Millsap v. Social Security Administration

1
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF NORTH DAKOTA
Lisa Millsap, 	)
) 	ORDER RE: CROSS MOTIONS FOR
Plaintiff, 	) 	SUMMARY JUDGMENT
)
)
vs. 	)
)
Nancy A. Berryhill, Acting Social Security 	)
Administration Commissioner, 	) 	Case No. 1:18-cv-105
)
Defendant. 	)
)
Plaintiff Lisa Millsap seeks judicial review of the Social Security Commissioner’s denial
of her application for disability insurance benefits. Before the court are competing motions for
summary judgment filed by Millsap and Nancy A. Berryhill, Acting Commissioner of the Social
Security Administration. (Doc. Nos. 11, 16). This court reviews the Commissioner’s final
decision pursuant to 42 U.S.C. § 405(g).
I. 	BACKGROUND
A. 	Procedural History
Millsap initially applied for disability benefits on June 3, 2015. (Doc. No. 9-5, p. 2). She
was determined “not disabled” on August 21, 2015. (Doc. No. 9-4, p. 2). On reconsideration,
Millsap’s claim for benefits was again denied in a determination dated October 22, 2015. (Doc.
No. 9-4, p. 9). Millsap then requested a hearing in front of an Administrative Law Judge, which
took place on May 2, 2017. (Doc. No. 9-2, p. 34-60).
On June 20, 2017, the ALJ issued an opinion denying Millsap’s claim for benefits. (Doc.
No. 9-2, pp. 13-25). Millsap requested review, but the Appeals Council upheld the ALJ’s
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 1 of 33

2
decision. (Doc. No. 9-2, p. 2).
Millsap initiated this action in federal court on May 22, 2018. (Doc. No. 1). She filed a
motion for summary judgment on October 15, 2018, and the Commissioner filed a combined
response and motion for summary judgment on December 19, 2018. (Doc. Nos. 11, 16). There
were no further responses, and the matter is ripe for the Court’s review.
B. 	Medical History
Several conditions are reflected in Millsap's medical records, which span from January
2005 to May 2012. See generally Doc. No. 9 (“Administrative Record.”) Her medical conditions
include poor eyesight, heart disease, anxiety, depression, and cognitive limitations due to
Alzheimer’s disease, all of which she allege limited her ability to work during the relevant time
period. These conditions are summarized briefly below.
1. 	Left Eye Impairment
At 18 years of age, Millsap had a cataract removed from her left eye, leaving her without
a lens in that eye and causing vision difficulties. (Doc. No. 9-8, p. 10). She was eventually fitted
for contact lenses and corrective surgery was discussed. (Doc. No. 9-8, p. 10-21). However, it is
not apparent that corrective surgery was ever performed.
2. 	Heart Disease
In early 2009, Millsap experienced several episodes of chest pain. (Doc. No. 9-7, p. 19;
Doc. No. 9-11, p. 22). Her providers note that she had experienced a heart attack in 2003. (Doc.
No. 9-11, p. 22). She underwent left-heart catheterization on April 7, 2009, and bypass surgery
on May 6, 2009. (Doc. No. 9-7 at 19, 24-28). After the surgery, she attended rehabilitation from
May 14 until May 20 due to lingering mental fogginess and weakness. (Doc. No. 9-7 p. 48-51).
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 2 of 33

3
By June 2, 2009, she was described by her cardiologist as “back to normal. Her memory is
totally normal, and she does not have any focal deficits.” (Doc. No. 9-12, p. 40).
On October 13, 2011, she again reported to Trinity Hospital because of chest pain. (Doc.
No. 9-9 at 2). On December 19, 2011, she had a left heart catheterization performed. (Doc. No.
9-12, p. 80).
3. 	Anxiety and Depression
In 2007, Millsap was diagnosed with depression, and attended therapy sessions for
several months. (Doc. No. 9-12 at 10-23).
On 	January 	18, 	2010, 	a 	behavioral 	health 	assessment 	was 	performed 	by 	Nicole
Amsbaugh, who noted that Millsap's depression was effectively controlled by medication and
planned to continue her current regimen. (Doc. No. 9-12, p. 44). Millsap followed up with
Amsbaugh every few months over the next several years. (Doc. No. 9-12 at 48, 50, 52, 54, 61,
63, 67, 82, 84; Doc. No. 9-14 at 76, 80, 86). Other providers occasionally note her depression
and/or anxiety. See, e.g., (Doc. No. 9-9, p. 9).
4. 	Memory and Cognitive Problems
Millsap first suffered memory issues after her heart surgery in May 2009 which resolved
by the following month. (Doc. No. 9-12, p. 40).
In June 2010, Millsap mentioned that she is “seemingly getting forgetful” to Amsbaugh.
(Doc. No. 9-12, p. 50). She denied feeling any confusion at that time.
The next mention of memory occurs in December 2013, when Millsap reports to
Amsbaugh that her husband is concerned about her memory and confusion. (Doc. No. 9-14 at
76).
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 3 of 33

4
From June 2014 to May 2015, Millsap underwent a series of neuropsychological
evaluations and assessments, with all providers noting cognitive dysfunction, although some
questioned the validity of the results. (Doc. No. 9-12, p. 86; Doc. No. 9-14, p. 47; Doc. No. 9-12
at 93, 97; Doc. No. 9-13, p. 3). Millsap was ultimately diagnosed in May 2015 with dementia
secondary to early onset-Alzheimer’s. (Doc. No. 9-13, p. 8).
After her diagnosis, she started medication, and saw a psychologist to work through her
stress. (Doc. No. 9-13, p. 24). One neurologist who saw her in 2016 expressed doubt as to the
Alzheimer’s diagnosis, and opined that she was suffering from “pseudodementia” due to her
anxiety and depression. (Doc. No. 9-14, p. 10-11). She was referred to occupational therapy and
completed one session before being discharged and told to complete home exercises. (Doc. No.
9-14 at p. 3-5).
C. 	Personal History
Millsap was born on May 27, 1960, making her 50 years old on her alleged disability
onset date of May 27, 2010. (Doc. No. 9-6, p. 2). She is married and has two adult children. Id. at
p. 70.
Millsap completed high school and one year of college. (Doc. No. 9-12, p. 8). She
performed several jobs over the years, working as a cashier, an accounting clerk, and a bank
teller. (Doc. No. 9-6, p. 19). She was dismissed from the bank in March of 2006, and afterwards
did some seasonal work in 2008 for a nursery. (Doc. No. 9-2, p. 41-42).
II. 	APPLICABLE LAW
A. 	Law Governing Eligibility for Disability Benefits
A disability is defined as the “inability to engage in any substantial gainful activity by
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 4 of 33

