Cullen v. Commissioner of Social Security Administration
Filing
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ORDER RULING ON REPORT AND RECOMMENDATION. After a thorough review of the Report, the applicable law, and the record in this case, the court declines to adopt the Report. Therefore, the Commissioner's decision is reversed and the matter is remanded for further administrative proceedings pursuant to sentence four of 42 U.S.C. § 405(g). Signed by Honorable Sherri A Lydon on 1/10/22. (arut)
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IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF SOUTH CAROLINA
GREENVILLE DIVISION
David Cullen,
Plaintiff,
vs.
Kilolo Kijakazi, Acting Commissioner of
Social Security Administration,
Defendant.
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Case No.: 6:20-cv-4061-SAL
OPINION AND ORDER
This matter is before the court for review of the October 28, 2021 Report and
Recommendation of United States Magistrate Judge Kevin F. McDonald (the “Report”), made in
accordance with 28 U.S.C. § 636(b) and Local Civil Rule 73.02 (D.S.C.). [ECF No. 15.] In the
Report, the Magistrate Judge recommends the Commissioner’s final decision denying Plaintiff’s
claim for Social Security disability benefits be affirmed. Id. Plaintiff filed timely objections to
the Report. [ECF No. 18.] Defendant filed a timely reply to Plaintiff’s objections. [ECF No.
19.] For the reasons outlined herein, the court respectfully declines to adopt the Report and
reverses and remands the Commissioner’s final decision for further administrative proceedings.
STANDARD OF REVIEW
The scope of federal court review under 42 U.S.C. § 405(g) is narrowly-tailored to determine
whether the findings of the Commissioner are supported by substantial evidence and whether the
Commissioner applied the proper legal standard in evaluating the claimant’s case. See id.,
Richardson v. Perales, 402 U.S. 389, 390 (1971); Walls v. Barnhart, 296 F.3d 287, 290 (4th Cir.
2002) (citing Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990)). “Under the substantialevidence standard, a court looks to an existing administrative record and asks whether it contains
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‘sufficien[t] evidence’ to support the agency’s factual determinations.” Biestek v. Berryhill, 139
S. Ct. 1148, 1154 (2019) (citing Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229 (1938)).
“Substantial evidence” is “more than a mere scintilla,” and means only “such relevant evidence
as a reasonable mind might accept as adequate to support a conclusion.” Id. (quoting
Consolidated Edison, 305 U.S. at 229).
The court’s function is not to “try these cases de novo or resolve mere conflicts in the
evidence.” Vitek v. Finch, 438 F.2d 1157, 1157–58 (4th Cir. 1971); see Pyles v. Bowen, 849
F.2d 846, 848 (4th Cir. 1988) (citing Smith v. Schweiker, 795 F.2d 343, 345 (4th Cir. 1986)).
Rather, the court must uphold the Commissioner’s decision if it is supported by substantial
evidence “even should the court disagree with such decision.” Blalock v. Richardson, 483 F.2d
773, 775 (4th Cir. 1972).
REVIEW OF A MAGISTRATE JUDGE’S REPORT
The Magistrate Judge makes only a recommendation to the court. The recommendation
carries no presumptive weight, and the responsibility to make a final determination remains with
this court. Mathews v. Weber, 423 U.S. 261, 270–71 (1976). The court is charged with making
a de novo determination of those portions of the Report to which specific objections are made,
and the court may accept, reject, or modify, in whole or in part, the recommendation of the
Magistrate Judge, or recommit the matter to the Magistrate Judge with instructions. See 28
U.S.C. § 636(b)(1). In the absence of specific objections to portions of the Report, this court is
not required to explain its reasons for adopting the recommendation. See Camby v. Davis, 718
F.2d 198, 199 (4th Cir. 1983). It must “only satisfy itself that there is no clear error on the face
of the record in order to accept the recommendation.” Diamond v. Colonial Life & Acc. Ins. Co.,
416 F.3d 310, 316 (4th Cir. 2005) (citing Fed. R. Civ. P. 72 advisory committee’s note).
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DISCUSSION
Plaintiff objects to the Magistrate Judge’s finding that the Administrative Law Judge (“ALJ”)
properly evaluated an opinion from his treating psychiatrist, J. Christopher Caston, M.D. (“Dr.
Caston”). Given the specificity of Plaintiff’s objection, the court reviews it de novo.
