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”) and Supplemental Security Income
(“SSI”). 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 the Commissioner's decision be reversed and
remanded for further proceedings as set forth herein.
September 24, 2015, Plaintiff protectively filed applications
for DIB and SSI in which she alleged her disability began on
September 30, 2014. Tr. at 95, 96, 249-55, 256-64. Her
applications were denied initially and upon reconsideration.
Tr. at 135-38, 139-42, 146-51. On November 30, 2017,
Plaintiff had a video hearing before Administrative Law Judge
(“ALJ”) Jerry Faust. Tr. at 33-62 (Hr'g Tr.).
The ALJ issued an unfavorable decision on February 14, 2018,
finding Plaintiff was not disabled within the meaning of the
Act. Tr. at 11-32. 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 November 29, 2018. [ECF No.
Plaintiff's Background and Medical History
was 55 years old at the time of the hearing. Tr. at 36. She
obtained a GED. Tr. at 36. Her past relevant work
(“PRW”) was as a restaurant server. Tr. at 54.
She alleges she has been unable to work since September 30,
2014. Tr. at 249.
presented to the emergency room (“ER”) at Aiken
Regional Medical Centers (“ARMC”) on October 9,
2014, complaining of joint pain. Tr. at 461. The attending
physician diagnosed chronic generalized pain and prescribed
nine Norco 5-325 mg tablets. Tr. at 464.
was admitted to Aurora Pavillion Behavioral Health Services
(“Aurora Pavillion”) on October 23, 2014, with
drug-induced delusions and paranoia. Tr. at 438, 440-41. She
tested positive for amphetamines, cannabinoids, and opiates.
Tr. at 441. She complained of poor sleep, depression, crying
spells, and lack of motivation. Tr. at 438. Merry Deleon,
M.D. (“Dr. Deleon”), indicated Plaintiff
“selectively attended” group sessions, was
“seclusive and minimally interactive with staff and
peers, ” and “was irritable at times with
medication seeking behavior.” Id. Plaintiff
was discharged on October 30, 2014, with diagnoses of
methamphetamine dependence, drug-induced psychosis,
polysubstance abuse, substance-induced mood disorder, and
borderline personality disorder trait. Tr. at 440. Dr. Deleon
assessed a global assessment of functioning
(“GAF”) score of 45 upon discharge. Id.
November 20, 2014, Plaintiff presented to Aiken Center for a
substance abuse assessment. Tr. at 393-407. She reported a
history of amphetamine, marijuana, and opiate use. Tr. at
397. She indicated she had initially used methamphetamine two
months prior, had spent up to $60 per day to support her
habit, and had checked into Aurora Pavillion upon noticing
that it was negatively affecting her health. Id. She
stated she had first used opioids following the birth of one
of her children, had used as many as six pills per day, and
would purchase pills off the street if she did not have a
prescription. Tr. at 398. She stated she last used
methamphetamine on October 22, 2014, cannabis on October 15,
2014, and opioids on September 25, 2014. Tr. at 397, 398.
Addiction counselor William Pressley (“Mr.
Pressley”), observed Plaintiff to appear adequately
groomed; to be cooperative; to have normal speech; to
indicate appropriate thought content; to be oriented to
person, place, situation, and time; to demonstrate intact
memory; to have focused coping ability; and to show affect
appropriate to content. Tr. at 399-400. He diagnosed
amphetamine dependence, opioid dependence, and cannabis
dependence and indicated all to be in remission. Tr. at 405.
He assessed mild occupational problems, problems related to
the social environment, problems with primary support group,
and economic problems and a global assessment of functioning
(“GAF”) score of 58. Id. Mr. Pressley
recommended Plaintiff participate in intensive outpatient
therapy. Tr. at 406. He transferred Plaintiff to another
program, but she failed to report and was discharged from
services. Tr. at 408, 476-77.
was hospitalized at Aurora Pavillion on September 21, 2015,
after threatening to kill her husband and another person. Tr. at
415-437. Upon presentation to Aurora Pavillion, Plaintiff
expressed suicidal ideation and was described as rambling,
hyperactive, hyperverbal, disheveled, thin, and demanding.
Tr. at 418, 430. She tested positive for methamphetamine,
cannabis, opiates, and benzodiazepines. Id.