5
reason of any medically determinable physical or mental impairment which can be expected to
result in death or which has lasted or can be expected to last for a continuous period of not less
than twelve months.” 42 U.S.C. § 423(d)(1)(A); accord 42 U.S.C. § 1382c(a)(3)(A); 20 C.F.R.
§§ 404.1505, 416.905. A claimant has a disability when they are not only unable to do their
previous work, but cannot—considering age, education, and work experience—engage in any
other kind of substantial gainful work which exists in significant numbers in the region where
they live or in several regions across the country. 42 U.S.C. §§ 423(d)(2)(a), 1382(a)(3)(B).
To determine whether a claimant has a disability within the meaning of the Social
Security Act, the Commissioner follows a five-step sequential evaluation process outlined in the
regulations. 20 C.F.R. §§ 404.1520, 416.920; see Kirby v. Astrue, 500 F.3d 705, 707 (8th Cir.
2007). First, the Commissioner considers the claimant’s work activity. If the claimant is engaged
in substantial gainful activity, then the claimant is not disabled. 20 C.F.R. §§ 404.1520(a)(4)(i),
416.920(a)(4)(i). If the claimant is not engaged in substantial gainful activity, the Commissioner
moves onto step two.
At 	step 	two, 	the 	Commissioner 	determines 	“whether 	the 	claimant 	has 	a 	severe
impairment that significantly limits the claimant’s physical or mental ability to perform basic
work activities.” Dixon v. Barnhart, 353 F.3d 602, 605 (8th Cir. 2003). The ability to do basic
work activities is defined as “the abilities and aptitudes necessary to do most jobs.” 20 C.F.R. §§
404.1521(b), 416.921(b). Abilities and aptitudes includes: (1) physical functions such as
walking, standing, sitting, lifting, pushing, pulling, reaching, carrying, or handling; (2) capacities
for seeing, hearing, and speaking; (3) understanding, carrying out, and remembering simple
instructions; (4) use of judgment; (5) responding appropriately to supervision, co-workers, and
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 5 of 33

6
usual work situations; and (6) dealing with changes in a routine work setting. Id.; see also Bowen
v. Yuckert, 482 U.S. 137 (1987). “The sequential evaluation process may be terminated at step
two only when the claimant’s impairment or combination of impairments would have no more
than a minimal impact on [their] ability to work.” Page v. Astrue, 484 F.3d 1040, 1043 (8th Cir.
2007) (internal quotation marks omitted).
Third, if the claimant has a severe impairment, then the Commissioner considers the
medical severity of the impairment. If the impairment meets or equals one of the presumptively
disabling impairments listed in the regulations, then the claimant is considered disabled,
regardless 	of 	age, 	education, 	and 	work 	experience. 	20 	C.F.R. 	§§ 	404.1520(a)(4)(iii),
404.1520(d), 416.920(a)(4)(iii), 416.920(d); see Kelley v. Callahan, 133 F.3d 583, 588 (8th Cir.
1998). If the claimant’s impairment is severe, but does not meet or equal one of the
presumptively disabling impairments, then the Commissioner will determine the claimant’s
residual 	functional 	capacity 	(“RFC”). 	20 	C.F.R.§§ 	404.1520(a)(4((iv), 	404.1545(a)(4),
416.920(a)(4)(iv), 416.945(a)(4). To determine a claimant’s RFC, the Commissioner examines
the claimant’s physical abilities to work. See Lewis v. Barnhart, 353 F.3d 642, 646 (8th Cir.
2003).
At 	step 	four, 	the 	Commission 	examines 	medical 	and 	non-medical 	evidence 	in
determining if the claimant has the RFC to perform past relevant work. 20 C.F.R. §§
404.1545(a)(3), 416.945(a)(3).
At step five, if the claimant does not have the RFC to perform past relevant work, the
Commissioner then has the burden to show there is other work the claimant can still do. See
Bladow v. Apfel, 205 F.3d 356, 358–59 n. 5 (8th Cir. 2000). If the Commissioner determines the
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 6 of 33

7
claimant has the RFC to perform some work, the Commissioner must then show that the work
claimant is able to do exists in significant numbers in the national economy. Eichelberger v.
Barnhart, 390 F.3d 584, 591 (8th Cir. 2004).
B. 	Standard of review
Upon review of the entire record, the court can affirm, modify, or reverse the decision of
the Commissioner, with or without remanding the case for rehearing. 42 U.S.C. § 405(g). To
affirm the Commissioner’s decision, the court must find that substantial evidence appearing in
the record as a whole supports the decision. See Id.; Cruse v. Bowen, 867 F.2d 1183, 1184 (8th
Cir. 1989). As the Eighth Circuit has repeatedly stated, the “substantial evidence on the record as
a whole” standard demands more rigorous review than the “substantial evidence” standard:
“Substantial evidence” is merely such “relevant evidence that a reasonable mind
might accept as adequate to support a conclusion.” “Substantial evidence on the record as
a 	whole,” 	however, 	requires 	a 	more 	scrutinizing 	analysis. 	In 	the 	review 	of 	an
administrative decision, “[t]he substantiality of evidence must take into account whatever
in the record fairly detracts from its weight.” Thus, the court must also take into
consideration the weight of the evidence in the record and apply a balancing test to
evidence which is contradictory.
Minor v. Astrue, 574 F.3d 625, 627 (8th Cir. 2009) (citing Wilson v. Sullivan, 886 F.2d 172, 175
(9th Cir. 1989)). See also Burress v. Apfel, 141 F.3d 875, 878 (8th Cir. 1998).
The court may disturb an ALJ’s decision only if the decision lies outside the available
“zone of choice.” Nicola v. Astrue, 480 F.3d 885, 886 (8th Cir. 2007) (citation omitted). An
ALJ’s decision is not outside the “zone of choice” simply because a court might have reached a
different result had it been the initial trier of fact. Id.
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 7 of 33

8
III. 	ANALYSIS
It is difficult to parse Millsap's exact claims. Her brief includes broad, boilerplate
criticisms which are ostensibly directed at the ALJ’s decision, but in reality are untethered to the
instant case. In some instances, Millsap criticizes the ALJ for actions the ALJ did not actually
take and cites medical events which did not actually occur. Relying on facts both supported by
the record and relevant to Millsap, her contention appears to be that she was totally disabled
because of her cognitive difficulties secondary to early-onset Alzheimer’s. The bulk of Millsap’s
criticism seems directed at the ALJ’s RFC assessment, wherein the ALJ found that Millsap could
perform less than the full range of light work and, based on vocational expert testimony, that she
was employable.
As such, this Court must analyze whether the ALJ’s RFC assessment was supported by
substantial evidence. First, the Court will recount the ALJ’s analysis, particularly in reference to
Millsap's cognitive difficulties and/or mental health issues. Then, the Court will summarize the
evidence of record regarding these issues. Finally, the Court will consider Millsap's specific
arguments.
A. 	ALJ’s Findings
The ALJ issued his written opinion on June 20, 2017. (Doc. 9-2, p. 13).
He first noted that Millsap's date last insured was September 30, 2011, and explained that
his decision would therefore address the period between May 27, 2010, her alleged disability
onset date, until September 30, 2011. Id. at 18. He found that Millsap did not engage in
substantial gainful activity during that time.
The ALJ proceeded to find that Millsap suffered from the following severe impairments
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 8 of 33

