MAURICE B. COHILL, Jr., Senior District Judge.
This case is before us on appeal from a final decision by the defendant, Commissioner of Social Security ("the Commissioner"), denying Melissa Dawn Christensen's claim for disability insurance benefits and supplemental security income under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 401-434 and 1381-1383f. The parties have submitted cross-motions for summary judgment. For the reasons stated below, we will grant the Plaintiff's motion for summary judgment to the extent she seeks a remand for further proceedings, deny Plaintiff's motion for summary judgment to the extent she seeks a reversal of the ALJ's decision and an award of benefits, and deny the Defendant's motion for summary judgment.
Melissa Dawn Christensen applied for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 401-434 and 1381-1383f on February 18, 2009, alleging a disability due to depression, back problems, and foot problems, with an alleged onset date of December 29, 2008. Plaintiffs claim was initially denied on June 8, 2009. A timely request for a hearing was filed by Plaintiff on June 26, 2009. A hearing was held before an Administrative Law Judge ("ALJ") on August 12, 2010, at which Plaintiff was represented by counsel, Gerald M. Sullivan, and testified. R. at 36-67. A vocational expert also testified at the hearing. R. 67-71.
By decision dated September 17, 2010, the ALJ determined that Plaintiff is not disabled under §§ 216(i), 223(d) and 1614(a)(3)(A) of the SSA. R. at 18-28.
Plaintiff filed a timely review of the ALJ's determination, which was denied by the Appeals Council on April 10, 2012. R. 1-6. Having exhausted her administrative remedies, Plaintiff filed the instant action seeking judicial review of the final decision of the Commissioner of Social Security denying her DIB and SSI application.
The Congress of the United States provides for judicial review of the Commissioner's denial of a claimant's benefits.
Under the SSA, the term "disability" is defined as the:
42 U.S.C. § 423. A person is unable to engage in substantial activity when he:
42 U.S.c. §§ 423(d)(1)(A), (d)(2)(A).
In determining whether a claimant is disabled under the SSA, a sequential evaluation process must be applied. 20 C.F.R. § 416.920(a).
The ALJ must also determine the claimant's residual functional capacity; that is, the claimant's ability to do physical and mental work activities on a sustained basis despite limitations from his impairments. 20 C.F.R. § 416.920(e). If the claimant does not have an impairment which meets or equals the criteria, at step four the Commissioner must determine whether the claimant's impairment or impairments prevent him from performing his past relevant work. 20 C.F .R. § 416.920(f). If so, the Commissioner must determine, at step five, whether the claimant can perform other work which exists in the national economy, considering his residual functional capacity and age, education and work experience. 20 C.F .R. § 416.920(g).
In the instant matter, in support of his Decision, the ALJ first focused on those records relevant to Plaintiffs obesity and back pain. He discussed the medical records from Plaintiffs primary care providers to the extent they contained a diagnosis of obesity. R. 21. He then discussed Plaintiff being diagnosed with lumbago and that although she was referred to physical therapy for her back, and testified that she went to therapy and it made her back pain worse, so she stopped attending therapy, there was not any evidence in the medical record that she ever attended physical therapy. R. 21. Next, the ALJ discussed Plaintiffs testimony that she'd had x-rays that showed narrowing of the spine, and that a January 12, 2009 x-ray of Plaintiff's lumbar spine noted mild posterior element sclerosis at LS-S1 but no evidence of acute fracture, malalignment, or significant degenerative change. R. 21. The ALJ further noted that there were no real positive findings on Plaintiff's back impairment in the Record, that treatment records regularly reflected that there was no known injury, that no objective testing had established the etiology of Plaintiffs back pain, and although she had received treatment for her complaints of back pain, the treatment had been excessively conservative in nature. R. 21. Based on all of the above, the ALJ concluded that "the evidence of record fails to establish that [Plaintiffs] back impairment causes more than a minimal limitation on [her] ability to perform basic work activities" and' [i]t is therefore, nonsevere under Social Security Regulations." R. 21.
The ALJ next focused on the evidence of record, both medical and non-medical, with respect to Plaintiffs mental health impairments. The ALJ first discussed Plaintiffs activities of daily living and found that she "has no restriction."
R. 22. The ALJ also referenced the conclusion of state agency psychologist Manella Link ("Dr. Link") that Plaintiff had no restriction in the area of activities of daily living. R.22. Concerning activities of daily living, thus, the ALJ concluded: "[t]he evidence of record, taken as a whole, supports a finding that [Plaintiff] has no restrictions in this domain." R. 22 (citations omitted)
The ALJ next discussed Plaintiffs social functioning and found that she has "moderate difficulties:"
R. 22 (citations omitted). The ALJ also referenced state agency psychologist Dr. Link's conclusion that Plaintiff had no difficulties in maintaining social functioning. R. 22. The ALJ concluded that "the preponderance of evidence in this case favors a finding that [Plaintiff] has moderate difficulties in this category. "R. 22.
The ALJ next discussed Plaintiffs "concentration, persistence, and pace" and concluded that in this area she has moderate difficulties:
R. 22 (citations omitted). The ALJ also referenced Dr. Link's conclusion that Plaintiff had moderate difficulties in maintaining concentration, persistence, or pace." R. 22. (citation omitted)
The ALJ also concluded that Plaintiff had not had any episodes of decompensation which have been of extended duration. R. 22. In support of this conclusion, the ALJ noted:
R. 22. The ALJ further noted that Dr. Link had also found that Plaintiff had not experienced any episodes of decompensation. R. 22 (citation omitted).
