United States District Court, D. South Carolina
REPORT AND RECOMMENDATION
V. Hodges United States Magistrate Judge
appeal from a denial of social security benefits is before
the court for a Report and Recommendation
(“Report”) pursuant to Local Civ. Rule
73.02(B)(2)(a) (D.S.C.). Plaintiff brought this action
pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3) to
obtain judicial review of the final decision of the
Commissioner of Social Security (“Commissioner”)
denying her claim for Disability Insurance Benefits
(“DIB”). The two issues before the court are
whether the Commissioner's findings of fact are supported
by substantial evidence and whether he applied the proper
legal standards. For the reasons that follow, the undersigned
recommends that the Commissioner's decision be reversed
and remanded for further proceedings as set forth herein.
January 5, 2015, Plaintiff protectively filed an application
for DIB in which she alleged her disability began on December
20, 2013. Tr. at 147- 50. Her application was denied
initially and upon reconsideration. Tr. at 93- 96, 101-06. On
June 29, 2017, Plaintiff had a hearing before Administrative
Law Judge (“ALJ”) Nicholas Walter. Tr. at 29-62
(Hr'g Tr.). The ALJ issued an unfavorable decision on
November 17, 2017, finding Plaintiff was not disabled within
the meaning of the Act. Tr. at 9-28. Subsequently, the
Appeals Council denied Plaintiff's request for review,
making the ALJ's decision the final decision of the
Commissioner for purposes of judicial review. Tr. at 1-6.
Thereafter, Plaintiff brought this action seeking judicial
review of the Commissioner's decision in a complaint
filed on October 16, 2018. [ECF No. 1].
Plaintiff's Background and Medical History
was 42 years old at the time of the hearing. Tr. at 35. She
completed high school. Tr. at 38. Her past relevant work
(“PRW”) was as an accounting clerk, a tax
auditor, a court clerk, and a loan clerk. Tr. at 58. She
alleges she has been unable to work since December 20, 2013.
Tr. at 42.
January 9, 2014, Plaintiff presented to Joseph Friddle, P.A.
(“P.A. Friddle”), for follow up for bipolar I
disorder. Tr. at 281. She reported stable mood and good sleep
and denied psychosis, suicidal ideation, and homicidal
ideation. Id. She complained of stress. Id.
P.A. Friddle indicated normal findings on mental status exam,
aside from poor judgment. Id. He changed
Plaintiff's Lamictal prescription to 100 mg twice a day
and continued Prozac and Seroquel. Id.
January 14, 2014, Plaintiff reported stiffness lasting three
hours, fatigue, weight gain, poor sleep, dry eyes, shortness
of breath, and pain in her legs, arms, hands, lower back, and
neck. Tr. at 392. She indicated she was unable to afford
Lyrica and was taking no medication for pain. Id.
She stated she had stopped working because of stress.
Id. She indicated she had been walking and
stretching. Id. Rheumatologist Mayur Patel, M.D.
(“Dr. Patel”), noted he was only able to
prescribe limited medications because of Plaintiff's
bipolar disorder. Id. He observed Plaintiff to have
greater than 12 tender points, but noted no other
abnormalities on physical exam. Tr. at 392-93. He stated
Plaintiff had experienced cognitive decline. Tr. at 393. He
indicated a diagnosis of fibromyalgia, instructed Plaintiff
to engage in regular exercise, and prescribed Flexeril 5 mg
and Tramadol 50 mg three times daily for pain. Id.
12, 2014, Plaintiff reported five hours of stiffness,
fatigue, weight gain, poor sleep, dry eyes, eye pain, cough,
shortness of breath, chest pain, nausea, vomiting, diarrhea,
reflux symptoms, scapular muscle tenderness, pain in her legs
and feet, stiffness in her elbows, and difficulty rising from
a squatting position. Tr. at 395. She indicated she had
stopped working because of pain and complained her
medications were too expensive. Id. Dr. Patel
observed Plaintiff to have greater than 12 tender points, but
noted no other abnormalities on physical exam. Tr. at 395-96.
