WILLIAM J. NEALON, District Judge.
On October 8, 2014, Plaintiff, Jill Kucharski, filed this appeal
Plaintiff protectively filed
On March 1, 2013, Plaintiff filed a request for review with the Appeals Council. (Tr. 25). On August 12, 2014, the Appeals Council concluded that there was no basis upon which to grant Plaintiff's request for review. (Tr. 1-3). Thus, the ALJ's decision stood as the final decision of the Commissioner.
Plaintiff filed the instant complaint on October 8, 2014. (Doc. 1). On December 22, 2014, Defendant filed an Answer and Transcript from the Social Security Administration ("SSA") proceedings. (Docs. 5 and 6). Plaintiff filed the brief in support of her complaint on December 29, 2014. (Doc. 7). Defendant filed a brief in opposition on January 26, 2015. (Doc. 8). Plaintiff did not file a reply brief. The matter is now ripe for review.
Disability insurance benefits are paid to an individual if that individual is disabled
Plaintiff was born in the United States on December 17, 1968, and at all times relevant to this matter was considered a "younger individual"
Plaintiff obtained her high school diploma, completed one (1) year of college, and can communicate in English. (Tr. 173-174). Her employment records indicate that she previously worked as a certified nurse's aid and a customer service representative. (Tr. 198).
The records of the SSA reveal that Plaintiff had earnings in the years 1983 through 2008 and 2010 through 2011. (Tr. 152). Her annual earnings range from a low of four hundred eighty-six dollars and eighty-two cents ($486.82) in 1984 to a high of forty-six thousand eight hundred twelve dollars and fifteen cents ($46,812.15) in 2004. (Tr. 152). Her total earnings during those twenty-seven (27) years were four hundred forty-five thousand seventy-one dollars and eighty-four cents ($445,071.84). (Tr. 152).
Plaintiff's alleged disability onset date is June 15, 2011. (Tr. 30, 171). The impetus for her claimed disability is Bipolar Disorder Type II. (Tr. 174).
In a document entitled "Function Report — Adult" filed with the SSA in July of 2011, Plaintiff indicated that she lived in a house with her family, and that she took care of her children and animals. (Tr. 191-192). From the time she woke up until the time she went to bed, Plaintiff stated that she "actually [slept] a majority of the day. . ." (Tr. 192). She stated that, "Anxiety [was] a huge issue for [her because her] bipolar [disease had] created a feeling of helplessness and hopelessness in [her] everyday activities [and she] had thought of suicide on a regular basis . . . [and that she] tried to work [but was prevented by] her illness and state of mind." (Tr. 191). She indicated that her husband did everything at home and "pre-planned for everything for when he [was] at work." (Tr. 192). She stated that her illness has affected her ability to care for herself and her children, to maintain her house, and to hold a job, and that her medications made her "sleep all the time." (Tr. 192). Plaintiff was able to prepare her own meals, but had a diminished interest in doing so due to loss of focus, even though she loved to cook before her illness began. (Tr. 193). Plaintiff was also able to load the dishwasher, do one (1) load of laundry per week, drive a car, and shop for groceries with her husband. (Tr. 193-194). When asked to check items that her illness, injuries, or conditions did not affect, Plaintiff did not check lifting, squatting, bending, standing, reaching, walking, sitting, kneeling, talking, stair climbing, seeing, or using hands. (Tr. 195).
Regarding her concentration and memory, Plaintiff needed reminders to shower, take her medicine, and complete her chores. (Tr. 192-193). She could pay bills, count change, handle a savings account, and use a checkbook. (Tr. 194). Plaintiff was able to pay attention for "30 minutes or so" and was not able to finish what she started. (Tr. 195). She stated she followed spoken instructions "not well at all [because she couldn't] focus" and that she followed written instructions "ok" as she would re-read something until she understood it. (Tr. 195). She did not handle stress well as she would usually throw up from anxiety and stress. (Tr. 196). She was "ok with changes" in routine. (Tr. 196).
Socially, Plaintiff went outside everyday, and was able to go out alone most of the time. (Tr. 194). Plaintiff had a hard time maintaining friendships because she "was easily hurt or just moody." (Tr. 195). She got along "fine" with authority figures, and had never been fired or laid off from a job because of problems getting along with other people. (Tr. 196). She noted that she was afraid that one (1) day she would kill herself due to her thoughts of self-worthlessness. (Tr. 196). Her medications listed included Cymbalta, Abilify, Trazadone, and Lamictal. (Tr. 197).
At her hearing, Plaintiff testified that since she completed the Adult Function Report, her husband did ninety-five (95) percent of the grocery shopping, did all the laundry, cooked, and left her a list of chores to motivate her to get out of bed. (Tr. 75, 83). She avoided driving because that is when her panic attacks occurred, so she would have her husband drive her when he could. (Tr. 65). Her typical day included excessive amounts of sleep, including during the day when her children were at school, and eating mainly at dinnertime, but also sometimes during the day. (Tr. 82).
