SHIVA V. HODGES, Magistrate Judge.
This appeal from a denial of social security benefits is before the court for a Report and Recommendation ("Report") pursuant to Local Civ. Rule 73.02(B)(2)(a) (D.S.C.). Plaintiff brought this action pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3) to obtain judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying her claim for Disability Insurance Benefits ("DIB"). The two issues before the court are whether the Commissioner's findings of fact are supported by substantial evidence and whether she applied the proper legal standards. For the reasons that follow, the undersigned recommends that the Commissioner's decision be reversed and remanded for further proceedings as set forth herein.
On November 9, 2012, Plaintiff protectively filed an application for DIB in which she alleged her disability began that day. Tr. at 117 and 223-30. Her application was denied initially and upon reconsideration. Tr. at 148-50 and 159-60. On April 12, 2016, Plaintiff had a hearing before Administrative Law Judge ("ALJ") Clarence Guthrie. Tr. at 46-87 (Hr'g Tr.). The ALJ issued an unfavorable decision on May 4, 2016, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 22-45. Subsequently, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner for purposes of judicial review. Tr. at 1-6. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on July 13, 2017. [ECF No. 1].
Plaintiff was 39 years old at the time of the hearing. Tr. at 50. She graduated from high school and obtained an associate's degree in culinary arts. Tr. at 55-56. Her past relevant work ("PRW") was as a bus driver, a fast food worker, and a sales clerk. Tr. at 80. She alleges she has been unable to work since November 9, 2012. Tr. at 51.
Plaintiff presented to Blanca I. Durand, M.D. ("Dr. Durand"), on November 5, 2012, for a nine-day history of intermittent vertigo. Tr. at 357. Dr. Durand noted nasal mucosa edema and inferior turbinate hypertrophy, but no other abnormalities. Tr. at 358. She assessed dizziness, benign paroxysmal positional vertigo, Eustachian tube dysfunction, and hypertrophy of nasal turbinates. Tr. at 358-59. She recommended Plaintiff avoid caffeine, follow a low-salt diet, and follow up for Epley maneuver. Tr. at 359. Plaintiff followed up with Michelle L. Dupont, PA-C ("Ms. Dupont"), for Epley maneuver treatment on November 7, 2012. Tr. at 356.
On November 19, 2012, Plaintiff complained of pain in her back and bilateral knees and shoulders. Tr. at 365. She reported fatigue, weakness, dry eyes and mouth, and skin sensitivity. Id. She indicated she had been very emotional. Id. Rheumatologist Pallavi Sharma, M.D. ("Dr. Sharma"), observed Plaintiff to have right shoulder abduction to 70 degrees and left shoulder abduction to 80 degrees. Tr. at 367. She noted tenderness in Plaintiff's right elbow, but full range of motion ("ROM") in the bilateral elbows and wrists. Id. She observed active tenderness in Plaintiff's bilateral proximal interphalangeal ("PIP") and right metacarpophalangeal ("MCP") joints. Id. She indicated tenderness and crepitus in Plaintiff's bilateral knees and tenderness with full ROM in her bilateral ankles. Id. She noted increased spasm in the lumbosacral spine. Id. Dr. Sharma indicated a complete metabolic profile was normal. Id. She stated Plaintiff had a negative rheumatoid factor, but positive antinuclear antibodies ("ANA") and Sjogren's syndrome antibodies ("SSA") greater than eight. Tr. at 367. She assessed Sjogren's syndrome, bilateral knee pain, back pain, fatigue, polyarthritis, and insomnia. Id. She administered Depo-Medrol injections to Plaintiff's bilateral shoulders, referred her for x-rays of her right shoulder and left knee, and instructed her to exercise and to apply warm, moist heat to her back. Id. Xrays of Plaintiff's bilateral shoulders showed mild degenerative change to the acromioclavicular joints. Tr. at 368 and 371. X-rays of Plaintiff's bilateral knees indicated osteoarthritis. Tr. at 369 and 370.
On January 18, 2013, Plaintiff complained of dry eyes and mouth and pain in her back, feet, hips, and shoulders. Tr. at 362. She reported many fibromyalgia flare ups. Id. She indicated her quality of life had decreased as a result of pain. Id. She reported weakened grip and indicated she experienced hand pain when she drove for long periods. Id. Dr. Sharma observed an erythematous and papulonodular rash on Plaintiff's cheeks and chin. Tr. at 363. She noted 12 of 18 fibromyalgia tender points. Id. She observed mild tenderness in Plaintiff's bilateral shoulders, moderate tenderness in her wrists, and tenderness in her MCP and PIP joints. Id. She indicated moderate tenderness and crepitus in Plaintiff's knees, moderate tenderness and lumbosacral spasm in her back, tenderness in her bilateral trochanteric bursa, and synovitis or deformity in her axial joints. Id. Dr. Sharma instructed Plaintiff to continue to take Plaquenil for Sjogren's syndrome and Duexis for pain and to initiate an aerobic exercise program for fibromyalgia. Id. She increased Plaintiff's Pamelor dosage to 25 mg, prescribed a topical cortisone cream for rash and Flexeril for back pain, and administered a Depo-Medrol injection for bilateral trochanteric bursitis. Id.
On January 29, 2013, Plaintiff presented to Johns Hopkins Bayview Medical Center for an initial evaluation of Sjogren's syndrome. Tr. at 374. She reported an initial onset of symptoms in July 2012 that included dry eyes and mouth, excessive thirst, exhaustion, trigger fingers, brain fog with impaired memory, diffuse body pain, and stiffness and burning in the joints of her knees, shoulders, hips, ankles, and hands. Id. George Moreno, M.D. ("Dr. Moreno"), observed Plaintiff to have full muscle strength; no focal sensory deficits; full ROM of all peripheral joints; diffuse tenderness over the small joints of the hands, without swelling; and no focal back tenderness. Tr. at 375. He stated the findings were "consistent with early Sjogren's syndrome/undifferentiated connective tissue disease with sicca." Tr. at 376. He noted that Plaintiff was at increased risk for dental caries and oral infections and recommended that she restrict her sugar intake and optimize her oral hygiene. Id. He advised her to use artificial tears and to increase her consumption of Omega-3 fatty acid to address dry eye symptoms. Id. He stated he would consider adding low-dose Methotrexate or Rituximab for inflammatory arthritis. Id. He indicated Plaintiff should continue to use Cymbalta and Lunesta for fibromyalgia. Id. He stated Plaintiff's brain fog and fatigue might respond to Hydroxychloroquine, Methotrexate, or Rituximab, but acknowledged that the symptoms were difficult to treat in patients with Sjogren's syndrome and that she might not respond to immunosuppressive therapy. Id. He assessed undifferentiated connective tissue disease/early Sjogren's syndrome, inflammatory arthritis, fibromyalgia, brain fog, and fatigue. Id.
Plaintiff presented to Piedmont Henry Hospital on February 3, 2013, following a syncopal episode. Tr. at 384. She reported pain throughout her body, dizziness, and headache. Tr. at 385 and 388. A physical examination was normal, aside from minimal tenderness over the left mastoid. Tr. at 389. A computed tomography ("CT") scan of Plaintiff's head showed mild sinus inflammatory disease and left mastoiditis. Tr. at 411. The attending physician diagnosed syncope and mastoiditis, prescribed Allegra and Augmentin, and advised Plaintiff to follow up with her physician on the following day. Tr. at 390.
Plaintiff followed up with Paul Free, M.D. ("Dr. Free"), on February 7, 2013. Tr. at 402. She complained of dizziness and pain and pressure in her head. Id. Dr. Free noted no abnormalities on physical examination. Tr. at 403. He assessed vertigo, headaches, and syncopal episode and prescribed Prednisone, Meclizine, and Imitrex. Tr. at 403-04.
On February 21, 2013, Plaintiff reported headaches, unsteadiness, and a spinning sensation. Tr. at 409. She indicated that Imitrex provided only minimal improvement. Id. Dr. Free noted no abnormalities on physical examination. Tr. at 410. He referred Plaintiff for magnetic resonance imaging ("MRI") of the brain. Id.
On February 25, 2013, Plaintiff presented to Stephen M. Cohen, M.D. ("Dr. Cohen"), with rectal pain, swelling, drainage, and bleeding. Tr. at 471. Dr. Cohen observed an external opening of an anterior fistula. Id. He performed a fistulectomy on March 15, 2013. Tr. at 485.
State agency medical consultant Madena Gibson, M.D. ("Dr. Gibson"), assessed Plaintiff's physical residual functional capacity ("RFC") on March 16, 2013. Tr. at 111-12. She found that Plaintiff could occasionally lift and/or carry 20 pounds; frequently lift and/or carry 10 pounds; stand and/or walk for about six hours in an eight-hour workday; and sit for about six hours in an eight-hour workday. Id. She indicated Plaintiff had no postural, manipulative, visual, communicative, or environmental limitations. Tr. at 112.
