Estep v. Astrue
Filing
16
MEMORANDUM OPINION The Court finds that the Commissioner's decision Is supported by substantial evidence; therefore, by Judgment Order entered this day, the final decision of the Commissioner is Affirmed and this matter is Dismissed from the docket of this Court. Signed by Magistrate Judge Cheryl A. Eifert on 7/30/2012. (cc: attys; any unrepresented party) (skm)
IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF WEST VIRGINIA
HUNTINGTON DIVISION
DUSTIN LEE ESTEP,
Plaintiff,
v.
Case No.: 3:11-cv-00487
MICHAEL J. ASTRUE,
Commissioner of the Social
Security Administration,
Defendant.
MEMORANDUM OPINION
This action seeks a review of the decision of the Commissioner of the Social
Security Administration (hereinafter “Commissioner”) denying Claimant’s applications
for a period of disability and disability insurance benefits (“DIB”) and supplemental
security income (“SSI”) under Titles II and XVI of the Social Security Act, 42 U.S.C. §§
401-433, 1381-1383f. (ECF No. 2). Both parties have consented in writing to a decision
by the United States Magistrate Judge. (ECF Nos. 12 and 13). The case is presently
pending before the Court on the parties’ cross motions for judgment on the pleadings as
articulated in their briefs. (ECF Nos. 11, 14, 15).1
The Court has fully considered the evidence and the arguments of counsel. For
the reasons that follow, the Court finds that the decision of the Commissioner is
supported by substantial evidence and should be affirmed.
ECF Nos. 14 and 15 are the same document—Defendant’s’ Brief in Support of Judgment on the
Pleadings. ECF No. 15 is a reformatted version of ECF No. 14. The Court will henceforth refer to ECF No.
15 when citing Defendant’s Brief in Support of Judgment on the Pleadings.
1
1
I.
Procedural History
Plaintiff, Dustin Lee Estep (hereinafter “Claimant”), filed applications for SSI and
DIB on March 15, 2007 (Tr. at 104–08, 109–11), alleging a disability onset date of
November 30, 2006 due to attention deficit hyperactivity disorder (“ADHD”), bipolar
disorder, post-traumatic stress disorder (“PTSD”), and thin membrane disease of the
kidneys. (Tr. at 142). The Social Security Administration (“SSA”) denied Claimant’s
applications on July 19, 2007. (Tr. at 50–54, 55–59). Claimant filed a request for
reconsideration, which was also denied on November 14, 2007. (Tr. at 72–74). Claimant
then requested a hearing in front of an Administrative Law Judge (hereinafter “ALJ”),
which was held before the Honorable Andrew J. Chwalibog on November 4, 2008. (Tr.
at 26–45). By written decision dated July 1, 2009, the ALJ denied Claimant’s SSI and
DIB claims. (Tr. at 12–25). The ALJ’s decision became the final decision of the
Commissioner on December 10, 2010 when the Appeals Council denied Claimant’s
request for review. (Tr. at 3–7). Claimant timely filed the present civil action seeking
judicial review of the administrative decision pursuant to 42 U.S.C. §405(g). (ECF No.
2). The Commissioner filed an Answer and a Transcript of the Administrative
Proceedings, and both parties filed their Briefs in Support of Judgment on the
Pleadings. (ECF Nos. 8, 9, 11, 14, 15). Consequently, the matter is ripe for resolution.
II.
Relevant Evidence
The Court has reviewed the Transcript of Proceedings in its entirety, including
the medical records in evidence, and summarizes below Claimant’s medical treatment
and evaluations to the extent that they are relevant to the issues in dispute or provide a
clearer understanding of Claimant’s medical background.
2
A.
Treatment Records
1.
Prior to Disability Onset
Over the course of 1993 and 1994, Claimant underwent five comprehensive
psychological evaluations at Prestera Centers for Mental Health (“Prestera”). (Tr. at
200–02, 203–05, 206–08, 209–11, 212–14). Claimant exhibited numerous behavioral
and emotional problems, including hyperactivity, a short attention span, and frequent
temper tantrums. Multiple treating sources found that Claimant’s interpersonal skills,
communication skills, and estimated intellectual level were average. He was diagnosed
with bipolar disorder, not otherwise specified (“NOS”), ADHD, and oppositional
defiance disorder. For treatment, Prestera staff recommended psychotherapy and
medication.
On March 11, 1996, when Claimant was nearly ten years old, he returned to
Prestera for an updated comprehensive psychiatric evaluation. (Tr. at 198). The
evaluating psychiatrist documented that Claimant’s behavior was cooperative; his affect
and mood were appropriate; his memory was intact; his speech was coherent and
relevant; he had no homicidal or suicidal ideation; and he denied experiencing any
hallucinations or delusions. (Id.). Several years later, on February 13, 1999, Claimant
received another comprehensive psychiatric evaluation at Prestera. (Tr. at 199). On this
occasion, Claimant was observed to be cooperative and verbal, but appeared slightly
anxious and nervous. (Id.). His memory was intact; his speech was coherent and
relevant; he demonstrated fair insight and judgment; and he denied any suicidal or
homicidal ideation, delusions, and hallucinations. (Id.).