In terms of vacation, she testified that she drove to Kansas with her youngest son in approximately March of 2011, and visited family there for two (2) weeks. (Tr. 68-69). The drive to Kansas took two (2) days. (Tr. 69). Plaintiff also admitted that she went on a vacation for one (1) week to Williamsburg in the summer of 2011. (Tr. 78). On this vacation, Plaintiff testified that she and her family toured Williamsburg for about two and a half (2 ½) hours, but Plaintiff cut the tour short because she was feeling anxious. (Tr. 78-79). Plaintiff stated she and her family spent most of their time at the pool during this vacation. (Tr. 78-79).
Plaintiff also testified about her work and school history. She stated that the last time she worked was for two (2) weeks as a customer service representative, and it was a "nightmare" because the training did not prepare her for the job, and she had constant thoughts running through her head that made it hard to focus. (Tr. 70). She could not remember what she was supposed to do, and she "kept making the same mistakes." (Tr. 71). Plaintiff did not look for another job because she "was so upset and devastated and felt worthless from trying so hard to work and provide for [her] family." (Tr. 71). She felt she could not work because her "anxiety [got] the best of [her] when [she was] expected to do something, like expected to be somewhere at a certain time . . ." (Tr. 71). She "hurt herself" before or during work to get out of having to work due to the anxiety "of knowing and having the pressure on [her]." (Tr. 71). Plaintiff's work history included working in the IT department from 1999 to 2004, and as a customer service representative at Bank of America from 2006 to 2010. (Tr. 71-72). Plaintiff testified that in approximately 2010, she earned eighteen (18) credits at Lackawanna College, and made the Dean's List. (Tr. 77-78). Plaintiff stated that she was not physically limited in her ability to work, that her husband's two (2) business endeavors in the radio industry were her family's source of income, and that she helped her husband with his business one (1) day a week, day and night, with data entry and connecting testing. (Tr. 62-63, 67).
In terms of finances, Plaintiff admitted that she had filed for bankruptcy in 2011, had her car repossessed, and that she and her family were still having financial difficulties. (Tr. 67). She testified that she would excessively spend money when going through a manic stage of her Bipolar Depression, but that she hadn't had a manic episode like this "for a while." (Tr. 81).
Regarding her children, at the time of her alleged onset date, Plaintiff's two (2) adopted sons were ages six (6) and four (4), and she acknowledged that she took care of them. (Tr. 64). At the time of the hearing, her sons were ages eight (8) and six (6), and they were in school full-time. (Tr. 64). In terms of childcare, Plaintiff testified that her sons attended a summer camp for three (3) hours each day the summer prior to the hearing. (Tr. 72). Her husband drove them to camp, and she walked to pick them up and took care of them for the remainder of the day. (Tr. 72). She admitted to being friendly with her neighbors, and that they helped her with taking care of her kids by letting her sons play with their children during the summer. (Tr. 73-74).
With regards to treatment, Plaintiff admitted that two (2) medication changes and counseling that she was attending every two (2) weeks was helping her feel "a little better." (Tr. 66, 74-75). She stated that at the time of the hearing, her panic attacks had settled down, and that she hadn't had any "as of lately." (Tr. 65-66). However, she also testified that she experienced morbid thoughts and "hurting other people to get out of doing things." (Tr. 79). She testified that at least ten (10) times over the past few years, she hurt herself to "get out of doing things" or to leave early, including slamming her arm in a door, throwing herself down the stairs, and burning herself. (Tr. 80).
Before the Court addresses the ALJ's decision and the arguments of counsel, Plaintiff's relevant mental health medical records will be reviewed in detail, beginning with records from his alleged disability onset date of June 15, 2011 through the date of the ALJ's decision on February 4, 2013.
On July 29, 2011, Plaintiff had an appointment with Matthew Berger, M.D. (Tr. 550). Plaintiff reported that she had been doing well, and was unaccompanied at her appointment. (Tr. 550). She stated that she had to leave her job after two (2) weeks of training because "`it was too much,'" that she had been anxious, unable to focus, and more irritable, that her mood had declined since she stopped working, and that she had poor focus. (Tr. 550). She reported having financial issues that were leading to filing for bankruptcy. (Tr. 550). She had not been experiencing mania, mood swings, impulsivity, excessive spending habits, or suicidal or homicidal ideations. (Tr. 550). She admitted to having morbid thoughts, and that Trazadone had not been as effective for sleep anymore leading to mild daytime fatigue. (Tr. 550). Her therapy with Tina had been very helpful. (Tr. 550). Plaintiff denied the following: expansive mood; grandiosity; overtalkativness; pressured speech; decreased need for sleep; homicidal or suicidal thoughts; indecisiveness; and sleep problems. (Tr. 550). She experienced the following: ongoing racing thoughts; increased anxiety; increased anhedonia; a good appetite; poor concentration; increased crying; frequent distractability; fair energy level, memory, and motivation; increased feelings of guilt; decreased feelings of helplessness; infrequent impulsiveness; good interest; more frequent irritability; more frequent isolative behavior; mood lability; being easily overwhelmed; frequent ruminations; increased sadness; and frequent feelings of worthlessness. (Tr. 550). She had symptoms present for years with a gradual onset with no precipitating event, and these symptoms had worsened to a moderate level of severity since her last visit. (Tr. 550). Her symptoms were aggravated by lack of sleep and stress, and alleviated by rest and medications. (Tr. 550). Her medications list at this appointment included Abilify, Metformin, Cymbalta, Enalapril Maleate, Protonix, Simvastatin, Lamictal, and Trazodone. (Tr. 552). Her exam revealed a cooperative attitude, an affect appropriate to mood, good eye contact, clear and fluent speech, coherent and logical thought processes, intact associative thinking, lack of delusions or hallucinations, a presence of suicidal thoughts, a lack of homicidal thoughts, intact memory, normal attention span and concentration, impulsive judgment, lack of insight, and knowledge and vocabulary consistent with her education. (Tr. 552). Her assessment noted that her mood swings were stable, and that her anxiety and depression were exacerbated and related to situational stressors. (Tr. 552). Her treatment plan included increasing Lamictal and Trazodone, and to return in four (4) weeks for a follow-up visit. (Tr. 552).
