United States District Court, Western District of Virginia, Danville Division
KENNETH J. COOKE, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
REPORT AND RECOMMENDATION
Joel C. Hoppe United States Magistrate Judge
Plaintiff Kenneth J. Cooke seeks review of the Commissioner of Social Security’s (“Commissioner”) final decision denying his application for disability insurance benefits (“DIB”) and supplemental security income (“SSI”) under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 401–434, 1381–1383f. On appeal, Cooke argues that the Commissioner erred in giving the opinion of his treating psychiatrist little weight. Cooke also argues that the Administrative Law Judge (“ALJ”) improperly assessed his credibility. This Court has jurisdiction pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), and this case is before the undersigned magistrate judge by referral under 28 U.S.C. § 636(b)(1)(B). After carefully reviewing the administrative record, the parties’ briefs, and the applicable law, I find that the ALJ’s decision is supported by substantial evidence, and I recommend that the Commissioner’s decision be affirmed.
I. Standard of Review
The Social Security Act authorizes this Court to review the Commissioner’s final determination that a person is not entitled to disability benefits. See 42 U.S.C. §§ 405(g), 1383(c)(3); see also Hines v. Barnhart, 453 F.3d 559, 561 (4th Cir. 2006). The Court’s role, however, is limited—it may not “reweigh conflicting evidence, make credibility determinations, or substitute [its] judgment” for that of agency officials. Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012). Instead, the Court asks only whether the ALJ applied the correct legal standards and whether substantial evidence supports the ALJ’s factual findings. Meyer v. Astrue, 662 F.3d 700, 704 (4th Cir. 2011).
“Substantial evidence” means “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971). It is “more than a mere scintilla” of evidence, ” id., but not necessarily “a large or considerable amount of evidence, ” Pierce v. Underwood, 487 U.S. 552, 565 (1988). Substantial evidence review takes into account the entire record, and not just the evidence cited by the ALJ. See Gordon v. Schweiker, 725 F.2d 231, 236 (4th Cir. 1984); see also Universal Camera Corp. v. NLRB, 340 U.S. 474, 487–89 (1951). Ultimately, this Court must affirm the ALJ’s factual findings if “‘conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled.’” Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir. 2005) (per curiam) (quoting Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996) (internal quotation marks omitted)). 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).
A person is “disabled” if he or she is unable 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 12 months.” 42 U.S.C. §§ 423(d)(1)(A), 1382c(a)(3)(A); 20 C.F.R. §§ 404.1505(a) (governing claims for DIB), 416.905(a) (governing adult claims for SSI). Social Security ALJs follow a five-step process to determine whether an applicant is disabled. The ALJ asks, in sequence, whether the applicant: (1) is working; (2) has a severe impairment; (3) has an impairment that meets or equals an impairment listed in the Act’s regulations; (4) can return to his or her past relevant work based on his or her residual functional capacity; and, if not (5) whether he or she can perform other work. See 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4); see also Heckler v. Campbell, 461 U.S. 458, 460–62 (1983). The applicant bears the burden of proof at steps one through four. Hancock, 667 F.3d at 472. At step five, the burden shifts to the agency to prove that the applicant is not disabled. See id.
II. Procedural History
Cooke was born on December 5, 1977 (Administrative Record, hereinafter “R.” 179), and at the time of the ALJ’s decision was considered a “younger person” under 20 C.F.R. §§ 404.1563(c), 416.963(c). He is a high school graduate (R. 217) and has prior work history as a laborer, assembler, salesperson, factory technician, and retail worker (R. 218, 241). Cooke applied for DIB on October 18, 2010 (R. 179-80), and for SSI on November 2, 2010 (R. 183-92). He alleged a disability onset date of September 1, 2009, due to bipolar disorder, depression, chronic pain, muscle spasms and stiffness, fatigue, shortness of breath, kidney problems, confusion, memory loss, heart problems, and high blood pressure. (R. 179, 183, 216.)
