C/A No. 2:18-cv-02521-JMC-MGB
REPORT AND RECOMMENDATION
This case is before the Court for a Report and Recommendation pursuant to Local 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). Plaintiff Marshall Dawson ("Plaintiff") brought this action pursuant to Section 205(g) of the Social Security Act, as amended, (42 U.S.C. § 405(g)), to obtain judicial review of a final decision of the Commissioner of Social Security Administration (the "Administration") regarding his claim for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under Titles II and XVI of the Social Security Act (the "Act"). For the reasons set forth below, the undersigned recommends that the Court affirm the Commissioner's decision.
RELEVANT FACTS AND ADMINISTRATIVE PROCEEDINGS
Plaintiff was 55 years old on his alleged disability onset date of June 15, 2012. (R. at 12, 22.) Plaintiff alleged disability due to, inter alia, generalized anxiety, hypertension, and schizoaffective disorder. (Id. at 72, 84.) Plaintiff has past relevant work as a construction laborer, stocker, warehouse loader, masonry helper, and material handler. (Id. at 67-68.)
Plaintiff filed applications for DIB and SSI on June 26, 2014. (Id. at 12, 96, 126.) His application was denied initially on October 30, 2014, and on reconsideration on or around October 5, 2015. (Id. at 96, 126.) After a hearing before the Administrative Law Judge ("ALJ") on June 16, 2017, (id. at 30-71), the ALJ issued a decision on October 3, 2017, in which he found that Plaintiff was not disabled (id. at 12-24). The Appeals Council denied Plaintiff's request for review, (id. at 1-3), making the ALJ's decision the Commissioner's final decision for purposes of judicial review.
In making the determination that Plaintiff is not entitled to benefits, the Commissioner has adopted the following findings of the decision:
(1) The claimant meets the insured status requirements of the Social Security Act through June 30, 2012.
(2) The claimant has not engaged in substantial gainful activity since June 15, 2012, the alleged onset date (20 CFR 404.1571 et seq., and 416.971 et seq.).
(3) The claimant has the following severe impairments: left knee patella osteophyte; affective disorder with psychotic features; and anxiety disorder (20 CFR 404.1520(c) and 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 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925 and 416.926).
(5) After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform medium work as defined in 20 CFR 404.1567(c) and 416.967(c) except the claimant can occasionally climb ladders, ropes, and scaffolds; the claimant can frequently climb ramps and stairs, balance, stoop, kneel, crouch, and crawl; the claimant can occasionally be exposed to hazards associated with unprotected dangerous machinery or unprotected heights; the claimant can concentrate, persist and maintain pace sufficient to understand, remember and carry out simple, routine tasks in a low stress work environment (defined as being free of fast-paced or team-dependent production requirements), involving simple work-related decisions, occasional
independent judgment skills and occasional work place changes; the claimant can perform jobs where the worker is largely isolated from the general public, dealing with data and things rather than people; the claimant can perform jobs where the work duties can be completed independently from coworkers; however, physical isolation is not required, and can respond appropriately to reasonable and customary supervision.(Id. at 14-23.)
(6) The claimant is unable to perform any past relevant work (20 CFR 404.1565 and 416.965).
(7) The claimant was born on December 7, 1956 and was 55 years old, which is defined as an individual of advanced age, on the alleged disability onset date (20 CFR 404.1563 and 416.963).
(8) The claimant has at least a high school education and is able to communicate in English (20 CFR 404.1564 and 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 CFR 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 CFR 404.1569, 404.1569(a), 416.969, and 416.969(a)).
(11) The claimant has not been under a disability, as defined in the Social Security Act, from June 15, 2012, through the date of this decision (20 CFR 404.1520(g) and 416.920(g)).
The Act provides that disability benefits shall be available to those persons insured for benefits, who are not of retirement age, who properly apply, and who are under a "disability." 42 U.S.C. § 423(a). The Act also provides that SSI disability benefits shall be available for aged, blind, or disabled persons who have income and resources below a specific amount. See 42 U.S.C. § 1381 et seq. "Disability" is defined in the Act as the inability to "engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than" twelve months. See 42 U.S.C. § 423(d)(1)(A) (DIB context); 42 U.S.C. § 1382(a)(3)(A) (SSI context).
"[T]he definition of disability is the same under both DIB and SSI. . . ." Manson v. Colvin, No. 9:12-cv-1157-TLW-BM, 2013 WL 4042188, at *2 n.2 (D.S.C. Aug. 8, 2013) (citing Emberlin v. Astrue, No. 06-cv-4136, 2008 WL 565185, at *1 n.3 (D.S.C. Feb. 29, 2008)).
To facilitate a uniform and efficient processing of disability claims, the 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 which equals an illness contained in the Administration's official Listing of Impairments found at 20 C.F.R. Part 404, Subpart P, Appendix 1, (4) has an impairment which prevents past relevant work, and (5) has an impairment which prevents him from doing substantial gainful employment. See 20 C.F.R. § 404.1520 (DIB context); 20 C.F.R. § 416.920 (SSI context). If an individual is found not disabled at any step, further inquiry is unnecessary. See 20 C.F.R. § 404.1520(a)(4) (DIB context); 20 C.F.R. § 416.920(a)(4) (SSI context); see also Hall v. Harris, 658 F.2d 260 (4th Cir. 1981).
The claimant bears the burden of proof with respect to the first four steps of the analysis. Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995). Once the claimant has established an inability to return to his past relevant work, the burden shifts to the Commissioner to show that the claimant—considering his age, education, work experience, and residual functional capacity—can perform alternative jobs and that such jobs exist in the national economy. See SSR 82-62, 1982 WL 31386, at *3; Grant v. Schweiker, 699 F.2d 189, 191 (4th Cir. 1983); see also Monroe v. Colvin, 826 F.3d 176, 180 (4th Cir. 2016). The Commissioner may satisfy this burden by obtaining testimony from a vocational expert. See Grant, 699 F.2d at 191-92.
The scope of judicial review by the federal courts in disability cases is narrowly tailored to determine whether the findings of the Commissioner "are supported by substantial evidence and whether the correct law was applied." Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990); see also Woods v. Berryhill, 888 F.3d 686, 691 (4th Cir. 2018); Mascio v. Colvin, 780 F.3d 632, 634 (4th Cir. 2015); 42 U.S.C. § 405(g); 42 U.S.C. § 1383(c)(3). Consequently, the Act precludes a de novo review of the evidence and requires that the court uphold the Commissioner's decision as long as it is supported by substantial evidence. Pyles v. Bowen, 849 F.2d 846, 848 (4th Cir. 1988) (citing 42 U.S.C. § 405(g) and Smith v. Schweiker, 795 F.2d 343, 345 (4th Cir. 1986)); see also Mascio, 780 F.3d at 640; Bird v. Comm'r of Soc. Sec. Admin., 699 F.3d 337, 340 (4th Cir. 2012).
Substantial evidence is "more than a mere scintilla of evidence but may be less than a preponderance." Pearson v. Colvin, 810 F.3d 204, 207 (4th Cir. 2015) (citing Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012)). "In reviewing for substantial evidence, [the court does] not undertake to reweigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [ALJ]." Hancock, 667 F.3d at 472. "Where conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled, the responsibility for that decision falls on the [ALJ]," not on the reviewing court. Id. However, "[a] factual finding by the ALJ is not binding if it was reached by means of an improper standard or misapplication of the law." Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987).
Although the ALJ concluded that Plaintiff suffered from both physical and mental impairments during the relevant period, Plaintiff challenges only those administrative findings that pertain to his mental limitations. Specifically, Plaintiff argues that the ALJ committed reversible error in weighing the evidence of his mental impairments by failing to adequately explain his rejection of Plaintiff's subjective complaints and testimony (Dkt. No. 16 at 29-32); improperly weighing the opinion of one-time examiner Dr. Rebecca Sorrow, Ph.D. (id. at 16-18); and giving insufficient weight to the lay testimony of Sheila Hollings, Plaintiff's fiancé (id. at 26-29). Plaintiff argues that the ALJ further erred in concluding that Plaintiff suffered only mild-to-moderate limitations under the relevant mental disorder Listings at step three of the sequential evaluation. (Id. at 12-16). Plaintiff claims that the ALJ also failed to explain how these mental limitations translated to an eight-hour workday, and did not account for such limitations in the residual functional capacity ("RFC") analysis. In particular, Plaintiff argues that the ALJ did not provide any restrictions in relation to Plaintiff's concentration, persistence and pace, or his medication side effects. (Id. at 18-26, 32-33).
