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Smith v. Berryhill

United States District Court, M.D. Pennsylvania

February 16, 2018

NANCY A. BERRYHILL[1] Acting Commissioner of Social Security Defendant.



          Martin C. Carlson United States Magistrate Judge

         I. Introduction and Litigation History

         In considering Antoinette Smith's (“Smith”) Social Security disability application we most assuredly do not write upon a blank slate. Quite the contrary, this is Smith's second social security appeal. Smith's legal journey began when she filed protectively under Title II of the Social Security Act for a period of disability and disability insurance benefits on September 14, 2011, and also filed protectively under Title XVI of the Social Security Act for supplemental security income on October 4, 2011. (Tr. 12.) For both filings Smith alleged disability due to various mental disorders with the onset of disability dated October 31, 2008. (Tr. 12; 384.) Smith has already appealed to the District Court for the Middle District of Pennsylvania on one prior occasion, and the Court is presented now with a second appeal from the ALJ hearing decision on remand which found that Smith is not disabled.[2] (Tr. 379.)

         The instant appeal calls upon us to assess whether substantial evidence supported the ALJ's determination that Smith could perform a limited range of work in the national economy. Given the nature of Smith's emotional impairments, which included depressive disorder, anxiety, dysthymic disorder, bipolar disorder, panic disorder, schizophrenia, paranoid type, schizoaffective disorder, posttraumatic stress disorder, and a personality disorder, that finding by the ALJ rested upon an assessment of the medical and psychiatric evidence amassed in this case. In particular, the ALJ was called upon to consider some five years of treatment records compiled by multiple treating sources, all of whom documented that Smith suffered from a profound level of emotional and mental impairment on an on-going basis over an extended period of time. Notwithstanding this treating source evidence, the ALJ concluded that Smith could meet the mental demands of a limited range of light work, apparently reaching this conclusion based solely upon the rejection of five years of treating source documentation and opinions.

         In our view, more is needed here to meet the Commissioner's burden of showing that this determination rested upon substantial evidence articulated in the record. Therefore, for the reasons set forth below, it is recommended that this case be remanded to the Commissioner for further proceedings.

         II. Factual Background

         At the time of her 2011 Social Security applications, Smith was a high school graduate who had completed some online college courses. (Tr. 30-31, 164, 439.) In the past Smith had worked as a collection agent, customer service representative, order processor, claims research clerk, microfilm operator, and clerk. (Tr. 138-46, 164, 179-86, 677-678.) In her disability applications, Smith reported that she has suffered from a number of severe mental health impairments including major depressive disorder, anxiety, dysthymic disorder, bipolar disorder (I and II), panic disorder with agoraphobia, schizophrenia, paranoid type, schizoaffective disorder, depressive type, posttraumatic stress disorder, and a personality disorder. (Tr. 201-14, 251-58, 260-69, 340-75, 755-782.) It is undisputed that these are severe medical conditions and that Smith has been hospitalized in the past due to the severity of her symptoms and her attempted suicide. (Tr. 201-14.)

         Smith's initial application for disability benefits was denied by the ALJ in a decision issued on February 6, 2013. (Tr. 9-26.) That initial decision failed to identify a number of Smith's medical impairments. (Id.) Smith appealed this adverse ruling to the United States District Court, and on September 22, 2014, the Court remanded this case to the Commissioner for further proceedings, finding that the ALJ had erred at Step 2 of the sequential process which governs Social Security appeals by failing to acknowledge a series of medically determinable impairments suffered by Smith, including, panic disorder, bipolar disorder, depressive disorder, anxiety disorder, chronic headaches and left eye blindness. Smith v. Colvin, Civil No.3:13-CV-1667 (Doc. 20.)

         While these legal proceedings were on-going, Smith's primary mental health care took place at T.W. Ponessa, where she received mental health care and treatment starting in June 2011. (Tr. 251-58, 340-75.) At Ponessa, Smith initially underwent psychotherapy treatments with psychiatrist Dr. Yury Yaroslavsky (“Dr. Yaroslavsky”) on September 7, 2011, and she continued to be treated by him until March 2013. (Tr. 774-775.) Over the course of her treatment with Dr. Yaroslavsky, the doctor often documented evidence of profound mental impairment on Smith's part. For example, on October 13, 2011, Smith reported seeing shadows all the time, and her thought processes were severely disorganized. (Tr. 360.) These behaviors led Dr. Yaroslavsky to suspect that she was psychotic. (Id.) On December 21, 2011, Smith confessed to hearing voices, seeing things, and smelling dead people in her dreams, but was embarrassed to talk about it. She also exhibited significant looseness of associations, paranoid delusions, hallucinations, and her insight and judgment were very limited. (Tr. 352-53.) On March 14, 2012, Ms. Smith presented with auditory and visual hallucinations; her thought process was more disorganized and difficult; she was more confused; made very limited eye contact, and displayed looseness of associations. (Tr. 346-47.)

