conditions affected his sleep,

appetite, and his ability to use the toilet and take care of his personal needs. She
reported that plaintiff had to be reminded to take his medicine.

She described

plaintiff as lacking in self-esteem, motivation, and energy. McMenomy stated that
plaintiff went shopping once a week to buy chips and soda. However, he became
anxious when in a crowd. Plaintiff spent only a limited amount of time with other

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people due to a lack of social skills and because of his anger, learning disability,
depression, and anxiety.
McMenomy also stated that plaintiff is unable to pay bills, count change,
handle a savings account, or use a checkbook because of his learning disability, low
IQ score, lack of education and compensation.

She reported that plaintiff uses a

cane when becomes off-balance, although no doctor prescribed it for him.
McMenomy stated that plaintiff has trouble lifting, squatting, bending, standing,
walking, sitting, kneeling, talking, hearing, with memory, stair-climbing, using
hands, completing tasks, concentrating, understanding, following instructions, and
getting along with others. According to McMenomy,

these issues stem from

plaintiff’s lack of social skills, lack of balance, hand injury, hearing loss and poor
education.

McMenomy reported that plaintiff does not get along with authority

figures because he lacks social skills, cannot follow instructions, and is angry.
McMenomy also stated that plaintiff has been fired or laid off from a job, which she
attributed to difficulty working with people because of his learning disability, poor
education, lack of social skills, and discomfort in crowds.

McMenomy stated that

since the denial of disability decision letter arrived, plaintiff has a high level of
anger, anxiety, emotional distress, and believes the future looks grim due to the
judge “basically making his funeral arrangements.” (Tr. 137).
4.

April 27, 2011 – Function Report

In a Disability Report dated April 27, 2011, plaintiff stated that since his
previous Disability Report he began to suffer increased balance issues, worsening
panic attacks, increased depression, lack of focus, and memory loss.

(Tr. 158-

165). Plaintiff also stated that he began to suffer headaches, anger issues, and a

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lack of urgency.

Plaintiff reported that he suffered from manic depression,

paranoia, anxiety attacks, lower back pain, and had to use a cane to stay stable.
Plaintiff also reported having suicidal thoughts.

Plaintiff stated that he had been

seeing a physician, Dr. Kamat, for four years to treat his mental condition,
depression, anxiety, and panic attacks. Plaintiff noted that he had been prescribed
Xanax and counseling. Plaintiff stated he also visited the Missouri Department of
Social Services for a medical evaluation related to Medicaid coverage.
5.

Undated Disability Report

In an undated Disability Report, plaintiff stated that he had suffered two
head injuries which resulted in hearing and memory loss, a loss of focus, a left
hand injury, a learning disability, depression and fatigue.

Plaintiff stated that he

stopped working on January 1, 1994, because of his condition. In his last job he
swept floors, mopped and emptied trash cans. Plaintiff stated that he had been in
special education classes when he was in school.3 Plaintiff also stated that he had
been seeing Dr. Kamat for physical and mental conditions since 2008 and had been
prescribed Alprazolam.
B. January 12, 2012 Hearing.
At the hearing on January 12, 2012, plaintiff testified in response to
questions posed by the ALJ and counsel. (Tr. 23). Plaintiff told the ALJ that he was
41 years old, 5’11” and weighed one-hundred and fifty pounds. (Tr. 24). Plaintiff
stated that he was temporarily living with his brother; but received his mail at his
parents’ address. (Tr. 24). Plaintiff testified that he receives two hundred dollars a
month in food stamps and has Medicaid. (Tr. 24-25).

3

The educational records reflect that plaintiff attended high school. (Tr. 561)

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Plaintiff stated that he was receiving medical treatment for psychiatric issues
from Dr. Kamat, who diagnosed him with bipolar disorder and generalized anxiety
disorder. (Tr. 25). Plaintiff testified that he was admitted to the hospital in July of
2011 because he was suicidal. (Tr. 25).

Plaintiff stated that he has had suicidal

ideation all of his life. (Tr. 31). Plaintiff also suffers from depression and a learning
disability. (Tr. 25). When asked about medications, plaintiff testified that he was
taking Abilify, Prozac, and Xanax, all prescribed by Dr. Kamat. (Tr. 25). Plaintiff
stated that the medications make his legs weak and impact his mood by making
him “not calm.” (Tr. 32).

Plaintiff confirmed that Dr. Kamat had diagnosed him

with bipolar disorder and generalized anxiety disorder. (Tr. 25).
Plaintiff testified that he doesn’t do well with social activities. (Tr. 26). In
response to questions about his educational background, plaintiff stated that he
was not a high school graduate and had been in special education classes since
third grade. (Tr. 26). Plaintiff also testified that he did not have a GED nor did he
have any specialized work training. (Tr. 33).
Plaintiff testified that he does not cook, unless he has a microwave. (Tr. 26).
Plaintiff stated that he rarely goes to the grocery store, and if he does, it is to
purchase a bag of chips or a soda.

(Tr. 26).

When asked about his personal

hygiene, plaintiff testified that he is able to shower and clean himself regularly, but
sometimes when he is depressed he does not regularly shower. (Tr. 27).
When asked about physical ailments, plaintiff testified that when he was
either eighteen or nineteen years old he cut his left hand on a piece of glass which
resulted in reduced grip strength and numbness on the inside of his hand. (Tr. 2728). Plaintiff testified that he could not hold more than a gallon of milk with his left

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hand because he suffers sharp, shooting pains through his fingertips.

(Tr. 28).

Plaintiff testified that he’d fractured his head in a fall from a roof when he was
younger. He also testified that he’d been hit in the head with a baseball bat, which
resulted in a complete loss of hearing in his right ear and a lengthy surgical scar.
(Tr. 28-29).
Plaintiff testified that he has daily anxiety attacks and trouble sleeping. (Tr.
29-30). Plaintiff stated that he does not read the newspaper and has trouble with
reading comprehension. (Tr. 32). Plaintiff testified that he spends most of his time
during the day watching television if one is available. (Tr. 31). Plaintiff stated that
he did not want any friends and avoids social situations.

(Tr. 30).

Plaintiff also

testified that he has a driver’s license but he does not drive. (Tr. 30).
During the day, plaintiff spent time with his brother and his pets but mostly
watched television.
years.

