Jones v. Colvin
REPORT AND RECOMMENDATION - It is RECOMMENDED that the plaintiffs appeal of the ALJs ruling be GRANTED and that this case be REMANDED for further consideration of the plaintiffs application for DIB and SSI. Objections to R&R due by 10/10/2017. Signed by Magistrate Judge Martin C. Carlson on September 25, 2017. (kjn)
IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF PENNSYLVANIA
CAROLYN W. COLVIN,
Acting Commissioner of
Civil No. 1:16-CV-1535
(Chief Judge Conner)
(Magistrate Judge Carlson)
REPORT AND RECOMMENDATION
In this action, the plaintiff, Jared Jones, appeals a decision issued by an
Administrative Law Judge (ALJ) denying Jones’s applications for disability
insurance benefits (DIB) and supplemental security income (SSI), which were
predicated on his asserted serious and assorted mental impairments. Despite an
administrative record which showed that Jones had, on multiple occasions within
the relevant time period, been hospitalized after episodes of decompensation and
suicidal ideation; and despite multiple treating medical professionals having opined
in varying degrees to the plaintiff’s profound limitations in functioning and
expressing informed doubts about the plaintiff’s functional abilities, the ALJ
concluded that the plaintiff was not disabled and retained sufficient residual
functional capacity to perform a limited range of work subject to very strict
Review of the ALJ’s decision, within the context of a body of medical
evidence that reveals that the plaintiff has long suffered from profound mental
impairments that episodically became so extreme that they required inpatient
hospitalization to stabilize along with drug intervention, it appears that the ALJ
selectively focused upon isolated and extremely limited examples contrary
evidence to justify rejecting the treating source opinions, and to conclude that the
plaintiff was both not credible and not disabled. Some of this evidence was no
more than a stray observation that the plaintiff demonstrated a “linear” thought
process or on occasion had a “euthymic mood” or affect, but other than to cite to
this evidence, the ALJ nowhere explains the significance ascribed to these isolated
snippets from the plaintiff’s voluminous medical file. Instead, these observations
are offered as justification for why the ALJ did not find the plaintiff, his girlfriend,
or five treating professionals to be fully credible. Yet, the ALJ cited these random
evidentiary shards as proof of an on-going ability to work, without taking into
account extended periods of complete disability and without sufficient explanation
as to why this fragmentary evidence relied upon by the ALJ supported the ALJ’s
conclusion in this regard, and overcame the vast body of contrary proof
documenting the plaintiff’s profound impairments.
Mindful that the ALJ has the discretion to evaluate and weigh the evidence
before her within the governing guidelines set by the Commissioner, we
nonetheless find that the ALJ’s decision in this case was not supported by
substantial evidence, and find that the ALJ failed adequately to explain and justify
the rejection of the treating source evidence and her finding that the plaintiff and
his girlfriend were incredible in their consistent testimony about the extent of his
mental disabilities and their effects upon his daily functioning. In so doing, the
ALJ also discounted the informed opinions of multiple treating medical
professionals, but offered scant support for doing so other than to assert generally
that the opinions were not entirely consistent with the overall record, and then
identified isolated and discrete instances showing modest improvement or
mitigation of the plaintiff’s condition as justification for this outcome. Because we
find the ALJ’s explanation in support of her adverse decision inadequate, and
unsupported by substantial evidence, it will be recommended that the plaintiff’s
appeal be granted and this matter returned to the Commissioner for further
consideration of the plaintiff’s application for DIB and SSI.
The plaintiff was born in 1987 and was thus a “younger individual” at all
times relevant whose age would not seriously affect his ability to adjust to other
work. (Tr. 316.) 20 C.F.R. §§ 404.1563(c), 416.963(c). He graduated from high
school, has two years of college education, and has worked in the past as a help
desk representative. (Tr. 70-71.) The plaintiff testified that he quit his last job in
February 2011 due to high stress that he experienced when talking to clients,
supervisors, and coworkers. (Tr. 42.)
Medical records reveal that throughout 2010, the plaintiff treated with
Valley Behavioral Health Associates for thoughts of self-harm, suicide, and
apparent sleep disorders.
At this time he was taking multiple
prescription medications including Abilify, Celexa, Depakote, and Wellbutrin.
Treatment notes from this time indicate that the plaintiff was
experiencing episodes of depression and paranoia, along with feelings of anger and
impulsive behavior. (Tr. 434-440.)
The plaintiff entered Holy Spirit Hospital on December 30, 2010, after
experiencing depression so severe that it led him to walk out onto a bridge and
consider committing suicide. (Tr. 43; 460.) Treatment notes indicated bipolar
disorder, and that he had previously been admitted at Winchester Hospital in
Virginia where he previously lived in 2009.
His patient history
indicated that he requested admission after having thoughts of running his car into
a bridge, cutting or shooting himself, and that he previously had access to a
firearm, which had since been removed by his girlfriend. (Tr. 460.) He also
informed treating physicians that he had difficulty maintaining his medications
because he had lost his job in October, and had increased feelings of hopelessness
and irritability. (Tr. 460.) He was discharged a week later, at which point his
mood was mildly depressed, with intact memory, normal appearance, good
hygiene and without thoughts of suicide, self-harm or harm to others. (Tr. 463-64.)
