Opinion
Civil Action 4:21-cv-1408
03-30-2023
TATYANA HOLLABAUGH, Plaintiff, v. KILOLO KIJAKAZI, Acting Commissioner of Social Security Defendant.
MANNION, D.J.
REPORT AND RECOMMENDATION
PETER E. ORMSBY UNITED STATES MAGISTRATE JUDGE
Plaintiff Tatyana Hollabaugh filed this action pursuant to 42 U.S.C. § 405(g), seeking review of the Commissioner of Social Security's denial of disability benefits. Hollabaugh claims she became disabled due mainly to multiple mental conditions, including depression, anxiety, attention deficit disorder (ADD), and bipolar disorder. An Administrative Law Judge (ALJ) found that Hollabaugh has significant work-related limitations resulting from her mental impairments and substance abuse. But the ALJ also found that, if Hollabaugh stopped her substance abuse, she would be able to perform certain jobs that are compatible with her mental functional abilities, such as jobs involving no more than incidental contact with others and occasional supervision. Hollabaugh's principal contentions are that the ALJ erred in finding that she could tolerate work with occasional supervision and in finding that her statements were not consistent with the medical evidence.
A federal court may review the Commissioner's denial of benefits only to determine whether the Commissioner applied the correct legal standards and whether the decision is supported by substantial evidence; a court may not re-weigh the evidence or substitute its judgment for the Commissioner's. See 42 U.S.C. § 405(g); see also Chandler v. Comm'r of Soc. Sec., 667 F.3d 356, 359 (3d Cir. 2008). After carefully considering the record in the context of this deferential standard of review, the undersigned concludes that Hollabaugh's appeal lacks merit. The record reflects that the ALJ's findings are supported by substantial evidence, including Hollabaugh's treatment records and the opinion of a medical expert. Accordingly, for the reasons discussed below, it is recommended that the Commissioner's decision be affirmed.
This matter has been referred to the undersigned magistrate judge to prepare a report and recommendation to the District Court pursuant to 28 U.S.C. § 636(b) and Rule 72(b) of the Federal Rules of Civil Procedure.
I. BACKGROUND
On December 14, 2017, Plaintiff Hollabaugh applied for disability insurance benefits (DIB) under Title II of the Social Security Act. (See Tr. 411-12.) She was 27 years old when she filed her DIB application. She alleges a disability onset date of January 15, 2017 (as amended). Hollabaugh's DIB application lists the following disabling conditions: “Bi Polar”; depression; anxiety; ADD; “Brain Damage”; “Fetal Alcohol Spectrum Disorder”; and “Syphilis.” (Tr. 457.)
The Commissioner has filed a transcript of the record of the administrative proceedings (Doc. 16), which will be cited as “Tr.” The page numbers refer to the numbers in bold typeface located in the bottom right corner of the transcript pages. Throughout this report, “Doc. ” refers to the docket entry numbers assigned by the Court's electronic filing system (CM/ECF). Page cites included with docket numbers (“at ”) refer to the electronically assigned page numbers found on the top right of each page.
Hollabaugh's application was denied initially on March 5, 2018. She then requested a hearing before an ALJ. ALJ Sharon Zanotto held four hearings before issuing a written decision on December 8, 2020. (Tr. 26-40.)
Hollabaugh requested the Social Security Administration's Appeals Council to review the ALJ's adverse decision. The Appeals Council denied review, rendering the ALJ's decision the Commissioner's final decision for purposes of judicial review. In considering Hollabaugh's challenge to the ALJ's decision, the evidence in the record will be summarized as it relates to the issues raised.
The Court must “scrutinize” the record to determine whether the ALJ's decision is supported by substantial evidence. Leslie v. Barnhart, 304 F.Supp.2d 623, 627 (M.D. Pa. 2003) (citing Smith v. Califano, 637 F.2d 968, 970 (3d Cir.1981)). The undersigned has reviewed the relevant medical records and other evidence. In this report, the record will be summarized to the extent it may be helpful in providing context for the specific issues Plaintiff raises.
A. Education, Work Experience, Symptoms, and Activities
Hollabaugh was born in Russia and later placed in an orphanage. (See Tr. 808, 998.) At age six, she was adopted by American parents and brough to the United States. (Id.) Hollabaugh attended school through the 11th grade. (Tr. 458.)
From December 2015 through May 2017, Hollabaugh worked intermittently as a housekeeper and fast-food server. (See id.) Those jobs generally lasted only a month or two. (Id.)
In support of her DIB application, Hollabaugh submitted a “Function Report.” (Tr. 481-88.) She stated that her ability to work is limited by her anxiety, depression, and bi-polar mood swings. (Tr. 481.) Her days consist of waking up mid-morning, drinking coffee, planning her day, but never getting anything done. (Tr. 482.) She occasionally cooks and sometimes does cleaning and laundry. (Tr. 483.) Hollabaugh reported that she does not spend time with others socially. (Tr. 485.)
In describing how her mental conditions affect her, Hollabaugh stated that she does not “understand what to do,” and she does not like people. (Tr. 486.) She also does not trust authority figures. (Id.)
Hollabaugh's adoptive mother, Tina Hollabaugh, also submitted a Function Report in support of her daughter's disability application. (Tr. 470-76.) Tina described her daughter's limitations as follows: “She is moody and her mind w[a]nders. She doesn't understand instructions.” (Tr. 470.) Hollabaugh's hobbies and interests are reading and watching TV. (Tr. 471.) Regarding Hollabaugh's social life, Tina stated that she does spend time others, going out to eat once a week. (Id.) According to Tina, Hollabaugh does not get along with authority figures and “maybe” has been fired due to problems getting along with people. (Tr. 477.)
B. The Medical Evidence
1. Mental Health Treatment Records
The issues raised by Hollabaugh focus on her mental health impairments. Her mental health treatment was somewhat sporadic and was interrupted by periods in which she was incarcerated (although she also received some treatment while in custody). Hollabaugh was incarcerated three times since her alleged disability onset date (January 15, 2017). (See Tr. 61-63.) The first two of those incarcerations stemmed from her drug use. (See Tr. 64-66.) A timeline may be helpful in putting Hollabaugh's mental health treatment records in context:
• January 15-29, 2017: admitted to the York Hospital psychiatric unit after using synthetic marijuana (Tr. 642-45).
• January - March 2017: treated at a WellSpan behavioral health clinic (Tr. 159).
• April 2017 - Dec. 2017: no mental health treatment (see Tr. 159).
• January 1 - March 5, 2018: incarcerated in the Adams County prison after a conviction for driving under the influence of a controlled substance (Tr. 61-62).
• April 2018: resumed treatment at WellSpan (Tr. 159-60).
• June 2018: discharged from WellSpan for missing appointments (Tr. 159, 161-62).
• October 2018 - December 2018: received mental health medications from general practitioner (Tr. 824-27).
• February 7, 2019 - July 2, 2019: incarcerated at the Adams County prison after a drug-related probation violation (Tr. 62, 150-51).
• July 2019 - April 2020: resided in a mental health group home and received treatment from TrueNorth Wellness Services (see Tr. 124, 1014-19, 1163).
• May 5, 2020 - July 1, 2020 (date of last hearing): incarcerated at the Adams County prison for violating probation rules (Tr. 62-63).
As relevant here, Hollabaugh's mental health treatment records begin with her admission to York Hospital on January 15, 2017, which is her alleged disability onset date. The hospital discharge report describes her as “a 26-year-old female with congenital fetal alcohol syndrome as well as polysubstance abuse with numerous relapses.” (Tr. 644.) She was “admitted with acute psychosis after imbibing in synthetic K2 marijuana in the company of her boyfriend.” (Id.) While in the hospital, she was treated with several medications.
