Hockstedler v. Social Security Administration, Commissioner of
Filing
18
MEMORANDUM OPINION. Signed by Magistrate Judge Debra C Poplin on 8/17/21. (JBR)
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF TENNESSEE
AT WINCHESTER
JUDITH A. HOCKSTEDLER,
Plaintiff,
v.
KILOLO KIJAKAZI 1,
Acting Commissioner of Social Security,
Defendant.
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No. 4:20-CV-025-DCP
MEMORANDUM OPINION
This case is before the undersigned pursuant to 28 U.S.C. § 636(b), Rule 73 of the Federal
Rules of Civil Procedure, and the consent of the parties [Doc. 15]. Now before the Court are
Plaintiff’s Motion for Judgment on the Pleadings [Doc. 13] and Defendant’s Motion for Summary
Judgment [Doc. 16]. Judith A. Hockstedler (“Plaintiff”) seeks judicial review of the decision of
the Administrative Law Judge (“the ALJ”), the final decision of Defendant Kilolo Kijakazi (“the
Commissioner”). For the reasons that follow, the Court will DENY Plaintiff’s motion and
GRANT the Commissioner’s motion.
I.
PROCEDURAL HISTORY
On September 3, 2014, Plaintiff protectively filed an application for disability insurance
benefits pursuant to Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq., claiming a period
of disability that began on August 10, 2012. [Tr. 122–23, 134]. Plaintiff requested a hearing after
her claim was denied initially [Tr. 134] and upon reconsideration [Tr. 154]. A hearing was held
before ALJ Frederick McGrath on June 26, 2017. [Tr. 101–21]. On September 18, 2017, ALJ
1
Kilolo Kijakazi became the Acting Commissioner of the Social Security Administration
(“the SSA”) on July 9, 2021. Pursuant to Rule 25(d) of the Federal Rules of Civil Procedure,
Kilolo Kijakazi is substituted for Andrew Saul as the defendant in this suit. See 42 U.S.C. § 405(g).
Case 4:20-cv-00025-DCP Document 18 Filed 08/17/21 Page 1 of 28 PageID #: 1039
McGrath found that Plaintiff was not disabled. [Tr. 158–66]. However, the Appeals Council
remanded the matter for further proceedings on April 6, 2018. [Tr. 173–75].
ALJ McGrath held a second hearing on September 4, 2018. [Tr. 68–100]. After ordered
x-rays were not completed, ALJ McGrath scheduled another hearing, which was held on February
4, 2019. [Tr. 46–66]. On April 11, 2019, ALJ McGrath again found that Plaintiff was not disabled.
[Tr. 15–38]. The Appeals Council denied Plaintiff’s request for review on April 6, 2020 [Tr. 1–
5], making the ALJ’s decision the final decision of the Commissioner.
Having exhausted her administrative remedies, Plaintiff filed a Complaint with this Court
on June 8, 2020, seeking judicial review of the Commissioner’s final decision under Section 405(g)
of the Social Security Act. [Doc. 1]. The parties have filed competing dispositive motions, and
this matter is now ripe for adjudication.
II.
ALJ FINDINGS
The ALJ made the following findings:
1. The claimant last met the insured status requirements of the
Social Security Act on December 31, 2017.
2. The claimant did not engage in substantial gainful activity during
the period from her alleged onset date of August 10, 2012 through
her date last insured of December 31, 2017 (20 CFR 404.1571 et
seq.).
3. Through the date last insured, the claimant had the following
severe impairments: osteoarthritis, hypertension, and obesity (20
CFR 404.1520(c)).
4. Through the date last insured, the claimant did not have an
impairment or combination of impairments that met or medically
equaled the severity of one of the listed impairments in 20 CFR Part
404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525,
404.1526).
2
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5. After careful consideration of the entire record, I find that,
through the date last insured, the claimant had the residual
functional capacity to perform light work as defined in 20 CFR
404.1567(b) except she could perform frequent bilateral fine and
gross manipulation, lifting, carrying, pushing, pulling, and all other
hand functions.
6. Through the date last insured, the claimant was capable of
performing past relevant work as an automotive parts purchaser,
Dictionary of Occupation Titles (DOT) code 249.367-058, light
exertional level as defined by the DOT, sedentary exertional level
as performed, skilled Specific Vocational Preparation (SVP) 5. This
work did not require the performance of work-related activities
precluded by the claimant’s residual functional capacity (20 CFR
404.1565).
7. The claimant was not under a disability, as defined in the Social
Security Act, from August 10, 2012, the alleged onset date, through
December 31, 2017, the date last insured (20 CFR 404.1520(f)).
[Tr. 18–37].
III.
STANDARD OF REVIEW
When reviewing the Commissioner’s determination of whether an individual is disabled
pursuant to 42 U.S.C. § 405(g), the Court is limited to determining whether the ALJ’s decision
was reached through application of the correct legal standards and in accordance with the
procedure mandated by the regulations and rulings promulgated by the Commissioner, and
whether the ALJ’s findings are supported by substantial evidence. Blakley v. Comm’r of Soc. Sec.,
581 F.3d 399, 405 (6th Cir. 2009) (citation omitted); Wilson v. Comm’r of Soc. Sec., 378 F.3d 541,
544 (6th Cir. 2004).
Substantial evidence is “more than a scintilla of evidence but less than a preponderance; it
is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”
Cutlip v. Sec’y of Health & Human Servs., 25 F.3d 284, 286 (6th Cir. 1994) (citations omitted). It
is immaterial whether the record may also possess substantial evidence to support a different
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conclusion from that reached by the ALJ, or whether the reviewing judge may have decided the
case differently. Crisp v. Sec’y of Health & Human Servs., 790 F.2d 450, 453 n.4 (6th Cir. 1986).
The substantial evidence standard is intended to create a “‘zone of choice’ within which the
Commissioner can act, without the fear of court interference.” Buxton v. Halter, 246 F.3d 762,
773 (6th Cir. 2001) (quoting Mullen v. Bowen, 800 F.2d 535, 545 (6th Cir. 1986)). Additionally,
the Supreme Court recently explained that “‘substantial evidence’ is a ‘term of art,’” and “whatever
the meaning of ‘substantial’ in other settings, the threshold for such evidentiary sufficiency is not
high.” Biestek v. Berryhill, 139 S. Ct. 1148, 1154 (2019) (citation omitted). Rather, substantial
evidence “means—and means only— ‘such relevant evidence as a reasonable mind might accept
as adequate to support a conclusion.’” Id. (quoting Consol. Edison Co. v. NLRB, 305 U.S. 197,
229 (1938)).
Therefore, the Court will not “try the case de novo, nor resolve conflicts in the evidence,
nor decide questions of credibility.” Garner v. Heckler, 745 F.2d 383, 387 (6th Cir. 1984) (citation
omitted). On review, the plaintiff “bears the burden of proving his entitlement to benefits.” Boyes
v. Sec’y. of Health & Human Servs., 46 F.3d 510, 512 (6th Cir. 1994) (citation omitted).
