Opinion
No. 4:18-CV-163-D
08-29-2019
KATRINA DEVONE NELSON, Plaintiff/Claimant, v. ANDREW SAUL, Commissioner of Social Security, Defendant.
MEMORANDUM AND RECOMMENDATION
This matter is before the court on the parties' cross-motions for judgment on the pleadings [DE-27, -30] pursuant to Fed. R. Civ. R 12(c). Claimant Katrina Devone Nelson ("Claimant") filed this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) seeking judicial review of the denial of her application for Supplemental Security Income ("SSI") payments. Claimant responded to Defendant's motion, [DE-33], and the time for filing a reply has expired. Accordingly, the pending motions are ripe for adjudication. Having carefully reviewed the administrative record and the motions and memoranda submitted by the parties, it is recommended that Claimant's Motion for Judgment on the Pleadings be allowed, Defendant's Motion for Judgment on the Pleadings be denied, and the case be remanded to the Commissioner for further proceedings consistent with the Memorandum and Recommendation.
I. STATEMENT OF THE CASE
Claimant protectively filed an application for a period of disability, DIB, and SSI on July 16, 2014, alleging disability beginning January 1, 2004. (R. 16, 188-200). Both claims were denied initially and upon reconsideration. (R. 16, 84-123). A hearing before the Administrative Law Judge ("ALJ") was held on March 29, 2017, at which Claimant, represented by counsel, and a vocational expert ("VE") appeared and testified. (R. 34-65). Also on March 29, 2017, Claimant amended her alleged onset date to July 16, 2014 and withdrew her request for a hearing on her claim for a period of disability and DIB. (R. 221). The ALJ determined that Claimant did not have disability insured status on the amended onset date, so the ALJ dismissed the claim for a period of disability and DIB. (R. 16). On June 27, 2017, the ALJ issued a decision denying Claimant's request for SSI. (R. 13-33). On July 17, 2018, the Appeals Council denied Claimant's request for review. (R. 1-7). Claimant then filed a complaint in this court seeking review of the now final administrative decision.
II. STANDARD OF REVIEW
The scope of judicial review of a final agency decision regarding disability benefits under the Social Security Act ("Act"), 42 U.S.C. § 301 et seq., is limited to determining whether substantial evidence supports the Commissioner's factual findings and whether the decision was reached through the application of the correct legal standards. See Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987). "The findings of the Commissioner . . . as to any fact, if supported by substantial evidence, shall be conclusive . . . ." 42 U.S.C. § 405(g). Substantial evidence is "evidence which a reasoning mind would accept as sufficient to support a particular conclusion." Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966). While substantial evidence is not a "large or considerable amount of evidence," Pierce v. Underwood, 487 U.S. 552, 565 (1988), it is "more than a mere scintilla . . . and somewhat less than a preponderance." Laws, 368 F.2d at 642. "In reviewing for substantial evidence, [the court should not] undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner]." Mastro v. Apfel, 270 F.3d 171, 176 (4th Cir. 2001) (quoting Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996), superseded by regulation on other grounds, 20 C.F.R. § 416.927(d)(2)). Rather, in conducting the "substantial evidence" inquiry, the court's review is limited to whether the ALJ analyzed the relevant evidence and sufficiently explained his or her findings and rationale in crediting the evidence. Sterling Smokeless Coal Co. v. Akers, 131 F.3d 438, 439-40 (4th Cir. 1997).
III. DISABILITY EVALUATION PROCESS
The disability determination is based on a five-step sequential evaluation process as set forth in 20 C.F.R. § 416.920 under which the ALJ is to evaluate a claim:
The claimant (1) must not be engaged in "substantial gainful activity," i.e., currently working; and (2) must have a "severe" impairment that (3) meets or exceeds [in severity] the "listings" of specified impairments, or is otherwise incapacitating to the extent that the claimant does not possess the residual functional capacity to (4) perform . . . past work or (5) any other work.Albright v. Comm'r of the SSA, 174 F.3d 473, 475 n.2 (4th Cir. 1999). "If an applicant's claim fails at any step of the process, the ALJ need not advance to the subsequent steps." Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995) (citation omitted). The burden of proof and production during the first four steps of the inquiry rests on the claimant. Id. At the fifth step, the burden shifts to the ALJ to show that other work exists in the national economy which the claimant can perform. Id.
