THOMAS P. SMITH, Magistrate Judge.
The plaintiff, Anna Marie Raleigh, brings this appeal under §§ 205(g) and 1631(c)(3) of the Social Security Act ("the Act"), as amended, 42 U.S.C. §§ 405(g), 1383(c)(3), seeking review of a final decision by the Commissioner of the Social Security Administration ("SSA") denying her application for Title II Disability Insurance Benefits ("DIB") and Title XVI Supplemental Security Income ("SSI"). The plaintiff has filed a motion for judgment on the pleadings or, in the alternative, remand for further administrative proceedings.
In reviewing a final decision of the Commissioner under 42 U.S.C. §§ 405(g) and 1383(c), the district court performs an appellate function.
In determining whether the evidence is substantial, the court must "take into account whatever in the record fairly detracts from its weight."
The regulations promulgated by the Commissioner establish a five-step analysis for evaluating disability claims.
While the claimant bears the burden of proving the first four steps, the Commissioner must prove the final one.
The facts and procedural history are familiar to the parties. As outlined above, the Commissioner uses a five-step sequential evaluation process when evaluating disability claims. 20 C.F.R. §§ 404.1520, 416.920. At step one, the ALJ found that the plaintiff had not engaged in any substantial gainful activity since her alleged onset date of September 24, 2009. (Tr. 78). At step two, the ALJ found that the plaintiff had the following severe impairments: bipolar disorder, obsessive-compulsive disorder and anxiety disorder.
Before proceeding to steps four and five, the ALJ evaluated the record, as it then existed, in order to determine the plaintiff's residual functional capacity. As noted by the ALJ, the plaintiff testified that she is unable to work due to overwhelming anxiety and panic attacks. (Tr. 82). She stated she lives with her husband and four children, and sees a therapist, Dr. Erum Shahab, on a monthly basis.
The ALJ next opined that the plaintiff's demeanor at the hearing was inconsistent with a severely or markedly disabled individual, and noted that no difficulties were observed by an agency official who conducted a previous face-to-face interview with the plaintiff. (Tr. 83-84). The ALJ also considered the plaintiff's testimony and answers to an Activities of Daily Living (ADL) questionnaire which showed that the plaintiff could generally care for herself, her children and her house.
Next, the ALJ considered the opinions of plaintiff's treating sources. In particular, he considered mental RFC reports completed by Lisa Archie, LSCW, and co-signed by Dr. Lori Sobel, the plaintiff's initial treating psychiatrist, as well as a letter from Dr. Shahab, her current treating psychiatrist.
The ALJ assigned the greatest weight with respect to the plaintiff's mental RFC to the opinion provided by Dr. Thomas Hill, a non-examining state agency medical consultant. (Tr. 86). Dr. Hill opined that the plaintiff has moderate limitations in several areas, including the ability to interact with the general public; respond appropriately to changes in a work setting; set realistic goals or make plans independently of others; perform activities within a schedule; maintain regular attendance; and be punctual within customary tolerances. (Tr. 66-67, 86). Dr. Hill also found the plaintiff to be moderately limited in her ability to complete a normal workday and workweek without interruptions from psychologically-based symptoms, and to perform at a consistent pace without an unreasonable number and length of rest periods. (Tr. 66, 86).
The ALJ stated that he took Dr. Hill's opinion with respect to these moderate limitations into consideration when formulating the plaintiff's RFC. The ALJ also noted Dr. Hill's opinion that, while the plaintiff has panic symptoms, depression and a low frustration tolerance for stress, which will at times disrupt optimal performance, she "does appear capable of engaging with adequate [concentration, persistence and pace] to perform [simple, routine and repetitive tasks] that are non time sensitive in nature, and do not require intense focus and concentration." (Tr. 66, 86). The ALJ further cited Dr. Hill's observation that the plaintiff has been dealing with her panic symptoms for the past decade, and has been able to work despite her panic disorder in the past. In support of this opinion, the ALJ again noted that the plaintiff left her job due to pregnancy considerations, rather than because of her psychiatric symptoms. (Tr. 86-87).
Based on this analysis, the ALJ found that the plaintiff retained the residual functional capacity to perform a full range of work at all exertional levels, with the following non-exertional limitations:
(Tr. 82). After making this finding, the ALJ proceeded to step four of the sequential evaluation and concluded that the plaintiff was unable to perform any past relevant work. (Tr. 87). The burden, therefore, shifted to the defendant to come forward with evidence that substantial gainful alternative employment exists which the claimant has the residual functional capacity to perform. 20 C.F.R. §§ 404.1520(a)(4)(v), 416.920(a)(4)(v). Relying on the testimony of a vocational expert, and considering the plaintiff's age, education, work experience and residual functional capacity, the ALJ determined that the plaintiff is "capable of making a successful adjustment to other work that exists in significant numbers in the national economy." (Tr. 87-88). Accordingly, the ALJ held that a finding of "not disabled" was appropriate under the Act. (Tr. 88). The plaintiff requested review of the ALJ's decision by the Appeals Council. (Tr. 7-8). The Appeals Council denied the request for review on March 16, 2012. (Tr. 1-6).
