SARAH NETBURN, District Judge.
Plaintiff April K. Drysdale brings this action pursuant to Section 205(g) of the Social Security Act (the "Act"), 42 U.S.C. § 405(g), seeking judicial review of the final determination of the Commissioner of Social Security (the "Commissioner") denying her application for Disability Insurance Benefits ("DIBs") and Supplemental Security Income ("SSI") (collectively, "disability benefits"). The plaintiff moved, and the Commissioner cross-moved, for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure.
The Court finds that the administrative law judge ("ALJ") correctly applied the treating physician rule, and the new evidence submitted to the Appeals Council is either cumulative or not material. Accordingly, the plaintiff's motion for judgment on the pleadings is DENIED, and the Commissioner's cross-motion is GRANTED.
On August 30, 2010, Drysdale applied for disability benefits, alleging a disability onset date of March 1, 2009, due to depression, bipolar disorder, and an injury to both arms. It is her fourth application for benefits since 2002. On December 22, 2010, the Social Security Administration ("SSA") denied the application, and Drysdale requested a hearing. Her request was untimely, but the SSA found that she had "demonstrated good cause for the late filing by explaining that she had been preoccupied with pressing housing issues and court appearances to resolve rent arrears." (AR 161.) On February 9, 2012, Drysdale appeared for a hearing before ALJ Mark Hecht. On June 8, 2012, the ALJ denied Drysdale's application, finding her not disabled under the Act. Drysdale filed an appeal, to which she attached new evidence. On December 3, 2013, the Appeals Council declined to consider the newly submitted evidence and denied her request for review, rendering the ALJ's decision final. On March 5, 2014, Drysdale filed this action, and on August 22, 2014, pro bono counsel entered an appearance on her behalf.
Drysdale and the Commissioner have each provided a summary of the relevant evidence contained in the administrative record.
A party may move for judgment on the pleadings "[a]fter the pleadings are closed — but early enough not to delay trial." Fed. R. Civ. P. 12(c). A Rule 12(c) motion should be granted "if, from the pleadings, the moving party is entitled to judgment as a matter of law."
A determination of the ALJ may be set aside only if it is based upon legal error or is not supported by substantial evidence.
"[I]n order to accommodate `limited and meaningful' review by a district court, the ALJ must clearly state the legal rules he applies and the weight he accords the evidence considered."
A claimant is disabled under the Act if he demonstrates an "inability to engage in any substantial gainful activity by 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 12 months." 42 U.S.C. § 423(d)(1)(A). A determinable physical or mental impairment is defined as one that "results from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques." 42 U.S.C. § 423(d)(3). A claimant will be determined to be disabled only if the impairments are "of such severity that he is not only unable to do his previous work but cannot, considering his 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)(2)(A).
Under the authority of the Act, the SSA has established a five-step sequential evaluation process when making disability determinations.
The regulations provide additional guidance for evaluating mental impairments. 20 C.F.R. § 404.1520a(c)(1). Calling it a "complex and highly individualized process," the section focuses the ALJ's inquiry on determining how the impairment "interferes with [the claimant's] ability to function independently, appropriately, effectively, and on a sustained basis." 20 C.F.R. § 404.1520a(c)(2). For mental disorders, a claimant must show in part that she has at least two of the so-called "paragraph B criteria" or the "paragraph C criteria." The paragraph B criteria require at least two of the following: (1) marked restriction of activities of daily living; (2) marked difficulties in maintaining social functioning; (3) marked difficulties in maintaining concentration, persistence, or pace; and (4) repeated episodes of decompensation. 20 C.F.R. Pt. 404, subpt. P, app'x 1 § 12.04(B). The first three are rated on a "five-point scale": none, mild, moderate, marked, and extreme. 20 C.F.R. § 404.1520a(c)(4). A "marked" limitation is "more than moderate but less than extreme" and "may arise when several activities or functions are impaired, or even when only one is impaired, as long as the degree of limitation is such as to interfere seriously with your ability to function independently, appropriately, effectively and on a sustained basis." 20 C.F.R. Pt. 404, subpt. P, app'x 1 § 12.00(c). The last area — episodes of decompensation — is rated on a "four-point scale": none, one or two, three, and four or more.
The Diagnostic and Statistical Manual of Mental Disorders ("DSM") defines "bipolar disorder, mixed" as:
Am. Psychiatric Ass'n,
On appeal, Drysdale argues that remand is appropriate because (1) the ALJ failed to apply the treating physician rule properly, and (2) the Appeals Council erred when it did not consider newly submitted evidence. The Commissioner argues that the Appeals Council's decision not to consider the new evidence was proper and that the ALJ's decision otherwise is free of legal error and supported by substantial evidence.