Furthermore, the Court is not under any obligation to scour the record for errors not identified by
the claimant and arguments not raised and supported in more than a perfunctory manner may be
deemed waived. See McPherson v. Kelsey, 125 F.3d 989, 995–96 (6th Cir. 1997) (noting that
conclusory claims of error without further argument or authority may be considered waived).
IV.
DISABILITY ELIGIBILITY
“Disability” means an individual cannot “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
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than 12 months.” 42 U.S.C. §§ 423(d)(1)(A) and 1382c(a)(3)(A). An individual will only be
considered disabled:
if his physical or mental impairment or impairments are of such
severity that he is not only unable to do his previous work but
cannot, considering his age, education, and work experience, engage
in any other kind of substantial gainful work which exists in the
national economy, regardless of whether such work exists in the
immediate area in which he lives, or whether a specific job vacancy
exists for him, or whether he would be hired if he applied for work.
42 U.S.C. §§ 423(d)(2)(A) and 1382c(a)(3)(B).
Disability is evaluated pursuant to a five-step analysis summarized as follows:
1. If claimant is doing substantial gainful activity, he is not
disabled.
2. If claimant is not doing substantial gainful activity, his
impairment must be severe before he can be found to be disabled.
3. If claimant is not doing substantial gainful activity and is
suffering from a severe impairment that has lasted or is expected to
last for a continuous period of at least twelve months, and his
impairment meets or equals a listed impairment, claimant is
presumed disabled without further inquiry.
4. If claimant’s impairment does not prevent him from doing his
past relevant work, he is not disabled.
5. Even if claimant’s impairment does prevent him from doing his
past relevant work, if other work exists in the national economy that
accommodates his residual functional capacity (“RFC”) and
vocational factors (age, education, skills, etc.), he is not disabled.
Walters v. Comm’r of Soc. Sec., 127 F.3d 525, 529 (6th Cir. 1997) (citing 20 C.F.R. § 404.1520).
A claimant’s residual functional capacity (“RFC”) is assessed between steps three and four and is
“based on all the relevant medical and other evidence in your case record.” 20 C.F.R. §§
404.1520(a)(4) and -(e), 416.920(a)(4), -(e). An RFC is the most a claimant can do despite his
limitations. 20 C.F.R. §§ 404.1545(a)(1) and 416.945(a)(1).
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The claimant bears the burden of proof at the first four steps. Walters, 127 F.3d at 529.
The burden shifts to the Commissioner at step five. Id. At the fifth step, the Commissioner must
prove that there is work available in the national economy that the claimant could perform. Her
v. Comm’r of Soc. Sec., 203 F.3d 388, 391 (6th Cir. 1999) (citing Bowen v. Yuckert, 482 U.S. 137,
146 (1987)).
V.
ANALYSIS
Plaintiff asserts that the ALJ’s disability determination is not supported by substantial
evidence because the ALJ’s finding that her mental health impairments were non-severe at Step
Two is not supported by substantial evidence. Additionally, Plaintiff claims that the ALJ did not
support his subjective complaint analysis with substantial evidence. The Court will address
Plaintiff’s allegations of error in turn.
A.
Severe Impairments
Plaintiff claims that the ALJ improperly found that her mental health impairments were not
severe at Step Two of the sequential evaluation. After remand from the Appeals Council, the ALJ
reviewed an extensive medical record with respect to Plaintiff’s mental impairments, which
consisted of numerous years of treatment notes and several medical opinions. The ALJ’s disability
decision sets forth in great detail the medical record with respect to Plaintiff’s mental impairments,
and Plaintiff does not claim that the ALJ failed to discuss any applicable opinion or portion of the
medical record. 2 Therefore, the Court will briefly summarize the relevant portions of the medical
record that the ALJ relied upon in the disability decision.
2
The parties’ briefing also extensively reviews the opinions and treatment notes regarding
Plaintiff’s mental impairments.
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1.
Background
Plaintiff underwent a consultative neuropsychological evaluation on September 6, 2012
with Leslie Jones, Ph.D. [Tr. 486]. The ALJ reviewed the evaluation findings in great detail and
noted that “[t]here was evidence that the claimant consistently endorsed items that would portray
her in an especially negative or pathological manner, and her PAI clinical profile was marked by
significant elevations across a number of different scales.” [Tr. 19]. In pertinent part, Dr. Jones
obtained Plaintiff’s background information, performed a behavioral observation and mental status
examination, conducted the Wechsler Adult Intelligence Scale-3rd edition (“WAIS-3”), conducted
the California Verbal Learning Test-2nd edition and Wechsler Memory Scale Revised to test
Plaintiff’s memory functions, conducted the Boston Naming Test to evaluate Plaintiff’s language
function, conducted the Trail Making A Test to assess Plaintiff’s visuomotor and executive
functions, and administered the Personality Assessment Inventory to evaluate Plaintiff’s affect and
personality. [Tr. 486–88]. Dr. Jones diagnosed mild cognitive impairment, bipolar II disorder,
and borderline and avoidant personality disorder traits. [Tr. 488]. The ALJ further noted that Dr.
Jones opined that:
Current neuropsychological evaluation results showed some mild executive
functioning deficits in an individual of low average overall intellectual ability. It
is likely that these executive functioning deficits are the cause of Ms. Hockstedler’s
perceived memory loss, and that the executive functioning deficits, in turn, are
caused by her mood and personality disorders. However—she did show
impairment in delayed visual recall; her forgetfulness about recent events and
conversations is troubling; it appears that her daily functioning has been
compromised by recent changes in her cognitive skills; and it is unclear why she
seems to have experienced a sudden worsening of symptoms. Therefore, she is
tentatively being given a diagnosis of Mild Cognitive Impairment . . . If her
forgetfulness continued, she should be re-assessed . . . It will then become clearer
whether she actually has a progressive dementia. Ms. Hockstedler’s more salient
diagnoses at this time involve her psychiatric conditions, and those should continue
to be the focus of treatment. She has an intense fear of rejection and criticism,
along with mood volatility and episodes of poorly controlled anger. These
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symptoms are typical of bipolar II disorder combined with borderline and avoidant
personality traits. She is in a great deal of distress, and seems to be seeking help
and attention while being unsure how best to do that.
[Tr. 20]; see [Tr. 488–89].
Dr. Jones also performed a Medical Source Statement on October 29, 2012. [Tr. 483]. Dr.
Jones opined that Plaintiff was mildly limited in the ability to understand, remember, and carry out
simple instructions; that she was moderately limited in the ability to make judgments on simple
work-related decisions, as well as understand, remember, and carry out complex instructions; and
that Plaintiff was markedly limited in the ability to make judgments on complex work-related
decisions. [Id.]. Further, Dr. Jones assessed that Plaintiff was mildly limited in the ability to
interact appropriately with the public and supervisors; that she was moderately limited in the
ability to interact with co-workers; and that she was markedly limited in the ability to respond
appropriately to usual work setting and to changes in a routine work setting. [Tr. 484].
