United States District Court, M.D. Pennsylvania
KAREN A. PLEACHER, Plaintiff,
CAROLYN W. COLVIN, COMMISSIONER OF SOCIAL SECURITY,
GERALD B. COHN, Magistrate Judge.
I. Procedural Background
On July 22, 2010, Plaintiff filed an application for disability insurance benefits ("DIB") and supplemental security income ("SSI") under the Social Security Act, 42 U.S.C. §§401-433, 1382-1383 (the "Act"). (Tr. 138-56). On September 7, 2010, the Bureau of Disability Determination denied these applications (Tr. 66-77), and Plaintiff filed a request for a hearing on October 19, 2010. (Tr. 78-19). On November 7, 2011, an ALJ held a hearing at which Plaintiff - who was represented by an attorney - and a vocational expert ("VE") appeared and testified. (Tr. 28-65). On March 22, 2012, the ALJ found that Plaintiff was not disabled and not entitled to benefits. (Tr. 11-27). On May 16, 2012, Plaintiff filed a request for review with the Appeals Council (Tr. 8-10), which the Appeals denied on September 13, 2013, thereby affirming the decision of the ALJ as the "final decision" of the Commissioner. (Tr. 1-6).
On November 12, 2013, Plaintiff filed the above-captioned action pursuant to 42 U.S.C. § 405(g) to appeal the decision of the Commissioner. (Doc. 1). On February 20, 2014, the Commissioner filed an answer and administrative transcript of proceedings. (Docs. 11, 12). On April 2, 2014, Plaintiff filed a brief in support of her appeal ("Pl. Brief"). (Doc. 13). On May 21, 2014, Defendant filed a brief in response ("Def. Brief"). (Doc. 16). On May 29, 2014, Plaintiff filed a brief in reply. ("Pl. Reply"). On November 19, 2014, the parties consented to transfer of this case to the undersigned for adjudication. (Doc. 19, 20). The matter is now ripe for review.
II. Standard of Review
When reviewing the denial of disability benefits, the Court must determine whether substantial evidence supports the denial. Johnson v. Comm'r of Soc. Sec., 529 F.3d 198, 200 (3d Cir. 2008); Brown v. Bowen, 845 F.2d 1211, 1213 (3d Cir. 1988). Substantial evidence is a deferential standard of review. See Jones v. Barnhart, 364 F.3d 501, 503 (3d Cir. 2004). Substantial evidence "does not mean a large or considerable amount of evidence, but rather such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'" Pierce v. Underwood, 487 U.S. 552, 565 (1988) (quoting Consol. Edison Co. of New York v. N.L.R.B., 305 U.S. 197, 229 (1938)). In other words, substantial evidence requires "more than a mere scintilla" but is "less than a preponderance." Jesurum v. Sec'y of U.S. Dep't of Health & Human Servs., 48 F.3d 114, 117 (3d Cir. 1995) (citing Richardson v. Perales, 402 U.S. 389, 401 (1971)).
III. Sequential Evaluation Process
To receive disability or supplemental security benefits, a claimant must demonstrate an "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. § 423(d)(1)(A); 42 U.S.C. § 1382c(a)(3)(A). The Act requires that a claimant for disability benefits show that he has a physical or mental impairment of such a severity that:
He is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy, regardless of whether such work exists in the immediate area in which he lives, or whether a specific job vacancy exists for him, or whether he would be hired if he applied for work.
42 U.S.C. § 423(d)(2)(A); 42 U.S.C. § 1382c(a)(3)(B).
The Commissioner uses a five-step evaluation process to determine if a person is eligible for disability benefits. See 20 C.F.R. § 404.1520; see also Plummer v. Apfel, 186 F.3d 422, 428 (3d Cir. 1999). If the Commissioner finds that a Plaintiff is disabled or not disabled at any point in the sequence, review does not proceed. See 20 C.F.R. § 404.1520. The Commissioner must sequentially determine: (1) whether the claimant is engaged in substantial gainful activity; (2) whether the claimant has a severe impairment; (3) whether the claimant's impairment meets or equals a listed impairment from 20 C.F.R. Part 404, Subpart P, Appendix 1 ("Listing"); (4) whether the claimant's impairment prevents the claimant from doing past relevant work; and (5) whether the claimant's impairment prevents the claimant from doing any other work. See 20 C.F.R. §§ 404.1520, 416.920. Before moving on to step four in this process, the ALJ must also determine Plaintiff's residual functional capacity ("RFC"). 20 C.F.R. §§ 404.1520(e), 416.920(e).