         Dr. Yaroslavsky continued to document these significant psychiatric symptoms on Smith's part throughout 2012 and 2013. Thus, on August 29, 2012, Smith presented with continued hallucinations and thought she was going to die; her mood and affect were anxious; she displayed some derailment in her thought process; and exhibited some bizarre, magical thinking. (Tr. 366-67.) Similarly, in January, 2013, the doctor reported that Smith continued to experience visual hallucinations, was disorganized, asked rhetorical questions, appeared quite perplexed, and exhibited limited insight and judgment. (Tr. 372-73.)

         In the course of this treatment, Dr. Yaroslavsky frequently evaluated the severity of Smith's impairments using a Global Assessment of Functioning, or GAF, scale. Using the GAF scale Dr. Yaroslavsky consistently assigned Smith GAF scores in the range of 45 to 50 during 2012 and 2013. Indeed, Smith's medical records disclose that Dr. Yaroslavsky reached these clinical findings regarding the severity of Smith's mental impairment no less than fifteen times during his treatment of the plaintiff. (Tr. 344, 346. 348, 350, 352, 354, 356, 358, 360, 362, 366, 368, 370, 372, and 374.)

         These were 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 Smith by this treating source consistently found that she suffered severe symptoms which included potentially serious impairments in social, occupational, or school functioning, or experienced psychiatric symptoms on the borderline between serious and moderate symptoms. Consistent with these thoroughly documented clinical findings Dr. Yaroslavsky also completed three Pennsylvania Department of Public Welfare (DPW) employability assessment forms stating that Smith was temporarily disabled for three consecutive time periods, which together spanned three years. (Tr. 754; 752; 750.) These time periods were December 14, 2011 - March 14, 2012, April 4, 2012 - April 3, 2013, and March 13, 2013 - March 12, 2014. (Tr. 754; 752; 750.)

         At T.W. Ponessa, Smith then briefly received mental healthcare treatment from psychiatrist Dr. Letitia Alida Covaci (“Dr. Covaci”) until Smith became a patient of Dr. Vassili V. Arkadiev (“Dr. Arkadiev”) in May 2013. (Tr. 774-782.) While in her care, Dr. Covaci also rated Smith with a GAF score of 45 to 50. (Tr. 774.) During the time period Dr. Arkadiev was treating Smith between 2013 and 2014, he conducted seven global assessment of functioning evaluations of Smith. With one exception when the doctor rated her GAF score as 50-55, (Tr. 770), Smith's GAF scores were consistently in the 45-50 range, GAF scores that were consistent with severe mental impairments. (Tr. 758, 760, 763, 767, 768, 772.)

         Further, in 2016, Smith started mental healthcare treatment with Julia L. Tilley (“Ms. Tilley”), MSW, LCSW. Ms. Tilley's treatment notes also documented paranoia, hallucinations, and severe depression on Smith's part. (Tr. 852-54.) Based upon this treatment history, Ms. Tilley reported in April of 2016 that Smith had marked restrictions in hosts of work-related spheres due to her mental health impairments. (Tr. 855.) Thus, between 2011 and 2016, while Smith's disability application was pending, no less than four separate treating sources have determined on multiple occasions that Smith suffers from severe impairments due to a cascading constellation of mental health conditions.

         Despite these consistent findings and opinions provided by Smith's treating mental health care providers from 2011 to 2016, on June 24, 2016, following the remand of this case for reconsideration by the Commissioner, the ALJ entered a decision that, once again, denied Smith's application for these benefits. (Tr. 379-88.) The ALJ found in his June 24, 2016 decision that Smith suffered from an array of severe impairments that affected her ability to work, including: (1) history of breast cancer, (2) personality disorder, (3) PTSD, (4) left long finger injury, (5) schizoaffective disorder, (6) obstructive sleep apnea, (7) panic disorder with agoraphobia, (8) obesity, (9) headaches, (10) depression with psychotic features, (11) bipolar disorder, and (12) blindness in one eye. (Tr. 381.) The ALJ also found that Smith did not meet any listings under 20 C.F.R. Part 404, Subpart P, Appendix 1. (Tr. 382; 388.)

         The ALJ's June 24, 2016 decision then concluded that Smith retained the residual functional capacity to perform a limited range of light work. (Tr. 383.) Despite Smith's well-documented history of on-going, profound emotional impairment, this residual functional capacity assessment addressed her ability to handle the mental demands of the workplace in a fleeting manner, simply stating that: “She is limited to simple routine tasks with few if any work place changes, no ...

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