PEIRSON v. ASTRUE

Filing 25

ENTRY ON JUDICIAL REVIEW: The Appeals Council concluded that the ALJ erred in correcting Dr. Kladder's report; however, the Appeals Council did not adequately remedy that error. Accordingly, this cause is REVERSED AND REMANDED such that the ALJ can either contact Dr. Kladder to clarify the discrepancy, as the Appeals Council suggested, or reevaluate Ms. Peirson's RFC, accepting Dr. Kladder's report as is (see Entry for additional information). Signed by Judge William T. Lawrence on 2/24/2014.(SWM)

UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF INDIANA
INDIANAPOLIS DIVISION
NICOLE PEIRSON,
Plaintiff,
vs.
CAROLYN W. COLVIN, acting
Commissioner of the Social Security
Administration,
Defendant.

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ENTRY ON JUDICIAL REVIEW
Plaintiff Nicole Peirson requests judicial review of the final decision of Defendant,
Carolyn W. Colvin, Commissioner of the Social Security Administration (“Commissioner”),
denying Ms. Peirson’s application for Disability Insurance Benefits (“DIB”) and Supplemental
Security Income (“SSI”) under Titles II and XVI of the Social Security Act (“the Act”). The
Court rules as follows.
I.

APPLICABLE STANDARD

Disability is defined as “the inability to engage in any substantial gainful activity by
reason of a medically determinable mental or physical impairment which can be expected to
result in death, or which has lasted or can be expected to last for a continuous period of at least
twelve months.” 42 U.S.C. § 423(d)(1)(A). In order to be found disabled, a claimant must
demonstrate that her physical or mental limitations prevent her from doing not only her previous
work, but any other kind of gainful employment which exists in the national economy,
considering her age, education, and work experience. 42 U.S.C. § 423(d)(2)(A).

In determining whether a claimant is disabled, the Commissioner employs a five-step
sequential analysis. At step one, if the claimant is engaged in substantial gainful activity she is
not disabled, despite her medical condition and other factors. 20 C.F.R. § 404.1520(b). At step
two, if the claimant does not have a “severe” impairment (i.e., one that significantly limits her
ability to perform basic work activities), she is not disabled. 20 C.F.R. § 404.1520(c). At step
three, the Commissioner determines whether the claimant’s impairment or combination of
impairments meets or medically equals any impairment that appears in the Listing of
Impairments, 20 C.F.R. pt. 404, subpt. P, App. 1, and whether the impairment meets the twelvemonth duration requirement; if so, the claimant is deemed disabled. 20 C.F.R. § 404.1520(d). At
step four, if the claimant is able to perform her past relevant work, she is not disabled. 20 C.F.R.
§ 404.1520(f). At step five, if the claimant can perform any other work in the national economy,
she is not disabled. 20 C.F.R. § 404.1520(g).
In reviewing the ALJ’s decision, the ALJ’s findings of fact are conclusive and must be
upheld by this court “so long as substantial evidence supports them and no error of law
occurred.” Dixon v. Massanari, 270 F.3d 1171, 1176 (7th Cir. 2001). “Substantial evidence
means such relevant evidence as a reasonable mind might accept as adequate to support a
conclusion,” id., and this Court may not reweigh the evidence or substitute its judgment for that
of the ALJ. Binion v. Chater, 108 F.3d 780, 782 (7th Cir. 1997). The ALJ is required to
articulate only a minimal, but legitimate, justification for his acceptance or rejection of specific
evidence of disability. Scheck v. Barnhart, 357 F.3d 697, 700 (7th Cir. 2004). In order to be
affirmed, the ALJ must articulate his analysis of the evidence in her decision; while he “is not
required to address every piece of evidence or testimony,” he must “provide some glimpse into

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[his] reasoning . . . [and] build an accurate and logical bridge from the evidence to [his]
conclusion.” Dixon, 270 F.3d at 1176.
II. BACKGROUND
Nicole Peirson protectively filed for SSI and DIB on June 3, 2010, alleging she became
disabled on February 1, 2009, primarily due to severe depression and panic attacks. Ms. Peirson
was born on July 6, 1972, and she was thirty-three years old on the alleged disability onset date.
Ms. Peirson obtained a GED and took classes through an online college, earning a two-year
degree in Human Resources. She has prior relevant work experience as a telemarketer and in
customer service.
Ms. Peirson’s application was denied initially on August 30, 2010, and again upon
reconsideration on October 28, 2010. Following the denial upon reconsideration, Ms. Peirson
requested and received a hearing in front of an Administrative Law Judge (“ALJ”). A hearing,
during which Ms. Peirson was represented by counsel, was held in front of ALJ William M.
Manico on November 9, 2012. The ALJ issued his decision denying Ms. Peirson’s claim on
February 9, 2012. The Appeals Council also denied Ms. Peirson’s request for review on October
26, 2012. After the Appeals Council denied review of the ALJ’s decision, Ms. Peirson filed this
timely appeal.
Medical Evidence
Ms. Peirson’s medical evidence begins in August 2009, when she saw Dr. Hatimi, her
primary care physician. Ms. Peirson complained of an earache, blurred vision, cough, vertigo,
depression, anxiety, hallucinations, and fatigue. Dr. Hatimi diagnosed Ms. Peirson with
endometriosis menorrhagia, hypertension, and sinusitis. Furthermore, he noted Ms. Peirson’s
nicotine abuse and family history of diabetes. Dr. Hatimi prescribed Depo-Provera, Veramyst,

