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Newton v. Berryhill

United States District Court, M.D. Pennsylvania

February 12, 2018

ALLAN B. NEWTON, Plaintiff,
v.
NANCY A. BERRYHILL[1]Acting Commissioner of Social Security Defendant.

          Conner Chief Judge.

          REPORT AND RECOMMENDATION

          Martin C. Carlson United States Magistrate Judge

         I. Introduction and Litigation History

         In considering Allan B. Newton's (“Newton”) Social Security disability application we most assuredly do not write upon a blank slate. Quite the contrary, through a series of prior administrative rulings, the question of Newton's entitlement to disability benefits prior to February of 2010 has been resolved. Likewise, in the last ruling by the ALJ, the ALJ found that Newton was entitled to benefits beginning March 24, 2013, but “was not under a disability within the meaning of the Social Security Act at any time through March 31, 2012.” (Tr. 825.) Therefore, all that remains before the Court is a judgment regarding whether Newton met the requirements for disability during the only relevant time period that has yet to be adjudicated, February 20, 2010 to March 31, 2012. (Tr. 816.)[2]

         As to this closed period of alleged disability, it is undisputed that Newton has long suffered from a severe form of mental illness, a schizoaffective disorder. In this appeal we are presented with the following question: Does substantial evidence support the ALJ's decision to afford little weight to the opinion of Newton's treating physician, Dr. Shah, who found that Newton “is permanently and totally disabled” (Tr. 785), when the ALJ's only explanation for this rejection was that Newton's “mental status examinations were within normal limits and do not support Dr. Shahs' opinion, ” (Tr. 822), and that justification advanced by the ALJ is contradicted by Dr. Shah's treatment notes, which consistently documented profound impairments for Newton, including persistent auditory hallucinations? Because we find that Dr. Shah's treatment records, which repeatedly describe Newton's on-going hallucinations, cannot be fairly characterized as mental status examinations that were within normal limits, for the reasons set forth below it is recommended that this case be remanded for further proceedings.

         II. Factual Background

         Allan Newton initially filed protectively under Title II of the Social Security Act for a period of disability and disability insurance benefits on April 8, 2010, and also filed protectively under Title XVI of the Social Security Act for supplemental security income on April 26, 2010. (Tr. 814.) The ALJ later determined that the relevant time period for this claim was from February 20, 2010 to March 31, 2012, Newton's date last insured, a closed period of claimed disability which is not disputed by the parties in this appeal. (Tr. 816.) In this application Newton alleged mental illness as the reason he was limited in his ability to work, (Tr. 187), and it is undisputed that Newton suffered from a schizoaffective disorder during this time, a form of mental illness which the ALJ conceded was a severe impairment in this case. (Tr. 818.)

         With Newton's disability claim framed in this fashion, the central issue with respect to this closed period claim is the disabling effect of Newton's schizoaffective disorder. On this score a significant body of evidence, including treating source opinions and records, indicated that Newton struggled with severe mental illness. Due to his schizoaffective disorder Newton has been hospitalized ten times and has required continuous outpatient psychiatric treatment. (Doc. 14 p. 3.) From what can be gleaned from the record, Newton has been treated by Dr. Shah for his schizoaffective disorder since the year 2008, and Dr. Shah has consistently reported in her treatment notes that Newton hears voices and has experienced auditory hallucinations. (Tr. 472-475; 477; 478-479; 481-483; 485-487; 489- 490; 494-495; 497-500; 775; 779-781; 785, 1182.) Dr. Shah has also reported instances in which Newton also experienced visual hallucinations, and described seeing shadowy figures. (Tr. 742, 473, 477, 486, 489, 497, 511.) These treatment notes also document episodes of suicidal ideation by Newton. (Tr. 453, 497, 506, 511.) Further, the treatment records reflect that his treating mental health professionals have assigned Global Assessment of Functioning, or GAF scores for Newton which range between 48 and 60. (Tr. 447, 463, 479 and 775.) These are clinically significant findings since:

A GAF score is a numerical summary of a clinician's judgment of an individual's psychological, social, and occupational functioning on a hypothetical continuum of mental health on a scale of one hundred. See Diagnostic and Statistical Manual of Mental Disorders, 32-34(4th ed. text rev. 2000) (hereinafter ‘DSM-IV'). A score is placed in a particular decile if either symptom severity or the level of functioning falls with that range. Id.