The ALJ also concluded that H[t]he record does not show a chronic affective disorder persisting for two or more years, despite pharmalogical treatment, resulting in `repeated' episodes of decompensation, or acceptable medical evidence supporting a prospective opinion that the [Plaintiffs] mental status would deteriorate if she were required to perform a minimum increase in mental demands, or a current history of one or more years of an inability to function outside a highly supportive living arrangement." R. 23.
The ALJ then decided, "after careful consideration of the entire record, I find that the [Plaintiff] has the residual functional capacity to perform medium work as defined in 20 CFR 404.1567(c) and 416.967(c) except that she is limited to simple tasks requiring little or no judgment; no interaction with the public, although the public could be around but no interacting required; and only occasional interaction with coworkers." R. 23. In so concluding, the ALJ stated: "[Plaintiff] testified that she is unable to perform the basic requirements of work activity because of the stressors of dealing with depression and that she is unable to do much of anything. She becomes irritable when other people talk to her. She is unable to concentrate, does not like being around other people, and is unable to keep up, according to her testimony. She reports loss of memory, lack of concentration, and crying all the time as factors which limit her ability to engage in work-like activities, and states that doing ajob would be difficult because her thoughts become preoccupied with problems in her personal life outside of work." R. 24 (citation omitted).
The ALJ then made the following conclusion with respect to Plaintiff's credibility: "after careful consideration of the evidence, I find that the [Plaintiff's] medically determinable impairments could reasonably be expected to cause the alleged symptoms; however, the [Plaintiffs] statements concerning the intensity, persistence and limiting effects of these symptoms are not credible to the extent they are inconsistent with the above residual functional capacity assessment." R. 24. In support of this credibility determination, the ALJ cited first to the fact that Plaintiff has been receiving unemployment benefits since January 2009, which means she "is representing to the state she is willing and able to work. While entitlement to unemployment benefits and a finding of disability under the Social Security Regulations are not mutually exclusive, the inherent inconsistency is not without significance." R. 24. Second, the ALJ noted an inconsistency between Plaintiffs explanation for why she stopped working in December 2008 and what was in the Record. "Although [Plaintiff] reported that she lost her job due to her inability to concentrate at work, the record indicates that the claimant left her job because her child was being returned to her by social services." R. 24. Third, the ALJ stated: "[Plaintiff] testified that the child was taken by social services at the hospital because of issues in her husband's past of which she was unaware. However, the record reflects that in May 2006, over a year before the child was born, she was, in fact, aware of the situation." R. 24 (citations omitted). Fourth, the ALJ noted: "[h]er testimony that she does not believe that she could perform her past work as a housekeeper now because of stressors with her family and husband is inconsistent with the basic principle of disability under our rules. If the barrier to a claimant's employment is something other than functional limitations caused by a claimant's impairment(s), then that claimant is not disabled under Social Security Regulations." R. 24. Finally, the ALJ explained that there was an inconsistency between Plaintiffs testimony that she does not like to leave her house and the fact that every other weekend she drives to her mother's house which is located 45 minutes away. R. 24.
The ALJ next evaluated Plaintiffs depression. He noted:
R. 24 (citations omitted). The ALJ then stated:
R. 24 (citations omitted). The ALJ also noted that Plaintiffs treatment providers appeared to still be adjusting her medications in an effort to achieve optimum improvement. R. 25 (citation omitted). He further explained that while Plaintiff states that her depression causes her not to want to leave her house, the evidence of record does not support this statement: the record indicates that she goes out daily for errands, shops in stores, and travels 45 minutes each way to visit her mother on a bi-weekly basis. R. 25. Ultimately, the ALJ concluded that with respect to Plaintiff's depression: "[0]verall, the preponderance of the evidence does not support that this condition causes the severity of functional limitations that would support a finding that [the Plaintiff] is unable to engage in any form of substantial gainful activity as a result of her depression. The above defined residual functional capacity assessment adequately accounts for the credibly established limitations attributable to claimant's depression." R. 25.
The ALJ then turned to Plaintiffs claims that "she has difficulty concentrating, problems with her memory, and an inability to complete tasks and noted that "[t]he record reflects a probable diagnosis of ADHD." R.25. The ALJ noted that Plaintiff reported to her treatment providers that she has difficulty with concentration and remembering things, but that she currently did not take medication for ADHD. R. 25. The ALJ also noted that "other than her subjective reporting, the record is devoid of any findings to substantiate [her] protestations of decreased concentration, memory loss, and task incompletion. Tellingly she has been enrolled in an online college program and, by all indications, has been performing satisfactorily, receiving As and Bs. This activity is inconsistent with her allegation that she has difficulty concentrating on anything." R. 25. Thus, the ALJ concluded: "[b]y limiting [Plaintiff] to simple tasks requiring little or no judgment, the limitations resulting from her ADHD are sufficiently accommodated." R. 25.
