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Viessman v. Saul

United States District Court, D. South Dakota, Southern Division

January 13, 2020

ANDREW M. SAUL, Commissioner of the Social Security Administration, Defendant.




         Plaintiff, Joy Lynn Viessman, seeks judicial review of the Commissioner's final decision denying her application for social security disability and supplemental security income disability benefits under Title II and Title XVI of the Social Security Act.[1]

         Ms. Viessman has filed a complaint and motion to reverse the Commissioner's final decision denying her disability benefits and to remand the matter to the Social Security Administration for further proceedings. See Docket Nos. 1 and 14. The Commissioner has filed his own motion seeking affirmance of the decision at the agency level. See Docket No. 16.

         This appeal of the Commissioner's final decision denying benefits is properly before the court pursuant to 42 U.S.C. § 405(g). The parties have consented to this magistrate judge handling this matter pursuant to 28 U.S.C. § 636(c).


         A. Statement of the Case

         This action arises from Ms. Viessman's application for social security disability benefits and supplemental security income benefits filed on May 9, 2016, alleging disability since May 8, 2016, due to depression, fear of leaving her home, anxiety, driving phobia, back pain, female issues, and fear of people and crowds. AR215, 225, 277.

         Ms. Viessman's claims were denied at the initial and reconsideration levels and Ms. Viessman requested an administrative hearing. AR170, 181, 187, 194.

         Ms. Viessman's administrative law judge (“ALJ”) hearing was held in May of 2018, at which different counsel represented Ms. Viessman. AR74. An unfavorable decision was issued August 6, 2018, by ALJ Richard Hlaudy. AR7.

         At Step 1 of the evaluation, the ALJ found that Ms. Viessman had not engaged in substantial gainful activity since May 8, 2016, the alleged onset of disability date, and that she was insured for benefits through December, 2021. AR12.

         At Step 2, the ALJ found that Ms. Viessman had severe impairments including status post L4-L5, L5-S1 fusion, depression and anxiety. AR13. The ALJ also found that Ms. Viessman had a medically determinable impairment of sleep apnea, but determined it was non-severe. AR13.

         At Step 3, the ALJ found that Ms. Viessman did not have an impairment that meets a Listing. AR13. The ALJ found that Ms. Viessman's mental impairments caused mild restrictions in understanding, remembering, or applying information; moderate limitations in concentration, persistence or maintaining pace, and that she had mild limitations in adapting or managing oneself. AR14.

         The ALJ determined that Ms. Viessman had the residual functional capacity (“RFC”) to perform:

less than a full range of sedentary work as defined in 20 C.F.R. 404.1567(a) and 416.967(a). The claimant can lift and/or carry 10 pounds occasionally and less than 10 pounds frequently. She can stand and walk 2 hours in an 8-hour workday and sit 6 hours. She can occasionally climb ramps and stairs, but can never climb ladders, ropes, or scaffolds. She can occasionally balance, stoop, kneel, crouch, and crawl. She must avoid even moderate exposure to hazards. The claimant is limited to performing simple routine repetitive tasks. She can have occasional and superficial interaction with the public and coworkers.


         Based on this RFC, the ALJ determined at Step 4 that Ms. Viessman could not perform her past relevant work. AR21-22.

         At Step 5, relying on the testimony of a vocational expert, the ALJ found that Ms. Viessman could perform the occupations of credit clerk (DOT 237.367-014), document preparer (DOT 249.587-018), and telephone quotation clerk (DOT 237.367-046). AR22-23.

         Ms. Viessman timely requested review by the Appeals Council, which denied review making the ALJ's decision final, and Ms. Viessman timely filed this action. AR1-6, 213.

         B. Plaintiff's Age, Education and Work Experience

         Ms. Viessman was 44 years old at the time of the decision, and she completed the 12th grade in 1992. AR225, 278. Ms. Viessman had relevant work as a day care owner and a travel agent. AR21.

         C. Relevant Medical Evidence (chronological order)

         Ms. Viessman contacted Sanford Family Medicine Clinic on October 26, 2015, to report that her anxiety had been much worse, that a panic attack the previous week required ambulance transfer from Dell Rapids Hospital, and that she had been prescribed Vistral for her anxiety. AR494.

