Mullins v. Colvin

Filing 16

MEMORANDUM OPINION. Signed by Magistrate Judge Pamela Meade Sargent on 05/02/2016. (Bordwine, Robin)

IN THE UNITED STATES DISTRICT COURT
FOR THE WESTERN DISTRICT OF VIRGINIA
BIG STONE GAP DIVISION
REBECCA L. MULLINS,
Plaintiff

)
)
)
)
)
CAROLYN W. COLVIN,
)
Acting Commissioner of Social Security, )
Defendant
)

Civil Action No. 2:14cv00050
MEMORANDUM OPINION
By: PAMELA MEADE SARGENT
United States Magistrate Judge

I. Background and Standard of Review
Plaintiff, Rebecca L. Mullins, (“Mullins”), filed this action challenging the
final decision of the Commissioner of Social Security, (“Commissioner”),
determining that she was not eligible for supplemental security income, (“SSI”),
under the Social Security Act, as amended, (“Act”), 42 U.S.C.A. § 1381 et seq.
(West 2012). Jurisdiction of this court is pursuant to 42 U.S.C. § 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). Mullins has requested oral argument in
this matter.
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 Mullins protectively filed her application for SSI on
June 21, 2011, alleging disability as of March 7, 2009, due to nerves; a back
condition; shoulder and hip problems; swelling of her feet; carpal tunnel syndrome;
a heart attack; breathing problems; depression; stomach problems; fatigue; and
difficulty concentrating. (Record, (“R.”), at 175-78, 188, 197, 226.) The claim was
denied initially and on reconsideration. (R. at 89-91, 95-97, 100, 103-05, 107-09.)
Mullins then requested a hearing before an administrative law judge, (“ALJ”). (R.
at 110-11.) A video hearing was held on May 10, 2013, at which Mullins was
represented by counsel. (R. at 27-57.)
By decision dated May 24, 2013, the ALJ denied Mullins’s claim. 1 (R. at 1121.) The ALJ found that Mullins had not engaged in substantial gainful activity
since June 21, 2011, the date of Mullins’s application. (R. at 13.) The ALJ
determined that the medical evidence established that Mullins suffered from severe
impairments, namely hypertension; cervical and lumbar degenerative disc disease;
obesity; a history of tachycardia; degenerative joint disease of the shoulders;
myalgias; post-traumatic stress disorder, (“PTSD”); major depressive disorder;
anxiety disorder; and possible borderline intellectual functioning, but he found that
Mullins did not have an impairment or combination of impairments listed at or
medically equal to one listed at 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. at
13.) The ALJ found that Mullins had the residual functional capacity to perform
1

Mullins also filed an application for disability insurance benefits, (“DIB”), which was
denied because she had not worked long enough to qualify for DIB. (R. at 85-87, 171-72.)
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sedentary work,2 that did not require more than two hours of standing and/or
walking in an eight-hour workday and six hours of sitting in an eight-hour
workday; that did not require more than occasional climbing, balancing, stooping,
kneeling, crouching or crawling; that did not require more than occasional
overhead reaching; that did not require constant reaching in all directions; that did
not require more than occasional interaction with co-workers and the public; that
allowed her to be off task 10 percent of an eight-hour workday and allowed her to
be absent up to one workday a month; and that did not require more than
occasional decision making and changes in the work setting. (R. at 16.) The ALJ
found that Mullins had no past relevant work. (R. at 19.) Based on Mullins’s age,
education, work history and residual functional capacity and the testimony of a
vocational expert, the ALJ found that jobs existed in significant numbers in the
national economy that Mullins could perform, including jobs as a general
production worker, a material handler and a packer. (R. at 20.) Thus, the ALJ
found that Mullins was not under a disability as defined by the Act and was not
eligible for SSI benefits. (R. at 21.) See 20 C.F.R. § 416.920(g) (2015).
After the ALJ issued his decision, Mullins pursued her administrative
appeals, (R. at 7), but the Appeals Council denied her request for review. (R. at 15.) Mullins 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. § 416.1481
(2015). The case is before this court on Mullins’s motion for summary judgment