When Hollabaugh was discharged on January 26, 2017, she “had good insight” and said that she was “motivated to stay abstinent and clean of illicit substances.” (Tr. 644-45.) Her diagnosis included “marijuana abuse[,] stimulant abuse[,] bipolar affective disorder[,] fetal alcohol syndrome[, and] nicotine dependence.” (Tr. 642.) She was referred to the WellSpan Gettysburg behavioral clinic for follow-up treatment. (Tr. 645.)
Beginning in February 2017, Hollabaugh made regular visits to WellSpan, where she received mental health treatment. (See Tr. 787-802.) Her condition improved during this time. For example, at her visit on March 7, 2017, Hollabaugh reported “overall mood stability, adequate ADL's [activities of daily living], some support and socialization.” (Tr. 787.) She “[v]olunteers at church and is quite social.” (Id.) Hollabaugh was observed to be “well groomed,” her mood was “fairgood,” her speech was “normal,” her thought processes were “goal oriented,” and her thought content was “normal.” (Tr. 788.) Hollabaugh expressed that her “current treatment is helping.” (Id.) However, she was still “not active with usual interests and functioning” and “further intervention” was deemed necessary. (Id.)
On March 16, 2017, Hollabaugh visited her general practitioner at Family First Health. She told them that she wanted to switch from the WellSpan behavioral health clinic “because she does not feel they are listening to her needs” and because the doses of medication she was receiving were “not enough to help.” (Tr. 818.) Hollabaugh was advised “that she needs to stay with a BH [behavioral health] office because this would be best for treatment of her conditions.” (Tr. 819.) After examining Hollabaugh that day, her medical provider made the following “psychiatric” observations: “Insight: good judgement. Mental Status: normal mood and affect[,] and active and alert. Thought Process: ordered. Orientation to time, place, and person. Speech[:] normal speech and comprehension.” (Tr. 819.)
Hollabaugh did not return to WellSpan or receive other specialized mental health treatment from April 2017 through November 2017. She explained during her hearing testimony that she stopped going to WellSpan because she “thought [she] didn't need [her] medicine,” and she “got scared” and did not want to talk about her problems. (Tr. 159.)
On November 24, 2017, Hollabaugh was seen at TrueNorth Wellness Services (TrueNorth) in Gettysburg, Pennsylvania, for a court ordered mental health evaluation. (Tr. 1050.) She had been charged with a second driving under the influence (DUI) offense and was “going to jail” on January 2, 2018. (Tr. 1052.) Hollabaugh reported mood symptoms, including agitation, anger, crying, impaired concentration, impaired sleep, and sadness. (Tr. 1050.) She was also experiencing excessive anxiety. (Id.) She attributed her stress to her second DUI charge and the loss of custody of her child. (Id.) To manage her stress, Hollabaugh would “smoke weed” and take “anxiety pills.” (Id.)
The mental status examiner noted that Hollabaugh was “well-groomed”; was oriented to “person, place, time”; was “relaxed and calm”; had an “appropriate, cooperative” manner; had “normal” speech; had “normal” though content; was not delusional; had “intact” judgment and memory; was “alert”; appeared “depressed, fatigued”; had a “flat” effect; and had “average” intelligence. (Tr. 1052-53.) In summarizing his impressions, the examiner stated that Hollabaugh was “struggling with depressive symptoms” and was “open to treatment.” (Tr. 1053.)
Hollabaugh did not return for mental health treatment until March 2018, which was after she was released from custody. While serving her sentence, Hollabaugh's mental health was monitored, and she was prescribed medications to address her symptoms. (See Tr. 832-63.) A prison mental health note dated January 3, 2018, reflects that Hollabaugh was “cooperative,” “oriented,” and “logical,” but she also had an “anxious mood.” (Tr. 855.) Hollabaugh was by then “already on work release,” and she was “functioning well, planning to go out with family and [go] job searching.” (Id.)
After Hollabaugh's release from custody on March 3, 2018, she again sought mental health treatment at WellSpan. (See Tr. 996-1007.) Her first return visit was on March 13, 2018. (Tr. 996.) At the time, Hollabaugh was on house arrest until April 2, 2018, and on probation until November 2019. (Tr. 997.) Hollabaugh stated “that she has had 24 jobs in 10 years mainly due to stress and attendance difficulties.” (Tr. 998.) She did not graduate from high school but was “working on her GED.” (Id.) Hollabaugh said “she want[ed] to get back on medications and address her marijuana problem.” (Tr. 997.)
The objective examination findings for this initial return visit included the following: Hollabaugh was “well-groomed”; she was “cooperative”; her eye contact was “normal”; her affect was “congruent, euthymic”; her speech was “normal”; she was “fully” oriented, and her cognition was “intact.” (Tr. 998.) In addition to those normal findings, she was also found to have “tangential” thought processes, poor insight, and limited judgment. (Id.) Hollabaugh was diagnosed with bipolar disorder, marijuana dependence, nicotine dependence, fetal alcohol syndrome, and ADD. (Tr. 997-98.) Her treatment plan included medications and follow-up care. (Tr. 996, 999.)
Hollabaugh returned to WellSpan for monthly visits from April through August 2018. (See Tr. 973-99.) The objective findings during those examinations were essentially normal. For example, during Hollabaugh's visit on May 15, 2018, she was “calm” and “cooperative,” with “normal” speech, orientation, thought process, and insight. (Tr. 985.) Her memory was “intact,” her intellectual functioning was “average,” and her judgment and ability to make reasonable decisions was found to be “good.” (Id.) Similar objective findings were made during Hollabaugh's July 2018 visit. (See Tr. 980.)
During Hollabaugh's visit to WellSpan on August 6, 2018, she reported she was “back on her medications,” and her “mood and affect [were] improved.” (Tr. 974.) Again, she was “cooperative” and other objective examination findings were consistent with her prior visits. (Id.) Similarly, when she visited her primary care provider three days later, on August 9, 2018, she “appear[ed] to be doing well,” and there were “[n]o significant findings” during her examination. (Tr. 820, 823.)
Soon thereafter, however, the WellSpan clinic discharged Hollabaugh from their care due to several missed appointments. (See Tr. 159, 824, 1014.) She returned to her primary care provider about two months later, on October 26, 2018, seeking medication refills. (Tr. 824.) Hollabaugh reported her mood was worsening since she ran out of her medications, and she was prescribed refills. (Tr. 824, 826.) On examination, Hollabaugh was observed to be “cooperative,” “calm,” “alert,” and “pleasant.” (Tr. 827.) Her judgement and thought processes were “intact,” and her thought content was “unremarkable.” (Id.)
Hollabaugh visited her primary care provider again on December 20, 2018, reporting that her “symptoms [had] improved.” (Tr. 828, 830.) She was again observed to be cooperative, calm, alert, and pleasant, with intact judgment and thought process. (Tr. 831.)
Unfortunately, Hollabaugh was incarcerated again from February 2019 to July 2019. She explained that she violated her probation by testing positive for methamphetamines (which she attributes to sharing her boyfriend's Adderall medication). (Tr. 1014, 1143.) While back in prison, her mental health was monitored, and she was prescribed medications to address her mental health symptoms. (See Tr. 959-63.) Prison records reflect that Hollabaugh generally did well while taking her medications. For example, a prison mental health counselor visited Hollabaugh on February 21, 2019. (Tr. 960.) Hollabaugh reported she was “doing okay overall, [and] happy to be back on her medications.” (Id.) She also reported that she was “getting along okay with [her] current cellmate.” (Id.) Objective observations included that Hollabaugh was “cooperative” and had a “normal mood,” with “logical” thought processes. (Id.)