         Ms. Viessman contacted the Sanford Family Medicine Clinic again on October 30, 2015, again with increased anxiety, and requested that her anxiety medication be switched back to Xanax. AR493. Ms. Viessman was seen at the Sanford Hospital ER the same day due to a panic attack, and she had been forced to close her day care and send the children home. AR489. Her diagnoses included low back pain, anxiety, severe major depression with psychotic features, insomnia, migraine, herniated disc, degenerative disk disease, lumbar radicular pain, panic attacks and morbid obesity. AR489-90. Ms. Viessman was given Ativan for her anxiety and the ER physician expressed concern with Ms. Viessman's long-term treatment of her anxiety with Xanax. AR493.

         Ms. Viessman was seen at USD Physicians Clinic on November 3, 2015, for her depression and anxiety. AR486. She reported that she has a phobia for highways and gets scared and anxious even as a passenger in a vehicle. AR486. Xanax and Lexapro were prescribed, and counseling was recommended. AR489.

         Ms. Viessman presented to the Sanford ER on November 11, 2015, reporting that her prescribed medications did not help and with complaints of anxiety, inability to sleep, and stress related neck and shoulder pain. AR482. Ms. Viessman was given Haldol, and counseling was recommended. AR485.

         Ms. Viessman returned to the ER again on November 14, 2015, with severe anxiety and left shoulder pain. She was given Toradol and valium, was told to follow-up with her primary care physician, and it was recommended she see a psychiatrist for her chronic anxiety. AR473, 477.

         Ms. Viessman was seen at USD Physicians Clinic on November 23, 2015, and reported ongoing anxiety. AR470. Her Xanax was continued, her Lexapro dosage was increased, Ativan was also prescribed, and it was recommended that she go to Avera Behavioral Health for an assessment. AR472.

         Ms. Viessman contacted the clinic later the same day to inform them that she was at Avera Behavioral Health[3] waiting for a psychological assessment. AR473.

         Ms. Viessman was seen at Sioux Falls Psychological Services on December 2, 2015, by referral from Avera Behavioral Health following inpatient treatment for suicidal ideations, anxiety, and depression. AR353. Ms. Viessman reported panic attacks in June and October, 2015, that led to 911 calls and hospitalization, and a prior suicide attempt in 1994. AR354. Her mood was depressed. AR354. She was scheduled for counseling the next week. AR356.

         Ms. Viessman was seen at USD Physicians Clinic on December 2, 2015, following inpatient treatment at Avera Behavioral Health for anxiety and suicidal ideations. AR466. Her Xanax had been stopped, and Klonopin and Remeron were prescribed. AR466. She was advised to start counseling as soon as possible. AR469.

         Ms. Viessman was seen for counseling at Sioux Falls Psychological Services on December 14, 2015. AR358. Ms. Viessman was observed to be tearful and moderately anxious and depressed. AR358. She noted that her ex-husband was staying with her and had been abusive since being released from jail. AR358. Ms. Viessman reported that her anxiety medication had been increased. AR358.

         On January 4, 2016, Ms. Viessman reported to therapists that she, with the encouragement of friends and family, decided to end contact with her ex-husband. AR360. After ending the contact Ms. Viessman reported feeling empowered, having decreased depression and anxiety, and having an increased ability to drive without panic. AR360. She continued counseling sessions through February, 2016. AR360-66.

         Ms. Viessman saw her primary care physician at USD Physicians Clinic on January 11, 2016, and reported that her depression and anxiety were significantly better. AR362, 364, 447-48. Ms. Viessman reported being satisfied with her medications, which included Remeron, Ativan, and Klonopin. AR448. She was seen again on January 29, 2016, for lower back and hip pain. AR444. Toradol was given and Flexeril prescribed. AR447.

         Ms. Viessman was also being seen during this period at the hospital and clinics for vaginal and abdominal pain and bleeding. See e.g., AR405, 414, 433, 437-38, 442. She eventually had a hysterectomy on June 15, 2016. AR394.