2

Sedentary work involves lifting items weighing up to 10 pounds at a time and
occasionally lifting or carrying articles like docket files, ledgers and small tools. Although a
sedentary job is defined as one which involves sitting, a certain amount of walking or standing is
often necessary in carrying out job duties. Jobs are sedentary if walking or standing are required
occasionally and other sedentary criteria are met. See 20 C.F.R. § 416.967(a) (2015).
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filed July 9, 2015, and the Commissioner’s motion for summary judgment filed
August 12, 2015.
II. Facts
Mullins was born in 1964, (R. at 31, 175), which, at the time of the ALJ’s
decision, classified her as a “younger person” under 20 C.F.R. § 416.963(c).
Mullins obtained her general equivalency development, (“GED”), diploma and has
a degree in photography. (R. at 31, 189.) She has worked as a cook; a caretaker for
the elderly; a housekeeper; and a waitress. (R. at 189.) Mullins stated that she
could sit for up to 30 minutes without interruption and stand for up to one hour
without interruption. (R. at 38.) She stated that she was molested by her brother
when she was a child and that she had been seeing a counselor for two years. (R. at
41.) Mullins stated that she had no problems cooking for herself or taking care of
her personal needs. (R. at 46.)
Robert Jackson, a vocational expert, also was present and testified at
Mullins’s hearing. (R. at 51-55.) Jackson was asked to consider a hypothetical
individual of Mullins’s age, education and no work history, who had the residual
functional capacity to perform medium3 work that did not require more than
occasional climbing, balancing, stooping, kneeling, crouching or crawling; and
who had no limitations on standing, walking or sitting. (R. at 51.) Jackson
identified jobs that existed in significant numbers at the medium, unskilled level
that such an individual could perform, including jobs as an assembler, a packer and
3

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, she
also can do sedentary and light work. See 20 C.F.R. § 416.967(c) (2015).
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a cleaner. (R. at 51-52.) Jackson was asked to consider a second hypothetical
individual, who had the residual functional capacity to perform light4 work that did
not require more than occasional climbing, balancing, stooping, kneeling,
crouching or crawling; who could occasionally overhead reach and frequently
reach; and who could stand/walk and sit for six hours in an eight-hour workday.
(R. at 52.) He identified jobs that existed in significant numbers at the light,
unskilled level that such an individual could perform, including jobs as an
inspector-grader, a packer and a cashier. (R. at 52.)
Jackson was asked to consider the second hypothetical individual, but who
could stand/walk for about two hours and sit for up to six hours in eight-hour
workday, who could only occasionally make decisions and be exposed to
occasional changes in the work setting; who could occasionally interact with the
public and co-workers; who would be off task 10 percent of the workday; and who
would be absent from work no more than one workday a month. (R. at 53.) He
identified jobs that existed in significant numbers at the sedentary, unskilled level
that such an individual could perform, including jobs as a small parts assembler, a
packer and a material handler. (R. at 53-54.)
Jackson was asked to consider a fourth hypothetical individual, who had the
residual functional capacity to perform light work that allowed a sit-stand option at
will; that did not require climbing ladders, ropes or scaffolds, balancing, kneeling,
crouching or crawling; that did not require more than occasional climbing of ramps
or stairs, pushing, pulling or stooping; that did not require more than occasional
4