Next, the ALJ proceeded to review Plaintiff’s treatment record at Tullahoma Psychiatric
with Allen Craig, M.D., including by reviewing Plaintiff’s presentation at appointments, the effect
of her prescribed medication, and mental status examination findings. [Tr. 20]. The ALJ then
detailed Plaintiff’s consultative psychological evaluation on December 16, 2015 with Tamara
Raphaeli, Psy.D. [Tr. 22]. Dr. Raphaeli reviewed Plaintiff’s function report and her examination
with Dr. Jones, as well as conducted a clinical interview and performed a mental status
examination. [Tr. 516]. Dr. Raphaeli assessed that Plaintiff “appears to fall into the low average
range of intellectual functioning,” that she showed evidence of mild impairment in her short-term
memory and ability to sustain concentration, but that she showed no evidence of impairment in
her long-term and remote memory functioning. [Tr. 519–20]. Further, Dr. Raphaeli found that
Plaintiff’s current psychiatric state was anxious, she showed no evidence of impairment in social
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relating or her ability to adapt to change, that she appeared able to follow instructions, and that she
had a long history working in a factory. [Tr. 520]. Dr. Raphaeli therefore diagnosed unspecified
depressive disorder and Bipolar II disorder (by history). [Id.].
After detailing Dr. Raphaeli’s opinion, the ALJ further discussed Plaintiff’s treatment notes
with Dr. Craig, including a mental status examination from February 26, 2016. [Tr. 22]. Dr. Craig
completed a Medical Source Statement, where he noted that he treated Plaintiff for panic disorder
and unspecified mood disorder, as well as that Plaintiff would miss more than two days per month
of work due to anxiety. [Tr. 522–23]. The ALJ summarized Dr. Craig’s opinion as assessing
“mild to moderate limitations in the claimant’s functional abilities.” [Tr. 23].
The ALJ then reviewed Plaintiff’s second neuropsychological evaluation on March 1, 2016
with Dr. Jones. [Tr. 23–24]. Dr. Jones conducted largely the same assessments and diagnosed
mild cognitive impairment, major depression, recurrent, severe, bipolar II disorder, and borderline
and dependent personality traits. [Tr. 538]. Dr. Jones summarized that:
Ms. Hockstedler’s current neuropsychological evaluation results showed mild
deficits in concentration and processing speed, and severe deficits on some, but not
all, of the verbal memory testing. She has had a mild decline in those areas since
her previous evaluation three and a half years ago. The rest of her results were
predominantly in the low average to average range and consistent with her previous
results. She has not shown the rate and type of decline which would be typical of
Alzheimer’s type dementia. She could possibly be developing a frontotemporal
dementia. She also continues to have a significant mood disorder, which could
certainly be having an adverse impact on her memory and concentration. Another
possibility is that Ms. Hockstedler has a previously undiagnosed attention deficit
disorder which has gotten worse due to stress and her psychiatric illness. I hesitate
to recommend any additional medication since she already takes quite a few, but
perhaps she could have a trial of ADD medication. If that proves helpful to her, it
might also benefit her mood.
Ms. Hockstedler remains independent in most of her activities of daily living;
although she has become increasingly dependent on her husband for driving,
financial matters, and emotional support. Because the etiology of Ms.
Hockstedler’s cognitive impairments remains unclear even after four years, it is
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recommended that she have a brain scan if she has not had one . . . [and] also
recommended that she resume counseling.
[Id.]. The ALJ proceeded to describe more of Plaintiff’s treatment records, including in September
and November 2016, as well as February 10, May 5, July 28, and October 20, 2017. [Tr. 24].
Plaintiff was again evaluated by Dr. Jones on August 8, 2017. [Tr. 571–72]. As noted by
the ALJ, “Dr. Jones again administered a battery of tests” and Plaintiff’s “results improved on
some tests and declined in others.” [Tr. 25]. The ALJ further summarized Dr. Jones’ evaluation
as Plaintiff’s “test results at her three evaluations had been inconsistent and not clearly indicative
of any particular type of dementia.” [Id.]. Additionally, Dr. Jones found that “it still seems most
likely that [Plaintiff’s] cognitive impairments are due to her psychiatric illness and medications”
and “because her visuomotor skills and her tremors appear to have worsened, it might be good to
obtain a neurological consultation and a brain MRI,” as well as attempt to decrease some of her
medication. [Tr. 572]. Lastly, Dr. Jones opined that Plaintiff’s “neuropsychological evaluation
results showed moderate impairment in visuomotor/spatial skills and executive functions
(processing speed, mental flexibility), as well as “mild impairment in memory and naming.” [Id.].
Plaintiff underwent an additional consultative examination with Dr. Raphaeli on May 8,
2018. [Tr. 555–61]. Dr. Raphaeli assessed that Plaintiff “appears to fall into the average range of
intellectual functioning,” as well as that she showed evidence of mild impairment in her short-term
memory and ability to sustain concentration, and evidence of impairment in her long-term and
remote memory functioning. [Tr. 558]. Additionally, Dr. Raphaeli found that Plaintiff’s current
psychiatric state was anxious, that she showed evidence of a mild impairment in her social relating,
appeared to be mildly impaired in her ability to adapt to change, and appeared to be able to follow
both written and spoken instructions. [Id.]. Therefore, Dr. Raphaeli opined that Plaintiff was not
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limited in the ability to make judgments on simple-work related decisions, as well as carry out
complex instructions; but that she was mildly limited in the ability to understand, remember, and
carry out simple instructions, understand and remember complex instructions, and make judgments
on complex work-related decisions. 3 [Tr. 559].
On October 8, 2018, Plaintiff underwent an additional consultative psychological
evaluation with Jerry Campbell, Psy.D. [Tr. 604–11]. In pertinent part, Dr. Campbell assessed
that Plaintiff “appears to fall into the average range of intellectual functioning,” showed evidence
of mild to moderate impairment in her short-term memory and ability to sustain concentration, as
well as showed evidence of mild impairment in her long-term and remote memory functioning.
[Tr. 608]. Dr. Campbell also completed a Medical Source Statement which assessed mild
limitations in the ability to understand, remember, and carry out simple instructions; in addition to
moderate limitations in the ability to understand, remember, and carry out complex instructions,
make judgments on complex work-related decisions. 4 [Tr. 609].
Dr. Craig then completed a second Medical Source Statement on October 22, 2018. [Tr.
614–16]. The ALJ noted that Dr. Craig indicated that he treated Plaintiff for chronic anxiety and
depression and opined that Plaintiff “would miss more than two days per month of work due to
her anxiety, and her anxiety would probably increase in a fulltime employment setting,” as well as
that Plaintiff would be off task thirty percent of the workday. [Tr. 27–28]. Additionally, Dr. Craig
3
While it is perplexing that Dr. Raphaeli noted on the check-box form that Plaintiff was
not limited in the ability to carry out complex instructions but mildly limited in the ability to carry
out simple instructions, the corresponding narrative summary by Dr. Raphaeli generally concludes
that “[Plaintiff] appears able to follow instructions, both written and spoken.” [Tr. 558].
