United States District Court, E.D. Virginia, Norfolk Division
REPORT AND RECOMMENDATION OF UNITED STATES MAGISTRATE JUDGE
TOMMY E. MILLER, Magistrate Judge.
This action was referred to the undersigned United States Magistrate Judge pursuant to the provisions of 28 U.S.C. § 636(b)(1)(B) and (C) and Rule 72(b) of the Federal Rules of Civil Procedure, as well as Rule 72 of the Rules of the United States District Court for the Eastern District of Virginia.
Plaintiff brought this action under 42 U.S.C. §§ 405(g) and 42 U.S.C. § 1383(c)(3), seeking judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying Plaintiff's applications for disability insurance benefits ("DIB") and Supplemental Security Income ("SSI") pursuant to sections 205(g) and 1631(c)(3) of the Social Security Act. The undersigned recommends that the decision of the Commissioner be VACATED and REMANDED to the Commissioner for further analysis consistent with this Report and Recommendation.
I. PROCEDURAL BACKGROUND
Plaintiff protectively applied for DIB and SSI on July 29, 2010, alleging disability since January 10, 2007,  caused by panic attacks, anxiety, bipolar, and arthritis. R. 185-98, 224. Plaintiff's applications were denied initially, R. 128-33, and on reconsideration, R. 138-51. Plaintiff requested a hearing by an Administrative Law Judge (ALJ), R. 152-53, which occurred on March 14, 2013. R. 45-70. Plaintiff, represented by counsel, and a vocational expert testified before the ALJ. R. 45-70.
On April 3, 2012, the ALJ found that Plaintiff was not disabled within the meaning of the Social Security Act. R. 27-40. The Appeals Council denied Plaintiff's request for administrative review of the ALJ's decision. R. 1-4. Therefore, the ALJ's decision stands as the final decision of the Commissioner for purposes of judicial review. See 42 U.S.C. §§ 405(g), 1383(c)(3); 20 C.F.R. §§ 404.981, 416.1481 (2012).
II. FACTUAL BACKGROUND
A. Plaintiff's Background
Born in 1965, Plaintiff was forty-two years old on her alleged disability onset date and forty-six years old at the time of her administrative hearing. R. 49. She has past relevant work as a cashier and a nursing assistant. R. 213. She last worked in 2010 at the Navy Exchange. R. 51. Her date last insured is June 20, 2014. R. 32.
B. Plaintiff's Medical History
1. Hospital and Emergency Room Visits
On September 29, 2009, Plaintiff was admitted to Sentara Bayside Hospital, complaining of chest pain and shortness of breath. R. 267-68. She was hyperventilating and had tingling feelings in her lips and fingers. R. 268. She admitted to feeling stressed, and the doctors noted a history of depression and anxiety. R. 268-69. She was diagnosed with dyspnea and anxiety, and was discharged from the hospital. R. 272-73.
On January 25, 2010, Plaintiff went to the emergency room at Sentara Norfolk General Hospital with atypical chest pains. R. 314. Doctors at the emergency room diagnosed Plaintiff's chest pain as being most likely caused by musculo-skeletal issues, but that anxiety and stress were also likely to cause the pain. R. 318.
2. Atlantic Psychiatric Services
On May 6, 2009, Plaintiff had an initial diagnostic evaluation at Atlantic Psychiatric Services, P.C., with Rebecca E. Barchas, M.D., F.A.P.A. R. 292-97. In the evaluation, Dr. Barchas noted that Plaintiff's chief complaints were stress, panic attacks, and depression, and indicated that Plaintiff got very depressed and had severe mood swings and anger. R. 292. Dr. Barchas opined that Plaintiff's first panic attack was in 1996, on a flight to Italy. R. 292. Plaintiff had a nervous breakdown in 2005, and could not go outside for a year because she was afraid the people outside were trying to kill her. R. 292. Dr. Barchas also noted that Plaintiff had delusions and hallucinations. R. 292. Plaintiff's mother was schizophrenic, and both parents used drugs. R. 293. Plaintiff smoked a third of a pack of cigarettes a day, and occasionally drank a bottle of white zinfandel. R. 293. Dr. Barchas also indicated that Plaintiff had not done other drugs for six years, but prior to that, cocaine was her drug of choice. R. 293. Plaintiff divorced before September 11,  and Dr. Barchas noted that there were domestic violence charges by Plaintiff's ex-husband. R. 293. Dr. Barchas also indicated that Plaintiff once lost thirty pounds in three months because she could not eat due to a nervous breakdown. R. 294.