Light work involves lifting items weighing up to 20 pounds at a time with frequent
lifting or carrying of items weighing up to 10 pounds. If someone can perform light work, she
also can perform sedentary work. See 20 C.F.R. §§ 404.1567(b), 416.967(b) (2015).
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overhead reaching and frequent reaching; that required no more than occasional
decision making and occasional changes in the work setting, occasional interaction
with the public and co-workers; and that allowed for being off task at least 20
percent of the workday and being absent from work at least two workdays a month
(R. at 54-55.) He stated that there would be no jobs available that such an
individual could perform. (R. at 55.)
In rendering his decision, the ALJ reviewed records from Russell County
Public Schools; Julie Jennings, Ph.D., a state agency psychologist; Dr. Richard
Surrusco, M.D., a state agency physician; Jo McClain, P.C., a state agency
professional counselor; Dr. Joseph Duckwall, M.D., a state agency physician;
Abingdon Orthopedic Associates, P.C.; Johnston Memorial Hospital; Crystal
Burke, L.C.S.W., a licensed clinical social worker; Dr. Charles Wilson, M.D.; Dr.
Thomas E. Roatsey, D.O.; Mountain View Regional Medical Center; and B.
Wayne Lanthorn, Ph.D., a licensed clinical psychologist.
By way of background, an MRI of Mullins’s neck and back performed in
2003 was within normal limits. (R. at 348.) In October 2004, an MRI of Mullins’s
lumbar spine showed a bulging disc at the L5-S1 level, but no nerve entrapment or
compression was noted. (R. at 298, 340.)
On April 24, 2008, Mullins was admitted to Johnston Memorial Hospital
with complaints of chest pain. (R. at 272-97.) An EKG was normal, as well as
chest x-rays. (R. at 273.) She was discharged the next day with diagnoses of chest
pain, hypertension, tobacco abuse and depression. (R. at 272-74.) Mullins saw her
primary care physician, Dr. Charles Wilson, M.D., on April 30, 2008, and her
blood pressure reading was 128/86. (R. at 321.) Mullins complained of some
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“intermittent anxiety” and reported that her antidepressant medication helped her
depression “considerably.” (R. at 321.) Dr. Wilson diagnosed moderately wellcontrolled blood pressure and minor anxiety. (R. at 321.) On March 12, 2009,
Mullins reported that she was still having problems with anxiety “from time to
time, but much better than before.” (R. at 314.) Her blood pressure was controlled,
and she was advised to quit smoking. (R. at 312.)
On June 25, 2009, Mullins sought treatment with Dr. Thomas E. Roatsey,
D.O., to establish a primary care physician. (R. at 390.) At that time, she
complained of hypertension, anxiety, depression, chronic low back pain and
muscle spasm. (R. at 390.) Mullins stated that she had to quit work due to back
pain and muscle spasms. (R. at 390.) Dr. Roatsey reported that Mullins had
tenderness in the lumbar spine with decreased range of motion and positive straight
leg raising on the left with weakness and a mild foot drop. (R. at 390.) He noted
that Mullins’s affect was flat, and she had poor eye contact. (R. at 390.) Dr.
Roatsey noted that, “I advised [patient] to file for disability. She is unable to work
and with her physical problems, mental problems, age, and education, she will not
be able to ever return to work.” (R. at 390.) Mullins returned to Dr. Roatsey in
October 2009 for a rash on her arm. (R. at 389.)
Mullins next saw Dr. Roatsey in February 2010, when she complained of
dizziness in the morning, head and neck pain with numbness and headaches. (R. at
388.) Examination revealed no abnormalities other than tenderness in the back. (R.
at 388.) Dr. Roatsey diagnosed vertigo, hypertension, low back pain and anxiety.
(R. at 388.) On December 6, 2010, Mullins complained of depression and back
pain. (R. at 499.) Dr. Roatsey noted that, although Mullins’s affect was a “little
flat,” she did not appear very anxious. (R. at 499.) Her blood pressure reading was