Upon review of the parties' arguments, the ALJ's decision, and the record as a whole, the undersigned finds that the ALJ did not err in his consideration of Plaintiff's mental impairments. Indeed, the ALJ's decision carefully evaluated Plaintiff's mental health treatment history and provided a detailed, well-reasoned explanation as to how he considered and weighed each piece of evidence in concluding that Plaintiff was not disabled. Accordingly, as set forth in greater detail below, the undersigned finds that the ALJ's decision is supported by substantial evidence and therefore recommends that the Court affirm his decision.
I. Plaintiff's Subjective Complaints
As the Commissioner aptly notes, Plaintiff largely relies on his subjective complaints, the medical opinion of Dr. Sorrow, and the lay testimony of Ms. Hollings as the central evidentiary support for many of his arguments. Thus, for purposes of clarity, the undersigned resolves these issues first, beginning with the ALJ's consideration of Plaintiff's subjective complaints.
In evaluating a claimant's subjective symptoms, the ALJ follows a two-step process under which he must first determine whether there is an underlying medically determinable physical or mental impairment that could reasonably be expected to produce the claimant's pain or other symptoms. Tyler v. Berryhill, No. 8:15-CV-04457-JDA, 2017 WL 461008, at *9 (D.S.C. Feb. 3, 2017). After determining the presence of an impairment, the ALJ must evaluate the intensity, persistence, and limiting effects of the claimant's symptoms to determine the extent to which those symptoms limited his functioning. Id. at *10.
The ALJ's decision "must contain specific reasons for the weight given to the individual's symptoms, be consistent with and supported by the evidence, and be clearly articulated so the individual and any subsequent reviewer can assess how the adjudicator evaluated the individual's symptoms." SSR 16-3p, 2017 WL 5180304, at *9. Specifically, the ALJ's decision must "consider all of the evidence in an individual's record," including, but not limited to, the claimant's daily activities; the location, duration, frequency, and intensity of the claimant's pain or other symptoms; factors that precipitate and aggravate the symptoms; the type, dosage, effectiveness, and side effects of any medication the claimant takes or has taken to alleviate pain or other symptoms; treatment, other than medication, the claimant receives or has received for relief of pain or other symptoms; any measures other than treatment the individual uses or has used to relieve pain or other symptoms; and any other factors concerning the individual's functional limitations and restriction due to pain or other symptoms. SSR 16-3p, at *2; see also 20 C.F.R. §§ 404.1529(c) and 416.929(c). The ALJ need not accept the claimant's subjective complaints "to the extent they are inconsistent with the available evidence, including objective evidence of the underlying impairment." Craig v. Chater, 76 F.3d 585, 594 (4th Cir. 1996).
Social Security Ruling 16-3p rescinded and superseded SSR 96-7p, on March 28, 2016. See 2017 WL 5180304, at *13. Plaintiff's applications were adjudicated after March 28, 2016, and, thus, the undersigned has analyzed Plaintiff's allegations under SSR 16-3p. The undersigned notes that SSR 16-3p discontinues use of the term "credibility;" however, "the methodology required by both SSR 16-3p and SSR 96-7, are quite similar. Under either, the ALJ is required to consider the claimant's report of his own symptoms against the backdrop of the entire case record." Best v. Berryhill, No. 0:15-CV-02990-DCN, 2017 WL 835350, at *4 n.3 (D.S.C. Mar. 3, 2017) (internal citations omitted).
Here, the ALJ found that while Plaintiff's "medically determinable impairments could reasonably be expected to produce the  alleged symptoms," his "statements concerning the intensity, persistence and limiting effects of these symptoms [were] not entirely consistent with the medical evidence and other evidence in the record. . . ." (R. at 19.) Plaintiff argues that in discounting his subjective complaints, the ALJ "cherry-picked from the evidence to reach an opinion" not otherwise supported by the record. (Dkt. No. 16 at 30.) For example, Plaintiff argues that the ALJ's assessment improperly relied on a handful of daily living activities—"such as driving, going to church, and visiting friends"—despite evidence indicating that Plaintiff had not engaged in such activities for several years. (Id. at 31-32.) Contrary to Plaintiff's contention, however, a review of the decision shows that the ALJ weighed Plaintiff's subjective complaints against the record as a whole and that his findings are consistent with and supported by substantial evidence.
In assessing the severity of Plaintiff's symptoms, the ALJ acknowledged Plaintiff's testimony regarding his mental impairments from the hearing on June 16, 2017. As stated in the decision, Plaintiff testified that he had experienced auditory hallucinations since 2012, and that he had these hallucinations two-to-three times each week, sometimes consisting of six-to-seven different voices. (R. at 18-19, 44-47.) Plaintiff also testified that he went into a deep depression following the deaths of several family members, and that because of his depression and anxiety, he felt lonely, did not like being around other people, had crying spells, and experienced nightmares. (Id. at 18-19, 44-48.) Plaintiff also told the ALJ that his medication made it difficult for him to think and concentrate. (Id. at 49.)
Plaintiff testified that the voices tell him to, "go do that, do it now, got to do it. If you don't do it I'm going to get you." (R. at 47.) Plaintiff claimed that he did not know what the voices wanted him to do because he would "holler back at them to make them leave." (Id.)
In considering Plaintiff's testimony from the hearing, the ALJ acknowledged that Plaintiff's "allegations [were] consistent with the record in that he  experienced hallucinations and other mental health symptoms during the period at issue such as depression and anxiety." (Id. at 19.) The ALJ explained, however, that the severity alleged by Plaintiff was inconsistent with the longitudinal record, which indicated "a significant improvement" in Plaintiff's symptoms. (Id.) The ALJ then provided the following review of Plaintiff's mental health treatment, citing specific notes in which Plaintiff himself reported noticeable improvement:
The claimant did not undergo treatment between 2012 and 2014, and subsequently underwent only infrequent treatment. In early 2014, the claimant reported experiencing auditory hallucinations that were telling him to ho outside, get in the car, and engage in other activities (Exhibit 10F/13-14). At a consultative examination in September 2014, Dr. Sorrow noted that the claimant was alert and oriented, but appeared on the verge of having a panic attack, and was hallucinating during the examination (Exhibit 4F/2). In October 2014, the claimant again reported experiencing auditory hallucinations (Exhibit 5F/2). However, by early 2015, the claimant's condition began to improve, and he reported doing better on medication and said that he was beginning to put his family tragedies behind him (Exhibit 7F/2). In July 2015, the claimant said that he was no longer hearing voices and was attending church services (Exhibit 10F/23). In later 2015 and early 2016, the claimant reported an exacerbation of his depression and panic attack symptoms (Exhibit 10F/19, 21). However, by April 2016, the claimant reported that he was feeling good, had developed new techniques for managing his anxiety, was doing well on his medication, and was dealing better with the grief stemming from his family tragedies (Exhibit 10F/17). By the end of 2016, the claimant reported a marked improvement in his condition, saying that he felt like "he had been lost, but now was found." (Exhibit 10F/15). The claimant reported that he was not [sic] attending youth groups, felt "blessed," and stated that his medication had "helped a lot" in managing his condition (Exhibit 10F/15).(Id. at 19-20.)
As evidenced by the ALJ's thorough review of the treatment records above, Plaintiff's mental impairments plainly improved with treatment and, despite occasional flare ups, were largely controlled with medication and stress-reduction techniques. (See id. at 426, 459, 461, 465, 467, 495, 497.) Moreover, notwithstanding Plaintiff's complaints that his medication made it difficult to concentrate, many of the treatment records cited in the ALJ's discussion belie Plaintiff's claims of debilitating memory and concentration issues. Indeed, as the ALJ noted elsewhere in his decision, most of Plaintiff's mental health examinations "showed that his memory was intact or only mildly impaired" and that his "attention and concentration were intact." (R. at 16, 403, 405, 412-13, 459, 461, 463, 465, 467, 471, and 497.) Thus, the undersigned concludes that the ALJ properly afforded less weight to Plaintiff's subjective complaints and testimony to the extent they conflicted with the noticeable improvements and examination observations reflected in the longitudinal medical record. See, e.g., Latten-Reinhardt v. Astrue, No. 9:11-CV-00881-RBH, 2012 WL 4051852, at *6 (D.S.C. Sept. 13, 2012) (concluding that ALJ appropriately considered plaintiff's reports of "symptom improvement" in the treatment records in discounting plaintiff's credibility); Kemp v. Astrue, No. 6:08-CV-313-HMH, 2009 WL 1586895, at *2 (D.S.C. June 4, 2009) (concluding that plaintiff's subjective complaints regarding the severity of her migraines "were not entirely credible" where her symptoms had improved with medical treatment); see also Tanner v. Comm'r., Soc. Sec. Admin., 602 F. App'x. 95, 99 (4th Cir. 2015) (concluding that ALJ's "adverse credibility determination" was supported by substantial evidence because the subjective complaints were inconsistent with the medical evidence).
