United States District Court, M.D. Pennsylvania
SIGRUN E. HOLLIDAY, Plaintiff
CAROLYN W. COLVIN, ACTING COMMISSIONER OF SOCIAL SECURITY, Defendant
Robert D. Mariani United States District Judge.
The above-captioned action is one seeking review of a decision of the Commissioner of Social Security ("Commissioner") denying Plaintiff Sigrun E. Holliday's claim for social security disability insurance benefits.
Holliday protectively filed her application for disability insurance benefits on December 15, 2010. Tr. 10, 164 and 288. The application was initially denied by the Bureau of Disability Determination on April 7, 2011. Tr. 10 and 165-169. On June 7, 2011, Holliday requested a hearing before an administrative law judge. Tr. 10 and 170-171. Subsequently hearings were held before an administrative law judge on April 10, July 2 and October 18, 2012. Tr. 29-150. Holliday was represented by counsel at the hearing held on October 12, 2012. Tr. 90-150. On December 26, 2012, the administrative law judge issued a decision denying Holliday's application. Tr. 10-22. As will be explained in more detail infra the administrative law judge found that Holliday failed to prove that she met the requirements of a listed impairment or suffered from work-preclusive functional limitations. \± Instead Holliday had the ability to perform a limited range of sedentary work. Tr. 21-22. On February 19, 2013, Holliday filed a request for review with the Appeals Council and after 12 months had elapsed the Appeals Council on February 21, 2014, concluded that there was no basis upon which to grant Holliday's request for review. Tr. 1-6 and 343-347.
Holliday then filed a complaint in this court on April 10, 2014. Supporting and opposing briefs were submitted and the appeal became ripe for disposition on November 12, 2014, when Holliday filed a reply brief.
Disability insurance benefits are paid to an individual if that individual is disabled and "insured, " that is, the individual has worked long enough and paid social security taxes. The last date that a claimant meets the requirements of being insured is commonly referred to as the "date last insured." It is undisputed that Holliday met the insured status requirements of the Social Security Act through June 30, 2013. Tr. 10 and 12.
Holliday was born in the United States on May 20, 1977, and at all times relevant to this matter was considered a "younger individual" whose age would not seriously impact her ability to adjust to other work. 20 C.F.R. § 404.1516©; Tr. 58, 164, 271, 288 and 875.
Holliday graduated from high school in 1995, and can read, write, speak and understand the English language and perform basic mathematical functions. Tr. 291, 305 and 494. During her primary and secondary schooling, Holliday attended regular education classes. Tr. 293. Holliday also during high school completed vocational courses in graphic arts and screen printing. Tr, 494. After graduating from high school Holliday attended college for two years and in 1997 obtained a degree from Thaddeus Stevens College of Technology, Lancaster, Pennsylvania, in printing technology. Id.
Holliday's work history covers 17 years and at least 4 different employers. Tr. 281-284, 315 and 339. The records of the Social Security Administration reveal that Holliday had earnings in the years 1993 through 1996, 1998 through 2008, and 2010 through 2011. Tr. 281 and 287. Holliday's annual earnings range from a low of $212.00 in 1996 to a high of $38, 937.71 in 2002. Id. Holliday's total earnings during those 17 years were $258, 647.19. Id. Holliday's earnings of $3464.00 during 2010 and $4479.00 during 2011 were from self-employment as an artist and the sale of miscellaneous home items. Tr. 104-105, 284 and 287. Holliday testified that in 2010 and 2011 she painted acrylic and water color paintings. Id.
Holliday in documents filed with the Social Security Administration stated that she worked as a film stripper for a printing company, Wickersham Printing Company, Inc., King of Prussia, Pennsylvania, from June, 1997, to April, 1998; as an electronic systems operator for a printing company, R.R. Donnelley & Sons Company, from January 1999 to June 2006; and as a server at two different restaurants, a Waffle House and Friendly's, from January, 2007, to March, 2008. Tr. 282-284, 315 and 339.
