United States District Court, M.D. Pennsylvania
ALLAN B. NEWTON, Plaintiff,
NANCY A. BERRYHILLActing Commissioner of Social Security Defendant.
REPORT AND RECOMMENDATION
C. Carlson United States Magistrate Judge
Introduction and Litigation History
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.)
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.
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.)
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.
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).
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.)
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.
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.)
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.)
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