On November 13, 2019, Plaintiff’s counsel or someone working on his behalf interviewed
Dr. Caston and memorialized the interview in a letter Dr. Caston subsequently signed. See Tr. at
358. Dr. Caston reported Plaintiff endorsed delusions that God was speaking to him through
colors in his environment. Tr. at 359. He noted Plaintiff’s delusions had initially manifested in
1999; had persisted, despite use of Seroquel; and had diminished somewhat with a recent change
in medications. Id. He indicated he had previously decreased Plaintiff’s Seroquel dose because
it had caused him to sleep for 12 to 14 hours daily. Id. He noted he had prescribed Clonazepam
to reduce Plaintiff’s anxiety, but Plaintiff continued to experience rapid thought processes that
sometimes kept him awake all night and necessitated he collapse and sleep throughout the
following day. Id. He stated Plaintiff’s academic and creative abilities were reduced to about
one-tenth of their prior levels. Id. He noted Plaintiff was reclusive and paranoid about his
condition. Id. He indicated Plaintiff was “unable to attend any sort of work without being
unable to function.” Id. He stated Plaintiff had trouble communicating. Id.
Plaintiff argues the Magistrate Judge erred in concluding the ALJ’s decision should be
affirmed. [ECF No. 18]. He contends the Magistrate Judge did not deny that the ALJ provided
only a conclusory rejection of Dr. Caston’s opinions, simply stating that his opinions were “not
consistent with the evidence of record,” and “essentially independently [finding] that Dr.
Caston’s opinions were inherently neither valuable nor persuasive” based on post hoc rationale.
Id. at 2–3. He maintains the Magistrate Judge pointed to the ALJ’s discussion of Dr. Caston’s
treatment records, but that such discussion included both positive and negative findings that he
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failed to reconcile with his conclusion. Id. at 3–4. He claims the Magistrate Judge erred in
accepting the ALJ’s conclusion that Dr. Caston’s opinions were vague because the ALJ should
have sought clarification from Dr. Caston as to any opinions he considered vague.1 Id. at 4. He
maintains the Magistrate Judge supplied reasons to support the ALJ’s findings as to
inconsistencies between his activities of daily living (“ADLs”) and Dr. Caston’s opinion that the
ALJ failed to cite. Id. at 5. He claims the Magistrate Judge ignored that the ALJ did not
adequately reconcile the opinion evidence. Id. at 6–7.
The Commissioner argues the Magistrate Judge rejected Plaintiff’s argument that the ALJ
provided only a conclusory statement that Dr. Caston’s opinion was inconsistent with the other
evidence. [ECF No. 19 at 2–3]. She maintains the Magistrate Judge noted the ALJ’s citation of
inconsistencies between Dr. Caston’s opinion and the evidence of record, opinions of the state
agency consultants and Dr. Ruffing, and Plaintiff’s ability to complete ADLs. Id. at 3. She
claims the Magistrate Judge appropriately noted that the ALJ had discussed Dr. Caston’s
treatment records prior to addressing the opinion, providing an explanation for his conclusion
that the opinion was unsupported by the treatment record. Id. at 3–4. The Commissioner
maintains the Magistrate Judge correctly noted the ALJ’s decision had addressed the
supportability and consistency of Dr. Caston’s opinion, in accordance with the applicable
regulation. Id. at 5. She argues the Magistrate Judge did not err in reviewing the entire
administrative record in explaining how the ALJ’s conclusion was supported by substantial
evidence. Id. She requests Plaintiff’s objections be overruled and the Magistrate Judge’s report
be adopted. Id. at 6.
1
The regulations and SSR applicable to cases filed prior to March 27, 2017, required the ALJ
“make every reasonable effort to recontact such sources for clarification.” SSR 96-5p, 1996 WL
374183, at *6. However, Plaintiff has cited no authority under the applicable regulation, 20
C.F.R. § 404.1520c, requiring an ALJ to recontact a medical source for clarification of an
opinion.
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In the Report, the Magistrate Judge concluded the ALJ did not err in evaluating Dr. Caston’s
opinion and finding it “not persuasive.” [ECF No. 15 at 5–12.] He found the ALJ addressed the
supportability and consistency of “Dr. Caston’s attorney-drafted letter regarding the plaintiff’s
functioning.” Id. at 7. The Magistrate Judge asserted the ALJ did not err in adopting limitations
identified by non-treating providers, to the exclusion of Dr. Caston’s opinion, as the amended
regulations place no special significance on treating providers’ opinions.
Id. at 7–8.
