United States District Court, E.D. Virginia, Norfolk Division
RHIANNON V. PARSONS, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner, Social Security Administration, Defendant.
REPORT AND RECOMMENDATION
LAWRENCE R. LEONARD UNITED STATES MAGISTRATE JUDGE
Rhiannon V. Parsons ("Plaintiff), proceeding pro
se, filed a complaint pursuant to 42 U.S.C. §
405(g) seeking judicial review of the final decision of Nancy
A. Berryhill, the Acting Commissioner of the Social Security
Administration ("the Commissioner"), denying
Plaintiffs claim for Supplemental Security Income
("SSI") under the Social Security Act ("the
Act"). Plaintiff filed a Motion for Summary Judgment,
ECF Nos. 12, 12-1, and a Memorandum of Law in Support, ECF
Nos. 13, & 13, attach. I. The Commissioner filed a
Cross-Motion for Summary Judgment and Memorandum of Law in
Support. ECF Nos. 14-15. Both Motions are now ready for
action was referred to the undersigned United States
Magistrate Judge ("the undersigned") pursuant to 28
U.S.C. §§ 636(b)(1)(B)-(C), Federal Rule of Civil
Procedure 72(b), Eastern District of Virginia Local Civil
Rule 72, and the April 2, 2002 Standing Order on Assignment
of Certain Matters to United States Magistrate Judges. After
reviewing the Administrative Record and the briefs submitted
by the parties, the undersigned makes this recommendation
without a hearing pursuant to Federal Rule of Civil Procedure
78(b) and Local Civil Rule 7(J). For the following reasons,
the undersigned RECOMMENDS that Plaintiffs
Motion for Summary Judgment, ECF No. 12, be
DENIED, the Commissioner's Motion for
Summary Judgment, ECF No. 14, be GRANTED,
the final decision of the Commissioner be
AFFIRMED, and that this matter be
DISMISSED WITH PREJUDICE.
initially filed her application for SSI on May 17, 2012,
alleging disability due to anemia, chronic urinary tract
infections, bipolar disorder, panic/anxiety disorder,
arrhythmia, and chronic pain in her hands, knees, and back,
with an alleged onset date of April 20, 2011. R. at 21, 23,
77, 213. Her application was initially denied on
October 26, 2012, R. at 112, and denied again upon
reconsideration on December 19, 2013, R. at 126. Plaintiff
then filed a request for a hearing with an administrative law
judge ("the ALJ") on February 3, 2014. R. at 133.
The ALJ, Stewart Goldstein, conducted a video hearing on
August 12, 2015, at which Plaintiff appeared and testified.
R. at 42. Also present were Plaintiffs father, who testified
on Plaintiffs behalf, and a vocational expert
("VE"). R. at 43. On October 22, 2015, the ALJ
issued a written decision denying Plaintiffs SSI application.
R. at 18. On December 21, 2015, Plaintiff then filed a
request with the Appeals Council for the Office of Disability
and Adjudication ("Appeals Council") to review the
ALJ's decision. R. at 16. On October 28, 2016, the
Appeals Council denied Plaintiffs request for review on the
grounds that the ALJ did not abuse his discretion, there was
no error of law, the ALJ's decision was supported by
substantial evidence, and the case did not present a policy
issue of public interest. R. at 1. Although, the Appeals
Council considered the additional evidence submitted by
Plaintiff, it determined that the additional information did
not provide a basis for changing the ALJ's decision. R.
at 2. Therefore, the ALJ's decision became the
Commissioner's final decision. R. at 1.
January 4, 2017, having exhausted her administrative
remedies, Plaintiff, acting pro se, filed the
instant Complaint for judicial review of the
Commissioner's final decision. ECF No. 3. The
Commissioner filed an Answer and the Administrative record,
and the matter was referred to the undersigned for
recommended disposition. ECF Nos. 8, 10. Plaintiff filed her
Motion for Summary Judgment, ECF No. 12, and the Commissioner
filed a Cross-Motion for Summary Judgment, a Memorandum in
Support, and a Roseboro notice, ECF Nos. 14-16. The
matter is now ripe for recommended disposition.
