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Buchholz v. Astrue

December 15, 2009


The opinion of the court was delivered by: Joe Billy McDADE United States District Judge


This matter is before the Court on Plaintiff's Motion for Summary Reversal (Doc. 12) and Defendant's Motion for Summary Affirmance (Doc. 13). Plaintiff asks this Court to review, pursuant to 42 U.S.C. § 405(g), the Commissioner of Social Security's determination that she is not disabled within the meaning of the Social Security Act and that she is not eligible for Disability Insurance Benefits and Supplemental Security Income under the Social Security Act. Also pending is Plaintiff's Motion for Leave to File Additional Information (Doc. 15). For the reasons stated below, Plaintiff's Motion for Summary Reversal is denied, and Defendant's Motion for Summary Affirmance is granted. Moreover, Plaintiff's Motion for Leave to File Additional Information is denied.


I. Procedural History

On June 28, 2005, Plaintiff filed applications for Disability Insurance Benefits and Supplemental Security Income, alleging that she became disabled on that date. (Tr. 82, 85). Her applications were denied; Plaintiff filed for reconsideration of the denials, which were subsequently affirmed. (Tr. 25-26, 35, 43-46). Plaintiff requested a hearing before an Administrative Law Judge ("ALJ"), which was held on March 27, 2008. (Tr. 40). The ALJ found that Plaintiff was not disabled on April 9, 2008. (Tr. 13-24). On June 27, 2008, the Appeals Council denied review of the ALJ's decision. (Tr. 4-6).

II. Relevant Medical History

A. Physical Concerns

On November 29, 2006, Plaintiff underwent an X-ray of her lumbar spine, on the order of Dr. John Johnson, her primary care physician, which showed moderate disc space narrowing, no abnormal bone lesion, and well-preserved disc spaces. (Tr. 279). Dr. Johnson saw Plaintiff on December 14, 2006, and found that she had a history of schizophrenia and arthritis, though her physical examination showed no abnormalities. (Tr. 277). On December 31, 2006, Dr. Johnson also filled out a form to allow Plaintiff to receive a reduced bus fare, as she had difficulty walking and boarding a bus.*fn1 (Tr. 273-76). To accompany this form,*fn2 he made a note on December 31, 2006 stating that "patient has degenerative joint disease schizophrenia paranoid fibromyalgia." (Tr. 272). Dr. Johnson saw Plaintiff again on January 18, 2007. He noted that Plaintiff was seeking more pain medication for her lower back, and that she gave inconsistent answers as to whether her current pain medication was effective. (Tr. 271).

On March 1, 2007, Dr. Johnson found that Plaintiff's blood pressure was extremely high, and decided to slowly discontinue Plaintiff's Lyrica medication in order to see if that is what caused the hypertension; he ordered an EKG and chest X-ray. (Tr. 268). The chest X-ray showed that Plaintiff's lungs were clear and that her cardiomediastinal silhouette and pulmonary vessels were within normal limits. It also showed that Plaintiff had a slight spinal curvature. (Tr. 267). Dr. Johnson found on March 12, 2007, that Plaintiff's lab work showed hyperlipidemia, for which he prescribed a heart healthy diet; he also prescribed medication for hypertension and arthritis of the spine. (Tr. 266). He noted that Plaintiff reported her back pain to be about a 7 out of 10, and that it was a dull ache which was worsened by long walks or lifting. (Tr. 266). As he had also previously reported, Dr. Johnson again noted Plaintiff's past medical history of psychological problems, schizophrenia, hypertension, hyperlipidemia, degenerative joint disease, and menopause. (Tr. 266). On the 30th of March, 2007, Plaintiff saw Dr. Johnson. (Tr. 265). There were no changes from the previous visit, except that Plaintiff had stopped taking all of her medications except the anxiety medication; Plaintiff had no complaints. (Tr. 265).

Dr. Johnson saw Plaintiff again on June 27, 2007. Plaintiff asked Dr. Johnson for Lyrica, which she had heard advertised for fibromyalgia. Dr. Johnson explained that Plaintiff had previously been on Lyrica for her arthritis*fn3 and did not like the medication. (Tr. 264). He also noted that Plaintiff was very non-compliant with her medications, stopping all medications on her own, becoming paranoid. (Tr. 264). On September 28, 2007, Plaintiff saw Dr. Johnson for a hypertension follow-up, at which he noted that she was taking medications for anxiety, depression, and menopause. (Tr. 263).