9
through the date last insured: coronary heart disease, depression, and anxiety. Id. He considered
her left eye impairments, but noted that since she worked with this condition in the past, it was
non-severe.
The ALJ then concluded that Millsap did not have an impairment or combination of
impairments that met or medically equaled a listed impairment. Considering first listings 12.04
and 12.06, he noted that Millsap had mild limitation in certain areas, e.g., in learning, recalling,
and using information, but that she lacked the marked limitations required to meet a listing in
Paragraph B of either listing. Id. at 20. He also analyzed the Paragraph C criteria, but concluded
that the evidence failed to establish the existence of a disorder over a period of two years
together with the requisite reliance on treatment and marginal capacity to adjust to changes in
daily life. Id. at 20.
The ALJ next made findings regarding Millsap's residual functional capacity (“RFC”),
concluding that she could perform less than a full range of light work as defined in 20 C.F.R. §
404.1567(b). Specifically, the ALJ found that during the relevant period, Millsap retained the
mental residual functional capacity to understand, remember, and carry out short, simple
instructions, and was limited to frequent interaction with supervisors, coworkers, and the general
public. Id. at 20. He found that she could have responded appropriately to changes in a work
routine setting and make judgments on simple work-related decisions. Id.
The ALJ explained that he came to his conclusions based on the alleged symptoms and
the extent to which they could be considered consistent with the objective medical evidence. Id.
at 20-21. He found that while Millsap's medically determinable impairments could reasonably be
expected 	to 	cause 	the 	symptoms 	she 	alleged, 	her 	statements 	concerning 	the 	“intensity,
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 9 of 33

10
persistence, and limiting effects of these symptoms are not entirely consistent with the medical
evidence and other evidence in the record.” Id. at 21.
The ALJ then performed an analysis of the medical evidence of record. Regarding
Millsap's history of heart problems, the ALJ noted that her condition always stabilized quickly
after her procedures and that she generally denied relevant symptoms, i.e., shortness of breath,
during office visits. Id. at 23. While acknowledging her heart condition would have caused some
limitation, he accepted the State agency consultant’s most recent opinion that she could perform
work within a light exertional range. Id.
Regarding Millsap's anxiety and depression, he discussed her treatment records from
January 2010 to March 2012. Id. at 22. He noted that at times she suffered increased symptoms
and crying spells, but that her condition apparently stabilized, and that she described herself as
“very good” and “happy” by November 2011. Id.
The 	ALJ 	also 	explained 	his 	analysis 	regarding 	Millsap's 	alleged 	memory 	issues.
Addressing the testimony regarding her memory problems, he acknowledged that the medical
record contains a diagnosis of early-onset dementia with severe effects on her mental capacity.
Id. at 22. However, he noted that the dementia diagnosis comes several years after the date last
insured, and determined that “the record does not support that the claimant had this level of
memory issues, or any at all, during the relevant timeframe.” Id. at 22-23. As such, he explained,
he “does not consider the impact the claimant’s dementia has on her ability to function, as this
diagnosis came years following her date last insured.” Id. at 23.
The ALJ also cited Millsap's work history, noting that it is sporadic and suggests “poor
work motivation.” Id. He also pointed to her global assessment of functioning score, indicating
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 10 of 33

11
“mild difficulties in social, occupation or school functioning,” and the assessments of State
agency consultants, as justifications for his residual functional capacity. Id.
Having thus provided the justification for his RFC assessment, the ALJ then found that
Millsap was unable to perform any of her past relevant work, nor did she have the RFC to
provide the full range of light work. Id. However, relying on the vocational expert testimony, he
concluded that Millsap was capable of making a successful adjustment to other available work.
Id. at 24-25. As such, he found her not disabled from May 27, 2010, her alleged disability onset
date, until September 30, 2011, the date last insured. Id.
B. 	Medical Records Relating to Mental Health and Cognitive Issues
Millsap argues that she was disabled from her May 27, 2010, through September 30,
2011, her date last insured. However, she supplies many medical records from outside this time
period.
1. 	Evidence from 2007 through 2009, predating the disability period.
The earliest record of Millsap's mental health condition stems from August 23, 2007,
when Millsap was referred to Jean Frueh for counseling by her primary care physician after
discontinuing birth control. (Doc. No. 9-12, p. 5). Millsap reportedly worried this medication
change would cause a resurgence of depression symptoms which had first emerged after her
heart attack in October 2003. Id. Millsap noted that her symptoms had improved over the last
few weeks due to a dosage increase in the Effexor, a medication which had taken for many years.
Id. at 7. She was provisionally diagnosed with major depressive disorder and premenstrual
dysphoric disorder. Id. at 8-9. Frueh recommended “weekly therapy to work to improve mood,”
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 11 of 33

12
with emphasis on coping skills, resolution of “relationship hurts,” and mood management
strategies. Id. at 10.
For several months after her assessment, Millsap returned to Frueh for therapy sessions.
See id. at 10-23. Much of the resulting medical records summarize conversations about Millsap's
personal struggles, such as conflict with her daughter. At one point during this time period, she
was prescribed Paxil to help with anxiety symptoms by a doctor at 5th Medical Group Internal
Medicine Clinic (“the Clinic). (Doc. No. 9-11, p. 44). Millsap's last visit with Frueh appears to
have been on November 19, 2007. (Doc. No. 9-12, p. 23).
In February 2009, Millsap visited the Clinic for chest pain, depression, and medication
questions. (Doc. No. 9-11, p. 22). She was said to be “doing well” on her current regime of Paxil
and Effexor.
In May 2009, approximately a year prior to her alleged onset date, Millsap had heart
bypass surgery. (Doc. No. 9-7, p. 27). Immediately after the surgery, she was slow to recover,
experiencing physical weakness and mental difficulties such as confusion. (Doc. No. 9-7, p. 48).
Accordingly, she was admitted to rehabilitation on May 14 and was discharged on May 20. (Doc.
No. 9-7 p. 50). Her discharge summary for rehab noted that Millsap eventually did “come around
very slowly.” Id. Speech was consulted for her memory lapses, and comprehension scores were 6
out of 7 and memory scores 5 out of 7 on discharge. Id. at 51.
At a follow-up on June 2, 2009, Millsap's cardiologist discussed her post-surgery
cognitive difficulties, and described her as “back to normal.” (Doc. No. 9-12, p. 40). He went on,
“Her memory is totally normal, and she does not have any focal deficits.” Id.
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 12 of 33

