ROBERT B. JONES, JR., Magistrate Judge.
This matter is before the court on the parties' cross-motions for judgment on the pleadings [DE-22, -26] pursuant to Fed. R. Civ. P. 12(c). Claimant Juanita Williams ("Claimant") filed this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) seeking judicial review of the denial of her applications for a period of disability, Disability Insurance Benefits ("DIB"), and Supplemental Security Income ("SSI") payments. The time for filing responsive briefing has expired, and the pending motions are ripe for adjudication. Having carefully reviewed the administrative record and the motions and memoranda submitted by the parties, it is recommended that Claimant's Motion for Judgment on the Pleadings be allowed, Defendant's Motion for Judgment on the Pleadings be denied, and the case be remanded for further proceedings.
Claimant filed applications for a period of disability, DIB, and SSI on October 24, 2014, alleging disability beginning February 15, 2014. (R. 238-45). The claims were denied initially and upon reconsideration. (R. 76-151). A hearing before an Administrative Law Judge ("ALJ") was held on October 4, 2016, at which Claimant, represented by counsel, and a vocational expert ("VE") appeared and testified. (R. 18-75). On January 19, 2017, the ALJ issued a decision denying Claimant's request for benefits. (R. 951-70). On March 31, 2017, the Appeals Council denied Claimant's request for review. (R. 1-6). Claimant then filed a complaint in this court seeking review of the now-final administrative decision.
The scope of judicial review of a final agency decision regarding disability benefits under the Social Security Act ("Act"), 42 U.S.C. § 301 et seq., is limited to determining whether substantial evidence supports the Commissioner's factual findings and whether the decision was reached through the application of the correct legal standards. See Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987). "The findings of the Commissioner . . . as to any fact, if supported by substantial evidence, shall be conclusive. . . ." 42 U.S.C. § 405(g). Substantial evidence is "evidence which a reasoning mind would accept as sufficient to support a particular conclusion." Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966). While substantial evidence is not a "large or considerable amount of evidence," fierce v. Underwood, 487 U.S. 552, 565 (1988), it is "more than a mere scintilla . . . and somewhat less than a preponderance." Laws, 368 F.2d at 642. "In reviewing for substantial evidence, [the court should not] undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner]." Mastro v. Apfel, 270 F.3d 171, 176 (4th Cir. 2001) (quoting Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996), superseded by regulation on other grounds, 20 C.F.R. § 416.927(d)(2)). Rather, in conducting the "substantial evidence" inquiry, the court's review is limited to whether the ALJ analyzed the relevant evidence and sufficiently explained his or her findings and rationale in crediting the evidence. Sterling Smokeless Coal Co. v. Akers, 131 F.3d 438, 439-40 (4th Cir. 1997).
The disability determination is based on a five-step sequential evaluation process as set forth in 20 C.F.R. §§ 404.1520 and 416.920 under which the ALJ is to evaluate a claim:
Albright v. Comm'r of the SSA, 174 F.3d 473, 475 n.2 (4th Cir. 1999). "If an applicant's claim fails at any step of the process, the ALJ need not advance to the subsequent steps." Pass v. Chafer, 65 F.3d 1200, 1203 (4th Cir. 1995) (citation omitted). The burden of proof and production during the first four steps of the inquiry rests on the claimant. Id. At the fifth step, the burden shifts to the ALJ to show that other work exists in the national economy which the claimant can perform. Id
When assessing the severity of mental impairments, the ALJ must do so in accordance with the "special technique" described in 20 C.F.R. §§ 404.1520a(b)-(c) and 416.920a(b)-(c). This regulatory scheme identifies four broad functional areas in which the ALJ rates the degree of functional limitation resulting from a claimant's mental impairment(s): activities of daily living; social functioning; concentration, persistence or pace; and episodes of decompensation. Id. §§ 404.1520a(c)(3), 416.920a(c)(3). The ALJ is required to incorporate into his written decision pertinent findings and conclusions based on the "special technique." Id §§ 404.1520a(e)(3), 416.920a(e)(3).
In this case, Claimant alleges the following errors by the ALJ: (1) improper assessment of medical opinion evidence; (2) failure to provide adequate reasons for his findings in the psychiatric review technique; and (3) failure to perform a proper drug addiction and alcoholism ("DAA") analysis pursuant to S.S.R. 13-2p. Pl.'s Mem. [DE-23] at 1.