Plaintiff became more cooperative after the methamphetamine
wore off, but frequently requested Klonopin and higher doses
of medication, which were denied. Id. She reported
intermittent swelling in her left hand and was prescribed
Ultram. Id. Plaintiff's discharge diagnoses
included polysubstance dependence, depression, acute anxiety,
amphetamine abuse, anxiety disorder, hypokalemia, and oral
pain. Tr. at 415. Dr. Deleon observed the following mental
status prior to Plaintiff's discharge on October 5, 2015:
appropriate, casual appearance; initiates interaction with
staff; oriented to person, place, time, and situation;
cooperative, pleasant behavior; anxious mood; no psychomotor
abnormalities; affect congruent with mood and thought
content; anxious, pleasant affect quality; constricted affect
range; linear, goal-directed thought process; coherent
thought content; no hallucinations; no delusions; understands
need for treatment; intact judgment; capable of reality-based
thinking; average intelligence; short attention span; and
short-term memory deficits. Tr. at 418.
presented to Aiken-Barnwell Mental Health Center
(“ABMHC”) for an initial clinical assessment
update on October 15, 2015. Tr. at 473. She complained of
depression, inability to sleep, loss of appetite, increased
isolation and irritability, and thoughts of hopelessness and
worthlessness. Tr. at 475. Carol J. Ardington, LMSW
(“S.W. Ardington”), stated Plaintiff
“presented neatly dressed, oriented to person, place
and time with motor activity appropriate to situation and
tearful affect . . . attitude was cooperative, mood was
depressed.” Id. She stated Plaintiff's
“[s]peech, thought process and content were
normal.” She indicated Plaintiff denied suicidal and
homicidal ideation, hallucinations, and delusions.
Id. She noted Plaintiff demonstrated poor judgment
and insight and good memory and concentration with average
fund of knowledge. Id. She recommended Plaintiff
participate in individual counseling twice a month to develop
coping skills needed to manage depression and substance abuse
and address maladaptive cognitive processing. Id.
followed up with ABMHC for an initial psychiatric medical
assessment on October 26, 2015. Tr. at 471. She endorsed
anxiety, low self-esteem, and depression. Id. The
clinician noted the following findings on psychiatric exam:
appearance within normal limits; guarded attitude; calm
behavior; normal eye contact; normal speech; intact
associations; logical/goal-directed thought processes; denies
delusions, suicidal ideation, homicidal ideation, obsessions,
and hallucinations; depressed and irritable mood; appropriate
affect; alert sensorium; oriented to time, place, and person;
mildly-impaired recent and remote memory; mildly impaired
concentration; average language; poor judgment and insight;
and average fund of knowledge. Tr. at 472. The clinician
assessed persistent depressive disorder, severe alcohol use
disorder, severe amphetamine-type disorder, and moderate
cannabis use disorder. Id. He prescribed Citalopram
20 mg, Risperdal 2 mg, Trazodone 200 mg, Trazodone 25 mg,
Remeron 15 mg, and Buspar 15 mg. Id.
followed up with Wanda Rowland, R.N. (“Nurse
Rowland”) at ABMHC for medication monitoring on
December 7, 2015. Tr. at 469. She reported symptoms of
anxiety, increased appetite, depression, and paranoia, as
well as medication-induced side effects of dry mouth and
weight gain. Id. She complained of depression,
crying spells, and increased anxiety during the day that
caused her to rock her body back and forth. Tr. at 470. She
requested a prescription for Vistaril and indicated Trazodone
was not helping. Id. Nurse Rowland noted Plaintiff
appeared neat and clean, demonstrated mildly anxious mood,
had clear and organized thoughts, and had gained 22 pounds
since October. Id.
presented to Salli E. Rish, MRC, LPC (“Counselor
Rish”), for individual therapy on December 17, 2015.
Tr. at 505. Counselor Rish observed Plaintiff to be
“struggling with rocking constantly” and
scheduled her for an appointment with the nurse to address
the rocking. Id. Plaintiff indicated she continued
to experience crying spell and anxiety. Id. She
agreed to practice one coping skill per day. Id.
December 31, 2015, x-rays of Plaintiff's left hand showed
no abnormalities. Tr. at 484. X-rays of her lumbar spine
indicated degenerative disc disease characterized by moderate
loss of intervertebral disc space and vacuum disc phenomenon
at the L5-6 level, as well as mild intervertebral disc space
narrowing and disc degeneration at ¶ 4-5. Id.
