United States District Court, E.D. Virginia, Richmond Division
REPORT AND RECOMMENDATION
DAVID J. NOVAK, Magistrate Judge.
Korissa Lynn Rose ("Plaintiff) is 36 years old and previously worked as a project manager/customer order clerk, music store manager and customer service representative. On August 4, 2010, Plaintiff filed for Disability Insurance Benefits ("DIB") under the Social Security Act ("Act"), alleging disability from bipolar disorder, depression, anxiety, obsessive/compulsive disorder ("OCD"), attention deficit disorder ("ADD") and borderline personality disorder features with an alleged onset date of November 10, 2008. An administrative law judge ("ALJ") denied Plaintiffs request for benefits on September 27, 2012. The Appeals Council subsequently denied Plaintiffs request for review on October 17, 2013.
Plaintiff seeks judicial review of the ALJ's decision in this Court pursuant to 42 U.S.C. § 405(g). Plaintiff challenges the ALJ's denial of benefits on the basis that the ALJ incorrectly determined that Plaintiff could perform work at all exertional levels with nonexertional limitations and that the ALJ erred in affording less than controlling weight to Plaintiffs treating physician's opinions. (Pl.'s Mem. of P. & A. in Supp. of Mot. for Summ. J. ("Pl.'s Mem.") (ECF No. 17) at 6-8.) The matter comes before the Court for a report and recommendation pursuant to 28 U.S.C. § 636(b)(1)(B) on cross-motions for summary judgment. For the reasons set forth below, the Court recommends that Plaintiffs Motion for Summary Judgment (ECF No. 15) be DENIED; that Defendant's Motion for Summary Judgment (ECF No. 18) be GRANTED; and that the final decision of the Commissioner be AFFIRMED.
Because Plaintiff challenges whether the ALJ erred in determining that Plaintiff had the ability to perform work at all exertional levels with nonexertional limitations and in affording less than controlling weight to Plaintiffs treating physician's opinion, Plaintiffs education and work histories, relevant medical history, Plaintiffs function report, third-party reports and Plaintiffs hearing testimony are summarized below.
A. Plaintiffs Education and Work Histories
Plaintiff is 36 years old. (R. at 19, 94.) She earned her GED in 2002 and attended some community college classes. (R. at 19, 166.) Plaintiff previously worked as a project manager/customer order clerk, music store manager and customer service representative. (R. at 102-03.)
B. Medical History
On June 10, 2008, Plaintiff underwent counseling from Natalie Relph, M.D. at Dominion Behavioral Healthcare. (R. at 451-53.) Dr. Relph conducted an initial psychiatric evaluation and noted that Plaintiff had a prior diagnosis of bipolar disorder but no history of consistent treatment. (R. at 451.) Plaintiff reported having chronic suicidal ideation, but no current intent. (R. at 451.) Plaintiff also indicated that she was frequently nervous and anxious and often had trouble sleeping. (R. at 451.) Dr. Relph noted that Plaintiff had soft speech, depressed mood, detached affect and logical thought process. (R. at 453.) Plaintiff demonstrated fair insight and impulse control, as well as intact memory. (R. at 453.) After the examination, Dr. Relph diagnosed Plaintiff with bipolar disorder type II and anxiety disorder, with a Global Assessment of Functioning ("GAF") score of 48. (R. at 453.) Dr. Relph prescribed Lamictal and Seroquel to treat Plaintiffs symptoms. (R. at 453.) On June 25, 2008, Plaintiff complained that her mood was down, that she experienced anxiety and that she had trouble sleeping. (R. at 450.) Dr. Relph noted that Plaintiff remained well-oriented, had logical thought process and exhibited fair judgment, insight and impulse control. (R. at 450.) Dr. Relph prescribed Geodon and Ativan, because Plaintiff did not tolerate Seroquel well and experienced several side-effects. (R. at 450.)
In August 2008, Plaintiff reported feeling "wonked out" and concerned about reacting negatively to the prescribed medications. (R. at 445.) Plaintiff also felt emotionally exhausted due to ongoing conflicts with her boyfriend and lack of consistent sleep. (R. at 444.) On September 16, 2008, Plaintiff described her emotions as less intense, but felt that her OCD symptoms became more problematic. (R. at 443.) Dr. Relph assessed Plaintiffs GAF at 50. (R. at 443.) On October 15, 2008, Dr. Relph prescribed Abilify for Plaintiff. (R. at 442.)
