SAM A. CROW, Senior District Judge.
This is an action reviewing the final decision of the Commissioner of Social Security denying the plaintiff disability insurance benefits and supplemental security income payments. The matter has been fully briefed by the parties.
The court's standard of review is set forth in 42 U.S.C. § 405(g), which provides that "the findings of the Commissioner as to any fact, if supported by substantial evidence, shall be conclusive." The court should review the Commissioner's decision to determine only whether the decision was supported by substantial evidence and whether the Commissioner applied the correct legal standards.
The Social Security Act provides that an individual shall be determined to be under a disability only if the claimant can establish that they have a physical or mental impairment expected to result in death or last for a continuous period of twelve months which prevents the claimant from engaging in substantial gainful activity (SGA). The claimant's physical or mental impairment or impairments must be of such severity that they are not only unable to perform their previous work but cannot, considering their age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy. 42 U.S.C. § 423(d).
The Commissioner has established a five-step sequential evaluation process to determine disability. If at any step a finding of disability or non-disability can be made, the Commissioner will not review the claim further. At step one, the agency will find non-disability unless the claimant can show that he or she is not working at a "substantial gainful activity." At step two, the agency will find non-disability unless the claimant shows that he or she has a "severe impairment," which is defined as any "impairment or combination of impairments which significantly limits [the claimant's] physical or mental ability to do basic work activities." At step three, the agency determines whether the impairment which enabled the claimant to survive step two is on the list of impairments presumed severe enough to render one disabled. If the claimant's impairment does not meet or equal a listed impairment, the inquiry proceeds to step four, at which the agency assesses whether the claimant can do his or her previous work; unless the claimant shows that he or she cannot perform their previous work, they are determined not to be disabled. If the claimant survives step four, the fifth and final step requires the agency to consider vocational factors (the claimant's age, education, and past work experience) and to determine whether the claimant is capable of performing other jobs existing in significant numbers in the national economy.
The claimant bears the burden of proof through step four of the analysis.
On December 24, 2013, administrative law judge (ALJ) Susan W. Conyers issued her decision (R. at 92-104). Plaintiff alleges that she had been disabled since February 28, 2004 (R. at 92). Plaintiff meets the insured status requirements for social security disability benefits through June 30, 2009 (R. at 94). At step one, the ALJ found that plaintiff did not engage in substantial gainful activity since the alleged onset date (R. at 94). At step two, the ALJ found that plaintiff had a severe combination of impairments (R. at 94-95). At step three, the ALJ determined that plaintiff's impairments do not meet or equal a listed impairment (R. at 96). After determining plaintiff's RFC (R. at 97-98), the ALJ found at step four that plaintiff has no past relevant work (R. at 103). At step five, the ALJ found that plaintiff could perform other jobs that exist in significant numbers in the national economy (R. at 103-104). Therefore, the ALJ concluded that plaintiff was not disabled (R. at 104).
On May 24, 2011, Dr. Schwartz performed a psychological evaluation on the plaintiff; plaintiff was interviewed for the evaluation (R. at 822-824). Dr. Schwartz opined that plaintiff's description of her symptomatology appears to be most consistent with a bipolar I disorder with frequent manias and then crashing. Dr. Schwartz further stated that he did not find any evidence of ADHD (attention deficit hyperactivity disorder) (R. at 823-824). In his diagnostic impressions, Dr. Schwartz diagnosed bipolar I disorder (R. at 824). Dr. Schwartz then stated the following regarding her potential of competitive employment:
(R. at 824).
The ALJ discussed the evaluation by Dr. Schwartz, but stated that the longitudinal records from Comcare and Cowley County "do not show bipolar symptoms, but focus more on the claimant's ADHD" (R. at 102). The ALJ further stated that there is no support for the interactive limits of the type Dr. Schwartz is discussing based on the longitudinal record, which shows moderate symptoms and that the plaintiff could function as a primary caregiver for two elderly people. For these reasons, Dr. Schwartz's opinion is given little weight (R. at 102).