         Ms. Viessman was seen at the Sanford Orthopedic Clinic on May 4, 2016, for thoracic back pain, bilateral shoulder pain, and hip pain that started a week earlier after starting a new job working with a conveyor belt that required repetitive arm/shoulder motions. AR428. She also complained of chronic low back pain and “limping on the right side.” AR428. Examination revealed a somewhat reduced range of motion of the spine, tenderness to right upper thoracic muscles but with normal strength and tone and intact reflexes. AR431. Prednisone was prescribed, along with Baclofen and physical therapy. AR431.

         Ms. Viessman was seen at USD Physicians Clinic on May 10, 2016, and reported her depression had gotten worse, she was not leaving her house, driving was not an issue, but she had lost two jobs. AR425. Mental status examination revealed normal behavior, judgment and thought content. AR408. Ms. Viessman was also waiting to see Dr. Boetel for her severe low back pain with a lot of radiation to her buttocks. AR425. Examination revealed lumbar tenderness, edema, pain and spasm, and a depressed mood. AR427. Toradol was given and counseling recommended. AR428.

         Ms. Viessman was seen for physical therapy on May 16, 2016, and examination revealed tenderness, limited range of motion and pain in shoulder area. AR421-22. The physical therapist noted that Ms. Viessman's rehabilitation potential was good. AR422. Ms. Viessman displayed a mobility dysfunction of the shoulder and the thoracic lumbar region as well as the stability motor control dysfunction of the scapular stabilizer musculature. AR422.

         Ms. Viessman was seen at USD Physicians Clinic on May 25, 2016, and reported increased anxiety and watery diarrhea leading to incontinence with continued low back pain. AR418. Ms. Viessman reported that a prior epidural injection had worked really well and that she wanted to receive additional shots. AR418. Physical examination revealed normal range of motion, reflexes, muscle tone, and coordination, and her lumbar back exhibited tenderness, pain and spasm. AR420. Mental status examination revealed normal behavior, judgment and thought content, and her mood was anxious and depressed. AR420.

         Following her hysterectomy, her abdominal pain had improved, but her back pain continued with Percocet prescribed for pain. AR379.

         Ms. Viessman was seen for another intake session at Sioux Falls Psychological Services on July 7, 2016, and her affect was labile, mood depressed and anxious, and her thought processes were inhibited by her anxiety, which in combination with her depression, made it difficult for her to leave her home. She was also unable to work. AR369-70.

         Ms. Viessman was seen at USD Physicians Clinic on July 11, 2016, for increased depression, and she was unable to be around people. AR375. Her Lexapro was discontinued, Celexa was prescribed, and her Klonopin dosage was increased. AR377.

         Ms. Viessman was seen at Sanford Acute Care on July 20, 2016, for bilateral hip and low back pain, which was worse since her hysterectomy. AR735. She reported numbness in the hip area in addition to pain, as well as numbness and tingling in her low back. AR735. Examination revealed tenderness across her low back, bilateral hips, and buttocks. AR735. Toradol was given, and also a few Percocet. AR735.

         Ms. Viessman was seen at USD Physicians Clinic on July 28, 2016, with ongoing low back pain, and she reported the Percocet was not helping her pain. AR731. Examination revealed tenderness and decreased range of motion in the hips, tenderness, pain, and spasm in the lumbar back, and depressed mood. AR734. Toradol was given and additional Percocet prescribed. AR734.

         Ms. Viessman was seen at Sanford Hospital on August 5, 2016, after her low back pain was exacerbated by a fall on her stairs. AR727.

         Ms. Viessman saw Dr. Boetel at Sanford Physical Medicine on August 23, 2016, for her hip and back pain. AR720. Examination revealed antalgic gait, lumbar and sacral sulcus tenderness, normal hip rotation, but with pain, and physical therapy was recommended. AR721.

         Ms. Viessman was seen at USD Physicians Clinic on September 21, 2016, and had been sick for over 10 days with cough and congestion, and she had not started PT for her back, stating she didn't think she could do PT if her pain was not under control. AR714. She also reported her anxiety and depression were worse and she was having problems communicating and going out of her house, and being compliant with her job. AR714. Ms. Viessman was given a stronger antibiotic, pain medication, and counseling was recommended. AR717.