Holliday has past relevant employment as (1) a film stripper for a printing company which was described by a vocational expert as skilled, light work; (2) a scanner operator which was described as skilled, medium work; and (3) a waitress described as semi-skilled, light work. Tr. 133 and 135-136.
Holliday initially contended that she became disabled on March 1, 2008, because of both physical and mental impairments. Tr. 271 and 292. At the administrative hearing held on October 18, 2012, Holliday amended her alleged disability onset date to October 23, 2009. Tr. 95-96. The physical impairments alleged by Holliday were degenerative disc disease,  chronic sciatica causing leg pain, carpal tunnel syndrome and obesity. Tr. 292. The mental impairments were depression, bipolar disorder, anxiety, posttraumatic stress disorder and borderline personality disorder. Id. Holliday has not engaged in any substantial gainful activity since March 1, 2008. Tr. 12. Holliday was apparently fired in March, 2008, from her last position as a waitress at Friendly's Restaurant because of frequent absences. Tr. 521.
The record reveals that Holliday was the victim of sexual abuse during her formative years and that she has a history of drug abuse (crack cocaine, heroin and marijuana). Tr. 358, 495-497 and 913.
The record reveals that Holliday engaged in a wide range of activities of daily living. Holliday cooked, cleaned, washed laundry, helped her parents with yard work and odd jobs on their farm, helped care for her 12 year old son and her boyfriend's four year old son, and enjoyed taking walks in the woods. Tr. 82, 84, 303, 497-498, 598, 791, 824 and 876. Also, as noted above, she sold artwork that she painted as well as miscellaneous household items at local markets and online. Tr. 61 and 104-105. Holliday took college courses, read, and wrote poetry and journal entries. Tr. 72, 79 and 495. She also attended church and narcotics anonymous meetings and had a close friend and a boyfriend. Tr. 305-306, 495 and 876.
For the reasons set forth below we will affirm the decision of the Commissioner denying Holliday's application for disability insurance benefits.
Standard of Review
When considering a social security appeal, we have plenary review of all legal issues decided by the Commissioner. See Poulos v. Commissioner of Social Security. 474 F.3d 88, 91 (3d Cir. 2007); Schaudeck v. Commissioner of Social Sec, Admin.. 181 F.3d 429, 431 (3d Cir. 1999); Krvsztoforski v. Chater. 55 F.3d 857, 858 (3d Cir. 1995). However, our review of the Commissioner's findings of fact pursuant to 42 U.S.C. § 405(g) is to determine whether those findings are supported by "substantial evidence." Id.; Brown v. Bowen. 845 F.2d 1211, 1213 (3d Cir. 1988); Mason v. Shalala. 994 F.2d 1058, 1064 (3d Cir. 1993). Factual findings which are supported by substantial evidence must be upheld. 42 U.S.C. §405(g); Faranoli v. Massanari. 247 F.3d 34, 38 (3d Cir. 2001)("Where the ALJ's findings of fact are supported by substantial evidence, we are bound by those findings, even if we would have decided the factual inquiry differently."); Cotter v. Harris. 642 F.2d 700, 704 (3d Cir. 1981)("Findings of fact by the Secretary must be accepted as conclusive by a reviewing court if supported by substantial evidence."); Keefe v. Shalala. 71 F.3d 1060, 1062 (2d Cir. 1995); Mastro v. Apfel. 270 F.3d 171, 176 (4th Cir. 2001); Martin v. Sullivan. 894 F.2d 1520, 1529 & 1529 n.11 (11th Cir. 1990).
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 Consolidated Edison Co. v. N.L.R.B.. 305 U.S. 197, 229 (1938)); Johnson v. Commissioner of Social Security. 529 F.3d 198, 200 (3d Cir. 2008); Hartranft v. Apfel. 181 F.3d 358, 360 (3d Cir. 1999). Substantial evidence has been described as more than a mere scintilla of evidence but less than a preponderance. Brown. 845 F.2d at 1213. In an adequately developed factual record substantial evidence may be "something less than the weight of the evidence, and the possibility of drawing two inconsistent conclusions from the evidence does not prevent an administrative agency's finding from being supported by substantial evidence." Consolo v. Federal Maritime Commission. 383 U.S. 607, 620 (1966).
