Castle v. Colvin

Filing 22

MEMORANDUM OPINION. Signed by Magistrate Judge Pamela Meade Sargent on 01/06/2015. (Bordwine, Robin)

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF VIRGINIA
BIG STONE GAP DIVISION
GREGORY ALLEN CASTLE,
Plaintiff
v.
CAROLYN W. COLVIN,
Acting Commissioner of
Social Security,
Defendant

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Civil Action No. 2:13cv00047
MEMORANDUM OPINION

By: PAMELA MEADE SARGENT
United States Magistrate Judge

I. Background and Standard of Review
Plaintiff, Gregory Allen Castle, (“Castle”), 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
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(4th Cir. 1966). “‘If there is evidence to justify a refusal to direct a verdict were the
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 Castle protectively filed his applications for SSI and
DIB on February 23, 2011, alleging disability as of February 3, 2011, due to
diabetes, numbness in his fingers, arthritis, hypertension and high cholesterol.
(Record, (“R.”), at 175-76, 193, 197.) The claims were denied initially and upon
reconsideration. (R. at 89-91, 96-99, 101-03.) Castle then requested a hearing
before an administrative law judge, (“ALJ”). (R. at 105.) A video hearing was held
on October 23, 2012, at which Castle was represented by counsel. (R. at 22-42.)

By decision dated November 2, 2012, the ALJ denied Castle’s claims. (R. at
12-21.) The ALJ found that Castle met the disability insured status requirements of
the Act for DIB purposes through December 31, 2014. (R. at 14.) The ALJ found
that Castle had not engaged in substantial gainful activity since February 3, 2011,
the alleged onset date. (R. at 14.) The ALJ found that the medical evidence
established that Castle had severe impairments, namely type II diabetes with
peripheral

neuropathy

in

the

fingers,

arthritis,

hypertension

and

hypercholesterolemia, but the ALJ found that Castle 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 14-16.) The ALJ
found that Castle had the residual functional capacity to perform medium work,1
that required no more than occasional pushing/pulling with the upper extremities,
1

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) (2014).
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climbing of ladders, ropes or scaffolds, kneeling and crawling, no more than
frequent climbing of ramps or stairs, balancing, stooping, crouching and feeling
with his upper extremities and that did not require concentrated exposure to
temperatures, vibrations, pollutants and chemicals and hazards such as moving
machinery and unprotected heights. (R. at 16-17.) The ALJ found that Castle was
unable to perform his past relevant work. (R. at 19.) Based on Castle’s age,
education, work history and residual functional capacity and the testimony of a
vocational expert, the ALJ found that a significant number of jobs existed in the
national economy that Castle could perform, including jobs as a hospital cleaner, a
kitchen helper and a hand packager. (R. at 20-21.) Thus, the ALJ concluded that
Castle was not under a disability as defined by the Act and was not eligible for
DIB or SSI benefits. (R. at 21.) See 20 C.F.R. §§ 404.1520(g), 416.920(g) (2014).

After the ALJ issued his decision, Castle pursued his administrative appeals,
(R. at 6-8), but the Appeals Council denied his request for review. (R. at 1-4.)
Castle 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 (2014). This case is before this court on Castle’s motion for summary
judgment filed March 3, 2014, and the Commissioner’s motion for summary
judgment filed June 4, 2014.
II. Facts 2

Castle was born in 1956, (R. at 175), which, at the time of the ALJ’s
decision, classified him as a “person of advanced age” under 20 C.F.R. §§
2

Because Castle does not challenge any of the ALJ’s findings with regard to his physical
impairments, the undersigned will focus on the facts relevant to Castle’s alleged mental
impairments.
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404.1563(e), 416.963(e). Castle has a high school education and past work
experience as a supervisor for a production plant, a machine operator and a
machine repairer. (R. at 26, 36, 198.) Castle testified at his hearing that he was
terminated from his previous job because he was taking extra bathroom breaks and
was not able to keep up with his job. (R. at 27.) Castle also testified as to the
effects of several of his physical impairments on his work-related abilities, but he
did not offer any testimony as to any mental impairment. (R. at 29-35.) Castle
admitted that he was not receiving any ongoing mental health treatment. (R. at 41.)