Plaintiff argues that the ALJ's assessment of his "improved" mental impairments is flawed because he failed to consider an apparent "psychotic episode" that occurred during the administrative hearing on June 16, 2017. (Dkt. No. 16 at 29-30.) Fairly early into the ALJ's questioning, Plaintiff experienced a breakdown, repeating, "Quit it. No. Stop, quit. Stop. Stop. Quit it. Stop. Leave me alone. Quit it, stop. . . . ." (R. at 36.) The ALJ went off the record, after which point Plaintiff claims that his fiancé had to enter the courtroom to calm him down. (Dkt. No. 16 at 8, 30.) Although the ALJ's decision does not discuss this particular episode, an ALJ is not required to cite or discuss every piece of evidence in considering a plaintiff's subjective complaints. Manigo v. Colvin, No. 0:13-CV-3185-BHH, 2015 WL 74954, at *5 (D.S.C. Jan. 6, 2015). "Of course not every piece of evidence must be inconsistent with the plaintiff's testimony for him to be found incredible. Some will be corroborative. . . . The simple fact that the ALJ did not reconcile every piece of evidence is not error." Id. Because the ALJ's assessment contained specific reasons for the weight given to the Plaintiff's symptoms and was well-supported by the evidence, the ALJ's failure to mention Plaintiff's breakdown during the hearing does not require remand. SSR 16-3p, 2017 WL 5180304, at *9; Holmes v. Berryhill, No. 2:16-CV-00844-RBH-MGB, 2017 WL 3279016, at *10 (D.S.C. July 17, 2017), adopted, No. 2:16-CV-00844-RBH, 2017 WL 3263889 (D.S.C. Aug. 1, 2017). Moreover, the undersigned notes that while the stress of the hearing may have triggered Plaintiff's symptoms, the episode does not, in and of itself, erase pages of medical records indicating that Plaintiff's symptoms had vastly improved and that he was feeling "the best that he had been" only several months before the hearing (R. at 495). See Marion v. Comm'r, Soc. Sec. Admin., No. 2:16-CV-3285-CMC-MGB, 2018 WL 3120646, at *7 (D.S.C. Jan. 30, 2018), adopted sub nom. Marion v. Berryhill, No. 2:16-CV-3285-CMC, 2018 WL 1324503 (D.S.C. Mar. 15, 2018) (suggesting that the claimant need not be symptom-free; rather, "the issue is whether the ALJ considered the record as a whole and properly determined that the extent and limiting effects of [his symptoms] were not as great as claimed") (internal citations omitted). Nevertheless, the ALJ still accounted for the "possible re-emergence of [Plaintiff's] symptoms" in formulating the RFC. (R. at 21; see infra pp. 31-32.) Thus, the undersigned finds that any failure to discuss Plaintiff's episode during the hearing is harmless error at most.
In addition to the inconsistencies between Plaintiff's testimony and the improvements reported in his medical records, the ALJ also noted that Plaintiff "offered a number of inconsistent, contradictory statements concerning his educational achievements, work history, activities of daily living, and the extent to which he confine[d] himself at home." (R. at 21.) More specifically,
[t]he claimant stated that he had a BA from the University of Buffalo, but stated elsewhere that [he] had only attended the school for a year and a half before leaving. The claimant alleged that he was laid off in 2013, but records indicate no earnings past 2008. He stated in February 2017 that he had not left his home for over a year, but other records from late 2016 indicate that he was routinely engaging in social activities towards the end of 2016 (Hearing Testimony, Exhibit 6D, Exhibit 2E/3, Exhibit 3E, Exhibit 3F/5, 7, Exhibit 4F/1, Exhibit 5F/2, Exhibit 10F/2, 14, 29, Exhibit 11F/4, Exhibit 12F/4, Exhibit 13F/1). . . . These contradictions and discrepancies raise serious questions about the true extent of the claimant's physical and mental impairments.(Id. at 21-22.)
Indeed, when questioned about his daily activities during the hearing on June 16, 2017, Plaintiff testified that he hardly ever left his home and explicitly denied attending church, leading youth groups, or spending time with his grandchildren. (R. at 52-53.) However, as the Commissioner correctly notes, the record is replete with treatment notes in which Plaintiff self-reported engaging in those same, and similar, activities. (Dkt. No. 17 at 13; see, e.g., R. at 400 (noting that Plaintiff attends church, plays basketball, and "deal[s] with youngsters"), 405 (noting that Plaintiff "continues to inspire the younger generations"), 409 (noting that Plaintiff cooks, "does the housekeeping to kill time," drives, grocery shops with his fiancé, and uses a cellphone), 426 (noting that Plaintiff reads the Bible), 459 (noting that Plaintiff goes to youth groups), 495 (noting that Plaintiff goes to church and sees friends from high school), and 497 (noting that church helps Plaintiff).) In fact, treatment notes show that only several months before the hearing, Plaintiff reported that he felt "the best that he [had] been in a while," and that he was going to church, walking, and spending time with his grandchildren. (R. at 495.) Thus, the ALJ properly considered these "contradictions and discrepancies" in assessing the true extent of Plaintiff's symptoms. See, e.g., Lee v. Astrue, No. 4:10-CV-2176-HMH-TER, 2011 WL 6318590, at *6 (D.S.C. Dec. 14, 2011) (concluding that internal inconsistencies in plaintiff's statements undermined plaintiff's credibility regarding the severity of her symptoms); Thompson v. Astrue, No. 7:06-CV-117-BO, 2008 WL 7759960, at *2 (E.D.N.C. Feb. 14, 2008), aff'd sub nom. Thompson v. Barnhart, 325 F. App'x 206 (4th Cir. 2009) (finding that the ALJ properly determined "that Plaintiff's assessments of her pain and limitations were not entirely credible," based on "the medical evidence indicating improvement of Plaintiff's ailments, as well as inconsistencies in Plaintiff's testimony").
For the reasons stated above, the undersigned finds that the ALJ properly assessed Plaintiff's subjective complaints against the record as a whole and set forth a detailed explanation supported by substantial evidence in concluding that Plaintiff's symptoms did not limit his functioning to the extent alleged. It is worth noting, however, that even with such substantial evidence, the ALJ still gave Plaintiff the benefit of the doubt by considering some of his subjective limitations during the RFC analysis. See Baker v. Colvin, No. 0:14-CV-4249-PJG, 2016 WL 527054, at *8 (D.S.C. Feb. 9, 2016) (affirming ALJ's decision where ALJ did not completely discount plaintiff's subjective allegations, but rather, accounted for them in a less strenuous RFC). Thus, Plaintiff's argument that the ALJ improperly discounted his subjective complaints is without merit.
II. Medical Opinions
With respect to the medical opinions of record, Plaintiff alleges that the ALJ erred in affording greater weight to the opinions of two non-examining state agency consultants over the opinion of an examining psychologist, Dr. Rebecca Sorrow, Ph.D. (Dkt. No. 16 at 16.) Viewing the ALJ's decision in its entirety, however, the undersigned finds that the weight assigned to the aforementioned opinions is supported by substantial evidence.
When, such as here, the record does not contain an opinion from a treating physician, the ALJ must consider all the medical opinions of record in view of the factors in 20 C.F.R. §§ 404.1527(c) and 416.927(c). Those factors include: (1) the examining relationship between the claimant and the medical provider; (2) the treatment relationship between the claimant and the medical provider, including the length of the treatment relationship and frequency of treatment and the nature and extent of the treatment relationship; (3) the supportability of the medical provider's opinion in his treatment records; (4) the consistency of the medical opinion with other evidence in the record; and (5) the specialization of the medical provider offering the opinion. See Praylow v. Berryhill, No. 9:15-CV-3557-TMC, 2017 WL 676580, at *4 (D.S.C. Feb. 21, 2017) (referencing SSR 96-2p and noting that, if the record does not contain an opinion from a treating physician, the ALJ must evaluate all other medical opinions pursuant to the factors in 20 C.F.R. §§ 404.1527(c) and 416.927(c)).
