R. CLARKE VanDERVORT, Magistrate Judge.
This is an action seeking review of the final decision of the Commissioner of Social Security denying the Plaintiff's application for Supplemental Security Income (SSI) under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381-1383f. By Standing Order entered June 12, 2013 (Document No. 4.), this case was referred to the undersigned United States Magistrate Judge to consider the pleadings and evidence, and to submit Proposed Findings of Fact and Recommendation for disposition, all pursuant to 28 U.S.C. § 636(b)(1)(B). This case is presently pending before the Court on the parties cross-Motions for Judgment on the Pleadings (Document Nos. 12 and 15.) and Plaintiff's Response. (Document No. 16.).
The Plaintiff, Linda Nicole Skeens, (hereinafter referred to as "Claimant"), filed an application for SSI on January 13, 2010 (protective filing date), alleging disability as of October 30, 2009, due to bipolar disorder, depression, anxiety, and asthma. (Tr. at 14, 203-08, 216, 220.) The claim was denied initially and upon reconsideration. (Tr. at 92-93, 94-96, 107-09.) On October 13, 2010, Claimant requested a hearing before an Administrative Law Judge (ALJ). (Tr. at 110-11.) Hearings were held on September 14, 2011, and March 13, 2012, before the Honorable Steven A. DeMonbreum. (Tr. at 32-68, 69-91.) By decision dated April 10, 2012, the ALJ determined that Claimant was not entitled to benefits. (Tr. at 14-25.) The ALJ's decision became the final decision of the Commissioner on May 16, 2013, when the Appeals Council denied Claimant's request for review. (Tr. at 1-5.) Claimant filed the present action seeking judicial review of the administrative decision on June 6, 2013, pursuant to 42 U.S.C. § 405(g). (Document No. 2.)
Under 42 U.S.C. § 423(d)(5) and § 1382c(a)(3)(H)(I), a claimant for disability benefits has the burden of proving a disability.
The Social Security Regulations establish a "sequential evaluation" for the adjudication of disability claims. 20 C.F.R. §§ 404.1520, 416.920 (2012). If an individual is found "not disabled" at any step, further inquiry is unnecessary.
When a claimant alleges a mental impairment, the Social Security Administration "must follow a special technique at every level in the administrative review process." 20 C.F.R. §§ 404.1520a(a) and 416.920a(a). First, the SSA evaluates the claimant's pertinent symptoms, signs and laboratory findings to determine whether the claimant has a medically determinable mental impairment and documents its findings if the claimant is determined to have such an impairment. Second, the SSA rates and documents the degree of functional limitation resulting from the impairment according to criteria as specified in 20 C.F.R. §§ 404.1520a(c) and 416.920a(c). Those sections provide as follows:
Third, after rating the degree of functional limitation from the claimant's impairment(s), the SSA determines their severity. A rating of "none" or "mild" in the first three functional areas (activities of daily living, social functioning; and concentration, persistence, or pace) and "none" in the fourth (episodes of decompensation) will yield a finding that the impairment(s) is/are not severe unless evidence indicates more than minimal limitation in the claimant's ability to do basic work activities. 20 C.F.R. §§ 404.1520a(d)(1) and 416.920a(d)(1).
20 C.F.R. §§ 404.1520a(e)(2) and 416.920a(e)(2).
In this particular case, the ALJ determined that Claimant satisfied the first inquiry because she had not engaged in substantial gainful activity during 2009. (Tr. at 16, Finding No. 1.) Under the second inquiry, the ALJ found that Claimant suffered from "asthma/chronic obstructive pulmonary disease (COPD), schizoaffective disorder, personality disorder, bipolar disorder, depression, and anxiety," which were severe impairments. (Tr. at 17, Finding No. 2.) At the third inquiry, the ALJ concluded that Claimant's impairments did not meet or equal the level of severity of any listing in Appendix 1. (Tr. at 17, Finding No. 3.) The ALJ then found that Claimant had a residual functional capacity ("RFC") to perform a full range of work at all exertional levels, but had nonexertional limitations, as follows:
(Tr. at 19, Finding No. 4.) At step four, the ALJ found that Claimant had no past relevant work. (Tr. at 24, Finding No. 5.) On the basis of testimony of a Vocational Expert ("VE") taken at the administrative hearing, the ALJ concluded that Claimant could perform jobs such as a food preparation worker, food counter attendant, and dining room and cafeteria kitchen helper and laundry worker at the unskilled medium level of exertion and jobs such as bottle packer and shirt presser at the unskilled light level of exertion. (Tr. at 24-25, Finding No. 9.) On this basis, benefits were denied. (Tr. at 25, Finding No. 10.)
