Opinion
Civil Action No. 6:18-2662-MGL-KFM
09-12-2019
Carol Lynn Littleton, Plaintiff, v. Andrew M. Saul, Commissioner of Social Security, Defendant.
REPORT OF MAGISTRATE JUDGE
This case is before the court for a report and recommendation pursuant to Local Civil Rule 73.02(B)(2)(a)(D.S.C.), concerning the disposition of Social Security cases in this District, and Title 28, United States Code, Section 636(b)(1)(B).
A report and recommendation is being filed in this case, in which one or both parties declined to consent to disposition by the magistrate judge.
The plaintiff brought this action pursuant to Sections 205(g) and 1631(c)(3) of the Social Security Act, as amended (42 U.S.C. 405(g) and 1383(c)(3)), to obtain judicial review of a final decision of the Commissioner of Social Security denying her claims for disability insurance benefits and supplemental security income benefits under Titles II and XVI of the Social Security Act.
ADMINISTRATIVE PROCEEDINGS
The plaintiff previously applied for disability benefits in 2006, which was denied (Tr. 138, 337-38). The plaintiff filed applications for disability insurance benefits ("DIB") and supplemental security income ("SSI") benefits on January 14, 2015. In both applications, the plaintiff alleged that she became unable to work on July 1, 2008. Through her attorney, the plaintiff amended the alleged disability onset date to February 27, 2014. Both applications were denied initially and on reconsideration by the Social Security Administration. On November 24, 2015, the plaintiff requested a hearing. The administrative law judge ("ALJ"), before whom the plaintiff and Julie Bose, an impartial vocational expert, appeared in a video hearing on June 29, 2017, considered the case de novo, and on August 31, 2017, found that the plaintiff was not under a disability as defined in the Social Security Act, as amended (Tr. 24-37). The ALJ's finding became the final decision of the Commissioner of Social Security when the Appeals Council denied the plaintiff's request for review on July 25, 2018 (Tr. 1-6). The plaintiff then filed this action for judicial review.
The plaintiff appeared with her attorney in Columbia, South Carolina, the ALJ presided over the hearing from St. Louis, Missouri, and the vocational expert appeared by telephone (Tr. 24, 50).
In making the determination that the plaintiff is not entitled to benefits, the Commissioner has adopted the following findings of the ALJ:
(1) The claimant meets the insured status requirements of the Social Security Act through December 31, 2017.
(2) The claimant has not engaged in substantial gainful activity since February 27, 2014, the amended alleged onset date (20 C.F.R §§ 404.1571 et seq., 416.971 et seq.).
(3) The claimant has the following severe impairments: disorder of the back, degenerative joint disease, a history of traumatic brain injury, affective/mood disorder, post-traumatic stress disorder, and a history of drug use/dependence (20 C.F.R. §§ 404.1520(c), 416.920(c)).
(4) The claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. §§ 404.1520(d), 404.1525, 416.920(d), 416.925, 416.926).
(5) After careful consideration of the entire record, I find that the claimant has the residual functional capacity to lift/carry/push/pull 20 pounds occasionally and 10 pounds frequently, stand and/or walk six hours total in an eight-hour workday, and sit for six hours total in an eight-hour workday. In
addition, the claimant can occasionally climb ramps and stairs, can never climb ladders, ropes, or scaffolds, and can occasionally balance, stoop, kneel, crouch, and crawl. Further, she should have no more than occasional exposure to unprotected heights and dangerous machinery. Furthermore, the claimant retains the mental residual functional capacity to understand, remember, and carry out simple tasks and instructions; she can concentrate, attend, and persist on simple tasks; she can interact adequately with supervisors and co-workers, but never the general public; and she can respond appropriately to simple, routine, workplace changes. Finally, the claimant will miss an occasional day of work because of mental health issues, with occasional defined as once every one to two months. The claimant's physical limitations are based on the State agency assessments at B9A and B10A, while her mental limitations are based on the State agency assessments at B3A, B4A, B9A, and B10A.
(6) The claimant is unable to perform any past relevant work (20 C.F.R. §§ 404.1565, 416.965).
(7) The claimant was born on April 10, 1969, and was 44 years old, which is defined as a younger individual age 18-49, on the amended alleged disability onset date (20 C.F.R. §§ 404.1563, 416.963).
(8) The claimant has at least a high school education and is able to communicate in English (20 C.F.R. §§ 404.1564, 416.964).
(9) Transferability of job skills is not material to the determination of disability because using the Medical-Vocational Rules as a framework supports a finding that the claimant is "not disabled" whether or not the claimant has transferable job skills (See SSR 82-41 and 20 C.F.R. Part 404, Subpart P, Appendix 2).
(10) Considering the claimant's age, education, work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that the claimant can perform (20 C.F.R. §§ 404.1569, 404.1569(a), 416.969, 416.969(a)).
(11) The claimant has not been under a disability, as defined in the Social Security Act, from February 27, 2014, through the date of this decision (20 C.F.R. §§ 404.1520(g), 416.920(g)).
The only issues before the court are whether proper legal standards were applied and whether the final decision of the Commissioner is supported by substantial evidence.
APPLICABLE LAW
Under 42 U.S.C. § 423(d)(1)(A), (d)(5) and § 1382c(a)(3)(A), (H)(i), as well as pursuant to the regulations formulated by the Commissioner, the plaintiff has the burden of proving disability, which is defined as an "inability to do 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 12 months." 20 C.F.R. §§ 404.1505(a), 416.905(a).
To facilitate a uniform and efficient processing of disability claims, the Social Security Act has by regulation reduced the statutory definition of "disability" to a series of five sequential questions. An examiner must consider whether the claimant (1) is engaged in substantial gainful activity, (2) has a severe impairment, (3) has an impairment that meets or medically equals an impairment contained in the Listing of Impairments found at 20 C.F.R. Pt. 404, Subpt. P, App. 1, (4) can perform his past relevant work, and (5) can perform other work. Id. §§ 404.1520, 416.920. If an individual is found not disabled at any step, further inquiry is unnecessary. Id. §§ 404.1520(a)(4), 416.920(a)(4).
A claimant must make a prima facie case of disability by showing he is unable to return to his past relevant work because of his impairments. Grant v. Schweiker, 699 F.2d 189, 191 (4th Cir. 1983). Once an individual has established a prima facie case of disability, the burden shifts to the Commissioner to establish that the plaintiff can perform alternative work and that such work exists in the national economy. Id. (citing 42 U.S.C. § 423(d)(2)(A)). The Commissioner may carry this burden by obtaining testimony from a vocational expert. Id. at 192.
Pursuant to 42 U.S.C. § 405(g), the court may review the Commissioner's denial of benefits. However, this review is limited to considering whether the Commissioner's findings "are supported by substantial evidence and were reached through application of the correct legal standard." Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996). "Substantial evidence" means "such relevant evidence as a reasonable mind might accept as adequate to support a conclusion; it consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance." Id. In reviewing the evidence, the court may not "undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner]." Id. Consequently, even if the court disagrees with Commissioner's decision, the court must uphold it if it is supported by substantial evidence. Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972).
