Wilson v. Colvin

Filing 22

MEMORANDUM OPINION. Signed by Magistrate Judge Pamela Meade Sargent on 09/21/2015. (Bordwine, Robin)

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF VIRGINIA
ABINGDON DIVISION
JUDSON S. WILSON,
Plaintiff
v.
CAROLYN W. COLVIN,
Acting Commissioner of
Social Security,
Defendant

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Civil Action No. 1:14cv00028
MEMORANDUM OPINION
By: PAMELA MEADE SARGENT
United States Magistrate Judge

I. Background and Standard of Review
Plaintiff, Judson S. Wilson, (“Wilson”), filed this action challenging the
final decision of the Commissioner of Social Security, (“Commissioner”), denying
his claims for disability insurance benefits, (“DIB”), and supplemental security
income, (“SSI”), under the Social Security Act, as amended, (“Act”), 42 U.S.C.A.
§§ 423 and 1381 et seq. (West 2011 & West 2012). Jurisdiction of this court is
pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). This case is before the
undersigned magistrate judge upon transfer by consent of the parties pursuant to 28
U.S.C. § 636(c)(1).
The court’s review in this case is limited to determining if the factual
findings of the Commissioner are supported by substantial evidence and were
reached through application of the correct legal standards. See Coffman v. Bowen,
829 F.2d 514, 517 (4th Cir. 1987). Substantial evidence has been defined as
“evidence which a reasoning mind would accept as sufficient to support a
particular conclusion. It consists of more than a mere scintilla of evidence but may
be somewhat less than a preponderance.” Laws v. Celebrezze, 368 F.2d 640, 642
(4th Cir. 1966). “‘If there is evidence to justify a refusal to direct a verdict were the
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case before a jury, then there is “substantial evidence.”’” Hays v. Sullivan, 907
F.2d 1453, 1456 (4th Cir. 1990) (quoting Laws, 368 F.2d at 642).
The record shows that Wilson filed his applications for SSI and DIB on
September 27, 2010, alleging disability as of June 15, 2008, due to depression,
mood disorder, anger issues, suicidal ideations and paranoia. (Record, (“R.”), at
234-35, 241-44, 270, 330.) The claims were denied initially and upon
reconsideration. (R. at 138-40, 143-45, 148-54, 163-65, 167-72, 174-76.) Wilson
then requested a hearing before an administrative law judge, (“ALJ”). (R. at 177.)
A hearing was held on December 18, 2012, at which Wilson was represented by
counsel. (R. at 28-56.)
By decision dated January 23, 2013, the ALJ denied Wilson’s claims. (R. at
14-22.) The ALJ found that Wilson met the disability insured status requirements
of the Act for DIB purposes through March 31, 2009. (R. at 16.) The ALJ found
that Wilson had not engaged in substantial gainful activity since June 15, 2008, the
alleged onset date. (R. at 16.) The ALJ found that the medical evidence established
that Wilson had severe impairments, namely depression, a mood disorder, an
anxiety disorder, post-traumatic stress disorder, (“PTSD”), a personality disorder
and a history of alcohol abuse, but he found that Wilson did not have an
impairment or combination of impairments that met or medically equaled one of
the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. at 16-18.)
The ALJ found that Wilson had the residual functional capacity to perform the full
range of work at all exertional levels. (R. at 19.) Due to his nonexertional
limitations, the ALJ found that Wilson could perform only simple, routine,
repetitive tasks in a low-stress environment that required no more than occasional
decision making, changes in the work setting and interaction with co-workers and
the public and that allowed him to be off task no more than 10 percent of a normal
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workday. (R. at 19.) The ALJ found that Wilson could perform his past relevant
work as a farm laborer and a ripsaw operator. (R. at 22.) Thus, the ALJ concluded
that Wilson was not under a disability as defined by the Act and was not eligible
for DIB or SSI benefits. (R. at 22.) See 20 C.F.R. §§ 404.1520(f), 416.920(f)
(2015).
After the ALJ issued his decision, Wilson pursued his administrative
appeals, but the Appeals Council denied his request for review. (R. at 1-6, 9.)
Wilson then filed this action seeking review of the ALJ’s unfavorable decision,
which now stands as the Commissioner’s final decision. See 20 C.F.R. §§ 404.981,
416.1481 (2015). This case is before this court on Wilson’s motion for summary
judgment filed October 28, 2014,1 and the Commissioner’s motion for summary
judgment filed January 5, 2015.
II. Facts
Wilson was born in 1971, (R. at 234, 241), which classifies him as a
“younger person” under 20 C.F.R. §§ 404.1563(c), 416.963(c). Wilson has a ninth
grade education 2 and past work experience as a farm worker and a saw operator.
(R. at 36, 48-49.) Wilson testified at his hearing that he no longer consumed
alcoholic beverages. (R. at 35.) He stated that he could not remember the last time
that he consumed an alcoholic beverage, but continued to state that “I don’t drink
much anymore.” (R. at 35.) Wilson stated that seeing and talking to a counselor

