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Lilja v. Berryhill

United States District Court, D. Minnesota

March 29, 2017

Diane F. Lilja, Plaintiff,
Nancy A. Berryhill, [1] Acting Commissioner of Social Security, Defendant.

          Edward C. Olson, and Karl E. Osterhout, Osterhout Disability Law, LLC, (for Plaintiff)

          Gregory G. Brooker, Acting United States Attorney, United States Attorney's Office, (for Defendant).


          Tony N. Leung United States Magistrate Judge


         Plaintiff Diane F. Lilja brings the present case, contesting Defendant Commissioner of Social Security's denial of her applications for disability insurance benefits (“DIB”) under Title II of the Social Security Act, 42 U.S.C. § 401 et seq., and supplemental security income (“SSI”) under Title XVI of the same, 42 U.S.C. § 1381 et seq. The parties have consented to a final judgment from the undersigned United States Magistrate Judge in accordance with 28 U.S.C. § 636(c), Fed.R.Civ.P. 73, and D. Minn. LR 72.1(c).

         This matter is before the Court on the parties' cross-motions for summary judgment. (ECF Nos. 13, 15.) Being duly advised of all the files, records, and proceedings herein, IT IS HEREBY ORDERED that Plaintiff's motion for summary judgment (ECF No. 13) is GRANTED IN PART and DENIED IN PART; the Commissioner's motion for summary judgment (ECF No. 15) is GRANTED IN PART and DENIED IN PART; and this matter is REMANDED for further proceedings.


         Plaintiff applied for DIB and SSI in October 2012, asserting that she has been disabled since October 2011 due to fibromyalgia, herniated discs, moderate depression, allergies, sleep difficulties, pain in her neck and back, arthritis, a concussion following a motor vehicle accident, memory problems, difficulties with reading comprehension, headaches, and hearing difficulties. (Tr. 10, 103, 105-06, 122, 124-25, 141, 143-44, 161, 163-64, 270, 271; see Tr. 243-55.) Plaintiff's applications were denied initially and again upon reconsideration. (Tr. 10, 103, 120, 122, 139, 141, 159, 161, 179, 183-89, 196-202; see Tr. 190-95.) Plaintiff appealed the reconsideration determination by requesting a hearing before an administrative law judge (“ALJ”). (Tr. 10, 203-04; see Tr. 205-11.) The ALJ held a hearing on September 22, 2014. (Tr. 10, 41-101; see Tr. 213-32, 237-42.) After receiving an unfavorable decision from the ALJ, Plaintiff requested review from the Appeals Council, which denied her request for review. (Tr. 1-6, 7-27, 36, 38.) Plaintiff then filed the instant action, challenging the ALJ's decision. (Compl., ECF No. 1.) Plaintiff moved for summary judgment on July 21, 2016 (ECF No. 13), and the Commissioner filed a cross motion for summary judgment on August 31, 2016 (ECF No. 15). This matter is now fully briefed and ready for a determination on the submissions.


         Although Plaintiff sought benefits based on both mental and physical impairments, the instant action relates only to Plaintiff's hearing and mental health impairments. Accordingly, the Court focuses on the evidence in the record concerning these impairments.

         A. 2011

         Around the middle of November 2011, Plaintiff was seen in consultation by Barbara M. Swenson, M.D., of the Noran Neurological Clinic for multiple neurological symptoms, including neck and lower-back pain, numbness, tingling in her arms and legs, and headaches. (Tr. 455.) During this visit, Dr. Swenson noted that Plaintiff has “significant hearing loss” and has been “told she has lost 50% of her hearing.” (Tr. 455.) Plaintiff also reported having a history of depression, but felt that Lexapro[2] was helping. (Tr. 456.)

         In relevant part, Dr. Swenson noted that Plaintiff appeared well, pleasant, and “very cheerful.” (Tr. 456.) Plaintiff was alert and oriented to person, place, and time. (Tr. 457.) Her speech and language were intact and she had “[g]ood naming and repetition.” (Tr. 457.) Plaintiff's comprehension was also intact. (Tr. 457.) While Plaintiff was unable to recall any of three words after distractions, she could recall all three with cues. (Tr. 457.) Plaintiff made one mistake when spelling the word “world” backwards. (Tr. 457.)