The plaintiff has identified four general areas of alleged error. She alleges that the ALJ failed to follow the Treating Physician Rule, failed to properly evaluate the plaintiff's credibility, and relied upon flawed vocational expert testimony. She also alleges that new evidence submitted to the Appeals Council requires remand. As addressed above, a reviewing court will "set aside the ALJ's decision only where it is based upon legal error or is not supported by substantial evidence."
At the outset, the Court notes that it has significant concerns about whether the decision was supported by substantial evidence on the record originally before the ALJ. Those concerns are based, in large part, on the ALJ's selective references to the medical records and his improper assignment of weight to the opinion evidence. In summarizing the medical evidence, the ALJ referenced only those treating records in which the plaintiff appeared to be "ok" or "doing well overall." He failed to mention, for example, the records showing she was experiencing "what sounds like intense rage where she apparently blacks out," is "on the back end of a panic attack always," had "not been doing well at all," and had recently put a fist through a wall "in an effort to not hit her mother." (Tr. 313, 349-350). The ALJ's synopsis of the medical records was incomplete, and remand is appropriate in order for the ALJ to properly evaluate the complete record.
Remand is also needed to rectify an error committed by the ALJ in his assignment of weight to the opinion evidence. The regulations provide that a treating physician's medical opinion is entitled to controlling weight if it concerns "the nature and severity of [the plaintiff's] impairment, is well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record."
While the ALJ generally should afford great weight to treating source opinions that are well-supported and consistent with the record, he is not required to accept every aspect of the treating physician's opinion. As explained in Social Security Ruling 96-2p, "[i]t is not unusual for a single treating source to provide medical opinions about several issues . . . [and] adjudicators must always be aware that one or more of the opinions may be controlling while others may not."
The ALJ accepted the opinions of Ms. Archie and Dr. Lori Sobel, to the extent they stated the plaintiff could maintain personal hygiene, use good judgment, carry out single or multi-step instructions, focus long enough to finish assigned simple tasks, perform basic work activities at a reasonable pace and finish on time without difficulties. (Tr. 85, 290-91, 302-03). However, the ALJ disagreed with, and applied little weight
In discrediting the assessment of a serious problem handling frustration appropriately, the ALJ cited only the plaintiff's ability to "essentially maintain a household with four very young children" with some help from her mother. (Tr. 85). According to the ALJ, maintaining such a household "certainly requires an ability to handle a lot of frustration."
The defendant has asserted in his brief that "[t]here is no further indication in the record that at any time [after the emergency room visit in] December, 2009, the [p]laintiff found herself unable to cope with the demands of caring for three or four children, or for that matter, with any other source of frustration." (Dkt. #19-1 at 20). The record demonstrates otherwise. On September 13, 2010, the plaintiff reported she "recently had a panic attack due to something her daughter did." (Tr. 333). The record also shows she put her fist through a wall in October, 2010 "in an effort to not hit her mother." (Tr. 343). The plaintiff's "low frustration tolerance for stress" was also noted by Dr. Thomas Hill, the state agency medical consultant whose opinion was afforded "the greatest weight" by the ALJ. (Tr. 45). Thus, Ms. Archie, Dr. Sobel and Dr. Hill all concurred that the plaintiff had a significant problem handling frustration, and the medical records support these opinions.
Moreover, on two separate occasions, in the comments directly below the assessment on the plaintiff's ability to handle frustration, Ms. Archie and Dr. Sobel noted that the plaintiff's intelligence is "an impediment at times in a work environment which might require more flexible thinking/authority figures being correct," and her "strong opinions, feelings of being correct can get in the way of cooperation necessary in work settings, limited tolerance for others idea/direction from authority." (Tr. 290, 302). Thus, even if the plaintiff was able to handle the frustration associated with running a household of small children, it would not likely constitute sufficient evidence for discrediting a treating source's opinion that a patient with mental disorders has a serious problem handling frustration with authority figures.
The medical records, as a whole, support Ms. Archie's and Dr. Sobel's opinions that the plaintiff has a serious problem handling frustration appropriately. These treating source opinions are consistent with the assessment of Dr. Hill, the state agency consultant, and are not inconsistent with other substantial evidence in the record. Thus, to the extent they were co-signed by Dr. Sobel, they are entitled to controlling weight. 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2). While Ms. Archie is not a physician, and thus her opinion is not entitled to controlling weight on its own, the opinions are entitled to, at least, substantial weight using the factors outlined in 20 C.F.R. §§ 404.1527(c)(2)-(6) and 416.927(c)(2)-(6). Accordingly, the ALJ's decision is not supported by substantial evidence in so much as it gives "little weight" to the opinions of Ms. Archie and Dr. Sobel that the plaintiff has a serious problem handling frustration appropriately. The Court finds it reasonable to conclude that the plaintiff's mental residual functional capacity is further restricted by her serious problem handling frustration, and that such a limitation may not have been properly raised to the vocational expert. On remand, the ALJ shall give, at minimum, substantial weight to the opinion that the plaintiff has a serious problem handling frustration appropriately, and assess her RFC accordingly.
