United States District Court, W.D. Virginia, Roanoke Division
CAROL K. GHAUL Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security Defendant.
Glen E. Conrad United States District Judge
plaintiff, Carol K. Ghaul, filed this action challenging
certain provisions of the final decision of the Commissioner
of Social Security, denying her application for disability
insurance benefits ("DIB") and establishing a
period of disability for purposes of her application for
supplemental security income benefits ("SSI")
pursuant to the Social Security Act ("the Act"), as
amended, 42 U.S.C. § 401 et seq., and 42 U.S.C.
§ 1381 et seq., respectively. Stated
succinctly, plaintiff challenges the disability onset date
established by the Commissioner. For the reasons that follow,
the court will affirm the Commissioner's final decision.
Social Security Administration is authorized to award DIB and
SSI benefits to persons who are deemed to be
"disabled" from all forms of substantial gainful
employment. Barnhart v. Thomas, 540 U.S. 20, 21
(2003). A claimant is considered "disabled, " and
thus, potentially eligible to receive DIB and/or SSI
benefits, if her "physical or mental impairment or
impairments are of such severity that [she] is not only
unable to do [her] previous work but cannot, considering
[her] age, education, and work experience, engage in any
other kind of substantial gainful work which exists in the
national economy." 42 U.S.C. §§ 423(d)(2)(A),
review, this court must affirm the disability determination
of an Administrative Law Judge ("ALJ") if it is
supported by substantial evidence and the ALJ applied the
correct legal standards. Lewis v. Berryhill 858 F.3d
858, 865 (4th Cir. 2017). Stated briefly, substantial
evidence has been characterized as such relevant evidence,
considering the record as a whole, as might be found adequate
to support a conclusion by a reasonable mind. Richardson
v. Perales, 402 U.S. 389, 401 (1971).
determine whether a claimant is disabled for both DIB and SSI
purposes, the ALJ applies a five-step sequential evaluation
process, which assesses "whether the claimant: (1) is
working; (2) has a severe impairment; (3) has an impairment
that meets or equals the requirements of a listed impairment;
(4) can return to [her] past relevant work; and if not, (5)
whether [she] can perform other work." Nelson v.
Berryhill No. 7:15-cv-573, 2017 U.S. Dist. LEXIS 27840,
at *3 n.5 (W.D. Va. Feb. 28, 2017) (citing Johnson v.
Barnhart 434 F.3d 650, 654 n.l (4th Cir. 2005) (per
curiam)); see also 20 C.F.R. §§
1520(a)(4); 416.920(a)(4). "The claimant bears the
burden to make the requisite showing during the first four
steps." Lewis, 858 F.3d at 861 (internal
citation omitted). Notably, "[i]f the claimant fails to
demonstrate she has a disability that meets or medically
equals a listed impairment at step three, the ALJ must assess
the claimant's residual functional capacity
('RFC') before proceeding to step four."
Id. If the claimant meets her burden under the first
four steps, then the burden shifts to the Commissioner at
step five. Id. If the claimant is determined to be
disabled, the ALJ must then establish the onset date of
disability. Social Security Ruling ("SSR") 83-20,
1983 SSR LEXIS 25 at *2.
the crucial factual determination is whether the claimant is
disabled from all forms of substantial gainful
employment. See 42 U.S.C. § 423(d)(2). There are four
elements of proof that must be considered in making such a
determination. These elements are summarized as follows:
objective medical facts and clinical findings; the opinions
and conclusions of treating physicians; subjective evidence
of physical manifestations of impairments, as described
through the claimant's testimony; and the claimant's
education, vocational history, residual skills, and age.
Vitek v. Finch, 438 F.2d 1157, 1159-60 (4th Cir.
1971); Underwood v. Ribicoff. 298 F.2d 850, 851 (4th
Cir. 1962). Accordingly, when assessing whether substantial
evidence supports a disability determination, the reviewing
court "must consider whether the ALJ analyzed all the
relevant evidence and whether the ALJ sufficiently explained
his findings and rationale in crediting the evidence."