         Dr. Swenson noted that she was “concerned that [Plaintiff] is having somatiform [sic] symptoms with underlying stressors that are not optimally addressed.” (Tr. 458.) Dr. Swenson recommended switching Plaintiff from “Lexapro to Cymbalta, [3] with hopes that it might help her pain as well as depression.” (Tr. 458.) Dr. Swenson also recommended that Plaintiff be referred to a psychologist or psychiatrist. (Tr. 458.)

         During a follow-up appointment approximately three weeks later to discuss results of certain testing regarding Plaintiff's neurological symptoms, Dr. Swenson noted that Plaintiff appeared well but was anxious. (Tr. 453.) Dr. Swenson expressed “concern[] that [Plaintiff's] environmental factors are exacerbating her symptoms.” (Tr. 453; accord Tr. 447.) Dr. Swenson again suggested switching to Cymbalta and “recommended cognitive behavioral therapy, or at least vising with psychology to address psychosocial stressors.” (Tr. 453; see Tr. 447.) Dr. Swenson further recommended increasing Plaintiff's gabapentin[4] dose, but noted that Plaintiff was already experiencing side effects, so Cymbalta should be considered first. (Tr. 453.)

         Plaintiff returned to Dr. Swenson one week later for a gabapentin refill. (Tr. 447.) Plaintiff was “mildly anxious.” (Tr. 448.) Dr. Swenson noted that Plaintiff had tried to make an appointment with her primary care provider, Todd Stolpman, M.D., but had been unable due to insurance reasons. (Tr. 447.) Dr. Swenson noted:

[Plaintiff's] greatest difficulty today is having to deal with the stress of addressing her physical symptoms in addition to dealing with financial stress and application for at least short term disability. Her friend and next-door neighbor accompanies her on her visit today and expresses concern that [Plaintiff] has been very down and anxious in dealing with her stressors, despite appearing to “keep it together” at her medical appointments.

(Tr. 447; see Tr. 449.)

         Dr. Swenson was concerned that Plaintiff's depression and anxiety were “becoming a primary issue for [Plaintiff], ” but did “not feel comfortable managing [Plaintiff's] medications for mood disorder” and “would rather defer this to [Plaintiff's] primary care [provider] or a psychiatrist.” (Tr. 449.) Dr. Swenson recommended that a psychiatrist be consulted “to assess which management of [Plaintiff's] mood disorder will be most appropriate and even if psychological therapy would be recommended for her.” (Tr. 449.) Dr. Swenson “believe[d] the most important things for [Plaintiff] right now are to get in to see psychiatry to stabilize mood disturbance and environmental stressors as well as make an appointment with her primary care provider for follow[]up.” (Tr. 449.) Dr. Swenson emphasized to Plaintiff the importance of following up with her primary care provider and refilled Plaintiff's gabapentin prescription. (Tr. 449.)

         The following day, Plaintiff saw Dr. Stolpman, for, among other things, a “routine follow up” with respect to her depression and anxiety. (Tr. 362.) Dr. Stolpman noted that Plaintiff had been diagnosed with depression several years ago. (Tr. 362.) Plaintiff reported feeling “a moderate degree of depression” and Dr. Stolpman noted that this episode had “been present for the past several months.” (Tr. 362.) Plaintiff's symptoms included “anhedonia, anxious mood, crying spells, decreased ability to concentrate, fatigue, sadness and feelings of worthlessness.” (Tr. 362.) Dr. Stolpman noted that Plaintiff was “well groomed.” (Tr. 363.) Dr. Stolpman instructed Plaintiff to taper off Lexapro and start Cymbalta.

         B. 2012

         Plaintiff next followed up with Dr. Stolpman towards the end of February 2012. (Tr. 364.) Plaintiff continued to experience depressive symptoms, but denied crying spells or feelings of worthlessness. (Tr. 364.) Plaintiff was again noted to be well groomed. (Tr. 365.) Dr. Stolpman increased the Cymbalta and referred Plaintiff to a psychologist. (Tr. 365-66.)