The sole issue before this Court is whether the final decision of the Commissioner denying the claim is supported by substantial evidence. In
A careful review of the record reveals the decision of the Commissioner is supported by substantial evidence.
Claimant was born on November 26, 1984, and was 27 years old at the time of the supplemental administrative hearing, March 13, 2012. (Tr. at 24, 37, 203) Claimant had at least a high school education and was able to communicate in English. (Tr. at 24, 37, 219, 221.) In the past, Claimant worked as a self-employed childcare attendant for her disabled son under Title 19. (Tr. at 24, 83, 222, 232-39.)
The Court has reviewed all the evidence of record, including the medical evidence of record, and will discuss it below as it relates to the undersigned's findings and recommendation.
Claimant alleges that the Commissioner's decision is not supported by substantial evidence because the ALJ erred in failing to give any weight to the opinion of employability of her treating psychologist, Ms. Jennings and limited weight to Ms. Jennings' medical source statement. (Document No. 12 at 9-15.) Claimant further alleges that the ALJ erred in giving limited weight to the opinions of Ms. Wyatt and Ms. McFadden. (
Claimant further alleges that the ALJ erred in giving great weight to the state agency opinion of Dr. Cloonan. (Document No. 12 at 14-15.) Claimant asserts that there were indications in Dr. Cloonan's report that if she had all the medical reports at the close of the record, her opinion may have been altered. (
In response, the Commissioner asserts that the ALJ thoroughly considered the evidence of record and formulated an RFC assessment that fully accommodated her credibly established functional limitations. (Document No. 15 at 12.) The Commissioner asserts that Ms. Jennings' assessment of inability to perform work was based on Claimant's subjective complaints and was unsupported by any objective evidence, including Ms. Jennings' treatment notes. (
The Commissioner contends that the ALJ's decision is supported by substantial evidence for many reasons. (
Claimant next alleges that the Commissioner's decision is not supported by substantial evidence of record because the ALJ erred in relying on the VE testimony. (Document No. 12 at 17-18.) Claimant contends that Dr. Cloonan's "most notable restriction was that [Claimant] was limited to uncomplicated work-like activities with minimal interactions with others." (
In response, the Commissioner asserts that Claimant mischaracterizes the limitations Dr. Cloonan assessed regarding Claimant's ability to relate to others in a work environment. (Document No. 15 at 17-18.) The Commissioner asserts that Dr. Cloonan did not indicate that Claimant was limited to no contact with any co-workers or supervisors. (
Claimant first alleges that the ALJ erred in assessing the opinion of her treating psychologist, Ms. Jennings. (Document No. 12 at 9-15.) Every medical opinion received by the ALJ must be considered in accordance with the factors set forth in 20 C.F.R. §§ 404.1527(d) and 416.927(d) (2011). These factors include: (1) length of the treatment relationship and frequency of evaluation, (2) nature and extent of the treatment relationship, (3) supportability, (4) consistency, (5) specialization, and (6) various other factors. Additionally, the Regulations state that the Commissioner "will always give good reasons in our notice of determination or decision for the weight we give your treating source's opinion."
Under §§ 404.1527(d)(1) and 416.927(d)(1), more weight is given to an examiner than to a non-examiner. Sections 404.1527(d)(2) and 416.927(d)(2) provide that more weight will be given to treating sources than to examining sources (and, of course, than to non-examining sources). Sections 404.1527(d)(2)(I) and 416.927(d)(2)(I) state that the longer a treating source treats a claimant, the more weight the source's opinion will be given. Under §§ 404.1527(d)(2)(ii) and 416.927(d)(2)(ii), the more knowledge a treating source has about a claimant's impairment, the more weight will be given to the source's opinion. Sections 404.1527(d)(3), (4) and (5) and 416.927(d)(3), (4), and (5) add the factors of supportability (the more evidence, especially medical signs and laboratory findings, in support of an opinion, the more weight will be given), consistency (the more consistent an opinion is with the evidence as a whole, the more weight will be given), and specialization (more weight given to an opinion by a specialist about issues in his/her area of specialty). Unless the ALJ gives controlling weight to a treating source's opinion, the ALJ must explain in the decision the weight given to the opinions of state agency medical or psychological consultants. 20 C.F.R. §§ 404.1527(f)(2)(ii) and 416.927(f)(2)(ii) (2012). The ALJ, however, is not bound by any findings made by state agency medical or psychological consultants and the ultimate determination of disability is reserved to the ALJ.