1

In his brief, Wilson requested oral argument; however, he filed a notice waiving oral
argument on March 26, 2015. (Docket Item No. 21.)
2

Although Wilson reported on his Disability Report that he completed the tenth grade,
(R. at 270), he testified at his hearing that he completed the ninth grade. (R. at 36.)
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helped him a lot. (R. at 35-36.) He stated that he quit his job as a farm worker
because he could not get along with his supervisor and co-workers. (R. at 36-37.)
John Newman, a vocational expert, also was present and testified at
Wilson’s hearing. (R. at 46-54.) Newman classified Wilson’s work as a farm
laborer as heavy3 and unskilled and his work as saw operator as medium 4 and
semi-skilled. (R. at 49-50.) Newman was asked to consider a hypothetical
individual of Wilson’s age, education and work experience who had no exertional
limitations, but who would be limited to simple, routine, repetitive tasks in a lowstress environment that did not require more than occasional decision making,
changes in the work setting or interaction with the public or co-workers. (R. at 50.)
Newman stated that such an individual could perform Wilson’s past work as a saw
operator and a farm worker. (R. at 50.) When asked if the same hypothetical
individual who would be off task 20 percent of the workday due to anxiety and
depression, and who would be expected to have 10 to 12 absences over the course
of a work year, Newman stated that such an individual could perform Wilson’s
past work as a farm worker and a saw operator. (R. at 50-51.) Newman was asked
to consider a hypothetical individual who could have no interaction with the
public, who could have only occasional interaction with supervisors, who would be
absent from work at least two days monthly and who would be off task 25 percent
of the workday, he stated there would be no jobs that such an individual could
perform, including Wilson’s past work as a farm worker and a saw operator. (R. at
3

Heavy work is defined as work that involves lifting no more than 100 pounds at a time
with frequent lifting or carrying of objects weighing up to 50 pounds. If an individual can do
heavy work, he also can do sedentary, light and medium work. See 20 C.F.R. §§ 404.1567(d),
416.967(d) (2015).
Medium work involves lifting items weighing up to 50 pounds at a time with frequent
lifting or carrying of items weighing up to 25 pounds. If an individual can do medium work, he
also can do sedentary and light work. See 20 C.F.R. §§ 404.1567(c), 416.967(c) (2015).
4

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51.) Newman stated that there would be no jobs available that an individual could
perform if he had a Global Assessment of Functioning score, (“GAF”), 5 of 45. 6 (R.
at 53.) When asked to consider a hypothetical individual who had no ability to
relate to co-workers, to deal with the public and to deal with work stresses,
Newman stated that there would be no jobs available that such an individual could
perform. (R. at 53.)
In rendering his decision, the ALJ reviewed medical records from Joseph
Leizer, Ph.D., a state agency psychologist; Dr. Michael Hartman, M.D., a state
agency physician; Dr. Andrew Bockner, M.D., a state agency physician; Smyth
County Community Hospital; Wellmont Bristol Regional Medical Center;
Meadowview Health Clinic; Southwestern Virginia Mental Health Institute;
Johnston Memorial Hospital; Highlands Community Services Board; Wade Smith,
M.S., a licensed senior psychological examiner; and Holston Family Health
Center. Wilson’s attorney also submitted additional medical evidence from
Southwest Virginia Community Health Systems, Inc., to the Appeals Council. 7
On September 12, 2009, Wilson presented to emergency room at Johnston
Memorial Hospital, (“Johnston Memorial”), with complaints of anxiety and
depression resulting from relationship issues. (R. at 448-54.) Wilson reported that
The GAF scale ranges from zero to 100 and “[c]onsider[s] psychological, social, and
occupational functioning on a hypothetical continuum of mental health-illness.” DIAGNOSTIC
AND STATISTICAL MANUAL OF MENTAL DISORDERS FOURTH EDITION, (“DSM-IV”), 32
(American Psychiatric Association 1994).
5