(Tr. 33).

(Tr. 30-32).

Plaintiff stated that he had not worked in 16

Plaintiff testified that while he was working he had issues with

management because “they knew something wasn’t right” and he felt that
management knew “that he wasn’t as smart as they were.”

(Tr. 33).

Plaintiff

testified that he primarily worked doing janitorial work. (Tr. 34). Plaintiff testified
that he does not have a bank account, and his sole income is from food stamps.
(Tr. 32).
C. October 13, 2013 Hearing
A second hearing was conducted on October 31, 2013, after the Court
reversed the decision of the ALJ and remanded the case for further evaluation of
plaintiff’s claim. (Tr. 429).
1.

Plaintiff’s Testimony

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At the hearing on October 13, 2013, plaintiff stated that he was 5’10” tall
and weighed one-hundred and sixty pounds. He lived in an apartment with a female
roommate. (Tr. 331).

Plaintiff testified that had been in learning disabled classes

for his entire life and that he reached the ninth grade. (Tr. 332). Plaintiff stated
that he quit school because he was failing miserably. (Tr. 332).
When asked about activities he engages in, plaintiff testified that he has no
hobbies or social activities and that he didn’t do much on a normal day beside
watch television.

(Tr. 339).

Plaintiff testified that in his previous jobs he was

teased because of his disability. (Tr. 343). Those jobs ended because he either got
fired or quit. (Tr. 343). Plaintiff also testified that he does not have access to a
computer and has never used a computer. (Tr. 348).
Plaintiff testified that in September 2013 he had a seizure.

(Tr. 336).

Plaintiff stated that he had not had a seizure since. (Tr. 336). A doctor told him
the seizure could occur again and prescribed medication.

(Tr. 337).

Plaintiff

testified that he has no hearing in his right ear, he has trouble remembering things,
and that he had occasional chest pains. . (Tr. 335, 337-338).
Plaintiff stated that he has been diagnosed with bipolar disorder which makes
him unable to focus. (Tr. 335). Plaintiff explained that he cannot focus on a task
for more than a half hour and that his thoughts are always racing. (Tr. 335-36).
Plaintiff stated that he sleeps for four hours a night at most. (Tr. 336). Plaintiff also
testified that he gets panic attacks in stressful situations. (Tr. 354).
Plaintiff stated that he was only able to lift up to 15 pounds with his left
hand.

(Tr. 332).

He testified that he did not have any difficulty with sitting or

standing, but noted that he had not walked for extended periods. (Tr. 332-333).

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Plaintiff stated that he does not drive because he has seizures and did not have a
car. (Tr. 333). When asked about personal hygiene, plaintiff stated that he needed
to be reminded to shower but was able to dress himself. (Tr. 334). Plaintiff also
stated that he does no cleaning, laundry, housework, or cooking around the
apartment. (Tr. 334).
Plaintiff testified about an incident in which he was found on the side of the
road and was taken to the hospital. (Tr. 344). Plaintiff stated that he had mixed
up some medications which caused him to “fall out.” (Tr. 345). Plaintiff testified
that he was not sure what he was taking at the time. (Tr. 346). Plaintiff testified
that he left against medical advice because he felt the hospital was “just letting
[him] sleep it off” and he could do that at home. (Tr. 347).
2.

Vocational Expert Testimony

A vocational expert, Denise Weaver, also testified before the ALJ. (Tr. 350).
The ALJ posed a hypothetical to Weaver asking her to assume an individual with the
same restrictions as plaintiff and determine whether there was any work available
in the national economy for such an individual. (Tr. 351). Weaver testified that the
individual could work as a cleaner in the hospital environment, a dining room
attendant, or a kitchen helper. (Tr. 350-352).
Plaintiff’s attorney expanded the hypothetical to include the assumption that
the individual would also be ten percent off-task during the workday with a ten
percent loss of productivity. (Tr. 352). Weaver stated that it is very possible, with
ten percent off-task activity, that an employer would find, “in a probationary
employee that that would not be acceptable.” (Tr. 352). Plaintiff’s attorney then
added the limitation of needing two extra fifteen-minute breaks throughout the day

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in addition to a lunch break and normal breaks through the day. (Tr. 352-353).
The expert testified that the employer would need to make an accommodation, in
the case of “a probationary employee in an unskilled setting,” that would not be
acceptable. (Tr. 353).
The ALJ posed an additional hypothetical to the expert, premised upon the
original but adding with no intense interactions with other people, no tandem jobs
performed, and with independent work.

(Tr. 354-356).

The vocational expert

identified landscape specialist and stubber as additional jobs that the hypothetical
individual could perform. (Tr. 356-358).
D. Medical Records
Sanjeev Kamat, M.D.
Dr. Sanjeev Kamat first evaluated plaintiff on October 2, 2007.

(Tr.178).

Plaintiff was 37 years old and presented for a psychiatric evaluation. (Tr. 178). For
the previous 3-4 weeks plaintiff explained he had felt depressed and sad, which
resulted in symptoms of feeling down, decreased engagement, fatigue, decreased
appetite, and lack of concentration.

(Tr. 178).

Plaintiff denied any suicidal or

homicidal ideations; as well as manic or psychotic symptoms. (Tr. 178). Plaintiff
informed Dr. Kamat that he had previously been diagnosed with depression. (Tr.
178). Plaintiff stated that he had a previous hand injury and two head injuries, one
at age nine and the other between the ages of twenty-three and twenty-four. (Tr.
180). Plaintiff stated his highest level of education was third grade. (Tr. 179).
On January 7, 2008, plaintiff told Dr. Kamat that he felt very anxious and
had problems with feeling restless.

(Tr. 183).

Plaintiff denied feeling depressed

and sad but stated that he worried a lot about various things. (Tr. 183). Plaintiff

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stated that he had tried two medications prescribed by Dr. Kamat but they were not
working. (Tr. 183). Dr. Kamat determined that plaintiff had generalized anxiety
disorder and prescribed Xanax. (Tr. 183).
On February 18, 2008, plaintiff stated that he still felt anxious and had to
take two Xanax pills at times.

(Tr. 184).

