Leedy v. Astrue

Filing 16

OPINION. Signed by Judge James P. Jones on 2/8/12. (sc)

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF VIRGINIA
BIG STONE GAP DIVISION
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LEAH BETH LEEDY,
Plaintiff,
v.
MICHAEL J. ASTRUE,
COMMISSIONER OF
SOCIAL SECURITY,
Defendant.

Case No. 2:11CV00005
OPINION
By: James P. Jones
United States District Judge

Lewey K. Lee, Lee & Phipps, PC, Wise, Virginia, for Plaintiff. Eric P.
Kressman, Regional Chief Counsel, Region III, Maija DiDomenico, Assistant
Regional Counsel, Robert W. Kosman, Special Assistant United States Attorney,
Office of the General Counsel, Social Security Administration, Philadelphia,
Pennsylvania, for Defendant.

In this social security case, I affirm the final decision of the Commissioner.

I
Plaintiff Leah Beth Leedy filed this action challenging the final decision of
the Commissioner of Social Security (the “Commissioner”) denying her claims for
disability insurance benefits (“DIB”) and supplemental security income (“SSI”)
benefits pursuant to Titles II and XVI of the Social Security Act (“Act”), 42

U.S.C.A. §§ 401-433, 1381-1383d (West 2003 & Supp. 2011). Jurisdiction of this
court exists pursuant to 42 U.S.C.A. §§ 405(g) and 1383(c)(3).
Leedy filed for benefits on July 26, 2007, alleging that she became disabled
on July 18, 2007. Her claim was denied initially and upon reconsideration. Leedy
received a hearing before an administrative law judge (“ALJ”), during which
Leedy, represented by counsel, and a vocational expert testified. The ALJ denied
Leedy’s claim, and the Social Security Administration Appeals Council denied her
Request for Reconsideration. Leedy then filed her Complaint with this court,
objecting to the Commissioner’s final decision.
The parties have filed cross motions for summary judgment, which have
been briefed. The case is ripe for decision.

II
Leedy was born on February 16, 1985, making her a younger person under
the regulations.

20 C.F.R. § 404.1563(c) (2011).

Leedy has a high school

education 1 and has worked in the past as a cashier, grocery clerk, food preparation
worker, and customer service representative.

1

She originally claimed she was

At the time of the administrative hearing, Leedy was enrolled in her second
semester of a respiratory therapy program at Mountain Empire Community College.
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disabled due to epilepsy, severe anxiety, back and knee problems, high blood
pressure, and sleeping problems.
In November 2005, Leedy sought treatment at Mountain Empire
Neurological Associates for complaints of seizures. Shawn K. Nelson, M.D.,
noted that an EEG and MRI of the brain were negative. Dr. Nelson prescribed
Topamax.
In January 2006, Leedy returned to Mountain Empire Neurological
Associates for a follow-up visit. She reported that she had not had any seizures
since taking Topamax. Leedy also complained of anxiety and was prescribed
Paxil.
Leedy visited the emergency room nine times for various complaints
between January 2007 and January 2008.

In January 2007, Leedy requested

examination for a possible seizure. She reported a history of seizures, but denied
taking her medication. A brain MRI was normal, and Leedy was encouraged to
consult with her primary care physician if her symptoms returned.
The following month, Leedy returned to the emergency room with
complaints of knee pain associated with Osgood-Schlatter disease. A physical
examination revealed normal findings. Leedy was prescribed pain medication and
ace bandages.

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Leedy reported to the emergency room with complaints of an anxiety attack
in April 2007. The emergency room physician noted that she smelled of alcohol.
Leedy was told to consult her primary care doctor for anxiety medication.
In June 2007, Leedy sought emergency care for complaints of back pain
after falling off a ladder. X rays of the sacrum, coccyx, thoracic spine, and lumbar
spine were normal.

