DAVID A. BAKER, Magistrate Judge.
The Plaintiff brings this action pursuant to the Social Security Act (the Act), as amended, Title 42 United States Code Section 405(g), to obtain judicial review of a final decision of the Commissioner of the Social Security Administration (the Commissioner) denying her claim for Supplemental Security Income (SSI) benefits under the Act.
The record has been reviewed, including a transcript of the proceedings before the Administrative Law Judge (ALJ), the exhibits filed and the administrative record, and the pleadings and memoranda submitted by the parties in this case. Oral argument has not been requested.
For the reasons that follow, the decision of the Commissioner is is
Plaintiff filed for SSI benefits on February 26, 2007, alleging an onset of disability on January 1, 2007, due to due to seizures, ovarian cancer, blindness in the right eye, high blood pressure, and anemia. R. 126-28, 143, 147. Her application was denied initially and upon reconsideration. R. 64-79. Plaintiff requested a hearing, which was held on October 29, 2009, before Administrative Law Judge Deborah Arnold (hereinafter referred to as "ALJ"). R. 33-58. In a decision dated January 13, 2010, the ALJ found Plaintiff not disabled as defined under the Act through the date of her decision. R. 12-26. Plaintiff timely filed a Request for Review of the ALJ's decision and the Appeals Council denied Plaintiff's request on December 16, 2010. R. 1-5. Plaintiff filed this action for judicial review on February 8, 2010. Doc. 1.
At the time of the hearing, Plaintiff was forty-two years old and had graduated from high school. R. 36-37. Plaintiff had been employed as an administrative clerk, a receptionist, an order clerk, a manager of a retail store, a manager of an office, and a salesperson in a jewelry store. R. 99, 230.
Plaintiff's medical history is set forth in detail in the ALJ's decision. By way of summary, Plaintiff complained of seizures, ovarian pain and problems, blindness in the right eye
Plaintiff now asserts two points of error. She claims the ALJ erred by finding she had the RFC to perform light work with certain restrictions even though the state agency physicians opined Plaintiff would have a more restrictive residual functional capacity. Plaintiff also argues that the ALJ erred by relying upon the testimony of the vocational expert (VE) when the hypothetical question to the VE failed to include all of Plaintiff's impairments. For the reasons that follow, the decision of the Commissioner is
The scope of this Court's review is limited to determining whether the ALJ applied the correct legal standards, McRoberts v. Bowen, 841 F.2d 1077, 1080 (11
"If the Commissioner's decision is supported by substantial evidence, this Court must affirm, even if the proof preponderates against it." Phillips v. Barnhart, 357 F.3d 1232, 1240 n. 8 (11th Cir. 2004). "We may not decide facts anew, reweigh the evidence, or substitute our judgment for that of the [Commissioner.]" Id. (internal quotation and citation omitted). Dyer v. Barnhart, 395 F.3d 1206, 1210 (11
The ALJ must follow five steps in evaluating a claim of disability. See 20 C.F.R. §§ 404.1520, 416.920. First, if a claimant is working at a substantial gainful activity, she is not disabled. 20 C.F.R. § 404.1520(b). Second, if a claimant does not have any impairment or combination of impairments which significantly limit her physical or mental ability to do basic work activities, then she does not have a severe impairment and is not disabled. 20 C.F.R. § 404.1520(c). Third, if a claimant's impairments meet or equal an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1, she is disabled. 20 C.F.R. § 404.1520(d). Fourth, if a claimant's impairments do not prevent her from doing past relevant work, she is not disabled. 20 C.F.R. § 404.1520(e). Fifth, if a claimant's impairments (considering her residual functional capacity, age, education, and past work) prevent her from doing other work that exists in the national economy, then she is disabled. 20 C.F.R. § 404.1520(f).
Plaintiff claims that the ALJ should not have found her able to perform a light work with simple, one-to-three step tasks and limited to superficial interaction with coworkers and the general public when the state agency physicians opined the claimant would have a more restrictive mental residual functional capacity. The Commissioner argues that the ALJ's RFC finding was consistent with the RFC assessments provided by the state agency consultants.
Residual functional capacity is an assessment based on all relevant evidence of a claimant's remaining ability to do work despite her impairments. 20 C.F.R. § 404.1545(a); Lewis v. Callahan, 125 F.3d 1436,1440 (11th Cir. 1997). The focus of this assessment is on the doctor's evaluation of the claimant's condition and the medical consequences thereof. Id. Substantial weight must be given to the opinion, diagnosis and medical evidence of a treating physician unless there is good cause to do otherwise. See Lewis, 125 F.3d at 1440; Edwards, 937 F.2d at 583; 20 C.F.R. §§ 404.1527(d), 416.927(d). If a treating physician's opinion on the nature and severity of a claimant's impairments is well-supported by medically acceptable clinical and laboratory diagnostic techniques, and is not inconsistent with the other substantial evidence in the record, the ALJ must give it controlling weight. 20 C.F.R. §§ 404.1527(d)(2), 416.927(d)(2). Where a treating physician has merely made conclusory statements, the ALJ may afford them such weight as is supported by clinical or laboratory findings and other consistent evidence of a claimant's impairments. See Wheeler v. Heckler, 784 F.2d 1073, 1075 (11th Cir. 1986); see also Schnorr v. Bowen, 816 F.2d 578, 582 (11th Cir. 1987).