On August 20, 2002, at age sixteen, Claimant was involuntarily admitted to River
Park Hospital on his mother’s petition. (Tr. at 250–58). He was initially assessed by Dr.
3
Charles Clements, who recorded the reasons for the admission to include depression,
stealing drugs and money, self-mutilation, and setting fires. Dr. Clements performed
physical and neurological examinations, which revealed no objective evidence of
abnormalities. Dr. Clements provisionally diagnosed Claimant with depression, tension
headaches, and back pain. (Id.). He recorded that Dr. Stephen Edwards was the
attending physician assigned to the case and would follow-up with a mental status
examination of Claimant. Claimant was admitted to the Adolescent Unit, where he
received medication as well as individual, group, and family counseling until his
discharge on August 27, 2002. At the time of discharge, Claimant was diagnosed by Dr.
Edwards with chronic PTSD; history of abuse; oppositional defiant disorder; cannabis
abuse; and borderline personality traits. (Tr. at 250-54). Dr. Edwards noted that
Claimant had a history of aggressive behavior with one prior psychiatric admission at
seven years of age and had been receiving outpatient psychological care from Prestera,
although Claimant refused to speak with a therapist. Dr. Edwards felt that Claimant’s
condition had improved, but recommended that he continue with outpatient
psychotherapy. Claimant was prescribed Depakote, Paxil, and Clonidine and was
referred for outpatient care.
Three days later, on August 30, 2002, Claimant was again brought to River Park
Hospital for complaints of major depression and reports of suicidal ideation. (Tr. at
246–49). Dr. Clements conducted the initial assessment and noted that Claimant had
recently broken up with his girlfriend. (Tr. at 246). Claimant’s physical and neurological
examinations were normal. Dr. Clements diagnosed Claimant with recurrent and severe
major depression, chronic back pain, chronic tension headaches, and chronic chest
pains. (Tr. at 249). Claimant was admitted to the services of Dr. Edwards.
4
On September 3, 2002, Dr. Edwards discharged Claimant with medications and
instructions to receive follow-up care. (Tr. at 242–45). Dr. Edwards attributed
Claimant’s acute suicidal thoughts to the problems he was having with his girlfriend. Dr.
Edwards noted that Claimant had responded well to therapy and medication in the
hospital setting and was improved at the time of discharge. (Id.).
On December 2, 2002, Claimant was readmitted to River Park Hospital pursuant
to a court order. Claimant had been complaining of suicidal ideations as well as
homicidal thoughts toward “people who abused me,” which included workers at the
Salem Detention Center where Claimant had been residing since his discharge from the
hospital in September. (Tr. at 225–28). Claimant’s physical and neurological
examinations were normal and he was referred to Dr. Edwards for inpatient care.
Claimant remained hospitalized until January 13, 2003. (Tr. at 218-224). During the
admission, Claimant received medication and psychotherapy, although he was not
always compliant with the treatment plan. At the time of discharge, Claimant was
diagnosed with depression, NOS; conduct disorder; chronic PTSD; ADHD; history of
abuse; and cannabis abuse. He was noted to have antisocial traits. Dr. Edwards also
observed that Claimant could be “very somatic in medication seeking, especially for pain
medications.” He was transferred from the hospital to the Barboursville School for
residential care and education. (Id.).
Claimant’s intake evaluation at Barboursville School was conducted by Patricia
Kelly, M.D., on January 13, 2003. (Tr. at 235–41). Dr. Kelly noted that in the past
eighteen months, Claimant had become increasingly difficult for his mother to control;
acting defiant, stealing, and engaging in substance abuse. He had been caught with
marijuana at school, which led to his suspension and, a few months later, his first of
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three admissions to River Park Hospital. Dr. Kelly diagnosed Claimant with bipolar
disorder NOS; PTSD status post-abuse; ADHD, conduct disorder, substance abuse,
kidney disease, right knee pain, lower back pain, headaches, and chest pain. (Tr. at 240–
41). After two months at the Barboursville School, Claimant’s educational performance
was evaluated. (Tr. at 260). Claimant’s math teacher noted that he put forth great effort
and was a good student. Claimant had all A’s and B’s in English, Geometry, Science,
History, Health, and Physical Education. (Id.). On April 3, 2003, almost three months
after his admission to the Barboursville School, Claimant was discharged to placement
at Pressley Ridge, a residential treatment center for troubled children. Dr. Holly Clark
completed Claimant’s discharge summary from the Barboursville School. (Tr. at 230–
34). She noted that Claimant had been admitted to the Barboursville School on a court
order and had a history of suicidal and homicidal thoughts. (Tr. at 230). Dr. Clark
observed that Claimant was sensitive to criticism; overreacted to minor problems;
trusted no one and was guarded in his social interactions; blamed others; and avoided
responsibility. (Tr. at 232). Dr. Clark diagnosed Claimant with bipolar disorder NOS,
ADHD, PTSD, and oppositional defiant disorder. (Tr. at 233). She indicated that
Claimant had shown improvement during his stay at the school and his mood was now
stable. (Id.). Claimant also demonstrated an improved attention span and a willingness
to cooperate with staff and peers. (Id.). Dr. Clark’s discharge prognosis for Claimant was
“fair.” (Tr. at 234). According to Dr. Clark, Claimant needed a stable environment with
direct consequences for his behavior to facilitate his recovery. (Id.).