RELEVANT FACTUAL BACKGROUND
alleged her disability onset date was April 20, 2011. R. at
21, 77. When Plaintiff filed her application for SSI on May
17, 2012, she was twenty-four (24) years old and had acquired
her GED. R. at 31-32, 201-11. Plaintiff does not have
consistent prior employment. R. at 201-11. Her work history
consists of retail sales positions, all of which seemingly
last less than one (1) year, R. at 67, 87, 201, as well as
sporadic modeling performances in fashion shows, see,
e.g., R. at 475, 683. On August 12, 2015, Plaintiff
testified before the ALJ at the administrative hearing and
provided additional information. R. at 42-76.
resides in Hampton, Virginia with her father, whom she
contends is severely disabled, R. at 46, 228, and her twin
children, then age 5, R. at 46. Her daughter, XXXXX has severe autism, and her son,
XXXXX has ADHD and anger issues. R.
at 57, 227. Plaintiff stated that both children receive SSI,
and both attend regular doctor appointments and therapy
sessions. R. at 46, 57-58. She is able, with the help of her
father, to dress her children for their appointments and
speak with doctors, and relies on both her father and fiance
to assist in getting the children to school. R. at 57-58. She
attempts to help with housework and chores as much as
possible, though she often needs help and encouragement to do
so. R. at 24, 229. Plaintiff visits friends once a month, and
goes to the movies twice a month at night in order to avoid
crowds. R. at 59. She owns a computer, which she uses to
access the Internet for websites like Facebook and YouTube.
R. at 59. Plaintiff has a driver's license, but does not
drive because she experiences panic attacks when doing so. R.
at 48, 230. She experiences similar anxiety when in a crowded
public place; for instance, when she goes grocery shopping
with her fiance. R. at 24, 49, 226.
time of the August 12, 2015 hearing, Plaintiff was prescribed
Hydrocodone, Naproxen, and Cyclobenzaprine for pain. R. at
54. She stated that Cyclobenzaprine and Naproxen no longer
provided pain relief, and the Hydrocodone was effective
approximately twenty-five percent (25%) of the time. R. at
55. Plaintiff also testified that she experiences depression
that makes it difficult for her to get out of bed, and
periods of mania where she becomes angry and closed off. R.
at 62. These manic periods can last between five (5) minutes
and three (3) to four (4) hours, and can sometimes cause her
to forget to eat. R. at 62-63, 228. Plaintiff claims she
experienced a ten (10) pound weight loss due forgetting to
eat or drink during manic periods, and "even when [she]
thinks about food . . . [she will] get really nauseous and
[she will] feel like" she needs to throw up. R. at 63.
Plaintiff also stated that during these manic episodes, she
can become "really angry, to the point where [she]
start[s] throwing things around the house, knocking things
over, not wanting to be around anybody, trying to close
[herself] off from everybody." R. at 62. Plaintiff also
finds that sometimes transitioning from a sitting position to
standing causes her to feel faint and black out. R. at 52.
These black out episodes can last anywhere between fifteen
(15) seconds and one (1) minute, though one time she
experienced a black out for two (2) minutes. R. at 53, 714.
During these episodes, Plaintiff sometimes falls to the
ground or into walls or doors. R. at 54.
Parsons ("Mr. Parsons"), Plaintiffs father, also
testified at the hearing. R. at 65-68. He testified that
Plaintiff has "a false awareness of reality," and
that her conditions are worse than she stated. R. at 65. Mr.
Parsons indicated that he is taking care of Plaintiffs
children, despite a recent heart attack. R. at 65. He stated
that he believes Plaintiff is autistic, and shows similar
symptoms to Plaintiffs mother, whose medical problems could
not be diagnosed and who died at age thirty-eight (38) of a
massive heart attack. R. at 66. Mr. Parsons testified that
when he is able to procure a job for Plaintiff, "within
a month she's calling [him] up freaking out" and he
has to pick her up. R. at 67. He then reiterated the opinion
of Dr. Mukesh Shah ("Dr. Shah"), Plaintiffs
psychiatrist, that Plaintiff is incapable of working. R. at
the ALJ's decision, Plaintiff continued treatment at
various medical facilities. ECF Nos. 12, 12-1. She was
subsequently diagnosed with Hypermobile Ehlers Danlos
Syndrome on November 14, 2016, Postural Orthopedic
Tachycardia Syndrome on December 27, 2016, and Raynaud's
Syndrome on March 20, 2017. ECF No. 13 at 2. She continued to
seek treatment from her psychiatrist for anxiety after her
August 12, 2015 hearing. R. at 762.
Relevant Medical Records Regarding Physical
Primary Care Physician Dr. Linda Schneider
to her medical records, Plaintiff was twenty-three (23) years
old on April 20, 2011, her alleged disability onset date. R.
at 21, 77. On May 17, 2011, about one month later, she sought
treatment from Dr. Linda Schneider ("Dr.
