United States District Court, W.D. Virginia, Harrisonburg Division
C. Hoppe United States Magistrate Judge
Derek Thomas Hall asks this Court to review the Commissioner
of Social Security's ("Commissioner") final
decision denying his applications for disability insurance
benefits ("DIB") and supplemental security income
("SSI") under Titles II and XVI of the Social
Security Act, 42 U.S.C. §§ 401-34, 1381-1383f. The
case is before me by the parties' consent under 28 U.S.C.
§ 636(c). Having considered the administrative record,
the parties' briefs and oral arguments, and the
applicable law, I find that the Commissioner's decision
is not supported by substantial evidence and that remand for
further administrative proceedings is necessary.
Standard of Review
Social Security Act authorizes this Court to review the
Commissioner's final decision that a person is not
entitled to disability benefits. See 42 U.S.C.
§ 405(g); 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 Administrative Law Judge ("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).
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 Universal Camera
Corp. v. NLRB, 340 U.S. 474, 487-89 (1951); Gordon
v. Schweiker, 725 F.2d 231, 236 (4th Cir. 1984).
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)). 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).
person is "disabled" if he or she is unable 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 12 months." 42 U.S.C. §§
423(d)(1)(A), 1382c(a)(3)(A); 20 C.F.R. §§
404.1505(a), 416.905(a). 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 Heckler v. Campbell, 461 U.S. 458, 460-62
(1983); 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4).
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.
filed for DIB and SSI on February 9, 2011. Administrative
Record ("R.") 295, 302, ECF No. 21. He was
thirty-six years old at the time, R. 295, and had worked most
recently as a game advisor, store manager, truck loader, and
wireless services worker, R. 344. Hall alleged disability
beginning December 1, 2010, because of stroke, bipolar
disorder, and borderline personality disorder. R. 339, 343.
had an administrative hearing before an ALJ on September 11,
2012. R. 39-82. Hall appeared with counsel and testified
about his past work, then-current activities, medical
conditions, and limitations his conditions caused. A
vocational expert ("VE") testified about the nature
of Hall's past work and then-current activities as well
as his ability to perform other jobs in the national and
September 28, 2012, the ALJ issued a written opinion denying
Hall's applications. R. 15-33. The ALJ found that Hall
had severe impairments of affective disorder, anxiety
disorder, personality disorder, substance abuse disorder, and
status post cerebrovascular accident, but none of these
severe impairments met or equaled a listing. R. 17-19. The
ALJ determined that Hall's headaches and obstructive
sleep apnea were not severe impairments and his "white
outs" were not a medically determinable impairment. R.
18. The ALJ found that Hall had the residual functional
capacity ("RFC") to perform a modified range of
light work with some postural limitations and
limitation to simple, routing work involving occasional
interaction with coworkers and only incidental interaction
with the public. R. 20. Relying on the VE's testimony,
the ALJ concluded at step four that Hall could not perform
his past work, but that he could perform other jobs in the
economy. R. 31-32. He therefore determined that Hall was not
disabled under the Act. Id. The Appeals Council
declined to review that decision, R. 1-4, and this appeal
challenging the Commissioner's final decision, Hall
argues that the ALJ erred in finding that his headaches were
a non-severe impairment and his "white outs" were
not a medically determinable impairment. PI. Br. 4-6. Hall
also argues that the ALJ improperly evaluated the opinions of
his treating physicians, particularly in rejecting
limitations in concentration and regularly attending work.
Id. at 7.
earliest treatment notes in the record begin on January 8,
2008, nearly three years before Hall's alleged onset. R.
511-14. On that date, Laura Tate-Santiago, M.D., conducted an
intake evaluation of Hall for psychiatric services at the
University of Virginia Health System ("UVAHS"). Dr.
Tate-Santiago noted that Hall had been diagnosed with bipolar
disorder in 2000. She found that Hall was difficult to assess
because his communication style was filled with exaggerations
and contradictions. She noted that he experienced panic
attacks and anger fits, had interpersonal relationship
problems, and had a history of substance abuse. Dr.
Tate-Santiago diagnosed bipolar disorder and personality
disorder for which she prescribed Depakote and Klonopin.
Although Dr. Tate-Santiago diagnosed tension headaches, they
did not cause any functional impairment, so she deferred
prescribing medication. In June 2008, Dr. Tate-Santiago noted
that Hall had been using unprescribed narcotics to treat his
headaches and that his primary care physician had prescribed
Ultram for migraine headaches. R. 505. Over the course of his
treatment, Hall requested Ultram numerous times to treat his
headaches. R. 495, 502, 503.
transfer summary from July 2009 recounts that Hall had been
seen every one to two months for medication management for
bipolar disorder. R. 488-90. During this time, he continued
to experience irritability, depressed mood, fatigue, and lack
of motivation, and his interpersonal problems with coworkers
and his wife persisted. Nassima Tiouririne, M.D., noted that
Hall regularly requested pain medication for a variety of
reasons. When confronted with the possibility that he had an
opiate addiction, Hall agreed that he had a serious problem
with them and would not request them anymore. Dr. Tiouririne
questioned the diagnosis of bipolar disorder given Hall's
poor self-esteem, poor coping skills, and hypersensitivity to
interpersonal issues. She also noted that he would not be
prescribed pain medication.