From May 2003 through March 2005, Claimant was seen by Dr. Edwards on 17
separate occasions. (Tr. at 285–92). During this period of time, Claimant’s mental
health was relatively stable. On May 8, 2003, Claimant was “doing well” and on June 12,
6
2003, he reported that he had not been having any problems. (Tr. at 292). On July 7,
2003 and August 19, 2003, Dr. Edwards again noted that Claimant was doing well. (Tr.
at 291). In November 2003 and January 2004, Claimant reported having difficulty
focusing and sleeping, but stated that he was doing “all right.” (Tr. at 290). On April 6,
2004, Claimant reported that he was feeling moody and irritable secondary to
medication and was still having trouble sleeping. Dr. Edwards observed that Claimant’s
mood was nonetheless stable. (Tr. at 289). In June 2004, Claimant complained of
feeling nervous and requested Valium. (Tr. at 288). Dr. Edwards prescribed a trial of
Neurontin with Seroquel. In September 2004, Claimant indicated that he was doing all
right, but felt he needed a higher dose of Neurontin. On December 21, 2004, Claimant
reported that he was doing well with his medication changes and his grades were
improving in school. (Tr. at 286). He expected to graduate in January and find a job as a
machinist. On March 8, 2005, Claimant informed Dr. Edwards that he had graduated
from high school, was working in a fast food restaurant, and was planning to attend
trade school. (Tr. at 285). Claimant was sleeping better, and his mood was observed to
be stable.
On September 14, 2006, Claimant was taken to St. Mary’s Medical Center after
being confronted by law enforcement officers and making suicidal threats. (Tr. at 409–
15). The triage assessment included a note stating that Claimant had not been on his
regular medication for two years and had taken three Xanax earlier in the evening. (Tr.
at 409). Claimant’s mother reported that Claimant had left home the prior evening
around midnight with thoughts of harming himself or someone else. He did not return
home and failed to meet her for lunch as they had planned. (Tr. at 412). She spent the
day searching for Claimant and eventually contacted one of Claimant’s friends who
7
reported that Claimant was cutting himself. (Id.). When Claimant’s mother arrived at
the friend’s house, the police were already there. (Id.). Lab results revealed an ETOH
level of 10 and Claimant’s drug screen was positive for barbiturates, benzodiazepine,
cocaine, THC, opiates, and oxycodone. (Id.). The Emergency Department physician
diagnosed Claimant with suicidal and homicidal ideations and polysubstance abuse. (Tr.
at 413). Claimant was too lethargic from his medication intake to undergo a psychiatric
evaluation, so he was held in the Emergency Room until he became more alert.
The next day, on September 15, 2006, Claimant underwent a psychiatric intake
and assessment. (Tr. at 396–405). Claimant denied that the events of the previous day
had been a suicide attempt. (Tr. at 396). Instead, he stated that he had flashbacks of
childhood abuse when the police handcuffed him, which greatly upset him and caused
him to react inappropriately. (Id.). Claimant’s mother spoke with the therapist and
advised that Claimant was unable to get along with people or hold down a job. She
indicated that Claimant’s quick temper and proclivity to “party” caused him to lose
employment positions. Nevertheless, based upon a psychiatric evaluation, Claimant was
not found to require hospital admission; instead, he was instructed to seek outpatient or
residential treatment. (Tr. at 404).
2.
Relevant Time Period
On July 4, 2007, Claimant was admitted to the emergency room at St. Mary’s
Medical Center after being struck in the head and back with a tire iron during an
altercation. (Tr. at 342, 344–45, 472–74). He admitted that he had been drinking prior
to the fight. The Emergency Department physician documented that Claimant had a
laceration on his head and had been pepper sprayed by the police. (Tr. at 342). Claimant
reported that he lost consciousness after being struck. (Id.). X-rays of Claimant’s head
8
revealed no significant abnormalities, and a CT scan of Claimant’s cervical spine showed
no evidence of cervical spine fracture or subluxation. (Tr. at 347–48). Claimant’s head
wound was sutured and he was discharged with instructions to shower in order to
remove all remnants of the pepper spray. Due to his acute alcohol intoxication, he was
released to his family for transportation home.
On August 25, 2007, Claimant returned to the emergency room with complaints
of vomiting, diarrhea, and difficulty urinating. (Tr. at 340–41, 343, 499–501). Claimant
was diagnosed with a urinary tract infection, urethritis, and gastroenteritis. (Tr. at 343).
His Emergency Room visit was noted to be “uneventful.” Claimant was discharged with
prescriptions and told to follow-up with his family physician.
B.
Agency Assessments
1.