After Hollabaugh was released from prison, she began living in a mental health group home. (See Tr. 124.) During this period, she received mental health treatment from TrueNorth, beginning with an initial visit and evaluation on July 9, 2019. (Tr. 1014-19.) The TrueNorth mental health provider diagnosed Hollabaugh with bipolar disorder, ADD, “parent-adopted child conflict,” PTSD, and “borderline personality disorder.” (Tr. 1018.)
From July 2019 through April 2020, Hollabaugh lived at the group home, attended therapy sessions, and was regularly evaluated by a TrueNorth mental health provider. (See Tr. 1014-19, 1021-24, 1067-70, 1085-1157, 1166-1248.) Her mental health condition was generally stable. For example, during a psychiatric evaluation on August 29, 2019, Hollabaugh “denied any hyper irritability,” but she “still has racing thoughts” and “still feels hopeless, helpless and worthless ‘all the time.'” (Tr. 1143.) The evaluating psychiatrist observed that she maintained good eye contact and was “cooperative during the interview.” (Tr. 1144.) Hollabaugh's mood was “okay” and her affect was “flat.” (Id.) Her remote memory was “intact,” her judgment was “not impaired,” and she had “fair” insight into her condition. (Id.)
Although Hollabaugh had some ups and downs in the following months, she seemed to be improving by December 2019. For example, a group progress note dated December 18, 2019, reflects that she was “elated” because her mother agreed to have her come home for Christmas. (Tr. 1123.) Hollabaugh committed to “maintain[ing] her exercise goal of 3 times per week” and wanted to begin a nutrition goal after the holidays. (Id.) She was also “working on weaning off bipolar meds.” (Tr. 1124.) That night Hollabaugh was going with staff and residents to see Christmas lights. (Id.)
Hollabaugh continued attending therapy sessions and receiving treatment from TrueNorth through about April 2020. (See Tr. 1166-1248.) In May 2020, however, she was again incarcerated due to a probation violation. (See Tr. 1163.) Hollabaugh explained that she was “kicked out of the group home” for “breaking a number of rules.” (Tr. 1460.) While in custody, she again received her medications, and she regularly met with a mental health counselor. (See Tr. 1460-63.) During an initial visit on May 6, 2020, Hollabaugh reported that she “ha[d] been taking her medications and going to counseling with success, [and she] denie[d] any significant concerns.” (Tr. 1460.) The counselor observed that Hollabaugh was “cooperative” and “alert and oriented,” with a “normal mood” and “broad affect.” (Id.) Other prison mental status reports reflected similar findings. (See Tr. 1460-63.) Hollabaugh was still in custody at the time of her final hearing before the ALJ. (Tr. 62-63.)
2. Opinion Evidence
In addition to mental health treatment notes, the record includes opinions from three medical sources: a consultative mental status examiner, Christopher Gipe, M.S.; a state agency psychological consultant, Helen Parshall, Ph.D.; and a testifying medical expert, Philip R. Braun, Ph.D. Dr. Braun's opinion will be described in summarizing the evidence presented at the fourth hearing.
a. Mr. Gipe
Mr. Gipe met with and evaluated Hollabaugh on February 23, 2018. (Tr. 808812.) This was during her second period of incarceration, although she was then participating in a work-release program. Hollabaugh described her symptoms, which included difficulty falling asleep, depression, anxiety, and “awful” short term memory. (Tr. 809.) She also said that “she has no friends” and “feels very uncomfortable out in public around a lot of people.” (Id.)
Mr. Gipe noted that Hollabaugh was “very talkative” and “cooperative throughout the examination.” (Tr. 810.) He also observed that Hollabaugh's “[s]peech was fluent and clear”; her “[t]hought process was coherent and goal directed”; her affect was “full range and appropriate”; she was “oriented x3”; her attention and concentration were “[i]ntact”; her recent and remote memory skills were “[g]enerally intact”; and her “[i]ntellectual functioning appeared to be within the average to below average range.” (Tr. 810-11.) Mr. Gipe diagnosed Hollabaugh with bipolar disorder, depressive disorder, panic disorder, agoraphobia, anxiety disorder, and posttraumatic stress disorder. (Tr. 811.)
Mr. Gipe also completed a form to assess Hollabaugh's ability to do mental work-related activities. (Tr. 813- 15.) He checked boxes indicating that Hollabaugh has “marked” limitations in interacting appropriately with supervisors, co-workers, and the public, as well as “marked” limitations in responding appropriately changes in a routine work setting. (Tr. 814.)
d. Dr. Parshall
About a week after Mr. Gipe completed his assessment, Dr. Parshall performed a mental residual functional capacity (RFC) assessment. (Tr. 184-86.) She reviewed Hollabaugh's available treatment records, as well as Mr. Gipe's assessment. Dr. Parshall concluded that Hollabaugh was “moderately” limited in the following areas: her ability to carry out detailed instructions; ability to accept instructions and respond appropriately to criticism from supervisors; and ability to complete a normal workday and workweek and to perform at a consistent pace. (Tr. 184-85.) As to other mental work-related activities, Dr. Parshall found that Hollabaugh was “not significantly limited,” including in her ability to interact with the public and get along with coworkers. (Tr. 185.) Dr. Parshall opined that while Hollabaugh's mental impairments are severe, they “do not prevent the claimant from performing simple routine daily activities and tasks.” (Tr. 186.)
C. The Evidentiary Hearings
The ALJ conducted four hearings. In addition, after the fourth hearing, the ALJ sent interrogatories to the vocational expert.
1. The First Hearing
The first hearing was held April 5, 2019. Hollabaugh was then serving a prison sentence and had been incarcerated since February 7, 2019. (Tr. 150-51.) A significant topic at this initial hearing was Hollabaugh's mental health treatment history. Because the record then contained limited documentation of Hollabaugh's mental health treatment, the ALJ asked Hollabaugh to clarify her somewhat sporadic treatment history. (Tr. 159-62.) The hearing was continued so that (among other things) additional treatment records could be obtained and considered. (Tr. 172.)
2. The Second Hearing
At the time of the second hearing, held August 22, 2019, Hollabaugh had been released from prison and was living in the mental health group home. (Tr. 124.) Hollabaugh described her work since her alleged disability onset date. (Tr. 124-28.) She had worked at a turkey plant for about a month, but she quit after straining her back. (Tr. 26 (“I just walked off.”).) Hollabaugh also had a job cleaning motel rooms. She lost that job because she was late one morning and did not go back to work because she assumed she was fired (although she was mistaken). (Tr. 127.) Hollabaugh worked at several other jobs, including a Wendy's restaurant, but she was fired for either being late or working too slowly. (Tr. 137.)
When Hollabaugh's counsel asked whether she ever had a problem “getting along with co-workers or supervisors,” she responded: “Not getting along with them, but . . . I just felt like nobody liked me there ‘cause I was slow ....” (Tr. 133.) At more than one of her jobs, Hollabaugh's supervisors counseled or disciplined her because she either could not remember or could not follow instructions. (Tr. 13334.)
In describing the “biggest thing” affecting her ability to work, Hollabaugh stated it was her “slowness”-both mentally and physically. (Tr. 128.) She also pointed to her anxiety and depression as hindering her ability to work. (Tr. 129.) Her sadness causes her to make mistakes, lack focus, and forget what she is supposed to do. (Tr. 129-30.)
Before receiving testimony from a vocational expert, the second hearing was continued to allow time for Hollabaugh to present testimony from her mental health caseworker. (Tr. 138.)
3. The Third Hearing
Hollabaugh testified again at the third hearing, which was held January 14, 2020. At the time of this hearing, Hollabaugh was still living at the group home. (See Tr. 82-83.) The ALJ again attempted to clarify the dates for Hollabaugh's prior employment and her reasons for leaving. (Tr. 85-89.)
