Opinion
Civil Action No. 6:18-983-MGL-KFM
03-13-2019
Vernon Ward, Plaintiff, v. Nancy A. Berryhill, Acting 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 Section 1631(c)(3) of the Social Security Act, as amended (42 U.S.C. 1383(c)(3)), to obtain judicial review of a final decision of the Commissioner of Social Security denying his claim for supplemental security income benefits under Title XVI of the Social Security Act.
ADMINISTRATIVE PROCEEDINGS
The plaintiff filed an application for supplemental security income ("SSI") benefits on April 15, 2014, alleging disability commencing August 24, 2007. The application was denied initially and on reconsideration by the Social Security Administration. On June 23, 2015, the plaintiff requested a hearing. The administrative law judge ("ALJ"), before whom the plaintiff and J. Adger Brown, Jr., an impartial vocational expert, appeared during a hearing on February 16, 2017, considered the case de novo, and on June 13, 2017, found that the plaintiff was not under a disability as defined in the Social Security Act, as amended (Tr. 7-26). 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 March 20, 2018 (Tr. 1-5). The plaintiff then filed this action for judicial review.
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 has not engaged in substantial gainful activity since April 15, 2014, the application date (20 C.F.R. § 416.971 et. seq.)
(2) The claimant has the following severe impairments: schizophrenia, paranoid type; depressive disorder NOS; and history of substance abuse (20 C.F.R. § 416.920(c)).
(3) The claimant does not have an impairment or combination of impairments that meets or medically equals the the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. §§ 416.920(d), 416.925 and 416.926).
(4) After careful consideration of the entire record, I find that the claimant has the residual functional capacity to perform a full range of work at all exertional levels but with the following nonexertional limitations: He is limited to unskilled work defined as performing simple, routine and/or repetitive tasks in 2-hour increments with customary breaks to complete an 8-hour workday. He is further limited to no work activity interaction with the public and no team-type interaction with coworkers; non-work activity incidental contact is allowed.
(5) The claimant has no past relevant work (20 C.F.R. § 416.965).
(6) The claimant was born on July 5, 1971, and was 42 years old, which is defined as a younger individual age 18-49, on the date the application was filed (20 C.F.R. § 416.963).
(7) The claimant has a limited education and is able to communicate in English (20 C.F.R. § 416.964).
(8) 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).
(9) Considering the claimant's age, education, work experience, and residual functional capacity, there are jobs in the national economy that the claimant can perform (20 C.F.R. § 416.969, 416.969(a)).
(10) The claimant has not been under a disability, as defined in the Social Security Act, since April 15, 2014, the date the application was filed (20 C.F.R. § 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. § 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. § 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. § 416.920. If an individual is found not disabled at any step, further inquiry is unnecessary. Id. § 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 born on July 5, 1971, and was 42 years old on the date the application was filed (April 15, 2014) and 45 years old on the date of the ALJ's decision (June 13, 2017). The plaintiff has a tenth grade education (Tr. 50). He is single and has 11 children (Tr. 51). He was incarcerated between 2009 and 2014 for grand larceny and cocaine distribution (Tr. 17, 55, 308). Prior to his incarceration, the plaintiff worked for two years as a car wash detailer (Tr. 235).
Evidence from South Carolina Department of Corrections from 2009 through 2010 revealed that the plaintiff had a history of treatment for hallucinations and post-traumatic stress disorder ("PTSD") symptoms. He frequently complained of hallucinations. Prior to his release, he stated he was "feeling alright," but endorsed hallucinations of "green eyes," which came to his cell and spoke to him. He appeared worried, down, and irritable. He was noted to make intermittent eye contact and rub his head a lot. He was rated as having a Global Assessment of Functioning ("GAF") score of 60. Medications included Celexa and Vistaril (Tr. 308-14). The plaintiff received medication treatment for schizophrenia in the Maryland Department of Corrections from 2013 to 2014 (Tr. 388-431).