Plaintiff denied feeling depressed or

hearing any voices. (Tr. 184). Dr. Kamat continued to prescribe Xanax. (Tr. 184).
On March 12, 2008, plaintiff stated that he felt better on his medication and
had no problems concerning his mood. (Tr. 185). Plaintiff denied feeling anxious
or depressed or feeling any paranoia. (Tr. 185). Dr. Kamat continued to prescribe
Xanax. (Tr. 185).
From May 14, 2008 until January 5, 2011, plaintiff stated that he continued
to feel better and was not feeling depressed, sad or anxious.4 Plaintiff continued to
note that he slept at night and denied hearing voices or experiencing paranoia.5
Dr. Kamat continued to assess plaintiff as having generalized anxiety disorder and
continued to prescribe plaintiff Xanax.6
On March 4, 2011, plaintiff stated he felt sad at times because his application
for disability benefits had been rejected. (Tr. 234). However, plaintiff stated that
he slept at night, had no feelings of paranoia and was not hearing voices.

(Tr.

234). Dr. Kamat continued to prescribe Xanax. (Tr. 234).

4

During this period plaintiff was seen by Dr. Kamat on the following occasions: (1) May 14, 2008 (Tr.
186), (2) June 18, 2008 (Tr. 187), (3) July 14, 2008 (Tr. 188), (4) September 9, 2008 (Tr. 189), (5)
October 13, 2008 (Tr. 190), December 18, 2008 (Tr. 191), (6) February 12, 2009 (Tr. 192), (7) April
12, 2009 (Tr. 193), (8) January 25, 2010 (Tr. 228), (9) April 19, 2010 (Tr. 229), (10) June 14, 2010
(Tr. 230), (11) September 14, 2010 (Tr. 231), (12) November 9, 2010 (Tr. 232), and (13) January 5,
2011 (Tr. 233).
5
See supra n. 3
6
See supra n. 3

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On May 1, 2011, plaintiff stated that he felt sad and depressed most times.
(Tr. 292).

Plaintiff also reported he had decreased energy at times and trouble

focusing and concentrating. (Tr. 292). Plaintiff stated that he felt worthless and
anxious at times, but that his medications helped with that. (Tr. 292). Dr. Kamat
also assessed plaintiff as having major depressive disorder and prescribed Prozac as
well as continuing to prescribe Xanax. (Tr. 292).
On July 27, 2011, plaintiff stated that he had episodes when he felt irritable,
had racing thoughts, and would get easily distracted.

(Tr. 293).

Plaintiff stated

that he was having trouble sleeping at night and often felt sad, depressed and
anxious.

(Tr. 293).

Plaintiff stated that he had been admitted to St. Louis

University Hospital for depression, anger, and suicidal ideation.

(Tr. 293).

Dr.

Kamat assessed plaintiff as having major depressive disorder, generalized anxiety
disorder, and ruled out bipolar affective disorder. (Tr. 293). Dr. Kamat prescribed
Abilify, Prozac, and Xanax. (Tr. 293).
On August 31, 2011 and October 25, 2011, plaintiff reported that he felt
better on his medications and denied feeling depressed. (Tr. 294-95). Plaintiff also
reported that he slept well at night and had no major panic attacks. (Tr. 294-95).
Plaintiff also stated that the Xanax helped his anxiety. (Tr. 294-95). Dr. Kamat
assessed plaintiff as having generalized anxiety disorder and type 2 bipolar
affective disorder. (Tr. 294-95). Dr. Kamat continued to prescribe Abilify, Prozac,
and Xanax. (Tr. 294-95).
On December 20, 2011, plaintiff stated that he felt sad and depressed. (Tr.
296). Plaintiff explained he had decreased energy and trouble concentrating. (Tr.

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296).

Plaintiff said he felt anxious at times.

(Tr. 296).

Plaintiff denied hearing

voices and stated he was not feeling paranoid. (Tr. 296).
On February 14, 2012, plaintiff stated that he felt sad and depressed at times
and had been denied disability again. (Tr. 569). Plaintiff stated that he was not
hearing voices and not feeling paranoid. (Tr. 569). Plaintiff stated that he slept
“okay” at night. (Tr. 569).
On April 10, 2012, plaintiff stated that he still felt sad and depressed at
times.

(Tr. 570).

Plaintiff noted that his anxiety was under control with his

medications. (Tr. 570).
On July 11, 2012, plaintiff stated he was admitted at Phelps County Regional
Medical Center for depression. (Tr. 571). Plaintiff stated that he was having a bad
few days but felt better and was no longer depressed, sad, or anxious. (Tr. 571).
Plaintiff stated that he was not hearing voices and had no paranoia present. (Tr.
571). Plaintiff reported no difficulty sleeping at night. (Tr. 571).
On August 29, 2012, plaintiff stated that he felt sad and depressed most
days. (Tr. 572). Plaintiff noted that he was not sleeping well at night. (Tr. 572).
Plaintiff also stated that he was not paranoid or hearing voices.

(Tr. 572).

Dr.

Kamat prescribed Abilify, Prozac, Xanax, and Ambien. (Tr. 572).
On October 24, 2012, plaintiff said that he felt less depressed. (Tr. 573). He
was not feeling anxious, hearing voices, or feeling paranoia.

(Tr. 573).

Plaintiff

stated that he was able to sleep at night. (Tr. 573).
On January 16, 2013, plaintiff stated that he was doing well on his current
medications. (Tr. 574). Plaintiff reported he was not feeling depressed or anxious

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and that he did not feel paranoid. (Tr. 574). Plaintiff stated that he was sleeping
at night and not feeling irritable. (Tr. 574).
On April 10, 2013, plaintiff stated he was having some panic attacks. (Tr.
575).

Plaintiff stated he was not feeling sad or depressed.

(Tr. 575).

Plaintiff

stated that he was not hearing voices and not feeling paranoia. (Tr. 575). Plaintiff
stated that he was sleeping at night and had a fair appetite. (Tr. 575).
On August 8, 2013, Dr. Kamat provided a Treating Source Statement. (Tr.
616). Dr. Kamat stated that plaintiff suffers from type 2 bipolar disorder and panic
disorder and was currently on Prozac, Abilify, Ambien, and Alprazolam. (Tr. 616).
Dr. Kamat stated that in his professional opinion, due to his diagnosis and
symptoms of depression, irritability, panic attacks, and stress, plaintiff is disabled
and unable to work and qualifies for disability. (Tr. 616).
Family Care Health Centers
On February 26, 2009, plaintiff was seen at Family Care Health Center by
Robin Musselman, R.N.C.S.
decreased
motivation.

mood

and

(Tr. 202).

