United States District Court, E.D. Michigan, Northern Division
THOMAS
L. LUDINGTON DISTRICT JUDGE.
MAGISTRATE JUDGE'S REPORT AND RECOMMENDATION ON
CROSS MOTIONS FOR SUMMARY JUDGMENT (R. 15, 18)
Patricia T. Morris United States Magistrate Judge.
I.
RECOMMENDATION
Plaintiff
Mary Caradonna challenges Defendant Commissioner of Social
Security's final decision denying her claim for Title II
Disability Insurance Benefits (DIB). The case was
referred to me for review. (R. 3); see 28 U.S.C.
§ 636(b)(1)(B); E.D. Mich. LR 72.1(b)(3). For the
reasons below, I conclude that substantial evidence does not
support the Commissioner's decision. Accordingly, I
recommend GRANTING Plaintiff's Motion
for Summary Judgment, (R. 15), DENYING the
Commissioner's Motion, (R. 18), and
REMANDING the case under “sentence
four” of 42 U.S.C. § 405(g).
REPORT
A.
Introduction and Procedural History
Plaintiff
filed the present application for DIB on September 11, 2014,
[1]
alleging that her disability began June 20, 2014. (R. 9,
PageID.220.) The Commissioner denied the claim.
(Id., PageID.114.) Plaintiff then requested a
hearing before an Administrative Law Judge (ALJ),
(id., PageID.123), and received two hearings; the
first occurred on December 13, 2016, (id.,
PageID.75-96), and the second on June 1, 2017, (id.,
PageID.58-74). The ALJ issued a decision on August 1, 2017,
finding Plaintiff not disabled during the relevant period.
(Id., PageID.42-52.) On August 13, 2018, the Appeals
Council denied review, (id., PageID.30-32), and
Plaintiff filed for judicial review on October 16, 2018. (R.
1). She moved for summary judgment on March 15, 2019, (R.
15), and the Commissioner countered with its own Motion the
following month, (R. 18). Briefing has completed and the case
is now ready for resolution.
B.
Standard of Review
The
court has jurisdiction to review the Commissioner's final
administrative decision pursuant to 42 U.S.C. § 405(g).
The district court's review is restricted solely to
determining whether the “Commissioner has failed to
apply the correct legal standard or has made findings of fact
unsupported by substantial evidence in the record.”
Sullivan v. Comm'r of Soc. Sec., 595 F
App'x. 502, 506 (6th Cir. 2014) (internal quotation marks
omitted). Substantial evidence is “more than a
scintilla of evidence but less than a preponderance.”
Rogers v. Comm'r of Soc. Sec., 486 F.3d 234, 241
(6th Cir. 2007) (internal quotation marks omitted).
“[T]he threshold for such evidentiary sufficiency is
not high. . . . It means-and means only-‘such relevant
evidence as a reasonable mind might accept as adequate to
support a conclusion.'” Biestek v.
Berryhill, 139 S.Ct. 1148, 1154 (2019) (citation
omitted).
The
Court must examine the administrative record as a whole, and
may consider any evidence in the record, regardless of
whether it has been cited by the ALJ. See Walker v.
Sec'y of Health & Human Servs., 884 F.2d 241,
245 (6th Cir. 1989). The Court will not “try the case
de novo, nor resolve conflicts in the evidence, nor decide
questions of credibility.” Cutlip v. Sec'y of
Health & Human Servs., 25 F.3d 284, 286 (6th Cir.
1994). If the Commissioner's decision is supported by
substantial evidence, “it must be affirmed even if the
reviewing court would decide the matter differently and even
if substantial evidence also supports the opposite
conclusion.” Id. at 286 (internal citations
omitted).
C.
Framework for Disability Determinations
Disability
benefits are available only to those with a
“disability.” Colvin v. Barnhart, 475
F.3d 727, 730 (6th Cir. 2007). “Disability” means
the inability
to engage in any substantial gainful activity by reason of
any medically determinable physical or mental impairment
which can be expected to result in death or which has lasted
or can be expected to last for a continuous period of not
less than [twelve] months.
42 U.S.C. § 1382c(a)(3)(A). The Commissioner's
regulations provide that disability is to be determined
through the application of a five-step sequential analysis:
(i) At the first step, we consider your work activity, if
any. If you are doing substantial gainful activity, we will
find that you are not disabled.