Applying the above-described sequential evaluation process, the ALJ found Claimant "not disabled" as defined in the Act. At step one, the ALJ found Claimant had not engaged in substantial gainful employment since the alleged onset date. (R. 953). Next, the ALJ determined Claimant had the following severe impairments: anxiety disorder; bipolar disorder; mood disorder; polysubstance abuse; degenerative disc disease of the cervical spine; and seizure/pseudo disorder. (R. 954). The ALJ also found Claimant had the following non-severe impairments: constipation; cyst on the right breast (benign); headaches; and angina. Id At step three, the ALJ concluded Claimant's impairments were not severe enough, either individually or in combination, to meet or medically equal one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. 954-55). Applying the technique prescribed by the regulations, the ALJ found that Claimant's mental impairments had resulted in mild restriction in her activities of daily living, and moderate difficulties in social functioning and with regard to concentration, persistence, or pace, with no episodes of decompensation. Id
Prior to proceeding to step four, the ALJ assessed Claimant's RFC, finding that Claimant had the ability to perform medium work
(R. 955-62). At step four, the ALJ concluded Claimant did have the RFC to perform the requirements of her past relevant work as a certified nurse assistant, companion, and sitter. (R. 962). Additionally, at step five, upon considering Claimant's age, education, work experience, and RFC, the ALJ determined' there are jobs that exist in significant numbers in the national economy that Claimant can perform. (R. 962-63).
Claimant contends the ALJ's RFC determination that she can "frequently interact with [her] supervisor, co-workers, and the public" was error in light of the amount of evidence to the contrary. Pl.'s Mem. [DE-23] at 10. The Commissioner argues the RFC assessment is supported by substantial evidence. Def's Mem. [DE-27] at 9.
An individual's RFC is the capacity an individual possesses despite the limitations caused by physical or mental impairments. 20 C.F.R. §§ 404.1545(a)(1), 416.945(a)(1); see also S.S.R. 96-8p, 1996 WL 374184, at *1 (July 2, 1996). "[T]he residual functional capacity `assessment must first identify the individual's functional limitations or restrictions and assess his or her work-related abilities on a function-by-function basis, including the functions' listed in the regulations." Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (quoting S.S.R. 96-8p). The RFC is based on all relevant medical and other evidence in the record and may include a claimant's own description of limitations arising from alleged symptoms. 20 C.F.R. §§ 404.1545(a)(3), 416.945(a)(3); see also S.S.R. 96-8p, 1996 WL 374184, at *5. Where a claimant has numerous impairments, including non-severe impairments, the ALJ must consider their cumulative effect in making a disability determination. 42 U.S.C. § 423(d)(2)(B); see Hines v. Brown, 872 F.2d 56, 59 (4th Cir. 1989) ("[I]n determining whether an individual's impairments are of sufficient severity to prohibit basic work related activities, an ALJ must consider the combined effect of a claimant's impairments.") (citations omitted). The ALJ has sufficiently considered the combined effects of a claimant's impairments when each is separately discussed by the ALJ and the ALJ also discusses a claimant's complaints and activities. Baldwin v. Barnhart, 444 F.Supp.2d 457, 465 (E.D.N.C. 2005) (citations omitted). The RFC assessment "must include a discussion of why reported symptom-related functional limitations and restrictions can or cannot reasonably be accepted as consistent with the medical and other evidence," as well as a "narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations)." Id; see also Clifford v. Apfel, 227 F.3d 863, 872 (7th Cir. 2000) (observing that the ALJ "must build an accurate and logical bridge from the evidence to his conclusion").
The ALJ discussed Claimant's social issues throughout the decision. He found her anxiety disorder, bipolar disorder, and mood disorder to be severe impairments. (R. 954). At step two, the ALJ stated the following:
Id. The ALJ then discussed Claimant's testimony, stating the following:
(R. 956). The ALJ determined that Claimant's statements concerning the intensity, persistence, and limiting effects of her symptoms are "not entirely consistent with the medical evidence and other evidence in the record for the reasons stated in the decision." (R. 956-57).