A GAF score of 41-50 indicates that the individual has “[s]erious symptoms ... OR any
serious impairment in social, occupational, or school functioning….” DSM-IV at 32.
6

7

Since the Appeals Council considered and incorporated this additional evidence into the
record in reaching its decision, (R. at 1-6), this court also must take these new findings into
account when determining whether substantial evidence supports the ALJ's findings. See Wilkins
v. Sec'y of Dep't of Health & Human Servs., 953 F.2d 93, 96 (4th Cir. 1991).
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he wanted to shoot his father. (R. at 448.) Wilson left the hospital without the
medical staff knowing. (R. at 449.) After a few hours, the police 8 were able to
detain Wilson, and he was returned to the hospital. (R. at 451.) Wilson was
diagnosed with alcohol intoxication and homicidal ideation. (R. at 453.) Wilson
was prescreened for treatment placement by Shirley Whited, M.S.W., a social
worker with Highlands Community Services Board. (R. at 460-67.) Whited
determined that mental illness and substance abuse were present. (R. at 460-67.)
She noted that there was a substantial likelihood of serious physical harm to others,
evidenced by Wilson’s report that he wanted to kill his father by “blowing his head
off.” (R. at 462.) Whited diagnosed depression, not otherwise specified, and
alcohol abuse. (R. at 462.) She assessed his then-current GAF score at 45. (R. at
462.) Wilson was not willing to be treated voluntarily. (R. at 465.) Involuntary
admission and inpatient treatment was recommended. (R. at 465.) However, no
psychiatric facility would accept him due to his intoxication. (R. at 452.) Wilson
contracted for safety, stating that he felt much calmer and did not intend to harm
anyone or himself, and was released to go home. (R. at 452.)
On June 26, 2010, Wilson presented to the emergency room at Johnston
Memorial for complaints of depression and suicide ideation. (R. at 473-75.) Wilson
reported that he had a plan to either hang himself or to shoot himself. (R. at 473.)
He stated that he had not experienced similar symptoms in the past. (R. at 473.) He
was transferred to Ridgeview Pavilion. 9 (R. at 474.)

8

An Emergency Custody Order was issued for Wilson for his return to Johnston
Memorial for completion of the evaluation. (R. at 457.)
9

The record does not contain the medical records from Ridgeview Pavilion.
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On June 27, 2010, Wilson was admitted to Wellmont Bristol Regional
Medical Center for depression and suicidal ideations. (R. at 373-410.) Wilson
reported that his most recent stressor was dealing with his biological father having
a relationship with his ex-girlfriend, the mother of his child. (R. at 373.) Wilson
denied any active medical problems. (R. at 373.) He denied drug or alcohol
problems, although when he was tested, his blood alcohol level was 0.187. (R. at
375.) His GAF score upon admission was assessed at 2010 to 30.11 (R. at 376.)
Wilson was given medication, and his psychiatric symptoms resolved by discharge
on July 1, 2010. (R. at 373.) Wilson was diagnosed with major depressive disorder.
(R. at 373.) His GAF score upon discharge was assessed at 50 to 55.12 (R. at 373.)
On August 6, 2010, Wilson presented to the emergency room at Johnston
Memorial after becoming despondent as a result of alcoholic consumption. (R. at
475-86.) Wilson stated that he wanted to harm his ex-girlfriend, his father and
himself. (R. at 477.) A temporary detention order was obtained. (R. at 477.) Wilson
was found to be intoxicated with a blood alcohol level of 0.441. (R. at 477, 483.)
His liver function tests also were elevated. (R. at 477.) Wilson reported consuming
five to eight beers on a daily basis. (R. at 477.) He was admitted and diagnosed
with alcohol intoxication, suicidal and homicidal ideation and elevated liver
function. (R. at 478.)