(ii) At the second step, we consider the medical severity of
your impairment(s). If you do not have a severe medically
determinable physical or mental impairment that meets the
duration requirement . . . or a combination of impairments
that is severe and meets the duration requirement, we will
find that you are not disabled.
(iii) At the third step, we also consider the medical
severity of your impairment(s). If you have an impairment(s)
that meets or equals one of our listings in appendix 1 of
this subpart and meets the duration requirement, we will find
that you are disabled.
(iv) At the fourth step, we consider our assessment of your
residual functional capacity and your past relevant work. If
you can still do your past relevant work, we will find that
you are not disabled.
(v) At the fifth and last step, we consider our assessment of
your residual functional capacity and your age, education,
and work experience to see if you can make an adjustment to
other work. If you can make an adjustment to other work, we
will find that you are not disabled. If you cannot make an
adjustment to other work, we will find that you are disabled.
20 C.F.R. § 404.1520; see also Heston v. Comm'r
of Soc. Sec., 245 F.3d 528, 534 (6th Cir. 2001).
“Through
step four, the claimant bears the burden of proving the
existence and severity of limitations caused by [his or] her
impairments and the fact that [he or] she is precluded from
performing [his or] her past relevant work.” Jones
v. Comm'r of Soc. Sec., 336 F.3d 469, 474 (6th Cir.
2003). The burden transfers to the Commissioner if the
analysis reaches the fifth step without a finding that the
claimant is not disabled. Combs v. Comm'r of
Soc. Sec., 459 F.3d 640, 643 (6th Cir. 2006). At the
fifth step, the Commissioner is required to show that
“other jobs in significant numbers exist in the
national economy that [the claimant] could perform given [his
or] her RFC [residual functional capacity] and considering
relevant vocational factors.” Rogers, 486 F.3d
at 241 (citing 20 C.F.R. §§ 416.920(a)(4)(v), (g)).
The RFC “is the most [the claimant] can still do
despite [his or her] limitations, ” and is measured
using “all the relevant evidence in [the] case
record.” 20 C.F.R. § 404.1545(a)(2).
D.
ALJ Findings
Following
the five-step sequential analysis, the ALJ determined that
Plaintiff was not disabled. (R. 9, PageID.42-52.) At step
one, the ALJ found that Plaintiff had not engaged in
substantial gainful activity since her alleged onset date of
June 20, 2014. (Id., PageID.44.) At step two, the
ALJ concluded that Plaintiff had the following severe
impairments: “bipolar disorder, alcohol abuse, cannabis
dependence and opioid use disorder in remission, personality
disorder, and schizoaffective disorder.” (Id.)
At step three the ALJ decided these impairments did not meet
or equal the severity of a listed impairment. (Id.,
PageID.45-46.)
Before
proceeding to the final steps, the ALJ found that Plaintiff
had the residual functional capacity (RFC) to perform
a full range of work at all exertional levels but with the
following nonexertional limitations: can never climb ladders,
ropes or scaffolds; must avoid all use of hazardous moving
machinery; must avoid all exposure to unprotected heights;
work is limited to simple, routine and repetitive tasks
performed in a work environment free of fast paced production
requirements involving only simple work related decision[s]
and routine work place changes; only occasional, superficial
interaction with the public and co- workers.
(Id., PageID.46.) At step four, the ALJ found
Plaintiff unable to perform any past relevant work.
(Id., PageID.51.) Finally, at step five, the ALJ
determined that Plaintiff could perform a significant number
of jobs in the national economy. (Id.,
PageID.51-52.)
E.
Administrative Record
1.
Medical Evidence
Sometime
in the summer of 2006, Plaintiff was involuntarily
hospitalized after a suicide attempt. (Id.,
PageID.364, 369.) She had brooded on suicide for about a
month, brought on in part by threats to her continued
employment as a housekeeper. (Id., PageID.368, 370.)
The hospital reports recount her history of chronic
depression. (Id., PageID.367.) Her first suicide
attempt occurred in 1990, and since then she had been
receiving psychiatric treatment. (Id.) Her current
roster of medications did not provide much help, and her mood
vacillated weekly. (Id., PageID.367-68.) At the
hospital, Plaintiff complained of generalized weakness and
fatigue, but she denied other physical ailments.
(Id., PageID.371.) On examination, she was
“awake, alert, and oriented times three. She appears in
no acute distress; however, she appears somewhat
anxious” and “very jittery.” (Id.,
PageID.371-72.) During a mental-status examination, Dr.