         When Dr. Stolpman saw Plaintiff again in early April, her symptoms and presentation remained the same. (Tr. 367-68.). Plaintiff reported that the increased dose of Cymbalta was helping with her depression and anxiety. (Tr. 368.) There were no changes in Plaintiff's depressive symptoms or changes made to her medication during a follow-up appointment in September. (Tr. 372-74)

         At a pain clinic appointment in November, Plaintiff completed the PHQ-9 questionnaire with a score of 15, “indicating symptoms of moderately severe depression.” (Tr. 548.) When Plaintiff next saw Dr. Stolpman in early December, there were again no changes to Plaintiff's depressive symptoms or medication, although Plaintiff did report that her symptoms were “frequent[]and present most days.” (Tr. 469; accord Tr. 478.)

         In early December, Dr. Stolpman wrote a letter in support of Plaintiff's applications for disability. (Tr. 590.) Dr. Stolpman wrote that Plaintiff has been a patient of his for many years and has experienced “progressive problems with her health.” (Tr. 590.) Dr. Stolpman noted Plaintiff's diagnoses of depression, anxiety, and “chronic fibromyalgia.” (Tr. 590.) Dr. Stolpman also noted that Plaintiff was being treated at a pain clinic for back pain. (Tr. 590.) Dr. Stolpman opined:

Unfortunately, [Plaintiff] has very limited ability to work. Her chronic pain limits her ability to focus and concentrate and perform tasks. She is limited in her ability to sit, stand, drive and walk at this time. Along with this, her fibromyalgia has added another layer to her chronic pain. [Plaintiff] is also having increased problems with hand pain, which limits her ability to perform fine motor tasks. Currently her depression and anxiety has been overwhelming because of her chronic pain and inability to work.

(Tr. 590.)

         Around the middle of December, Plaintiff met with Lana Saffert, M.A., a licensed psychologist, for the first time. (Tr. 567.) At times, Saffert's handwritten notes are difficult to read. Plaintiff described trust issues, flashbacks, and physical problems, including hearing loss. (Tr. 567.) Plaintiff reported being married for 25 years before divorcing her husband and described the relationship as abusive. (Tr. 570, 571.) Plaintiff has three adult children, two sons and a daughter. (Tr. 571.) Plaintiff currently stayed at her parents' home. (tr. 571.) Plaintiff reported that her family does not understand how difficult it is for Plaintiff to live with them. (Tr. 567.) Plaintiff stated they were “good to her, ” but she did not feel like she belonged there and had “‘no place of [her] own to call a home.'” (Tr. 567.) Plaintiff further reported that she had applied for Social Security benefits. (Tr. 567.)

         Plaintiff reported a variety of symptoms, including depression, crying, irritability, and decreased energy. (Tr. 572.) Plaintiff also reported difficulties sleeping and concentrating, stating she could focus for ten minutes, as well as memory problems. (Tr. 572.) Plaintiff's health, living situation, finances, and lack of employment made her feel helpless, worthless, and guilty. (Tr. 572.) Plaintiff also felt hopeless. (Tr. 527.) Plaintiff reported experiencing panic attacks accompanied by shortness of breath, dizziness/faintness, palpitations/chest pain, trembling, sweating, nausea/abdominal distress, numbness/tingling, and temperature flashes. (Tr. 573.) Plaintiff also reported a fear of going out of control and a fear of being in certain places or situations. (Tr. 573.) Plaintiff's anxiety caused tension in her neck and shoulders and she engaged in vigilance/scanning. (Tr. 573.) Plaintiff further reported ritualistic counting and thinking that others are often mad at her. (Tr. 573.) Plaintiff also had difficulty with anger/temper, avoidance, dependency, impulse control, and submissiveness. (Tr. 573.)