On December 8, 2008, Dr. Relph noted that Plaintiffs mood remained the same. (R. at 440.) Plaintiff expressed anxiety about starting school in January, and she felt a decline in focus during the previous three months. (R. at 440.) By April 2009, Plaintiff reported feeling anxious and irritable and found school stressful. (R. at 439.) Dr. Relph prescribed Prozac to Plaintiff, finding that Plaintiff could no longer tolerate Abilify. (R. at 439.) By June 5, 2009, Plaintiffs anxiety and focus had improved, making it easier for Plaintiff to attend classes. (R. at 437.)
On September 24, 2009, Plaintiff sought treatment from Dr. Relph for pharmacologic management at Commonwealth Counseling Associates, P.C. (R. at 335.) Dr. Relph noted that Plaintiff had a prior history of bipolar disorder, but ruled out borderline personality disorder. (R. at 335-36.) Plaintiff reported no problematic anxiety and demonstrated logical and coherent speech, appropriate motor activity, clear and lineal thought process and appropriate hygiene and dress. (R. at 335.) Plaintiffs primary concern was her ability to focus and concentrate and found it difficult to be back in school full-time and complete classwork. (R. at 335.) Dr. Relph noted that Plaintiff had no history consistent with adult attention deficit disorder. (R. at 335.)
On December 1, 2009, Plaintiff reported increased irritability when she stopped taking Lithium, but her symptoms decreased by taking one pill daily. (R. at 338.) Plaintiff remained unfocused and forgetful despite lowering her Lithium dosage. (R. at 338.) Dr. Relph noted that Plaintiff appeared well-oriented with appropriate motor skills, clear judgment and good thought process. (R. at 338.) Dr. Relph diagnosed Plaintiff with bipolar disorder and borderline personality features and referred Plaintiff for cognitive testing. (R. at 339.) Dr. Relph assessed Plaintiffs GAF at 60. (R. at 339.)
On December 18, 2009, Plaintiff underwent a psychiatric diagnostic interview examination based on Dr. Relph's referral. (R. at 340-42.) During the examination, Plaintiff appeared anxious and depressed, but her thought process remained logical. (R. at 340.) The interviewer assessed Plaintiffs GAF at 55 and determined that Plaintiffs anxiety was a major factor in her difficulty concentrating, but thought it unlikely to be adult attention deficit disorder. (R. at 342.)
On February 16, 2010, Plaintiff reported to Dr. Relph that she felt unmotivated, depressed and unfocused. (R. at 343.) As a result, Plaintiff reduced her school course load because of her inability to manage it. (R. at 343.) Dr. Relph noted that Plaintiff appeared well-oriented and exhibited good insight, judgment, memory and impulse control. (R. at 343.) Plaintiffs GAF score remained at 55. (R. at 344.) On March 16, 2010, Plaintiffs depressive symptoms remained the same, but she complained of increased anxiety and obsessiveness. (R. at 346.) Dr. Relph's examination of Plaintiff remained unchanged and assessed Plaintiffs GAF at 55. (R. at 347.)
In April and May 2010, Plaintiff experienced continued depression, anxiety and poor focus. (R. at 349, 351.) Dr. Relph's GAF assessment remained at 55 for both examinations. (R. at 348, 350.) On May 25, 2010, Plaintiff had been taking Wellbutrin, and she experienced no adverse side effects. (R. at 352.) Plaintiff noted that her energy and motivation felt better, and she began walking and jogging approximately six miles per day with her boyfriend. (R. at 352.) Plaintiff also planned a trip with a friend to New York, despite feeling apprehensive about traveling. (R. at 352.) Dr. Relph noted that Plaintiff remained well-oriented, and her judgment, memory and impulse control were intact. (R. at 352.)
On June 24, 2010, Plaintiff complained of continued depression and obsessive compulsiveness. (R. at 356.) Plaintiff reported feeling increased inflexibility, especially related to germs and symmetry, and she refused to sit down in the waiting room for fear of stray hairs (R. at 356.) Dr. Relph discussed solutions for Plaintiff, particularly to help with scheduling activities, but Plaintiff rejected most of Dr. Relph's ideas. (R. at 356.) In August 2010, Plaintiff began taking Luvox CR and experienced no adverse side effects. (R. at 360.) Plaintiff also planned to take a four-day car trip to Florida with her boyfriend. (R. at 360.) Plaintiff expressed concern that the trip would trigger her anxiety and her phobias, but she wanted to try. (R. at 360.) Plaintiff exhibited good insight, judgment, thought process and impulse control. (R. at 360.)