(Tr. 202).

periods

of

Plaintiff reported that he frequently had

anger,

fatigue,

hypersomnia,

and

lacked

Plaintiff further reported that he was anxious throughout

the day; he denied wanting to hurt himself or others.

(Tr. 202).

Plaintiff had

complete range of motion to all extremities and equal muscle strength to upper and
lower extremities. (Tr. 202).
On May 26, 2009, plaintiff was again seen at Family Care Health Center. (Tr.
199). He stated that he had come because he was told that he needed a “regular
doctor” in order to get a Medicaid card.

(Tr. 199).

Plaintiff also requested a

statement that he was disabled and unable to work; his request was denied.

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Plaintiff rejected offers to be seen by a doctor for evaluation of his cognitive ability
and refused to have any lab work done.

Plaintiff was described as “somewhat

hostile; but not threatening.”. (Tr. 199).
Kyle DeVore, Ph.D.
On January 7, 2008, plaintiff was seen by Kyle DeVore, Ph.D. (Tr. 215).
Plaintiff stated that he felt anxious, restless, was experiencing palpitations, but
denied feeling depressed or sad. (Tr. 215). On May 14, 2008, plaintiff stated that
he continued to do well on his medications and denied feeling sadness, moodiness,
or paranoia. (Tr. 215). On April 8, 2009, plaintiff stated that he felt fine, denied
anxiety, or extreme worrying.

(Tr. 215).

Plaintiff also stated that he was not

hearing voices and had not been experiencing paranoia. (Tr. 215).
On August 12, 2009, Dr. DeVore determined that plaintiff had major
depressive disorder. (Tr. 208). He also found that plaintiff had generalized anxiety
disorder. (Tr. 209). Dr. DeVore concluded that plaintiff had a mild restriction of
activities in daily living. (Tr. 213). He found that plaintiff had moderate difficulties
in maintaining social functioning. (Tr. 213). He also found that plaintiff had mild
difficulties in maintaining concentration, persistence, or pace.

(Tr. 213).

Dr.

DeVore noted no degree of limitation in repeated episodes of decompensation. (Tr.
213).

On August 12, 2009, Dr. DeVore concluded that the plaintiff retained the

ability to perform simple, repetitive tasks in a limited social environment.

(Tr.

218).
Raymond Leung, M.D.
On August 28, 2009, plaintiff was seen by Raymond Leung, M.D. (Tr. 219).
Dr.

Leung noted that plaintiff had a history of head trauma and was completely

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deaf in his right ear. (Tr. 221). He also noted that plaintiff had decreased long and
short term memory.

(Tr. 221).

He further noted that plaintiff had weakened

strength in his left hand and was unable to pick up a penny with his hands. (Tr.
221).

Lynne A. Meyers – Case Analysis
On March 30, 2011, Lynne A. Meyers performed a case analysis of plaintiff’s
medical records. (Tr. 37). Meyers reported that plaintiff was claiming a hearing
impairment and a left hand injury. (Tr. 37).

Meyers found that plaintiff had

diminished hearing in the right ear but not the left.

(Tr. 37).

She found

that

plaintiff’s allegations of severe disability and almost no daily activities were not
credible because there was no medical documentation that was consistent with the
allegations. (Tr. 37).
Keith L. Allen, Ph.D.
On April 8, 2011, plaintiff was seen by Keith L. Allen, Ph.D. (Tr. 235-246).
Dr. Allen stated that plaintiff was upset about being denied disability benefits. (Tr.
245). Based upon the preponderance of case file information, Dr. Allen found that,
with treatment compliance, plaintiff had been stable and improved with no reported
anxiety or depression.

(Tr. 245).

Plaintiff had no issues with understanding,

coherency, concentrating, talking, or answering during the interview, except for
anger about his previous denial of disability benefits. (Tr. 671). Plaintiff stated he
had problems understanding, following instructions, getting along with others,
memory, completing tasks, and with concentration. (Tr. 671). Dr. Allen found this

- 18 -

inconsistent with the medical evidence.

(Tr. 671).

He noted that plaintiff was

cooperative, behaved appropriately, spoke spontaneously, was cooperative and had
logical thoughts. (Tr. 671).

Dr. Allen concluded that based on the preponderance

of case file information plaintiff was upset about being denied disability; however,
the medical record indicated that with treatment compliance, plaintiff had been
stable and improved with no reported anxiety or depression. (Tr. 671).
1.

St. Louis University Hospital

On July 7, 2011, plaintiff presented at the emergency room of Saint Louis
University Hospital with complaints of anxiety, depression, and suicidal ideation.
(Tr. 265). Plaintiff was seen by Dr. Michelle Greenberg. (Tr. 265). Plaintiff stated
that he had planned to either hang or shoot himself. (Tr. 265). However, plaintiff
also stated that he did not own or have access to a gun. (Tr. 280). Plaintiff stated
that he was hearing voices telling him to hurt himself. (Tr. 265).

Plaintiff also

stated that he had been trying to get on disability and that he was “at the end of
[his] rope.” (Tr. 265). Plaintiff stated that he had felt hopeless and suicidal for his
entire life, but was now feeling worse because his Xanax and Prozac were stolen six
days prior. (Tr. 267).

Plaintiff described his mood as bad; however his thought

process was goal-oriented with no suicidal or homicidal ideations except a passive
death wish. (Tr. 273). Plaintiff took an IQ test, which was found to be extremely
low for a person who was communicating as properly as plaintiff. (Tr. 273). It was
believed that the low IQ score was a result of malingering by plaintiff. (Tr. 273).
Plaintiff was advised to call 911 or go to the nearest emergency room if he became
suicidal or homicidal again.

He was prescribed fluoxetine, hydroxyzine, and

trazodone and was discharged on July 12, 2011. (Tr. 272-273).