While the opinions of examining physicians are "generally accorded more weight than non-examining physicians" under 20 C.F.R. §§ 404.1527(c) and 416.927(c), Pinckney v. Berryhill, No. 0:15-CV-5059-RMG, 2017 WL 2711534, at *4 (D.S.C. June 23, 2017), the ALJ may afford an examining physician's opinion "significantly less weight" if his or her findings are inconsistent with other substantial evidence in the record. Craig, 76 F.3d at 590. As a result, the ALJ ultimately may end up giving more weight to the opinion of a non-examining state agency consultant if the evidence so requires. Smith v. Schweiker, 795 F.2d 343, 345-46 (4th Cir. 1986.) The ALJ need only demonstrate that he "considered and applied all the factors and accorded each opinion appropriate weight in light of the evidence of record." See Nash v. Comm'r of Soc. Sec. Admin., No. 1:16-CV-2478, 2017 WL 1906965, at *10 (D.S.C. Apr. 27, 2017), adopted sub. nom., 2017 WL 1836972 (D.S.C. May 8, 2017) (explaining that the ALJ is not required to "expressly discuss each factor in 20 C.F.R. § 404.1527(c) and § 416.927(c)").
Plaintiff was referred to Dr. Sorrow for a mental health examination on September 17, 2014. Based on this one-time examination, Dr. Sorrow found that Plaintiff had "very poor concentration" and opined that he was unable "to perform simple tasks or follow basic instructions." (R. at 410.) Dr. Sorrow explained her findings as follows:
Summary: Marshall Dawson is a 57 year old male referred for a Mental Status Evaluation to assist in determining his eligibility for disability benefits. The information and findings gathered from this evaluation indicate that Mr. Dawson is severely depressed and that he is having hallucinations. His problems started with a series of losses and a panic attack at work when his mother was hospitalized. He has been unable to sleep, has poor appetite, expresses hopelessness, has very low self esteem, and social isolation. He continues to have episodes of anxiety as well.
Activities of Daily Living: Mr. Dawson said that he does the housekeeping to kill time. He can cook and sometimes goes with his wife/girlfriend to buy groceries. He has a driver's license and does drive. He has a cell phone but finds using a computer to be too stressful. He used to take care of his own finances but now his wife does it. Mr. Dawson is able to attend to his own grooming and hygiene and said that he does okay with it.
Social Function: Mr. Dawson related poorly during the evaluation. He was very polite and cooperative and his communication skills are good. He was extremely anxious, however and put his hands over his ears and looked fearful at times. . . . He
avoids going out because people expect him to be the man he used to be and he can't do it. He said that he goes to church and watches a little sports on television. He can't concentrate well enough to read. He said that he got along "real good" with people in the past.(Id. at 409-10.)
Concentration, Persistence, and Pace: Mr. Dawson appears to be functioning in the Average range intellectually based on his educational history, functional assessment, and interaction. . . . His concentration and focus were very poor and he was not able to do the Folstein MMSE. His functional assessment, and his behavior during the examination indicate that he is probably not able to perform simple tasks and follow basic instructions at this time. He is in treatment but is taking only a tricyclic antidepressant for sleep. His level of functioning has been severely impacted by his depression and the accompanying psychosis.
In considering Dr. Sorrow's opinion, the ALJ concluded as follows:
The undersigned gives some weight to the September 2014 opinion of consultative examiner Dr. Sorrow, who assessed the claimant as having very poor concentration and not being able to perform simple tasks or follow basic instructions (Exhibit 4F/4). Dr. Sorrow [sic] assessment is based on a one time, specialized examination of the claimant. Greater weight is not given as the opinion was rendered during a time when the claimant was not receiving treatment and is not corroborated by the longitudinal record, which demonstrates subsequent mental health improvement (Exhibit 7F/2, Exhibit 10F/15, 17, 23).(Id. at 20.) Plaintiff argues that this explanation is insufficient under 20 C.F.R. §§ 404.1527(c) and 416.927(c) because it fails to account for Dr. Sorrow's specialization in psychology and her in-person examination of Plaintiff, and awards greater weight to the opinions of the state agency consultants, who did not have the benefit of examining Plaintiff. (Dkt. No. 16 at 17.) Plaintiff's argument fails for several reasons.
At the outset, the examining relationship is only one factor in considering the weight of a medical opinion. 20 C.F.R. §§ 404.1527(c) and 416.927(c). Thus, while the ALJ properly acknowledged Dr. Sorrow's "specialized evaluation" of Plaintiff in affording her opinion "some weight" under the regulations, he also heavily weighed—as is his prerogative—the inconsistencies between the longitudinal medical record and Dr. Sorrow's opinion that Plaintiff had poor concentration and was unable to handle simple instructions. (R. at 20.) Specifically, the ALJ cited numerous treatment notes and examinations indicating that Plaintiff's memory was only mildly impaired, his attention and concentration were intact, and his mental conditions had improved with medication subsequent to Dr. Sorrow's September 2014 examination. (See id., referencing R. at 426, 459, 461, 467.) As discussed above, the ALJ also included a detailed review of Plaintiff's mental health treatment elsewhere in the decision, further highlighting that the limitations in Dr. Sorrow's opinion were at odds with the subsequent improvements documented by Plaintiff's treating physicians. (See id. at 19-20, referencing Plaintiff's reports to his medical providers that he was no longer hearing voices (R. at 467); he was feeling good, doing well on his medication, and had developed new techniques for managing anxiety (R. at 461); felt like "he had been lost, but now was found" (R. at 459); and stated that his medication had "helped a lot" in managing his condition (R. at 459).) See Gordon v. Berryhill, No. 2:17-CV-02280-MGL-MGB, 2019 WL 653966, at *7 (D.S.C. Jan. 28, 2019), adopted, No. 2:17-CV-02280-MGL, 2019 WL 652073 (D.S.C. Feb. 14, 2019) (explaining that while much of the ALJ's discussion of the medical record took place elsewhere in decision, "that does not undermine the ALJ's compliance with [20 C.F.R. §§ 404.1527(c) and 416.927(c)]").
Unlike Dr. Sorrow, the two state agency consultants found that while Plaintiff's mental impairments caused certain limitations, he was not so limited as to be precluded from performing simple tasks or following basic instructions. Indeed, Dr. Silvie Kendall, Ph.D. (October 2014 opinion) and Dr. Douglas Robbins, Ph.D. (July 2015 opinion) both opined that Plaintiff was "capable of understanding, remembering, and carrying out simple but not detailed instructions, maintaining attention and concentration for two hour periods, and doing best in situations not requiring ongoing interactions." (See R. at 20, referencing R. at 79-81, 91-93, 108-10, 122-23.) In affording these opinions "substantial weight," the ALJ explained,
Although they are non-treating and non-examining physicians, Dr. Kendall and Dr. Robbins are specialists in the of [sic] area [of] mental health, are familiar with Social Security policies, regulations and definitions regarding disability, and have the advantage of reviewing the longitudinal record. Further, evidence received at the hearing level demonstrates significant improvement in the claimant's mental health, which is described in more detail above (Exhibit 7F/2, Exhibit 10F/15, 17, 23).(See id., referencing R. at 426, 459, 461, 467.)
Based on the weight of this evidence, the undersigned finds no error in the ALJ's decision to afford greater weight to the opinions of the two state agency consultants. Indeed, as discussed throughout the ALJ's decision, the longitudinal record reflects gradual improvement in Plaintiff's mental health symptoms and generally shows intact concentration, attention, and memory subsequent to September 2014. (See id. at 19-20, referencing R. at 426, 459, 461, 465, 467, 495, 497.) Thus, it is not unreasonable that the ALJ found the state consultants' less restrictive limitations more consistent with the longitudinal picture of Plaintiff's improved mental health. (Id. at 20.) See, e.g., Lee v. Colvin, No. 0:14-CV-292, 2015 WL 3966235, at *12 (D.S.C. June 30, 2015) ("[O]pinions from non-examining physicians, which in this case are opinions from state agency reviewers, can constitute substantial evidence in support of an ALJ's decision over the opinion of an examining physician so long as the opinions from the non-examining physicians are consistent with the record as a whole."); Tanner, 602 F. App'x at 101 (affirming weight assigned to state agency consultants where the ALJ "made clear that their findings were consistent with the evidence of record, including evidence submitted since the date of reconsideration"); Stanley v. Barnhart, 116 F. App'x 427, 429 (4th Cir. 2004) (disagreeing with the argument that the ALJ improperly gave more weight to residual functioning capacity assessments of non-examining state agency physicians over those of examining physicians and finding that the ALJ properly considered evidence provided by those physicians in context of other medical evidence).