The ALJ then discussed the following medical evidence of record regarding Claimant's mental impairments. On October 23, 2014, Claimant presented to Cumberland County Hospital with complaints of a "weird feeling," and stated that "she was also slashed with a knife about a week prior." (R. 957). On October 30, 2014, Claimant presented to Greater Image Community Care Clinic, where Claimant reported that she had been in an altercation with her girlfriend the week prior, which resulted in her having to go to the emergency room. Id. At this visit, Claimant reported that "she gets angry at least once a day and often when she is angry she will become physically aggressive," "she could not keep a job or relationship due to her anger," and she believed this anger stemmed from being sexually abused as a child. Id. Lastly, she reported at this visit that "she has had anger problems since her childhood and now believes she has a serious problem." Id On January 2, 2015, Claimant returned to Greater Image where she reported that she was not happy with the medications that she had been prescribed for her anger issues because they were not working. Id She reported that she had been attending sessions with a psychiatrist for two months but that the psychiatrist has not been helping her with her bipolar disorder. Id. At this visit, Claimant's grandmother reported that Claimant's anger has worsened as she has aged, and that Claimant "assaulted her girlfriend three weeks ago and has three assault charges pending." Id Her grandmother stated that Claimant "fights very often and gets arrested several times." Id On January 20, 2015, Claimant presented to Dr. David C. Johnson for a psychological evaluation, where it was reported she was "generally polite and cooperative[,] however she cursed frequently and sometimes stuttered." (R. 958). Claimant stated that "she had been unable to work mainly because of seizures," and that she "was a good worker, but she cursed people out all the time." Id Dr. Johnson diagnosed Claimant with bipolar I disorder, severe, possibly with psychotic features; unspecified personality disorder, severe; unspecified anxiety disorder with PTSD and generalized symptoms; and multiple physical problems. Id In a medical source statement completed on May 25, 2016, Dr. Jonathan Glover opined that Claimant "had marked restrictions of activities of daily living; extreme difficulties in maintaining social functioning; deficiencies of concentration, persistence, and pace resulting in frequent failure to complete tasks in a timely manner; and repeated episodes of deterioration or compensation at work or work like setting." Id Claimant was admitted to Behavioral Healthcare from March 11-13, 2015 with a diagnosis of mood disorder (not otherwise specified); borderline personality disorder; and cocaine abuse, and she went to the emergency room stating that "she had suicidal and homicidal ideations toward her family, and she was getting angry." (R. 959). She stated that she "had choked her friend the other day," and tested positive for cocaine. Id
The ALJ then assessed the opinion evidence related to Claimant's mental impairments. State agency consultants provided opinions on April 12, 2015, and on August 21, 2015, both of which assess Claimant with having mild restrictions in activities of daily living, and moderate difficulties in maintaining social functioning and concentration, persistence, and pace, with no repeated episodes of decompensation. (R. 959) (citing Exs. IA, 2A, 5A, and 6A). The ALJ assigned "partial weight" to the opinions, stating the following:
(R. 959-60). The ALJ assigned "partial weight" to the consultative examiner opinion of David Johnson, stating the following:
(R. 960). The ALJ assigned "little weight" to the opinion of Dr. Jonathan Glover
Lastly, the ALJ stated that the RFC assessment is supported by the medical evidence. (R. 961). With respect to Claimant's mental impairments, the ALJ explained the following:
Id With respect to Claimant's anger issues, the ALJ stated the following:
Id The ALJ concluded the decision by stating the evidence supports the finding that Claimant "could frequently respond appropriately to supervisor, co-workers, and the public." (R. 962).
It is evident that the ALJ failed to build "an accurate and logical bridge" between the evidence and his conclusion in the RFC that Claimant can frequently interact with supervisors, co-workers, and the public. See Monroe v. Colvin, 826 F.3d 176, 189 (4th Cir. 2016) (citing Clifford, 227 F.3d at 872). The ALJ does not indicate how any of the evidence-testimony, medical records, or opinion evidence-supports the conclusion that Claimant can have frequent social interaction. To the contrary, the evidence cited by the ALJ, without more, seems to support the opposite conclusion. The ALJ cites evidence that Claimant has been in multiple physical altercations (some of which required medical treatment), gets angry at least once a day, cannot keep a job or a relationship due to her anger, has multiple assault charges pending, attacked her grandmother (resulting in her being kicked out of the house), had suicidal and homicidal ideations (resulting in her being hospitalized), and has been diagnosed with bipolar disorder, personality disorder, and anxiety disorder. (R. 957-58). The ALJ failed to cite any records that refute the evidence that Claimant has severe anger issues that affect her social skills. In discounting the opinion evidence regarding Claimant's social deficiencies, the ALJ stated "there is no indication that the claimant has problems interacting with members of the general public based on post alleged onset date work history"; "[t]here is nothing to show that she does not have social skills"; and Dr. Glover's opinion of severe and extreme limitations is "not supported by the bulk of the objective evidence of record as a whole" and is "inconsistent with the claimant's level of functioning as a certified nurse assistant and her post-alleged onset date work." (R. 960). Yet, the ALJ fails to specify what medical evidence refutes the opinion evidence, and instead cites an abundance of evidence that seems to support greater social limitations.
With respect to the ALJ's proposition that post-alleged onset date work is evidence that Claimant does not suffer greater limitations, Claimant testified that "she got fired from all her jobs because she has a split personality, experiences outbursts, and has anger issues." (R. 956). The ALJ found Claimant's testimony to be "not entirely consistent with the medical evidence," but failed to state anywhere in the decision what medical evidence refutes her testimony. (R. 957). See Mascio, 780 F.3d at 640 (finding the ALJ's lack of explanation required remand where the ALJ failed to explain how he decided which statements to believe and which to discredit). Further, in discounting the opinion evidence specifically with respect to Claimant's social skills, the ALJ differentiated between interaction with the public and interaction with supervisors and co-workers. (R. 960) ("[T]here is no indication that the claimant has problems interacting with members of the general public based on post[-]alleged onset date work history; great limitations were placed on her ability to interact with authority figures and co-workers based on indication in the medical evidence of record of the claimant's difficulties with authority figures on occasion and getting fired from several jobs."). However, the RFC makes no such distinction, instead finding Claimant can "frequently interact with supervisors, co-workers, and the public." (R. 955) (emphasis added).