The ALJ then turned to the opinion evidence contained in the Record. He started with the opinion evidence of Mary Evelyn Pifer, RPA-C. R. 25. Ms. Pifer had checked a box on a medical assessment form which indicated that Plaintiff suffered from a "temporary incapacity," defined as a "physical or mental condition [which] precludes him/her from participating in ANY FORM of employment or training activity at this time, but the condition is expected to improve," that this condition prevented her from working as of December 29, 2008, and that her temporary incapacity was expected to keep her "from working or participating in training for 20 or more hours per week" until June 29, 2009." R. 229. The ALJ also noted that on January 7, 2009, Ms. Pifer indicated that Plaintiff was currently unemployed due to medical conditions. R. 25. The ALJ then concluded that while he had considered Ms. Pifer's opinion consistent with SSR 06-3p, he had given Ms. Pifer's opinion evidence little weight "because the basis for Mr. Pifer's determination is unknown as there is no accompanying explanation, only generic diagnoses, the opinions are against the weight of the medical evidence of record, and the detennination of disability does not meet the 12-month durational requirement for a finding of disability under Social Security Regulations." R. 25. The ALJ also noted that "[m]oreover, an opinion that a claimant is disabled or unable to work is an issue reserved to the Commissioner" and that "Ms. Pifer is not an acceptable medical source under 20 CFR 404.1513 and 404.913." R.25.
The ALJ then discussed the opinion evidence from Paul Fox, M.D., a state agency physician who had reviewed Plaintiffs records with respect to her alleged physical impainnents. The ALJ noted that Dr. Fox had reviewed the evidence in Plaintiffs file and concluded that she retained "retained the ability to occasionally lift or carry 20 Ibs., and frequently lift or carry 10 lbs., that she could stand or walk about 6 hours in an 8-hour workday, that her ability to sit was unlimited, and that her ability to push and pull was limited to the same extent as her ability to carry," and that she had limitations in perfonning postural maneuvers as well. R. 25. The ALJ then concluded that he afforded Dr. Fox's opinion "little weight, as the limitations he has ascribed to claimant's ability to lift or carry, stand or walk, and perfonn postural maneuvers is inconsistent with the overall evidence of record, including Dr. Fox's own report." R.25. In support thereof, the ALJ stated:
R. 25-26 (internal citation omitted).
The ALJ next discussed the opinion evidence of Dr. Link with respect to Plaintiffs mental impairments:
R. 26 (internal citations omitted). The ALJ concluded with respect to Dr. Link that: "[t]his opinion is well supported by the medical evidence of record as a whole and is afforded significant weight." R. 26.
The ALJ next discussed a psychiatric evaluation conducted on March 8, 2010 at Stairways Behavorial Health wherein Plaintiff was determined to have a GAF score of 43. The ALJ concluded that this assessment was "indicative of serious symptoms" and "runs counter to the weight of the evidence, including the examiner's own report." R. 26. In support of this conclusion, the ALJ reasoned: "Initially, the findings reported in this evaluation are based entirely on [Plaintiffs] subjective reporting and not on past medical findings or any type of longitudinal history of treatment. Secondly, the mental status examination was essentially normal. Finally, the diagnosis from this evaluation was the generic unspecified episodic mood disorder." R. 26. Thus, the ALJ concluded: "[t]his combination of factors, together with the other evidence of record, does not support a GAF assessment of 43." R.26. The ALJ further concluded that:
R. 26.
The ALJ next discussed the opinion evidence of Kelly Weary, the certified registered nurse practitioner at Stairways Behavorial Health. The ALJ explained that Ms. Weary had completed a form on August 6, 2010 in which she checked "yes" or "no" to four questions. Specifically, Ms. Weary had checked "no" to the first three questions on the form, and "indicated that [Plaintiff] is incapable of maintaining concentration or attention on a regular and continuing basis, maintaining regular attendance, interacting appropriately with fellow workers and supervisors and responding appropriately to supervisory criticism." R. 26. Ms. Weary then checked "yes" to the final question which explained that "her opinion [was] based upon observation of the [Plaintiff], clinical history, and review of signs and symptoms." R. 26. Ultimately, the ALJ explained, while he considered Ms. Weary's opinion consistent with SSR regulations, he gave little weight to Ms. Weary's opinion because he found that the basis of her opinion was undisclosed, there was no accompanying explanation, the opinion was against the weight of the medical evidence of record, it was unclear if her determination of disability met the 12-month durational requirement for a finding of disability under the Social Security Regulations, and she "is not an acceptable medical source under 20 CFR 404.1513 and 404.913." R.26.
Thus, the ALJ concluded, his residual functional capacity assessment was "supported by the opinion of Dr. Link, the ongoing treatment records from Stairways Behavorial Health, other than the opinion offered by Nurse Weary as discussed, and the medical and non-medical evidence contained in the overall longitudinal record." R. 27.
The ALJ then went on to conclude that Plaintiff was capable of performing her past relevant work as a housekeeper because this work does not require the performance of work-related activities that are precluded by her residual functional capacity as found by the ALJ. R. 27. "In comparing the [Plaintiffs] residual functional capacity with the physical and mental demands of this work, I find that the claimant is able to perform it as actually and generally performed." R. 27.