Vocational expert, Anthony T. Michael, Jr., testified at Castle’s hearing. (R.
at 35-40, 154.) The ALJ asked Michael to consider a hypothetical individual of
Castle’s age, education and work experience who could perform medium work
with only occasional pushing and pulling with the upper extremities, climbing of
ladders, ropes and scaffolds, kneeling and crawling, who could frequently climb
ramps or stairs and balance, stoop, crouch and feel with his upper extremities and
who would need to avoid concentrated exposure to cold and heat, vibration,
irritants, chemicals and hazards such as moving machinery and heights. (R. at 37.)
Michael testified that such an individual could not perform any of Castle’s past
work. (R. at 37.) Michael identified jobs that existed in significant numbers in the
national or regional economy that such an individual could perform, including jobs
as a hospital cleaner, a kitchen helper and a hand packager. (R. at 37-38.) Michael
stated that a significant number of jobs existed should the same individual be
limited to light work, including jobs as a mail clerk, a routing clerk and a price
marker. (R. at 38-39.) Michael also stated that there would be no jobs available that
the individual could perform should he be required to take two additional breaks of
15 to 20 minutes each throughout the workday or if he would miss at least two
days of work per month. (R. at 39-40.)
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In rendering his decision, the ALJ reviewed records from Dr. John Sadler,
M.D., a state agency physician; Holston Medical Group; The Regional Eye Center;
Dr. William Humphries, M.D.; Baker Eye Associates; Dr. Bryan Arnette, M.D.;
and B. Wayne Lanthorn, Ph.D., a licensed clinical psychologist.

Treatment notes from Holston Medical Group from March 2005 through
February 2010 show that Castle had a normal mental status. (R. at 251, 265, 269,
275, 278, 281, 285, 290, 293, 298, 302, 304, 376, 446.) On March 28, 2012, Castle
reported that he was depressed and anxious. (R. at 576.) He reported feeling
worthless because he was unable to do anything. (R. at 576.) Dr. Bryan Arnette,
M.D., diagnosed major depression, single episode. (R. at 578.) He prescribed
alprazolam, or generic Xanax, and paroxetine hydrochloride, or generic Paxil. (R.
at 579.) On April 30, 2012, Castle reported that his depression was “doing much
better.” (R. at 568.) He reported that he was tolerating Paxil well. (R. at 568.) Dr.
Arnette noted that Castle’s depression was stable. (R. at 571.) Dr. Arnette
diagnosed major depression, single episode. (R. at 570.) On August 29, 2012,
Castle reported that his mood was up and down. (R. at 596.) He reported that he
had not been taking his alprazolam “that much,” but that he was doing okay. (R. at
596.)

On August 21, 2012, B. Wayne Lanthorn, Ph.D., a licensed clinical
psychologist, evaluated Castle at the request of Castle’s attorney. (R. at 583-91.)
The Wechsler Adult Intelligence Scale-Fourth Edition, (“WAIS-IV”), was
administered, and Castle obtained a full-scale IQ score of 67. (R. at 584.) Castle
reported consuming “one or two beers” daily. (R. at 586.) He denied receiving any
formal psychiatric or psychotherapeutic intervention. (R. at 586.) Castle reported
seeing flashes of animals, which he associated with his diabetes and visual
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problems. (R. at 586.) He reported that he was often “nervous” and that he would
“shake all over.” (R. at 587.) Lanthorn described Castle’s mood as an agitated
depression. (R. at 587.) Lanthorn diagnosed major depressive disorder, single
episode, severe; generalized anxiety disorder; pain disorder associated with both
psychological factors and general medical conditions, chronic; and borderline
intellectual functioning. (R. at 590.) He assessed Castle’s then-current Global
Assessment of Functioning score, (“GAF”), 3 at 50.4 (R. at 590.)

Lanthorn completed a mental assessment indicating that Castle had a
limited, but satisfactory, ability to understand, remember and carry out simple job
instructions and to maintain personal appearance. (R. at 592-94.) He found that
Castle had a seriously limited ability to follow work rules, to function
independently, to understand, remember and carry out detailed instructions and to
behave in an emotionally stable manner. (R. at 592-93.) Lanthorn further found
that Castle had no useful ability to relate to co-workers, to deal with the public, to
use judgment, to interact with supervisors, to deal with work stresses, to maintain
attention/concentration, to understand, remember and carry out complex
instructions, to relate predictably in social situations and to demonstrate reliability.
(R. at 592-93.) Lanthorn also opined that Castle would be absent from work more
than two days a month due to his impairments. (R. at 594.)