Sheldon Siegel observed that Plaintiff was agitated.
(Id., PageID.368.) She could not recall the correct
date, nor did she remember two of the most recent presidents.
(Id., PageID.369.)
Dr.
Siegel assessed bipolar 2 disorder, anxiety disorder, and a
Global Assessment of Functioning (GAF) score of 30.
(Id.) Bipolar 2 requires at least one major
depressive episode and one hypomanic episode, the former
lasting at least 2 weeks and the latter at least 4 days.
Psychiatric Ass'n, Diagnostic and Statistical Manual
of Mental Disorders 135 (5th ed., 2000) (DSM
V). The GAF score signified that Plaintiff's
“[b]ehavior is considerably influenced by delusions or
hallucinations OR serious impairment in communication or
judgment . . . OR inability to function in almost all
areas.” Psychiatric Ass'n, Diagnostic and
Statistical Manual of Mental Disorders 34 (4th ed.,
2000) (DSM-IV).[2]
Medical
records from 2007 and 2008 indicate that she remained on
multiple psychotropics, she was properly oriented, her affect
was often appropriate but sometimes flat, and she continued
to suffer from “major affective disorder.”
(Id., PageID.418-22.)
She was
hospitalized again, on a “petition, ” in May
2008. (Id., PageID.394, 400.) The past month, she
had lived in a hotel and was experiencing paranoid ideations
and irritability. (Id.) The paranoia led her to
sleep with a handgun. (Id.) She had not been taking
her medications. (Id.) Her initial stay in the
hospital was from May 22 to May 27. (Id.) At the
time she was discharged, she was cooperative and friendly,
but also vague and guarded; her thought content was
appropriate and her mood appeared euthymic; she denied
hallucinations or delusions but still seemed “mildly
paranoid.” (Id.) She remained afraid of her
husband and refused to meet with him or any other family
members. (Id., PageID.401.) But her medications were
helping and she no longer appeared to be a danger.
(Id.) Her GAF score was 36, indicating “[s]ome
impairment in reality testing or communication . . . OR major
impairment in several areas, such as work or school, family
relations, judgment, thinking, or mood.”
DSM-IV, supra at 34.
She
left the hospital on May 27 but returned, apparently of her
own accord, the following day. (Id., PageID.397,
403.) During her time away, she stopped taking her
medications and grew “extremely paranoid and
suspicious, ” particularly of her husband, who she
thought was having an affair with her stepmother.
(Id., PageID.403.) She also believed that a friend
had planted listening devices in her room. (Id.,
PageID.397.) It was noted that her “examination is
appropriate to the thought content, ” her mood was
“mildly anxious and depressed, ” her speech was
brief but coherent and goal directed, she denied suicidal
ideations or hallucinations, she was paranoid and suspicious,
she was alert and oriented, her memory was fair, she had
limited insight, and her judgment was impaired.
(Id., PageID.398.) Her GAF score was 22, which was
in the same range as her earlier score of 30.
DSM-IV, supra at 34.
She was
discharged on June 2, 2008. (Id., PageID.403.) At
that time, she was euthymic and her judgment had improved to
“average.” (Id.) She felt better,
acknowledging her bipolar disorder and the need for
medications and to stop drinking. (Id., PageID.404.)
Her GAF score stood at 40, (id., PageID.404), which
indicated the same basic findings as her earlier score of 36.
DSM-IV, supra at 34.
In
November 2008, Plaintiff sought services at Macomb County
Community Mental Health. (Id., PageID.444.) The
intake paperwork stated that Plaintiff lacked medical
insurance and therefore had not being seeing a private
psychiatrist. (Id., PageID.444, 447.) At the time
she was unemployed and either “looking or on
layoff.” (Id., PageID.446.) She slept only
five hours a night, her “responses” were slower,
she remained paranoid, and she was hearing voices and seeing
people, although she later denied hallucinations.
(Id., PageID.447.) The notes further stated that
records from the past summer indicated a suicide attempt.
(Id.) She had attempted suicide three times
throughout her life, although she was not currently
considering it. (Id., PageID.447-48.) Presently, she
was going through a divorce and had begun dating.
(Id.) She was not taking psychotropics.
(Id., PageID.447.) Plaintiff explained that in May
2008 she began using alcohol to cope with marital stress.
(Id.) During this period, she thought people were
trying to hurt her, and that her husband was attempting to
poison her. (Id.)