The Commissioner rejected Cooke’s applications initially and on reconsideration. (R. 17.) On January 3, 2012, the ALJ held an administrative hearing at which Cooke was represented by counsel. (R. 34-68.) In an opinion dated January 20, 2012, the ALJ found that Cooke had respiratory disorder, essential hypertension, vertebrogenic disorder, obesity, anxiety disorder, affective disorder, bipolar disorder, depressive disorder, and substance abuse disorder, which qualify as severe impairments. (R. 19.) None of the impairments met or equaled the severity of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. 21-23.) The ALJ found that Cooke had the residual functional capacity (“RFC”) to perform less than a full range of light work,  and he can occasionally climb ramps or stairs, stoop, kneel, crouch, and crawl; can never climb ladders, ropes, or scaffolds; can no more than frequently balance; and must avoid concentrated exposure to heat, wetness, humidity, vibrations, irritants, and workplace hazards. (R. 23.) Additionally, his work must be limited to simple, routine, and repetitive tasks with only occasional interaction with supervisors. (Id.) Relying on the testimony of a vocational expert, the ALJ determined that Cooke was capable of performing his past work as an assembler. (R. 27.) The ALJ also made an alternate finding that Cooke could perform other work at both the light and sedentary levels. (R. 28.) Accordingly, the ALJ determined that Cooke was not disabled under the Act. (R. 29.) The Appeals Council denied Cooke’s request for review (R. 1-5), and this appeal followed.
III. Statement of Facts
A. Medical Evidence
On November 30, 2009, Cooke complained of knee, neck, and wrist pain to Amy Branson, a physician’s assistant. (R. 338). Branson’s physical exam of these three areas revealed full ranges of motion and otherwise normal signs. (R. 338-39.) She also noted that Cooke was alert and oriented times three, and he had appropriate speech and affect. (R. 338.) On January 26, 2010, Cooke complained of joint and back pain and fatigue. (R. 343.) Branson noted seven tender points in Cooke’s back, shoulder, and hips, but made no other physical findings. (R. 344.) Cooke reported no psychological symptoms, and Branson found normal psychological signs. (R. 343-44.)
On June 25, 2010, Cooke was admitted under a temporary detention order to Community Memorial Hospital after stating that he would kill himself if he could not get relief from his chronic pain. (R. 305.) Dr. Masoud Hejazi, M.D., found that Cooke’s memory in the recent and short term was good, his speech was coherent and appropriate with no looseness of association, his affect and mood were subdued and depressed, he was oriented to time, place, person, and situation, his fund of knowledge was fair, and he did not seem acutely psychotic, suicidal, or homicidal. (R. 306.) On June 28, a different attending physician found that Cooke did not remember the events of the two days preceding his hospitalization, a condition the physician attributed to Cooke’s abuse of cocaine. (R. 307-08.) Although Cooke denied current drug use, his urine screen was positive for cocaine. (R. 307, 310.) He admitted to using heroin, cocaine, crack, and marijuana in the past. (R. 305, 310.) Dr. Veeraindar Goli, M.D., diagnosed opiate dependence; major depressive disorder, recurrent, moderate, severe; and cocaine abuse, and he opined that Cooke’s prognosis was guarded. (R. 310, 313.) Upon discharge on July 2, Cooke’s Global Assessment of Functioning (“GAF”) score was 65 to 70,  but it had been 25 to 50 upon admission. (R. 310.) Cooke was prescribed various medications, including Wellbutrin, Prolixin, Depakote, and Effexor and instructed to follow-up with the community services board. (R. 313.)
On July 5, 2010, Cooke was admitted to the Center for Behavioral Health on a temporary detention order after he threatened his father and step-mother with a knife and then threatened to kill himself. (R. 321.) Cooke did not remember these events. (Id.) He denied suicidal intent and stated that he was upset because his pain prevented him from holding a job and he suspected he had lung cancer. (Id.) At intake, Cooke reported experiencing hallucinations and thoughts of suicide, which he later denied. (R. 321-22, 324.) Cooke also reported depressed mood, decreased energy and interests, and anxiety symptoms. (R. 322.) He admitted using cocaine two weeks ago and otherwise intermittently. (R. 321.) He also admitted using Percocet that he obtained from a street dealer, but his urine screen was positive only for tricyclics (antidepressants). (R. 321, 329.) Dr. Charlotte Hagan, M.D., noted that Cooke was drowsy, but could become alert. (R. 324.) She also noted that his mood was depressed, affect was flat, and memory, judgment, and insight were impaired. (Id.) His thought process showed amnesia for events leading up to his admission, his impulse control was intact although recently impaired, and his reliability was fair to poor. (Id.) She noted Cooke’s history of polysubstance abuse. (R. 322.) His treatment plan involved group, individual, and milieu therapies and medication management. (R. 326.) During his admission, Cooke completed a Beck Depression Inventory that indicated severe depression based on his self-reported symptoms. (R. 328.) Dr. Hagan decreased Cooke’s dose of Effexor and discontinued his use of Wellbutrin and Prolixin. (R. 327-28.) Dr. Hagan diagnosed polysubstance abuse, schizophrenic disorder, and amnestic disorder, not otherwise specified. (R. 330.) She opined that his prognosis was good if he “remained sober from controlled substances.” (Id.) On July 12, Dr. Hagan noted that Cooke’s mood had stabilized, and she discharged him with instructions to follow-up with the community services board and his primary care provider. (R. 329.)