He
maintained the ALJ summarized Dr. Caston’s treatment records in noting they did not support
his opinion, as they were vague and lacked explanation as to purported areas of improved and
deteriorated functioning and reflected Plaintiff consistently arrived on time, was fully oriented,
was dressed appropriately, had a neat appearance and good hygiene, and was cooperative. Id. at
8. The Magistrate Judge further found the ALJ noted inconsistencies between Dr. Caston’s
opinion and Plaintiff’s ADLs, the state agency psychological examiners’ opinions, and the
observations and opinions of consultative examiner James Ruffing, Psy. D. (“Dr. Ruffing”). Id.
at 9–11. He cited additional inconsistencies between Dr. Caston’s opinion and treatment records
from Joseph Friddle, P.A. (“PA Friddle”), and Lisa Speach, N.P. (“NP Speach”). Id. at 11.
The Magistrate Judge appropriately noted the ALJ was required to consider the medical
opinions of record in accordance with 20 C.F.R. § 404.1520c, which provides that the
adjudicator is not to defer to or give any specific weight to a medical opinion based on its source.
20 C.F.R. § 404.1520c(a). The ALJ must consider in the decision how persuasive he found all
the medical opinions based on the following factors: (1) supportability; (2) consistency; (3)
relationship with the claimant; (4) specialization; and (5) other factors that tend to support or
contradict a medical opinion. 20 C.F.R. § 404.1520c(b), (c). However, he is only required to
specifically articulate how he considered the supportability and consistency factors because they
are considered the most important factors in assessing the persuasiveness of an opinion. 20
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C.F.R. § 404.1520c(a), (b)(2). Applicable to the supportability evaluation, “[t]he more relevant
the objective medical evidence and supporting explanations presented by a medical source are to
support his or her medical opinion(s) . . . the more persuasive the medical opinion . . . will be.”
20 C.F.R. § 404.1520c(c)(1). In evaluating the consistency factor, “[t]he more consistent a
medical opinion . . . is with the evidence from other medical sources and nonmedical sources in
the claim, the more persuasive the medical opinion . . . will be.” 20 C.F.R. § 404.1520c(c)(2).
The ALJ’s conclusions as to the supportability and consistency of a medical opinion must be
supported by substantial evidence.
The ALJ addressed Dr. Caston’s opinion as follows:
In a letter drafted by the claimant’s attorney, but signed by Dr. Caston, dated
November 13, 2019, Dr. Caston opined that the claimant’s academic and creative
abilities have been reduced to about a tenth of what he once had, and that “He is
just unable to attend any sort of work without being unable to function.” (Exhibit
8F). Although the quoted statement appears to have been typed incorrectly, it
appears that Dr. Caston’s opinion is that the claimant is not capable of any work
activity. This opinion is not persuasive, as it is not consistent with the evidence of
record, or with the opinions of the State agency psychological consultants, or Dr.
Ruffing. The opinion also encroached on opinions reserved solely to the
Commissioner. The claimant has worked in only one occupation in the last 15
years that is demanding and highly stressful. The totality of evidence supports the
claimant being able to function in lower stress work. The record shows that the
claimant is able to complete his activities of daily living, and that he otherwise
has no severe physical impairments.
Tr. at 21.
The Magistrate Judge did not err in pointing out that Dr. Caston’s opinion that Plaintiff
would be unable to function in any sort of work was not a medical opinion as defined by the
applicable regulations. See [ECF No. 15 at 7 (citing 20 C.F.R. § 404.1520b(c)(3) (specifying
“[s]tatements that you are or are not disabled, blind, able to work, or able to perform regular or
continuing work” are “inherently neither valuable nor persuasive to the issue of whether you are
disabled or blind under the Act” and that the adjudicator is not required to “provide any analysis
about how [h]e considered such evidence in [his] determination or decision, even under §
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404.1520c”)]; see also 20 C.F.R. § 404.1513(a)(2) (defining medical opinions). The ALJ
recognized the same. See Tr. at 21.
The Magistrate Judge also properly noted that the ALJ did not reject Dr. Caston’s opinion
merely because it included a statement that did not require further analysis but proceeded to
consider the persuasiveness of the opinion. This was appropriate because other impressions
within Dr. Caston’s letter would be considered medical opinions pursuant to 20 C.F.R. §
4040.1513(a)(2). See Tr. at 359 (suggesting persistent delusions, rapid thought processes, sleep
disturbance causing daytime somnolence, reclusiveness, paranoia, and difficulty communicating
would hinder Plaintiff’s ability to complete mental demands of work activity).
