ALAN N. BLOCH, District Judge.
AND NOW, this 28
Therefore, IT IS HEREBY ORDERED that Plaintiff's Motion for Summary Judgment (Doc. no. 7) is DENIED and Defendant's Motion for Summary Judgment (Doc. no. 9) is GRANTED.
First, the Court finds no merit in Plaintiff's contention that the ALJ erred in failing to consider properly all the evidence in formulating Plaintiff's RFC. In particular, Plaintiff argues that the ALJ did not adequately discuss, nor did he assign specific weight to, the examination records of treating physicians Humberto R. Dorta, M.D., and Frank Yohe, M.D. It is well-established that "[t]he ALJ—not treating or examining physicians or State agency consultants— must make the ultimate disability and RFC determinations."
It should be noted at the outset that, because the evidence from Dr. Dorta and Dr. Yohe consists of medical treatment records, and not opinions specifically describing Plaintiff's functional capacity, the ALJ did not need to assign a particular amount of weight to those records in setting forth his decision. Rather, the ALJ was required to properly consider those records in conducting his analysis. An ALJ is not required, however, to make reference to every relevant treatment note in his decision, as long as the Court can discern the basis for the ALJ's decision.
For instance, included in his discussion of Plaintiff's treatment with Dr. Yohe at Stairways Behavioral Health, the ALJ stated that, in June, 2012, Dr. Yohe evaluated Plaintiff and noted that she was not taking any psychotropic medications, yet he did not appreciate any debilitating symptoms. (R. 26-27). Dr. Yohe prescribed Paxil for Plaintiff and recommended outpatient psychotherapy, but Plaintiff soon stopped attending sessions, claiming that she did not have time for them. (R. 27). The ALJ noted that, despite Plaintiff's failure to follow treatment, she did not decompensate and her condition remained stable. (R. 27).
In reviewing Dr. Dorta's treatment, the ALJ stated that Plaintiff originally treated with Dr. Dorta in December, 2010, but was discharged from treatment for failing to attend her appointments. (R. 26). Then, in February, 2013, Plaintiff returned to treat with Dr. Dorta because she was not pleased with her treatment at Stairways. (R. 27). Nevertheless, like Dr. Yohe, the ALJ explained that "Dr. Dorta failed to appreciate any evidence of psychosis, hallucination, delusions, suicidal thoughts, homicidal ideation, an abnormal thought process, or neurological deficits." (R. 27). The ALJ also noted that no significant changes were reported during Dr. Dorta's assessments in May, June, and July of 2013. (R. 27). Additionally, the ALJ cited the doctors' Global Assessment Functioning ("GAF") scores, advising that, although scores between 40 and 50 had been assigned at various times, "neither treating psychiatrist appreciated any evidence of impaired reality, defiance, suicidal ideation, severe obsessional rituals, illogical speech, delusional thinking, audio or visual hallucinations, or psychosis." (R. 27). Additionally, the ALJ emphasized that, during the relevant period under consideration, Plaintiff failed to follow prescribed treatment, yet no inpatient psychiatric treatment had been necessary. Thus, considering the evidence overall, the ALJ stated that his RFC is more than accommodating, is not inconsistent with opinion evidence in the record, and is "otherwise supported by the preponderance of the evidence." (R. 27).
Accordingly, the Court finds that the ALJ properly discharged his duty to consider and discuss the medical treatment evidence, as well as the other relevant evidence addressing Plaintiff's alleged impairments, that was presented in the record. The Court finds that substantial evidence supports the ALJ's evaluation of the doctors' evidence and his decisions in determining Plaintiff's RFC.
Plaintiff also contends that the ALJ should not have relied on the opinion of state agency reviewing psychologist Emanuel Schnepp, Ph.D., in making his RFC determination. In September, 2012, Dr. Schnepp examined Plaintiff's records, noted her impairments and her activities of daily living, and found that Plaintiff has no more than moderate limitations and that she could perform heavy/very heavy exertion work. (R. 78-82). The ALJ cited to Dr. Schnepp's findings in rating the degree of Plaintiff's functional limitations, and he explained that his RFC assessment is "not inconsistent with the opinion of Dr. Schnepp, the State agency psychologist (Exhibit 1A), and otherwise supported by the preponderance of the evidence." (R. 23-24, 27). Although Plaintiff would prefer that the Court disregard Dr. Schnepp's opinion, the Court of Appeals for the Third Circuit has stated that, in making an RFC determination, an ALJ may give more weight to a non-examining professional's opinion if that opinion is better supported by the record.