In evaluating the opinions of treating sources, the Commissioner generally must give more weight to the opinion of a treating physician because the physician is often most able to provide "a detailed, longitudinal picture" of a claimant's alleged disability.
If the ALJ determines that a treating physician's opinion should not be afforded controlling weight, the ALJ must then analyze and weigh all the evidence of record, taking into account the factors listed in 20 C.F.R. §§ 404.1527 and 416.927(d)(2)-(6).
The medical evidence reveals that on July 28, 2010, Ms. Jennings conducted a psychological evaluation. (Tr. at 20, 417-23.) On mental status exam, Ms. Jennings noted that Claimant was cooperative and spontaneously generated conversation and had mildly deficient immediate and remote memory and moderately deficient recent memory. (Tr. at 20, 419.) Ms. Jennings administered the Minnesota Multiphasic Personality Inventory (MMPI-2), the Beck Anxiety Inventory Assessment, and the Beck Depression Inventory Assessment. (Tr. at 20, 420.) These tests indicated intense feelings of inferiority and insecurity and the suggestion of difficulty of becoming emotionally involved with other people. (
Ms. Jennings opined that Claimant "has had difficulty navigating the typical stressors encountered in gainful employment; including the need to interact appropriately with others and maintain consistency and attendance. She is able to maintain her current position with title XIX waiver due to it involves taking care of her disabled son and she has significant family support through her husband and her mother. It is not felt that she would be able to maintain competitive employment in an outside her home work environment." (Tr. at 20, 421.)
Ms. Jennings also completed a form Medical Source Statement of Ability to Do Work-Related Activities (Mental), on which she assessed that Claimant had many marked and extreme functional limitations, including the ability to interact appropriately with co-workers and supervisors. (Tr. at 20-21, 422-23.)
Ms. Jennings sent Claimant's attorney a letter on August 22, 2011, indicating that she had seen Claimant sporadically since 2004, for individual counseling. (Tr. at 20-21, 494-95.) Ms. Jennings noted that Claimant returned for therapy in 2006, because she had to leave a job as an aide at Family Connections due to extreme job stress, problems with mood swings, and not being able to control her anger. (
In addition to Ms. Jennings' treatment and opinions, the record contains the evaluation report of Melinda Wyatt, M.S., a licensed psychologist, who conducted a psychological evaluation on October 20, 2009. (Tr. at 20, 363-66.) On mental status exam, Ms. Wyatt noted that Claimant appeared anxious and her affect was restricted. (Tr. at 20, 364.) Nevertheless, she maintained adequate eye contact, was oriented in all spheres, generated brief responses to direct questions in a soft-spoken manner, presented her thoughts in an organized and logical manner, had adequate insight and judgment, and had adequate concentration. (
Claimant also underwent a consultative examination with Tonya McFadden, M.A., on September 25, 2010. (Tr. at 21, 438-44.) Claimant reported that she had difficulty dealing with the public, experienced intense feelings of anger that lasted up to three hours, felt depressed, had difficulty concentrating and experienced auditory hallucinations that were not so intense when she was on her medications. (Tr. at 21, 439-40.) On mental status exam, Ms. McFadden noted relevant and coherent speech, an anxious mood and restricted affect, normal thought process and content, fair insight and normal judgment, normal immediate memory, intact remote memory, and moderately deficient recent memory, and normal persistence and pace. (Tr. at 21., 442.) She opined that Claimant's persistence was limited, her social functioning was mildly to moderately limited, and her pace was normal. (
In addition to the examination evidence, the medical record contains the opinions of the state agency physicians, Dr. Holly Cloonan, Ph.d. (Tr. at 21-22, 453-66, 467-70.) and Jeff Boggess, Ph.d. (Tr. at m 388-401.) Dr. Cloonan completed a form Psychiatric Review Technique, on which she opined that Claimant had mild restriction of activities of daily living; marked difficulty in maintaining social functioning; moderate difficulty maintaining concentration, persistence, or pace; and no episodes of decompensation each of extended duration. (Tr. at21-22, 453-66.) Dr. Cloonan also completed a form Mental RFC Assessment on which she assessed a marked limitation in the ability to interact appropriately with the general public. (Tr. at 21-22, 467-70.) She assessed either moderate limitation or noted that Claimant was not limited significantly in all other functional areas. (