Physical Health Assessments
On May 10, 2007, Kip Beard, M.D., completed an internal medicine examination
of Claimant at the request of the West Virginia Disability Determination Service. (Tr. at
297–301). Claimant reported that he had been diagnosed with thin basement membrane
disease when he was approximately 15 years old. (Tr. at 297). According to Claimant, he
experienced an intermittent burning sensation in his flanks, which occasionally resulted
in nausea and vomiting. (Id.). Claimant was not aware of any significant renal
dysfunction. (Id.). Dr. Beard noted that Claimant did not take any medication for his
kidney condition and limited documentation was available. (Tr. at 298–99).
Dr. Beard conducted a physical examination of Claimant. (Tr. at 299). He noted
that Claimant presented without ambulatory aids or assistive devices and his gait was
normal. (Id.). Claimant could stand unassisted, arise from his seat, and step up and
down from the examination table without difficulty. (Id.). During the assessment,
9
Claimant complained of bilateral flank pain. (Id.). Dr. Beard diagnosed Claimant with
thin basement membrane disease and chronic recurrent flank pain. (Tr. at 301).
According to Dr. Beard, the examination revealed some mild costovertebral angle
tenderness and mild abdominal tenderness with no palpable masses. (Id.). Dr. Beard
found no edema or evidence of renal failure on examination. (Id.).
On July 17, 2007, Atiya Lateef, M.D., completed a Residual Functional Capacity
(“RFC”) assessment. (Tr. at 331–38). Dr. Lateef’s primary diagnosis was of chronic flank
pain with a secondary diagnosis of thin membrane renal disease. Dr. Lateef found that
Claimant had no exertional, manipulative, visual, or communicative limitations. (Tr. at
332). Claimant’s postural limitations restricted him to activities that never required
balancing. (Tr. at 333). Claimant’s environmental limitations required him to avoid all
exposure to hazards, such as machinery and heights. (Tr. at 335). Dr. Lateef reviewed
Claimant’s allegations, noting that he had a history of thin membrane disease and
chronic bilateral flank pain. (Tr. at 338). Dr. Lateef further noted that Claimant was not
taking any medications. In conclusion, Dr. Lateef found that Claimant’s renal function
was fairly normal with no evidence of pedal edema or end stage renal disease. (Id.).
On November 2, 2007, Amy Wirts, MD, completed a second RFC assessment.
(Tr. at 363–70). Dr. Wirts found that Claimant had no exertional, postural,
manipulative, visual, communicative, or environmental limitations. (Tr. at 364–67). Dr.
Wirts found that Claimant was only partially credible and that the alleged severity of his
impairments was not well supported by the medical record. (Tr. at 368). In particular,
Dr. Wirts noted that Claimant’s kidney function tested normal in June 2007 and records
from May 2007 included no evidence of edema or renal failure. (Id.). Further,
Claimant’s hemoglobin and hematocrit were within normal limits as of May 2007. (Id.).
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Therefore, Dr. Wirts concluded that Claimant’s physical impairments did not meet
Listing criteria. (Id.).
2.
Mental Health Assessments
On May 30, 2007, Lisa Tate, M.A., completed a psychological evaluation at the
request of the West Virginia Disability Determination Services. (Tr. at 303–10). As part
of her assessment, Ms. Tate conducted a clinical interview and a mental status
examination and administered the Wechsler Adult Intelligence Scale, Third Edition
(WAIS III), and Wide Range Achievement Test, Third Revision (WRAT-3). (Tr. at 303).
Claimant’s chief complaints were ADHD, bipolar disorder, PTSD, and kidney problems.
(Tr. at 304). Claimant discussed his health history at length with Ms. Tate. According to
Claimant, he was diagnosed with ADHD when he was five years old; he no longer took
medication for ADHD and had not for the previous two and a half years. (Id.). Claimant
stated that he had difficulty completing tasks, was easily distracted, and had problems
with attention and concentration. (Id.).
Next, Claimant discussed his history of bipolar disorder and PTSD. Claimant
could not remember when he was diagnosed with bipolar disorder. (Id.). Further, he
informed Ms. Tate that he had not taken any medication for this condition for the
previous two years. (Id.). He described his symptoms as rapid mood fluctuations that
would occur without warning. (Id.). Claimant also reported that he had been diagnosed
with PTSD at age 15. This diagnosis was based on reports of trauma from several years
of abuse during his childhood. (Tr. at 304). Claimant reported having violent impulses
that he could not control, as well as nightmares and flashbacks to the abuse. (Id.).
Crowds made Claimant feel uncomfortable, leading to tightness in his chest and
difficulty breathing. (Id.).
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Ms. Tate then reviewed Claimant’s history of substance abuse and mental health
treatment. (Tr. at 305). Claimant reported a history of alcohol use with no noted
problems. (Id.). Claimant additionally admitted a history of drug abuse when he was
younger and stated that drug use typically exacerbated his depression. (Id.). Ms. Tate
noted that Claimant was not receiving any mental health treatment, but that he had
previously been hospitalized several times, most recently at the age of 18. (Id.). Next,
Ms. Tate considered Claimant’s educational history and vocational background. (Id.).