Plaintiff presented to consultative psychologist Gary Kittrell, Ph.D. ("Dr. Kittrell"), for a mental status examination on April 2, 2013. Tr. at 460-64. She reported chronic anxiety and stress-induced panic episodes. Tr. at 461. She endorsed symptoms of depression that included being easily bored, having poor motivation, anhedonia, restlessness, agitation, excessive worry, and anticipatory anxiety. Id. She indicated her depressive symptoms were exacerbated by pain and personal limitations. Id. She endorsed visual hallucinations, but denied delusions. Id. She reported problems with planning, organizing, multitasking, concentrating, remembering, and maintaining attention. Id. She stated her medication caused side effects that included confusion, nausea, fatigue, and drowsiness. Id. Dr. Kittrell observed Plaintiff to have adequate hygiene and grooming and to be oriented to person, place, and general situation. Tr. at 462. He stated Plaintiff was able to follow three-step directions in providing identification, filling out office forms, and completing various mental status tasks. Id. He noted Plaintiff had below average concentration and memory to presented tasks, as evidenced by her inabilities to repeat five digits backward, to spell "house" backward, and to recite the days of the week backward. Tr. at 462-63. He stated Plaintiff had average cognitive pace, but below average frustration tolerance. Tr. at 463. He indicated Plaintiff's overall social behavior was inadequate, as evidenced by her inability to maintain eye contact or to socially respond in interactions during the interview. Id. He stated Plaintiff had an average general fund of information and below average insight. Id. He noted that Plaintiff had adequate practical reasoning and general hazard recognition abilities. Id. Dr. Kittrell indicated Plaintiff's behavior was consistent with adequate effort and average persistence. Id. He stated Plaintiff demonstrated below average attention and concentration and adequate comprehension. Id. He indicated Plaintiff interacted at an average pace and demonstrated no signs of significant mental confusion. Id. He assessed chronic, complex post-traumatic stress disorder ("PTSD") and a global assessment of functioning ("GAF') score
On April 19, 2013, Plaintiff complained of dry eyes and mouth and pain in her bilateral thighs, shoulders, and hips. Tr. at 522. Dr. Sharma noted normal strength, gait, sensation, and muscle tone. Tr. at 523. She indicated Plaintiff had no synovitis, crepitus, or deformity in her extremities. Id. She stated Plaintiff demonstrated 12 of 18 fibromyalgia tender points. Id. She documented significant tenderness in Plaintiff hips, knees, feet, and the MCP and PIP joints of her hands. Id. She noted synovitis or deformity in the sternoclavicular joints, as well as costochondral and entheseal tenderness. Id. She observed Plaintiff to have reduced bilateral shoulder abduction to 80 degrees, bilateral knee crepitus, and positive Faber test. Id. She discontinued Duexis and prescribed Sulindac. Id. She advised Plaintiff to increase her fluid intake, to use Biotin products for oral care, to wear comfortable shoes, to use artificial tears, and to engage in aerobic exercise. Id.
Plaintiff reported mild rectal discomfort and bright red blood in her stools on April 24, 2013. Tr. at 472. Dr. Cohen noted that Plaintiff's wounds were still healing, but indicated she would need a colonoscopy. Id.
On April 28, 2013, state agency psychological consultant Vicki Prosser, Ph.D. ("Dr. Prosser"), considered Listing 12.06 for anxiety-related disorders and found that Plaintiff had moderate restriction of activities of daily living ("ADLs"); moderate difficulties in maintaining social functioning; and moderate difficulties in maintaining concentration, persistence, or pace. Tr. at 110-11. She assessed Plaintiff's mental RFC and found that she was moderately limited in her abilities to understand and remember detailed instructions; to carry out detailed instructions; to maintain attention and concentration for extended periods; to perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances; to sustain an ordinary routine without special supervision; to work in coordination with or in proximity to others without being distracted by them; to complete a normal workday and workweek without interruptions from psychologically-based symptoms; to perform at a consistent pace without an unreasonable number and length of rest periods; to interact appropriately with the general public; to accept instructions and respond appropriately to criticism from supervisors; to get along with coworkers or peers without distracting them or exhibiting behavioral extremes; to maintain socially appropriate behavior; to adhere to basic standards of neatness and cleanliness; to respond appropriately to changes in the work setting; and to be aware of normal hazards and take appropriate precautions. Tr. at 112-14. Dr. Prosser indicated as follows:
Tr. at 114.
Plaintiff complained of pain in her back and bilateral arms, legs, and knees on July 10, 2013. Tr. at 519. She indicated she had experienced several flare ups of fibromyalgia. Id. She reported numbness and tingling in her arms that interrupted her sleep, bilateral leg pain that radiated to her feet, and severe shoulder pain that affected her ADLs. Id. Dr. Sharma observed Plaintiff to have normal gait, strength, sensation, and muscle tone. Tr. at 520. She noted no crepitus, synovitis, or deformity in Plaintiff's extremities. Id. She indicated Plaintiff had 12 of 18 fibromyalgia tender points. Id. She stated Plaintiff's bilateral shoulders were significantly tender and that she had abduction reduced to 110 degrees. Id. She indicated Plaintiff's bilateral feet were significantly tender. Id. She stated both of Plaintiff's knees showed crepitus. Id. She noted lumbosacral spasm and significant tenderness in Plaintiff's back. Id. Dr. Sharma assessed abnormal kidney function, chronic back pain, bursitis, fibromyalgia, Sjogren's syndrome, and shoulder joint pain. Tr. at 520-21. She instructed Plaintiff to avoid nonsteroidal antiinflammatory drugs ("NSAIDS") because of abnormal kidney function; to use warm, moist heat and exercise for her back; to start aerobic exercise for fibromyalgia; and to start Pilocarpine for Sjogren's syndrome. Id. She administered Depo-Medrol injections to Plaintiff's shoulders. Id.
On August 5, 2013, Plaintiff reported brain fog as a result of poor sleep. Tr. at 536. She endorsed decreased tasks, concentration, and focus. Id. Psychiatric nurse practitioner Jeanette Spence, APRN ("Ms. Spence"), observed Plaintiff to have casual and neat appearance. Id. She stated Plaintiff was alert and oriented times four, but was easily distracted. Id. She described Plaintiff's affect as restricted and her thought content as helpless, hopeless, and confused. Id. She indicated Plaintiff had endorsed passive suicidal ideation. Id. She assessed PTSD and major depressive disorder and indicated a GAF score of 35.
On August 26, 2013, Plaintiff reported poor sleep and requested that her medications be adjusted. Tr. at 537. She endorsed feelings of inadequacy, self-pity, and self-blame. Id. Ms. Spence observed Plaintiff to appear casual and neat. Id. She indicated Plaintiff's speech was slow at times and that she had slowed motor activity. Id. She described Plaintiff as oriented times four, but indicated her concentration was fair-to-poor and she was easily distracted. Id. She stated Plaintiff's thought process was preoccupied, but goal-directed. Id. She described Plaintiff's thought content as hopeless, helpless, and confused. Id. She indicated Plaintiff was experiencing intrusive thoughts and flashbacks. Id. Ms. Spence referred Plaintiff for a partial hospitalization program assessment. Id.
On August 29, 2013, Plaintiff reported five flare ups of fibromyalgia since her last visit. Tr. at 515. She complained of pain in her bilateral knees and thighs, hips, shoulders, and bilateral legs. Id. She indicated the injections to her shoulders had improved her quality of life and requested that Dr. Sharma administered injections to her bilateral hips. Id. Dr. Sharma observed Plaintiff to have normal gait, strength, sensation, and muscle tone. Tr. at 516. She noted no crepitus, synovitis, or deformity in Plaintiff's upper or lower extremities. Id. She indicated Plaintiff had 12 of 18 fibromyalgia tender points. Id. She stated Plaintiff's bilateral shoulder abduction was reduced to 70 degrees. Id. She indicated both of Plaintiff's hips and feet were moderately tender. Id. She stated both of Plaintiff's knees showed crepitus and were significantly tender. Id. She indicated Plaintiff's bilateral trochanteric bursa were significantly tender. Id. Dr. Sharma advised Plaintiff to increase her fluid intake, to use Biotin products for oral care and artificial tears, to follow up with an ophthalmologist, and to start aerobic exercise. Id. She prescribed Prednisone, Voltaren gel, and Duexis; instructed Plaintiff to increase her dose of Pamelor and to stop Pennsaid; referred her for x-rays of her bilateral knees; and administered bilateral trochanteric bursa injections. Tr. at 516-17. X-rays of Plaintiff's bilateral knees showed mild degenerative changes. Tr. at 508 and 509.
On September 4, 2013, Plaintiff reported decreased concentration and focus, poor sleep and appetite, and low energy. Tr. at 538. She indicated she was scheduled to begin the partial hospitalization program the following day. Id. Ms. Spence observed Plaintiff to demonstrate soft and slow speech, to be easily distracted, to have a low mood, and to have hopeless, helpless, and confused thought content. Id. She noted that Plaintiff was experiencing intrusive thoughts and flashbacks. Id. She recommended that Plaintiff continue her current level of care. Id.
On October 3, 2013, a second state agency psychological consultant, Jeanne Wright, Ph.D. ("Dr. Wright"), considered Listing 12.06 and assessed the same degree of impairment as Dr. Prosser. Compare Tr. at 96-97, with Tr. at 110-11. She also indicated the same limitations in a mental RFC assessment. Compare Tr. at 101-03, with Tr. at 112-14.
On October 9, 2013, Plaintiff reported four flare ups of fibromyalgia since her prior visit. Tr. at 791. She endorsed dry eyes and mouth and pain and stiffness in her bilateral arms, knees, and hips. Id. She complained of occasional finger locking, but stated the injections had helped her hips and her medications were working well. Id. Dr. Sharma observed Plaintiff to have normal muscle tone, gait, and muscle strength; no synovitis, crepitus, or deformity in her extremities; 12 of 18 fibromyalgia tender points; decreased abduction to 70 degrees in her bilateral shoulders; moderate-to-significant tenderness in her shoulders; moderate tenderness in her wrists and hips; and crepitus and significant tenderness in her knees. Tr. at 792. She discontinued Duexis, decreased Plaintiff's Methotrexate, and prescribed Prednisone and folic acid. Id. She instructed Plaintiff to avoid NSAIDs and to start aerobic exercise.
On October 25, 2013, Plaintiff reported poor sleep and appetite and low energy. Tr. at 559. She endorsed weekly crying spells, paranoia, intrusive thoughts, and panic attacks. Id. Ms. Spence observed Plaintiff to have poor concentration and slowed motor activity. Id. She stated Plaintiff was easily distracted and had a flat and restricted affect. Id. She indicated Plaintiff appeared neat and casual, was oriented times four, and had normal speech. Id. She described Plaintiff's thoughts as preoccupied and hopeless, helpless, and confused. Id. She assessed a GAF score of 35 to 40. Id.