August 19, 2011, Mark Hite, M.D. performed a Psychiatric Review Technique ("PRT") and Mental Residual Functional Capacity ("RFC") Assessment of Plaintiff. (Tr. 106-114). Both assessments were current and took into consideration the entire medical record. (Tr. 106-114). In the PRT, Dr. Hite considered Listings 12.04
(Tr. 110). In the Mental RFC, Dr. Hite opined that while Plaintiff had a medically determinable impairment that could reasonably be expected to produce her symptoms, her statements about the intensity, persistence, and functionally limiting effects of the symptoms could not be substantiated by the objective medical evidence alone. (Tr. 111). He also opined that Plaintiff: (1) did not have limitations with her memory or understanding; (2) had sustained concentration and persistence limitations, with her ability to maintain attention and concentration for extended periods being moderately limited, but no significant limitations in her ability to carry out short and simple instructions, to carry out detailed instructions, to perform activities within a schedule, to maintain regular attendance, to be punctual within customary tolerances, to sustain an ordinary routine without special supervision, to work in coordination with or in proximity to others without being distracted by them, to make simple work-related decisions, or to complete a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods; (3) had limitations in social interactions as she was moderately limited in her ability to interact appropriately with the general public, but otherwise was not significantly limited in her ability to ask simple questions or request assistance, to accept instructions and respond appropriately to criticism from supervisors, to get along with coworkers or peers without distracting them or exhibiting behavioral extremes, to maintain socially appropriate behavior, or to adhere to basic standards of neatness and cleanliness; and (4) had no adaption limitations. (Tr. 112-114). Dr. Hite opined that Plaintiff was capable of performing most routine activities of daily living and self-care because she was able to prepare easy meals, do laundry and light chores, drive, go out alone, shop, pay bills, use a checkbook, follow instructions, and manage changes in routine. (Tr. 114).
On September 26, 2011, Lee T. Besen, M.D. performed a consultative examination of Plaintiff. (Tr. 509). Plaintiff explained to Dr. Besen that she was diagnosed with Bipolar Disease in 1999, had tried various medications, was misdiagnosed for "a quite period of time," and was a patient of Dr. Berger for the past four (4) years. (Tr. 509). She was intelligent, and was able to fully discuss her issues. (Tr. 509). She had not had any manic phases for many years, but was more depressed as she was "down, crying, and regularly anhedonic just as not enjoying anything." (Tr. 509). She had occasional suicidal thoughts with no plans. (Tr. 509). She had her medicines switched multiple times, wanted to sleep all the time, and had no energy. (Tr. 509). She worked as a certified nurse's assistant until February of 2011 when she felt she was "unable to maintain task, [had] no focus, [was] fatigue[d], [and felt] sleepy and just unable to perform her functions." (Tr. 509). Dr. Besen noted, "Other than her psychology type review of systems [Plaintiff had] normal sensorium, [was] able to discuss issues at hand, [had] normal judgment, [and her] remote and recent memory [were] fine." (Tr. 509). Her listed medications included Trazadone, Cymbalta, Metformin, Vasotec, Abilify, Protonix, Simvastatin, Lamictal, and laxative pills. (Tr. 510). Dr. Besen's impression was that Plaintiff had Bipolar Disease with residual depressive symptoms, and impaired fasting sugar due to psychotropics. (Tr. 511). Dr. Besen completed a Medical Source Statement of Plaintiff's ability to perform work-related physical activities. (Tr. 513). He opined that Plaintiff could frequently lift and carry up to twenty (20) pounds, could occasionally lift and carry twenty-five (25) pounds, and had no limitations in standing, walking, sitting, pushing and pulling or any other physical functions. (Tr. 513-514). Plaintiff could frequently bend, kneel, stoop, crouch, balance, and climb, and had no environmental restrictions. (Tr. 514).