The plaintiff testified that he felt somewhat better for approximately one month,
with his depression increasing until his job ended in February 2011. (Tr. 44.) The
plaintiff experienced continued depression, anxiety and panic attacks, but
acknowledged that these symptoms moderated somewhat because he mostly stayed
at home during this time. (Tr. 45.) He was also hospitalized overnight from April
18 until April 19, 2011, for suicidal thoughts or gestures. (Tr. 463-65, 479-98.)
Towards the end of 2012, the plaintiff overdosed on psychiatric medication,
which led to hospitalization for 4 days at the Pennsylvania Psychiatric Institute.
(Tr. 45; Tr. 582-83.) His GAF score upon admission was 30; upon discharge it
was 38. (Tr. 582, 588.) Both of these scores were emblematic of profound
psychological impairment. A GAF score, or a Global Assessment Functioning
scale, was a psychometric tool which took into consideration psychological, social,
and occupational functioning on a hypothetical continuum of mental health-illness.
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision, 34, Washington, DC, American Psychiatric Association, 2000. (“DSMIV-TR”). In this regard, GAF scores “in the range of 61–70 indicate ‘some mild
symptoms [of depression] or some difficulty in social, occupational, or school
functioning.’ Diagnostic and Statistical Manual of Mental Disorders (‘DSM IV’)
34 (American Psychiatric Assoc. 2000). GAF scores in the 51–60 range indicate
moderate impairment in social or occupational functioning.” Cherry v. Barnhart,
29 Fed.Appx. 898, 900 (3d Cir. 2002). DaVinci v. Astrue, 1:11-CV-1470, 2012
WL 6137324 (M.D. Pa. Sept. 21, 2012) report and recommendation adopted,
Davinci v. Astrue, 1:11-CV-1470, 2012 WL 6136846 (M.D. Pa. Dec. 11, 2012).
“A GAF score of 41–50 indicates ‘serious symptoms (e.g., suicidal ideation, severe
obsessional rituals, frequent shoplifting) [or] any serious impairment in social,
occupational, or school functioning (e.g., no friends, unable to keep a job).’ DSM–
IV at 34. A score of 50 is on the borderline between serious and moderate
symptoms.” Colon v. Barnhart, 424 F. Supp. 2d 805, 809 (E.D. Pa. 2006). See
Shufelt v. Colvin, No. 1:15-CV-1026, 2016 WL 8613936, at *2 (M.D. Pa. Sept. 15,
2016), report and recommendation adopted sub nom. Shulfelt v. Colvin, No. 1:15CV-1026, 2017 WL 1162767 (M.D. Pa. Mar. 29, 2017). A GAF score of 31-40
signifies some impairment in reality testing or communication (e.g., speech is at
times illogical, obscure, or irrelevant) or major impairment in several areas, such as
work or school, family relations, judgment, thinking, or mood. A GAF scores as
low as 30 typically indicate behavior that is considerably influenced by delusions
or hallucinations, or serious impairment in communication or judgment, or an
inability to function in almost all areas. Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision, 34, Washington, DC, American
Psychiatric Association, 2000. (“DSM-IV-TR”).
During this time, and while his symptoms intensified, he attested that he
stopped doing chores around the house, his hygiene suffered, and he felt anxiety
when he was not in bed. (Tr. 46.) His daily activities consisted largely of playing
games on his phone and watching television. (Tr. 47.) With regards to his anxiety,
he testified that it worsened if he knew that he had to leave his house, which he did
on occasion. (Tr. 47.) When he was discharged, treatment notes indicated that his
mood had improved and he denied having further thoughts of self-harm. (Tr. 58384.)
The plaintiff sought inpatient treatment again in February 2014 and in March
2014. In February, the plaintiff’s medications were adjusted, and this was found to
help his mood and decrease his irritability and anger. (Tr. 603.) In what became a
pattern of emotional instability for the plaintiff, Jones’s progress was fleeting and
In March, the plaintiff again overdosed on psychotropic
medications following an argument with his girlfriend, which led him to seek
treatment. (Tr. 659.) He stayed in the hospital for 5 days, after which he again
denied suicidality and exhibited a euthymic mood and affect. He was diagnosed
with depressive disorder. (Tr. 659.)
The plaintiff’s testimony offered some insight into his cyclical depressive
episodes, and resultant treatment.
He stated that he consistently took his
medications except when he lost his insurance. (Tr. 49.) In January 2011, for
example, the plaintiff attested that he did not fill his Abilify prescription because
he knew that once his current prescription ran out he would be unable to afford
more.1 Likewise, records indicate that the plaintiff became noncompliant with his
medication regimen while treating in Virginia because of lapses in insurance and
lack of funds. (Tr. 435.) One of the plaintiff’s treating doctors also noted that the
plaintiff lacked insurance and could not afford medication. (Tr. 460.) Treatment
notes also reveal the cyclical nature of the plaintiff’s depressive condition, noting
in May 2011 that even after completing a partial hospitalization program at that
time, the plaintiff’s depression and irritability had increased. (Tr. 459.)
The plaintiff initially filed a claim for disability benefits on May 25, 2011,
alleging an onset date of December 30, 2010. That claim was denied on April 2,
In response, the ALJ questioned the plaintiff why he did not ask his doctor for
sample medication if he could not afford his prescription. (Tr. 51.) The plaintiff
conceded that this might have been a good idea, but did not think of it at the time.
