United States District Court, W.D. Louisiana, Lake Charles Division
REPORT AND RECOMMENDATION
H.L. Perez-Montes, United States Magistrate Judge.
Kaye Richard (“Richard) filed an application for
disability insurance benefits (“DIB”) on October
9, 2013, alleging a disability onset date of May 20, 2011
(Doc. 11-1, p. 132/249) due to bipolar disorder 1 mixed,
agoraphobia, fibromyalgia, depression, anxiety/panic
disorder, chronic fatigue syndrome, and general pain disorder
(Doc. 11-1, p. 150/249). That application was denied by the
Social Security Administration (“SSA”) (Doc.
11-1, p. 80/249).
de novo hearing was held before an administrative
law judge (“ALJ”), at which Richard appeared with
her attorney and a vocational expert (“VE”) (Doc.
11-1, p. 30/249).
found that, although Richard suffers from a severe
impairment, fibromyalgia, she has the residual functional
capacity to do the full range of sedentary work and,
therefore, could still do her past relevant work as an
administrative coordinator and a cash accounting clerk (Doc.
11-1, pp. 15, 19, 23/249). The ALJ concluded that Richard was
not disabled at any time from May 11, 2011 through the date
of his decision on August 15, 2015 (Doc. 11-1, p. 24/249).
requested a review of the ALJ's decision, but the Appeals
Council declined to review it (Doc. 11/1, p. 4/249) and the
ALJ's decision became the final decision of the
Commissioner of Social Security (“the
next filed this appeal for judicial review of the ALJ's
decision. Richard raises the following issues on appeal (Doc.
1. The ALJ failed to properly assess Richard's mental
impairments at Step 2.
2. The residual functional capacity determination of
“light” work is not supported by substantial
Commissioner filed a response to Richard's appeal (Doc.
16), to which Richard replied (Doc. 17). Richard's appeal
is not before the Court for disposition.
2011, Richard was treated at Brentwood Hospital, in
Shreveport, Louisiana, for mixed bipolar disorder I and
depression (Doc. 11-1, pp. 232-33/249).
October 2012, Richard was treated by Dr. Said H. Cantu, a
neuropsychiatrist (Doc. 11-1, pp. 225-26/249). Dr. Cantu
found Richard suffered from fatigue, hypersomnia, and a
euthymic (normal) mood, and he diagnosed bipolar disorder
(Doc. 11-1, pp. 225-26/249). Dr. Cantu continued
Richard's medications (Inderal, Cogentin, Geodon, and
Xanax) (Doc. 11-1, p. 226/249). Richard's symptoms were
the same in January 2013, and her medications were continued
(Doc. 11-1, pp. 223-24/249).
February 2013, Richard's mood was dysthymic/depressed and
her affect was abnormal and constricted (Doc. 11-1, p.
221/249). Richard was diagnosed with bipolar affective
disorder and prescribed Zoloft (Doc. 11-1, p. 221/249).
2013, Richard's mood was euthymic and her affect was
normal (Doc. 11-1, p. 218/249). Richard was taking Geodon,
Xanax, Cogentin, and Inderal for her bipolar disorder, manic
unspecified, and Zoloft for her bipolar affective disorder
(Doc. 11-1, p. 220/249). Richard's medications were
continued (Doc. 11-1, p. 217/249).
August 2013, Richard's mood was dysthymic/depressed, her
affect was abnormal and constricted, and she reported anxiety
and smoking every day (Doc. 11-1, p. 216/249). In November
2013, Richard's condition was the same, except her affect
was normal (Doc. 11-1, pp. 213-14/249). Dr. Cantu found
Richard's overall condition was fair, diagnosed bipolar
disorder and moderate depression, continued her Geodon,
propranolol, Xanax, and Cogentin, and increased her Zoloft
dosage (Doc. 11-1, pp. 213-14/249).
January 2014, Dr. Cantu noted Richard was anxious and wanted
to stop taking Zoloft, claiming it was not working (Doc.