In this case, the ALJ determined Plaintiff's residual functional capacity was light work with certain restrictions:
R. 20. The ALJ also found that Plaintiff was not capable of performing past relevant work, but that there were other jobs in the national economy that Plaintiff could perform, based on VE testimony. R. 24-25.
Plaintiff argues that although the ALJ found the opinions of the state agency physicians to be "persuasive" (R 24), the ALJ erred by failing to include all of the limitations outlined by the state agency physicians, Theodore Weber, Psy.D. and Dr. Pamela D. Green, in Plaintiff's RFC.
On August 21, 2007, Dr. Weber noted Plaintiff had moderate difficulties in maintaining social functioning; moderate difficulties in maintaining concentration, persistence, or pace; and one or two episodes of decompensation. R. 401. Dr. Weber opined that Plaintiff would be moderately limited in the ability to understand and remember detailed instructions; the ability to carry out detailed instructions; the ability to maintain attention and concentration for extended periods; the ability to complete a normal work day and work week without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods; the ability to accept instructions and respond appropriately to criticism from supervisors; the ability to get along with coworkers or peers without distracting them or exhibiting behavioral extremes; the ability to respond appropriately to changes in the work setting; and the ability to set realistic goals or make plans independently of others. R. 405-06. Another state agency psychologist, Dr. Green, on February 23, 2008 noted that Plaintiff had moderate limitations in many of the same areas and opined: Plaintiff was moderately limited in the ability to understand and remember detailed instructions; the ability to carry out detailed instructions; the ability to maintain attention and concentration for extended periods; the ability to complete a normal work day and work week without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods; the ability to respond appropriately to changes in the work setting; and the ability to set realistic goals or make plans independently of others; she also had moderate difficulties in maintaining social functioning; moderate difficulties in maintaining concentration, persistence, or pace; and one or two episodes of decompensation. R. 483-84, 497.
Plaintiff argues that the ALJ erred by failing to include all of these moderate limitations — other than Plaintiff could "perform simple, one-to-three step tasks and have only superficial interaction with coworkers and the general public" (R. 20) — even though the ALJ found both of these psychologist's opinions to be persuasive. R 24. Plaintiff argues that in particular, the ALJ failed to discuss or include her moderate limitations in the ability to maintain attention and concentration for extended periods; her inability to complete a normal work day and work week without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods; the ability to respond appropriately to changes in the work setting; and the ability to set realistic goals or make plans independently of others. R. 405-06, 483-84. Although both of the state agency physicians noted that Plaintiff had moderate difficulties in maintaining concentration, persistence, or pace and one or two episodes of decompensation (R. 401, 497), Plaintiff argues that it is not clear how the ALJ factored these limitations into the ALJ's residual functional capacity assessment, or if the ALJ considered them at all.
The Commissioner argues that the ALJ adequately accounted for Plaintiff's difficulties with social functioning and concentration, persistence, and pace in the RFC assessment and in the hypothetical question by limiting Plaintiff to simple, one-to-three step tasks and superficial interaction with coworkers and the general public (R. 19-20, Finding No. 4). The Commissioner highlights the ALJ's adoption of portions of Section III (as opposed to Section I) of the MRFC assessments
An ALJ cannot generally account for a claimant's deficiencies in concentration, persistence, and pace by restricting the vocational expert's inquiry to simple, routine tasks or unskilled work unlessthe medical evidence demonstrates that a claimant retains the ability to engage in simple, routine, repetitive tasks or unskilled work despite deficiencies in concentration, persistence, and pace and these restriction sufficiently account or such deficiencies. See Winschel v. Commissioner, 631 F.3d 1176, 1181 (11th Cir. 2011) (holding that where an ALJ finds a moderate impairment in concentration, persistence or pace, he must indicate that the medical evidence suggested the claimant could work despite the limitation); Richter v. Commissioner of Social Security, No. 09-12674, 379 Fed.Appx. 959, 961-62 (11th Cir. 2010) (unpublished) (same).