2013, and the plaintiff requested a hearing which was held at the Harrisburg Office
of Disability Adjudication and Review before an ALJ. (Tr. 80.) The ALJ issued
an unfavorable decision on May 23, 2013. (Tr. 160.) The plaintiff requested
review from the Appeals Council, and the Appeals Council remanded the matter on
September 25, 2014. (Tr. 178.) This remand was based on new evidence provided
by Stevens Mental Health Center which suggested that the plaintiff had no useful
ability in interacting with the public and in responding appropriately to changes in
the work environment. A new hearing before the ALJ was held on February 20,
2015, who then issued a second unfavorable decision on March 27, 2015. (Tr. 10.)
The plaintiff requested review of this decision and the Appeals Council denied the
request on June 24, 2016. Thereafter the plaintiff initiated the instant appeal of the
ALJ’s decision to deny his application.
Substantial Evidence Review – the Role of the Administrative
Law Judge and the Court
Resolution of the instant social security appeal involves consideration of the
respective roles of two adjudicators–the ALJ and this Court. At the outset, it is the
responsibility of the ALJ in the first instance to determine whether a claimant has
met the statutory prerequisites for entitlement to benefits. To receive benefits
under the Social Security Act by reason of disability, a claimant must demonstrate
an inability to “engage in any substantial gainful activity by reason of any
medically determinable physical or mental impairment which can be expected to
result in death or which has lasted or can be expected to last for a continuous
period of not less than twelve months.” 42 U.S.C. §1382c(a)(3)(A); see also 20
C.F.R. §416.905(a). To satisfy this requirement, a claimant must have a severe
physical or mental impairment that makes it impossible to do his or her previous
work or any other substantial gainful activity that exists in the national economy.
42 U.S.C. §1382c(a)(3)(B); 20 C.F.R. §416.905(a).
In making this determination at the administrative level, the ALJ follows a
five-step sequential evaluation process.
20 C.F.R. §416.920(a).
process, the ALJ must sequentially determine: (1) whether the claimant is engaged
in substantial gainful activity; (2) whether the claimant has a severe impairment;
(3) whether the claimant’s impairment meets or equals a listed impairment; (4)
whether the claimant is able to do his or her past relevant work; and (5) whether
the claimant is able to do any other work, considering his or her age, education,
work experience and residual functional capacity (“RFC”).
Between steps three and four, the ALJ must also assess a claimant’s RFC.
RFC is defined as “that which an individual is still able to do despite the
limitations caused by his or her impairment(s).” Burnett v. Comm’r of Soc. Sec.,
220 F.3d 112, 121 (3d Cir. 2000) (citations omitted); see also 20 C.F.R.
§§416.920(e), 416.945(a)(1). In making this assessment, the ALJ considers all of
the claimant’s medically determinable impairments, including any non-severe
impairments identified by the ALJ at step two of his or her analysis. 20 C.F.R.
At steps one through four, the claimant bears the initial burden of
demonstrating the existence of a medically determinable impairment that prevents
him or her in engaging in any of his or her past relevant work.
§1382c(a)(3)(H)(i)(incorporating 42 U.S.C. §423(d)(5) by reference); 20 C.F.R.
§416.912; Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993).
Once this burden has been met by the claimant, it shifts to the Commissioner
at step five to show that jobs exist in significant number in the national economy
that the claimant could perform that are consistent with the claimant’s age,
education, work experience and RFC. 20 C.F.R. §416.912(f); Mason, 994 F.2d at
Once the ALJ has made a disability determination, it is then the
responsibility of this Court to independently review that finding. In undertaking
this task, this Court applies a specific, well-settled and carefully articulated
standard of review. In an action under 42 U.S.C. § 405(g) to review the decision
of the Commissioner of Social Security denying plaintiff’s claim for disability
benefits, Congress has specifically provided that the “findings of the
Commissioner of Social Security as to any fact, if supported by substantial
evidence, shall be conclusive[.]” 42 U.S.C. § 405(g). Thus, when reviewing the
Commissioner’s final decision denying a claimant’s application for benefits, this
Court’s review is limited to the question of whether the findings of the final
decision-maker are supported by substantial evidence in the record. See 42 U.S.C.
§405(g); 42 U.S.C. §1383(c)(3); Johnson v. Comm’r of Soc. Sec., 529 F.3d 198,
200 (3d Cir. 2008); Ficca v. Astrue, 901 F.Supp.2d 533, 536 (M.D.Pa. 2012).
Substantial evidence “does not mean a large or considerable amount of evidence,
but rather such relevant evidence as a reasonable mind might accept as adequate to
support a conclusion.”
Pierce v. Underwood, 487 U.S. 552, 565 (1988).
Substantial evidence is less than a preponderance of the evidence but more than a
mere scintilla. Richardson v. Perales, 402 U.S. 389, 401 (1971). A single piece of
evidence is not substantial evidence if the ALJ ignores countervailing evidence or
fails to resolve a conflict created by the evidence. Mason v. Shalala, 994 F.2d
1058, 1064 (3d Cir. 1993).
But in an adequately developed factual record, substantial evidence may be
“something less than the weight of the evidence, and the possibility of drawing two
inconsistent conclusions from the evidence does not prevent [the ALJ’s decision]
from being supported by substantial evidence.”