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and Claritin, in addition to ordering labs and an electrocardiogram. Ms. Peirson met with Dr.
Hatimi again on September 14, 2009, for a follow-up appointment. She complained of
depression and frequent urination; Dr. Hatimi thus prescribed Celexa and Detrol LA. He also
recommended counseling for Ms. Peirson’s depression.
On October 26, 2009, Ms. Peirson went to the Anderson Psychiatric Clinic complaining
of depression, panic attacks, and anxiety. A Mental Status Examination was performed, and she
was diagnosed with depressive disorder, panic disorder, and agoraphobia. She was also assessed
a score of 48 on the Global Assessment of Functioning (“GAF”) Scale. Ms. Peirson went to the
Anderson Psychiatric Clinic several times thereafter, treating with Robert Hacks, a social
worker. Her treatment at the Anderson Psychiatric Clinic concluded in June 2010 because Ms.
Peirson “failed to return” and her “goals were partially achieved.” Ms. Peirson’s GAF at
discharge had risen to a score of 55.
On November 11, 2009, Ms. Peirson met with Dr. Hatimi for a check-up. She explained
that she was experiencing side effects from her medications; specifically, she was experiencing
dizziness from Celexa. At the appointment, Ms. Peirson indicated having a medical history of
anxiety and depression; however, during his evaluation, Dr. Hatimi noted that Ms. Peirson
denied depression, anxiety, memory loss, mental disturbance, suicidal ideation, hallucinations,
and paranoia. Nevertheless, Dr. Hatimi diagnosed Ms. Peirson with anxiety and depression. He
advised her to continue taking Celexa and also prescribed Buspar for her anxiety.
Ms. Peirson met with Dr. Hatimi for another follow-up appointment in December 2009.
She complained that the Buspar medication was not working. Dr. Hatimi diagnosed her with
anxiety and prescribed Klonopin for her panic attacks.

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In January and April of 2010, Hacks completed two 90-day Outpatient Psychiatric
Reviews of Ms. Peirson that were reviewed by John Wenger, Ph.D. The Reviews contained
DSM-IV diagnoses of anxiety, dysthymic disorder, and agoraphobia, as well as GAF scores of
48 and 51 respectively.
On April 20, 2010, Ms. Peirson met with Dr. Susan Anderson, a psychiatrist. She
reported suffering from depression, constant crying, and panic attacks. Dr. Anderson diagnosed
Ms. Peirson with panic disorder, agoraphobia, and depressive disorder. Dr. Anderson
recommended that Ms. Peirson resume taking both Celexa and Xanax. Ms. Peirson met with Dr.
Anderson again on May 11, 2010, for a follow-up appointment. She noted that her medications
were starting to work because she was less irritable and her panic attacks decreased in severity.
Ms. Peirson met with Dr. Anderson twice in June 2010. At her June 8th appointment, she
noted that she was suffering from visual hallucinations and had been for approximately one year.
Dr. Anderson recommended that Ms. Peirson begin taking Navane. At her June 30th
appointment, Ms. Peirson reported that the Navane was working.
In July 2011, Dr. F. Kladder, Ph.D., a State Agency doctor, diagnosed Ms. Peirson as
having depressive and anxiety disorders. He opined that Ms. Peirson had the mental Residual
Functional Capacity (“RFC”) to perform unskilled work in a setting where her contact with other
was limited. On August 17, 2010, Ms. Peirson underwent a Mental Status Evaluation at the
request of the State Agency. Dr. Brandon Robbins, a licensed clinical psychologist, diagnosed
Ms. Peirson with social phobia and major depressive disorder. He assessed her with a GAF
score of 51. He noted that Ms. Peirson did have some limitations with regard to social
interactions, and therefore concluded that she would benefit from a work environment where she

