Murphy v. Colvin
Filing
20
MEMORANDUM AND ORDER re: 13 SOCIAL SECURITY BRIEF filed by Plaintiff Timmothy Murphy, 16 SOCIAL SECURITY CROSS BRIEF re 13 SOCIAL SECURITY BRIEF filed by Defendant Carolyn W. Colvin. IT IS HEREBY ORDERED that the decision of the Commissioner is REVERSED and REMANDED. Signed by District Judge Audrey G. Fleissig on 8/5/16. (CSG)
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
SOUTHEASTERN DIVISION
TIMMOTHY MURPHY,
Plaintiff,
v.
CAROLYN COLVIN,
Acting Commissioner of Social Security,
Defendant.
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Case No. 1:15-CV-00131-AGF
MEMORANDUM AND ORDER
This action is before this Court for judicial review of the final decision of the
Commissioner of Social Security’s finding that Plaintiff Timmothy Murphy was not
disabled, and, thus, not entitled to disability insurance benefits under Title II of the Social
Security Act, 42 U.S.C. §§ 401, et seq., or supplemental security income (“SSI”) under
Title XVI of the Social Security Act, 42 U.S.C. §§ 1381, et seq. For the reasons set forth
below, the decision of the Commissioner will be reversed and the case remanded for
further proceedings consistent with this Memorandum and Order.
BACKGROUND
Plaintiff, who was born on November 14, 1979, filed his applications for disability
insurance benefits and supplemental security income on May 25, 2011, alleging disability
beginning July 1, 2009, at age 29. Plaintiff alleged disability due to a wide range of
physical impairments including seizures and pain stemming from a car crash Plaintiff
experienced in 2001, and psychological impairments including depression, anxiety, bipolar
disorder, and posttraumatic stress disorder. (Tr. 279-291.) After Plaintiff’s application
was denied at the initial administrative level, he requested a hearing before an
Administrative Law Judge (“ALJ”). Such a hearing was twice postponed while Plaintiff
obtained counsel, and was finally held on January 10, 2014. By decision dated January
23, 2014, the ALJ found that Plaintiff suffered from the following severe impairments:
seizure disorder, degenerative disc disorder, disc bulges, history of lumbar laminectomies,
anxiety, depression, posttraumatic stress disorder, bipolar disorder, and a history of
polysubstance abuse. However, the ALJ also determined that Plaintiff had the residual
functional capacity (“RFC”) to perform certain jobs that were available in the national
economy, and was thus not disabled under the Social Security Act. Plaintiff’s request for
review by the Appeals Council of the Social Security Administration was denied on May
21, 2015.
Plaintiff has thus exhausted all administrative remedies, and the ALJ’s
decision stands as the final agency action now under review. On application for judicial
review, Plaintiff makes argument only with regard to his mental and psychological
impairments, and alleges that the ALJ erred by failing to find his mental and psychological
impairments severe and disabling.
Medical Evidence
Plaintiff has an extensive medical history dating back to his motor vehicle accident
on July 30, 2001. (Tr. 680.) The Court will summarize Plaintiff’s medical records to the
extent they are relevant to his instant action for judicial review, and will focus primarily on
Plaintiff’s history of mental and psychological treatment.
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Plaintiff initially began mental health treatment following DUI arrests in 1997 and
1998. (Tr. 683.) Plaintiff’s self-reported medical history suggested he began drinking
alcohol at the age of twelve and began drinking daily at the age of twenty-two. However,
Plaintiff reported to a psychiatrist that he stopped drinking altogether on October 16, 2005,
and he attended Alcoholics Anonymous from 2008 to 2010. Plaintiff also admitted to
using heroin from the age of 22 until 2005, when he was arrested on heroin-related charges.
In 2009, Plaintiff received treatment regularly from primary care physician Dr. Kara
Fess at Hygienic Institute Community Health Center (“HICHC”). Plaintiff presented to
Dr. Fess on January 23, 2009, complaining of panic attacks sometimes accompanied by
fainting spells. Plaintiff reported that one such panic attack was triggered by stress
Plaintiff endured at work. Dr. Fess ordered a CT and other neurological exams. Plaintiff
returned to the clinic in February 2009 and reported anxiety, tingling, and back pain. (Tr.
769.)