Comm’n, 383 U.S. 607, 620 (1966).
Consolo v. Fed. Maritime
“In determining if the Commissioner’s
decision is supported by substantial evidence the court must scrutinize the record
as a whole.” Leslie v. Barnhart, 304 F.Supp.2d 623, 627 (M.D.Pa. 2003). The
question before this Court, therefore, is not whether a plaintiff is disabled, but
whether the Commissioner’s finding that the claimant is not disabled is supported
by substantial evidence and was reached based upon a correct application of the
relevant law. See Arnold v. Colvin, No. 3:12-CV-02417, 2014 WL 940205, at *1
(M.D.Pa. Mar. 11, 2014)(“[I]t has been held that an ALJ’s errors of law denote a
lack of substantial evidence.”)(alterations omitted); Burton v. Schweiker, 512
F.Supp. 913, 914 (W.D.Pa. 1981)(“The Secretary’s determination as to the status
of a claim requires the correct application of the law to the facts.”); see also Wright
v. Sullivan, 900 F.2d 675, 678 (3d Cir. 1990)(noting that the scope of review on
legal matters is plenary); Ficca, 901 F.Supp.2d at 536 (“[T]he court has plenary
review of all legal issues . . . .”).
The ALJ’s disability determination must also meet certain basic substantive
requisites. Most significant among these legal benchmarks is a requirement that
the ALJ adequately explain the legal and factual basis for this disability
Thus, in order to facilitate review of the decision under the
substantial evidence standard, the ALJ's decision must be accompanied by "a clear
and satisfactory explication of the basis on which it rests." Cotter v. Harris, 642
F.2d 700, 704 (3d Cir. 1981). Conflicts in the evidence must be resolved and the
ALJ must indicate which evidence was accepted, which evidence was rejected, and
the reasons for rejecting certain evidence. Id. at 706-707. In addition, “[t]he ALJ
must indicate in his decision which evidence he has rejected and which he is
relying on as the basis for his finding.” Schaudeck v. Comm’r of Soc. Sec., 181 F.
3d 429, 433 (3d Cir. 1999). Moreover, in conducting this review we are cautioned
that “an ALJ's findings based on the credibility of the applicant are to be accorded
great weight and deference, particularly since an ALJ is charged with the duty of
observing a witness's demeanor and credibility.’ Walters v. Commissioner of
Social Sec., 127 F.3d 525, 531 (6th Cir.1997); see also Casias v. Secretary of
Health & Human Servs., 933 F.2d 799, 801 (10th Cir.1991) (‘We defer to the ALJ
as trier of fact, the individual optimally positioned to observe and assess witness
credibility.’).” Frazier v. Apfel, No. 99-715, 2000 WL 288246, *9 (E.D. Pa.
March 7, 2000). Furthermore, in determining if the ALJ's decision is supported by
substantial evidence the court may not parse the record but rather must scrutinize
the record as a whole. Smith v. Califano, 637 F.2d 968, 970 (3d Cir. 1981).
“[A]n ALJ's findings based on the credibility of the applicant are to be
accorded great weight and deference, particularly since an ALJ is charged with the
duty of observing a witness's demeanor and credibility.’ Walters v. Commissioner
of Social Sec., 127 F.3d 525, 531 (6th Cir.1997); see also Casias v. Secretary of
Health & Human Servs., 933 F.2d 799, 801 (10th Cir.1991) (‘We defer to the ALJ
as trier of fact, the individual optimally positioned to observe and assess witness
credibility.’).” Frazier v. Apfel, No. 99-715, 2000 WL 288246, *9 (E.D. Pa.
March 7, 2000). In order to aid ALJs in this task of assessing claimant credibility
Social Security Rulings and Regulations provide a framework under which a
claimant's subjective complaints are to be considered. 20 C.F.R. § 404.1529; SSR
96–7p. First, symptoms, such as pain or fatigue, will only be considered to affect a
claimant's ability to perform work activities if such symptoms result from an
underlying physical or mental impairment that has been demonstrated to exist by
medical signs or laboratory findings.
20 C.F.R. § 404.1529(b); SSR 96–7p.
During this credibility assessment, the ALJ must determine whether the claimant's
statements about the intensity, persistence or functionally limiting effects of his or
her symptoms are substantiated based on the ALJ's evaluation of the entire case
record. 20 C.F.R. § 404.1529(c); SSR 96–7p. This includes, but is not limited to:
medical signs and laboratory findings, diagnosis and other medical opinions
provided by treating or examining sources, and other medical sources, as well as
information concerning the claimant's symptoms and how they affect his or her
ability to work. Id. Thus, to assist in the evaluation of a claimant's subjective
symptoms, the Social Security Regulations identify seven factors which may be
relevant to the assessment of the severity or limiting effects of a claimant's
impairment based on a claimant's symptoms. 20 C.F.R. § § 404.1529(c)(3). These
factors include: activities of daily living; the location, duration, frequency, and
intensity of the claimant's symptoms; precipitating and aggravating factors; the
type dosage, effectiveness, and side effects of any medication the claimant takes or
has taken to alleviate his or her symptoms; treatment, other than medication that a
claimant has received for relief; any measures the claimant has used to relieve his
or her symptoms; and, any other factors concerning the claimant's functional
limitations and restrictions. Id. See George v. Colvin, No. 4:13–CV–2803, 2014
WL 5449706, at *4 (M.D.Pa. Oct. 24, 2014); Martinez v. Colvin, No. 3:14-CV1090, 2015 WL 5781202, at *8–9 (M.D. Pa. Sept. 30, 2015).