When assessing the severity of mental impairments, the ALJ must do so in accordance with the "special technique" described in 20 C.F.R. § 416.920a(b)-(c). This regulatory scheme identifies four broad functional areas in which the ALJ rates the degree of functional limitation resulting from a claimant's mental impairment(s): understanding, remembering, or applying information; interacting with others; concentrating, persisting, or maintaining pace; and adapting or managing oneself. Id. § 416.920a(c)(3). The ALJ is required to incorporate into his written decision pertinent findings and conclusions based on the "special technique." Id. § 416.920a(e)(3).
In this case, Claimant alleges the following errors: (1) the ALJ failed to adequately account for Claimant's limitations in maintaining concentration, persistence, and pace in the RFC; (2) the ALJ failed to adequately account for Claimant's limitations in adapting and managing herself in the RFC; and (3) the ALJ improperly weighed Claimant's Global Assessment of Functioning ("GAF") scores. Pl.'s Mem. [DE-28] at 7-23.
IV. ALJ'S FINDINGS
Applying the above-described sequential evaluation process, the ALJ found Claimant "not disabled" as defined in the Act. At step one, the ALJ found Claimant had not engaged in substantial gainful employment since July 16, 2014, the alleged onset date. (R. 19). Next, the ALJ determined Claimant had the following severe impairments: schizophrenia, paranoid type; an affective mood disorder; an anxiety disorder; and a history of polysubstance abuse. Id. The ALJ also found Claimant had nonsevere impairments of tachycardia, back strain/chronic back pain, sciatica, coronary atherosclerosis, hypokalemia, bronchitis, elevated blood pressure, diabetes mellitus, obesity, hysterectomy/fibroids/irregular menstrual bleeding, skin abscesses, chronic pain syndrome in the right hip, right leg pain, and hyperthyroidism. (R. 20). The ALJ found that Claimant had a non-medically determinable impairment of lumbar radiculopathy. (R. 20-21). However, at step three, the ALJ concluded these impairments were not severe enough, either individually or in combination, to meet or medically equal one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. 21-22). Applying the technique prescribed by the regulations, the ALJ found that Claimant's mental impairments have resulted in moderate limitations in understanding, remembering, or applying information; interacting with others; concentrating, persisting, or maintaining pace; and adapting or managing herself. Id.
Prior to proceeding to step four, the ALJ assessed Claimant's RFC, finding Claimant had the ability to perform a full range of work at all exertional levels but with the following non-exertional limitations:
Sedentary work involves lifting no more than 10 pounds at a time and occasionally lifting or carrying articles like docket files, ledgers, and small tools. Although a sedentary job is defined as one which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required occasionally and other sedentary criteria are met. 20 C.F.R. § 416.967(a); S.S.R. 96-9p, 1996 WL 374185, at *3 (July 2, 1996). "Occasionally" generally totals no more than about 2 hours of an 8-hour workday. "Sitting" generally totals about 6 hours of an 8-hour workday. S.S.R. 96-9p, 1996 WL 374185, at *3. A full range of sedentary work includes all or substantially all of the approximately 200 unskilled sedentary occupations administratively noticed in 20 C.F.R. Part 404, Subpart P, Appendix 2, Table 1. Id.
Light work involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very little, a job is in this category when it requires a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm or leg controls. To be considered capable of performing a full or wide range of light work, you must have the ability to do substantially all of these activities. If an individual can perform light work, he or she can also perform sedentary work, unless there are additional limiting factors such as the loss of fine dexterity or the inability to sit for long periods of time. 20 C.F.R. § 416.967(b).