December 2009, Hall underwent a sleep study. He was diagnosed
with severe sleep apnea and provided a Continuous Positive
Airway Pressure ("CPAP") machine. R. 638-40,
641-45. By April 2010, Hall's sleep had improved, and he
was not fatigued when he woke in the morning. R. 639.
discharge summary from July 2010, Nicolas Canon-Salazar,
M.D., wrote that since January 2008, the clinic had provided
Hall medication management for his affective disorder and
episodic opiate abuse. R. 471-73. Hall had exhibited symptoms
of depressed mood, moderate anxiety, and severe emotional
lability from interpersonal difficulties with his wife.
Hall's physicians tried various medications to address
these symptoms. Ultimately, Effexor produced progressive
improvement of his mood symptoms, and clonazepam
significantly reduced his anxiety. To address his
interpersonal-relationship problems, Hall was offered group
therapy and prescribed various medications, such as Ambien
and Lamictal. After Hall's wife mentioned divorce, he
experienced passive suicidal ideation and was voluntarily
admitted for a week at the Wellness Recovery Center. He was
diagnosed with major depressive disorder, opiate abuse,
generalized anxiety disorder, migraine headaches, sleep
apnea, and chronic interpersonal difficulties. He was
assigned a Global Assessment of Functioning
("GAF") score of 61-70.
19, Hall was evaluated by Darin L. Christensen, M.D. R. 849.
Hall reported experiencing anger, depression, and trouble
with his wife and coworkers. Dr. Christensen noted that Hall
was calm and cooperative and had a depressed mood and
euthymic, appropriate affect. He diagnosed major depressive
disorder and prescribed Klonopin and Ambien. A month later,
Hall reported that his wife wanted to separate from him, and
Dr. Christensen added prescriptions for Effexor and Seroquel.
R. 848. Hall called Dr. Christensen's office multiple
times in July and August to request changes in his
medications. R. 847-48.
October 7, 2010, Hall was seen by Jonathan Fellers, M.D., for
medication management at UVAHS. R. 635-36. Dr. Fellers noted
that since Hall began taking a monoamine-oxidase inhibitor
("MAOI") for depression, he had experienced
dramatic improvement in mood, anxiety, and interpersonal
relationships. On mental status exam, Dr. Fellers noted that
Hall had euthymic mood, appropriate affect, and good
concentration and memory. He diagnosed Hall with atypical
depression, panic disorder with agoraphobia, personality
disorder, and economic and psychosocial problems. He assessed
a GAF of 61-70 and prescribed clonazepam and gabapentin. At a
follow-up in November, Hall expressed worries about
separating from his wife and moving out of their residence,
although his mood and interpersonal resilience were improved.
R. 631-33. After Hall admitted to taking more than the
prescribed amounts of MAOIs, Dr. Fellers admonished him not
to change his dose unilaterally. Dr. Fellers's
observations on mental status exam and his diagnosis were
unchanged from October.
November 23, Hall went to the emergency room complaining of
tunnel vision. R. 537-38. Magnetic Resonance Imaging
("MRI") of his brain was ordered because of stroke
concerns, and the MRI showed no abnormalities. R. 564. Hall
was diagnosed with migraine headache and provided Dilaudid,
which helped him rest. R. 538.
later Hall told Dr. McLaughlin that he was having trouble
urinating and that straining to urinate caused headaches. R.
712-13. Dr. McLaughlin prescribed Fioricet for headaches,
warned him of possible addiction, and told him not to drive
or work after taking it.
December 2, Hall had slurred speech, trouble walking and
urinating, and blurry vision; he was admitted to the
emergency room at Augusta Health Hospital. R. 515-17. Donald
S. Molinar, M.D., noted that Hall had a history of
depression, prescription drug abuse, and headaches and that
the night before Hall had taken too many Fioricet and Nardil.
An initial CT scan did not show abnormalities, but an MRI
showed acute brain stem infarct of the left pons and severe
occlusion of the distal right basal artery. He was diagnosed
with left pons cerebrovascular accident, essentially a
stroke. After Hall was stabilized, he was transferred to
UVAHS and admitted to the Neurology Intensive Care Unit. R.
608-11, 625-28. Over the course of his treatment, Hall's
symptoms significantly improved: he had only mild dysarthria
and mild right upper extremity weakness and dysmetria. He was
prescribed Warfarin and Dalteparin for the ...