He discontinued Flexeril, prescribed Tizanidine 2 mg twice
daily, and continued Tramadol. Tr. at 396. He advised
Plaintiff to follow up with her primary care physician for
10, 2014, Plaintiff continued to be pleased with her
medications. Tr. at 282. P.A. Friddle indicated normal
findings on mental status examination, aside from poor
presented to Spartanburg Regional Emergency Center for chest
pain on August 24, 2014. Tr. at 285. A chest x-ray and
cardiac enzymes were normal. Id.
September 11, 2014, Plaintiff reported she had discontinued
Tramadol, Lyrica, and Tizanidine because one of the
medications was making her sick and causing drowsiness. Tr.
at 397. She complained of pain all over. Id. Dr.
Patel noted greater than 12 tender points and flat affect,
but no other abnormalities on physical exam. Tr. at 397-98.
He instructed Plaintiff to stop Flexeril and Tizanidine, hold
Tramadol, and take Lyrica 75 mg twice daily. Tr. at 398. He
stated he might need to refer Plaintiff to a pain management
was transported to Wallace Thomson Hospital on September 29,
2014. Tr. at 339. She admitted that she had overdosed on
medication in a suicide attempt. Id. She had two
seizures while in the emergency room and was subsequently
nonresponsive. Id. The attending physician admitted
Plaintiff to the intensive care unit with acute respiratory
failure, aspiration pneumonia, septic shock, drug overdose,
bipolar disorder with depression, suicidal actions, metabolic
and lactic acidosis, multiple seizures, elevated ammonia
level, and herpes zoster. Tr. at 333. He discharged Plaintiff
to an inpatient psychiatric facility on October 13, 2014,
after her conditions stabilized. Tr. at 336.
was involuntarily committed to Patrick B. Harris Psychiatric
Hospital from October 13 through October 28, 2014. Tr. at
382-88. Upon admission, she reported feeling depressed over
the prior year. Tr at 382. Psychiatrist Amara Chudhary, M.D.
(“Dr. Chudhary”), prescribed Venlafaxine ER 150
mg, Topamax 75 mg, Latuda 20 mg, Lamictal 50 mg, and Protonix
40 mg. Id. Plaintiff reported improvement and denied
side effects from medication. Tr. at 382-83. Dr. Chudhary
recommended Plaintiff's outpatient psychiatrist continue
to titrate Lamictal up to an optimal dose of 200 mg. Tr. at
383. She also instructed Plaintiff's roommate to maintain
her medications and dispense them to her at the appropriate
times. Id. She diagnosed bipolar disorder, not
otherwise specified (“NOS”) and pain disorder
associated with both psychological factors and general
medical condition. Id. She observed Plaintiff to
have no abnormalities on mental status exam and assessed a
global assessment of functioning
(“GAF”) score of 65 at the time of discharge.
Id. She noted Plaintiff was court-ordered to follow
up with an outpatient mental health provider. Tr. at 384.
presented to Union Mental Health for an initial clinical
assessment on November 4, 2014. Tr. at 406. James W. Platt,
M. Div. (“Mr. Platt”), indicated the following
abnormal findings on mental status exam: tearful affect;
anxious, depressed mood; difficulty with word-finding and
organizing thoughts; decreased appetite; and phobias. Tr. at
408-09. He recommended individual treatment with cognitive
behavioral therapy (“CBT”) twice a month and
indicated Plaintiff should consider group therapy, as well.
Tr. at 409.
presented to Austin McElhaney, M.D. (“Dr.
McElhaney”), on November 7, 2014. Tr. at 389. Dr.
McElhaney noted no abnormalities on physical exam. Tr. at
390. He planned to slowly taper Plaintiff off Topamax because
she had no history of seizures prior to her suicide attempt.
Tr. at 391. He decreased Topamax from 75 mg to 25 mg twice a
day and replaced Protonix with Ranitidine 75 mg twice a day.