10

A GAF score of 11 to 20 indicates that the individual has “[s]ome danger of hurting
self or others ... OR occasionally fails to maintain minimal personal hygiene ... OR gross
impairment in communication ....” DSM-IV at 32.
11

A GAF score of 21 to 30 indicates that the individual’s “[b]ehavior is considerably
influenced by delusions or hallucinations OR serious impairment in communication or judgment
… OR inability to function in almost all areas….” DSM-IV at 32.
A GAF score of 51-60 indicates that the individual has “[m]oderate symptoms ... OR
moderate difficulty in social, occupational, or school functioning....” DSM-IV at 32.
12

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On August 7, 2010, Wilson was admitted to the Southwestern Virginia
Mental Health Institute, (“SVMHI”), on a temporary detention order. (R. at 43031, 487-94.) It was noted that Wilson had contacted SVMHI three years prior and
made suicidal and homicidal statements regarding both his father and ex-girlfriend.
(R. at 430.) Wilson reported that he made these threats after having too much to
drink. (R. at 430.) Wilson was placed on an alcohol withdrawal regimen. (R. at
430.) Upon discharge on August 9, 2010, Wilson’s mood was euthymic, and he
had an appropriate affect. (R. at 431.) His memory was intact for both recent and
remote events. (R. at 431.) Wilson’s insight was limited, and his judgment was
deemed as fair. (R. at 431.) He was diagnosed with alcohol intoxication, resolved;
alcohol dependence; nicotine dependence; and mood disorder, secondary to
alcohol intoxication. (R. at 430-31.) Wilson’s then-current GAF score was assessed
at 55. (R. at 431.)
On February 3, 2011, Joseph Leizer, Ph.D., a state agency psychologist,
completed a Psychiatric Review Technique form, (“PRTF”), indicating that Wilson
suffered from an affective disorder and an alcohol substance addiction disorder. (R.
at 99.) He opined that there was insufficient evidence to determine what effect
Wilson’s impairments had on his performance of activities of daily living, on his
ability to maintain social functioning and to maintain concentration, persistence or
pace. (R. at 99.) Leizer noted that Wilson was scheduled for a consultative
examination and failed to keep the appointment. (R. at 99.) Leizer opined that the
evidence did not show that Wilson’s condition was disabling. (R. at 101.)
On June 14, 2011, Carol Wilson, F.N.P., a family nurse practitioner with
Meadowview Health Clinic, saw Wilson for hypertension, abdominal pain and
anxiety. (R. at 503-04, 557-58.) Wilson reported that he did not consume alcoholic
beverages; however, Nurse Wilson reported that he smelled of alcohol. (R. at 503,
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557.) Nurse Wilson reported that Wilson made poor eye contact, had a flat affect
and had no suicidal or homicidal ideations. (R. at 503, 557.) Wilson was diagnosed
with anxiety disorder, not otherwise specified, and behavioral health counseling
was recommended. (R. at 504, 558.) On June 28, 2011, Donna E. Boggs,
L.C.S.W., a licensed clinical social worker with Meadowview Health Clinic, saw
Wilson for a behavioral health counseling evaluation. (R. at 505, 559.) Wilson
reported having a difficult time dealing with his father starting a relationship with
his ex-girlfriend, the mother of his child. (R. at 505, 559.) He stated that he had
been so depressed that he had contemplated harming himself. (R. at 505, 559.) He
reported having nightmares and obsessively thinking about the situation, admitting
that he could not “move past it.” (R. at 505, 559.) Boggs diagnosed PTSD. (R. at
505, 559.)
On July 5, 2011, Wilson stated that he had overcome some of the emotional
pain in regard to his father and ex-girlfriend, but was feeling angry. (R. at 506,
560.) Boggs noted that Wilson was careful to say that he had no plans to harm
anyone. (R. at 506, 560.) Boggs reported smelling alcohol on Wilson, and she
planned to address alcohol abuse at the next scheduled session. (R. at 506, 560.)
On July 12, 2011, Wilson was very agitated and angry. (R. at 507, 561.) He stated
that his ex-girlfriend stayed all week with his father, who lived next door to him.
(R. at 507, 561.) Boggs reported the smell of alcohol on Wilson, but he did not
appear to be intoxicated. (R. at 507, 561.) Boggs suspected that Wilson was
drinking to self-medicate. (R. at 507, 561.) Wilson stated that he consumed only a
couple of beers occasionally. (R. at 507, 561.) On July 27, 2011, Wilson had an
improved affect and mood. (R. at 508, 562.) Wilson reported that he was beginning
to manage the strong emotions around his issues with his father and ex-girlfriend.
(R. at 508, 562.) On July 29, 2011, Nurse Wilson saw Wilson for complaints of
depression and sleep disturbance. (R. at 509-11, 563-65.) Wilson stated that he
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consumed beer only when his father bought it and that he would consume only
four to five beers. (R. at 509, 563.) Nurse Wilson diagnosed depression with
anxiety and alcohol abuse. (R. at 509-10, 563-64.)
On August 30, 2011, Boggs reported that Wilson presented with a “fairly
calm demeanor.” (R. at 567.) Wilson reported that he no longer ruminated on the
issue of his father. (R. at 567.) He reported that he did not like a lot of social
interaction and that he was easily angered and agitated. (R. at 567.) On September
14, 2011, Wilson reported that he felt “fairly stable.” (R. at 568.) He stated that he
was not as depressed. (R. at 568.) Boggs diagnosed major depression, not
otherwise specified. (R. at 568.) On September 21, 2011, Wilson reported that he
continued to be depressed, but that he was managing his symptoms better. (R. at
569.) He stated that he preferred to be alone and was socially isolative. (R. at 569.)
Boggs noted that Wilson had some prominent schizoid features. (R. at 569.) She
reported that she had not noticed any obvious sign of alcohol abuse. (R. at 569.)
On September 30, 2011, Boggs completed a Patient Injury And Work Status
(Medical Opinion) form, indicating that Wilson was unable to work due to his
diagnoses