Medium work involves lifting no more than 50 pounds at a time with frequent lifting or carrying objects weighing up to 25 pounds. If someone can do medium work, she can also do sedentary and light work. 20 C.F.R. § 416.967(c).
work is limited to performing only simple, routine, and repetitive tasks, in a low-stress job (defined as no more than occasional decision-making required and no more than occasional changes in the work setting); no production-rate or paced-work (such as would be done on an assembly line); no interaction with the general public; no more than occasional interaction with co-workers, and such interaction is further limited to superficial interaction (such as a brief greeting or a brief exchange of information) and/or interaction that is incidental to the work being performed, with no tandem tasks.(R. 22-26). In making this assessment, the ALJ found Claimant's statements about the intensity, persistence, and limiting effects of her symptoms not entirely consistent with the medical and other evidence. (R. 23).
At step four, the ALJ concluded Claimant has no past relevant work. (R. 26). At step five, upon considering Claimant's age, education, work experience, and RFC, the ALJ determined Claimant is capable of adjusting to the demands of other employment opportunities that exist in significant numbers in the national economy. (R. 26-27).
V. DISCUSSION
A. The ALJ adequately accounted for Claimant's moderate limitation in concentrating, persisting, and maintaining pace.
Claimant contends the ALJ erred in formulating the RFC because the ALJ did not adequately account for Claimant's moderate limitations in maintaining concentration, persistence or pace. Pl.'s Mem. [DE-28] at 7-16. An individual's RFC is the capacity she possesses despite the limitations caused by physical or mental impairments. 20 C.F.R. § 416.945(a)(1); see also S.S.R. 96-8p, 1996 WL 374184, at *1 (July 2, 1996). "[T]he residual functional capacity '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' listed in the regulations." Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (quoting S.S.R. 96-8p). The RFC is based on all relevant medical and other evidence in the record and may include a claimant's own description of limitations arising from alleged symptoms. 20 C.F.R. § 416.945(a)(3); see also S.S.R. 96-8p, 1996 WL 374184, at *5. Where a claimant has numerous impairments, including non-severe impairments, the ALJ must consider their cumulative effect in making a disability determination. 42 U.S.C. § 423(d)(2)(B); see Hines v. Brown, 872 F.2d 56, 59 (4th Cir. 1989) ("[I]n determining whether an individual's impairments are of sufficient severity to prohibit basic work related activities, an ALJ must consider the combined effect of a claimant's impairments.") (citations omitted). The ALJ has sufficiently considered the combined effects of a claimant's impairments when each is separately discussed by the ALJ and the ALJ also discusses a claimant's complaints and activities. Baldwin v. Barnhart, 444 F. Supp. 2d 457, 465 (E.D.N.C. 2005) (citations omitted). The 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." S.S.R. 96-8p, 1996 WL 374184, at *7. 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)." Id.; see also Clifford v. Apfel, 227 F.3d 863, 872 (7th Cir. 2000) (observing that the ALJ "must build an accurate and logical bridge from the evidence to his conclusion").
Claimant contends the ALJ erred in failing to include greater non-exertional limitations to account for her moderate impairment in maintaining concentration, persistence, or pace. Pl.'s Mem. [DE-28] at 7-16. The Fourth Circuit held in Mascio that "an ALJ does not account 'for a claimant's limitation in concentration, persistence, and pace by restricting the hypothetical question to simple, routine tasks or unskilled work.'" 780 F.3d at 638 (quoting Winschel v. Comm'r of Soc. Sec., 631 F.3d 1176, 1180 (11th Cir. 2011) Coining the Third, Seventh, and Eighth Circuits)). The court explained that "the ability to perform simple tasks differs from the ability to stay on task" and that "[o]nly the latter limitation would account for a claimant's limitation in concentration, persistence, or pace." Id. The court implicitly acknowledged there could be instances where a moderate limitation in concentration, persistence, or pace at step three does not require a limitation in the RFC; however, the failure to explain such a result is error requiring remand. Id. ("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. . . . But because the ALJ here gave no explanation, a remand is in order.").