Schneider"), complaining of anxiety, pain, and
allergies. R. at 434. Plaintiff claimed that the onset of her
anxiety "was year(s) ago," and that the condition
worsens with "stress and [l]oss of sleep." R. at
434. Dr. Schneider noted that Plaintiff relieved her symptoms
through medication and counseling, and that Plaintiff was
negative for panic attacks or suicidal ideation. R. at 434.
Plaintiff described her physical pain as residing in her
lower back, and that it was "an ache and sharp." R.
at 434. Dr. Schneider's report states that the
"symptoms are aggravated by daily activities" and
"are relieved by stretching." R. at 434. At the
time of the exam, the physician found that Plaintiff had
regular heart rate and rhythm, with "no murmurs, gallops
or rubs." R. at 435. Dr. Schneider also found that
Plaintiffs balance, gait, and coordination were intact, and
Plaintiff experienced no sensory loss or motor weakness. R.
September 26, 2011, Plaintiff returned to Dr. Schneider for
back pain and fatigue. R. at 431. Dr. Schneider found spinal
tenderness and paravertebral muscle spasm, as well as
periscapular trigger points. R. at 432. There was also
"some audible crepitus" in her neck. R. at 432.
However, Dr. Schneider noted that Plaintiff had no joint
deformity and normal range of motion for her age, including
normal range of motion in her neck. R. at 432.
December 12, 2011, Plaintiff returned to Dr. Schneider for
back pain. R. at 428. Plaintiff described the pain as
"numbness and sharp [, ]" and noted that the
symptoms worsened "by changing positions, lifting,
sitting and twisting." R. at 428. Pain medication
provided some relief, but she had trouble sleeping despite
taking her prescribed muscle relaxer, Cyclobenzaprine. R. at
428. During the appointment, Dr. Schneider found decreased
lumbar mobility and tenderness, but no spasm. R. at 429.
Plaintiffs results were also negative for a straight leg
raising test. R. at 429. Dr. Schneider prescribed Ibuprofen
and Tylenol. R. at 429.
March 28, 2012, Plaintiff visited Dr. Schneider again for
back pain, anxiety, and allergies. R. at 424. Dr. Schneider
noted that at that time Plaintiff was prescribed
Cyclobenzaprine and Ibuprofen as needed for pain. R. at 424.
The physical exam showed regular heart rate and rhythm with
no murmurs, gallops, or rubs. R. at 424. In a visit on June
5, 2012 for constipation and hemorrhoids, Dr. Schneider noted
that Plaintiff was "negative for chest pain,
claudication, edema and irregular heartbeat/palpitations . .
. negative for anxiety, depression, [and] negative for back
pain, joint pain and joint swelling." R. at 658.
October 2, 2012, Plaintiff saw Dr. Schneider for hand spasms,
back pain, and palpitations. R. at 653. The examination
showed spasms along her cervical spine, thoracic spine, and
lumbar spine, but full range of motion and no deformity in
her elbows and hands. R. at 655. Plaintiff saw Dr. Schneider
on November 14, 2012 for a burning sensation in the left side
of her face. R. at 649. Her heart rate and rhythm during that
examination were regular, with no murmurs, gallops, or rubs.
R. at 651. On January 24, 2013, Plaintiff saw Dr. Schneider
for cold symptoms and breast tenderness, R. at 645, at which
time her heart rate and rhythm were regular, R. at 647.
March 18, 2013, Plaintiff sought treatment for
Gastroesophageal reflux disease ("GERD"). R. at
642. Another treating physician in Dr. Schneider's
practice saw Plaintiff, and noted abdominal tenderness, but
no distention. R. at 643. Plaintiff had a regular heart rate
and rhythm, with no murmurs, gallops, or rubs. R. at 643. On
July 16, 2013, Plaintiff returned to Dr. Schneider for back
pain and chest discomfort. R. at 635. Her physical
examination showed tenderness in Plaintiffs spine, with no
spasm or deformity. R. at 635. Plaintiff continued to have
normal range of motion. R. at 635. Plaintiff was tachycardic
when sitting, which accelerated with strain and slowed to
normal with lying down. R. at 635. Dr. Schneider treated
Plaintiff conservatively, instructing her to avoid caffeine
and to drink enough fluids to keep urine light in color. R.