Markoch v. Colvin, No. 3:14-CV-00780, 2015 WL 2374260, at *10 (M.D. Pa. May 18, 2015). Moreover, under the GAF score system:

GAF scores in the 51-60 range indicate moderate impairment in social or occupational functioning.” Cherry v. Barnhart, 29 Fed.Appx. 898, 900 (3d Cir. 2002). DaVinci v. Astrue, 1:11-CV-1470, 2012 WL 6137324 (M.D. Pa. Sept. 21, 2012) report and recommendation adopted, Davinci v. Astrue, 1:11-CV-1470, 2012 WL 6136846 (M.D.
Pa. Dec. 11, 2012). “A GAF score of 41-50 indicates ‘serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) [or] any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).' DSM-IV at 34. A score of 50 is on the borderline between serious and moderate symptoms.” Colon v. Barnhart, 424 F.Supp.2d 805, 809 (E.D. Pa. 2006). See Shufelt v. Colvin, No. 1:15-CV-1026, 2016 WL 8613936, at *2 (M.D. Pa. Sept. 15, 2016), report and recommendation adopted sub nom. Shulfelt v. Colvin, No. 1:15-CV-1026, 2017 WL 1162767 (M.D. Pa. Mar. 29, 2017).

Jones v. Colvin, No. 1:16-CV-1535, 2017 WL 4277289, at *2 (M.D. Pa. Sept. 25, 2017), report and recommendation adopted sub nom. Jones v. Berryhill, No. 1:16-CV-1535, 2017 WL 4314572 (M.D. Pa. Sept. 27, 2017).

         Thus, the GAF scores assigned to Newton by this treating source characterized his degree of impairment as ranging between moderate and severe. Consistent with these clinical findings, on June 22, 2011, Dr. Shah issued a statement to the Pennsylvania Department of Revenue stating that Newton “is permanently and totally disabled” within the meaning of the Social Security Act. (Tr. 785.)

         Dr. Shah's treating source opinion drew additional support and credence from a consultative psychological examination conducted by Dr. Charles Lajeunesse on March 15, 2013. (Tr. 1556-63.) Following this consultative examination, Dr. Lajeunesse issued a report which found that Newton had marked mental and social limitations and a GAF score of 50, a score which was emblematic of severe-to-moderate mental impairment. (Tr. 1559.)

         It was against the backdrop of this medical and mental health record that the ALJ issued an opinion denying Newton's claim for this closed period of disability benefits on May 24, 2016. (Tr. 809-26.) Although the ALJ found that Newton qualified for disability benefits after March 2013, the ALJ found that Newton was not entitled to benefits as a result of any disabling mental health conditions between February 2010 and March 2012. The ALJ's May 24, 2016 decision found that Newton suffered from the following five severe impairments that affected his ability to work: (1) schizoaffective disorder, (2) coronary artery disease, (3) obesity, (4) left rotator cuff tear, and (5) history of substance abuse. (Tr. 818.) The ALJ further found that Newton did not meet any listings under 20 C.F.R. Part 404, Subpart P, Appendix 1 and did not suffer from a disability at any time during the relevant period of this appeal. (Tr. 818; 825.) The ALJ then determined that Newton has the residual functional capacity (RFC) to perform light work, but Newton could not perform overhead work, crawling, kneeling, or climbing of ladders or scaffolds. (Tr. 819.) The ALJ also limited Newton “to simple, routine, repetitive work generally described as unskilled” where Newton will “have no interaction with the public and occasional interaction with co-workers and supervisors.” (Tr. 819.)

         In the course of reaching this conclusion, the ALJ gave “little weight” to Dr. Shah's treating source opinion that Newton's mental health condition was permanently and totally disabling. (Tr. 822.) Despite Dr. Shah's specialization in the psychological field and history of treating Newton, the ALJ rejected Dr. Shah's opinion. (Tr. 822.) The ALJ's treatment of this treating source opinion was cursory and the only explanation offered by the ALJ for rejection of this treating source opinion was that Newton's “mental status examinations were within normal limits and do not support Dr. Shahs' opinion.” (Tr. 822.) The ALJ's decision did not reconcile this assertion that Newton's “mental status examinations were within normal limits, ” (Id.), with Newton's thoroughly documented treating source history of auditory hallucinations, visual hallucinations, suicidal thoughts, or GAF scores which confirmed severe to moderate mental impairments. Nor did the ALJ reconcile this decision to afford little weight to this treating source opinion with the corroborating support of Dr. Lajeunesse's March 15, 2013 consultative examination report which found that Newton had marked mental and social limitations and a GAF score of 50, a score which was emblematic of severe-to-moderate mental impairment. (Tr. 1559.) Instead, curiously, the ALJ gave Dr. Lajeunesse's opinion “moderate” weight, while completely discounting the report's conclusion that Newton had marked limitations in social interactions, based solely upon a notation that Newton's eye contact and behavior were normal. (Tr. 823.)

         This appeal followed. (Doc. 1.) On appeal, Newton presents the following five issues: (1) the ALJ erred by rejecting the testimony of the Commissioner's medical expert, Dr. Freemont, opining that Newton's mental impairment met a listing, (2) The ALJ erroneously rejected the medical opinion of treating psychiatrist Dr. Shah, (3) the ALJ erred failing to credit Dr. Lajeunesse's opinion, (4) the hypothetical presented to the VE did not contain all of Newton's credibly established limitations, and (5) the ALJ did not ...


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