JOI ELIZABETH PEAKE, District Judge.
Plaintiff Donald Thames ("Plaintiff") brought this action pursuant to Section 205(g) of the Social Security Act (the "Act"), as amended (42 U.S.C. § 405(g)), to obtain judicial review of a final decision of the Commissioner of Social Security denying his claim for Disability Insurance Benefits under Title II of the Act. The parties have filed cross-motions for judgment, and the administrative record has been certified to the Court for review.
Plaintiff protectively filed his application for Disability Insurance Benefits on November 9, 2012, alleging a disability onset date of October 2, 2012. (Tr. at 13. 161-63.)
Federal law "authorizes judicial review of the Social Security Commissioner's denial of social security benefits."
"Substantial evidence means `such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'"
"In reviewing for substantial evidence, the court should not undertake to re-weigh conflicting evidence, make credibility determinations, or substitute its judgment for that of the [ALJ]."
In undertaking this limited review, the Court notes that in administrative proceedings, "[a] claimant for disability benefits bears the burden of proving a disability."
"The Commissioner uses a five-step process to evaluate disability claims."
A finding adverse to the claimant at any of several points in this five-step sequence forecloses a disability designation and ends the inquiry. For example, "[t]he first step determines whether the claimant is engaged in `substantial gainful activity.' If the claimant is working, benefits are denied. The second step determines if the claimant is `severely' disabled. If not, benefits are denied."
On the other hand, if a claimant carries his or her burden at each of the first two steps, and establishes at step three that the impairment "equals or exceeds in severity one or more of the impairments listed in Appendix I of the regulations," then "the claimant is disabled."
In the present case, the ALJ found that Plaintiff had not engaged in "substantial gainful activity" since his amended alleged onset date. Plaintiff therefore met his burden at step one of the sequential evaluation process. At step two, the ALJ further determined that Plaintiff suffered from the following severe impairments: "obstructive sleep apnea; gastro-esophageal reflux disorder (GERD); hypertension; hyperlipidemia; obesity; fibromyalgia; history of umbilical hernia; major depressive disorder; and generalized anxiety disorder." (Tr. at 15.) The ALJ found at step three that none of these impairments met or equaled a disability listing. determined by the ALJ only after [the ALJ] considers all relevant evidence of a claimant's impairments and any related symptoms (e.g., pain)."
(Tr. at 18.) Based on this determination, the ALJ found under step four of the analysis that Plaintiff could not return to his past relevant work. (Tr. at 24.) However, based on the vocational expert's testimony, the ALJ determined at step five, that, given Plaintiff's age, education, work experience, and RFC, he could perform other jobs available in the national economy. (Tr. at 25.) Therefore, the ALJ concluded that Plaintiff was not disabled under the Act. (Tr. at 25-26.)
Plaintiff now challenges the ALJ's decision in two respects. First, at step three of the sequential analysis, Plaintiff contends that the ALJ failed to appropriately consider whether his depression met 20 C.F.R. Part 404, Subpart P, Appendix 1 § 12.04 (hereinafter "Listing 12.04"). Second, Plaintiff argues that the ALJ failed to properly weigh the opinion of Dr. Marshall, Plaintiff's treating psychiatrist at Piedmont Psychiatric Associates, PA. (Pl.'s Br. [Doc. #14] at 3.) Because Dr. Marshall's opinion forms the primary basis for Plaintiff's step three argument, the Court addresses Plaintiff's claims in reverse order.
Plaintiff contends that the ALJ erred by failing to give controlling weight to the medical opinions of Dr. Marshall in accordance with 20 C.F.R. § 404.1527(c)(2), better known as the "treating physician rule." The treating physician rule generally requires an ALJ to give controlling weight to the well-supported opinion of a treating source as to the nature and severity of a claimant's impairment, based on the ability of treating sources to
20 C.F.R. § 404.1527(c)(2). However, if a treating source's opinion is not "well-supported by medically acceptable clinical and laboratory diagnostic techniques or is inconsistent with other substantial evidence in the case record," it is not entitled to controlling weight. Social Security Ruling ("SSR") 96-2p, 1996 WL 374188, at *2; 20 C.F.R. § 404.1527(c)(2);
In the present case, Dr. Marshall issued multiple opinions regarding Plaintiff's functional abilities, including a Psychiatric Review Technique ("PRT") and letter, both issued in December of 2012, and a second PRT and form medical statement, both issued in January of 2014. (Tr. at 332-44, 346, 364-70, 417-28.) In the first PRT, completed in December 2012, Dr. Marshall indicated that Plaintiff experienced the following symptoms of depression from 2000 through the assessment date of December 6, 2012: "anhedonia or pervasive loss of interest in almost all activities," "sleep disturbance," "psychomotor . . . retardation," "feelings of guilt or worthlessness," and "difficulty concentrating or thinking." (Tr. at 332, 335.) Dr. Marshall further opined that, throughout the 12-year period covered by the assessment, Plaintiff's depression caused "extreme" limitations in his activities of daily living and his ability to maintain concentration, persistence, or pace, "marked" difficulties in his ability to maintain social functioning, and had resulted in four or more "episodes of decompensation, each of extended duration." (Tr. at 342.) In fact, Dr. Marshall indicated in the PRT that Plaintiff's depression was so severe that it "resulted in such marginal adjustment that even a minimal increase in mental demands or change in the environment would be predicted to cause [Plaintiff] to decompensate," and that Plaintiff's mental health history included "1 or more years' inability to function outside a highly supportive living arrangement with an indication of continued need for such an arrangement." (Tr. at 343.)