4
Dr. Campbell assessed both mild and moderate limitations concerning Plaintiff’s ability
to make judgments on complex work-related decisions. [Id.].
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opined that Plaintiff was moderately limited in her ability to understand and remember detailed
instructions, carry out detailed instructions, maintain attention and concentration for extended
periods, perform activities within a schedule, complete a normal workweek without interruptions
from psychologically based symptoms, and tolerate normal levels of stress.
[Tr. 614–16].
However, Dr. Craig found that Plaintiff was either mildly or not limited in the remainder of her
abilities related to understanding and memory, sustained concentration and persistence, social
interaction, and adaption. [Id.].
Therefore, the ALJ found that Plaintiff’s “medically determinable impairments of anxiety
disorder and bipolar disorder, considered singly and in combination do not cause more than
minimal limitation in [her] ability to perform basic mental work activities and are therefore
nonsevere.” [Tr. 28]. First, the ALJ found that Plaintiff had mild limitations in understanding,
remembering, or applying information. [Id.]. Here, the ALJ noted that Plaintiff had undergone
numerous psychological and neuropsychological evaluations, but “the results of testing have
varied significantly,” and Plaintiff did not pursue therapy or obtain a brain MRI as recommended
by Dr. Jones. [Id.]. Additionally, the ALJ found “throughout the treatment records from her
treating psychiatrist, Dr. Craig, no deficits in cognitive function were noted; the claimant’s mental
status evaluation was consistently normal with only occasional anxiety or depression noted; and
the claimant consistently reported that her medication[s] were working well and controlling her
mood.” [Tr. 28–29]. The ALJ cited to Plaintiff’s consultative examinations with Dr. Raphaeli
finding mild impairment in Plaintiff’s short-term memory and ability to sustain concentration,
while no impairment in her long-term and remote memory functioning. [Tr. 29].
Ultimately, while the ALJ noted that Dr. Jones’ evaluations “indicated potential deficits in
the claimant’s memory,” the ALJ found that her treatment record did not support more than mild
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limitations in Plaintiff’s ability to understand, remember and apply information. [Id.]. Similarly,
the ALJ found that while Dr. Campbell assessed mild to moderate limitations in Plaintiff’s memory
and her ability to understand and remember information, his examination notes did not support the
assessed limitations. [Id.].
Second, the ALJ found that Plaintiff had mild limitations in interacting with others. [Id.].
In support, the ALJ assessed that Plaintiff interacted appropriately with her physicians, “was
almost exclusively noted to be alert and fully oriented during examination,” and Dr. Raphaeli
opined that Plaintiff showed no evidence of impairment in social relating during her first
evaluation and mild impairment in her second evaluation. [Id.]. The ALJ acknowledged Dr.
Campbell’s assessed moderate limitations in social interaction but contrasted that opinion with his
notation that she was cooperative throughout the evaluation, maintained good eye contact, as well
as reported daily activities of going grocery shopping weekly, and interacting with family
regularly. [Id.]. Further, the ALJ acknowledged Dr. Craig’s assessed moderate limitations in
social interaction in his 2016 Medical Source Statement but found that Dr. Craig’s “treatment notes
reflect no reports of difficulty interacting with others, and by October 2018, Dr. Craig assessed
only mild limitation in the claimant’s ability to accept instructions and respond appropriately to
criticism from supervisions.” [Tr. 29–30].
Third, the ALJ found that Plaintiff also had only mild limitations in concentrating,
persisting, or maintaining pace. [Tr. 30]. The ALJ reviewed Plaintiff’s reported daily activities,
including that she “reported no difficulty performing housework, performing yard work, or
preparing meals.” [Id.]. Additionally, the ALJ summarized that “[d]uring Dr. Jones’ 2012
evaluation, [Plaintiff] showed relative strength on subtests assessing sustained concentration and
nonverbal reasoning ability,” that Dr. Raphaeli assessed mild impairment in Plaintiff’s ability to
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sustain concentration in 2015 and 2018, and that Dr. Jones opined in 2016 that Plaintiff’s
neuropsychological evaluation results showed mild deficits in concentration and processing speed.
[Id.]. The ALJ stated that Dr. Campbell opined mild to moderate impairment in this ability, but
there were no concentration difficulties mentioned in his evaluation notes, as well as that Plaintiff’s
treatment notes with Dr. Craig failed to document complaints of concentration difficulties. [Id.].
Lastly, the ALJ found that Plaintiff had only mild limitations in adapting or managing
oneself. [Id.]. The ALJ cited to examination findings that Plaintiff was able to remain independent
in her activities of daily living and “[t]hroughout the record, [Plaintiff] reported that she was able
to drive, prepare simple meals, wash dishes, sweep, vacuum, wash laundry, and perform yard
work.” [Id.]. The ALJ noted Dr. Craig’s 2016 opinion that Plaintiff exhibited moderate limitations
in her ability to respond appropriately to changes in the work setting but distinguished this with
his later opinion that Plaintiff “exhibited only mild limitations in this area of functioning.”
Accordingly, “[b]ecause [Plaintiff’s medically determinable mental impairments cause no more
than ‘mild’ limitation in any of the functional areas,” the ALJ found these impairments to be
nonsevere. [Id.].
In the RFC determination, the ALJ found that Plaintiff’s “statements about the intensity,
persistence, and limiting effects of her symptoms . . . are inconsistent because the treatment record
as a whole does not support her level of limitation alleged.” [Tr. 32]. Specifically, the ALJ noted
that while Plaintiff “has a long history of complaints of memory problems, despite extensive
testing and mental health treatment, no diagnoses [have] been made that would account for the
claimant’s reported memory issues.” [Id.]. Additionally, the ALJ reviewed how Plaintiff’s
“performance on neuropsychological testing has varied significantly.” [Id.].
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The ALJ found that “[w]hile looking only to Dr. Jones’ evaluations, it would be easy to
infer that the claimant has significant psychological limitations, the results of Dr. Jones’ testing
and her opinions are not supported by the record as a whole.” [Id.]. Specifically, the ALJ reviewed
that Plaintiff “is consistently noted to be doing well on medication” throughout her treatment
records with Dr. Craig, and that she “occasionally reported increased anxiety or depression, usually
related to external stressors . . . however, her mood would quickly stabilize, and her mental status
examinations would return to normal.” [Id.]. Additionally, the ALJ cited to Dr. Raphaeli’s
consultative examinations finding “no evidence of greater than mild psychological limitations.”
[Tr. 32–33].