On May 29, 2009, Plaintiff began treatment at North Central Behavioral Health
System for substance abuse, where he attended numerous counseling sessions and
participated in group therapy, and completed 75 hours of treatment on September 25, 2009.
He again presented at HICHC in September 2009 stating that he “had an anxiety attack
back in [February] and now needs clearance stating he is ok to return to work.” (Tr. 757.)
Plaintiff also reported being “off Xanax” at that appointment, and stated that he was doing
well. Id. He presented again in October 2009 for an updated work release, and again
reported not having any problems. (Tr. 755.)
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Thereafter, Plaintiff was sent to Continued Care, but was discharged from North
Central Behavioral Health System on December 1, 2009, for failing to follow through with
recommended substance abuse treatment. Although Plaintiff presented again to HICHC
at various times throughout 2010 and 2011, these visits were related to physical
symptoms—in several instances, stemming from physical altercations between Plaintiff
and others—and Plaintiff’s psychological symptoms were not significantly addressed.
Plaintiff was seen by Mark Langgut, Ph.D., for a psychological assessment on July
22, 2011. Dr. Langgut described Plaintiff as “fidgety, and initially emotionally guarded.”
(Tr. 681.) At the time of Dr. Langgut’s evaluation, Plaintiff was taking Celexa, an
antidepressant, but was not otherwise engaged in ongoing mental health treatment. He
was also under a prescription for Valium and Dilantin, which were prescribed “by a
neurologist in Peru [Illinois].” (Tr. 683.) Plaintiff reported to Dr. Langgut that these
medications helped “reduce his depressive symptoms.” Id. Plaintiff also reported to Dr.
Langgut his significant history of substance abuse. Dr. Langgut ultimately diagnosed
Plaintiff with dysthymic disorder, generalized anxiety disorder, and alcohol and heroin
abuse in remission.
Plaintiff was subsequently seen by Patricia Russell, M.D., on August 6, 2011. Dr.
Russell diagnosed Plaintiff with seizure disorder, anxiety, and depression. On February
15, 2013, Plaintiff was evaluated at Big Springs Medical Clinic (“Big Springs”) following
convulsions.
The treating doctor diagnosed him with sinusitis, migraines, bipolar
disorder, and depression and anxiety.
(Tr. 880.)
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Plaintiff reported anxiety during
another visit to Big Springs on March 5, 2013, during which visit he reported he was
unable to go to Wal-Mart because he felt like he was being stared at. He also reported a
poor appetite. (Tr. 877.) Dr. Georgia Jones diagnosed bipolar disorder. (Tr. 878.)
Plaintiff saw Dr. Jones again at Big Springs on April 9, 2013, and reported an anger
episode that had occurred over the weekend involving his father. Dr. Jones saw Plaintiff
again on April 30, 2013, and again diagnosed bipolar disorder and noted Plaintiff’s blunted
expression. Dr. Jones also reported that Plaintiff was on Vicodin , Dilantin (for seizures),
and Celexa at that time, and that he “push[ed] a little for [benzodiazepines] but not too
hard.” (Tr. 876.) Dr. Jones noted Plaintiff’s depressed mood during the visit. Plaintiff
was also noted to be anxious during a physical exam on September 18, 2013. (Tr. 825.)
Plaintiff was seen by Sandra Keeling, LPC, at Family Counseling Center in October
2013. (Tr. 831.) Plaintiff reported his history of posttraumatic stress disorder, bipolar
disorder, and depression, and also reported severe anger outbursts, explaining that he has
“harmed [people]” in the past as a result of these outbursts. Id.
Finally, Plaintiff was seen at C&S Family Medical by Casey Dement, a physician’s
assistant, on November 25, 2013. Ms. Dement—who, according to Plaintiff’s hearing
testimony, saw Plaintiff once a month beginning in 2013 and served as Plaintiff’s primary
healthcare provider, and refilled his prescriptions for Celexa, Dilantin, and
Klonopin—completed a mental Medical Source Statement for Plaintiff. In it, she opined
in a checkbox form that Plaintiff suffered marked limitation in six areas: ability to maintain
concentration and attention for extended periods; ability to perform activities regularly and
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within a schedule; ability to work in coordination with or proximity to others without being
distracted by them; ability to complete a normal workday and workweek without
interruption from psychologically-based symptoms; ability to interact appropriately with
the general public; and finally, ability to travel in unfamiliar places or use public
transportation. (Tr. 885-86.)