Finally, Dr. Boggess completed a form Psychiatric Review Technique on March 8, 2010, and concluded that Claimant's mood disorder vs schizoaffective disorder was not a severe impairment. (Tr. at 388-401.) He opined that Claimant had no restriction of activities of daily living; mild difficulties in maintaining social functioning, concentration, persistence, or pace; and no episodes of decompensation. (Tr. at 398.) Dr. Boggess noted that Claimant's last counseling session in 2009, demonstrated a stability in mood, with few symptoms reported. (Tr. at 400.) He further noted that the more recent treatment notes from Southern Highlands revealed much less severe pathology. (
The ALJ gave no weight to Ms. Jennings' opinion that Claimant was not able to perform competitive work outside her home. (Tr. at 21.) He gave limited weight to her opinion that Claimant had marked and extreme limitations in concentration, persistence, and pace, and extreme limits in all areas of social functioning. (
The ALJ gave greater weight to the opinion of Dr. Cloonan because her opinion was consistent with the findings in Claimant's mental status exams by Ms. Jennings, Ms. Wyatt, and Ms. McFadden; Claimant's treatment history; and her daily activities. (Tr. at 23.) For the reasons discussed, Dr. Cloonan's opinion is consistent with the mental exams of the three examining sources and Claimant's treatment history. The record indicates that Claimant's treatment was sporadic, and therefore, she was not compliant with her medications. Claimant admitted, however, that her symptoms improved when she was compliant with her medications. Respecting her daily activities, the ALJ noted that Claimant performed her personal care independently, prepared simple foods, did laundry and cleaning, drove a vehicle, shopped, paid bills, counted change, used a checkbook, spent time with family, watched television, played with her son, played basketball, used skates, and played cards. (Tr. at 18.) She also cared for her disabled son. (
Accordingly, in view of the foregoing, the undersigned finds that the ALJ's decision to give no weight to Ms. Jennings' opinion of disability and limited weight to her opinion, as well as Ms. Wyatt's and Ms. McFadden's opinions, is supported by the substantial evidence of record.
Claimant also alleges that the ALJ erred in relying on the testimony of the VE. (Document No. 12 at 17-18.) To be relevant or helpful, a vocational expert's opinion must be based upon consideration of all evidence of record, and it must be in response to a hypothetical question which fairly sets out all of the claimant's impairments.
In the ALJ's first hypothetical question to the VE, the ALJ asked the VE to assume an individual of the same age, education, and work experience as Claimant, who must avoid concentrated exposure to cold, fumes, odors, dust, gases, and poor ventilation; who is limited to simple, easy to learn, repetitive, unskilled work with no interaction with the public and only superficial interaction with co-workers and supervisors. (Tr. at 84.) In response, the VE testified that she could perform jobs such as a kitchen helper, laundry worker, bottle packer, and shirt presser. (Tr. at 85-86.) The ALJ then noted Claimant's testimony of difficulty getting along with supervisors. (Tr. at 86.) He posed a second hypothetical that included minimal interaction with co-workers and supervisors, meaning that they would give a demonstration on how to work and Claimant would have no contact with them, and then they would come after her to inspect her work. (
The undersigned agrees with the Commissioner and finds that Dr. Cloonan did not eliminate entirely Claimant's contact with others, including supervisors. Dr. Cloonan opined that Claimant was able to perform work-like activities with "minimal interactions with others." (Tr. at 469.) Among her checked-box limitations, she assessed that Claimant was only moderately limited in her ability to request assistance, get along with co-workers or peers, and accept instructions and respond to criticism appropriately from supervisors. (Tr. at 468.) If she had intended to eliminate any and all contact with supervisors, then one would think that these limitations would have been assessed as more extreme. Dr. Cloonan did indicate Claimant's ability to interact with the general public as markedly limited. (
For the reasons set forth above, it is hereby respectfully
The parties are notified that this Proposed Findings and Recommendation is hereby
Failure to file written objections as set forth above shall constitute a waiver of
The Clerk is directed to file this Proposed Findings and Recommendation and to transmit a copy of the same to counsel of record.