On October 20, 2011, Plaintiff had an appointment with Dr. Berger. (Tr. 546). Plaintiff attended the appointment unaccompanied and stated that she had been feeling well. (Tr. 546). She reported that she had three (3) panic attacks in the last month and was more anxious and irritable due to financial issues and having to file for bankruptcy, but that overall her mood had been "even" with no mania or impulsivity. (Tr. 546). She rated her mood at a six (6) out of ten (10), and admitted to having morbid thoughts. (Tr. 546). She had been seeing a counselor named Tina for therapy, which had been helpful. (Tr. 546). In the patient "History of the Present Illness" section, it was noted that Plaintiff reported symptoms of Bipolar Disorder, including increased anxiety, racing thoughts, crying episodes, increased feelings of guilt, frequent irritability, frequent distractability, more frequent isolative behavior, mood lability, feeling easily overwhelmed, ongoing ruminations, increased sadness, and frequent feelings of worthlessness. (Tr. 546). She denied experiencing grandiosity, overtalkativeness, pressured speech, a decreased need for sleep, a poor appetite, and the presence of homicidal and suicidal thoughts. (Tr. 546). She reported that her level of anhedonia had improved, her ability to concentrate, memory, motivation, and energy level were fair, and her feelings of helplessness had decreased. (Tr. 546). Her symptoms were reported as being a gradual onset with no precipitating event, were moderate in severity, had been present for years with no change since her last visit, and were alleviated by medications and rest. (Tr. 546). Her suicide attempts included jumping out of a car in 2000 and cutting her wrists, but these were noted as being attention seeking attempts, not true attempts. (Tr. 546). Her previous psychiatric admissions occurred in 1999 and 2000 for severe anxiety. (Tr. 546). Her exam revealed that she was cooperative and anxious, and had an appropriate mood, good eye contact, clear, fluent and spontaneous speech, intact language processing, a coherent and logical thought process, intact associative thinking, intact immediate, recent, and remote memory, normal concentration and attention span, impulsive judgment, appropriate insight, and knowledge and vocabulary consistent with her education. (Tr. 548). Her previous medications included Prozac, which worked well, but that she stopped taking after seven (7) to eight (8) months of treatment. (Tr. 546). She had also tried Topamax, Neurontin, Zoloft, Effexor, Elavil, Seroquel, and Tegretol. (Tr. 546). The medications she was taking at the time of the appointment included Trazodone, Abilify, Metformin, Cymbalta, Enalapril Maleate, Protonix, Simvastatin, and Lamotrigine. (Tr. 548). Her assessment noted that her anxiety was exacerbated and related to situational stressors including marriage and workplace problems, that her depression was improved and was related to situational stressors, and that her mood swings were stable. (Tr. 548). Plaintiff's Axis I diagnosis was Bipolar Disorder, not otherwise specified, her Axis II diagnosis was Personality Disorder, not otherwise specified, and her Global Assessment of Functioning Score ("GAF")
On November 18, 2011, Plaintiff had an appointment with Dr. Berger. (Tr. 738). Plaintiff attended her appointment unaccompanied. (Tr. 738). She reported that she was feeling "a little better," that her mood had improved with medication changes, that she was less irritable, that her mood had been "even," and that seeing Tina for therapy had been very helpful. (Tr. 738). She had been feeling fatigued, anxious, and easily overwhelmed, and had morbid thoughts, but she had not had any panic attacks or experienced mania or impulsivity. (Tr. 738). She denied experiencing the following: expansive mood, grandiosity, overtalkativeness, pressured speech, decreased need for sleep, presence of homicidal and suicidal ideations, indecisiveness, increased sadness, or sleep problems. (Tr. 738). She reported that she had the following: frequent flight of ideas, ongoing racing thoughts, improved anhedonia, improved anxiety, good appetite, fair energy level, motivation, memory, and ability to concentrate, decreased crying episodes, frequent distractability, ongoing feelings of guilt, decreased feelings of helplessness, infrequent impulsiveness, good interest, less frequent irritability, more frequent isolative behavior, mood lability, ongoing sadness, ongoing ruminations, and feelings of worthlessness. (Tr. 738). It was noted that she had improved since her last visit. (Tr. 738). Her medications list included Cymbalta, Lamictal, Trazodone, Abilify, Metformin, Enalapril Maleate, Protonix, and Simvastatin. (Tr. 740). An exam revealed the that Plaintiff had anxiety, an affect appropriate to her mood, good eye contact, clear and fluent speech, intact language processing, coherent and logical thought processes, intact associative thinking, no delusions or hallucinations, intact memory, normal attention span and concentration, impulsive judgment, appropriate insight, and knowledge and vocabulary consistent with her education. (Tr. 740). Plaintiff's Axis I diagnosis was Bipolar Disorder, her Axis II diagnosis was personality disorder, and her GAF was a fifty-two (52). (Tr. 740). Her treatment plan involved continuing her current medications, and returning to the office in eight (8) weeks. (Tr. 741).