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 51 and 60 indicates moderate symptoms or moderate difficulty 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 April 24, 2014, the plaintiff had an initial clinic assessment at Charleston Mental Health for history of schizophrenia and depression. He had been treated with Thorazine and Doxapin, which he had run out of two days prior. He reported auditory hallucinations, sometimes command in nature, since he was a child. The voices were quieter when he was on medication and did not bother him as much. He was well groomed, cooperative, organized with a full range affect, and fully oriented. His mood was euthymic, and his speech was of normal rate and tone as well as relevant and coherent. His thought process was normal, with some paranoia at times, but there was no evidence of delusions or hallucinations. His memory was intact, he was able to concentrate, and his fund of knowledge was average. His GAF score was 65. He reported he was paranoid most of the time, worried people were out to get him and hyper vigilant around others. When he left home, he would go with his father. He had PTSD symptoms associated with a fatal motor vehicle accident he witnessed when he was 17. He was diagnosed with schizophrenia, undifferentiated type by history, cannabis abuse by history, rule out schizoaffective disorder and rule out PTSD (Tr. 325-29).
A GAF score between 61 and 70 indicates some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well. DSM-IV, 32-34.
On May 25, 2014, the plaintiff visited at Charleston Mental Health and reported poor appetite and difficulty enjoying activities since his release from prison. He tried to avoid cars due to PTSD symptoms and did not want to be around people. On examination, his mood was "alright" with constricted affect, auditory hallucinations, and paranoia. He had a GAF of 35. He was prescribed Latuda for schizophrenia, paranoid type, depressive disorder NOS, and cocaine abuse (Tr. 334-36).
A GAF score between 31 and 40 indicates some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. Id.
On July 9, 2014, during a followup mental status examination, the plaintiff was cooperative, and his affect was appropriate. His mood was euthymic, and his speech was normal rate and tone as well as relevant and coherent. His thought process was normal, with some paranoia at times, but there was no evidence of delusions or hallucinations. His memory was intact, he was able to concentrate, and his fund of knowledge was average. He had a GAF score of 65 (Tr. 338)
A progress summary from July 23, 2014, indicated that the plaintiff was progressing and adjusting to society. His GAF was 45 (Tr 332).
A GAF score between 41 and 50 indicates serious symptoms or any serious impairment in social, occupational, or school functioning. Id.
On November 5, 2014, the plaintiff reported hearing voices that sometimes told him to hurt people or stab himself. He endorsed being aggressive due to paranoia, isolating, and being very impulsive. He had increased stressors at home due to his mother's illness. Mental status examination findings were otherwise normal, including intact recent and remote memory, euthymic mood, and good insight and judgment. Abilify was added to Latuda and Doxepin (Tr. 339-40).
On November 26, 2014, Madhri Sisodia, M.D., evaluated the plaintiff in a consultative examination. The plaintiff reported mental health issues since he was 15 and low back pain for 15 to 20 years. His pain was aggravated by bending or standing for over 45 minutes, sitting for over 30 minutes, walking over three blocks, lifting heavy objects, and climbing over six to seven steps. He also reported auditory and visual hallucinations and poor sleep. He had problems with "impulsivity" without medications. Except for some limitation of range of motion of the spine because of discomfort, his examination was unremarkable. Assessment included schizoaffective schizophrenia, history of depression, and lumbago. A consultative lumbar x-ray revealed slight lumbar levoscoliosis. There were probable central disc protrusions into the superior end plates of T12, L1, and L2. Straightening of the usual lumbar lordosis was suggestive of muscle spasm (Tr. 316-21).
On January 19, 2015, a progress summary at Charleston Mental Health revealed that the plaintiff experienced significant cognitive impairments due to mental illness and would decompensate without continued treatment (Tr. 333).
On January 28, 2015, the plaintiff's treatment notes indicated that he attended counseling once per month and was making progress in the management of his mood and emotions. He reported that medication worked and reduced his auditory and visual hallucination symptoms (Tr. 333).
On February 9, 2015, the plaintiff reported at Charleston Mental Health he was not sleeping and was stressed about his mother. His girlfriend reported he had mood lability and paranoia. He denied suicidal ideation but had thoughts of hurting his brother, who was getting on his nerves. He continued to experience command hallucinations. He was prescribed Depakote ER and discontinued Doxepin (Tr. 343-344). On followup on February 25, 2015, he was stable and reported continued command hallucinations, but with his medication changes, he was able to ignore them (Tr. 345-46).
On April 21, 2015, state agency medical consultant, Cal VanderPlate, Ph.D., reviewed the evidence and determined that the plaintiff was capable of understanding, remembering, and carrying out uncomplicated three-step commands and simple tasks. Dr. VanderPlate reviewed the evidence under the criteria of Listings 12.04 and 12.09 and found that the severity requirements of the listings were not met or equaled (Tr. 87-91).