EVIDENCE PRESENTED
The plaintiff was 44 years old on her amended alleged disability onset date (February 27, 2014) and 48 years old at the time of the ALJ's decision (August 31, 2017). She completed her education through two years of college, and she has past relevant work as a certified nursing assistant ("CNA"), telemarketer, and customer service clerk (Tr. 34, 52, 82-83, 342-43).
On September 10, 2013, the plaintiff was seen at Baptist Hospital emergency room ("Baptist ER") for an anxiety reaction because her ex-boyfriend had chased her while she was at Transitions, a homeless shelter. She was given Ativan and Zofran IV and had marked improvement. She was discharged to follow up with her primary care physician and Transitions staff (Tr. 1009-10).
On February 27, 2014, the plaintiff was admitted to Richland Hospital after an assault by her boyfriend that caused jaw fractures and resulted in surgery to repair her jaw. A CT scan of her cervical spine revealed multilevel degenerative disc facet disease, especially at C5-6 and C6-7 with central canal narrowing, greatest at C6-7. There was neural foraminal narrowing bilaterally at C4-5 and on the right at C6-7 (Tr. 556, 591). On March 2, 2014, an MRI of her brain showed a diffuse axonal injury (Tr. 555).
On March 19, 2014, the plaintiff was treated at Baptist ER for jaw pain because she had pulled a surgical wire out. She had taken Norco, was very sleepy, and complaining of chest pain (Tr. 1011-12).
On April 12, 14, and 23, 2014, the plaintiff was seen at Richland Hospital for post-surgery jaw pain (Tr. 750, 753, 756). On April 14, 2014, she also sought treatment at Lexington Medical Center for facial pain after her boyfriend hit her in the chest and on the side of her face. On examination, she was alert and oriented. Her mood, affect, and behavior were normal. She was prescribed Percocet (Tr. 880-82). On April 15, 2014, she was seen at Baptist Hospital ER for an anxiety reaction after an altercation with her boyfriend. She was given Ativan, which made her feel much better (Tr. 1014).
On May 5, 2014, the plaintiff was seen at Baptist ER after she ran away from someone and after having an altercation with her ex-husband. She was very anxious. She was given medication for anxiety and pain, and her symptoms improved (Tr. 1016). On May 6, 2014, she had anxiety attacks, palpitations, and face pain after being punched in the face by her ex-boyfriend. Examination was generally normal. She was slightly anxious. Diagnoses were anxiety and status post-assault with facial contusions. She was prescribed Norco and Ativan (Tr. 1018). On May 17, 2014, the plaintiff felt she was having tachycardiac spells due to anxiety or due to her supraventricular tachycardia ("SVT"). She had an EKG and was watched for two hours and had no tachycardic spells while on the monitors. Clinical impression was anxiety, and Vistaril was prescribed (Tr. 1020-21). On May 22, 2014, the plaintiff was seen at Baptist ER after she had taken five or six Ativan due to facial pain. She had an altered mental status due likely due to the medication. On first examination, she was drowsy and had slurred speech. Upon re-examination, she was alert and stated she could call her sister to pick her up. She was advised to take her medications only as prescribed and was discharged in stable and improved condition (Tr. 1024-25). On May 23, 2014, she was seen at Baptist ER for palpitations, chronic anxiety, and an abrasion on her right upper extremity. On examination, mild anxiety was noted. She received a prescription for Ultram, was discharged to home, and was asked to follow up with her primary care physician (Tr. 1029).
On May 24, 2014, the plaintiff was seen multiple times within a 24-hour period at the Richland Hospital ER. She had vague complaints, which kept changing. She first claimed to have chest pain and that she had been bitten by animals, then complained of a bruise on her arm, and then complained that she had facial pain that had resolved. She was defensive and called the staff names when they asked her why she repeatedly returned to the ER. She was discharged with a clinical impression of "malingering" (Tr. 763-64). On May 26, 2014, the plaintiff was seen at the Richland Hospital ER for chest palpitations related to assaults and suicidal ideation. On examination, she was cooperative, and her behavior was appropriate. Her affect was constricted, and mood was congruent. She had normal speech. Thought process was linear, logical, and goal-directed. She had no delusions or hallucinations. Her insight and judgment were poor. Attention and concentration were good, and memory was intact. She was diagnosed with chronic depression. She was discharged and outpatient followup was best indicated (Tr. 769-73). She also went to Baptist ER on May 26th with abrasions on both knees. It was noted that she had a history of psychiatric disorders, was homeless, and could not find shelter from the rain. She was evaluated by psychiatry, who felt she was alright to go home. She received a dose of Flexiril and Tylenol, and her symptoms resolved (Tr. 1033-34).
On May 28, 2014, the plaintiff was evaluated at the Columbia Area Community Mental Health Clinic ("CAMHC") after walking into the path of a car. She heard voices that sounded like her own voice. Upon receiving records from Richland, it was noted that over the weekend and on the 28th her thoughts of self-harm varied with each clinician she talked to. There was no indication that she placed herself in front of the car (Tr. 1128-29).
On June 6, 2014, at Richland ER, the plaintiff reported dental pain, and she had an anxious appearance. It was noted that she had more than a dozen visits to the ER over the past month. She was discharged home and advised to follow up with an oral surgeon (Tr. 776-77). On June 11 and 12, 2014, she returned to Baptist ER and Richland Hospital, respectively, for palpitations and anxiety (Tr. 779, 1037). On June 15, 2014, she was seen at Lexington Medical Center for facial pain. Examination was generally normal with facial pain upon palpation (Tr. 889-93).
On June 16, 2014, the plaintiff was treated at CAMHC for suicidal ideation. She had depressive symptoms of insomnia, nightmares, and flashbacks. She had poor judgment and poor insight. Her medications for depression and anxiety were reviewed (Tr. 1112-13).
On June 23 and 25, 2014, the plaintiff was seen at Baptist Hospital ER for facial pain and a fast heart beat due to anxiety. She was given a short supply of Norco for breakthrough pain (Tr. 1039-42).
On June 30, 2014, the plaintiff received referrals from the Community Free Clinic in Columbia for neurology, ophthalmology, and dental (Tr. 707).
On July 4, 2014, the plaintiff went to Lexington Medical Center for reported anxiety, tachycardia, and excessive worry. She also reported frequent headaches. Her examination was normal. She was diagnosed with anxiety and headache. Percocet and Ativan were prescribed (Tr. 898-90). On July 21, 2014, she was seen twice at Lexington Medical Center - once with facial pain after an altercation with her boyfriend. Her sister picked her up, and she jumped out of the car and returned to the hospital. She was diagnosed with a psychiatric problem due to her bizarre behavior. On psychiatric evaluation, it was noted that this was an acute problem that had resolved in one day. She denied suicidal or homicidal ideation. She was given a prescription for Percocet (Tr. 912-15). She returned on July 22, 2014, with chest pain. Diagnoses were Hepatitis C, post traumatic stress disorder ("PTSD"), SVT, anxiety, panic attacks, psychiatric disorder, drug seeking behavior, seizures, nerve damage, and kidney stone. Examination was normal. She was stable and discharged (Tr. 917-20).