While reviewing the opinion evidence, the ALJ assigned “little weight to the opinions of
the State Agency psychological consultants who found affective disorders and anxiety disorders
severe,” as while Plaintiff “has had long-term mental health treatment, extensive
neuropsychological testing has no[t] yielded any consistent results, the claimant’s mental health
treatment indicates that her mental health symptoms have been consistently well controlled with
medication, and the claimant has not followed through on multiple recommendations to obtain
mental health counselling [sic] or a brain MRI.” [Tr. 33]. The ALJ also stated that the consultants
did not personally examine Plaintiff or review a complete medical record. [Id.].
The ALJ proceeded to review Dr. Jones’ opinions and afforded them some weight, finding
that the limitations varied from exam to exam and “during the final evaluation, Dr. Jones opined
that the claimant’s reported limitations may be caused by her medication.” [Tr. 34]. The ALJ
afforded significant weight to Dr. Raphaeli’s opinions, as “her opinion that the claimant exhibits
no more than mild limitations is consistent with the treatment record as a whole, which indicates
that her psychological impairments are well controlled with medication.” [Tr. 35]. Next, the ALJ
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afforded little weight to Dr. Campbell’s opinion, finding the opinion was inconsistent with “his
own examination notes, Dr. Raphaeli’s examination notes, and Dr. Craig’s treatment notes.” [Tr.
36]. Lastly, the ALJ gave “little weight to the assessments provided by Dr. Craig, as they are not
supported by his own treatment notes or the other notes in the file.” [Id.]. After extensively
reviewing again Dr. Craig’s treatment notes, the ALJ found that “[a]t no point in his treatment
records does Dr. Craig discuss limitations consistent with those he assessed on the medical source
statements.” [Tr. 37]. Additionally, the ALJ noted that “the other evaluations performed by Dr.
Raphaeli exhibit no more than mild limitations in the claimant’s functional abilities.” [Id.].
2.
Analysis
At step two, the ALJ is required to consider whether Plaintiff’s alleged impairments
constitute “medically determinable” impairments. See 20 C.F.R. §§ 404.1508; 416.920(a)(4)(ii);
404.1520(a)(4)(ii). A medically determinable impairment “must result from anatomical,
physiological, or psychological abnormalities which can be shown by medically acceptable
clinical and laboratory diagnostic techniques,” and “must be established by medical evidence
consisting of signs, symptoms, and laboratory findings, not only by [the claimant’s] statement of
symptoms.” 20 C.F.R. §§ 404.1508; 416.908. Additionally, an impairment must meet the
durational requirement, meaning, “it must have lasted or must be expected to last for a continuous
period of at least 12 months.” 20 C.F.R. § 404.1509.
To be found disabled, “the ALJ must find that the claimant has a severe impairment or
impairments” at step two. Farris v. Sec’y of Health & Human Servs., 773 F.2d 85, 88 (6th Cir.
1985). An impairment, or combination of impairments, will be found severe if the impairment(s)
“significantly limit[ ] [a claimant’s] physical or mental ability to do basic work activities.” 20
C.F.R. § 416.920(c). The step two determination is “a de minimis hurdle” in that “an impairment
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will be considered not severe only if it is a slight abnormality that minimally affects work ability
regardless of age, education, and experience.” Higgs v. Brown, 880 F.2d 860, 862 (6th Cir. 1988)
(citing Farris, 773 F.2d at 90). “A severe mental impairment is ‘established by medical evidence
consisting of signs, symptoms, and laboratory findings, not only by [a plaintiff’s] statement of
symptoms.’” Griffith v. Comm’r of Soc. Sec., 582 F. App’x 555, 559 (6th Cir. 2014) (quoting 20
C.F.R. § 416.908).
At the outset, the Court will address Plaintiff’s argument that the ALJ’s finding that her
mental health impairments were nonsevere at Step Two is not supported by substantial evidence.
Although the Step Two determination is a de minimis hurdle, the Court finds that substantial
evidence supports the ALJ’s decision, as he first reviewed the medical record in great detail
regarding Plaintiff’s mental impairments. The ALJ found that Plaintiff’s longstanding treatment
record with Dr. Craig, as well as the medical opinions of record, did not support more than mild
limitations in area of the four broad areas of mental functioning, and as a whole, Plaintiff’s anxiety
disorder and bipolar disorder did not cause more than minimal limitation in Plaintiff’s ability to
perform basic work activities. [Tr. 28]. See, e.g., Church v. Saul, No. 2:18-CV-36-HBG, 2019
WL 3070313, at *9 (E.D. Tenn. July 12, 2019) (finding substantial evidence supported the ALJ’s
finding that Plaintiff’s depression was a nonsevere impairment where the ALJ noted that Plaintiff’s
treatment records demonstrated a history of depression aggravated by alcohol abuse, that
Plaintiff’s depressive symptoms were conservatively treated and well-managed with medication,
and that Plaintiff’s depression did not cause more than minimal limitations in the ability to perform
basic mental work related activities); Knox v. Colvin, No. 2:16CV155-TFM, 2016 WL 6897791,
at *4 (M.D. Ala. Nov. 22, 2016) (finding substantial evidence supported the Commissioner’s
finding that the claimant’s anxiety and depression did not constitute severe mental impairments
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where the conditions were treated conservatively and the ALJ found that the claimant had only
mild limitations in the paragraph B criteria). Ultimately, “disability is determined by the functional
limitations imposed by a condition, not the mere diagnosis of it.” Hill v. Comm’r of Soc. Sec., 560
F. App’x 547, 551 (6th Cir. 2014) (citing Higgs, 880 F.2d at 863).
Plaintiff claims that “the ALJ unduly dismissed Dr. Jones’ analysis, which was supported
by testing and which concurred with treating opinions, an examining opinion, and the nonexamining opinions.” [Doc. 14 at 14]. Additionally, Plaintiff submits that “[u]nadorned raw data
from clinical notes and the opinion of one of two consultative examiners does not substantially
contradict these sources that support finding [her] medical impairments severe.” [Id.]. However,
the Court finds that the ALJ reasonably considered and weighed the medical opinion evidence in
reaching his step-two conclusions. Plaintiff does not support her argument that the ALJ could not
find that Dr. Raphaeli’s opinions, as well as Dr. Craig’s treatment notes, conflicted with Dr. Craig’s
opinions, Dr. Jones’ opinions, Dr. Campbell’s opinion, and the opinions of the nonexamining state
agency consultants. Ultimately, the ALJ weighed the medical opinions, as well as cited to specific
treatment notes exhibiting medication controlling Plaintiff’s symptoms and normal mental status
findings. [Tr. 29–30]. Additionally, the ALJ noted that despite Dr. Jones’ recommendations,
Plaintiff did not pursue therapy or obtain a brain MRI. [Tr. 28–29].