The Magistrate Judge did not accept Plaintiff’s argument that the ALJ provided only a
conclusory explanation as to his consideration of the factors relevant to the persuasiveness
evaluation. He pointed out the ALJ had explained the finding as to the consistency factor was
based on perceived inconsistencies between Dr. Caston’s opinion and the evidence of record, the
state agency consultants’ opinions, Dr. Ruffing’s examination and opinion, and Plaintiff’s ability
to complete his ADLs, which he had discussed in greater detail elsewhere in the decision. See
[ECF No. 15 at 7–8, 9–10.]
The Magistrate Judge cited observations from PA Friddle2 as supporting the ALJ’s
conclusion that Dr. Caston’s opinion was inconsistent with the other evidence of record. [ECF
No. 15 at 11.] This conclusion was supported by the ALJ’s discussion of Dr. Friddle’s normal
mental status exams and other findings prior to and during the relevant period. See Tr. at 16, 19–
20. Also consistent with the Magistrate Judge’s deduction that the ALJ had provided more than
a conclusory explanation of his finding of inconsistency, the ALJ noted earlier in the decision the
2
The Magistrate Judge also cited NP Speach’s observations, but her observations were of limited
relevance because she did not examine Plaintiff after his alleged onset date of disability. See
generally Tr. at 323–39 (reflecting treatment between May 8, 2017 and September 11, 2017).
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state agency consultants’ conclusions that Plaintiff was mildly limited in his abilities to
understand, remember, or apply information and adapt and manage himself and moderately
limited in his abilities to interact with others and concentrate, persist, and maintain pace. Tr. at
21. He also provided a more detailed assessment earlier in the decision to support his finding of
inconsistency between Dr. Caston’s report and Plaintiff’s ADLs, noting Plaintiff’s reports of
independence with eating, grooming, bathing, dressing, toileting, and mobility, as well as his
abilities to live alone, prepare simple meals, complete household chores, drive a car, travel
independently, and handle his own finances. Tr. at 17.
Nevertheless, a review of the ALJ’s decision lends support to Plaintiff’s argument that the
Magistrate Judge ignored the ALJ’s failure to adequately explain his finding of inconsistency
between Dr. Caston’s opinion and Dr. Ruffing’s observations and opinion. The ALJ summarized
Dr. Ruffing’s findings as follows:
In the report from his consultative psychological examination of the claimant, Dr.
Ruffing opined that the claimant is able to understand and respond to the spoken
word; would likely have moderate limitation in independent function and would
struggle to interact appropriately with others because of depression; is able to
understand, and comprehend simple tasks, but might struggle with complex tasks
because of his depression; that the claimant’s concentration and memory appeared
to be impaired to a moderate degree; and that the claimant was capable of
managing his own finances (Exhibit 3F). Dr. Ruffing’s opinion is mostly
persuasive, because it is generally congruent with his examination findings, and
appears to be consistent with the claimant’s self-report of his activities of daily
living and treatment reports.
Tr. at 21. The ALJ’s decision suggests that, like Dr. Caston, Dr. Ruffing recognized that
Plaintiff would be limited in his abilities to function independently, interact with others
appropriately, and maintain concentration in a work setting. Compare Tr. at 21, with Tr. at 359.
The ALJ did not reconcile those similarities with his finding that Dr. Ruffing’s observations and
opinion were inconsistent with Dr. Caston’s opinion. The Magistrate Judge provides a more
thorough explanation to support the finding of inconsistency, ECF No. 15 at 10–11, but this
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cannot cure the insufficient explanation in the ALJ’s decision. See Patterson v. Commissioner of
Social Security Administration, 846 F.3d 656, 663 (4th Cir. 2017) (recognizing the dispute arose
“from a problem that has become all too common among administrative decisions challenged in
this court—a problem decision makers could avoid by following the admonition they have no
doubt heard since their grade-school math classes: Show your work.”). Despite the Magistrate
Judge’s additional references to the record, the court is left to guess why the ALJ found Dr.
Ruffing’s opinion to conflict with Dr. Caston’s opinion.
The Magistrate Judge referenced the ALJ’s discussion of Dr. Caston’s treatment records and
agreed with his finding that the records did not support Dr. Caston’s opinion, as they showed
Plaintiff’s functioning was affected by situational stressors and lacked explanation for findings of
improvement and deterioration.
[ECF No. 15 at 8–9.]