The
intake forms also indicated that she independently bathed,
dressed, completed housekeeping, prepared food, travelled in
the community, maintained appropriate public behavior, used
the toilet; she needed reminders, however, to eat, structure
her time effectively, find purposeful activities, make
reasonable long-term plans, budget and shop, maintain
hygiene, and drive or arrange public transportation.
(Id., PageID.449-50.) She needed instruction to take
her medications, handle money, and pay bills. (Id.,
PageID.450.) Plaintiff clarified that her hygiene suffered
during spells of depression, she relied on her boyfriend for
transportation, and she did not have any hobbies.
(Id., PageID.451.)
Therapist
Amy Bischof concluded that Plaintiff had proper orientation
but flat affect, preoccupied and tangential thought process,
limited insight, and dysphoric mood. (Id.,
PageID.447.) Further, Plaintiff was passive, withdrawn,
fearful, anxious, ruminative, apathetic, and dysphonic.
(Id., PageID.451.) Her perceptions were marked as
normal, yet Bischof also noted Plaintiff had delusions and
hallucinations. (Id., PageID.451, 463.)
Plaintiff's judgment was poor, as evidenced by her
history of suicide attempts, her insight and impulse control
were poor, and her sleep and appetite were decreased.
(Id., PageID.451-52.) In addition, an alcohol and
substance abuse screen “strongly indicate[d]
dependence, ” although Plaintiff denied any drinking
since the summer 2008 (or, as she later said, October 2008)
and any drug use whatsoever. (Id., PageID.452-53,
461.) Overall, Bischof diagnosed bipolar 1 disorder,
(id., PageID.453), which is marked by a manic
episode preceded or followed by a hypomanic or major
depressive episode. DSM-V, supra at 123.
Plaintiff's GAF score was 55, suggesting
“[m]oderate symptoms . . . OR moderate difficulty in
social, occupational, or school functioning.”
DSM-IV, supra at 34. Plaintiff was very
depressed and qualified for services due to the diagnosis and
her “significant functional disability”
(including in self-direction, activities of daily living, and
social transactions and interpersonal relationships),
“certain prior service utilization, ” and the
“sufficient duration of the illness.”
(Id., PageID.455.)
On
November 26, 2008, Plaintiff saw psychiatrist Sarath
Hemachandra, MD, at Macomb County Community Health.
(Id., PageID.463.) Plaintiff was tearful,
emotionally labile, and moderately depressed, but she denied
experiencing hallucinations, paranoia, or delusions, and she
also denied using alcohol or having suicidal ideations.
(Id., PageID.463- 64.) During the examination, she
remained tearful but cooperative, her thoughts were racing,
she had average intelligence and no memory impairment, her
speech rate and rhythm were decreased, she was properly
oriented, her judgment was generally good, and she recognized
her own strengths and weaknesses. (Id.,
PageID.464-65.) Dr. Hemachandra diagnosed bipolar 1.
(Id., PageID.465.)
Plaintiff
saw Dr. Hemachandra again in December 2008. (Id.,
PageID.473.) Her depression continued, at a moderate level,
but her sleep had improved and she no longer believed the FBI
was monitoring her. (Id.) She had no hallucinations,
delusions, suicidal ideations, or paranoia. (Id.) At
the examination, Plaintiff's speech was normal, her
manner was guarded, her affect was labile and appropriate to
her mood (depressed), her thought process was logical, she
was properly oriented, her hygiene was appropriate, no
blunted affect was observed, she answered promptly, she was
mildly irritable or expansive occasionally, there was no
evidence of conceptual disorganization or inability to form
relationships, her suspiciousness was very mild, and she had
no unusual thought content. (Id., PageID.474-77.)
Overall, Plaintiff's condition was slowly improving.
(Id., PageID.477.)
At an
appointment with Dr. Hemachandra in January 2009, Plaintiff
stated, “I am doing allright [sic]. I still
feel a little depressed. I am drowsy during [the] daytime,
” although her sleep was noted to be adequate.
(Id., PageID.466.) The depression was mild to
moderate, as was her anxiety. (Id., PageID.466,
468.) She continued to deny hallucinations, delusions, and
paranoia. (Id.) It appeared to Dr. Hemachandra that
“[s]ome improvement” had occurred. (Id.)