Leedy was diagnosed with a lumbar muscle spasm and

prescribed pain medication and a muscle relaxant.
The following month, Leedy complained of left knee pain. She reported no
known injury and stated it “just act[ed] up ever so often.” (R. at 267.) Michael
Sanders, M.D., noted that Leedy had normal range of motion, normal gait, and no
vascular compromise in her left knee. Dr. Sanders administered a steroid injection
and prescribed pain reliever and anti-inflammatory medication.
At the referral of Dr. Sanders, Leedy consulted with Daryl Larke, M.D., of
Community Orthopedics, in July 2007. She complained of sporadic left knee pain
for six or seven years, but was unable to identify any specific injury. Dr. Larke
observed no bruising, swelling, discoloration, or other abnormalities. He noted
normal range of motion in both knees. Dr. Larke opined that Leedy’s knee pain
complaints were “out of proportion to what c[ould] be seen clinically.” (R. at 278.)
In November 2007, Frank Johnson, M.D., a state agency physician,
reviewed Leedy’s medical records to assess her physical residual functional
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capacity. He opined that Leedy had no significant physical limitations and was
capable of performing a range of work. Joseph Duckwall, M.D., independently
reviewed Leedy’s medical records in February 2008 and agreed with Dr. Johnson’s
conclusions.
Julie Jennings, Ph.D., a state agency psychologist, also reviewed Leedy’s
medical records in November 2007. Dr. Jennings reported that Leedy’s anxiety
caused mild restrictions in her daily activities, but that her mental impairment was
not severe.

In February 2008, Louis Perrott, Ph.D., another state agency

psychologist, independently reviewed Leedy’s medical records and also concluded
that her anxiety was not a severe impairment.
In December 2007, Leedy reported to the emergency room with complaints
of back pain associated with her fall off the ladder from five months earlier. With
the exception of decreased range of motion in her back, the emergency room
physician reported normal physical findings and diagnosed acute lumbar
myofascial strain.
In April 2008, B. Wayne Lanthorn, Ph.D., completed a psychological
evaluation of Leedy at the request of her attorney. Leedy stated that she currently
was enrolled in community college and that her grades were “pretty good.” (R. at
419.) She reported smoking one and a half packs of cigarettes daily and admitted a
history of illicit drug use. Upon examination, Dr. Lanthorn noted that Leedy was
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pleasant, oriented, fully cooperative, and displayed no signs of ongoing psychotic
processes or delusional thinking. However, Dr. Lanthorn stated that Leedy had
marked difficulties with anxiety and other areas of emotional conflict.

He

diagnosed her with generalized anxiety disorder, major depressive disorder, social
phobia, panic disorder, and personality disorder. Dr. Lanthorn assessed a GAF
score of 55-60. 2
Leedy attended monthly medication management visits with a psychiatrist,
Uzma Ehtesham, M.D., from January 2008 through July 2009. Dr. Ehtesham
consistently reported that Leedy avoided eye contact and had an anxious affect, but
that she had no attention problems, no hallucinations or delusions, no suicidal
ideations, normal thought content, intact judgment, and improved reality testing.
Dr. Ehtesham assessed a GAF score of 60. She diagnosed Leedy with panic
disorder, generalized anxiety disorder, and bipolar disorder.

However, at

numerous visits, Dr. Ehtesham reported that Leedy’s depression was improving or
stable with Klonopin.
In April 2009, Dr. Ehtesham noted that Leedy was able to maintain a job.
(R. at 460.) Yet, in June 2008 and July 2009, Dr. Ehtesham completed mental
2

The GAF scale is a method of considering psychological, social and occupational
function on a hypothetical continuum of mental health. The GAF scale ranges from 0 to 100,
with serious impairment in functioning at a score of 50 or below. Scores between 51 and 60
represent moderate symptoms or a moderate difficulty in social, occupational, or school
functioning, whereas scores between 41 and 50 represent serious symptoms or serious
impairment in social, occupational, or school functioning. See Am. Psychiatric Ass’n, Diagnostic
and Statistical Manual of Mental Disorders 32 (4th ed. 1994).
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residual functional capacity assessments stating that Leedy was “permanently
disabled” and unable to work. (R. at 432.)
At the administrative hearing held in September 2009, Leedy testified on her
own behalf. Leedy confirmed that she was able to complete many daily activities
such as attend college classes, do homework, clean her room, do laundry, care for
her personal needs, prepare simple meals, drive, and shop in stores.