         Ms. Viessman was seen for PT on October 5, 2016, and examination revealed moderate antalgic gait, limited range of motion with pain, and pain with sit to and from stand. AR710. She was found limited in her ability to walk, engage in prolonged standing, and sleep. AR710.

         Ms. Viessman was seen at the Sanford ER on October 7, 2016, after her leg gave out while bending to pick something up and she fell. AR705. Examination revealed right leg weakness with pain when raising the right leg. AR708. A lumbar MRI and hip x-ray were not acute and Viessman was told to follow-up with her primary care physician for the exacerbation of a chronic issue. AR709. The hip x-ray did reveal mild degenerative changes. AR747.

         Ms. Viessman followed up at USD Physicians Clinic on October 10, 2016, and reported a lot of weakness, worse pain and she was using a cane. AR701. Continued PT was recommended and her pain medication was continued. AR704.

         Ms. Viessman was seen at USD Physicians Clinic on October 13, 2016, following a fall, and presented crying and in a wheelchair. AR699. She was sent to the Sanford Orthopedic walk-in clinic. AR699. She was crying in the exam room and unable to be examined due to pain. AR699. Transfer to the ER was recommended. AR699. A CT of her spine was obtained which revealed no acute fractures or hardware changes in her prior fusion, but showed diffuse sclerotic changes of the sacroiliac joints which may be related to an element of sacroiliitis. AR744-45. The ER gave her Toradol and prescribed Neurontin. AR698.

         Ms. Viessman was discharged from PT following two PT sessions and one water therapy session when she missed her last appointment on November 2, 2016. AR700.

         Ms. Viessman was seen at USD Physicians Clinic on November 18, 2016, for tingling in her right arm and leg and twitching in her right eye, and complained that she felt she may have attention deficit disorder. AR684. She was scheduled for an ADHD evaluation and EMG nerve conduction testing on upper and lower extremities was also planned. AR686.

         The ADHD or mental health evaluation was done on November 21, 2016, at Sanford Family Medicine Clinic and the diagnoses were anxiety disorder, depressive disorder, history of panic attacks, and rule out personality disorder and ADHD, and she was referred to Sanford Psychiatry for further evaluation. AR682. Sanford Case Management initiated contact with Ms. Viessman on November 29, 2016, and noted she continued to ambulate with a cane. AR677.

         Ms. Viessman was seen at Sanford Neurology on January 16, 2017, for continued low back pain and increased intermittent tingling in her right arm and right leg, numbness and weakness in her right leg, and intermittent shaking in her right arm. AR668. She also reported impaired gait, joint pain, stiffness and swelling, and muscle pain in her low back. AR668. Examination revealed limited strength test for hips due to pain, decreased sensation to pinprick in upper and lower extremities, reduced vibration sensation on the right, unsteadiness with eyes closed, and antalgic gait with unsteady tandem walk. AR671. Muscle bulk and tone were normal. AR671. An x-ray revealed that the L1 through L4 disc spaces appeared maintained. AR671. EMG nerve conduction tests, physical therapy evaluation, head MRI, ENT referral for hearing loss, and psychiatric referral for anxiety were planned. AR672. The brain MRI was normal. AR665.

         Ms. Viessman saw a psychiatrist at Sanford Psychiatric Clinic on January 24, 2017, for depression and anxiety. AR819. She reported that her grandfather had recently died, and she had not spoken to her family since the prior May. AR819. Ms. Viessman reported struggling with mood swings 2-3 times per day, making impulsive decisions, anger, irritability, and poor concentration and energy level. AR819. Examination revealed Ms. Viessman was ambulating with a cane, had lost one hundred pounds over the last year, experienced back pain, appeared older than her age, was anxious, endorsed some paranoia, and her insight and judgment were fair. AR822. Her diagnoses included anxiety disorder, and differential of Bipolar 2, unspecified mood disorder. AR822. Seroquel was added to her Lexapro, Klonopin, and Neurontin, and individual therapy was encouraged. AR822.