On July 25, 2014, the plaintiff was seen at Baptist ER with leg pain and a racing heart. Examination was generally normal, but she appeared to be mildly dehydrated. She was given a liter of fluids. She was advised to follow up with her primary care physician (Tr.1045-46). On November 6, 2014, the plaintiff was seen at Baptist ER for head trauma followup. She reported a headache and anxiety. She felt she was forgetting long periods of time, and she also complained of chest pain. Physical examination was normal. It was noted that her loss of chunks of time might be related to her psychiatric illness. She was given a dose of Tylenol and discharged in stable condition (Tr. 1048-49).
On August 22, 2014, the plaintiff was admitted at Lexington Medical Center for an overdose. She was placed on antipsychotics and was discharged to Three Rivers Behavioral Health due to psychosis and paranoia (Tr. 931-71). She was treated at Three Rivers from August 28 to September 19, 2014, for bipolar affective disorder, PTSD, substance use, and anxiety disorder. Upon discharge, she had a Global Assessment of Functioning ("GAF") score of 45. She was noted to be very needy and seeking frequent reassurance. Her symptoms improved with treatment, and she was discharged in stable condition. The discharge summary from Three Rivers showed that the plaintiff was stable on medications, and she had no symptoms of psychosis. Her prognosis was guarded. It was noted that she would be in a long term substance abuse program at Morris Village in Columbia (Tr. 559-61). The plaintiff underwent treatment for substance use dependence at Morris Village from September 19 to October 21, 2014, and her symptoms improved enough for discharge (Tr. 580-81).
A GAF score is a number between 1 and 100 that measures "the clinician's judgment of the individual's overall level of functioning." See Am. Psychiatric Ass'n, Diagnostic & Statistical Manual of Mental Disorders, 32-34 (Text Revision 4th ed. 2000) ("DSM-IV"). A GAF score between 41 and 50 indicates serious symptoms or any serious impairment in social, occupational, or school functioning. Id. The court notes that the fifth edition of the DSM, published in 2013, has discontinued use of the GAF for several reasons, including "its conceptual lack of clarity (i.e., including symptoms, suicide risk, and disabilities in its descriptors) and questionable psychometrics in routine practice." See Am. Psychiatric Ass'n, Diagnostic & Statistical Manual of Mental Disorders, 16 (5th ed. 2013) ("DSM-V").
On November 18, 2014, the plaintiff returned to Baptist ER with back pain. It was noted that the plaintiff had been there before and that this was her 35th or 36th visit. Review of systems showed she had seizures, anxiety, and PTSD. It was also noted that she had 28 prescriptions written by 15 different doctors that were filled at 11 different pharmacies. She was given a short course of Ultram and advised to follow up with her family doctor or Midlands Orthopaedics (Tr. 1051-52). On December 11, 2014, she was seen at Baptist ER for a medication refill because she was arrested the night before for trespassing, and law enforcement had taken her seizure medication. She also complained of migraines, pain, nausea, and photophobia. Physical examination was normal. It was noted that she had significant ER visits. She was given Compazine IM and one dose of gabapentin and instructed to follow up with her primary care physician (Tr. 1062-63).
On January 7, 2015, the plaintiff was seen at the Community Free Clinic for facial pain, hypothyroidism, anxiety, and medication refills (Tr. 665-67, 705-06).
On January 10, 2015, the plaintiff was treated at Baptist ER for an abrasion to her face. Examination was normal, and she declined workup. She stated she wanted an ice pack and something for pain. She was discharged home and instructed to take Tylenol or Motrin for pain (Tr. 1064-65). On January 26, 2015, she felt like she was going to have a seizure. Examination was normal, and she had no seizure. She was given a dose of gabapentin and a prescription for it. She was instructed to find a primary care physician and to get gabapentin as normally prescribed by them (Tr. 1069). On January 27 and February 10, 2015, the plaintiff was seen at Baptist ER for a migraine headache. On January 27th, examination was normal. She was given IV fluids, compazine, and Tylenol. Her headache resolved. On February 10th, she was given Dilaudid, Phenergan, and Ativan. Christopher A. Anderson, M.D., told her that further treatment would be limited to no narcotics for her headache due to her very extensive past history of visiting the ER for migraine headaches (Tr. 1071-73). On February 13, 2015, she returned with a headache and jaw pain. Examination was normal. She was treated with Compazine, Benadryl, fluids, and Tylenol, and felt much better at the time of discharge. She was instructed to follow up with her primary care physician (Tr. 1075-76). On February 18 and March 2, 2015, she was seen for anxiety at Baptist ER. She told Dr. Anderson that she would like to have something for her anxiety. At the February visit, she was given a a dose of Ativan and a prescription and instructed to follow up with the Free Clinic or the 1801 Clinic. In March, she was given a dose of Ativan and a prescription for Vistaril. She was encouraged to follow up with CAMHC (Tr. 1078-80).
On March 9, 2015, radiological examinations were performed for seizure, fall, and neck pain. The CT of the plaintiff's cervical spine showed multilevel degenerative disc disease and facet disease with moderate neural foraminal narrowing. An x-ray of her right knee showed degenerative changes. A CT of her facial bones found further healing and old fractures. A head CT showed ventricles and sulci overall within normal limits. There was no intracranial hemorrhage or calvarial fracture. An x-ray of her hand showed a possible tiny avulsion fracture fragment, foreign body, or incidental chronic calcification (Tr. 788-94).
On March 10, 2015, the plaintiff as seen at Richland Hospital after a possible seizure (Tr. 784). She also returned to Lexington Medical Center on March 10th after a physical assault. She had facial and right arm pain (Tr. 990-94).
On March 26, 2015, the plaintiff went to Baptist ER for anxiety, headache, chest pain, and dizziness. It was noted that she was well known to the ER staff. The plaintiff reported that she was out of her Ativan. On physical examination, it was noted that the plaintiff appeared to be older than her stated age of 45. Examination was otherwise normal. She was given IV fluids, Reglan, and Benadryl, which calmed her, but did not alleviate her headache. She was given a dose of Fioricet and provided a very short prescription for outpatient use and a prescription for Vistaril. She was discharged home in stable condition and advised to follow up with CAMHC and her primary care doctor (Tr. 1082).