Consultative Medical Evaluation
Dr. Patricia Beers, Ph.D., a state agency psychological consultant, completed a
Mental Residual Functional Capacity Assessment for Plaintiff on August 9, 2011. Dr.
Beers’ assessment contained three parts. In the first, Dr. Beers checked a variety of boxes
to assess Plaintiff’s mental capabilities and limitations. In this first section, Dr. Beers
checked a box indicating that Plaintiff had marked limitation in his ability to interact
appropriately with the general public. (Tr. 708.) She also checked boxes indicating
moderate limitation in the following areas: ability to work in coordination with or
proximity to others without being distracted; ability to accept instruction and respond
appropriately to criticism from supervisors; ability to get along with coworkers or peers;
ability to maintain socially appropriate behavior and adhere to basic standards of neatness
and cleanliness; ability to respond appropriately to changes in the work setting; and ability
to set realistic goals and make plans independently of others. Id. In the remaining mental
activities listed on the form, Dr. Beers assessed Plaintiff as not significantly limited. (Tr.
707-708.)
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No additional comment was or given or necessarily required in the second part of
the assessment form, which merely required an explanation for any category where there
was insufficient information to assess Plaintiff. In the third section, Dr. Beers gave a
functional capacity assessment in narrative form. Dr. Beers commented that Plaintiff
suffered from dysthymia and anxiety disorder, and that his “social skills and judgment are
impaired.” (Tr. 709.) Although Dr. Beers opined that Plaintiff would be capable of
performing work, she expressly stated in the third section that he “is best suited to a
vocational setting that requires only very limited interactions with coworkers and
supervisors and no interactions with the general public.” Id.
Agency Forms
In Plaintiff’s disability self-reporting forms, Plaintiff recounted taking care of his
school-age daughter on a regular basis, but otherwise having little to no planned or regular
activity. Plaintiff reported suffering from “high anxiety,” “panic attacks,” and depression.
(Tr. 433.) With regard to dressing and bathing, he reported that “some days [I have] no
desire to change clothes [and] don’t care for a shower[.]” (Tr. 434.) He reported
receiving help from his sister and mother, who assist him in bringing medications and
reminding him to take them. He also reported eating infrequently, and having “no
interest” in eating. (Tr. 435.) He explained that he doesn’t drive, infrequently goes
outside, and has difficulty with money. (Tr. 436.) He reported that he doesn’t “like to be
around people,” and that “confrontation gives [him] anxiety.” (Tr. 438.) In describing
changes in social activities since the onset of his symptoms, Plaintiff described that he
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“[doesn’t] date, I don’t go out, don’t deal with people, don’t want [anyone] around me.”
(Tr. 438.)
Plaintiff’s disability file also includes a third-party report from his sister, Sirena
Nive, who reported spending two to three hours each day with Plaintiff. Nive reported
that Plaintiff’s physical pain made it difficult for him to sleep through the night, and that he
often forgot to take medications. She stated that Plaintiff performed light housework and
chores, but that his pain made it difficult. She reported that he was occasionally social and
visited friends, “if [he was] feeling good that day.” (Tr. 402.) However, she also
reported that he was prone to becoming “agitated and angry” (Tr. 403), and that he did not
handle stress well. (Tr. 404.) She also explained that Plaintiff had difficulty following
directions and needs frequent reminders.
Evidentiary Hearing of January 10, 2014
Plaintiff testified to the ALJ that that he had difficulty talking and dealing with
people, reporting that he gets “really high anxiety,” and is prone to “start shaking and
sometimes have an anxiety attack.” (Tr. 55.) He expressed that he often feels others are
looking at him while in public, and must suppress urges to be physically violent toward
others. (Tr. 60.) Plaintiff also testified that his seizures could be brought on by anxiety
and stress. (Tr. 57.)
Also testifying at the hearing was Paul Hammond, a vocational expert (“VE”).