The ALJ also asked Hollabaugh about her ability to get along with others. Hollabaugh explained that it is hard for her to make friends; although she tries, she is afraid she will be hurt. (Tr. 89.) During Hollabaugh's housekeeping work, she had little interaction with the other housekeepers, other than when she was trained. (Tr. 90.) But she had no difficulties with them, and she was never disciplined based on how she treated a co-worker, supervisor, or a customer. (Id.) Although Hollabaugh did not have difficulties with others, she would isolate herself. (Id.) Her supervisors told her she worked too slowly. (Tr. 97.)
Hollabaugh's parents have full custody of her son, and she has partial custody. (Tr. 103.) Hollabaugh did not feel she could take care of her son on her own because she has trouble waking up early enough to take him to school and because she cannot financially provide for him. (Tr. 103-04.) But in the future, if she gets a job, Hollabaugh believes she will be able to take care of her son. (Tr. 104.)
A vocational expert also testified, but his testimony became essentially moot because another vocational expert testified at the fourth hearing. The ALJ scheduled the fourth hearing mainly to receive testimony from a medical expert. (See Tr. 120.)
4. The Fourth Hearing: Medical Expert Testimony
The fourth-and final hearing-was held on July 1, 2020. Hollabaugh was again in custody at the time of this hearing. (Tr. 61-63.) Three witnesses testified: a medical expert, Philip R. Braun, Ph.D.; Hollabaugh; and a vocational expert, Rebecca Zugg.
Dr. Braun is a licensed clinical psychologist. (Tr. 41.) Before testifying, he was given access to the administrative record, including Hollabaugh's mental health treatment records. (Tr. 40-41.) Dr. Braun stated that he had sufficient evidence to form a medical opinion regarding Hollabaugh's medical status. (Tr. 42.)
Dr. Braun found that Hollabaugh has several medically determinable mental impairments, including affective disorder, depressive disorder, anxiety-based disorder, post-traumatic stress disorder, and substance abuse disorder. (Tr. 44-45.) Dr. Braun stated that Hollabaugh can understand and follow through on simple tasks involving no more than several variables. (Tr. 49.) The doctor estimated her intellectual functioning “to be average to slightly below average.” (Tr. 49.)
As to Hollabaugh's ability to interact with others, Dr. Braun opined that Hollabaugh could tolerate “occasional supervision.” (Tr. 50.) He agreed with the ALJ that “occasional” meant “zero to one-third of the workday.” (Id.) Dr. Braun also found that “she would be better with no interactions with co-workers or the public.” (Id.) He clarified that Hollabaugh could have informal, non-task related interaction with co-workers, but she would “do best with limited to no interdependence or needing to work with someone in a team.” (Tr. 51-52.)
In evaluating whether Hollabaugh met any of the Social Security listed disabling conditions (“listings”), Dr. Braun made the following findings:
I would consider her ability to understand, remember, and apply information to be unimpaired or moderately impaired; her ability to interact with others, markedly impaired; her ability to concentrate, persist, and maintain pace, moderately impaired; and her ability to adapt and manage herself, moderately impaired.(Tr. 57.) Based on these findings, Dr. Braun concluded that Hollabaugh did not met any of the listings. (Tr. 57-58.)
If Hollabaugh adhered to her medication regimen and otherwise remained drug free, Dr. Braun believed that she would have no problems with punctuality or absences from work. (Tr. 53.) Further, if she did those things, Dr. Braun opined that “she'd be able to achieve substantial gainful activity and be able to . . . be employable.” (Tr. 59.) However, if she abused drugs, it would be “very difficult to make behavioral predictions.” (Tr. 54.) In that event, Dr. Braun concluded that Hollabaugh would meet one or more of the listings. (Tr. 58.)
Counsel asked Hollabaugh about her ability to interact with supervisors. Hollabaugh stated that she did not trust people in authority. (Tr. 67-66.) When told by someone what to do, she always questions them and argues with them. (Tr. 68.) But in the end, she relents and says, “okay, fine. I [will] just do what you say.” (Id.)
The vocational expert, Ms. Zugg, testified that Hollabaugh's prior work as a housekeeper was performed at a heavy exertion level. (Tr. 70.) In response to questions from the ALJ and Hollabaugh's counsel, Ms. Zugg stated that if an individual often challenged a supervisor about the reason for doing a task, it would be difficult for such an individual to maintain employment. (See Tr. 72-74.) The ALJ also asked Ms. Zugg a hypothetical question, but her response was later superseded by her responses to the ALJ's post-hearing interrogatories.
5. Post-Hearing Interrogatories to the Vocational Expert
After the hearing, the ALJ asked Ms. Zugg follow-up questions by interrogatories dated September 10, 2020. (Tr. 583-86.) Those questions included a hypothetical asking whether a person with Hollabaugh's work experience and limited education could perform any jobs assuming she had the residual functional capacity to do work at all exertional levels and assuming several mental functional limitations, including “no more than incidental interaction with others” and “no more than occasional supervision.” (Tr. 585.) Ms. Zugg responded that there would be jobs the person could do and identified three such jobs at the medium exertional level and three at the light level. (Id.)
D. The ALJ's Decision
The ALJ issued her decision on December 8, 2020. (Tr. 15-27.) In deciding Hollabaugh's DIB claim, the ALJ applied the five-step method for evaluating disability claims. See 20 C.F.R. § 404.1520. Because there was medical evidence suggesting a substance abuse disorder, the ALJ conducted a dual analysis to consider whether a substance use disorder was a contributing factor material to determining disability. See 20 C.F.R. § 404.1520.
The five-step disability analysis and dual substance abuse analysis will be explained further in the Standard of Review section of this report, infra Part II.A.
The ALJ found (at step one) that Hollabaugh had not engaged in substantial gainful activity since the alleged onset date, January 15, 2017. (Tr. 17-18.) In considering the severity of Hollabaugh's impairments (step two), the ALJ determined that she had the following “severe” medical impairments: “an affective disorder diagnosed as bipolar and depressive disorders, anxiety disorder, post-traumatic stress disorder, attention-deficit hyperactivity disorder, personality disorder, and polysubstance abuse.” (Tr. 18.)
The ALJ next determined (at step three) that Hollabaugh's impairments were severe enough-if her substance abuse is included-to meet or medically equal one of the listed impairments in the regulations (“listings”). (Tr. 18-19.) However, if Hollabaugh “stopped the substance use,” she “would not have an impairment or combination of impairments that meets or medically equals the severity of one of the [listings]”. (Tr. 20.) In reaching this conclusion, the ALJ discussed in detail the relevant mental impairment listings. (Tr. 20-21.)
Before proceeding to the next step in the disability analysis, the ALJ assessed Hollabaugh's residual functional capacity (RFC) to do physical and mental work activities-assuming she “stopped the substance use.” (Tr. 22.) The ALJ made the following RFC finding:
After careful consideration of the entire record, the undersigned finds that, if the claimant stopped the substance use, the claimant has had the residual functional capacity to perform a full range of work at all exertional levels except that the claimant is limited to tasks with no greater than several variables such as those requiring a reasoning level of 3; no more than occasional work setting, process, and tool changes; no more than incidental interaction with others, requiring no more than occasional supervision; as unable to perform work that requires coordination with others; as unable to perform work requiring directing, controlling, or planning the activities of others; and as unable to perform work requiring the influencing of people's opinions, attitudes, or judgments.(Tr. 32.)