         Ms. Viessman had an MR angiogram of her neck on January 26, 2017, that was normal. AR737. Ms. Viessman had a brain MRI performed on January 25, 2017, which was normal. AR739-40.

         Ms. Viessman saw a psychologist at Sanford Psychiatric Clinic on February 6, 2017, and reported she had been unable to start taking Seroquel because she could not afford it. AR827. Examination revealed disturbed sleep, up and down mood, anger, back pain, fair to good memory, insight and judgment. AR828-29. Ms. Viessman's PHQ-9 score indicated severe depression. AR829. The diagnoses were major depression, anxiety, and rule out personality disorder, and additional therapy was planned. AR830. Ms. Viessman continued therapy with her third session on May 12, 2017. AR823. Her rule out personality diagnoses had been updated to unspecified personality disorder. AR833.

         Ms. Viessman saw her psychiatrist at Sanford Psychiatric Clinic on May 23, 2017, and reported worsening depression and anxiety. AR835. Her Lexapro medication was stopped and Cymbalta was added for depression, anxiety and chronic pain; trazodone was also prescribed. AR836.

         Ms. Viessman was seen at the Sanford ER on June 19, 2017, presenting with a panic attack after stopping her medications a week earlier. AR781. She had contacted her psychiatric doctor and her pain doctor and they told her to resume her medications and go to the ER. AR781. Ms. Viessman was taking Percocet and Neurontin. AR781. Examination revealed tenderness and pain in her low back, but she had normal strength and no swelling, edema, or neurological deficits. AR787. Examiners also noted anxious mood, rapid pressured speech, agitation, and that Ms. Viessman was crying. AR787. Ativan, Zofran, Toradol, Oxycodone, Valium, and Fentanyl were administered. AR787-78. Her diagnoses were opioid withdrawal, panic attack, and having stopped her recommended medications. AR779.

         Ms. Viessman saw her psychiatrist at Sanford Psychiatric Clinic on June 27, 2017, and reported she had restarted her medications on June 20, 2017. AR839. She reported high anxiety and feeling anxious leaving her home and being in public places or talking to people. AR839. She also reported depressed mood with feelings of hopelessness and suicidal ideation without any plan. AR839. Ms. Viessman said her energy level was variable with some days very high and others very low, and her concentration was poor. AR839. Her assessments were anxiety disorder, social anxiety disorder, bipolar II disorder, and a differential diagnosis of unspecified mood disorder. AR840. Her Cymbalta dosage was increased and counseling encouraged.

         Ms. Viessman was seen at the Sanford ER on July 17, 2017, with exacerbated low back pain after tripping over a hole and falling. AR789. Examination revealed low back tenderness, pain and reduced range of motion, and Ms. Viessman was ambulating with a cane. AR789.

         Ms. Viessman saw a new psychiatrist at Sanford Psychiatric Clinic on August 1, 2017, and reported worsening depression and anxiety after stopping Cymbalta about one month earlier due to being unable to afford it; being unemployed and without insurance. AR843. Ms. Viessman said she had severe withdrawal symptoms and was fearful of taking another similar medication. AR843. She reported looking for a therapist at Carroll Institute because she did not feel there was a good working relationship with her psychologist at Sanford. AR843. Ms. Viessman continued to report suicidal ideations without any plan. AR844. The diagnoses were modified to bipolar II versus major depression with psychotic features versus personality traits. AR845. Prozac was prescribed, her Trazodone dosage increased and counseling encouraged. AR845. Psychological testing should be considered if Ms. Viessman obtained insurance in the future. AR845.

         Ms. Viessman saw another new psychiatrist at Sanford Psychiatric Clinic on September 25, 2017, and reported the Prozac had caused severe sedation and was switched to Lexapro about one week prior. AR847. Sandra Peynado, M.D., noted that Ms. Viessman made good eye contact, exhibited normal psychomotor activity, and denied suicidal ideation and hallucinations. AR851. Dr. Peynado also noted no impairment in cognition, intact memory, and fair insight and judgment. AR851. Dr. Peynado's diagnoses included generalized anxiety disorder, social anxiety disorder with agoraphobia, and bipolar disorder type II and her differential diagnoses included cluster B traits, major depressive disorder recurrent and paranoid personality disorder. AR851.