Hammond testified that Plaintiff’s past work consisted of four distinct positions: caulker,
forklift operator, factory laborer, and maintenance. The ALJ then asked the VE to assume
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a person of Plaintiff’s age, education, and work experience, who is limited to lifting no
more than 20 pounds occasionally and ten pounds frequently; would be able to sit, stand, or
walk six hours in a work day; could not climb ropes, ladders or scaffolds; occasionally
climbing ramps or stairs; would be limited to seizure precautions; and would be limited to
only superficial contact with coworkers, supervisors, and the general public.1 The VE
testified that such an individual could meet the requirements of representative occupations
including assembler and small products assembler. Upon questioning from Plaintiff’s
counsel, Hammond testified that frequent physical or verbal confrontation would preclude
employment, as would missing three to four days a month of work. (Tr. 76.)
1
The precise hypothetical question posed was as follows:
Let’s assume a person the same age, education, past work as you
described the claimant. Let’s further assume this person would
be limited to lifting no more than 10 pounds occasionally.
Excuse me, 20 pounds occasionally, 10 pounds frequently.
Would be able to sit, stand, or walk six hours in an eight hour day.
Would not—no ladders, ropes or scaffolding. Occasional be
able to walk on—climb stairs, ramps, stoop, kneel, balance,
crouch, crawl. Further assume this person would be limited to
seizure precautions. No working around dangerous heights or
dangerous machinery. No working around open bodies of water.
No working in confined spaces. No working around large open
vessels or vats. Further, let’s assume this person would be
limited to only superficial contact with co-workers, supervisors
and the general public. By superficial I would mean no
negotiation,
arbitration,
mediation,
confrontation,
or
supervision[.] [W]ould that person be able to return to the past
work of the claimant? . . . Would there be any other jobs in the
national or regional economy such a person could perform?
(Tr. 74.)
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ALJ’s Decision of January 23, 2014
The ALJ found that Plaintiff suffered from the severe impairments of seizure
disorder, degenerative disc disorder, disc bulges, history of lumbar laminectomies, anxiety,
depression, posttraumatic stress disorder, bipolar disorder, and a history of polysubstance
abuse. However, the ALJ determined that no impairment or combination of impairments
met or medically equaled the severity of one of the listed impairments in 20 CFR Part 404,
Subpart P, Appendix 1. Specifically with regard to Plaintiff’s mental impairments, the
ALJ determined that the “Paragraph B” criteria were not satisfied because Plaintiff
suffered only mild restriction in activities of daily living, moderate difficulties in social
functioning, mild difficulties with regard to concentration, persistence, and pace, and had
not experienced an episode of decompensation of any extended duration. (Tr. 15-16.) In
making this determination, the ALJ noted Plaintiff’s sister’s report that he took care of his
daughter and occasionally performed chores around the home, and that he socialized every
few days. (Tr. 15.)
The ALJ assigned little weight to the opinions proffered by Casey Dement, finding
she was not an acceptable medical source. The ALJ further expressed that Ms. Dement’s
findings were “not supported by the laboratory findings [or] diagnostic evidence,” and
noted that her course of treatment had been short. (Tr. 21.) The ALJ gave “some
weight” to the opinions of the state agency consultants, including the psychiatric review
and Mental Residual Functional Capacity Assessment completed by Dr. Patricia Beers.
However, in his decision, the ALJ did not give a detailed analysis of Dr. Beers’ opinions,
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nor did he express which of the limitations in those opinions he considered entitled to
weight.
The ALJ determined that Plaintiff could not perform past relevant work, but
retained the RFC to perform light work with some additional limitations, including
superficial interaction with the public, coworkers, or supervisors. Based on the vocational
expert’s testimony that a hypothetical individual with Plaintiff’s limitations would be able
to perform the requirements of representative occupations including assembler and small
products assembler, the ALJ determined that Plaintiff was not under a disability. The ALJ
found that the vocational expert’s testimony was consistent with the information contained
in the DOT, and was in accordance with the vocational expert’s training and experience.
Arguments of the Parties
On application for judicial review, Plaintiff makes just one argument. Plaintiff
argues that the ALJ’s assigned RFC is improper because it is not supported by substantial
evidence, as required by SSR 96-8p. Specifically, Plaintiff points out that the ALJ
“accepted” and gave “some weight” to reviewing psychologist Dr. Beers’ opinion in
determining that Plaintiff retained the RFC to perform a limited range of light work.