On April 8, 2015, the plaintiff was seen at CAMHC and reported another altercation with her ex-boyfriend. She reported nightmares, insomnia, living in a tent, depressed mood, anxiety, and auditory hallucinations. On examination, she had poor insight and poor judgment. She was disheveled and unkempt. She was diagnosed with major depressive disorder, severe, with psychotic features, and PTSD. She had been taking drugs (Tr. 1109-11, 1134). On April 9, 2015, she was seen at the Community Free Clinic for headaches (Tr. 1165).
On April 17, 2015, the plaintiff had x-rays for a fracture of the left foot. The x-ray showed bone resorption along the mid shaft fracture of the metatarsal of the second toe. There was stable alignment (Tr. 1254).
On April 20, 2015, at Richland ER, the plaintiff was seen for concerns about her medications. She stated that she was seen last week at CAMHC and was started back on her medications. She did not like the way they made her feel (Tr. 1097).
On April 28, 2015, at CAMHC, the plaintiff reported that she had missed her appointment due to misinformation. She stated she knew she needed her medications and that she had been out of them for the past week. She stated she was staying with her boyfriend for protection. Despite suicidal urges and hearing voices, she felt she would be okay if she got back on her medications. Her appearance was unkempt, and she experienced auditory hallucinations. Her GAF score was 45 (Tr. 1107-08).
On April 29, 2015, the plaintiff was treated at Baptist ER for an overdose of her Invega. It was noted that she had multiple visits to the ER for similar mental health complaints and that she had been to Baptist ER the day before (Tr. 1098-99).
On May 8, 2015, the plaintiff was seen at CAMHC. She required constant redirection. Her thought process was tangential, and her thought content was paranoid. She exhibited poor decisionmaking skills that adversely affected herself and others. It was noted that the plaintiff was well known at Baptist and Richland ERs. Her symptoms were managed with individual therapy and medication, and she stated that she knew she needed help (Tr. 1169-73).
On May 27, 2015, Timothy Laskis, Ph.D., a state agency psychological consultant, opined that the plaintiff had moderate limitations in maintaining social functioning and concentration, persistence, or pace. Dr. Laskis indicated that the plaintiff could attend to and perform simple unskilled work for reasonable periods of time without special supervision; attend work regularly, although she might miss an occasional day to her mental illness; make work-related decisions; protect herself from hazards; travel to and from work independently; and accept supervision and interact appropriately with co-workers, although she might not be suited for work with the general public (Tr. 128-29, 132-33, 144-46, 149-50).
On May 29, 2015, the plaintiff was treated for depression at CAMHC. It was noted on the monitoring form that the plaintiff was not compliant with medication. She was skipping doses, and the medication was partially working. Her symptoms were hallucinations, anxiety, depression, paranoia, suicidal and homicidal ideation, and sleep disturbances (Tr. 1184). On June 1, 2015, she reported multiple psychological issues and minimized her issues with drugs. It was noted that her complaints of memory issues were questionable as she was able to give dates of upcoming court appearances and medical appointments. She stated she got primary care at the Free Clinic. It was noted that she appeared to have drug seeking behavior and took little responsibility for her actions. On psychiatric examination, she was cooperative and calm; her speech was normal, and her thought process was concrete; she denied suicidal and homicidal ideation, obsessions, and delusions; her affect was appropriate, and she was alert and oriented; her memory and attention were intact; and she had poor judgment and poor insight. Her clinician commented that she continued to go to the ER and had at least four visits in May, which showed ongoing drug seeking behavior. She was very focused on her problems and need for medications. Her primary issues were drug seeking and PTSD (Tr. 1181-83).
On June 2, 2015, the plaintiff was seen by James A. O'Leary, M.D., at Midlands Orthopaedics and was put in a Cam Walker boot for her left foot fracture (Tr. 1147-50).
On June 11, 2015, the plaintiff went to the CAMHC with symptoms of hallucinations, anxiety, depression, flashbacks, legal problems, sleep disturbance, akathisia, and fatigue. It was noted on the monitoring form that she was not compliant with her medication, she was skipping doses, and the medication was partially effective. The plaintiff stated that she had about 15 suicide attempts. She was asking for Risperdal. She was having fleeting thoughts of suicide but had no plans (Tr. 1179-80). On June 15, 2015, she was seen at CAMHC and reported having hit two people over the weekend because voices told her to do it. She was irritable, tearful, hostile, and angry. She stated that she needed to be put back on Risperdal. She stated that she was compliant with Cymbalta and denied any ER visits over the weekend. She reported that one of the individuals she struck was asking her for pain medication because they saw that she had broken her foot (Tr. 1178). On June 18, 2015, she was seen for followup. When the clinician discussed her multiple ER visits and getting pain medications, she became angry. There was no evidence of a thought disorder. The plaintiff became very angry when the doctor refused to look into giving her an antipsychotic as it was not indicated. The plaintiff verbally threatened her. The doctor noted that the plaintiff did not have a psychotic illness. She had long term substance abuse dependence, PTSD, and multiple psychosocial issues, and she needed ongoing care for drug rehabilitation. In light of the plaintiff's loud threatening behavior, the doctor recommended closing her case. On psychiatric examination, the plaintiff was well groomed and had a hostile attitude. Eye contact was intense, and speech was loud. Associations were intact. She denied delusions, suicidal and homicidal ideation, obsessions, and hallucinations. Her mood was angry. She was alert and oriented, and her memory and concentration were intact. She had poor insight and judgment. Primary diagnosis was polysubstance dependence. The plaintiff was also diagnosed with PTSD, personality disorder NOS, seizure disorder, hypothyroidism, SVT, asthma, and chronic obstructive pulmonary disease ("COPD"). She was unemployed, a victim of criminal domestic violence, and had poor coping skills. The plaintiff had pending criminal charges for shoplifting and petit larceny. The plaintiff was discharged as a patient at CAMHC (Tr. 1176-77).
On September 1, 2015, the plaintiff was seen as a new patient by Tisha Boston, M.D., after multiple (26) visits to the ER since the beginning of the year. She was treated for right foot pain, COPD, and schizoaffective disorder. She stated she had reflex sympathetic dystrophy of her lower extremity and depression. The plaintiff admitted that she was not able to return to CAMHC because she had threatened the doctor there. She stated that she had been off her antipsychotic medication for two months and that this had greatly affected her mood. Dr. Boston noted that the plaintiff's major issue appeared to be mental health and incomplete treatment. Dr. Boston believed she needed to be on an antipsychotic and started Seroquel. Dr. Boston advised the plaintiff to avoid her boyfriend due to the abusive nature of their relationship (Tr. 1231-33). On September 15, 2015, she was seen for followup after starting Seroquel. Examination was normal. She was alert and oriented, cooperative, had appropriate mood and affect, normal judgment, and was non- suicidal. Dr. Boston recommended an additional does of Seroquel to control mood and to keep her appointment with CAMHC in two days because they might change her medications. Dr. Boston told the plaintiff to stay off her foot as much as possible and to add Tylenol to her pain regimen (Tr. 1226-29).