Substantial evidence exists only "in relationship to all the other evidence in the record, " Cotter. 642 F.2d at 706, and "must take into account whatever in the record fairly detracts from its weight." Universal Camera Corp. v. N.L.R.B.. 340 U.S. 474, 488 (1971). A single piece of evidence is not substantial evidence if the Commissioner ignores countervailing evidence or fails to resolve a conflict created by the evidence. Mason. 994 F.2d at 1064. The Commissioner must indicate which evidence was accepted, which evidence was rejected, and the reasons for rejecting certain evidence. Johnson. 529 F.3d at 203; Cotter. 642 F.2d at 706-707. Therefore, a court reviewing the decision of the Commissioner must scrutinize the record as a whole. Smith v. Califano. 637 F.2d 968, 970 (3d Cir. 1981); Dobrowolsky v. Califano. 606 F.2d 403, 407 (3d Cir. 1979).
Sequential Evaluation Process
To receive disability benefits, the plaintiff 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. § 432(d)(1)(A). Furthermore,
[a]n individual shall be determined to be under a disability only if his physical or mental impairment or impairments are of such 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. For purposes of the preceding sentence (with respect to any individual), "work which exists in the national economy" means work which exists in significant numbers either in the region where such individual lives or in several regions of the country.
42 U.S.C. § 423(d)(2)(A).
The Commissioner utilizes a five-step process in evaluating disability insurance and supplemental security income claims. See 20 C.F.R. §404.1520; Poulos. 474 F.3d at 91-92. This process requires the Commissioner to consider, in sequence, whether a claimant (1) is engaging in substantial gainful activity,  (2) has an impairment that is severe or a combination of impairments that is severe,  (3) has an impairment or combination of impairments that meets or equals the requirements of a listed impairment,  (4) has the residual functional capacity to return to his or her past work and (5) if not, whether he or she can perform other work in the national economy. Id. As part of step four the administrative law judge must determine the claimant's residual functional capacity. Id.
Residual functional capacity is the individual's maximum remaining ability to do sustained work activities in an ordinary work setting on a regular and continuing basis. See Social Security Ruling 96-8p, 61 Fed. Reg. 34475 (July 2, 1996). A regular and continuing basis contemplates full-time employment and is defined as eight hours a day, five days per week or other similar schedule. The residual functional capacity assessment must include a discussion of the individual's abilities, id; 20 C.F.R. § 404.1545; Hartranft. 181 F.3d at 359 n.1 ("'Residual functional capacity' is defined as that which an individual is still able to do despite the limitations caused by his or her impairment(s).").
Before we address the administrative law judge's decision and the arguments of counsel, we will review in detail Holliday's medical records. Initially, we will note that the relevant time period is from March 1, 2008, through the date the administrative law judge issued a decision denying Holliday's application. The administrative record in this case is 1446 pages in length. Holliday has primarily contended that she is disabled because of back pain, lower extremity pain and mental health impairments. The court in its review of the records will primarily focus on those conditions.
For background purposes we will commence with some medical records which predate the alleged disability onset date of March 1, 2008. In September, 2005, Holliday underwent a bilateral L5-S1 laminectomy and right L5-S1 diskectomy without complications and post-operatively she did well. Tr. 462-463. On February 8, 2006, when Holliday established a primary care relationship with Brian P. Sullivan, M.D., of Family Practice Associates of Lancaster, her only concern was her weight, a history of high blood pressure and menometrorrhagia. Tr. 490. Holliday reported that she smoked 1 pack of cigarettes per day. Id. After performing a physical examination, Dr. Sullivan's diagnostic assessment was that Holliday suffered from high blood pressure, morbid obesity and a history of menometrorrhagia. Id. The reported objective physical examination findings were normal other than Holliday's blood pressure was 180/98. Id. Dr. Sullivan adjusted Holliday's blood pressure medications, ordered blood tests and scheduled a 1 month follow-up appointment. Id. At the follow-up appointment on March 8, 2006, Holliday reported that she "had no complaints [and] generally [had been] doing well" but she continued to smoke one pack of cigarettes per day. Tr. 490. Most of the appointment time was spent "counseling [Holliday] regarding smoking cessation." ]d Dr. Sullivan noted that Holliday's blood pressure had improved and he was satisfied with the result. Id.