Turner v. Astrue. No. 2:08cv0006, 2008 U.S. Dist.
LEXIS 88453, at *39-40 (W.D. Va. Oct. 21, 2008) (citing
Sterling Smokeless Coal Co. v. Akers. 131 F.3d 438,
439-40 (4th Cir. 1997)).
the court emphasizes that the ALJ is uniquely tasked with
resolving discrepancies in the record and making credibility
determinations. See Felton-Miller v. Astrue, 459
Fed.App'x 226, 228 (4th Cir. 2011). Therefore, even when
"conflicting evidence allows reasonable minds to differ,
" this court must give great deference to the ALJ's
assessment of recorded discrepancies and the credibility of
the claimant's allegations as long as the ALJ's
determination is supported somewhere in the record. See id
(internal quotation marks omitted).
& Procedural History
Ghaul was born on December 24, 1967. (Tr. 64.) After earning
her GED, she worked as a roof truss builder, saw operator,
and pin drafter machine operator. (Tr. 73.) Aside from two
temporary positions that each lasted about a month, Ms. Ghaul
has remained unemployed since her employer's company shut
down in 2008. (See Tr. 20, 47-48.) Ms. Ghaul filed
for DIB on August 15, 2013 (Tr. 211), and SSI on September 6,
2013 (Tr. 213). In both applications, Ms. Ghaul alleged that
she became disabled beginning February 10, 2012, due to pain
in her neck, back, knees, and feet; arthritis in her back;
depression; anxiety; and past suicide attempts. (Tr. 64, 88.)
As to her application for DIB, the record reveals that Ms.
Ghaul met the insured status requirements of the Act through
March 31, .2015. See 42 U.S.C. § 423(a)(1)(A), (c)(1);
20 C.F.R. §§ 404.101(a), 404.131(a). Accordingly,
Ms. Ghaul is only eligible for DIB if she has established
that she became disabled from all forms of substantial
gainful employment on or before March 31, 2015.
Ghaul's applications were both denied initially and upon
reconsideration. (Tr. 13.) Thereafter, Ms. Ghaul requested a
hearing before an ALJ, which was subsequently held on October
7, 2015. (Tr. 13.) On December 15, 2015, the ALJ issued a
partially favorable opinion concluding that Ms. Ghaul was
able to perform a limited range of light work until a
motorcycle accident rendered her disabled on August 25, 2015.
(Tr. 30.) Consequently, Ms. Ghaul was found to be disabled
for purposes of her claim for SSI benefits, beginning on
August 25, 2015. (See Tr. 31.) Additionally, based
on the conclusion that Ms. Ghaul failed to prove that she
became disabled from all forms of substantial gainful
employment on or before March 31, 2015, the ALJ completely
denied Ms. Ghaul's DIB claim. (See Tr. 31.) The
ALJ's partially favorable opinion was subsequently
adopted as the final decision of the Commissioner by the
Social Security Administration's Appeals Council. Having
exhausted all available administrative remedies, Ms. Ghaul
appeals to this court pursuant to 42 U.S.C. § 405(g).
succinctly, the ALJ found that Ms. Ghaul did not become
disabled until experiencing physical injuries in a motorcycle
crash, which occurred on August 25, 2015. The ALJ stated as
In reaching this conclusion, I find that beginning August 25,
2015, [Ms. Ghaul's] allegations regarding her symptoms
and limitations are generally credible. On this date, [Ghaul]
was involved in a motorcycle crash as a passenger. She
presented to the emergency room for complaints [of] pain.
Imaging confirmed fractures in the right forearm, wrist, and
ankle, as well as [factures in] several lumbar discs and the
right side of the pelvis. [Ghaul] required multiple surgeries
and was hospitalized until September 2, 2015. [Ghaul] was
then sent for inpatient rehabilitation. When discharged on
September 12, 2015, it was noted that though stable, [Ghaul]
continued to experience posttraumatic and postoperative pain.
[Ghaul] has continued to follow up with her orthopedist.