13
Notes from Millsap's post-surgery evaluation at the Clinic on September 17, 2009,
reported that she “is going great overall and has essentially returned to her usual activities. . .
patient continues to do very well on her current regiment for depression/anxiety.” (Doc. No. 9-
11, p. 4).
2. 	Medical Records from 2010
On January 5, 2010, several months before her alleged onset date, a note from a Clinic
visit reflects that Millsap is “doing well” on her depression medications of Paxil and Effexor, “an
uncommon but seemingly effective regimen.” (Doc. No. 9-10, p. 84-85). The provider, described
later as a new primary care physician, noted that he would keep her on the regimen for the
present as Millsap had been on the medications for two years, but referred her to psychiatry as
apparently had been done previously, but never followed up on. Id.
In response to this referral, a behavioral health assessment was performed by Nichole
Amsbaugh on January 18, 2010. (Doc. No. 9-12, p. 44).
Amsbaugh noted that Millsap had a long history of depression, and has been on a
combination of Paxil and Effexor for two years. Id. When asked how the medications were
working, Millsap responded “they work great.” Id. She noted that her crying and decreased mood
had resolved, and the combination of medication “works quite well.” Id. She noted fatigue and
that she needs to “rest a bit more.” Id. Millsap reported that her concentration was “better than
ever.” Id. She reported intermittent suicidal ideation since age 12. Id. at 45. Amsbaugh also
performed a mental status exam, and describes Millsap as having “logical and linear” thought
processes. Id. She wrote that Millsap sometimes gives too much information in response to
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 13 of 33

14
specific questions. Id. She wrote, “Her memory is intact both recent and remote. Her insight and
judgment are good.” Id. at 46.
Amsbaugh then wrote that Millsap should continue her current medication regimen,
because she has been on it for three years and “feels she is doing wonderful.” Id.
On March 31, 2010, Millsap followed up with Amsbaugh. (Doc. No. 9-12 at 48). Millsap
related that her depression was improved and the provider planned to discontinue her Paxil. Id.
In performing mental status exam on Millsap, Amsbaugh noted that she was quiet, shy, and
difficult to engage with some incongruencies in the information related, yet she appeared honest.
Id.
On June 8, 2010, Millsap followed up again with Amsbaugh. (Doc. No. 9-12, p. 50). She
reported trouble reducing her Paxil dosage, and decided to stay at the 20 mg level. Id. She denied
confusion, but mentioned that “she seemingly is getting forgetful,” speculating that this could be
because she just turned 50. Id. Millsap also reported feeling suicidal when decreasing the Paxil,
but was not suicidal currently. Id. Her mental status was described as initially quiet, but then
engaging and involved, with logical and linear thought processes and regular rate and tone of
speech. Id. at 51.
On September 14, 2010, Millsap followed up again with Amsbaugh. Id. at p. 52. She
reported that she was feeling depressed, crying, feeling down, and experiencing a lack of energy
and disinterest in activities. Id. She was agreeable to increasing her Paxil dosage back to 40 mg.
Id. She revealed that she was feeling suicidal. Id. She also related a number of interpersonal
stressors, disclosing for the first time that she does not get along with her daughter, and that her
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 14 of 33

15
granddaughter, who was visiting for the summer, was planning to move in permanently, causing
tension between her and her husband. Id.
On December 1, 2010, Millsap followed up again with Amsbaugh. Id. at 54. She reported
that she had been crying a little, but “definitely better” than previously. Id. She reported an
improved mood, less irritability, and denied suicidal thoughts as things were going relatively
well. Id. Overall, she reported being “pleased with the way the Effexor has managed.” Id.
3. 	Medical Records from 2011
On January 12, 2011, a Clinic provider noted in a review of systems: “Psychological
symptoms: no anxiety and no sleep disturbances. Anhedonia tearful sometimes.” (Doc. No. 9-10,
p. 78).
On January 15, 2011, during an admission for chest pain, a doctor noted her past medical
history of depression, writing she is “on medication and doing good.” (Doc. No. 9-8, p. 41).
On January 26, 2011, her cardiologist noted that Millsap had “severe anxiety issues” and
had asked him to be referred to a primary care doctor at his hospital. (Doc. No. 9-12, p. 59).
On March 29, 2011, she followed up again with Amsbaugh. (Doc. No. 9-12, p. 61). She
mentioned her recent diagnosis of anxiety from her cardiologist. Id. She cried when discussing it
with Amsbaugh. Id. She stated that she had lost weight because she did not feel like eating. After
hesitating, she disclosed her son announced his upcoming wedding, and every day since then she
had been throwing up, and felt as though she is losing her son and best friend. Id. She spoke
extensively to Amsbaugh about her problems with her son’s relationship. Id. Amsbaugh
recommended the drug Remeron, stating, “this seems to be more a situational stressor, and
patient is expressing feelings of abandonment.” Id. Millsap reported that she awoke that morning
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 15 of 33

16
feeling fine, but thinking about the marriage depresses her mood. During the mental status exam,
Amsbaugh described Millsap as becoming very tearful, hyperventilating, and able to do some
deep breathing exercises. Id. at 62.
On May 5, 2011, she followed up again with Amsbaugh. Id. at 63. Her husband attended
the appointment. Id. She stated she feels the Effexor is working, but thought that there may be
“room for improvement” and was interested in increasing the dosage. Id. She said that at time
she is anxious and has to use the Xanax, but it made her sleepy. Id. She reported crying spells at
time that come out of nowhere but are “much less.” Id. She reported taking an extra Effexor to
control these crying spells two-three times a week. She mentioned feeling sleepy and low-
energy. Id.
On October 26, 2011, she followed up again with Amsbaugh. (Doc. No. 9-12, p. 67). She
stated she had a “difficult time” over the summer, and had undergone chest pain and stent
placement. 	Id. She said that over the last month and particularly the last week, she felt “very
good,” and “happy.” Id. She reported no difficulty with sleep and that her energy was beginning
to improve. Id. She noted that cardiac rehabilitation had helped her energy returns. Id. She also
reported her weight loss and nausea was a result of her cholesterol medication and had improved.
Id. In her mental status exam, Amsbaugh wrote that Millsap's facial expression was animated,
and she was much more talkative, reporting a good mood.
On December 19, 2011, her cardiologist noted her heart symptoms and wrote, “aside
from the above, she feels good. She has no other significant symptoms. She was a bit tearful in
the office.” (Doc. No. 9-12 at 70).
4. 	Medical Records After the Date Last Insured, from 2012 to 2017
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 16 of 33