Sentara Port Warwick Emergency Department
October 14, 2011, Plaintiff went to Sentara Port Warwick
Emergency Department ("the Emergency Department")
for chest pain and anxiety "that started [that] morning
while in court during a very stressful custody hearing."
R. at 343, 346. The attending Physician's Assistant
("PA") ordered CK total and CKMB tests, which
revealed a friction rub, though Plaintiff had a normal heart
rate and rhythm and no gallop or murmur. R. at 348. An
echocardiogram ("EKG") showed "normal sinus
rhythm, no ectopy." R. at 349. She had normal range of
motion, and normal gait and coordination. R. at 348, 351. The
Emergency Department prescribed Lorazapem for anxiety, which
was later cancelled by a nurse per "patient
choice." R. at 351-52.
February 8, 2012, Plaintiff returned to the Emergency
Department for neck muscle strain, acute upper respiratory
infections, and back pain. R. at 358-59. Plaintiff reported
worsening neck and back pain over the previous two-week
period, and that the pain was "severe and associated
with some nausea." R. at 360. She also reported
experiencing anemia. R. at 363. During the physical exam, the
PA found no lighted-headedness, dizziness, or other
complaints that signified the Plaintiff had such a condition.
R. at 363. The PA did find that Plaintiff had full range of
motion in her neck and back, as well as regular heart rate
and rhythm. R. at 361. Plaintiff showed normal affect and
thought content. R. at 362. Imaging of Plaintiffs spine
showed "some muscle spasm in cspine and osteophytosis of
thoracic back, but no concerning osseous abnormalities."
R. at 363. The PA prescribed Flexeril and Naprosyn for
symptomatic relief. R. at 363.
23, 2013, Plaintiff returned to the Emergency Department
complaining of chest pain. R. at 592. On exam, Plaintiff had
a normal heart rate and rhythm with no murmur, and full range
of motion in all extremities. R. at 594. A chest x-ray showed
"no acute cardiopulmonary process[, ]" while an EKG
noted sinus rhythm with ventricular premature complex. R. at
Cardiologist Dr. Eric Chou
initially sought care from cardiologist Dr. Eric Chou
("Dr. Chou") in 2009. R. at 714. At that time, Dr.
Chou did not find any "obvious cardiac etiology"
for shortness of breath and irregular pulse. R. at 714.
Plaintiff returned to Dr. Chou in 2011, referred by Dr.
Schneider, for "ongoing palpitations, chest pain, and
recurrent syncopal episodes." R. at 714. Dr. Chou
ordered a stress test and a two-week event recorder. R. at
714. At the follow up appointment on July 28, 2012, Dr. Chou
reviewed Plaintiffs stress echocardiogram from October 31,
2011, R. at 437, as well as the event recorder, R. at 303.
The event recorder showed that Plaintiff experienced
"some episodes of sinus tachycardia, but there [were] no
prolonged pauses or other significant arrhythmias noted.
There were no syncopal episodes." R. at 303.
Additionally, "[t]he stress echo was unremarkable."
R. at 303. Based on these exam results, Dr. Chou determined
that there was no primary cardiac etiology for Plaintiffs
symptoms. R. at 303.
returned to see Dr. Chou on October 31, 2013 for the same
symptoms she exhibited in 2011. Dr. Chou performed an EKG,
the results of which showed a sinus arrhythmia. R. at 714. He
then recommended another two-week event recorder "to
evaluate for any significant arrhythmia causing her syncopal
episodes." R. at 716. During the physical examination
portion of the appointment, Dr. Chou found that Plaintiff had
regular heart rate and rhythm. R. at 716. Because of the
unremarkable results in cardiac testing, Dr. Chou attributed
the cause of Plaintiff s concerns to anxiety and dehydration,
and noted that if the repeated event recorder did "not
show any significant arrhythmias, [he did] not think [he]
would pursue any further cardiac testing" at that time.
R. at 717.
Urinary Tract Infections
claimed in her SSI application that she experiences
continuous urinary tract infections ("UTIs").
See, e.g., R. at 319, 331, 383, 396, 417. Plaintiff
went to Urgent Care for this problem on April 13, 2011, July
2, 2011, September 30, 2011, November 13, 2011 (at which time
she was admitted to the emergency room), and March 20, 2012.
See R. at 319, 331, 383, 396, 417. However, Dr.
Schneider noted in September 2012 that "it is unclear
... if [Plaintiff] is actually having urinary tract
infections" as the only bacterial culture positive for
infection on file was taken in August of 2007. R. at 528.
