Akkerhuis v. Colvin

Filing 17

ORDER reversing the decision of the Commissioner pursuant to Sentence Four, remanding for further consideration. Signed on 7/1/14 by Magistrate Judge Robert E. Larsen. (Wilson, Carol)

IN THE UNITED STATES DISTRICT COURT FOR THE
WESTERN DISTRICT OF MISSOURI
SOUTHERN DIVISION
CARALEE R. AKKERHUIS,
Plaintiff,
v.
CAROLYN W. COLVIN, Acting
Commissioner of Social Security,
Defendant.

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Case No.
13-3159-CV-S-REL-SSA

ORDER REVERSING THE DECISION OF THE COMMISSION
AND REMANDING FOR FURTHER CONSIDERATION
Plaintiff Caralee Akkerhuis seeks review of the final decision of the Commissioner of
Social Security denying plaintiff’s application for disability benefits under Titles II and XVI of
the Social Security Act (“the Act”). Plaintiff argues that the ALJ erred in (1) ignoring plaintiff’s
consistently low GAF scores, and (2) improperly finding that plaintiff’s mental impairment
does not meet Listing 12.08 (personality disorders). I find that the ALJ’s decision is not
supported by the substantial evidence in the record. However, I also find that the evidence in
the record is insufficient for a finding of disability at this time. Substantial evidence in the
record suggests that plaintiff may be disabled due to a mental impairment that has not been
adequately addressed by any medical professional, nor has it been adequately considered by
the ALJ. Because there is insufficient evidence in the record to determine whether plaintiff is
disabled, I reluctantly1 find that remand is necessary. Therefore, the decision of the
Commissioner will be reversed and this case will be remanded in accordance with the
discussion below.

1

This case has been pending for many years and has already bounced back and forth from
the administrative court to federal court; therefore, it is unfortunate that a final decision
cannot be made at this time. However, I believe plaintiff is entitled to have her case considered
further and that additional evidence will be required to make a valid determination regarding
her ability to work.

I.

BACKGROUND
On August 6, 2007, plaintiff applied for disability benefits alleging that she had been

disabled since April 4, 2007. Plaintiff’s disability stems from arthritis in her legs and back, a
right leg injury, high blood pressure, memory loss, a heart condition, and post traumatic stress
disorder. Plaintiff’s application was denied. On March 25, 2009, a hearing was held before
an Administrative Law Judge. On May 18, 2009, Administrative Law Judge Edward Starr
found plaintiff disabled as of November 13, 2008, which was approximately a year and a half
after her alleged onset date (Tr. at 37-47). Plaintiff appealed the partially favorable decision.
On December 9, 2010, the Appeals Council denied review (Tr. at 683). Plaintiff appealed to
federal district court, and on October 3, 2011, Judge Nanette Laughrey reversed the decision of
the Commissioner and remanded for further consideration (Tr. at 687-698). On December
19, 2011, the Appeals Council vacated the final decision of the Commissioner pursuant to the
court’s sentence four reversal and remand, and directed the ALJ to offer plaintiff an
opportunity for a hearing and “take any further action needed to complete the administrative
record and issue a new decision.” (Tr. at 701).
On November 27, 2012, a hearing was held before Administrative Law Judge David
Fromme. On February 11, 2013, the ALJ found that plaintiff was not under a “disability” as
defined in the Act.2 Therefore, the decision of the ALJ stands as the final decision of the
Commissioner.

2

I note that plaintiff, in her brief, described the ALJ’s order as containing a “markedly
vindictive tone” (see plaintiff’s brief at pages 1-2). I do not agree with plaintiff’s
characterization of the ALJ’s order. I also point out that plaintiff did not object to the ALJ’s
legal analysis as far as what decision was left to be made after the first remand from federal
court.

2

II.

STANDARD FOR JUDICIAL REVIEW
Section 205(g) of the Act, 42 U.S.C. § 405(g), provides for judicial review of a “final

decision” of the Commissioner. The standard for judicial review by the federal district court is
whether the decision of the Commissioner was supported by substantial evidence. 42 U.S.C. §
405(g); Richardson v. Perales, 402 U.S. 389, 401 (1971); Mittlestedt v. Apfel, 204 F.3d 847,
850-51 (8th Cir. 2000); Johnson v. Chater, 108 F.3d 178, 179 (8th Cir. 1997); Andler v.
Chater, 100 F.3d 1389, 1392 (8th Cir. 1996). The determination of whether the
Commissioner’s decision is supported by substantial evidence requires review of the entire
record, considering the evidence in support of and in opposition to the Commissioner’s
decision. Universal Camera Corp. v. NLRB, 340 U.S. 474, 488 (1951); Thomas v. Sullivan, 876
F.2d 666, 669 (8th Cir. 1989). “The Court must also take into consideration the weight of the
evidence in the record and apply a balancing test to evidence which is contradictory.”
Wilcutts v. Apfel, 143 F.3d 1134, 1136 (8th Cir. 1998) (citing Steadman v. Securities &
Exchange Commission, 450 U.S. 91, 99 (1981)).
Substantial evidence means “more than a mere scintilla. It means such relevant
evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson
v. Perales, 402 U.S. at 401; Jernigan v. Sullivan, 948 F.2d 1070, 1073 n. 5 (8th Cir. 1991).
However, the substantial evidence standard presupposes a zone of choice within which the
decision makers can go either way, without interference by the courts. “[A]n administrative
decision is not subject to reversal merely because substantial evidence would have supported
an opposite decision.” Id.; Clarke v. Bowen, 843 F.2d 271, 272-73 (8th Cir. 1988).

III.

BURDEN OF PROOF AND SEQUENTIAL EVALUATION PROCESS
An individual claiming disability benefits has the burden of proving he is unable to

return to past relevant work by reason of a medically-determinable physical or mental

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impairment which 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). If the plaintiff establishes that he is unable to return
to past relevant work because of the disability, the burden of persuasion shifts to the
Commissioner to establish that there is some other type of substantial gainful activity in the
national economy that the plaintiff can perform. Nevland v. Apfel, 204 F.3d 853, 857 (8th Cir.
2000); Brock v. Apfel, 118 F. Supp. 2d 974 (W.D. Mo. 2000).
The Social Security Administration has promulgated detailed regulations setting out a
sequential evaluation process to determine whether a claimant is disabled. These regulations
are codified at 20 C.F.R. §§ 404.1501, et seq. The five-step sequential evaluation process used
by the Commissioner is outlined in 20 C.F.R. § 404.1520 and is summarized as follows:
1.

Is the claimant performing substantial gainful activity?
Yes = not disabled.
No = go to next step.

2.
Does the claimant have a severe impairment or a combination of impairments
which significantly limits his ability to do basic work activities?
No = not disabled.
Yes = go to next step.
3.

Does the impairment meet or equal a listed impairment in Appendix 1?
Yes = disabled.
No = go to next step.

4.

Does the impairment prevent the claimant from doing past relevant work?
No = not disabled.
Yes = go to next step where burden shifts to Commissioner.

5.

Does the impairment prevent the claimant from doing any other work?
Yes = disabled.
No = not disabled.

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IV.

THE RECORD
The record consists of the testimony of plaintiff and vocational experts Patti Kent and

Michael Lala, in addition to documentary evidence admitted at the hearings.

A.

ADMINISTRATIVE REPORTS
The record contains the following administrative reports:

Earnings Record
The record establishes that plaintiff earned the following income from 1978 through
2012, shown in actual and indexed figures:
Year

Actual
Earnings

Indexed
Earnings

1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006

$ 2,602.92
4,735.32
4,382.72
5,004.68
7,353.58
7,559.98
7,651.34
9,296.06
9,000.72
10,458.22
9,384.50
11,550.65
10,350.48
11,803.60
15,958.14
2,504.13
2,500.47
8,421.58
3,662.13
6,790.43
5,791.04
8,093.24
11,978.78
4,072.50
7,510.92
8,793.55
8,520.77
4,417.13
11,760.10

$ 9,111.91
15,243.23
12,942.41
13,427.45
18,700.02
18,331.85
17,523.29
20,420.06
19,201.39
20,973.15
17,936.49
21,235.82
18,189.13
19,997.51
25,711.33
4,000.19
3,889.94
12,596.39
5,222.16
9,149.21
7,414.60
9,815.25
13,766.25
4,571.14
8,346.86
9,539.06
8,832.55
4,417.13
11,760.10

5

2007
2008
2009
2010
2011
2012

1,492.20
0.00
0.00
0.00
0.00
0.00

1,492.20
0.00
0.00
0.00
0.00
0.00

(Tr. at 98-99, 779).
Function Report - Adult
In this form dated August 20, 2007, plaintiff described her day as follows: “Get my 11
yr old off to school. Organize my day and get it done by 3:00 pm. Get [my son’s] homework
done, cook dinner, get everything ready for next day and do it again M-F.” (Tr. at 136-143).
She is able to bathe and feed cats and dogs. Her memory is so bad she cannot remember if she
has showered, and she needs someone to remind her to take her medicine. She is able to
prepare complete meals for herself and her son every day. Her son does the laundry and the
household chores. She goes out of her home daily either walking or using public
transportation. She is able to go out alone. She cannot drive because her leg hurts too much to
use the gas pedal. She shops in stores and by computer. She is able to pay bills, count change,
and handle bank accounts. Her hobbies include “anything outdoors” but she can no longer
participate in these hobbies due to “way too much pain in right leg.”
Plaintiff visits and shops with others as often as she can and at least once a week. She
goes to church on a regular basis. She needs to be reminded to go, but she does not need
anyone to accompany her. She has problems getting along with others because she has no
patience.
Plaintiff’s condition affects her ability to climb stairs, bend, stand, kneel, walk, squat, sit,
concentrate and complete tasks. Her condition does not affect her ability to lift, use her hands,
understand, remember, follow instructions, reach, or get along with others. She can walk 1/4
mile before needing to rest for 5 to 10 minutes. She can follow written instructions well.

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B.

SUMMARY OF TESTIMONY
There have been three administrative hearings in this case: March 25, 2009; August 3,

2012 (with no testimony taken); and November 27, 2012.
During the March 25, 2009, hearing, plaintiff testified; and Patti Kent, a vocational
expert, testified at the request of the ALJ. Prior to the hearing she completed interrogatories
(Tr. at 173-175).
Plaintiff’s testimony.
Plaintiff was born in 1959 (Tr. at 9, 788). She was 47 on her alleged onset date and is
currently 55 years of age. She is 5’7” tall and weighs 286 pounds (Tr. at 22, 801). She
weighed this much in 2003 (Tr. at 22, 801). In 1993 she weighed 190 pounds (Tr. at 22-23,
801-802). She gained almost 100 pounds because she eats too much, she has thyroid
problems, and she has not been able to do much of anything (Tr. at 23, 802). Plaintiff was in a
“pretty bad” car accident in April 2007 (Tr. at 11-12, 790-791). She has not worked since
then (Tr. at 12, 791). Prior to that, in June 2006 and in February 2007, plaintiff slipped at
work and was injured (Tr. at 12, 791).
Plaintiff is unable to work because she cannot concentrate, she cannot stand, she gets
nervous and has terrible panic attacks (Tr. at 13, 792). From 2001 to 2003 plaintiff was hit in
the head and knocked out five or six times by her former husband (Tr. at 13, 792). Plaintiff
has intermittent explosive behavior, and she will all of a sudden start screaming and cussing
(Tr. at 13, 792). Then she does not remember why she was doing it (Tr. at 13, 792). Plaintiff
has episodes where she does not know who she is or where she is (Tr. at 16, 795). She gets
scared and she gets very loud (Tr. at 17, 796). This happens approximately every other day
and gets “real bad” when she does not take her medicine (Tr. at 17, 796). When the episode is

7

over, she does not know what she said to people (Tr. at 17, 796). She had an episode the day
before the administrative hearing (Tr. at 17, 796).
Plaintiff had difficulty filling out forms because she cannot remember things and she
does not understand (Tr. at 23, 802).
Plaintiff’s knees pop out, and her legs swell so that she cannot put on her shoes (Tr. at
14, 793). Her right knee is worse (Tr. at 14, 793). She has moderate to severe pain in her
right knee every day (Tr. at 15, 794). She has mild pain about one-fourth of the time in her
left knee (Tr. at 15, 794). She has pain in her shoulders every few days (Tr. at 15-16, 794795). She has pain in her lower back every four or five days (Tr. at 16, 795). She gets a
headache first and then the pain moves to her lower back (Tr. at 16, 795).
Plaintiff lives with a man and her son (Tr. at 20, 799). On a typical day plaintiff spends
most of the day in her bed (Tr. at 18, 797). She reads while she is in bed, but she does not
remember what she read afterward (Tr. at 18, 797). She reads cowboy stories (Tr. at 18, 797).
Plaintiff does not own a television because she hears things from the television (Tr. at 18-19,
797-798). Plaintiff tries not to go anywhere because she does not want to have an episode in
public (Tr. at 19, 798). If she has an episode while home alone, it is hard for her to come out
of it (Tr. at 19, 798).
Plaintiff has trouble staying focused and she has trouble with her memory (Tr. at 1920, 798-799). She has to write down her doctor appointments or she will not remember them
(Tr. at 20, 799). Plaintiff goes to bed around 9:30 or 10:00 at night but sometimes she does
not go to sleep until 3:00 or 4:00 in the morning (Tr. at 20, 799). Her mind “plays like a . . .
movie that . . . just goes over and over” (Tr. at 20, 799).
Plaintiff has highs and lows from bipolar disorder (Tr. at 21, 800). When she is on a
high, she cannot stop talking (Tr. at 21, 800). That happens about once a week (Tr. at 21,

8

800). Most of the time she is “low” (Tr. at 21, 800). Plaintiff does not want to be around
anyone because people make her nervous (Tr. at 21-22, 800-801). Plaintiff was in Ozark
Behavioral Health in 2002, so she has had this problem for a long time, but now her symptoms
are more frequent (Tr. at 22, 801).
Vocational expert testimony.
Vocational expert Patti Kent testified at the request of the Administrative Law Judge. On
the day of the hearing, Ms. Kent completed interrogatories containing the following
hypothetical: A person who is a younger individual with a high school education who can lift
and carry 20 pounds occasionally and 10 pounds frequently; sit for 6 hours; stand or walk for
2 hours; who has moderate restrictions in maintaining social functioning; activities of daily
living; and maintaining concentration, persistence and pace; is moderately limited in
understanding, remembering and carrying out detailed instructions, responding appropriately
to usual work situations and routine work changes, and in the ability to interact appropriately
with the public. “Moderately limited means there is more than a slight limitation, but the
person can still perform in a satisfactory manner.” The person is capable of doing work in
which interpersonal contact is incidental to the work performed, complexity of tasks is learned
and performed by rote, with few variables and little judgment required. Supervision required
is simple, direct, and concrete. The vocational expert indicated that such a person could work
as a production worker or machine tender.3
The second hypothetical incorporated the findings of Vann Smith, Ph.D., and the
vocational expert responded that no jobs would be available due to the inability to complete a
normal workday without rest and the inability to perform at a consistent pace.

3

There is a third job listed, but it is illegible.

9

The first hypothetical posed at the hearing involved a person who consistently misses at
least one day of work per month (Tr. at 25, 804). A person limited to unskilled work could not
perform substantial gainful activity with this limitation (Tr. at 25, 804). If a person were not
able to perform at a competitive pace for 10 percent of the day, the person could not work (Tr.
at 25, 804). If the person blows up at a supervisor or coworker for five minutes at a time every
other day, the person “would lose his job” (Tr. at 25, 804).
During the August 3, 2012, hearing, no testimony was taken. The ALJ indicated that
because the Appeal’s Council vacated the first decision of the ALJ, at the direction of the district
court, the issue of whether plaintiff is or has ever been disabled is what needs to be resolved.
Plaintiff had been under the impression that only the issue of whether her disability began in
April 2007 versus November 2008 would be revisited. The ALJ took a recess during the
hearing, and then stated as follows:
The situation is this. We have an order of the U.S. District Court remanding the case
without limiting consideration to any particular period of time. The Appeals Council
order vacates the final decision of the Commissioner and remands it to me for
consideration of the case without limitation to any specific period of time. And so it is
thought that I am to proceed on the case without limiting consideration to any specific
period of time. And your request for withdrawal of the request for hearing jeopardizes
and likely would end entitlement because there is no decision at all at this point as far
as I can tell. There is no final decision. It’s been vacated. So we’re starting from scratch
and that’s -- I don’t know what else I can say. That’s just the way it shows up to me and
that I don’t have any option but to go ahead.
Plaintiff then requested a continuance of the hearing because her caretaker, Norman Mings,
was not present but would be able to provide testimony relevant to plaintiff’s condition
subsequent to November 2008 (Tr. at 660-675). That request was granted.
During the November 27, 2012, hearing, plaintiff testified, and vocational expert
Michael Lala testified at the request of the ALJ.