After graduating from high school, Claimant attended an electrician training program
and obtained his apprenticeship license. (Id.). Claimant had also worked as a cook and
as a dishwasher. (Tr. at 305).
Ms. Tate subsequently completed a mental status examination, observing that
Claimant’s mood was euthymic2 and that his affect was broad and reactive. (Tr. at 306).
Claimant’s thought processes, thought content, insight, judgment, immediate memory,
recent memory, concentration, and psychomotor behavior were all found to be within
normal limits. (Id.). Claimant denied suicidal and homicidal ideation and reported no
instances of hallucination or psychosis. (Id.).
Finally, Ms. Tate reviewed Claimant’s daily activities and evaluated his functional
limitations. (Tr. at 308–09). According to Claimant, he had no set sleep routine. (Tr. at
308). On a daily basis, he watched television and waited around his family’s house until
his mother got off of work. (Id.). On a weekly basis, he cleaned the house, talked to
neighbors, and showered. (Id.). On a monthly basis, Claimant reported cooking, mowing
the lawn, and spending time with friends. (Id.). Claimant’s social functioning,
2
A normal mood in which the range of emotions is neither depressed nor highly elevated. Mosby's
Medical Dictionary, 8th edition. © 2009, Elsevier.
12
persistence, and pace were all found to be within normal limits. (Tr. at 309). In
conclusion, Ms. Tate found that Claimant was competent to manage any benefits he
might receive. (Tr. at 310).
On June 29, 2007, Karl Hursey, Ph.D, completed a Psychiatric Review Technique
(“PRT”) at the request of the SSA. (Tr. at 313–26). Dr. Hursey found that Claimant’s
mental impairments were not severe. (Tr. at 313). He reviewed the paragraph B criteria
and evaluated Claimant’s functional limitations. (Tr. at 323). Dr. Hursey found that
Claimant’s activities of daily living were mildly restricted but that Claimant had no
limitations on his social functioning, concentration, persistence, or pace. (Id.). Based on
the medical record, Dr. Hursey found that Claimant had experienced one or two
episodes of decompensation. (Id.). He determined that the evidence did not establish
the presence of paragraph C criteria. (Tr. at 324). In conclusion, Dr. Hursey found that
Claimant was “generally credible” based on the medical record. (Tr. at 325). Dr. Hursey
observed that Claimant did not take any medication for his mental impairments and
that any limitations he experienced were likely the result of physical, rather than
psychological, impairments. (Id.).
On November 12, 2007, Debra Lilly, Ph.D, completed a second PRT at the request
of the SSA. (Tr. at 371–84). Dr. Lilly found that there was insufficient evidence to
evaluate Claimant’s mental impairments. (Tr. at 371). Dr. Lilly noted that Claimant had
not returned his self-function reports after his initial filing. (Id.). Although medical
records indicated that Claimant had been hospitalized on July 4, 2007 after being struck
with a tire iron, Dr. Lilly stated that the functional consequences of that injury could not
be assessed without more evidence. (Tr. at 383).
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III.
Summary of ALJ’s Decision
Under 42 U.S.C. § 423(d), a claimant seeking disability benefits has the burden of
proving a disability. See Blalock v. Richardson, 483 F.2d 773, 774 (4th Cir. 1972). A
disability is defined as the “inability to engage in any substantial gainful activity by
reason of any medically determinable impairment which can be expected to last for a
continuous period of not less than 12 months.” 42 U.S.C. 423(d)(1)(A).
The Social Security regulations establish a five step sequential evaluation process
for the adjudication of disability claims. If an individual is found “not disabled” at any
step of the process, further inquiry is unnecessary and benefits are denied. 20 C.F.R. §§
404.1520, 416.920. The first step in the sequence is determining whether a claimant is
currently engaged in substantial gainful employment. Id. §§ 404.1520(b), 416.920(b). If
the claimant is not, then the second step requires a determination of whether the
claimant suffers from a severe impairment. Id. §§ 404.1520(c), 416.920(c). If severe
impairment is present, the third inquiry is whether this impairment meets or equals any
of the impairments listed in Appendix 1 to Subpart P of the Administrative Regulations
No. 4 (the “Listing”). Id. §§ 404.1520(d), 416.920(d). If the impairment does, then the
claimant is found disabled and awarded benefits.
However, if the impairment does not, the adjudicator must determine the
claimant’s residual functional capacity, which is the measure of the claimant’s ability to
engage in substantial gainful activity despite the limitations of his or her impairments.
Id. §§ 404.1520(e), 416.920(e). After making this determination, the next step is to
ascertain whether the claimant’s impairments prevent the performance of past relevant
work. Id. §§ 404.1520(f), 416.920(f). If the impairments do prevent the performance of
past relevant work, then the claimant has established a prima facie case of disability,
14
and the burden shifts to the Commissioner to prove, as the final step in the process, that
the claimant is able to perform other forms of substantial gainful activity, when
considering the claimant’s remaining physical and mental capacities, age, education,
and prior work experiences. 20 C.F.R. §§ 404.1520(g), 416.920(g); see also McLain v.