John

Newman, a vocational expert, also testified. He classified Leedy’s past work as a
cashier as light, unskilled; her past work as a grocery clerk as medium, unskilled;
her past work as a food preparation worker as light, unskilled; and her past work as
a customer services representative as sedentary, semi-skilled.
After reviewing all of Leedy’s records and taking into consideration the
testimony at the hearing, the ALJ determined that she had severe impairments of
arthropathies, anxiety disorder, and history of seizures, but that none of these
conditions, either alone or in combination, met or medically equaled a listed
impairment.
Taking into account Leedy’s limitations, the ALJ determined that Leedy
retained the residual functional capacity to perform a range of medium exertional
work that involved lifting and/or carrying 50 pounds occasionally and 25 pounds
frequently, and sitting or standing for six hours out of an eight-hour workday.
However, the ALJ stated that Leedy could not work at unprotected heights, climb
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ladders, ropes, or scaffolds, or work around hazardous machinery or vibrating
surfaces.

She was limited to jobs with only occasional interactions with the

general public. The vocational expert testified that someone with Leedy’s residual
functional capacity could work as a laundry worker, a packer, or an assembler.
The vocational expert testified that those positions existed in significant numbers
in the national economy. Relying on this testimony, the ALJ concluded that Leedy
was able to perform work that existed in significant numbers in the national
economy and was therefore not disabled under the Act.
Leedy argues that the ALJ’s decision is not supported by substantial
evidence because the ALJ improperly determined Leedy’s residual functional
capacity. For the reasons below, I disagree.

III
The plaintiff bears the burden of proving that she is under a disability.
Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972). The standard for
disability is strict.

The plaintiff must show that her “physical or mental

impairment or impairments are of such severity that [s]he is not only unable to do
h[er] previous work but cannot, considering h[er] age, education, and work
experience, engage in any other kind of substantial gainful work which exists in
the national economy . . . .” 42 U.S.C.A. § 423(d)(2)(A).
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In assessing DIB and SSI claims, the Commissioner applies a five-step
sequential evaluation process. The Commissioner considers whether the claimant:
(1) has worked during the alleged period of disability; (2) has a severe impairment;
(3) has a condition that meets or equals the severity of a listed impairment; (4)
could return to her past relevant work; and (5) if not, whether she could perform
other work present in the national economy. See 20 C.F.R. §§ 404.1520(a)(4),
416.920(a)(4) (2011). If it is determined at any point in the five-step analysis that
the claimant is not disabled, the inquiry immediately ceases.

Id.; McLain v.