While Plaintiff may disagree with the way in which the ALJ weighed the medical opinions under the factors in 20 C.F.R. §§ 404.1527(c) and 416.927(c), it is not this Court's place to re-weigh conflicting opinions or substitute its judgment for that of the ALJ, especially in light of Dr. Kendall's and Dr. Robbins' highly qualified expertise in Social Security disability evaluation. See Craig, 76 F.3d at 589 (explaining that where the record contains conflicting medical evidence, it is the purview of the ALJ to consider and weigh the evidence and resolve conflicts); see also Marion v. Comm'r, Soc. Sec. Admin., No. 2:16-CV-3285-CMC-MGB, 2018 WL 3120646, at *6 (D.S.C. Jan. 30, 2018), adopted sub nom. Marion v. Berryhill, No. 2:16-CV-3285-CMC, 2018 WL 1324503 (D.S.C. Mar. 15, 2018) (noting that state agency psychological consultants are experts in the Social Security disability programs and the ALJ is therefore required to consider their findings of fact about the nature and severity of an individual's impairments).
Accordingly, the undersigned finds that the ALJ did not err in weighing the aforementioned medical opinions and that his decision to ultimately afford greater weight to the findings of the non-examining state agency consultants was supported by substantial evidence. See Hendrix v. Astrue, No. 1:09-CV-01283-HFF, 2010 WL 3448624, at *2 (D.S.C. Sept. 1, 2010) (citing Koonce v. Apfel, No. 98-1144, 1999 WL 7864, at *2 (4th Cir. Jan. 11, 1999) (noting that an "ALJ's determination as to the weight to be assigned to a medical opinion will generally not be disturbed absent some indication that the ALJ has dredged up 'specious inconsistencies' or has not given good reason for the weight afforded a particular opinion").
III. Lay Witness Testimony
Plaintiff also argues that the ALJ failed to afford proper weight to the testimony of Sheila Hollings, Plaintiff's partner (now fiancé) of thirty-two (32) years. (Dkt. No. 16 at 26-29; R. at 62.) Specifically, Hollings testified at the hearing that Plaintiff continued to hear voices (R. at 63); was paranoid around other people (id. at 65); and rarely left the house other than to accompany Hollings on her errands over the weekends (id. at 63-64). Hollings further testified that Plaintiff had not driven a car or gone to church in at least two (2) years, and that he did not participate in leading any youth groups. (Id. at 61.) When asked why Plaintiff's physicians repeatedly noted his involvement in such activities in their medical records, Hollings suggested that Plaintiff simply "imagine[d] and hallucinate[d]" doing those things. (Id.)
Although the ALJ may consider evidence from lay witnesses (e.g., spouses, parents, and other caregivers) in assessing the severity of the claimant's impairments and ability to function, the ALJ is not required to give such non-medical sources significant weight. See SSR 06-03P, 2006 WL 2329939, at *2; Bazar v. Colvin, No. 9:14-537-TMC, 2015 WL 1268012, at *12 (D.S.C. Mar. 19, 2015); see also Morgan v. Barnhart, 142 F. App'x. 716, 720 (4th Cir. 2005). This is especially true "[w]here a lay witness's testimony merely repeats the allegations of a plaintiff's own testimony and is likewise contradicted by the same objective evidence discrediting the plaintiff's testimony." See White v. Colvin, No. 8:15-CV-01873-MGL-JDA, 2016 WL 3912076, at *11 (D.S.C. June 23, 2016), adopted, No. 8:15-CV-01873-MGL-JDA, 2016 WL 3902834 (D.S.C. July 19, 2016) (noting that "specific reasons are not necessary for dismissing the lay witness's testimony" if he or she simply reiterates the claimant's discredited testimony).
Although SSR 6-3p was rescinded for claims filed on or after March 27, 2017, Plaintiff's applications were filed prior to this date and, thus, SSR 06-03P is applicable to the instant case. Manos v. Berryhill, No. 1:17-CV-00079-FDW, 2018 WL 3059615, at *5 (W.D.N.C. June 20, 2018).
In affording Hollings' hearing testimony "some weight," the ALJ provided the following explanation:
The undersigned has given this testimony some consideration due to a longitudinal history consistent with SSR 96-8p, but it is  based upon casual observation, rather than objective medical examination and testing. Further, it is potentially influenced by the dynamics of relationship and self-interest in the outcome of this claim. Ms. Hollings' testimony certainly does not outweigh the accumulated medical evidence, which is more persuasive regarding the extent to which the impairments limit the claimant's functional abilities. Further, Ms. Hollings' testimony was vague concerning the claimant's hallucinations, which he alleges occur on a daily basis. Ms. Hollings also testified that she leaves the claimant at home unsupervised during the day when she is at work, which is inconsistent with the frequency and severity of mental health limitations alleged.(R. at 21.) Plaintiff argues that in considering Hollings' statements, the ALJ improperly "minimized" evidence that significantly corroborated Plaintiff's own testimony regarding his impairments; specifically, Plaintiff seems to suggest that Hollings' testimony is especially important in explaining why Plaintiff's treatment records reflect inaccurate daily activities. (Dkt. No. 16 at 26-29.) Thus, Plaintiff argues that the ALJ's failure to afford appropriate weight to such "supporting testimony" is cause for remand. (Id.) Plaintiff is mistaken.
As discussed above, the ALJ properly found that Plaintiff's subjective complaints regarding the intensity and limiting effects of his mental impairments were inconsistent with his treatment records, which reflected improvements in Plaintiff's mental health, as well intact concentration, attention, and memory. (See supra pp. 8-13.) Plaintiff's complaints were also internally inconsistent, which further diminished the weight afforded his testimony. (Id.) As Plaintiff so adamantly argues, however, Hollings' testimony largely echoes his subjective complaints of extreme impairment. (Dkt. No. 16 at 26-27.) As a result, Hollings' testimony is likewise discredited by the same treatment notes and medical evidence on which the ALJ relied in discounting Plaintiff's allegations. Therefore, the ALJ was not required to provide specific reasons in dismissing Hollings' testimony. See White, 2016 WL 3912076, at *11 (finding that the ALJ did not need to provide specific reasons in dismissing husband's testimony because it was largely cumulative of his wife's (the claimant) testimony, which was belied by her daily activities and conservative treatment); see also Fray v. Berryhill, No. 6:16-CV-2916-TMC, 2018 WL 1224687, at *4 (D.S.C. Mar. 9, 2018).
Although the ALJ was not required to provide specific reasons in discounting Hollings' statements, the ALJ nevertheless provided a clear, well-reasoned explanation of the weight he afforded her testimony. (R. at 21.) Indeed, contrary to Plaintiff's contention, the ALJ was well within his discretion to consider Hollings' personal relationship with Plaintiff and the possibility that her self-interest and/or loyalty to Plaintiff influenced her testimony. See, e.g., Engle v. Berryhill, No. 5:18-CV-103-GCM, 2019 WL 3047626, at *4 (W.D.N.C. July 10, 2019) (finding that the ALJ properly discounted testimony of plaintiff's mother because she was not a disinterested third party); Manos v. Berryhill, No. 1:17-CV-00079-FDW, 2018 WL 3059615, at *5 (W.D.N.C. June 20, 2018) (concluding that ALJ properly considered testimony from plaintiff's mother and husband, "finding neither could be considered substantial evidence because of possible familial influence"). Moreover, as the Commissioner correctly notes, the ALJ was also justified in considering the lack of objective medical support in discrediting Hollings' hypothesis that Plaintiff repeatedly reported driving and attending church to his physicians because he hallucinated about engaging in those activities. See Engle, 2019 WL 3047626, at *4 (finding that ALJ properly discounted testimony of plaintiff's mother because she also was not medically trained to make exacting observations regarding Plaintiff's impairments). Thus, the undersigned finds that the ALJ properly considered Hollings' testimony as a lay witness, and that his decision to afford her testimony only "some weight" is supported by substantial evidence.
IV. Listing Analysis
Having addressed Plaintiff's subjective complaints, Dr. Sorrow's medical opinion, and Ms. Hollings' hearing testimony, the undersigned now turns to Plaintiff's contention that the ALJ failed to properly apply this evidence in evaluating the criteria under Listings 12.03, 12.04, and 12.06. (Dkt. No. 16 at 11-16.) In order to establish disability, the claimant must present evidence that his impairment or combination of impairments meets or equals one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. See 20 C.F.R. §§ 404.1520(a)(4)(iii), 416.920(a)(4)(iii). To determine whether a claimant's impairments meet or equal a listed impairment at step three of the sequential analysis, the ALJ must identify the relevant listed impairments and compare the listing criteria with the evidence of the claimant's symptoms. Peck v. Colvin, No. 8:12-CV-02594-DCN, 2014 WL 994925, at *12 (D.S.C. Mar. 13, 2014). Because the Listings define impairments that would entirely preclude an adult from performing any gainful activity, the medical criteria are set at a higher level than the statutory standard for disability. Sullivan v. Zebley, 493 U.S. 521, 532 (1990).
