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Gayle Winter v. Michael Astrue

September 5, 2012

GAYLE WINTER,
PLAINTIFF,
v.
MICHAEL ASTRUE, COMMISSIONER OF SOCIAL SECURITY,
DEFENDANT.



The opinion of the court was delivered by: Barbara A. McAuliffe United States Magistrate Judge

FINDINGS AND RECOMMENDATIONS REGARDING PLAINTIFF'S SOCIAL SECURITY COMPLAINT

BACKGROUND

Plaintiff Gayle Winter ("Plaintiff") seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner" or "Defendant") denying her application for supplemental security income ("SSI") benefits and disability insurance benefits pursuant to Titles II and XVI, respectively, of the Social Security Act. Before the Court is Plaintiff's Opening Brief (Doc.19) and the Commissioner's Response (Doc. 24). The matter is currently before the Court on the parties' briefs, which were submitted, without oral argument, to Magistrate Judge Barbara A. McAuliffe, for findings and recommendations to the District Court.

FACTS AND PRIOR PROCEEDINGS*fn1

Plaintiff filed an application for benefits on January 18, 2008, alleging disability beginning February 28, 2006, which she later amended to August 31, 2007. AR 88-92, 96-100. Plaintiff's application was denied initially and on reconsideration, and she requested a hearing before an Administrative Law Judge ("ALJ"). AR 100. ALJ Timothy Snelling held a hearing and subsequently issued an order denying benefits on December 15, 2009, finding Plaintiff was not disabled. AR 26-41. This appeal followed.

Medical Record

The record is summarized here in chronological order with particular regard to the reports relating to Plaintiff's alleged mental impairments. Nonetheless, the record as a whole was reviewed and will be specifically referenced as necessary to this Court's decision. AR 233-352.

Notes prior to Plaintiff's alleged disability onset date of August 31, 2007, reveal that Plaintiff had a long history of a bipolar disorder and alcohol abuse. AR 234. Such notes further show that Plaintiff was seen in April 2006 by Paul McGrew, M.D., and reported that she had not been to a doctor in more than four years. AR 245. At that time, Plaintiff stated that she had been off her medications for several weeks and needed refills. AR 245.

On August 31, 2007, Robert Chin, M.D., treated Plaintiff for complaints of depression. AR 244. Dr. Chin diagnosed bipolar affective disorder, moderate depression, and "unspecified" alcoholism and noted a prescription for Depakote and Lexapro. AR 244. The following month, Plaintiff told Dr. Chin that her depression was "about the same." AR 243. Dr. Chin noted that Plaintiff had appropriate judgment, mood, and affect and normal memory. AR 243. Dr. Chin's diagnosis remained unchanged. AR 243. Dr. Chin wrote new prescriptions for Wellbutrin, Seroquel, and Depakote and discontinued Divalproex. AR 243. At Plaintiff's October 2007 visit, Dr. Chin noted that "Seroquel caused excess sedation." AR 242. Dr. Chin made no changes to Plaintiff's diagnosis or prescriptions. AR 242. The next month, Dr. Chin noted that Plaintiff had appropriate judgment, mood, and affect but also pressured speech and verbosity and was in a manic phase. AR 241. The doctor switched Plaintiff to Zyprexa. AR 241.

Later in the month, Dr. Chin observed that Plaintiff's speech was less pressured. AR 240. Dr. Chin prescribed Zyprexa and discontinued Seroquel. AR 240. Dr. Chin again noted appropriate judgment, mood, and affect and normal memory. AR 240. In December 2007, Dr. Chin again noted appropriate judgment, mood, and affect and normal memory and diagnosed bipolar affective disorder and moderate depression. AR 239. The doctor continued Plaintiff's prescription of Zyprexa. AR 239.

In a January 2008 follow-up visit with Dr. Chin, Plaintiff reported less inactivity and "[s]till feel[ing] some depression" but "feel[ing] better" since stopping Zyprexa several days earlier. AR 238. Dr. Chin again noted appropriate judgment, mood, and affect and normal memory and wrote a new prescription for Celexa. AR 238.

At her March 2008 visit with Dr. Chin, Plaintiff stated that she was sleeping "okay" and not hypomanic. AR 276. She acknowledged that when she was manic, she over-shopped. AR 276. Dr. Chin continued her prescription of Depakote. AR 276. At Plaintiff's visit the following month, Dr. Chin's diagnosis remained unchanged. AR 275. Dr. Chin wrote a new prescription for Olanzapine-Fluoxetine. AR 275. In May 2008, Dr. Chin put Plaintiff on a "trial" of Topamax. AR 274. At the June 2008 visit, Dr. Chin encouraged Plaintiff to increase Topamax "as tolerated." AR 273. Dr. Chin again remarked that Plaintiff had appropriate judgment, mood, and affect and normal memory, and the doctor's diagnoses remained unchanged. AR 273. In August 2008, Plaintiff reported that she felt unmotivated but had stopped drinking alcohol one month earlier. AR 271. Dr. Chin noted that Plaintiff had a mildly depressed affect and depression. AR 271.

In October 2008, M.J. Hetnal, M.D., a psychiatrist, began treating Plaintiff. AR 290-93. Plaintiff reported that she was hypomanic and energetic "most of her life" and "did okay" until 1995 or 1996 when she was raped by her boss. AR 290. She admitted to "periods of times lasting for a few days at the time with excessive energy, money spending, impulsiveness and lack of sleep." AR 290.

During one of those periods, she claimed to have purchased six cars. AR 290. She reported "feeling increasingly depressed in the last nine months with increasing symptoms in the last three months." AR 290. She told Dr. Hetnal that she was sad, unable to enjoy things, felt worthless, slept excessively, and had no energy or motivation. AR 290. She admitted to crying spells, being isolated, and having suicidal thoughts but no intent or plan to kill herself. AR 290. She reported tolerating medication well. AR 291. She said she worried excessively, experienced one prior panic attack, and acknowledged being "quite angry-verbally." AR 291. She denied significant mood swings since 2003, and Dr. Hetnal observed that she appeared "predominantly depressed at present." AR 291. She admitted that Depakote helped with her mood swings but said she could not tolerate Seroquel, Wellbutrin, or Topamax. AR 291. Plaintiff also admitted to abusing alcohol, having 8 to 10 drinks per day and a history of blackouts, but asserted that she had been sober for previous six months. AR 291.

On examination, Dr. Hetnal observed that Plaintiff was alert, oriented, and cooperative and that her speech was "somewhat slow" but goal-oriented. AR 292. The psychiatrist noted that Plaintiff appeared depressed and admitted to suicidal thoughts but denied intent and had no gross thought disorder. AR 292. Plaintiff reported that her memory was not as good as it used to be, and Dr. Hetnal noted that Plaintiff's concentration and attention were "somewhat decreased." AR 292. Dr. Hetnal, however, found that Plaintiff's cognitive functioning and (remote and recent) memory were intact and that her judgment and insight were good. AR 292. Dr. Hetnal diagnosed bipolar disorder with current depressive disorder, ruleout anxiety and panic disorders, and alcohol abuse in remission. AR 292. Dr. Hetnal also noted financial stress and "disability from work" and assigned a Global Assessment Functioning (GAF) score of 50.*fn2 AR 292. More specifically, Dr. Hetnal stated that Plaintiff had a history of bipolar disorder since 1995 and was "predominately depressed for the last nine months." AR 293. Dr. Hetnal made no changes to Plaintiff's medications and noted that Plaintiff "remain[ed] disabled from work." AR 293.

Notes in the latter half of 2009 show that Plaintiff's doctors continued to make adjustments to ...


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