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Mercy Clinic-Salem
On July 31, 2012, plaintiff went to Mercy Clinic-Salem complaining of
migraines and insomnia.

(Tr. 589).

Plaintiff also stated that he had issues with

gastroesophageal reflux disease, abusive head trauma from when he was beaten
with a baseball bat, a learning disability, anxiety, depression, and chronic bipolar
affective disorder.

(Tr. 589).

Plaintiff was prescribed Zantac, Vistaril, Desyrel,

Abilify, Prozac, Desyrel, Toprol XL, and Fioricet. (Tr. 590-591).
On October 29, 2012, plaintiff went to the clinic again for a follow-up exam.
He reported headache, insomnia, and depression.

(Tr.

597). Plaintiff was

prescribed Toprol XL, and Desyrel. (Tr. 597).
On July 15, 2013, plaintiff complained of depression. (Tr. 588). There is no
medical evaluation in the record.
2.

Salem Memorial Hospital

On June 7, 2013, plaintiff was found on the side of the road by police. (Tr.
578). Plaintiff had filled a prescription for Xanax the previous day on June 6, 2013.
(Tr. 578). When plaintiff was found on June 7, 2013, there was only one Xanax pill
remaining in the bottle.

(Tr. 578).

When observed at the hospital, plaintiff

appeared confused, but also alert, awake, and well-developed.
hospital concluded that plaintiff overdosed on Xanax.

(Tr. 580).

(Tr. 584).

The

Plaintiff stated

that he was not suicidal. (Tr. 584).
On September 19, 2013, plaintiff was found at home with complaints of
hypertension and was brought to the emergency room. (Tr. 617).

When found,

plaintiff stated that he did not recall what had happened and that he woke up in the
back of an ambulance. (Tr. 621).

Greg Maynard, M.D., determined that plaintiff

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had had a seizure in which he became unresponsive, his eyes rolled back in his
head, and he stopped breathing. (Tr. 624). Plaintiff stated that he had been dizzy
and sweaty since the morning.

(Tr. 619).

Examinations of plaintiff’s head and

chest determined he was clear of other issues.

(Tr. 629-630).

Plaintiff was

discharged later that day. (Tr. 629).
On October 9, 2013, plaintiff was seen by Dr. Maynard for an issue
concerning his mood. (Tr. 682). He was prescribed Lamictal. (Tr. 682).
On October 11, 2013, Dr. Maynard provided a Medical Source Statement.
(Tr. 657).

Dr. Maynard stated that plaintiff is not able to maintain gainful

employment due to the degree of difficulty the plaintiff was having with irritability
and anxiety, as well as his new diagnosis of seizure disorder.

(Tr. 657).

Dr.

Maynard further stated that based on his medications and instability of medical
problems, plaintiff would be a liability and recommended that plaintiff pursue
disability. (Tr. 657).
Sachin B. Thorat, M.D.
On October 10, 2013 plaintiff underwent an electroencephalogram (EEG) test
to evaluate plaintiff’s brain activities. (Tr. 653). Plaintiff had a normal awake EEG,
which Dr. Thorat noted did not rule out epilepsy. (Tr. 653). Dr. Thorat suggested
clinical correlation to corroborate his interpretation of the EEG test. (Tr. 653). Dr.
Thorat prescribed plaintiff Lamictal. (Tr. 655).
Mercy Hospital-Lebanon
On October 22, 2013, plaintiff was seen at Mercy Hospital-Lebanon for a
sleep study. (Tr. 659). Plaintiff presented with a number of sleep-related issues,

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including having trouble breathing while sleeping.

(Tr. 659).

He was diagnosed

with obstructive sleep apnea. (Tr. 660).
Thomas J. Spencer
On December 13, 2013, plaintiff was seen by Thomas J. Spencer, for a
psychological evaluation to assist in the determination of eligibility for disability
benefits.

(Tr. 686).

Plaintiff’s primary complaint was that he had a learning

disability. (Tr. 686). Spencer noted plaintiff obtained an IQ score of 46; however
Spencer did not consider that to be an accurate representation of plaintiff’s present
functioning after speaking with him and reviewing the available records. (Tr. 688689).
Spencer provided a Medical Source Statement pertaining to plaintiff’s ability
to do work-related activities on a sustained basis. (Tr. 690). Spencer determined
that plaintiff had mild restrictions in terms of understanding and remembering
simple instructions and carrying out simple instructions. (Tr. 690). Spencer further
determined that plaintiff had moderate restrictions in terms of making judgment on
simple and complex work-related decisions, understanding and remembering
complex instructions and carrying out complex instructions.

(Tr. 690).

Spencer

determined that plaintiff had mild restrictions in interacting appropriately with the
public, supervisor(s), and co-workers. (Tr. 691). Spencer found that plaintiff had a
moderate restriction in responding appropriately to usual work situations and
changes in a routine work setting. (Tr. 691).
E. Educational Records
Plaintiff was classified as needing special education in 1978.

(Tr. 560).

Educational records show that plaintiff consistently tested in the bottom quintile in

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fifth and sixth grade on the Cognitive Abilities Test (CogAT). (Tr. 559). In 1982,
plaintiff scored in the third percentile based upon age and seventh percentile based
upon grade for verbal skills, in the sixth percentile based upon age and fourteenth
percentile based upon grade for quantitative skills, in the eleventh percentile based
upon age and nineteenth percentile based upon grade for nonverbal skills.
559).

(Tr.

In 1983, plaintiff scored in the eleventh percentile based upon age and

seventeenth percentile based upon grade for verbal skills, in the fifth percentile
based upon age and eighth percentile based upon grade for quantitative skills, and
in the third percentile based upon age and fourth percentile based upon grade for
nonverbal skills. (Tr. 559). Plaintiff attended Roosevelt High School through the
end of the tenth grade with a cumulative 0.5 GPA. (Tr. 561).
III.