In discussing Plaintiff's mental impairment, the ALJ described Plaintiff's mental limitations:
R. 18-19, 22.
Although the ALJ cited some of the findings from Dr. Clements' consultative examination report, she failed to cite the complete findings which indicated Plaintiff had experienced more episodes of decompensation (by Plaintiff's report) and the equivocal nature of the consultative examiner's memory findings, which recommended "memory testing to rule out an impairment":
R. 387-88 (emphasis added — dated July 9, 2007). Dr. Clements diagnosed Plaintiff with Major Depressive Disorder, recurrent, moderate, and Borderline Personality Disorder, with Sleep Disorder Due to Chronic Pain, Insomnia Type [rule out] memory impairment. R. 388. No additional memory testing was performed, the ALJ concentrated only on Dr. Clements' notes that Plaintiff "demonstrated fair recall of recent and remote events" suggesting no severe short-term or long-term memory problem," and the ALJ ignored Dr. Clements' recommendation of "memory testing to rule out a problem." R. 388. Particularly in Plaintiff's case, where CT scans of her brain indicated bullet fragments were present (R. 355, 359, 467) and she had trouble with her "speech and thought processes" which "were logical but not always coherent," and she had language expression problems, word finding problems, articulation problems, and problems pronouncing certain sounds. R. 387. The ALJ's failure to accurately reflect Dr. Clements' restrictions, or order the memory testing that Dr. Clements recommended, was not based on substantial evidence.
Neither of the opinions of the non-examining state psychologists, Drs. Weber and Green, reflect recognition of Plaintiff's "multiple" Baker Act commitments. Dr. Weber's Mental RFC assessment, dated August 21, 2007 noted:
R. 407 (emphasis added). Dr. Green, the other state non-examining mental health physician, noted:
R. 499 (emphasis added). Dr. Green appended an update on reconsideration noting Plaintiff's hospitalization from September 28 to October 3 for bipolar disorder and borderline personality traits. R. 499.
Although both Drs. Weber and Green found there was "no documented history of admissions," their were several references in the mental health treatment records to Plaintiff's repeated commitments for suicidal thoughts and cutting herself. Records from Seminole Community Mental Health Center state, "Patient has history of multiple admissions and Baker Acts to our Crisis Unit here and at Lakeside and Florida Hospital and different treating facilities. She tried to cut her wrists at younger age and she started having suicidal thoughts and gestures since age 13." R. 476. Plaintiff reported having a mental illness from her teenage years," and "she had cut on her wrists in the past also and had tried to overdose a year ago." R. 478. Records from 2002 indicate that Plaintiff had been Baker Acted at Seminole Community Mental Health Center after she got into an argument and decided "to cut on herself." R. 486. She gave a history of having "cut herself in the past." R. 480.
Records from Lakeside Behavioral Healthcare from September-October 2007 indicate Plaintiff was admitted to the locked Crisis Stabilization Unit where she was admitted complaining of suicidal ideation and threats to cut herself, but without a specific plan. R. 431, 450. She had a history of prior inpatient treatment at the University of Pennsylvania in 1986 when she was 18 years old. She also reports a history of "at least 10 [Baker Act admissions] to date. She has been treated at Florida Hospital, South Seminole and [Lakeside Behavioral Health]. Old records are not currently available." R. 450. A Comprehensive Psychiatric Evaluation performed on September 17, 2008 at Orange Blossom Family Health also noted Plaintiff's report of past psychiatric history of treatment at Seminole Community Mental Health Center and Lakeside Behavioral Healthcare. R. 555. The ALJ's reliance on the opinions the non-examining state psychologists, who failed to recognize Plaintiff's multiple hospitalizations, was in error and her opinion was not based on substantial evidence
Plaintiff contends that the ALJ erred in relying on the testimony of the Vocational Expert after posing a hypothetical question that did not adequately reflect Plaintiff's limitations. At step four of the five-step sequential evaluation process, the ALJ must determine whether or not the claimant is able to return to his or her past relevant work. If the claimant is found to be able to perform the duties of her past relevant work, then he or she is considered not disabled and therefore ineligible for benefits. The claimant bears the burden of proving the inability to perform his or her previous work. Lucas v. Sullivan, 918 F.2d 1567, 1571 (11th Cir. 1990). The claimant must show the inability to do the type of work performed in the past, not merely the specific job he or she held. Jackson v. Bowen, 801 F.2d 1291, 1293 (11th Cir. 1986). The ALJ must consider all of the duties of the past work and evaluate the claimant's ability to perform those duties in spite of the impairments. Lucas, 918 F.2d at 1574 n. 3.
On remand, once the ALJ has properly determined Plaintiff's mental residual functional capacity for memory, concentration, persistence, and pace, and ability to follow complex and simple directions, those limitations at the appropriate level are to be factored into limitations in a hypothetical posed to the VE.
For the reasons set forth above, the ALJ's decision is not consistent with the requirements of law and is not supported by substantial evidence. Accordingly, the Court