Schweiker, 715 F.2d 866, 868-69 (4th Cir. 1983). The fourth and fifth steps of the
inquiry require an assessment of the claimant’s residual functional capacity, which
is then compared with the physical and mental demands of the claimant’s past
relevant work and of other work present in the national economy. Id. at 869.
In accordance with the Act, I must uphold the Commissioner’s findings if
substantial evidence supports them and the findings were reached through
application of the correct legal standard. Craig v. Chater, 76 F.3d 585, 589 (4th
Cir. 1996). Substantial evidence means “such relevant evidence as a reasonable
mind might accept as adequate to support a conclusion.” Richardson v. Perales,
402 U.S. 389, 401 (1971) (internal quotation marks and citation omitted).
Substantial evidence is “more than a mere scintilla of evidence but may be
somewhat less than a preponderance.” Laws v. Celebrezze, 368 F.2d 640, 642 (4th
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Cir. 1966). It is the role of the ALJ to resolve evidentiary conflicts, including
inconsistencies in the evidence. Seacrist v. Weinberger, 538 F.2d 1054, 1956-57
(4th Cir. 1976). It is not the role of this court to substitute its judgment for that of
the Commissioner. Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990).
Leedy argues that the ALJ’s determination of her residual functional
capacity is not supported by substantial evidence. Specifically, Leedy asserts that
the ALJ improperly discounted the opinions of Dr. Lanthorn and Dr. Ehtesham,
and erroneously afforded weight to the opinions of the state agency mental health
experts.
In weighing medical opinions, the ALJ must consider factors such as the
examining relationship, the treatment relationship, the supportability of the
opinion, and the consistency of the opinion with the record. 20 C.F.R. §§
404.1527(d), 416.927(d) (2011). Although treatment relationship is a significant
factor, the ALJ is entitled to afford a treating source opinion “significantly less
weight” where it is not supported by the record. Craig, 76 F.3d at 590.
In the present case, the ALJ considered the opinion of Dr. Lanthorn, but
gave little weight to his assessment, for several reasons. First, Dr. Lanthorn’s
relationship with Leedy was limited — his opinion is based on a one-time
examination, made at the request of Leedy’s attorney. Second, Dr. Lanthorn’s
opinion is inconsistent with his own mental status evaluation as well as the other
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medical evidence of record. For instance, Dr. Lanthorn indicated that Leedy had
marked difficulties with anxiety and other areas of emotional conflict; however, he
assigned Leedy a GAF score of 55-60, indicating only moderate symptoms or
limitations. (R. at 425.)

Furthermore, contrary to Dr. Lanthorn’s opinion of

debilitating mental limitations, the medical evidence demonstrates that Leedy was
never hospitalized for mental problems, and that her anxiety required only
conservative treatment and was controlled with medication. (R. at 454, 460, 470,
472, 474.) “If a symptom can be reasonably controlled by medication or treatment,
it is not disabling.” Gross v. Heckler, 785 F.2d 1163, 1166 (4th Cir. 1986).
With respect to Dr. Ehtesham, the ALJ’s evaluation of her opinion is also
supported by substantial evidence. Although Dr. Ehtesham was Leedy’s treating
psychiatrist, her assessment is not well-supported by the other medical evidence of
record and is contrary to her own treatment notes. Dr. Ehtesham concluded that
Leedy was “permanently disabled” and unable to work, even though her mental
status findings were largely unremarkable, she reported on numerous occasions
that Leedy’s symptoms were improving or stable with Klonopin, and she
consistently assessed Leedy a GAF score of 60, indicating only moderate
symptoms and limitations. (R. at 430-39, 454-87.) Dr. Ehtesham’s opinion was
also inconsistent with her earlier finding in April 2009 that Leedy was able to
maintain a job. (R. at 460.)
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Finally, substantial evidence supports the ALJ’s decision to afford weight to
the opinions rendered by the state agency mental health experts. Leedy argues that
the opinions of Dr. Jennings and Dr. Perrott are unreliable because they were given
prior to Leedy’s treatment by Dr. Ehtesham. However, this argument has no merit.
Dr. Jennings and Dr. Perrott both opined that Leedy’s anxiety disorder was not
severe. While the ALJ afforded some weight to these opinions, she did not adopt
them outright. (R. at 24.) Instead, the ALJ properly reviewed and considered Dr.
Ehtesham’s treatment records, as well as the other medical evidence of record,
before determining that Leedy’s anxiety disorder was a severe impairment that
limited her to jobs with only occasional contact with the general public. The fact
that Dr. Jennings and Dr. Perrott conducted their reviews before the record was
closed does not render the ALJ’s decision unsupported by substantial evidence.

IV
For the foregoing reasons, the plaintiff’s Motion for Summary Judgment will
be denied, and the defendant’s Motion for Summary Judgment will be granted. A
final judgment will be entered affirming the Commissioner’s final decision
denying benefits.
DATED: February 8, 2012
/s/ James P. Jones
United States District Judge
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