On June 3, 2015, the plaintiff reported grief about his mother's death in March. He experienced auditory and visual hallucinations that included hearing his mom and command voices telling him to run in the streets. His appetite varied depending on his mood. Latuda was increased, and he was continued with Abilify and Depakote (Tr. 373-74).
A progress summary dated July 23, 2015, showed the plaintiff struggled with paranoid thoughts and depression. He experienced hallucinations that affected his ability to focus on tasks and ability to distinguish internal stimuli versus reality. It was reported he would decompensate without continued treatment, and he had a history of violence (Tr. 365).
On July 30, 2015, the plaintiff reported at Charleston Mental Health that he had continued hallucinations and suicidal ideation without a plan. He had a variable appetite, loss of interest, and anhedonia. His mood was depressed. Prozac was prescribed (Tr. 375-76).
On October 1, 2015, at a followup with at Charleston Mental Health, the plaintiff reported daily hallucinations, poor appetite, and difficulty getting to sleep. He related that he was doing okay and that he lived with his father. The mental status examination showed that he was alert, oriented with cooperative attitude, calm behavior, and normal eye contact and speech. He reported that Prozac and Latuda were effective. Medications were adjusted including an increase in Prozac and Abilify. Benadryl was recommended for sleep since he could not afford trazodone (Tr. 377-78).
On December 23, 2015, at a followup with Charleston Mental Health, the plaintiff reported insomnia, poor appetite, and voices "chattering all the time." Trazodone was added for sleep. On March 30, 2016, at a followup, he had continued non-command auditory hallucinations. He saw shadowy people most days and had minimal paranoia. He also had a poor appetite and difficulty falling asleep. Trazodone was increased (Tr. 379-82).
On August 30, 2016, the plaintiff reported feeling stressed and anxious because he had failed his urine drug screen and had to go to court. Except for depressed mood, the plaintiff's mental status examination was essentially within normal limits (Tr. 383-84).
On September 29, 2016, the plaintiff returned to Charleston Mental Health and was assessed by Gloria K. Wilson-Dignam, APRN. He was upset that "bad things are happening and I am not doing good, you know man." He had witnessed a motor vehicle accident in August where the driver was ejected and suffered severe head trauma, and his girlfriend had been cheating on him. He endorsed depression, low energy, anhedonia, not sleeping well, and poor appetite. He had occasional suicidal and homicidal ideation and some auditory hallucinations, which were not threatening (Tr. 385-86).
In October 2016, the plaintiff had missed his counseling appointments for the calendar quarter because he been incarcerated for failure to pay child support (Tr. 372).
The plaintiff appeared with his attorney at the hearing held before the ALJ on February 16, 2017. He testified that he lived with his father and sister in a mobile home, and he had cared for his mother until her recent death. He testified that he helped her wash and took her outside. He testified that her death was "a lot on me" and that he had lost a significant amount of weight after her death. He confirmed that he had been incarcerated several times (Tr. 50-58). The plaintiff testified that he spent his day in his room. He did yard work for his 70-year-old father. He testified that he heard voices, and the voices directed him to hurt people. His counselors were aware of his symptoms and were trying to adjust his medications to better control them. He had difficulty watching television and falling asleep (Tr. 60-63).
The vocational expert identified the occupations of assembler and quality control examiner as representative light, unskilled jobs that a hypothetical worker of the plaintiff's age, education, work experience, and RFC could perform. The vocational expert further testified that, if the worker could not maintain concentration, persistence, and pace for two-hour increments, he would not be capable of any work in the national economy. Further, it the worker had marked restrictions in carrying out simple instructions, making simple decisions, or responding appropriately to work-related situations, he would not be capable of any work (Tr. 67-69).