On November 22, 2013, Ms. Spence and Elizabeth Jeffords, M.D. ("Dr. Jeffords"), completed a psychiatric/psychological impairment questionnaire. Tr. at 568-74. They indicated Plaintiff had initiated treatment on August 5, 2013, had last been seen on November 22, 2013, and had been presenting for monthly treatment. Tr. at 568. They stated Plaintiff's diagnoses included major depressive disorder and post-traumatic stress disorder. Id. They also indicated a need to rule out borderline personality disorder. Id. They assessed Plaintiff's current GAF score as 35 and indicated her lowest GAF score during the prior year had been 55.
On December 20, 2013, Ms. Spence described Plaintiff as hypervigilant. Tr. at 557. Plaintiff reported that she was not sleeping. Id. Ms. Spence observed Plaintiff to demonstrate soft and slow speech; to have poor memory; to be easily distracted; to have a restricted affect; and to endorse hopeless, helpless, and confused thought content. Id. She assessed a GAF score of 35 and added a prescription for Ativan. Id.
On January 7, 2014, a visual examination showed Plaintiff to have abnormal confrontation visual field. Tr. at 545. Joseph Manno, M.D. ("Dr. Manno"), assessed open angle glaucoma in both eyes. Tr. at 546. He stated Plaintiff "should be able to function in a well lit environment." Id. He indicated Plaintiff's side vision was affected, but he was unable to assess the extent of the impairment. Id.
State agency medical consultant Michele Spero, M.D. ("Dr. Spero"), completed a physical residual functional capacity ("RFC") assessment on January 7, 2014. Tr. at 98-101. She indicated Plaintiff could occasionally lift and/or carry 20 pounds; could frequently lift and/or carry 10 pounds; could stand and/or walk for a total of about six hours in an eight-hour workday; could sit for about six hours in an eight-hour workday; could occasionally balance, stoop, kneel, crouch, crawl, and climb ramps and stairs; could never climb ladders, ropes, or scaffolds; could frequently reach overhead with the bilateral upper extremities; would be limited to jobs requiring limited field of vision; and should avoid all exposure to hazards. Id.
On January 15, 2014, Plaintiff reported variable sleep, poor appetite, and low energy. Tr. at 556. Ms. Spence observed Plaintiff to have slow and casual speech; to be oriented times four; to be easily distracted; to have poor memory; to be very sad; and to endorse hopeless, helpless, and confused thought content. Id. She noted that Plaintiff was seeing a therapist once a week who was helping her with chronic issues and coping strategies. Id.
On January 24, 2014, Plaintiff reported fibromyalgia flares. Tr. at 794. She endorsed insomnia, memory confusion, dry mouth and throat, severe pain in her shoulders, and constant pain in her knees, feet, and back. Id. She requested a steroid injection to her shoulders. Id. Dr. Sharma observed Plaintiff to have normal muscle tone, muscle strength, and gait; no synovitis, crepitus, or deformity in her extremities; 12 of 18 fibromyalgia tender points; crepitus in her knees; significant tenderness in her shoulders, knees, feet, and back; and lumbosacral spasm. Id. She prescribed Cymbalta and Prednisone, increased Plaintiff's dosage of Methotrexate, and advised her to avoid NSAIDs, increase her fluid intake, wear comfortable shoes, engage in aerobic exercise, use artificial tears, practice good oral care, and use warm, moist heat for her back. Tr. at 795-96. She administered a Depo-Medrol injection. Tr. at 796.
On April 14, 2014, Plaintiff reported poor sleep and appetite and low energy. Tr. at 744. Ms. Spence indicated Plaintiff was easily distracted; demonstrated slowed motor activity; had poor memory; endorsed a hopeless mood; had hopeless, helpless, and confused thought content; showed a tearful affect; and endorsed passive suicidal ideation. Id. She assessed a GAF score of 40 and instructed Plaintiff to follow up with her therapist in two weeks. Id.
On April 25, 2014, Plaintiff complained of dry eyes and mouth, inability to taste, and pain in her knees, ankles, back, shoulder, elbows, feet, and hands. Tr. at 798. She reported many fibromyalgia flare ups. Id. Dr. Sharma indicated Plaintiff demonstrated normal gait and muscle tone and strength and no synovitis, crepitus or deformity in her extremities, aside from her knees. Tr. at 799. She noted significant tenderness in Plaintiff's shoulders, elbows, bilateral MCP and PIP joints, knees, ankles, feet, and back. Id. She observed abduction to 80 degrees in Plaintiff's shoulders, swelling in her knees, and spasm in her lumbosacral spine. Id. She prescribed Lyrica, increased Plaintiff's dose of Methotrexate, and recommended increased fluid intake, oral care, use of artificial tears, aerobic exercise, calcium and vitamin D supplements, and warm, moist heat. Tr. at 799-800.
On May 14, 2014, Plaintiff reported significant grief following the death of her grandmother. Tr. at 566. Ms. Spence described Plaintiff as having preoccupied thought content and depressed mood, but indicated no other abnormalities on mental status examination. Id. She stated Plaintiff was mildly worse than she had been during the prior visit. Tr. at 567. Plaintiff indicated she would follow up with her therapist. Tr. at 566.
On July 18, 2014, Plaintiff presented to Edward A. Nielsen, M.D. ("Dr. Nielsen"), after having sustained a fall. Tr. at 576. She complained of pain in her back and knees. Id. Dr. Nielsen observed normal ROM of the left knee, no crepitus or joint instability, and no obvious ligamentous instability, deformity, bruising, effusion, or overlying skin changes. Tr. at 577. He indicated the x-ray of Plaintiff's left knee indicated no acute process, but hinted at osteoarthritis. Id. He prescribed Diclofenac. Id.
On August 1, 2014, Plaintiff complained of dry eyes and mouth, multiple fibromyalgia flare ups, insomnia, fatigue, memory confusion, pain and numbness in her shoulders and arms, and pain in her back, neck, hip, and ankle. Tr. at 801. She reported that steroid injections to her shoulders had previously provided significant pain relief and requested additional injections. Id. Dr. Sharma observed Plaintiff to have normal muscle tone, strength, and gait and no synovitis, crepitus, or deformity in her extremities, aside from crepitus in her bilateral knees. Tr. at 802. She noted reduced abduction of Plaintiff's bilateral shoulders to 60 degrees and significant tenderness in Plaintiff's shoulders, hands, hips, knees, ankles, feet, and trochanteric bursa. Id. She prescribed Methotrexate, Skelaxin, and a Medrol Dose Pack, increased Lyrica, and administered Depo-Medrol injections to Plaintiff's bilateral shoulders. Tr. at 802-03.
On August 18, 2014, Ms. Spence noted Plaintiff had poor recent memory; distractible attention/concentration; agitated motor activity; preoccupied, agitated, and easily reactive thought content; fearful perception; constricted affect; and dysphoric and anxious mood. Tr. at 748. She changed Plaintiff's dosages of Latuda and Gabapentin. Tr. at 749. She stated Plaintiff was mildly worse than she had been during the prior visit. Id.
Plaintiff presented to Tameika Turner-Noland, Ph.D. ("Dr. Turner-Noland"), for a psychotherapy intake session on August 22, 2014. Tr. at 1008-09. Dr. Turner-Noland described Plaintiff as being alert and oriented, having an appropriate affect and euthymic mood, and demonstrating interactive interpersonal communication and intact functional status. Tr. at 1009. Plaintiff described familial stressors related to her husband, mother, and aunt. Id. She followed up for counseling sessions with Dr. Turner-Noland every one-to-two weeks between September 4, 2014, and June 11, 2015. Tr. at 933-1006.
On September 17, 2014, Ms. Spence noted Plaintiff had poor recent memory, distractible attention/concentration, obsessive thought content, constricted affect, suicidal ideation, and very low, depressed mood. Tr. at 750. She increased Plaintiff's dosages of Latuda and Ativan and indicated Plaintiff desperately needed to see her counselor. Id.
Plaintiff was hospitalized at Three Rivers Behavioral Health from September 23 to September 26, 2014, for suicidal ideation with plan. Tr. at 663. She was indicated to be a danger to herself with a need for a controlled environment; had failed to response to outpatient treatment; and was experiencing impaired mood, depression, mood swings, and suicidal ideation. Tr. at 663. A mental status examination was normal, aside from anxious mood and flat affect. Tr. at 663. Plaintiff was discharged with a diagnosis of major depressive disorder and a GAF score of 70.
Plaintiff followed up with Ms. Spence on September 29, 2014. Tr. at 754. Ms. Spence noted Plaintiff had psychomotor retardation, preoccupied thought content, fearful perception, constricted affect, passive suicidal ideation, and dysphoric mood. Id. She indicated Plaintiff appeared normal, was appropriately dressed, had fair insight and judgment, demonstrated normal speech and flow of thought, and was oriented to person, place, and time. Id. She stated Plaintiff was moderately worse than she had been during her most recent prior visit and changed her dosage of Cymbalta. Tr. at 755.
On October 31, 2014, Plaintiff complained of severe dry eyes and mouth, insomnia, fibromyalgia flare ups, and pain in her hands, hips, knees, shoulders, and back. Tr. at 805. Dr. Sharma observed Plaintiff to have normal muscle tone, strength, and gait and no synovitis, crepitus, or deformities in her extremities, aside from bilateral knee crepitus. Tr. at 806. She noted reduced abduction to 110 degrees in Plaintiff's bilateral shoulders; significant tenderness in her shoulders, proximal and distal interphalangeal joints, hips, knees, and back; Heberden's and Bouchard's nodes in her hands; and spasm in her lumbosacral spine. Id. She prescribed Sulindac, encouraged Plaintiff to exercise as tolerated, and administered Depo-Medrol injections to Plaintiff's bilateral shoulders. Tr. at 806-07.