Here, the ALJ found that Claimant has moderate difficulties with regard to concentration, persistence, or pace. (R. 21). The ALJ stated the following:
With regard to concentrating, persisting, or maintaining pace, again, the claimant
has moderate limitations. The combination of her symptoms would certainly cause some trouble in this area. However, the records show her medical providers have consistently noted unremarkable mental status exam findings, as discussed below, and she has inconsistently sought mental health treatment within the period in question. Despite the inconsistent treatment there have been no psychiatric hospitalizations since 2015, as discussed below. Therefore, the record shows that the claimant's impairments interfere with her ability to sustain focused attention and concentration to the extent that they hinder her from the timely completion of tasks commonly found in work setting [sic], but it shows they do not do so in a marked manner.(R. 21). In the RFC, the ALJ limited Claimant to "performing only simple, routine, and repetitive tasks, in a low-stress job (defined as no more than occasional decision-making required and no more than occasional changes in the work setting); no production-rate or paced-work (such as would be done on an assembly line)"; and limited interaction with others. (R. 22).
Cases addressing how the ALJ accounts for limitations in a claimant's ability to maintain pace or to stay on task generally look to whether the ALJ has provided a production-work limitation in the RFC. See, e.g., Sizemore v. Berryhill, 878 F.3d 72, 79 (4th Cir. 2017) (holding that limitations working in a low stress non-production job with no public contact were sufficient to account for moderate limitations in concentration, persistence, or pace); Bowen v. Berryhill, No. 5:16-CV-65-F, 2017 WL 1194462 (E.D.N.C. Mar. 31, 2017) (holding that an RFC of simple, routine, repetitive tasks, no production work and only occasional interaction with other people was sufficient to account for moderate limitation in concentration, persistence, or pace). Here, there is a production-work limitation in the RFC—the ALJ limited Claimant to "no production-rate or paced-work (such as would be done on an assembly line)." (R. 21).
Claimant contends that the production-rate limitation is insufficient and analogizes her case Perry v. Berryhill, 765 F. App'x 869, 872 (4th Cir. 2019) and Thomas v. Berryhill, 916 F.3d 307, 310 (4th Cir. 2019). In Perry, the ALJ limited the claimant to a "non-production oriented work setting." 765 F. App'x at 872. The Fourth Circuit held that the limitation was so lacking in analysis that the court could not meaningfully review the RFC determination. Id. at 871. Specifically, the Court held that "non-production oriented work setting" was not a term of art defined in the regulations, it was not commonly used in case law, it was not self-explanatory, and "the ALJ offered no explanation of her own for what she meant." Id. at 872. Accordingly, the Fourth Circuit was unable to determine what the phrase meant, and it remanded the case for further explanation. Id. at 873. Likewise, in Thomas, the RFC limited the claimant to "no work requiring a production rate or demand pace," and the Fourth Circuit held that the ALJ "did not give us enough information to understand what those terms mean." 916 F.3d at 312.
The present case is distinguishable from Perry and Thomas because here, the ALJ offered an explanation for what he meant by "no production-rate or paced-rate work"—the ALJ wrote in a parenthetical, "such as would be done on an assembly line." (R. 21). Additionally, the ALJ included other limitations to account for Claimant's difficulty staying on task, such as "a low-stress job (defined as no more than occasional decision-making required and no more than occasional changes in the work setting)," no interaction with the public, and occasional interaction with co-workers. (R. 21).