Further, even if the ALJ erred by failing to find Plaintiff’s anxiety disorder and bipolar
disorder severe impairments, it is well settled that the ALJ’s failure to identify some impairments
as “severe” is harmless where the ALJ continues the disability determination and considers both
severe and nonsevere impairments at subsequent steps of the sequential evaluation as required by
the regulations. See Fisk v. Astrue, 253 F. App’x 580, 583 (6th Cir. 2007) (“And when an ALJ
considers all of a claimant’s impairments in the remaining steps of the disability determination, an
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ALJ’s failure to find additional severe impairments at step two ‘[does] not constitute reversible
error.’”) (quoting Maziarz v. Sec’y of Health & Human Servs., 837 F.2d 240, 244 (6th Cir. 1987));
Pompa v. Comm’r of Soc. Sec., 73 F. App’x 801, 803 (6th Cir. 2003) (“Because the ALJ found
that Pompa had a severe impairment at step two of the analysis, the question of whether the ALJ
characterized any other alleged impairment as severe or not severe is of little consequence.”).
In the RFC determination, the ALJ again extensively reviewed Plaintiff’s mental
impairments. Cf. Bacon v. Saul, No. 3:19-CV-183-HBG, 2020 WL 4923957, at *9 (E.D. Tenn.
Aug. 21, 2020) (“However, the disability decision does not contain any indication that the ALJ
considered Plaintiff’s nonsevere mental impairments past Step Two of the sequential evaluation.
Other than the brief mention detailed above, the ALJ failed to explain why Plaintiff’s anxiety
disorder did not result in any work-related limitations.”); Stephens v. Astrue, No. 09-55-JBC, 2010
WL 1368891, at *2 (E.D. Ky. Mar. 31, 2010) (“The ALJ thoroughly examined the medical
evidence of Stephens’s mental impairments in arriving at her conclusion that they were not severe
at the second step, but the fourth step, where the ALJ made findings regarding Stephens’s RFC,
was devoid of any explicit reference to those impairments.”).
The ALJ discussed Plaintiff’s testimony regarding her mental impairments and
summarized that throughout Plaintiff’s treatment with Dr. Craig, she was “consistently noted to be
doing well on medication,” as she “occasionally reported increased anxiety or depression . . . [but]
her mental status examinations would return to normal.” [Tr. 32]. Further, the ALJ reviewed the
medical opinions of record with regard to Plaintiff’s mental impairments and detailed why Dr.
Craig’s opinions, Dr. Jones’ opinions, and Dr. Campbell’s opinion were not supported by the
medical record. See, e.g., White v. Comm’r of Soc. Sec., No. 2:17-CV-1063, 2018 WL 5303060,
at *5 (S.D. Ohio Oct. 25, 2018) (finding the ALJ “properly considered Plaintiff’s mental
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impairments in assessing her RFC and that substantial evidence supports the ALJ’s decision to
omit nonexertional limitations attributable to her mental impairments” where “[t]he ALJ
thoroughly explained the grounds for his RFC determination, which included consideration of
Plaintiff’s allegations and hearing testimony, treatment history/lack of treatment history, the
opinions of Drs. O’Connell, Tangeman, and Goldsmith, and a function-by-function discussion of
the ‘paragraph B’ criteria”), report and recommendation adopted by 2018 WL 6271593 (S.D. Ohio
Nov. 30, 2018). For example, when affording great weight to Dr. Rapheli’s opinion that Plaintiff
exhibited no more than mild limitations, the ALJ found that this opinion was “consistent with the
treatment record as a whole, which indicates that her psychological impairments are well
controlled with medication.” [Tr. 35].
Ultimately, the ALJ’s finding of mild limitations in the four areas of mental functioning
did not require him to include mental limitations in Plaintiff’s RFC. See Ceol v. Berryhill, No.
3:15–CV–315–CCS, 2017 WL 1194472, at *10 (E.D. Tenn. Mar. 30, 2017) (“Therefore, a finding
by the ALJ that the Plaintiff has mild limitations in the areas of daily living activities, social
functioning, and concentration, persistence, or pace, does not necessarily mean that the Plaintiff
will have corresponding limitations with regard to her RFC.”). “Accordingly, the Court’s inquiry
turns to whether substantial evidence supports the ALJ’s determination not to include mental
limitations in Plaintiff’s RFC.” Fannin v. Berryhill, No. 3:17-CV-236-DCP, 2019 WL 1434653,
at *10–11 (E.D. Tenn. Mar. 29, 2019)
Plaintiff asserts that the ALJ improperly found that “while the claimant has a long history
of complaints of memory problems, despite extensive testing and mental health treatment, no
diagnoses [have] been made that would account for the claimant’s reported memory issues.” [Tr.
32]; see [Doc. 14 at 15]. However, the Court finds that the ALJ’s conclusion referred to Dr. Jones’
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August 8, 2017 opinion that Plaintiff’s “test results at her three evaluations had been inconsistent
and not clearly indicative of any particular type of dementia.” [Tr. 572]. Additionally, Dr. Jones
found that “it still seems most likely that [Plaintiff’s] cognitive impairments are due to her
psychiatric illness and medications” and “because her visuomotor skills and her tremors appear to
have worsened, it might be good to obtain a neurological consultation and a brain MRI,” as well
as attempt to decrease some of her medication. [Id.]. While Plaintiff claims that the ALJ
improperly focused on the presence of dementia, which she does not allege as a basis for disability,
the Court finds that the ALJ reviewed the opinion of the consultative examiner that Plaintiff’s
memory problems were not attributable to any specific mental impairment.
Plaintiff claims that the ALJ improperly afforded great weight to the opinions of Dr.
Raphaeli over those of Dr. Craig (her treating physician) and Dr. Jones (who conducted extensive
testing). In considering a claim of disability, the ALJ generally must give the opinion of the
claimant’s treating physician “controlling weight.” 20 C.F.R. §§ 404.1527(c); 416.927(c)(2). 5
However, a treating physician’s opinion as to the nature and severity of an impairment must be
given “controlling weight” only if it is (1) well-supported by medically acceptable clinical and
laboratory diagnostic techniques and (2) is not inconsistent with the other substantial evidence in
the case record. 20 C.F.R. §§ 404.1527(c); 416.927(c)(2). When an opinion does not garner
controlling weight, the appropriate weight to be given to the opinion will be determined based
5
The treating physician rule has been abrogated as to claims filed on or after March 27,
2017. See 20 C.F.R. §§ 404.1520c; 416.920c (“We will not defer or give any specific evidentiary
weight, including controlling weight, to any medical opinion(s) . . . including those from your
medical sources.”); see also Revisions to Rules Regarding the Evaluation of Medical Evidence, 82
Fed. Reg. 5844-01, 2017 WL 168819, at *5852–57 (Jan. 18, 2017). The new regulations eliminate
the term “treating source,” as well as what is customarily known as the treating physician rule. As
Plaintiff’s application was filed before March 27, 2017, the treating physician rule applies. See
id. §§ 404.1527; 416.927.
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upon the length of treatment, frequency of examinations, nature and extent of the treatment
relationship, amount of relevant evidence that supports the opinion, the opinion’s consistency with
the record as a whole, the specialization of the source, and other factors which tend to support or
contradict the opinion. Id.