On January 18, 2012, Plaintiff had an appointment with Dr. Berger, which she attended alone. (Tr. 742). Plaintiff stated she was doing better, and that she was "doing well with [her] current education." (Tr. 742). She reported that her mood was fairly even, and that she was not experiencing mania, impulsivity, or irritability. (Tr. 742). Her anxiety was mild, and she had not had any panic attacks. (Tr. 742). She had been unable to attend therapy with Tina due to finances. (Tr. 742). She rated her mood at a five (5) to six (6) out of ten (10), and reported that she continued to have morbid thoughts, but no suicidal or homicidal ideations. (Tr. 742). Plaintiff denied expansive mood, gradiosity, overtalkativeness, pressured speech, decreased need for sleep, decreased crying episodes, presence of homicidal or suicidal thoughts, and sleep problems. (Tr. 742). She reported that she had the following: frequent flight of ideas, ongoing racing thoughts, improved anhedonia, improved anxiety, good appetite, fair energy level, motivation, memory, and ability to concentrate, decreased crying episodes, frequent distractability, ongoing feelings of guilt, decreased feelings of helplessness, infrequent impulsiveness, good interest, less frequent irritability, more frequent isolative behavior, mood lability, ongoing sadness, ongoing ruminations, and feelings of worthlessness. (Tr. 742). It was noted that her condition had not changed since her last visit. (Tr. 742). Her medications list included Cymbalta, Lamictal, Trazodone, Abilify, Metformin, Enalapril Maleate, Protonix, and Simvastatin. (Tr. 744). An exam revealed that Plaintiff had anxiety, an affect appropriate to her mood, good eye contact, clear and fluent speech, intact language processing, coherent and logical thought processes, intact associative thinking, no delusions or hallucinations, intact memory, normal attention span and concentration, impulsive judgment, appropriate insight, and knowledge and vocabulary consistent with her education. (Tr. 744). Plaintiff's Axis I diagnosis was Bipolar Disorder, her Axis II diagnosis was personality disorder, and her GAF was a fifty-two (52). (Tr. 744). Her treatment plan involved continuing her current medications, and returning to the office in twelve (12) weeks. (Tr. 745).
On April 18, 2012, Plaintiff had a follow-up appointment with Dr. Berger and attended the appointment alone. (Tr. 746). Plaintiff reported that she had been feeling "`not the greatest,'" that she had been down for the last month, that she hadn't left the house, and that she hadn't felt stable since before Christmas. (Tr. 746). She stated she had been experiencing a low mood, fatigue, racing thoughts, anxiety, and some panic attacks, but that she had not been experiencing mania, impulsivity, or irritability. (Tr. 746). Plaintiff denied expansive mood, gradiosity, overtalkativeness, pressured speech, decreased need for sleep, presence of homicidal or suicidal thoughts, and sleep problems. (Tr. 746). She reported that she had the following: frequent flight of ideas, ongoing racing thoughts, worsened anhedonia, increased anxiety, good appetite, fair memory, motivation, and ability to concentrate, poor energy levels, increased crying episodes, frequent distractability, ongoing feelings of guilt, decreased feelings of helplessness, infrequent impulsiveness, good interest, less frequent irritability, more frequent isolative behavior, mood lability, increased sadness, ongoing ruminations, and feelings of worthlessness. (Tr. 746). It was noted her condition had not changed since her last visit. (Tr. 742). Her medications list included Cymbalta, Lamictal, Trazodone, Abilify, Metformin, Enalapril Maleate, Protonix, and Simvastatin. (Tr. 747). An exam revealed the that Plaintiff had anxiety and sadness, an affect appropriate to her mood, good eye contact, clear and fluent speech, intact language processing, coherent and logical thought processes, intact associative thinking, no delusions or hallucinations, intact memory, normal attention span and concentration, impulsive judgment, appropriate insight, and knowledge and vocabulary consistent with her education. (Tr. 747-748). Plaintiff's Axis I diagnosis was Bipolar Disorder, her Axis II diagnosis was personality disorder, and her GAF was a fifty-two (52). (Tr. 748). Her treatment plan involved increasing her Cymbalta dose, adding Klonopin, and returning to the office in four (4) weeks. (Tr. 748).