of

recurrent

major

depression

with

schizoid

features

and

suicidal/homicidal ideations. (R. at 521.)
On January 25, 2012, Boggs noted that Wilson seemed to be in a “somewhat
better place” with the issues regarding his father and ex-girlfriend. (R. at 544.) On
March 6, 2012, Boggs reported that Wilson was “fairly stable.” (R. at 539.) Wilson
reported becoming more depressed and agitated when he did not attend treatment.
(R. at 539.) On March 10, 2012, Wilson reported an increase in depression and
anxiety. (R. at 534.) He reported alcohol use. (R. at 534.) Nurse Wilson reported
that Wilson had poor eye contact and poor concentration. (R. at 535.) She
diagnosed major depression, not otherwise specified, and alcohol abuse, not
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otherwise specified. (R. at 535.) On March 13, 2012, Wilson reported that he
continued to have transient thoughts of self-harm and at times wanted to harm his
father and ex-girlfriend. (R. at 537.) He stated that he was using the skills that he
learned to move beyond these thoughts. (R. at 537.) On May 25, 2012, Wilson
reported that he felt shaky every day. (R. at 530.) He stated that he worked puzzles
when he became stressed. (R. at 530.) On July 18, 2012, Wilson reported
deterioration in his progress since his last visit. (R. at 633-34.) Melissa DoaneWilliams, L.C.S.W., a licensed clinical social worker with Meadowview Health
Clinic, reported that Wilson had slow, withdrawn behavior, minimal insight,
depressed mood, flat and angry affect, slowed speech and thoughts of helplessness
and worthlessness. (R. at 633.) Doane-Williams diagnosed dysthymia. (R. at 633.)
She assessed Wilson’s then-current GAF score at 50. (R. at 633.)
On August 15, 2012, Wilson reported feeling more paranoid, stating that he
would hide in bushes when a car passed by. (R. at 631-32.) Nurse Wilson
diagnosed dysthymia. (R. at 632.) On August 22, 2012, Doane-Williams reported
that Wilson had appropriate behavior, improved insight, flat affect, slowed speech
and thoughts of helplessness and worthlessness. (R. at 629-30.) She completed a
Patient Injury And Work Status (Medical Opinion) form, indicating that Wilson
was unable to work due to his diagnosis of dysthymia. (R. at 611.) On August 31,
2012, Doane-Williams reported that Wilson had appropriate behavior, appropriate
insight, depressed mood, flat affect, slowed speech and coherent thought processes.
(R. at 627-28.) On September 14, 2012, Wilson stated that his mood seemed to
“roller coaster.” (R. at 624-25.) He stated that he was feeling better, but knew that,
later, his mood would start to feel down. (R. at 624.) Nurse Wilson diagnosed
depression with anxiety and alcohol abuse, not otherwise specified. (R. at 624.) On
September 28, 2012, Doane-Williams reported that Wilson had appropriate
behavior, appropriate insight, cheerful mood, bright affect, normal speech and
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coherent thought processes. (R. at 622-23.) Doane-Williams diagnosed dysthymia.
(R. at 622.) She assessed Wilson’s then-current GAF score at 50. (R. at 622.)
On October 24, 2012, Doane-Williams completed a mental assessment
indicating that Wilson had an unlimited ability to maintain personal appearance.
(R. at 613-14.) She opined that Wilson had a seriously limited, but not precluded,
ability to follow work rules; to use judgment; to interact with supervisors; to
function independently; to maintain attention and concentration; to understand,
remember and carry out simple instructions; to behave in an emotionally stable
manner; to relate predictably in social situations; and to demonstrate reliability. (R.
at 613-14.) Doane-Williams opined that Wilson had no useful ability to relate to
co-workers; to deal with the public; to deal with work stresses; and to understand,
remember and carry out complex and detailed instructions. (R. at 613-14.)
On October 26, 2012, Wilson reported deterioration in his progress since his
last visit. (R. at 617.) Doane-Williams reported that Wilson had appropriate
behavior, limited insight, depressed mood, flat affect, normal speech and coherent
thought processes. (R. at 617.) On November 14, 2012, Doane-Williams reported
that Wilson had lost 10 pounds and appeared to be underweight. (R. at 615.)
Wilson had appropriate behavior, limited insight, depressed mood, flat affect,