While an "ALJ is not required to explicitly identify and discuss every possible listing," the ALJ "is compelled to provide a coherent basis for [the] Step Three determination." Ezzell v. Berryhill, 688 F. App'x. 199, 200 (4th Cir. 2017) (internal citations omitted). Thus, "[i]n cases where there is 'ample factual support in the record' for a particular listing, the ALJ must provide a full analysis to determine whether the claimant's impairment meets or equals the listing." See Peck, 2014 WL 994925, at *12 (citing Cook v. Heckler, 783 F.2d 1168, 1172 (4th Cir. 1986)). Nevertheless, "if the ALJ's opinion read as a whole provides substantial evidence to support the ALJ's decision at step three, such evidence may provide a basis for upholding the ALJ's determination." See McDaniel v. Colvin, No. 2:14-CV-28157, 2016 WL 1271509, at *4 (S.D.W. Va. Mar. 31, 2016) (referencing Smith v. Astrue, 457 F. App'x. 326, 328 (4th Cir. 2011)) ("Reading the ALJ's decision as a whole, substantial evidence supports the finding at step three of the sequential evaluation process as the ALJ's analysis at subsequent steps of the evaluation are inconsistent with meeting [the listing].") Ultimately, "[a] cursory explanation in step three is satisfactory so long as the decision as a whole demonstrates that the ALJ considered the relevant evidence of record and there is substantial evidence to support the conclusion." See id. (referencing Smith, 457 F. App'x. at 328).
Here, the ALJ identified the following relevant mental disorder Listings at step three of the sequential analysis: Listing 12.03 (Schizophrenic, Paranoid and Other Disorders); Listing 12.04 (Affective Disorders); and Listing 12.06 (Anxiety Related Disorders). (R. at 16.) To establish disability under one of these Listings, the claimant must show an extreme limitation of one, or marked limitation of two, of the following areas of mental functioning: (1) understand, remember, or apply information; (2) interact with others; (3) concentrate, persist, or maintain pace; and (4) adapt or manage oneself. 20 C.F.R. Pt. 404, Subpt. P, App'x. 1, § 12.00.F; 20 C.F.R. §§ 404.1520a(c)(3), 416.920a(c)(3). An extreme limitation means that the claimant does not have the ability to function independently, appropriately, effectively, and on a sustained basis in a particular mental functioning area. See Suber v. Berryhill, No. 1:18-CV-424-RMG-SVH, 2019 WL 2870947, at *14 (D.S.C. June 10, 2019), adopted sub nom. Suber v. Berrryhill, No. 1:18-CV-424-RMG, 2019 WL 2870725 (D.S.C. July 3, 2019) (referencing 20 C.F.R. Pt. 404, Subpt. P, App'x 1, § 12.00F). A marked limitation means that the claimant's ability to function in a particular mental functioning area is "seriously limited." (Id.) In the instant case, the ALJ concluded that Plaintiff suffered only mild-to-moderate limitations in the four areas of mental functioning.
The first functional area, understanding, remembering, or applying information, refers to an individual's "abilities to learn, recall, and use information to perform work activities." 20 C.F.R. Pt. 404, Subpt. P, App'x 1, § 12.00E. Examples include "following one- or two-step oral instructions to carry out a task," "asking and answering questions and providing explanations," "identifying and solving problems," and "using reason and judgment to make work-related decisions." Id. In finding that Plaintiff had only mild limitations in the ability to understand, remember, and apply information, the ALJ noted that Plaintiff has a 12th grade education and some post-high school education, although there is conflicting testimony regarding the extent of that subsequent education. (R. at 16.) The ALJ also discussed Plaintiff's conflicting testimony regarding his ability to follow instructions, noting that while Plaintiff indicated having difficulties following both spoken and written instructions in one of his function reports, he also ranked his ability to follow spoken instructions as an "eight" on a scale of ten in a different report. (See id., referencing R. at 265, 291.) In resolving this conflicting evidence, the ALJ reasoned that "mental status examinations conducted during the period at issue typically revealed that the claimant's memory was either mildly impaired or intact and that his intelligence was in the average range." In support, the ALJ cited an extensive list of treatment notes from the record: R. at 379, 382, 402, 405, 410, 412, 426, 459, 461, 463, 465, 467, 469, 471, 473, 475, 477, 484, 488, 495, and 497. (Id.)
Plaintiff also provided inconsistent testimony regarding his personal care. In one function report, Plaintiff stated that he did not require reminders to tend to his personal care, but stated that he did need reminders to take his medication. (See R. at 16, referencing R. at 262.) In another function report, however, Plaintiff stated that he required reminders to do both. (See id., referencing R. at 288.)
The second functional area, interacting with others, "refers to the abilities to relate to and work with supervisors, co-workers, and the public." 20 C.F.R. § 404, Subpt. P, App'x 1, § 12.00E. Examples include "cooperating with others," "initiating or sustaining conversation," "responding to requests, suggestions, criticism, correction, and challenges," and "keeping social interactions free of excessive irritability, sensitivity, argumentativeness, or suspiciousness." Id. In concluding that Plaintiff had moderate limitations in interacting with others, the ALJ again pointed to Plaintiff's function reports, which stated that he socialized with others on the phone, attended church services, went to sporting events, and spent time at the community center. (See R. at 16, referencing R. at 264, 288.) The ALJ referenced other daily living activities later in his discussion of Plaintiff's longitudinal medical record, noting that Plaintiff attended church and youth groups. (Id. at 20.) The ALJ also noted that Plaintiff reported no significant issues in getting along with friends, family, neighbors, or authority figures, and that he had never been fired from a job due to difficulties interacting with others. (See id., referencing R. at 264-65, 291.) In further support, the ALJ cited numerous mental status examinations conducted during the period at issue, which revealed that Plaintiff was cooperative, well-groomed, and able to interact successfully with treatment providers. (See id., referencing R. at 345, 369, 384, 389, 401, 403, 405, 407-09, 412, 416, 426, 433, 438, 457, 459, 461, 463, 465, 467, 469, 471, 473, 475, 477, 486, 491, 495, 497.)
The third functional area, concentrating, persisting, or maintaining pace, "refers to the abilities to focus attention on work activities and stay on task at a sustained rate." 20 C.F.R. § 404, Subpt. P, App'x 1, § 12.00E. Examples include "initiating and performing a task that you understand and know how to do," "working at an appropriate and consistent pace," "completing tasks in a timely manner," "ignoring or avoiding distractions while working," and "working a full day without needing more than the allotted number or length of rest periods during the day." Id. Here, the ALJ concluded that Plaintiff had moderate limitations in concentrating, persisting, and maintaining pace. (R. at 17.) In reaching this determination, the ALJ acknowledged Plaintiff's statements that he could pay attention for only five (5) to ten (10) minutes at a time and that he did not finish what he started. (See id., referencing R. at 291.) The ALJ also discussed Dr. Sorrow's consultative examination, during which Plaintiff reported having difficulty concentrating, and Dr. Sorrow found Plaintiff's concentration and focus to be "very poor." (Id., referencing R. at 408, 410.) Reviewing the medical evidence of record, however, the ALJ found that mental status examinations conducted during the period at issue "typically revealed that the claimant's ability to maintain attention and concentration were intact." (See id., referencing R. at 402-03, 405, 426, 458-59, 461, 463, 465, 467, 469, 471, 475, 477, 495, and 497.) The ALJ further reasoned that Plaintiff "remained capable of shopping, driving, and managing money." (See id., referencing R. at 262-63, 489-91.) The ALJ also discussed the extent of Plaintiff's ability to concentrate in his review of the other medical opinions of record, noting that both Dr. Kendall and Dr. Robbins concluded that Plaintiff was capable of maintaining attention and concentrating for two (2) hours at a time. (Id. at 20.)
The fourth and final functional area, 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'x 1, § 12.00E. Examples 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. In determining that Plaintiff had moderate limitations in adapting and managing himself, the ALJ acknowledged that Plaintiff stated in his function reports that he had difficulty managing stress and changes in routine. (R. at 17.) The ALJ also acknowledged Plaintiff's testimony that he experienced hallucinations. (Id.) However, the ALJ noted that Plaintiff still remained capable of tending to all aspects of his personal care, shopping, driving, and managing money. (See id., referencing R. at 262-63, 489-91.) The ALJ's decision also cited medical treatment notes in which Plaintiff displayed logical, concrete, and goal-directed thought process and appropriate affect. (Id. at 412, 426, 459, 461, 463.) See Williams v. Berryhill, No. 5:18-CV-214-FL, 2019 WL 2970850, at *6 (E.D.N.C. Apr. 29, 2019), adopted sub nom. Williams v. Saul, No. 5:18-CV-214-FL, 2019 WL 2932741 (E.D.N.C. July 8, 2019) (affirming ALJ's conclusion that plaintiff was only mildly limited in adapting or managing himself where exams showed clear, logical, goal-directed thought processes and appropriate mood and affect).