ANALYSIS
The plaintiff argues that the ALJ erred in failing to properly weigh the opinions of his mental health therapists (doc. 15 at 9-12). "Medical opinions are statements from acceptable medical sources that reflect judgments about the nature and severity of your impairment(s), including your symptoms, diagnosis and prognosis, what you can still do despite impairment(s), and your physical or mental restrictions." 20 C.F.R. § 416.927(a)(1). For applications like the plaintiff's that were filed before March 27, 2017, the regulations define "acceptable medical sources" as licensed physicians, psychologists, optometrists, podiatrists, and qualified speech-language pathologists. Id. § 416.902(a)(1)-(5). The regulations state that opinions from medical sources who are not acceptable medical sources and from nonmedical sources should be considered using the same factors as those considered in weighing medical opinions and that the adjudicator "generally should explain the weight given to opinions from these sources or otherwise ensure that the discussion of the evidence in the . . . decision allows a claimant or subsequent review to follow the adjudicator's reasoning . . . . Id. § 416.927(f). The factors for consideration include: (1) the examining relationship; (2) the length of the treatment relationship and the frequency of the examinations; (3) the nature and extent of the treatment relationship; (4) supportability; (5) the consistency of the opinion; and (6) specialization. Id. § 416.927(c)(1)-(5).
For applications filed on or after March 27, 2017, a new regulatory framework for considering and articulating the value of medical opinions has been established. See 20 C.F.R. § 416.920c. See also 82 Fed. Reg. 5844-01, 2017 WL 168819 (revisions to medical evidence rules dated Jan. 18, 2017, and effective Mar. 27, 2017).
The plaintiff contends that the ALJ erred in weighing the opinions provided by Charles B. Greene, M.A., M.H.P., a mental health therapist, and Ms. Wilson-Dignam, a licensed advanced practice registered nurse. On December 29, 2016, Mr. Greene reported that the plaintiff had been treated for schizophrenia since April 2014 at Charleston Mental Health. He indicated that the plaintiff suffered from depressive syndrome characterized by anhedonia, appetite disturbance with change in weight, sleep disturbance, decreased energy, feelings of guilt, difficulty concentrating or thinking, and thoughts of suicide and hallucinations, delusions, or paranoid thinking. His symptoms resulted in marked difficulties in maintaining social functioning and deficiencies of concentration, persistence, or pace (Tr. 356-57). Mr. Greene and Ms. Wilson-Dignam also completed a form stating the plaintiff suffered from psychotic features with deterioration from a previous level of functioning, with persistent delusions or hallucinations. This resulted in marked restriction of activities of daily living, marked difficulties in maintaining social functioning, and deficiencies of concentration, persistence, or pace (Tr. 358-59).
Also on December 29, 2016, Mr. Greene completed a medical source statement regarding the plaintiff's ability to perform mental work-related activities. Mr. Greene indicated the plaintiff had marked limitations in carrying out simple instructions, making judgments on simple work related decisions, understanding and remembering complex instructions, carrying out complex instructions, and making judgments on complex work-related decisions. He had marked inability to interact appropriately with the public, supervisors, and co-workers; respond appropriately to usual work situations; and respond appropriately to changes in a routine work setting. Mr. Greene stated that auditory hallucinations and paranoia would impact the plaintiff's ability to interact with the public in a competitive work environment. The plaintiff was isolated in his home, and his family relationships were strained due to symptoms (Tr. 354-55, 360).
The ALJ summarized each of the opinions in the RFC assessment (Tr. 22-23). The ALJ first noted that "none of the medical source statements are 'acceptable medical sources' as defined by Social Security regulations; however, they are 'other sources' whose evidence may be used, and I have considered these opinions within that context and find that the limitations are not supported by the overall record" (Tr. 23). As set out above, for applications like the plaintiff's that were filed before March 27, 2017, the regulations do not include therapists and licensed advanced practice registered nurses as "acceptable medical sources." 20 C.F.R. § 416.902(a)(1)-(5).
For claims filed on or after March 27, 2017, the definition of "acceptable medical source" has been somewhat expanded. See 20 C.F.R. § 416.902(a)(6)-(8). The new regulations also do not include therapists and counselors, such as Mr. Greene, as acceptable medical sources. See id. However, licensed advanced practice registered nurses, such as Ms. Wilson-Dignam, are included as acceptable medical sources for impairments within his or her licensed scope of practice. Id. § 416.902(7).
The ALJ further noted that while the plaintiff had several mental impairments, the record indicated that he was stable when being compliant with his medications (Tr. 23). The ALJ also noted that, despite the plaintiff's allegations, he was able to care for his aged mother and drive an automobile (Tr. 23). The ALJ also stated that the marked limitations indicated on the assessments appeared to be based on the plaintiff's own self-reports and were inconsistent with the mental health treatment records (Tr. 23).
