Dixon v. Astrue

JAMES S. DIXON, Plaintiff,

v.MICHAEL J. ASTRUE, Commissioner of Social Security Defendant.

Case No. 2: 09CV55 MLM

UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF MISSOURI

NORTHERN DIVISION

Dated: January 03, 2011

MEMORANDUM OPINION

This is an action under 42 U. S. C. § 405(g) for judicial review of the final decision of Commissioner of Social Security Michael J. Astrue ("Defendant") denying the application for Supplemental Security Income ("SSI") under Title XVI of the Social Security Act, 42 U. S. C. §§ 1381 et seq., filed by Plaintiff James S. Dixon ("Plaintiff'). Plaintiff has filed a Brief in Support of Complaint. Doc. 16. Defendant has filed a Brief in Support of Answer. Doc. 20. The parties have consented to the jurisdiction of the undersigned United States Magistrate Judge pursuant to 28 U. S. C. § 636(c)(1). Doc. 21.

I. PROCEDURAL HISTORY

On March 28, 2005, Plaintiff filed an application for SSI, alleging a disability onset date of May 1, 1993. Tr. 53. Plaintiff's application was denied initially on May 26, 2005. Tr. 27; 42-43. ¹

Plaintiff requested a hearing before an Administrative Law Judge ("ALJ"), which was held on April 16, 2007. Tr. 44, 931. By decision, dated September 19, 2007, the ALJ found Plaintiff not disabled. Tr. 19-25. On September 11, 2009, the Appeals Council denied Plaintiff's request for review of the ALJ's decision. Tr. 3-5. Thus, the decision of the ALJ stands as the Commissioner's final decision.

II. MEDICAL RECORDS

A. Missouri Department of Corrections ("MDC") Records:

A Report by Bobbie J. Meinershagen, dated March 31, 2001, reflects that Plaintiff had trouble sleeping and was withdrawn, sad, and "restless or 'bored'"; that he had no symptoms of psychosis; that he had a history of "substance use/abuse, " including alcohol, cocaine, methamphetamine, heroine, marijuana, and acid; that he reported being "'drugged up'" when he committed the crimes for which he was incarcerated and did not remember committing those crimes; and that he reported having mental health problems since he was ten years old and being in and out of residential care from a young age. Ms. Meinershagen also noted that Plaintiff reported memory problems, "but he was able to recall vital information when asked"; that he "seem[ed] to be of average intellectual functioning"; that his diagnoses included bipolar disorder, polysubstance abuse, and antisocial personality disorder; that his Global Assessment of Functioning ("GAF") score was 68; and that he was taking valproic acid and amitriptyline. Tr. 122.

Records of April 11, 2001, reflect that Plaintiff stated he had right ankle and back pain for several years, and physical examination showed that Plaintiff was ambulatory; that he had normal gait; that his back exam was "essentially negative"; that his knee was not swollen or tender; that he had laxity of ligament allowing extreme internal rotation. Tr. 158. Records of April 28, 2001, reflect that Plaintiff was working two shifts at his job and had a GAF of 68. Tr. 123-24. Additional records from the same day reflect that Plaintiff visited the MDC medical staff complaining of back pain; that Plaintiff had equal strength in his extremities and a "range of motion within acceptable limits"; and that Plaintiff had equal and appropriate coordination. Tr. 161.

It was reported on June 21, 2001, that Plaintiff's gait was normal and that there was nothing abnormal in his right hip or knee. Tr. 162. Ms. Meinershagen reported on June 30, 2001, that Plaintiff said he was "doing fine on [his] current medications with counseling every 90 days, " and that his GAF was 62. Tr. 124-25. On August 25, 2001, Ms. Meinershagen reported that Plaintiff was non-compliant with his medications; that his diagnoses included bipolar disorder, polysubstance abuse, and antisocial personality disorder; and that his GAF was 63. Tr. 126-27. On November 30, 2001, Ms. Meinershagen reported that Plaintiff was "doing fine on current meds" with no evidence of psychosis, depression, or anxiety disorder. Tr. 127-28.

On December 13, 2001, Dr. Sadashiv Parwatikar diagnosed Plaintiff with "mood disorder due to head injury [gunshot wound]. " Tr. 128-29. Beverly J. Arndt evaluated Plaintiff on December 17, 2001, and reported that his medications were helping and causing no side effects; that Plaintiff sometimes missed his medications because he got busy; that Plaintiff was oriented, his flow of thought was organized, and his conversation was reality based; that his hygiene was good; that his speech was normal; and that Plaintiff's GAF was 58. Tr. 129-30. On March 4, 2002, Plaintiffwas diagnosed with myopia and astigmatism. Tr. 174.