normal speech and coherent thought processes. (R. at 615.) On December 27,
2012, Wilson reported having a difficult time getting through the holiday season
due to the situation with his father and ex-girlfriend. (R. at 666.) Doane-Williams
reported that Wilson had a depressed mood and angry affect. (R. at 666.) She
assessed his then-current GAF score at 50. (R. at 666.) On January 10, 2013,
Wilson was counseled to assist him with anger management and depression. (R. at
659.) Wilson reported an increase in depressive symptoms since the holidays. (R.
at 664.) He reported increased thoughts of suicide. (R. at 664.) On January 22,
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2013, Nurse Wilson reported that Wilson had poor eye contact, flat affect and poor
concentration. (R. at 661-63.) On January 30, 2013, Wilson was counseled to assist
him with his relationship issues. (R. at 664.) Wilson had a bright affect and
cheerful mood. (R. at 659.) Doane-Williams assessed Wilson’s then-current GAF
score at 55. (R. at 659.)
On September 15, 2011, Wade Smith, M.S., a licensed senior psychological
examiner, evaluated Wilson at the request of Disability Determination Services.
(R. at 515-19.) Wilson reported being charged with driving under the influence on
three occasions. (R. at 515.) Smith noted a fine tremor in Wilson’s hand when he
extended his arm. (R. at 516.) Wilson had intact attention, concentration, shortterm memory and recent and remote memory. (R. at 517.) Smith reported that
Wilson’s interpersonal skills were limited by anxiety and personality traits. (R. at
518.) Smith found that Wilson was able to comprehend and follow both simple and
some detailed job instructions. (R. at 518.) Wilson’s concentration and persistence
appeared adequate to meet the demands of simple or detailed work-related
decisions. (R. at 518.) Wilson had a moderately to markedly impaired ability to
interact with others in an appropriate manner and to tolerate normal job stress. (R.
at 518.) Wilson had no limitations in his ability to adapt to changes in the
workplace, to be aware of normal hazards or to take appropriate precaution. (R. at
518.) Smith diagnosed anxiety disorder, not otherwise specified; depressive
disorder, not otherwise specified; rule out alcohol abuse; and personality disorder,
not otherwise specified. (R. at 519.) He assessed Wilson’s then-current GAF score
at 45. (R. at 519.)
On October 3, 2011, Dr. Andrew Bockner, M.D., a state agency physician,
completed a PRTF, indicating that Wilson suffered from an affective disorder, an
anxiety-related disorder and a personality disorder. (R. at 122.) Dr. Bockner opined
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that Wilson had mild difficulties in his ability to perform activities of daily living
and in maintaining concentration, persistence or pace. (R. at 122.) He found that
Wilson had moderate difficulties in maintaining social functioning and had
experienced no repeated episodes of decompensation of extended duration. (R. at
122.)
Dr. Bockner completed a mental assessment, indicating that Wilson had no
significant limitations in his ability to remember locations and work-like
procedures; to understand, remember and carry out very short, simple instructions;
to perform activities within a schedule, maintain regular attendance and be
punctual within customary tolerances; to sustain an ordinary routine without
special supervision; to make simple work-related decisions; to ask simple
questions or request assistance; and to maintain socially appropriate behavior and
to adhere to basic standards of neatness and cleanliness. (R. at 124-25.) He found
that Wilson had moderate limitations in his ability to understand, remember and
carry out detailed instructions; to maintain attention and concentration for extended
periods, to work in coordination with or in proximity to others without being
distracted by them; to complete a normal workday and workweek without
interruptions from psychologically based symptoms and to perform at a consistent
pace without an unreasonable number and length of rest periods; to interact
appropriately with the general public; to accept instructions and respond
appropriately to criticism from supervisors; and to get along with co-workers or
peers without distracting them or exhibiting behavioral extremes. (R. at 124-25.)
On October 4, 2011, Dr. Michael Hartman, M.D., a state agency physician,