The "treating physician rule" instructs the ALJ to give controlling weight to the opinions of a claimant's treating physician, as long as the opinion is well-supported by medical findings and is not inconsistent with the other evidence in the record. 20 C.F.R. § 404.1527(c)(2). Affording a treating physician's opinion controlling weight reflects the reasoned judgment that treating physicians are "most able to provide a detailed, longitudinal picture of [the claimant's] medical impairment(s) and may bring a unique perspective to the medical evidence that cannot be obtained from the objective medical findings alone or from reports of individual examinations, such as consultative examinations or brief hospitalizations." 20 C.F.R. § 404.1527(c)(2).
Licensed clinical social workers are not "acceptable medical sources" due controlling weight under the treating physician rule, but they are still "important" "other sources" to whom the ALJ should look to show the severity of a claimant's impairments or ability to work.
Where mental health treatment is at issue, the treating physician rule takes on added importance. A mental health patient may have good days and bad days; she may respond to different stressors that are not always active. Thus, the longitudinal relationship between a mental health patient and her treating physician provides the physician with a rich and nuanced understanding of the patient's health that cannot be readily achieved by a single consultative examination.
The ALJ can discount a treating physician's opinion, however, if the ALJ believes that it "lack[s] support or [is] internally inconsistent."
When the ALJ discredits the opinion of a treating physician, the regulations direct her to "always give good reasons in [her] notice of determination or decision for the weight [given a] treating source's opinion." 20 C.F.R. § 404.1527(c)(2);
The ALJ gave "significant weight" to the findings of treating psychiatrist Dr. Pierre-Antoine from his October 2011 report that Drysdale was "moderately limited" for most mental tasks. (AR 169.) Neither party disputes that this portion of the ALJ's decision is supported by substantial evidence and does not contain legal error. The ALJ gave "little weight," however, to the conclusion that Drysdale has "markedly limited ability to maintain socially appropriate behavior, respond appropriately to changes in the work setting, or tolerate even low stress work." (
Drysdale contends that the ALJ set the bar too high when deciding whether to afford Dr. Pierre-Antoine's opinion controlling weight. She argues that requiring "objective evidence" guts the treating physician rule because that rule favors opinions supported by appropriate diagnostic techniques, not cold objective facts.
Drysdale's argument is well taken to the extent it highlights the value the SSA assigns to opinion evidence. But that opinion cannot be unmoored from clinical findings, which are, of course, a form of objective evidence. And it cannot be substantially contradicted by the evidence in the record. Dr. Pierre-Antoine's opinion is not supported by clinical findings and is undermined by his own conclusions and the conclusions of other examiners. Accordingly, because the Court must affirm the ALJ so long as the decision is supported by substantial evidence and free of legal error — even if the Court might come to a different disability determination — Drysdale's argument is rejected.
Drysdale saw Dr. Pierre-Antoine and social worker Gilbert Calcano of the Upper Manhattan Mental Health Center ("UMMHC") bi-weekly for 21 months, beginning on March 9, 2010. Midway through her treatment, on October 29, 2011, Dr. Pierre-Antoine completed a Psychiatric/Psychological Impairment Questionnaire. He identified the following "positive clinical findings" in support of his opinion: poor memory; decreased energy; generalized persistent anxiety; feelings of guilt/worthlessness; difficulty thinking or concentrating; and disturbances of appetite, sleep, and mood. (AR 446.) These clinical findings are also consistent with her "primary symptoms" that he identified as dysphoria, sleep disturbance, fluctuating appetite, and poor concentration and memory problems. (AR 445.) He did not list a deficiency in social functioning as a symptom. Moreover, Dr. Pierre-Antoine did not indicate other positive clinical findings that would have supported the marked limitations he later identified and which the ALJ rejected. For example, he did not select from a list of clinical findings that Drysdale exhibits "hostility or irritability," "catatonia or grossly disorganized behavior," "social withdrawal or isolation," or "illogical thinking or loosening of associations." (AR 446.) These findings would have been more consistent with a conclusion that Drysdale was markedly limited in her ability to maintain socially appropriate behavior, respond appropriately to changes in the work setting, or adhere to basic standards of neatness.
In addition, Dr. Pierre-Antoine concluded that Drysdale was "incapable" of even low work stress. (AR 457.) But again, when identifying the positive clinical findings to support his diagnosis, he did not select from the list "emotional lability" or "recurrent panic attacks" — both of which might be present for someone incapable of experiencing any workplace stress. (AR 446.) Finally, while Dr. Pierre-Antoine concluded that Drysdale's impairments — her generalized dissatisfaction with life and sleep, appetite, and mood disturbances — were expected to last 12 months and that she would likely miss work more than three times a month, he also diagnosed her as a malingerer. In light of these clinical findings, which the Court assumes are supported by diagnostic techniques, the ALJ was well within his discretion to reject certain of Dr. Pierre-Antoine's conclusions.