The ALJ then determined that in addition to working as a housekeeper, there were other jobs existing in the national economy that Plaintiff also was able to perform. R. 27. In so finding, the ALJ explained that he "asked the vocational expert whether jobs exist in the national economy for an individual with the [Plaintiff's] age, education, work experience, and residual functional capacity." R. 28. The ALJ then explained that the vocational expert testified that such an individual "would be able to perform the requirements of representative occupations such as surveillance system monitor at the sedentary exertionallevel with 115,000 jobs existing in the national economy, document preparer at the light exertionallevel with 300,000 jobs existing in the national economy, and bench assembler at the medium exertionallevel with 300,000 jobs existing in the national economy." R. 28.
The ALJ then concluded, "[blased on the testimony of the vocational expert," that "considering the [Plaintiffs] age, education, work experience, and residual functional capacity, the [Plaintiff] is capable of making a successful adjustment to other work that exists in the national economy" and therefore, a finding of "not disabled" under section 216(i), 223(d) and 1614(a)(3)(A) of the Social Security Act was appropriate. R. 28.
Medical records from the Medical Group of Corry, Inc. ("MGC") show that Plaintiff went to medical practice on numerous occasions from March 27, 2008 until March 19, 2009. R. 315. As of March 27, 2008, Plaintiff was taking 10 mg of Lexapro, an anti-depressant. R. 313.
A treatment note from April 22, 2008 indicates that Plaintiff "[d]enies depression" and was taking Lexapro. R. 311. A treatment note from April 22, 2008 indicates that Plaintiff "[d]enies depression." R. 308. A treatment note from April 29, 2008 indicates that Plaintiff was taking Lexapro. R. 307. A treatment note from May 20, 2008 indicates that Plaintiff was taking Lexapro. R. 301. A treatment note from May 29, 2008 indicates that Plaintiff "[d]enies depression" and was taking Lexapro. R. 298. A treatment note from June 16, 2008 indicates that Plaintiffs Lexapro prescription was refilled. R.296. A treatment note from July 1, 2008 indicates that Plaintiff "[d]enies depression" and was taking Lexapro. R. 292.
A treatment note from September 10, 2008, when Plaintiff went to MGC related to her obesity, indicates that Plaintiff "reports depression." R. 289. Plaintiffs Lexapro prescription was refilled and the assessment included "Depressive Disorder Not Elsewhere Spec[ified]." R. 290.
A treatment note from October 6, 2008 indicates that Plaintiff was taking Lexapro. R. 285.
On October 27, 2008, treating physician's assistant Mary Evelyn Pifer, RPA-C, wrote a "To whom it may concern" letter that stated: "PT HAS A HISTORY OF DEPRESSION. PT IS CURRENTL Y BEING TREATED." R. 284.
At her November 13, 2008 appointment at MGC, the nurse's note indicated the visit was for a follow-up of Plaintiffs depression. R. 282. It was noted that: [c]ondition has been worsening since last visit. Present for awhile. Onset being gradual following social issues. Appetite is poor. Patient has difficulty falling asleep and patient has difficulty staying asleep." R. 282. Plaintiff also reported anxiety, mild crying, poor energy level, feeling moderately overwhelmed, moderate racing thoughts, moderate sadness, moderate insomnia, associated difficulty concentrating, fatigue, stress and excessive worry. R. 282. Plaintiff denied associated frequent crying, change in sex pattern and suicidal thoughts. R. 282. On exam it was noted Plaintiff displayed anxiety, depression, and sadness. R. 282. Her affect was depressed, her thought processes appeared normal, there were no delusions or hallucinations, her memory was intact, and her attention span and concentration were normal. R. 282. Her Lexapro prescription was increased from 10 mg to 20 mg. R. 283. Assessment included "Depressive Disorder Not Elsewhere Spec[ified]." R. 283.
At her December 10, 2008 visit to MGC, the nurse's note indicates that Plaintiff was there for follow up of her depression and forms. R. 279. Plaintiffs "[m]ood is normal. Affect is normal. Memory is intact." R. 280. She was "[a]lert and oriented x3." R. 280. She was taking Lexapro. R. 278. Assessment included "Depressive Disorder Not Elsewhere Spec[ified]." R. 280. That same day, Ms. Pifer, the treating physician's assistant, filled out 2 forms for Plaintiff. First, she completed a Health-Sustaining Medication Assessment Form wherein she indicated that in order for Plaintiff to be employable or continue with employment she needs Lexapro to help stabilize moods. R.231. She also completed a state Medical Assessment Form wherein she indicated that Plaintiff suffered from depression, back pain and bilateral feet pain, that Plaintiff was following a prescribed treatment plan, and that she was able to work without any accommodations. R. 233-234.
Plaintiff returned to MGC on January 7, 2009 to follow-up on her depression. R. 275. The nurse's note from the visit states "[c]ondition has been mostly well controlled since last visit. Present for awhile. Onset being gradual following financial stresses and home related sis. The note indicates that Plaintiffs appetite was unchanged, she had difficulty staying asleep, she reported her depressed feelings to be fair, reported memory loss and associated difficulty concentrating, fatigue, stress and excessive worry, but denied associated frequent crying, change in sex pattern, anxiety, insomnia, and suicidal thoughts. R. 275. On exam, no signs of apparent distress were noted, Plaintiff displayed depression during the encounter, her affect was depressed, her thought processes appeared normal, and she did not have delusions, hallucinations, obsessions or preoccupations. R. 275. She was told to continue taking Lexapro; her assessment included "Depressive Disorder Not Elsewhere Spec[ified]." R. 26.