Following a renal and urinary bladder ultrasound in 2012 to
rule out wider health concerns, Plaintiffs renal functions
and bladder were deemed normal. R. at 526-27.
Relevant Medical Records Regarding Mental
Psychiatrist Dr. Mukesh Shah
April 20, 2011, Plaintiff had her first appointment with Dr.
Mukesh Shah ("Dr. Shah"), Plaintiffs psychiatrist.
R. at 501. During that visit, Plaintiff reported that she was
diagnosed as bipolar when she was fifteen or sixteen years
old, and at the time of diagnosis was prescribed Risperdal.
R. at 501. Plaintiff continued use of this medication for
approximately two (2) years. R. at 501. She claimed that the
medication made her feel "like a zombie ... so she
decided to stop taking it ... to see how she did without
medications." R. at 501. Additionally, Plaintiff stated
in the evaluation that in 2009, she visited her Primary Care
Physician ("PCP"), whom this court assumes is Dr.
Schneider, for insomnia and anxiety, which reportedly came on
"in public places, and sometimes even at her home, where
suddenly she would [start to experience] an increase in her
heart rate and could not breathe." R. at 501. Plaintiff
also reported that she had "given up her job in the past
because of her anxiety spells at work[.]" R. at 501. The
report states that Plaintiffs PCP prescribed Seroquel and
Paxil in 2010 for her anxiety and mood symptoms. R. at 501.
Although Plaintiff alleged an onset date of April 20, 2011,
during the visit with Dr. Shah on this day Plaintiff denied
any physical ailments. R. at 502. During the mental
examination that accompanied that evaluation, Plaintiff was
alert and oriented, her speech was spontaneous, and her
thought process remained mostly goal-directed. R. at 502. She
had occasional flight of ideas, and increased psychomotor
activity. R. at 502. Her concentration was "okay"
and her memory appeared "grossly intact." R. at
502. At the end of the evaluation, Dr. Shah assigned
Plaintiff a Global Assessment of Functioning
(GAF) score of 55,  and increased Plaintiffs
dosage of Seroquel. R. at 503.
sought continued care with Dr. Shah from 2011 to the time of
the hearing. R. at 455-97, 504-10, 647-748. On May 18, 2011,
Dr. Shah noted that Plaintiff "report[ed] a definite
improvement in her mood symptoms." R. at 497. Dr. Shah
posited that Plaintiffs improvement might also have related
to reduction in stress after winning her custody case. R. at
497. Plaintiff was alert and oriented, and made good eye
contact. R. at 497. Her speech was coherent and relevant, her
mood unremarkable, and her affect bright. R. at 497. Dr. Shah
continued Plaintiffs prescriptions for Seroquel and Paxil. R.
August 8, 2011, Plaintiff reported that her medications might
have been too strong, but that "she [was] doing
well." R. at 487. Plaintiff was alert and oriented, made
good eye contact, and her speech was "spontaneous,
coherent and relevant." R. at 487. Her mood was
unremarkable, and her affect bright. R. at 487. Dr. Shah
reduced her prescriptions for Paxil and Seroquel. R. at 487.
On November 17, 2011, Dr. Shah noted that Plaintiff reported
was "doing well" but was "not taking Paxil as
prescribed due to her having nausea from it." R. at 473.
Her mood was stable, and she did not report any panic
attacks. R. at 471. Plaintiff was alert, made good eye
contact, and her speech was coherent and relevant. R. at 473.
Her mood was unremarkable and her affect bright. R. at 471.
Plaintiff continued her prescriptions for Paxil and Seroquel.
R. at 471.
February 9, 2012, Plaintiff attended her appointment with her
father and twins. R. at 466. She reported "spells of
anxiety, where she gets a significant increase in her heart
rate, shortness of breath, and chest pain." R. at 466.
Plaintiffs father inquired about the possibility of Plaintiff
having Asperger's syndrome. R. at 466. Dr. Shah did not
notate his opinion about this assertion. See R. at
466. She reported getting easily overwhelmed when taking care
of her children. R. at 466. Plaintiff reportedly continued
her medication as prescribed. R. at 466. She was alert and
oriented, made good eye contact, and her mood was
unremarkable. R. at 466. Dr. Shah removed Paxil from
Plaintiffs medications, and introduced Zoloft. R. at 466.