On October 16, 2015, the plaintiff was again seen at CAMHC. She continued to experience nightmares and auditory hallucinations, and she was hyperactive and experienced anxiety. She had paranoid thoughts that others were going to hurt her. On examination, her mood was depressed and anxious, her affect was appropriate, her speech was normal and thought process was logical and goal directed, she was oriented and had mild memory and concentration impairment, judgment and insight were fair, and her fund of knowledge was average (Tr. 1285-87). On October 28, 2015, she reported she cut herself when she was overwhelmed. She was living in the woods, and her mood was irritable and anxious. Her affect was blunted, labile, and tearful. Her speech was pressured, and she experienced racing thoughts and auditory hallucinations. Her judgment and memory were poor. The plaintiff could concentrate, and her fund of knowledge was average. She had poor sleep and nightmares. She was out of Elavil and Cymbalta and asking for prescriptions. CAMHC staff offered to call in Cymbalta and advised her to get Elavil at the Free Clinic. The plaintiff declined and left the clinic (Tr. 1458-60). On November 24, 2015, the plaintiff reported that she was banned from the homeless shelter and began to cry immediately. She appeared disheveled and unkempt. She was oriented times three and reported cutting herself when she became overwhelmed. She stated that she was out of her medications (Tr. 1536). On December 2, 2015, the plaintiff was seen for anxiety and said she could not sit still. She reported that her prescription for 20 mg of Latuda was not enough, so she was taking 40 mg and that was a little better. She had been seen at CAMHC since 2013 and always had relationship issues and angry outbursts with irritability. On examination, she was cooperative, and her speech was normal. Thought process was circumstantial; she denied delusions, obsessions, suicidal and homicidal ideation; her mood was irritable and anxious; and she exhibited a circumstantial thought process and poor insight and judgment. It was noted that the plaintiff knew the system and that she was trying to get disability. She was talkative and wanted to try Latuda 80 mg (Tr. 1495-97).
On December 8, 2015, the plaintiff called Dr. Boston's office and stated that she ran out of her prescriptions while she was in the hospital for kidney stones. Dr. Boston wrote that the plaintiff was a patient in her practice and was homeless. It would be beneficial for her to secure benefits as soon as possible due to her complicated medical and psychiatric history and multiple medications (Tr. 1301, 1334).
The plaintiff was seen at Baptist ER on December 15, 2015, after an assault with pain in her left eye and left elbow. On examination, she had a large bruise on her elbow and multiple abrasions. She was alert and oriented. She left without workup (Tr. 1388-89).
On December 31, 2015, the plaintiff was seen at CAMHC. She was compliant with medication, and it was partially working. She reported increased crying spells and anger outbursts. She had a hard time sitting still with increased anxiety. Latuda was increased to 120 mg as requested by the plaintiff (Tr. 1499-1502, 1539). On January 6, 2016, she stated that she had run out of Latuda. She reported some restlessness and nightmares. She denied suicidal and homicidal ideation and had no hallucinations. On psychiatric examination, she was cooperative and calm, her speech was normal, associations were intact, thought processes were circumstantial, she had a depressed and anxious mood, her affect was appropriate, and she was oriented times three. Her memory, concentration, and attention were intact. Judgment was fair and insight was poor. Fund of knowledge was average. She was diagnosed with PTSD; other specified schizophrenia spectrum and other psychiatric disorder; sedative, hypnotic, or anxiolytic use disorder, mild; opioid use disorder, mild. Goals were symptom reduction, medication adherence, and maintain therapeutic gains. It was noted that she fell three days prior and received a Dilaudid shot in her hip. She also had hit her head in the shower and took a pain pill at the ER. She stated she is trying not to abuse substances (Tr. 1503-05).
Also on January 6, 2016, psychiatrist Srinivasa Reddy, M.D., opined that the plaintiff was markedly limited in her ability to maintain attention and concentration for extended periods, in her ability to interact appropriately with the general public, and in her ability to get along with co-workers or peers without distracting them or exhibiting behavioral extremes. She had moderate difficulties in completing a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a constant pace without an unreasonable number and length of rest periods. She had moderate difficulties in her ability to accept instructions and respond appropriately to criticism from supervisors (Tr. 1487-88).
On February 2, 2016, the plaintiff was seen at CAMHC for followup. She was tearful and endorsed a depressed mood, crying spells, irritability, loss of pleasure, difficulties with concentration, and disrupted sleep. She remembered that her symptoms started three weeks ago after she ran out of Cymbalta. On psychiatric examination, her attitude was cooperative, and eye contact was normal. She was anxious and tearful, speech was normal, associations were intact, thought process was logical and goal directed, mood was depressed, and she denied suicidal and homicidal ideation and hallucinations. She had mild memory and concentration impairment. Her attention was intact, and judgment and insight were fair (Tr. 1508-09). On February 10, 2016, the plaintiff presented at CAMHC for a referral to an apartment complex. She was disheveled and had a body odor. She appeared to be in a much better mood. She reported short-term memory problems and concentration problems. She denied suicidal and homicidal ideation as well as hallucinations (Tr. 1542).
On March 1, 2016, the plaintiff was seen by Dr. Boston for a well woman examination. She stated she felt much better when she stayed "in an environment that [kept] her around positive people" and remained drug-free. When she was compliant with treatment and not abusing substances, her mental symptoms were described as "stable" (Tr. 1296-99).
On December 28, 2016, the plaintiff was seen at CAMHC by George A. Saul, LMSW. She reported that she had been without her medicine and that she needed them because she was hearing voices. Mr. Saul noted her history of treatment with CAMHC and that her case had been closed because of her failure to attend multiple appointments. She was appropriately dressed and meticulously groomed. She was alert and fully oriented. She was irritable, and her mood was low. She was preoccupied with restarting medication and defensive about having dropped out of treatment. Mr. Saul listed her diagnoses as major depressive disorder, recurrent moderate; PTSD; other specified schizophrenia spectrum; and other psychotic disorder. Mr. Saul consulted with the nurse manager, and the plaintiff was given an appointment on December 29, 2016, for diagnosis and treatment recommendations (Tr. 1547). On December 29, 2016, she was seen by Joyce L. Davis, RN, to re-establish care with CAMHC. She said she was hearing voices again and that they told her she did not have to take her medications, so she stops them, "and then I get sick." She was irritable, and her mood appeared low. She had frequent crying, social isolation, and low energy and motivation. She was hypervigilant, restless, and agitated. On examination, the plaintiff's appearance and speech were normal, she was cooperative with intense eye contact, associations were circumstantial, and she had logical and goal-directed thought process. She denied delusions, obsessions, and suicidal and homicidal ideation. She had auditory hallucinations. Her mood was euthymic, and her affect was appropriate. She was alert and oriented with intact memory and concentration. Her language was average, and she had fair judgment and insight. Fund of knowledge was above average. Ms. Davis' primary diagnosis was major depressive disorder, recurrent episode, moderate. Other diagnoses were PTSD; other specified schizophrenia spectrum and other psychotic disorder; sedative, hypnotic, or anxiolytic use disorder, mild; and opioid use disorder, mild. Ms. Davis reordered the plaintiff's medications and gave her instructions. The plaintiff understood the directions regarding her medications and was very agreeable to the plan of treatment (Tr. 1480-84).