3

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).
4

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

The Commissioner uses a five-step process in evaluating DIB and SSI
claims. See 20 C.F.R. §§ 404.1520, 416.920 (2014). 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) (2014).

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
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).

In his brief, Castle argues that the ALJ erred by failing to find that he
suffered from a severe mental impairment. (Plaintiff’s Memorandum In Support Of
His Motion For Summary Judgment, (“Plaintiff’s Brief”), at 4-6.) The Social
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Security regulations define a “nonsevere” impairment as an impairment or
combination of impairments that does not significantly limit a claimant's ability to
do basic work activities. See 20 C.F.R. §§ 404.1521(a), 416.921(a) (2014). Basic
work activities include walking, standing, sitting, lifting, pushing, pulling,
reaching, carrying, handling, seeing, hearing, speaking, understanding, carrying out
and remembering simple job instructions, use of judgment, responding
appropriately to supervision, co-workers and usual work situations and dealing
with changes in a routine work setting. See 20 C.F.R. §§ 404.1521(b), 416.921(b)
(2014). The Fourth Circuit held in Evans v. Heckler, that “[a]n impairment can be
considered as ‘not severe’ only if it is a slight abnormality which has such a
minimal effect on the individual that it would not be expected to interfere with the
individual's ability to work, irrespective of age, education, or work experience.”
734 F.2d 1012, 1014 (4th Cir. 1984) (quoting Brady v. Heckler, 724 F.2d 914, 920
(11th Cir. 1984)) (citations omitted).

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 her findings and her rationale in crediting evidence.
See Sterling Smokeless Coal Co. v. Akers, 131 F.3d 438, 439-40 (4th Cir. 1997).

At particular issue in this case is when an ALJ may reject the only
psychological evidence of record and then find that a claimant does not suffer from
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a severe mental impairment. The Social Security regulations address how the ALJ
must evaluate opinion evidence in 20 C.F.R. §§ 404.1527, 416.927. Among the
factors to be considered in the ALJ’s weighing of a medical opinion are whether a
treatment relationship existed, the length, nature and extent of treatment, whether
the source examined the claimant, the specialized training of the source and the
opinion’s supportability and consistency with the other evidence of record. See 20
C.F.R. §§ 404.1527(c)(1)-(6), 416.927(c)(1)-(6) (2014). This regulation also states
that the Commissioner will not give any significance to a medical source’s opinion
on an issue reserved for the Commissioner’s decision, such as the decision as to
whether an impairment is severe. See 20 C.F.R. §§ 404.1527(d)(1)-(3),
416.927(d)(1)-(3) (2014).

In this case, the only psychological evidence of record was the report of
Lanthorn’s August 21, 2012, evaluation. The ALJ’s opinion states that he
“considered Dr. Lanthorn’s opinion, though it has less probative weight … because
Dr. Lanthorn examined the claimant just one time and the evidence of record does
not fully support the opinion.” (R. at 15.) The ALJ then continues to detail how
Lanthorn’s opinion as to the severity of Castle’s mental impairment is inconsistent
with the other evidence of record. (R. at 15-16.) While the court may not agree
with the ALJ’s weighing of the evidence, as stated above, the court may not
substitute its judgment for the ALJ’s, as long as the ALJ’s weighing is supported
by the substantial evidence, as it is here.

Even so, once Lanthorn’s opinion as to the severity of Castle’s mental
impairment is set aside, the remaining uncontradicted evidence of record shows
that Castle suffered from major depression serious enough to warrant his treating
physician prescribing medication in an attempt to treat it. (R. at 568, 570-71, 578-9-

79, 596). Likely because Lanthorn’s evaluation occurred after the state agency’s
initial and reconsideration determinations, the record does not contain any
Psychiatric Review Technique forms or any assessments of Castle’s mental
impairment on his work-related abilities completed by state agency psychologists.
That being the case, I cannot find that substantial evidence supports the ALJ’s
finding that Castle does not suffer from a severe mental impairment. I will remand
Castle’s claim to the Commissioner for further development of the record as to the
severity of Castle’s mental impairment. An appropriate order and judgment will be
entered.

DATED:

January 6, 2015.

/s/

Pamela Meade Sargent
UNITED STATES MAGISTRATE JUDGE

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