Plaintiff continued her use of Seroquel. R. at 466. On March
7, 2012, Dr. Shah noted that Plaintiff "denie[d] any
side effects from the current dosage" of Zoloft. R. at
463. On examination, Plaintiff was alert and oriented, made
good eye contact, and had relevant and coherent speech. R. at
463. Dr. Shah continued Plaintiffs prescriptions for Zoloft,
Xanax, and Seroquel. R. at 463.
Shah's May 2, 2012 medication evaluation, Plaintiff
reported that she was "definitely doing better" and
only had to use Xanax one time in two months. R. at 459. She
maintained a stable mood and experienced adequate sleep. R.
at 459. Plaintiff reported that "she remain[ed] busy
taking care of her twins." R. at 459. Dr. Shah continued
Plaintiff on her medications. R. at 459. In his July 11, 2012
quarterly medication evaluation, Dr. Shah reported that
Plaintiff maintained stability and used Xanax only one time
in three months. R. at 455, 675. She denied any sleep
disturbance and side effects from her medications. R. at 455,
675. Her mood was unremarkable and her affect was bright. R.
at 455, 675. Plaintiffs speech was coherent, she had fair eye
contact, and her judgment appeared intact. R. at 455, 675.
Dr. Shah reported continued use of her medications (Seroquel,
Zoloft, and Xanax), as well as individual counseling. R. at
October 1, 2012, Dr. Shah noted that Plaintiff
"maintained stability during [that] review period. She
denie[d] any side effects from her medications." R. at
671. Plaintiff was alert and oriented, made good eye contact,
and had a "friendly" mood and bright affect. R. at
671. She continued her prescriptions of Zoloft and Seroquel.
R. at 671. On November 19, 2012, Plaintiff reported increased
stress due to having to find a new place to live and taking
care of her father. R. at 688. Plaintiff was alert and
oriented, with coherent and relevant speech. R. at 688. Her
mood was unremarkable, "however, she did talk about some
of her anxiety and sadness due to increased stress." R.
February 15, 2013, Dr. Shah's progress notes show that
Plaintiff was doing "reasonably well," and that she
required minimal use of Xanax over the prior three-month
period. R. at 696. Plaintiffs mood was unremarkable, her
speech coherent and spontaneous, and she showed fair
judgment. R. at 696. In an appointment with another physician
in Dr. Shah's office on May 17, 2013, Plaintiffs mood was
"stressed," but she spoke spontaneously and had
good eye contact. R. at 704. She reported trouble sleeping,
and more frequent use of her Xanax. R. at 704. She continued
Seroquel, Zoloft, and Xanax. R. at 705. On July 17, 2013,
Plaintiff reported she was "doing reasonably well at
[that] time." R. at 712. She was alert and oriented,
made good eye contact, and had coherent and relevant speech.
R. at 712. Her mood was unremarkable and her affect bright.
R. at 712. Plaintiff continued her medications. R. at 712.
January 17, 2014, Plaintiff attended her appointment with her
father and daughter. R. at 746. She stated that she was
"not doing well at all" without her medication. R.
at 746. Dr. Shah noted that Plaintiffs father asked him to
write a letter attesting to Plaintiffs ability to work, and
Dr. Shah opined in his patient notes that Plaintiff could not
"return to work at [that] time or in the next twelve
(12) months." R. at 746. Plaintiff was alert and
oriented, but seemed overwhelmed. R. at 746. She allowed her
father to take care of her daughter when she became
disruptive, and Plaintiff did not intervene with her
father's discipline. R. at 746. Plaintiffs speech was
coherent and relevant, though her mood was
"dysphoric" and affect "tense to a
degree." R. at 746. Plaintiff agreed to retry a higher
dose of Zyprexa (though the record is unclear when Plaintiff
was prescribed Zyprexa prior to this appointment), as well as
Xanax. R. at 747. She received a GAF score of 45. R. at 747.
On January 23, 2014, Dr. Shah wrote a letter stating that
Plaintiffs bipolar diagnosis would not allow her to work for
the next twelve (12) months. R. at 719.
February 21, 2014, Plaintiff reported that she was
"doing reasonably well." R. at 743. She was alert
and oriented, made some eye contact, and had coherent and
relevant speech. R. at 743. Her mood was unremarkable and
affect appropriate. R. at 743. She continued her medication,
and had a GAF score of 51. R. at 743. During her May 15, 2014
visit, Plaintiff reported she was "not doing well."
R. at 740. She experienced increased stress due to the
behavioral issues of her children. R. at 740. She was alert
and oriented, had coherent and relevant speech, and
interacted appropriately with her son, who attended the