On November 19, 2014, Ms. Spence observed the following abnormalities on mental status examination: poor recent memory with daily forgetfulness, very distractible attention/concentration, preoccupied thought content, dysphoric mood, and passive suicidal ideation. Tr. at 760. She indicated Plaintiff was oriented to person, place, and time and had appropriate dress, affect, and interview behavior and normal general appearance, motor activity, perception, flow of thought, and speech. Id. Plaintiff complained of familial stressors and indicated her mother was living in her home and undermining her authority with her daughter. Id. Despite noting that Plaintiff was mildly worse than she had been during the prior visit, Ms. Spence made no changes to Plaintiff's medications. Tr. at 761.
On December 10, 2014, Ms. Spence indicated the following abnormalities on mental status examination: poor recent and remote memory, distractible attention/concentration, psychomotor retardation, preoccupied thought content, hypervigilant perception, fair-to-poor judgment, perseverated flow of thought, constricted affect, apathetic interview behavior, passive suicidal ideation, and dysphoric, anxious mood. Tr. at 765. Plaintiff described conflict with her mother. Id. Ms. Spence indicated Plaintiff had been unable to work since 2010 because of physical and emotional disability. Id. She indicated no changes in Plaintiff's condition and made no adjustments to her medications. Tr. at 766-67.
On January 12, 2015, Ms. Spence observed Plaintiff to have poor recent memory; distractible attention/concentration; normal motor activity, general appearance, thought flow, and speech; orientation to person, place, and time; thought content preoccupied by loss; fair insight and judgment; hypervigilant perception; appropriate affect and behavior; and dysphoric, but stable mood. Tr. at 727. She instructed Plaintiff to adjust her Latuda dosage based on her response and to continue to participate in counseling for coping skills. Tr. at 728-29.
On February 12, 2015, Ms. Spence indicated the following abnormalities on mental status examination: poor recent memory, distractible attention/concentration, preoccupied thought content, hypervigilant perception, constricted affect, and dysphoric mood. Tr. at 730. She described Plaintiff as having normal general appearance, appropriate dress, normal motor activity, fair insight and judgment, normal flow of thought, appropriate interview behavior, normal speech, and orientation to person, place, and time. Id. Plaintiff complained of feeling tired and defeated by multiple life stressors. Id. She reported that her doctor had instructed her not to drive, but that she felt she had to drive to medical appointments. Id. She indicated she drove slowly and carefully and traveled only five miles. Id. Ms. Spence stated Plaintiff was tolerating her medications well. Id.
On February 24, 2015, Plaintiff reported dry eyes and mouth, insomnia, fibromyalgia flare ups, and pain in her hands, hips, knees, shoulders, and back. Tr. at 809. Dr. Sharma noted 12 of 18 fibromyalgia tender points; no deformities, cyanosis, clubbing, edema, synovitis, crepitus, or deformity in Plaintiff's extremities; and normal gait and muscle strength and tone. Tr. at 810. She stated Plaintiff was significantly tender in her shoulders, PIP and distal interphalangeal ("DIP") joints, and knees; had Heberden's and Bouchard's nodes in her hands; and demonstrated lumbosacral spasm in her back. Id. She prescribed Sulindac for pain, increased Plaintiff's dosages of Methotrexate and Lyrica, and administered Depo-Medrol injections to Plaintiff's shoulders. Tr. at 810-11.
On April 23, 2015, Plaintiff reported feeling depressed and overwhelmed, but sleeping a little better with medication. Tr. at 735. Ms. Spence observed Plaintiff to have poor recent and remote memory, inability to focus, psychomotor retardation, preoccupied and obsessive thought content, hypersensitive and hypervigilant perception, fair-to-poor judgment, perseveration of thought, sad affect, depressed mood, hesitant speech, and passive suicidal thought. Id. She refilled Plaintiff's medications and instructed her to continue to participate in counseling and to try yoga, acupuncture, or massage monthly. Tr. at 733.
On May 29, 2015, Ms. Spence observed the following abnormalities on mental status examination: poor recent and remote memory; distractible attention/concentration characterized by intrusive thoughts of past trauma; thought content preoccupied by multiple life stressors; hypervigilant perception; and perseveration of thought. Tr. at 741. She changed Plaintiff's dosage of Cymbalta. Tr. at 742.
On July 24, 2015, Lynn Hicks Snoddy, M.D. ("Dr. Snoddy"), assessed primary open-angle glaucoma, severe stage glaucoma, rheumatoid arthritis in multiple joints, and current use of high-risk medication. Tr. at 717. She indicated Plaintiff had increased intraocular pressure and advised her to follow up in one to two weeks for a recheck. Id. She instructed Plaintiff to discontinue Lumigan and to restart Latanaprost. Id.
On July 29, 2015, Plaintiff continued to grieve the loss of her grandmother. Tr. at 720. Ms. Spence reminded Plaintiff that there was no "magic pill" to make her grief disappear and emphasized that she would need to cycle through the grief process. Id. She described Plaintiff as having poor recent or remote memory when stressed out or tired; poor ADLs with difficulty dressing and engaging in self-care; distractible attention/ concentration; motor retardation at times; thoughts preoccupied with life stressors; hypersensitive and hypervigilant perception; fair-to-poor judgment; constricted affect; apathetic interview behavior; and depressed mood. Tr. at 722. She noted that Plaintiff's mood was "so low she would find some way to end the physical, mental and psychological pain, if she could." Id. She further described Plaintiff as having no motivation, energy, or joy in her life. Id. She stated Plaintiff was much worse than she had been during her prior visit. Tr. at 724. Ms. Spence indicated Plaintiff needed more intensive care and was willing to go to Palmetto Health's partial hospitalization program. Tr. at 722. She stated Plaintiff desperately needed a counselor. Tr. at 724.
On July 31, 2015, Plaintiff complained of multiple fibromyalgia flare ups, dry eyes and mouth, swelling, insomnia, headaches, depression, memory problems, confusion, anxiety attacks, fatigue, insomnia, and pain in her hands, hips, knees, shoulders, back, neck, and feet. Tr. at 813. Dr. Sharma observed Plaintiff to have normal gait, muscle tone, and strength; 12 of 18 fibromyalgia tender points; no deformities, clubbing, cyanosis, edema, synovitis, deformity, or crepitus in her extremities; tenderness in her shoulders, proximal and distal interphalangeal joints, hips, and knees; lumbosacral spasm; and Heberden's and Bouchard's nodes in her hands. Tr. at 814. She administered Depo-Medrol injections to Plaintiff's bilateral shoulders. Tr. at 815.
Plaintiff presented to Bryan Wolf, M.D. ("Dr. Wolf"), to establish care on September 10, 2015. Tr. at 1045. She endorsed generalized fatigue, weakness, fever, heat intolerance, eye pain and dryness, hair loss, vertigo, oral sicca, dysphagia, odynophagia, pleuritic chest pain, dyspnea, ankle edema, frequent abdominal pain, diffuse arthralgia and myalgia, swelling of the hands and lower extremities, three or more hours of morning stiffness, headaches, numbness and paresthesia in the arms and feet, depression, anxiety, confusion, and insomnia. Id. Dr. Wolf noted no abnormalities on physical examination. Tr. at 1047. He referred Plaintiff for baseline serologic studies and indicated he would review her records and follow up with her in two weeks. Tr. at 1049.
On September 24, 2015, Plaintiff rated her pain as an eight on a 10-point scale. Tr. at 1034. Dr. Wolf prescribed an increased dose of Methotrexate for Sjogren's syndrome. Tr. at 1044. He suspected that fibromyalgia was "the etiology behind the majority" of Plaintiff's symptoms. Id. He increased Plaintiff's dose of Lyrica, but declined to increase her dosages of Tizanidine and Cymbalta because of side effects that included significant somnolence. Id.
Plaintiff presented to rheumatologist Bruce Goeckeritz, M.D. ("Dr. Goeckeritz"), to establish care on November 24, 2015. Tr. at 1026. She reported little relief from Plaquenil, Methotrexate, and other medications for fibromyalgia. Id. Dr. Goeckeritz observed Plaintiff to have normal ROM, stability, and muscle strength and tone of her upper and lower extremities and normal gait and station. Tr. at 1028. He noted tenderness in Plaintiff's knees. Id. He discontinued Plaintiff's immunosuppressive medications and indicated he would reassess her medications in two months. Id. He indicated he did not see strong evidence that inflammatory arthritis was affecting the small joints of Plaintiff's hands. Id.
On December 29, 2015, Plaintiff complained of bilateral knee pain and requested injections. Tr. at 1022. She endorsed left shoulder and arm discomfort. Id. Dr. Goeckeritz noted that x-rays of Plaintiff's knees showed mild medial joint space osteoarthritis with mild medial joint space narrowing and reactive spur formation involving the medial femoral condyle and medial tibial plateau. Tr. at 1023. Dr. Goeckeritz observed tenderness in Plaintiff's bilateral knees and swelling in her left knee, but no other abnormalities on physical examination. Tr. at 1024. He aspirated synovial fluid and administered Synvisc injections to Plaintiff's knees. Tr. at 1023.
On January 5, 2016, Plaintiff complained of left shoulder pain with paresthesia that radiated through her arms. Tr. at 1011. She endorsed foot pain and requested a referral to a podiatrist. Id. Dr. Goeckeritz noted that xrays showed cervical spine straightening, degenerative disc disease, and neuroforaminal encroachment. Id. He appreciated abnormalities in Plaintiff's left upper extremity, but the physical examination was otherwise normal. Tr. at 1015. He noted Plaintiff had normal reflexes and strength in her left arm and ordered an MRI of the cervical spine to evaluate for nerve root irritation. Tr. at 1016. He instructed Plaintiff to stop Tizanidine HCl and to start Cyclobenzaprine HCl and administered Kenalog and Lidocaine injections to the left side of Plaintiff's shoulder and upper back. Tr. at 1015.
On January 6, 2016, Plaintiff complained of worsened vision. Tr. at 1076. She reported occasional increased pain and pressure behind her eyes and endorsed problems with distance and peripheral vision. Id. She stated she had stopped driving at night. Id. Dr. Snoddy noted increased intraocular pressure and increased Plaintiff's dosage of Trusopt to three times a day. Tr. at 1080.