On May 18, 2012, Plaintiff had an appointment with Dr. Berger, and attended this appointment alone. (Tr. 749). She reported that she was "`about the same,'" did not have too much improvement in mood with the increased Cymbalta, had ongoing depression and anxiety, had a poor energy level with "`no motivation,'" and was seeing Tina again for therapy, which had been helpful. (Tr. 749). Her sleep and appetite were ok. (Tr. 749). She rated her mood at a four (4) out of ten (10). (Tr. 749). She admitted to morbid thinking with occasional thoughts of suicide, but no intent or plan. (Tr. 749). Plaintiff denied expansive mood, gradiosity, overtalkativeness, pressured speech, decreased need for sleep, presence of homicidal or suicidal thoughts, and sleep problems. (Tr. 749). She reported that she had the following: frequent flight of ideas, ongoing racing thoughts, worsened anhedonia, increased anxiety, good appetite, fair memory, motivation, and ability to concentrate, poor energy levels, increased crying episodes, frequent distractability, ongoing feelings of guilt, decreased feelings of helplessness, infrequent impulsiveness, good interest, less frequent irritability, more frequent isolative behavior, mood lability, increased sadness, ongoing ruminations, and feelings of worthlessness. (Tr. 749). It was noted that her condition had not changed since her last visit. (Tr. 749). Her medications list included Klonopin, Cymbalta, Lamictal, Trazodone, Abilify, Metformin, Enalapril Maleate, Protonix, and Simvastatin. (Tr. 751). An exam revealed the that Plaintiff had anxiety and sadness, an affect appropriate to her mood, good eye contact, clear and fluent speech, intact language processing, coherent and logical thought processes, intact associative thinking, no delusions or hallucinations, intact memory, normal attention span and concentration, impulsive judgment, appropriate insight, and knowledge and vocabulary consistent with education. (Tr. 751). Plaintiff's Axis I diagnosis was Bipolar Disorder, her Axis II diagnosis was personality disorder, and her GAF was a fifty-two (52). (Tr. 751). Her treatment plan involved increasing her Lamictal dose, and returning to the office in four (4) weeks. (Tr. 752).
On June 7, 2012, Plaintiff had an appointment with Dr. Berger, which she attended alone. (Tr. 753). She reported that she was "`about the same,'" was irritable, depressed, and easily overwhelmed, had a poor energy level and motivation, and that her sleep and appetite were ok. (Tr. 753). She admitted to having morbid thoughts with occasional thoughts of suicide, but no intent or plan. (Tr. 753). She noted that therapy with Tina had been helpful. (Tr. 753). Plaintiff denied expansive mood, gradiosity, overtalkativeness, pressured speech, decreased need for sleep, presence of homicidal or suicidal thoughts, and sleep problems. (Tr. 753). She reported that she had the following: frequent flight of ideas, ongoing racing thoughts, worsened anhedonia, increased anxiety, good appetite, fair memory and ability to concentrate, poor energy levels and motivation, ongoing crying episodes, frequent distractability, ongoing feelings of guilt, decreased feelings of helplessness, infrequent impulsiveness, good interest, less frequent irritability, more frequent isolative behavior, mood lability, increased sadness, ongoing ruminations, suicidal thoughts, and feelings of worthlessness. (Tr. 753). It was noted that her condition had not changed since her last visit. (Tr. 753). Her medications list included Cymbalta, Lamictal, Trazodone, Abilify, Metformin, Enalapril Maleate, Protonix, and Simvastatin. (Tr. 755). An exam revealed the that Plaintiff displayed sadness and a subdued mood, an affect appropriate to her mood, good eye contact, clear and fluent speech, intact language processing, coherent and logical thought processes, intact associative thinking, no delusions or hallucinations, intact memory, normal attention span and concentration, impulsive judgment, appropriate insight, and knowledge and vocabulary consistent with her education. (Tr. 755). Plaintiff's Axis I diagnosis was Bipolar Disorder, her Axis II diagnosis was personality disorder, and her GAF was a fifty-two (52). (Tr. 755). Her treatment plan involved increasing her Abilify and Lamictal doses, adding Benztropine, and returning to the office in three (3) weeks. (Tr. 756).
On July 27, 2012, Plaintiff had an appointment with Dr. Berger, and attended this appointment alone. (Tr. 757). Plaintiff reported increasing frustration and irritability, and remained easily overwhelmed. (Tr. 757). She admitted to an increase in morbid thinking about hurting someone, although she stated she never would hurt someone. (Tr. 757). She denied any physical aggression with her children, but admitted to occasional thoughts of suicide with no intent or plan. (Tr. 757). Therapy with Tina had been helpful. (Tr. 757). Plaintiff denied expansive mood, gradiosity, overtalkativeness, pressured speech, decreased need for sleep, presence of homicidal or suicidal thoughts, and sleep problems. (Tr. 757). She reported that she had the following: frequent flight of ideas, ongoing racing thoughts, worsened anhedonia, increased anxiety, good appetite, fair memory, motivation, and ability to concentrate, poor energy levels, increased crying episodes, frequent distractability, ongoing feelings of guilt, decreased feelings of helplessness, infrequent impulsiveness, good interest, less frequent irritability, more frequent isolative behavior, mood lability, increased sadness, ongoing ruminations, and feelings of worthlessness. (Tr. 757). It was noted that her condition had not changed since her last visit. (Tr. 757). Her medications list included Cymbalta, Lamictal, Trazodone, Abilify, Metformin, Enalapril Maleate, Prilosec, Benztropine Mesylate, and Simvastatin. (Tr. 759). An exam revealed that Plaintiff displayed sadness and a subdued mood, an affect appropriate to her mood, good eye contact, clear and fluent speech, intact language processing, coherent and logical thought processes, intact associative thinking, no delusions or hallucinations, intact memory, normal attention span and concentration, impulsive judgment, appropriate insight, and knowledge and vocabulary consistent with her education. (Tr. 759). Plaintiff's Axis I diagnosis was Bipolar Disorder, her Axis II diagnosis was personality disorder, and her GAF was a fifty (50). (Tr. 759). Her treatment plan involved tapering and discontinuing Abilify, adding Latuda, decreasing Cymbalta, and returning to the office in three (3) weeks. (Tr. 760).