On May 26, 2017, the plaintiff sought treatment with Deana Caldwell, MS, LPC, at Lexington County Community Mental Health Center. She stated that she needed to get back on medication. She reported hearing voices, irritability, nightmares, depressed mood, withdrawal, paranoia, and migraines. She stated her short term and immediate memory were not good. She could not work because of the results of two severe assaults. She stated that she had been dealing with these problems with medication and therapy. She was not taking any medication. On mental status examination, the plaintiff's attitude was cooperative and agitated, she was hyperactive and had normal eye contact, affect was appropriate, mood was irritable/angry, her speech was normal, thought process was circumstantial, and she denied suicidal ideation. She was confused but oriented to place and circumstance. Memory and attention were mildly impaired. Judgment was poor, and insight was limited. Diagnoses were PTSD and schizoaffective disorder, bipolar type. Ms. Caldwell noted that improvement was possible but would require a lot of repetition so the plaintiff could retain information. Ms. Caldwell wrote that the plaintiff would need individual therapy every other week (Tr. 1570-77).
On June 14, 2017, Ms. Caldwell wrote that the plaintiff had depressive symptoms of anhedonia, appetite disturbances, sleep disturbance, decreased energy, feelings of guilt or worthlessness, difficulty concentrating or thinking, hallucinations, delusions, and paranoid thinking. She also had symptoms of a manic syndrome such as hyperactivity, pressure of speech, flight of ideas, hallucinations, easily distracted, and involvement in activities that had a high probability of painful consequences which were not recognized. The plaintiff had diagnoses of schizoaffective disorder, bipolar disorder, and PTSD. Ms. Caldwell opined that the plaintiff had marked restrictions of activities of daily living; she had extreme difficulties in maintaining social functioning; extreme deficiencies of concentration, persistence, or pace resulting in a failure to complete tasks in a timely manner; she was not able to understand, remember, or carry out simple instructions; she was not able to respond appropriately on a sustained basis to supervision or to co-workers; and she was unable to respond appropriately or deal with changes in a routine work setting on a sustained basis (Tr. 1565-68).
On June 29, 2017, at the administrative hearing, the plaintiff testified that most of her past work was in customer service and in nursing homes. She was a CNA and took care of patients. She also did some telemarketing. The plaintiff was unsure how long most of her jobs lasted. She could not say for sure if her longest job lasted six months or more. The most she lifted was 50 pounds. When she performed customer service work, she mostly sat. Some employers required her to stand, but she still had to answer calls (Tr. 52-57).
The plaintiff testified that she became disabled on July 1, 2008. She had to leave her jobs because she was schizoaffective. She heard voices and saw things that made her feel scared, like she needed to get away, and it was hard to work. She also had bipolar disorder, PTSD, seizures, nerve damage, COPD, asthma, reflex sympathetic dystrophy, and degenerative disc disease. The plaintiff explained she had permanent brain damage as a result of domestic violence. She had to have total facial reconstruction because her jaw was broken in three places. She had a brain injury. Her attorney amended the onset date to February 27, 2014, the date of her jaw injury. She also suffered from migraine headaches (Tr. 57-61). The plaintiff reported she had breathing problems, which were worse outside. She needed respiratory therapy and had three rescue inhalers. She was trying to quit smoking and was down to half a pack from two packs a day. Cleaning supplies also made her breathing worse. She became short of breath if she tried to exercise or walk for any period of time. Her lower back also bothered her. The back pain radiated down her right leg to her knee. She took hot baths with Epsom salts, but they only provided minimal, short-term help (Tr. 62-64).
The plaintiff testified that she experienced side effects from her psychiatric medication. Her medication caused her to pace non-stop. Other medications were prescribed to stop the side effects, but they did not help. She still heard voices, but they were not as loud. She did not have health insurance, but Welvista helped with payment of some medications. The plaintiff said she could carry a gallon of milk from one room to the next. She did not know if she could carry a gallon of milk from the back of the grocery store to the front of the store because her brain injury made her forget where she was going. She felt horrible because she graduated with honors, but now she could not remember anything. She did not recall any specific difficulties with carrying things. If she washed the dishes, she needed to alternate sitting and standing. She estimated she could stand for an hour before she would have to sit. The plaintiff had difficulties walking because her feet caused her problems. Sitting offered some relief, but she would have to get up and move after a while because of her back. Bending over and climbing stairs were hard. Her COPD also made it hard to climb stairs (Tr. 65-69).
The plaintiff said she had permanent nerve damage in her right knee that caused reflex sympathetic dystrophy. She said she had to sit down after standing for 30 minutes or an hour. She was in a horseback riding accident that required surgery and caused the nerve damage. Sometimes her right knee went out on her. The plaintiff testified she had problems with her memory, and if someone asked her to go into the store for five things, she would not be able to remember any of the five items. Prior to her injuries, she would have remembered all five of them. She cried all the time because she felt stupid, and nothing worked like it did before. She had a hard time concentrating and focusing. She could read the same page in a book 100 times, and she would not know what it said. The plaintiff had difficulties in crowds. She spent time with her sister and fiancé and that was all. She would be uncomfortable if a stranger tried to make small talk with her about the weather while in line at the convenience store. The plaintiff lived with her fiancé. She was always with him or her sister (Tr. 69-72).
The plaintiff testified that she received food stamps. Her sister helped her with her hair, but she tried to do it by herself. She cooked sometimes, but it was not a good idea because she forgot things. Her fiancé had to remind her that she left the stove on. She could do some vacuuming, but she could not clean the house in one day. She would need to do one thing a day. She no longer had hobbies, and she did not do anything. She had some difficulties in the past with substance abuse, but she was clean now as she had not taken any drugs since 2015. She went to mental health counseling, which helped a little. She had migraines once or twice a week. Each headache lasted one day. She was extra sensitive to noise. She had not had a seizure in a while, and she was not aware of any problems related to her hepatitis C (Tr. 72-75).
The plaintiff had problems getting along with people. She felt like others were plotting against her. She tried to work at Waffle House, but she heard voices telling her to get out. She was unable to sit down and watch a movie because she could not concentrate or focus. She watched television for 20 or 30 minutes if she could pay attention. Her jaw hurt on the right side every day. She had panic attacks where she could not catch her breath, and it felt like someone was choking her. She had a panic attack once or twice a week. She had panic attacks when she had to go places like the store. She was afraid to go out alone because she was afraid of the voices and of what her past boyfriend did to her. She tried to go to bed around 9:00 or 10:00 p.m., but sometimes she stayed up all night because her mind was racing. She had nightmares or flashbacks that prevented her from sleeping. Most of the plaintiff's previous jobs involved interaction with people all day (Tr. 76-80).