Configuration of the vertebrae and vertebral body height were
normal. Id. Pedicles and posterior elements were
intact. Id. No malalignment, spinal stenosis, or
destructive lesions were detected. Id.
January 11, 2016, Counselor Rish observed Plaintiff to appear
neat and clean. Tr. at 506. She again observed Plaintiff to
be rocking back and forth during the session. Id.
Plaintiff complained of feeling tired and lacking motivation.
Id. Counselor Rish encouraged her to use coping
tools to deal with stress and anxiety. Id.
January 13, 2016, Plaintiff complained of erratic sleep,
anxiety, occasional panic, poor focus and concentration, low
self-esteem, anhedonia, left hand swelling, and rocking back
and forth. Tr. at 503. She stated her family did not want her
to take medication because the medication made her seem
“zombie-like.” Id. Plaintiff indicated
she was attending substance abuse meetings. Id.
Psychiatrist Khoa Tran, M.D. (“Dr. Tran”), noted
the following on mental status exam: appearance within normal
limits; cooperative attitude; calm behavior; normal eye
contact and speech; intact associations;
logical/goal-directed thought process; euthymic mood;
constricted affect; alert sensorium; oriented to time, place,
person, and circumstance; intact recent and remote memory,
attention, and concentration; average language and fund of
knowledge; good insight and judgment; and good to excellent
knowledge of current events. Tr. at 504. He noted Plaintiff
denied hallucinations, delusions, and suicidal and homicidal
ideation. Id. He discontinued Risperdal and
prescribed Citalopram 20 mg, Trazodone 100 mg, Remeron 15 mg,
Buspar 15 mg, Vistaril 50 mg, Buspirone 15 mg, Celexa 40 mg,
and Seroquel 100 mg. Tr. at 504.
presented to Stephen A. Schacher, M.D. (“Dr.
Schacher”), for a consultative medical examination on
January 15, 2016. Tr. at 487-92. She complained of migraine
headaches, left hand nerve damage, back and leg problems, and
impaired vision. Tr. at 487. She reported abilities to stand
for three minutes, walk 50 yards, and lift 10 pounds.
Id. She indicated inability to write, open jars, and
use a keyboard with her left hand. Id. She stated
she could dress and groom, shop in a grocery store using a
“push buggy, ” cook, wash dishes, do laundry,
sweep, and mop. Tr. at 488. She indicated she was unable to
drive because she did not have a license. Id. She
claimed she sometimes became agitated in the store and had to
leave. Id. She denied engaging in yard work, using a
computer, and vacuuming. Id. She stated she
“sits and rocks” for most of the day.
Id. Dr. Schacher stated Plaintiff “navigate[d]
the exam table normally.” Id. A neurological
examination was normal. Id. Dr. Schacher observed
Plaintiff to demonstrate weakened left hand grip of 3/5 and
decreased range of motion (“ROM”) of the left
shoulder. Id. He noted no sensory loss, normal gait
and balance, and normal mood and cognition. Id. He
stated no diagnosis could be made regarding Plaintiff's
weakened left hand grip based on exam alone. Id.
Plaintiff demonstrated normal ROM of the cervical spine,
lumbar spine, elbows, wrists, knees, hips, and ankles and had
normal straight-leg raising. Tr. at 490.
presented to consultative examiner John B. Bradley, Ph.D.
(“Dr. Bradley”), for a mental status examination
on January 19, 2016. Tr. at 494-99. She reported pain in her
back and left leg resulting from sciatica, as well as left
hand swelling. Tr. at 494. She stated she had difficulty
standing for long periods and using her left hand.
Id. Plaintiff reported a history of depression and
prior suicide attempt. Id. She indicated she felt
sad on most days, experienced crying spells, found little
enjoyment in life, had difficulty sleeping, felt tired all
the time, had difficulty concentrating, and had poor
self-esteem. Id. She endorsed fleeting suicidal
ideation, paranoia, and hallucinations. Id.
Plaintiff reported she had not used drugs since her admission
to Aurora Pavillion. Tr. at 497. She endorsed abilities to
manage self-care, perform a few household chores,
occasionally cook, and manage her own money. Id. She
stated she was not motivated and did little more than sit and
rock during a typical day. Id.