Tr. at 390. Dr. McElhaney referred Plaintiff to a
neurologist. Tr. at 391.
January 20, 2015, Plaintiff reported four hours of stiffness,
fatigue, poor sleep, shortness of breath, nausea, reflux, and
side effects from medications. Tr. at 399. She complained of
pain in the left trochanteric bursa and denied performing
exercises. Id. Dr. Patel indicated left trochanteric
bursitis, flat affect, and greater than 12 tender points on
physical exam. Tr. at 400. He administered a Cortisone
injection for left trochanteric bursitis and recommended
Plaintiff engage in 20 minutes of daily yoga and 10-15
minutes of daily meditation. Id.
January 29, 2015, Plaintiff presented to neurologist Carol A.
Kooistra, M.D. (“Dr. Kooistra”), for an initial
examination. Tr. at 402-03. She indicated her headaches were
controlled and she had no history of seizures, aside from the
two she experienced while hospitalized for an overdose. Tr.
at 402. Dr. Kooistra noted no abnormalities on physical exam.
Id. She advised Plaintiff to taper off Topamax by
reducing it to one pill a day for two weeks and then
discontinuing it. Id.
progress summary dated February 2, 2015, Mr. Platt noted
Plaintiff was attending weekly group therapy and monthly
individual therapy. Tr. at 405. He requested authorization
for Plaintiff to attend twice monthly individual therapy
sessions. Id. He stated Plaintiff needed to remain
in treatment to reduce panic and increase functioning through
CBT and mood mindfulness. Id.
March 10, 2015, Plaintiff presented to psychiatrist Eric K.
Winter, M.D. (“Dr. Winter”), for an initial
psychiatric medical assessment. Tr. at 425- 26. Dr. Winter
noted Plaintiff had been ordered by the court to attend
treatment and that her partner was administering her
medications. Tr. at 425. Plaintiff reported anxiety and
difficulty sleeping, but indicated fewer depressive symptoms
and no suicidal ideation. Id. A mental status
examination was normal, aside from depressed and anxious
mood. Tr. at 425. Dr. Winter assessed bipolar I disorder and
a GAF score of 55. Tr. at 426. He prescribed Lamictal 100 mg,
Venlafaxine XR 150 mg, and Latuda 20 mg. Id.
agency consultant Silvie Kendall, Ph.D. (“Dr.
Kendall”), reviewed Plaintiff's records and
completed a psychiatric review technique (“PRT”)
form on March 17, 2015. She considered Listing 12.04 for
affective disorders and assessed the following degrees of
functional limitation: moderate restriction of activities of
daily living (“ADLs”); moderate difficulties in
maintaining social functioning; moderate difficulties in
maintaining concentration, persistence, or pace; and one or
two repeated episodes of decompensation. Tr. at 68. She
completed a mental residual functional capacity
(“RFC”) assessment and found Plaintiff to be
moderately limited with respect to the following abilities:
to understand and remember detailed instructions; to carry
out detailed instructions; to maintain attention and
concentration for extended periods; and to interact
appropriately with the general public. Tr. at 71-73. She
explained Plaintiff could “understand and remember
simple instructions, but may have difficulty with detailed
instructions”; could “carry out simple tasks and
instructions”; could “maintain concentration and
attention for periods of at least 2 hours”; could
“carry out simple tasks for 2 hours at a time”;
“would perform best in situations that do not require
ongoing interaction with the public”; and could
“be aware of normal hazards and take appropriate
precautions.” Tr. at 73. She stated Plaintiff's
impairments “would not preclude the performance of
simple, repetitive work tasks” and “would not
preclude her from carrying out basic work functions.”
March 17, 2015, state agency medical consultant Donna Stroud,
M.D. (“Dr. Stroud”), reviewed Plaintiff's
records and completed a physical RFC assessment. Tr. at
69-71. She indicated the following limitations: occasionally
lifting and/or carrying 50 pounds; frequently lifting and/or
carrying 25 pounds; standing and/or walking for a total of
about six hours in an eight-hour workday; sitting for about
six hours in an eight-hour workday; frequently climbing
ramps, stairs, ladders, ropes, and scaffolds; unlimited
balancing, stooping, kneeling, crouching, and crawling; and
avoiding concentrated exposure to hazards. Id.