These same principles apply to an ALJ’s credibility determinations as they
relate to statements made by a claimant’s family and friends, like the fiancé report
made in this case. When evaluating such evidence “ALJs should consider ‘such
factors as the nature and extent of the relationship, whether the evidence is
consistent with other evidence, and any other factors that tend to support or refute
the evidence’ when evaluating evidence from non-medical sources such as family
or friends.” Zirnsak v. Colvin, 777 F.3d 607, 612 (3d Cir. 2014). Moreover:
To properly evaluate these factors, the ALJ must necessarily make
certain credibility determinations, and this court defers to the ALJ's
assessment of credibility. See Diaz v. Comm'r, 577 F.3d 500, 506 (3d
Cir.2009) (“In determining whether there is substantial evidence to
support an administrative law judge's decision, we owe deference to
his evaluation of the evidence [and] assessment of the credibility of
witnesses....”). However, the ALJ must specifically identify and
explain what evidence he found not credible and why he found it not
credible. Adorno v. Shalala, 40 F.3d 43, 48 (3d Cir.1994) (citing
Stewart v. Sec'y of Health, Education and Welfare, 714 F.2d 287, 290
(3d Cir.1983)); see also Stout v. Comm'r, 454 F.3d 1050, 1054 (9th
Cir.2006) (stating that an ALJ is required to provide “specific reasons
for rejecting lay testimony”).
Zirnsak v. Colvin, 777 F.3d 607, 612 (3d Cir. 2014).
The ALJ’s Failure to Adequately Address the Medical Evidence
in This Case, Particularly the Multiple Opinions of Treating
Physicians, Warrants Remand
The plaintiff makes three interrelated arguments in support of his appeal.
First, he argues that the ALJ erred by not sufficiently crediting the opinions of
treating physicians or in not assigning enough weight to their individual opinions,
and not applying traditional rules which provide that treating physicians are
entitled to great weight, particularly when their opinions are essentially consistent.
Second, the plaintiff argues that the ALJ erred in failing to cite to specific
evidence in the record to support his residual functional capacity analysis and
Finally, the plaintiff argues that the ALJ erred in finding that the plaintiff
and his girlfriend, Colleen Austin, were not credible, and in failing to support that
finding with meaningful evidence in the record.
This report and recommendation focuses on the first of these arguments,
which we conclude warrants remand in this case.
The plaintiff refers the Court to the so-called treating physician rule set forth
at 20 C.F.R. 404.1527(c)(2), which provides that in general, ALJs are to give more
weight to medical opinions from treating sources because those sources are more
likely to be medical professionals who are those “most able to provide a detailed,
longitudinal picture” of a claimant’s medical impairments “and may bring a unique
perspective to the medical evidence that cannot be obtained from the objective
medical findings alone or from reports of individual examinations, such as
consultative examinations or brief hospitalizations.” Id. In keeping with this
regulation, the value of a treating source’s opinion will be affected by the length of
the treating relationship, the frequency of examination, the nature and extent of the
relationship, and the consistency of the opinion with the record as a whole, the
specialization of the source. Id. at § 404.1527(c)(2)-(6).
Notably, the regulation also provides that “[w]e will always give good
reasons in our notice of determination for the weight we give your treating source’s
medical opinion.” Id. Likewise, the regulation provides that a treating medical
opinion will be given more weight the more consistent it is with the record as a
whole. 20 C.F.R. § 404.1527(c)(4). The regulation also provides, however, that
the ultimate decision regarding a claimant’s disability is a matter reserved for the
Commissioner, and thus a treating medical source’s opinion on this ultimate issue
is not entitled to any “special significance”. Id. at § 404.1527(d)(3).
The Third Circuit Court of Appeals has explained and amplified the
application of this longstanding regulation regarding the weight to be given to
treating physicians, noting that “[a] cardinal principle guiding disability eligibility
determinations is that the Administrative Law Judge accord treating physicians’
reports great weight, especially ‘when their opinions reflect expert judgment based
on a continuing observation of the patient’s condition over a prolonged period of
time.’” Morales v. Apfel, 225 F.3d 310, 317 (3d Cir. 2000) (citing Plummer v.
Apfel, 186 F.3d 422, 429 (3d Cir. 1999)).
Thus, the opinions of a treating
physician are typically entitled to substantial, and sometimes controlling weight.
Johnson v. Comm’r of Soc. Sec., 529 F.3d 198, 202 (3d Cir. 2008) (quoting
Fargnoli v. Massanari, 247 F.3d 34, 43 (3d Cir. 2001)). When an ALJ rejects a
treating physician’s opinion, the ALJ is obligated to explain reasons for doing so.
Fargnoli, 247 F.3d at 43-44 (citing Burnett v. Comm’r of Soc. Sec., 220 F.3d 112,
121 (3d Cir. 2000)). In doing so, an ALJ must not make “’speculative inferences
from medical reports,’” and may not reject a treating physician’s opinion “due to
his or her own credibility judgments, speculation or lay opinion.” Morales v.