The examination recorded the following: Plaintiff's
speech was normal, her manner was guarded, her affect was
full and appropriate to her mood, her thought process was
logical, her hygiene was appropriate, she responded promptly
to questioning, her level of excitement was mild and
“of doubtful clinical significance, ” there was
no evidence of inability to form relationships, no conceptual
disorganization was observed, her suspiciousness was very
mild, she had no unusual thought content, and there was no
evidence of blunted affect. (Id., PageID.467-68.)
The
following month, however, she told Dr. Hemachandra that she
remained moderately depressed. (Id., PageID.503.)
Her other claims stayed about the same as in the last
session, although she now also cited her “male
friend” as a source of emotional support.
(Id.) The examination results were similar as well,
except this time she was tearful. (Id.,
PageID.504-07.) Now, Dr. Hemachandra concluded that
Plaintiff's condition had deteriorated. (Id.,
PageID.507.) Later that month, at another appointment,
Plaintiff reported “doing ok.” (Id.,
PageID.496.) Her claims and the examination results remained
nearly identical, except her affect was “[f]ull”
rather than tearful. (Id., PageID.497-500.) Her
status continued “[d]eteriorating, ” Dr.
Hemachandra wrote. (Id., PageID.501.)
In
March, Plaintiff reported to Dr. Hemachandra that she was
getting married and “feeling better.”
(Id., PageID.491.) Her depression was now mild, as
confirmed by examination, but her other statements and
examination results were otherwise identical to those
recorded in the previous visit. (Id.,
PageID.490-94.) Her condition was improving, the report
stated. (Id., PageID.494.) By the following month,
she was married and began noticing her anxiety had increased.
(Id., PageID.483.) She also denied mood swings or
racing thoughts; her statements and the examination results
remained the same as last time, although her manner was now
guarded and her anxiety was moderate. (Id.,
PageID.483-87.) She continued to improve, Dr. Hemachandra
concluded. (Id., PageID.488.)[3]
The
medical record then jumps to June 2014, when police took her
to the hospital after finding her wandering the streets in
bunny slippers; when stopped, she “could not recall
what she was doing nor could she remember the last five
days.” (Id., PageID.575.) She remained in the
hospital for over a month, apparently by court order.
(Id., PageID.580, 612, 722-23.) At the hospital she
reported that since her divorce in 2008, she had not taken
her bipolar disorder medications. (Id., PageID.575)
Further, she reported having vatic powers. (Id.)
Although she failed to report depression, hallucinations, and
the like, Plaintiff's paranoia about her husband was
evident to the intake interviewer. (Id.)
On
examination, she was labile, she had delusions, her thought
process was circumstantial, she did not “fully
appreciate [her] clinical condition, ” her judgment was
passive as regarded her care, she was fully oriented, and she
had no suicidal ideations. (Id., PageID.576.) She
was confused and only partially responsive. (Id.,
PageID.536, 588-89.) On yet another examination, it was noted
that her “[c]ognition and memory are not impaired. She
exhibits normal recent memory, ” yet she was
“[u]nable to recall where she lives.”
(Id., PageID.537, 540; see also id.,
PageID.589 (noting normal memory).) Her thought process was
marked by loose associations and she suffered impairments in
concentration and executive function. (Id.,
PageID.589.) However, her perceptions were normal.
(Id.)
Later
examination results varied, with many abnormalities noted
along with normal results. (Id., PageID.595-96
(cooperative, displayed a relieved and calm mood, had
goal-directed thoughts, and had normal speech, affect,
thought content, memory, concentration, and executive
functioning), 598 (failed to appreciate condition or actively
engage with care, her thought processes were marked by loose
associations, and she had delusions, illusions, impaired
concentration, but normal executive function), 601 (same),
606 (cooperative, displayed a relieved and calm mood, had
goal-directed thoughts, and had normal speech, affect,
thought content, memory, concentration, and executive
functioning), 611 (noting calm but labile mood,
circumstantial thought process, impaired visual-spatial
functioning, failure to appreciate condition, and passive
engagement with care, but otherwise normal), 615 (fast
talking, calm but labile mood, failure to appreciate
condition or engage with care, circumstantial thought
processes, impaired visual-spatial functioning, but otherwise
normal), 619 (same), 623 (same), 626 (same), 629-30 (same),
634 (same except mood was elated and affect was congruent
with mood), 638 (same), 643 (same and alert with good eye
contact), 648 (same), 652 (same except affect had increased
intensity, her thought process was tangential, and she had
delusions), 656 (same), 659 (cooperative, elated mood, affect
had increased intensity, no delusions, appreciated condition,
engaged in care, hallucinations), 662-63 (same), 665-66 (same
but mood “happy”), 669-70 (same except no
hallucinations), 675 (same), 677-78 (uncooperative, calm but
intrusive, affect had increased intensity, grandiose
delusions, evasive thought processes, normal but poor
concentration, impaired executive function and visual spatial
function, failure to appreciate condition or engage with
care; otherwise normal), 681-82 (same), 684 (same), 686
(same), 690-91 (same), 695 (same but thought process was
tangential), 698 (same but not intrusive and “visual
spatial” was not assessed), 701 (same), 705 (same but
thought process was “loose associations”), 708
(cooperative, goal-directed thought process, and otherwise
normal), 717 (alert, labile, delusions, circumstantial
thought process, failure to fully appreciate condition or
actively engage in care; otherwise normal).)