         Plaintiff completed a questionnaire regarding the level of stress she was experiencing, support available to her, and her expectations for therapy. (Tr. 575.) Plaintiff rated her current level of stress as “extreme, ” which caused her to want to be alone and avoid talking about herself to others even when they notice something is wrong. (Tr. 575.) Plaintiff also felt a bit lost. (Tr. 575.) Plaintiff's stress also impacted her other health problems. (Tr. 575.) Plaintiff reported that her boyfriend was “100%” supportive, but felt that she received no support from anyone else, noting that her family did not understand her health issues or why she is unable to work. (Tr. 575.) Plaintiff hoped to become more confident through therapy and be able to cope better when under stress. (Tr. 575.) Plaintiff reported that she found therapy to be helpful in the past. (Tr. 575.)

         Saffert noted that Plaintiff was anxious and crying. (Tr. 567.) Saffert diagnosed Plaintiff with generalized anxiety disorder, adjustment disorder, panic disorder, major depressive disorder, and posttraumatic stress disorder. (Tr. 574.) Plaintiff's treatment goals included decreasing her depression and anxiety; increasing her self-esteem and self-care; achieving a living arrangement that was as independent as possible; and improving her relationship with her daughter, including communication and emotional support. (Tr. 574.) Saffert recommended treatment on a weekly basis. (Tr. 574.)

         C. 2013

         Plaintiff next saw Dr. Stolpman around the middle of January. (Tr. 484.) Plaintiff continued to “feel[]a moderate degree of depression.” (Tr. 484.) Plaintiff's current symptoms were “anhedonia, decreased ability to concentrate and fatigue.” (Tr. 484.) Plaintiff denied feeling anxious, sad, or worthless as well as crying spells. (Tr. 484.) Plaintiff was “well groomed.” (Tr. 485.)

         Plaintiff had three appointments with Saffert in January. (Tr. 562-66.) Saffert described Plaintiff as anxious and tearful. (Tr. 564, 565.) Saffert also noted Plaintiff's “obvious hearing loss.” (Tr. 564.) Plaintiff's mood was “pretty good-could be better if was less depressed” and “[a]nx[ious], stressed.” (Tr. 564, 565.) Plaintiff reported that her typical day includes taking care of the cats, attending appointments, running errands, using her computer for about ten minutes, washing dishes, and helping prepare meals. (Tr. 565.) Plaintiff also reported doing laundry approximately once per week. (Tr. 565.)

         During these appointments, Plaintiff discussed personal relationships with her family, children, and boyfriend. (See Tr. 562-66.) Plaintiff discussed not being able to spend time with her daughter over Christmas and feeling like her daughter was choosing Plaintiff's ex-husband over her. (Tr. 565.) Plaintiff also reported isolating herself in her room while her parents had a New Year's Eve party. (Tr. 566.) Plaintiff reported that she “isolates a lot.” (Tr. 566.) Although not entirely clear, it appears that one of Plaintiff's sisters may have also moved into their parents' home as well, resulting in Plaintiff moving into the basement. (See Tr. 562, 564, 571.) Plaintiff also reported that she was going to be gone for one month. (Tr. 564.)

         At the end of January, Saffert completed a medical report regarding Plaintiff. (Tr. 475-77.) Saffert indicated that she had seen Plaintiff three times between December 2012 and January 2013. (Tr. 475.) Saffert listed Plaintiff's diagnoses as generalized anxiety disorder, adjustment disorder, panic disorder, major depressive disorder, and posttraumatic stress disorder. (Tr. 475-76.)

         With respect to Plaintiff's generalized anxiety disorder, Saffert noted that Plaintiff experiences excessive worry and anxiety which she was unable to control, fatigue, difficulty concentrating, and significant distress. (Tr. 475.) Concerning Plaintiff's adjustment disorder, Saffert noted that Plaintiff experiences anxiety and depression regarding her divorce, the behavior of one of her sons, finances, and moving into her parents' home. (Tr. 475.) As for Plaintiff's panic disorder, Saffert noted that Plaintiff experiences recurrent panic attacks with the most recent attack in early December 2012. (Tr. 476.) Saffert additionally noted that Plaintiff has a “persistent concern” over additional panic attacks and worry. (Tr. 476.) In conjunction with her major depressive disorder, Saffert noted that Plaintiff has a depressed mood, “weight/appetite loss (client clearly underweight-appears frail), ” and sleep disturbance. (Tr. 476.) Plaintiff also had decreased energy and motivation as well as low self-esteem. (Tr. 476.) Saffert further noted that Plaintiff was isolating, indecisive, and experiencing significant distress over finances, housing, and her “dependent status.” (Tr. 476.) With respect to Plaintiff's posttraumatic stress disorder, Saffert noted that Plaintiff had been physically abused by a spouse for 25 years, which caused Plaintiff to have intense fear. (Tr. 476.) Plaintiff experienced flashbacks and nightmares as well as loss of interest and detachment. (Tr. 476.) Further, Plaintiff was hypervigilant and had difficulty concentrating. (Tr. 476.)

