Gillespie v. Commissioner of Social Security
Filing
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OPINION AND ORDER: The Court now GRANTS Gillespie's request to remand this case. 21 . This case is REMANDED to the Commissioner for further proceedings consistent with this opinion. The Clerk is DIRECTED to terminate the case. Signed by Magistrate Judge Michael G Gotsch, Sr on 10/4/2016. (lhc)
UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF INDIANA
SOUTH BEND DIVISION
AMANDA S. GILLESPIE,
Plaintiff,
v.
CAROLYN W. COLVIN,
Acting Commissioner of Social Security,
Defendant.
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CAUSE NO. 1:14-CV-00356-MGG
OPINION AND ORDER
On November 14, 2014, Plaintiff Amanda S. Gillespie (“Gillespie”) filed a complaint in
this Court seeking reversal or remand of the Social Security Commissioner’s Defendant Acting
Commissioner of Social Security’s (“Commissioner”), final decision denying her application for
Social Security Income (“SSI”) and Disability Insurance Benefits (“DIB”). (Doc. No. 1 at 1).
On May 22, 2015, Gillespie filed her opening brief. (Doc. No. 19). On August 27, 2015,
Defendant, Commissioner of Social Security (“the Commissioner”), filed a Memorandum in
Support of the Commissioner’s Decision requesting the Court to affirm the decision denying SSI
and DIB. (Doc. No. 25). On November 05, 2015, Gillespie filed a reply brief. (Doc. No. 28).
This Court may enter a ruling in this matter based on the parties consent, 28 U.S.C. § 636(c), and
42 U.S.C. § 405(g).
I.
PROCEDURE
On September 7, 2011, Gillespie filed an application for SSI and DIB with the Social
Security Administration (“SSA”) alleging disability beginning September 30, 2008. The SSA
denied Gillespie’s application initially on December 12, 2012, and then again on February 8,
2012, after reconsideration was granted. On August 6, 2013, a hearing was held before an
administrative law judge (“ALJ”) where Gillespie, Gillespie’s fiancé Steve Newsome, and an
impartial vocational expert appeared and testified. On January 14, 2014, the ALJ issued his
decision finding that Gillespie was not disabled at Step Five of the evaluation and denied her
application for DIB and SSI. On September 17, 2014, the Appeals Council denied Gillespie’s
request for review, making the ALJ’s decision the final decision of the Commissioner. Through
this action, Gillespie seeks judicial review of the Commissioner’s final decision pursuant to
sentence four of 42 U.S.C. § 405(g).
II.
FACTS
Gillespie was born on February 25, 1975, making her 33 years old on the date of her SSI
and DIB applications, and has at least a high school education. (Doc. No. 11 at 36). At the time
of the August 2014 hearing, Gillespie was unemployed. Prior to the alleged onset date, Gillespie
reportedly worked as a bench press operator and a certified nurse aide. (Doc. No. 21 at 2).
A.
Relevant Medical Evidence of Gillespie’s Mental Impairments1
As a part of her disability application, Gillespie provided the ALJ with medical evidence
from her mental health counselor, psychiatrists, nurse practitioner, and primary care physicians
over the twelve years between November 2001 and October 2013—two months past the date of
her hearing. Throughout this period, Gillespie was treated with a varying medication regimen
for depression, bipolar disorder, anxiety disorder, and polysubstance abuse. She was
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Because Gillespie only alleges problems with the ALJ’s analysis of her residual functional capacity related to her
mental impairments, the Court need not outline evidence related to her physical impairments in this opinion.
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hospitalized for brief periods in July 2007 for suicidal thoughts and in October 2013 for opiate
withdrawal. The record shows that her symptoms ebbed and flowed as she was treated.
After submitting her DIB and SSI application, Gillespie was examined by State Agency
physicians. In November 2011, Dr. Russell G. Coulter-Kern examined Gillespie diagnosing her
with bipolar II disorder and social anxiety disorder. Dr. Coulter-Kern noted Gillespie’s poor
immediate but fair recent and past memory as well as her appropriate eye contact with a logical
and persistent thought process. In February 2012, H. M. Bacchus, Jr., M.D., performed a
physical consultative examination in which he assessed Gillespie’s bipolar disorder and
depression noting that she had a slightly depressed mood and an intact memory.
Of greatest relevance to this action, Gillespie was examined by State Agency
psychologist, Benetta E. Johnson, Ph.D. in December 2011. On December 9, 2011, Dr. Johnson
completed a Psychiatric Review Technique (“PRT”) worksheet, in which she rated Gillespie’s
functional limitations related to the Paragraph B criteria involved in the Step Three Listing
Analysis. On the PRT, Dr. Johnson opined that Gillespie had mild restrictions in maintaining
social functioning and activities of daily living, moderate difficulty with maintaining
concentration, persistence, and pace, and no episodes of decompensation of extended duration.