At step three of the sequential evaluation process, the ALJ reviewed the evidence and found that the "paragraph B and C" criteria of Listings 12.03 (Schizophrenia spectrum and other psychotic disorders) and 12.04 (Depressive, bipolar and related disorders) were not satisfied (Tr. 13). In the opinions set out above, Mr. Greene and Ms. Wilson-Dignam opined that the plaintiff met the requirements of prior versions of these listings (see Tr. 356-57 (Listing 12.04); Tr. 358-59 (Listing 12.03)).
In finding that the plaintiff's impairments did not meet or medically equal these listings, the ALJ discussed the evidence of record (Tr. 13-16). In the area of understanding, remembering, or applying information, the ALJ found that the plaintiff had mild limitation (Tr. 13). The ALJ noted that on June 5, 2014, Isis Frazier, a family friend, reported that the plaintiff completed household activities and yard work when he was encouraged and praised (Tr. 13; see Tr. 216). The ALJ also noted that the plaintiff admitted that he was able to take care of his personal needs with reminders and that he was able to walk and go out alone (Tr. 13; see Tr. 225-27).
In the area of interacting with others, the ALJ found that the plaintiff had moderate limitation, given his report that he did not like to be around others and did not socialize (Tr. 13). The ALJ noted that the treatment evidence indicated that the plaintiff had a good relationship with his father, mother, six sisters, and two brothers and that the plaintiff had a girlfriend since 2007 (Tr. 14; see Tr. 327). The ALJ also explained that the plaintiff admitted that he helped his father around the house, talked to his children on the phone daily, attended church on Sundays, and was his mother's caregiver (Tr. 13; see Tr. 226, 228).
In the area of concentrating, persisting, or maintaining pace, the ALJ found that the plaintiff had moderate limitation given his reports of problems with memory, completing tasks, and concentrating (Tr. 14). The ALJ explained that Ms. Frazier and the plaintiff himself had reported that he was able to pay bills, count change, and handle a savings account (Tr. 14; see Tr. 217, 227). The ALJ also explained that the plaintiff was able to recall and give his health history to Dr. Madhri and that the plaintiff reported that he was able to handle his finances and watched television and listened to music (Tr. 14; see Tr. 86, 318).
In the area of adapting or managing self, the ALJ found that the plaintiff had moderate limitation (Tr. 14). The ALJ noted that the plaintiff had indicated that he could follow written instructions if verbalized and depending on his mood, and he could follow spoken instructions as long as he was not disrespected (Tr. 14; see Tr. 229).
With regard to the "paragraph C" criteria of Listings 12.03 and 12.04, the ALJ found that the record did not establish that the plaintiff had only marginal adjustment, that is, a minimal capacity to adapt to changes in his environment or to demands that are not already part of his daily life (Tr. 15).
In the step three analysis, the ALJ noted that no state agency psychological consultant concluded that a mental listing was met or medically equaled (Tr. 15). Specifically, Dr. VanderPlate reviewed the evidence and found that the severity requirements of the listings were not met or equaled (Tr. 87-88).