Bradley noted Plaintiff appeared to be minimizing her drug
abuse history. Tr. at 497. He observed Plaintiff to be
cooperative and polite; to be dressed appropriately and
demonstrate good grooming; to have normal gait and posture;
to respond to questions and comply with requests; to
comprehend and follow simple instructions; to be alert and
oriented to time, place, and person; to show a flat affect;
to demonstrate a sad facial expression and a depressed mood;
to speak in a normal voice and at a normal rate; to discuss
appropriate content; to display no evidence of phobias,
obsessions, compulsions, or homicidal thinking; to have
normal attention and concentration; to demonstrate reasonable
memory; to be functioning at a normal level of intelligence;
and to have adequate insight and judgment. Tr. at 497-98.
Plaintiff obtained a score of 29 on the Folstein Mini-Mental
State Examination, which was consistent with no significant
cognitive impairment. Tr. at 498. She reported suicidal
ideation, but denied suicidal intent. Id.
Bradley diagnosed polysubstance dependence in remission by
client report and persistent depressive disorder.
Id. He noted Plaintiff had reported difficulty
standing for long periods and lifting and stated “[s]he
appears to be mildly limited in this area.”
Id. He stated Plaintiff denied significant problems
in social functioning, but found she had moderate limitations
in this area. Tr. at 499. Dr. Bradley assessed moderate
limitation in Plaintiff's ability to maintain
concentration, persistence, or pace. Id.
January 20, 2016, state agency medical consultant Ronald
Collins, M.D. (“Dr. Collins”), provided the
following physical residual functional capacity
(“RFC”) assessment: occasionally lift and/or
carry 50 pounds; frequently lift and/or carry 25 pounds;
stand and/or walk for a total of about six hours in an
eight-hour workday; sit for a total of about six hours in an
eight-hour workday; frequently balancing, stooping, kneeling,
crouching, crawling, and climbing ramps/stairs; and never
climbing ladders/ropes/scaffolds. Tr. at 70-72, 84-86. A
second state agency medical consultant, Stephen Burge, M.D.
(“Dr. Burge”), assessed the same physical RFC on
May 16, 2016. Compare Tr. at 70-72, 84-86,
with Tr. at 107-08, 124- 25.
Rish described Plaintiff as “rock[ing]
constantly” during an individual psychotherapy session
on January 26, 2016. Tr. at 507. She helped Plaintiff to
realize her rocking would cease when she relaxed.
Id. Plaintiff reported the rocking helped to soothe
her anxiety. Id. She acknowledged her mood improved
and anxiety decreased when she reduced her focus on negative
thoughts and feelings. Id. She stated coloring
helped to reduce her anxiety. Id.
January 26, 2016, state agency consultant Janet Boland, Ph.D.
(“Dr. Boland”), reviewed the record and completed
a psychiatric review technique (“PRT”). Tr. at
68-69, 82-83. She considered Listings 12.04 for affective
disorders, 12.06 for anxiety-related disorders, and 12.09 for
substance addiction disorders, as well as drug and alcohol
abuse. Tr. at 68, 82. In evaluating the paragraph
“B” criteria under Listings 12.04 and 12.06, Dr.
Boland found no repeated episodes of decompensation and
assessed mild restriction of activities of daily living
(“ADLs”), moderate difficulties in maintaining
social functioning, and moderate difficulties in maintaining
concentration, persistence, or pace. Id. She
provided a mental RFC assessment, finding Plaintiff was
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; to work in coordination
with or proximity to others without being distracted by them;
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; to interact appropriately with the
general public; to accept instructions and respond
appropriately to criticism from supervisors; to get along
with coworkers or peers without distracting them or
exhibiting behavioral extremes; to respond appropriately to
changes in the work setting; and to set realistic goals or
make plans independently of others. Tr. at 72-74, 86-88. She
provided the following additional explanation:
Cl[ai]m[an]t should be able to attend to and perform simple
unskilled work for reasonable periods of time without
supervision. She can attend work regularly, but might miss an
occasional day due to her mental illness. She can make
work-related decisions, protect herself from work-related
safety hazards and travel to and from work independently. She
can accept supervision and interact appropriately with
co-workers, but might not be suited for work with the general
12, 2016, a second state agency consultant, Douglas Robbins,
Ph.D. (“Dr. Robbins”), considered the same
listings as Dr. Boland and assessed the same degree of
limitation in the PRT. Compare Tr. at 68-69, 82- 83,
with Tr. at 103-05, 120-22. He also assessed the same mental
RFC. Compare Tr. at 72-74, 86-88, with Tr.
at 108-11, 125-28.
presented to the ER at ARMC with lower back pain and nausea
on October 29, 2016. Tr. at 511. Plaintiff's blood
pressure was low at 69/39 mm/Hg. Tr. at 513. James Mock, M.D.