On May 21, 2006, Holliday visited the emergency department at the Lancaster General Hospital complaining of a sore throat. Tr. 454-456. During that visit Holliday reported no neck pain, no joint pain, no back pain, no headaches, no paresthesias (pins and needles), no focal weakness and no sensory changes, Id. The reported physical and mental status examination findings were essentially normal. Id. The diagnostic assessment was that Holliday suffered from uvulitis which resulted from untreated sleep apnea. Tr. 455. Holliday was prescribed the antibiotic amoxicillin and advised to follow-up with her primary care physician, Dr. Sullivan. Id. The follow-up appointment occurred on May 22, 2006, at which time Dr. Sullivan reported no adverse objective physical examination findings other than Holliday's throat appeared "mildly erythematous" but her uvula did not appear "overly enlarged[.]" Tr. 489. Dr. Sullivan referred Holliday to a pulmonologist for a sleep evaluation. Id.
On May 31, 2006, Holliday had an appointment with John T. Joseph, M.D., of Conestoga Pulmonary & Sleep Medicine. Tr. 486-488. After conducting a clinical interview, a physical examination and reviewing a prior sleep study, Dr. Joseph's impression was as follows: "Previously documented obstructive sleep apnea. This patient, in the interval, has gained 45 lbs. since her study two years ago." Tr. 488. Dr. Joseph prescribed a CPAP machine. Id. Notably, during the clinical interview Holliday denied any neurological problems, weakness, muscle aches or joint pain, Tr. 487. The physical examination revealed that she had normal muscle strength, Id.
At an appointment with Dr. Sullivan on August 31, 2006, Holliday complained of lower extremity edema which Dr. Sullivan concluded possibly was related to the blood pressure medication which Holliday was taking. Tr. 485. Dr. Sullivan prescribed a different medication, Id. On September 22, 2006, Holliday complained of swelling in her throat which Dr. Sullivan attributed to her blood pressure medication and again he discontinued the medication and prescribed a different medication. Tr. 484. On April 9, 2007, Holliday appears to have had an appointment with either an associate of Dr. Sullivan or a nurse or physician's assistant employed by Dr. Sullivan regarding bilateral conjunctivitis (pink eye). Tr. 483. Holliday was treated with eye drops and an antibiotic. Id. In July and August, 2007, Holliday was treated by Kathleen Sheridan, M.D., a gynecologist, for persistent menorrhagia and endometrial hyperplasia. Tr. 420-423, 540-543 and 549-554.
From August 22 to 24, 2007, Holliday underwent a psychiatric hospitalization at the Lancaster Regional Medical Center for a suicide attempt. Tr. 353-359 and 365-384. It was reported that Holliday consumed twenty-one 100mg tablets of the antidepressant Wellbutrin around 7:00 p.m. on August 21, 2007, and she arrived at the emergency department of Lancaster Regional Medical Center at about 10:59 p.m. by ambulance. Tr. 375 and 380. Holliday "was found to be quite stable, as far as her vital signs [were] concerned, but the poison center  recommended some sedation and ongoing observation for any seizure potential and other serotonin syndromes." Tr. 375. At the time of admission, the diagnostic assessment was that Holliday suffered from depressive disorder, not otherwise specified and she was given a Global Assessment of Functioning (GAF) score of 50. Tr. 359. During the psychiatric hospitalization, Holliday reported that she smoked one to two packs of cigarettes per day; she lived with her son who was nine years old and her sister; and she worked at the Waffle House in Lancaster, Tr. 375-376, 380 and 384. Holliday reported no pain and the results of the physical examination were essentially normal. Tr. 376 and 380. Holiday denied any history of alcohol or drug abuse. Tr. 367. Holliday was discharged from the hospital on August 24th with the same diagnostic assessment and GAF score. Tr. 353. The course of Holliday's psychiatric hospitalization was described in the discharge summary as follows:
The patient's stay in the hospital was brief. She quickly showed improved affect. She was able to contract for safety, recognize the fact that the relationship [with a boyfriend] may not be working well in her favor and was no longer suicidal, was able to participate in unit activities and individual sessions. Subsequently the patient was started on Prozac 20 mg daily, the use of medication was explained to patient. She showed interest in continuing her medicine and following up with Dr. Sullivan in the Family Practice Associates of Lancaster and also being referred to MH/MR for follow-up.