On August 16, 2012, Plaintiff went unaccompanied to her appointment with Dr. Berger. (Tr. 761). She reported that she was "`about the same,'" and was experiencing ongoing irritability, frustration, and morbid thoughts of suicide without intent or plan. (Tr. 761). Plaintiff denied expansive mood, gradiosity, overtalkativeness, pressured speech, decreased need for sleep, presence of homicidal or suicidal thoughts, and sleep problems. (Tr. 761). She reported that she had the following: frequent flight of ideas, ongoing racing thoughts, worsened anhedonia, increased anxiety, good appetite, fair memory, motivation, and ability to concentrate, poor energy levels, increased crying episodes, frequent distractability, ongoing feelings of guilt, decreased feelings of helplessness, infrequent impulsiveness, good interest, less frequent irritability, more frequent isolative behavior, mood lability, increased sadness, ongoing ruminations, and feelings of worthlessness. (Tr. 761). It was noted that her condition had not changed since her last visit. (Tr. 761). Her medications list included Benztropine Mesylate, Klonopin, Lamictal, Trazodone, Metformin, Cymbalta, Enalapril Maleate, simvastatin, Prilosec, and Latuda. (Tr. 763). An exam revealed that Plaintiff displayed sadness and a subdued mood, an affect appropriate to her mood, good eye contact, clear and fluent speech, intact language processing, coherent and logical thought processes, intact associative thinking, no delusions or hallucinations, intact memory, normal attention span and concentration, impulsive judgment, appropriate insight, and knowledge and vocabulary consistent with education. (Tr. 763). Plaintiff's Axis I diagnosis was Bipolar Disorder, her Axis II diagnosis was personality disorder, and her GAF was fifty (50). (Tr. 763). Her treatment plan involved increasing Latuda, continuing her other medications, attending therapy with Tina, and returning to the office in two (2) weeks. (Tr. 764).
When considering a social security appeal, the court has plenary review of all legal issues decided by the Commissioner.
Substantial evidence "does not mean a large or considerable amount of evidence, but `rather such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'"
Substantial evidence exists only "in relationship to all the other evidence in the record,"
To receive disability benefits, the plaintiff must demonstrate an "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. § 432(d)(1)(A). Further,
42 U.S.C. § 423(d)(2)(A).
The Commissioner uses a five-step process in evaluating disability and claims for disability insurance benefits.
"At step five, the burden of proof shifts to the Social Security Administration to show that the claimant is capable of performing other jobs existing in significant numbers in the national economy, considering the claimant's age, education, work experience, and [RFC]."
Initially, the ALJ concluded that Plaintiff met the insured status requirements of the Social Security Act through December 31, 2016. (Tr. 32). The ALJ then proceeded through each step of the sequential evaluation process and determined that Plaintiff was not disabled. (Tr. 32).
At step one, the ALJ found that Plaintiff had not engaged in substantial gainful work activity from her alleged onset date of June 15, 2011. (Tr. 32).
At step two, the ALJ determined that Plaintiff suffered from the severe
At step three of the sequential evaluation process, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. §§ 404.1520(d), 404.1525 and 404.1526). (Tr. 33).
At step four, the ALJ determined that Plaintiff had RFC to perform a full range of work at all exertional levels with the following nonexertional limitations:
(Tr. 34-35).
At step five of the sequential evaluation process, considering the Plaintiff's age, education, work experience, and RFC, the ALJ determined "there are jobs that exist in significant numbers in the national economy that the [Plaintiff] can perform (20 C.F.R. 404.1569, 404.1569(a), 416.969, and 416.969(a))." (Tr. 40).
Thus, the ALJ concluded that Plaintiff was not under a disability as defined in the Social Security Act at any time between the alleged onset date of June 15, 2011 through the date of the ALJ's decision. (Tr. 41).
In her complaint and brief in support, Plaintiff is alleging that the ALJ erred in failing to give controlling weight to the opinion of Plaintiff's treating physician, Dr. Berger. (Doc. 7, pp. 7, 10-13). Defendant disputes this contention. (Doc. 8, pp. 15-23).
The preference for the treating physician's opinion has been recognized by the Third Circuit Court of Appeals and by all of the federal circuits.
However, when the treating physician's opinion conflicts with a non-treating, non-examining physician's opinion, the ALJ may choose whom to credit in his or her analysis, but "cannot reject evidence for no reason or for the wrong reason."
