MICHAEL A. TELESCA, District Judge.
Robert Mills ("Plaintiff"), represented by counsel, brings this action pursuant to Titles II and XVI of the Social Security Act ("the Act"), seeking review of the final decision of the Commissioner of Social Security ("the Commissioner") denying her application for Supplemental Security Income ("SSI") and disability insurance benefits ("DIB"). The Court has jurisdiction over this matter pursuant to 42 U.S.C. § 405(g). Presently before the Court are the parties' competing motions for judgment on the pleadings pursuant to Federal Rule of Civil Procedure 12(c).
Plaintiff protectively filed applications for DIB and SSI on March 10, 2011, both of which were denied. T.50-60, 128-42.
Plaintiff began treating with psychiatrist Ronald Spurling, M.D., on July 28, 2011. T.479. On August 10, 2011, Plaintiff presented for follow-up regarding his bipolar disorder and PTSD. T.426-29. Plaintiff reported that he was tolerating his medications well, aside from some sedation upon waking in the morning. He stated that his mood was more even, and he was less depressed. However, he complained of continued general anxiety and social anxiety. Plaintiff also reported continued daily use of marijuana, which he felt helped to "even out his mood." T.426. Plaintiff presented as being appropriately groomed and dressed; his facial expression appeared pleasant; his motor activity was within normal limits; and his affect was calm. Plaintiff described his own mood as normal. His language processing and associative thinking were intact; he was alert and oriented; and his memory, attention and concentration, and impulse control were all grossly intact. Judgment and insight were fair; and he evidenced no delusions, hallucinations, obsessions, preoccupations, or somatic thoughts. R427-28. During the examination, Plaintiff displayed anxiety periodically; his speech was pressured and rapid; his thought processes demonstrated circumstantial thinking; he showed increased tangentiality and some loosening of associations as the session progressed. Although Plaintiff had no "frank delusions," some of Plaintiff's statements "seem[ed] to border on the delusional." T.427-28.
Dr. Spurling diagnosed PTSD (309.81), Bipolar I Disorder Current Depressed Mild (296.51), and Cannabis Abuse Continuous (305.21). T.428. He noted that Plaintiff seemed to have some improvement with the addition of lithium and low-dose risperidone (Risperdal). T.428. Dr. Spurling prescribed a trial of guanfacine at bedtime to address Plaintiff's complaints of anxiety and difficulty with concentration. T.428. Dr. Spurling also counseled Plaintiff to cease using marijuana and cigarettes. Dr. Spurling opined that individual psychotherapy would not be particularly beneficial at that time due to Plaintiff's "significant Axis I symptoms,"
Plaintiff returned to Dr. Spurling for follow-up on September 21, 2011, T.430-32, reporting that the medications were working very well for him, his mood was much more even, and he was sleeping well. However, his psoriasis (including ocular) had been worsening, so he stopped taking the lithium and other prescribed medications the previous day. R430. He also reported that he had been more social recently, and he continued to look employment but had not been offered many opportunities. Plaintiff reported continued daily use of marijuana. T.430. Dr. Spurling noted that Plaintiff had seemed very much improved on lithium, so it was unfortunate that he was unable to tolerate that medication due to a psoriasis flare. Dr. Spurling prescribed Depakote, and he instructed Plaintiff to restart Risperdal and guanfacine. T.431. Plaintiff was counseled to stop smoking cigarettes and marijuana (which Plaintiff continued to insist was helpful for him).
On October 20, 2011, Plaintiff reported to Dr. Spurling that he was doing very well on the Depakote, and he liked it better than the lithium. T.467-69. He continued to occasionally use hydroxyzine as needed. T.467. Overall, he felt that his mood was "fine." T.467. He slept about 7 hours per day, but he might stay up late reading and then sleep in. He denied any further difficulty with "rages" or anger episodes. T.467. He complained of stressors related to his finances and being isolated in his current housing situation, and he admitted to continued marijuana use.
On November 17, 2011, Plaintiff returned to Dr. Spurling reporting that he was doing very well on the Depakote, and stating that his mood was "very good." R470-72. His psoriasis had also dramatically improved. Plaintiff reported that he had been taking his medications more regularly. He also stated that he had stopped smoking marijuana altogether, at which point he started having nightmares. T.470. However, his sleep was now normal, and he was sleeping approximately eight hours per night.