determined that there was insufficient evidence to support a decision on Wilson’s
claim. (R. at 113-14.)
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On February 24, 2012, Wilson was seen at Holston Family Health Center for
anxiety and depression. (R. at 528.) Pat Baston, L.C.S.W., a licensed clinical social
worker, noted that Wilson was obviously very angry. (R. at 528.) Wilson reported
having suicidal thoughts, but denied intent. (R. at 528.) Baston reported that
Wilson was “slightly paranoid” when in a group setting. (R. at 528.) She diagnosed
major depressive disorder, recurrent, moderate; and panic disorder, with
agoraphobia. (R. at 528.) On March 2, 2012, Wilson was seen for anxiety and
depression. (R. at 527.) Wilson reported that his ex-girlfriend was not allowing him
to have visitation with his daughter. (R. at 527.) It was reported that Wilson was
anxious. (R. at 527.) Wilson was diagnosed with major depressive disorder,
recurrent, moderate; and panic disorder with agoraphobia. (R. at 527.)
III. Analysis
The Commissioner uses a five-step process in evaluating DIB and SSI
claims. See 20 C.F.R. §§ 404.1520, 416.920 (2015). See also Heckler v. Campbell,
461 U.S. 458, 460-62 (1983); Hall v. Harris, 658 F.2d 260, 264-65 (4th Cir. 1981).
This process requires the Commissioner to consider, in order, whether a claimant
1) is working; 2) has a severe impairment; 3) has an impairment that meets or
equals the requirements of a listed impairment; 4) can return to his past relevant
work; and 5) if not, whether he can perform other work. See 20 C.F.R. §§
404.1520, 416.920. If the Commissioner finds conclusively that a claimant is or is
not disabled at any point in this process, review does not proceed to the next step.
See 20 C.F.R. §§ 404.1520(a), 416.920(a) (2015).
Under this analysis, a claimant has the initial burden of showing that he is
unable to return to his past relevant work because of his impairments. Once the
claimant establishes a prima facie case of disability, the burden shifts to the
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Commissioner. To satisfy this burden, the Commissioner must then establish that
the claimant has the residual functional capacity, considering the claimant’s age,
education, work experience and impairments, to perform alternative jobs that exist
in the national economy. See 42 U.S.C.A. §§ 423(d)(2)(A), 1382c(a)(3)(A)-(B)
(West 2011 & West 2012); McLain v. Schweiker, 715 F.2d 866, 868-69 (4th Cir.
1983); Hall, 658 F.2d at 264-65; Wilson v. Califano, 617 F.2d 1050, 1053 (4th Cir.
1980).
Wilson argues that substantial evidence does not exist to support the ALJ’s
finding that he could perform his past relevant work. (Brief In Support Of Motion
For Summary Judgment, (“Plaintiff’s Brief”), at 8-11.) Wilson argues that the ALJ
erred by ignoring the restrictions placed upon him by psychologist Smith.
(Plaintiff’s Brief at 8-9.) Wilson does not contest the ALJ’s findings with regard to
his physical residual functional capacity.
As stated above, the court’s function in this case is limited to determining
whether substantial evidence exists in the record to support the ALJ’s findings.
This court must not weigh the evidence, as this court lacks authority to substitute
its judgment for that of the Commissioner, provided her decision is supported by
substantial evidence. See Hays, 907 F.2d at 1456. In determining whether
substantial evidence supports the Commissioner’s decision, the court also must
consider whether the ALJ analyzed all of the relevant evidence and whether the
ALJ sufficiently explained his findings and his rationale in crediting evidence. See
Sterling Smokeless Coal Co. v. Akers, 131 F.3d 438, 439-40 (4th Cir. 1997).
Wilson argues that the ALJ erred by failing to give full consideration to the
restrictions placed upon him by psychologist Smith when determining the severity
of his mental impairments and the resulting effects on his work-related abilities.
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(Plaintiff’s Brief at 8-9.) Wilson notes that Smith assigned a GAF score of 45,
denoting serious symptoms. (Plaintiff’s Brief at 9.) Wilson also asserts that Smith
found him to be credible because he stated that Wilson was not exaggerating his
symptoms in order to obtain disability benefits. (Plaintiff’ Brief at 9.) Based on my