Defendant contends that the present case is analogous to Sizemore, 878 F.3d at 79, and the court agrees. In Sizemore, the Fourth Circuit found no error in an RFC that accounted for moderate limitations in concentrating, persisting, and maintaining pace by limiting the claimant to "work only in a low stress setting defined as non-production jobs without any fast-paced work and with no public contact." Id. at 79-81. Likewise, here, Claimant was limited to non-production rate or paced-rate work (such as would be done on an assembly line), and no public contact. That description was sufficient for the court to meaningfully review the RFC; unlike in Perry and Thomas, the court is not left to guess what the ALJ meant. See Dunston v. Berryhill, No. 5:17-CV-380-FL, 2018 WL 4576783, at *1 (E.D.N.C. June 5, 2018) (finding no error when the Claimant had a moderate limitation in concentrating, persisting, and maintaining pace and the RFC limited the claimant to simple, routine, repetitive tasks; occasional interaction with coworkers; no interaction with the public; and no performance of tasks that require a production pace), adopted by 2018 WL 4204639 (E.D.N.C. Sept. 4, 2018); Simmons v. Berryhill, No. 5:17-CV-4-D, 2018 WL 577243, at *7 (E.D.N.C. Jan. 10, 2018) (holding that an RFC limiting the claimant to "no quotas or fast-paced production work with uninvolved oral and written instructions in two-hour segments" adequately accounted for moderate limitations in concentrating, persisting, and maintaining pace), adopted by 2018 WL 576845 (E.D.N.C. Jan. 26, 2018). The ALJ adequately accounted for Claimant's moderate difficulties concentrating, persisting, and maintaining pace, and the ALJ's RFC formulation contains sufficient explanation for meaningful review. See Duffin v. Saul, No, 2:18-CV-27-D, 2019 WL 3731135, at *4 (E.D.N.C. June 28, 2019), adopted by 2019 WL 3731309 (E.D.N.C. Aug. 6, 2019). Accordingly, the ALJ did not err in formulating the RFC as it relates to Claimant's ability to stay on task.
B. The ALJ adequately accounted for Claimant's moderate limitations in adapting or managing herself.
Claimant contends the ALJ erred in formulating the RFC because the ALJ did not adequately account for her moderate limitations in adapting or managing herself. Pl.'s Mem. [DE-28] at 17-18. Adapting or managing oneself "refers to the abilities to regulate emotions, control behavior, and maintain well-being in a work setting." 20 C.F.R. § 404, subpt. P, app. 1, 12.00E.4. Some examples that illustrate this area of functioning include "responding to demands," "adapting to changes," "distinguishing between acceptable and unacceptable work performance," "setting realistic goals," and "maintaining personal hygiene and attire appropriate to a work setting." Id.
Here, the ALJ limited Claimant to "simple, routine, and repetitive tasks, in a low-stress job (defined as no more than occasional decision-making required and no more than occasional changes in the work setting); no production-rate or paced-work (such as would be done on an assembly line); no interaction with the general public; [and] no more than occasional interaction with co-workers." (R. 21). In limiting Claimant to occasional changes in the work setting, no interaction with the public, and occasional interaction with co-workers, the ALJ adequately accounted for Claimant's moderate difficulty in adapting or managing herself. See Rayonda P. v. Comm'r, Soc. Sec. Admin., No. 7.T8-CV-190, 2019 WL 3242069, at *5 (W.D. Va. July 18, 2019) (holding that the ALJ adequately accounted for moderate limitations in adapting and managing oneself when he limited the claimant to "only occasional changes in the work setting" and "only frequent responses to the public and coworkers"). Claimant cites no authority to the contrary, but instead contends that the ALJ erred in failing to explain how she could stay on task for an eight-hour day, given her moderate limitation in adapting or managing herself. Pl.'s Mem. [DE-28] at 18. The limitations in the RFC to account for Claimant's difficulty staying on task are discussed above. See Mascio, 780 F.3d at 638 (holding that the ability to stay on task is related to a limitation for concentrating, persisting, or maintaining pace). Accordingly, the ALJ did not err in limiting Claimant to occasional changes in the work setting, no interaction with the public, and occasional interaction with co-workers to account for her moderate limitation in adapting or managing herself.