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112/80. (R. at 499.) Mullins’s back was “a little tender with decreased range of
motion.” (R. at 499.) Dr. Roatsey recommended diet and exercise and advised her
to return in six months or as needed. (R. at 499.) On April 13, 2011, Mullins
complained that her heart had been racing, and she had been tired and weak. (R. at
497.) Her blood pressure reading was 98/60. (R. at 497.) Mullins had no abnormal
physical examination findings other than a dog bite on her leg. (R. at 497.) Dr.
Roatsey diagnosed fatigue, hyperlipidemia, hypertension and tachycardia. (R. at
497.) An EKG showed no abnormalities. (R. at 497.) On April 16, 2011, Mullins
was admitted to Mountain View Regional Medical Center for complaints of chest
pain. (R. at 405-11, 413-64.) At that time, Mullins’s blood pressure reading was
144/89, and a cardiac monitor showed a normal sinus rhythm. (R. at 404, 407.)
Chest x-rays were normal, and an ECG was consistent with an infarction. (R. at
491.) She was diagnosed with chest pain of unknown etiology that was treated with
aspirin and nitroglycerin paste. (R. at 407, 411.)
On May 5, 2011, Mullins’s physical examination was normal, with the
exception of some tenderness in her back. (R. at 495.) Mullins reported that her
medication had made a difference in her chest pain and hypertension and that she
felt good. (R. at 495.) On June 6, 2011, Mullins reported muscle pain after starting
Zocor. (R. at 493.) Physical examination revealed mild musculoskeletal tenderness
and a blood pressure reading of 130/78. (R. at 493.) Dr. Roatsey diagnosed
myalgias secondary to Zocor. (R. at 493.) On October 7, 2011, Mullins saw Dr.
Roatsey to discuss increasing her dosage of Zoloft. (R. at 606-08.) A mental status
examination revealed a depressed mood and affect, but appropriate insight and
judgment. (R. at 608.) Mullins’s physical examination was normal, except for
impaired range of motion and tenderness in the low back, but Mullins had normal
strength, reflexes and gait. (R. at 607-08.)
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On February 17, 2012, Mullins stated that she felt well with minor
complaints of congestion and anxiety. (R. at 600.) Although Mullins had
tenderness and reduced range of motion of the lumbosacral spine, she had normal
strength and reflexes. (R. at 601-02.) A mental status examination revealed a
depressed mood, but appropriate insight and judgment. (R. at 601.) On July 26,
2012, Mullins complained of fatigue and weight gain after quitting smoking three
months earlier. (R. at 593.) A mental status examination revealed a normal mood
and affect, as well as appropriate judgment and insight. (R. at 595.) Blood tests to
evaluate Mullins’s fatigue were normal. (R. at 595-96.) On September 27, 2012,
Mullins reported that she felt well and had a “good energy level.” (R. at 588.)
Physical examination revealed a well-controlled blood pressure of 120/74 and no
abnormalities other than tenderness of the right knee. (R. at 589-90.) Mental status
examination revealed a normal mood and affect and appropriate judgment and
insight. (R. at 589.) On April 1, 2013, Mullins reported decreased energy and poor
sleep. (R. at 619.) She denied any medication side effects and considered her
medication effective. (R. at 619.) A physical examination revealed general
musculoskeletal tenderness and tenderness with abnormal tissue texture at the T5T6 level. (R. at 621.) A mental status examination revealed an anxious mood and
affect, but appropriate insight and judgment. (R. at 621.) Dr. Roatsey noted that
Mullins was “doing well” on Klonopin. (R. at 622.)
On May 2, 2013, Dr. Roatsey completed a physical assessment, indicating
that Mullins could occasionally lift and carry items weighing 15 to 20 pounds and
frequently lift and carry items weighing 10 to 15 pounds. (R. at 639-41.) He opined
that Mullins could stand and/or walk a total of two hours in an eight-hour workday
and that she could do so for 30 minutes to one hour without interruption. (R. at
639.) Dr. Roatsey opined that Mullins could sit a total of three hours in an eight-9-