That same day, Dr. Johnson also completed a mental residual functional capacity
(“MRFC”) assessment intended to assist the ALJ in his RFC determination. In Section I of the
MRFC form, entitled “Summary Conclusions,” Dr. Johnson checked boxes in several categories
assessing Gillespie’s limitation in sustained concentration and persistence. In Section III of the
MRFC form entitled “Functional Capacity Assessment,” Dr. Johnson provided a narrative about
Gillespie’s mental limitations. In January 2012 and February 2012, State Agency psychologist,
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Joseph A. Pressner, Ph.D., affirmed Dr. Johnson’s opinions after reviewing the evidence in
Gillespie’s file to date.
B.
Hearing Testimony
At the ALJ hearing, Gillespie testified that she was unable to work due to her inability to
take care of herself by doing household chores or taking medications. She also expressed
difficulty with concentration. Gillespie also testified that her symptoms were cyclical, and her
depressive periods occurred five to six times per month. In addition, Gillespie explained that her
medications and visitations with her psychiatrist every month helped her condition. She also
noted that she lived with her four-year-old son and Steve Newsom (“Newsom”), her fiancé, and
that she could drive to the gas station, grocery store, and doctor appointments. Furthermore,
Gillespie testified that she could perform basic activities, including taking care of her dogs,
watching television, taking her son to the park, and cleaning her house. Similar to Gillespie’s
testimony, Newsom testified that Gillespie would endure day-long crying spells and odd
behavior, such as heating up their pans without any material inside the pans. Newsom further
explained that Gillespie’s depression and anxiety worsened during her depressive periods,
resulting in her lack of attention and communication with her son.
C.
ALJ Opinion
After the hearing, the ALJ issued a written decision reflecting the following findings. At
Step One of the five-step disability analysis, the ALJ found that Gillespie had not engaged in
substantial gainful activity since her alleged onset date of September 30, 2008. At Step Two, the
ALJ found that Gillespie had the following severe impairments: depression, bipolar disorder,
anxiety disorder, and history of polysubtance abuse. At Step Three, the ALJ found that Gillespie
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did not have an impairment or combination of impairments that met or medically equaled the
severity of a listed impairment. After defining Gillespie’s RFC, the ALJ found at Step Four that
Gillespie was unable to perform any past relevant work. At Step Five, the ALJ found that—
considering Gillespie’s age, education, work experience, and RFC—there are jobs that exist in
significant numbers in the national economy that she could perform. Based on these findings,
the ALJ determined that Gillespie had not been disabled from September 30, 2008, the alleged
onset date, through February 13, 2015, the date of the ALJ’s decision. Consequently, the ALJ
denied DIB and SSI benefits to Gillespie. After the Appeals Council denied Gillespie’s request
for review, the ALJ’s decision became the final decision of the Commissioner for purposes of
judicial review.
III.
ANALYSIS
A.
Standard of Review
The Social Security Act authorizes judicial review of the final decision of the agency and
indicates that the Commissioner’s factual findings must be accepted as conclusive if supported
by substantial evidence. 42 U.S.C. § 405(g). Thus, a court reviewing the findings of an ALJ will
reverse only if the findings are not supported by substantial evidence or if the ALJ has applied an
erroneous legal standard. See Briscoe v. Barnhart, 425 F.3d 345, 351 (7th Cir. 2005).
Substantial evidence is more than a mere scintilla but may be less than the weight of the
evidence. Sheck v. Barnhart, 357 F.3d 697, 699 (7th Cir. 2004). Thus, substantial evidence is
simply “such relevant evidence as a reasonable mind might accept as adequate to support a
conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971); Kepple v. Massanari, 468 F.3d
513, 516 (7th Cir. 2001).
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A reviewing court is not to substitute its own opinion for that of the ALJ or to re-weigh
the evidence, but the ALJ must build a logical bridge from the evidence to his conclusion.
Haynes v. Barnhart, 416 F.3d 621, 626 (7th Cir. 2005). Minimally, an ALJ must articulate his
analysis of the evidence in order to allow the reviewing court to trace the path of his reasoning
and to be assured that the ALJ considered the important evidence. See Scott v. Barnhart, 297
F.3d 589, 595 (7th Cir. 2002). The ALJ need not specifically address every piece of evidence in
the record, but must present a “logical bridge” from the evidence to his conclusions. O’ConnorSpinner v. Astrue, 627 F.3d 614, 618 (7th Cir. 2010).
B.
Issue for Review
Gillespie seeks reversal and remand of the ALJ’s decision, arguing that the ALJ’s
hypothetical to the Vocational Expert (“VE”) at the hearing did not reflect the full extent of the
moderate limitations he found in Gillespie’s concentration, persistence, or pace. As such,
Gillespie argues that the ALJ’s Step Five analysis was improper. Notably, the ALJ’s
hypothetical incorporated all the limitations included in the ALJ’s RFC determination.