Along with his PRT, Dr. Marshall submitted a letter to Plaintiff's attorney, dated December 20, 2012, which read as follows:
(Tr. at 331.)
Just over a year later, on January 2, 2014, Dr. Marshall completed a second PRT, this time characterizing the assessment as spanning from approximately 1993 through the present. (Tr. at 417.) At that time, in addition to the depressive symptoms identified in the 2012 assessment, Dr. Marshall also indicated that Plaintiff had "decreased energy" and "thoughts of suicide." (Tr. at 420.) However, in rating the severity of Plaintiff's functional limitations, Dr. Marshall found only moderate restrictions in terms of activities of daily living and social functioning, as opposed to the "extreme" and "marked" limitations posited in 2012. (Tr. at 427.) The degree of limitation in Plaintiff's concentration, persistence, and pace remained extreme, and Dr. Marshall again asserted that Plaintiff's depression had caused "repeated episodes of decompensation, each of extended duration" and that "even a minimal increase in mental demands or change of environment would be predicted to cause [him] to decompensate." (Tr. at 427-28.) Dr. Marshall included no notes explaining the basis for his opinions. (Tr. at 430.)
One week later, on January 9, 2014, Dr. Marshall filled out and signed an attorney-provided checklist form mirroring the PRT. However, when asked to rate Plaintiff's degree of limitation due to depression, Dr. Marshall indicated "extreme" restrictions in activities of daily living and "marked" difficulties in social functioning, which was inconsistent with his opinion from only one week earlier. (Tr. at 365.) For example, on January 2, Dr. Marshall opined that Plaintiff had only "moderate" restrictions in daily living, but on January 9, Dr. Marshall opined that Plaintiff had "extreme" restrictions in activities of daily living. Similarly, on January 2, Dr. Marshall opined that Plaintiff had "moderate" limitations in social functioning, but on January 9, Dr. Marshall opined that Plaintiff had "marked" limitations in social functioning. There is no medical evidence indicating any change in Plaintiff's condition during that week, or any record of any treatment during that time period. In the comments section of the questionnaire on January 9, Dr. Marshall noted that Plaintiff was "completely unable to maintain focus needed to work even on a part-time basis," but did not provide any further explanation. (
In her decision, the ALJ cited each of the above opinions but ultimately assigned them little weight. (Tr. at 23.) In doing so, she recounted the internal inconsistencies described above and concluded that Dr. Marshall's opinions should be given little weight in light of the "internal inconsistencies between his opinions." (Tr. at 23.) The ALJ further explained that:
(Tr. at 23.)
The ALJ then contrasted and adopted the opinions of State Agency Psychological Consultants Jeff Long and Nancy Lloyd, issued in July and August, respectively, of 2013. Drs. Long and Lloyd opined that Plaintiff had moderate limitations in activities of daily living, social functioning, and concentration, persistence, and pace, and had suffered no episodes of decompensation. (Tr. at 24, 76-78, 90.) "Further, despite these limitations, they opined [that Plaintiff] could perform the demands of simple tasks with minimum interaction with others." (Tr. at 24.) The ALJ went on to explain that:
(Tr. at 24.)