In November 2007, Plaintiff met with Dr. Johnson, requesting medication for the pain she had had in her knee and foot for about two months. Dr. Johnson ordered the medication, as well as an X-ray of her knee and foot, which showed no injury to her foot, and a "possibly evolving bone infarct" of the left knee's distal femur. (Tr. 261-62). Plaintiff reported to Dr. Johnson on November 30, 2007 that the medication he prescribed for her foot, leg, and knee was effective. (Tr. 260). By January 11, 2008, though, Plaintiff had stopped taking all of her medications. She complained to Dr. Johnson of left shoulder pain for the last ten years, for which he ordered an X-ray. (Tr. 258). This X-ray revealed no fracture or dislocation, though an MRI was recommended as there was an area of rarefaction within the humeral head. (Tr. 259). On February 1, 2008, Dr. Johnson noted on a prescription pad that Plaintiff had an abnormal left shoulder X-ray, and that she should have an MRI and consultation with an orthopedic specialist. (Tr. 257).

On January 14, 2008, Plaintiff went to the emergency room with low back pain. (Tr. 284-85). The emergency room doctor's record shows that Plaintiff's pain began with a recent injury caused by sneezing. (Tr. 291). She reported that her pain level was 10 out of 10. (Tr. 287). A physical exam showed full range of motion in Plaintiff's extremities, but a limited range of motion and tenderness in her back, as well as pain on raising her legs. (Tr. 292).

B. Mental Health Concerns

Plaintiff sought treatment at the Robert Young Center, which is a mental health center, on September 29, 2005 for stress and anxiety. (Tr. 346-53). She was initially diagnosed with a delusional disorder, and the interviewer noted paranoid ideation. (Tr. 347, 351). In addition, Plaintiff was given a score of 45 on the Global Assessment of Functioning ("GAF") scale,*fn4 which corresponds to serious symptoms, and was assessed with a severe level of impairment in functioning. (Tr. 347-48).

On October 27, 2005, Plaintiff again visited the Robert Young Center, and was seen by Dr. Ralph Saintfort. (Tr. 343-45). Plaintiff reported feeling intense anxiety, primarily about her ex-husband and her unemployment, though she demonstrated intact reality testing when probed about possible worrisome situations. (Tr. 345-46). Dr. Saintfort noted that Plaintiff had no prior psychiatric history; he diagnosed generalized anxiety disorder and panic attacks without agoraphobia, and gave Plaintiff a GAF score of 55-60, which indicates moderate symptoms. (Tr. 343, 345).

Plaintiff gave a good report to Jan Willis, a counselor at the Robert Young Center, who noted a diagnosis of generalized anxiety disorder and a provisional diagnosis of delusional disorder. (Tr. 342). During a visit on December 8, 2005, Plaintiff stated that she was not moving forward or backward, but felt anxious and jumped from task to task through the day. (Tr. 341). On December 12, 2005, Plaintiff reported to Dr. Saintfort that she had had no recurring anxiety or panic attacks, was sleeping well, had been less frantic, and had no paranoia. (Tr. 340).

Plaintiff again met with Ms. Willis on January 4, 2006, at which meeting Ms. Willis noted that Plaintiff was mildly anxious and that her thinking was delusional. She also noted that Plaintiff went for a five-block walk every day, read, went to the library, and did word searches, though she had to stand up every ten minutes. (Tr. 339). An Individual Treatment Plan was approved by Dr. Saintfort for Plaintiff on January 11, 2006, in which it was noted that she had generalized anxiety disorder, and that delusional disorder should be ruled out. (Tr. 337-38). In addition, Plaintiff was assessed at a GAF level of 60, which indicates moderate to mild symptoms. (Tr. 338). On that same date, Plaintiff was asked about some of the comments made to Ms. Willis that had led Ms. Willis to speculate that Plaintiff was delusional; Plaintiff explained that her comments were misunderstood. The evaluator found that Plaintiff showed intact reality testing, and was calm, organized, and well-related. (Tr. 336).