10

Plaintiff’s testimony.
At the time of this hearing, plaintiff was living alone in a house (Tr. at 630). She had
medical insurance (Tr. at 630-631). Plaintiff has a GED but no further education (Tr. at 631).
Up until 1998 plaintiff worked at Subway, first as a sandwich maker and later as an assistant
manager (Tr. at 631). She worked as a cashier at Wal-Mart in 1998 (Tr. at 631). She worked
there full time for three years and left that job because she moved (Tr. at 631-632). In 2000
she was a cashier at a convenience store and left there to take a job at Richard Brothers, a deli
(Tr. at 632). She left that deli in 2002 when she moved to Arkansas (Tr. at 632). In 2003 she
started a part-time job at a day care, and in 2005 she took a job at a deli at Town and Country
Discount Foods (Tr. at 632). That was a full-time job, and she left that job when her part-time
job at a pizza restaurant became full time (Tr. at 633). That job ended when she was in a car
accident on April 4, 2007, and she has not worked since (Tr. at 633).
Plaintiff did not work after April 4, 2007, because her back and her knee were hurting
too much (Tr. at 634). She went to the emergency room several times to get pain medication
(Tr. at 634). Her pain is constant and is moderate to severe (Tr. at 635). Her pain was so bad
that she could not stand it even with her pain medication (Tr. at 635). Her knee pain is also
constant and is moderate in severity (Tr. at 635). Her pain prevented her from sleeping (Tr. at
635). Plaintiff’s attorney went over plaintiff’s medications from that time period -- Celexa,
Lisinopril, Zantac, Toprol, and Levothyroid -- and then asked, “Tell us if you will, was the pain
medicine that you were taking, did it help at all?” (Tr. at 636). I note that none of those
medications is for pain. Celexa is an antidepressant, Lisinopril treats hypertension, Zantac
treats stomach acid, Toprol treats hypertension, and Levothyroid treats hypothyroidism.
Plaintiff testified that none of her medication helped her pain.

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Plaintiff’s back and knee pain continue to affect her sleep (Tr. at 638). She sleeps 2 to 2
1/2 hours a night (Tr. at 638). She is so tired during the day that she just blanks out (Tr. at
638).
Plaintiff has suffered from migraines for about ten years (Tr. at 639). Although she gets
fewer migraines now, they are worse than before (Tr. at 639). She has a migraine about once
or twice a month and they last for 12 to 13 hours (Tr. at 639).
Plaintiff has suffered from hallucinations since 2000 (Tr. at 636). Plaintiff does not
leave her home unless she has to because she “can’t be around people. . . . [I]t’s like they’re
saying things about me and I get real paranoid, real scared. And then I hear things that aren’t
really happening, come to find out, and I act out on them very aggressively.” (Tr. at 637). This
has been happening since before she lost her last job, but she coped by staying away from
crowds or people, “anything that I couldn’t control.” (Tr. at 637). She goes to the grocery store
in the morning when there are few people there (Tr. at 646). Plaintiff shops once a month (Tr.
at 647). Sometimes (but not often) she walks around the block, or she may walk on a walking
track before it gets light out (Tr. at 647).
In June 2006 while working at the grocery store deli, plaintiff fell at work and filed a
worker’s compensation claim (Tr. at 634).
Since her last hearing, plaintiff was concerned about having to pay medical bills
because she thought she might be “cut off” (Tr. at 639). This has kept her from going to the
doctor because she is afraid she will have to pay the doctor back (Tr. at 640). Plaintiff testified
she had not been going to the doctor because she misunderstood and thought she was not
covered by Medicaid (Tr. at 640, 646). She knows now that she has to go to the doctor and get
on her medication (Tr. at 646).

12

Since plaintiff stopped working in 2007, her weight has “gotten out of control” (Tr. at
641). Her weight at the hearing was 285 pounds (Tr. at 641). Plaintiff had gained about 100
pounds since before 2000 (Tr. at 641).
Before this hearing, plaintiff had an evaluation by a psychologist and she was there for
almost two hours (Tr. at 641). Plaintiff was honest with the psychologist (Tr. at 641). She told
him about hallucinations and does not know why he didn’t include that in his report (Tr. at
650). Plaintiff hears voices from the other room when she is in her house (Tr. at 642). She
cannot understand what the voices are saying, but she thinks the voices are talking about her:
“she this she that” (Tr. at 642). Plaintiff takes a 1 1/2 hour nap in the morning and a 2 1/2
hour nap in the afternoon (Tr. at 642). Plaintiff can only be productive for a total of about an
hour a day (Tr. at 642-643). She can only do anything for a total of 20 minutes at a time (Tr.
at 643). She needs to rest both physically and mentally (Tr. at 643). She has trouble focusing
and remembering (Tr. at 644). She thought Norman (apparently someone she had intended to
call as a witness) had done something because the voices said he had, but he hadn’t -- yet she
beat him up (Tr. at 645). The only joy plaintiff has in her life is her 16-year-old son but he
lives with his father (Tr. at 645). He has lived with his father for the past three years (Tr. at
649).
Plaintiff let her driver’s license expire two years earlier (Tr. at 648). She was driven to
the hearing by “a friend . . . that I’ve known for years” (Tr. at 648). Plaintiff prepares her own
meals, does her own laundry (Tr. at 648). She let her garden go this year; a neighbor cuts her
grass; she visits with one friend mostly on the phone; and when they get together, they watch
movies and eat (Tr. at 649). Plaintiff watches news on television for about an hour in the
morning and an hour at night (Tr. at 649). About once every month or two, people from her
church come to her home and they all read the Bible together and she serves coffee (Tr. at

13

650). This has been occurring for the past year; before that, plaintiff attended church services
(Tr. at 650).
Plaintiff used to drink alcohol, but her last drink was “New Year’s last year, maybe” (Tr.
at 650). When she had the altercation with her friend, she had had a few beers (Tr. at 651).
In the early 2000s plaintiff’s husband would beat her until she was unconscious three
or four times a week, sometimes more often (Tr. at 651). That was another reason she stopped
worked, “I couldn’t go there all beat up” (Tr. at 651).
Vocational expert testimony.
Plaintiff’s past relevant work includes skilled work as an assistant restaurant manager,
skilled work as a pizza cook, semi-skilled work as a retail cashier, and unskilled jobs (Tr. at
652-653).
The first hypothetical involved a person able to lift 20 pounds occasionally and 10
pounds frequently; could stand or walk 2 hours per day; could sit for 6 hours per day; is
limited in his ability to cope with stress; would not be able to carry out a job requiring fastpaced activity or a job requiring the person to meet strict and explicit quotas, deadlines, or
schedules; would not be able to sustain a high level of concentration and so could not be
required to perform precision work or work that requires a sustained attention to detail. The
person could sustain a simple routine or a simple, repetitive tasks. The person should not be
required to interact personally with the public or have close personal interaction with
coworkers. Supervision should be only incidental to the work performed (Tr. at 653). Mr. Lala
testified that such a person could work as an assembler of plastic hospital products, an
unskilled job, with 2,400 in the state and 235,000 in the country (Tr. at 654). The person
could work as a bench assembler, an unskilled job, with 1,400 in the state and 117,000 in the

14

country (Tr. at 654). These are both light level jobs that would permit a person to alternate
sitting and standing as needed (Tr. at 654).
If the person in the first hypothetical needed to be redirected to his work on a frequent
basis due to a lack of concentration, the person could not work (Tr. at 655).
The next hypothetical involved a person who could only produce about half as much as
the typical person (Tr. at 656). Although this limitation would erode the available job base, it
would not preclude employment (Tr. at 656).
A GAF score of 50 or below vocationally means that the person could not hold a job (Tr.
at 657).

C.

SUMMARY OF MEDICAL RECORDS
On January 6, 1996, plaintiff was seen at Cox Medical Centers approximately 2 months

before the birth of her child (Tr. at 344). She weighed 270 pounds.
On January 22, 1996, plaintiff saw John Powell, M.D., for abdominal pain during
pregnancy (Tr. at 332-335, 340-343). “She quit smoking three years ago. She denies any
alcohol or drug use. . . . She denies seizure disorder.”
On March 13, 2001, plaintiff weighed 280 pounds (Tr. at 202).
On July 30, 2001, plaintiff weighed 280 pounds (Tr. at 203).
On January 3, 2002, plaintiff was seen by Shirley Eyman, M.D. (Tr. at 237-241). Her
chief complaint was, “I had some kind of attack.” Plaintiff had left her husband and was
staying with her son at Russell House and the second night there had a nightmare about her
husband coming through a window to get her. She was crying and shaking and the staff at
Russell House asked her to go to the emergency room. The staff at the emergency department
“were talking about having her come up to the Center for Psychiatric Services and she got very
frightened and upset.” Plaintiff admitted having a history of depression and said she had

15

recently been taking Prozac but ran out of it a couple weeks earlier. “While she was taking the
Prozac she thinks her depression was under good control and she wasn’t having depressive
symptoms although she was upset about her husband’s abusiveness.” After running out of
Prozac she began having insomnia, anorexia, fatigue, crying spells, poor concentration, and
feelings of being overwhelmed “although she denies ever having had any suicidal ideation”
and she specifically denied suicidal ideation on this date. Plaintiff did report a history of panic
attacks. She said she had given birth to two children but “lost one baby”. Plaintiff was
unemployed -- several months earlier she lost her job after her husband wrecked her car and
she lost her ability to get to work. “The patient reports that she uses alcohol about once a
month. May have 4-5 drinks and she denies any withdraw[al] symptoms. She denies using any
other drugs.” Plaintiff reported never having seen a psychiatrist and never having any prior
psychiatric hospitalizations, although she had seen family doctors who prescribed medication
for depression. “Prozac helped her a lot.” Plaintiff was assessed with major depression,
recurrent moderate; rule out histrionic personality;4 and GAF of 55. Dr. Eyman prescribed
Prozac and Desyrel for sleep. “She will participate in individual and group psychotherapy.”
Plaintiff was discharged six days later, on January 9, 2002. The Prozac worked well for
her. Her mood improved, her sleep improved, and she continued to deny suicidal ideation. On
discharge she was free of suicidal ideation, free of depressive symptoms.

4

Symptoms include constantly seeking attention; excessively emotional, dramatic or sexually
provocative to gain attention; speaks dramatically with strong opinions, but few facts or details
to back them up; easily influenced by others; shallow, rapidly changing emotions; excessive
concern with physical appearance; thinks relationships with others are closer than they really
are.
http://www.mayoclinic.org/diseases-conditions/personality-disorders/basics/symptoms/con
-20030111

16

On March 4, 2002, plaintiff saw Bruce Harms, a licensed clinical social worker (Tr. at
248-254). “[T]he information pertaining to her addiction and the situation associated with the
death of her daughter [at birth in 1994] seemed unclear.” Plaintiff had gone back to live with
her husband after her January hospitalization because in late January her husband was
hospitalized at the Neuropsychiatric Unit “and also because Division of Family Services had
been involved with their children since late January to early February, due to her husband’s
failure to take the children, a 14 year old step son, a 12 year old step son, and a six year old
son, to school. The client stated she wanted to eliminate Division of Family Services
involvement in their lives, so she returned to live with her husband.” Plaintiff reported daily
depressed mood, diminished ability to concentrate, fatigue most every day, difficulty falling or
staying asleep, feelings of worthlessness, and symptoms of post-traumatic stress disorder.
These symptoms had been present for the past two years or maybe longer. She also reported
significant weight gain since 1996. Plaintiff reported angry outbursts, mostly verbal and some
physical, and difficulty concentrating for at least six years and probably closer to eight or nine
years.
Plaintiff said her husband had tried to commit suicide by drinking a lot of alcohol,
taking a lot of pills and trying to poison himself with carbon monoxide. Her relationship with
her husband had improved recently.
She . . . described having difficulty with her anger. She stated that she has difficulty
controlling her anger, and has had several verbal outbursts that are out of proportion to
the triggering events, mostly involving her husband. She stated that she nearly did
serious damage to a 16 year old niece two to three months ago. She stated that she was
very angry during the New Year’s Eve party [two days before her hospitalization], and
almost hurt several people there before her husband pushed her down and she hit her
head. She also described several incidents of, in her words, ‘out of control’ anger in her
life.
Plaintiff reported that she started smoking marijuana at age 13 and started drinking
alcohol at age 15. She used both substances on a daily basis until August of 1992 (when she

17

was 33 years of age). Since that time she has occasionally smoked marijuana and used alcohol.
“She stated that the last time she drank was New Year’s Eve in 2001 [or approximately two
months ago]. She stated that she always used drugs or drank alcohol in order to get drunk or
stoned. . . . She stated that she had tried acid, cocaine, and mushrooms in her late teen years,
for a period of approximately two and a half years, but stopped using them thereafter. When
asked if she felt she had a drug and alcohol problem, she stated that she did, but it was in the
past.”
Plaintiff stated that her eight-year marriage had suffered from the beginning “by
outbursts of physical and emotional abuse by both her and her husband, aimed one towards
the other. She stated that she has had difficulty controlling her anger, due to the fact that her
husband regularly assaults her.” Plaintiff was arrested for domestic violence “at least once, six
years ago. She also reported some other arrests resulting in time spent in jail, but stated that
she was never charged. She indicated that she was trying to get a job in the Mt. Grove area as
a typist, but could not get the job because there was a record on file of her incarceration. . . .
She indicated that she has hired an attorney to get rid of her file.”
Plaintiff reported some difficulty in school “as a result of her alcohol and drug use. She
did not describe any other cognitive or physical limitations to learning.” Plaintiff is a few
hours short of having an Associate’s degree in business, and she completed a course in daycare
management in 1989.
A mental status exam was performed. Mr. Harms assessed major depressive disorder,
recurrent, severe, without psychotic features; intermittent explosive disorder; post traumatic
stress disorder; alcohol dependence by history; and a GAF of “40 to 50.” The diagnoses were
based on plaintiff’s “statement” of symptoms. “The client indicated that she is at a low risk for
harming herself or others.”

