United States District Court, M.D. Pennsylvania
REPORT AND RECOMMENDATION
C. Carlson United States Magistrate Judge
case we are called upon to determine whether substantial
evidence supported the findings of an Administrative Law
Judge (ALJ) that the plaintiff, Sugeily Castillo, who was
unemployed during the period of her claimed disability, could
nevertheless work full-time in a limited capacity.
Administrative Law Judges (ALJs) evaluating cases like
Castillo's, Social Security disability determinations
frequently entail an informed assessment of competing medical
opinions coupled with an evaluation of a claimant's
subjective complaints. Once the ALJ completes this task, on
appeal it is the duty and responsibility of the district
court to review these ALJ findings, judging the findings
against a deferential standard of review which simply asks
whether the ALJ's decision is supported by substantial
evidence in the record, see 42 U.S.C. § 405(g);
Johnson v. Comm'r of Soc. Sec., 529 F.3d 198,
200 (3d Cir. 2008); Ficca v. Astrue, 901 F.Supp.2d
533, 536 (M.D. Pa. 2012), a quantum of proof which
“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).
instant case, an ALJ denied Castillo's application for
Social Security Disability Insurance Benefits based on a
determination that Castillo was not disabled and could
perform a limited range of light work. Mindful of the fact
that substantial evidence is less than a preponderance of the
evidence but more than a mere scintilla, Richardson v.
Perales, 402 U.S. 389, 401 (1971), we find that
substantial evidence supported the ALJ's findings in this
case. Therefore, for the reasons set forth below, we will
recommend that this court affirm the decision of the
Commissioner denying this claim.
Statement of Facts and of the Case
The Plaintiff's Background and Medical
Castillo is a 38-year old woman who speaks little English and
does not possess either a high school degree or GED. (Tr.
48). She currently lives with her friend, Celeste Rivera
(“Rivera”). (Tr. 53). Over the past fifteen
years, Castillo has worked as a line seamstress, poultry
de-boner, server, and lumber cutter for Weaver Lumber. (Tr.
48). In October of 2014, Castillo injured her back and right
arm and shoulder while working at Weaver Lumber. (Tr. 364).
She was diagnosed with adhesive capsulitis of the right
shoulder and bicipital tenosynovitis which she claims caused
her, and continues to cause her, great pain in her right
shoulder and arm. (Tr. 369). She has not worked since that
time. (Tr. 24). After her injury, she was treated by an
orthopedist and a physical therapist and was taking
medication for pain management in addition to shoulder
injections. (Tr. 376, 502). Eventually, she underwent
shoulder arthroscopy, but claims that her pain persisted.
(Tr. 49-51, 482). In early 2016, Castillo received an MRI
which revealed apparent scoliosis and multilevel degenerative
disc disease, but some movement during the MRI degraded its
accuracy. (Tr. 29). Her medical records demonstrate a course
of pain management treatment effectuated through routine
visits to her primary care provider at Good Samaritan Family
Practice Center, who prescribed pain medications and muscle
relaxers to make her more comfortable. (Tr. 540-72).
also began treatment for depression and other mental health
issues in the fall of 2014. (Tr. 402, 405, 418). She saw a
specialist at Philhaven for a psychiatric evaluation in
November of 2014 and has continued outpatient treatment,
evaluation, and therapy through at least 2017 to manage her
medications and symptoms. (Tr. 418, 451, 887). She complained
of auditory and visual hallucinations, severe depression,
anxiety, irritability, sleeplessness, paranoia, panic
attacks, crying spells, and, at times, thoughts of harming
herself and others. (Tr. 581, 590, 592, 605, 626, 675). While
certain complaints appear more sporadic throughout her
treatment records, she claimed that her depression, anxiety,
panic attacks, and crying spells were still present at the
hearing with the ALJ on July 14, 2017. (Tr. 53-54, 73).
March 17, 2015, Castillo saw Spencer Long, M.D. for an
independent medical consultative examination. (Tr. 461).
Castillo reported pain in her right shoulder and back as well
as depression. (Id.) Dr. Long found a decreased
range of motion with Castillo's right hand and arm which
would prevent her from ever reaching, lifting, carrying, and
pushing or pulling, but allowed for occasional handling,
fingering, or feeling. (Tr. 466, 472-75). Otherwise, Castillo
appeared to be in no acute distress, despite her reports of
back pain, and was able to walk with a normal gait, squat
fully, walk on her toes and heels without difficulty, and did
not need assistance changing for the exam, getting on or off
the exam table, or getting up from a chair in the exam room.
(Tr. 462). Castillo claimed it was too painful to bend for
Dr. Long to examine her back for scoliosis, but a subsequent
X-ray of her spine revealed no significant abnormality. (Tr.
465). Dr. Long filled out a medical source statement in which
he found that Castillo could sit for 8 hours, stand for 40
minutes, and walk for 30 minutes total in an 8 hour workday.