Schweiker, 715 F.2d 866, 868-69 (4th Cir. 1983). The Commissioner must establish two
things: (1) that the claimant, considering his or her age, education, skills, work
experience, and physical shortcomings has the capacity to perform an alternative job,
and (2) that this specific job exists in significant numbers in the national economy.
McLamore v. Weinberger, 538 F.2d. 572, 574 (4th Cir. 1976).
When a claimant alleges a mental impairment, the SSA “must follow a special
technique at every level in the administrative review.” 20 C.F.R. §§ 404.1520a,
416.920a. First, the SSA evaluates the claimant’s pertinent signs, symptoms, and
laboratory results to determine whether the claimant has a medically determinable
mental impairment. If such impairment exists, the SSA documents its findings. Second,
the SSA rates and documents the degree of functional limitation resulting from the
impairment according to criteria specified in 20 C.F.R. §§ 404.1520a(c), 416.920a(c).
After rating the degree of functional limitation from the claimant’s impairment(s), the
SSA determines the severity of the limitation. A rating of “none” or “mild” in the first
three functional areas (activities of daily living, social functioning, and concentration,
persistence or pace) and “none” in the fourth (episodes of decompensation) will result in
a finding that the impairment is not severe unless the evidence indicates that there is
more than minimal limitation in the claimant’s ability to do basic work activities. 20
C.F.R. §§ 404.1520a(d)(1), 416.920a(d)(1).
15
Next, if the claimant’s impairment is deemed severe, the SSA compares the
medical findings about the severe impairment and the degree of functional limitation to
the criteria of the appropriate listed mental disorder to determine if the severe
impairment meets or is equal to a listed mental disorder. 20 C.F.R. §§ 404.1520a(d)(2),
416.920a(d)(2). Finally, if the SSA finds that the claimant has a severe mental
impairment, which neither meets nor equals a listed mental disorder, the SSA assesses
the
claimant’s
416.920a(d)(3).
residual
functional
capacity.
20
C.F.R.
§§
404.1520a(d)(3),
The regulation further specifies how the findings and conclusion
reached in applying the technique must be documented at the ALJ and Appeals Council
levels as follows:
The decision must show the significant history, including examination and
laboratory findings, the functional limitations that were considered in
reaching a conclusion about the severity of the mental impairment(s). The
decision must include a specific finding as to the degree of limitation in
each functional areas described in paragraph (c) of this section.
20 C.F.R. §§ 404.1520a(e)(2), 416.920a(e)(2).
In the present case, the ALJ determined as a preliminary matter that Claimant
met the insured status requirement of the Social Security Act through June 30, 2008.
(Tr. at 17, Finding No. 1). At the first step of the sequential evaluation, the ALJ found
that Claimant had not engaged in substantial gainful activity since November 30, 2006,
the alleged date of disability onset. (Id., Finding No. 2). Turning to the second step of
the evaluation, the ALJ determined that Claimant’s thin basement membrane kidney
disease and secondary flank pain were severe impairments. (Id., Finding No. 3). The
ALJ considered Claimant’s history of ADHD, bipolar disorder, and PTSD, but found
these mental impairments to be non-severe. (Id.). Under the third inquiry, the ALJ
determined that Claimant did not have an impairment or combination of impairments
16
that met or medically equaled any of the impairments detailed in the Listing. (Tr. at 20,
Finding No. 4). Accordingly, the ALJ assessed Claimant’s RFC, finding that Claimant
had the residual functional capacity to perform work limited to medium exertion. (Tr. at
21, Finding No. 5). In addition, Claimant could not climb ladders or scaffolds and could
never work at unprotected heights or around hazards. (Id.).
The ALJ then analyzed Claimant’s past work experience, age, and education in
combination with his RFC to determine his ability to engage in substantial gainful
activity. (Tr. at 23, Finding Nos. 6–10). The ALJ considered that (1) Claimant was
unable to perform past relevant work; (2) he was born in 1986, and at age 20, was
defined as a younger individual age 18–49 (20 CFR §§ 404.1563, 416.963); (3) he had a
high school education and could communicate in English; and (4) transferability of job
skills was not material to the disability determination because the Medical-Vocational
Rules framework supported a finding that Claimant was not disabled regardless of the
transferability of job skills. (Id.). Based on the testimony of a vocational expert, the ALJ
found that Claimant could make a successful adjustment to employment positions that
existed in significant numbers in the national economy, such as a product packager,
cleaning positions, kitchen helper, product packer, machine tender, and non-emergency
dispatcher. (Tr. at 23–24). Therefore, the ALJ concluded that Claimant was not disabled
and, thus, was not entitled to benefits. (Tr. at 24, Finding No. 11).
IV.
Claimant’s Challenge to the Commissioner’s Decision
Claimant contends that the Commissioner’s decision is not supported by
substantial evidence because the ALJ erred in finding that Claimant’s mental
impairments were not severe. (ECF No. 11 at 7–10).
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V.