After citing the above-referenced evidence, the ALJ concluded his decision by stating that Claimant "clearly" suffers from anger issues, but that the record shows this "could be related to her use of drugs." (R. 961) (emphasis added). The ALJ does not support this statement with any specific evidence, but rather restates Claimant's testimony and Claimant's grandmother's opinion regarding Claimant's anger issues, and subsequently states that the entire record and the claimant's testimony support the RFC. Id This is insufficient. Accordingly, the court finds the ALJ erred by not sufficiently building "an accurate and logical bridge" from the evidence to the RFC finding that Claimant can frequently interact with supervisors, co-workers, and the public. See Reinhard v. Colvin, No. 5:12-CV-284-BO, 2013 WL 3990687 (E.D.N.C. Aug. 2, 2013) (holding the ALJ erred and remand was appropriate where the ALJ failed to build a logical bridge between the claimant's alleged symptoms and limitations and the ALJ's RFC determination); Walker v. Berryhill, No. 7:16-CV-70-D, 2017 WL 2819901 (E.D.N.C. June 2, 2017) (holding the ALJ erred and remand was appropriate where the ALJ failed to build a logical bridge from the evidence to the conclusions reached regarding opinion evidence); Brandt v. Colvin, No. 2:16-CV-4-FL, 2017 WL 499945 (E.D.N.C. Jan. 19, 2017) (holding the ALJ erred and remand was appropriate where the ALJ failed to build a logical bridge to the conclusions reached regarding a claimant's credibility).
The Commissioner contends that any error regarding the RFC is harmless and therefore does not require remand because the ALJ alternatively found at step five that Claimant, even with the more restrictive hypothetical limiting Claimant to only occasional interaction with supervisors, co-workers, and the public, could still perform the jobs of janitor, packager, and dishwasher. Def.'s Mem. [DE-27] at 11. The court disagrees. Given the evidence recounted by the ALJ, the court cannot say that on proper consideration the ALJ may not find a restriction greater than occasional contact to be appropriate, and it is not for the court to decide. By the ALJ failing to build "an accurate and logical bridge from the evidence to [the] conclusion[s]," the court is precluded from conducting a meaningful substantial-evidence review of the ALJ's decision, a ground independently requiring remand. Monroe, 826 F.3d at 189-91 (holding that the ALJ's explanation that he gave "limited weight" to medical opinions because "the objective evidence or the claimant's treatment history did not support" them and similarly cursory explanations of other opinions precluded meaningful substantial-evidence review (internal quotation marks omitted)) (citing Radford v. Colvin, 734 F.3d 288, 295 (4th Cir. 2013)); Fox v. Colvin, 632 F. App'x 750, 756 (4th Cir. 2015) (holding that explanation by ALJ that he gave "less weight" to medical opinions because they were "not well-supported by the medical record" was so "cursory and conclusory" as to preclude meaningful review and remanding case (internal quotation marks omitted)). Accordingly, it is recommended that the case be remanded.
The issues raised in Claimant's remaining assertions of error-improper consideration of the medical opinion evidence and improper analysis regarding Claimant's drug addiction and alcoholism-may be impacted by the ALJ's further consideration of the RFC. Accordingly, it is recommended that these issues receive additional consideration on remand, as necessary. See Jones v. Astrue, No. 5:11-CV-206-FL, 2012 WL 3580482, at *8 (E.D.N.C. Apr. 19, 2012), ("Because this court finds that remand on the issue of the treating physician's opinion will affect the remaining issues raised by Claimant, it does not address those arguments."), adopted by 2012 WL 3580054 (E.D.N.C. Aug. 17, 2012).
For the reasons stated above, it is RECOMMENDED that Claimant's Motion for Judgment on the Pleadings [DE-22] be ALLOWED, Defendant's Motion for Judgment on the Pleadings [DE-26] be DENIED, and the case be REMANDED for further proceedings.
IT IS DIRECTED that a copy of this Memorandum and Recommendation be served on each of the parties or, if represented, their counsel. Each party shall have until
If a party does not file written objections to the Memorandum and Recommendation by the foregoing deadline, the party will be giving up the right to review of the Memorandum and Recommendation by the presiding district judge as described above, and the presiding district judge may enter an order or judgment based on the Memorandum and Recommendation without such review. In addition, the party's failure to file written objections by the foregoing deadline will bar the party from appealing to the Court of Appeals from an order or judgment of the presiding district judge based on the Memorandum and Recommendation. See Wright v. Collins, 766 F.2d 841, 846-47 (4th Cir. 1985).