Also on January 7.2009, Ms. Pifer wrote a "To whom it may concern" letter wherein she stated: "PT IS CURRENTlY UNEMPLOYED DO [sic] TO MEDICAL CONDITIONS." R. 277.
At a January 30, 2009 visit for MGC, when Plaintiff was at the doctor's office for a re-check of low back pain, she "denie[d] depression" and it was noted that her affect and mood were normal and her memory intact. R. 262-263.
Plaintiff was seen again on January 16, 2009 for back pain. R. 269. It was noted that she was taking the Lexapro. R. 269.
She was seen again at MGC on numerous visits between January 19, 2008 and January 27, 2008; each time her Lexapro use was noted. R. 264-267.
On January 30, 2009, Plaintiff went to MGC for are-check of her low back pain. R. 260. There is no mention of her using Lexapro, but she was taking Citalopram, another anti-depressant, and her mood and affect were normal. R. 260.
Plaintiff returned to MGC on February 13, 2009 for a re-check for depression. R. 259. It was noted that Plaintiff presented with depression and that "condition has been improving since last visit. Present for awhile. Appetite is good. Sleep pattern is good. Reports concentration is poor. Denied crying. Reports irritability. Denied feeling overwhelmed. Reports associated difficulty concentrating and stress, but denied associated frequent crying, fatigue, change in sex pattern, suicidal thoughts and excessive worry." R. 258. She also denied anxiety. R. 258. On exam it was noted that Plaintiffs mood, affect, thought processes, attention span and concentration were normal, memory was intact, and judgement and insight were grossly intact. Her use of Citalopram was noted and the assessment included "Depressive Disorder Not Elsewhere Spec[ified]." R. 259. She was told to continue taking her current medications. R. 259.
On February 13, 2009, Ms. Piper again filled out a state Medical Assessment Form; this time she indicated that Plaintiff was following a prescribed treatment plan and was temporarily incapacitated from participating in any form of employment or training activity from December 29, 2008 until, Ms. Piper expected, June 29, 2009, due to depression and lumbago. R.229-230.
Plaintiff returned to MGC on February 24, 2009 due to fatigue and abdominal pain. R. 254. Her use of Citalopram was noted. R. 255. It also was noted that Plaintiffs affect was normal. R. 256. Plaintiff was seen again at MGC on March 11, 2009 for a possible UTI. R. 252. She was seen again on March 19, 2009 complaining of abdominal pain. R. 249. Her affect was normal. R. 250.
Plaintiff was treated at MGC on March 11, 2009 for a possible UTI. R. 252. Her use of Citalopram was noted. R. 251.
Plaintiffs final treatment note from MGC is dated March 19, 2009 when she presented with abdominal pain. R. 248. It was noted that her affect was normal and she was using Citalopram. R. 249 and 250.
The first record of Plaintiff going to Counseling Services Center — Corry ("CSC") and being seen by Dr. Hridayesh Pathak, M.D., a Psychiatrist, is from May 13, 2006. R. 327. At that time, Dr. Pathak wrote a detailed Psychiatric Evaluation on Plaintiff, noted her "psychomotor activity is within the normal range," "[h]er mood is fairly euthymic," and "[h]er cognitive functions are intact and insight and judgment is good;" he diagnosed Plaintiff with Major Depressive Disorder Recurrent, Moderate, without Psychotic Feature, noted Partner Relational Problems and Severe Psychosocial Stressors, that being interaction with court and legal system, and gave her a GAF of 55.
Dr. Pathak's partner was Dr. Asha Prabhu, M.D., also a Psychiatrist. Records from CSC's office show Plaintiff was again seen in their office on May 8, 2006, May 12, 2006, July 11, 2006, and August 30, 2006. Plaintiff missed appointments at the office on June 2, 2006, June 8, 2006, June 19, 2006, June 21, 2006, August 1, 2006, August 2, 2006, and August 8, 2006.
On May 13, 2009, approximately 3 years after her last visit to esc, Plaintiff began to be treated again by Dr. Prabhu. On that date, Plaintiffs chief complaint was that "I am having my depression which is really bad." R. 327. Plaintiff explained that she has been depressed since 2000, but recently the depression was getting worse. R. 327. Her stressors were separation from her husband for one month, not seeing her children, and financial stressors. R. 327. She also explained that she was getting very anxious and had a lot of crying spells, irritability, getting very short tempered, forgetful and not sleeping and not eating. R. 327. She had feelings of helplessness and hopelessness. R. 327. She also stated that she felt very restless and gets overwhelmed. R. 327. She denied any paranoia, auditory or visual hallucinations and did not have OCD symptoms. R. 327.
Plaintiff explained to Dr. Prabhu that she was currently taking on-line college courses for an associate business degree, and that she had had to quit her last job "otherwise they would not give her son back." R. 327.
Dr. Prabhu noted that Plaintiff was oriented to person, place, and date, her mood was depressed and her affect was blunted, her memory times three was intact, serial 7, she could only go down to 93, abstract thinking was intact, her concentration was fine, her intelligence was average and her insight and judgment were intact. R. 327. Dr. Prabhu's diagnoses were major depressive disorder, recurrent episode, mode, and moderate to severe psychosocial stressors. R. 328. He gave her a current GAF score of 50.