Dr. Barchas noted that Plaintiff's sleep, appetite, energy, interests, socialization, mood, sex drive and self-esteem were depressed, her guilt was elevated, and her weight remained constant. R. 294. Dr. Barchas also indicated that Plaintiff had elevated, expansive and irritable mood changes, and during those changes she exhibited grandiosity, decreased need for sleep, increased talkativeness, flight of ideas or racing thoughts, distractability, increased goal-oriented activity or psychomotor agitation, and excessive involvement in pleasurable activities that have a high potential for painful consequences. R. 293. However, Dr. Barchas did indicate that there was no evidence that Plaintiff was a risk to herself or others. R. 293. Plaintiff's impulse control, judgment, insight and concentration/attention were marked as impaired, but the report indicated that Plaintiff was neither suicidal nor homicidal. R. 296. Dr. Barchas diagnosed bipolar disorder with psychotic thoughts, panic disorder, vaginosis, psychological stressors of work, family and money, and a GAF of 45. R. 296. She established short-term goals of establishing a therapeutic relationship, preventing or reducing self-defeating behaviors, establishing a sense of hope for change, improving and stabilizing mood, and improving control over impulses, anger, and anxiety. R. 297. She also established long-term treatment goals of improved and stabilized mood, interpersonal relationships, and functioning at work. R. 297.
Plaintiff saw Dr. Barchas for treatment from June 2009 through August 2010. R. 284-91. Treatment notes from June indicate that Plaintiff had low self-esteem, anxiety, severe mood swings, and paranoid thoughts. R. 291. On June 17, 2009, Dr. Barchas started Plaintiff on a lithium trial. R. 291. On June 30, 2009, Dr. Barchas noted that the lithium had a calming effect on Plaintiff's moods, and noted that Plaintiff was improving and/or much improved. R. 290. She also noted, however, that Plaintiff suffered from anxiety. R. 290. On August 18, 2009, Dr. Barchas noted that Plaintiff was suffering from anxiety, depression, delusions, hallucinations, anorexia and bulimia, and stated that Plaintiff was regressing. R. 290. She opined that Plaintiff was starting to feel as if people were watching her and trying to get her, and also that no one cared about her. R. 290. She also noted that Plaintiff complained of feeling "heavy." R. 290. On August 26, 2009, Dr. Barchas stated that Plaintiff was much improved, and that Plaintiff's medication had reduced her psychotic thoughts and anxiety. R. 289. On September 22, 2009, however, Dr. Barchas indicated that Plaintiff was suffering from anxiety, depression and anger, and had regressed. R. 289. Dr. Barchas opined that Plaintiff was wound up and had a paranoid thread to her thinking. R. 289. She also indicated that Plaintiff had stopped taking lithium. R. 289. On October 1, 2009, Dr. Barchas noted that Plaintiff had gone to the emergency room because she had a panic attack that she believed was a heart attack. R. 289. Dr. Barchas indicated that Plaintiff had anxiety, panic, depression and mania, and started Plaintiff on lithium again. R. 289.
On October 20, 2009, Dr. Barchas indicated that Plaintiff suffered from anxiety, depression, mania and anger, and that she appeared to be unchanging from the previous appointment. R. 288. Dr. Barchas described Plaintiff as having much lability of mood, and noted work issues. R. 288. On January 12, 2010, Dr. Barchas noted that Plaintiff was anxious and depressed, but that she was improving. R. 287. On January 28, 2010, Dr. Barchas indicated that Plaintiff had not had a panic attack for seventy-two hours. R. 287. Dr. Barchas also opined that on January 25, 2010, Plaintiff had gone to the emergency room because she believed she was having a heart attack, but she was diagnosed with having a panic attack. R. 287. On February 9, 2010, Plaintiff showed improvement, but Dr. Barchas still noted that she suffered from anxiety and depression. R. 286. On March 9, 2010, Dr. Barchas noted anxiety, depression and anger, and indicated that ...