18

On April 2, 2002, plaintiff saw Colleen Brill, a registered nurse, for a psychiatric
evaluation after having been referred by Mr. Harms (Tr. at 255-257). Plaintiff reported
having suffered with depression since 1994. Plaintiff had reconciled with her husband
“[b]asically because Division of Family Services was going to take his children whom she has
raised. She says they are about to lose the house and are having a lot of financial problems.”
Plaintiff reported only sleeping about four hours per night and having a low energy level, daily
crying spells, and mood swings. “She denies any suicidal thoughts at present, but does indicate
she had some of these after baby died [in 1994].” Plaintiff said that on New Year’s Eve her
husband tried to choke her. Plaintiff reported memory problems, episodes where she will
clean for 2 or 3 days without stopping and then get very tired, and “panic attacks that may be
possibly related to her thyroid and has been on thyroid medicine and since then has been fairly
well controlled with this.” Plaintiff reported feeling anxious around other people and going to
the emergency room three times from hives caused by nervousness.
Plaintiff said that after her baby died she tried to commit suicide. “She took a gun out
back and sat and contemplated this for about five hours and then decided not to.” Plaintiff said
she had had two miscarriages due to physical abuse. Plaintiff’s last drink was on New Year’s
Eve. “About nine years ago she reportedly had a problem for about five of six years where she
was drinking 1.75 liter a day of hard liquor.” Her last use of marijuana was five or six years
ago, and she was smoking it every day. She reported having tried methamphetamine, LSD, and
speed 15 to 20 years ago. Plaintiff was smoking 5 cigarettes per day.
Ms. Brill prescribed Zoloft and Trazodone and told plaintiff to come back in a month.
On April 23, 2002, plaintiff returned to see Colleen Brill, MSN, RN (Tr. at 258).
Plaintiff reported sleeping 6 hours a night with Trazodone. “She is back to work and doing
well.” Plaintiff said she was a little irritable but she was not feeling depressed and her energy

19

level was high. “She reports feeling anxious at times and said that she saw her grandmother’s
watch in the pawn shop [and] went ballistic and they had to call the police.” Plaintiff reported
that she was enjoying her life and was able to do her activities of daily living. She denied
suicidal thoughts. She and her husband were getting along better since he went to rehab
although he left early. Ms. Brill observed that plaintiff’s affect was bright, she was well
groomed, and she exhibited slightly pressured speech. Her Zoloft was increased, and she
reported no side effects with that medication.
On June 10, 2002, plaintiff returned to see Ms. Brill (Tr. at 260). Plaintiff said her
husband “left last night after drinking and he took the children.” Plaintiff had been extremely
upset and crying since then. Plaintiff “ha[d] an accident at work yesterday. she indicates she
came home, found him drunk in the shop, and when she woke up from a nap she found he
had taken the children and left. He did leave her son with her, however his children from
previous relationships that she had raised he took with him. She also indicates, ‘He destroyed
my vehicle.’” Plaintiff was observed to be extremely distraught and tearful. She was able to
discuss her feelings and she appeared “more calm and her affect is brighter upon leaving.”
She was continued on the same doses of Zoloft and Trazodone.
On June 12, 2003, plaintiff weighed 296 pounds (Tr. at 204).
On December 4, 2003, plaintiff saw Michael Hagaman, M.D., who increased her
hypertension and thyroid medications (Tr. at 189). Plaintiff weighed 286 pounds.
On December 15, 2003, plaintiff saw Dr. Hagaman who noted that plaintiff had lost
about 30 pounds in the last month and was currently 279 pounds (Tr. at 206). “She’s been on
the Atkins diet.”
On June 14, 2004, plaintiff weighed 277 pounds (Tr. at 208). She saw Dr. Hagaman
and complained of dizziness and lightheadedness over the past couple of weeks when bending

20

over. She was working at a day care.
On October 15, 2004, plaintiff saw Dr. Hagaman (Tr. at 209). “[C]omes in today
feeling bad, crying, not sleeping.” Plaintiff had been going through a divorce for the past 2
1/2 years and was having a difficult time with it. She weighed 290 pounds. Dr. Hagaman
prescribed Lexapro.
On November 3, 2004, plaintiff was seen by R. Stephen Austin, M.D., for a Medicaid
review (Tr. at 348). “Based on review of the client and current clinical information treatment
is considered medically and psychiatrically necessary at the present time.”
On November 22, 2004, plaintiff was seen by Dr. Austin for depression (Tr. at 349351). Plaintiff was working at a preschool and was very happy with her job. Plaintiff said she
had been going through a divorce for the past 2 1/2 years and it had almost gone through
“when they found a typographical error which threw the whole thing out.” Plaintiff reported
being the youngest of four girls and “always felt as if she was the add-on element.” (However,
in other medical records plaintiff said she was the third child with a sister several years
younger.) Plaintiff said she was “always at the bottom apparently of the love chain.” Plaintiff
said that about every third or fourth day she would get depressed and “wondered if she was
going to lose it.” She was sleeping about 4 hours per night. Her energy level was erratic.
Plaintiff reported enjoying going with her son to watch him shoot hoops, and she would “chase
the balls down” when they left the court. She reported that her attention span was okay. She
reported that her mother and a sister have bipolar disorder, although in other medical records
plaintiff reported no family history of mental health problems. Plaintiff had been off her
Lexapro for about a week and noticed that her crying spells had restarted. She reported being
an occasional drinker. She said she smoked marijuana for the last time 15 years earlier and
that she quit smoking a year ago. Plaintiff was alert and oriented times three. Her personal

21

hygiene was good. She was pleasant and cooperative, polite, appropriate, and motivated for
treatment. Behavior was spontaneous and well organized. Psychomotor activity was within
normal limits. She denied auditory and visual hallucinations. She had a sad mood and affect,
and she teared up for about 30 seconds. Eye contact was good. Speech was normal. She never
had any flight of ideas or racing thoughts. Intelligence was estimated at above average.
“Memory for long-term, short-term and recall are within normal limits. Attention span tests
okay. Insight and judgment are fair.” Dr. Austin assessed dysthymic disorder, anxiety disorder
not otherwise specified, and personality disorder not otherwise specified, with a GAF of 50. He
prescribed Lexapro and Trazodone.
On January 12, 2005, plaintiff saw Dr. Hagaman for a well-woman exam (Tr. at 210).
She weighed 279 pounds. He refilled her Lexapro at the same dose.
On January 14, 2005, plaintiff saw Dr. Austin for a group medical review/treatment
update (Tr. at 353-354). Plaintiff reported problems sleeping. “During the group she found
out one of the other clients also had problems with a DHS worker in Missouri and she
exploded a little bit and said she had the same problem and that she had a good lawyer she
could refer the other client to and actually got together after the group and exchanged phone
numbers for that to happen.” Plaintiff was alert and oriented times three. She denied auditory
and visual hallucinations, she denied suicidal ideation. Her mood and affect were slightly
depressed. She was assessed with a GAF of 50. Her Trazodone was increased to help her sleep
and her Lexapro was continued.
On March 23, 2005, plaintiff saw Dr. Hagaman and reported that her nerves were
“giving her a hard time” (Tr. at 211). She was having trouble sleeping. “Going back to court
w/her ex-husband. Tearful in clinic.” She weighed 273 pounds. Dr. Hagaman gave plaintiff
samples of Zoloft and a prescription for Elavil to take at night. “She has no money and really

22

can’t afford to get anything filled.”
On April 1, 2005, plaintiff saw Dr. Austin for a medication review/treatment plan
update (Tr. at 355). Plaintiff said she did not do well on the Lexapro, and one of her doctors
put her on Zoloft about two weeks ago. She stopped taking the Trazodone because it did not
work. “I am going to put her back on it at 200 mg at bedtime and see how she does. I am also
going to give her Ambien 10 mg at bedtime for a short while. She does not have any side
effects to her medication.” Plaintiff was alert and oriented times three. She denied
hallucinations and suicidal ideation. Mood and affect were slightly depressed. She was
assessed with a GAF of 50.
On May 25, 2005, plaintiff saw Dr. Austin (Tr. at 352). “Caralee comes in today and
states she has been through a very bad period the last six weeks. She called about four weeks
ago to make this appointment. She did turn in some child abusers but it all backfired on her as
they have all come back on her. She had the police called on her three times in one night even
when she had not done anything. Apparently she was put in jail for 4-5 hours. She called her
ex-husband in North Carolina who actually bailed her out. She seems to be having quite a bit
of a problem with any kind of authority. She seems to be doing well on her medication.”
Plaintiff was alert and oriented times three. She denied visual or auditory hallucinations, and
she denied suicidal ideation. Affect and mood were observed to be euthymic. She was assessed
with a GAF of 50. Dr. Austin prescribed Zoloft, Trazodone, and Ambien (treats insomnia).
On July 11, 2005, plaintiff saw Dr. Hagaman and requested a “Depo shot5 for her
cycles” (Tr. at 212). “She is in a real mess right now. Her child was taken away from her and

5

Depo-Provera is a birth control method for women. It is made up of a hormone similar to
progesterone and is given as an injection by a doctor into the woman’s arm or buttocks. Each
shot provides protection against pregnancy for up to 14 weeks, but the shot must be received
once every 12 weeks for the patient to remain fully protected against pregnancy.

23

she is currently living in the Gamma House. She is having a lot of stress and anxiety. Her BP is
142/102 and she continues to smoke.” Plaintiff was not taking her Toprol or Lisinopril, both
for hypertension. Dr. Hagaman gave her samples of Toprol and gave her a prescription for
Lisinopril “which she can get filled at the Christian Clinic. . . . If she would stop smoking and
get her blood pressure down in good control, then we will have no problems putting her on the
Depo shot.”
On October 24, 2005, plaintiff saw Sandra Haslauer in Dr. Austin’s office (Tr. at 356365). Her last contact with this office was noted to have been May 25, 2005. She said she was
depressed, was trying to get divorced, and was having panic attacks. “[She] did not follow thru
w[ith] the recommendations; last seen 5/25/05; cancelled last 3 appointments.” She said she
had been sober since November 7, 2003, and that before then she was drinking a pint of
alcohol per day. Plaintiff reported that she was depressed, trying to get divorced, had problems
sleeping, mood swings, anxiety. She said she gets confused and overwhelmed and has no
emotional support. Her symptoms had been on and off since November 2003. She was
experiencing panic attacks. She had recently gone back to school to study early childhood
development. Plaintiff said her biggest fear was that her husband would get custody of their
son. She reported decreased concentration and focus, weekly mood swings, regular difficulty
going to sleep. Plaintiff was described as cooperative, well groomed, with clear speech. She
did not report any aggressive behavior or hallucinations. Her thought process were logical.
She was depressed, anxious and irritable with a flat affect Her judgment and insight were
good. Her memory was normal (long and short term). Her attention was normal,
concentration was diminished. She had good judgment and insight. Plaintiff was assessed with
bipolar I disorder, panic disorder, and personality disorder not otherwise specified. She was
prescribed Zoloft, Trazodone and Ambien.

24

On January 23, 2006, plaintiff saw Dr. Hagaman for medication refills (Tr. at 213).
“She just got insurance. She basically has not been on any of her meds.” Plaintiff continued to
smoke a half a pack of cigarettes per day. Plaintiff weighed 254 pounds. Dr. Hagaman
prescribed Paxil in addition to plaintiff’s hypertension and thyroid medications.
On February 16, 2006, plaintiff saw Mary Burr, a nurse practitioner (Tr. at 214).
Plaintiff weighed 252 pounds.
On March 20, 2006, plaintiff saw Dr. Hagaman and reported trouble sleeping “as she
is going through a lot of stress with legal issues” (Tr. at 215). Plaintiff weighed 259 pounds.
He prescribed Trazodone to help her sleep and he continued her on Paxil.
On June 2, 2006, plaintiff went to the emergency room after falling at work (Tr. at
193-199, 224-226). She said she “did the splits” and was suffering pain in her lower back,
right knee and shoulder. She did not lose consciousness. Under her past medical history she
reported arrhythmias, hypertension and thyroid problems but no stroke. She was smoking 1
1/2 packs of cigarettes per day and reported occasional alcohol use. She was alert and
oriented times three and was described as pleasant and in no acute distress. She was taking no
medication for any mental condition. On exam she was noted to have “a little bit of
discomfort” in the shoulder but with full rotation and a normal knee with no fracture. X-rays
of the shoulder were normal. X-rays of the knee showed “some mild degenerative changes.”
X-rays of the lumbar spine showed “moderate degenerative disc change at L4-L5” but no acute
changes. Melissa Quevillon, M.D., recommended ibuprofen and “she can take some Ultram”
as needed.
On June 5, 2006, plaintiff saw Gregory Elders regarding a worker’s compensation
evaluation for Town and Country Supermarket (Tr. at 216). Plaintiff reported working 16
hours a day in two jobs. She had finished her prescription for Ultram. “She is able to walk

25

now and did work today without difficulty.” Plaintiff had full range of motion in her knee.
“Okay to return to work. . . . Return to full duty.”
On July 8, 2006, plaintiff saw Christiana Thompson, a nurse practitioner (Tr. at 217).
“47-year-old who presents today for her ‘nerves’. This very pleasant lady lost a good friend
yesterday in a terrible motorcycle accident. . . . She is very upset and understandably stressed.
We talk[ed] at length about the grieving process and how difficult it is to lose a friend or family
member from trauma. She knows that there are grief services available in the area. . . . There
is no indication today of suicide ideation as this is just normal grief response.” Shew as
assessed with stress and anxiety associated with grief response. She was prescribed Xanax, 20
pills with one refill only.
On August 30, 2006, plaintiff was seen at Mountain Home Christian Clinic (“MHCC”)
and reported smoking 1+ packs of cigarettes a day for 30 years and consuming alcohol
occasionally.
On September 7, 2006, plaintiff saw D. Riley, a physician’s assistant at MHCC for a
refill of her medications (Tr. at 188). She complained of her leg swelling. She weighed 249
pounds. She was diagnosed with hypertension, hypothyroid, and GERD.
On January 4, 2007, plaintiff saw Dr. Hagaman (Tr. at 218). Plaintiff reported almost
passing out due to cough, congestion and shortness of breath. “She continues to smoke. She
cannot afford her inhalers or antidepressants secondary to not having any money. However,
she is able to continue to buy her cigarettes. She has been off her Paxil for some time. She is
again tearful and depressed. She wants to go back on this.” Plaintiff weighed 261 pounds. Dr.
Hagaman assessed COPD. “She needs to be on the albuterol, however, she cannot afford this. I
do talk with her about possibly stopping her cigarettes and she might be able to afford some of
these medications. She is going to think about that. I also recommend seeing us at the

26

Christian Clinic, which I also work at. We provide medication, which would benefit her.” He
gave her samples of Spiriva for COPD. He refilled her Paxil and told her to get that
prescription filled at the Christian Clinic.
April 4, 2007, is plaintiff’s alleged onset date. This is also the date she alleges she was
in a terrible car accident that resulted in her inability to work. There are no records of any car
accident. She completed her application for disability benefits on August 6, 2007.
On August 26, 2007, plaintiff was seen in the emergency room (Tr. at 231-232).
When asked about her past medical history, she reported hypertension and toe issues, but she
did not report a history of stroke, and she did not report having been in a terrible car accident
four months earlier. She was smoking a pack a day and reported no alcohol consumption for
the past 10 to 12 years.
On September 20, 2007, plaintiff was examined by Hassan Najeeb Albataineh, M.D., in
connection with her disability application (Tr. at 261-268). Plaintiff reported she had heart
arrhythmias and could walk one block without chest pain. She reported depression and
anxiety. She weighed 243 pounds. On exam her heart, lunch, abdomen, neck, skin and spine
were all normal, including her range of motion. She had no detectable muscle spasms. Straight
leg raising was normal. Her range of motion was normal everywhere except her knees where
she had 120 degrees of flexion with 150 degrees being normal. She had no joint
abnormalities. Muscle strength was normal and she had no muscle atrophy. Gait and
coordination were normal. Tandem walk was normal. She was able to hold a pen and write,
grip, stand and walk without assistive devices, squat and arise from a squatting position. She
was oriented to person, place and time. She showed no evidence of psychosis or serious mood
disorder. X-rays of her lumbar spine and right knee were normal other than degenerative

27

changes. Based on his examination, Dr. Albataineh found that plaintiff had “mild limitations
[in her] ability to walk, lift & carry.”
On October 16, 2007, plaintiff was evaluated by Terry Efird, Ph.D., in connection with
her disability application (Tr. at 278-284).
When asked about reasons for applying for disability, the claimant reported “first of all
my knees keep popping out; and, I drop down. I can’t remember anything anymore.”
When asked about other mental/emotional symptoms, claimant reported “depression
and post traumatic stress.” Claimant was interviewed for criteria for major depressive
disorder. Mood was described as “I don’t wake up depressed. Everything just doesn’t
seem to work out.” This was described as occurring daily for about the past year. . . . A
problem with sleep onset . . . was reported, with ruminative thoughts. Energy level was
described as “not real low” - “I do everything I have to do.” . . . A problem
concentrating was reported (e.g., “everything is just a mess”). Claimant denied suicidal
ideations.
. . . Symptoms of increased arousal endorsed included problems with sleep onset;
difficulty concentrating; hypervigilance; and, an exaggerated startle response. These
symptoms have reportedly been occurring at least since 2003. They cause significant
distress; and, impair social functioning. . . . Symptoms have reportedly become worse
in the past year.
The claimant reported receiving outpatient mental health services for about one year in
2003. The response was described as “I felt better when I left there. I had more hope.”
Claimant did not bring medications to this evaluation. She reported being prescribed
Celexa 20 mg QD. This medication is reportedly prescribed by her PCP; and, has been
prescribed for about five months. It is reportedly taken as prescribed; and, claimant
denied noticing any effects. A possible side effect of headaches was reported. Financial
obstacles to treatment were reported.
Claimant presently lives in a homeless shelter, with her son. They have lived in this
setting for about two months. Claimant reported the ability to perform ADL’s
satisfactorily. . . . Legal and military histories were denied. She did report some hot
check charges earlier this year, which was influenced by a banking error.
Claimant has reportedly worked primarily as a cook in restaurants and bakery. She
reportedly last worked in February, 2007. She quit this job at a pizza place at that time,
secondary to having been working 10 hours per day, 7 days a week. She reported
working some odd jobs, cleaning houses or lawns since that time. Relationships with
coworkers and supervisors were described as having typically been satisfactory.
However, she was fired from one job secondary to not getting along with her
supervisor, within the past year.