Plaintiff visited the Robert Young Center again on January 19, 2007, at which time a Diagnostic Assessment Update was completed. (Tr. 331-34). Plaintiff reported that she did not like either Dr. Saintfort or Ms. Willis, and was seeking a new doctor. (Tr. 334). No diagnosis change was indicated: Plaintiff was still diagnosed with generalized anxiety disorder. (Tr. 334). Plaintiff showed agitated activity, a depressed and anxious mood, and agitated behavior, and was normal on other mental status observations. (Tr. 333). Plaintiff was concerned that people that she formerly knew from her work in mental health would see her at the Robert Young Center. (Tr. 332-34). In addition, a new Individual Treatment Plan was prepared on January 29, 2009, in which diagnoses of generalized anxiety disorder and panic disorder without agoraphobia were noted. The objective of Plaintiff's treatment was to reduce her anxiety from a 6 out of 10 to a 2 out of 10. (Tr. 328-29).

Dr. Ernest Galbreath saw Plaintiff on March 21, 2007, at which she reported having anxiety attacks. (Tr. 326-27). On May 23, 2007, Plaintiff met with Dr. Galbreath, who reported that Plaintiff's anxiety was reduced and that she had had no panic attacks since the last visit; she also expressed no feelings of self harm or suicidal thoughts. (Tr. 321). On August 11, 2007, a modified Individual Treatment Plan was prepared for Plaintiff, in which her generalized anxiety disorder and panic disorder were noted, as was her GAF score of 52. (Tr. 319-20).

On August 15, 2007, Plaintiff met with Dr. Todd Pogue at the Robert Young Center for a medication evaluation. (Tr. 317-18). Dr. Pogue noted that Plaintiff complained that other doctors have labeled her a "paranoid schizophrenic" in the past, and that these records were removed from her files. Plaintiff stated she felt she only had anxiety and not paranoid schizophrenia. (Tr. 318). Plaintiff denied hallucinations and paranoid or delusional thoughts. (Tr. 318). Dr. Pogue again met with Plaintiff on August 21, 2007, at which meeting Dr. Pogue discontinued Plaintiff's existing medication, as she appeared to be allergic to it; Dr. Pogue planned to start a new medication in its place. (Tr. 315-16). On September 11, 2007, Dr. Pogue increased the dosage of Plaintiff's new medication, which had been helpful to her. (Tr. 313-14). He assessed Plaintiff with generalized anxiety disorder, panic disorder, and post-traumatic stress disorder. (Tr. 314).

On October 10, 2007, Dr. Pogue signed off on a new Individual Treatment Plan, which listed diagnoses of panic disorder and generalized anxiety disorder, and assessed Plaintiff's GAF level at 52, which indicates moderate symptoms. (Tr. 312). On October 3 and October 31, 2007, Dr. Pogue found that the new medication was effective for Plaintiff; he reported the assessments of generalized anxiety disorder, panic disorder, and post-traumatic stress disorder. (Tr. 309-10). On these dates, Dr. Pogue gave Plaintiff GAF scores of 61-63, which indicate mild symptoms. (Tr. 309-10).

On November 5, 2007, Carla Mohr completed a Diagnostic Annual ReAssessment of Plaintiff. (Tr. 302-08). In this assessment, Ms. Mohr noted that Plaintiff was being treated for anxiety that had resulted in panic attacks. She also noted that Plaintiff had a history of severe abuse as a child and an adult, and had had flashbacks, nightmares, paranoia, and extreme fear. Ms. Mohr found that all of these symptoms had gone into remission, and that Plaintiff was trying to become more social and interact with the world. In addition, she noted that Plaintiff continued to try to obtain disability benefits, as Plaintiff did not think that she could work. (Tr. 308). Plaintiff had paranoia about crowds and about encountering her ex-husband. (Tr. 307). Plaintiff was given a GAF score of 65, which indicates mild symptoms. (Tr. 302).

Plaintiff met with Dr. Pogue on December 20, 2007, and he noted that her therapy was going well and that Plaintiff's medication worked well when she was able to purchase it. (Tr. 301). He signed off on an Individual Treatment Plan on that date, as well, in which he noted that Plaintiff had been diagnosed with generalized anxiety disorder and panic disorder. In addition, a treatment goal of reducing Plaintiff's anxiety from 3 to 1 on ...

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