Regardless, the ALJ has the duty to adequately explain the evidence that he rejects or to which he affords lesser weight.
In his opinion, the ALJ initially gave great weight to the opinion of Dr. Hite rendered in the PRT and Mental RFC. (Tr. 38). He noted that he gave little weight to the portion of the opinion that stated Plaintiff had no difficulty in activities of daily living because the record supported that Plaintiff had mild difficulty in this area. (Tr. 38). The ALJ also gave great weight to the opinion of Dr. Besen in that Plaintiff had no limitations in standing, walking, or sitting. (Tr. 38). He gave little weight to the portion of Dr. Besen's opinion that Plaintiff could only occasionally lift and/or carry twenty-five (25) pounds maximum because this "[was] not in line with [Dr. Besen's] essentially normal examination findings." (Tr. 39). The ALJ then gave great weight to the GAF scores of fifty-two (52) and fifty-six (56) assigned to Plaintiff in May, July, October, and November of 2011, and January, April, May, and June of 2012 because they were "consistent with the medical evidence of record, which show[ed] no more than moderate objective mental status examination findings during this period[.]" (Tr. 39).
Little weight was assigned to the GAF score of fifty (50) assigned to Plaintiff during a two (2) month span in July and August of 2012 because they were not "clearly supported in the evidence of record." (Tr. 39). The ALJ also gave little weight to GAF scores assigned to Plaintiff and an opinion rendered by Ms. Margaret Marshall, who was not an acceptable medical source, that Plaintiff had difficulties in social functioning and in concentration persistence, because these were not consistent with the record and were rendered before the alleged onset date. (Tr. 39-40). Lastly, the ALJ gave little weight to Dr. Berger's opinion from July of 2011 that Plaintiff had marked difficulties in responding to work changes and understanding, remembering, and carrying out detailed work instructions. (Tr. 39). The ALJ stated:
(Tr. 39). Therefore, the ALJ was explaining that the evidence of record, and Dr. Berger's own examination, did not support his opinion that Plaintiff had marked difficulties in responding to work changes and understanding, remembering, and carrying out detailed work instructions.
Ultimately, the ALJ determined that Plaintiff had the RFC to perform a full range of work at all exertional levels with the following nonexertional limitations: (1) Plaintiff was limited to occupations requiring no more than simple, routine tasks, not performed in a fast-paced production environment, involving only simple, work-related decision, and in general, relatively few work place changes; (2) Plaintiff was limited to occupations that required no more than occasional interaction with supervisors and coworkers and no interaction with, but within general proximity to, members of the general public; and (3) Plaintiff was limited to occupations that required low stress, defined as occasional decision-making required. (Tr. 35-36). Therefore, the ALJ erred on the side of caution in determining Plaintiff's RFC, and included nonexertional limitations regarding social functioning and concentration, persistence, and pace.
Upon review of the record and the ALJ's decision, it is determined that the ALJ appropriately afforded weight to the aforementioned opinions. The opinions of Dr. Hite and Dr. Besen and the GAF scores from May, July, October, and November of 2011 and January, April, May, and June of 2012 were consistent with and well-supported by the medical evidence and record as a whole. As noted by the ALJ, Plaintiff repeatedly told her physicians and testified at her oral hearing that she was doing better, that her anxiety and depression were improving with medications and therapy, and that her panic attacks had settled down. (Tr. 37, 65-66, 74-75). Additionally, as noted by the ALJ, Plaintiff testified that she was able to go on vacation to Williamsburg for one (1) week in the summer of 2011, travel to Ohio for Thanksgiving in 2011, prepare meals, shop, attend appointments unaccompanied, take care of her two (2) children, help her husband with his business, socialize with neighbors, and handle savings and checking accounts without difficulty. (Tr. 38, 64, 68-69, 72-74).
Additionally, it was repeatedly noted by Dr. Berger that Plaintiff's memory was intact, her attention span and concentration were normal, her language processing and associative thinking were intact, her speech was clear, fluent, and spontaneous, her eye contact was good, and her mood swings were stable. (Tr. 37, 552, 548, 740, 744, 747-748, 751, 755, 759, 763). Also, as discussed by the ALJ, Plaintiff's treatment was routine and conservative and did not require any inpatient treatment, hospitalizations or emergency room visits. (Tr. 37).
Moreover, the RFC determined by the ALJ accommodated Plaintiff's limitations as it limited her to simple, unskilled work, with limitations in workplace changes and decision-making and with a limitation of no interaction with the general public, supervisors, or co-workers. (Tr. 35-37).
As such, based on a review of the record, it is determined that substantial evidence supports the ALJ's RFC determination, and it will not be disturbed on appeal.
The Court's review of the administrative record reveals that the decision of the Commissioner is supported by substantial evidence. Therefore, pursuant to 42 U.S.C. § 405(g), Plaintiff's appeal will be denied, and the decision of the Commissioner denying disability insurance benefits will be affirmed.
A separate Order will be issued.
42 U.S.C. § 423(d)(2)(A).