         Saffert described Plaintiff as anxious, “physically frail, ” well groomed, and fidgety. (Tr. 475.) Saffert also noted that Plaintiff had an “obvious hearing impairment.” (Tr. 475.) Saffert listed the following activities when describing a typical day for Plaintiff: showering, getting dressed, making her bed, preparing some meals for herself, washing dishes, doing light laundry, watching television, socializing with some family members but avoiding her sister, napping, and spending most of her time in her room at her parents' home. (Tr. 475.) Plaintiff's interests were “a relationship with a friend.” (Tr. 475.) Saffert stated that Plaintiff appears to behave and have a lifestyle “consistent with [the] symptoms she endorses.” (Tr. 477.)

         In response to a question regarding how Plaintiff gets along with family members and others, Saffert stated that Plaintiff was “compliant, passive [and] avoidant.” (Tr. 475.) Saffert described Plaintiff's persistence as “minimal as per chronic pain, depression, [and] anxiety” and stated that Plaintiff described her pace as “slow” due to her lack of motivation and energy as well as fatigue. (Tr. 477.) Saffert described Plaintiff's concentration as “very limited as per client's report (and appears so in session).” (Tr. 477.) Saffert was also asked to comment on Plaintiff's ability to respond appropriately to work pressure, supervision, and coworkers. (Tr. 477.) Saffert responded that work pressure would be “debilitating” for Plaintiff; Plaintiff would be “easily intimidated” by supervisors; and due to Plaintiff's passivity, she would be “easily taken advantage of” by coworkers. (Tr. 477.) Saffert opined that Plaintiff would be able to manage benefit payments. (Tr. 477.)

         As for Plaintiff's prognosis, Saffert “assume[d] no recovery” for Plaintiff's impaired hearing and described Plaintiff's prognosis as “poor re[garding] recovery in other aspects.” (Tr. 477.) Saffert noted that Plaintiff's prognosis was “fair” regarding her ability to “gain[] coping skills.” (Tr. 477.)

         In early March, Plaintiff presented twice to the emergency room for anxiety along with itching, tingling and numbness. (Tr. 506, 509, 512.) Plaintiff reported that when she is anxious, she itches. (Tr. 506.) During each visit, Plaintiff appeared well and was noted to be independent in her activities of daily living. (Tr. 506, 510, 512.)

         Plaintiff saw Saffert again towards the end of March. (Tr. 561.) Plaintiff was tearful during the appointment. (Tr. 561.) Plaintiff reported that she was again staying with her parents. (Tr. 561.) Plaintiff reported that her hearing was worsening and she was scheduled to have it checked in April. (Tr. 561.) Plaintiff's hearing difficulties were causing anxiety and she was having particular difficulty hearing in groups. (Tr. 561.) Plaintiff was relieved to have the appointment scheduled. (Tr. 561.)

         During an unrelated appointment in early April, Dr. Stolpman noted that Plaintiff had an “appropriate affect and demeanor.” (Tr. 495.) Dr. Stolpman made similar observations at a subsequently follow-up appointment approximately one month later. (Tr. 499.)

         Plaintiff had three appointments with Saffert in April. (Tr. 559-61.) Plaintiff most often reported that she was tired. (Tr. 559, 561.) During one appointment, Plaintiff attributed her tiredness to being “overworked, ” noting that she feels obligated to contribute around her parents' house because they basically support her.” (Tr. 561.) At another appointment, Plaintiff attributed her tiredness to “chronic pain.” (Tr. 559.) At times, Plaintiff also reported feeling deflated and having no energy. (Tr. 559, 561.) Towards the end of April, Plaintiff reported she was “[p]retty good” but worried about her daughter. (Tr. 559.) During these appointments, Saffert described Plaintiff's appearance and affect as “blah, ” “fatigued, ” and “anxious.” (Tr. 559.)