Scope of Review
The issue before the Court is whether the final decision of the Commissioner is
based upon an appropriate application of the law and is supported by substantial
evidence. In Blalock v. Richardson, the Fourth Circuit Court of Appeals defined
“substantial evidence” to be:
[E]vidence 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. If there is evidence to
justify a refusal to direct a verdict were the case before a jury, then there is
“substantial evidence.”
Blalock v. Richardson, 483 F.2d 773, 776 (4th Cir. 1972) (quoting Laws v. Celebrezze,
368 F.2d 640, 642 (4th Cir. 1966)). This Court is not charged with conducting a de novo
review of the evidence. Instead, the Court’s function is to scrutinize the totality of the
record and determine whether substantial evidence exists to support the conclusion of
the Commissioner. Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990). The decision
for the Court to make is “not whether the claimant is disabled, but whether the ALJ’s
finding of no disability is supported by substantial evidence.” Johnson v. Barnhart, 434
F. 3d 650, 653 (4th Cir. 2005) (citing Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 2001)).
If substantial evidence exists, then the Court must affirm the decision of the
Commissioner “even should the court disagree with such decision.” Blalock, 483 F.2d at
775. Applying this legal framework, a careful review of the record reveals that the
decision of the Commissioner is based upon an accurate application of the law and is
supported by substantial evidence.
VI.
Analysis
Claimant asserts that the ALJ erred by finding Claimant’s mental impairments to
be non-severe. Claimant argues that the contrary is true; that is, his chronic psychiatric
18
conditions substantially interfere with his ability to engage in basic work activities. In
support of this contention, Claimant emphasizes his health care records, which
substantiate extensive mental health treatment over a period of fifteen years and include
documentation of four admissions to behavioral health units or facilities. While
Claimant did provide ample historical evidence of mental health treatment, the records
produced predominantly reflect Claimant’s psychiatric condition prior to the alleged
disability onset date; none of these treatment records establish the state of Claimant’s
mental health during the relevant time frame. Further, multiple agency experts
concluded that Claimant’s mental impairments were either not severe or were not
sufficiently active to substantiate their alleged severity. Based on the lack of mental
health treatment during the relevant time period and the findings of the state agency
experts, the ALJ appropriately determined that Claimant’s mental impairments were
not severe.
At the second step of the sequential evaluation process, the ALJ is required to
evaluate the severity of a claimant’s alleged impairments. 20 C.F.R. §§ 404.1520(c),
416.920(c). A “severe” impairment is an impairment or combination of impairments
that significantly limits a claimant’s physical or mental ability to do basic work activities.
Id. at §§ 404.1521(a), 416.921(a). “Basic work activities” refers to “the abilities and
aptitudes necessary to do most jobs.”3 Id. at §§ 404.1521(b), 416.921(b). An impairment
is not severe when it is only “a slight abnormality (or a combination of slight
abnormalities) that has no more than a minimal effect on the ability to do basic work
3 Examples of “basic work activities” are (1) physical functions such as walking, standing, sitting, lifting,
pushing, pulling, reaching, carrying, or handling; (2) capacities for seeing, hearing, and speaking; (3)
understanding, carrying out, and remembering simple instructions; (4) use of judgment; (5) responding
appropriately to supervision, co-workers and usual work situations; and (6) dealing with changes in a
routine work setting. 20 C.F.R. §§ 404.1521(b), 416.921(b).
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activities.” SSR 96-3p (citing SSR 85-28); see also Albright v. Commissioner of Social
Sec. Admin., 174 F.3d 473, 478 n. 1 (4th Cir. 1999) (citing Evans v. Heckler, 734 F.2d
1012, 1014 (4th Cir. 1984)). “A determination that an individual's impairment(s) is not
severe requires a careful evaluation of the medical findings that describe the
impairment(s) (i.e., the objective medical evidence and any impairment-related
symptoms), and an informed judgment about the limitations and restrictions the
impairment(s) and related symptom(s) impose on the individual's physical and mental
ability to do basic work activities.” SSR 96-3p (citing SSR 96-7p).
In the case of a mental impairment, the ALJ determines severity by examining
the claimant’s limitations in the following four broad functional areas known as the
paragraph “B” criteria: activities of daily living; social functioning; concentration,
persistence, or pace; and episodes of decompensation. See 12.00C of the Listing of
Impairments. When the ALJ rates the degree of limitation in the first three functional
areas (activities of daily living; social functioning; and concentration, persistence, or
pace), he uses a five-point scale: None, mild, moderate, marked, and extreme. When he
rates the degree of limitation in the fourth functional area (episodes of
decompensation), he uses a four-point scale: None, one or two, three, four or more. The
last point on each scale represents a degree of limitation that is incompatible with the
ability to do any gainful activity. On the other hand, a rating of “none” or “mild” in the
first three functional areas (activities of daily living, social functioning, and
concentration, persistence or pace) and “none” in the fourth (episodes of
decompensation) results in a finding that the impairment is not severe unless the
evidence indicates that there is more than minimal limitation in the claimant’s ability to
do basic work activities. 20 C.F.R. §§ 404.1520a(d)(1), 416.920a(d)(1).