hour workday and that she could do so for up to one hour without interruption. (R.
at 640.) He found that Mullins could occasionally stoop and never climb, kneel,
balance, crouch or crawl. (R. at 640.) Dr. Roatsey found that Mullins’s abilities to
reach and to push/pull were limited. (R. at 640.) He found that Mullins was limited
in her ability to work around heights, moving machinery, temperature extremes,
humidity and vibration. (R. at 641.) He found that Mullins would be absent from
work more than two days a month. (R. at 641.)
That same day, Dr. Roatsey completed a mental assessment, indicating that
Mullins had a limited, but satisfactory, ability to maintain personal appearance. (R.
at 643-45.) He opined that Mullins had a seriously limited ability to follow work
rules; to relate to co-workers; to interact with supervisors; to function
independently; to maintain attention/concentration; to understand, remember and
carry out complex, detailed and simple job instructions; to behave in an
emotionally stable manner; to relate predictably in social situations; and to
demonstrate reliability. (R. at 643-44.) Dr. Roatsey opined that Mullins had no
useful ability to deal with the public; to use judgment; and to deal with work
stresses. (R. at 643.) He found that Mullins would be absent from work more than
two days a month. (R. at 645.)
On December 29, 2010, Crystal Burke, L.C.S.W., a licensed clinical social
worker, saw Mullins for complaints of depression. (R. at 395-96.) Mullins also
reported several incidences of sexual assault from the ages eight to 18. (R. at 395.)
Burke reported that Mullins appeared depressed and tearful. (R. at 395.) Burke
diagnosed major depressive disorder and PTSD. (R. at 395.) On September 26,
2011, Mullins reported that her symptoms of depression had increased after she
was denied disability benefits and had recently separated from her husband. (R. at
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503.) Mullins stated that she thought about driving off the road after she learned
that her disability claim had been denied. (R. at 503.) Burke reported that Mullins
was dressed appropriately, she had good hygiene, and her conversation and eye
contact were good. (R. at 503.) Burke diagnosed depression and anxiety. (R. at
503.) She assessed Mullins’s then-current Global Assessment of Functioning,
(“GAF”), 5 score at 75. 6 (R. at 503.) On February 20, 2013, Mullins reported pain
and depression. (R. at 613.) A mental status examination revealed a depressed
mood with hopelessness and helplessness, but no obvious psychotic symptoms. (R.
at 613.) Burke diagnosed depressive disorder and anxiety. (R. at 613.) On March
20, 2013, Mullins reported several stressors, including stress with a neighbor, as
well as family, financial and health stressors. (R. at 612.) Mullins also reported
poor daily functioning and poor life quality due to pain. (R. at 612.) Burke
diagnosed depressive disorder and anxiety disorder. (R. at 612.)
On March 26, 2013, Burke completed a mental assessment indicating that
Mullins had a seriously limited ability to make all occupational, performance and
personal/social adjustments. (R. at 615-17.) She opined that Mullins would be
absent from work more than two days a month. (R. at 617.)
On July 26, 2011, Dr. Richard Surrusco, M.D., a state agency physician,
opined that Mullins could perform medium work. (R. at 64-65.) He opined that
Mullins could occasionally climb, balance, stoop, kneel, crouch and crawl. (R. at
5