While signs of healing have been noted, [Ms. Ghaul's]
current complaints of pain and the need to rest are supported
by the severe polytraumas incurred in the motorcycle
accident. Given the nature of her injuries, it is likely that
these limitations would continue for at least a year.
court believes that in determining that Ms. Ghaul was not
disabled prior to August 25, 2015, the ALJ properly applied
the sequential disability evaluation. With regard to the
first step of the sequential evaluation process, the ALJ
found that Ms. Ghaul has not engaged in substantial gainful
activity since her alleged onset date of February 10, 2012.
(Tr. 15.) At the second step, the ALJ decided that prior to
the established onset date of August 25, 2015, Ms. Ghaul
"had the following severe impairments: degenerative disc
disease of the cervical and lumbar spines and medical
meniscus tear status post repair." (Tr. 16.)
Additionally, the ALJ classified Ms. Ghaul's
"medically determinable mental impairments of depression
and substance addiction" as non-severe. (Tr. 16.) With
regard to the third step, since her alleged onset date of
February 10, 2012, none of Ms. Ghaul's impairments or a
combination thereof met or was the medical equivalent of one
of the listed impairments. (Tr. 16.) Before proceeding to the
next step, the ALJ concluded that, prior to the established
onset date, Ms. Ghaul had the RFC to perform light work.
(See Tr. 18.) At the fourth step, the ALJ found that
Ms. Ghaul could perform her past relevant work as a roof
truss machine operator prior to the established onset date.
(Tr. 28.) Since Ms. Ghaul was capable of performing her past
relevant work, the ALJ concluded that Ms. Ghaul was not
disabled prior to August 25, 2015. (Tr. 29.) Accordingly, as
she was unable to prove that she became disabled from all
forms of substantial gainful employment on or before March
31, 2015 (i.e., the date she last enjoyed her
requisite insured status), the ALJ denied Ms. GhauFs DIB
claim. (See Tr. 31.) The ALJ found that Ms. Ghaul
was not entitled to a period of disability for purposes of
her SSI claim until August 25, 2015.
the issues before the court, Ms. Ghaul contests the ALJ's
step two and RFC determinations. Regarding the ALJ's step
two analysis, Ms. Ghaul argues that the ALJ erred in
classifying her depression as non-severe. Ms. Ghaul further
contends that the ALJ's RFC is unsupported by substantial
evidence because the ALJ erroneously failed to conduct a
comprehensive function-by-function analysis and properly
assess the credibility of Ms. Ghaul's subjective
evidence. The court addresses these arguments in turn and
concludes that the ALJ's findings are supported by
substantial evidence in the record.
evidence supports classifying Ms. GhauFs depression as
Ghaul first contests the ALJ's finding that her
depression was non-severe. Before reviewing the ALJ's
step two analysis, however, the court first highlights that
the record conspicuously omits evidence showing that Ms.
Ghaul received any meaningful and continuous psychological
treatment. More specifically, the medical records before the
court only reference Ms. Ghaul's psychological treatment
in three instances, including her receipt of "mental
health support services" from The Phoenix Center (Tr. at
268; see also Tr. 24, 804, 816-27); Ms. Ghaul's
weeklong hospitalization, which occurred subsequent to her
debatable suicide attempt on March 27, 2012 (see Tr. 20-21,
327-369, 417-41); and Ms. Ghaul's four office visits to
the Center for Emotional Care between July 19-October 30,
2013 (see Tr. 23-24, 785-97). As these instances are
relevant to the ALJ's classification of Ms. Ghaul's
depression as non-severe, the following summarizes the
applicable medical records.
with regard to the "mental health support services"
that Ms. Ghaul received from The Phoenix Center, the ALJ
noted: "[i]n a letter dated, November 3, 2013, Drs.
Rochelle Potter and [Ashley] Callahan stated that [Ghaul]
began receiving treatment at The Phoenix Center since
December 26, 2012; however, no treatment notes were provided.
An individual treatment plan from December 26, 2013, was
later provide[d]. Again, however, no mental status
examinations were included." (Tr. 24 (internal citations
omitted).) Since the record excludes documentation of the
treatment she received from The Phoenix Center, neither the
ALJ nor this court could assess Ms. Ghaul's alleged
treatment with this facility. However, based on Ms.