Ms. Arndt saw Plaintiff, on July 2, 2002, and reported that his mood was "pretty decent... most of the time"; that Plaintiff made good eye contact, initiated conversation, responded to questions, was cooperative, and did not appear anxious or depressed; and that her diagnosticimpressions included bipolar disorder and polysubstance dependence "per psych, " a history of a gunshot wound to the head, and a GAF of 64. Tr. 133.

On July 16, 2002, Plaintiff presented to Nurse Bonnie J. Hayes complaining that since slipping in some water the previous afternoon, while attempting to sit down in his cell, his back hurt in the mid-thoracic region, his ribs felt bruised, and it hurt to take a deep breath. Nurse Hayes reported that Plaintiff's discomfort increased with movement or position change; that he stated that he had two fused discs in his back; that he had no bruising, edema, or redness; that his gait was steady; that he had equal strength in his extremities; that his range of motion was within acceptable limits; that he had equal and appropriate coordination; and that his lungs sounded clear. Nurse Hayes recommended restricting Plaintiff's sports and weight lifting and that he have a "lay in from work and recreation" for 48 hours. Tr. 181-82.

Kathy M. Randolph reported that Plaintiff attended and actively participated in his first weekly group depression therapy session on September 9, 2002; that Plaintiff's psychosocial and environmental stressor was incarceration; and that his GAF was 70. Tr. 136.

Dr. Angeline A. Stanislaus saw Plaintiff on September 24, 2002, and noted that Plaintiff reported "doing well" and that he was tired, which he attributed to his medication; that Plaintiff "appear[ed] to have some cognitive slowing from head injury"; and that he had bipolar disorder, a history of polysubstance abuse, and a gunshot wound to the head "with possible cognitive deficits. " Tr. 138.

On September 30, 2002, Ms. Randolph noted that Plaintiff had been dropped from the depression group therapy group because he had two unexcused absences, and that she was unable to determine Plaintiff's GAF. Tr. 138-39.

Dr. Stanislaus reported on November 19, 2002, that Plaintiff was compliant with his medications and "doing well. " Tr. 139-40. Ms. Randolph reported on January 7, 2003, that Plaintiff "appeared calm and relaxed during this interview and appear[ed] to be maintaining his mental health, " and that Plaintiff's GAF was 70. Tr. 141-42.

Dr. Stanislaus reported, on March 11, 2003, that Plaintiff said that he had felt more depressed recently and that he had trouble sleeping, worsening anxiety, and "significant heartburn" from the valproic acid, which Maalox did not fully control. Dr. Stanislaus prescribed Zantac (ranitidine) to better control Plaintiff's heartburn. Tr. 145-46.

On March 20, 2003, Jane L. Walton saw Plaintiff and reported that Plaintiff's "affect and presentation [had] improved" and that Plaintiff told her he had not had any heartburn since starting Zantac; that he had a good appetite and slept more than seven hours per night; that his depression and anxiety had decreased; that he had no mood swings; and that he read to divert his attention and manage his symptoms. Ms. Walton also reported on this date that Plaintiff's GAF was 60 and that, "per the psychiatrist, " Plaintiff's bipolar disorder was in remission. Tr. 146-47.

Dr. Stanislaus reported, on April 8, 2003, that Plaintiff was doing better after his Elavil and valproic acid dosages were increased; that he slept eight hours and had good appetite, concentration, and energy; that his mood was stable and he had no anxiety symptoms; that his gastric problems had improved since starting Zantac; that he had no side effects from the Zantac and Maalox; and that he refused to allow the medical staff to take his valproic acid level. Tr. 147-49. On May 6, 2003, Dr. Stanislaus reported that there were "no acute stresses. " Tr. 149-50.

Ms. Randolph saw Plaintiff on April 21, 2003, for a 30-day review and stated that Plaintiff did not appear distressed, anxious, or depressed; that he "appear[ed] to be maintaining his mentalhealth"; that he had "no current mental health issues that clinically contraindicate[d] further placement in segregation"; and that his GAF was 70. Tr. 150-51.

Dr. Stanislaus reported on June 11, 2003, that Plaintiff's bipolar disorder was in remission; that he was compliant with his medications and "doing well" with "no complaints"; and that he had refused blood level and lab work twice. Tr. 151. Melissa A. Sanders, who evaluated Plaintiff's mental health the same day, reported that Plaintiff "appeared[ed] to be functioning adequately" and that his GAF was 58. Tr. 151-52.

An MDC physical examination report, dated June 1, 2003, states that Plaintiff had asthma dating to 1995; that he still had asthma at the time of the June 1, 2003 examination; that Plaintiff smoked one and a half packs of cigarettes per day for twenty-eight years; that Plaintiff had acne and joint pain and denied cardiovascular problems; that he had lost weight and was stout; that his lungs exhibited inspiratory wheezing; and that his diagnosis was asthma. Tr. 154-55.

On July 2, 2003, Dr. Michael J. Baglino diagnosed Plaintiff with asthma and prescribed an albuterol inhaler. Tr. 200. Dr. William D. McKinney...