In making this finding, the ALJ described Hollabaugh's testimony and statements and summarized the medical evidence regarding her mental health treatment. (Tr. 22-24.) The ALJ also described and evaluated the medical opinion evidence from Mr. Gipe, Dr. Parshall, and Dr. Braun. (Tr. 24-25.) The ALJ found Mr. Gipe's opinion “partially persuasive,” but did not accept his opinion as to Hollabaugh's adaptability because it was not “fully supported by the record.” (Tr. 25.) The ALJ found Dr. Braun's opinion “persuasive” because it was consistent with the other evidence in the record. (Tr. 24-25.) As to Dr. Parshall's opinion, the ALJ found it was unpersuasive because evidence received after the opinion was rendered “demonstrates the claimant has a greater limitation in her ability to interact appropriately with others.” (Tr. 25.)
Next, because the ALJ found (at step four) that Hollabaugh “has no past relevant work,” the ALJ considered whether Hollabaugh could perform any other type of work (step five). (Tr. 25-26.) Relying on the vocational expert's interrogatory responses, the ALJ found that-if Hollabaugh “stopped the substance use”-she could perform multiple jobs that exist in significant numbers in the national economy. (Tr. 26.) From this, the ALJ concluded that Hollabaugh is not disabled.
E. Request for Judicial Review
As noted earlier, Plaintiff sought administrative review of the ALJ's decision. After the Appeals Council denied that request, Plaintiff filed the instant action seeking judicial review of the Commissioner's decision pursuant to 42 U.S.C. § 405(g). (Doc. 1.) The issues raised by Plaintiff have been briefed by the parties and will be analyzed in light of the applicable standard of review. (Doc. 21, 22, 23.)
II. ANALYSIS
A. Standard of Review
To qualify for benefits under the Social Security Act (the “Act”), Plaintiff bears the burden of proving she is disabled. 42 U.S.C. § 423(d)(5)(A) (“An individual shall not be considered to be under a disability unless he furnishes such medical and other evidence of the existence thereof as the Commissioner of Social Security may require.”); see also Chandler v. Comm'r of Soc. Sec., 667 F.3d 356, 359 (3d Cir. 2011) (noting the claimant's “burden to produce evidence supporting her disability claim”). The Act defines disability as the “inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve months.” 42 U.S.C. § 423(d)(1)(A).
To determine whether a claimant is disabled within the meaning of the Act, the Commissioner applies a five-step inquiry:
(1) whether the claimant is currently working in substantial gainful employment;
(2) whether the claimant suffers from a severe impairment;
(3) whether the claimant's severe impairment is sufficient under the pertinent regulations (“listings”) to support a finding of disability;
(4) whether the claimant is capable of returning to his or her past relevant work; and, if not,
(5) whether the impairment prevents the claimant from doing any other work.See 20 C.F.R. § 404.1520. Before moving to the fourth step in the analysis, the ALJ must determine the claimant's residual functional capacity (RFC). RFC is defined as “that which an individual is still able to do despite the limitations caused by his or her impairment(s).” Burnett v. Comm'r of Soc. Sec., 220 F.3d 112, 121 (3d Cir. 2000) (citations omitted); see also 20 C.F.R. § 404.1545(a)(1).
“Where substance abuse is an issue, a dual analysis must be conducted.” Kich v. Colvin, 218 F.Supp.3d 342, 352 (M.D. Pa. 2016). This is because “Congress amended Title II of the Social Security Act in 1996 to bar the award of disability benefits based on alcoholism or drug addiction.” Torres v. Chater, 125 F.3d 166, 169 (3d Cir. 1997) (citing 42 U.S.C. § 423(d)(2)(C)). Section 423(d)(2)(C) of the Act provides: “An individual shall not be considered to be disabled . . . if alcoholism or drug addiction would . . . be a contributing factor material to the Commissioner's determination that the individual is disabled.” 42 U.S.C. § 423(d)(2)(C).
The regulations implementing § 423(d)(2)(C) explain that the “key factor . . . is whether we would still find you disabled if you stopped using drugs or alcohol.” 20 C.F.R. § 404.1535(b)(1). As a practical matter, the regulations require ALJs to conduct a dual analysis by “mandate[ing] consideration of whether drug addiction or alcoholism is a contributing factor material to the determination of disability only after the ALJ finds the claimant disabled.” Brown v. Apfel, 192 F.3d 492, 498 (5th Cir. 1999).
At steps one through four of the disability analysis, the burden of proof is on the claimant to show that she is disabled. Rutherford v. Barnhart, 399 F.3d 546, 551 (3d Cir. 2005). If the claimant satisfies this responsibility, the burden then shifts to the Commissioner at step five of the process to show that there is other gainful employment the claimant can perform despite her existing impairments. Id. The claimant's initial burden to prove disability extends to whether substance abuse is a material factor in determining disability. See Sperring v. Saul, No. CV 20-393, 2021 WL 2474437, at *3 (W.D. Pa. June 17, 2021) (“The longstanding policy is that the claimant continues to have the burden of proving disability throughout the DAA [drug addiction and alcoholism] materiality analysis.”) (citing SSR 13-2p, 2013 WL 621536, at *4 (Feb. 20, 2013)).
See also Doughty v. Apfel, 245 F.3d 1274, 1280 (11th Cir. 2001) (agreeing with the Fifth Circuit and holding “that in materiality determinations pursuant to 42 U.S.C. § 423(d)(2)(C), the claimant bears the burden of proving that his alcoholism or drug addiction is not a contributing factor material to his disability determination”) (citing Brown, 192 F.3d at 298).
In this case, the ALJ applied a dual five-step analysis because the medical evidence reveals that Hollabaugh struggles with substance abuse. Considering the effects of Hollabaugh's substance abuse, the ALJ found at step three that she would be disabled. However, the ALJ also found that if Hollabaugh stopped using drugs or alcohol, her remaining limitations would not be disabling. Specifically, the ALJ concluded at step five that Hollabaugh was not disabled because, if she “stopped the substance use,” she could perform jobs existing in significant numbers in the national economy.
Hollabaugh challenges the ALJ's RFC determination that led to her finding of no disability at step five. She does not specifically contest the ALJ's finding “that a substance use disorder is a contributing factor material to the determination of disability.” (Tr. 16.)
A federal court's review of the Commissioner's final decision is limited to determining whether the Commissioner applied the correct legal standards and whether the decision is supported by substantial evidence. See Chandler, 667 F.3d at 359. As the Supreme Court has emphasized, substantial evidence review is deferential:
Under the substantial-evidence standard, a court looks to an existing administrative record and asks whether it contains “sufficien[t] evidence” to support the agency's factual determinations. Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229, 59 S.Ct. 206, 83 L.Ed. 126 (1938) (emphasis deleted). And whatever the meaning of “substantial” in other contexts, the threshold for such evidentiary sufficiency is not high. Substantial evidence, this Court has said, is “more than a mere scintilla.” Ibid.; see, e.g., Perales, 402 U.S. at 401, 91 S.Ct. 1420 (internal quotation marks omitted). It means-and means only-“such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Consolidated Edison, 305 U.S. at 229, 59 S.Ct. 206. See Dickinson v. Zurko, 527 U.S. 150, 153, 119 S.Ct. 1816, 144 L.Ed.2d 143 (1999) (comparing the substantial-evidence standard to the deferential clearly-erroneous standard).
Biestek v. Berryhill, 139 S.Ct. 1148, 1154 (2019). In applying this standard, “[c]ourts are not permitted to re-weigh the evidence or impose their own factual determinations.” Chandler, 667 F.3d at 359 (citing Richardson v. Perales, 402 U.S. 389, 401 (1971)).