In
short updates about her progress in therapy sessions, various
observations were made: Plaintiff did not attend many
therapeutic activities early in her stay; she was cooperative
and pleasant on occasion, but also quiet and withdrawn; she
could “engage in productive activity, ” but she
also was “restless and easily distracted”; her
mood was labile; and she made bizarre or paranoid comments.
(Id., PageID.535; see also id., PageID.616
(noting impulsivity and distraction, but cooperativeness),
617 (noting difficulty remaining on task and poor personal
boundaries), 621 (noting Plaintiff was withdrawn but became
engaged with prompting, and was polite and calm), 627 (noting
that she participated when prompted, and demonstrated
appropriate social skills), 631 (noting she was cooperative
and polite), 641 (easily distracted), 650 (noting
distraction, impaired concentration, impaired socialization,
bizarre statements), 657 (calm and pleasant), 661 (actively
participated), 664 (active participation but constricted
affect and confusion), 667 (active participation but
tearful), 668 (active participation), 672 (sad affect that
improved, logical interactions with others), 672
(“profane, refuses to participate, interruptive,
irritable”), 680 (“easily distracted, impaired
social skills, ” anxious, illogical, but engaged with
prompting), 683 (alert and attentive), 687 (“impaired
concentration, anxious, impaired social, isolating”),
688 (“[l]imited coping skills, ” but logical,
calm, and goal-directed), 689 (impaired social skills and
concentration but polite and cooperative), 692
(“initially resistive, scattered”), 696
(“impaired concentration, impaired
socialization”), 720 (irritable, intrusive,
inappropriate, sexually preoccupied with male peer), 723
(appropriate, pleasant, agreeable), 724 (easily distracted,
bizarre or paranoid comments), 727 (pressured, repetitive
speech, cooperative), 728 (rude, labile), 729-31 (making
delusional statements, irritable, confused, intrusive, angry,
loud, hypomanic), 733 (pleasant but manic, intrusive,
aggravating, attempting to incite riots, mean, sarcastic,
impulsive), 735 (delusional), 737 (cooperative and pleasant,
but earlier she was agitated and belligerent), 738-40
(anxious but cooperative), 745-46 (cooperative, completed
daily activities), 747 (“uncooperative, agitated, loud,
paranoid, delusional, grandiose”), 911 (isolating,
confused, poor activities of daily living, but behavior
controlled).)
The
notes stated that she was defiant during a large portion of
her stay, refusing to take medications. (Id.,
PageID.580; see also id., PageID.594-95 (noting her
refusal to take medications).) During this period-which
lasted sometime into July, near her discharge- her behavior
was inappropriate, her mood vacillated, and she displayed
signs of mania and psychosis, with moderate but constant
symptoms; she could not function outside the hospital.
See, e.g., (Id., PageID.594-95, 601, 605,
610, 614, 629, 637, 708.) Plaintiff expressed guilt for not
wanting to work anymore, and she mentioned her plans to apply
for disability; the therapist discussed how she might be able
to resume working in the future if she made her mental health
a priority first. (Id., PageID.624.)
Other
notes, including from just a few days before discharge,
reported Plaintiff's hyperverbal and pressured speech,
her intrusiveness and irritability, the continued lack of
insight into her condition, the persistent thought
disorganization, and her overall cooperative nature. See,
e.g., (Id., PageID.605, 609-10 (same), 614
(same), 676-77 (thought disorganization, mood instability,
psychosis), 680-81 (thought disorganization, psychosis,
anxiety, mood instability (all moderate to severe)), 683
(same), 690 (same), 694 (same), 697 (same).) At times, she
reported that medication and group therapy helped her
symptoms. See, e.g., (Id., PageID.614, 618,
622, 668.) She also, on occasion, experienced insomnia.