28

Claimant denied the use of illegal substances. She did report smoking marijuana until
about three years ago. Regarding alcohol usage, claimant reported drinking a beer
about twice a year.
Plaintiff was observed to be cooperative and appropriately dressed and groomed. Her
mood was sad and anxious. Affect was appropriate to content with tearful affect noted.
Thought processes were typically logical, relevant and goal-directed. Suicidal ideations were
denied. “Distinct visual and auditory hallucinations were denied. Claimant did report
believing she hears people talking at times, at night. This was described as unclear. This type of
experience reportedly began about 4-5 months ago; and, reportedly occurs about twice per
week.” Plaintiff was oriented to person, place and time. She readily produced basic personal
demographic information. She recalled past presidents, large cities, states bordering Arkansas.
Her fund of general information “appeared consistent with probably low average intellectual
functioning.”
Claimant also talked about problems with memory. However, no remarkable problems
with memory were noted during this evaluation. Claimant also reported believing that
she hears voices. However, she is unable to make out the words. These experiences do
not appear to be clearly psychotic, and possibly associated with the mood disorder and
environment.
Dr. Efird assessed major depressive disorder, moderate to severe; post-traumatic stress
disorder, chronic, and a GAF of 42-52.
The claimant denied driving since April 4, 2007. She had an MVA [motor vehicle
accident] at that time; and, did not renew her driver’s license. Claimant reported the
ability to shop independently; and, reportedly walks to a nearby grocery store. Claimant
related the ability to handle personal finances. Socially, claimant reported going to
church twice a week; and, seeing a friend about twice per month. Claimant reported
the ability to perform most ADL’s satisfactorily.
Claimant appeared capable of adequate and appropriate communication during this
evaluation. Claimant essentially interacted in an intelligible and effective manner.
The claimant performed serial threes satisfactorily; and, recalled two of three items
after an approximately five minute delay. Other cognitive tasks were performed
satisfactorily. Therefore, in terms of basic cognitive tasks, this claimant appears to be
able to function adequately.

29

Claimant appeared able to sustain attention/concentration adequately for the purposes
of this evaluation. She was able to track and respond to shifting demands of this
evaluation.
In general, this claimant appeared to sustain persistence satisfactorily during this
evaluation. Some encouragement was offered at times.
The claimant did not display remarkable slowing during this evaluation. Claimant
completed tasks within a reasonable time frame.
Formal validity assessment techniques were not employed. It was not my clinical
impression that the claimant remarkably exaggerated severity of reported
symptoma[to]logy. Cognitive tasks were performed fairly consistent with estimated
intellectual functioning. Adequate effort was noted during this evaluation. I did not
detect any remarkable evidence of malingering and the present results are viewed as
likely representing a valid estimate of current functioning.
On October 17, 2007, Paul Cherry, Ph.D., completed a Psychiatric Review Technique
(Tr. at 286-299). He found that plaintiff suffers from major depressive disorder, moderate to
severe, and anxiety. He found that plaintiff suffers from moderate restriction of activities of
daily living; moderate difficulties in maintaining social functioning; moderate difficulties in
maintaining concentration, persistence or pace; and no episodes of decompensation. In
support of these findings, Dr. Cherry wrote in part as follows: “Records showed that she
responded well to Prozac, and the abuse from her husband was also a major factor leading to
the admit.. . . Notes show she was married to a physically abusive husband, and she has a hx.
of alcohol abuse. She has been followed as an outpatient through individual and group
therapy. . . . Clt is not currently being seen for any formal mental health tx. She stated that she
currently takes Celexa. . . . She currently resides in a homeless shelter with her son, and she is
able to perform her ADLs satisfactorily. . . . She had adequate fund of general knowledge with
no clear memory problems based on her responses and the doctor’s observations.
Concentration, pace, and persistence were adequate.”
That same day, October 17, 2007, Dr. Cherry completed a Mental Residual Functional
Capacity Assessment (Tr. at 300-302). He found that plaintiff was not significantly limited in

30

the following:
P

The ability to remember locations and work-like procedures

P

The ability to understand and remember very short and simple instructions

P

The ability to carry out very short and simple instructions

P

The ability to maintain attention and concentration for extended periods

P

The ability to perform activities within a schedule, maintain regular attendance, and be
punctual within customary tolerances

P

The ability to sustain an ordinary routine without special supervision

P

The ability to work in coordination with or proximity to others without being distracted
by them

P

The ability to make simple work-related decisions

P

The ability to ask simple questions or request assistance

P

The ability to accept instructions and respond appropriately to criticism from
supervisors

P

The ability to get along with coworkers or peers without distracting them or exhibiting
behavioral extremes

P

The ability to maintain socially appropriate behavior and to adhere to basic standards of
neatness and cleanliness

P

The ability to be aware of normal hazards and take appropriate precautions

P

The ability to travel in unfamiliar places or use public transportation

P

The ability to set realistic goals or make plans independently of others

He found that she was moderately limited in the following:
P

The ability to understand and remember detailed instructions

P

The ability to carry out detailed instructions

P

The ability to complete a normal workday and workweek without interruptions from
psychologically based symptoms and to perform at a consistent pace without an
unreasonable number and length of rest periods

P

The ability to interact appropriately with the general public

31

P

The ability to respond appropriately to changes in the work setting

He concluded with the following: “Clt retains the ability to perform simple and routine work
activities.”
On January 16, 2008, Vann Smith, Ph.D., completed a neuropsychological evaluation
in connection with plaintiff’s application for disability benefits (Tr. at 318-322). Dr. Smith
had requested plaintiff’s medical records but they had not been reviewed at the time the report
was written.
The patient is referred, by her attorney, for formal neuropsychodiagnostic evaluation,
in support of an ongoing application for Social Security Disability benefits. She presents
with a history of worsening neurocognitive symptoms including: 1) impaired recall
memory, 2) impaired attention to sequential detail, 3) dysexecutivism, 4) word finding
difficulty, 5) sleep pattern disturbance and 6) affective lability.
Plaintiff reported a history of seizure disorder, even though there are no medical
records suggesting seizure disorder and plaintiff specifically denied seizures in many of her
treatment records. Plaintiff described her physical pain as an 8 out of 10. “She related a
history of multiple closed head injuries (MVAs and alleged assaults by spouse) and at least one
incident of being ‘choked’ to unconsciousness. . . . She is a non-drinker who smokes one pack
of cigarettes per day.”
Dr. Smith performed a neurocognitive status examination which revealed a well
groomed, alert, cooperative, polite patient oriented in all spheres. “Her memory was impaired.
Her judgment and insight were intact. . . . Her native intelligence was estimated to lie within
the normal range.” Dr. Smith performed a battery of tests and determined that plaintiff’s full
scale IQ was 105.
In overview, this patient’s clinical history, mental status examination and
neuropsychodiagnostic screening test profile data reveal a pattern of diffuse organic
brain dysfunction. The pattern of abnormal findings observed across this patient’s
neuropsychodiagnostic test profile is similar to that seen commonly in association with:
1) cerebrovascular, hypoxic, toxic or metabolic encephalopathies, 2) traumatic brain
insult and the sequelae thereof and 3) the dysregulation of key central neurochemistry

32

(eg. Serotonin, GABA, Acetylcholine, Norepinepherine) believed now to be precipitated
by the brain and spinal cord’s adaptive response to chronically painful disease process
(eg. DJD [degenerative joint disease], DDD [degenerative disc disease], Fibromyalgia,
Myalgic Encephalomyelitis, Syringomyelia, Peripheral Neuropathies). Resulting
neurocognitive symptoms (impaired memory, impaired attention, dysexecutivism,
affective lability, “depression”, sleep pattern disturbance, etc.) interfere significantly
with the patient’s capacity to carry out routine daily activities in a consistent manner.
This renders the patient, in my clinical opinion, disabled at this time.
In summary, this patient’s clinical history, mental status examination and
neuropsychodiagnostic screening test profile data, reveal a pattern of abnormal
findings consistent with the diagnosis(es) of:
1.

Cognitive Dysfunction, Non-psychotic, Secondary to General Medical
condition(s)*
* TBI (Multiple) with Grade III concussion, per patient history.
* DJD [degenerative joint disease], per patient history.
* HTN [hypertension], per patient history.
* Hypothyroidism, per patient history.
* Cardiac dysrhythmia, (PATs) per patient history.
* Seizure Disorder, per patient history.
* Chronic, Multifocal, Non-psychogenic, marginally controlled, pain.

On January 28, 2008, Dr. Smith completed a Mental Functional Capacity
Questionnaire (Tr. at 323-327). Dr. Smith wrote “294.10” as his Axis I assessment.
According to DSM-IV, a diagnosis of 294.10 means one of three things: “Dementia Due to
[Indicate the General Medical Condition], Without Behavioral Disturbance,” “Dementia of the
Alzheimer’s Type, With Early Onset, Without Behavioral Disturbance,” or “Dementia of the
Alzheimer’s Type, With Late Onset, Without Behavioral Disturbance.” He assessed her GAF as
40 to 80; however, the words “past year” were scratched out and what he wrote instead is
illegible. Her prognosis was “fair.” Her signs and symptoms were noted to be decreased
energy; difficulty thinking or concentrating; psychological or behavioral abnormalities
associated with a dysfunction of the brain with a specific organic factor judged to be
etiologically related to the abnormal mental state and loss of previously acquired functional

33

abilities; emotional lability; easy distractibility; memory impairment - short, intermediate or
long term; and sleep disturbance.
He found that plaintiff’s abilities were limited but satisfactory in the following:
P

Understand and remember very short and simple instructions

P

Make simple work-related decisions

P

Ask simple questions or request assistance

P

Interact appropriately with the general public

P

Maintain socially appropriate behavior

P

Adhere to basic standards of neatness and cleanliness
He found that plaintiff’s abilities were seriously limited but not precluded in the

following:
P

Carry out very short and simple instructions

P

Work in coordination with or proximity to others without being unduly distracted

P

Accept instructions and respond appropriately to criticism from supervisors

P

Get along with co-workers or peers without unduly distracting them or exhibiting
behavioral extremes

P

Respond appropriately to changes in a routine work setting

P

Deal with normal work stress

P

Be aware of normal hazards and take appropriate precautions

P

Travel in unfamiliar place

P

Use public transportation
He found that plaintiff was unable to meet competitive standards in the following:

P

Remember work-like procedures

P

Maintain regular attendance and be punctual within customary, usually strict
tolerances

34

P

Sustain an ordinary routine without special supervision

P

Complete a normal workday and workweek without interruptions from psychologically
based symptoms

P

Perform at a consistent pace without an unreasonable number and length of rest
periods

P

Understand and remember detailed instructions

P

Carry out detailed instructions

P

Set realistic goals or make plans independently of others

P

Deal with stress of semiskilled and skilled work
He found that plaintiff would be likely to miss work more than four days per month due

to her impairments or treatment.
Plaintiff did not present any treatment records for 2008 until November 2 of that year.
On November 2, 2008, plaintiff went to the emergency room complaining that her leg was
itching all the time (Tr. at 588, 598).
On November 11, 2008, plaintiff was in jail6 and was “talking incessantly regarding
delusions of others poisoning her (Tr. at 379-380, 384). She reportedly was restless and
pacing. She was reportedly grandiose stating, ‘I have more degrees than you do.’” (Tr. at 367604). Plaintiff wound up having a psychiatric assessment (Tr. at 372).
Plaintiff reported having a masters degree in early childhood education (Tr. at 367,
390). However, she reported that she was disabled and was receiving SSI and SSD (Tr. at 390).
She was living in a home with her spouse (Tr. at 368). She said she had been seeing a
psychiatrist privately until 1 1/2 years ago when she had a car accident and lost her job (Tr. at
372). She had not been taking any medication for any condition, mental or physical, since
March 2008 (Tr. at 389). Plaintiff said she had recently learned that her middle son was using
6

The charge is illegible but it was marked as a misdemeanor (Tr. at 372).

35

methamphetamine with his father and had been since April 2008, which caused her to become
extremely stressed landing her in the hospital (Tr. at 450-451, 453). Elsewhere in the records,
plaintiff indicated that she had gone to the hospital due to a nose bleed (Tr. at 450). When she
was at the hospital, “they” would not allow her contact with her youngest son (Tr. at 451). “Pt
reports becoming loud, verbally abusive & threatening staff. Pt states that she was taken to
‘lock up’ & screened by Ozark Counseling Services.” (Tr. at 451). Plaintiff said she has been
diagnosed with post traumatic stress disorder, bipolar disorder, and paranoid schizophrenia
(Tr. at 451). “During the session, patient was a good historian. Cooperative & maintains good
eye contact.” (Tr. at 451).
Plaintiff denied anxiety or depression, but reported symptoms of mania (Tr. at 374,
384, 388). Plaintiff reported a history of post traumatic stress disorder and obsessive
compulsive disorder (Tr. at 388). Plaintiff reported having taken a shot of whiskey (Tr. at
374). “She reports she drank Crown Royal last week. She use[d] to pass out when she drank
alcohol.” (Tr. at 453). Plaintiff said she had been diagnosed with post traumatic stress disorder
and bipolar disorder. She said she did not know her phone number, had poor judgment, poor
attention, poor concentration, and some insight (Tr. at 374). She denied prescription drug
abuse, non-prescription drug abuse, illegal drug use, and alcohol abuse over the past 12
months (Tr. at 375). Her GAF was assessed at 35, and her diagnoses were anxiety, post
traumatic stress disorder per client, and bipolar disorder per client (Tr. at 376).
Plaintiff agreed to be seen at Ozark Counseling Services and said she would walk to her
appointments (Tr. at 374). Two days after her initial evaluation in jail, she was voluntarily
hospitalized in the Arkansas State Hospital where she was treated by Linda Parker, M.D., a
psychiatrist, and Natalie Strode, a case manager (Tr. at 369, 382). Her admission date was
November 13, 2008 (Tr. at 384). According to the records, plaintiff was taken by ambulance

36

to the state hospital for a 72-hour hold prior to agreeing to be admitted (Tr. at 599). She was
noted to be cussing a lot: “I can’t believe these motherfuckers they tricked me, I’ll get that
nurse bitch, I’ll see her again” (Tr. at 599). Plaintiff was noted to be angry, she wanted to go to
Missouri to check on her children, and she refused Haldol (Tr. at 602).
On admission, plaintiff was observed to be neatly groomed, cooperative and pleasant
with good eye contact (Tr. at 384, 390). Psychomotor status was normal “but could quickly
become tangential and almost have flight of ideas” (Tr. at 384). Intellectual functioning
appeared to be average based on vocabulary and syntax; recent and past memory appeared
intact as she was able to give a chronological history (Tr. at 385). Plaintiff’s physical exam was
normal except she was obese (Tr. at 385). A drug screen was negative (Tr. at 385).
“Psychological evaluations were ordered but were not able to be done prior to her discharge”
(Tr. at 385). She was started on Risperdal for psychosis on November 17, 2008, and on
November 25, 2008, her dosage was increased (Tr. at 385). Plaintiff participated in individual
and group therapy during her stay (Tr. at 385).
During her stay, plaintiff was given tests to evaluate her mental condition, and she was
given a physical examination (Tr. at 390-391, 398). She was tearful during various moments
in the assessment “and with all the stressors she has it [is] most likely she is clinically
depressed” (Tr. at 418). She denied back pain, but reported falls, arthritis, and chronic pain
for which she was taking Aleve (Tr. at 409). She had normal strength in all of her extremities
(Tr. at 398). She weighed 274 pounds (Tr. at 401). A suicide assessment shows that plaintiff
denied history of suicide attempt or self harm (Tr. at 393, 411). Hallucinations were also
denied (Tr. at 393). A violence risk assessment completed on November 13, 2008, shows that
plaintiff did not display violence during previous admissions, she was not known to have
displayed violence in the community, and she did not display extreme agitation or aggression