On October 8, 2010, Plaintiff informed Dr. Relph that she had lost her health insurance coverage and could not afford to pay for Luvox, but would continue to pay for Lithium. (R. at 374.) On November 23, 2010, Plaintiff described increased irritability after stopping her medications. (R. at 377.) Dr. Relph noted that Plaintiff continued to demonstrate good impulse control, judgment and insight. (R. at 377.) Dr. Relph assessed Plaintiffs GAF at 55. (R. at 378.) On July 20, 2011, Plaintiff reported increased flexibility in her OCD, but felt foggy and anxious. (R. at 409.) Dr. Relph assessed Plaintiffs GAF at 55 and noted that Plaintiff continued to have good judgment, thought process and impulse control. (R. at 409-10.) On September 21, 2011, Plaintiff complained of increased irritability and stress due to a recent move and two pending court cases. (R. at 411.) Dr. Relph assessed Plaintiffs GAF at 55 and noted that Plaintiff appeared well-oriented with good judgment, thought process and impulse control. (R. at 411-12.)
On January 23, 2012, Dr. Relph informed Plaintiff that she was discontinuing the doctor-patient relationship due to Plaintiffs failure to attend regular appointments and lack of insurance coverage. (R. at 414.) Dr. Relph recommended that Plaintiff seek additional treatment through her community health board or health organization. (R. at 414.)
On June 18, 2012, Plaintiff was admitted to the Richmond Behavioral Health Authority ("RBHA") for depression, obsessive thoughts, anxiety, fatigue, decreased concentration and sleep disturbance. (R. at 457.) On June 21, 2012, RBHA staff noted that Plaintiff felt "much calmer, '" that her symptoms were "at baseline" and that her sleep had improved. (R. at 457.) RBHA discharged Plaintiff on June 22, 2012 and referred Plaintiff to the Daily Planet for further treatment. (R. at 457-58.)
Dr. Nestor Vozza treated Plaintiff at RBHA from June 18, 2012 through June 21, 2012. (R. at 454-56.) On June 21, 2012, Dr. Vozza completed a standard Mental Capacity Assessment form evaluating Plaintiffs degrees of limitations resulting from psychological factors. (R. at 454-55.) The form addressed areas of "sustained concentration and persistence, " "social interaction" and "adaptation." (R. at 454-55.) Dr. Vozza opined that Plaintiff primarily demonstrated "marked" or "extreme"  limitations to each respective statement. (R. 454-55.) Dr. Vozza found Plaintiff to have "extreme" limitations in all social interaction and adaptation statements. (R. at 455.) Dr. Vozza determined that Plaintiff exhibited either "marked" or "extreme" limitations in sustained concentration and persistence statements, but Plaintiff only had "moderate" limitations with regard to "[t]he ability to make simple work-related decisions" and "[t]he ability to perform at a consistent pace with a one hour lunch break and two 15 minute rest periods." (R. at 454.) Dr. Vozza also opined that Plaintiffs onset date of disability had existed for twenty years. (R. at 456.)
C. Function Report
On September 13, 2010, Plaintiff completed a Function Report. (R. at 246-53.) Plaintiff indicated that she lived in a house with her significant other. (R. at 246.) She took medication for her bipolar disorder, depression and anxiety. (R. at 232.) These conditions affected her ability to sleep. (R. at 247.) Plaintiff tended to her personal care and indicated that she relied on her boyfriend to remind her to make phone calls and run errands. (R. at 247-48.)
Plaintiff prepared simple meals several days a week. (R. at 248.) She performed household chores, including cleaning and laundering her clothing, but relied on reminders or encouragement from her boyfriend. (R. at 248.) Plaintiff went outside two days a week and would travel by riding in a car. (R. at 249.) She could drive, but typically did not want to go out alone. (R. at 249.) Plaintiff shopped in stores for groceries and toiletries. (R. at 249.) She could count change, handle her savings account and use a checkbook/money order. (R. at 249.) Her ability to handle money had not changed since the onset of her condition. (R. at 250.)
Plaintiffs hobbies included reading and listening to music, but she ceased doing them since the onset of her condition. (R. at 250.) She spent time with friends every few months and went to the store every other week. (R. at 250.) Plaintiff indicated that she needed to be reminded to go places and needed someone to accompany her. (R. at 250.)Plaintiff had no difficulty getting along with family, friends and neighbors, but her condition ...