The ALJ’s Decision
A. February 6, 2012
In the decision issued on February 6, 2012, the ALJ made the following

findings with respect to plaintiff’s application for disability insurance benefits:
1. The plaintiff has not engaged in substantial gainful activity since February
11, 2011, the application date.
2. The plaintiff has the following severe impairments: a bipolar affective
disorder and anxiety disorder.
3. The plaintiff does not have an impairment or combination of impairments
that meets or medically equals the severity of one of the listed impairments in 20
CFR Part 404, Subpart P, Appendix 1.
4. The plaintiff has the residual functional capacity to perform a full range of
work at all exertional levels but with the following nonexertional limitations: he is
restricted to the performance of simple, routine, and repetitive work tasks.
5. Plaintiff has no relevant work.
6. Plaintiff was born on July 13, 1970 and was 40 years old, which is defined
as a younger individual age 18-49, on the date the application was filed.
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7. The claimant has a limited 10th grade education and is able to
communicate in English.
8. Transferability of job skills is not an issue because the plaintiff does not
have past relevant work.
9. Considering the plaintiff’s age, education, work experience, and residual
functional capacity, there are jobs that exist in significant numbers in the national
economy that the claimant can perform.
10. The plaintiff has not been under a disability, as defined in the Social
Security Act, since February 11, 2011, the date the application was filed.
(Tr. 7-20).
B. February 28, 2014
In the decision issued on February 28, 2014, the ALJ made the following
findings with respect to plaintiff’s application for disability insurance benefits:
1. The plaintiff has not engaged in substantial gainful activity since February
9, 2011, the application date.
2. The plaintiff has the following severe impairments: bipolar disorder type 2
and panic disorder.
3. The plaintiff does not have an impairment or combination of impairments
that meets or medically equals the severity of one of the listed impairments in 20
CFR Part 404, Subpart P, Appendix 1.
4. The plaintiff has the residual functional capacity to perform a full range of
work at all exertional levels but with the following nonexertional limitations: he can
understand, remember and carry out simple instructions consistent with unskilled
work; he can work within a low-stress environment where there are no strict
production quotas and where he will not be subject to the demands of fast-paced
production work, he can perform simple decision making related to basic work
functions; and he can tolerate only minor, infrequent changes within the workplace.
5. Plaintiff has no relevant work.
6. Plaintiff was born on July 13, 1970 and was 40 years old, which is defined
as a younger individual age 18-49, on the date the application was filed.
7. The claimant has a limited education and is able to communicate in
English.
8. Transferability of job skills is not an issue because the plaintiff does not
have past relevant work.

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9. Considering the plaintiff’s age, education, work experience, and residual
functional capacity, there are jobs that exist in significant numbers in the national
economy that the claimant can perform.
10. The plaintiff has not been under a disability, as defined in the Social
Security Act, since February 9, 2011, the date the application was filed.
(Tr. 301-322).
IV.

Legal Standards
The Court must affirm the Commissioner’s decision “if the decision is not

based on legal error and if there is substantial evidence in the record as a whole to
support the conclusion that the plaintiff was not disabled.” Long v. Chater, 108 F.3d
185, 187 (8th Cir. 1997). “‘Substantial evidence is less than a preponderance, but
enough so that a reasonable mind might find it adequate to support the
conclusion.’” Estes v. Barnhart, 275 F.3d 722, 724 (8th Cir. 2002) (quoting Johnson
v. Apfel, 240 F.3d 1145, 1147 (8th Cir. 2001)). If, after reviewing the record, the
Court finds it possible to draw two inconsistent positions from the evidence and one
of those positions represents the Commissioner’s findings, the Court must affirm
the decision of the Commissioner. Buckner v. Astrue, 646 F.3d 549, 556 (8th Cir.
2011) (quotations and citation omitted).
To be entitled to disability benefits, a plaintiff must prove that he is unable to
perform any substantial gainful activity due to a medically determinable physical or
mental impairment that would either result in death or which has lasted or could be
expected to last for at least twelve continuous months. 42 U.S.C. § 423(a)(1)(D),
(d)(1)(A); Pate-Fires v. Astrue, 564 F.3d 935, 942 (8th Cir. 2009). The
Commissioner has established a five-step process for determining whether a person
is disabled. See 20 C.F.R. § 404.1520; Moore v. Astrue, 572 F.3d 520, 523 (8th Cir.

- 25 -

2009). “Each step in the disability determination entails a separate analysis and
legal standard.” Lacroix v. Barnhart, 465 F.3d 881, 888 n.3 (8th Cir. 2006).
Steps one through three requires the plaintiff to prove (1) he is not currently
engaged in substantial gainful activity, (2) he suffers from a severe impairment,
and (3) his disability meets or equals a listed impairment. Pate-Fires, 564 F.3d at
942. If the plaintiff does not suffer from a listed impairment or its equivalent, the
Commissioner’s analysis proceeds to steps four and five. Id.
APrior to step four, the ALJ must assess the claimant=s residual functioning
capacity (>RFC=), which is the most a claimant can do despite her limitations.@
Moore, 572 F.3d at 523 (citing 20 C.F.R. ' 404.1545(a)(1)). “RFC is an
administrative assessment of the extent to which an individual’s medically
determinable impairment(s), including any related symptoms, such as pain, may
cause physical or mental limitations or restrictions that may affect his or her
capacity to do work-related physical and mental activities.” Social Security Ruling
(SSR) 96-8p, 1996 WL 374184, *2. “[A] plaintiff’s RFC [is] based on all relevant
evidence, including the medical records, observations by treating physicians and
others, and an individual’s own description of his limitations.” Moore, 572 F.3d at
523 (quotation and citation omitted).
In determining a plaintiff’s RFC, the ALJ must evaluate the plaintiff’s
credibility. Wagner v. Astrue, 499 F.3d 842, 851 (8th Cir. 2007); Pearsall v.
Massanari, 274 F.3d 1211, 1218 (8th Cir. 2002). This evaluation requires that the
ALJ consider “(1) the plaintiff’s daily activities; (2) the duration, intensity, and
frequency of the pain; (3) the precipitating and aggravating factors; (4) the
dosage,

effectiveness,

and

side

effects

- 26 -

of

medication;