17
On February 29, 2012, Millsap followed up again with Amsbaugh. 	(Doc. No. 9-12 at
82). She stated she was “feeling much better,” with reduced stress and greater calmness. Id. She
explained her energy is good some days and that she is able to care of housework, and that she is
crying less, less irritable, and things are “going much better in her life.” Id. 	Her mental status
exam revealed “her thought processes are logical and linear,” and her mood was “very good.” Id.
On July 17, 2012, she again followed up with Amsbaugh. Id. at 84. She was “quite
tearful,” and explained that she had a lot of stress because her granddaughter. Id. She stated that
her 	mood 	is 	low, 	she 	cries 	continuously, 	and 	her 	anxiety 	level 	ramped 	up 	when 	her
granddaughter came and rises the longer she is here. Id. She expressed passive suicidal thoughts.
Id. at 85.
On March 18, 2013, she followed up again with Amsbaugh. (Doc. No. 9-14 at 86). She
reported that her depression had decreased over the last several months, reporting her good is
mood, and some days she feels happier than she has felt in a long time. Id. She was back to her
activity of horseback riding and has even purchased a pony. Id. She reported that summer is
usually stressful because her granddaughter visits, but now, it seems that her granddaughter
might not visit. Id. Amsbaugh wrote that Millsap's thought processes were logical and linear,
insight and judgment were good, memory was intact, and her affect was very bright. Id. at 87.
On September 16, 2013, Millsap visited Amsbaugh at the behavior health clinic. Id. at 80.
She reported increased depression over the last few months, anxiety, and irritability. Id. She
stated her anxiety is primarily because she feels her husband is tired of her illness. Id. She has
conflict with her granddaughter, daughter, and husband. Id. at 80-81. Psychiatrically, Amsbaugh
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 17 of 33

18
noted that her insight and judgment were limited, her memory appeared to be intact, and her
mood depressed. Id. at 81.
On December 9, 2013, she visited Amsbaugh at the Behavioral Health Clinic. (Doc. No.
9-14 at 76). Her chief complaint is that her husband is concerned about her memory, confusion,
crying, and difficulty focusing. Id. She says she has trouble completing tasks and gets lost in
conversation which upsets her husband. Id. She reported nervousness because she was worried
she was not telling the right symptoms, but reports her mood and activity level is good. Id. at 77.
Amsbaugh ultimately ordered neuropsychological testing and noted that Millsap had complained
of memory problems in the past. Id. at 78.
On June 24 and June 26, 2014, she underwent a neuropsychological evaluation in
Kearney, Missouri, following an admission to the mental health unit of a local hospital on June
17, 2014. (Doc. No. 9-12, p. 86). The evaluation consisted of a diagnostic interview, mental
status examination, and cognitive testing. Id. at 87. The psychologist suggested the diagnosis of
major neurocognitive disorder and mood disorder, with severe difficulty functioning. Id. at 89.
He noted significant difficulties with cognitive function and significant memory difficulties. Id.
at 89-90.
On September 26, 2014, she was referred to the neurology clinic for evaluation and
management regarding her neurological symptoms, and saw Dr. SaId. (Doc. No. 9-14, p. 47).
Her husband reported that for the last five years or so she has suffered from memory problems
that have gradually worsened over time and became more prominent in the last two years. Id. He
reported that she repeats question and forgets people’s names. Dr. Said performed a mini mental
status exam. Id. at 48. He instructed her to return in four weeks. Id. at 49.
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 18 of 33

19
On October 20, 2014, Millsap returned to the neurology clinic. Dr. Said discussed her
previous EEG and MRI results, planned to follow up with a PET scan, and referred them to
Mayo Clinic at their request. Id. at 40.
Another neuropsychological assessment was performed on January 19, 2015, by Dr.
Rodney Swenson. (Doc. No. 9-12 at 93). Ultimately, the psychologist determined that the testing
was “unfortunately clinically suboptimal” in terms of validity. Id. at 95. He opined that the test
results underrepresented her neuropsychological capacity yet accurately confirmed that she is
functioning abnormally. Id. He concluded by recommending that she undergo studies which do
not require patient effort, such as neuroimaging studies. Id. at 95.
A week later, on January 26, 2015, Millsap returned to Dr. Swenson to discuss her test
results. (Doc. No. 9-12 at p. 97). Dr. Swenson noted that Millsap remembered her earlier visit,
and stated that if one were to take her previous testing results at face value, she would not
remembered it at all. Id. He reaffirmed the need for further diagnostic workup as the
neuropsychological testing was not sensitive or specific enough to determine her condition. Id. at
98.
On May 19, 2015, Millsap visited the Mayo Clinic for several assessments. (Doc. No. 9-
13, p. 3). She was first evaluated by Dr. Eoin Flanagan, who took a history from the patient and
her husband indicating that she first developed symptoms between 2000 and 2003, and had
struggled a little bit at work. Id. at 4. He wrote, “over the last five years in particular, things have
progressed,” and described her troubles with forgetfulness and word-finding. Id. Dr. Flanagan
reviewed her past testing and MRI, and arranged for a PET scan to be performed. Id. at 5-6.
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 19 of 33

20
On the same date, Millsap was also evaluated by Dr. Knopman at the Mayo Clinic. Id. at
6. He recounted her history of cognitive difficulties that has gradually worsened. Id. He also
noted that she had anxiety and depression which led some observers to wonder whether her
primary diagnosis was psychiatric. Id. He noted that the mental status exam performed by Dr.
Flanagan showed substantial cognitive impairment. Id. at 8. He attributed her symptoms to
neurodegenerative disease, and confirmed that PET scan will be performed. Id.
Later on May 19, 2015, Dr. Flanagan reviewed Millsap's PET results. Id. at 3. He stated
that they were consistent with young-onset Alzheimer’s disease. Id. He prescribed Aricept and
counseled Millsap on staying active. Id.
On August 10, 2015, she was seen at the Neurology Clinic at Trinity Hospital. (Doc. No.
9-14, p. 21). Dr. Lee noted a history of progressive memory loss for 5 years or longer, assessing
it as “probably Alzheimer disease.” Id. He noted that the Aricept prescribed to her at the Mayo
Clinic was helpful. Id. at 22.
On October 19, 2015, Millsap visited psychologist Mary Solberg for clinical intake.
(Doc. No. 9-13, p. 24). She was seeking treatment to “work through her medical issues and
dealing with Alzheimer’s. Id. Dr. Solberg wrote that she would treat Millsap with cognitive
behavioral therapy to increase coping techniques for stressful situations. Id. at 26. Millsap
followed up with her again on November 2 and December 21, 2015, as well as February 15,
2016, mostly discussing life history and events. Id. at p. 21-26.
On March 14, 2016, Millsap visited the Neurology Clinic at Trinity Hospital. (Doc. No.
9-14, p. 10). The Doctor noted that she had a history of memory difficulties for the past year,
possibly related to Alzheimer’s. Id. She complained of headaches, which the doctor opined were
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 20 of 33