April 25, 2015, Joseph G. Grace, Ph.D. (“Dr.
Grace”), provided a psychological evaluation for
disability that was based on findings from clinical
interviews of Plaintiff and testing administered on April 17
and 25, 2015. Tr. at 411. Plaintiff reported the following
symptoms: depressed mood for the entirety of most days;
anhedonia; obsessional worry and increased anxiety; initial
and terminal sleep disturbances; extreme fatigue with little
stamina; loss of motivation for productive and recreational
activities; decreased concentration and short-term memory;
decreased ability to make routine decisions; increased
irritability and decreased frustration tolerance; decreased
libido; increased social withdrawal; frequent, intense pain
symptoms; recurring and distressing thoughts regarding
traumatic experiences; recurring and distressing dreams;
persistent, bothersome thoughts, discomfort and awkwardness
around others; panic episodes in public places; shortness of
breath and dizziness without exertion; and gastrointestinal
(“GI”) upset. Tr. at 414-15. She indicated she
had withdrawn socially to prevent panic attacks. Tr. at 415.
She stated the following symptoms were made less intense by
use of prescribed medications: extreme mood and energy
fluctuations; pressure of speech; racing thoughts; episodes
of poor judgment; fluctuations in quantity and quality of
work; feelings of restlessness, agitation, and anger without
provocation; extreme problems with attention and
concentration; alternating periods of great optimism and
pessimism; and moods interfering with productivity and
interpersonal relationships. Id. Dr. Grace
administered the Minnesota Multiphasic Personality Inventory,
second edition (“MMPI-2”) and interpreted
Plaintiff's scores to be a valid reflection of her
personality dynamics and emotional stability. Id. He
stated the clinical scales revealed Plaintiff to be
“profoundly depressed, severely anxious and in rather
tenuous contact with reality.” Id. He noted
Plaintiff was “overwhelmed with problems, guilt-ridden
and fe[lt] hopeless, helpless and inadequate.”
Id. He observed Plaintiff to be “extremely
despondent, slowed in thought and action, lacking in energy,
unable to concentrate, very distressed and [to] feel
miserable.” Id. He stated Plaintiff had
“distanced herself physically and emotionally from
others to avoid hurt and rejection, ” causing her to be
“very withdrawn, alienated, feel misunderstood”
and to not be “part of her social community.”
Id. He indicated Plaintiff was “an obsessional
worrier who [was] quite tearful and extremely insecure with
numerous phobias.” Tr. at 415-16. He indicated
Plaintiff was “emotionally unstable, bitter over her
plight in life and prone to exercise poor judgment.”
Tr. at 416. He noted from a positive perspective that
Plaintiff was empathic, considerate of others, had the
propensity to be rather idealistic, and had the capacity to
be realistic and responsible. Id. He concluded
Plaintiff had “been handicapped psychiatrically,
socially, physically and vocationally by her mother's
abandonment of her at age 5, her father's untimely death
at age 17, and a poor psychiatric and organic genetic
endowment.” Id. He assessed panic disorder,
agoraphobia, posttraumatic stress disorder
(“PTSD”), bipolar II disorder, borderline
personality disorder, and schizoid personality disorder
features. Tr. at 416-17. He noted a GAF score of
progress summary dated May 3, 2015, Mr. Platt noted Plaintiff
had discontinued group therapy, but was attending individual
therapy twice a month. Tr. at 424. He indicated Plaintiff was
progressing toward goals, but needed to remain in treatment
to prevent decompensation. Id. On June 3, 2015, Mr.
Platt indicated Plaintiff was attending individual therapy
twice a month and making progress toward her goals. Tr. at
23, 2015, Plaintiff denied significant side effects and
indicated her medications had helped to stabilize her mood.