review of the record, I do not find Wilson’s arguments persuasive.
The ALJ considered Smith’s assessment and acknowledged the GAF score
of 45. (R. at 21.) The ALJ concluded that Smith’s commentary about Wilson’s
ability to work indicated that Wilson could do simple work with limited interaction
with others and limited job stress. (R. at 21, 518.) Smith reported that Wilson
presented with a normal level of energy and that his fine and gross motor skills
appeared to be within normal limits. (R. at 518.) Smith found that Wilson was able
to comprehend and follow both simple and some detailed job instructions. (R. at
518.) Wilson’s concentration and persistence appeared adequate to meet the
demands of simple or detailed work-related decisions. (R. at 518.) Wilson reported
that he needed no special reminders to take care of his personal needs and
grooming or to take his medication. (R. at 287-88.) He also reported that he
finished what he started. (R. at 291.) The record shows that Wilson had an intact
memory for both recent and remote events. (R. at 431, 517.) Smith described
Wilson’s ability for attention and concentration as intact. (R. at 517.) Smith
reported that Wilson had no limitations in his ability to adapt to changes in the
workplace, to be aware of normal hazards or to take appropriate precaution. (R. at
518.) While Smith opined that Wilson showed a moderately to markedly impaired
ability to interact with others in an appropriate manner and to tolerate normal job
stress, the ALJ accommodated these limitations by limiting Wilson to no more than
occasional interaction with the public or co-workers in a low-stress environment.
(R. at 19, 518.) See Washington v. Soc. Sec. Admin., Comm’r, 503 Fed. App’x 881,
883 (11th Cir. 2013) (finding that a limitation to “occasional interaction with the
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general public and co-workers” adequately accommodated a claimant’s moderate
limitation in social functioning).
While Smith assessed Wilson’s GAF score at 45, (R. at 519), the record
includes significantly higher GAF scores ranging between 50 and 55, denoting
moderate symptoms, after treatment for depression and cessation of alcohol. (R. at
373-74, 431, 615, 617, 622, 627, 629, 633, 638, 640, 642, 647, 651, 653, 655, 657,
659, 664, 666.) Smith reported that Wilson was not seen as exaggerating his
symptoms, but noted the inconsistency between Wilson’s statement that he did not
abuse alcohol and the results of his June 2010 blood alcohol testing. (R. at 375,
516-17.) In addition, the record shows that Wilson’s symptoms of anxiety,
depression and anger were worse when he consumed alcohol. (R. at 503, 506, 507,
509-10, 534-35.) In March 2012, Nurse Wilson noted that Wilson had resumed
alcohol consumption and she instructed him to stop alcohol consumption due to its
depressant effects. (R. at 535.)
The ALJ noted that he was assigning some weight to the opinions of Boggs
and Doane-Williams, although neither of them are acceptable medical sources. (R.
at 21.) See 20 C.F.R. §§ 404.1513(a), (d), 416.913(a), (d) (2015). The ALJ noted
that their opinions were not fully consistent with the evidence of record, including
their own progress notes. (R. at 21.) Doane-Williams assessed Wilson with
dysthymia, a mild chronic depression. (R. at 640.) On July 13, 2012, Wilson
presented with a brighter affect and mood. (R. at 638.) He reported that he was
better and less depressed. (R. at 638.) He stated that counseling helped him “a lot.”
(R. at 35-36.) In addition, the record shows that with medication and the abstinence
of alcohol, Wilson’s psychiatric symptoms resolved. (R. at 373, 508, 539, 562,
568, 569, 622.) “If a symptom can be reasonably controlled by medication or
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treatment, it is not disabling.” Gross v. Heckler, 785 F.2d 1163, 1166 (4th Cir.
1986).
Based on the above reasoning, I find that substantial evidence exists to
support the ALJ’s weighing of the medical evidence in determining Wilson’s
mental residual functional capacity. I also conclude that substantial evidence
supports the ALJ’s finding that Wilson could perform his past relevant work as a
farm laborer and a saw operator. An appropriate order and judgment will be
entered.

DATED:

September 21, 2015.

Pamela Meade Sargent

/s/
UNITED STATES MAGISTRATE JUDGE

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