Plaintiff argues that the ALJ erred in determining that Plaintiff did not suffer from marked limitations in any of the above functional areas because he relied on "cherry-picked" evidence and "incorrect facts," while ignoring "uncontested" testimony from Plaintiff and his fiancé, Ms. Hollings. (Dkt. No. 16 at 12-16.) For example, Plaintiff claims that the ALJ's reliance on certain daily living activities ignored testimony from the administrative hearing in which both Plaintiff and Hollings confirmed that Plaintiff had not driven a car or attended church in several years, often had to leave the grocery store due to his paranoia, and experienced auditory hallucinations as frequently as several times each week. (Id.) Plaintiff's argument, however, serves as yet another attempt to improperly reweigh conflicting evidence already resolved by the ALJ and, thus, fails to warrant remand.
As discussed at length above, the ALJ properly considered Plaintiff's subjective testimony in light of the entire record, including the hearing testimony, and ultimately concluded that Plaintiff's statements (and Hollings' statements) regarding the intensity and limiting effects of his impairments were inconsistent with the substantial weight of that evidence. (See supra pp. 8-13, 19-21.) Accordingly, in explaining Plaintiff's limitations under each functional area, the ALJ appropriately discounted such testimony in favor of evidence found in the medical treatment notes and medical opinions, and provided extensive citations in support of his conclusions. While Plaintiff has identified selective evidence in support of greater limitations, the undersigned cannot undertake to reweight evidence or make credibility determinations simply because Plaintiff "can produce conflicting evidence which might have resulted in a contrary interpretation." Owens v. Colvin, No. 0:13-CV-386-BHH, 2014 WL 7043215, at *4 (D.S.C. Dec. 12, 2014) (citing Craig, 76 F.3d at 589); Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990); see also Smith v. Colvin, No. 2:14-CV-3424-TMC, 2016 WL 943667, at *4 (D.S.C. Mar. 14, 2016); Hancock, 667 F.3d at 472. Because there is substantial evidence, cited by the ALJ and otherwise in the record, to support the ALJ's conclusion that Plaintiff was no more than moderately limited under the four mental areas of functioning discussed above, the undersigned finds no reversible error under step three of the sequential analysis.
Plaintiff makes a cursory argument that the ALJ also failed to consider alternative criteria under the relevant mental disorder Listings (Dkt. No. 16 at 15-16), which requires the claimant to show a medically documented history of the existence of the mental disorder in the listing category over a period of at least two (2) years, and evidence that the disorder satisfies both of the following criteria: (1) reliance, on an ongoing basis, upon medical treatment, mental health therapy, psychosocial support(s), or a highly structured setting(s), to diminish the symptoms and signs of the claimant's mental disorder; and (2) despite this treatment, achievement of only marginal adjustment. 20 C.F.R. § 404, Subpt. P, App'x 1, § 12.00G. Plaintiff's argument is based on his subjective testimony that he spent two (2) years "primarily staying in his room with limited occasional shopping and medical appointments." (Dkt. No. 16 at 16.) However, as discussed above, the ALJ properly considered and discredited much of Plaintiff's subjective testimony regarding his daily activities, and properly concluded that Plaintiff was far less housebound than he and Ms. Hollings alleged. (See supra pp. 8-13.) Regardless, the ALJ still considered this alternative criteria in determining that Plaintiff did not meet any of the mental disorder Listings, explaining that "[t]he record does not establish that the claimant has only marginal adjustment, that is, a minimal capacity to adapt to changes in the claimant's environment or to demands that are not already part of the claimant's daily life." (R. at 17.) The ALJ concluded, "[w]hile the evidence establishes that the claimant has some limitations stemming from [his] mental impairments, there is no evidence that [he] has a minimal capacity to adapt to changes." (Id.) Accordingly, Plaintiff's argument regarding the alternative criteria is without merit.
V. Limitations in Plaintiff's Residual Functional Capacity
A. Concentration, Persistence, and Pace
To the extent the Court agrees with the ALJ's determinations under the Listings criteria above, Plaintiff argues that the ALJ's decision failed to account sufficiently for Plaintiff's moderate difficulties in maintaining concentration, persistence and pace under Mascio v. Colvin, 780 F. 3d 632, 637-38 (4th Cir. 2015), when he limited Plaintiff to "simple, routine tasks in a low stress work environment (defined as being free of fast-paced or team-dependent production requirements), involving simple work-related decisions, occasional independent judgment skills and occasional work place changes." (See Dkt. No. 16 at 18-26; R. 18.)
In Mascio, an ALJ found that the claimant had moderate difficulties in concentration, persistence and pace, but had not included this limitation in the vocational expert ("VE") hypothetical or in the RFC. 780 F.3d at 634-35, 637-38. The ALJ found that the claimant was limited to "light work", that she was limited to changing "between sitting and standing every 30 minutes (sit/stand option); only occasional climbing, balancing, bending, stooping, crouching or crawling . . ." and that "due to her adjustment disorder, [the claimant could perform] only unskilled work." Id. at 635.
The Fourth Circuit found the ALJ's decision "sorely lacking in the analysis needed for [the court] to review meaningfully" the ALJ's conclusions. Id. at 636. Although the ALJ concluded that the claimant could perform certain functions, the ALJ said nothing about the claimant's ability to perform them for a full workday. Id. at 637. Additionally, the hypothetical to the VE "said nothing about Mascio's mental limitations." Id. The Fourth Circuit found the "missing analysis . . . especially troubling because the record contain[ed] conflicting evidence as to Mascio's residual functional capacity—evidence that the ALJ did not address." Id. The Fourth Circuit specifically found that "an ALJ does not account 'for a claimant's limitations in concentration, persistence and pace by restricting the hypothetical questions to simple, routine tasks or unskilled work'" Id. at 638 (citing Winschel v. Comm'r of Soc. Sec., 631 F.3d 1176, 1180 (11th Cir. 2011) (joining the Third, Seventh and Eighth Circuits). The Fourth Circuit stated that "[p]erhaps the ALJ can explain why Mascio's moderate limitation in concentration, persistence, or pace . . . does not translate into a limitation in Mascio's residual functional capacity." Id.
The undersigned notes that the RFC also appears to account for Plaintiff's other mental limitations by removing Plaintiff from significant interaction with the public and his coworkers, limiting workplace changes, and limiting him to simple work-related decisions. (R. at 18.)
the claimant can concentrate, persist and maintain pace sufficient to understand, remember and carry out simple, routine tasks in a low stress work environment (defined as being free of fast-paced or team-dependent production requirements), involving simple work-related decisions, occasional independent judgment skills and occasional work place changes; the claimant can perform jobs where the worker is largely isolated from the general public, dealing with data and things rather than people; the claimant can perform jobs where the work duties can be completed independently from coworkers; however, physical isolation is not required, and can respond appropriately to reasonable and customary supervision.(R. at 18.) Although Mascio requires a case-by-case inquiry to determine whether an RFC adequately accounts for a claimant's limitations in concentration, persistence, and pace, district courts within this Circuit have consistently found similar RFC determinations sufficient to account for such limitations. See, e.g., Greene v. Berryhill, No. 2:16-CV-2894-DCC-MGB, 2018 WL 3120644, at *3-5 (D.S.C. Jan. 30, 2018), adopted sub nom. Greene v. Comm'r of Soc. Sec., No. 2:16-CV-2894-DCC, 2018 WL 1516853 (D.S.C. Mar. 28, 2018) (finding that ALJ adequately accounted for the plaintiff's moderate limitations in her concentration, persistence, or pace in her residual functional capacity by limiting her to "simple, routine, repetitive tasks not performed fast paced production environment and involving only simple work-related instructions and decisions and relatively few work place changes with no more than occasional interaction with co-workers or the general public"); Sizemore v. Berryhill, 878 F.3d 72, 80-81 (4th Cir. 2017) (accounting for moderate limitations in concentration, persistence and pace by limiting claimant to simple tasks in a "low stress" setting, without any "fast-paced work" or "public contact"); Martini-Roth v. Colvin, No. 1:14-CV-4683-TLW-SVH, 2015 WL 12602443, at *26-27 (D.S.C. Nov. 23, 2015) (finding that ALJ adequately considered plaintiff's subjective reports of difficulty concentrating in limiting her to "unskilled work in a low-stress environment free of fast-pace production requirements, with few workplace changes, and only occasional interaction with the public"); Graham v. Saul, No. 1:18-CV-403, 2019 WL 3767041, at *8 (M.D.N.C. Aug. 9, 2019), adopted, No. 1:18-CV-403, 2019 WL 5783543 (M.D.N.C. Sept. 3, 2019) (finding that ALJ properly accommodated plaintiff's limitations in concentration, persistence, and pace by prohibiting "fast paced production work"); Baker v. Colvin, No. 3:15-CV-00637-HEH, 2016 WL 3581859, at *3 (E.D. Va. June 7, 2016), adopted, No. 3:15-CV-637-HEH, 2016 WL 3582071 (E.D. Va. June 28, 2016) (finding that RFC limiting an individual to work in "a non-production oriented environment" properly addressed an individual's ability to stay on task).