Ghaul's response in her Disability Report Appeal Form,
dated January 27, 2014 (see Tr. 267-72), it is
unclear whether The Phoenix Center actually provided
psychological treatment. Ms. Ghaul stated that she
"receive[d] mental health support services" from
The Phoenix Center, but she described these services to
include coordinating her medical care, transporting her to
her appointments, and "get[ting] [her] out of [her]
house." (Tr. 269, 287.)
regard to her weeklong hospitalization, the court believes
that the ALJ justifiably questioned the events leading up to
Ms. Ghaul's hospitalization. When she applied for DIB and
SSI benefits, Ms. Ghaul claimed that she attempted to commit
suicide three times. One of those attempts allegedly resulted
in her weeklong hospitalization, beginning March 27, 2012.
(See Tr. 21, 251.) However, the ALJ recognized that
while Ms. Ghaul's hospital records contain some
conflicting evidence (see, e.g., Tr. 21, 349-50,
439), most of her hospital physicians documented that Ms.
Ghaul adamantly denied ever attempting to commit suicide
(see, e.g., Tr. 21, 352, 354-55, 366, 369, 417-18,
420, 423, 431, 438). More specifically, Ms. Ghaul's
weeklong hospitalization initiated on March 27, 2012, when
she was found unresponsive and lying next to prescription
bottles. (See Tr. 417.) Ms. Ghaul justified her
condition to one of her treating physicians by explaining
that she took "her typical dose of Lortab and Flexeril,
but she had been drinking as well and she does not think that
she made a suicide attempt." (Tr. 417.) Her hospital
records also evidenced that Ms. Ghaul was "found to be
positive for cocaine and benzodiazepenes in the [Emergency
Room]" (Tr. 338); that Ms. Ghaul claimed that she only
"felt depressed 'a little bit'" (Tr. 21,
417, 420); and that Ms. Ghaul demanded to be discharged,
refused patient care, and pushed a hospital staffer after she
was not allowed to go into the hospital waiting room
(see Tr. 21, 350).
given the limited record before the court, it appears that
Ms. Ghaul received her most significant and continuous
psychological treatment when she visited the Center for
Emotional Care four times between July 19-October 30, 2013.
(See Tr. 23-24, 785-97.) Although the Center for Emotional
Care listed Ms. Ghaul's diagnosis as "major
depressive disorder, " her treatment provider, Molly B.
Sharp, P.A., noted that throughout her four office visits,
Ms. Ghaul was not suicidal or homicidal and had no reports of
hallucinations or delusions. (See Tr. 786, 789,
793.) Rather, during each visit, Ms. Sharp noted that Ms.
Ghaul had fair judgment, good attention, and . concentration;
she was cooperative, alert, and thinking coherently and in a
goal-oriented manner; and Ms. Ghaul's recent and remote
memory was intact. (See Tr. 786, 789-90, 793, 796.)
Additionally, Ms. Ghaul testified on October 7, 2015, that
she believed that the limited counseling therapy she received
was helpful (see Tr. 57), and she was on a waiting
list to receive further mental health treatment and
medication (see Tr. 20, 46).
Ms. Ghaul's above-mentioned psychological treatment in
mind, the court turns to the ALJ's step two analysis to
assess whether substantial evidence supports the ALJ's
classification of Ms. Ghaul's depression as non-severe.
The regulations state that an impairment "is not severe
if it does not significantly limit [the claimant's]
physical or mental ability to do basic work activities."
20 C.F.R. § 404.1521(a). With regard to the
claimant's mental functioning, "basic work
activities" include the claimant's capacity to
"understand, carr[y] out, and remember simple
instructions; us[e] judgment; respond appropriately to
supervision, co-workers and usual work situations; and deal
with changes in a routine work setting." Id.
§ 404.152l(b)(2)-(6). Although "[t]his is not a
difficult hurdle for the applicant to clear, " the court
"must affirm the ALJ's severity finding if she
applied the correct legal ...