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worked with only a few other individuals and that required minimal social interactions. Dr.
Randal-Horton confirmed these conclusions in October 2010.
Ms. Peirson continued to meet with Dr. Anderson throughout 2011, although Dr.
Anderson did note that Ms. Peirson missed several scheduled appointments. In February 2011,
Ms. Peirson complained that her medication was not working and that she was feeling angry; Dr.
Anderson adjusted Ms. Peirson’s medication. In June 2011, Ms. Peirson admitted to Dr.
Anderson that she had been hurting herself by burning her wrist with cigarettes and punching
walls.
Ms. Peirson returned to the Anderson Psychiatric Clinic in June 2011 and saw Jean
Manis, a social worker. Ms. Manis noted that Ms. Pierson suffered from depression, obsessive
compulsive disorder, self-mutilation, anxiety, post-traumatic stress disorder, panic attacks, and
agoraphobia.
In July 2011, Dr. Anderson filled out a Mental RFC Questionnaire. She diagnosed Ms.
Peirson with post-traumatic stress disorder, panic disorder with agoraphobia, and personality
disorder. Dr. Anderson noted Ms. Peirson’s current GAF score was 50 and that her highest GAF
score was 55. Dr. Anderson reported that Ms. Peirson had “minimal response to medication at
this time” and noted her prognosis as “fair.”
In August 2011, Dr. Anderson discontinued the Celexa and started Ms. Peirson on
Effexor XR. In September 2011, Dr. Anderson noted that Ms. Peirson responded better to the
Effexor XR.
Hearing Testimony
At the hearing, Ms. Peirson testified that she was unable to work due to severe anxiety,
panic attacks, and depression. She testified that she lives with her three children and relies on

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her daughter to prepare her meals. While she has a valid driver’s license, she does not drive, but
relies on others to transport her places. She also testified that she sleeps during much of the day,
only waking up to take her medications, and does not leave the house at night. She testified that
she was fired from her previous job because she missed work due to her panic attacks.
After Ms. Peirson concluded her testimony, the ALJ heard testimony from Jean Manis, a
licensed clinical social worker with the Anderson Psychiatric Clinic, who began seeing Ms.
Peirson in June 2011. She testified that Ms. Peirson suffered from hallucinations, obsessive
compulsive disorder, depression, and post-traumatic stress disorder. She also noted that Ms.
Peirson had burned her wrist with cigarettes.
The ALJ also heard testimony from the Vocational Expert (“VE”), Stephanie Archer.
The ALJ asked the VE to consider a hypothetical individual with Ms. Peirson’s age, education
and work experience who could work with the following restrictions: working with a small
number of people; working in a low-stress environment; and working in a position that allows
for breaks approximately every two hours. The VE testified that such an individual could
perform work as a packer, cleaner, and machine feeder.
III.

DISCUSSION

In her brief in support of her complaint, Ms. Peirson argues that the ALJ’s finding at step
five was not based upon substantial evidence in view of the entire record. To that end, she
directs the Court to several alleged errors: 1) the ALJ incorrectly “corrected” Dr. Kladder’s
report; 2) the ALJ’s conclusions regarding Dr. Anderson’s Mental RFC Questionnaire were
incorrect; and 3) the ALJ erred in failing to consider the testimony and treatment notes of Jean
Manis. Ms. Peirson also alleges the ALJ erred in failing to amend her onset date. The Court will
address her arguments below.

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A. Substantial Evidence
As noted above, Ms. Peirson contends that the ALJ’s finding at step five—that she could
perform other work in the national economy—is not supported by substantial evidence in the
record. She advances two reasons, in addition to her other related RFC arguments discussed
below. First, she argues that the ALJ only considered the reports of the State Agency
psychologists, who did not have the advantage of reviewing Ms. Peirson’s longitudinal record of
mental health treatment. And second, she claims the ALJ improperly “jettisoned” her GAF
scores.
The Court disagrees with Ms. Peirson that the ALJ only relied on Dr. Robbins, Dr.
Kladder, and Dr. Randal-Horton’s reports in crafting her RFC. The ALJ specifically noted that
he “assign[ed] significant weight to . . . Dr. Anderson” in determining Ms. Peirson’s RFC. R. at
25. While the State Agency physicians completed their reports in 2010, Dr. Anderson completed
her report in 2011, and had “the advantage of reviewing the longitudinal record of Ms. Peirson’s
mental health treatment.” Pl.’s Brief at 14-15. As the Court explains below, Dr. Anderson’s
report, along with the other reports and objective evidence in the record, supports the ALJ’s RFC
determination. See Pepper v. Colvin, 712 F.3d 351, 362-63 (noting substantial evidence exists
when there is “such relevant evidence as a reasonable mind might accept as adequate to support a
conclusion.”) (quoting McKinzey v. Astrue, 641 F.3d 884, 889 (7th Cir. 2011) (internal quotation
marks omitted)).
In regard to her GAF scores, the Court does not agree with Ms. Peirson that the ALJ
“simply disregarded the scores.” Pl.’s Brief at 16. It is curious to the Court why the ALJ felt the

