United States District Court, M.D. Pennsylvania
RICHARD P. CONABOY, District Judge.
Here we consider Plaintiff's Appeal of Defendant's denial of Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under Titles II and XVI of the Social Security Act ("Act"), 42 U.S.C. §§ 401-433, 1381-1383f. (Doc. 1.) The Administrative Law Judge ("ALJ") who evaluated the claim found that Plaintiff had the residual function capacity ("RFC") to perform light work with certain limitations and that such work was available. (R. 7-25.) The ALJ therefore denied Plaintiff's claim for benefits. ( Id. ) With this action, Plaintiff argues that the determination of the Social Security Administration is error for three reasons: 1) the ALJ substituted his own opinion for that of Plaintiff's treating physician; 2) the ALJ failed to explain how he considered evidence and failed to give her treating physician's opinion controlling weight; and 3) the ALJ erred in failing to find Plaintiff and her witness credible. (Doc. 10 at 7.) For the reasons discussed below, we conclude Plaintiff's appeal of the Acting Commissioner's decision is properly denied.
A. Procedural Background
On September 29, 2010, Plaintiff filed an application for DIB and SSI alleging disability beginning on January 23, 2007. (R. 74.) In the December 13, 2010, Disability Report, Plaintiff listed four conditions that rendered her unable to work: 1) two screws in each leg; 2) legally blind in left eye; 3) right eye is at high risk for retina detachment; and 4) manic depressive. (R. 167.) The claims were initially denied on April 21, 2011. (R. 76, 80.) Plaintiff filed a request for a review before an ALJ on June 16, 2011. (R. 87.) On October 19, 2012, Plaintiff, with her attorney and a witness, appeared at a hearing before ALJ Patrick Cutter. (R. 26.) Vocational Expert Dr. Anderson also testified at the hearing. ( Id. ) At the hearing, Plaintiff amended her alleged onset date of disability to December 31, 2010. (R. 55.) The ALJ issued his unfavorable decision on November 20, 2012, finding that Plaintiff was not disabled under the Social Security Act during the relevant time period. (R. 21.)
On January 29, 2013, Plaintiff filed a Request for Review with the Appeal's Council. (R. 5-6.) The Appeals Council denied Plaintiff's request for review of the ALJ's decision. (R. 1-4.) In doing so, the ALJ's decision became the decision of the Acting Commissioner. (R. 1.)
On May 6, 2014, Plaintiff filed her action in this Court appealing the Acting Commissioner's decision. (Doc. 1.) Defendant filed her answer and the Social Security Administration transcript on July 7, 2014. (Docs. 8, 9.) Plaintiff filed her supporting brief on August 21, 2014. (Doc. 10.) Defendant filed her opposition brief on September 3, 2014. (Doc. 11.) Plaintiff did not file a reply brief, and the time for doing so has passed. Therefore, this matter is ripe for disposition.
B. Factual Background
Plaintiff was born on June 4, 1964. (R. 19.) She completed high school and some college. (R. 19, 30.) Plaintiff last worked three days per week at a gas station in 2010 for a few months. (R. 38.) Her last full-time employment was in 2007: she stopped working in January 2007 because she was away from home a lot, the job put a strain on her legs, and she had a disabled daughter at home who had some mental problems and needed someone with her. (R. 167.) As noted above, Plaintiff initially claimed disability due to the following: 1) two screws in each leg; 2) legally blind in left eye; 3) right eye is at high risk for retina detachment; and 4) manic depressive. (R. 167.) At the ALJ hearing, Plaintiff testified she has agoraphobia, panic attacks, depression, obsessive compulsive disorder, arthritis, and screws in both legs. (R. 31.)
1. Physical Impairment Evidence
X-ray evidence from March 1997 shows Plaintiff had a nondisplaced spiral fracture in the first metatarsal of her right ankle. (R. 227.) A radiology report of the left knee dated May 22, 1998, noted evidence of previous surgery with two orthopedic screws in the proximal tibia. (R. 268.)
