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Castillo v. Berryhill

United States District Court, M.D. Pennsylvania

September 6, 2019

SUGEILY FELICIA CASTILLO, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          Mariani Judge

          REPORT AND RECOMMENDATION

          Martin C. Carlson United States Magistrate Judge

         I. Introduction

         In this 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.

         For 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).

         In the 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.

         II. Statement of Facts and of the Case

         A. The Plaintiff's Background and Medical History

         Ms. 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).

         Castillo 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).

         On 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).

         On the 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.)

         Castillo's 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.

         In 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).

         B. The ALJ's Determination

         Castillo 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.

         Using 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).

         Between Steps 3 and 4, the ALJ fashioned a residual functioning capacity (“RFC”), taking into account Castillo's limitations:

[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.

(Tr. 27).

         In 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).

         Given 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).

         Castillo 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.

         III. Discussion

         A. Substantial Evidence Review - the Role of this Court

         When 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).

         The 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 ...


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