Therefore, the Court now reviews the ALJ’s RFC analysis to determine whether Gillespie’s
arguments justify remand.
C.
Analysis
A claimant’s RFC indicates her ability to do physical and mental work activities on a
sustained basis despite functional limitations caused by any medically determinable
impairment(s) and their symptoms. 20 C.F.R. § 404.1545; SSR 96-8p 1996. In making a proper
RFC determination, the ALJ must consider all of the relevant evidence in the record and cannot
ignore evidence that supports a disability finding. Goble v. Astrue, 385 Fed. App’x 588, 593 (7th
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Cir. 2010) (citing Myles v. Astrue, 582 F.3d 672, 678 (7th Cir. 2009)); 20 C.F.R. § 404.1545.
The record may include medical signs, diagnostic findings, the claimant’s statements about the
severity and limitations of symptoms, statements and other information provided by treating or
examining physicians and psychologists, third party witness reports, and any other relevant
evidence. SSR 96-7p 1996.
The crux of Gillespie’s challenge to the ALJ’s decision is her claim that the RFC did not
account for her moderate difficulties in concentration, persistence, and pace. Both an RFC and a
hypothetical to the VE must account for all of a claimant’s limitations, including deficiencies in
concentration, persistence, and pace. O’Connor-Spinner v. Astrue, 627 F.3d 614, 619 (7th Cir.
2010). However, an RFC for simple or unskilled work does not necessarily or inherently capture
all of a claimant’s work-related mental limitations. Id. at 620. For instance, “employing terms
like ‘simple, repetitive tasks’ [in an RFC and hypothethical] will not necessarily exclude from
the VE’s consideration [] positions that present significant problems of concentration,
persistence, and pace.” Id.
Nevertheless, there is no per se requirement that an RFC and hypothetical must include
the specific terminology of “concentration, persistence, and pace.” Id. at 619. Moreover, a
claimant’s moderate limitations in concentration, persistence, or pace do not automatically
establish that a claimant cannot satisfactorily function to perform available jobs. See Givens v.
Colvin, 551 Fed. App’x 855, 862 (7th Cir. 2013).
Gillespie does not disagree with these general rules, but argues that the ALJ failed to
include all of Dr. Johnson’s findings—as noted in her MRFC dated December 9, 2011, and later
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affirmed by Dr. Presser—about Gillespie’s limitations of concentration, persistence, and pace
into the RFC and hypothetical. The ALJ held that Gillespie retained the RFC to
perform a full range of work at all exertional levels with the following limitations:
[Gillespie] is limited to simple, routine, and repetitive tasks. [Gillespie] can
maintain the concentration required to perform simple tasks. [Gillespie] is limited
to low stress work defined as requiring only occasional decision making and only
occasional changed in the work setting. [Gillespie] can tolerate predictable
changes in the work environment.
Doc. No. 11 at 30. In Section I of her MRFC, however, Dr. Johnson checked boxes assessing
Gillespie’s abilities related to “Sustained Concentration and Persistence” that included, among
other things, findings that Gillespie was moderately limited in the categories of (1) ability to
maintain attention and concentration for extended periods; (2) ability to perform activities within
a schedule, maintain regular attendance, and be punctual within customary tolerances; and (3)
ability 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. Doc. No. 11 at 396–97.
Gillespie acknowledges the RFC’s reference to her ability to “maintain the concentration
required to perform simple tasks” in the RFC, but argues that the RFC is incomplete because it
does not account for her limitations related to attention, regular attendance, punctuality, and rest
periods reflected in Dr. Johnson’s opinion. On the other hand, the Commissioner contends that
the ALJ’s RFC and hypothetical mirrored the Dr. Johnson’s opinion making them both proper.
In support of remand, Gillespie cites Varga v. Colvin, 794 F.3d 809, 816 (7th Cir. 2015).
In Varga, the plaintiff challenged the ALJ’s hypothetical question to the VE, alleging it was
flawed because it did not account for Varga’s moderate difficulties in concentration, persistence,
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and pace that the State Agency psychologist noted in Section I of the MRFC form he completed.
794 F.3d at 813. The Seventh Circuit held that the ALJ committed reversible error because he
did not address all of the moderate limitations in concentration, persistence, and pace in his
hypothetical question to the VE. Id. at 814. The court reasoned that there were seven areas
related to concentration, persistence, and pace, identified by the State Agency psychologist in the
Section I of the MRFC form, in which the claimant was moderately limited but that the ALJ
failed to incorporate into the RFC and hypothetical. Id.