C. The ALJ erred in weighing the GAF scores.
Claimant contends that the ALJ did not properly weigh her GAF scores as medical opinions. Pl.'s Mem. [DE-28] at 18-22. "The GAF scale measures a person's overall psychological, social, and occupational functioning." Coppage v. Colvin, No. 4:14-CV-211-D, 2015 WL 9899342, at *11 (E.D.N.C. Dec. 14, 2015), adopted by 2016 WL 270217 (E.D.N.C. Jan. 21, 2016). GAF scores are weighed as medical opinion evidence. Lamb v. Berryhill, No. 2:16-CV-56-FL, 2017 WL 3332919, at *11 (E.D.N.C. July 6, 2017), adopted by 2017 WL 3325075 (E.D.N.C. Aug. 3, 2017). The ALJ is not required to expressly discuss each GAF score in the record, but the ALJ's decision must demonstrate "a careful consideration of the entire record, including the reasons supporting the GAF scores that were given." Sizemore, 878 F.3d at 82; see also Tew v. Colvin, No. 5:14-CV-607-D, 2015 WL 5311340, at *6 (E.D.N.C. Aug. 11, 2015) (holding that an ALJ properly evaluated GAF scores when he "referenced the range of GAF scores contained in the record" and considered them "along with all of the record evidence"), adopted by 2015 WL 5330267 (E.D.N.C. Sept. 10, 2015).
The ALJ discussed the GAF scores as follows:
Little weight is given to the low Global Assessment of Functioning (GAF) scores that are noted in the record, assessed by the claimant's treating provider(s), such as found at Exhibits 4F, 7F, 9F, and 14F. GAF scores are for treatment only and not for the establishment of disability. Without knowing what they are based on, significant weight cannot be assessed to them.(R. 25).
Here, it appears that the ALJ did not adequately consider the GAF scores in the context of the entire record. See Hollingsworth v. Berryhill, No. 1:16-CV-1316, 2018 WL 851378, at *8 (M.D.N.C. Feb. 13, 2018) (finding no error where "the ALJ considered not only Plaintiff's GAF scores, but also the text supporting them," and "cited and discussed the medical records containing Plaintiff's GAF scores"), adopted by 2018 WL 1474360 (M.D.N.C. Mar. 26, 2018). The ALJ stated that he could not give greater weight to the scores without knowing their basis, but the ALJ did not sufficiently discuss the records surrounding the GAF scores, and those records show a basis for the scores.
First, the ALJ fails to mention Claimant's 1999 GAF score of 35 following her suicide attempt. (R. 760). While the ALJ's failure, alone, is not necessarily reversible error, Sizemore, 878 F.3d at 82, the ALJ's discussion of the suicide attempt was cursory at best; the ALJ wrote, "she has a history of several suicide attempts dating back to 1999" and noted that all the suicide attempts involved substance abuse or a failure to take medication or seek treatment. (R. 24).
Next, the record contains six GAF scores from Claimant's assessments at PORT Human Services from February to July 2014. (R. 449, 1212, 453, 456, 1145, 459, 1148, 462, 1151, 465, 1154). The ALJ mentions those GAF scores briefly by writing, "such as found at Exhibit[] 4F." (R. 25). However, the ALJ barely discusses Claimant's treatment at PORT Human Services. He mentions her attempt to take a computer class, and he writes, "she reported improvement, and the mental status exams were unremarkable during that time, after some increases in her medication(s)." (R. 24). Contrarily, the record indicates that Claimant's mental examinations at PORT in 2014 showed flattened affect, depressed mood, auditory hallucinations, poor sleep, a belief that Claimant would be harmed, frequent crying, panic attacks, and weight loss. (R. 448, 454-55). She was diagnosed with schizophrenia, paranoid type. (R. 453). On June 5, 2014, it was noted that Claimant was sleeping better and had less crying and panic attacks after an increased dose of Ability. (R. 458). However, on June 23, 2014, Claimant reported that she could not take a computer class or go to the grocery store because of her panic attacks. (R. 461). In July 2014, Claimant reported that her medication was effective for her hallucinations but not for her panic attacks and anxiety. (R. 464-65). The record does not support the ALJ's assertion that Claimant's "mental status exams were unremarkable during that time." (R. 24).
There are duplicate records from PORT; the pages numbered in the 400s are identical to the pages numbered in the 1100s.
