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Hall v. Colvin

United States District Court, W.D. Virginia, Harrisonburg Division

September 30, 2016

CAROLYN W. COLVIN, Acting Commissioner, Social Security Administration, Defendant.


          Joel C. Hoppe United States Magistrate Judge

         Plaintiff 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.

         I. Standard of Review

         The 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).

         "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 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).

         A 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.

         II. Procedural History

         Hall 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, [1]because of stroke, bipolar disorder, and borderline personality disorder. R. 339, 343.

         Hall 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 local economy.

         On 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[2] 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 followed.

         III. Discussion

         In 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.

         A. Medical Evidence

         The 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.

         A 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.

         In 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.

         In a 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")[3] score of 61-70.[4]

         On July 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.

         On 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.

         On 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.

         A week 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.

         On 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 ...

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