         Jeffrey C. Manlove, M.D., evaluated Plaintiff's hearing loss also towards the end of April. (Tr. 501, 587-88; see Tr. 589.) Plaintiff reported that the hearing loss had been present for a number of years and was “slightly worsening.” (Tr. 501; accord Tr. 587.) Plaintiff stated that her ears “pop” and feel like they are “full.” (Tr. 501; accord Tr. 587.) In a letter to Dr. Stolpman, Dr. Manlove noted that Plaintiff's “audiometric evaluation shows that she has significant hearing loss.” (Tr. 501: accord Tr. 587.) Plaintiff's “[r]eported speech discrimination score [wa]s worse on the left than the right; 44% on the right, 32% on the left.” (Tr. 501; accord Tr. 587; see Tr. 588.) Among other things, Dr. Manlove recommended that Plaintiff “make a hearing aid evaluation appointment.” (Tr. 501; accord Tr. 588; see Tr. 499.) Plaintiff was ultimately fitted for and received hearing aids. (Tr. 576-78.)

         Plaintiff met with Saffert an additional three times in May. (Tr. 557-58.) Again, Saffert's handwritten notes are quite difficult to read. (See Tr. 557-58.) Plaintiff continued to worry about her daughter and wanted to improve their relationship. (Tr. 558.) Plaintiff described herself as “[s]tressed” at the beginning of May, but was doing “[p]retty good” towards the end of May. (Tr. 557-58.) Saffert described Plaintiff as “[t]earful/anx[ious], ” but also more assertive and with a “brighter aff[ect].” (Tr. 557-58.)

         In the month of June, Plaintiff had four appointments with Saffert. (Tr. 556-57, 708-11.) During the first appointment, Plaintiff reported that she was doing “ok.” (Tr. 557.) Plaintiff discussed difficulties with mental processing and tracking as well as feeling disoriented. (Tr. 557.) Plaintiff stated she had shared these symptoms with her other treatment providers. (Tr. 557.) Saffert noted that Plaintiff had difficulty tracking during the appointment and appeared distracted. (Tr. 557.) At the second appointment, Plaintiff was “[t]ired-but good.”[5] (Tr. 556; see Tr. 708.) Plaintiff was positive about the future and Saffert noted that she had a bright affect. (Tr. 556. But see Tr. 708 (noting fatigue and a depressed mood).) Plaintiff reported that she was “now completely dependent on . . . [her] parents for housing, food, etc.” (Tr. 708-09.)

         During her third appointment, Plaintiff reported increased facial pain and headaches over the past two days. (Tr. 708.) Plaintiff also reported increased family conflict over her dependence on her parents, stating that two of her siblings did not believe that Plaintiff deserved financial help from their parents. (Tr. 708.) Saffert described Plaintiff as “sad.” (Tr. 708.) At the fourth appointment, Plaintiff was tired and frustrated with the treatment recommendations of the pain clinic. (Tr. 710.) Plaintiff reported, however, that she was going up north with a friend for approximately two weeks. (Tr. 710.) Saffert noted Plaintiff was “angry.” (Tr. 710.)

         At an appointment to address facial pain towards the end of June, Plaintiff reported feeling stressed out/overwhelmed, having low energy, and experiencing crying spells. (Tr. 618.) Plaintiff also reported having difficulty sleeping, concentrating, and relaxing. (Tr. 618.) Plaintiff additionally reported that she felt like taking her own life within the past six months. (Tr. 618.) Among other things, Plaintiff also reported depression and anxiety. (Tr. 623.)