21
myofascial in origin. Id. at 11. He noted that she appeared severely depressed, and noted that she
had personal issues with her husband. Id. He stated, “Finally, I am somewhat concerned that a
55-year-old female with really no past medical history or no clear genetic disposition for
Alzheimer’s disease is diagnosed with a dementia. In my opinion, I do feel that she is
experiencing a form of pseudodementia from the anxiety and depression.” Id.
On March 28, 2016, she attended an occupational therapy initial evaluation. (Doc. No. 9-
14 at p. 3). The “reason for referral” was given as Alzheimer’s. In the notes for “Home
Environment,” “Patient’s Responsibilities” were listed at “Caregiver for child/parent/spouse,
Driving, Housework, Laundry, Meal Preparation, Other: leisure includes horse riding, 4
wheelers, camp.” He recommended a home exercise program. Id. at 5. A note entered on June
17, 2016, indicates she did not return for therapy and was discharged back to her doctor’s care.
Id. at 3.
C. 	Hearing Testimony
At the hearing, Millsap herself testified briefly. (Doc. No. 9-2 at 39). She explained that
she had trouble at work due to confusion. However, she expressed difficulty answering counsel’s
questions, and agreed to his suggestion that her husband, Melbourne, testify instead. Id. at 40.
Melbourne reported that Millsap was fired from her job at the bank for shredding the
wrong documents. Id. According to counsel’s clarification, this firing occurred in March of 2006.
Id. at 42.
When asked about his wife’s condition in 2010, the start of the relevant period,
Melbourne testified that Millsap needed to sleep all the time, and that she had confusion and lack
of focus which worsened over time. Id. at 43. He testified that she would forget to take care of
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 21 of 33

22
the family’s horses and dogs and forget to take showers. Id. Melbourne also described Millsap's
problems turning on and using a computer and writing checks. He stated that she would forget
how to write her own name, and how to write in general. Id. at 45.
When asked by Millsap's attorney whether she would have been able to work in 2010,
Melbourne reported that she would not have been able to keep to an employer’s schedule and
would require a great deal of patience during the day. Id. at 46-47. He testified that she often had
uncontrollable crying spells, and stopped engaging with other people. Id. at 47. He stated that her
condition as of the hearing date was was very similar to her condition in 2011, and gave specific
examples from the relevant time period such as failing to recognize friends, and being unable to
unlock a car door. Id. at 51.
Melbourne also submitted a written statement. (Doc. No. 9-6, p. 71). He states that she
had problems focusing and negative thoughts as early as September 2007, and memory issues as
early as June 2008. Id.
Millsap’s daughter also submitted a partial statement, attesting to “subtle differences and
changes” prior to June 2011, such as forgetting how to operate a camera and losing her train of
thought. (Doc. No. 9-6, p. 69).
D. 	Millsap's Arguments
Millsap makes several arguments, some broad and some general. They are addressed
sequentially below.
1. 	Whether the Medical Records Generally Support the ALJ’s RFC
Determination
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 22 of 33

23
Millsap claims that the medical records in general support her claim of debilitating
cognitive issues. She writes that her anxiety and depression caused “severe limitations,” and that
she suffered cognitive issues such as learning, processing information, and memory loss that
were “debilitating” during the relevant time period. The Commissioner responds at length, citing
in detail to the record in support of its argument that the contemporaneous medical evidence fails
to support the limitations Millsap alleges. As such, the Commissioner urges that this Court affirm
the ALJ’s analysis.
Turning first to the records pertaining to depression and anxiety, the Court is not
persuaded by Millsap's claim that they show severe limitations. Before the relevant period,
Millsap's depression seems effectively controlled by medication. She did not appear to seek
treatment at all between November 2007 and January 2010, during which time her depression
appears to have been well-controlled by her combination of Paxil and Effexor. (Doc. No. 9-10, p.
84-85). As of March 31, 2010, just before her alleged onset date, she reported improved
depression and planned to discontinue her Paxil. (Doc. No. 9-12 at 48).
During the critical the period between May 2010 and September 2011, Millsap shows
some struggles with depression and anxiety. However, these are largely tied to interpersonal
issues. For instance, when she reports depression and crying spells to Amsbaugh in September
2010, her feelings of “overwhelming” stress stem from current conflict with her daughter and her
husband. (Doc. No. 9-12, p. 52-53). Similarly, when Millsap told Amsbaugh in March 2011 that
she was losing weight because she did not feel like eating, she admitted that her emotional
turbulence resulted from her son’s upcoming wedding and negative feelings about her new
daughter-in-law. (Doc. No. 9-12, p. 61). At the time, Amsbaugh prescribed additional medication
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 23 of 33

24
and wrote, “This seems to be more a situational stressor, and patient is expressing feelings of
abandonment.” Id.
The medical evidence from the relevant period also reflects stretches of time in which
Millsap's symptoms were apparently resolved. In December 2010, Millsap describes herself as
“definitely better,” and “pleased” with her medication. (Doc. No. 9-12, p. 54). In October 2011,
approximately a month after the end of the relevant period, she reports feeling “very good” and
“happy.” Id. at 67. By February 2012, almost six months after the date last insured, she reports to
Amsbaugh that she feels “much better,” with reduced stress and greater calmness. Id. at 82. She
stated that her energy is good some days and that she is able to take care of housework, and that
she is crying less, less irritable, and things are “going much better in her life.” Id.
In short, the Court agrees with the ALJ’s assessment that the majority of records from the
relevant period show that Claimant’s condition was well-controlled through medications, and
that increased symptoms “were caused by situational stressors caused by her family.” The Court
does not agree with that Millsap's contention that the record reveals “severe limitations” from her
depression and anxiety. At the very least, the ALJ’s decision to find her only mildly to
moderately limited from these conditions is supported by substantial evidence on the record as a
whole.
The Court also finds that Millsap's claims of severe cognitive limitations during the
relevant timeframe, such as memory loss or difficulty concentrating, are not supported by the
medical records. About a year before her alleged onset date, she does indeed suffer short-term
cognitive difficulties after surgery in May 2009, requiring admission to rehabilitation. (Doc. No.
9-7, p. 48-50). Yet she was described as “back to normal,” with a “totally normal” memory by
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 24 of 33

25
the following month. (Doc. No. 9-12, p. 40). Similarly, in a follow-up at the Clinic in September,
her provider writes that Millsap “is going great overall and has essentially returned to her usual
activities” 	and 	patient 	“continues 	to 	do 	very 	well 	on 	her 	current 	regiment 	for
depression/anxiety.” (Doc. No. 9-11, p. 4). These objective medical records describe a medical
condition that has resolved.
The next mention of Millsap's memory issues – and the only one during the relevant
timeframe – comes on June 8, 2010, when she describes herself to Amsbaugh as “seemingly”
forgetful. 	(Doc. No. 9-12, p. 50). Yet at the same visit, she denied confusion, and her thought
processes are described as logical and linear. Millsap does not complain of memory problems
again until December 9, 2013, three and a half years after the June 2010 mention of forgetfulness
and 	over 	two 	years 	after 	the 	date 	last 	insured. 	At 	that 	point, 	Amsbaugh 	ordered
neuropsychological testing; it is not until June 2014 that a neuropsychological evaluation reveals
difficulties with cognitive function and memory. (Doc. No. 9-12, p. 86-90). Even after that point,
doctors seem to struggle to pinpoint the extent of her limitations. See, e.g., Doc. No. 9-12 at 93,
(Dr. Swenson noting “clinically suboptimal” test results in January 2015). Even after Millsap's
diagnosis of dementia, at least one of her treating physician disputes the diagnosis, postulating
that she is instead suffering from “pseudo-dementia” from anxiety and depression. (Doc. No. 9-
14, p. 10).
Millsap seems to argue that her 2015 dementia diagnosis should be interpreted as causing
her symptoms from 2010-2011. It is true that medical evidence after the date last insured “can be
relevant. . . in helping elucidate a medical condition during the time for which benefits might be
rewarded,” Pyland v. Apfel, 149 F.3d 873, 876–77 (8th Cir. 1998). But here there is little to
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 25 of 33