         Ms. Viessman saw the psychiatrist again on October 23, 2017, and reported ongoing depression without help from the medication, and financial struggles and no insurance; she had not been to counseling. AR853. Ms. Viessman reported feeling tired on Lexapro and spending most of the days watching TV on the couch with no motivation. AR853. Electroconvulsive therapy (ECT) was planned for her resistant depressive symptoms, and her other medications were continued. AR854.

         Ms. Viessman saw the psychiatrist again on January 30, 2018, but the treatment note does not mention ECT treatment or whether it was performed. AR857.

         D. Consultative Physical Examination

         Ms. Viessman was referred to Dr. Lichter by the state agency for a disability exam on October 10, 2016. AR642. She reported working part-time at a hotel and said it “keeps her sane” because it gets her out of the house, but it does aggravate her mental and physical health. AR642. Ms. Viessman explained that she experienced a lot of anxiety at work and felt like she might snap at customers, and that sitting during her 4-6 hour shift at the front desk hurt her back, but they do let her sit. AR642-43. Ms. Viessman reported that for her back she was in physical therapy, taking Percocet for pain, and a recent MRI showed her back was stable, and also that her primary care physician had completed a form for her to get a handicap sticker. AR643. She reported that being in one position too long makes her pain worse, and she can only sit or stand for 10 minutes at a time, had increased weakness in her right leg, used a cane to walk, could not stoop, climb or kneel, could only lift up to 10 pounds and avoided any activity which might flare up her back. AR643. Examination revealed tenderness over the lumbar and sacral regions, muscle spasm on the right side, positive straight leg raise at 30 degrees on the right and 45 degrees on the left, strength at 4 out of 5 in bilateral lower extremities, decreased sensation in the right leg, reduced range of motion secondary to pain, increased pain with internal and external rotation of both hips, walks with a limp, and utilized a cane for ambulation. AR644. Dr. Lichter suspected the decreased strength was due to pain. AR644. Dr. Lichter's physical diagnosis was chronic low back pain with right radiculopathy. AR644. Dr. Lichter stated that based on her objective exam findings Ms. Viessman would be limited to lifting and carrying 10 pounds occasionally and no more at any time, and Ms. Viessman would have difficulty standing, walking, or sitting during an 8-hour workday, but she would do better if allowed to change positions frequently. AR644. Dr. Lichter stated Ms. Viessman could not stoop, climb, or kneel. AR644. Dr. Lichter stated the prognosis for Ms. Viessman's chronic low back pain was poor as she had already had surgery and injections. AR644. Dr. Lichter invited questions and provided her phone number. AR644.

         E. Consultative Psychological Examination

         Ms. Viessman was referred to psychologist, Dr. VanKley, by the state agency for a disability exam on October 21, 2016. AR652. Ms. Viessman reported that she was working 20 hours per week at the time. AR654. Dr. VanKley observed Ms. Viessman to have an anxious and depressed mood with congruent affect, and she conveyed a strong sense of being overwhelmed with various difficulties and viewing disability benefits as her only means of subsistence. AR655. Dr. VanKley stated that despite Ms. Viessman's emotional distress, she was cooperative and appeared to respond in a forthright manner, so the results provide a reasonable indication of her functioning. AR655. Examination revealed a depressed and anxious mood with several occasions of tearfulness. AR655. Dr. VanKley diagnosed panic disorder, obsessive-compulsive disorder, depression, and personality disorder, and he assessed Ms. Viessman's GAF at 45. AR658. Dr. VanKley stated the results of his evaluation indicated Ms. Viessman indeed struggled with a combination of anxiety and mood-related problems, and her panic disorder made it difficult to venture into the public; symptoms of obsessive-compulsive disorder consumed an inordinate amount of time; and her existence was dominated by anxiety, which contributed to her depression, which was “readily evident during the clinical interview.” AR658. Dr. VanKley stated her impairments interfered with her ability to get along with people, and she became highly reactive to interpersonal conflict. AR659. Dr. VanKley did not recommend a representative payee for Ms. Viessman's disability benefits, noting she was anxiously meticulous about such matters. AR659.