The vocational expert testified that a hypothetical individual with the same age, education, and work experience as the plaintiff with the same limitations identified in the residual functional capacity ("RFC") assessment could not perform any of the plaintiff's past work. However, the individual could perform work as a laundry folder, Dictionary of Occupational Titles ("DOT") No. 302.685-010, with 95,300 to 95,400 jobs nationally; housekeeping cleaner, DOT No. 323.687-014, with 115,200 to 115,300 jobs nationally; and cleaner/polisher, DOT No. 709.687-010, with 23,900 to 24,000 jobs nationally (Tr. 83-85). The ALJ proposed a second hypothetical individual with a limitation to lifting, carrying, pushing, and pulling up to ten pounds occasionally and ten pounds or less frequently and standing and/or walking two hours in an eight-hour workday (Tr. 85). The vocational expert testified the individual could not perform the plaintiff's past relevant work but could perform other sedentary work (Tr. 85-86). The ALJ asked about an individual who had the limitations described above in either of the first two hypotheticals with further restrictions in the ability to concentrate, attend, and persist such that every 30 to 60 minutes, the individual would need redirection to get back on task, and the individual would have two to four absences per month. The vocational expert stated there would be no work for such an individual (Tr. 86).
ANALYSIS
The plaintiff argues that the ALJ erred by (1) failing to properly account for her moderate limitations in concentration, persistence, or pace in the RFC assessment; (2) failing to explain in the RFC assessment how the determination was made that she had only moderate difficulties in social functioning; (3) failing to explain in the RFC assessment how the determination was made that she had only moderate difficulties in adapting or managing oneself; (4) failing to properly assess the medical opinion evidence from Dr. Boston, Dr. Reddy, and Ms. Caldwell; and (5) failing to adequately evaluate whether she met Listing 12.04 (doc. 18 at 18-34).
Residual Functional Capacity
The plaintiff first argues that the ALJ failed to properly account for her moderate limitations in concentration, persistence, or pace in the RFC assessment. The regulations provide that a claimant's RFC is the most that she can still do despite her limitations. 20 C.F.R. §§ 404.1545(a), 416.945(a). It is the ALJ's responsibility to make the RFC assessment, id. §§ 404.1546(c), 416.946(c), and the ALJ does so by considering all of the relevant medical and other evidence in the record, id. §§ 404.1545(a)(3), 416.945(a)(3).
Social Security Ruling ("SSR") 96-8p provides in pertinent part:
The RFC assessment must first identify the individual's functional limitations or restrictions and assess his or her work-related abilities on a function-by-function basis, including the functions in paragraph (b), (c), and (d) of 20 C.F.R. §§ 404.1545 and 416.945. Only after that may RFC be expressed in terms of the exertional level of work, sedentary, light, medium, heavy and very heavy.SSR 96-8p, 1996 WL 374184, at *1. The ruling further provides:
The RFC assessment must include a narrative discussion describing how the evidence supports each conclusion, citing specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities, observations). In assessing RFC, the adjudicator must discuss the individual's ability to perform sustained work activities in an ordinary work setting on a regular and continuing basis (i.e., 8 hours a day, for 5 days a week, or an equivalent work schedule), and describe the maximum amount of each work-related activity the individual can perform based on the evidence available in the case record. The adjudicator must also explain how any material inconsistencies or ambiguities in the evidence in the case record were considered and resolved.Id. at *7 (footnote omitted). Further, "[t]he RFC assessment must include a discussion of why reported symptom-related functional limitations and restrictions can or cannot reasonably be accepted as consistent with the medical and other evidence." Id. Moreover, "[t]he RFC assessment must always consider and address medical source opinions. If the RFC assessment conflicts with an opinion from a medical source, the adjudicator must explain why the opinion was not adopted." Id.
The plaintiff argues (doc. 18 at 19-22) that the decision of the United States Court of Appeals for the Fourth Circuit in Mascio v. Colvin requires remand of this case. 780 F.3d 632 (4th Cir. 2015). The undersigned agrees. In Mascio, the plaintiff argued that the ALJ failed to properly account for her mental limitations in the RFC assessment. Id. at 637-38. Specifically, the ALJ found at step three that, as a side effect of her pain medication, the plaintiff had moderate difficulties in maintaining concentration, persistence, or pace, but in the RFC assessment, the ALJ provided no mental limitations other than limiting the plaintiff to unskilled work. Id. at 638. The court held, "[W]e agree with other circuits that an ALJ does not account 'for a claimant's limitations in concentration, persistence, and pace by restricting the hypothetical question to simple, routine tasks or unskilled work.'" Id. (quoting Winschel v. Comm'r of Soc. Sec., 631 F.3d 1176, 1180 (11th Cir. 2011) (joining the Third, Seventh, and Eighth Circuits)). The court noted that "the ability to perform simple tasks differs from the ability to stay on task" and that "only the latter limitation would account for a claimant's limitation in concentration, persistence, or pace." Id. The court found it reversible error that the ALJ did not explain his consideration of the plaintiff's moderate limitation in concentration, persistence, or pace in the RFC, stating as follows:
Perhaps the ALJ can explain why Mascio's moderate limitation in concentration, persistence, or pace at step three does not translate into a limitation in Mascio's residual functional capacity. For example, the ALJ may find that the concentration, persistence, or pace limitation does not affect Mascio's ability to work, in which case it would have been appropriate to exclude it from the hypothetical tendered to the vocational expert. But because the ALJ here gave no explanation, a remand is in order.Id. (internal citation omitted).
At step three of the sequential evaluation process, the ALJ in this case found that "with regard to concentrating, persisting, or maintaining pace, the [plaintiff] has moderate limitations." The ALJ also found the plaintiff had moderate limitations in understanding, remembering, or applying information; in interacting with others; and in adapting or managing oneself. The ALJ stated that "[t]he evidence regarding these limitations is discussed below" (Tr. 28).
In the RFC assessment, the ALJ found as follows with regard to the plaintiff's mental limitations:
[T]he [plaintiff] retains the mental residual functional capacity to understand, remember, and carry out simple tasks and instructions; she can concentrate, attend, and persist on simple tasks; she can interact adequately with supervisors and co-workers, but never the general public; and she can respond appropriately to simple, routine, workplace changes. Finally, the [plaintiff] will miss an occasional day of work because of mental health issues, with occasional defined as once every one to two months. The [plaintiff's] . . . mental limitations are based on the State agency assessments at B3A, B4A, B9A, and B10A.(Tr. 28). At the administrative hearing, the ALJ posed a hypothetical to the vocational expert that included the same limitations as those provided in the RFC assessment (Tr. 83-85). The vocational expert identified other work in the national economy that such an individual could perform (Tr. 86), and the ALJ relied on that testimony at step five in finding that the plaintiff was not disabled (Tr. 35-36).