(5)

any

functional

restrictions; (6) the plaintiff’s work history; and (7) the absence of objective
medical evidence to support the plaintiff’s complaints.” Buckner, at 558 (quotation
and citation omitted). “Although ‘an ALJ may not discount a plaintiff’s allegations of
disabling pain solely because the objective medical evidence does not fully support
them,’ the ALJ may find that these allegations are not credible ‘if there are
inconsistencies in the evidence as a whole.’” Id. (quoting Goff v. Barnhart, 421 F.3d
785, 792 (8th Cir. 2005)). After considering the seven factors, the ALJ must make
express credibility determinations and set forth the inconsistencies in the record
which caused the ALJ to reject the plaintiff’s complaints. Singh v. Apfel, 222 F.3d
448, 452 (8th Cir. 2000); Beckley v. Apfel, 152 F.3d 1056, 1059–60 (8th Cir.
1998).
At step four, the ALJ determines whether a plaintiff can return to his past
relevant work, by comparing the RFC with the physical and mental demands of a
plaintiff’s past work. 20 C.F.R. § 404.1520(f). The burden at step four remains with
the plaintiff to prove her RFC and establish that he cannot return to his past
relevant work. Moore, 572 F.3d at 523; accord Dukes v. Barnhart, 436 F.3d 923,
928 (8th Cir. 2006); Vandenboom v. Barnhart, 421 F.3d 745, 750 (8th Cir. 2005).
If the ALJ holds at step four of the process that a plaintiff cannot return to
past relevant work, the burden shifts at step five to the Commissioner to establish
that the plaintiff maintains the RFC to perform a significant number of jobs within
the national economy. Banks v. Massanari, 258 F.3d 820, 824 (8th Cir. 2001); see
also 20 C.F.R. § 404.1520(f).
If the plaintiff is prevented by his impairment from doing any other work, the
ALJ will find the plaintiff to be disabled.

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V.

Discussion
Plaintiff raises the following issues in this matter: (1) whether the ALJ erred

in the credibility analysis and (2) whether the ALJ erred in determining plaintiff’s
mental limitations.
A. Mental Impairments
Plaintiff argues that the ALJ committed a reversible error by failing to give
great weight to the opinions of Drs. Kamat and Maynard. Each doctor’s opinion will
be addressed in turn.
According to 20 C.F.R. § 404.1527(c) an ALJ will consider several factors to
decide the weight that should be afforded to a medical opinion, including the (1)
examining relationship, (2) length of the treatment relationship and frequency of
examination, (3) nature and extent of the treatment relationship, (4) supportability
of the opinion, (5) consistency with the record as a whole, (6) specialization of the
expert, and (7) any other factors brought to the ALJ’s attention. 20 C.F.R. §
404.1527(c)(1)-(6).
A

treating physician’s

opinion on the

“nature

and severity” of the

impairments will receive controlling weight if it “is well-supported by medically
acceptable clinical and laboratory diagnostic techniques and is not inconsistent with
the other substantial evidence in [the] case record.” 20 C.F.R. § 416.927(d)(2); see
also Reed v. Barnhart, 399 F.3d 917, 920 (8th Cir. 2005). Part and parcel to this
analysis is whether the treating physician’s opinion is internally inconsistent –

- 28 -

“[w]hen a treating physician’s notes are inconsistent with his or her residual
functional capacity assessment, we decline to give controlling weight to the residual
functional capacity assessment.” Pirtle v. Astrue, 479 F.3d 931, 933 (8th Cir.
2007); see also Davidson v. Astrue, 578 F.3d 838, 842 (8th Cir. 2009) (discrediting
a treating physician’s opinion that was inconsistent with his treatment records).
Therefore, “[a]lthough a treating physician’s opinion is entitled to great weight, it
does not automatically control or obviate the need to evaluate the record as [a]
whole.” Hogan v. Apfel, 239 F.3d 958, 961 (8th Cir. 2001).
Plaintiff argues that the ALJ committed reversible error by failing to give
great weight to Dr. Kamat’s opinion. Dr. Kamat opined that plaintiff was unable to
work due to his symptoms of depression, anxiety, and panic attacks.

(Tr. 616).

The ALJ was entitled to not give controlling weight to Dr. Kamat’s opinion because it
involves an issue reserved for the Commissioner and therefore is not the type of
medical opinion to which the Commissioner gives controlling weight.

Ellis v.

Barnhart, 392 F.3d 988, 994 (8th Cir. 2005) (finding that a medical source opinion
that an applicant is disabled or unable to work involves an issue reserved for the
Commissioner of Social Security and therefore is not the type of medical opinion to
which the Commissioner gives controlling weight). The ALJ noted that Dr. Kamat’s
own records showed numerous normal mental status examinations of the claimant,
which were inconsistent with Dr. Kamat’s subsequent opinion.

(Tr. 313, 616).

Courts are obligated to give controlling weight to the opinion of a treating
physician, if it is not inconsistent with the other substantial evidence.

Michel v.

Colvin, 640 F. App'x 585, 597 (8th Cir. 2016); see also Blackburn v. Colvin, 761
F.3d 853, 860 (8th Cir. 2014) (holding that even a treating source does not receive

- 29 -

controlling weight if the source's opinions are inconsistent, or inconsistent with
other substantial evidence in the record).
Upon reviewing Dr. Kamat’s treatment records, the Court finds that the
decision of the ALJ to not give controlling weight to Dr. Kamat is supported by
substantial evidence on the record. (Tr. 287-296, 313, 568-575). During plaintiff’s
previous visits to Dr. Kamat, it was noted that plaintiff was feeling less depressed
on his current medications. (Tr. 573-575). On April 10, 2013, Dr. Kamat did note
that plaintiff was having panic attacks; however that was the only symptom
presented since August 29, 2012. (Tr. 572, 575). The notes provided by Dr. Kamat
are inconsistent with his stated opinion that plaintiff was unable to work due to his
symptoms of depression, irritability, panic attacks and stress. Further, Dr. Kamat’s
notes are consistent with the rest of the record; it is his proffered opinion which is
inconsistent and fails to support his determination of a disability such that plaintiff
is unable to work. The Court finds that substantial evidence supports the ALJ’s
determination to assign little weight to the opinion of Dr. Kamat.
Plaintiff also argues that the ALJ improperly gave little weight to the opinion
of Dr. Maynard. Dr. Maynard opined that plaintiff was unable to maintain gainful
employment due to the degree of difficulty plaintiff has with irritability and anxiety,
and his diagnosis of seizure disorder. (Tr. 657). A treating physician's opinion is
normally entitled to great weight, but such an opinion does not automatically
control, since the record must be evaluated as a whole.” Prosch v. Apfel, 201 F.3d
1010, 1013 (8th Cir. 2000).
The ALJ stated that little weight was given to the opinion of Dr. Maynard
because his opinion was not well supported or consistent with the evidence.