(Tr. 467). He also stated that she could occasionally climb
stairs and ramps, but never ladders or scaffolds, and that
she could occasionally kneel, but never crouch, crawl, or
stoop. (Tr. 469). Dr. Long diagnosed her with a right
shoulder injury, pain and weakness of the right shoulder,
arm, and hand with a tremor, thoracic back pain, and a
history of scoliosis. (Tr. 463).
same date, Castillo saw Michael DeWulf, Ph.D. for an
independent psychological consultative examination. (Tr.
451). She reported difficulty sleeping, depression, crying
spells, irritability, social withdrawal, anxiety, and
auditory and visual hallucinations. (Tr. 452). Dr. DeWulf
found her coherent and goal-oriented with no evidence of
hallucinations, delusions, or paranoia during the course of
the evaluation. (Tr. 453). Her attention and concentration
appeared mildly impaired, which Dr. DeWulf attributed to
either a learning disability or emotional distress stemming
from her mental health problems. (Id.) Overall, he
found the results of the exam consistent with psychiatric and
cognitive problems, but did not find her impairments
significant enough to interfere with her ability to function
on a daily basis. (Tr. 454). He diagnosed her with
schizophrenia, persistent depressive disorder, and an anxiety
disorder, and recommended that she continue on the course of
treatment she had been receiving. (Id.) Dr. DeWulf
also filled out a medical source statement in which he found
that Castillo faced mild limitations in understanding,
remembering, and carrying out complex instructions,
interacting appropriately with the public, supervisors, and
co-workers, and responding appropriately to usual work
situations and changes in work routine, whereas she faced no
limitation with understanding, remembering, and carrying out
simple instructions. (Tr. 456-57). He attributed these mild
difficulties to a possible learning disability and
hallucinations and depression. (Id.)
medical records thereafter indicate intermittent issues with
hypertension and persistent complaints of shoulder and arm
pain which she often rated at a “ten out of ten”
pain level, but curiously, routine visits to her primary care
provider indicate that she, at all times, appeared well and
lacked signs of acute distress. (Tr. 478, 576). Likewise, she
reported depression and intermittent auditory and visual
hallucinations, but primary care providers, and some
psychologists, did not report witnessing any objective
impairments attributable to these claims.
September of 2016 and January of 2017, Castillo underwent
mental residual functional capacity assessments from Nhien
Duc Nguyen, M.D. (Tr. 766-69). In this initial 2016
assessment Dr. Nguyen opined that Castillo suffered from
marked limitations in her ability to understand, remember,
and carry out short and simple instructions, and extreme
limitations once those instructions became detailed or
complex. (Tr. 729). She also reportedly faced extreme
limitations with maintaining attention, concentration,
punctuality, and socially appropriate behavior. (Tr. 729-30).
She faced moderate limitations only with sustaining a
routine, asking simple questions, and recognizing and
responding to normal hazards, whereas the remainder of her
ratings were either marked or extreme. (Tr. 729-31). In
contrast, Dr. Nguyen's 2017 assessment revealed a few
more areas of Castillo's functioning where she faced
moderate limitations, rather than the previous marked or
extreme ratings. (Tr. 767-69). Nevertheless, Dr. Nguyen did
not believe that Castillo could work since she was too
depressed and “still psychotic.” (Tr. 769).
The ALJ's Determination
first applied for disability and disability benefits on
October 30, 2014, alleging an onset date of October 16, 2014.
(Tr. 22). The claim was denied, and Castillo requested a
hearing, which was held on July 14, 2017. (Tr. 74). In a
decision dated August 21, 2017, the ALJ found the following:
(1) Castillo met the insured status requirements of the
Social Security Act through December 31, 2019; (2) Castillo
had not engaged in substantial gainful activity since October
16, 2014, the alleged onset date; (3) Castillo did not have
an impairment that met the severity of the listed
impairments; (4) Castillo could perform light work, with
restrictions on the use of her right extremity, provided she
was limited to simple and routine tasks at a slower pace than
production rate pace, and permitted only occasional
interactions with co-workers, but never around the public;
and finally (5) Castillo could not perform her past work, but
could perform light work as a cleaner or housekeeper, a
bakery worker on the conveyor line, or a potato chip sorter.
(Tr. 24-35). Thus, Castillo was found not disabled.
the five-step sequential analysis, the ALJ first found that
Castillo met the insured status requirements through December
31, 2019, and that she had not engaged in substantial gainful
activity since October 16, 2014, the alleged onset date. (Tr.
24). At Step 2, the ALJ found severe impairments of anxiety,
depression with psychosis, adhesive capsulitis of the right
shoulder, bicipital tenosynovitis, hypertension, cervical
degenerative disc disease, scoliosis, cervicalgia, and mild
right hand tremors. (Tr. 24-25). However, at Step 3, it was
determined that these severe impairments did not meet or
equal the severity of the listed impairments. (Tr. 25).