The ALJ is not required to explain how he considered each of these factors but must
nonetheless give “good reasons” for giving a treating physician’s opinion less than controlling
weight. Francis v. Comm’r of Soc. Sec., 414 F. App’x 802, 804 (6th Cir. 2011); see also Morr v.
Comm’r of Soc. Sec., 616 F. App’x 210, 211 (6th Cir. 2015) (holding “good reasons” must be
provided “that are sufficiently specific to make clear to any subsequent reviewers the weight given
to the treating physician’s opinion and the reasons for that weight”). Opinions from non-treating
sources are never assessed for controlling weight but are evaluated using the regulatory balancing
factors set forth in 20 C.F.R. § 416.927(c). Gayheart v. Comm’r of Soc. Sec., 710 F.3d 365, 376
(6th Cir. 2013) (citing 20 C.F.R. § 404.1527(c)). These opinions are weighed “based on the
examining
relationship
(or
lack
thereof),
specialization,
consistency,
and
supportability.” Id. (citing 20 C.F.R. § 404.1527(c)). “Other factors ‘which tend to support or
contradict
the
opinion’
may
be
considered
in
assessing
any
type
of
medical
opinion.” Id. (quoting 20 C.F.R. § 404.1527(c)(6)). Ultimately, there is no rule that requires an
articulation of each of these factors. Albaugh v. Comm’r of Soc. Sec., No. 14-CV-10963, 2015
WL 1120316, at *6 (E.D. Mich. Mar. 11, 2015).
In the disability decision, the ALJ extensively reviewed the medical opinions of record and
provided good reasons for why Dr. Craig’s opinions were not afforded controlling weight, finding
them inconsistent with his own treatment notes. [Tr. 36]. See Fry v. Comm’r of Soc. Sec., 476 F.
App’x 73, 75–76 (6th Cir. 2012) (concluding that the ALJ properly discounted the plaintiff’s
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treating psychiatrist’s opinion as inconsistent with his own objective clinical findings in
his treatment notes and other evidence in the record); Dungey v. Comm’r of Soc. Sec., No. 1:12CV-1190, 2014 WL 1232661, at *10 (W.D. Mich. Mar. 25, 2014) (concluding that the ALJ’s
decision to give less than controlling weight to the plaintiff’s treating psychiatrist’s opinion was
supported by substantial evidence because the plaintiff “responded well to conservative treatment
and demonstrated significant improvement when taking her medication as prescribed”).
Importantly, the ALJ specifically detailed the treatment notes that he found inconsistent with Dr.
Craig’s opinions, such as that on October 22, 2018, the same day as Dr. Craig completed a Medical
Source Statement, “Dr. Craig’s treatment notes indicate that the claimant was doing well with her
current psychiatric medication regimen” and “Dr. Craig noted that the claimant’s affect was
appropriate, and her mood was stable with no indication of hypomania, mania, or depression.”
[Tr. 36–37]. The ALJ also specifically found that Dr. Craig’s opinion was inconsistent with Dr.
Raphaeli’s opinions. [Tr. 37]. Cf. Wilson v. Berryhill, No. 3:16-CV-95-HBG, 2017 WL 2790186,
at *5 (E.D. Tenn. June 27, 2017) (“The ALJ does not identify with specificity any treatment
records, examining findings, diagnostic studies, or other evidence that specifically undermines Dr.
Laman’s opinions. While the ALJ discussed the medical evidence of record in general, the Court
is unable to determine how the ALJ arrived at his conclusion . . . .”).
With respect to Dr. Jones’ opinions, the Court finds that the ALJ appropriately detailed that
he assigned some weight to the assessments but distinguished that “the limitations she assessed
varied from exam to exam, and during the final evaluation, Dr. Jones opined that the claimant’s
reported limitations may be caused by her medication.” [Tr. 34]. The ALJ also noted that
Plaintiff’s “treatment notes from Dr. Craig consistently noted that the claimant’s mood was well
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controlled with medication, and, aside from periodic anxiety and depression, the claimant’s mental
status examinations were largely normal.” [Id.].
While Plaintiff claims that the ALJ improperly failed to find her mental impairments as
severe, due to his finding of at least one severe impairment, Plaintiff more accurately challenges
the RFC determination and the lack of functional limitations stemming from her mental health
impairments. Ultimately, an ALJ is responsible for determining a claimant’s RFC after reviewing
all the relevant evidence of record. Rudd v. Comm’r of Soc. Sec., 531 F. App’x 719, 727–28 (6th
Cir. 2013). The Court notes that although an ALJ is required to consider every medical opinion
in the record, 20 C.F.R. § 404.1527(c), he is not bound to adopt any particular opinion when
formulating a claimant’s RFC. See Rudd, 531 F. App’x at 728. The ALJ is responsible for
weighing medical opinions, as well as resolving conflicts in the medical evidence of
record. Richardson v. Perales, 402 U.S. 389, 399 (1971); see also 20 C.F.R. § 416.946(c) (stating
the final responsibility for assessing a claimant’s RFC rests with the ALJ). Here, the Court finds
that the ALJ appropriately considered the medical opinions of record, as well as Plaintiff’s mental
impairments, but found that they caused no more than mild limitations. Therefore, the ALJ’s
failure to include limitations in the RFC stemming from Plaintiff’s mental impairments does not
constitute a basis for remand.
B.
Subjective Symptom Evaluation
Plaintiff claims that the ALJ failed to support his evaluation of Plaintiff’s subjective
complaints with substantial evidence, as “the ALJ assessed Plaintiff’s subjective complaint[s] by
discussing Dr. Jones[’] testing—which was flawed.” [Doc. 14 at 23]. Plaintiff states that “Dr.
Jones consistently noted that Plaintiff’s performances on examinations were ‘similar,’” and “[t]he
label of somewhat inconsistent is specifically attached to dementia (T 572), which Plaintiff does
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not allege.” [Id.]. Lastly, Plaintiff claims that the ALJ failed to consider the potential plateauing
of her condition before considering the effect of her treatment record.
The ALJ’s decision postdates Social Security Ruling 16-3p, which eliminates the use of
the term “credibility” from the applicable policy regulation and clarifies that a “subjective
symptom evaluation is not an examination of an individual’s character.” 2016 WL 1119029, at *1
(Mar. 16, 2016); see also Rhinebolt v. Comm’r of Soc. Sec., No. 2:17-CV-369, 2017 WL 5712564,
at *8 (S.D. Ohio Nov. 28, 2017) (noting that under SSR 16-3p, “an ALJ must focus on the
consistency of an individual’s statements about the intensity, persistence and limiting effects of
symptoms, rather than credibility”), report and recommendation adopted by 2018 WL 494523
(S.D. Ohio Jan. 22, 2018). However, “[t]he two-step process and the factors ALJs consider when
assessing the limiting effects of an individual’s symptoms have not changed with the advent of
SSR 16-3p.” Holder v. Comm’r of Soc. Sec., No. 1:17-CV-00186-SKL, 2018 WL 4101507, at *10
n.5 (E.D. Tenn. Aug. 28, 2018).