However, Dr. Beers’ opinion included that Plaintiff had marked limitation in his ability to
interact appropriately with the general public (Tr. 708), and that Plaintiff suffered from
moderate limitations in his ability to work in coordination with or proximity to others
without being distracted by them, accept instructions and respond appropriately to
criticism from supervisors, get along with coworkers or peers, maintain socially
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appropriate behavior, adhere to basic standards of neatness and cleanliness, respond
appropriately to changes in the work setting, and set realistic goals or make plans
independently of others. (Tr. 707-708.)
Plaintiff argues that, while the ALJ could properly choose to accept only some of
the limitations proffered by Dr. Beers, he was required to set forth and explain why some of
Dr. Beers’ limitations were not adopted since he expressly accepted and gave weight to her
opinion as a whole. Plaintiff points out that the only mental limitation the ALJ included in
Plaintiff’s RFC was that Plaintiff could only interact superficially with coworkers and
supervisors; but none of Dr. Beers’ additional mental limitations, including dysthymia,
anxiety, and impaired judgment, were mentioned or addressed, and moreover, Dr. Beers’
specific limitation that Plaintiff could not interact with the public was wholly disregarded.
In response, Defendant argues that because Dr. Beers completed her opinion on a
Mental Residual Functional Capacity Assessment (“MRFCA”) form, and because most of
the limitations mentioned by Plaintiff were documented in the first section, “Summary
Conclusions,” and not in the third section that constitutes the physician’s opinion in
narrative form, the ALJ did not err by failing to include those limitations in his RFC or give
reasons for not including them.
Defendant also argues that even if the limitations
proffered by Plaintiff were in fact part of Dr. Beers’ opinions, they were properly excluded
because the ALJ afforded Dr. Beers’ opinion only “some weight.” Finally, Defendant
argues that Dr. Beers’ opinion was inconsistent with the record to the extent it required the
limitations suggested by Plaintiff.
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DISCUSSION
Standard of Review and Statutory Framework
In reviewing the denial of Social Security disability benefits, a court “must review
the entire administrative record to ‘determine whether the ALJ’s findings are supported by
substantial evidence on the record as a whole.’” Johnson v. Astrue, 628 F.3d 991, 992
(8th Cir. 2011). The court “‘may not reverse . . . merely because substantial evidence
would support a contrary outcome. Substantial evidence is that which a reasonable mind
might accept as adequate to support a conclusion.’” Id. (citations omitted).
To be entitled to benefits, a claimant must demonstrate an inability to engage in
substantial gainful activity which exists in the national economy, by reason of a medically
determinable impairment which has lasted or can be expected to last for not less than 12
months. 42 U.S.C. ' 423(d)(1)(A). The Commissioner has promulgated regulations,
found at 20 C.F.R. ' 404.1520, establishing a five-step sequential evaluation process to
determine disability. The Commissioner begins by deciding whether the claimant is
engaged in substantial gainful activity.
If so, benefits are denied.
If not, the
Commissioner decides whether the claimant has a severe impairment or combination of
impairments, defined as “any impairment or combination of impairments which
significantly limits [claimant’s] physical or mental ability to do basic work activities.” 20
C.F.R. §§ 416.920(c), 404.1520(c).
“The sequential evaluation process may be
terminated at step two only when the claimant’s impairment or combination of
impairments would have no more than a minimal impact on [his or] her ability to work.”
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Page v. Astrue, 484 F.3d 1040, 1043 (8th Cir. 2007) (quoting Caviness v. Massanari, 250
F.3d 603, 605 (8th Cir. 2001).
If the impairment or combination of impairments is severe and meets the duration
requirement, the Commissioner determines at step three whether the claimant’s
impairment meets or is equal to one of the deemed-disabling impairments listed in
Appendix I. If not, the Commissioner asks at step four whether the claimant has the RFC
to perform his past relevant work. A disability claimant’s RFC is the most he can still do
despite his limitations. 20 C.F.R. § 404.1545(a)(1).
If the claimant can perform his past work, the claimant is not disabled. If he cannot
perform his past relevant work, the burden of proof shifts at step five to the Commissioner
to demonstrate that the claimant retains the RFC to perform work that is available in the
national economy and that is consistent with the claimant=s vocational factors—age,
education, and work experience. Halverson v. Astrue, 600 F.3d 922, 929 (8th Cir. 2010).