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need to dedicate six repetitive footnotes in his decision to those scores.1 Nevertheless, by
placing them in his decision, he clearly did not disregard them. His footnotes simply reflect the
fact that a certain GAF score, standing alone, does not automatically mean a claimant is disabled.
See Denton v. Astrue, 596 F.3d 419, 425 (7th Cir. 2010) (“[N]owhere do the Social Security
regulations or case law require an ALJ to determine the extent of an individual’s disability based
entirely on his GAF score.”) (quoting Wilkins v. Barnhart, 69 Fed. Appx. 775, 780 (7th Cir.
2003)). The Court reads the ALJ’s decision as considering Ms. Peirson’s ranging GAF scores—
from a high of 55 to a low of 40—as one piece of evidence he considered when determining her
RFC. In so doing, the ALJ did not err.
B. Correction of Dr. Kladder’s Report
Ms. Peirson next takes issue with the ALJ “correcting” a Psychiatric Review Technique
Form (“PRTF”) completed by Dr. Kladder. In his decision denying benefits, the ALJ noted:
In the PRTF (see 1A: 4), Dr. Kladder checks the marked box for social
functioning. This would appear, however, to be an error as he only indicates
moderate limitations in his mental rfc at 1A: 6 . . . Moderate restrictions are also
consistent with Dr. Kladders’s [sic] analysis at 1A: 6.
R. at 17, n. 3 (emphasis added).2 Ms. Peirson made this same argument on appeal to the Appeals
Council. The Appeals Council agreed with Ms. Peirson that the ALJ “erred in correcting Dr.

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The footnotes all read, “A GAF score of [insert score] is not indicative of disability. To
the contrary, GAF scores are only an indication of one’s function the day of assessment and
provide no longitudinal application.” R. at 16, 24.
2
While noting “marked” limitations on page 4 of the PRTF, in terms of her social
interaction limitations, Dr. Kladder noted on page 6 that Ms. Peirson was “moderately limited”
in: 1) her ability to interact appropriately with the general public; 2) her ability to accept
instructions and respond appropriately to criticism from supervisors; 3) and her ability to get
along with coworkers or peers without distracting them or exhibiting behavioral extremes. She
was “not significantly limited” in her ability to ask simple questions or request assistance; and in
her ability to maintain socially appropriate behavior and to adhere to basic standards of neatness
and cleanliness. R. at 74. The Court presumes this is why the ALJ assumed the “marked”
classification was made in error.
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Kladder’s opinion statement, especially without recontacting him for clarification.” Id. at 2.
However, it upheld the ALJ’s ultimate determination that Ms. Peirson was not disabled stating,
“the evidence as a whole supports the finding that the claimant possesses only a moderate
limitation in her social functioning.” Id.
Ms. Peirson takes issue with one particular line in the Appeals Council’s decision. It
noted that “because the record as a whole still supports the findings made, even if all of Dr.
Kladder’s statements are ignored, we will not disturb the decision at this time.” Id. (emphasis
added). The Court agrees with Ms. Peirson that this line is perplexing. In the Court’s view, the
appropriate remedy would have been for the Appeals Council to note that even if the ALJ had
taken Dr. Kladder’s report as is, the record as a whole still substantially supported his conclusion
that Ms. Peirson’s social limitations were moderate. The problem, therefore, lies in the fact that
the Appeals Council noted that the ALJ erred in “correcting” Dr. Kladder’s report, but then
failed to remedy that problem by simply ignoring the report all together.
While the Court believes that the ALJ’s conclusion regarding Ms. Peirson’s social
limitations is well-reasoned, the Appeals Council failed to adequately address the “error” it
claims he committed. Unfortunately, this requires remand. On remand, the ALJ should either
contact Dr. Kladder to clarify the discrepancy, as the Appeals Council suggested, or reevaluate
Ms. Peirson’s RFC, accepting Dr. Kladder’s report as is—that is, with the “marked” notation.
C. Dr. Anderson’s Mental RFC
Ms. Peirson also argues that the ALJ was simply wrong in concluding that Dr.
Anderson’s Mental RFC “does not support claimant’s allegations of disability.” Id. at 21. Again,
the Court disagrees. Dr. Anderson did opine that Ms. Peirson had serious limitations in a
number of categories relating to her mental abilities to perform unskilled work, including, among