Plaintiffretumed to see Dr. Prabhu on July 29, 2009. R. 359. She told Dr. Prabhu that she gets irritable and tense. R. 359. Dr. Prabhu indicated that Plaintiffs mood was euthymic and stable during the visit. R.359. He increased her Celexa from 30 mg to 40 mg due to her irritability. R. 359.
Plaintiff saw Dr. Prabhu again on November 11, 2009. R. 358.
Plaintiff next saw Dr. Prabhu on February 3, 2010. R. 358.
On March 3, 2010, Plaintiff presented to Stairways Behavorial Health and was seen by Dr. Matt Meyer, D.O. for a psychiatric evaluation. R. 363. Dr. Meyer explained that Plaintiff presented with chief complaints of depression, mood swings, decreased concentration, auditory hallucinations and "dissociative states." R. 363. He also indicated that Plaintiff told him that she has been suffering from mood disturbances for most of her life, but feels that they have gotten pretty severe over the past six months. R.363. She explained that she lost her job in December 2008, she has significant issues surrounding her husband and her children and she is crying daily. R. 363. Plaintiff also indicated that she does have occasional suicidal thoughts, but no plans, and no intent and would not harm herself because of her children. R. 363. Plaintiff further indicated to Dr. Meyer that she does not like to leave the house, she tends to isolate herself, she thinks a lot about death, and she has some paranoia: "This is tied very closely to her anxiety." R. 363. Dr. Meyer noted that Plaintiff has auditory hallucinations daily which are in the form of hearing people trying to talk to her. R. 363. He also noted that Plaintiff has been suffering from maintenance insomnia, sleeping around 5 hours at the most during the night and her appetite was decreased. R. 363. Dr. Meyer noted that she has significant problems with her husband and that while Plaintiff had four children only one lived with her. R. 363.
At the time Plaintiff saw Dr. Meyers she was only taking Prilosec. R. 363. She indicated that she had also taken Celexa (Citalopram), Cymbalta and Effexor in the past and that she does not feel that they have helped her. R. 363. She also explained that she'd been prescribed Vistaril, but never took it. R. 363.
Dr. Meyers relayed that Plaintiff had told him that she was not currently working, was collecting disability, last worked on December 29, 2008 when she lost her job because of not showing up to work, having mood swings, and too many external stressors to care about work. R. 364.
Dr. Meyer's impression of Plaintiff was that she was alert and oriented to person, place and time and was cooperative. R. 364. She made appropriate eye contact and has adequate hygiene. R. 364. She showed no signs of psycho motor retardation, her speech was spontaneous at a regular rate of rhythm, her thought processes appeared to be logical and coherent without any signs of internal preoccupation or loosening associations. R. 364. She had auditory hallucinations in the form of hearing voices, but realizes that there is no one there. She does admit to mild paranoia, but does not appear delusional. R. 364. Dr. Meyer found her judgment and insight to be fair to poor. R. 364. He found her mood was currently euthymic with a history of being irritable, and that her affect was currently euthymic. R. 364. He further explained that Plaintiff stated that she had significant problems with her memory and concentration and she has periods of "spacing out." R. 364.
Dr. Meyer diagnosed Plaintiff with Unspecified Episodic Mood Disorder, unspecified Hyperkinetic Syndrome of Childhood, Borderline Personality Disorder, listed her Axis IV (Severity of Psychosocial Stressors) as severe, and rated her current OAF at a 43. R. 364. Dr. Meyer recommended Plaintiff see an individual therapist and noted one was scheduled for March 18, 2010. R. 364. He started her on Prozac for her depressive mood, Abilify as an adjunct, to help her with her auditory hallucinations, and Strattera to help with her concentration, focus, and memory. R. 364.
Plaintiff was next seen by Dr. Meyer on April 9, 2010. R. 362. Under Nursing Review it was noted that Plaintiff had difficulty falling asleep and frequent awakening, she was sleeping between 4 and 5 hours a night, her back pain was an eight, she was going to see a physical therapist 2 days a week, and with respect to her current mental health issues: "Doesn't feel anything is changed. Depressed, easily agitated. Very tearful. Mood swings and racing thoughts, no energy. Difficulty even getting to appts. Focus and concentration poor. Falling behind with on-line schooling. Can't sit and when she does sit down she can't focus. Not taking Strattera [because] wasn't covered by insurance." R. 362. Under Physician Section it was noted that Plaintiff's motor activity, speech, sensorium, behavior, thought content, thought flow, affect, judgement, illness insight, and extra pyramidal were within norrnallimits, her mood was depressed and anxious and her anxiety state was mildly elevated. R. 362. Dr. Meyer indicated that Plaintiff was not stable on current psychotropic medications, Plaintiff had told him she could not get her Strattera prescription filled, she felt nothing from other medications, she was getting agitated easily with others. R. 362. His plan was to increase her Prozac and AbilitY before considering another medication. R. 362.
