SAM A. CROW, Senior District Judge.
This is an action reviewing the final decision of the Commissioner of Social Security denying the plaintiff disability insurance benefits and supplemental security income payments. The matter has been fully briefed by the parties.
The court's standard of review is set forth in 42 U.S.C. § 405(g), which provides that "the findings of the Commissioner as to any fact, if supported by substantial evidence, shall be conclusive." The court should review the Commissioner's decision to determine only whether the decision was supported by substantial evidence and whether the Commissioner applied the correct legal standards.
The Social Security Act provides that an individual shall be determined to be under a disability only if the claimant can establish that they have a physical or mental impairment expected to result in death or last for a continuous period of twelve months which prevents the claimant from engaging in substantial gainful activity (SGA). The claimant's physical or mental impairment or impairments must be of such severity that they are not only unable to perform their previous work but cannot, considering their age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy. 42 U.S.C. § 423(d).
The Commissioner has established a five-step sequential evaluation process to determine disability. If at any step a finding of disability or non-disability can be made, the Commissioner will not review the claim further. At step one, the agency will find non-disability unless the claimant can show that he or she is not working at a "substantial gainful activity." At step two, the agency will find non-disability unless the claimant shows that he or she has a "severe impairment," which is defined as any "impairment or combination of impairments which significantly limits [the claimant's] physical or mental ability to do basic work activities." At step three, the agency determines whether the impairment which enabled the claimant to survive step two is on the list of impairments presumed severe enough to render one disabled. If the claimant's impairment does not meet or equal a listed impairment, the inquiry proceeds to step four, at which the agency assesses whether the claimant can do his or her previous work; unless the claimant shows that he or she cannot perform their previous work, they are determined not to be disabled. If the claimant survives step four, the fifth and final step requires the agency to consider vocational factors (the claimant's age, education, and past work experience) and to determine whether the claimant is capable of performing other jobs existing in significant numbers in the national economy.
The claimant bears the burden of proof through step four of the analysis.
Before going from step three to step four, the agency will assess the claimant's residual functional capacity (RFC). This RFC assessment is used to evaluate the claim at both step four and step five. 20 C.F.R. §§ 404.1520(a)(4), 404.1520(e, f, g); 416.920(a)(4), 416.920(e, f, g).
On May 4, 2012, administrative law judge (ALJ) Alison K. Brookins issued her decision (R. at 9-23). Plaintiff alleges that he had been disabled since January 1, 2005 (R. at 9). Plaintiff meets the insured status requirements for social security disability benefits through June 30, 2010 (R. at 11). At step one, the ALJ found that plaintiff did not engage in substantial gainful activity since the alleged onset date (R. at 11). At step two, the ALJ found that plaintiff had the following severe impairments: schizophrenia (paranoid type), attention deficit hyperactivity disorder (ADHD), impulse control disorder, and substance abuse (R. at 12). At step three, the ALJ determined that plaintiff's impairments do not meet or equal a listed impairment (R. at 12). After determining plaintiff's RFC (R. at 14), the ALJ determined at step four that plaintiff has no past relevant work (R. at 21). At step five, the ALJ found that plaintiff can perform jobs that exist in significant numbers in the national economy (R. at 22). Therefore, the ALJ concluded that plaintiff was not disabled (R. at 23).
The opinions of physicians, psychologists, or psychiatrists who have seen a claimant over a period of time for purposes of treatment are given more weight than the views of consulting physicians or those who only review the medical records and never examine the claimant. The opinion of an examining physician is generally entitled to less weight than that of a treating physician, and the opinion of an agency physician who has never seen the claimant is entitled to the least weight of all.
A treating physician's opinion about the nature and severity of the claimant's impairments should be given controlling weight by the Commissioner if well supported by clinical and laboratory diagnostic techniques and if it is not inconsistent with other substantial evidence in the record.
(1) the length of the treatment relationship and the frequency of examination;
(2) the nature and extent of the treatment relationship, including the treatment provided and the kind of examination or testing performed;
(3) the degree to which the physician's opinion is supported by relevant evidence;
(4) consistency between the opinion and the record as a whole;
(5) whether or not the physician is a specialist in the area upon which an opinion is rendered; and
(6) other factors brought to the ALJ's attention which tend to support or contradict the opinion.
After considering the above factors, the ALJ must give good reasons in his/her decision for the weight he/she ultimately assigns the opinion. If the ALJ rejects the opinion completely, he/she must then give specific, legitimate reasons for doing so.
Plaintiff received mental health treatment at COMCARE between February 24, 2009 and February 28, 2012. She was seen by LMSW Compton, ARNP Born, ARNP Harris, ARNP Koehn, Dr. Lear, LSCSW Belt-Newton, LMSW Mills and Philip Crayton, a substance abuse counselor (R. at 463-505, 555-574, 595-601, 618-628). Dr. Lear saw plaintiff himself on April 7, 2010, September 1, 2010 and February 21, 2012 (R. at 569-572, 596-598, 621-624). Dr. Lear is a psychiatrist and the medical director of COMCARE (R. at 613). On October 6, 2011, Dr. Lear made the following statement:
(R. at 613-614, emphasis added).