The ALJ is still tasked with first determining whether there is an “underlying medically
determinable physical or mental impairment(s) that could reasonably be expected to produce an
individual’s symptoms, such as pain.” SSR 16-3p, 2016 WL 1119029, at *2–3. Then, the ALJ is
responsible for determining the intensity, persistence, and limiting effects of an individual’s
symptoms, including assessing their: (1) daily activities; (2) the location, duration, frequency, and
intensity of pain or other symptoms; (3) factors that precipitate and aggravate the symptoms; (4)
the type, dosage, effectiveness, and side effects of any medication an individual takes or has taken
to alleviate pain or other symptoms; (5) treatment, other than medication, an individual receives
or has received for relief of pain or other symptoms; (6) any measures other than treatment an
individual uses or has used to relieve pain or other symptoms; and (7) any other factors concerning
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an individual’s functional limitations and restrictions due to pain or other symptoms. Id. at *4–8.
As stated above, in the disability decision, the ALJ found that Plaintiff’s statements about
the intensity, persistence, and limiting effects of her symptoms were inconsistent “because the
treatment record as a whole does not support her level of limitation alleged,” as “while the claimant
has a long history of complaints of memory problems, despite extensive testing and mental health
treatment, no diagnoses [have] been made that would account for the claimant’s reported memory
issues.” [Tr. 32]. Further, the ALJ found that Plaintiff’s “performance on neuropsychological
testing has varied significantly,” in addition to Dr. Jones’ opinion “that it seemed most likely that
the claimant’s cognitive impairments were due to her psychiatric illness and medication side
effects.” [Id.]. Similarly, the ALJ noted that while Plaintiff reported increased tremors, no cause
was established for the tremors and Plaintiff had minimal tremors present when preforming testing
activities. [Id.]. Then, the ALJ summarized his finding by stating that “[w]hile looking only to
Dr. Jones’ evaluations, it would be easy to infer that the claimant has significant psychological
limitations, the results of Dr. Jones’ testing and her opinions are not supported by the record as a
whole.” [Id.]. The ALJ detailed that Dr. Craig’s treatment records displayed that Plaintiff was
consistently doing well on medication, and her mood would quickly stabilize after occasional
increased anxiety or depression related to external family stressors. [Id.]. Lastly, the ALJ pointed
to Dr. Raphaeli’s opinions as conflicting with Plaintiff’s claims of disabling limitations. [Id.].
“Despite the linguistic clarification, courts continue to rely on pre-SSR 16-3p authority
providing that the ALJ’s credibility determinations are given great weight.” Getz v. Comm’r of
Soc. Sec., No. CV 18-11625, 2019 WL 2710053, at *3–4 (E.D. Mich. June 10, 2019), report and
recommendation adopted by, 2019 WL 2647260 (E.D. Mich. June 27, 2019) (citing Kilburn v.
Comm’r of Soc. Sec., No. 1:17-CV-603, 2018 WL 4693951, at *7 (S.D. Ohio Sept. 29, 2018); Duty
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v. Comm’r of Soc. Sec., No. 2:17-CV-445, 2018 WL 4442595, at *6 (S.D. Ohio Sept. 18, 2018)).
First, the Court finds that Plaintiff fails to point to any evidence in the medical record or
supporting case law that would require the ALJ to consider the potential plateauing of her
condition. The language of Social Security Ruling 16-3p regarding whether the claimant has
“reached a plateau” is in the context of utilizing available treatments. See Michael R. v. Saul, No.
18 CV 50217, 2019 WL 4014203, at *7 (N.D. Ill. Aug. 26, 2019) (finding the ALJ failed to analyze
whether the plaintiff’s condition had reached a plateau where the ALJ concluded that the plaintiff’s
treatment was too limited to support his allegations, as “[t]he ALJ has not established that more
visits or different treatments would have changed anything”). However, in the present case, the
ALJ relied upon Dr. Jones’ recommendation that Plaintiff obtain a brain MRI and psychological
testing.
[Tr. 32].
Plaintiff has also failed to point to evidence “expressly linking” her
noncompliance with Dr. Jones’ recommendation to any mental disorder. See Borden v. Comm’r
of Soc. Sec., No. 5:20-CV-1391, 2021 WL 3492105 (N.D. Ohio Aug. 9, 2021).
Next, the Court finds that the ALJ appropriately detailed how Dr. Craig’s treatment records
were inconsistent with Plaintiff’s disabling complaints due to her mental limitations. The Court
has previously found that the ALJ properly characterized these treatment records and Dr.
Raphaeli’s opinions in the RFC determination. See, e.g., Christian v. Comm’r of Soc. Sec., No.
3:20-cv-1617-JDG, 2021 WL 3410430, at *17 (N.D. Ohio Aug. 4, 2021) (“The ALJ referenced
Christian’s allegations and then contrasted them with the medical evidence, including examination
findings, as well as the opinion evidence . . . Reading the decision as a whole, it is clear why the
ALJ did not accept the entirety of Christian’s allegations.”).
Therefore, the ALJ’s decision regarding the intensity, persistence, and limiting effects of
Plaintiff’s symptoms was within the ALJ’s discretion. See Ritchie v. Comm’r of Soc. Sec., 540 F.
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App’x 508, 511 (6th Cir. 2013) (recognizing that the Sixth Circuit holds the ALJ’s credibility
findings to be virtually “unchallengeable”) (internal citations omitted). An ALJ’s findings on
credibility “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. Comm’r of Soc. Sec.,
127 F.3d 525, 531 (6th Cir. 1997). Here, the Court finds that the ALJ appropriately reviewed the
intensity, persistence and limiting effects of Plaintiff’s symptoms pursuant to SSR 16-3p. See
Ulman v. Comm’r of Soc. Sec., 693 F.3d 709, 713–14 (6th Cir. 2012) (“As long as the ALJ cite[s]
substantial, legitimate evidence to support his factual conclusions, we are not to second-guess.”).
Accordingly, the Court finds that the ALJ’s finding that the objective record evidence did not
support Plaintiff’s claims of disabling limitations is supported by substantial evidence. The ALJ
was not required to adopt Plaintiff’s testimony in full, and the ALJ appropriately detailed his
reasoning for finding that Plaintiff’s statements concerning the intensity, persistence and limiting
effects of his symptoms were not entirely consistent with the medical evidence and other evidence
in the record.
VI.
CONCLUSION
Based on the foregoing, Plaintiff’s Motion for Judgment on the Pleadings [Doc. 13] will
be DENIED, and the Commissioner’s Motion for Summary Judgment [Doc. 16] will be
GRANTED. The decision of the Commissioner will be AFFIRMED. The Clerk of Court will
be DIRECTED to close this case.
ORDER ACCORDINGLY.
Debra C. Poplin
United States Magistrate Judge
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