Although the substantial evidence standard is deferential, this does not mean a court may accept unsupported or unexplained findings. For meaningful judicial review to occur, the Third Circuit “requires an ALJ to set forth the reasons for his decision.” Burnett, 220 F.3d at 119 (citing Cotter v. Harris, 642 F.2d 700, 704-06 (3d Cir. 1981)). The “ALJ must consider all evidence before him” and “must give some indication of the evidence which he rejects and his reason(s) for discounting such evidence.” Burnett, 220 F.3d at 121-22 (citing Plummer v. Apfel, 186 F.3d 422, (3d Cir. 1999) and Cotter, 642 F.2d at 705) (holding that the ALJ erred in failing to mention and explain contradictory medical and non-medical evidence).
B. Issues
In seeking review of the Commissioner's denial of benefits, Plaintiff frames the issues as follows:
I. The Plaintiff asserts that the Administrative Law Judge erred in not accounting for the Plaintiff's marked limitation in interacting appropriately with others in the RFC findings.
II. The Plaintiff asserts that there was not substantial evidence supporting the Administrative Law Judge's finding that the Plaintiff could tolerate occasional supervision.
III. The Plaintiff asserts that the Administrative Law Judge erred in finding the Plaintiff's statements were not consistent with the medical evidence.(Doc. 21 at 17.) In responding to these claims, the Commissioner contends that they lack merit and that the ALJ's decision should be affirmed because it is supported by substantial evidence. (Doc. 22.) Plaintiff filed a reply brief in support of her claims. (Doc. 23.) Plaintiff's first two issues are related and will be addressed together.
C. The ALJ's Finding that Plaintiff Can Tolerate Occasion Supervision
Plaintiff's first two issues challenge whether the ALJ's RFC assessment adequately accounts for her limitation in interacting with others. (See Doc. 21 at 1820.) The ALJ found she had a marked limitation in interacting with others and limited her to no more the incidental interaction with others. But the ALJ also found that Hollabaugh could tolerate occasional supervision. According to Plaintiff, the “ALJ failed to clearly explain why she allowed greater interactions with supervisors than with coworkers or the public.” (Id. at 18.) The Commissioner responds that the ALJ adequately explained her RFC assessment and that it is supported by substantial evidence. (Doc. 22 at 16-21.)
As noted, a claimant's RFC is “the most [the claimant] can do despite [her] limitations.” 20 C.F.R. §§ 404.1545(a)(1), 416.945(a)(1); see also Burnett, 220 F.3d at 121. At the administrative hearing stage, the ALJ is responsible for assessing the claimant's RFC. 20 C.F.R. § 404.1546(c). In making that assessment, the ALJ considers all the evidence and all the claimant's medically determinable impairments, including any non-severe impairments identified at step two of the disability analysis. 20 C.F.R. § 404.1545(a)(2)-(3).
Where “mental impairments are at issue, additional inquiries are layered on top of the basic five-step disability analysis.” Hess v. Comm'r Soc. Sec., 931 F.3d 198, 202 (3d Cir. 2019) (citations omitted). Those additional inquiries begin at step two with the ALJ's determination of whether the claimant has any severe medically determinable impairments. Id. (citations omitted).
Here, at step two, the ALJ found that Hollabaugh has multiple severe medically determinable mental impairments. (Tr. 18.) Next, at step three, the ALJ considered whether Hollabaugh's severe mental impairments met the criteria for one of the listings. To do this, an ALJ must assess the four areas of mental functioning, called the “paragraph B criteria”: “understand, remember, or apply information”; “interact with others”; “concentrate, persist, or maintain pace”; and “adapt or manage oneself.” See 20 C.F.R. Pt. 404, Subpt. P, App. 1 § 12.00(E); see also 20 C.F.R. § 404.1520a(c)(3). In assessing the paragraph B criteria, the ALJ uses “a five-point rating scale consisting of none, mild, moderate, marked, and extreme limitation.” 20 C.F.R. § Pt. 404, Subpt. P, App. 1 § 12.00(F)(2); see also 20 C.F.R. § 404.1520a(c)(4). “To satisfy the paragraph B criteria, [a claimant's] mental disorder must result in ‘extreme' limitation of one, or ‘marked' limitation of two, of the four areas of mental functioning.” 20 C.F.R. § Pt. 404, Subpt. P, App. 1 § 12.00(A)(2)(b).
The ALJ found that Hollabaugh's mental impairments did not satisfy the paragraph B criteria if she “stopped the substance use.” (Tr. 20-21.) In that event, Hollabaugh would have a marked limitation in interacting with others but no more than a moderate limitation in the other mental functioning areas. (Id.) The ALJ explained her assessment of Hollabaugh's ability to interact with others as follows:
If the claimant stopped the substance abuse, in interacting with others, the claimant would have a marked limitation. Though the record shows the claimant has continued to perform some socialization activities, the claimant continues to report significant anxiety in public places. Additionally, the claimant's record reveals a history of legal difficulties and hospitalizations secondary to problems in this area. Even absent the effects of her substance abuse, Dr. Braun testified the claimant would continue to have marked limitations in this area.(Tr. 20.)
After concluding at step three that Hollabaugh's mental impairments did not meet a listing, the ALJ then assessed Hollabaugh's RFC, including limitations relating to the paragraph B criteria. As the Third Circuit has explained, “no incantations are required at steps four and five simply because a particular finding has been made at steps two and three.” Hess, 931 F.3d at 209. As with other findings an ALJ is required to make, the ALJ need not “use particular language or adhere to a particular format in conducting his [or her] analysis,” so long as there is “sufficient development of the record and explanation of findings to permit meaningful review.” Jones v. Barnhart, 364 F.3d 501, 505 (3d Cir. 2004). The ALJ's decision should be “read as a whole.” Id.
According to Plaintiff, the ALJ's RFC is defective because she “inexplicably found that the Plaintiff could still tolerate occasional supervision even with a marked limitation in interacting with others.” (Doc. 21 at 18-19.) Plaintiff appears to suggest that there is an inherent inconsistency between those step three and RFC findings. If so, Plaintiff is mistaken.
Courts have recognized that a step three finding of “marked” limitation in ability to interact with others may be accommodated by an RFC limitation of “occasional” interaction with supervisors and co-workers. See, e.g., Rinaldi v. Kijakazi, No. 3:21-CV-00714, 2022 WL 4357474, at *5 (M.D. Pa. Sept. 20, 2022) (holding that the ALJ's RFC limiting the plaintiff to “occasional interaction with supervisors and coworkers” accommodated a doctor's opinion that “the plaintiff has marked limitations in the plaintiff's ability to interact appropriately with coworkers, supervisors, and the public”); Weimer v. Kijakazi, No. CV 20-1850, 2022 WL 3156421, at *1 n.1 (W.D. Pa. Aug. 8, 2022) (holding that “the ALJ adequately accounted for Plaintiff's marked limitation in interacting with others by limiting her to no work-related interaction with the public, only occasional and superficial interaction with co-workers, and only occasional supervision”). There is “no inherent inconsistency” between such findings. Weimer, 2022 WL 3156421, at *1 n.1.
See also Christopher V. v. Comm'r, Soc. Sec. Admin., No. 3:17-CV-01503-HZ, 2019 WL 93502, at *6 (D. Or. Jan. 2, 2019) (“agree[ing] with Defendant that the occasional limitation [on interaction with supervisors and co-workers] is not inconsistent with the definition of ‘marked”'); Phelps v. Colvin, No. 15-257, 2017 WL 372738, at *2 n.3 (W.D. Pa. Jan. 26, 2017) (approving an “RFC limit[ing] Plaintiff to no work with the public; only occasional contact with supervisors and co-workers; and only simple tasks, decisions, and instructions” and stating that “[a] limitation to occasional interaction may accommodate a marked limitation”) (citations omitted); Davis v. Colvin, No. 2:13-CV-00892, 2014 WL 3891643, at *5-6 (W.D. Pa. Aug. 7, 2014) (rejecting plaintiff's argument “that the ALJ's limitation Continued on next page . . .