Tr. at 451. Dr. Winter noted Plaintiff was mildly anxious and
not very forthcoming, but was endorsing improvement.
Id. He observed anxious mood and mild impairment to
attention and concentration, but indicated no other
abnormalities on mental status exam. Id. He assessed
a GAF score of 60 and instructed Plaintiff to follow up in
four months. Id.
22, 2015, Plaintiff reported three to four hours of stiffness
during the day, constant symptoms, and a pain level of eight.
Tr. at 435. She complained of fatigue, weight gain, poor
sleep, dry and red eyes, shortness of breath, nausea,
diarrhea, constipation, reflux symptoms, and bruising.
Id. She indicated she was engaging in yoga and pool
exercises. Id. Dr. Patel noted kyphosis of the
spine, multiple paraspinal pains, flat affect, and greater
than 12 tender points, but stated Plaintiff had normal ROM,
strength and tone in her bilateral upper and lower
extremities. Tr. at 436. He prescribed Naltrexone 4.5 mg at
bedtime and refilled Robaxin 500 mg and Tylenol with Codeine
300-30 mg. Tr. at 436-37.
August 11, 2015, a second state agency consultant, Janet
Telford-Tyler, Ph.D. (“Dr. Telford-Tyler”),
completed a PRT form and mental RFC assessment. Tr. at 83-84,
87-89. She considered Listing 12.04 for affective disorders
and assessed the following degrees of functional limitation:
mild restriction of ADLs; moderate difficulties in
maintaining social functioning; moderate difficulties in
maintaining concentration, persistence, or pace; and no
episodes of decompensation. Tr. at 84. She indicated on a
mental RFC assessment that Plaintiff had moderately-limited
abilities to maintain attention and concentration for
extended periods; to complete a normal workday and workweek
without interruptions from psychologically-based symptoms; to
perform at a consistent pace without an unreasonable number
and length of rest periods; and to interact appropriately
with the general public. Tr. at 87-89. She stated Plaintiff
was able to “understand, remember, and carry out simple
and detailed instructions and to follow work related
procedures with infrequent difficulty on complex tasks
possible.” Tr. at 89. She indicated Plaintiff could
“maintain attention and perform at an acceptable
consistent pace on simple and detailed tasks for 2 hour
periods, over 8 hour work days and 40 hour work weeks with
normal breaks and without interruption from psychologically
based symptoms[, ] but would have occasional difficulty with
complex tasks.” Id. She noted Plaintiff would
be able to work “under ordinary supervision, ”
“make simple work-related decisions, ” and
“maintain regular attendance and punctuality.”
Id. She stated Plaintiff was “capable of
relating appropriately on a casual basis with the general
public[, ] but would do better on tasks requiring minimal
contact with the general public in order to avoid
stress.” Id. She indicated Plaintiff was
capable of “accept[ing] direction and criticism from
supervisors, ” “relat[ing] appropriately to
co-workers without unduly distracting them or exhibiting
behavioral extremes, ” “asking simple and
detailed questions, ” “making requests for
assistance, ” “adapt[ing] to routine changes in
the work setting, ” “avoid[ing] normal hazards
and tak[ing] appropriate precautions when needed, ”
“setting realistic goals, ” and “making
plans independently of others.” Id.
August 27, 2015, Dr. Winter authorized Plaintiff to attend
weekly individual therapy. Tr. at 448.
September 11, 2015, a second state agency medical consultant,
Sannagai Brown, M.D. (“Dr. Brown”), assessed the
following limitations on a physical RFC assessment:
occasionally lifting and/or carrying 20 pounds; frequently
lifting and/or carrying 10 pounds; standing and/or walking
for about six hours in an eight-hour workday; sitting for
about six hours in an eight-hour workday; occasionally
climbing ramps and stairs; never climbing ladders, ropes, or
scaffolds; frequently balancing, stooping, kneeling,
crouching, and crawling; and avoiding even moderate exposure
to hazards. Tr. at 85-87.