Plaintiff presented to Agape Counseling Services for an initial assessment on January 26, 2016. Tr. at 1200. She indicated she had given up her career to care for her husband. Id. She endorsed decreased sleep and appetite, low self-esteem, decreased confidence, and feelings of worthlessness. Id. Sheryl Williams, LPC ("Ms. Williams"), diagnosed major depression and PTSD and recommended cognitive behavioral therapy. Tr. at 1201. On February 8, 2016, Ms. Williams described Plaintiff as having a mixed depressed/sad and anxious mood; demonstrating appropriate and cooperative behavior; and having normal speech. Tr. at 1202. She identified Plaintiff's presenting problems as health, anxiety, adjustment to change, depression, stressors, and self-esteem. Tr. at 1203. On February 15, 2016, Ms. Williams indicated Plaintiff was tearful and upset. Tr. at 1205. She noted slight progress on February 22 and 29, March 7 and 14, and April 12, 2016. Tr. at 1210, 1213, 1216, 1219, and 1224
Plaintiff participated in physical and aquatic therapy from February through April 2016. Tr. at 1136-41, 1144-56, 1164-69, and 1171-98. Her long-term goals were to be pain-free with cervical and shoulder ROM and to be able to lift a gallon of milk and open doors without pain. Tr. at 1140. The physical therapist indicated Plaintiff's prognosis was extremely guarded in light of her impairments. Id.
On March 10, 2016, Plaintiff complained of bilateral foot pain that was exacerbated by walking, standing, and climbing stairs. Tr. at 1157. Thomas Adams, D.O. ("Dr. Adams"), noted that Plaintiff's gait and stance were normal and that her mobility was not limited. Tr. at 1159. He referred Plaintiff to a podiatrist. Id.
At the hearing on April 12, 2016, Plaintiff testified that her diagnoses included Sjogren's syndrome, fibromyalgia, and arthritis. Tr. at 58. She indicated arthritis caused swelling in her joints and fibromyalgia caused a burning, numb, and tingling sensation throughout her body. Tr. at 58-59. She indicated she had been diagnosed with rheumatoid arthritis, osteoarthritis, lupus, and glaucoma. Tr. at 59-60. She stated she had poor peripheral vision on both sides and high ocular pressure that caused headaches. Tr. at 60. She indicated she had sustained several falls as a result of arthritis in her knees, vertigo, and Sjogren's syndrome. Tr. at 71-72.
Plaintiff testified that she experienced flare ups of Sjogren's syndrome that were characterized by constant fatigue, inability to concentrate, lack of motivation, inability to complete tasks, and memory impairment. Tr. at 63. She stated the flare ups occurred three or four times per week and lasted for a majority of the day. Id. She indicated she would lie down, elevate her feet at or above waist-level, and read during flare ups. Tr. at 64.
Plaintiff described arthritis flare ups that caused the joints in her knees and ankles to become hot and swollen. Id. She stated she took her medicine, rested, and elevated her feet to treat arthritis flare ups. Tr. at 65.
Plaintiff testified that she had been diagnosed with PTSD and depression. Tr. at 65. She stated she had developed PTSD after she was assaulted in the workplace. Tr. at 74. She reported hypervigilance, being easily startled, flashbacks, and inability to function in groups of more than five non-family members. Tr. at 65-66. She stated she experienced symptoms of depression that included feelings of worthlessness, unwillingness to trust others, and isolation in her home. Tr. at 66-67.
Plaintiff indicated her medications caused her to have difficulty focusing and recalling things and to feel sleepy and nauseated. Tr. at 73. She stated her eye drops triggered a burning sensation in her eyes. Id.
Plaintiff estimated that she could lift a maximum of two to three pounds. Tr. at 69. She indicated she could likely sit in a chair for 15 minutes. Tr. at 70. She stated she could stand in one place for five to ten minutes, but would develop excruciating pain in her feet and legs if she did not switch positions. Id. She testified that she could walk for five to ten minutes at a time. Tr. at 71. She indicated that she alleviated the pain in her feet and legs by elevating them. Tr. at 70. She stated she attended physical therapy four days a week and had been doing so for approximately a month and a half. Tr. at 86-87.
Plaintiff testified that her vision problems caused her difficulty when driving. Tr. at 60. She stated she would drive to a store that was five minutes from her home once or twice a month. Tr. at 69. She confirmed that she was able to drive to her medical appointments. Tr. at 75. She stated she typically scheduled her medical visits early in the morning to avoid having to wait in a room with other patients. Id. She admitted that she had attended a retreat for wives of wounded warriors, but testified that she remained in her room because there were too many other women at the retreat. Id. She denied that she had hosted a baby shower in her home. Tr. at 76. She stated that she was scheduled to host the event, but did not follow through because she was feeling overwhelmed and her husband did not want others in their home. Tr. at 77.
Plaintiff indicated she elevated her feet for a majority of a typical day. Tr. at 65. She stated she no longer cooked as often as she had in the past because she had lost her senses of taste and smell. Tr. at 67-68. She endorsed difficulty in following recipes. Tr. at 68. She indicated she could sometimes load the dishwasher, but was unable to do so when her hands and feet were hurting. Id.
Plaintiff testified that she would be unable to perform her PRW as a cook because her senses of smell and taste were impaired. Tr. at 78. She stated she could not perform her PRW as a bus driver because of visual disturbances. Id. She indicated she could no longer perform administrative duties like those she performed in the past because she was no longer dependable. Id.
Vocational Expert ("VE") Brenda J. White reviewed the record and testified at the hearing. Tr. at 79-84. The VE categorized Plaintiff's PRW as a bus driver, Dictionary of Occupational Titles ("DOT") number 913.463-010, as medium with a specific vocational preparation ("SVP") of four; a fast food worker, DOT number 311.472-010, as light with an SVP of two; and a sales clerk, DOT number 211.462-014, as light with an SVP of three. Tr. at 80. The ALJ described a hypothetical individual of Plaintiff's vocational profile who could perform sedentary work with the following additional restrictions: no climbing of ladders, ropes, or scaffolds; only occasional exposure to weather, humidity, extreme cold, and extreme heat; no exposure to workplace hazards such as moving mechanical parts and high, exposed places; vision limited to avoiding ordinary hazards in the workplace and to occupations that do not require peripheral vision; simple, routine tasks with the ability to make simple, work-related decisions; occasional changes in the work setting; occasional interaction with the public; occasional interaction with coworkers; and no commercial driving. Tr. at 80-81. The VE testified that the hypothetical individual would be unable to perform Plaintiff's PRW. Tr. at 81. The ALJ asked whether there were any other jobs that the hypothetical person could perform. Id. The VE identified sedentary jobs with an SVP of two as a pager, DOT number 654.687-014, with 206,600 positions in the national economy; a stuffer, DOT number 731.685-014, with 372,210 positions in the national economy; and a preparer, DOT number 700.687-062, with 206,600 positions in the national economy. Tr. at 81-82.
The ALJ asked the VE to consider that the individual would miss work on four or more days per month because of a combination of impairments, medications, and pain. Tr. at 82. He asked if the restriction would preclude work. Id. The VE confirmed that it would. Id.
The ALJ asked the VE to consider that the individual would be off task for 20 percent of the workday in addition to normal breaks. Id. He asked if the restriction would preclude work. Id. The VE indicated it would. Id.
Plaintiff's attorney asked the VE to consider that the individual would be off task for 15 percent of the work day. Tr. at 83. He asked if there would be any jobs that would accommodate that restriction. Id. The VE testified that most employers would not tolerate the restriction. Id.
Plaintiff's attorney asked the VE to consider that the individual would need to elevate her legs above waist-level for at least two hours during a typical workday. Tr. at 84. He asked if there were jobs that would accommodate the restriction. Id. The VE testified that there would be an insufficient number of jobs that would accommodate the restriction in the national economy. Id.
In his decision dated May 4, 2016, the ALJ made the following findings of fact and conclusions of law:
Tr. at 27-39.
Plaintiff alleges the Commissioner erred for the following reasons:
The Commissioner counters that substantial evidence supports the ALJ's findings and that the ALJ committed no legal error in his decision.
The Act provides that disability benefits shall be available to those persons insured for benefits, who are not of retirement age, who properly apply, and who are under a "disability." 42 U.S.C. § 423(a). Section 423(d)(1)(A) defines disability as:
42 U.S.C. § 423(d)(1)(A).
To facilitate a uniform and efficient processing of disability claims, regulations promulgated under the Act have reduced the statutory definition of disability to a series of five sequential questions. See, e.g., Heckler v. Campbell, 461 U.S. 458, 460 (1983) (discussing considerations and noting "need for efficiency" in considering disability claims). An examiner must consider the following: (1) whether the claimant is engaged in substantial gainful activity; (2) whether she has a severe impairment; (3) whether that impairment meets or equals an impairment included in the Listings;
A claimant is not disabled within the meaning of the Act if she can return to PRW as it is customarily performed in the economy or as the claimant actually performed the work. See 20 C.F.R. Subpart P, § 404.1520(a), (b); Social Security Ruling ("SSR") 82-62 (1982). The claimant bears the burden of establishing her inability to work within the meaning of the Act. 42 U.S.C. § 423(d)(5).
Once an individual has made a prima facie showing of disability by establishing the inability to return to PRW, the burden shifts to the Commissioner to come forward with evidence that claimant can perform alternative work and that such work exists in the regional economy. To satisfy that burden, the Commissioner may obtain testimony from a VE demonstrating the existence of jobs available in the national economy that claimant can perform despite the existence of impairments that prevent the return to PRW. Walls v. Barnhart, 296 F.3d 287, 290 (4th Cir. 2002). If the Commissioner satisfies that burden, the claimant must then establish that she is unable to perform other work. Hall v. Harris, 658 F.2d 260, 264-65 (4th Cir. 1981); see generally Bowen v. Yuckert, 482 U.S. 137, 146 n.5 (1987) (regarding burdens of proof).