Thus, upon review, the Court finds that the ALJ properly discharged his duty to address not just the records of Dr.Yohe and Dr. Dorta, but also the other medical evidence of record. Throughout his decision, the ALJ clearly considered the relevant evidence, provided discussion to support his evaluation, and ultimately concluded that certain evidence was not consistent with the evidence as a whole. Thus, the Court finds that substantial evidence supports the ALJ's evaluation of the medical evidence presented in making his ultimate determinations regarding Plaintiff's RFC.
Plaintiff's second claim is that the ALJ erred in evaluating her credibility and the credibility of her witness, mental health care caseworker Shelly Peterson. In support of this argument, Plaintiff contends, in essence, that the ALJ misconstrued the evidence of record. The Court finds, however, that the ALJ did in fact properly address the evidence presented in finding the statements of Plaintiff and Ms. Peterson regarding Plaintiff's limitations to be not entirely credible.
In determining whether a claimant is disabled, the ALJ must consider all of a claimant's symptoms, including allegations of pain, and the extent to which the symptoms can reasonably be accepted as consistent with the objective medical evidence.
In his decision, the ALJ discussed at significant length Plaintiff's medical treatment and Plaintiff's own statements, as well as the statements of Ms. Peterson, in connection with Plaintiff's alleged impairments. The ALJ found that Plaintiff has the severe impairments of major depressive disorder (recurrent) and borderline personality disorder. (R. 22). Upon review of all the evidence of record, however, the ALJ ultimately concluded that the evidence as a whole simply does not support the extreme limitations Plaintiff alleges.
For example, the ALJ noted that the alleged onset date, May 25, 2012, does not correspond to any accident, urgent medical treatment or hospitalization. (R. 26). Plaintiff testified that she does not bathe or dress herself daily, but other evidence in the record indicates that her hygiene is normal. (R. 26). Plaintiff testified that she does not go shopping, but Ms. Peterson testified that Plaintiff does shop. (R. 26). The ALJ also noted that, although Plaintiff alleges that she has attempted to commit suicide on several occasions by cutting herself, when asked to reveal her scars to her treating physician, she stated that her scars had healed. (R. 26). Also, Plaintiff denied any inpatient psychiatric stays. (R. 26). Similarly, Plaintiff claims to have severe anger issues and "blackouts," but there is no medical evidence of record documenting such incidents, nor has Ms. Peterson witnessed any anger management problems. (R. 26). Furthermore, despite her claims of disabling mental limitations, the ALJ found it to be worth noting that the record contains evidence of Plaintiff's having relationships, maintaining her household, raising her three-year-old daughter independently, and sharing custody of her five-year-old daughter with the child's father. (R. 23, 27-28).
While the ALJ discussed Ms. Peterson's statements at some length, he ultimately found her testimony to be not credible. (R. 26). Along the same lines, the record also contains a letter from Ms. Peterson describing Plaintiff and opining that Plaintiff is not capable of being "gainfully employed to the point that she would be able to support herself and children." (R. 312). The ALJ found Ms. Peterson's opinion, however, to be "inconsistent with the mental health care progress notes of record and contrary to the opinion of the State agency psychologist, Dr. Schnepp, who believes the limitations resulting from the claimant's mental impairments do not preclude her from performing basic mental demands of competitive work on a sustained basis." (R. 28). The Court finds that, although Ms. Peterson was not an acceptable medical source within the meaning of 20 C.F.R. § 416.913, the ALJ considered her opinion pursuant to S.S.R. 06-3p, and was justified in giving her opinion less weight in making his determination.
Thus, the ALJ stated that, after careful consideration of all of the evidence, Plaintiff's "medically determinable impairments could reasonably be expected to cause the alleged symptoms. However, I find the statements of the claimant and her mental healthcare caseworker concerning the intensity, persistence and limiting effects of the claimant's symptoms are not credible to [the] extent they are inconsistent with the above [RFC]." (R. 26). The Court finds that the ALJ did not err in evaluating Plaintiff's subjective complaints, nor did he err in evaluating the testimony and opinion of Ms. Peterson, because he thoroughly reviewed them in accordance with the regulations, and he provided sufficient explanation as to why he found their statements to be not entirely credible.
Finally, the Court finds no merit in Plaintiff's argument that—because the ALJ allegedly failed to include all the limitations supported by the record in her RFC—the hypothetical question to the VE was incomplete. In fact, the hypothetical question to the VE must accurately portray the claimant's impairments, but such question need only reflect those impairments that are adequately supported by the record.
As discussed,
In sum, the Court finds that the ALJ addressed all relevant evidence in the record, including full consideration of the opinion and other medical evidence, and he thoroughly discussed the basis for his RFC finding. Additionally, the Court finds that the ALJ did not err in assessing Plaintiff's credibility, nor did the ALJ err in posing his hypothetical question to the VE. Accordingly, the Court affirms.