Apfel, 225 F.3d 310, 317 (3d Cir. 2000) (“[T]he ALJ’s credibility judgments . . .
alone do not carry the day and override the medical opinion of a treating physician
that is supported by the record.”). An ALJ may not substitute her lay opinion for
the medical opinion of a treating physician, “especially in cases involving mental
disabilities.” Rivera v. Astrue, 9 F. Supp. 3d 495, 502 (E.D. Pa. 2014) (citing
Morales, 225 F.3d at 319).
In this case, the ALJ was presented with multiple opinions and medical
statements from treating sources who had direct involvement in the plaintiff’s care,
both in the management of his mental health condition and in response to acute
episodes of decompensation, and she assigned these opinions limited weight.
These opinions came from the plaintiff’s mental-health providers at Valley
Behavioral Health Associates, Holy Spirit Hospital, and the Pennsylvania
Psychiatric Institute, and from four doctors – Drs. Coulter, Schneck, Kaiser, and
Fonder – all of whom found at different times that the plaintiff presented with GAF
scores of 50 or below. Also discounted was an opinion of a psychologist who
provided a mental source statement indicating that the plaintiff had marked and
extreme limitations and, in his opinion, was unemployable as a result. The ALJ
declined to give these opinions – most of which were substantially consistent and
all indicated that the plaintiff had substantial mental-health impairments –
significant or controlling weight, but in doing so failed to explain the basis for her
decision other than to offer generic assertions that these multiple opinions were
somehow not supported by the record as a whole. Then the ALJ endeavored to
support this interpretation of the record by highlighting limited, isolated individual
statements contained in various places in the record, but in many cases without
explaining what the isolated observations signified, or why she deemed them to be
For example, the ALJ points to a statement of Dr. Kaiser on November 6,
2012, which indicated that the plaintiff had “linear thought processes.” Other than
to cite to this observation, the ALJ does not explain in any way what the
observation means in the context of this case, much less why it was deemed
sufficiently contrary evidence to cause the plaintiff’s multiple treating sources to
warrant less significant weight. The ALJ’s opinion gives no guidance as to how
the plaintiff having a “linear thought process” on one day--November 6, 2012--is
somehow adequate to override the substantial evidence in the record that
periodically and cyclically indicated that the plaintiff suffered from profound
limitations as a result of his mental impairments, or how the fact that he appeared
coherent and non-psychotic on one specific day mitigated the examples of
longstanding chronic depression, impaired judgment, anxiety, anger that are noted
throughout the record over a considerable period of time.
Likewise, the ALJ relied on a statement from Dr. Fonder in March 2014,
that the plaintiff exhibited a euthymic mood and affect, but other than to cite to this
single observation does not explain why it was sufficient to cast doubt upon the
treating physicians’ opinions, or that it somehow was a better or more significant
indicator of the plaintiff’s overall wellbeing, particularly in the context of a case
where the record indicates multiple examples of decompensation, including
hospitalization and treatment that followed several episodic instances where the
plaintiff’s anxiety and depression caused him to consider suicide or self-harm.
Indeed, the observation of the plaintiff exhibiting a euthymic mood was made at
the end of the plaintiff’s most recent hospitalization at Holy Spirit, and is thus
consistent with the plaintiff exhibiting a measure of improvement following
intensive treatment, which the record indicates is part of a pattern of periodic
decompensation, treatment, and some improvement, which was repeated on
The ALJ also appears to have relied upon an occasion in January of 2011,
immediately following a week-long in-patient hospital stay and psychiatric
observation, where Dr. Herrada indicated that the plaintiff’s depression had
decreased to a level 4 on a scale of 1 to 10. The absence of any explanation as to
why this treatment note was a better indicator of the plaintiff’s mental condition in
the context of the overall record makes it especially weak, particularly since it
again appears that this treatment note came at the end of a hospital stay that
commenced on December 30, 2010, after the plaintiff experienced depression so
severe that he walked out onto a bridge and considered jumping from it. (Tr. 43.)
That the plaintiff experienced a modest recovery following this hospital stay would
seem to be of even less significance given that the record shows he very soon
thereafter experienced yet another bout of depression that gradually worsened until
his last job ended in February 2011. Indeed, on April 8, 2011, just three months
after Dr. Herrada’s treatment note, the plaintiff went back into Holy Spirit
Behavioral after he overdosed on Lexapro.
The ALJ does not
sufficiently justify her reliance on this stray treatment note in the context of the
overall medical record.
The record does contain evidence indicating that the plaintiff continued to
feel anxiety and to suffer panic attacks, which abated somewhat after he stopped
going to work. However, the plaintiff explains this as having resulted from the fact
that after leaving his employment he mostly remained confined to his house and
did not have to interact with others – a key aspect of the plaintiff’s mental
impairment that was offered in support of his claim. Furthermore, the emphasis
assigned to single observations that followed treatment and hospitalization is
further weakened by the fact that the following year, towards the end of 2012, the
plaintiff again overdosed on his psychiatric medication, leading to yet another
hospitalization at the Pennsylvania Psychiatric Institute. (Tr. 45.) This pattern of
episodic decompensation continued into 2014, when the plaintiff was voluntarily
admitted to Holy Spirit Hospital again after experiencing thoughts of self-harm,
and then two weeks later when he was admitted to Philhaven for additional
treatment. Given this longitudinal history, which is marked by periods of extreme
depression and anxiety, the assignment of weight to a single level-4 rating on a
scale of depression on a single day provides especially limited evidentiary support
to justify discounting the opinions of treating professionals.