The ALJ in this case also provided a sufficient explanation for the Court to conduct a meaningful review of the RFC. Indeed, taken as a whole, the ALJ's decision thoroughly and fairly detailed the Plaintiff's mental health records, which noted gradual improvements in Plaintiff's symptoms, as well as participation in activities consistent with a less severe level of limitation. (R. at 19-20.) The decision also discussed the medical opinions of record, all of which indicated that Plaintiff drove, socialized, and participated in other daily living activities consistent with moderately limited concentration, persistence, and pace. (Id. at 20.) Notably, the ALJ explained that the state agency consultants found Plaintiff could maintain attention and concentration for two (2) hours at a time, which further supported the decision to limit Plaintiff's RFC to simple tasks. (Id.) Although Plaintiff's subjective complaints were largely inconsistent with the aforementioned evidence, the ALJ still accounted for a possible exacerbation of his symptoms, explaining that,
Indeed, while Plaintiff argues that the ALJ should have afforded greater weight to Dr. Sorrow's opinion, the undersigned notes that she too confirmed Plaintiff's reports of driving and socializing. (R. at 409.)
As evidenced by his reliance on the state agency consultants' opinions, the ALJ did in fact consider how Plaintiff's limitations in concentration, persistence, and pace would translate to an eight-hour workday. See, e.g., Wilkerson v. Colvin, No. 1:15-CV-00944, 2016 WL 3264311, at *5-6 (M.D.N.C. June 14, 2016) (finding the ALJ's reliance on the state agency consultant's determination was sufficient because the consultant concluded "that, despite moderate limitation in [concentration, persistence or pace], Plaintiff could maintain attention concentration for at least two hours at a time as required for the performance of simple tasks"); Sizemore v. Berryhill, 878 F.3d 72, 80-81 (4th Cir. 2017) (explaining that an individual who can maintain attention for at least two hours is "mentally capable of independently performing basic, routine tasks on a sustained basis"). Thus, Plaintiff's contention to the contrary is without merit. (Dkt. No. 16 at 22-26.)
while the claimant's mental impairments appear successfully managed with medication, in consideration of the claimant's subjective complaints and giving some consideration to a possible re-emergence of his symptoms, he is restricted to performing simple, routine tasks, along with a number of other work-related mental limitation involving his ability to interact socially and maintain concentration, which are consistent with the opinions of Dr. Kendall and Dr. Robbins.(Id. at 21.) Accordingly, the undersigned finds, particularly in light of the persuasive, recent case law affirming similar RFC determinations, that the ALJ adequately accounted for Plaintiff's moderate limitations in concentration, persistence, and pace in determining his RFC.
The undersigned finds that the ALJ also accounted for such limitations in his hypothetical to the VE, which mirrors the RFC above:
[O]ver the course of an eight-hour workday, in two-hour increments with normal and acceptable work breaks this person could perform work at the medium exertional level as defined in the rules and regulations. This person could occasionally climb ladders, ropes, and scaffolds. This person can frequently climb ramps and stairs, balance, stoop, kneel, crouch, and crawl. This person can occasionally be exposed to hazards associated with unprotected dangerous machinery or unprotected heights. This person can concentrate, persist, and maintain pace sufficient to understand, remember, and carryout simple, routine tasks in a low stress work environment that we will define as being free of fast-paced or team dependent production requirements involving simple work-related decisions, occasionally independent judgment skills, and occasional workplace changes. . . . [T]his person can perform jobs where they are largely isolated from the general public, and dealing with data and things rather than people. This person can perform jobs where the work duties can be completed independently from coworkers, but physical isolation would not be required. And finally this person can respond appropriately to reasonable and customary supervision.
B. Medication-Related Side Effects
Plaintiff also argues that the ALJ failed to consider his medication-related side effects in determining the RFC. (Dkt. No. 16 at 32-33.) Specifically, Plaintiff contends that the ALJ's RFC assessment failed to consider that Plaintiff's medications caused his hands to shake, made him drowsy, and impeded his ability to concentrate. (Id. at 32-33.) The undersigned disagrees.
In reaching a determination regarding a plaintiff's RFC, the ALJ must base the decision on "all of the relevant evidence in the case record" including the side effects of medication. SSR 96-8P, 1996 WL 374184 (July 2, 1996). However, "[t]he ALJ is not required to accept unquestioningly all alleged side effects of medications; complaints of side effects may properly be discredited by inconsistent evidence." See Goodwater v. Barnhart, 579 F. Supp. 2d 746, 759 (D.S.C. 2007) (citing Johnson v. Barnhart, 434 F.3d 650, 659 (4th Cir. 2005)).
Here, the ALJ expressly acknowledged Plaintiff's subjective testimony that his "medication makes it hard for him to think, and causes other side effects such as tremors in his hands." (R. at 19.) However, as the Commissioner correctly notes, the ALJ adequately discussed his consideration of Plaintiff's subjective testimony—including these medication side effects—and clearly explained why he found that Plaintiff was not as limited as he claimed. (Dkt. No. 17 at 23, referencing R. at 19-24.) See Riley v. Berryhill, No. 8:16-CV-00352-JDA, 2017 WL 3381293, at *8 (D.S.C. Aug. 7, 2017) (explaining that the ALJ need not accept alleged side effects if he "fully explains why the claimant's testimony should be discredited"). The ALJ also discussed Plaintiff's limitations in concentration, persistence, and pace, and explicitly accounted for such difficulties in the RFC. (Id.)
With respect to Plaintiff's hand tremors, the ALJ cited multiple medical treatment records in which Plaintiff reported significant improvement in his symptoms as a result of his medication and reported no side effects in relation thereto. For example, on April 26, 2016, Plaintiff reported that he was "very appreciate of his treatment and his medication," and "[did] not complain of side effects." (R. at 461.) On July 26, 2016, Plaintiff's physician noted, "[Plaintiff] has no complaints about his medication—says it has helped a lot." (Id. at 459.) Moreover, reviewing these medical records, there are no treating physician opinions or other medical source statements suggesting that the hand tremors that resulted from Plaintiff's medication rendered him unable to work.
Accordingly, the undersigned finds that the ALJ properly considered Plaintiff's medicinal side effects, and that his RFC determinations are therefore supported by substantial evidence. See, e.g., Hay v. Colvin, No. 8:15-CV-00236-JDA, 2016 WL 536746, at *8 (D.S.C. Feb. 11, 2016) (finding, despite ALJ's failure to explicitly mention limitations from alleged medication-related side effects, that substantial evidence supported ALJ's credibility analysis and RFC determination where plaintiff's medical history revealed only generalized complaints of fatigue and contained no opinions that such side effects impaired plaintiff's ability to work); Riley v. Berryhill, No. 8:16-CV-00352-JDA, 2017 WL 3381293, at *8 (D.S.C. Aug. 7, 2017) (emphasizing that ALJ was not required to accept all alleged medication-related side effects where medical records did not reflect any such complaints and physicians provided no opinions that medications rendered plaintiff unable to work); see also Baker, 2016 WL 527054, at *8 (citing Burns v. Barnhart, 312 F.3d 113, 131 (3d Cir. 2002), for the proposition that, "[d]rowsiness often accompanies the taking of medication, and it should not be viewed as disabling unless the record references serious functional limitations").
It is therefore RECOMMENDED, for the foregoing reasons, that the Commissioner's decision be AFFIRMED.
IT IS SO RECOMMENDED.
MARY GORDON BAKER
UNITED STATES MAGISTRATE JUDGE January 23, 2020 Charleston, 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
Post Office Box 835
Charleston, South Carolina 29402
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).
(R. at 68-69.)