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).
6

A GAF score of 71 to 80 indicates that “[i]f symptoms are present, they are transient
and expectable reactions to psychosocial stressors ...; no more than slight impairment in social,
occupational, or school functioning....” DSM-IV at 32.
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64-65.) No manipulative, visual, communicative or environmental limitations were
noted. (R. at 65.)
On August 2, 2011, Julie Jennings, Ph.D., a state agency psychologist,
completed a Psychiatric Review Technique form, (“PRTF”), finding that Mullins
suffered from an affective disorder and an anxiety-related disorder. (R. at 62-63.)
She opined that Mullins was mildly restricted in her ability to perform her
activities of daily living, in maintaining social functioning and in maintaining
concentration, persistence or pace. (R. at 62.) Jennings opined that Mullins had not
experienced repeated episodes of decompensation of extended duration. (R. at 62.)
On December 8, 2011, Dr. Joseph Duckwall, M.D., a state agency physician,
opined that Mullins could perform medium work. (R. at 75-77.) He opined that
Mullins could occasionally climb, balance, stoop, kneel, crouch and crawl. (R. at
76.) No manipulative, visual, communicative or environmental limitations were
noted. (R. at 76-77.)
On December 12, 2011, Jo McClain, P.C., a state agency professional
counselor, completed a PRTF, finding that Mullins suffered from an affective
disorder and an anxiety-related disorder. (R. at 74-75.) She opined that Mullins
was mildly restricted in her ability to perform her activities of daily living, in
maintaining social functioning and in maintaining concentration, persistence or
pace. (R. at 74.) McClain opined that Mullins had not experienced repeated
episodes of decompensation of extended duration. (R. at 74.)
On April 23, 2013, B. Wayne Lanthorn, Ph.D., a licensed clinical
psychologist, evaluated Mullins at the request of Mullins’s attorney. (R. at 624-34.)
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The Wechsler Adult Intelligence Scale - Fourth Edition, (“WAIS-IV”), was
administered, and Mullins obtained a full-scale IQ score of 79. (R. at 625.) Mullins
reported that her anti-depressant medication was helpful; however, she stated that
her depression level was a seven on a scale of one to 10. (R. at 628.) Lanthorn
reported that Mullins was nervous, tense and fidgety. (R. at 629.) The Minnesota
Multiphasic Personality Inventory – 2 (“MMPI-2”), was administered and
indicated that Mullins’s psychopathology was serious and included confused
thinking, difficulties with logic and concentration and impaired judgment. (R. at
630, 632.) Mullins reported that she used to have frequent nightmares related to
childhood sexual abuse, but they were now less frequent. (R. at 628.) Lanthorn
diagnosed chronic PTSD; major depressive disorder, recurrent, moderate or
possibly greater; anxiety disorder with generalized anxiety due to chronic physical
problems, limitations, etc.; and borderline intellectual functioning. (R. at 632.)
Lanthorn assessed Mullins’s then-current GAF score at 50.7 (R. at 633.)
Lanthorn completed a mental assessment, indicating that Mullins had a more
than satisfactory ability to understand, remember and carry out simple job
instructions. (R. at 635-37.) He opined that Mullins had a seriously limited ability
to follow work rules; to relate to co-workers; to deal with the public; to use
judgment; to interact with supervisors; to deal with work stresses; to function
independently; to maintain attention/concentration; to understand, remember and
carry out detailed job instructions; to maintain personal appearance; to behave in
an emotionally stable manner; to relate predictably in social situations; and to
demonstrate reliability. (R. at 635-36.) Lanthorn found that Mullins had no ability
to understand, remember and carry out complex job instructions. (R. at 636.) He
7

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.
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found that Mullins would be absent from work more than two days a month. (R. at
637.)
III. Analysis
The Commissioner uses a five-step process in evaluating SSI claims. See 20
C.F.R. § 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 her past relevant work; and 5) if not, whether
she can perform other work. See 20 C.F.R. § 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. § 416.920(a) (2015).
Under this analysis, a claimant has the initial burden of showing that she is
unable to return to her past relevant work because of her 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. § 1382c(a)(3)(A)-(B) (West 2012);
McLain v. Schweiker, 715 F.2d 866, 868-69 (4th Cir. 1983); Hall, 658 F.2d at 26465; Wilson v. Califano, 617 F.2d 1050, 1053 (4th Cir. 1980).
Mullins argues that the ALJ erred by improperly determining her residual
functional capacity. (Plaintiff’s Memorandum In Support Of Her Motion For
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Summary Judgment, (“Plaintiff’s Brief”), at 5-7.) In particular, Mullins argues that
the ALJ erred by failing to give controlling weight to her treating physician, Dr.
Roatsey, and her counselor, Burke. (Plaintiff’s Brief at 5-7.) She further argues that
the ALJ should have given more weight to psychologist Lanthorn’s opinion.
(Plaintiff’s Brief at 6-7.)
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).
Thus, it is the ALJ’s responsibility to weigh the evidence, including the
medical evidence, in order to resolve any conflicts which might appear therein.
See Hays, 907 F.2d at 1456; Taylor v. Weinberger, 528 F.2d 1153, 1156 (4th Cir.
1975). Furthermore, while an ALJ may not reject medical evidence for no reason
or for the wrong reason, see King v. Califano, 615 F.2d 1018, 1020 (4th Cir. 1980),
an ALJ may, under the regulations, assign no or little weight to a medical opinion,
even one from a treating source, based on the factors set forth at 20 C.F.R. §
416.927(c), if he sufficiently explains his rationale and if the record supports his
findings.