37

at the time of her admission (Tr. at 413). She was asked if she had ever been in a severe
accident, and she reported that she was hit by a cement truck when she was a teenager (Tr. at
417). She was asked if she ever has flashbacks (she answered, “no”), nightmares (she
answered, “no”), or whether she stays away from other people (she answered, “no”) (Tr. at
417).
Plaintiff was smoking 1 to 2 packs of cigarettes per day (Tr. at 394). Her hobbies were
horseshoes and computers (Tr. at 405). In the past six months plaintiff had spent a lot of time
drawing and planting roses “with family and friends” (Tr. at 406). When asked whether she
likes doing leisure activities alone, with just one other person, with 3 to 5 others, or with 6 or
more people, plaintiff said, “with 3 to 5 others” (Tr. at 407).
Progress noted dated November 17, 2008, indicate that “Patient was told that DHS
needed to discuss possibility of her 12 yr old son entering foster care. Conference call was
made to Baxter Co. DCFS and it was agreed that the son would remain with their next door
neighbor until patient is discharged from ASH [Arkansas State Hospital].” (Tr. at 455). Plaintiff
reported that she was in severe pain and could not walk on her leg (Tr. at 455). Two days
later, plaintiff participated in her first group therapy session and was noted to be “attentionseeking” (Tr. at 458). “Patient was intrusive in group both days as evident of ‘talking while
other patients are presenting their information, not really paying attention, or agreeing with
everything said even if it not reality” (Tr. at 458). On November 22, progress notes state that
plaintiff was “very somatic during the beginning of this week as evidenced by c/o headache,
leg pains, nosebleed, panic attacks, needing her Bible, where are her personal belongings and
who is going to take care of her things at home.” (Tr. at 518). Plaintiff had begun to improve - she was interacting with her peers better, had become more positive, learning to use coping
skills more appropriately (Tr. at 518). Her blood pressure had been normal (Tr. at 518). On

38

November 23, plaintiff was noted to be cooperative with the staff, interacting appropriately
with her peers, showing some insight into her surroundings (Tr. at 500).
In progress notes dated November 24, 2008, it was noted that plaintiff had arranged
for her son’s care (Tr. at 459). “Caralee still plans to return to her trailer after discharge -- she
reported having been evicted, but says she has a lawyer who has worked out arrangements
with her landlord. Only problem with a discharge is that Caralee still refuses to be referred to
DCS for follow-up care. She wants to make other arrangements.” (Tr. at 459). The following
day, Dr. Parker noted that plaintiff “state[d] she was paranoid last night when she thought she
was going to jail. She was jovial today but did become tearful as she talked about her
husband.” (Tr. at 459-460). Plaintiff denied suicidal thoughts; she denied medication side
effects (Tr. at 460). On November 25, she was noted to be easily frustrated and overreacted
when things were not at her request (Tr. at 504). On November 26, plaintiff participated in
group therapy “activity and made positive contributions. Speech was relevant and coherent.”
(Tr. at 462). She was noted to have been cooperative and pleasant (Tr. at 506). On November
28 progress notes reflect that plaintiff “makes excuses for her choices/decisions. Pt has
difficulty accepting positive advice.” (Tr. at 510). On November 30, progress notes state that
plaintiff “plays the victim role and can be very defensive when she disagrees” but was
improving since she was assigned a new roommate (Tr. at 514).
Progress notes dated December 1, 2008, indicate that plaintiff was optimistic about her
situation, she planned to return home after discharge (Tr. at 446). “She will need to work on
communicating needs in reality based manner, as progress notes indicate attention seeking
behavior and not being in reality.” Plaintiff wrote, “I feel I’m in reality & this statement is
false” before signing the form (Tr. at 446). The following day plaintiff “was very tearful
during our session, stating that she was being evicted from her mobile home & all of their

39

personal items were being thrown in the dumpster. Pt. stated that they received only $395.00
per month total household income. Pt. stated that she wanted to be discharged today.
Discussion of pro/con of patient being discharged AMA [against medical advice]. Several tel
call to community supportive agencies to assist with rent, and talking with landlord about pt
remaining within the mobile home until 12/15/08. DHS/DCFS sent a caseworker out to talk
with the landlord about patient remaining in the mobile home.” (Tr. at 465). Also on that day
she went to the beauty shop to have her hair done and was crying out, “my nerves are bad and
I’m itching” (Tr. at 519). She was given Haldol and Benadryl which were noted to be effective
(Tr. at 519).
On December 3 she was noted to have participated in group therapy (Tr. at 462). She
was friendly and cooperative, her speech was relevant and coherent (Tr. at 462). On
December 5 and 6, plaintiff complained of agitation (Tr. at 463) but she was noted to be “less
paranoid and agitated” on both those days as well as on December 8 (Tr. at 466, 468).
Plaintiff was given Trazodone “per request for insomnia” and Haldol “per request for
agitation” on December 6 (Tr. at 466).
Plaintiff was discharged in stable condition on December 9, 2008, with no restrictions
on physical activity (Tr. at 386, 469, 535). “She is able to make general decisions, financial
decisions and live independently (Tr. at 386). Her discharge medications were Risperdal and
medications for hypertension (Tr. at 386). Her discharge diagnosis was mood disorder not
otherwise specified (Tr. at 386). Her GAF score, which had been 33 on admission, was 55 on
discharge (Tr. at 386). Her prognosis was guarded “due to poor coping skills and limited
understanding of her illness and need for treatment” as evidenced by her failure to comply
with treatment for the past year and a half (Tr. at 387 390).

40

The only pain medication plaintiff was ever given during her hospital stay was Tylenol
(Tr. at 542-545). During those times, she rated her pain a 5/5 or a 4/5 (Tr. at 542-545). The
day before her discharge her weight was 281 pounds (Tr. at 546).
There are no medical records from plaintiff’s discharge on December 9, 2008, until
March 5, 2010, fifteen months later. On March 5, 2010, plaintiff was seen at Ozarks Medical
Center for fever, chills and cough (Tr. at 877-879). Plaintiff was a smoker. She was observed
to be oriented times three with normal mood and affect. Chest x-rays were normal. She was
prescribed Albuterol inhaler and was told to stop smoking. That same day plaintiff saw
Michael Ball, D.O., for arthritis pain (Tr. at 921). She said her back pain was an 8/10 but she
took Aleve and it helped. Her exam was normal.
On March 20, 2010, plaintiff was seen at Mountain Grove Medical Complex for an
unrelated issue, and she said she needed a refill of Flexeril, a muscle relaxer (Tr. at 905-907).
On May 28, 2010, plaintiff saw Dr. Ball for back pain (Tr. at 922). She said her pain
was an 8/10 and she had been taking Tramadol for years which was not helping. On exam,
Dr. Ball checked “abnormal” as to plaintiff’s abdomen, back and extremities. No further
elaboration was provided. He assessed hypertension, hypothyroidism and obesity.
On June 14, 2010, plaintiff was seen by Mandy Browning, a social worker, at Mt.
Grove Clinic for a clinical assessment (Tr. at 880-887). Plaintiff arrived alone and was
described as cooperative. Plaintiff referred to when she “had that last stroke.” Plaintiff said she
was with a good man now and she did not want to lose him. “I’m drawing disability on my
mental state, and I’m 100% disabled on my mental and physical state. Horrible crying spells, I
couldn’t stop if I wanted to. . . . I got up to 300 pounds, and now I’m down to about 270, I’ve
been doing a lot of walking. . . . The first stroke was November 12, 2008. The last one was
October 12 or 14 of 2009.” Plaintiff said she could hear people talking about her outside her

41

trailer. “I’ve had that on and off my whole life, but I can control it when I ‘m on the right
medication.” Plaintiff said she was administered shock therapy in 1980 when she lived in New
York. Plaintiff said she had been hospitalized for psychiatric problems “at least every two years
since the age of 17.” Plaintiff said she currently had fibromyalgia and “breast, ovarian and
possibly colon cancer”. She reported occasionally using alcohol. “My dad was an alcoholic; I
never want to be that way, and I can go years without drinking.”
Caralee reports frequently using cannabis “just hits, passing a joint, passing a bowl. I
don’t crave it, but the last five years the pain has gotten so bad, it seems to help. . . .
Caralee reports previously using methamphetamine, last used in 2007. She first started
using it when her husband put it in her and her son’s coffee in the late 1990s, “and
every now and then I’ll take a ball or something, but I haven’t taken any since April
25th and I don’t plan on taking any.” Caralee reports occasionally misusing
prescription medications: “sometimes I’ll buy it off the black market if I’m feeling really
bad.” Caralee reports previously using other drugs, crack “back when I was a needle
junkie 1977-1980”. . . . Caralee reports that the drugs most commonly preferred were
marijuana and the amount and frequency of use was “I look forward to it and see the
people coming, but I’ve never bought it myself.”
Plaintiff had been smoking since age 12 and was smoking a little under two packs of
cigarettes per day. Plaintiff said she drinks at least a pot of coffee each morning and she
gambled compulsively “on and off when I had those down years.”
Caralee reports “my husband I’m still married to, he won’t divorce me. . . . He’s got my
son John now, he’s 14. He’s down in Arkansas living with friends. I visited him and
he’s doing good, but he doesn’t get any of his check, he gets $418 and his brothers take
it. . . . [T]hey declared me too defective to take care of a 15 year old son, but now I can
walk again and I just have to get a court date and I’ll get him back again”. . . . She
reports physical abuse by her mother when she was growing up as well.
Plaintiff said she had 7 siblings -- 4 sisters and 3 half brothers. Plaintiff said her
mother hit her father and set him on fire.
Plaintiff was currently living with her significant other. “Caralee graduated college;
she has a Master’s degree in Early Childhood Education and taught for 20 years. Caralee
reports learning disabilities, dyslexia.” She reported going to church three nights a week.

42

Plaintiff said she wrote hundreds of thousands of dollars’ worth of bad checks and spent a little
over a year in prison. She said she had “a lot of really good friends who love me.”
Plaintiff was described as calm and cooperative with appropriate behavior yet
distractible thought process. Her judgment and insight were moderately impaired. Immediate
memory was noted to be impaired. She was 75% on task as far as attention and concentration.
She was assessed with major depressive disorder, recurrent, severe with psychotic features;
post traumatic stress disorder; panic disorder without agoraphobia; cannabis abuse;
polysubstance dependence; and rule out bipolar disorder. Her current GAF was 38-40.
On July 13, 2010, plaintiff saw Richard Alken, M.D., at Mt. Grove Clinic (Tr. at 888889). Plaintiff reported difficulty sleeping, and she said she would all of a sudden start crying
for no reason. Plaintiff said that she had been having panic attacks. “Her mood has been
affected since she had a stroke on November 13, 2008.” I note that on November 13, 2008,
plaintiff was admitted to the Arkansas State Hospital after she was evaluated in jail 2 days
earlier. Plaintiff did not have a stroke. Plaintiff told Dr. Alken that she had been taking
Depakote for seizures that she had been experiencing since her stroke. Plaintiff said she
occasionally hears people talking outside her trailer but there is no one there. She was assessed
with major depressive disorder with a GAF of 32. “I shall re-start this patient’s medication.”
He did not list the medications he prescribed, so it is unclear whether plaintiff was given a
prescription for Depakote; however, she had never been prescribed this medication in the past.
On December 16, 2010, plaintiff was seen at Cox Health South emergency department
after having fallen at home (Tr. at 935-948). She did not lose consciousness, but she arrived in
an ambulance. She described her pain as a 10/10. She reported a past medical history
including seizures, hypertension and emphysema. She said her normal gait is to shuffle due to
having had a stroke, and she fell while walking. “The patient has not experienced similar

43

symptoms in the past.” “Patient talking on cell phone. The patient is laughing, no evidence of
discomfort, the patient smiles.” X-rays of her lumbar spine and pelvis were normal. Plaintiff
was given morphine for her pain. She was discharged with prescriptions for Flexeril (muscle
relaxer) and Ultram (for pain).
On December 26, 2010, plaintiff was seen at Cox Health Urgent Care complaining of
back pain after having fallen down the stairs (Tr. at 925-932). Plaintiff was crying and
anxious. She reported her past medical conditions to include depression, seizures,
hypertension, stroke, and emphysema. She continued to smoke. “Pt. had a stroke 3 years ago
since then has been quite emotional all the time, has shuffling gait and frequent falls. The
patient has experienced similar episodes in the past, multiple times.” Plaintiff had not taken
her thyroid medication for several months due to lack of funds. X-rays of her lumbar spine
and pelvis were normal. She was prescribed Flexeril, a muscle relaxer.
On January 5, 2011, plaintiff was seen by Jennifer Whitaker, Advanced Practice
Registered Nurse, at the Mt. Grove Clinic (Tr. at 890-891). Plaintiff arrived alone. She
reported that some nights she sleeps for 12 hours, other nights not as well. Plaintiff had been
out of her Trazodone for 3 months. Plaintiff said her mood was “awesome” on Pristiq, but she
had not taken that medication “for awhile.” Plaintiff said she had seizure disorder. “Tells me
she has recently been out and getting her hair done and she enjoys this.” Plaintiff was alert
and oriented times three. Grooming, dress, and hygiene were good. Her affect was pleasant,
“but she also has some bizarre mannerisms.” Ms. Whitaker restarted all of plaintiff’s
medications. This medical record is the first one showing that plaintiff was prescribed
Depakote.
On January 6, 2011, plaintiff was seen at Mountain Grove Medical Complex for knee
pain and a rash (Tr. at 897-900). She continued to smoke a pack of cigarettes per day.

44

Plaintiff said she twisted her knee when she stepped off her porch. She said she had taken
Zanaflex (muscle relaxer) and cyclobenzaprine in the past which worked well. She said she
has a history of headache and seizures and is not able to take Depakote because it causes
involuntarily movements. However, plaintiff had been prescribed Depakote the day before,
possibly for the first time as it does not appear in any prior medical records, and she would
again be prescribed Depakote in the future. Plaintiff weighed 271 pounds. Under plan, the
doctor noted that plaintiff would need an x-ray when she her insurance became effective, and
that they would “begin process of evaluating knee pain and back pain.”
On January 19, 2011, plaintiff saw Jennifer Whitaker, APRN, at the Mt. Grove Clinic
(Tr. at 892-893). Plaintiff came in alone. “For some reason her Medicaid card is inactive and
she does not know why and she is not able to get her medications.” Plaintiff said she had no
money and could not fill her last prescription. Plaintiff was told she could fill her prescription
at the Family Pharmacy until her Medicaid comes through. She was alert and oriented times
three. Grooming, dress, and hygiene were “just fair.” Eye contact was good. Her mood was
down. She said her son had gone to live with her ex-husband and was only calling her once
every other week.
On January 21, 2011, plaintiff was seen at Mountain Grove Medical Complex to pick
up her medication (Tr. at 901-904). She had not had lab work done as directed. She weighed
273.8 pounds. Her medications were refilled and she was told to have her lipids checked
before her next appointment.
On February 9, 2011, plaintiff was seen at Ozarks Medical Center complaining of
diarrhea (Tr. at 874-875). Her back and extremities were normal; she was alert and oriented
times three with normal mood and affect.

45

On February 10, 2011, plaintiff had a pelvic ultrasound for an unrelated condition (Tr.
at 876).
On March 1, 2011, plaintiff was seen at Ozarks Medical Center (Tr. at 873). She had
an x-ray of her chest which was normal. She was assessed with shortness of breath.
On March 19, 2011, plaintiff was seen at Ozarks Medical Center for rib pain and a
cough (Tr. at 868-872). She was smoking a pack of cigarettes per day. Plaintiff said she had
been treated for pneumonia three weeks earlier; however, there are no records diagnosing her
with pneumonia. Chest x-rays were normal; chest CT scan was essentially normal. Plaintiff
was prescribed an Albuterol inhaler and told to follow up with her primary care physician.
On June 1, 2011, plaintiff saw Shelley Sutton, D.O., at Mt. Grove Clinic (Tr. at 894896). Plaintiff said she had been off her medications from December 2010 through April
2011 due to “medication coverage issues.” Plaintiff had restarted her medications two weeks
earlier. “She has a recent stressor of breaking up with fiancé. . . . She has had multiple
psychiatric hospitalizations. First hospitalization was in 1999 due to ‘nervous breakdown.’ Last
hospitalization was in 2008 at the State Hospital in Arkansas for 2 months. She had been
aggressive towards husband. . . . She used to drink a 6 pack and a pint [of] whiskey per day.
She has had withdrawal and tolerance with alcohol. She quit drinking alcohol about 3 weeks
ago.” Plaintiff reported that her sister was currently in a long-term psychiatric facility for
bipolar disorder and that her mother had that illness as well. Plaintiff was described as
disheveled with fair grooming. She was cooperative and mildly restless. Plaintiff denied
auditory or visual hallucinations. Memory and concentration were fair. Plaintiff was
diagnosed with bipolar disorder mixed severe with psychotic features, post traumatic stress
disorder, and alcohol dependence with a GAF of 40. She was started on Seroquel XR and
continued on Depakote and Pristiq.