Dr. Lear completed a mental RFC assessment in which he found plaintiff markedly impaired in 16 categories and moderately limited in 4 categories (R. at 615-616). Dr. Lear further stated:
(R. at 616-617).
The ALJ for a number of reasons gave "very little weight" to this opinion (R. at 20-21). The court will examine many of those reasons for giving very little weight to the opinions of Dr. Lear.
The ALJ stated that "Dr. Lear's recitation of the claimant's symptoms appears to rely heavily on the claimant's self-report and subjective complaints, despite the suspect nature of these claims" (R. at 20). In the case of
Subsequently, in the case of
121 Fed. Appx. at 823-824.
As
Furthermore, the practice of psychology is necessarily dependent, at least in part, on a patient's subjective statements.
Second, the ALJ asserted that Dr. Lear did not examine plaintiff between April 2010 and February 2012, and thus had very little opportunity for the "recollections and observations" referred to in his opinion (R. at 20). However, Dr. Lear saw plaintiff on September 1, 2010. He found plaintiff's attention and concentration were impaired (R. at 596-598). Plaintiff was also seen at COMCARE on September 3, 2010 in which plaintiff reported he was kicked out of the homeless shelter because of an altercation with another resident (R. at 599-600).
Third, the ALJ states that Dr. Lear makes no explanation for his findings that plaintiff had marked difficulties with activities of daily living, extreme difficulties with social functioning and maintaining concentration, persistence and pace, and repeated episodes of decompensation. The ALJ asserts that he offers no explanation for these conclusions, and further asserts that there is no evidence of "any" episodes of decompensation (R. at 20). However, the COMCARE records and the report from Dr. Lear note he was on probation for domestic violence and assault, that he was kicked out of the homeless shelter due to an altercation, and stole a can of tuna fish and beat up a store employee. When plaintiff was kicked out of the homeless shelter, he went to his mother's home, but she became upset and called to request assistance; plaintiff ended up going to a friend's house (R. at 599-600). Claimant reported that he is homeless and has burned a lot of bridges because he is hard to live with because of his mental illness (R. at 599). Impaired, limited, only fair, or fair to poor attention and concentration were noted in numerous treatment records from 2007-2012 (R. at 403, 465, 478 482, 487, 491, 495, 500, 570, 596, 622).
Fourth, the ALJ asserts that the "marked" limitations found by Dr. Lear on the mental RFC assessment do not agree with the "extreme" limitations previously found by Dr. Lear (R. at 20). This argument is without merit. The PRTF form is used to determine the severity of an impairment at steps 2 and 3 of the sequential evaluation process. 20 C.F.R. § 404.1520a(c)(4). A claimant is rated in four broad areas. That form has 5 rating options for the first three areas (activities of daily living, difficulties in maintaining social functioning, and difficulties in maintaining concentration, persistence and pace): none, mild, moderate, marked, and extreme (R. at 523, 585). Dr. Lear found plaintiff extremely limited in 2 of those 3 categories (R. at 614).
Dr. Lear then filled out a mental RFC assessment. This assessment is used at steps four and five of the sequential evaluation process. SSR 96-8p, 1996 WL 374184 at *4. This assessment rates a claimant in 20 detailed categories, and has 5 rating options: not significantly limited, moderately limited, markedly limited, no evidence of limitation, and not ratable (R. at 527-528, 589-590, 615-616). On that form, Dr. Lear found plaintiff markedly limited in 16 categories and moderately limited in 4 categories (R. at 615-616). As can be seen by evaluating the assessment form, there is no category of "extremely" limited. That category only is on the PRTF form. For this reason, there is no merit to the ALJ's contention that extreme limitations found on the PRTF form do not agree with marked limitations on the more detailed mental RFC assessment.
Fifth, the ALJ discounts the findings of Dr. Lear by noting that he gave plaintiff a GAF of 54
Furthermore, standing alone, a GAF score, which can reflect social and/or occupational functioning, does not necessarily evidence whether an impairment seriously interferes with a claimant's ability to work.
In addition, there is no medical opinion evidence that the GAF scores do not correlate with the opinions of Dr. Lear. The adjudicator is not free to substitute his own medical opinion for that of a disability claimant's treatment providers and other medical sources.
As set forth above, the court found numerous errors in the ALJ's assessment of the opinions from Dr. Lear, plaintiff's treatment provider, who oversaw plaintiff's treatment at COMCARE from 2009-2012. For this reason, the court finds that substantial evidence does not support the ALJ's RFC findings and determination that plaintiff is not disabled; the court will remand this case in order for the ALJ to reevaluate the opinions of Dr. Lear.
Plaintiff raises other issues, primarily dealing with the ALJ's credibility analysis. The court will not address these remaining issues in detail because they may be affected by the ALJ's resolution of the case on remand after the ALJ properly evaluates the medical opinions of Dr. Lear.
IT IS THEREFORE ORDERED that the judgment of the Commissioner is reversed and remanded pursuant to sentence four of 42 U.S.C. § 405(g) for further proceedings consistent with this memorandum and order.
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (4th ed., text revision, American Psychiatric Association 2000 at 34) (emphasis in original).