Plaintiff was next seen by Dr. Meyer on May 7, 2010. R. 361. Under Nursing Review it was noted that Plaintiff suffered from frequent awakening and complained of broken sleep, and being up at night at least three times. R. 361. Her back pain had decreased to a six and she was seeing a physical therapist. R. 361. With respect to her current mental health issues it was noted that Plaintiff had been off AbilitY for one week because it was giving her nightmares. She did not have any side effects from the Prozac but her irritability had increased, she was exploding at people, had heavy mood swings, and was paranoid and nervous "all the time." R. 361. She can't sit still, wants to constantly be doing something, or going somewhere but admitted to staying home more. R. 361. She does enjoy being by herself and has weeks she doesn't want to see or be around people she has to be with. R. 361. In terms of school, Plaintiff had explained that she does a lot of reading but can't stay focused and isn't comprehending what she is to learn. R. 361. Under Physician Section it was noted that Plaintiffs motor activity, speech, sensorium, behavior, anxiety state, thought content, thought flow, and extra pyramidal were within normal limits. R. 361. Her mood was listed as irritable, her affect was anxious, her judgement and illness insight were considered fair, and she was not stable on current psychotropic medications. R. 361. Dr. Meyer's Notes said Plaintiff was still reporting difficulty concentrating on her school work, she had stopped the Abilify on her own due to nightmares, he gave a probable diagnosis of ADHS, predominantly inattentive type, he was going to try to get Strattera approved for Plaintiff, Plaintiff reported irritability and he was going to start her on Risperdal .5 mg for two months. R. 361.
Plaintiff was next seen at Stairways Behavorial Health on May 26, 2010 by Kelly Weary, a Certified Registered Nurse Practitioner ("CRNP"). R. 360. Under Nursing Review it was noted that Plaintiff suffered from frequent awakening from sleep, she was sleeping 3 hours max, she was not in pain, and Plaintiff reported that she is unable to stay asleep, she has extreme itchiness in her head, she is having problems with anger, and she had not hit anyone but gets extremely irritated. R. 360. Ms. Weary noted that Plaintiff was medication compliant but had stopped taking the Risperdal due to bad stomach pains. R. 360.
Under Physician Section it was noted that Plaintiffs motor activity, speech, sensorium, thought content, judgement, illness insight, and extra pyramidal were within normal limits, and that her mood was listed as anxious, her anxiety state was mildly elevated, she was having auditory hallucinations, her affect was anxious, and she was not stable on current psychotropic medications. R. 360. Under Notes, Ms. Weary reported Plaintiff had stopped Risperdal due to gastrointestinal symptoms, had not started taking Adderall yet, and reported irritability, anger-rage, throws things, "flys off the handle," and hearing her name called. R. 360. Ms. Weary educated Plaintiff on Geodon, a new medication Plaintiff was prescribed. R. 360.
Plaintiff called the office on May 28, 2010 wanting to talk about her taking the Adderall. R. 377. Plaintiff again called into the office on June 1, 2010, stating she has been taking the Adderall, couldn't sleep, and was having racing thoughts, "ten times worse than before." R. 378. Plaintiff was told to hold off taking the Adderall until she met with Dr. Meyer on July 2, 2010, but to keep taking the Geodon. R. 378.
Plaintiff missed her appointment with Dr. Meyer on July 2, 2010 and was not seen again at Stairways until July 20, 2010 when she was seen by Ms. Weary. R. 376. Plaintiff was still having problems with frequent awakening at night and she was sleeping 5 hours per night. R. 376. Her appetite had decreased and her weight had increased. R. 376. Plaintiff indicated that "she is having too many days `where I think I am going insane'." R. 376. Plaintiff told Ms. Weary that she has a lot of stress from her husband, no patience, is snapping, getting angry easily, depressed, and feeling overwhelmed. R. 376. She also felt the Geodon was not doing what it should for her mood. R. 376.
Under Physician Section it was noted that Plaintiffs motor activity, speech, sensorium, behavior, thought content, judgement, illness insight, and extra pyramidal were within normal limits, that her mood was depressed and anxious, her anxiety state was mildly elevated, she was having auditory hallucinations, her affect was flat, and she was not stable on current psychotropic medications. R. 376.
Under Notes, Ms. Weary indicated that Plaintiff reported: (1) that the trial of Adderall XR did not go "well" `made everything worse';" (2) poor sleep, irritability, racing thoughts, anxiety, and auditory hallucinations — no commands; and (3) high stress with husband, emotional abuse, is considering separation which "will take a few months," R. 376. Ms. Weary indicated that Plaintiff was to discontinue taking Adderall, continue Prozac, increase Geodon, add Trazodone for mood and sleep, and continue [individual counseling]." R. 376.
Plaintiff was seen that same day by Linda Graves, a licensed social worker, who wrote a Treatment Progress Review. R. 375. Plaintiffs objectives were listed and it was noted that "[plaintiff] has not attended Ie since 5/7/1 O. At that last session, she reported increased irritability and difficulties with concentration. She was starting Strattera per her doctor. Therapist had introduced the concept of managing mood through cognitive strategies, but [Plaintiff] has not returned to assess her progress with this." R. 375.
Plaintiff was next seen at Stairways Behavorial Health on August 4, 2010 by Ms.Weary. R. 374. Under Nursing Review it was noted that Plaintiff suffered from frequent awakening from sleep, she was sleeping 6 hours per night, she gets up once or twice per night, her appetite was within normal limits, no pain was observed or reported, and Plaintiff reported that she still has racing thoughts, her "head is constantly rolling," she remains irritable but feels the anxiety may have lessened slightly, feels increased "hopelessness," she was looking into couples counseling, and had been in the emergency room for a migraine, where her blood pressure was very high. R. 374.