Ronald Vandergriff, D.O., performed a consulting orthopedic examination on April 5, 2011. (R. 296-99.) Plaintiff reported she was unable to work becuase of pain in both lower extremities, sites where she had surgery. (R. 296.) Dr. Vandergriff noted Plaintiff's "Past Surgigal History" to be "[l]eft lower extremity tib fib in 1995" and "[r]ight lower extremity proximal tib fib in 2000." (R. 297.) Complaining of discomfort and pain with any continual walking, Plaintiff had not seen anyone for the reported problem since surgical followup in 2000. (R. 296.) Plaintiff also reported a history of depression for which she was last seen in 2008. ( Id. ) At the time of the examination, Plaintiff denied any suicidal or homicidal ideation. ( Id. ) Plaintiff was not taking any medication at the time. (R. 297.) She also reported that in 2006 an opthalmologist in Kansas diagnosed her as legally blind in one eye and at high risk for rentinal detachment in her right eye. ( Id. ) Plaintiff was not seeing anyone for the problem. ( Id. ) Plaintiff's "Past Medical History" included depression. ( Id. ) A "Physical Description" of Plaintiff included the observation that she was "extremely obese, " "odorous of tobacco, " and "able to ambulate to and from the exam room and get on and off the examination table on her own without assistance other than a stepstool." (R. 298.) An x-ray of the right lower extremity taken at the time of the evaluation showed mild arthritic changes in the right knee joint. (R. 298.) Dr. Vandergriff found Plaintiff to be alert, answering questions in an appropriate manner, with normal quantity and quality of speech, calm affect, appropriate mood, intact memory, and logical and coherent thought processes. (R. 299.) He recorded the following "Diagnosis/Impression": bilateral surgical intervention of proximal tib fib; history of depression; legal blindness in left eye; risk of retinal detachment of right eye "per claimant, " and exophthalmus. ( Id. ) Dr. Vandergriff made the following recommendations: Plaintiff should be seen by an orthopedic surgeon for evaluation and further testing of her legs; Plaintiff should be seen by a psychiatrist due to her history of depression; Plaintiff should be seen by an opthalmologist for an evaluation of her eyes; and she should have certain laboratory tests done. ( Id. ) He did not complete the physical limitation form. (R. 301-02.)
2. Mental Impairment Evidence
On April 7, 2011, Stanley E. Schneider, Ed.D., performed a consulting psychological evaluation. (R. 303-11.) Plaintiff related to Dr. Schneider that she had been fired from her job at the gas station for stealing five dollars, explaining that she took the money to get something to eat and intended to pay it back. (R. 303.) When asked why she was applying for disability, Plaintiff said she had been through several jobs and had trouble completing them, reporting that she had no motivation and referring to problems sitting and standing for any length of time. (R. 304.) Plaintiff reported that she had been diagnosed with bipolar disorder in 1995 and had tried to end her life three times-the first in 1995 and the last two years before the evaluation. ( Id. ) Plaintiff also reported a history of anxiety and compulsive behavior, and she did not like to leave the house because of the way she felt when around other people. ( Id. ) She was not receiving any mental health treatment at the time. (R. 305.) Plaintiff stated that she was previously taking Paxil, Zoloft, and Seroquel, which offered some relief, but she had no money and could not afford her medications. ( Id. ) When asked if she believed she could work, Plaintiff responded that she probably could work at a sedentary job with the allowance to get up and move around. ( Id. ) Plaintiff also reported she had been sexually molested by her father beginning at age fifteen and ending when she was 16, and she had sometimes been subject to bullying. ( Id. ) Although Plaintiff reported that she does not like to interact with or relate to people, she said she related acceptably with supervisors. (R. 306.) Dr. Schneider recorded that Plaintiff was "highly distressed" throughout his assessment-she was very anxious, nervous and tense. (R. 306.) Plaintiff regularly had suicidal ideations, but denied intent or plan. (R. 307.) Dr. Schneider diagnosed Plaintiff with bipolar disorder and general anxiety disorder. (R. 308.) He opined that Plaintiff's prognosis was poor and she would benefit from medication. (R. 307.) He found that Plaintiff had between moderate and marked limitations in the following areas: her ability to understand and remember detailed instructions; her ability to interact appropriately with the public; and her ability to respond appropriately to changes in a routine work setting. (R. 310.) In other areas of functioning, Plaintiff was found to have slight to moderate limitations. (R. 310-11.)
On April 20, 2011, with evidence which included the reports of Dr. Vandergriff and Dr. Schneider (R. 59), state agency consultant Jonathan Rightmyer, Ph.D., found that Plaintiff had mild restrictions in activities of daily living, maintaining social functioning, and maintaining concentration, persistence or pace. (R. 61.) Dr. Rightmyer found Plaintiff had no repeated episodes of decompensation, each of extended duration. ( Id. ) He further noted that Plaintiff reported no suicidal ideation to Dr. Vandergriff but reported continuous suicidal thoughts to Dr. Schneider. ( Id. )
On September 20, 2011, and September 27, 2011, Plaintiff was seen at The Stevens Center. (R. 317-23.) Henry Wehman, M.D., is listed as the principal psychiatrist. (R. 317, 321.) Rose Holland performed the September 20, 2011, assessment. (R. 326.) Presenting problems were identified as depression, anxiety, and trauma. ( Id. ) Plaintiff's strengths were noted to be "persistent, kind, intelligent, hobbies - plays on computer." (R. 317.) At the time, Plaintiff reported crying a lot, irritability, pulling at eyebrows when she was anxious, worrying about finances, and sleep problems. ( Id. ) Plaintiff's "current" diagnosis was Major Depressive Disorder, Severe, Generalized Anxiety Disorder, and Post Traumatic Stress Disorder. (R. 317, 321.) Plaintiff's GAF was 50. ( Id. )