Otherwise, and throughout her treatment with Dr. Pierre-Antoine and Calcano, Drysdale was calm and cooperative with coherent and goal-directed thought processes and appropriate affect. These records are inconsistent with a marked limitation in social functioning. For example, at her January and February 2012 appointments, Calcano described her as well-dressed with fair insight and judgment. Drysdale described feeling anxious and depressed because she had moved in with her mother and her fourth disability benefits application was pending.
She also exhibited limited intellectual capacity and poor impulse control. Dr. Pierre-Antoine diagnosed Drysdale with multiple substance abuse and bipolar disorder, mixed (296.62), and assigned her a global assessment of functioning ("GAF") score that varied during her treatment between 50 and 60. In a form letter dated November 19, 2011, Calcano checked a box indicating that Drysdale "is totally disabled without consideration of any past or present drug and/or alcohol use. Drug and/or alcohol use is not a material cause of this individuals' disability." (AR 450.) He further concluded that her "use of drugs and/or alcohol is a symptom of her condition, and/or is a form of self-medication. The disability is independent of any use." (
The record also contains reports by providers at Conifer Park inpatient treatment program, consultative psychiatrist Dr. Haruyo Fujiwaki, and consultative internist Dr. Aurelio Salon. These records provide substantial support for the ALJ's findings.
Before being admitted to Conifer Park in May 2010, Drysdale reported that she had been using alcohol at a rate of four to five pints daily; using cocaine at the rate of an "eight ball" every three to four days; and was still smoking cigarettes, "3-4 pkg when high, 3-4 days per week." (AR 397-406.) Upon admission, mental status findings indicated that Drysdale was wellgroomed, cooperative, and hyperactive. Her mood was moderately anxious and depressed, and her affect was appropriate. She reported isolation and poor sleep. Upon discharge approximately two weeks later, her mental status findings indicated that her thought process was coherent, goal directed and appropriate. She was diagnosed with general anxiety disorder. Her prognosis was "fair," and Drysdale was deemed "employable." (AR 393-94, 408.) She relapsed at least twice since her discharge. At her hearing before the ALJ on February 9, 2012, Drysdale admitted that she had started to use cocaine again the month before.
On November 9, 2010, Drysdale took the subway to her appointments with Drs. Fujiwaki and Salon. She reported that she was drinking two to three bottles of liquor two to three times per week, and used cocaine one month ago. She self-reported feeling "always depressed," frequently waking during the night, and sometimes hearing voices calling her name. (AR 409.) She described being able to dress, bathe, and groom herself, but that she lacked the energy to "do cooking, cleaning, laundry, and food shopping." (AR 411.) Dr. Fujiwaki found that Drysdale was cooperative, related well to him, and had "adequate" social skills and overall presentation. (AR 410.) Her thought processes were coherent and goal directed, her insight and judgment were "fair to poor," and she had below average intellectual functioning. (
(AR 412.) Dr. Fujiwaki attributed much of the limitations on Drysdale's ability to work to her substance abuse. He diagnosed her with mood disorder not otherwise specified ("NOS"), depressive disorder NOS, anxiety disorder NOS, psychotic disorder NOS, and alcohol and cocaine dependence.
Drysdale was also examined by Dr. Salon, an internist. The mental health screen was a minor part of her overall physical examination (and Drysdale does not challenge the ALJ's conclusions related to physical limitations). Dr. Salon noted that Drysdale was accompanied to the exam facility by a social worker, dressed appropriately, maintained good eye contact, and appeared oriented. He also found her affect to be "normal" and indicated that there was no evidence of hallucinations, delusions, impaired judgment, or "significant memory impairment." (ARE 416.)
The ALJ considered all of this evidence. Overall, all of the providers found that Drysdale consistently related well, was cooperative, and had coherent, goal-directed thoughts. She also consistently demonstrated fair to poor judgment, was limited to average intellectual functioning, and demonstrated poor impulse control. The ALJ acknowledged Drysdale's moderate impairments, but also found that her impairments were not as "marked" as she purports them to be. The evidence in the record supports the ALJ's decision to give "little weight" to the findings of marked limitation.
That the ALJ weighed the evidence and reached a different conclusion than another factfinder might have reached does not establish legal error. He was not required to afford every finding by Dr. Pierre-Antoine controlling weight in light of the less favorable findings in the record.