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others: 1) her ability to ask simple questions; 2) her ability to deal with normal work standards;
and 3) her ability to work with others without being distracted. See id. at 356. Nevertheless, Dr.
Anderson concluded that while Ms. Peirson was seriously limited in these areas, she was not
precluded from being able to perform these tasks—as the Commissioner notes, there are two
categories above the “seriously limited, but not precluded” ranking: “Unable to meet
competitive standards” and “No useful ability to function.” See id.
Ms. Peirson also argues that “[t]he ALJ rejected the vocational expert’s opinion,” Pl.’s
Reply at 5, when she was asked if someone with these serious limitations could work. While the
VE did note that working would be “difficult” for someone with these serious limitations, she
noted this was relative to the various work limitations that might be imposed. See R. at 66 (“No,
that’s not my answer, there are no jobs. But my answer is there’s just very various work
limitations.”). To this point, the ALJ specifically restricted Ms. Peirson’s work environment,
accounting for the serious limitations Dr. Anderson found:
Claimant is able to perform simple, unskilled work where interpersonal contact
with others is routine, superficial and incidental to work performed, and where
she works with only a relatively small number of people. She is also limited to
low stress work that requires a regular work break approximately every 2 hours.
Id. at 19-20. The Court sees no error in the ALJ concluding that while Dr. Anderson’s report
noted various serious limitations, it did not support a finding of total disability.
D. Jean Manis
Ms. Peirson next argues that the ALJ erred in failing to consider Ms. Peirson’s social
worker’s notes and testimony. Ms. Peirson concedes that Ms. Manis is not an “acceptable
medical source” as defined in 20 C.F.R. § 404.1513; rather, as a social worker, Ms. Manis is
considered an “other source.” Social Security Ruling (“SSR”) 06-03p states that information
from these other sources “may provide insight into the severity of the impairment(s) and how it
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affects the individual’s ability to function” and “should be evaluated on key issues such as
impairment severity and functional effects, along with the other relevant evidence in the file.”
The Court believes the ALJ has satisfied his obligation in this regard and disagrees with Ms.
Peirson’s interpretation of the ALJ’s treatment of Ms. Manis’ notes and testimony as a
“rejection.” The ALJ discussed Ms. Peirson’s treatment notes from the Anderson Clinic at
length in his decision, see R. at 24; however, because Ms. Manis’ opinions were based solely on
Ms. Peirson’s statements and not on any other evidence or testing, he assigned her opinion little
weight. This was not an error. See e.g., 20 C.F.R. § 404.1527 (“The more a medical source
presents relevant evidence to support an opinion, particularly medical signs and laboratory
findings, the more weight we will give that opinion. The better an explanation a source provides
for an opinion, the more weight we will give that opinion.”).3
E. Ms. Peirson’s Onset Date
Finally, Ms. Peirson argues that the ALJ committed harmful error by not amending her
date of onset to October 1, 2009, as he indicated he would do at the hearing. She stated she was
harmed by this because, “[i]t is possible that the Commissioner could argue that since Mr. [sic]
Peirson was not disabled on January 1, 2006 the Unfavorable Decision stands (notwithstanding
the occurrence of a later disability).” Pl.’s Reply at 7. Inasmuch as the Commissioner does not
argue that Ms. Peirson’s decision should stand because she was not disabled as early as January

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While this provision specifically addresses one factor an ALJ should consider when
evaluating “acceptable medical sources,” ALJs are to use the same factors when evaluating
“other sources.” See SSR 06–03p; Phillips v. Astrue, 413 Fed. Appx. 878, 884 (7th Cir. 2010)
(“In deciding how much weight to give to opinions from these ‘other medical sources,’ an ALJ
should apply the same criteria listed in § 404.1527[.]”).

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1, 2006, this argument has no merit. Ms. Peirson has failed to show any actual harm resulting
from this oversight.
IV.

CONCLUSION

As set forth above, the Appeals Council concluded that the ALJ erred in correcting Dr.
Kladder’s report; however, the Appeals Council did not adequately remedy that error.
Accordingly, this cause is REVERSED AND REMANDED such that the ALJ can either
contact Dr. Kladder to clarify the discrepancy, as the Appeals Council suggested, or reevaluate
Ms. Peirson’s RFC, accepting Dr. Kladder’s report as is.
SO ORDERED: 02/24/2014
_______________________________
Hon. William T. Lawrence, Judge
United States District Court
Southern District of Indiana

Copies to all counsel of record via electronic communication.

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