The ALJ addressed Dr. Caston’s
treatment records as follows:
The claimant became a patient of Dr. Caston on March 31, 2018. Dr. Caston
reported that the claimant was oriented to time, place, person, and situation; the
claimant had no organic brain symptoms, his affect was severely constricted, with
minimal spontaneity; he had ideas of reference and paranoid delusions. Dr.
Caston concluded that severe depression symptoms were present with psychotic
features (Exhibit 2F). The reports from Dr. Caston’s subsequent meetings with the
claimant are vague, with Dr. Caston reporting that the claimant’s general mental
status suggested possible improvements and deteriorations in functional areas
such as overall appearance, cognitive functioning, memory, perceptual
functioning, and emotional functioning, but not providing any examples of how
the claimant was experiencing improvement or deterioration in any of these areas
(Exhibits 2F and 6F). Dr. Caston’s records also reflect that he was providing
counseling to the claimant in regard to issues pertaining to marriage and custody
issues, which became and [sic] source of stress with the claimant reporting on
February 27, 2019 that the police and social services became involved after he
spanked his 10-year-old son and left marks (Exhibit 6F).
After the incident involving the claimant’s son, Dr. Caston’s records suggest that
the status of the claimant’s relationship with his wife and children became the
focus of the sessions, with Dr. Caston referring to suggested marital conferences
and therapy in the treatment notes from the claimant’s May 11, 2019, May 13,
2019, May 17, 2019, June 12, 2019, and July 10, 2019 visits (Exhibit 6F).
Tr. at 20.
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The court sustains Plaintiff’s objection to the Magistrate Judge’s conclusion as to the ALJ’s
evaluation of the supportability of Dr. Caston’s opinion. A review of the decision supports
Plaintiff’s argument that the ALJ cited positive and negative findings in Dr. Caston’s reports and
did not adequately explain how the findings were inconsistent with the opinion. The ALJ
acknowledged Dr. Caston’s documentation of Plaintiff’s severely constricted affect, ideas of
reference, paranoid delusions, and severe depressive symptoms with psychotic features. These
findings could reasonably support Dr. Caston’s opinion that persistent delusions, rapid thought
processes, sleep disturbance causing daytime somnolence, reclusiveness, paranoia, and difficulty
communicating would hinder Plaintiff’s ability to complete mental demands of work activity
related to maintaining concentration, persistence, or pace and responding appropriately to
supervision, coworkers, or work pressures in a work setting.
Although the Magistrate Judge agreed with the ALJ’s conclusion that Dr. Caston’s opinion
was vague as to his indications of improvement and deterioration, a thorough review of Dr.
Caston’s records yields more details that supported the impressions than the ALJ and the
Magistrate Judge recognized.
The Fourth Circuit has admonished that “[a]n ALJ has the
obligation to consider all relevant medical evidence and cannot simply cherrypick facts that
support a finding of nondisability while ignoring evidence that points to a disability finding.”
Lewis v. Berryhill, 858 F.3d 858, 869 (4th Cir. 2017) (quoting Denton v. Astrue, 596 F.3d 419,
425 (7th Cir. 2010). In addition to the findings the ALJ referenced that appeared to support the
opinion, Dr. Caston documented the following over 28 sessions between March 31, 2018 and
October 21, 2019: treatment goals to control mood swings, delusions, anxiety, insomnia, and
depression; Plaintiff’s reports of feelings of inadequacy, difficulty communicating with others,
perceptual dysfunctions, avoidant and isolative behavior, rarely leaving his house, anxiety
attacks while driving to psychotherapy sessions, persistent anxiety, insomnia, sleep deprivation,
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and difficulty recalling what he read; and observations during some sessions of minimized and
slowed affective reactions with little variability, emotional and tangential speech, anxious and
suspicious expressions, defensive and hostile interactions, and moderate-to- severe anxiety,
suspiciousness, anger, and depression. Tr. at 290–30, 341–57.
Because the ALJ’s assessment of the persuasiveness of Dr. Caston’s opinion reflects
inadequate explanation of evidence relevant to the consistency and supportability factors, the
court finds it is not supported by substantial evidence and declines to adopt the Magistrate
Judge’s Report.
CONCLUSION
After a thorough review of the Report, the applicable law, and the record in this case, the
court declines to adopt the Report. Therefore, the Commissioner’s decision is reversed and the
matter is remanded for further administrative proceedings pursuant to sentence four of 42 U.S.C.
§ 405(g).
IT IS SO ORDERED.
January 10, 2022
Florence, South Carolina
Sherri A. Lydon
United States District Judge
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