In giving the opinions little weight, the ALJ noted that the extreme limitations opined by Mr. Greene and Ms. Wilson-Dignam were inconsistent with the plaintiff's mental health treatment notes (Tr. 23), and, in the RFC assessment, the ALJ discussed those treatment notes (Tr. 18-24). The ALJ recognized that records from the Maryland prison system showed that the plaintiff was treated for schizophrenia and depression; he reported doing fine on his medications; and examinations consistently revealed that he was stable (Tr. 18; see Tr. 389-430). The ALJ also noted that, on April 24, 2014, the plaintiff reported that since being on medication, the voices that he heard had quieted down a great deal and that he had minimal concerns about them (Tr. 19; see Tr. 325). During the mental status examination, the plaintiff was cooperative; his affect was appropriate; his mood was euthymic; speech was of normal rate and tone as well as relevant and coherent; his thought process was normal, with some paranoia at times, but there was no evidence of delusions or hallucinations; his memory was intact; he was able to concentrate; his fund of knowledge was average; and his GAF was rated at 65, indicating mild symptoms (Tr. 19; see Tr. 325-29). Similar mental status findings were observed during a follow-up examination in July 2014, and his GAF score was again assessed at 65 (Tr. 23; see Tr. 337-38). In November 2014, the plaintiff reported continuing to hear voices, sometimes command in nature, and he reported being aggressive due to paranoia (Tr. 20; see Tr. 339). As the ALJ noted, the plaintiff's increased symptoms were attributed to his mother's serious illness, and the mental status examination findings were otherwise normal, including intact recent and remote memory, euthymic mood, and good insight and judgment (Tr. 20; see Tr. 339). In January 2015, the plaintiff's treatment notes indicated that he was attending counseling once per month and was making progress in the management of his mood and emotions (Tr. 20; see Tr. 332-33). The plaintiff reported that his medication worked and reduced his auditory and visual hallucination symptoms (Tr. 20; see Tr. 333). In October 2015, the plaintiff related that he was doing okay and that he was living with his father; he was taking Prozac and Latuda and reported that both were effective; and the mental status examination showed that he was alert, oriented with the cooperative attitude and behavior, and had normal eye contact and normal speech (Tr. 21; see Tr. 377). In August 2016, the plaintiff reported feeling stressed and anxious because he had failed his urine drug screen and had to go to court (Tr. 21; see Tr. 383). Except for depressed mood, the plaintiff's mental status examination was essentially within normal limits (Tr. 21; see Tr. 383-84). In October 2016, the plaintiff had missed his counseling appointments for the calendar quarter because he been incarcerated due to failure to pay child support (Tr. 22; see Tr. 373).
In assessing the plaintiff's RFC, the ALJ also gave great weight to the opinion of state agency psychological consultant Dr. VanderPlate, who reviewed the evidence in April 2015 and determined that the plaintiff was capable of understanding, remembering, and carrying out uncomplicated three-step commands and simple tasks; could maintain attention and concentration for at least two-hour periods during an eight-hour workday; and could manage stress, adust to a task setting, and deal with normal changes (Tr. 24; see Tr. 90-91). The ALJ was required to consider the state agency medical and psychological consultants' assessments as opinion evidence as they "are highly qualified and experts in Social Security disability evaluation." See 20 C.F.R. § 416.913a(b).
The ALJ also gave partial weight to the GAF scores assessed by the plaintiff's mental health providers (Tr. 24). As the ALJ noted, the plaintiff's lowest GAF score of 35 in May 2014 was primarily based on his subjective complaints as his exam was essentially benign, and his GAF score of 50 in November 2014 was given when the plaintiff was reportedly drinking daily (Tr. 23; see Tr. 334-36, 339-40). The ALJ observed that the remainder of the plaintiff's GAF scores ranged from 53, indicating moderate symptoms, to 65, indicating mild symptoms (Tr. 23).
As argued by the Commissioner, the ALJ's decision, read as a whole, allows for meaningful judicial review of the step three finding and RFC assessment and the reasons for affording little weight to the opinions of Mr. Greene and Ms. Wilson-Dignam. As the ALJ stated, the opinions were inconsistent with the plaintiff's admitted improvement on medication and his mental health treatment notes (Tr. 18-24).
The plaintiff also complains that the ALJ did not apply the regulatory criteria to the opinions and relied only on her own speculation (doc. 15 at 12). However, the ALJ applied the supportability and consistency factors for weighing opinion evidence, as discussed above. See 20 C.F.R. § 416.927(d). Further, "ALJs are not required to expressly discuss each factor set forth in [the regulations], but their decisions should demonstrate they considered and applied all the factors and accorded each opinion appropriate weight in light of the evidence of record." Jones v. Berryhill, C.A. No. 1:17-3155-DCC-SVH, 2019 WL 267536, at *22 (D.S.C. Jan. 3, 2019), R&R adopted by 2019 WL 266800 (D.S.C. Jan. 18, 2019) (citations omitted). Here, the undersigned finds that the ALJ appropriately considered and accorded appropriate weight to the opinions provided by Mr. Greene and Ms. Wilson-Dignam in light of the evidence of record.
CONCLUSION AND RECOMMENDATION
The Commissioner's decision is based upon substantial evidence and is free of legal error. Now, therefore, based upon the foregoing,
IT IS RECOMMENDED that the Commissioner's decision be affirmed.
IT IS SO RECOMMENDED.
s/Kevin F. McDonald
United States Magistrate Judge March 13, 2019
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). Greenville, South Carolina