The ALJ’s inadequate explanation regarding her discounting of multiple
opinions from treating sources in the context of the overall record is compounded
by an insufficient consideration of the evidence in the record indicating that the
plaintiff had been assigned GAF scores below 50 on multiple occasions, while also
finding more reliable some GAF scores that came in above 50 without fully
explaining the difference in her assessment of this evidence other than to generally
state that the higher scores were more consistent with the overall record.
As noted, the record indicates that over a multi-year period, the plaintiff
suffered periodic episodes of decompensation, followed by some period of
recovery, and that this pattern repeated itself on multiple occasions. Thus, when he
was admitted to Holy Spirit Hospital on December 30, 2010, the plaintiff was
assessed a GAF score of between 21-30 – an especially low score. (Tr. 461.)
When the plaintiff was admitted to the Pennsylvania Psychiatric Institute in
November 2012, he was assessed a GAF of 30.
When he was
discharged, his GAF was assessed at 38. (Tr. 582.) In February 2014, the plaintiff
was admitted to Holy Spirit Behavioral for suicidal and homicidal thoughts, and
told staff that he had killed a dog and a cat in his neighborhood. (Tr. 600.) He was
assessed a GAF of between 30 and 40 and doctors gave him a guarded prognosis.
(Id.) His final diagnosis at this time included a GAF of 55. (Tr. 603.) When he
was admitted to Philhaven in March 2014, the plaintiff was adjudged to have a
GAF score of 30, and was discharged with a GAF of 55. (Tr. 659.) One of the
plaintiff’s doctors specifically cautioned that his assignment of a higher GAF
should not be misinterpreted as meaning that the patient was capable of working.
It is difficult to read the medical record as indicating anything other than that
this cautionary guidance was correct: the plaintiff repeatedly presented to treating
centers with an array of mental health impairments, suicidal thoughts, and a
frequently low GAF score assessed by treating physicians, which thereafter
climbed higher with the benefit of treatment and medication. Rather than engage
in a detailed discussion of this evidence, the ALJ does little more than assert that
she gave less weight to the lower GAF scores and the opinions of treating
physicians as being “not supported by the record as a whole” and because they
were “not consistent” with one doctor’s opinion that on November 6, 2012, the
plaintiff was found to have “linear thought processes.” (Tr. 20-21.) In contrast,
the ALJ gave greater weight to those GAF scores that were 51 or higher, asserting
that “they are supported by the record as a whole and are consistent with Dr.
Fonder’s observation on March 24, 2014 that the claimant has a “euthymic mood
and affect.” (Tr. 21.) This minimal examination of the plaintiff’s multiple scores,
or to discuss the fact that they adjusted somewhat typically after a period of
treatment in a cyclical pattern, was insufficient.
A GAF score is a “numerical summary of a clinician’s judgment of [an]
individual’s overall level of functioning . . . .” DSM-IV-TR at 32.2 Courts have
consistently found that an ALJ’s failure to specifically discuss a GAF score that
indicates serious impairments in social or occupational functioning may be cause
for remand. See, e.g., Rivera, 9 F. Supp. 3d at 504-05; West v. Astrue, No. 092650, 2010 WL 1659712, at *4-6 (E.D. Pa. Apr. 26, 2010); Sweeney v. Comm’r of
Soc. Sec., 847 F. Supp. 2d 797, 805 (W.D. Pa. 2012); Metz v. Astrue, No. 10-383,
2010 WL 3719075, at *14 (W.D. Pa. Sept. 17, 2010) (ALJ’s determination not
supported by substantial evidence where ALJ “did not mention any GAF scores at
all and provided no rationale for rejection of this evidence.”); Wiggers v. Astrue,
No. 09-86, 2010 WL 1904015, at *8-9 (W.D. Pa. May 10, 2010) (GAF scores
recognized as acceptable medical evidence that needs to be addressed by ALJ in
The Court recognizes that GAF scores are no longer recognized in the most
recent edition of the DSM, but we do not find that this means that the ALJ’s
assessment of the GAF scores in this case is irrelevant to the assessment of the
plaintiff’s claim for benefits. The ALJ was presented with the GAF scores as part
of treating physicians’ opinions regarding the plaintiff’s level of functioning, and
those factors were part of her assessment of the claim of disability, albeit an
insufficient one. Courts have recognized that the GAF scale constitutes
“acceptable and reliable medical evidence.” Rivera, 9 F. Supp. 3d at 504 (citing 65
Fed. Reg. 50746, 50764-65 and Colon v. Barnhart, 424 F. Supp. 2d 805, 812 (E.D.
making a disability determination); Holmes v. Barnhart, No. 04-5765, 2007 WL
951637, at *11 (E.D. Pa. Mar. 26, 2007) (remand required because of ALJ’s failure
to acknowledge GAF score of 50); Span ex rel. R.C. v. Barnhart, No. 02-7399,
2004 WL 1535768, at *6-7 (E.D. Pa. May 21, 2004) (finding it was insufficient for
ALJ to mention GAF scores without adequately explaining why they were
discounted); Escardrille v. Barnhart, 2003 WL 21499999, at *6-7 (E.D. Pa. June
24, 2003) (remanding ALJ’s decision because the opinion did not adequately
reveal that he gave serious consideration to claimant’s GAF score below 50). “In
other words, in explaining the rationale for denying disability, the ALJ must
demonstrate that he seriously considered and weighed the importance of GAF
scores.” Rivera, 9 F. Supp. 3d at 505; see also Schaudeck v. Comm’r of Soc. Sec.,
181 F.3d 429, 435 (3d Cir. 1999) (“Where competent evidence supports a
claimant’s claims, the ALJ must explicitly weigh the evidence . . . .”).