The need to remand this case is further amplified by the additional evidence provided to the Appeals Council after the ALJ had issued his decision. This new evidence consisted of a mental RFC opinion from her current treating psychiatrist, Dr. Shahab, a mental RFC opinion from her current treating licensed clinical social worker, Ms. Roberts, and medical records concerning her visit to the Waterbury Hospital emergency room and crisis center. The Appeals Council determined that the evidence did not "include any information warranting a change in the outcome of [the plaintiff's] claim." (Tr. 2). All of these reports are part of the administrative record for judicial review.
Pursuant to the Commissioner's regulations, the Appeals Council must consider any evidence submitted to it which is new and material to the relevant time period.
The reports are also "material." In order to be material, there must be "a reasonable probability that the new evidence would have influenced the [ALJ] to decide [the plaintiff's] claim differently."
The Court agrees with the plaintiff that Dr. Shahab's opinion is significantly dissimilar to that of Ms. Archie and Ms. Roberts. That is, Dr. Shahab assessed the plaintiff as significantly more limited than either Ms. Archie, Ms. Roberts, or the ALJ found. For example, Dr. Shahab assessed the plaintiff as "markedly limited" in sixteen of the twenty specific areas of mental functioning, as compared to the one area identified by Ms. Roberts. (Tr. 468-70, 477-79). However, that is not to say that Dr. Shahab's opinion is wholly unsubstantiated by the record, as the defendant argues. Dr. Shahab's September 13, 2010 progress note indicates the plaintiff reported she is "on the back end of a panic attack always." (Tr. 349). On October 10, 2010, the plaintiff reported to Dr. Shahab that she had "not been doing well at all," and had recently put a fist through a wall "in an effort to not hit her mother." (Tr. 350). Dr. Shahab's report also cites the plaintiff's visit to the emergency room as a result of a panic attack, the records of which were not available to the ALJ or the consulting examiner, Dr. Hill. (Tr. 4, 426-462, 480). These records lend support to Dr. Shahab's conclusions that the plaintiff is incapable of even "low stress" at work, and has a marked limitation in her ability to complete a normal workweek without interruptions from psychologically based symptoms. (Tr. 478, 480). There is also support for his opinion, which he shares with Ms. Roberts, that the plaintiff is likely to be absent from work "more than three times a month" as a result of the impairments or treatment, rendering her incapable of performing any of the representative jobs offered by the vocational expert. (Tr. 26, 481).
In fact, Dr. Shahab's opinion, when combined with those of Dr. Sobel, Ms. Archie and Ms. Roberts, brings the count to four separate professionals who have opined that the plaintiff either has a marked limitation in her ability to complete a normal workweek, or would likely be absent from work more than three times per month. While the ALJ disagreed with Ms. Archie's and Dr. Sobel's opinion regarding the plaintiff's marked limitation in ability to complete a normal workweek, on the grounds that she stopped working due to her pregnancy complications, it is "reasonably probable" that the addition of the new reports to the administrative record would lead to a different conclusion.
The Court finds there is a "reasonable probability" that, had the ALJ and the consulting examiner had the opportunity to review the documents submitted to the Appeals Council, the ALJ's analysis of the opinion evidence, evaluation of the plaintiff's credibility, and determination of the plaintiff's mental RFC would have been adjusted in a manner favorable to the plaintiff. Thus, there is a "reasonable probability" that consideration of the new evidence would have influenced the ALJ to decide the plaintiff's claim differently. In this case, the ALJ relied heavily on the opinions of a non-examining state agency consultant. That consultant, Dr. Hill, did not have the opportunity to consider the opinions of Dr. Shahab or Ms. Roberts, or the records from the visit to the Waterbury Hospital emergency room and crisis center. Accordingly, on remand, the ALJ is directed to provide the consultant with the entire medical record, including the material that was not available when he assessed the plaintiff's impairments. After obtaining the necessary medical opinions, the ALJ shall reconsider the case based on all of the evidence, and in accordance with the regulations.
The plaintiff's motion for judgment on the pleadings or, in the alternative, remand for further administrative proceedings
The parties may timely seek review of this recommended ruling in accordance with Rule 72(b) of the Federal Rules of Civil Procedure. Fed. R. Civ. P. 72(b). Failure to do so may bar further review. 28 U.S.C. § 636(b)(1)(B);