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Mullins argues that the ALJ did not controlling weight to her treating
physician, Dr. Roatsey, and her counselor, Burke. (Plaintiff’s Brief at 5-7.) Based
on my review of the record, I find this argument unpersuasive. The ALJ must
generally give more weight to the opinion of a treating physician because that
physician is often most able to provide “a detailed, longitudinal picture” of a
claimant’s alleged disability. 20 C.F.R. § 416.927(c)(2) (2015). However,
“[c]ircuit precedent does not require that a treating physician’s testimony ‘be given
controlling weight.’” Craig v. Chater, 76 F.3d 585, 590 (4th Cir. 1996) (quoting
Hunter v. Sullivan, 993 F.2d 31, 35 (4th Cir. 1992) (per curiam)). In fact, “if a
physician’s opinion is not supported by clinical evidence or if it is inconsistent
with other substantial evidence, it should be accorded significantly less weight.”
Craig, 76 F.3d at 590.
The ALJ found that Mullins had the residual functional capacity to perform
sedentary work, that did not require more than two hours of standing and/or
walking in an eight-hour workday and six hours of sitting in an eight-hour
workday; that did not require more than occasional climbing, balancing, stooping,
kneeling, crouching or crawling; that did not require more than occasional
overhead reaching; that did not require constant reaching in all directions; that did
not require more than occasional interaction with co-workers and the public; that
allowed her to be off task 10 percent of an eight-hour workday and allowed her to
be absent up to one workday a month; and that did not require more than
occasional decision making and changes in the work setting. (R. at 16.)
In making this finding, the ALJ noted that he considered Dr. Roatsey’s
opinion dated June 2009, wherein he opined that Mullins was unable to work. (R.
at 14.) The ALJ noted that he was not giving this opinion any weight because the
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commentary contained no specific exertional or nonexertional limitations. (R. at
14.) As noted by the ALJ, determination of disability is reserved to the
Commissioner. (R. at 14.) See 20 C.F.R. § 416.927(d) (stating “[a] statement by a
medical source that you are ‘disabled’ or ‘unable to work’ does not mean that we
will determine that you are disabled.”) In addition, the ALJ considered the physical
and mental assessments completed by Dr. Roatsey and Burke in 2013 and noted
that he was giving them “limited weight.” (R. at 18.) The ALJ noted that the
restrictions placed on Mullins’s work-related abilities were inconsistent with their
treatment notes and Mullins’s daily activities. (R. at 18.)
Burke completed a mental assessment indicating that Mullins had a seriously
limited ability to make all occupational, performance and personal/social
adjustments. (R. at 615-17.) She opined that Mullins would be absent from work
more than two days a month. (R. at 617.) The ALJ noted that Burke’s assessment
was inconsistent with her progress notes and the medical evidence of record. (R. at
18.) Burke saw Mullins in September 2011 for complaints of increased depression
after being denied disability benefits. (R. at 503.) Burke diagnosed Mullins with
depression and anxiety and assessed her then-current GAF score at 75, indicating
no more than slight impairments. (R. at 503.) It appears that Burke next counseled
Mullins in February and March 2013 for complaints of depression and stress
resulting from a divorce, family and financial matters. (R. at 612-13.)
The ALJ further noted that Dr. Roatsey’s mental and physical restrictions
were inconsistent with his treatment notes and the evidence of record. (R. at 18.) In
June 2009, Dr. Roatsey documented numerous positive examination findings
related to Mullins’s lumbar spine problems, including tenderness, decreased range
of motion, a positive straight leg raising test on the left, weakness and foot drop,
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(R. at 390), but many of these findings either were never again documented or
specifically noted to be negative during his examinations. (R. at 388, 493, 495,
497, 499, 589-90, 601-02, 607-08, 621.) In addition, the diagnostic studies of
record fail to show significant limitations. An MRI of Mullins’s spine performed in
2003 was within normal limits. (R. at 348.) An MRI of Mullins’s lumbar spine
performed in 2004 revealed only a bulging disc at the L5-S1 level, but no nerve
entrapment or compression. (R. at 298, 340.)
In addition, Dr. Roatsey’s own office notes often documented no abnormal
findings and failed to document findings consistent with the degree of mental
limitations he identified in his mental assessment. (R. at 390, 493, 495, 497, 499,
589, 595, 601, 608, 621.) In April 2008, Mullins complained of some “intermittent
anxiety.” (R. at 321.) Dr. Wilson diagnosed only minor anxiety. (R. at 321.) In
March 2009, Mullins reported that she had problems with anxiety “from time to
time, but much better than before.” (R. at 314.) In December 2010, Dr. Roatsey
noted that, although Mullins’s affect was a “little flat,” she did not appear very
anxious. (R. at 499.) In October 2011 and February 2012, Mullins had a depressed
mood and affect, but appropriate insight and judgment. (R. at 601, 608.) In July
2012, Mullins had a normal mood and affect, as well as appropriate judgment and
insight. (R. at 595.) In September 2012, Mullins reported that she felt well and had
a “good energy level.” (R. at 588.) She had a normal mood and affect and
appropriate judgment and insight. (R. at 589.) In April 2013, although Mullins had
an anxious mood and affect, she considered her medication effective. (R. at 619,
621.) Dr. Roatsey noted that Mullins was doing well on her medication. (R. at
622.)