November 17, 2015, Plaintiff indicated her symptoms had
improved on medication. Tr. at 443. She expressed concern
over drug interactions, and Dr. Winter found possible
negative interactions between Latuda and her other
medications. Id. Dr. Winter noted no abnormalities
on mental status examination. Id.
January 20, 2016, Plaintiff endorsed constant symptoms of
polyarthritis with limited improvement in response to medical
therapy. Tr. at 432. She indicated she was using medication
and rest to improve her symptoms. Id. She reported
her pain as an eight on a 10-point scale and complained of
stiffness. Id. She endorsed the following additional
symptoms: fatigue, poor sleep, dry eyes, cough, shortness of
breath, chest pain, nausea, vomiting, diarrhea, and reflux
symptoms. Tr. at 433. Plaintiff reported some relief with
Tylenol with Codeine and Robaxin, but complained that
Naltrexone caused nausea. Id. She endorsed pain in
her left hip and right radial thumb following a recent fall.
Id. Dr. Patel noted greater than 12 tender points,
kyphosis in the spine, and multiple pains in the paraspinal
region, but also observed Plaintiff to have normal range of
motion (“ROM”), strength, and tone in the
bilateral upper and lower extremities. Id. He
administered Lidocaine and Methyl Prednisolone SR injections
to treat left trochanteric bursitis and right
DeQuervain's tenosynovitis. Id. He recommended
Plaintiff engage in regular exercise and continued her
prescriptions for Robaxin and Tylenol with Codeine. Tr. at
January 25, 2016, Plaintiff presented to gastroenterologist
Peter J. Kobes, M.D. (“Dr. Kobes”), for fecal
incontinence, left lower quadrant pain, nausea, vomiting,
diarrhea, constipation, and rectal pain. Tr. at 459. She
reported up to six episodes of frequency diarrhea per day on
four days per week, often followed by several days of
constipation. Id. Dr. Kobes recommended a high fiber
diet and full colonic evaluation. Tr. at 461. He prescribed
Levsin 0.125 mg. Tr. at 462.
January 26, 2016, Plaintiff reported anxiety, depression,
irritability, and sleep disturbance. Tr. at 440. She
complained of more frequent and severe depressive episodes.
Tr. at 441. She stated she was experiencing nightmares and
was only sleeping for two hours in a 24-hour period.
Id. Kristal T. Tribble, R.N. (“Nurse
Tribble”), notified Dr. Winter and reminded Plaintiff
that she had an upcoming visit scheduled with him.
progress summary dated February 2, 2016, Mr. Platt indicated
Plaintiff was scheduled for weekly group therapy and twice
monthly individual therapy. Tr. at 439. He stated Plaintiff
was participating actively in group therapy sessions, but
considered coping mechanisms to be minimally effective.
March 8, 2016, Plaintiff complained that Latuda caused
increased anxiety. Tr. at 438. Dr. Winter observed Plaintiff
to demonstrate akathisia, fidgetiness, and anxiety.
Id. He noted the following findings on mental status
examination: cooperative attitude; calm behavior; intact
associations; logical/goal-directed thought process; no
suicidal or homicidal ideation; depressed and anxious mood;
appropriate affect; mildly impaired attention and
concentration; and fair insight and judgment. Id.
Dr. Winter discontinued Latuda and increased Lamictal to 250
mg daily. Id.
participated and interacted well with others during group
therapy sessions on April 7 and 21, 2016. Tr. at 529-30.
4, 2016, Plaintiff complained of abdominal pain and cramping,
nausea, vomiting, diarrhea, and occasional bowel
incontinence. Tr. at 549. She reported weight gain, frequent
urination, and excessive thirst and requested that her blood
sugar be checked. Id. Tiffany Nobles, FNP-BC
(“N.P. Nobles”), noted tenderness to palpation of
Plaintiff's abdomen, but indicated no other abnormalities
on physical exam. Tr at 549-50. She encouraged Plaintiff to
follow up with her GI specialist for irritable bowel syndrome
(“IBS”) with diarrhea, referred her for lab work,
counseled her on diet and exercise, and advised her to lose
weight and to take a daily multivitamin. Tr. at 550.