Tr. 354. Holliday's discharge medications were Prozac, the high blood pressure medication Atenolol/Chlorthalidone and Provera, to treat her menorrhagia. Id.
On September 18, 2007, Holliday had a follow-up appointment with Dr. Sullivan at which Holliday reported that she was "seeing a counselor through church and [felt] a lot of issues going on, while not resolved, [were] starting to improve." Tr. 482. It was noted that Holliday was taking Tenoretic for blood pressure control; she denied shortness of breath; she was currently smoking; and she was working full-time at the Waffle House. Id. Dr. Sullivan reported that Holliday's blood pressure was stable; she seemed to be doing much better psychologically; and her sleep apnea was stable, Id. He further noted that Holliday was still being treated by a gynecologist for a history of uterine bleeding and polycystic ovarian syndrome.
From the date Holliday had a her back surgery in 2005 through November, 2007, Holliday's medical records do not reveal that she complained of low back pain or lower extremity pain, id The first time that Holliday complained of lower extremity pain was at an appointment with Dr. Sullivan on December 17, 2007. Tr. 481. Holliday stated that since her 2005 surgery "her back [had] been relatively stable but over the past week or so she  had some increasing pain down her [right] leg and yesterday it became more severe." Id. Holliday stated that the pain was similar to "when she had her previous back problems" and the "pain goes the whole way to her foot." id. Holliday denied any numbness, tingling or weakness, Id. Holliday also reported some depression, Id. A physical examination revealed tenderness to palpation over the right lumbar area and the sciatic area; a positive straight leg raise test on the right; and no detectable weakness on the right. Id. Dr. Sullivan's diagnostic assessment was that Holliday suffered from radicular pain and depression and he prescribed medications. Id.
At an appointment with Dr. Sullivan on January 11, 2008, Holliday reported "worsening problems with anxiety" but that her sister gave her a Xanax pill and "[s]he was able to go to two job interviews[.]" Tr. 480. No objective physical examination findings were recorded by Dr. Sullivan and the entire appointment "was spent in counseling and discussion." Id. Dr. Sullivan prescribed the antidepressant Lexapro and the anxiety medication Xanax (alprazolam), Id. At the end of January, Holliday fell on an icy patch on her sidewalk and landed on her right side. Tr. 479. Holliday used her right arm to break her fall and in the process injured her right wrist. Id. Other than some palpable pain and swelling in the right wrist, the results of a physical examination were normal. Id. Dr. Sullivan suspected that Holliday primarily suffered a soft tissue injury and advised her to apply ice to her wrist and take ibuprofen or Aleve. Id. At a follow-up appointment with Dr. Sullivan on February 4, 2008, Holliday continued to complain of wrist pain but also reported right shoulder pain. Tr, 479. Again other than noting palpable pain in the wrist and shoulder area, the results of a physical examination were normal. Id. Dr. Sullivan ordered x-rays of Holliday's right wrist and shoulder and referred her to physical therapy. Id. He also prescribed the narcotic-like pain medication tramadol and Percocet (a combination of acetaminophen and oxycodone). id An x-ray of the wrist and shoulder performed on February 4th revealed no fractures or dislocations Tr. 451, 477-478 and 688.