According to the ALJ, the treatment records do not show bipolar symptoms, as diagnosed by Dr. Schwartz. However, treatment records from the Behavioral Health and Addiction Services diagnose bipolar I disorder on 11 occasions from January 30, 2009 through March 4, 2010 (R. 585-605). The initial psychiatric evaluation from Cowley County Mental Health and Counseling Center, dated September 14, 2010, diagnosed "rule out bipolar disorder" (R. at 645). On September 18, 2012, COMCARE notes state that they would continue to assess whether client's difficulties with concentration and focus are a result of her bipolar disorder or ADHD (R. at 932). On July 3, 2013 the COMCARE records diagnose bipolar disorder (R. at 941). On July 11, 2013, another treatment provider also diagnosed bipolar disorder (R. at 944).
The ALJ discounted the opinions of Dr. Schwartz, in part, because of the ALJ's assertion that the treatment records do not show bipolar symptoms. However, the treatment records from 2009-2013 repeatedly indicate a diagnosis of bipolar disorder. The statement by the ALJ that the treatment records do not show bipolar symptoms is clearly erroneous. Furthermore, the court cannot say that this error is harmless, given the fact that the limitations put forward by Dr. Schwartz are solely based on his diagnosis of bipolar disorder, which in his opinion, would make it difficult for the plaintiff to interact appropriately and be reliable on the job.
The court will next examine a psychological assessment done by Dr. Maxfield, a non-examining medical source, on June 28, 2011 (R. at 181-182, 185-186). Dr. Maxfield had an opportunity to examine the report from Dr. Schwartz (R. at 182, 183). Dr. Maxfield found that plaintiff was moderately limited in her ability to understand, remember and carry out detailed instructions, in her ability to maintain attention and concentration for extended periods, in her ability to work in coordination with or in proximity to others without being distracted by them, in her ability to interact appropriately with the general public, and in her ability to get along with coworkers or peers without distracting them or exhibiting behavioral extremes (R. at 185-186). Dr. Maxfield then set forth the following opinions regarding plaintiff's mental RFC:
(R. at 185-186). Dr. Cummings affirmed these findings on April 17, 2012 (R. at 890). In his report, he noted limitations due to ADHD and bipolar disorder (R. at 890). The ALJ found that this report was "substantially persuasive and informs the mental limitations in the above residual functional capacity" (R. at 103). In the ALJ's mental RFC findings, he concluded that plaintiff can perform "simple
An exact correspondence between a medical opinion and the RFC is not required.
In the case of
The ALJ erred by failing to explain why her RFC findings allowed plaintiff to perform intermediate tasks when she had given great weight to a medical source opinion limiting plaintiff to simple tasks.
As noted above, Dr. Schwartz had opined that the diagnosis of bipolar disorder would make it difficult for her to interact appropriately and be reliable on the job.
Plaintiff also argues that the opinion of Dr. Maxfield that plaintiff would do best with limited interactions with the general public and with coworkers (R. at 186) is not consistent with the ALJ's RFC finding that she should have no more than occasional interaction with the general public, coworkers and supervisors (R. at 98). Occasional is defined as an activity or condition which exists up to 1/3 of the time.
On April 23, 2013, Dr. Friesen wrote a letter indicating that plaintiff was physically and emotionally unable to continue in school (R. at 1094). On August 28, 2013, Dr. Friesen signed a letter discussing plaintiff's physical impairments and limitations, including a limitation of sitting or standing for less than 4 hours a day (R. at 1209-1212). The ALJ discussed these opinions by Dr. Friesen, and for a number of reasons accorded them little weight (R. at 100-101).
The court will not reweigh the evidence or substitute its judgment for that of the Commissioner.