On January 19, 2012, Plaintiff returned to Dr. Spurling for follow-up. T.473-75. Plaintiff stated that he was "not too good" that day, and he complained of having frequent "little tantrums," frustration, and inability to focus or accomplish tasks. T.473. Plaintiff thought he was drinking too much coffee and admitted that he had "not been taking his medication like he should be." T.473. Though he was "very evasive about exactly how frequently" he was taking the medication, it seemed to Dr. Spurling that he was primarily treating himself "as needed" with hydroxyzine and marijuana.
Dr. Spurling noted that Plaintiff was "perseverative" on multiple stressors, and thinking about a "geographical solution." T.474-75. Plaintiff requested that Dr. Spurling treat him with stimulants to help with his difficulties with attention and focus, but Dr. Spurling refused, as Plaintiff was not taking his other medications regularly. T.475. Dr. Spurling also noted his concern about Plaintiff's relapse of marijuana use, and that, while Plaintiff may feel that it was helping with his anxiety, it clearly was making his motivation and other aspects of his illness worse. Dr. Spurling urged Plaintiff to take his prescribed medications regularly, and again counseled him to limit and ultimately stop smoking cigarettes and marijuana.
Dr. Spurling completed a form titled, "Evaluation of the Residual Functional Capacity of the Mentally Impaired Patient", on February 10, 2012. T.476-79. At that point, he had seen Plaintiff between July 28, 2011, and January 19, 2012, but indicated that his opinion regarding Plaintiff's limitations commenced as of January 1, 2010. T.479. Dr. Spurling opined that Plaintiff had "fair" ability (defined in the form as "the ability to function in this area is seriously limited and will result in periods of unsatisfactory performance at unpredictable times") to remember detailed instructions; respond appropriately to supervision (citing difficulty with irritability and mood changes); function independently on a job (citing decreased concentration and focus); ability to complete a normal workday on a sustained basis (citing sleep pattern deregulation); exercise appropriate judgment (citing impulsivity and difficulty with processing instructions); concentrate and attend to a task over an eight-hour period (citing difficulty concentrating); maintain social functioning (citing irritability and mood changes); and tolerate customary work pressures in a work setting (citing poor stress tolerance with irritability and mood changes). T.477-78. Dr. Spurling opined that Plaintiff had "good" (defined as "the ability to function in this area is limited but satisfactory") abilities in all other listed areas of functioning, including the ability to: comprehend and carry out simple instructions, remember work procedures, respond appropriately to co-workers, abide by occupational rules/regulations, make simple work-related decisions, and be aware of normal hazards and make necessary adjustments to avoid those hazards. T.476-78. Dr. Spurling opined that Plaintiff's condition was likely to deteriorate if he were placed under stress, especially the stress typically found in the workplace. However, Dr. Spurling was not aware of such deterioration having occurred in the past, in light of Plaintiff's limited employment since his incarceration. T.478. Dr. Spurling indicated that Plaintiff's impairments had lasted or was expected to last for at least 12 months and were likely to produce "good days" and "bad days." Consequently, Plaintiff likely would be absent from work about four days per month. T.479. Dr. Spurling did not indicate that there were any restrictions on the number of hours or days that Plaintiff could be present at a work site.
On March 19, 2012, Plaintiff returned to Dr. Spurling for follow-up. T.481-83. Plaintiff reported that things were "fair." He reported that he was taking the Wellbutrin in the morning, and taking hydroxyzine as need if he gets "overexcited." Otherwise, he was not taking any of the other prescribed medications. He also reported continued use of marijuana and cigarettes, and he continued to bite his nails. His sleep was "okay" and his motivation was "all right". He got out of the house sometimes, mostly to go to town or to walk the dog. Plaintiff complained of occasionally developing some anxiety and pacing behaviors, but then he would take a hydroxyzine, which helped. He also reported relief because his teeth were repaired, and he had been able to put away some money, which helped his anxiety about finances. Plaintiff reported that his roommate had a new job and was now out of the house more often. He also intended to take a short trip or vacation. On examination revealed, Plaintiff's speech was clear and appropriate, and other findings were essentially unchanged. Dr. Spurling concluded that, despite Plaintiff's ongoing regular use of marijuana, and his self-discontinuation of most of the prescribed medications, he "seem[ed] to be doing fairly well." T.483. He noted that Plaintiff did report continued use of Wellbutrin and hydroxyzine, as needed. Dr. Spurling again counseled Plaintiff on marijuana and smoking cessation. Plaintiff declined the offer to be trialed on other medications, Since Plaintiff was on minimal medications and "seem[ed] to be fairly stable,"
In an undated report, Plaintiff's primary care physician Dr. Thaddeus Zyleszewski stated that he had first seen Plaintiff on July 21, 2011, and last examined him on August 15, 2011. T.423-24; T.441-46 (7/21/11), T.447-51 (8/15/11 visit). Dr. Zyleszewski declined to check any boxes relating to specific functional limitations. T.423-24. He opined that Plaintiff required "minimal stress exposure, minimal concentration requirement secondary to mental/psychiatric [issues]," and that Plaintiff had no physical limitations. T.424. Dr. Zyleszewski stated that these restrictions were expected to last longer than 90 days. Dr. Zyleszewski also checked a box indicating that, if substance abuse also were found, Plaintiff's impairments would be expected to continue even if his use of drugs and/or alcohol were to cease.