Additionally, the record contains two GAF scores from Carolina East Health System. (R. 417, 890). The ALJ references those scores by noting that they are "found at Exhibits 4F, 7F, 9F, and 14F." However, the ALJ does not thoroughly discuss the record surrounding those GAF scores. A score of 15 was noted on February 21, 2014 while Claimant was hospitalized for severe auditory suicidal hallucinations. (R. 416). The ALJ wrote, "she was voluntarily hospitalized for five days for an acute exacerbation of schizophrenia, and the notes show positive cocaine and cannabis screenings at that time (Exs. 6F, 9F & 12F)." (R. 24). The ALJ noted that Claimant did not take medication or seek treatment since her 1999 suicide attempt, and her symptoms recurred recently. Id. The ALJ did not mention that Claimant was noted to have flat affect, dysphoric mood, and impaired judgment. Id.
In May 2015, Claimant was given a GAF score of 25 at Carolina East Health System when she reported to the Emergency Department for depression, suicidal thoughts, auditory hallucinations telling her to hurt herself, and lack of sleep. (R. 888-90). She was disheveled and displayed psychomotor retardation, underproductive speech, depressed mood, flat affect, evasive thought process, suicidal ideations, auditory hallucinations, impaired attention and concentration, poor insight, and poor judgment. (R. 889). She was diagnosed with schizophrenia and admitted for intensive inpatient treatment. (R. 890). The entirety of the ALJ's discussion of the May 2015 hospitalization was: "She was, however, briefly hospitalized for suicidal ideation in May 2015 (at which time drug screens were positive for cocaine and marijuana), but she showed great improvement with treatment while in the hospital." (R. 24-25).
In summary, the ALJ's decision fails to demonstrate "a careful consideration of the entire record, including the reasons supporting the GAF scores that were given." Sizemore, 878 F.3d at 82. The ALJ stated that he did not know what the GAF scores were based on, but only cursorily discussed the accompanying records. A review of the record surrounding the GAF scores shows diagnoses of schizophrenia and symptoms such as depressed mood, fiat affect, lack of sleep, hallucinations, impaired judgment, and suicidal ideations. The ALJ did not adequately consider the GAF scores in the context of the record, and the court cannot follow the ALJ's reasoning in assigning the scores little weight. Accordingly, remand is appropriate for the ALJ to adequately consider the record so that he may discern the bases of Claimant's GAF scores.
VI. CONCLUSION
For the reasons stated above, it is RECOMMENDED that Claimant's Motion for Judgment on the Pleadings [DE-27] be ALLOWED, Defendant's Motion for Judgment on the Pleadings [DE-30] be DENIED and the case be REMANDED to the Commissioner for further proceedings consistent with the Memorandum and Recommendation.
IT IS DIRECTED that a copy of this Memorandum and Recommendation be served on each of the parties or, if represented, their counsel. Each party shall have until September 12, 2019 to file written objections to the Memorandum and Recommendation. The presiding district judge must conduct his or her own review (that is, make a de novo determination) of those portions of the Memorandum and Recommendation to which objection is properly made and may accept, reject, or modify the determinations in the Memorandum and Recommendation; receive further evidence; or return the matter to the magistrate judge with instructions. See, e.g., 28 U.S.C. § 636(b)(1); Fed. R. Civ. P. 72(b)(3); Local Civ. R. 1.1 (permitting modification of deadlines specified in local rules), 72.4(b), E.D.N.C. Any response to objections shall be filed by within 14 days of the filing of the objections.
If a party does not file written objections to the Memorandum and Recommendation by the foregoing deadline, the party will be giving up the right to review of the Memorandum and Recommendation by the presiding district judge as described above, and the presiding district judge may enter an order or judgment based on the Memorandum and Recommendation without such review. In addition, the party's failure to file written objections by the foregoing deadline will bar the party from appealing to the Court of Appeals from an order or judgment of the presiding district judge based on the Memorandum and Recommendation. See Wright v. Collins , 766 F.2d 841, 846-47 (4th Cir. 1985).
Submitted, this the 29th day of August, 2019.
/s/_________
Robert B. Jones, Jr.
United States Magistrate Judge