The Commissioner argues that this case is factually distinct from Mascio because the ALJ did not merely limit the plaintiff to unskilled work, as the ALJ did in Mascio (doc. 20 at 8-9). Rather, as set forth above, the ALJ included in the RFC assessment the following mental limitations: "understand, remember, and carry out simple tasks and instructions; . . . concentrate, attend, and persist on simple tasks; . . . interact adequately with supervisors and co-workers, but never the general public; and . . . respond appropriately to simple, routine, workplace changes" (Tr. 28). The Commissioner further argues that, unlike in Mascio, the ALJ here "carefully evaluated all of the evidence and discussed why, based on the overall record, Plaintiff's RFC did not warrant further mental limitations" (doc. 20 at 9) (citing Tr. 28-34).
In the RFC assessment, the ALJ noted the plaintiff's complaints of side effects from medications and significant difficulty with memory, completing tasks, concentration, understanding, and following instructions (Tr. 29). The ALJ then summarized the plaintiff's treatment history and noted evidence that the plaintiff's mental health symptoms improved when she was compliant with treatment, and her symptoms increased when she was not on medication; that "although she complained of memory issues, she was able to give dates of her problems very well and minimized her drug issues"; that she demonstrated evidence of drug-seeking behavior, malingering, manipulation, shelter-seeking, and medication non-compliance; that she had been hospitalized for episodes of significant mental health difficulties, and that she demonstrated verbal aggression and threatening behavior toward her providers and others (Tr. 28-34). The ALJ also considered the medical opinions and gave great weight to the opinions of the state agency psychological consultants who concluded that the plaintiff could perform simple, unskilled work; would occasionally miss a day due to mental illness, and might not be suited for work with the general public (Tr. 32) (citing Tr. 120-52, 157-94). The ALJ gave little weight to the opinions of psychiatrist Dr. Reddy, who found the plaintiff had several moderate to marked mental health limitations, and mental health counselor Ms. Caldwell, who found the plaintiff had extreme and marked mental health limitations, stating that the opinions were not supported by the objective medical evidence that showed the plaintiff "frequently demonstrated behaviors that suggested her limitations were not as severe as she alleged and that conservative treatment was generally effective when she was compliant with medications" (Tr. 32-33). However, nowhere in the RFC's narrative discussion did the ALJ explain his rationale for why the restrictions in the RFC accounted for the plaintiff's ability to stay on task for a full eight-hour workday in light of her moderate limitations in concentration, persistence, or pace. Thus, the ALJ failed to "'build an accurate and logical bridge from the evidence to his conclusion.'" Monroe v. Colvin, 826 F.3d 176, 189 (4th Cir. 2016) (quoting Clifford v. Apfel, 227 F.3d 863, 872 (7th Cir. 2000)).
Among other limitations, Dr. Reddy opined that the plaintiff was markedly limited in her ability to maintain attention and concentration for extended periods and had moderate difficulties in completing a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a constant pace without an unreasonable number and length of rest periods (Tr. 1487-88).
Among other limitations, Ms. Caldwell opined that the plaintiff had extreme deficiencies of concentration, persistence, or pace resulting in a failure to complete tasks in a timely manner; she was not able to understand, remember, or carry out simple instructions; and she was unable to respond appropriately or deal with changes in a routine work setting on a sustained basis (Tr. 1565-68).
In a similar case, Rushton v. Berryhill, the ALJ in the underlying decision found at step three that the plaintiff had "moderate difficulties" with "regard to concentration, persistence or pace" and later in the decision found that the plaintiff had the RFC to perform "simple, routine tasks for two hour blocks of time with normal rest breaks during an eight hour day; and occasional interaction with the public." C.A. No. 8:17-cv-840-AMQ-JDA, 2018 WL 4103336, at *3 (D.S.C. Aug. 29, 2018). The ALJ indicated that the RFC accounted for the plaintiff's mental impairments by restricting the pace and skill of her work, as well as her interactions with the public. Id. The district court remanded the case because the ALJ failed to explain how a limitation to simple, routine, tasks for two-hour blocks of time with normal rest breaks addressed the plaintiff's moderate difficulties in concentration, persistence, or pace, and included no discussion regarding the ALJ's consideration of the plaintiff's ability to stay on task. Id. at *2-4.
Based upon the foregoing, the decision should be reversed and remanded for further consideration of the plaintiff's RFC in compliance with Mascio.
Remaining Allegations of Error
In light of the court's recommendation that this matter be remanded for further consideration as set forth above, the court need not address the plaintiff's remaining issues as they may be rendered moot on remand. See Boone v. Barnhart, 353 F.3d 203, 211 n.19 (3d Cir.2003) (remanding on other grounds and declining to address claimant's additional arguments). On remand, the ALJ will be able to reconsider and re-evaluate the evidence as part of the reconsideration. Hancock v. Barnhart, 206 F. Supp.2d 757, 763-64 n.3 (W.D. Va. 2002) (on remand, the ALJ's prior decision has no preclusive effect as it is vacated and the new hearing is conducted de novo). Accordingly, as part of the overall reconsideration of this claim upon remand, the ALJ should also consider and address the additional allegations of error raised by the plaintiff.
CONCLUSION AND RECOMMENDATION
Based upon the foregoing, this court recommends that the Commissioner's decision be reversed under sentence four of 42 U.S.C. § 405(g), with a remand of the cause to the Commissioner for further proceedings as discussed above.
IT IS SO RECOMMENDED.
s/Kevin F. McDonald
United States Magistrate Judge September 12, 2019
Greenville, South Carolina
Notice of Right to File Objections to Report and Recommendation
The parties are advised that they may file specific written objections to this Report and Recommendation with the District Judge. Objections must specifically identify the portions of the Report and Recommendation to which objections are made and the basis for such objections. "[I]n the absence of a timely filed objection, a district court need not conduct a de novo review, but instead must 'only satisfy itself that there is no clear error on the face of the record in order to accept the recommendation.'" Diamond v. Colonial Life & Acc. Ins. Co., 416 F.3d 310 (4th Cir. 2005) (quoting Fed. R. Civ. P. 72 advisory committee's note).
Specific written objections must be filed within fourteen (14) days of the date of service of this Report and Recommendation. 28 U.S.C. § 636(b)(1); Fed. R. Civ. P. 72(b); see Fed. R. Civ. P. 6(a), (d). Filing by mail pursuant to Federal Rule of Civil Procedure 5 may be accomplished by mailing objections to:
Robin L. Blume, Clerk
United States District Court
300 East Washington Street
Greenville, South Carolina 29601
Failure to timely file specific written objections to this Report and Recommendation will result in waiver of the right to appeal from a judgment of the District Court based upon such Recommendation. 28 U.S.C. § 636(b)(1); Thomas v. Arn, 474 U.S. 140 (1985); Wright v. Collins, 766 F.2d 841 (4th Cir. 1985); United States v. Schronce, 727 F.2d 91 (4th Cir. 1984).