Weight Afforded to Dr. Beers’ Opinion
When determining a plaintiff’s RFC, an ALJ must consider “all relevant evidence,”
but ultimately, the determination of the plaintiff’s RFC is a medical question. Lauer v.
Apfel, 245 F.3d 700, 704 (8th Cir. 2001). As such, the determination of plaintiff’s ability
to function in the workplace must be based on some medical evidence. Id.; see also
Nevland v. Apfel, 204 F.3d 853, 858 (8th Cir. 2000). When determining the RFC, “‘[t]he
opinion of a consulting physician who examines a claimant once or not at all does not
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generally constitute substantial evidence.’” Singh v. Apfel, 222 F.3d 448, 452 (8th Cir.
2000) (quoting Kelley v. Callahan, 133 F.3d 583, 589 (8th Cir. 1998)).
However, this Court has previously held that where an ALJ does assign weight to a
consultative physician’s opinion, or otherwise finds it persuasive, he must give an
explanation if he then disregards the opinion in formulating a plaintiff’s RFC. Reynolds v.
Astrue, No. 1:06 CV 64 CDP DDN, 2007 WL 5100461, at *3 (E.D. Mo. Aug. 7, 2007). In
Reynolds, a non-examining consultative physician opined that the plaintiff had mental
limitations of depression and anxiety. The ALJ stated that he found the non-examining
consultative physician’s opinion “well rationalized,” and did not explain whether or in
what respects he found it not credible. When the ALJ chose not to adopt the physician’s
opinions regarding the claimant’s limitations, the Court reversed and remanded, explaining
that “[w]hile the ALJ is not required to give great weight to a consulting physician’s
opinion, here, the ALJ stated that he found [the] opinion ‘well rationalized,’ and did not
explain why he found it not credible.” Reynolds, 2007 WL 5100461 at *4. The Eighth
Circuit has similarly held that while the opinion of a non-examining consultative physician
may be disregarded, the ALJ must at least explain the decision to disregard such an
opinion. See McCadney v. Astrue, 519 F.3d 764, 767 (8th Cir. 2008) (“Our primary
difficulty is not with the possibility that the ALJ discounted [the consultative physician’s]
opinion, as an ALJ is free to discount a physician’s report if the record warrants this . . . .
The problem with the ALJ’s opinion is that it is unclear whether the ALJ did discount [the]
opinion, and, if it did so, why.”).
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In the instant matter, the ALJ found that the state agency consultants, including Dr.
Beers, “provided specific reasons for their opinions . . . showing that these opinions were
grounded in the evidence of record, including careful consideration of the objective
medical evidence[.]” (Tr. 21.) The ALJ then “accepted” these opinions, and assigned
Dr. Beers’ opinion “some weight.” Id. The ALJ appeared to incorporate Dr. Beers’
assessment of Plaintiff’s moderate limitations—generally speaking, his limitations in
getting along and working with others—by assigning an RFC wherein Plaintiff is capable
only of superficial interaction with the public, coworkers, or supervisors.
However, the ALJ did not incorporate into Plaintiff’s RFC Dr. Beers’ opinion that
Plaintiff should have no interactions with the general public.
In fact, Dr. Beers
specifically opined that Plaintiff “is best suited to a vocational setting that requires only
very limited interactions with coworkers and supervisors and no interactions with the
general public.” (Tr. 709.) Neither did the ALJ account for Dr. Beers’ articulated
opinions regarding Plaintiff’s dysthymia, anxiety disorder, and impaired judgment in
Plaintiff’s RFC.
In fact, the ALJ specifically found that “medical records show
limitations in judgment and social skills,” but in Plaintiff’s assigned RFC and in the
hypothetical question posed to the vocational expert at Plaintiff’s hearing, the only
identified mental limitation was the aforementioned “superficial interaction with the
public, coworkers, or supervisors.” 2 (Tr. 16.) Thus, the ALJ rejected several important
2 Indeed, in the hypothetical posed to the VE, the ALJ appeared to further narrow the
scope of the restriction by explaining that “superficial interaction” meant “no negotiation,
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parts of Dr. Beers’ opinion. The Court agrees that based on the ALJ’s initial assignment
of weight to Dr. Beers’ opinion, and his finding that the opinion was well-supported by the
record, the ALJ erred by failing to give reasons for partially rejecting Dr. Beers’ opinion.