Finally, despite Drysdale's significant impairments, DIBs and SSI are not simply a diagnosis-based benefits program: under the Act, it is not enough for an applicant to be diagnosed with bipolar disorder or to have some impairments. An applicant must have diagnoses that impair her capacity plus an inability to do past work or adjust to other work.
"Disputes concerning the relevancy of diagnoses made after a denial of SSI benefits are driven by the tension between the need for finality and the search for truth."
Under 42 U.S.C. § 405(g), the Court may remand a case "upon a showing that there is new evidence which is material and that there is good cause for the failure to incorporate the evidence into the record in a prior proceedings."
Evidence is new if it did not exist before the ALJ decision and it is not merely cumulative of evidence already in the record.
The vast majority of cases remanded to consider new evidence involve physical, rather than mental, disabilities.
The results in cases involving new evidence related to mental developments are less consistent. In part, this is due to the difficulty of distinguishing between new evidence which "reflects the severity of the plaintiff's impairment as it existed during the time period for which benefits were denied" and that which "represents new impairments which would not have affected the decision below, and which would be better considered in a new application for benefits."
Drysdale submitted to the Appeals Council additional medical records that pertain to and are dated after June 8, 2012. These records are "new" because they "did not exist at the time of the ALJ's hearing."
The new evidence includes (1) five months of social worker reports from Harlem East Life Plan Chemical Dependency Program ("Harlem East") from February 11, 2013 through July 13, 2013; (2) a one-time psychiatric assessment by Dr. Moussavian, dated July 1, 2013; and (3) a one-time Federation Employment & Guidance Service ("FEGS") biopsychosocial assessment, dated August 20, 2013. The earliest of these is eight months after the ALJ's decision.
The Harlem East reports and Dr. Moussavian's report do not paint a significantly different picture of Drysdale than the evidence already considered by the ALJ. In the Harlem East reports, Drysdale exhibited average intelligence, was described as cooperative, motivated, and self-aware, and demonstrated positive communication skills. She also described feeling depressed, suffering from mood swings, and self-reported that she did "not want to work" and did "not want help to find employment and/or further education/training." (AR 118-32.) She was diagnosed with bipolar disorder, diagnosed a GAF of 60, and characterized as suffering from low self-esteem. In addition to her mental health impairments, the reports also demonstrate significant external stressors weighing on Drysdale: her recent homelessness, the absence of vocational training, her lack of family or peer support, limited recreational/leisure skills, and substance abuse. Despite these stressors, Drysdale reported attending Alcoholics Anonymous and Narcotics Anonymous and expressed interest in obtaining her GED. Dr. Moussavian's report is similar, but noteworthy for Drysdale's update that she stopped attending appointments at UMMHC and stopped taking her medications, causing her to feel more depressed and anxious. Accordingly, regardless of whether the Harlem East and Dr. Moussavian reports relate back to the time period before the ALJ's decision, they are cumulative of the medical evidence in the record and would "not add so much as to make the ALJ's decision contrary to the weight of the evidence."
The one-time consultative FEGS evaluation, conducted a month after Dr. Moussavian's report, represents stronger evidence of the severity of Drysdale's impairments — although it is unclear whether Drysdale had resumed taking her prescribed medications and/or had reacclimated to them by that point. Dr. Hun Han opined that Drysdale would need a low stress environment, and that she has restrictions of activities of daily living that prevent adherence to a regular work routine. Dr. Beatrice Spinelli recommended that Drysdale's exertion level of her workload or pacing be modified, that she be allowed a flexible/modified schedule that allows taking leave as needed, that she be allowed to use stress reducing devices/equipment, and that she receive additional time to be trained. Both doctors ultimately concluded that Drysdale has substantial functional limitations to employment and a regular work routine due to medical conditions that will last for at least 12 months and make her unable to work.
The FEGS evaluation, however, is a one-time consultative examination based on Drysdale's self-reporting, rather than a doctor's longitudinal relationship with, and observations of, Drysdale. It is possible that, as a malingerer, her self-reporting does not accurately reflect her impairments. It is also possible that her condition worsened after the ALJ's decision because she was not compliant with her medications and continued to abuse cocaine and alcohol. The Court finds that this report does not necessarily disclose the severity and continuity of impairments existing before the ALJ's decision, make the ALJ's decision contrary to the weight of the evidence, or contain a reasonable likelihood of influencing the ALJ's decision.
For these reasons, the plaintiff's motion is DENIED, and the Commissioner's cross-motion is GRANTED. The Clerk of Court is directed to terminate the motions at Docket Entry No. 44 and 46 and close this case.