11-1, p. 245/249). Dr. Cantu found Richard's mood was
dysthymic and depressed, and her affect was abnormal and
constricted (Doc. 11-1, p. 244/249). Dr. Cantu diagnosed
bipolar disorder and moderate depression, and prescribed
Wellbutrin XL (Doc. 11-1, p. 245/249).
February 2014, a state disability determinations consultant,
Joseph Kahler, Ph.D., reviewed Richard's medical records
and found her affective disorders were not severe (Doc. 11-1,
pp. 75/249). Dr. Kahler found Richard had no more than mild
restrictions in functioning, and there was no evidence of
more than mild work-related limitations attributable to
mental disorders (Doc. 11-1, p. 75/249).
April 2014, Dr. Cantu found Richard's affect was normal,
but her mood was still dysthymic and depressed, and continued
her medications (Doc. 11-1, p. 242-43/249). In May 2014,
Richard's affect was normal and her mood was dysthymic,
Dr. Cantu diagnosed bipolar disorder, manic (unspecified),
and prescribed tramadol HC1 (Doc. 11-1, p. 241/249). In
October 2014, Richard's mood was still dysthymic, and she
had anergia, poor ambition to do things, and was isolated and
withdrawn (Doc. 11-1, p. 239/249). Richard was prescribed
Wellbutrin XL, Xanax, XR, Geodon, Cogentin, propranolol HCl,
and Adipex-P (Doc. 11-1, p. 2239-40/249).
Cantu filled out a mental residual functional capacity
assessment of Richard in November 2014, to assess her bipolar
disorder and anxiety (Doc. 11-1, p. 234/249). Richard's
symptoms were decreased energy, feelings of guilt or
worthlessness, difficulty concentrating or thinking, thinking
about suicide but not planning it, generalized persistent
anxiety, emotional withdrawal and isolation, and decreased
energy (Doc. 11-1, p. 234/249). Dr. Cantu noted that
Richard's husband usually accompanies her when she leaves
home (Doc. 11-1, p. 234/249). Dr. Cantu found that, in a
normal workday and workweek, Richard is moderately limited in
her ability to understand and remember very short and simple
instructions; extremely limited in her ability to understand
and remember detailed instructions; moderately limited in her
ability to carry out very short and simply instruction;
extremely limited in her ability to carry out detailed
instructions; extremely limited in her ability to perform
activities within a schedule, maintain regular attendance,
and be punctual within customary tolerances; markedly limited
in her ability to sustain an ordinary routine without special
supervision; markedly limited in her ability to make
judgments on simple work-related decisions; extremely limited
in her ability to interact appropriately with the public;
extremely limited in her ability to ask simple questions or
request assistance; moderately limited in her ability to
accept instructions and respond appropriately to criticism
from supervisors; markedly limited in her ability to respond
appropriately to changes in the work setting; and extremely
limited in her ability to set realistic goals or make plans
independently of others (Doc. 11-1, pp. 235-36249). Dr. Cantu
further stated that Richard has anxiety issues, especially
with people; and social anxiety that causes panic and makes
her an unstable employee (Doc. 11-1, p. 236/249).
January 2015, Richard reported doing well on her medications,
was not feeling fatigue, had lost 20 pounds, and had more
sexual desire, but her mood was still dysthymic (Doc. 11-1,
was evaluated by Dr. Ladislas Lazaro IV, a rheumatologist, in
July 2013. Dr. Lazaro noted Richard's diagnosis of
fibromyalgia five years before, and her history of symptoms
prior to that (Doc. 11-1, p. 204/249). Richard complained of
hurting all over all of the time, the pain fluctuating in
intensity based on activity and causing her to become
increasingly sedentary over the past few years (Doc. 11-1, p.
204/249). Richard did not have any arthritic joint swelling,
but had weight gain and mild edema (Doc. 11-1, p. 204/249).
Richard had not exercised in the past five years (Doc. 11-1,
p. 204/249). Richard also complained of constant fatigue
(Doc. 11-1, p. 204/249). Richard was 5' 3 ½”
tall, weighed 221 pounds, and her blood pressure was 130/76
(Doc. 11-1, ...