Even if the Court accepts Defendant’s argument that the “Summary Conclusions”
section of the form does not constitute a medical opinion, Dr. Beers’ written opinion in the
third section is a medical opinion that the ALJ disregarded in determining Plaintiff’s RFC.
It was in this third, narratively-structured section that Dr. Beers espoused an opinion
regarding Plaintiff’s dysthymia, anxiety disorder, and impaired judgment. The Court
similarly rejects Defendant’s argument that because the ALJ used the phrase “some
weight,” he was not required to explain and give reasons for his failure to assign an RFC
that accords with the opinion. The ALJ’s statement that Dr. Beers’ opinion is “grounded
in the evidence of record,” and his confirmation that he “accepted” the opinion, in turn
requires that he give reasons for disregarding important parts of it when assigning
Plaintiff’s RFC; he is not relieved of this obligation simply by using the mitigating phrase
“some weight.” Just as in McCadney, 519 F.3d at 767, and Reynolds, 2007 WL 5100461
at *4, the ALJ’s failure to explain his decision to disregard the consultative opinion was
error.
Dr. Beers’ Limitations May Be Supported by the Record
The ALJ’s decision to disregard Dr. Beers’ opinions could be overlooked if those
opinions were not supported by the record. See McCadney, 519 F.3d at 767. However,
arbitration, mediation, confrontation or supervision.” (Tr. 74.)
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that is not the case here. As noted above, the ALJ in the instant matter expressly found
that Dr. Beers “provided specific reasons for [her] opinions . . . showing that these opinions
were grounded in the evidence of record, including careful consideration of the objective
medical evidence” (Tr. 21), and yet nonetheless disregarded Dr. Beers’ opinion with regard
to Plaintiff’s ability to handle interactions with the public in formulating his RFC. And
Dr. Beers’ opinion in this regard finds support in the record, as the ALJ initially noted.
Defendant cites a number of instances in Plaintiff’s medical records where his
demeanor was described as attentive, cooperative, and appropriate, or where he was
otherwise assessed to have an unremarkable affect. See, e.g., Tr. 976-1012, 630-642.
But Plaintiff’s medical history also indicates that he has repeatedly and consistently been
diagnosed with depression, anxiety, posttraumatic stress disorder, and dysthymia by a
number of health care providers. See, e.g., Tr. 681-683, 831, 876-78, 885-86. The record
also indicates—by way of self-reporting, medical diagnosis, and circumstantial evidence,
given Plaintiff’s frequent injuries resulting from physical altercations—that Plaintiff’s
psychological limitations manifest in aggression, which would support a finding that
Plaintiff’s impairments limit him from a job requiring interaction with the general public,
and may otherwise affect his ability to work. Despite taking medication and otherwise
addressing his psychological impairments on a somewhat consistent basis, Plaintiff has
continued to suffer symptoms. (Tr. 683.) Plaintiff reported to a medical provider that
could not go to Wal-Mart because he felt he was being stared at, and he experienced urges
to act out in violence toward others (Tr. 877). He reported altercations with both strangers
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and family members resulting from anger. See, e.g., Tr. 876. His agency forms suggest
he cries or yells at family members “for no reason,” and that such actions “don’t feel like
me sometimes.”
(Tr. 439.)
Plaintiff’s sister and the physician’s assistant also
corroborated Plaintiff’s mental health limitations.
In short, there appears to be ample evidence in the record supporting Dr. Beers’
opinion that Plaintiff suffers from significant mental impairments—which the ALJ
presumably recognized in initially assigning Dr. Beers’ opinion weight. Therefore, the
ALJ should have explained—and should explain on remand—why he ultimately
disregarded significant portions of Dr. Beers’ opinion in formulating Plaintiff’s RFC.
CONCLUSION
For the foregoing reasons,
IT IS HEREBY ORDERED that the decision of the Commissioner is
REVERSED and REMANDED.
_______________________________
AUDREY G. FLEISSIG
UNITED STATES DISTRICT JUDGE
Dated on this 5th day of August, 2016.
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