On October 6, 2011, Plaintiff had a psychiatric evaluation by Dr. Wehman at The Stevens Center. (R. 326-28.) Dr. Wehman noted that Plaintiff had seen Rose Holland on September 20, 2011, but would be referred to a different individual therapist who is available on Mondays. ( Id. ) Dr. Wehman recorded that Plaintiff had been hospitalized in Kansas for a suicide attempt and diagnosed with "major depressive disorder, recurrent and severe without psychotic features." (R. 326.) She had last been treated in Kansas in 2005 (approximately) and moved to this area in 2010 to be with her boyfriend, after having met him online in 2008. (R. 326-27.) In addition to the history of depression, Dr. Wehman noted that Plaintiff has panic attacks with agoraphobia. (R. 326.) Plaintiff was not taking any medications but in the past had tried Paxil, Effexor, Zoloft, Trazadone, and Ambien, all of which made here "feel like a zombie with no emotions." ( Id. ) In his "Mental Status Examination, " Dr. Wehman noted the following: speech is relevant, productive, and goal directed; affect is somewhat constricted; mood is depressed; stream of thought is normal; content of thought is without delusions, phobias, suicidal or homicidal ideation; obsessions and compulsions relating to symmetry and order as well as trichotillomania; no hallucinations; cognitive functions within normal limits; partial insight; and normal judgment. ( Id. ) Dr. Wehman diagnosed Plaintiff with major depressive disorder, recurrent and severe without psychotic features, panic disorder with agoraphobia, obsessive compulsive disorder, and a GAF of 50. (R. 327-28.) He recommended that Plaintiff continue individual therapy and begin family therapy. (R. 328.) Plaintiff was to begin a trial of Luvox and begin Lorazepam. ( Id. ) She was to return for a follow-up medication visit in six weeks. ( Id. )
On November 28, 2011, Plaintiff saw Dr. Wehman for a Medication Review. (R. 330.) Plaintiff reported medication compliance and progress. ( Id. ) Dr. Wehman recorded the following: GAF of 75; relevant, productive and goal-directed speech; normal range and intensity in affect; euthymic mood; normal stream and content of thought (with occasional obsessions or compulsions); no homicidal or suicidal ideation; no hallucinations; and generally intact cognitive and executive functions. ( Id. )
At a February 27, 2012, Medication Review, Dr. Wehman reported the following: GAF of 70; relevant, productive and goal-directed speech; normal range and intensity in affect; normal stream and content of thought; no homicidal or suicidal ideation; no hallucinations; and generally intact cognitive and executive functions. (R. 329.) Subjectively, Plaintiff reported medication compliance, regression regarding progress, and that she is good throughout the day but gets irritable about 7 p.m. ( Id. )
At the May 21, 2012, Medication Review, Dr. Wehman noted that Plaintiff subjectively reported the following: "positive response to medications, but employment would not be able to be done principally because of her inability to interact with supervisors, public [and] coworkers [and] difficulty with complex instructions." (R. 361.) Objectively, Dr. Wehman reported the following: relevant, productive and goal-directed speech; normal range and intensity in affect; euthymic mood; normal stream and content of thought; no homicidal or suicidal ideation; no hallucinations; generally intact cognitive and executive functions; and a GAF of 80. ( Id. )
Also on May 21, 2012, Dr. Wehman completed a "Medical Source Statement of Ability to Do Work-related Activities" form. (R. 333-35.) Based on her work history and presentation, Dr. Wehman opined that Plaintiff had marked limitations in her ability to carry out complex instructions, make judgments on complex work-related decisions, and respond appropriately to usual work situations and to changes in a routine work setting. (R. 333-34.) Again based on work history and presentation, he found she had extreme limitations in her abilities to interact appropriately with the public, interact appropriately with supervisors, and interact appropriately with coworkers. (R. 334.)
On August 13, 2012, Plaintiff again saw Dr. Wehman for a Medication Review. (R. 360.) She subjectively reported regression. ( Id. ) Objectively, Dr. Wehman reported the following: GAF of 60; relevant, productive and goal-directed speech; constricted affect; anxious mood; normal stream of thought; notations (illegible) as to content of thought; no homicidal or suicidal ideation; no hallucinations; and generally intact cognitive and executive functions. ( Id. )
At the October 8, 2012, Medication Review, Plaintiff subjectively reported no progress. (R. 359.) Dr. Wehman reported the following: relevant, productive, goal-directed speech; constricted affect; anxious mood; normal stream of thought; notations (illegible) as to thought content; no homicidal or suicidal ideation; no hallucinations; generally intact cognitive and executive functions; and a GAF of 60. ( Id. )
Dr. Wehman provided a Note on GAF scores:
The GAF scores indicated in the Medication Review notes represent functioning with respect [to] psychiatric signs and symptoms, not necessarily social and occupational functioning. In the 10-15 minute medication check visit, the essential goal is to determine the patient's mental state and to manage medication accordingly. Thus, the GAF as defined above (a modified GAF, if you will) is a clinically more useful outcome measure for this function.
(R. 331, R. 364.)
3. Function Reports and ALJ ...