         F. State Agency Assessments

         Ms. Viessman's case was reviewed at the initial level on November 16, 2016, and the state agency physician found that she had severe disorders of the back-discogenic and degenerative. AR113, 122. The physician found Ms. Viessman could lift 10 pounds occasionally, and less than 10 pounds frequently, stand and/or walk two hours of an 8-hour workday, sit about six hours of an 8-hour workday, and that she had additional postural limitations. AR118. The agency physician stated Ms. Viessman's statements about intensity, persistence and functionally limiting effects of her symptoms were substantiated by the objective medical evidence alone. AR116. The agency physician noted findings from the consultative physical exam, but did not explain why they failed to adopt all of the limitations noted. AR116.

         Ms. Viessman's file was reviewed by a state agency physician at the reconsideration level on February 6, 2017, and the reconsideration level physician made identical findings, including that Ms. Viessman's statements about intensity, persistence and functionally limiting effects of her symptoms were substantiated by the objective medical evidence alone. The State agency physician at the reconsideration level again noted the findings from the consultative physical exam, but again did not explain why he failed to adopt all of the limitations noted. AR146-49.

         Regarding her psychological limitations, Ms. Viessman's file was reviewed at the initial level on November 28, 2016, by a “single decision maker” or SDM who found Ms. Viessman had severe affective disorder, severe anxiety disorder, and severe personality disorder. AR113, 115. The SDM found that she had mild restrictions in activities of daily living, moderate difficulties in maintaining social functioning and moderate difficulties in maintaining concentration, persistence or pace. AR114. The SDM noted results from the consultative psychological evaluator who had assessed Ms. Viessman's GAF at 45, but did not discuss any of the findings. The SDM more specifically found Ms. Viessman moderately limited in carrying out detailed instructions, maintaining attention and concentration for extended times, working with others, interacting appropriately with the public, and traveling in unfamiliar places or using public transportation. AR118-20. The SDM stated Ms. Viessman's anxiety will lead to periods of reduced concentration, but she would be able to follow simple instructions. AR119. The SDM also stated Ms. Viessman would have difficulty with increased social demands and interpersonal conflict leading to the need for brief breaks. AR119. The SDM stated Ms. Viessman retained the ability to engage in simple, routine and repetitive work in environments with limited social demands and interactions with the public. AR120.

         The state agency psychological consultant at the reconsideration stage reviewed the file on February 7, 2017, and made similar findings as prepared by the SDM at the initial level. AR144, 149-51. The consultant at the reconsideration level was a psychologist. AR151.

         G. Testimony at the ALJ Hearing

         1. Ms. Viessman's Testimony

         Ms. Viessman testified that she was 5'7” tall and weighed 195 pounds, but has lost 115 pounds in the last four years, and she was right-handed. AR80.

         Ms. Viessman testified that she worked at Fit My Feet part-time but stopped because of “all the crap in my head” and her back situation, which limits her to not standing more than 20 or 30 minutes. AR81-82. Ms. Viessman testified that her last work was at a hotel where she had an “explosion.” AR86. She explained that she became super mad, super aggravated, people were coming in and she just couldn't contain “the shut off in my brain to be safe, or like, are they going to hurt me….” AR86. She said she was scared of new people which is why she maybe left her home five or eight times this whole year. AR86, 88. Ms. Viessman said, “Like if I open the door it's like - if I see somebody on the street and I happen to step outside, it feels like Flash Gordon coming right at me; like what are they going to do to me. You know? So I go back in and lock the doors and don't move.” AR87.

         Ms. Viessman testified that one day when she was home alone somebody knocked on the door and she ran and hid in the closet. AR99.

         Ms. Viessman testified, “But I want to be fixed. I've always worked. You know, I worked hard. And I don't know. I wish I could just pound it out. Like I go to bed and it just turns and turns and turns about stuff that I have like no control over or --.” AR100.

         Ms. Viessman testified her psychiatrist recommended electroconvulsive therapy, but she couldn't ...

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