(“Dr. Mock”), diagnosed hypotension, sciatica,
and adrenal insufficiency. Tr. at 516.
presented to ARMC Medical Center with low back pain and
syncopal episode on January 9, 2017. Tr. at 535. Robert
Walker, M.D. (“Dr. Walker”), assessed acute
kidney injury secondary to dehydration, depression,
hypokalemia, sciatic pain, and syncope and collapse. Tr. at
536-37. He ordered fluid resuscitation, potassium repletion,
echocardiography with telemetry, bilateral carotid
ultrasonography, and venous thromboembolism prophylaxis. Tr.
at 537. Plaintiff's lab work showed some abnormalities,
but other diagnostic tests, including x-rays of the lumbar
spine, were negative. Tr. at 545, 574. Dr. Walker added
Lidoderm for Plaintiff's sciatic pain. Id. He
discharged Plaintiff on January 12, 2017, with instructions
to follow up with her family doctor within five days. Tr. at
February 2, 2017, Plaintiff presented to ARMC with a rash on
her right buttocks, chest, left upper arm, and lower legs.
Tr. at 577. She reported shortness of breath while lying down
and facial numbness that had presented earlier in the day.
Id. She indicated she self-treated with Benadryl and
Morphine 15 mg. Id. Plaintiff denied use of
amphetamines, but her drug screen was positive for both
opiates and amphetamines. Tr. at 580. Aaron High, M.D.,
diagnosed contact dermatitis and bronchitis and ordered
Tylenol and Atarax. Tr. at 580-81. Plaintiff verbalized
frustration and indicated she planned to go to go to another
hospital upon discharge. Tr. at 580.
presented to the ER at Augusta University Medical Center
later that day. Tr. at 596. The ER physician diagnosed
cutaneous sporotrichosis, impetigo, insect bites, and
maculopapular rash. Tr. at 597. He discharged Plaintiff with
prescriptions for Acetaminophen 325 mg, Clindamycin 300 mg,
Itraconazole 100 mg, and Prednisone 50 mg. Id.
was again hospitalized at Aurora Pavillion from February 18
to March 1, 2017, after presenting with depression, anxiety,
and suicidal ideation with a plan to overdose. Tr. at 586,
590. She reported her mother had recently passed away, one
week after being diagnosed with end-stage lung cancer. Tr. at
589. She endorsed worsened mood, insomnia, anhedonia, and
difficulty concentrating. Id. Plaintiff's drug
screen was positive for cannabinoids and opiates. Tr. at 591.
Zachary Zuschlag, D.O. (“Dr. Zuschlag”), observed
the following on mental status exam: appears older than
stated age; poor hygiene and grooming; calm and cooperative
behavior; no psychomotor agitation or retardation;
appropriate rate, rhythm, and volume of speech; bad mood;
constricted affect; positive suicidal ideation; no auditory
or visual hallucinations or other signs of psychosis; linear
and coherent thought process; grossly intact memory; fully
oriented; and poor judgment and insight. Id.
Plaintiff reported her medications included Buspar,
Gabapentin, Remeron, and Adderall, but Dr. Zuschlag indicated
it did not appear that the medications had been refilled
since 2015. Id. Dr. Zuschlag discontinued Buspar and
Remeron, increased Plaintiff's dose of Gabapentin, and
started Celexa 20 mg and Seroquel 50 mg. Tr. at 592. He
stated Plaintiff “spent the majority of her time with
me asking for pain meds, benzos and whatever pill she could
get.” Tr. at 589. He noted he had informed Plaintiff he
“was not going to continue to add more and more pills
and that she had to learn to deal with her feelings whether
positive or negative.” Id.
returned to ABMHC for a new clinical assessment on March 21,
2017. Tr. at 603. She reported difficulty coping with the
death of her mother and obtaining medications. Id.
She complained of difficulty eating and sleeping.