Under Physician Section it was noted that Plaintiffs motor activity, speech, sensorium, behavior, thought content, judgement, and extra pyramidal were within normal limits, that her mood was anxious, her anxiety state was mildly elevated, her affect was anxious, her illness insight was fair and she was not stable on current psychotropic medications. R. 374.
Under Notes, it was stated that Plaintiff reported she had been sleeping better, and feeling less anxious but still had daily anxiety, high level of irritability and racing thoughts. R. 374. Plaintiff also reported she had had fatigue, which she related to anemia and B-12 deficiency. R. 374. Plaintiff felt she was tolerating the morning dose of Geodon so decision was made to increase the morning dose of Geodon to 40 mg., continue her other medications, and continue individual counseling. R. 374.
On August 6, 2010, Ms. Weary completed a form with respect to Plaintiff that had been sent to her from Plaintiffs attorney. The form explained:
On April 9, 2009, Plaintiff completed a Function Report wherein she described her activities of daily living to be: "I get up get dressed [and] use the restroom. Get my son out of bed change him dress him [and] take him to daycare. Then I come back home [and] make sure my house is clean. I pick my son up at 4:30 pm [and] come home. Make dinner, feed him, clean up give him a bath and put him to bed at 8:00. I then take a shower, relax, and by 10:00 pm go to bed." R. 186. She also indicated that she had one dog that fed daily and tied her out. R. 187. She also explained that her parents helped her with her son "quite a bit. They help change him feed him, bath him, dress him, etc." R. 187. She also indicated that she could dress, bathe, care for her hair, prepare her own food daily albeit more simple items, feed herself and use the toilet; she usually didn't shave because she did not feel she had any reason to, which could be embarrassing, and she needed to be reminded to take her medication. R. 187-188. She also cleaned and did dishes daily and laundry and cleaning up after the dog weekly. R. 188. Finally, she noted that she went outside daily to do errands and take her son to daycare, and that when she went out, she could go out alone and would drive a car. R. 189. When she would go shopping, she would do it typically twice a month for about an hour maximum. R. 189. She indicated that she can pay bills, count change, and handle a savings account, but that she cannot use a checkbook/money orders without errors being made. R. 189.
Plaintiff listed her hobbies to be sewing, playing games, horses and watching movies, but then qualified her response to be that she watches t.v. a lot but hardly does any of the others due to her depression becoming worse. R. 190. She also indicated that she does not spend time with others and doesn't normally go anywhere unless she has to, but that when she does got out, she does not need someone to accompany her. R. 190. She further explained that she no longer hangs out with friends or goes on social outings. R 191. She also indicated: `[t]he depression has gotten to where I don't remember things complete any task on time or concentrate on anything. R. 191. She opined that she can pay attention for ten minutes "if your lucky," she does not finish what she starts, she does not follow written directions well, and follows spoken instructions fairly well, but not as well as she used to. R. 191. She indicated that she got along fairly well with authority figures, she had never been fired or laid off from a job because of problems of getting along with others, and she does not handle stress well at all. R. 192.
In support of her Motion for Summary Judgment, Plaintiff argues that the ALJ's decision is not supported by substantial evidence because the ALJ failed to address all of the relevant medical evidence in the Record in determining her residual functional capacity; he improperly evaluated the opinions of non-examining state agency psychologist Dr. Manella Link, Ph.D, and treating certified registered nurse practitioner Kelly Weary; and he improperly evaluated Plaintiff's credibility.
When determining a claimant's residual functional capacity, an ALJ must consider all of the relevant evidence.
We agree with Plaintiff that the ALJ failed to consider all of the medical evidence relevant to Plaintiff's mental health issues in determining Plaintiff's residual functional capacity. In particular, the ALJ failed to discuss the May 2009 psychiatric evaluation wherein treating psychiatrist Dr. Prabhu evaluated Plaintiffs mental health and found her current OAF to be a 50. An individual with a OAF score of 50 may have "[s]erious symptoms (e.g. suicidal ideation. ...)" or "impairment in social, occupational, or school function (e.g. no friends, unable to keep a job). American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) 34 (4th ed. 2000). As explained in
Furthermore, while the ALJ concluded "[a]lthough the severity of her symptoms does fluctuate, the overall treatment record reflects a fairly well-controlled condition that is responding reasonably well to medication," R. 24, a review of the Record shows that each of the five (5) times Plaintiff was seen at Stairways from April 2010 to August 2010, she was found to not be stable on her medications and the medication prescribed was either increased or changed to a different medication altogether. See R. 360-362, 374-376.
Finally, part of the reasoning behind the ALJ's disregard of Dr. Meyer's finding that Plaintiff had a OAF of 43 on March 8, 2010 was that "the mental status examination was essentially normal" and that "the diagnosis from the evaluation was the generic unspecified episodic mood disorder."
In light of our conclusion that the ALJ failed to consider all of the relevant medical evidence in determining Plaintiffs residual functional capacity, we must conclude that there is not substantial evidence to support the ALJ's conclusion that Plaintiff retained the residual functional capacity to perform her past job as a housekeeper, and that the Commissioner's motion for summary judgment must be denied. Substantial evidence is defined as "more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion."
"Despite the deference due to administrative decisions in disability benefit cases, `appellate courts retain a responsibility to scrutinize the entire record and to reverse or remand if the [Commissioner]'s decision is not supported by substantial evidence.'
An appropriate Order will follow.