26
elucidate, considering the vanishingly mild symptoms reflected in Millsap's medical records. The
two-year gap between the date last insured and Millsap's first serious complaint of symptoms
does little to establish the presence of a disabling condition before her insured status expired. The
ALJ did find some limitations during the relevant period. See Doc. No. 9-2, p. 18 (ALJ noting
mild limitations with regards to understanding, remember, and applying information, and
moderate limitation with regards to concentrating, persisting, and maintaining pace). The ALJ’s
assessment of the severity of her cognitive limitations during the relevant time period is well
within the “zone of choice.”
2. 	Dr. Knopman’s 2017 Letter
Millsap makes several specific arguments on the basis of an April 24, 2017 letter written
by Dr. Knopman, a treating physician. She contends that the ALJ should have re-contacted Dr.
Knopman to gain further information as to his opinion, and argues that the ALJ improperly
substituted his judgment for that of a physician when he declined to find Millsap disabled on the
basis of the letter.
Dr. Knopman’s letter reads in its entirety:
I saw Mrs. Lisa Millsap on April 20, 2017, and had first met her and
examined her on May 19, 2015. She has a diagnosis that is unequivocal to
dementia due to Alzheimer's disease that is moderately severe at this point. In
retrospect, she was experiencing cognitive difficulties for at least ten years before
we diagnosed her in 2015. There is no question that she was experiencing
cognitive functioning issues for many years preceding her diagnosis, and it is
reasonable to conclude that it is all part of the same process that has currently
reached the severe stage now.
(Doc. No. 9-14, p. 88).
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 26 of 33

27
Millsap summarizes the above letter, writing, “[t]here was no equivocation about the
opinion nor contradiction of record. The ALJ failed in his duty to develop the facts fully and
fairly…”
The Commissioner responds that Millsap herself bears the burden of submitting medical
evidence, and that the record in this case contains ample evidence to support the ALJ’s decision.
The Commissioner then discusses the evidence of record, arguing that the contemporaneous
medical evidence from the period of May 2010 to September 2011 contradicts Millsap's claims
of severe cognitive difficulties during this timeframe. The Commissioner also criticizes Dr.
Knopman’s 2017 opinion as conclusory, retrospective, and unsupported by the medical evidence.
As a threshold matter, the Court agrees with the Commissioner that the ALJ did not fail
in his duty to develop the record by failing to recontact Dr. Knopman. While the ALJ has a duty
to develop the record, Snead v. Barnhart, 360 F.3d 834, 838 (8th Cir. 2004), the ALJ is only
required to develop a reasonably complete record even when claimant is pro se. Whitman v.
Colvin, 762 F.3d 701, 707 (8th Cir. 2014). Here, claimant is represented by counsel. The record
here contains extensive medical records from 2005 until 2017, as well as hearing testimony and
opinions from State agency physicians. The ALJ’s decision to refrain from expanding the record
further was appropriate and is supported by substantial evidence.
The next issue is the ALJ’s treatment of Dr. Knopman’s 2017 letter. A treating
physician’s opinion is given controlling weight if “it is well-supported by medically acceptable
clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial
evidence.” Whitman v. Colvin, 762 F.3d 701, 706 (8th Cir. 2014), citing Goff v. Barnhart, 421
F.3d 785, 790 (8th Cir. 2005). Furthermore, in determining the weight to give the opinion of a
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 27 of 33

28
treating physician, the ALJ must should consider “the length of the treatment relationship and the
frequency of examinations.” Whitman, 762 F.3d at 706, citing Casey v. Astrue, 503 F.3d 687,
692 (8th Cir. 2007).
The court first notes that the Dr. Knopman’s 2017 letter does not appear to be the
incontrovertible evidence of disability that Millsap believes it to be. Even if the ALJ had
explicitly cited Dr. Knopman’s 2017 letter as authoritative and given it controlling weight, it is
not clear whether and to what extent the RFC determination would have changed. Dr. Knopman
stated broadly that Millsap was “experiencing cognitive difficulties” and “cognitive functioning
issues” since around 2005. (Doc. No. 9-14, p. 88). But Dr. Knopman distinguishes these previous
issues from Millsap's condition as the date of the letter, by which time her dementia has
worsened to become “moderately severe.” Presumably, then, her difficulties during the relevant
period were less severe, although he gives no specific details as to her condition in 2010 and
2011. As his letter is ultimately devoid of specificity beyond the broad assertions of “difficulties”
and “issues,” is not necessarily inconsistent with ALJ’s assessment of Millsap's impairments,
which includes some cognitive difficulties: the ALJ found that Millsap was moderately limited
with regard to concentration and pace, and mildly limited in other areas related to mental
function. (Doc. No. 9-2, p. 19-20).
But even if, arguendo, greater reliance on Dr. Knopman’s 2017 letter would indeed have
resulted in a more limited RFC determination, the ALJ’s decision not to proceed in such a
manner was supported by substantial evidence.
First, there is the retrospective nature of the letter. It is dated April 24, 2017, refers to a
diagnosis made in 2015, and opines as to cognitive difficulties starting a full decade earlier. The
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 28 of 33

29
length of the treating relationship and frequency of examinations are factors in determining the
weight to give a treating physician’s opinion. Whitman, 762 F.3d at 706. Here, it appears that
Knopman saw Millsap once in 2015 and again in April 2017, but no treatment records are
presented from the second visit other than the letter itself. This relatively short treating
relationship and low frequency of examinations diminishes the relevance of Knopman’s opinion.
Furthermore, Knopman makes no mention of medical records or other evidence he relies
upon to make his assertions of cognitive difficulties stemming from 2005. Presumably he is
relying on Millsap's self-reports, but his failure to articulate the basis of his opinion does not
allow the Court to conclude that it was based on “medically acceptable clinical and laboratory
diagnostic techniques.” Whitman, 762 F.3d at 706.
Lastly, there is the matter of the other evidence of record. To be given controlling weight,
a treating physician’s opinion must be “not inconsistent with the other substantial evidence.”
Whitman, 762 F.3d at 706. 	As discussed at length above, the contemporaneous medical
evidence does not reflect significant limitations during the relevant period, nor does the evidence
suggest the presence of limitations until several years later. To the extent that Dr. Knopman’s
letter does suggest severe limitations in 2010-2011 (which is not at all clear to the Court, as
described above), his conclusion is inconsistent with the other evidence of record.
For all of the above reasons, the ALJ’s decision not to rely on Knopman’s letter to further
restrict Millsap’s RFC was supported by substantial evidence.
3. 	Seratonin Syndrome
Millsap also makes arguments regarding Seratonin Syndrome. She writes:
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 29 of 33