Furthermore, and relevant here, “the ALJ may not ‘cherry-pick’ higher GAF scores
in his analysis and ignore GAF scores that may support a disability.” Rivera, 9 F.
Supp. 3d at 505 (citations omitted). As another district court explained in a
decision remanding a case that included multiple GAF scores of 50 or below:
Because a GAF score constitutes medical evidence
accepted and relied upon by a medical source, it should
be addressed by an ALJ in making a determination
regarding a claimant's disability. Clearly, the five GAF
scores of 50 or below received by plaintiff indicate
serious symptoms. Yet, after examining the record and
the GAF scores contained therein, the Court finds that
while the ALJ provided an explanation regarding the
evidence upon which she relied, the ALJ failed to
disclose any reasons for not considering the five GAF
scores of 50 or below received by plaintiff. For this
reason, the Court is unable to conclude that the ALJ's
disability determination is supported by substantial
evidence, and remands the case for consideration of
plaintiff's GAF scores in conjunction with the
other mental health evidence in the record and their effect
on her [residual functional capacity]. The Court makes
clear that it does not find that the GAF scores in question
necessarily indicate that plaintiff is “disabled” under the
Act. Instead, the Court merely requires that the ALJ,
on remand, address the multiple GAF scores received by
plaintiff of 50 or below.
West, 2010 WL 1659712, at *6.
It is submitted that the same reasoning should apply in this case. The ALJ’s
scant discussion regarding the plaintiff’s lower GAF scores – some of which were
extremely low – and failure to provide any substantial discussion of the reason why
the lower scores were deemed entitled to less weight than moderately higher scores
that typically followed a period of intensive treatment, was in our judgment
erroneous. Aside from giving little more than passing reference to scores below
and above 50, the ALJ did little to meaningfully explain why she concluded that
the lower scores were not consistent with the overall medical record, or to explain
why the higher scores were deemed more consistent, other than to offer generic
language and to cite two isolated observations made by doctors following periods
of hospitalization or other treatment. We recognize that the failure to discuss GAF
scores in detail does not necessarily mean that the opinion was erroneous or require
remand where the ALJ also conducted a thorough analysis of the medical evidence.
Rivera, 9 F. Supp. 3d at 506-07; Coy v. Astrue, No. 08-1372, 2009 WL 2043491,
at *13-14 (W.D. Pa. July 8, 2009). In this case, however, we have found that the
ALJ did not conduct the thorough analysis of the medical evidence as required, and
thus the failure to meaningfully address the GAF scores and more fulsomely
explain why the lower scores were given less weight than the higher scores
warrants remand for further consideration and, if necessary, explanation.
The plaintiff has also taken issue with the ALJ’s assessment of his and his
girlfriend’s credibility, and with the ALJ’s residual functional capacity assessment.
In our judgment, assessment of these claims of error is not necessary at this point
because there is a clear basis in the record to warrant remand for further
consideration of the medical record evidence. To the extent the plaintiff urges
different or further assessment of his RFC, it is submitted that such arguments are
more appropriately made in further administrative proceedings which may, if
necessary, be reviewed should the ALJ issue another unfavorable decision.
Moreover, assessment of the plaintiff’s credibility and RFC likely will be
influenced by reconsideration of the overall body of medical and opinion evidence,
and thus further assessment of those findings is unnecessary here.
For the foregoing reasons it is RECOMMENDED that the plaintiff’s appeal
of the ALJ’s ruling be GRANTED and that this case be REMANDED for further
consideration of the plaintiff’s application for DIB and SSI.
The parties are further placed on notice that pursuant to Local Rule 72.3:
Any party may object to a magistrate judge's proposed findings,
recommendations or report addressing a motion or matter described in
28 U.S.C. § 636 (b)(1)(B) or making a recommendation for the
disposition of a prisoner case or a habeas corpus petition within
fourteen (14) days after being served with a copy thereof. Such party
shall file with the clerk of court, and serve on the magistrate judge and
all parties, written objections which shall specifically identify the
portions of the proposed findings, recommendations or report to which
objection is made and the basis for such objections. The briefing
requirements set forth in Local Rule 72.2 shall apply. A judge shall
make a de novo determination of those portions of the report or
specified proposed findings or recommendations to which objection is
made and may accept, reject, or modify, in whole or in part, the
findings or recommendations made by the magistrate judge. The
judge, however, need conduct a new hearing only in his or her
discretion or where required by law, and may consider the record
developed before the magistrate judge, making his or her own
determination on the basis of that record. The judge may also receive
further evidence, recall witnesses or recommit the matter to the
magistrate judge with instructions.
Recommendation may constitute a waiver of any appellate rights.
Submitted this 25th day of September 2017.
s/Martin C. Carlson
Martin C. Carlson
United States Magistrate Judge
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