46

On June 6, 2011, plaintiff was seen at Mountain Grove Medical Complex due to
vaginal bleeding (Tr. at 913-915). “Discussed possible need for endometrial biopsy depending
on the test results.”
On September 9, 2011, plaintiff had a pelvic ultrasound for an unrelated condition (Tr.
at 867).
On October 6, 2011, plaintiff was seen at Mountain Grove Medical Complex (Tr. at
917-919). She had been out of her Flexeril and Naproxen (muscle relaxer and non-steroidal
anti-inflammatory). She had not been taking Pristiq (antidepressant), she was out of Vistaril
(treats anxiety), she was out of Depakote but denied seizures, and she was out of her thyroid
medication. She was told to resume all of her medications as previously prescribed.
On December 30, 2011, plaintiff saw Mazhar Rahman, M.D., at Ozarks Medical Center
(Tr. at 852-866). She arrived by ambulance and complained of chest pain that had started 3
hours earlier but was better upon arrival. Her chest pain had been a 10/10 but after receiving
nitroglycerin from the paramedics it was reduced to a 1/10. Plaintiff reported her weight as
280 pounds. She was alert and oriented, anxious, in mild distress. Her cardiac exam was
normal, she had normal range of motion in her extremities, her EKG was normal, chest x-ray
was normal. She had a nuclear stress test. “As per the patient, last night she was going to her
boyfriend’s place, and while she was climbing the stairs, all of a sudden, she felt extremely
short of breath, not able to breathe and then she started having chest pain. . . She does have a
history of emphysema and she uses inhaler and as per the patient, she has been off her inhaler
for two days. . . . [S]he did mention she has diarrhea going on for two weeks now. As per the
patient, it was a viral illness and her boyfriend and most of the people there have been having
diarrhea.” Plaintiff said she lost her inhaler. Plaintiff said she stopped smoking three months
ago; she denied drinking and drug abuse history. Plaintiff denied seizure activity, she said she

47

had only common arthralgias in her musculoskeletal system, and her mood was noted to be
stable. She was assessed with chest pain caused by COPD exacerbation. She was discharged
on her normal medication: Advair (inhaler), Synthroid (for hypothyroidism), Lisinopril (for
hypertension), Toprol XL (for hypertension), Pristiq (treats depression), and Albuterol
(inhaler). She was given new prescriptions for Plavix (blood thinner) because she is allergic to
aspirin, and nitroglycerin until she was able to see a doctor on an outpatient basis.
On January 9, 2012, plaintiff saw Dr. Ball and said she wanted a refill of Valium (Tr. at
923). No record to date shows that plaintiff was ever prescribed Valium. Plaintiff was assessed
with anxiety on this day and was prescribed Valium, 10 pills.
On February 7, 2012, plaintiff saw Connie Armstrong, a nurse practitioner, at Ozarks
Medical Center (Tr. at 849-851). She complained of nausea and shortness of breath about 9
hours earlier, but it had resolved by the time she arrived. Plaintiff denied headaches, and she
denied joint pain. Plaintiff continued to smoke, but she reported no alcohol or drug use.
Plaintiff was noted to be alert and oriented times three and in no acute distress, but she was
anxious. Her blood pressure was normal. On exam her back was normal. Extremities had
normal range of motion. She was assessed with “moderate nausea, probable anxiety reaction.”
She was told to rest, with no strenuous activity, “avoid tobacco smoke. Do not smoke. Lose
weight. No alcohol.” She was given a two-day prescription for nausea medication.
On May 11, 2012, plaintiff was seen by Michael Walsh, M.S., a licensed psychologist,
in connection with her disability case (Tr. at 818-827). Plaintiff provided a driver’s license for
identification. Plaintiff’s hygiene was good and she was dressed appropriately. She was
described as positive and cordial. No abnormal gait, posture or motor movements were
observed. Mr. Walsh had no records to review; he relied on plaintiff as the sole source of
information. Plaintiff stated that she was disabled because of arthritis in her legs and back,

48

right leg injury, blood pressure, severe memory loss, heart problems, post traumatic stress
disorder, and chronic migraine headaches. She also alleged disability due to bipolar disorder
“which was not indicated on the allegations form provided by SSDD.”
Plaintiff said that Metoprolol has controlled her heart condition and her hypertension.
Plaintiff said she was an abused wife from 1992 until 2001 when she was hospitalized for 10
days in Arkansas and was discharged to a battered woman’s facility. Plaintiff reported
continuing to have flashbacks to the abuse which give her panic-like symptoms. Plaintiff said
she was diagnosed with bipolar disorder in 2007 when she sought treatment in Mountain
Home, Arkansas, following her inpatient treatment at the Arkansas State Hospital.
She reported that at the time of her diagnosis, she was having mood swings, described
as “being happy and high one moment, unhappy and crying the next.” Asked to
identify her current symptoms related to her bipolar disorder, the claimant reported,
“These mood swings are the only things I can think of.”
Plaintiff said that her severe memory loss began when she working for a pizza place in
2006. “When I worked at Town and Country Donuts, I tried to work, but had memory
problems there also. I’d forget that I had put bread in the oven. Things like that.”
Plaintiff denied any form of abuse during her childhood or adolescence. She said she
has an older sister, age 63, and a younger sister, age 48. Plaintiff was 52 at the time. She was
living with her boy friend and her 16-year-old son at the time of this evaluation. She reported
frequent attendance at a Baptist church. Her hobbies included watching television and
gardening.
Plaintiff has a GED and she completed two college courses in child development.
She stated that her last employment was as a cold food prep delivery driver for Nima’s
Pizza in Mountain Home, Arkansas, where she worked from 2006 until she had a
stroke in 2008. . . . She reported that she has never been terminated or forced to resign
under duress from any of her jobs.

49

Plaintiff said she had last seen Michael Moore, M.D., her primary care doctor, two
months ago for treatment of symptoms related to panic attacks. She reported that he put her on
Valium which was working well. There are no records from a Dr. Moore from two months
earlier, and the records show that plaintiff was prescribed 10 Valium pills by Dr. Ball in
January, but none before and none after that.
Plaintiff reported taking medication for thyroid and hypertension as well as Pristiq
(treats depression) and Depakote (mood stabilizer). She was on no pain medication.
This individual reported having experienced two seizures in her 40s, which she
indicated she was told “were caused by stress.” She indicated one job-related injury: In
1989 while working as an inserter at the Harold Tribune newspaper, “the machine
broke; and some paper fell onto my lower back and messed up two discs. I don’t have
any cartilage in them now. That’s what makes it hard to move.” Medical history is
negative for serious head injuries or loss of consciousness.
The claimant reported no history of psychiatric problems prior to 1994, at which time
she reported that she became acutely suicidal following the stillbirth of her daughter.
She claims at that time, she obtained a gun with the intent of shooting herself. However,
she did not complete the act; and she reported no follow-up mental health treatment as
a result of that episode.
In 2001, the claimant stated that she was placed into the Phelps County Medical
Center’s psychiatric ward for 10 days for treatment of posttraumatic stress disorder
secondary to domestic physical and emotional abuse directed against her by her second
husband. Upon discharge from this admission, she reported that she was referred to a
battered woman’s shelter for assistance. The claimant reported that she did not engage
in outpatient mental health services for continued treatment of this problem following
her release from the Phelps County facility. The clamant reported that her second
psychiatric hospitalization occurred in 2007 at which time she claims to have been
admitted into the Arkansas State Hospital for 45 days of treatment, following discharge
from a two-day stay for treatment at the Baxter County Regional Medical Center
following a “stroke.” I am unclear as to the nature of her report here, as medical
records are unavailable for review and her account of the nature of th is medical
episode makes little clinical sense. If her alleged “stroke” represented a significant
vascular event with debilitating sequelae warranting post-rehabilitation treatment, it is
unlikely that her acute stay at the regional medical facility would be of such short
duration. Further, the Arkansas State Hospital does not provide rehabilitation treatment
for post-stroke injury. The claimant does not evidence any noticeable residual
physiological or linguistic effects consistent with a post-stroke presentation; so I do not
know quite what to make of this report.

50

Plaintiff reported receiving no outpatient mental health services prior to 2007
following her discharge from the Arkansas State Hospital. She was treated in Arkansas from
2007 through 2009 when she moved to Missouri and began treatment at Ozarks Medical
Center.
Despite claiming serious memory problems, plaintiff was able to report that she had
been arrested three or four times for domestic dispute issues, once for possession of marijuana,
twice for public intoxication, once for DWI, and once for a “hot check charge.”
The claimant reported that she has not consumed any alcohol since April 6th of this
year, although she is “trying to quit using it altogether.” She reported that her alcohol
beverage of choice is whiskey; and she noted that at her heaviest usage of this
substance, she has been known to consume a fifth of it at one sitting. Although the
claimant reported a number of alcohol-related criminal convictions, she denied having
a problem handling her alcohol use. This individual reported that she has not used
illicit substances recreationally since 2005 at which time she reported smoking a joint
of marijuana socially in Arkansas. The claimant reported no history of formal
treatment for alcohol or drug-related activity.
The claimant’s ability to engage in age-appropriate ADLs does not appear to be
significantly impaired at the present time, as evidenced by her ability to meet her basic
needs, to engage in housekeeping chores, and to engage in leisure activities including
gardening and other related outdoor activity.
Mr. Walsh administered myriad tests to measure plaintiff’s mental abilities. He
observed that she was alert and oriented to person, place, time, and situation. Attention,
concentration, and working memory were good generally based on her test results. Her
cognitive function was normal, quality of thinking was good, mental control was intact,
intelligence was average. Her eye contact was direct and appropriate. Plaintiff reported that
her mood was tired and depressed. She said her family and friends argue and then try to drag
her into it, but she does not want to take sides. Mr. Walsh observed that plaintiff exhibited
“appropriate periods of smiling and laughter” during the examination. Plaintiff reported that
she sleeps for about 10 hours each night undisturbed. “No physiological, cognitive, or
behavioral indicators of anxiety were noted during the evaluation.” She had no suicidal

51

ideation, she spoke in a spontaneous manner, her speech was normal, thought processes were
logical, coherent and goal directed. “The claimant denied auditory and visual hallucinations;
and there was no objective evidence to suggest any problem with a perceptual disturbance.”
The claimant made no spontaneous reports regarding issues related to her degenerative
arthritis or to her migraine headaches when asked to identify her reasons for seeking
disability, suggesting that these problems likely are either well controlled with her
current medication regimen or that they are not of consequential intensity to warrant
focused attention at the present time. . . . Although she reported a history of bipolar
disorder, she was unable to describe symptoms of her experience of this disorder apart
from generalized “mood swings.” The claimant reported a history of “severe” memory
loss dating back to 2006, although no evidence of such memory loss was observed
during today’s evaluation.
Mr. Walsh assessed post traumatic stress disorder, chronic; bipolar II disorder, most
recent episode depressed, in partial remission; alcohol dependence without physiological
dependence, early full remission; and cannabis abuse by history. With regard to post
traumatic stress disorder and “[b]ased on the claimant’s presentation and on her report of the
experience, however, I believe that this condition is currently of mild severity, perhaps given
her current medication regimen in combination with outpatient therapy; and I do not believe
that it would preclude her ability to engage successfully in gainful employment at this time.”
The claimant reported mood swings consistent with what is often seen in persons with
bipolar disorder. I was unable to elicit from her a history of sufficient intensity of
clinical symptoms that would lead me to believe that she had ever experienced a true
manic episode. Given her description of her symptoms together with her psychosocial
history, intensity of at least one hypomanic episode is more likely. Certainly symptoms
consistent with the depressive spectrum of this disorder are present, although they do
not appear at the moment to meet the requisite number in order to establish a full
major depressive episode. Thus, a diagnosis of Bipolar II Disorder, Most Recent Episode
Depressed, in Partial Remission seems appropriate. This claimant’s current medication
regimen seems to be effective in ameliorating many of the symptoms associated with
this disorder.
He assessed a GAF of 63 and found that plaintiff’s ability to perform work-related functions
“does not appear to be significantly impaired at the present time.” He found that plaintiff is
able to understand and remember complex instructions; sustain concentration and persistence

52

with complex tasks; and interact in high contact situations involving work supervisors,
coworkers, and the general public and adapt to a complex environment (Tr. at 827-830).
On August 28, 2012, plaintiff was evaluated by Philip Brown, Ph.D., in connection with
her disability case (Tr. at 834-842). Plaintiff reported feeling depressed every now and then.
She starts crying for no reason and cannot stop. This happens several times a week, but in
between crying spells she feels relatively good. “I can’t concentrate anymore. I can’t
remember nothing. It’s like in one ear and out of the other.” Plaintiff reported becoming
easily overwhelmed with household chores such as doing laundry or dishes. “Forgetting really
bothers her and leaves her wondering, at times, whether it is worth going on with life.”
Plaintiff has thoughts of suicide “but ‘not real often. It’s been awhile.’ When asked if she has
any intentions of following through on those thoughts, she said, ‘No, because I can’t figure out
how. I don’t think I could ever really hurt myself physically.” Nonetheless, she said that in
April 2011 she ‘drank a massive amount of alcohol, whiskey, in an attempt to ‘kill myself.’ She
said the reason she wanted to kill herself in April 2011 was that she was ‘just tired of being
alone. Not being able to function like I used to.’”
Plaintiff said it takes her forever to get to sleep, and she has had sleep problems for the
last two years. She sleeps for about five hours a night.
Ms. Akkerhuis said there have been times since “2007” when she has heard things.
“It’s like the radio, like you can’t dial it in. And then I’ll go, and the radio isn’t even on.”
She said that in 2010 her son asked to go live with his father, because he grew scared of
her after she started talking about hearing things and asking him if he heard what she
was hearing.
Plaintiff said she wanted to kill herself in April 2011 because she was tired of being
alone. Yet she said later that whenever she is around anyone besides her son, she feels anxious
and panicky, with rapid breathing and difficulty catching her breath. Plaintiff said her
husband tried to kill her three times. Twice he tried to strangle her while she was sleeping,

53

and once he jumped her outside her house with a knife in his hand and attempted to stab her.
She screamed and he froze and then ran away. She has flashbacks “once in a great while.”
Even when she does have flashbacks, they are not as bad as they used to be. She said she
stopped driving because driving a car would spark a flashback because the smell of a car
reminded her of her husband, who was a mechanic. She said she is ok riding in a car if
someone she knows and trusts is driving.
Plaintiff reported a psychiatric hospitalization in 2001 or 2002 after she had a nervous
breakdown. She was in a battered woman’s shelter and could not stop crying. She was
discharged after two weeks. Her second psychiatric hospitalization occurred on November 2,
2007, when she began a more-than-30-day stay at the Arkansas State Hospital due to a second
nervous breakdown. Plaintiff received outpatient services until March 2011 when her
insurance changed to Medicare which required that she pay a co-payment -- “she did not
have the money to pay for any part of the cost of her services.” Plaintiff reported having
several head injuries through the years and “several have resulted in her being rendered
unconscious.”
Plaintiff reported that Valium was helping to control her anxiety, but then added,
“‘staying away from people’ has helped ‘relieve a lot of that stress, that awful panic feeling.’”
Plaintiff reported that she gets along with her 17-year-old son “pretty good.” She had not seen
either stepson since 2008. One of them “robbed her of everything she had” and she was never
close to the other. Plaintiff has one friend to whom she talks on the phone four or five times a
week. In her spare time, she watches television, sits outside when the weather is nice, and
sometimes walks to the store. She goes early in the morning when not many people are
around.