Steps 3 and 4, the ALJ fashioned a residual functioning
capacity (“RFC”), taking into account
[T]he claimant has the residual functional capacity to
perform light work as defined in 20 CFR 404.1567(b) except
with frequent reaching, handling, fingering, and feeling with
the right upper extremity, occasional balancing, stooping,
kneeling, and crouching but never climbing ropes or scaffolds
or crawling. The claimant is limited to simple routine tasks,
but not at a production rate pace, such as assembly line
work. She can have occasional interaction with coworkers or
supervisors but never work around the public.
making this determination, the ALJ considered Castillo's
symptoms to the extent which they could reasonably be
accepted as consistent with the objective medical evidence,
as well as the medical and opinion evidence on the record.
(Id.) The ALJ found that Castillo's statements
regarding the intensity, persistence, and limiting effects of
her symptoms were inconsistent with the medical evidence on
the record. (Tr. 31). As part of this assessment the ALJ was
also required to evaluate multiple medical opinions. In this
regard the ALJ gave great weight to the state agency medical
consultant responsible for the initial disability
determination, Louis Poloni, Ph.D., who opined that Castillo
was able to lift 50 pounds occasionally and 25 frequently,
stand or walk for 6 hours, and sit for 6 hours with limited
right overhead reaching. In contrast, the ALJ gave little
weight to the opinions of Dr. Long, the examining source from
2015, and Dr. Nguyen, Castillo's treating psychologist
from 2014-17, and partial weight to the opinion of Dr.
DeWulf, also an examining source from 2015. (Tr. 32-33).
Lastly, the ALJ found the testimony of Castillo's friend,
Rivera, regarding the severity of Castillo's impairments
to be only partially persuasive. (Tr. 31).
this RFC assessment, the ALJ found at Step 4 that Castillo
could not perform any of her past relevant work. (Tr. 34).
However, it was determined at Step 5 that there were jobs in
significant numbers in the national economy that Castillo
could perform, including a cleaner or housekeeper, a bakery
worker on the conveyor line, or a potato chip sorter. (Tr.
35). These jobs were identified by the vocational expert
(“VE”) at the administrative hearing in response
to the ALJ's hypothetical, which posed a question of what
jobs a claimant with Castillo's age, experience,
education, and limitations could perform. (Tr. 68). The VE
testified that the three jobs identified were consistent with
the Dictionary of Occupational Titles (“DOT”).
(Tr. 72). Ultimately, the ALJ determined that Castillo was
not disabled and was not entitled to benefits. (Tr. 35). This
appeal followed. (Doc. 1).
raises four issues in her appeal. First, Castillo argues that
the ALJ erred by failing to consider the extent of the
limitations on her RFC caused by what the ALJ had identified
as severe impairments, i.e., Castillo's anxiety,
depression with psychosis, right shoulder injuries, and back
injuries. Second, she similarly claims that the ALJ erred by
failing to factor in her right arm and shoulder weakness,
sleep disorder, and paranoia to his RFC determination, and
that he accordingly mischaracterized them as non-severe
impairments. Third, she asserts that the state agency medical
consultant's opinion was afforded too much weight in the
ALJ's determination. Finally, she challenges the
ALJ's decision for failing to consider the side effects
from her medications on her RFC.
Substantial Evidence Review - the Role of this
reviewing the Commissioner's final decision denying a
claimant's application for benefits, this Court's
review is limited to the question of whether the findings of
the final decision-maker are supported by substantial
evidence in the record. See 42 U.S.C. § 405(g);
Johnson v. Comm'r of Soc. Sec., 529 F.3d 198,
200 (3d Cir. 2008); Ficca v. Astrue, 901 F.Supp.2d
533, 536 (M.D. Pa. 2012). 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). Substantial
evidence is less than a preponderance of the evidence but
more than a mere scintilla. Richardson v. Perales,
402 U.S. 389, 401 (1971). A single piece of evidence is not
substantial evidence if the ALJ ignores countervailing
evidence or fails to resolve a conflict created by the
evidence. Mason v. Shalala, 994 F.2d 1058, 1064 (3d
Cir. 1993). But 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
[the ALJ's decision] from being supported by substantial
evidence.” Consolo v. Fed. Maritime
Comm'n, 383 U.S. 607, 620 (1966). “In
determining if the Commissioner's decision is supported
by substantial evidence the court must scrutinize the record
as a whole.” Leslie v. Barnhart, 304 F.Supp.2d
623, 627 (M.D. Pa. 2003).
question before this Court, therefore, is not whether the
claimant is disabled, but rather whether the
Commissioner's finding that he is not disabled is
supported by substantial evidence and was reached based upon
a correct application of the relevant law. See Arnold v.
Colvin, No. 3:12-CV-02417, 2014 WL 940205, at *1 (M.D.
Pa. Mar. 11, 2014) (“[I]t has been held that an
ALJ's errors of law denote a lack of substantial
evidence”) (alterations omitted); Burton v.
Schweiker, 512 F.Supp. 913, 914 (W.D. Pa. 1981)
(“The Secretary's determination as to the status of
a claim requires the correct application of the law to the
facts.”); see also Wright v. Sullivan, 900