The Act permits a claimant to obtain judicial review of "any final decision of the Commissioner [] made after a hearing to which he was a party." 42 U.S.C. § 405(g). The scope of that federal court review is narrowlytailored to determine whether the findings of the Commissioner are supported by substantial evidence and whether the Commissioner applied the proper legal standard in evaluating the claimant's case. See Richardson v. Perales, 402 U.S. 389, 390 (1971); Walls, 296 F.3d at 290 (citing Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990)).
The court's function is not to "try these cases de novo or resolve mere conflicts in the evidence." Vitek v. Finch, 438 F.2d 1157, 1157-58 (4th Cir. 1971); see Pyles v. Bowen, 849 F.2d 846, 848 (4th Cir. 1988) (citing Smith v. Schweiker, 795 F.2d 343, 345 (4th Cir. 1986)). Rather, the court must uphold the Commissioner's decision if it is supported by substantial evidence. "Substantial evidence" is "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Richardson, 402 U.S. at 390, 401; Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir. 2005). Thus, the court must carefully scrutinize the entire record to assure there is a sound foundation for the Commissioner's findings and that her conclusion is rational. See Vitek, 438 F.2d at 1157-58; see also Thomas v. Celebrezze, 331 F.2d 541, 543 (4th Cir. 1964). If there is substantial evidence to support the decision of the Commissioner, that decision must be affirmed "even should the court disagree with such decision." Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972).
Plaintiff argues the ALJ did not explain his RFC assessment, as required by SSR 96-8p. [ECF No. 17 at 20]. The Commissioner maintains that substantial evidence supports the ALJ's RFC assessment. [ECF No. 18 at 8].
A claimant's RFC represents the most she can still do despite her limitations. 20 C.F.R. § 404.1545(a). It must be based on all the relevant evidence in the case record and should account for all of the claimant's medically-determinable impairments. Id. The RFC assessment must include a narrative discussion describing how all the relevant evidence in the case record supports each conclusion and must cite "specific medical facts (e.g., laboratory findings) and non-medical evidence (e.g., daily activities, observations)." SSR 96-8p, 1996 WL 374184 at *7 (1996). The ALJ must determine the claimant's ability to perform work-related physical and mental abilities on a regular and continuing basis. Id. at *2. He must explain how any material inconsistencies or ambiguities in the record were resolved. Id. at *7. "[R]emand may be appropriate . . . where an ALJ fails to assess a claimant's capacity to perform relevant functions, despite contradictory evidence in the record, or where other inadequacies in the ALJ's analysis frustrate meaningful review." Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015), citing Cichocki v. Astrue, 729 F.3d 172, 177 (2d Cir. 2013).
The undersigned has considered Plaintiff's specific allegations of error in light of the foregoing authority.
Plaintiff argues the ALJ erred in assessing moderate, as opposed to marked, limitations in concentration, persistence, or pace and failed to properly account for her difficulties. [ECF No. 17 at 21]. She claims the record shows frequent findings of distractible or poor attention and concentration. Id. at 23-24.
The Commissioner argues the ALJ adequately accounted for Plaintiff's moderate limitations in concentration, persistence, or pace by limiting her to simple, routine tasks. [ECF No. 18 at 8]. She maintains the ALJ specified that Plaintiff had average cognitive pace and accepted Dr. Kittrell's opinion that she should be able to understand simple and more complex instructions and had moderate difficulties in following through with work tasks and meeting general productivity standards. Id. at 8-9.
In Mascio, 780 F.3d at 638, the court found that the ALJ erred in assessing the plaintiff's RFC. Id. It stated "we agree with other circuits that an ALJ does not account `for a claimant's limitations in concentration, persistence, and pace by restricting the hypothetical question to simple, routine tasks or unskilled work.'" Id. The court explained that it was possible for the ALJ to find that the moderate concentration, persistence, or pace limitation did not affect the plaintiff's ability to work, but that remand was required "because the ALJ here gave no explanation." Id. This court has interpreted the Fourth Circuit's holding in Mascio to emphasize that an ALJ must explain how he considered the claimant's limitation in concentration, persistence, or pace in assessing her RFC. See Sipple v. Colvin, No. 8:15-1961-MBS-JDA, 2016 WL 4414841, at *9 (D.S.C. Jul. 29, 2016), adopted by 2016 WL 4379555 (D.S.C. Aug. 17, 2016) ("After Mascio, further explanation and/or consideration is necessary regarding how Plaintiff's moderate limitation in concentration, persistence, or pace does or does not translate into a limitation in his RFC.").
The ALJ cited Dr. Kittrell's opinion as supporting a finding that Plaintiff had moderate difficulties in concentration, persistence, or pace. Tr. at 32. He included restrictions in the RFC assessment for simple, routine tasks that involved occasional changes in the work setting and occasional interaction with coworkers and the public. Tr. at 33. He found that Plaintiff had the ability to make work-related decisions. Id.
The ALJ's decision lacks an explanation as to why he assessed moderate, as opposed to marked difficulties in concentration, persistence, or pace. Although the ALJ accepted Dr. Kittrell's opinion in finding that Plaintiff would have moderate difficulties in following through with work tasks, meeting general productivity standards, and adapting to normal work stressors, Dr. Kittrell had indicated Plaintiff would have moderate-to-marked impairment in these areas. See Tr. at 464.
The ALJ cited evidence that showed normal findings during some treatment visits, but significant impairment in concentration, persistence, or pace during other visits. He noted that Dr. Kittrell had assessed Plaintiff as having below average attention and concentration, but had found her cognitive pace to be in the average range. Tr. at 32. He recognized that Dr. Kittrell had assessed Plaintiff as having below average frustration tolerance, but appropriate thought content, average general fund of knowledge, and adequate practical reasoning and hazard recognition. Tr. at 29. He cited notations from Dr. Kittrell's evaluation, May and November 2014 treatment notes, and a September 2014 hospital discharge summary as suggesting Plaintiff had no signs of significant mental confusion, good attention/concentration, and good recall ability. Tr. at 32. However, he also recognized that Plaintiff's medical providers had observed her to have preoccupied thought content in May 2014; poor recent memory, distractible attention/concentration, and preoccupied and agitated thought content in August 2014; very distractible attention and concentration in November 2014; and poor recent memory and distractible attention/concentration in January and February 2015. Tr. at 29 and 32. He noted that Plaintiff had testified to having a hard time focusing, following through, and recalling things. Tr. at 32.
Despite his acknowledgment that the record showed Plaintiff to have variable abilities to recall information, tolerate frustration, remain on task, and maintain attention and concentration, the ALJ credited Dr. Kittrell's opinion only to the extent he suggested moderate, as opposed to marked limitations in Plaintiff's abilities to follow through with work tasks, meet general productivity standards, and adapt to normal work stressors and assessed overall moderate difficulties in concentration, persistence, or pace. The record is devoid of clarification as to why the ALJ concluded that the evidence supported moderate, as opposed to marked limitations. The ALJ also failed to explain why he found that a restriction to simple, routine tasks with only occasional changes adequately addressed Plaintiff's difficulties in concentration, persistence, or pace. In light of the inadequacies in the ALJ's analysis, the undersigned recommends the court find that he did not comply with the provisions of 20 C.F.R. § 404.1545(a), SSR 96-8p, or the Fourth Circuit's holding in Mascio and that substantial evidence does not support his RFC finding.
Plaintiff argues the ALJ did not account for her problems with reaching, handling, and manipulation. [ECF No. 17 at 24]. The Commissioner contends that Plaintiff's allegations of limitations in reaching, handling, and fingering are not substantially supported by the record. [ECF No. 18 at 9-10].
The ALJ acknowledged that the record contained evidence of reduced abduction in Plaintiff's bilateral shoulders; x-ray findings of mild degenerative changes to the acromioclavicular joints of the shoulders; Heberden's and Bouchard's nodes; and active tenderness in her wrists, shoulders, and MCP and bilateral PIP and DIP joints. Tr. at 27 and 28. He noted Plaintiff's complaints of pain in her hands and shoulders and indicated that Dr. Sharma had administered steroid injections for rapid relief of symptoms. Tr. at 28. However, he cited findings of no synovitis in Plaintiff's upper extremities during multiple visits and normal ROM of all peripheral joints in January 2013. Tr. at 27-28.
The record contains additional information that the ALJ did not cite in his decision with respect to the functional effects of Plaintiff's impairments on her ability to use her shoulders, arms, and hands. Plaintiff reported that she experienced numbness and paresthesia in her shoulders and arms and occasional locking of her fingers. Tr. at 791, 801, and 1011. She complained that her shoulder pain affected her ability to perform ADLs. Tr. at 519. She testified that her ability to use her hands was limited by pain. Tr. at 68. Dr. Sharma indicated Plaintiff experienced locking of her hands while performing simple tasks, and had minimal abilities to grasp, turn, and twist objects; use her hands and fingers for fine manipulations; and use her arms for reaching. Tr. at 660, 850, and 854.
Even though the ALJ acknowledged some of the evidence cited above that would suggest impairment to Plaintiff's ability to use her fingers, arms, and hands, he neither included nor provided reasons for declining to impose restrictions in the RFC assessment that pertained to Plaintiff's upper extremities. See Tr. at 33 (setting forth the RFC assessment). Therefore, the undersigned recommends the court find the ALJ erred in declining to adequately evaluate Plaintiff's ability to perform relevant functions, despite contradictory evidence in the record. See Mascio, 780 F.3d at 636.
Plaintiff argues the ALJ did not adequately assess the medical opinions of record. [ECF No. 17 at 25]. The Commissioner maintains that substantial evidence supports the ALJ's weighing of the medical opinions. [ECF No. 18 at 10].