Perhaps most significantly, the proper approach to this issue is reflected by the District Court's holding in Tooley v. Colvin, No. 3:14-CV-1840, 2015 WL 3866061 (M.D. Pa. June 23, 2015). There the plaintiff alleged she “was unable to work due to depression, bipolar disorder and anxiety.” Id. at *2. The ALJ accepted the opinion of a consultative psychologist that the plaintiff had a “marked limitation on her ability to interact with co-workers but nonetheless found that plaintiff could have occasional interaction with co-workers.” Id. at *3. The ALJ also found that the plaintiff should have no interaction with the public. Id. The plaintiff “dispute[d] whether the ALJ's limitation to occasional interaction with co-workers accurately accounted for her marked limitation” in interacting with others. Id.
The Court held that “the ALJ's RFC finding adequately accounted for the marked limitation to interact with co-workers . . . by restricting plaintiff to only occasional interaction with co-workers, i.e., very little up to one third of the workday.” Id. at *4. “Simply because . . . plaintiff had marked limitation in her of her potential jobs to those involving only occasional interaction with the public, coworkers, and supervisors is insufficient to account for his finding that she has marked limitations in social functioning” and observing that “other courts have found limitation of a claimant to occasional interaction with the public, coworkers, and supervisors to adequately reflect marked limitations in social functioning”) (footnotes and citations omitted). ability to interact with co-workers, does not mean that plaintiff was completely precluded from having any interaction with co-workers.” Id. (citing Fissella v. Astrue, 2011 WL 4368369, *3 (W.D. Pa. Sept. 19, 2011)). Ultimately, the Court concluded “that the ALJ's decision that plaintiff could have occasional interaction with co-workers despite her marked limitation in this area was supported by substantial evidence.” Id. at *5.
Plaintiff attempts to bolster her argument by citing Bylsma v. Kijakazi, No. 3:20-CV-1377, 2021 WL 4978444 (M.D. Pa. Sept. 16, 2021), report and recommendation adopted, 2021 WL 4975077 (M.D. Pa. Oct. 26, 2021). (Doc. 21 at 18.) However, the circumstances that led the Court to order a remand in Bylsma are readily distinguishable from this case. The Court's thorough analysis in Bylsma reflects that the ALJ erred in multiple ways, including by “failing to obtain a medical opinion as to the RFC” and by “failing to call a medical expert to testify.” 2021 WL 4975077, at *8, *10-*11. The absence of such evidence (along with other errors) led the Court to conclude that “the ALJ's RFC is not supported by substantial evidence.” Id. at *9. Here, in contrast, the ALJ considered medical opinion evidence from multiple sources, including a testifying medical expert. The availability of such evidence contributes to the conclusion (discussed above) that the ALJ's RFC determination in this case is supported by substantial evidence.
The Court's holding in Tooley highlights the key issue here: whether substantial evidence supports the ALJ's RFC finding that despite Hollabaugh's mental impairments, she retains the ability to do work involving occasional supervision. Plaintiff contends “there was no medical evidence in the record that supported the Plaintiff's ability to even occasionally interact appropriately with supervisors.” (Doc. 21 at 20.) Plaintiff's statement overlooks significant evidence supporting the ALJ's RFC assessment.
Most importantly, the ALJ's finding that Hollabaugh can tolerate occasional supervision is supported by the opinion of the medical expert, Dr. Braun. He testified that Hollabaugh's “ability to interact with others [is] markedly impaired.” (Tr. 57.) In assessing Hollabaugh's functional limitation from this marked impairment, Dr. Braun opined she would be limited to occasional supervision (i.e., “zero to one-third of the workday”) and that “she would be better with no interactions with co-workers or the public.” (Tr. 59.) Dr. Braun further stated that, if Hollabaugh were to remain substance free, “she'd be able to achieve substantial gainful activity and be . . . able to be employable.” (Tr. 59.)
Dr. Braun was questioned at the hearing about the “occasional supervision” limitation. Hollabaugh's counsel asked Dr. Braun whether Hollabaugh would have difficulty accepting occasional supervision, given her marked social interaction limitation. (See Tr. 59-60.), Dr. Braun responded that the record reflected “no reference to any difficulties with cooperation.” (Tr. 59.) The doctor added that Hollabaugh's “prison record is relatively benign” and that the mental status exams and consultative exam indicate that she was cooperative. (Tr. 59-60.)
The ALJ found Dr. Braun's opinion “persuasive” and noted Dr. Braun “had the opportunity to review the entire medical record.” (Tr. 24-25.) The ALJ also found that Dr. Braun's “opinion is generally consistent with the results of the claimant's repeated mental status examinations showing stability in her functioning,” as well as her “admissions regarding her performance of sustained daily activities.” (Tr. 25.) Based on these findings, the ALJ's RFC assessment incorporated Dr. Braun's opinion regarding Hollabaugh's social interaction limitations.
The ALJ's evaluation of Dr. Braun's opinion is supported by substantial evidence. As Dr. Braun stated, and as summarized earlier in this report, see supra Part I.B.1, the record shows that multiple medical providers observed that Hollabaugh was consistently cooperative during mental status exams. (See, e.g., Tr. 827, 831, 855, 974, 980, 985, 991, 1031, 1052, 1071, 1144, 1166-67, 1184, 1187, 1189, 1209.) Prison mental health providers likewise noted that Hollabaugh was cooperative. (See Tr. 855, 960-61, 1460.) In addition, the consultative examiner, Mr. Gipe, observed that Hollabaugh was “very talkative” and “cooperative throughout the examination with adequate manner of relating.” (Tr. 810.)
Plaintiff complains in her reply brief that evidence of her cooperation with medical providers, the consulting examiner, and prison staff are not “the same as a supervisor in a work setting.” (Doc. 23 at 2.) While Plaintiff's statement is literally true, it is not persuasive. Dr. Braun testified as a mental health expert. (Tr. 41-42; see also Tr. 1158-60 (Dr. Braun's resume).) He cited those medical findings in support of his opinion that Hollabaugh could tolerate occasional supervision. It is the ALJ's role to weigh the evidence, and she did not abuse her discretion in accepting Dr. Braun's opinion. See Brown v. Astrue, 649 F.3d 193, 196 (3d Cir. 2011) (holding that “the ALJ is entitled to weigh all evidence in making its finding,” including evidence from medical experts); see also Beavers v. Kijakazi, No. 3:20-CV-01415, 2022 WL 989024, at *8 (M.D. Pa. Mar. 31, 2022) (“The ALJ's duty is to weigh the evidence and resolve conflicts.”) (citing Richardson v. Perales, 402 U.S. 389, 410 (1971) and Fargnoli v. Massanari, 247 F.3d 34, 40 (3d Cir. 2001)).
In addition to Dr. Braun's opinion and the treatment records, Hollabaugh's activities tend to support the ALJ's finding regarding her social interaction limitations. For example, the ALJ noted that Hollabaugh's ability to “shop in stores for groceries suggests the claimant is capable of identifying purchase needs, making a list, selecting food items, managing money, and interacting appropriately with checkout personnel.” (Tr. 22.) Such activities, the ALJ reasoned, “suggest the claimant retains a greater capacity for cognitive, social, and adaptive skills than alleged.” (Id.)
In sum, the ALJ's RFC finding that Hollabaugh can do work involving occasional supervision is supported by substantial evidence. As such, Plaintiff's claims challenging that finding lack merit.