(Id., PageID.614, 643, 655, 677, 694, 700; see
also id., PageID.727 (noting that Plaintiff
“[a]ppears [to have] . . . difficulty falling asleep
and staying asleep”), 739 (noting that sleep was a
problem but that she slept well the previous evening);
but see id., PageID.665 (noting a restful night
sleep).)
According
to the discharge notes, once she started taking her
medication, she “quickly changed and improved.”
(Id., PageID.580.) On discharge, Plaintiff's
condition was “fair.” (Id.) She denied
suicidal ideations, her personal care had improved, she
attended groups and activities, her sleep and appetite were
normal, she was not experiencing hallucinations or delusions,
her thinking became “more reality based, ” and
she “agreed to pursue . . . Social Security Benefits
since she is not able to work.” (Id.) She was
cooperative, displayed a relieved and calm mood, and had
goal-directed thoughts with normal speech, affect, thought
content, memory, concentration, and executive functioning.
(Id., PageID.581.) The end diagnosis was
“[b]ipolar disorder with severe mania.”
(Id.)
A few
days she after discharge, she returned to Macomb County
Community Mental Health. (Id., PageID.917.) In new
intake paperwork, it was noted that Plaintiff had claimed
crying spells, sleep troubles, lack of motivation and energy,
attention issues, mood swings, impulsive behavior, memory
issues, and decreased appetite. (Id., PageID.924.)
Further, Plaintiff's recent hospitalization was explained
as resulting from the discontinuance of her medications
because she could no longer afford them. (Id.,
PageID.941.) She “presented as a poor historian due to
[the] severity of [her] reported memory problems.”
(Id., PageID.924.) She was not currently suicidal.
(Id., PageID.926.) On examination, she was
cooperative, her communication was unremarkable, her
perceptions were normal, she had delusions, she was anxious,
she had poor judgment, her impulse control was poor, her
insight was fair, and her sleep was normal. (Id.,
PageID.926-27.) Her GAF score of 43 indicated
“[s]erious symptoms . . . OR moderate difficulty in
social, occupational, or school functioning.”
DSM-IV, supra at 34.
At a
follow-up with Dr. N.B. Murthi a few days later, on July 31,
2014, Plaintiff's examination results were as follows:
her speech was normal; her mood was stable; her affect was
euthymic; her thoughts were logical; she denied
hallucinations and delusions; she had no memory impairment;
she was properly oriented; her judgment was
“[g]enerally good”; and she had limited
understanding of her condition. (Id.,
PageID.942-43.) Plaintiff stated that she had improved while
taking her current medications. (Id., PageID.943.)
The
following month, Plaintiff returned to see Dr. Murthi.
(Id., PageID.946, 954.) Sleep had been difficult
recently, she noted; she was diagnosed with insomnia.
(Id., PageID.954, 959.) More generally, she stated
that she enjoyed reading, coloring, and art projects; she
could get to appointments-her boyfriend took her around-but
could not work; she could cook, take care of her cat, do
household chores, do crafts, listen to the radio, and talk to
her boyfriend on the phone; she hoped to travel once she got
better. (Id., PageID.946.) Dr. Murthi observed
Plaintiff's good grooming and hygiene, logical thought
processes, normal affect, very mild depression, very mild
excitement (“of doubtful clinical significance”),
very mild anxiety, euthymic mood, and cooperative behavior,
and that she had contact with reality, her speech was
coherent and goal-directed, her affect was equable, and there
were “no signs of an active thought disorder or
psychosis.” (Id., PageID.954-57.) Plaintiff
denied delusions, hallucinations, and suspiciousness.
(Id., PageID.955, 958-59.) There was no evidence
that Plaintiff lacked the ability to form relationships, had
unusual thought content, or had conceptual disorganization.
(Id., PageID.958.) Dr. Murthi concluded that
Plaintiff was improving. (Id., PageID.959.)
The
record from Plaintiff's visit with Dr. Murthi in
September 2014 is nearly identical to the August record,
except Plaintiff's affect was labile, she was mildly
irritable or expansive, and she denied anxiety.
(Id., PageID.964-69.) But it was clear to Dr. Murthi
that that ...