         In July, Saffert completed a medical source statement regarding Plaintiff. (Tr. 583.) Saffert listed Plaintiff's diagnoses as generalized anxiety disorder, adjustment disorder, panic disorder, major depressive disorder, and posttraumatic stress disorder. (Tr. 583.) Saffert gave Plaintiff a GAF score of 45[6] and described Plaintiff's prognosis as “guarded.” (Tr. 583.) Saffert noted that Plaintiff's “hearing loss contributes to [her] anxiety” and “chronic pain contributes to [her] anxiety [and] depression.” (Tr. 583.) Saffert opined that Plaintiff had a “[m]edically[]documented history of chronic organic mental, schizophrenic, affective, or other disorder of at least 2 years' duration that has caused more than a minimal limitation of ability to do any basic work activity, with signs or symptoms currently attenuated by medication or psycho-social support” accompanied by “[a] residual disease process that has resulted in such marginal adjustment that even a minimal increase in mental demands or change in the environment would be predicted to cause the individual to decompensate” as well as “[a] current history of 1 or more years' inability to function outside a hugely supportive living arrangement with an indication of continued need for such an arrangement.” (Tr. 585.) Saffert indicated that Plaintiff's symptoms have lasted or are expected to last more than 12 months and that Plaintiff was not a malingerer. (Tr. 583.)

         When asked to describe Plaintiff's “treatment and response, including any medication side effects which may affect [her] ability to work, ” Saffert wrote, “N/A.” (Tr. 583.) Saffert similarly wrote “N/A” when asked if Plaintiff would need any unscheduled breaks during an 8-hour work day and to estimate how many days per month Plaintiff would likely be absent from work. (Tr. 585.) Saffert explained that Plaintiff “cannot maintain an 8-h[ou]r work day.” (Tr. 585.) indicate serious symptoms or any serious impairment in social, occupational, or school functioning.” Id. (citation omitted). The Court notes that the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (5th ed. Am. Psychiatric Ass'n 2013) “discontinued use of the GAF scale.” Mabry v. Colvin, 815 F.3d 386, 391 n.6 (8th Cir. 2016).

         Saffert was also asked to evaluate Plaintiff's ability to sustain approximately 20 mental activities and maintain a productive level of functioning. (Tr. 583-84.) Saffert opined that Plaintiff had no or mild limitation in her abilities to accept instructions and respond appropriately to criticism as well as maintain socially appropriate behavior and adhere to basic standards of neatness and cleanliness. (Tr. 584.) Plaintiff was moderately limited in her abilities to interact appropriately with the public, ask simple questions or request assistance, and get along with coworkers or peers without distracting them or exhibiting behavioral extremes. (Tr. 584.) Plaintiff had marked limitations in her abilities to understand and remember very short and simple instructions, work in coordination with or close proximity to others without being distracted by them, and be aware of normal hazards and take appropriate precautions. (Tr. 584.) In all other areas, Saffert opined that Plaintiff was extremely limited. (Tr. 584.) Saffert further opined that Plaintiff's history of multiple head traumas over time limited her “[o]rientation/mental tracking.” (Tr. 585.)

         When Plaintiff returned to see Saffert in mid-July, Plaintiff was “not good” and reported experiencing back pain after minimal cleaning of her room.” (Tr. 710.) Plaintiff again noted that she “wanted to contribute.” (Tr. 710.) Plaintiff described her pain as exhausting and needed to take breaks. (Tr. 710.) Saffert noted that Plaintiff was “physically fatigued” and “walking slowly [and] carefully.” (Tr. 710.) Plaintiff had two additional appointments in July. (Tr. 712-13.) At one point, Plaintiff reported that she was “[p]retty good, ” but Saffert noted that Plaintiff was tearful and sad at both appointments. (Tr. 712.) Saffert's handwritten notes are again difficult to read, but it appears that Plaintiff discussed relationships in her life. (See Tr. 712-13.)

         Plaintiff also had an appointment with Dr. Stolpman in July. (Tr. 626-29.) Plaintiff's mental impairments were not among her chief complaints. (Tr. 626.) Dr. Stolpman noted that Plaintiff was negative for psychiatric symptoms, was well groomed, and had an appropriate affect and demeanor. (Tr. 626, 628.)