On February 26, 2008, Holliday had an appointment with Dr. Sullivan regarding nasal congestion and frequent bloody noses. Tr. 476. After performing a physical examination, the results of which were essentially normal other than edema in the nasal passages and what appeared to be a nasal polyp, Dr. Sullivan decided to "treat her empirically for sinusitis with Amoxicillin, " an antibiotic. Id.
After Holiday's alleged disability onset date of March 1, 2008, Holliday phoned Dr. Sullivan's office on March 15th complaining of back pain. Tr. 474. In response, Dr. Sullivan issued a prescription for the nonsteroidal anti-inflammatory drug Voltaren (diclofenac), the muscle relaxant Flexeril and the narcotic pain medication Vicodin. Id. On March 20, 2008, Dr. Sullivan provided Holliday with a prescription for the narcotic pain medication Percocet and on March 26th the anxiety medication Xanax, kl On the note relating to the Percocet prescription Dr. Sullivan stated that he was going to have an "impossible time" finding a back specialist for Holliday in light of her lack of insurance. Id.
On March 28, 2008, Holliday visited the emergency department of the Lancaster General Hospital complaining of left lower back pain and tenderness and decreased range of motion of the back. Tr. 639-641. Holliday described the pain as going down the left buttock and into the posterior hamstring (muscles of the back of the upper leg). Tr. 639. Holliday had no weakness or tingling in the her left lower extremity, Id. The results of a physical examination were essentially normal, including she had a negative straight leg raising test, normal lower extremity range of motion, no motor or sensory deficits, normal deep tendon reflexes and no lower extremity edema. Tr. 640. The only adverse objective findings were that Holliday had some paraspinal tenderness, in the lower back, palpable pain in the hamstring but not the knee joint, and increased pain with active and passive proximal leg straightening. Id. Holliday was discharged the same day with a diagnosis of sciatica and advised to apply heat to the affected area 3-4 times per day, take Tylenol or Advil for pain, and follow-up with Dr. Sullivan. Id. On discharge Holliday was also given ten 2 mg tablets of the narcotic pain medication Dilaudid to be taken every 4-6 hours as needed. Id.
On April 2, 2008, Holliday had a follow-up appointment with Dr. Sullivan at which she reported that the Dilaudid was helping but "she continue[d] to have really severe pain. Tr. 473. In contrast to what she told the emergency department personnel at Lancaster General Hospital regarding pain in her left lower back and left lower extremity, she now reported that the pain was "in her [right] lower back radiating into her leg" with "some numbness down into her leg as well as pain." Id. Holliday also reported irritability, depression and mood swings but denied any thoughts of suicide and she contracted with Dr. Sullivan "for safety." Id. No physical examination was performed by Dr. Sullivan and the entire appointment was "spent in counseling & discussion." Id. Dr. Sullivan prescribed the drugs Lexapro, Zyprexa and Dilaudid. id.
At an appointment with Dr. Sullivan on April 14, 2008, Holliday complained of very severe low back pain which sometimes radiated down into her legs. Tr. 472. Holliday reported that the pain gets worse the longer she walks, id, Holliday also reported that she was having less problems with racing thoughts since starting Zyprexa and that she was sleeping better. Id. She stated that her overall mood had improved and that she was not having suicidal thoughts. Id. The objective physical examination findings reported by Dr. Sullivan were essentially normal other than Holliday had some tenderness over the lower back and buttocks and a positive straight leg raising test but Dr. Sullivan did not report on which side. Id. Holliday's strength was normal. Id. It was noted that Holliday now had insurance and Dr. Sullivan ordered an MRI of Holliday's lumbar spine and referred her to physical therapy and back specialist, Dr. Kager, who performed her prior surgery. Id. Dr. Sullivan prescribed the medications Dilaudid and Xanax. Id.
An MRI of Holliday's lumbar spine performed on April 25, 2008, revealed "[p]ostsurgical changes at L5-S1 without disc herniation or distortion to the thecal sac"and "degenerative facet disease at L4-5 which has mildly progressed since the old exam." Tr. 744. A notation on the report of the MRI dated May 6, 2008, by Dr. Sullivan stated that "overall the MRI doesn't really show much to explain the degree of pain she is having. Hopefully, Dr. Kager can help sort it all out." Tr. 471.