30
In January 27, 2010, Lisa Millsap was admitted into Trinity Medical Center with a
probable diagnosis of Seratonin Syndrome (Exhibit 9F). She was confused, had gait
difficulty and was hard to engage. Ms. Millsap had subsequent consultative exams and
neuropsychological testing which detailed her major cognitive dysfunction. And, the
medical professionals note that her issues were present at least from 2010.
Seratonin Syndrome has many onset sources, but chiefly, anti-depressant medication and
other psychotropic medicines can contribute to its onset. And, as of May 27, 2010, Ms.
Millsap' s amended onset date, she was an aged 50 woman significant for heart disease;
depression; anxiety; and cognitive memory impairment.
(Doc. No. 12, p. 7).
Millsap argues support for this paragraph with a reference to “Exhibit 9F,” cited without
a page number. About halfway through Exhibit 9F’s 80 pages, there is a record for a visit that
occurred on January 18, 2010. See Doc. No. 9-12, p. 44. This note was signed on January 27,
2010, which the undersigned can only assume was misinterpreted by counsel as a visit date.
During the visit – which was an appointment with a therapist, not a hospital admission – Millsap
and Amsbaugh discussed Millsap's primary care physician’s concern about serotonin syndrome,
a potential side effect of a drug Millsap was taking. Amsbaugh writes, “I did review signs and
symptoms of serotonin syndrome including confusion, difficulty with gait, and we did review the
emergency symptoms. I did refer her to the Mayo.com for a printout…” After some more
discussion, Amsbaugh announces her plan to continue Millsap on the current medication
regimen, because Millsap reports that she is “doing wonderful.”
At first glance, it seems improbable that the above encounter could be the source of
Millsap's allegation that she was admitted to the hospital for serotonin syndrome, despite the
similarity between the date that this alleged admission took place and the date the therapy note
was signed. Accordingly, allowing for the possibility that counsel gave both the wrong exhibit
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 30 of 33

31
number and the wrong date in the brief, the undersigned performed a careful review of the entire
administrative record beyond Exhibit 9F for any hint of the supposed hospital visit. The search
was fruitless. Millsap occasionally mentions concerns about serotonin syndrome, but her
providers assured her that the risk was quite low. See, e.g., Doc. No. 9-12, p. 50. The Court
cannot see how Millsap's counsel interpreted review of potential side effects as a hospital
admission and diagnosis. No further discussion appears warranted.
4. 	Melbourne’s Testimony
Lastly, Millsap claims her husband’s testimony describing her functional difficulties
establishes her disability prior to the date last insured. She contends that the ALJ found her/her
husband’s testimony not credible, and that this conclusion was erroneous. She writes that “her
ability to do some chores” does not reflect an ability to perform competitive employment.
The United States responds that the ALJ did not use the term “credibility,” in accordance
with the governing law, and that the ALJ’s consideration of Millsap’s subjective complaints was
proper.
As a threshold issue, the Court notes that the ALJ did not rely on or even mention
Millsap's “ability to do some chores.” The origin of this argument is unclear.
Overall, the Court finds the ALJ’s failure to fully adopt Melbourne’s account of his
wife’s limitations to be supported by substantial evidence. Melbourne describes someone
“essentially unable to live independently,” but the contemporaneous medical records tell a
different story. For instance, Millsap and her husband claim that she was fired from her job in
2006 for cognitive difficulties. But in 2007, she told a therapist the following about her departure
from this job:
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 31 of 33

32
She informs me that she is contemplating the possibility of going back to
work. She states that this is not for reason of financial need as that is not the
situation. She states that this idea is because her husband is concerned that she is
not socially connected enough in her life. She states, however, that she enjoys
being home and satisfied with the friends that she has in her life.
Today she talked about her history of her past job in which her husband
had pushed her to apply for a job in a bank. She states that this is the one time
that, "I let him talk me into it," referring to the decision to leave her job that she
was on at the time and take on this new job. In the context of that situation, she
ended up being in a very highly stressful and unhealthy environment, her anxiety
increased significantly, and she experienced a significant amount of stress on that
position. She states within six months of taking that job she had her heart attack
and attributes that event to the stress that she incurred in this new position because
of personality problems with coworkers who excluded her or would not accept her
in this position. She was eventually let go from this position and she states that it
was the best thing that they could have done for her.
She reports that she is now nervous about the prospect of going back to
work because she is enjoying fairly stress free lifestyle at home. She has concern
about increased stress going back into a work environment because of this past
experience and also because she has learned in recent years that stress was a
contributing leading cause in her opinion of her heart attack. She does not want
this to occur again.
Doc. No. 9-12, p. 19. A.R. 544.
While Millsap certainly relates stress, it appears to relate to “personality problems” and
strife with other coworkers, rather than cognitive issues. Nothing from this record appears to
indicate a person unable to function to the extent Millsap’s husband described.
Other records even after the date last insured show an active life. For instance, Millsap
tells Amsbaugh in 2013 that her depression had decreased over the last several months, reporting
her good is mood, and some days she feels happier than she has felt in a long time. Id. She is
back to her activity of horseback riding and has even purchased a pony. Id. (Doc. No. 9-14 at
86). 	On balance, the records simply do not support Melbourne’s portrayal of someone barely
with extreme difficulty functioning in daily life.
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 32 of 33

33
Examining the record as a whole, the Court finds that the ALJ’s decision to discount
some of Millsap's subjective claims was supported by substantial evidence. While Melbourne
may well have testified with perfect accuracy as to Millsap's eventual condition – after all, the
hearing occurred almost seven years after her date last insured – the ALJ’s findings of only mild
and moderate limitations during the relevant period are supported by substantial evidence.
IV. 	CONCLUSION
Having carefully reviewed the record as a whole and the parties’ arguments, the Court
concludes that the ALJ’s decision is well-supported by substantial evidence and is within the
applicable “zone of choice.” While it appears Millsap may well be suffering from serious
cognitive difficulties now, the reality of her date last insured precludes a finding of error.
For the above reasons, Millsap's Motion for Summary Judgment (Doc. No. 11) is
DENIED and the Social Security Administration’s Motion for Summary Judgment (Doc. No.
16) is GRANTED.
IT IS SO ORDERED.
Dated this 6th day of November, 2020.
/s/ Clare R. Hochhalter
Clare R. Hochhalter, Magistrate Judge
United States District Court
Case 1:18-cv-00105-CRH Document 20 Filed 11/06/20 Page 33 of 33