As indicated by the ALJ, Dr. Marshall's treatment records fail to reflect the severe depressive symptoms and functional limitations set out in his opinions. Approximately a year before Plaintiff's onset date, on October 20, 2011, Dr. Marshall noted that Plaintiff had been seen at Piedmont Psychiatric Associates since before 2000 for a combination of psychotherapy and medication management for dysthymic disorder, and that he had no history of inpatient psychiatric interventions. At that time, Plaintiff's symptoms were noted to have "escalated" to include "mild" depression, and his dose of Wellbutrin was increased. (Tr. at 315.) Treatment notes through August 2012 consistently noted improvement in Plaintiff's depression on that dosage. (Tr. at 312-14.) However, on October 4, 2012, two days after his alleged onset date, Plaintiff returned to Dr. Marshall and reported "walk[ing] off of his job after 14 years as he hated it and was increasingly having trouble with memory and concentration. Especially worse after recently being moved to customer service." (Tr. at 311.) At that appointment, Dr. Marshall "[d]iscussed not using Ambien which could be affecting [Plaintiff's] memory" and switched his sleep medication to trazodone. (
Notably, the records from Plaintiff's next three appointments, in March, June, and September of 2013, specifically reflect "[s]table affect and mood with good focus and conversational flow [and n]o evidence of mania, depression, or psychosis." (Tr. at 389, 390, 403.) These records also indicate that Plaintiff continued to take Ambien, despite Dr. Marshall's earlier concerns about its effect on Plaintiff's memory. (
As noted by the ALJ, the above objective findings are clearly inconsistent with Dr. Marshall's assessment of "extreme" concentration difficulties due to depression during the same time period and his opinion that Plaintiff remained "completely unable to maintain focus needed to work even on a part-time basis" from October 2012 forward. (Tr. at 365.) Moreover, the record contains no evidence that Plaintiff's experienced any episodes of decompensation prior to Dr. Marshall's assessments, in direct contrast to that physician's assertion that Plaintiff experienced four or more such episodes, each lasting for at least two weeks. Further, Dr. Marshall opined in December 2012 that Plaintiff had a "[c]urrent history of 1 or more years' inability to function outside a highly supportive living arrangement with an indication of continued need for such an arrangement," (Tr. at 343), which is patently inconsistent with the treatment records indicating that Plaintiff lived alone and had no history of psychiatric interventions (Tr. at 315) and Plaintiff's reported activities of daily living. In light of these inconsistencies and lack of support in the medical record, substantial evidence supports the ALJ's assignment of little weight to Dr. Marshall's opinions.
Plaintiff next argues that substantial evidence fails to support the ALJ's adverse step three finding as to Listing 12.04. Listing 12.04 encompasses affective disorders, including depressive, manic, and bipolar syndromes, and may be met in one of two ways. Most commonly, a claimant first must manifest certain paragraph A criteria, i.e., specific symptoms set out in the listing itself. Pertaining to depression, a claimant must provide medical documentation of at least four of the following:
20 C.F.R. Part 404, Subpart P, Appendix 1 § 12.04(A)(1). These criteria, in turn, must result in at least two of the following paragraph B criteria:
20 C.F.R. Part 404, Subpart P, Appendix 1 § 12.04(B). In other words, a claimant must meet both paragraphs A and B.
Here, the ALJ determined at step three that Plaintiff was only moderately limited in terms of activities of daily living, social functioning, and concentration, persistence, or pace, and had experienced no episodes of decompensation. (Tr. at 16-17.) She therefore concluded that Plaintiff did not meet the paragraph B criteria of Listing 12.04. (
In challenging the ALJ's step three finding, Plaintiff relies entirely on (1) his own testimony as to the severity of his symptoms and (2) the opinion evidence offered by Dr. Marshall. (Pl.'s Br. at 9-10.) However, the ALJ found Plaintiff's statements regarding the intensity, persistence, and limiting effects of his symptoms less than credible (Tr. at 20), and Plaintiff does not challenge that credibility finding. Moreover, as set out above, substantial evidence supports the ALJ's decision to assign little weight to the extreme, and largely unsupported, limitations opined by Dr. Marshall. As further explained above, the remainder of the record fails to demonstrate that Plaintiff suffered at least marked restrictions in two or more of the paragraph B criteria as required by Listing 12.04. Instead, the ALJ in the present case specifically analyzed Listing 12.04 at step three of the sequential analysis, but concluded that Plaintiff suffered no more than moderate limitations in any paragraph B criteria. (Tr. at 16-17.) Substantial evidence supports this determination.
IT IS THEREFORE RECOMMENDED that the Commissioner's decision finding no disability be AFFIRMED, that Plaintiff's Motion for Judgment on the Pleadings [Doc. #13] be DENIED, that Defendant's Motion for Judgment on the Pleadings [Doc. #16] be GRANTED, and that this action be DISMISSED with prejudice.