On April 30, 2008, Dr. Kager examined Holliday and then prepared a report of his findings which was transcribed on May 7, 2008, and forwarded to Dr. Sullivan. Tr. 728. In the report of the examination Dr. Kager stated that Holliday smokes one pack of cigarettes per day; she drinks occasionally; and she was not working apparently because of her psychiatric issues. Tr. 729. The results of a physical examination performed by Dr. Kager were essentially normal other than Holiday was obese and she had some tenderness to palpation in the right sacroiliac joint region. Tr. 729-730. Dr. Kager noted that Holliday's gait was normal; her muscle strength and tone were normal; her sensation was normal; her reflexes and coordination were normal; she had a negative straight leg raise test; and a negative Babinski and Hoffman's sign. Tr. 730, Dr. Kager stated that he could not correlate Holliday's complaints of pain directly to her lumbar spine. Id. His diagnostic impression was merely "[r]ight buttock, lower extremity pain." Id. Dr. Kager recommended that Holliday commence physical therapy and because she was complaining about right hip pain ordered an x-ray of her pelvis and hip. Id. The x-ray was performed on May 1, 2008, and revealed that the bones were intact and normally mineralized; the joint spaces were well maintained; and there was no evidence of soft tissue calcification to indicate bursitis or tendinitis. Tr. 743.
On May 14, 2008, Holliday had an appointment with Dr. Sullivan at which Holliday continued to complain of pain in her lower back and down into her right buttocks. Tr. 470. Holliday did report that her psychiatric symptoms were improved, including her mood was much better and she was sleeping throughout the night without difficulty. Id. The results of a physical examination were essentially normal other than she had some tenderness in the lower back, more so on the right than the left and into the buttocks. Id. Straight leg raising tests were negative. Id. Holliday did have some pain with internal and external rotation of the hip. ]d However, overall her range of motion was pretty good and she had normal deep tendon reflexes. Id. Dr. Sullivan continued Holliday's current medications. Id.
On June 27, 2008, Holliday had an appointment with Dr. Sullivan at which she reported that she had been on the antidepressant Celexa "now for a month and half or so" to treat her depression and it "seern[ed] to be working well." Tr. 492. Holliday told Dr. Sullivan that "a few months ago when things were bad she got in with the wrong crowd of people and was abusing cocaine but she has been clean for 1 month." Id. Holliday reported that she ran out of the Zyprexa and was having some problems with sleeping, Id. No physical examination was performed during this appointment and the entire time was spent in counseling and discussion. Id. Dr. Sullivan gave Holliday a prescription for Zyprexa. Id.
On July 17, 2008, Holliday was evaluated by Lynette G. Ruch, Ph.D., a psychologist, on behalf of the Bureau of Disability Determination. Tr. 493-499. After performing a clinical interview and a mental status examination, Dr. Ruch concluded that Holliday suffered from posttraumatic stress disorder, chronic, mild to moderate; dysthymic disorder, early onset, mild to moderate; and personality disorder, not otherwise specified, moderate to severe. Tr. 498. Dr. Ruch gave Holliday a current GAF score of 45. Id. Dr. Ruch also noted that she could not rule out the possibility that Holliday suffered from polysubstance abuse. Id. Specifically, Dr. Ruch stated as follows: " Ms. Holliday reports she has been in recovery for 60 days from crack cocaine. She reports she used for 2 1/2 months and this was a relapse. Apparently in the past she has also used marijuana. She denied any history of alcohol. She reports she is fearful of being an alcoholic. It is not clear how accurate this history is." Tr. 495-496. In a separate document entitled "Medical Source Statement of Ability to Do Work-Related Activities (Mental)" Dr. Ruch stated that Holliday's ability to understand, remember, and carry out instructions was not impacted by her mental health impairments. Tr. 501. Dr. Ruch further indicated that Holliday was only moderately limited ...