54

Plaintiff reported occasional use of alcohol. “She said there was never a time in her life
when she consumed alcohol daily, but she said that for a period of time after completing high
school she engaged in binge drinking. She said she has never used street drugs”.
Dr. Brown noted that plaintiff smiled at times, her thoughts were organized, she was
alert and oriented in all spheres. “There were several times during this evaluation that she
seemed to had [sic] considerable difficulty remembering parts of her past; she said she has had
problems with her long- and short-term memory functions since ‘2007’.” Plaintiff’s speech
was clear and easily understood, her hygiene was good, and her gait was steady and
unimpaired.
Dr. Brown assessed panic disorder with agoraphobia; major depressive disorder,
recurrent, severe with psychotic features; and post traumatic stress disorder. He assessed a
GAF of 52.
Despite the severity of her psychiatric symptoms and the strong negative impact they
have on her ability to work and interact with others, she has not been actively involved
in psychiatric treatment since March 2011. She cited her primary reason for dropping
out of psychiatric treatment as being unable to afford the co-payment her insurance
(Medicare) required her to pay for such services. Additionally, though, she voiced
dissatisfaction with the services she found saying they did not provide her the progress
toward treatment objective achievement she desired and needed. She does, however,
continue taking two psychotropic medications she had been prescribed prior to
discontinuing her psychiatric services, and it is her primary care physician who has
been prescribing those medications.
Ms. Akkerhuis has been taking an anti-depressant that possibly attenuated her
symptoms of depression to some extent. However, given the frequency of the
unprovoked crying spells she has been experiencing, it appears likely her antidepressant is losing its effectiveness and is, at best, inadequate as a stand-alone
treatment for her depression. She is prescribed and takes an anti-anxiety medication,
but it alone is not and will likely never yield remission of her anxiety symptoms. Her
anxiety is comprised of numerous symptoms including panic attacks, which she is
prone to experience when she has to interact with groups of people, intense fear, strong
feelings of vulnerability, and flashbacks of traumatic events that tend to occur when she
attempts to drive herself to appointments or engagements. Consequently, she has
avoided social contact as much as she possibly can for the past four years, and she
drives herself nowhere.

55

The severity, chronicity, and number of symptoms experienced by Ms. Akkerhuis all
combine to greatly impair her social functioning. With her unable to interact with
others in meaningful, goal-directed ways, it is very unlikely she would be able to secure
and maintain gainful employment -- the problems she faces are numerous. Specifically,
it was apparently to this clinician that she had significant impairment in her abilities to
remember and recall information, and those impairments would make it very difficult
for her to remember work-like procedures, make anything more than the simplest
work-related decisions, and sustain an ordinary routine without special supervision.
The hypervigilance she experiences when she is among a number of people would
almost certainly result in her being unable to establish and sustain the focus needed for
her to perform even simple work-related tasks and see those tasks through to
completion. Her agoraphobic fears are so pronounced that attempting to drive herself
anywhere is something she no longer undertakes. As well, those same fears escalate to
panic when she is in crowded situations and would, thus, preclude her from utilizing
public transportation to and from a job. Her depressed state and symptoms of anxiety
compromise her coping abilities. Her limited threshold for stress-laden situations would
make it very difficult to impossible for her to accept instructions and respond
appropriately to any perceived criticism from supervisors and for her to respond
appropriately to changes in even a routine work setting.
Indeed, Ms. Akkerhuis is in need of mental health treatment. Without ongoing
psychiatric and psychological services, it is very unlikely she will ever be a candidate
for employment. Even with such services in place, getting her symptoms attenuated and
restoring her ability to function adequately among others would be a costly and timeconsuming process. At the very least, she is in need of being re-evaluated by a
psychiatrist and started on a medication regimen that could at least lift her mood and
calm her anxieties. Medication alone would not be enough, though, to restore her
ability to function socially and occupationally. For such to occur, she would have to be
involved in ongoing, regularly scheduled psychotherapy and not supportive
therapy/counseling. Through psychotherapy she could engage in treatments that would
help her learn the cognitive change skills and behavior modifications that could result
in her attenuating and, perhaps, eliminating her panic symptoms. Additionally, in
psychotherapy she could be exposed to cognitive-behavioral procedures that would
help improve her sense of self-esteem and her self-confidence. Again, no one form of
treatment in isolation will ever yield the symptom remission and functional
improvements needed for Ms. Akkerhuis to be able to re-enter the workforce in any
meaningful way, and even with proper treatments, her prognosis is, at best, fair.
On September 3, 2012, Dr. Brown completed a Mental Residual Functional Capacity
Questionnaire (Tr. at 842-847). He found that plaintiff had no mental ability that he would
rate “unlimited or very good.” He found that plaintiff’s abilities are limited but satisfactory in
the following areas:
P

Understand and remember very short and simple instructions

56

P

Carry out very short and simple instructions

P

Ask simple questions or request assistance

P

Be aware of normal hazards and take appropriate precautions

P

Adhere to basic standards of neatness and cleanliness

P

Travel in unfamiliar place
He found that plaintiff’s abilities were seriously limited but not precluded in the

following areas:
P

Remember work-like procedures

P

Maintain attention for two hour segment

P

Maintain regular attendance and be punctual within customary, usually strict
tolerances

P

Sustain an ordinary routine without special supervision

P

Make simple work-related decisions

P

Perform at a consistent pace without an unreasonable number and length of rest
periods

P

Accept instructions and respond appropriately to criticism from supervisors

P

Get along with co-workers or peers without unduly distracting them or exhibiting
behavioral extremes

P

Respond appropriately to changes in a routine work setting

P

Set realistic goals or make plans independently of others

P

Interact appropriately with the general public

P

Maintain socially appropriate behavior

P

Use public transportation
He found that plaintiff was unable to meet competitive standards in the following areas:

P

Work in coordination with or proximity to others without being unduly distracted

57

P

Complete a normal workday and workweek without interruptions from psychologically
based symptoms

P

Deal with normal work stress

P

Understand and remember detailed instructions

P

Carry out detailed instructions

P

Deal with stress of semiskilled and skilled work
He found that plaintiff does not have reduced intellectual functioning and that

plaintiff’s psychiatric condition does not exacerbate plaintiff’s experience of pain or any other
physical symptom. He predicted that plaintiff would likely miss more than four days of work
per month due to her impairments or treatment. Plaintiff is able to manage her own funds,
and alcohol or drug use did not play a part in Dr. Brown’s findings.
Curiously, Dr. Brown also completed a second check-the-box form regarding plaintiff’s
abilities that was a part of this form; however, his findings were not entirely consistent (Tr. at
845-847). For example, despite finding that plaintiff’s ability to understand, remember and
carry out very short and simple instructions was “limited but satisfactory” on page 2 of the
form (Tr. at 846), he found “no observable limits” in plaintiff’s ability to understand,
remember and carry out very short, simple instructions on page 5 of the form (Tr. at 846). He
found no observable limits in plaintiff’s ability to ask simple questions or request assistance on
page 5, but found that plaintiff’s ability to ask simple questions or request assistance was
limited but satisfactory on page 2. He found that plaintiff’s ability to travel in unfamiliar
locations was limited but satisfactory on page 2, but he marked the greatest restriction possible
for this ability on page 5. He found that plaintiff’s ability to set realistic goals or make plans
independently of others was seriously limited but not precluded on page 2, but he again
marked the greatest restriction possible for this ability on page 5.

58

V.

FINDINGS OF THE ALJ
Administrative Law Judge David Fromme entered his opinion on February 11, 2013 (Tr.

at 608-621). Plaintiff’s last insured date is March 31, 2013 (Tr. at 608, 610).
Step one. Plaintiff has not engaged in substantial gainful activity since her alleged onset
date (Tr. at 611).
Step two. Plaintiff has the following severe impairments: lumbosacral degenerative
disc disease; right knee degenerative joint disease; osteoarthritis of the lumbar spine, right
knee, and ankle -- all exacerbated by obesity -- as well as major depressive disorder,
intermittent explosive disorder, post-traumatic stress disorder, and polysubstance abuse (Tr. at
611). Plaintiff did not seek medical treatment for migraine headaches and therefore that
alleged impairment is not medically determinable (Tr. at 611). Plaintiff’s hypothyroidism,
endocrine disorder, hypertension and slight perfusion defects of the heart are non-severe
impairments (Tr. at 611-612). Plaintiff’s chronic obstructive pulmonary disease is non-severe
as plaintiff continued to smoke, chest x-rays were normal, her lungs were clear on
examination, and she has not required any aggressive treatment for this impairment (Tr. at
612). Plaintiff’s alleged history of cerebrovascular accident and multiple traumatic brain
injuries with loss of consciousness are non-severe as they have not required aggressive
treatment and the evidence of their existence is plaintiff’s allegations to emergency room
personnel and others that she has this history (Tr. at 612).
Step three. Plaintiff’s impairments do not meet or equal a listed impairment (Tr. at
612-615).
Step four. Plaintiff has the residual functional capacity to lift and carry 20 pounds
occasionally and 10 pounds frequently, stand and walk for 2 hours per day, and sit for 6 hours
per day. She can perform simple, routine, low-stress work not requiring the following: fast-

59

paced activity, strict and explicit quotas, deadlines, schedules, frequent or unusual changes in
the work setting, interaction with the public, close personal interaction with coworkers, more
than occasional interaction with supervisors, a high level of concentration such as work
requiring sustained attention to detail (Tr. at 616). With this residual functional capacity,
plaintiff is unable to perform her past relevant work as a sandwich maker, assistant restaurant
manager, retail cashier, cashier II, delicatessen cutter/slicer, or pizza cook (Tr. at 620).
Step five. Plaintiff is capable of working as an assembler of plastic hospital products or
a bench assembler, both of which are available in significant numbers (Tr. at 621). Therefore,
plaintiff is not disabled (Tr. at 621).

VI.

CREDIBILITY OF PLAINTIFF
Plaintiff argues that the ALJ erred in finding that plaintiff’s testimony was not credible.
The credibility of a plaintiff’s subjective testimony is primarily for the Commissioner to

decide, not the courts. Rautio v. Bowen, 862 F.2d 176, 178 (8th Cir. 1988); Benskin v.
Bowen, 830 F.2d 878, 882 (8th Cir. 1987). If there are inconsistencies in the record as a
whole, the ALJ may discount subjective complaints. Gray v. Apfel, 192 F.3d 799, 803 (8th Cir.
1999); McClees v. Shalala, 2 F.3d 301, 303 (8th Cir. 1993). The ALJ, however, must make
express credibility determinations and set forth the inconsistencies which led to his or her
conclusions. Hall v. Chater, 62 F.3d 220, 223 (8th Cir. 1995); Robinson v. Sullivan, 956 F.2d
836, 839 (8th Cir. 1992). If an ALJ explicitly discredits testimony and gives legally sufficient
reasons for doing so, the court will defer to the ALJ’s judgment unless it is not supported by
substantial evidence on the record as a whole. Robinson v. Sullivan, 956 F.2d at 841.
In this case, I find that the ALJ’s decision to discredit plaintiff’s subjective complaints is
supported by substantial evidence. Subjective complaints may not be evaluated solely on the
basis of objective medical evidence or personal observations by the ALJ. In determining

60

credibility, consideration must be given to all relevant factors, including plaintiff’s prior work
record and observations by third parties and treating and examining physicians relating to
such matters as plaintiff’s daily activities; the duration, frequency, and intensity of the
symptoms; precipitating and aggravating factors; dosage, effectiveness, and side effects of
medication; and functional restrictions. Polaski v. Heckler, 739 F.2d 1320, 1322 (8th Cir.
1984). Social Security Ruling 96-7p encompasses the same factors as those enumerated in the
Polaski opinion, and additionally states that the following factors should be considered:
Treatment, other than medication, the individual receives or has received for relief of pain or
other symptoms; and any measures other than treatment the individual uses or has used to
relieve pain or other symptoms (e.g., lying flat on his or her back, standing for 15 to 20
minutes every hour, or sleeping on a board).
The specific reasons listed by the ALJ for discrediting plaintiff’s subjective complaints of
disability are based on the lack of clinical and objective findings to substantiate plaintiff’s
complaints of physical limitations, self-reported activities of daily living which are inconsistent
with disability, inconsistencies in her allegations regarding suicide attempts, a failure to avail
herself of treatment for her allegedly disabling mental disorders while seeking medical
treatment for physical conditions, evidence that plaintiff used her Medicaid benefits for other
conditions while claiming she did not know she had the coverage for her allegedly disabling
impairments, and evidence that she stopped working for reasons other than her impairments.
The record in this case supports the ALJ’s determination that plaintiff’s subjective
complaints are not credible. However, disturbingly, I note that plaintiff’s inconsistent
allegations span many years, are sometimes bizarre in nature, and are sometimes provided not
to further her own interests -- the things she says to medical professionals are not always
designed to secure disability benefits or even to secure prescriptions for drugs she might find

61

desirable. There are personality disorders characterized by, among other things, a long history
of “frequent and repeated lying for which no apparent psychological motive or external
benefit can be discerned,” i.e., not told to obtain external benefit or to avoid punishment, but
are rather apparently purposeless. In some cases, the inconsistencies might be
self-incriminating or damaging, which makes the behavior even more incomprehensible.7
This record is replete with instances of far-fetched, easily disproved, and sometimes
bizarre contradictions on plaintiff’s part. Some examples:
—

In a Function Report plaintiff said she cannot drive because her leg hurts too much to
use the gas pedal. She told Dr. Efird in October 2007 in connection with her disability
claim that she let her license expire because of a car accident in April 2007. In 2012 in
connection with her disability claim she said she stopped driving because the smell of a
car triggered flashbacks of her abusive husband, even though she does not have trouble
riding in a car.

—

Plaintiff testified that she weighed 190 pounds in 1993. There are no medical records
from 1993; however, in January 1996 she weighed 270 pounds. She testified in
November 2012 that since she stopped working in April 2007 her weight has “gotten
out of control.” However, her medical records show that from 1996 through 2012, her
weight remained stable, although she was obese that entire time.

—

Plaintiff testified that she was in a bad car accident in April 2007. There are medical
records dating back to 1996; however, there are no medical records substantiating
plaintiff’s testimony that she was ever in a car accident. She did not mention it during a
hospital visit four months later, and she did not mention it to Dr. Efird in October 2007
when he examined her in connection with her disability claim. In November 2008
when plaintiff was hospitalized, she was asked if she had ever been in a severe accident.
She did not report any accident from April 2007, but she did say she had been hit by a
cement truck when she was a teenager, an allegation that appears nowhere else in this
record.

—

Plaintiff testified that she suffered falls at work in June 2006 and February 2007. The
medical records support her allegation of a fall in June 2006; however, there are no
medical records substantiating her claim of a fall in February 2007.

—

Plaintiff testified during the first hearing that she was hit in the head and knocked
unconscious five or six times by her husband. During the second hearing, she testified

7

http://www.psychiatrictimes.com/articles/pathological-lying-symptom-or-disease#sthash.3
vjJe27K.dpuf

62

that her husband would beat her until she was unconscious three or four times a week,
sometimes more often. Plaintiff’s medical records from June 2, 2006, establish that
when she fell at work, she did not lose consciousness. Plaintiff told Dr. Smith in
January 2008 during a consultative examination that she had a history of multiple
closed head injuries due to car accidents and assaults by her spouse, and at least one
incident of being choked to unconsciousness. In May 2012 plaintiff denied any history
of unconsciousness. In August 2012 she told Dr. Brown in connection with her
disability case that she had experienced several head injuries through the years, several
of which had rendered her unconscious.
—

Plaintiff testified in November 2012 that she has a GED and no further education. She
told a social worker in March 2002 that she was a few hours short of having an
Associate’s degree in business. Plaintiff told emergency room personnel in November
2008 that she had a Master’s degree in early childhood education. She told a social
worker in June 2010 that she had a Master’s degree in early childhood education and
taught for more than 20 years. Plaintiff told psychologist Michael Walsh that she had a
GED and had completed two years of college courses in child development.