Gillespie, however, fails to discuss a fact in this case that is significantly different than
Varga. The standard MRFC forms used by the State Agency psychologist in both Varga and this
case include Section I, which provides checkboxes for the reporting of claimant limitations in
pre-identified categories, and Section III, which provides space for the psychologist to opine
narratively as to the claimant’s mental RFC. In Varga, the State Agency psychologist included
no narrative opinion as to the claimant’s RFC in Section III. Here, however, Dr. Johnson opined
in Section III that:
The evidence suggest that [Gillespie] can understand, remember, and carry-out
simple tasks. [Gillespie] can relate on at least a superficial basis. The claimant
can attend for sufficient periods of time to complete simple tasks. [Gillespie] can
manage light stresses involved in work related tasks. [Gillespie] can manage
unskilled tasks.
Doc. No. 11 at 398.
The court in Varga acknowledged the importance of this distinction in response to the
Commissioner’s argument that Section I of the MRFC is “merely a worksheet to aid doctors in
deciding the presence and degree of functional limitations” and that “the ALJ is only required to
include findings made at Section III[, the narrative portion,] of the MRFCA form, in which the
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doctor is to ‘translate’ his or her worksheet observation into a mental RFC.” Id. at 816.
Specifically, the court stated that “an ALJ may rely on a doctor’s narrative RFC, rather than the
checkboxes, where that narrative adequately encapsulates and translates those worksheet
observations.” Id. The court also noted that the Section I “worksheet observations” may be “less
useful to an ALJ than a doctor’s narrative RFC assessment,” but nevertheless held that they
cannot be ignored. Id. Without any Section III narrative opinion to compare to the State Agency
psychologist’s Section I observations, the court concluded that the ALJ committed reversible
error by failing to account for the Section I observations about concentration, persistence, and
pace in the RFC and hypothetical. Id.
As such, the Court cannot determine whether the ALJ improperly excluded Dr. Johnson’s
Section I observations from Gillespie’s RFC without considering the more nuanced question of
whether Dr. Johnson’s narrative in Section III adequately encapsulated and translated her Section
I checkbox-findings about Gillespie’s limitations in concentration, persistence, and pace to the
extent that the ALJ could have relied on the Section III narrative RFC without having to
incorporate all of the limitations identified in the Section I checkboxes. See id.; see also Goo v.
Colvin, Case No. 15 C 5858, 2016 WL 3520191, at *9–*10 (N.D. Ill. June 28, 2016); Kraus v.
Colvin, No. 13-C-0578, 2014 WL 1689717, at *16 (E.D. Wis. Apr. 29, 2014); Lichtsinn v.
Astrue, Cause No.: 1:08-cv-307, 683 F. Supp. 2d 811, 821 (N.D. Ind. 2010). In some cases
where the consulting expert’s mental RFC restricts the claimant to the same limitations
incorporated in the ALJ’s RFC and hypothetical, the ALJ commits no legal error. Lichtsinn, 683
F. Supp. 2d at 821. However, when an ALJ fails to mention areas where the State Agency
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psychologist finds moderate limitations in reliance on even an adequately translated mental RFC,
the court cannot be unconcerned. Yurt v. Colvin, 758 F.3d 850, 858 (7th Cir. 2014).
In this case, the RFC and hypothetical mirrored the “simple tasks” and “low stress work”
limitations Dr. Johnson included in her Section III mental RFC narrative. Yet neither Dr.
Johnson’s mental RFC nor the ALJ’s RFC and hypothetical reflect fully Gillespie’s limitations in
concentration, persistence, and pace as identified by Dr. Johnson Section I of the MRFC form.
Missing from both are any references to or translations of Gillespie’s moderate limitations in
performing within a schedule, maintaining regular attendance, being punctual, completing
normal work without interruptions from psychologically based symptoms, or performing at a
consistent pace without unreasonable rest periods. Even though the ALJ’s opinion discusses
thoroughly a wide range of medical evidence included in the record, it fails to account for the full
range of moderate limitations in concentration, persistence, and pace identified by Dr. Johnson.
Standing alone, the ALJ’s omission of moderate limitations without explanation is an
error of law justifying remand. However, the ALJ has also failed to build a logical bridge
between the evidence in the record, particularly Dr. Johnson’s opinion reflected in Section I of
the MRCA, and the RFC. As such, the ALJ’s RFC determination is not supported by substantial
evidence and must be remanded for further proceedings.
IV.
CONCLUSION
For the reasons stated above, the Court now GRANTS Gillespie’s request to remand this
case. [Doc. No. 19]. This case is REMANDED to the Commissioner for further proceedings
consistent with this opinion. The Clerk is DIRECTED to terminate the case.
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SO ORDERED.
Dated this 4th day of October, 2016.
S/Michael G. Gotsch, Sr.
Michael G. Gotsch, Sr.
United States Magistrate Judge
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