ALJs "must always carefully consider medical source opinions about any issue." SSR 96-5p. The regulations direct ALJs to accord controlling weight to treating physicians' opinions that are well-supported by medically-acceptable clinical and laboratory diagnostic techniques and that are not inconsistent with the other substantial evidence of record. 20 C.F.R. § 404.1527(c)(2). If a treating physician's opinion is not well-supported by medically-acceptable clinical and laboratory diagnostic techniques or if it is inconsistent with the other substantial evidence of record, the ALJ may decline to give it controlling weight. SSR 96-2p, 1996 WL 374188 at *2 (1996). However, if the ALJ issues a decision that is not fully favorable, his decision "must contain specific reasons for the weight given to the treating source's medical opinion, supported by the evidence in the case record, and must be sufficiently specific to make clear to any subsequent reviewers the weight the adjudicator gave to the treating source's medical opinion and the reason for that weight." Id. at *5. The ALJ must "always give good reasons" for the weight he accords to a treating physician's opinion. 20 C.F.R. § 404.1527(c)(2).
If the ALJ declines to give controlling weight to a treating physician's opinion, he is required to consider it along with all the other medical opinions of record based on the relevant factors in 20 C.F.R. § 404.1527(c), which include (1) the examining relationship between the claimant and the medical provider; (2) the treatment relationship between the claimant and the medical provider, including the length of the treatment relationship and frequency of treatment and the nature and extent of the treatment relationship; (3) the supportability of the medical provider's opinion in his or her own treatment records; (4) the consistency of the medical opinion with other evidence in the record; and (5) the specialization of the medical provider offering the opinion.
The undersigned has considered the ALJ's evaluation of Dr. Sharma's and Dr. Kittrell's opinions in light of the foregoing authority.
Dr. Sharma indicated in an impairment questionnaire
Dr. Sharma completed a second questionnaire on July 31, 2015. Tr. at 848-52. She indicated she had treated Plaintiff every two-to-three months beginning on November 9, 2012. Tr. at 848. She did not respond to a question about whether Plaintiff met the diagnostic criteria for systemic lupus erythematosus. Id. She identified Plaintiff's signs and symptoms as severe fatigue, trouble sleeping, weight gain, and depression. Tr. at 849. She indicated Plaintiff could perform work in seated and standing positions for less than one hour each in an eight-hour workday. Tr. at 850. She stated Plaintiff could rarely lift and carry zero to five pounds and specified that she could lift two pounds. Id. She indicated Plaintiff had significant limitations in reaching, handling, or fingering. Id. She stated Plaintiff could never or rarely grasp, turn, and twist objects, use her fingers and hands for fine manipulations, and use her bilateral arms for reaching. Id. She identified Plaintiff's medications as Sulindac, Methotrexate, Plaquenil, Pamelor, Cymbalta, Lyrica, Skelaxin, and Pennsaid. Tr. at 851. She noted that Plaintiff's symptoms were likely to increase if she were placed in a competitive work environment. Id. She stated Plaintiff's condition was "chronic & severe at this time," rendering her "unable to work in a normal capacity due to the frequency of flare-ups." Id. She indicated Plaintiff's experience of pain, fatigue, or other symptoms would frequently be severe enough to interfere with attention and concentration. Id. She stated Plaintiff's ongoing impairments were expected to last at least 12 months and her limitations applied as far back as August 1, 2012. Tr. at 851 and 852. She indicated Plaintiff would need to take unscheduled breaks to rest at unpredictable intervals during an eight-hour workday. Tr. at 851. She specified that Plaintiff would require a break after working for 30 minutes and would have to rest for seven hours before returning to work. Id. She anticipated that Plaintiff would likely be absent from work more than three times a month because of her impairments or treatment. Tr. at 852. She stated the following: "Patient has chronic and severe SJOGREN's and fibromyalgia. Mrs. Scott is unable to perform at any capacity or competitive work environment." Id.
Dr. Sharma also wrote a letter on July 31, 2015, detailing Plaintiff's condition and limitations. Tr. at 854-55. She stated repeated lab work confirmed Plaintiff's diagnoses of Sjogren's syndrome, fibromyalgia, and seronegative rheumatoid arthritis. Tr. at 854. She indicated Plaintiff's Methotrexate dose had been increased from six to eight tablets per week over time. Id. She noted that Plaintiff experienced side effects of medications that included dizziness, elevated liver function, hair loss, hives, color vision loss, sedation, "loopy" feeling, suicidal thoughts, headaches, heart palpations, nausea, and compromised immunity. Id. She stated Plaintiff was unable to participate in full-time employment as a result of chronic pain that prevented her from sitting or standing for prolonged periods; locking of her hands while performing simple tasks; constant tiredness; difficulty recalling information; and impaired "train of thought" and memory. Id. She indicated Plaintiff's symptoms included "disabling fatigue, malaise, weakness, lethargy, anxiety, depression, mental confusion, memory loss, and impaired ability to concentrate." Id. She stated Plaintiff had difficulty performing self-care and ADLs and relied on her family and friends for assistance. Id. She noted that Plaintiff used a cane for balance while ambulating through her home. Id. She stated Plaintiff experienced light sensitivity and would have difficulty staring at a computer screen. Id. She indicated that Plaintiff was "capable of only mild intermittent activity, for short periods of time that is rather unpredictable." Id. She noted that Plaintiff's impairments were expected to last for the remainder of her life. Id.
Plaintiff argues the ALJ did not properly explain his assignment of weight to Dr. Sharma's opinions. [ECF No. 17 at 28]. She maintains Dr. Sharma's opinions were supported by her status as a treating physician, the number of examinations she conducted, her specialization as a rheumatologist, her findings on examination, x-ray findings, and other medical providers' observations. Id. at 28-29. She contends that because of the nature of fibromyalgia, the ALJ erred in using the absence of objective findings as a reason to discount Dr. Sharma's opinion. Id. at 29-32.
The Commissioner argues the ALJ properly gave partial weight to Dr. Sharma's 2013 opinion because it was inconsistent with the evidence, not supported by contemporaneous clinical findings or an accompanying explanation, and based primarily on Plaintiff's subjective complaints. [ECF No. 18 at 10-11]. She maintains that the ALJ gave partial credit to opinions Dr. Sharma provided after Plaintiff's insured status expired, and that Plaintiff has failed to present convincing evidence that these opinions applied to the earlier period.
The ALJ indicated he had given "great weight to the assessment provided by Dr. Sharma, a treating source at Exhibit 2F, page 6, as it is consistent with the record as a whole." Tr. at 36. It is not entirely clear from the ALJ's decision to what he accorded great weight, as Exhibit 2F, page 6 is the first page of a two-page summary of Plaintiff's November 9, 2012 visit with Dr. Sharma. See Tr. at 366. It notes Plaintiff's subjective complaints, a review of symptoms, her social history, her family history, and documents that she has no allergies, but contains no objective findings or limitations. See id.
The ALJ gave "only partial weight" to Dr. Sharma's other opinions. Tr. at 36. He acknowledged that Dr. Sharma was a treating source, but found that the limitations she assessed were not consistent with the other evidence, supported by her clinical records, or bolstered by an explanation. Tr. at 36-37. He found that the limitations Dr. Sharma assessed appeared "to be based primarily on the claimant's subjective complaints" and were "inconsistent with activities/abilities she ha[d] reported to other treating sources."
Earlier in the decision, the ALJ indicated the following:
Tr. at 35. He acknowledged that Plaintiff had complained of multiple flares between each of her visits, but found that the flares did not occur with the frequency she endorsed during the hearing. Id. He stated the record did not show that Plaintiff complained of side effects from medications or that her physicians instructed her to elevate her feet. Id. He noted that Plaintiff often reported her medications were not working and received steroid injections for rapid relief of symptoms. Id. He pointed out that Dr. Sharma repeatedly instructed Plaintiff to exercise. Id.
The record reflects that Dr. Sharma treated Plaintiff on 12 occasions between November 19, 2012, and July 31, 2015, typically examining her every three months. See generally Tr. at 361-72, 493-533, and 770-846. She treated Plaintiff for a longer period than any other medical source. Because Dr. Sharma was a rheumatologist who specifically treated Plaintiff for Sjogren's syndrome and fibromyalgia, she was particularly qualified to provide an opinion as to the limiting effects of these impairments. See 20 C.F.R. § 404.1527(c)(2)(ii) ("When the treating source has reasonable knowledge of your impairment(s), we will give the source's medical opinion more weight than we would give it if it were from a nontreating source."); 20 C.F.R. § 404.1527(c)(5) ("We generally give more weight to the medical opinion of a specialist about medical issues related to his or her area of specialty than to the medical opinion of a source who is not a specialist."). Despite acknowledging that Dr. Sharma was a treating source (Tr. at 36), the ALJ failed to consider the length of the treatment relationship, the frequency of examination, the nature and extent of the treatment relationship, and Dr. Sharma's specialization as factors that weighed in favor of her opinion. See 20 C.F.R. § 404.1527(c)(2).
In light of the nature of Plaintiff's impairments, the ALJ erred to the extent that he allocated reduced weight to Dr. Sharma's opinion based on the absence of additional objective findings in her clinical records. Fibromyalgia is "a complex medical condition characterized primarily by widespread pain in the joints, muscles, tendons, and nearby soft tissues." SSR 12-2p, 2012 WL 3104869, at *2. The ALJ must consider the longitudinal treatment record "because the symptoms of FM can wax and wane so that a person may have `bad days and good days.'" Id., at *6. As the ALJ acknowledged, Dr. Sharma's records reflected findings of tenderness in multiple areas of Plaintiff's body during all visits and crepitus in her knees and spasm in her back during most visits. See Tr. at 35; see also Tr. at 363, 367, 520, 523, 792, 794, 799, 802, 806, and 814. Plaintiff consistently reported pain during visits and flares between visits. See generally Tr. at 361-72, 493-533, and 770-846. In light of the foregoing, the ALJ did not properly consider the supportability of Dr. Sharma's opinion in her treatment records. See 20 C.F.R. § 404.1527(c)(3).