Id. She endorsed suicidal thoughts, but denied
suicidal ideation. Id. Counselor Rish indicated the
following observations on mental status exam: disheveled
appearance and hygiene; appropriate motor activity;
cooperative attitude; appropriate affect; depressed, angry,
and hopeless mood; normal rate and tone of speech; normal,
appropriate, coherent, and relevant thought process; ideas of
hopelessness and worthlessness and suicidal thoughts;
auditory and visual hallucinations; no evidence of delusions;
alert and oriented to person, place, time, and situation;
usually able to make sound decisions; acknowledges and
understands problems; intact memory; easily distracted
concentration and calculations; and average fund of
knowledge. Tr. at 605-06. She diagnosed amphetamine abuse in
sustained remission, mild cannabis abuse, and depressive
disorder, not otherwise specified. Tr. at 606. She stated
Plaintiff was struggling with depression, low motivation, and
grief and had reported panic attacks while in public and in
large crowds. Id.
15, 2017, Plaintiff complained of feeling depressed and
suicidal. Tr. at 600. Dr. Tran noted Plaintiff had returned,
after missing appointments since January 2016. Id.
Plaintiff stated she was angry with her mother, who had
passed away eight months prior, because she had not raised
her. Id. She indicated she was having difficulty
raising her 11-year-old grandson. Id. She stated a
friend was allowing her to live with her in exchange for
maintaining the household chores. Id. She reported
being depressed and anxious, but denied outward agitation.
Id. She endorsed fluctuations in mood, hopelessness,
helplessness, low self-esteem, guilt, low motivation, social
anxiety, crying spells three to four times per week, panic
attacks two to three times per week, fluctuating sleep, poor
energy, fair appetite, low memory and concentration, and
nightmares/flashbacks. Id. Plaintiff indicated good
response to Risperdal, over-sedation from Seroquel, poor
response to Buspirone, insomnia from Trazodone, and
ineffective treatment with Prazosin. Id.
Tran observed the following on mental status exam: appearance
within normal limits; cooperative attitude; calm behavior;
normal speech and eye contact; intact associations;
logical/goal-directed thought process; persecutory delusions;
homicidal ideation present without plan; obsessions; auditory
hallucinations; euthymic mood; appropriate affect; alert
sensorium; oriented to time, place, person, and circumstance;
intact recent and remote memory, attention, and
concentration; average language; fair insight; good judgment;
good fund of knowledge; and poor to no knowledge of current
events. Tr. at 601. He prescribed Latuda 40 mg, Vistaril 25
mg, Wellbutrin SR 100 mg, and Amitriptyline 25 mg.
Id. He also noted Plaintiff's prescriptions for
Gabapentin 400 mg and Tramadol 50 mg for neuropathy and
sciatica. Tr. at 601-02.
16, 2017, Dr. Tran completed a medical opinion RFC form. Tr.
continued to endorse depression related to her mother's
death on August 16, 2017. Tr. at 599. Dr. Tran indicated he
had increased Plaintiff's doses of Risperdal, Wellbutrin,
and Amitriptyline, after she reported no response to Latuda.
Tr. at 599. Plaintiff reported compliance with medication and
denied side effects. Id. She indicated her cousin
was providing her money for medications in exchange for
cleaning her house and noted she was doing housework for a
friend while the friend worked. Id. She reported
increased crying spells caused by the anniversary of her
mother's death. Id. She stated her anxiety was
high, but she stayed busy to cope with it. Id. She
indicated she had experienced panic attacks in public.
Id. She endorsed more good than bad days.
Id. She indicated she was no longer babysitting her
grandson as often, as he had returned to school. Id.
She stated her anger lessened with the increase in
medication. Id. She reported sleeping roughly four
hours per night, but endorsed good energy and appetite.
Id. She indicated her memory and concentration were
poor. Id. She was unhappy with her counselor.
Id. Dr. Tran observed the following on mental status
exam: appearance within normal limits; cooperative attitude;
calm behavior; eye contact within normal limits; normal
speech; intact associations; logical/goal-directed thought
process; persecutory delusions; suicidal ideation without
plan; euthymic mood; appropriate affect; alert sensorium;
oriented to time, place, person, and circumstance; intact
recent and remote memory, attention, and concentration;
average language; fair judgment; good insight; and average
fund of knowledge with good to excellent knowledge of current
November 3, 2017, Dr. Tran provided an additional opinion
statement. Tr. at 607.