On July 19, 2010, Cooke complained to physician’s assistant Branson of pain, fatigue, and depression, and he stated that medications did not help his depression. (R. 345.) Branson found that Cooke was pleasant, alert and oriented times three, and talkative and had an appropriate affect, appropriate speech, and good eye contact. (Id.) On August 19, Cooke told Branson that he had started taking Seroquel and that other than being tired, he felt good. (R. 347.) Branson noted normal psychological signs. (Id.) On September 22, Cooke complained of lower back pain and trouble urinating. (R. 350.) He did not complain of fatigue, and he reported walking and performing activities of daily living with no difficulty. (Id.) Branson found that Cooke had normal range of motion of the spine and normal gait, sensation, and strength. (Id.) Her psychological findings were normal. (Id.)
Psychiatrist William Trost, M.D., conducted an initial psychiatric evaluation of Cooke on August 13, 2010. (R. 620-22.) Dr. Trost noted Cooke’s prior hospitalizations, including two from the previous months, and several drug treatment program admissions. (R. 620-21.) He surmised that Cooke’s condition was bipolar disorder rather than pure depression because it was marked by periods of elevated mood with euphoria followed by days of withdrawal and depression. (Id.) Cooke reported primary symptoms of depression and pain and stated that he spent most of his time in bed. (R. 621.) In his last job, Cooke worked for a friend who understood his limitations, but he was laid off during a downturn in the economy. (Id.) Cooke reported experiencing some auditory and visual hallucinations and some passive suicidal thoughts. (Id.) On mental status exam, Dr. Trost noted a constricted affect; depressed mood; appropriate, pleasant, and cooperative attitude; linear and goal directed thought processes; no gross deficit in memory; some difficulty in long term memory; and fair insight. (Id.) Dr. Trost diagnosed bipolar disorder, not otherwise specified, history of opiate dependence, and history of cocaine abuse, and he assigned a GAF score of 45 to 50. (R. 622.) He prescribed Seroquel, Gabapentin, and Cyclohezaprine. (R. 621.)
On September 7, 2010, Cooke reported improved symptoms, but still significant anxiety. (R. 620.) On November 2, Cooke reported irritability with his father. (R. 619.) Dr. Trost noted that Cooke showed no signs of mania or psychosis. (Id.) On December 28, Cooke reported increased depression and some passive thoughts of suicide. (R. 618-19.) Dr. Trost’s mental status exam was normal other than findings of depressed mood and affect. (R. 619.) He noted concern over Cooke’s “worsening mood” and “suicidality” and adjusted Cooke’s medication. (Id.) A month later, Dr. Trost noted normal psychological findings, including euthymic mood, and found that Cooke’s symptoms had substantially improved. (R. 618.) From month to month during March through October 2011, Cooke’s depressive symptoms worsened and then improved with medication adjustment. (R. 613-17.) During this period, Dr. Trost determined that Cooke’s “diagnostic picture is becoming clearer and looks increasingly like bipolar I with rapid cycling.” (R. 615.)
While being treated by Dr. Trost, Cooke also received “cognitive behavioral psychotherapy, to help better manage pain, mood and stress” from Dr. Lora Baum, Ph.D., and Nurse Lara Myers, N.P., at the University of Virginia Pain Management Center. (R. 558.) Notes of Cooke’s first appointment with Dr. Baum on October 6, 2010, chronicle Cooke’s mental health history. (R. 561.) When Cooke was five years old, he was molested by an older cousin. At age 16, he began using heroin, cocaine, marijuana, and pills. In 2003, his mother died of lung cancer, and he attempted suicide by overdosing, after which he participated in extensive drug counseling. In 2008 he started a home improvement business. A downturn in the economy and an increase in Cooke’s back pain caused him to abandon this business. In July 2010, he attempted suicide again by overdosing on heroin and cocaine. He is seeking disability because of his pain and depression. On mental status exam, Dr. Baum found that Cooke was depressed and anxious, but oriented. He had a labile affect, crying at times; intact thought process; good ...