6, 2016, Plaintiff reported to Mr. Platt that her visit with
N.P. Nobles had been unpleasant because N.P. Nobles was
hateful and did not spend adequate time with her. Tr. at 526.
Mr. Platt affirmed Plaintiff's feelings and noted her
accomplishment in not reacting drastically to N.P. Nobles.
7, 2016, Plaintiff complained of poor sleep, pain, stomach
problems, and headache. Tr. at 524. She discussed conflict in
her relationship. Id. Mr. Platt encouraged Plaintiff
to avoid conflict. Id.
9, 2016, Jessica McCraw, MA, LMPT (“Ms. McCraw”),
observed Plaintiff to be engaged and to laugh with others
during group therapy. Tr. at 523. She stated Plaintiff
continued to “be dealing with a lot of pain and health
p[roblems].” Id. She indicated Plaintiff's
depression might improve if her health problems were better
21, 2016, Plaintiff complained of insecurities regarding her
relationship. Tr. at 522. Mr. Platt observed Plaintiff to be
a little less worried than during the prior visit.
23, 2016, Ms. McCraw observed Plaintiff to be engaged in the
group and to laugh during the session. Tr. at 521. Plaintiff
reported going out to dinner and a movie. Id. She
endorsed problems with pain, but no major mental health
29, 2016, Plaintiff followed up with Dr. Kobes for abdominal
pain and diarrhea. Tr. at 455. She reported frequent pain in
her left upper quadrant, occasional pain in her lower
abdomen, and watery diarrhea occurring between three and six
times per day. Id. She stated Levsin had provided no
benefit. Id. Dr. Kobes assessed chronic diarrhea
with probable IBS and prescribed Bentyl. Tr. at 457.
McCraw observed Plaintiff to be engaged and to appear well
during a group therapy session on June 30, 2016. Tr. at 520.
Plaintiff discussed a negative encounter with her mother and
processed her reaction with members of the group.
5, 2016, Plaintiff complained of sleep disturbance,
nightmares, and weird dreams. Tr. at 519. Mr. Platt noted
Plaintiff was reflecting on prior choices and losses and felt
confused and unable to focus on reading and math.
7, 2016, Ms. McCraw noted Plaintiff had some difficulty
completing the painting assignment “because of her
hands.” Tr. at 518. She instructed Plaintiff on a
relaxation technique to address her reports of sleep
13, 2016, Plaintiff reported relief from the injections Dr.
Patel administered during the prior visit. Tr. at 468. She
complained of left hip pain, migraines, and pain and
stiffness in her neck that was exacerbated by turning her
head. Id. She endorsed symptoms that included
fatigue, red and dry eyes, shortness of breath, constipation,
diarrhea, nausea, vomiting, arthralgias, myalgias, sleep
disturbance, and three hours of morning stiffness. Tr. at
468-69. Dr. Patel noted the following abnormalities on
physical exam: pain and stiffness in the cervical spine,
paraspinal pain and tenderness, pain in the left trochanteric
bursa, and greater than 12 tender points. Tr. at 469. He
continued Plaintiff's prescriptions for Robaxin and
Tylenol with Codeine and administered a Depo-Medrol injection
to her left trochanteric bursa. Tr. at 470.
14, 2016, Ms. McCraw noted Plaintiff participated less and
was more quiet than she had been during prior group sessions.
Tr. at 517. A medication monitoring form reflects symptoms of
anxiety, decreased appetite, depression, flight of ideas,
hyperactivity/inattention, irritability, paranoia, thought
disorganization, sleep disturbance, and being hyperverbal.
Tr. at 516. Plaintiff denied side effects from medications.
22, 2016, Mr. Platt indicated Plaintiff was “making a
little progress overall.” Tr. at 515. Plaintiff
reported benefits from ...