D. The ALJ's Assessment of Plaintiff's Statements
Plaintiff's third claim is that the ALJ erred in finding that her statements about her symptoms were not consistent with the medical evidence. (Doc. 21 at 20-21.) Plaintiff asserts that her statements are corroborated by her mother, and their statements, “particularly in regard to relating with other people, were well supported by the opinions of Dr. Braun and Dr. Gipe.” (Id. at 21.) In other words, Plaintiff's argument again focuses on the ALJ's RFC assessment as it relates to her ability to interact with others. According to Plaintiff, the ALJ erred in discounting her statements without pointing to any contrary medical evidence. The Commissioner responds that the ALJ's findings are entitled to deference and supported by substantial evidence. (Doc. 22 at 21-24.)
An ALJ has a “duty to consider seriously” a claimant's subjective complaints. Reefer v. Barnhart, 326 F.3d 376, 381 (3d Cir. 2003). But “the ALJ is not required to credit them.” Chandler, 667 F.3d at 363 (citing 20 C.F.R. § 404.1529(a)).
In Social Security Ruling 16-3p, the Commissioner describes the two-step process an ALJ should follow in evaluating a claimant's statements about her symptoms:
First, we must consider whether there is an underlying medically determinable physical or mental impairment(s) that could reasonably be expected to produce an individual's symptoms, such as pain. Second, once an underlying physical or mental impairment(s) that could reasonably be expected to produce an individual's symptoms is established, we evaluate the intensity and persistence of those symptoms to determine the extent to which the symptoms limit an individual's ability to perform work-related activities ....SSR 16-3P, 2016 WL 1119029 (S.S.A. Mar. 16, 2016.)
Here, the ALJ's written decision reflects that she properly applied the principles underlying SSR 16-3p.The ALJ found that Hollabaugh has medically determinable mental impairments that cause significant functional limitations. (Tr. 22.) In assessing the extent of those limitations, the ALJ began by summarizing Hollabaugh's testimony and written statement describing her mental impairments and their impact on her ability to work. (Id.) The ALJ also noted the supporting statement filed by Hollabaugh's mother. (Id.) Next, the ALJ discussed Hollabaugh's activities, her medical records, and the opinion evidence. (Tr. 22-25.)
Unlike most social security written decisions, the ALJ's decision in this case does not include boilerplate language describing the two-step approach outlined in SSR 16-3p. Apparently based on that omission, Plaintiff argues that the ALJ “failed to apply SSR 16-3p in evaluating the Plaintiff's subjective symptoms.” (Doc. 21 at 21.) Because Plaintiff does not otherwise elaborate on this one-sentence argument, it need not be addressed. In any event, although the ALJ did not include the usual boilerplate language about SSR 16-3p, her analysis reflects that she applied the principles underlying that ruling, as discussed above. See Jones, 364 F.3d at 505 (stating that the ALJ need not “use particular language or adhere to a particular format in conducting his [or her] analysis”).
Based on the ALJ's review of the evidence, she concluded that Hollabaugh's statements about the extent of her symptoms “are not entirely consistent with the medical evidence and other evidence in the record.” (Tr. 22.) The ALJ summarized the reasons for her RFC assessment as follows:
The record demonstrates the claimant suffers from bipolar disorder, anxiety disorder, post-traumatic stress disorder, attention-deficit hyperactivity disorder, personality disorder resulting in complaints of impaired sleep, feelings of hopelessness and worthlessness, fatigue, loss of energy, social withdrawal, excessive worry, restlessness,
difficulty concentrating, being uncomfortable in public, and panic attack symptoms of palpitations, sweating, dizziness, breathing difficulties, trembling, and chest pain. To accommodate these reported symptoms, the undersigned limited the claimant as noted [in the RFC assessment]. The objective signs, the clinical findings and observations, the claimant's treatment history, the opinion of Dr. Braun, and the claimant's admissions regarding her continued performance of a wide range of daily activities support this assessment.(Tr. 24-25.)
Plaintiff is mistaken in contending that “there is no contrary medical evidence in the record suggesting that the Plaintiff can interact appropriately with supervisors on a sustained basis.” (Doc. 21 at 21.) As discussed in the preceding section, see supra Part II.C, the ALJ's assessment of Hollabaugh's ability to interact with supervisors is fully supported by Dr. Braun's opinion, which the ALJ adopted. As also explained, Dr. Braun's reasoning is supported by the medical evidence. Such evidence is sufficient to support the ALJ's evaluation of Hollabaugh's statements about her symptoms. See Louis v. Comm'r Soc. Sec., 808 Fed.Appx. 114, 122 (3d Cir. 2020) (holding that the ALJ's decision to discount a lay witness report because it was inconsistent with medical evidence and medical opinions “was sufficient by itself to support the ALJ's decision”) (citing Bayliss v. Barnhart, 427 F.3d 1211, 1218 (9th Cir. 2005).)
To be sure, the record reflects evidence that tends to support Hollabaugh's statements about her symptoms. But that is not the issue here. Rather, the issue is whether the ALJ's assessment is supported by substantial evidence. See Chandler, 667 F.3d at 359.
Significantly, the ALJ did not completely discount the statements by Hollabaugh and her mother about her limitations. To the contrary, the ALJ found that Hollabaugh's mental impairments result in significant functional limitations, including the following: she is “limited to tasks with no greater than several variables”; she can have “no more than incidental interaction with others”; she is “unable to perform work that requires coordination with others”; she is limited to “occasional supervision,” and she is unable to perform work requiring her to direct, control, or influence others. (Tr. 22.) The ALJ adopted these limitations to “accommodate [Hollabaugh's] reported symptoms.” (Tr. 25.)
It is also noteworthy that the ALJ did not simply accept the opinion of the state agency psychological consultant, Dr. Parshall, who found that Hollabaugh's ability to interact with supervisors was only moderately limited. (Tr. 185.) Instead, the ALJ found the opinions of Dr. Braun and Mr. Gipe more persuasive as to that issue. (Tr. 25.) This further suggests that the ALJ properly fulfilled her role to “weigh the evidence and resolve conflicts.” Beavers, 2022 WL 989024, at *8.
In this case, the record reflects significant evidence that Plaintiff Hollabaugh struggles with difficult mental health conditions. Such evidence includes her own testimony and statements. But a federal court is “not permitted to re-weigh the evidence or impose their own factual determinations.” Chandler, 667 F.3d at 359. Because the ALJ properly considered Hollabaugh's statements about her symptoms in the context of the other evidence in the record, and because the ALJ's findings are supported by substantial evidence, Plaintiff's third claim lacks merit.
III. RECOMMENDATION
For the foregoing reasons, the undersigned recommends that the Commissioner's decision be AFFIRMED. It is also recommended that the Clerk be directed to CLOSE this case.
NOTICE TO THE PARTIES
Any party may obtain review of this Report and Recommendation pursuant to Local Rule 72.3, which provides:
Any party may object to a magistrate judge's proposed findings, recommendations or report addressing a motion or matter described in 28 U.S.C. § 636 (b)(1)(B) or making a recommendation for the disposition of a prisoner case or a habeas corpus petition within fourteen (14) days after being served with a copy thereof. Such party shall file with the clerk of court, and serve on the magistrate judge and all parties, written objections which shall specifically identify the portions of the proposed findings, recommendations or report to which objection is made and the basis for such objections. The briefing requirements set forth in Local Rule 72.2 shall apply. A judge shall make a de novo determination of those portions of the report or specified proposed findings or recommendations to which objection is made and may accept, reject, or modify, in whole or in part, the findings or recommendations made by the magistrate judge. The judge, however, need conduct a new hearing only in his or her discretion or where required by law, and may consider the record developed before the magistrate judge, making his or her own determination on the basis of that record. The judge may also receive further evidence, recall 44 witnesses, or recommit the matter to the magistrate judge with instructions.