The disability determination involves shifting burdens of proof. The claimant bears the burden of proof at steps one through four. If the claimant satisfies this burden, then the Commissioner must show at step five that jobs exist in the national economy that a person with the claimant's abilities, age, education, and work experience can perform. Mason v. Shalala, 994 F.2d 1058, 1064 (3d Cir. 1993). The ultimate burden of proving disability within the meaning of the Act lies with the claimant. See 42 U.S.C. § 423(d)(5)(A); 20 C.F.R. § 416.912(a).
IV. Relevant Facts in the Record
Plaintiff was born on April 28, 1986 and was classified by the Regulations as a younger individual through the date of the ALJ decision. (Tr. 22). 20 C.F.R. § 404.1563. Plaintiff has at least a high school education and no past relevant work. (Tr. 22).
A. Function Report and Testimony
On August 14, 2010, 2011, Plaintiff submitted a Function Report. (Tr. 192-200). She indicated that she cares for her husband and son, but her mother-in-law and her husband help when she is "having issues." (Tr. 193). She indicated that nightmares of childhood abuse interfere with her sleep. (Tr. 193). She indicated problems bathing, but no other problems with personal care. (Tr. 193). She reported that she cooks "mostly complete meals" on a "daily" basis for thirty minutes to an hour. (Tr. 194). She indicated that she does household chores for up to three hours once a week, and her mother-in-law takes her son while she is doing them. (Tr. 194). She reported that she goes outside "when needed, " but does not "do too well with people" and cannot go out alone or drive due to anxiety. (Tr. 195). She indicated that she spends time with her neighbors and husband. (Tr. 196). She reported problems getting along with her family because she believes they are "responsible for what happened" to her and does not "trust anyone" except for her husband. (Tr. 197). She reported problems talking, hearing, memory, and getting along with others, but no physical problems. (Tr. 197). She indicated that she can walk for two and a half miles. (Tr. 197). She reported that she does not finish what she starts, follows written instructions "pretty well, " but cannot follow spoken instructions. (Tr. 197). She indicated that she had been "known to be belligerent with authority figures." (Tr. 198). She reported that she cannot handle stress or changes in routine and was "terrified of the dark." (Tr. 198). She indicated, "I don't have any [physical] pain." (Tr. 201).
On November 7, 2011, Plaintiff appeared and testified before the ALJ. (Tr. 36). She testified that she was able to drive, and drove to the hearing that day, but was unable to drive when she was not comfortable. (Tr. 36). She testified that she had been unable to graduate from any of the four colleges she had attended due to problems getting along with authority figures and feeling threatened by other students. (Tr. 36-39). She testified that she had been unable to maintain employment due to a distrust of others "because of what happened to [her] when [she] was younger." (Tr. 39). She reported that she "can appear normal for a short amount of time, anywhere between three months to six months. But once people start to see through that and they start to see [her] and see what's wrong with [her], " she was afraid they would physically or emotionally retaliate against her. (Tr. 40). She indicated that she was afraid of the dark, "afraid of people that [she] can't see but [she] can hear and [she] know[s] that they're there and [she] know[s] they're going to hurt [her]." (Tr. 42). She explained that "anyone... within of 20 foot radius of" her may hurt her. (Tr. 42). She indicated that she had been in foster homes until 2004, but did not receive mental health treatment after her discharge from Stony Ridge in 2001. (Tr. 29). She reported that she cannot work because she does not trust people, is scared all the time, has flashbacks all the time, and "black[s] out and lose[s] time." (Tr. 50). She testified that medications only help "to an extent" and cause side effects like jitteriness and sleepiness. (Tr. 54). She reported "forty-eight" suicide attempts in the past, most recently in "September of last year." (Tr. 56). She also testified that she could not be left alone because it would make her anxious. (Tr. 58). She admitted that she had "no" problems completing her homework, and spends "eight hours a day, probably approximately thirty to forty hours a week, " on her schoolwork. (Tr. 62).
B. Medical Records
Plaintiff was treated at Stone Bridge Transitional Care Home in 2001, when she was fifteen years old for about six weeks. (Tr. 243). She was discharged without suicidal ideation or prescription medications. (Tr. 244). Notes indicate that she would benefit from continued therapy, but there is no evidence of treatment in the record for nine years, from May 4, 2001 to June 21, 2010. (Tr. 244).