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The ALJ also noted that Mullins had only mild restrictions in activities of
daily living because she lived alone and performed her own cooking, cleaning,
laundry and shopping. (R. at 15, 44-46, 216.) Mullins also reported that she
maintained social contacts with friends and visited her grandchildren. (R. at 15, 4748, 217.) Furthermore, Mullins routinely reported that her medication helped her
symptoms of anxiety and depression. (R. at 619, 622, 628.) “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).
The ALJ also considered Lanthorn’s opinion and gave it “limited weight.”
(R. at 19.) The ALJ noted that Lanthorn’s opinion was inconsistent with the other
evidence of record and not well-supported by his own examination findings. (R. at
19.) Lanthorn’s mental status examination revealed no ongoing psychotic
processes, nor evidence of delusional thinking. (R. at 628.) Mullins made good eye
contact, and a rapport was easily established. (R. at 628.) She reported that her
memory was “mostly alright,” and her concentration was “fine as long as she is not
disturbed.” (R. at 628.) Lanthorn indicated that Mullins’s communication skills
were good, and she was capable of exercising appropriate self-care. (R. at 633.)
Based on this, I find that the ALJ properly weighed the medical evidence
and that substantial evidence exists to support the ALJ’s finding with regard to
Mullins’s residual functional capacity. An appropriate Order and Judgment will be
entered.
I will deny the plaintiff’s request to present oral argument based on my
finding that the written arguments adequately address the relevant issues.

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DATED:

May 2, 2016.
/s/

Pamela Meade Sargent

UNITED STATES MAGISTRATE JUDGE

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