Plaintiff makes numerous arguments regarding the weight the ALJ accorded to the opinions of Dr. Friesen. However, many of these arguments involve the reweighing of evidence or weighing evidence which is capable of more than one reasonable interpretation. The court will not reweigh the evidence. However, the court would note that the ALJ discounted some of the opinions of Dr. Friesen regarding plaintiff's mental impairments and limitations, stating that he is not a mental health expert (R. at 100). However, on remand, the opinions of Dr. Friesen regarding plaintiff's mental impairments and limitations must be considered after giving proper consideration to the opinions of Dr. Maxfield, Dr. Cummings and Dr. Schwartz. In discussing the treatment records from Dr. Friesen and in discounting the opinions of Dr. Friesen, the ALJ made two statements: (1) plaintiff indicated that "her whole back hurt," which, according to the ALJ, is not supported by medical imagery (citing to R. at 1063-1065), and (2) plaintiff had a "normal range of motion" (citing to 1066-1067) (R. at 100).
Defendant explains that these are merely "minor" discrepancies (Doc. 24 at 11). However, this court is very concerned when the ALJ misstates the record, and defendant's brief acknowledges that those statements do not appear in the record. The record should be accurately reported. There is no legitimate excuse for stating that plaintiff had a normal or full range of motion or that "her whole back hurt" (which the ALJ put in quotes, R. at 100) when the record did not contain either statement, and the record is more ambiguous than the statements asserted by the ALJ. On remand, the ALJ should reevaluate the opinions of Dr. Friesen after taking into consideration the medical opinion evidence regarding plaintiff's mental impairments and limitations, and make new findings regarding the weight to be accorded to his opinions which are clearly supported by the record.
Finally, the court would note that, according to the ALJ, the letter of Dr. Friesen dated April 23, 2013 was based on plaintiff's self-report, and is not a functional assessment of the plaintiff (R. at 100). In the case of
Subsequently, in the case of
121 Fed. Appx. at 823-824.
As
Plaintiff argued that the ALJ did not find plaintiff's ADHD as a severe impairment (Doc. 18 at 4). In fact, the ALJ did find that plaintiff's ADHD was a severe impairment at step two (R. at 94-95). On remand, the ALJ shall make new mental RFC findings after conducting a proper evaluation of all the evidence, including the opinions of Dr. Maxfield, Dr. Cummings (who noted limitations due to ADHD and bipolar disorder, R. at 890)), and Dr. Schwartz.
At step two, the ALJ found that plaintiff's headaches were a non-severe impairment, and found that plaintiff's bladder incontinence was a severe impairment (R. at 95). Plaintiff argues that the ALJ erred in her evaluation of these impairments. On remand, the ALJ should address the issues raised by plaintiff, including records of emergency room treatment and rebound headaches. However, the court would note that plaintiff has failed to point to any evidence that these impairments resulted in limitations not included in the ALJ's RFC findings.
In the case of
Finally, the court would note plaintiff's argument regarding plaintiff's drug history, which was cited by the ALJ in evaluating plaintiff's credibility. This involves the potential application of legislation and regulations governing the impact of drug and/or alcohol use. In 1996, Congress passed Public Law 104-121. It added the following language to 42 U.S.C. § 423(d)(2):
20 C.F.R. § 404.1535 (disability insurance) and § 416.935 (SSI) are identical, and are the implementing regulations governing this issue. The implementing regulations make clear that a finding of disability is a condition precedent to an application of §423(d)(2)(C). The Commissioner must first make a determination that the claimant is disabled. He must then make a determination whether the claimant would still be found disabled if he or she stopped abusing alcohol or drugs. If so, then the alcohol or drug use is not a contributing factor material to the finding of disability. If however, the claimant's remaining impairments would not be disabling without the alcohol or drug abuse, then the alcohol or drug abuse is a contributing factor material to the finding of disability. The ALJ cannot begin to apply §423(d)(2)(C) properly when he has not yet made a finding of disability.
After reviewing the arguments of the parties, and the ALJ decision, the court finds no clear error in the ALJ's consideration of plaintiff's drug use. There is no reason why an ALJ cannot consider drug use as part of the credibility analysis and when evaluating other medical evidence. The consideration of plaintiff's drug use, on the facts of this case, did not require the application of the legislation and regulations noted above.
IT IS THEREFORE ORDERED that the judgment of the Commissioner is reversed and remanded pursuant to sentence four of 42 U.S.C. § 405(g) for further proceedings consistent with this memorandum and order.