Plaintiff treated with Dr. Richard R. Stout for various eye complaints between August 2011, and March 2012. T.485-96. Plaintiff reported on March 27, 2012, that he thought his eyes bothered him because he was on the computer for approximately eight hours per day, and his "eye sight comes back better when not on [the] computer." T.496. Dr. Stout's impressions were rosacea, dermatochalasis, and refractive error. T.496.
On June 3, 2011, psychologist Dr. Christina Caldwell examined Plaintiff at the Commissioner's request. T.377-81. Plaintiff's manner of relating, social skills, and overall presentation were adequate; his attention and concentration, and recent and remote memory were intact; and his intellectual functioning was average. T.378-79. Dr. Caldwell's Axis I diagnoses were as follows: learning disability (previous diagnosis); attention deficit disorder (previous diagnosis); depressive disorder, not otherwise specified ("NOS"); post-traumatic stress disorder ("PTSD"); and panic disorder without agoraphobia. T.380. Axis III (physical condition) diagnoses were left shoulder pain, poor eyesight, and difficulty hearing. T.380. Dr. Caldwell opined that Plaintiff could follow and understand simple directions instructions and perform simple tasks independently; maintain attention and concentration; and maintain a regular schedule. However, Dr. Caldwell, stated, he is unable to learn new tasks easily; he is unable to perform complex tasks independently; he is unable to make appropriate decisions; he is unable to relate adequately with others; and he is unable to appropriately deal with stress. T.380. According to Dr. Caldwell, these difficulties were caused by Plaintiff's Axis I diagnoses, physical limitations, and cognitive deficits. The results of her evaluation "appeared to be consistent" with Plaintiff's allegations. T.380. His prognosis was "fair." T.380. Dr. Caldwell recommended that Plaintiff pursue individual psychotherapy and psychiatric intervention. T.380.
Also on June 3, 2011, internist Dr. Kalyani Ganesh performed a consultative internal medicine examination at the Commissioner's request. T.382-85. Dr. Ganesh diagnosed Plaintiff with a history of left shoulder third-degree dislocation, anxiety, depression, and psoriasis. T.384. Plaintiff had no gross physical limitations in sitting, standing, walking, or using his right upper extremity; but he had mild to moderate limitations in lifting, carrying, pushing, and pulling with the left upper extremity. T.384.
On June 9, 2011, State agency medical consultant Dr. A. Hochberg, a psychologist, reviewed the file and concluded that Plaintiff had "mild" difficulties in maintaining concentration, persistence, or pace; and no restriction in activities of daily living or difficulties in maintaining social function; and therefore concluded that Plaintiff did not have a "severe" mental impairment. T.386-99.
Title 42 U.S.C., § 405(g) authorizes district courts "to enter, upon the pleadings and transcript of the record, a judgment affirming, modifying, or reversing the decision of the Commissioner of Social Security, with or without remanding the cause for a rehearing." This Court's function is not to determine
The ALJ found that Plaintiff has not engaged in any substantial gainful activity for the requisite time; that he has "severe" impairments of degenerative joint disease, depressive disorder, PTSD, panic disorder, and cannabis abuse; and that these "severe" impairments, either singly or in combination, do not meet or equal a listed impairment. T.13-15; 20 C.F.R. §§ 404.1520(b)-(d), 416.920(b)-(d); 20 C.F.R. Part 404, Subpart P, Appendix 1. The ALJ assessed Plaintiff's residual functional capacity (RFC), and concluded he had the ability to perform light work as defined in 20 C.F.R. §§ 404.1567(b) and 416.967(b), with the following limitations: occasional pushing, pulling, and overhead reaching using the non-dominant upper extremity; and never crawling or climbing ladders, ropes, or scaffolds. With regard to the skill level of work, Plaintiff is limited to performing only unskilled work that involves simple, routine, and repetitive tasks; simple, work-related decisions; and few, if any, workplace changes; and only occasional interactions with supervisors and co-workers; and no contact with the public. T.15-21. At step four, the ALJ found that Plaintiff could not perform his past relevant work. T.21. At step five, the ALJ relied on the vocational expert's testimony to concluded that there are jobs existing in significant numbers in the economy that Plaintiff can perform. T.21-22. Accordingly, the ALJ entered a finding of not disabled.
Plaintiff contends that the ALJ erroneously gave "little weight" to Dr. Spurling's opinion and failed to identify "good reasons" any legally sufficient reason for doing so, as required by the regulations.
The Second Circuit has explained that "[a]lthough the treating physician rule generally requires deference to the medical opinion of a claimant's treating physician, the opinion of the treating physician is not afforded controlling weight where . . . the treating physician issued opinions that are not consistent with other substantial evidence in the record. . . ."
The Court agrees that Dr. Spurling is a treating source for purposes of applying the treating physician rule. The regulatory factors regarding the length of the treatment relationship and the nature of Dr. Spurling's practice clearly favor giving controlling weight to his opinion. As noted above, Dr. Spurling is a specialist in the field of psychiatry, and he treated Plaintiff on a consistent basis over several years. However, the ALJ found Dr. Spurling's opinion entitled to only "little weight". The ALJ's rationale for this conclusion consists of the following two sentences:
Decision, p. 10.
As an initial matter, it is apparent that there is a disconnect between the ALJ's understanding of the terms "fair" and "good" and Dr. Spurling's understanding of those terms as defined in the form he completed. In rejecting Dr. Spurling's opinion as internally inconsistent, the ALJ evidently gave "fair" its dictionary meaning, e.g., "sufficient but not ample: adequate[.]"
The ALJ's second reason for according only little weight to Dr. Spurling's opinion-that there is "little in [his] records that support this [restrictive] finding, particularly in light of the claimant's noncompliance," is so vague and conclusory as to be meaningless. The reference to Plaintiff's lack of compliance with his medication regimen simply does not make any sense in the context of the sentence. Accordingly, the ALJ's second reason for discounting Dr. Spurling's opinion also is not a "good reason" for purposes of the regulations.
The Second Circuit has observed that courts "do not hesitate to remand when the Commissioner has not provided `good reasons' for the weight given to a treating physician[']s opinion[,]" and has instructed that courts "[should] continue remanding when [they] encounter opinions from ALJ's that do not comprehensively set forth reasons for the weight assigned to a treating physician's opinion."
As sufficient bases exist for ordering the matter remanded, the Court need not determine whether Plaintiff's other alleged errors warrant remand. The Court will briefly address several other errors asserted by Plaintiff so that they may be avoided on remand.
Plaintiff argues that to support his RFC finding, the ALJ was required "to do more than merely catalogue the medical records." Plaintiff's Brief (Dkt #7-1) at 18. The Court agrees that "[i]t is well-settled that `[t]he RFC assessment must include a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations).'"
Here, the ALJ gave his conclusion as to Plaintiff's RFC assessment and proceeded to summarize the medical evidence without discussing how the medical evidence supported the various aspects of his RFC assessment. This was error.
Under the regulations, an ALJ first must decide whether the claimant suffers from a medically determinable impairment that could reasonably be expected to produce the symptoms he alleges, and if so, the ALJ then must consider the extent to which the claimant's symptoms can reasonably be accepted as consistent with the objective medical evidence and other evidence of record.
For the foregoing reasons, the Commissioner's denial of DIB and SSI was erroneous as a matter of law. Therefore, the Commissioner's motion for judgment on the pleadings (Dkt #9) is denied. Plaintiff's motion for judgment on the pleadings (Dkt #7) is granted to the extent that the Commissioner's decision is reversed, and the matter is remanded for further administrative proceedings consistent with this Decision and Order. In particular, the ALJ is directed to (1) re-evaluate Dr. Spurling's treating source opinion and, if the ALJ elects not to accord it controlling weight, give "good reasons" in accordance with the regulations for the decision not to assign it controlling weight; (2) re-assess Plaintiff's RFC and provide a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations); and (3) re-evaluate Plaintiff's credibility under the proper two-step standard, discussing the appropriate symptom-related factors set forth in the regulations.