         Plaintiff had another three sessions with Saffert in August. (Tr. 714-16.) While Plaintiff reported she was doing “[p]retty good” and spending more time with her daughter at the beginning of August, she was less positive during the next two appointments. (Compare Tr. 714 with Tr. 714, 716.) Plaintiff was anxious regarding her pending applications for Social Security benefits and experiencing side effects from a new pain medication, which caused her to feel tired, nauseated, abdominal distress, and muscle fatigue. (Tr. 714, 16.) Plaintiff again discussed how it was difficult to be dependent on others for necessities and brought up financial issues with respect to her car. (Tr. 714.) Saffert described Plaintiff as anxious, depressed, and occasionally tearful during these appointments. (Tr. 714-16.)

         In early September, Plaintiff told Saffert that she had been denied Social Security disability benefits and was afraid to tell her family. (Tr. 717.) Plaintiff was concerned over what the reaction might be. (Tr. 717.) Plaintiff told Saffert that she would work if she was able to, but she cannot. (Tr. 717.) Saffert noted that Plaintiff was tearful, depressed, and anxious. (Tr. 717.) About one week later, Plaintiff's outlook was better. (Tr. 717.) Plaintiff had spoken with her caseworker and was going to seek reconsideration of the disability determination. (Tr. 717.) Plaintiff still, however, harbored feelings of anxiety, frustration, and sadness over the decision. (Tr. 718.) Plaintiff described her life as being “in limbo” while she waited. (Tr. 718.) During her next appointment about one week later, Plaintiff discussed competing relationships in her life. (Tr. 719.) Saffert described Plaintiff as struggling with her emotions. (Tr. 719.)

         Plaintiff saw both Dr. Stolpman and Saffert in October. When she saw Dr. Stolpman in early October, Plaintiff's mental impairments were not among her chief complaints and Dr. Stolpman noted that Plaintiff was negative for psychiatric symptoms, was well groomed, and had an appropriate affect and demeanor. (Tr. 633, 635.) Around the middle of October, Plaintiff met with Saffert. (Tr. 719.) Plaintiff reported that she had spent some time in International Falls, Minnesota, and now had a clearer idea of where a relationship with a friend was going. (Tr. 719.) Plaintiff also reported that she was worried over her mother's illness. (Tr. 719.) Saffert noted that Plaintiff had a “brighter affect.” (Tr. 719.)

         Plaintiff had two additional appointments with Saffert in October. (Tr. 720-21.) Plaintiff reported that she was “[a]lright” and discussed results of medical testing. (Tr. 720.) Saffert noted that Plaintiff gets stressed when discussing money and this was a trigger for Plaintiff's flashbacks. (Tr. 720.) Saffert described Plaintiff as “anxious.” (Tr. 720.) During her appointment at the end of October, Plaintiff was feeling “tired” and “drained.” (Tr. 720.) The cold weather was causing an increase in her pain and she had a persistent headache the day before. (Tr. 720.) Plaintiff and Saffert discussed some of Plaintiff's functional abilities. Plaintiff stated that she had problems lifting and could lift about two pounds comfortably. (Tr. 720.) Plaintiff reported that a “leaning position” is the most difficult for her and one and one-half hours was the tolerable limit for standing. (Tr. 720, 721.) Plaintiff also stated she is unable to kneel because her knees are damaged. (Tr. 721.) According to Plaintiff, she “would not be able to live on [her] own.” (Tr. 721.) Plaintiff reiterated that finances cause emotional flashbacks for her. (Tr. 721.) Saffert described Plaintiff as “fatigued.” (Tr. 720.)

         Plaintiff also had a follow-up appointment regarding her hearing aids at the end of October. (Tr. 603.) Plaintiff reported that “things are going well with the hearing aids.” (Tr. 603.) A few adjustments were made. (Tr. 603.)

         Plaintiff saw Dr. Stolpman in early November for, among other things, a routine check of her depression. (Tr. 643.) Plaintiff described her depression as “moderate” and Dr. Stolpman noted that “[t]his episode of depression has been present for the past several years.” (Tr. 643.) Plaintiff's current symptoms were anhedonia, decreased concentration, and fatigue. (Tr. 643.) Plaintiff denied feeling anxious, sad, or worthless as well as crying spells. (Tr. 643.) Plaintiff reported that Cymbalta was helpful. (Tr. 643.) ...

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