Although the ALJ pointed to perceived inconsistencies between Dr. Sharma's opinion and the other evidence of record, he failed to explain how the evidence he cited conflicted with Dr. Sharma's opinion and did not cite any inconsistencies between Dr. Sharma's opinion and other treating sources' impressions. While the ALJ pointed to activities that Plaintiff reported to her counselors, he failed to explain how her ability to engage in these isolated activities undermined Dr. Sharma's opinion about her ability to function on a regular and continuing basis in a work setting. See Tr. at 933-1006 and 1210-24. Contrary to the ALJ's assertion, the record is consistent with Dr. Sharma's opinion in that it reflects Plaintiff's complaints of side effects from medications. See Tr. at 461 (reporting to Dr. Kittrell that her medications caused confusion, nausea, fatigue, and drowsiness), 520-21 (instructing Plaintiff to avoid NSAIDs because of abnormal kidney function), and 1044 (declining to increase Plaintiff's dosages of Tizanidine and Cymbalta because of significant somnolence). The ALJ did not consider that Dr. Sharma's opinion was generally supported by Dr. Moreno's indications that Plaintiff had increased risk of infection and that her brain fog and fatigue might not respond to medication because the symptoms were difficult to treat in patients with Sjogren's syndrome. See Tr. at 376. He also failed to consider consistency between Dr. Sharma's opinion and Plaintiff's physical therapist's indication that her rehabilitation prognosis was guarded in light of her impairments. Tr. at 1140. Therefore, the ALJ did not provide sufficient support for his conclusion that Dr. Sharma's opinion was inconsistent with the other evidence of record. See 20 C.F.R. § 404.1527(c)(4).
In light of the foregoing, the undersigned recommends the court find that substantial evidence does not support the ALJ's allocation of only partial weight to Dr. Sharma's opinions.
Dr. Kittrell stated the following:
Tr. at 464.
Plaintiff argues that despite the ALJ's indication that Dr. Kittrell's assessment was consistent with the record as a whole, he failed to account for the restrictions Dr. Kittrell included in the RFC assessment. [ECF No. 17 at 32-33]. She contends that Dr. Kittrell's opinion is supported by Ms. Spence's findings. Id. at 33.
The Commissioner argues the ALJ reasonably gave partial weight to Dr. Kittrell's opinion. [ECF No. 18 at 12]. She maintains the ALJ identified Plaintiff's ability to perform significant activities as being consistent with moderate, as opposed to marked, difficulty following through with work tasks, maintaining general productivity standards, adapting to normal work stressors, and demonstrating adequate social skills. Id. at 12-13.
The ALJ accorded partial weight to Dr. Kittrell's opinion. Tr. at 36. He found that Dr. Kittrell's opinion that Plaintiff "should be able to understand and remember simple and more complex instructions" was "consistent with the record as a whole." Id. As noted above, the ALJ accepted Dr. Kittrell's opinion about Plaintiff's ability to follow through with work tasks, meet general productivity standards, and adapt to normal work stressors to the extent that Dr. Kittrell suggested moderate, as opposed to marked, limitation in these areas. Id. He gave great weight to Dr. Kittrell's opinion that Plaintiff's social skills seemed inadequate for many work settings because "this would imply that her social skills would be adequate for some work settings." Id.
The ALJ's decision to accord partial weight to Dr. Kittrell's opinion lacks an adequate evaluation of the relevant factors in 20 C.F.R. § 404.1527(c). Although the ALJ found part of Dr. Kittrell's opinion to be "consistent with the record as a whole," he failed to explain why other parts of the opinion were unsupported by the record. As discussed above, the ALJ provided an inadequately explanation as to why he concluded that Plaintiff's abilities to follow through with work tasks, meet general productivity standards, and adapt to normal work stressors were consistent with moderate, as opposed to marked, limitation. In addition, as Plaintiff points out in her brief, the ALJ did not consider the supportability of Dr. Kittrell's opinion in his examination findings or the consistency between Dr. Kittrell's and Ms. Spence's opinions regarding her abilities to accept instructions and respond appropriately to criticism from supervisors. ECF No. 17 at 33, citing Tr. at 463 and 572; see also 20 C.F.R. § 404.1527(c)(3), (4).
In light of the foregoing, the undersigned recommends the court find that substantial evidence does not support the ALJ's allocation of partial weight to Dr. Kittrell's opinion.
Plaintiff argues the ALJ did not follow the provisions of SSR 16-3p in evaluating her objective allegations of symptoms. [ECF No. 17 at 33-34]. She claims the ALJ relied exclusive on objective evidence and did not consider the entire record. Id. at 34.
The Commissioner argues the ALJ did not rely exclusively on the lack of objective medical evidence, but reasonably reviewed the record in evaluating Plaintiff's subjective allegations. [ECF No. 18 at 13]. She contends the ALJ considered Plaintiff's testimony, her ADLs, the objective medical tests, and Dr. Sharma's observations and recommendations. Id. at 13-14.
The Social Security Administration uses a two-step process to evaluate a claimant's subjective symptoms. First, the ALJ must determine whether the claimant has a medical impairment that results from anatomical, physiological, or psychological abnormalities and that could reasonably be expected to produce the pain or other symptoms alleged. 20 C.F.R. § 404.1529(b) (effective Jun. 13, 2011 to Mar. 26, 2017). After having determined that the medical signs or laboratory findings support the existence of a medically-determinable impairment that could reasonably be expected to produce the alleged symptoms, the ALJ should evaluate the intensity and persistence of the claimant's symptoms to determine how they affect her capacity for work. 20 C.F.R. § 404.1529(c) (effective Jun. 13, 2011 to Mar. 26, 2017). This requires an assessment of all the available evidence, to include the claimant's treatment history; signs and laboratory findings; statements from the claimant, the claimant's treating and non-treating medical sources, and other persons; and the medical opinions of record. 20 C.F.R. § 404.1529(c)(1) (effective Jun. 13, 2011 to Mar. 26, 2017).
The ALJ is not to "evaluate an individual's symptoms based solely on objective medical evidence unless that objective medical evidence supports a finding that the individual is disabled. SSR 16-3p, 2016 WL 1119029 at *4 (2016). "Since symptoms sometimes suggest a greater severity of impairment than can be shown by objective medical evidence alone," the ALJ is to "carefully consider any other information" about the claimant's symptoms. 20 C.F.R. § 404.1529(c)(3) (effective Jun. 13, 2011 to Mar. 26, 2017). The following factors are relevant to the claimant's symptoms: her ADLs; the location, duration, frequency, and intensity of her pain or other symptoms; factors that precipitate and aggravate her pain; the type, dosage, effectiveness, and side effects of any medication she takes or has taken to alleviate pain or other symptoms; treatment, other than medication, she receives or has received for relief of pain or other symptoms; any measures other than treatment she uses or has used to relieve pain or other symptoms; and any other factors concerning her functional limitations and restrictions due to pain or other symptoms. Id.; SSR 16-3p, 2016 WL 1119029 at *7.
In evaluating the non-objective evidence, the ALJ is to consider the claimant's "statements about the intensity, persistence, and limiting effects of symptoms" and should "evaluate whether the statements are consistent with objective medical evidence and other evidence." SSR 16-3p, 2016 WL 1119029 at *6. He may compare the claimant's statements to information she provided to her medical sources regarding the onset, character, and location of her symptoms; factors that precipitate and aggravate her symptoms; the frequency and duration of her symptoms; change in her symptoms (e.g., whether worsening, improving, or static); and ADLs. Id.
The ALJ found that Plaintiff's medically-determinable impairments "could reasonably be expected to cause the alleged symptoms," but that her "statements concerning the intensity, persistence and limiting effects of these symptoms" were "not entirely consistent with the medical evidence and other evidence in the record." Tr. at 35. Contrary to Plaintiff's assertion, the ALJ did not consider the objective medical evidence alone, but also considered her reported ADLs and subjective complaints. See Tr. at 35. Nevertheless, the ALJ's decision does not reflect an adequate evaluation of the entire record. The ALJ specifically failed to reconcile conflicting evidence and did not thoroughly consider Plaintiff's medical sources' opinions as to the effects of her impairments on her ability to engage in work activity on a regular and continuing basis. An ALJ's decision must "build an accurate and logical bridge from the evidence" to his conclusion regarding the claimant's credibility. Monroe v. Colvin, 826 F.3d 176, 189 (4th Cir. 2016), citing Clifford v. Apfel, 227 F.3d 872 (7th Cir. 2000). In the absence of "an accurate and logical bridge" between the evidence of record and the ALJ's conclusion that Plaintiff's subjective allegations were not entirely consistent with the medical evidence, the undersigned recommends the court find that substantial evidence does not support the ALJ's finding.
The court's function is not to substitute its own judgment for that of the ALJ, but to determine whether the ALJ's decision is supported as a matter of fact and law. Based on the foregoing, the court cannot determine that the Commissioner's decision is supported by substantial evidence. Therefore, the undersigned recommends, pursuant to the power of the court to enter a judgment affirming, modifying, or reversing the Commissioner's decision with remand in Social Security actions under sentence four of 42 U.S.C. § 405(g), that this matter be reversed and remanded for further administrative proceedings.
IT IS SO RECOMMENDED.
The parties are advised that they may file specific written objections to this Report and Recommendation with the District Judge. Objections must specifically identify the portions of the Report and Recommendation to which objections are made and the basis for such objections. "[I]n the absence of a timely filed objection, a district court need not conduct a de novo review, but instead must `only satisfy itself that there is no clear error on the face of the record in order to accept the recommendation.'" Diamond v. Colonial Life & Acc. Ins. Co., 416 F.3d 310 (4th Cir. 2005) (quoting Fed. R. Civ. P. 72 advisory committee's note).
Specific written objections must be filed within fourteen (14) days of the date of service of this Report and Recommendation. 28 U.S.C. § 636(b)(1); Fed. R. Civ. P. 72(b); see Fed. R. Civ. P. 6(a), (d). Filing by mail pursuant to Federal Rule of Civil Procedure 5 may be accomplished by mailing objections to:
