KIMBERLY E. WEST, Magistrate Judge.
Plaintiff Deborah Albertson (the "Claimant") requests judicial review of the decision of the Commissioner of the Social Security Administration (the "Commissioner") denying Claimant's application for disability benefits under the Social Security Act. Claimant appeals the decision of the Administrative Law Judge ("ALJ") and asserts that the Commissioner erred because the ALJ incorrectly determined that Claimant was not disabled. For the reasons discussed below, it is the recommendation of the undersigned that the Commissioner's decision be REVERSED and REMANDED for further proceedings.
Disability under the Social Security Act is defined as the "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment ..." 42 U.S.C. § 423 (d) (1) (A) A claimant is disabled under the Social Security Act "only if his physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work but cannot, considering his 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) (2) (A). Social Security regulations implement a five-step sequential process to evaluate a disability claim. See, 20 C.F.R. §§ 404.1520, 416.920.
Judicial review of the Commissioner's determination is limited in scope by 42 U.S.C. § 405(g). This Court's review is limited to two inquiries: first, whether the decision was supported by substantial evidence; and, second, whether the correct legal standards were applied.
Claimant was born on September 3, 1957 and was 50 years old at the time of the ALJ's first decision. Claimant completed her high school education. Claimant has worked in the past as a nurse's aide, wiper, riveting machine operator, material handler, and hand packer. Claimant alleges an inability to work beginning January 1, 2003 due to limitations resulting from pain in her back, hands, and feet, asthma, hypothyroidism, obesity, bipolar disorder, and attention deficit disorder.
On September 7, 2005, Claimant protectively filed for disability insurance benefits under Title II (42 U.S.C. § 401, et seq.) and supplemental security income pursuant to Title XVI (42 U.S.C. § 1381, et seq.) of the Social Security Act. Claimant's applications were denied initially and upon reconsideration. After the ALJ issued an unfavorable decision which the Appeals Council declined to review, this Court reversed the ALJ's decision on July 14, 2009 and remanded the case for further proceedings. The Appeals Council reversed the ALJ's decision and the matter was remanded.
A second administrative hearing was conducted before ALJ Lantz McClain on January 4, 2010. On June 23, 2010, the ALJ issued a second unfavorable decision on Claimant's applications. Claimant did not appeal to the Appeals Council. As a result, the decision of the ALJ represents the Commissioner's final decision for purposes of further appeal. 20 C.F.R. §§ 404.981, 416.1481.
The ALJ made his decision at step four of the sequential evaluation. He determined that while Claimant suffered from severe impairments, she did not meet a listing and retained the residual functional capacity ("RFC") to perform her past relevant work as a riveting machine operator.
Claimant asserts the ALJ committed error in: (1) failing to consider all of her severe impairments; (2) reached an improper RFC based upon the evidence; and (3) finding Claimant can perform her past relevant work.
In his decision, the ALJ determined Claimant suffered from the severe impairments of hypothyroidism, asthma, possible right heel spur, obesity, depression, anxiety, and borderline intellectual functioning. (Tr. 266). He concluded Claimant retained the RFC to occasionally lift and/or carry 20 pounds, frequently lift and/or carry 10 pounds, stand and/or walk at least 6 hours in an 8 hour workday, sit for at least 6 hours in an 8 hour workday — all with normal breaks, avoid concentrated exposure to such things as dust or fumes, and limited to simple, repetitive tasks, having no more than incidental contact with the public. These restrictions limited Claimant to light work. (Tr. 269) After consultation with a vocational expert, the ALJ determined Claimant could perform her past relevant work as a riveting machine operator, which is classified as light work. (Tr. 272).
Claimant contends the ALJ failed to consider her diagnosed personality disorder as a severe impairment. Dr. Robert Spray evaluated Claimant's mental condition in a consultative evaluation conducted on September 10, 2007. Dr. Spray found Claimant's orientation, memory and concentration, fund of information, abstract reasoning, and judgment were appropriate. (Tr. 197-98) Dr. Spray estimated Claimant's IQ to be low average. (Tr. 198) Dr. Spray found possible exaggeration in the Beck Depression Inventory-II. (Tr. 199). The Personality Assessment Inventory performed by Claimant "produced a grossly exaggerated, invalid PAI profile." Nevertheless, Dr. Spray diagnosed Claimant with Bipolar Disorder, NOS, by medical records, with psychotic features, Anxiety Disorder, NOS (with possible PTSD issues), and Personality Disorder, NOS, with schizotypal, avoidant, and borderline features.
Dr. Spray completed a form entitled Residual Functional Capacity Secondary to Mental Impairments, including Pain, Fatigue, and Hysterical Paralysis. He found severe restrictions in Claimant's ability to relate to co-workers, interact with supervisors, deal with work stresses, maintain regular attendance, work in coordination or proximity to others without being distracted by them, complete a normal workday, complete a normal workweek, demonstrate reliability, behave in an emotionally stable manner, accept instructions and respond appropriately to criticism from supervisors, get along with co-workers or peers without distracting them or exhibiting behavioral extremes. (Tr. 200-201) .
Dr. Spray authored a letter dated February 8, 2008 concerning Claimant's condition. He states in a "to whom it may concern" correspondence that his conclusions were not influenced by the fact Claimant was referred by counsel and were not based upon certain testing, which he considered to be invalid. Rather, he states, his conclusions were based upon the "interview/mental status" and "drawn from the interview and medical history." (Tr. 237).
On July 14, 2009, this Court reversed the ALJ's decision and remanded the case for a re-evaluation of Dr. Spray's opinions. Specifically, the ALJ was directed to provide a discussion of the weight the ALJ gave to Dr. Spray's opinions and to consider whether his findings of a personality disorder should be a severe impairment. This Court also instructed the ALJ to re-assess Claimant's RFC in light of the reconsideration of Dr. Spray's opinions and to provide a proper analysis under step four of the demands of Claimant's past relevant work as a riveter. (Tr. 274-84).
On remand, Claimant underwent a psychological assessment by Dr. Denise LaGrand on February 12, 2010. Dr. LaGrand found Claimant's thoughts to be organized, logical, and goal-directed, noting Claimant could stay focused on the exam. Claimant's overall cognitive functioning was in the Borderline Intellectual Functioning range. Her full scale IQ score under the Wechsler Adult Intelligence Scale — 4th Edition was 75. (Tr. 378). Dr. LaGrand also found the results of the MMPI were invalid due to over-endorsement of symptoms leading to elevations in all clinical scales. (Tr. 379) Her final diagnosis was Major Depressive Disorder, moderate, Generalized Anxiety Disorder, and Borderline Intellectual Functioning. Her GAF was measured as 45. (Tr. 380) .
Dr. LaGrand also completed a Mental Source Statement of Ability to Do Work-Related Activities (Mental) on Claimant dated February 22, 2010. Dr. LaGrand found Claimant to be markedly limited in the areas of the ability to make judgments on simple work-related decisions, the ability to carry out complex instructions and the ability to make judgments on complex work-related decisions. Claimant was determined to be moderately limited in the areas of understanding and remembering simple instructions, carrying out simple instructions, understanding and remembering complex instructions, interacting appropriately with the public, supervisors and co-workers, and the ability to respond appropriately to usual work situations and to changes in a routine work setting. (Tr. 383-84). Dr. LaGrand noted that stress and anxiety interfered with Claimant's functioning. (Tr. 384).
In his second decision after remand, the ALJ found that Dr. Spray's and Dr. LaGrand's opinions should be afforded equal weight, noting that both gave Claimant moderate limitations in mental functioning. (Tr. 272) The ALJ also noted that virtually all of the formal testing was found to be invalid by both doctors due to over-reporting by Claimant. Id. He then stated that both doctors' reports supported a limitation upon Claimant to simple, repetitive tasks having no more than incidental contact with the public. Id.
Clearly, both doctors were concerned with Claimant's exaggeration of the testing, including the personality disorder testing performed by Dr. Spray. Additionally, the ALJ properly re-evaluated and explained the weight he gave to Dr. Spray's opinion as directed by this Court. Given both of these facts, this Court cannot find the ALJ's consideration but failure to include Claimant's personality disorder as a severe impairment to be error. The fact a condition has been diagnosed does not translate into a disability. See,
Claimant next contends the ALJ's RFC assessment failed to include all of her limitations found by Dr. Spray and Dr. LaGrand. The ALJ determined that Dr. Spray's and Dr. LaGrand's opinions were entitled to equal weight and that "[b]oth gave the claimant moderate limitations in mental functioning." (Tr. 272). In fact, Dr. Spray found Claimant's limitations were "severe" in 13 areas referenced in the RFC mental assessment form. "Severe" limitation is defined in the form as "[s]ignificantly more than serious limitation with very little sporadic or intermittent remaining ability to function." (Tr. 200). Areas included with this limitation are relating to co-workers, interacting with supervisors, dealing with work stresses, maintaining regular attendance, working in coordination or proximity to others without being distracted by them, making simple work-related decisions, completing a normal workday (without interruptions from psychologically-based or pain-related symptoms), completing a normal workweek (without interruptions from psychologically-based or pain-related symptoms), performing at a consistent pace, demonstrating reliability, behaving in an emotionally stable manner, accepting instructions and responding appropriately to criticism from supervisors, and getting along with co-workers or peers without distracting them or exhibiting behavioral extremes. Claimant was also found to be "marked" limited in 9 additional areas. (Tr. 200-01). The ALJ's limitations upon Claimant's RFC to "simple, repetitive tasks having no more than incidental contact with the public" does not accommodate these severe restrictions as the ALJ asserts. In particular, the ALJ did not consider the restrictions in associating with supervisors and co-workers that Dr. Spray's assessment describes. While this Court is sympathetic to the difficulties brought about by the different forms utilized by Dr. Spray and Dr. LaGrand, the ALJ must address the restrictions clearly contained in Dr. Spray's opinion since both evaluators' opinions were given equal weight and consideration.
Claimant also asserts that she cannot return to her past relevant work and that the ALJ's evaluation was incomplete. The evaluation at step four has been determined to be comprised of three phases. In the first phase, the ALJ must evaluate a claimant's physical and mental RFC. In the second phase, an ALJ must determine the physical and mental demands of a claimant's past relevant work. In the third and final phase, the ALJ determines whether the claimant has the ability to meet the job demands found in phase two despite the mental and physical limitations found in phase one.
The decision of the Commissioner is not supported by substantial evidence and the correct legal standards were not applied. Therefore, the Magistrate Judge recommends for the above and foregoing reasons, the ruling of the Commissioner of Social Security Administration should be