On June 21, 2010, Plaintiff was evaluated by Dr. Muhammad Qamar, M.D, at Universal Community Behavioral Health Outpatient Clinic ("Universal"). (Tr. 252-53). She wanted to "get back on medications so [she] can go back to work.'" (Tr. 252). Plaintiff reported feeling depressed, irritable, and she does not enjoy anything. (Tr. 252). Plaintiff reported that she had been treating with a psychiatrist after her admission in 2001, but that he left the area. (Tr. 252). She also reported that she had stopped taking her medications because she wanted to get pregnant, and was "not very comfortable with present situation of her moods." (Tr. 252). She indicated "a little bit of problems with sleep." (Tr. 252). She reported low energy and feelings of worthlessness, hopelessness, and helplessness. (Tr. 252). Her attention and concentration were "okay." (Tr. 252). She reported symptoms of mania one year earlier. (Tr. 252). She reported auditory hallucinations. (Tr. 252). Plaintiff denied being anxious but reported symptoms of PTSD from a history of abuse as a child. (Tr. 253). On examination, Plaintiff's mood was "mildly depressed, " and her thought process was "illogical and disorganized." (Tr. 254). She had fair insight and judgment and her "capacity for activities of daily living" was "good." (Tr. 254). Dr. Qamar diagnosed Plaintiff with bipolar disorder, psychotic disorder, and borderline personality disorder. (Tr. 255). He assessed her to have a global assessment of functioning ("GAF") of 55. (Tr. 255). He prescribed Lamictal, Risperdal and Cogentin. (Tr. 255).
On July 26, 2010, Plaintiff reported to Dr. Qamar that she was dealing with a lot of stress, "feeling very frustrated, " and "having some thoughts of harming self and others, but has no intent to act on these plans." (Tr. 250). On examination, Plaintiff's mood was "depressed and anxious." (Tr. 250). Plaintiff reported "some auditory hallucinations once in a while." (Tr. 250). Her insight and judgment were fair and she was assessed a GAF of 55. (Tr. 250-51). Dr. Qamar prescribed lithium and increased her Risperdal. (Tr. 351). On August 10, 2010, notes indicate that Plaintiff was "under a lot of stress due to conflict in marriage" and that she had made no progressive toward her objectives. (Tr. 248).
On August 20, 2010, X-rays of Plaintiff's chest indicated "early infiltrate at her left lung base posteriorly." (Tr. 301).
On August 24, 2010, Plaintiff established care at Mount Union Medical Center. (Tr. 288-92). Plaintiff had been "diagnosed with bronchitis in the [emergency room] on 8/20, however... a chest X-ray here... shows for an early infiltrate left lung base posterior." (Tr. 292). Plaintiff had been given a five day prescription of Avelox and was "feeling much improvement, however, not completely." (Tr. 292). She still complained of shortness of breath and a cough. (Tr. 292). On examination, Plaintiff had "hoarse breath sounds throughout" and she was diagnosed with pneumonia. (Tr. 292). On August 31, 2010, Plaintiff followed-up and reported "doing a lot better now, some nasal congestion only." (Tr. 291). Plaintiff was started on Chantix to quit smoking cigarettes. (Tr. 291).
On September 3, 2010, state agency physician Dr. Edward Jones, PhD, reviewed Plaintiff's file and issued an opinion. He opined that Plaintiff would have moderate difficulties with detailed instructions, completing a normal routine with supervisions, getting along with coworkers, supervisors, and peers, and responding appropriately to changes in the work setting. (Tr. 261-62). He explained that she was "maintained in outpatient mental health, " was "independent in [activities of daily living], caring for her minor child, and "appear[ed] to be cognitively intact, overall." (Tr. 263). He noted that she had a "history of mania, but of late has been experiencing primarily some depressive symptoms. She has occasional [auditory hallucinations] historically, but ignores them." (Tr. 263). He found her to be only "partially credible" and concluded that she "can perform simple, routine, repetitive work in a stable environment.... make simple decisions... is capable of asking simple questions and accepting instruction, " although she had a low frustration tolerance. (Tr. 263). He also concluded that Plaintiff was "able to meet the basic mental demands of competitive work on a sustained basis despite the limitations resulting from her impairment." (Tr. 263). He opined that she had mild restriction of activities of daily living, moderate difficulties in maintaining social functioning, and mild difficulties in maintaining concentration, persistence, or pace. (Tr. 274).
On October 19, 2010, Plaintiff followed-up at Mount Union. (Tr. 290). Plaintiff requested a pill for weight loss, and then requested gastric bypass surgery. (Tr. 290). Plaintiff also complained of pain in her right leg when her child sat on her knee. (Tr. 290). Plaintiff was assessed to have morbid obesity and "unspecific complaint of right lower extremity discomfort." (Tr. 290). Plaintiff was instructed to follow a 1200 calorie ...