- 30 -

Dr.

Maynard opined that plaintiff was not able to maintain gainful employment due to
the degree of difficulty he was having with irritability and anxiety, which required
an adjustment of medications, in addition to his diagnosis of seizure disorder. (Tr.
657).

The ALJ stated that Dr. Maynard’s treatment records do not reflect any

psychiatric symptoms or functional limitations. (Tr. 313). The treatment records
show seizure medication was prescribed to plaintiff, but also show plaintiff had a
normal EEG, no seizure activity, and no reported side effects from the seizure
medication. (Tr. 313). The medical evidence on record from Dr. Maynard does not
present any psychological symptoms or functional limitations.

(Tr. 682-685).

Plaintiff claims this is inaccurate because plaintiff was diagnosed with depression
and received medication for insomnia. However, the medical records do not show
how those diagnoses demonstrate any psychological symptoms or functional
limitations.

Dr. Maynard’s records state that plaintiff was seen for a “mood

problem,” but provide no detail as to what plaintiff’s psychological symptoms or
functional limitations actually are.

(Tr. 682).

The record does not contain an

assessment of plaintiff; only a breakdown of the medication prescribed. (Tr. 682).
While Dr. Maynard reports that plaintiff suffered a seizure, no evidence was
presented that plaintiff had been diagnosed with a seizure disorder.

(Tr. 684).

Both Dr. Maynard and Dr. Thorat found plaintiff to have a normal awake EEG. (Tr.
653, 684). Neither doctor diagnosed plaintiff with any disease in their records,
however neither doctor ruled out epilepsy.

(Tr. 653, 684). If a treating source

“renders inconsistent opinions that undermine the credibility of such opinions,” the
treating source's opinion may be discounted or disregarded. Blackburn v. Colvin,
761 F.3d 853, 860 (8th Cir.2014). Dr. Maynard’s opinion is inconsistent with his

- 31 -

own medical records, and the overall evidence of the record.

Further, Dr.

Maynard’s opinion is inconsistent with the results of the more recent, December 13,
2013 psychological testing and evaluation done by Thomas J. Spencer, whose
opinion the ALJ gave “great weight.” (Tr. 686). When the Court finds it possible to
draw two inconsistent positions from the evidence and one of those positions
represents the Commissioner’s findings, the Court must affirm the decision of the
Commissioner. Buckner v. Astrue, 646 F.3d 549, 556 (8th Cir. 2011). The Court
finds substantial evidence in the record to support the ALJ’s determination to assign
little weight to the opinion of Dr. Maynard.
B. Mental Limitations
Plaintiff next contends that the ALJ committed reversible error by failing to
find that plaintiff had a severe impairment related to his learning disability and
cognitive disorder. The ALJ did find that plaintiff had a severe impairment related
to his cognitive disorder. However, the ALJ determined that the impairment, while
severe, was not severe enough to equal the severity of one of the listed
impairments in 20 CFR Part 404, Subpart P, Appendix 1.
Plaintiff argues that there is a multitude of evidence that a cognitive
disorder/learning disability exists and that Dr. Maynard indicated that the
impairment is severe. Plaintiff points to medical records showing a prior traumatic
brain injury and poor cognitive function, as well as being in special education and
performing poorly while in school.
The ALJ specifically stated that the plaintiff’s type 2 bipolar disorder and
panic disorder were severe impairments.

(Tr. 307).

The ALJ stated that she

considered those impairments to be more than slight abnormalities which have

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more than a minimal effect on the plaintiff’s ability to perform basic work activities.
(Tr. 307). The ALJ took into account these impairments in determining plaintiff’s
residual functional capacity. Plaintiff cites Easter v. Bowen, 867 F.2d 1128, 1131
(8th Cir. 1989), to argue that the ALJ did not have sufficient evidence for this
determination. In Easter, the 8th Circuit found that the ALJ erred by failing to fully
consider the medical record.

Id. at 1130-31. Here, the ALJ cited substantial

evidence from the record in their opinion and reviewed each physician’s treatment
records in making their determination.

The ALJ noted that the record provided

evidence that plaintiff’s fund of knowledge appeared normal, and that on two
occasions examiners invalidated intelligence quotient test on the basis of the
claimant providing false response. (Tr. 308). The ALJ also noted that while there is
evidence of failing grades in high school and a special education designation in
elementary school; there is no evidence of an individual education plan or special
education classes. (Tr. 308).
“The claimant bears the burden of proving disability and providing medical
evidence as to the existence and severity of an impairment.”

Kamann v. Colvin,

721 F.3d 945, 950 (8th Cir. 2013) (citing Snead v. Barnhart, 360 F.3d 834, 838
(8th Cir.2004)). Here, plaintiff has not provided any medical evidence in the record
demonstrating a learning disability diagnosis. Further, when assessing a disability
benefits application, even the fact that a party has a learning disability or cognitive
disorder does not mean that the party has a severe impairment.

Buckner v.

Astrue, 646 F.3d 549, 557 (8th Cir. 2011). Each of the issues plaintiff presents are
ones that the ALJ addresses in his opinion with substantial supporting evidence. If
two inconsistent positions can be drawn from the evidence, and one of those

- 33 -

positions represents the ALJ's decision, it will be affirmed. Perkins v. Astrue, 648
F.3d 892, 897 (8th Cir.2011). The ALJ took into account the medical evidence in
accounting

for

plaintiff’s

limitations

in

the

residual

functional

capacity

determination. (Tr. 309).
*

*

*

*

*

For the reasons discussed above, the Court finds that the Commissioner’s
decision is supported by substantial evidence in the record as a whole.
Accordingly,
IT IS HEREBY ORDERED that the decision of the Commissioner is
affirmed.
A separate judgment in accordance with this Memorandum and Order will be
entered this same date.
CAROL E. JACKSON
UNITED STATES DISTRICT JUDGE
Dated this 31st day of March, 2017.

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