—

On January 22, 1996, plaintiff denied seizures. The first time seizures were mentioned
by plaintiff was during a consultative examination with Vann Smith, Ph.D., in January
2008 in connection with her disability application. Plaintiff told Dr. Alken in July 2010
that she was taking Depakote for seizures she had been having since her stroke.
Plaintiff had never been prescribed Depakote up to that point and there is no medical
support for her allegation of stroke. In December 2010, plaintiff went to the
emergency room after allegedly falling. She reported a past medical history of seizures.
Plaintiff reported a history of seizures when she was seen at the emergency room in
December 2010. In January 2011 plaintiff told Nurse Jennifer Whitaker that she had a
history of seizures. Ms. Whitaker wrote plaintiff a prescription for Depakote. The very
next day, plaintiff was seen by another medical provider for a rash. She again reported
a history of seizures and said she is not able to take Depakote because it causes
involuntary movements, but that she had taken Flexeril and Cyclobenzaprine (Valium)
in the past which had worked well. Despite her requesting these two medications, it is
not clear that any prescriptions were written that day. In October 2011, plaintiff
denied seizures although she said she had been out of her Depakote. In December
2011, plaintiff went to the emergency room after having fallen down the stairs, and she
denied seizure activity. She was discharged on her normal medication which did not
include any psychotropic medication or seizure medication. In May 2012 plaintiff told
psychologist Michael Walsh, in connection with her disability claim, that she had had
two seizures in her 40s which were caused by stress.

—

On January 3, 2002, plaintiff denied ever having had suicidal ideation. In April 2002,
she said she thought about suicide in 1994 when her baby died -- she took out a gun
and contemplated committing suicide for about five hours. In April 2005, plaintiff
denied suicidal ideation. On October 16, 2007, plaintiff denied suicidal ideation when
being examined in connection with her disability claim. In November 2008 when she
was hospitalized, plaintiff completed a suicide assessment in which she denied a history
of suicide attempt or self harm. In May 2012 in connection with her disability case, she
said she got a gun in 1994 with the intention of shooting herself. In August 2012, she

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told Dr. Brown, in connection with her disability case, that forgetting causes her to
wonder whether it is worth going on with life. She reported that in April 2011 she
drank a large amount of whiskey in an attempt to kill herself.
—

Plaintiff testified in November 2012 that she had to go to the emergency room several
times after her alleged car accident to get pain medication. Plaintiff’s medical records
do not show emergency room visits for pain medication. Plaintiff told a nurse in April
2002 that she had been to the emergency room multiple times due to hives associated
with anxiety and nervousness. The medical records do not support this allegation.

—

Plaintiff testified in November 2012 that she has suffered with migraine headaches for
ten years and that she gets a migraine headache once or twice a month, each lasting for
12 or 13 hours. In February 2012, plaintiff saw Connie Armstrong at Ozarks Medical
Center and denied headaches. There is no complaint of migraine headaches in any
medical record.

—

Plaintiff testified in November 2012 that she has suffered with hallucinations since
2000. In November 2004, she denied hallucinations when being treated by Dr. Austin
for her mental condition. In April 2005, plaintiff saw Dr. Austin for her mental
condition and denied hallucinations. In May 2005, plaintiff denied hallucinations. The
first mention of hallucinations in any medical record is in an October 2007 report of
Dr. Efird who examined plaintiff in connection with her disability claim. She said these
auditory hallucinations started about 4 or 5 months earlier, or in May or June 2007,
and they occur about twice a week. In November 2008 while hospitalized, plaintiff
denied hallucinations. In June 2010, plaintiff told a social worker she had experienced
auditory hallucinations her entire life but they could be controlled with the right
medication. In May 2012 plaintiff denied hallucinations to Mr. Walsh in connection
with her disability case. In August 2012, in connection with her disability case, she told
Dr. Brown that she has experienced auditory hallucinations since 2007.

—

Plaintiff testified in March 2009 that she does not own a television set because she
hears voices from them. Yet in November 2012 she described her day as including
watching movies and the news on television every day.

—

On June 2, 2006, plaintiff denied a history of stroke. On August 26, 2007, she denied a
history of stroke. On June 14, 2010, plaintiff told a social worker that she had a history
of stroke. She said her first stroke occurred on November 12, 2008; however, medical
records show she was in jail on November 11 and was admitted to Arkansas State
Hospital for psychiatric treatment on November 13, and nothing was ever said about a
stroke. Plaintiff said her second stroke occurred on October 12 or 14, 2009; however,
she did not provide any medical records for the entire year of 2009. Plaintiff told Dr.
Alken in July 2010 that she had a stroke on November 13, 2008, again right after she
was in jail. In December 2010, plaintiff went to the emergency room after having
allegedly fallen. She reported that she had had a stroke sometime in the past which
caused her to shuffle rather than walk normally. In December 2010 plaintiff reported
having had a stroke three years earlier. In May 2012, she told psychologist Michael
Walsh, in connection with her disability case, that she had had a stroke in 2008 which
he did not appear to believe.

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—

Plaintiff alleged that she wound up in the hospital in November 2008 because she had
recently learned one of her sons was using methamphetamine which caused her to
become extremely stressed, landing her in the hospital. Elsewhere in the records of that
hospitalization, she said she went to the hospital due to a nose bleed. When she was not
allowed to call her son, she became abusive toward hospital staff and was taken to jail
where she had a psychological screening.

—

Plaintiff reported on March 4, 2002, to a social worker that she started smoking
marijuana at age 13 and using alcohol at age 15. She said she used acid, cocaine, and
mushrooms for 2 1/2 years in her teens. In April 2002, she told a nurse that in
approximately 1993 she drank 1.75 liters of hard liquor every day and that until 5 or 6
years ago she used marijuana on a daily basis. She said she had used
methamphetamine, LSD and speed in the past. In October 2005, plaintiff said she had
been sober since November 7, 2003, and that before then she had been drinking a pint
of alcohol per day. On August 30, 2006, she reported drinking alcohol occasionally. A
year later, on August 26, 2007, she said she had not had any alcohol for the past 10 to
12 years. In October 2007, plaintiff told Dr. Efird in connection with her disability
claim that she had not smoked marijuana in three years and that she has a beer about
twice a year. Plaintiff told Dr. Smith in connection with her disability case in January
2008 that she was a non-drinker. In November 2008, she described having consumed
whiskey the week before. In June 2010 plaintiff told a social worker that she frequently
uses marijuana, “passing a joint, passing a bowl” which, I note, suggests more
interaction with others than is currently alleged. She alleged last using
methamphetamine in 2007. She said she misuses prescription medications, and she
said she was a needle junkie from 1977 through 1980. In June 2011, plaintiff
reported to Dr. Sutton that she previously drank a six pack and a pint of whiskey per
day but that she stopped drinking alcohol 3 weeks earlier. In December 2011, plaintiff
denied drinking and she denied history of drug abuse. In May 2012 plaintiff told Mr.
Walsh that she had not consumed any alcohol since April 6, 2012, and that she had
been known to consume a fifth of whiskey at one sitting. She said she last smoked
marijuana in 2005. Plaintiff told Dr. Brown that there was never a time in her life
when she drank alcohol daily, but she binge drank for a time after completing high
school. She also told him that she “has never used street drugs.”

—

Regarding New Year’s Eve 2001, plaintiff at one time said her husband pushed her
down because she was physically assaulting others, and another time said her husband
tried to choke her that night.

—

Plaintiff told Dr. Austin in November 2004 that she was the youngest of four girls and
always felt like the “add on,” at the bottom of the love chain. In other medical records
plaintiff said she was the third child with a sister several years younger. Plaintiff told a
social worker in June 2010 that she is one of 8 children. She told psychologist Michael
Walsh in May 2012, in connection with her disability case, that she had one older and
one younger sibling.

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In addition to the allegations that are easily disproved, there are many unusual
stories8 told by plaintiff as reflected in her medical records and appear to have no ulterior
motive beyond simply relaying the story:
—

In April 2002, plaintiff told a nurse that she saw her grandmother’s watch in a pawn
shop and went ballistic, requiring the police to be called. However, plaintiff said
elsewhere that her parents were both from New York where she grew up before she
moved away. It is unclear how she would have seen her grandmother’s watch in a
pawn shop in the Midwest. Regardless, there are no other records that mention this
episode.

—

In May 2005, plaintiff told Dr. Austin that she turned in child abusers who came back
on her and she had the police called on her three times in one night and was put in jail
for 4 to 5 hours; her ex husband bailed her out of jail from North Carolina.

—

In October 2007, plaintiff told Dr. Efird, in connection with her disability claim, that
she had been arrested on hot check charges, but that was due to a banking error. She
told a social worker in June 2010 that she wrote hundreds of thousands of dollars’
worth of bad checks and spent a little over a year in prison as a result.

—

Plaintiff told Dr. Austin in November 2004 that she had been going through a divorce
for 2 1/2 years and a typographical error resulted in the whole thing being “thrown
out.”

—

In July 2006, plaintiff told a nurse that she had lost a very good friend the day before in
a terrible motorcycle accident. That traumatic event was never mentioned again in any
of plaintiff’s medical or counseling records.

—

In June 2010, plaintiff told a social worker she had been administered shock therapy in
1980. She said she had been hospitalized for psychiatric reasons at least every 2 years
since she was 17. Yet the records reflect a total of 2 hospitalizations, one prior to
plaintiff’s alleged onset date.

—

Plaintiff told a social worker in June 2010 that she had fibromyalgia, but she has never
even alleged symptoms of fibromyalgia much less been diagnosed with that condition.
She also reported having had breast, ovarian and possibly colon cancer; however, her
medical records do not support these allegations.

—

Plaintiff said she started using methamphetamine in the late 1990s after her husband
put some in her coffee and her son’s coffee. She used it until 2007.

8

I do not mean to suggest that all of these allegations are false. However, given the obvious
conflicting reports given by plaintiff on numerous occasions and the extreme nature of many
of these additional stories, doubt is cast upon their truthfulness as well.

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—

Plaintiff told a social worker that she buys prescription drugs off the black market. She
also reported to the social worker that her mother hit her father and set him on fire.

—

Plaintiff told Michael Walsh in connection with her disability claim that she had been
arrested three or four times for domestic dispute issues, once for possession of
marijuana, twice for public intoxication, once for DWI and one for a hot check charge.
This does not seem to include the alleged arrest after plaintiff turned in child abusers.

—

Plaintiff told Dr. Brown in 2012 that her husband tried to strangle her in her sleep
twice, and once he jumped her with a knife and tried to stab her.

—

One of her step sons robbed her of everything she had.

—

In June 2011, plaintiff saw Dr. Sutton and reported, for the first time, that her sister
was in a long-term psychiatric facility due to bipolar disorder and that her mother
suffered from that condition as well. On that day, plaintiff was given her first
prescription for Seroquel in addition to a refill of Depakote.
I set out these examples of conflicting allegations on plaintiff’s part not merely to affirm

the decision of the Commissioner on this issue but to demonstrate the very strange nature of
plaintiff’s conduct. As mentioned above, this does not appear to be a case where plaintiff’s
conflicting allegations are goal-directed. In fact, in some instances she seems to be sabotaging
her efforts to help herself, for example by describing a serious history of illegal drug abuse and
arrest while attempting to get Social Security disability benefits, when it is not at all clear that
those damaging things actually occurred.
According to the Mayo Clinic:9
Cluster B personality disorders are characterized by dramatic, overly emotional or
unpredictable thinking or behavior. They include antisocial personality disorder,
borderline personality disorder, histrionic personality disorder and narcissistic
personality disorder. It’s not necessary to exhibit all the signs and symptoms listed for a
disorder to be diagnosed.
Antisocial personality disorder
• Disregard for others’ needs or feelings
• Persistent lying, stealing, using aliases, conning others

9

http://www.mayoclinic.org/diseases-conditions/personality-disorders/basics/symptoms/con
-20030111

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• Recurring problems with the law
• Repeated violation of the rights of others
• Aggressive, often violent behavior
• Disregard for the safety of self or others
• Impulsive behavior
• Consistently irresponsible
• Lack of remorse for behavior
Borderline personality disorder
• Impulsive and risky behavior, such as having unsafe sex, gambling or binge eating
• Unstable or fragile self-image
• Unstable and intense relationships
• Up and down moods, often as a reaction to interpersonal stress
• Suicidal behavior or threats of self-injury
• Intense fear of being alone or abandoned
• Ongoing feelings of emptiness
• Frequent, intense displays of anger
• Stress-related paranoia that comes and goes
Histrionic personality disorder
• Constantly seeking attention
• Excessively emotional, dramatic or sexually provocative to gain attention
• Speaks dramatically with strong opinions, but few facts or details to back them up
• Easily influenced by others
• Shallow, rapidly changing emotions
• Excessive concern with physical appearance
• Thinks relationships with others are closer than they really are
Narcissistic personality disorder
• Belief that you’re special and more important than others
• Fantasies about power, success and attractiveness
• Failure to recognize others’ needs and feelings
• Exaggeration of achievements or talents
• Expectation of constant praise and admiration
• Arrogance
• Unreasonable expectations of favors and advantages, often taking advantage of others
• Envy of others or belief that others envy you
Although some of these disorders were mentioned briefly in some of the medical
records, plaintiff has never been examined with an eye toward determining whether she truly
suffers from any of these conditions. In fact, every time plaintiff has been examined by a
mental health expert, her subjective allegations were relied upon heavily and are shown above

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to be not entirely true. As a result, it is not possible to determine, based on this record, whether
plaintiff is currently disabled or whether she was disabled at any time in the past.
Plaintiff argues that she meets Listing 12.08 which reads as follows:
12.08 Personality disorders: A personality disorder exists when personality traits are
inflexible and maladaptive and cause either significant impairment in social or
occupational functioning or subjective distress. Characteristic features are typical of the
individual’s long-term functioning and are not limited to discrete episodes of illness.
The required level of severity for these disorders is met when the requirements in both
A and B are satisfied.
A.

Deeply ingrained, maladaptive patterns of behavior associated with one of the
following:
1.

Seclusiveness or autistic thinking; or

2.

Pathologically inappropriate suspiciousness or hostility; or

3.

Oddities of thought, perception, speech and behavior; or

4.

Persistent disturbances of mood or affect; or

5.

Pathological dependence, passivity, or aggressivity; or

6.

Intense and unstable interpersonal relationships and impulsive and
damaging behavior;

AND
B.

Resulting in at least two of the following:
1.

Marked restriction of activities of daily living; or

2.

Marked difficulties in maintaining social functioning; or

3.

Marked difficulties in maintaining concentration, persistence, or pace; or

4.

Repeated episodes of decompensation, each of extended duration.

Although several mental health professionals have rendered opinions with regard to
plaintiff’s restrictions in activities of daily living; maintaining social functioning; and
maintaining concentration, persistence or pace, as mentioned above, none of these

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professionals has been presented with the overwhelming evidence of plaintiff’s tendency to
present largely conflicting reports about her condition and her past; rather they have relied on
plaintiff’s allegations on that given day without the ability to compare those allegations to her
other statements.

VII.

CONCLUSIONS
The evidence is clear that plaintiff’s physical impairments are not disabling. Physical

examination by Hassan Najeeb Albataineh, M.D., was normal on September 20, 2007.
Physical examination at Arkansas State Hospital was normal in November 2008. When
plaintiff was hospitalized in November 2008, she rated her physical pain the worst it could get,
yet her only pain medication in the hospital was Tylenol. Physical exam in February 2012 was
normal. Plaintiff has almost no medical history of treatment for physical pain.
I also find that the evidence supports the ALJ’s finding that Dr. Brown’s opinion is
deserving of little if any weight. Much of his opinion deals with issues reserved to the
Commissioner, such as whether plaintiff can work. In addition, as discussed above, his opinion
relies heavily on plaintiff’s noncredible subjective allegations, and his opinion is internally
inconsistent.
Finally, I note that during almost all of the time covered by these medical records,
plaintiff was not taking her medication as prescribed or was not participating in therapy as
recommended. Therefore, in addition to determining what plaintiff’s impairments and
restrictions truly are, the Commissioner shall determine whether those impairments can be
controlled if plaintiff were to comply with recommended treatment.
Based on all of the above, I find that the substantial evidence in the record as a whole is
not sufficient to determine whether plaintiff is disabled. Therefore, it is

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ORDERED that the decision of the Commissioner is reversed pursuant to Sentence Four.
It is further
ORDERED that this case is remanded for further consideration which shall include an
additional medical opinion. The medical professional rendering the opinion shall be provided
not only with plaintiff’s medical records but with this order which provides a very detailed
summary of plaintiff’s 948-page administrative transcript for the purpose of tying together all
of her allegations in connection with medical treatment and her attempt to secure disability
benefits. The Commissioner shall conduct another hearing during which plaintiff shall be
given an opportunity to address the issues raised in this order.

ROBERT E. LARSEN
United States Magistrate Judge
Kansas City, Missouri
July 1, 2014

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