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Here, the ALJ reviewed the evidence and examined Claimant’s limitations under
the four functional categories. He determined that Claimant had only mild impairment
in activities of daily living based upon the evaluation of Ms. Tate and Claimant’s own
descriptions of his activities around the house. Likewise, the ALJ found Claimant to
have only a mild limitation in concentration, persistence and pace. According to the
ALJ, Ms. Tate observed mild deficiencies in Claimant’s ability to concentrate, but felt
that his persistence and pace were normal. In the category of social functioning, the ALJ
determined that Claimant had mild limitations. The ALJ explained that Claimant had
problems as a child with fighting in school, but appeared to have outgrown that
behavior. Moreover, Claimant admitted that he regularly interacted with his neighbors
and saw friends on a weekly basis; accordingly, the evidence reflecting his current
relationships with others did not suggest a significant limitation. Finally, the ALJ
examined the record for episodes of decompensation of extended duration and found
none. The ALJ noted that one non-examining consultant opined that Claimant had 1-2
such episodes; however, Ms. Tate, who personally examined Claimant, found no such
episodes. Based upon Ms. Tate’s opinion and the lack of records detailing episodes of
decompensation on or after November 30, 2006, the ALJ concluded that Claimant’s
mental impairments were not severe. (Tr. at 19-20).
Clearly, the ALJ assessed the severity of Claimant’s mental impairments at the
proper step of the sequential evaluation process and followed the appropriate procedure
in making his determination. Consequently, the issue for the Court is whether that
determination is supported by substantial evidence. Having thoroughly reviewed the
record, the Court does find substantial evidentiary bases for the ALJ’s conclusion.
According to the records, Claimant’s biggest battles with his psyche occurred prior to his
21
eighteenth birthday. Although Claimant’s IQ was measured in the above average range,
he did poorly in school, was distracted and aggressive, and had temper outbursts. He
was difficult for his mother to control and started to abuse alcohol and drugs. However,
with the use of medications and psychotherapy, Claimant showed significant
improvement over the ensuing years. At age sixteen, Claimant was admitted to an
inpatient mental health facility for depression, suicidal tendencies, self-mutilation,
arson, and theft. On discharge, he was placed at the Barboursville School for residential
treatment. Less than a year later, Claimant was assessed as putting forth a good effort at
his education and was described as a good student. He began regular treatment with Dr.
Edwards and his mood started to stabilize. Claimant’s hyperactivity was successfully
treated with Adderall. He ultimately graduated from high school and received additional
training as a machinist. The records reflect that Claimant went more than a year and a
half without any major medical or psychiatric issues. Then in September 2006, Claimant
was admitted to the hospital for suspected suicidal ideations after he had ingested a
significant quantity of drugs. The following day, however, Claimant denied having
suicidal thoughts and after undergoing a psychiatric evaluation, he was discharged to
outpatient care. He had no further psychiatric admissions. During the relevant time
frame, Claimant apparently functioned without psychiatric medications, psychotherapy,
crisis management, or inpatient care.
In reaching his decision, the ALJ relied heavily on the findings of the consultative
psychological evaluator, Ms Tate. (Id.). Ms. Tate was the only mental health care
provider who performed a face-to-face assessment of Claimant during the relevant time
period. The ALJ reviewed Claimant’s history and symptoms at length and compared
them to the diagnostic test results, objective evidence, and observations of Ms. Tate. (Tr.
22
at 18–19). The ALJ noted that Claimant had stopped taking his medication for ADHD
and bipolar disorder more than two years prior to his examination by Ms. Tate and had
been able to graduate from high school and complete an electrician training program in
the interim. (Tr. at 19). The ALJ further noted that Ms. Tate found Claimant’s
psychological functioning to be within normal limits with no functional limitations. (Tr.
at 306, 308). The ALJ emphasized that none of the other mental health consultants
found Claimant’s mental impairments to be severe. Dr. Hursey found that Claimant’s
activities of daily living were only mildly restricted and that Claimant had no limitations
on his social functioning, concentration, persistence, or pace. (Tr. at 323). Dr. Lilly felt
there was insufficient evidence to evaluate Claimant’s mental impairments because no
treatment records existed for the period at issue. (Tr. at 371).
Claimant would like the Court to extrapolate from his childhood history of
emotional and behavioral problems that his mental impairments severely impede his
ability to perform basic work activities as an adult. However, there simply is no evidence
upon which to make that analytical leap. To the contrary, the lack of treatment records
confirming significant and ongoing mental health issues suggests that Claimant has
learned to manage his mental health conditions. Claimant does display a tendency to
over indulge his use of alcohol, but that fact, alone, does not overcome the
reasonableness of the ALJ’s determination regarding the severity of Claimant’s mental
impairments or their functional impact on Claimant’s ability to work.
VII. Conclusion
After a careful consideration of the evidence of record, the Court finds that the
Commissioner’s decision IS supported by substantial evidence. Therefore, by Judgment
Order entered this day, the final decision of the Commissioner is AFFIRMED and this
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matter is DISMISSED from the docket of this Court.
The Clerk of this Court is directed to transmit copies of this Order to the Plaintiff
and counsel of record.
ENTERED: July 30, 2012.
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