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Cantrell v. Berryhill

United States District Court, E.D. Virginia, Richmond Division

February 12, 2018

ANTHONY CANTRELL, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          REPORT AND RECOMMENDATION

          David J. Novak, United States Magistrate Judge

         On May 7, 2013, Anthony Cantrell ("Plaintiff) applied for Social Security Disability Benefits ("DIB") under the Social Security Act ("Act"), alleging disability from depression, anxiety, inability to perform minimal tasks and other mental illness, with an alleged onset date of December 1, 2012. The Social Security Administration ("SSA" or "Agency") denied Plaintiffs claims both initially and upon reconsideration. Thereafter, an Administrative Law Judge ("ALJ") denied Plaintiffs claims in a written decision and the Appeals Council denied Plaintiffs request for review, rendering the ALJ's decision as the final decision of the Commissioner.

         Plaintiff now seeks judicial review of the ALJ's decision pursuant to 42 U.S.C. § 405(g), arguing that the ALJ erred in (1) affording little weight to the opinion of the consultative examiner and to Plaintiffs Global Assessment of Functioning ("GAF") scores; (2) failing to conduct a proper Craig analysis; and, (3) failing to properly account for Plaintiffs anger in the residual functional capacity ("RFC"). (Mem. in Support of Pl's Mot. For Summ. J. ("Pl's Mem.") (ECF No. 11) at 4-12.) This matter now comes before the Court for a Report and Recommendation pursuant to 28 U.S.C. § 636(b)(1)(B) on the parties' cross-motions for summary judgment, rendering the matter ripe for review.[1] For the reasons that follow, the Court recommends that Plaintiffs Motion for Summary Judgment (ECF No. 9) and Motion to Remand (ECF No. 10) be DENIED, that Defendant's Motion for Summary Judgment (ECF No. 12) be GRANTED and that the final decision of the Commissioner be AFFIRMED.

         I. PROCEDURAL HISTORY

         On May 7, 2013, Plaintiff filed an application for DIB with an alleged onset date of December 1, 2012. (R. at 163-64, 173.) The SSA denied these claims initially on January 23, 2014, and again upon reconsideration on July 28, 2014. (R. at 74-103.) At Plaintiffs written request, the ALJ held a hearing on December 10, 2015. (R. at 50-70.) On February 3, 2016, the ALJ issued a written opinion, denying Plaintiffs claims and concluding that Plaintiff did not qualify as disabled under the Act, because he could perform other work existing in significant numbers in the economy, including as a hand packer, material handler/mover and stock clerk/order filler. (R. at 30-44.) On October 18, 2016, the Appeals Council denied Plaintiffs request for review, rendering the ALJ's decision as the final decision of the Commissioner subject to review by this Court. (R. at 1-4.)

         II. STANDARD OF REVIEW

         In reviewing the Commissioner's decision to deny benefits, a court "will affirm the Social Security Administration's disability determination 'when an ALJ has applied correct legal standards and the ALJ's factual findings are supported by substantial evidence.'" Mascio v. Colvin, 780 F.3d 632, 634 (4th Cir. 2015) (quoting Bird v. Comm 'r of Soc. Sec. Admin., 699 F.3d 337, 340 (4th Cir. 2012)). Substantial evidence requires more than a scintilla but less than a preponderance, and includes the kind of relevant evidence that a reasonable mind could accept as adequate to support a conclusion. Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012); Craig v. Chafer, 16 F.3d 585, 589 (4th Cir. 1996). Indeed, "the substantial evidence standard 'presupposes ... a zone of choice within which the decision makers can go either way, without interference by the courts. An administrative decision is not subject to reversal merely because substantial evidence would have supported an opposite decision.'" Dunn v. Colvin, 607 F. App'x. 264, 274 (4th Cir. 2015) (quoting Clarke v. Bowen, 843 F.2d 271, 272-73 (8th Cir. 1988)). To determine whether substantial evidence exists, the court must examine the record as a whole, but may not "undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [ALJ]." Hancock, 667 F.3d at 472 (quoting Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir. 2005)). In considering the decision of the Commissioner based on the record as a whole, the court must "take into account whatever in the record fairly detracts from its weight." Breeden v. Weinberger, 493 F.2d 1002, 1007 (4th Cir. 1974) (quoting Universal Camera Corp. v. N.L.R.B., 340 U.S. 474, 488 (1951)). The Commissioner's findings as to any fact, if substantial evidence in the record supports the findings, bind the reviewing court to affirm regardless of whether the court disagrees with such findings. Hancock, 667 F.3d at 477. If substantial evidence in the record does not support the ALJ's determination or if the ALJ has made an error of law, the court must reverse the decision. Coffman v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987).

         The Social Security Administration regulations set forth a five-step process that the Agency employs to determine whether disability exists. 20 C.F.R. § 404.1520(a)(4); see Mascio, 780 F.3d at 634-35 (describing the ALJ's five-step sequential evaluation). To summarize, at step one, the ALJ looks at the claimant's current work activity. § 404.152O(a)(4)(i). At step two, the ALJ asks whether the claimant's medical impairments meet the regulations' severity and duration requirements. § 4O4.l52O(a)(4)(ii). Step three requires the ALJ to determine whether the medical impairments meet or equal an impairment listed in the regulations. § 404. l52O(a)(4)(iii). Between steps three and four, the ALJ must assess the claimant's RFC, accounting for the most that the claimant can do despite his physical and mental limitations. § 404.1545(a). At step four, the ALJ assesses whether the claimant can perform his past work given his RFC. § 4O4.l52O(a)(4)(iv). Finally, at step five, the ALJ determines whether the claimant can perform any work existing in the national economy. § 404.152O(a)(4)(v).

         III. THE ALJ'S DECISION

         On December 10, 2015, the ALJ held a hearing during which Plaintiff (represented by counsel) and a VE testified. (R. at 50-70.) On February 3, 2016, the ALJ issued a written opinion, finding that Plaintiff did qualify as disabled under the Act. (R. at 30-44.)

         The ALJ followed the five-step evaluation process established by the Social Security Act in analyzing Plaintiffs disability claim. (R. at 30-44). At step one, the ALJ found that Plaintiff had not engaged in substantial gainful activity since the alleged onset date, December 1, 2012. (R. at 32.) At step two, the ALJ determined that Plaintiff had the following severe impairments: obesity; mood disorder; anxiety disorder; personality disorder; and, a history of substance abuse. (R. at 32-33.) At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. (R. at 33-35.)

         In assessing Plaintiffs RFC, the ALJ found that Plaintiff could perform medium work with additional limitations. (R. at 35.) Plaintiff could never climb ladders, ropes or scaffolds, but he could frequently perform other postural activities, including balancing and stooping. (R. at 35.) The ALJ precluded Plaintiff from concentrated exposure to hazards, such as unprotected heights and dangerous moving machinery. (R. at 35.) Plaintiff could perform simple, routine tasks, as well as detailed, complex tasks, while maintaining his concentration for two-hour segments. (R. at 35.) Finally, Plaintiff could respond appropriately to change in a routine work setting, and he could have infrequent interaction with co-workers, supervisors and the public. (R. at 35.) At step four, the ALJ found that Plaintiff could not perform his past relevant work. (R. at 43.) At step five, the ALJ determined that Plaintiff could perform jobs existing in significant numbers in the national economy. (R. at 43-44.) Therefore, Plaintiff did not qualify as disabled under the Act. (R. at 44.)

         IV. ANALYSIS

         Plaintiff, forty-six years old at the time of this Report and Recommendation, previously worked as a highway inspector. (R. at 173, 178.) He applied for Social Security Benefits, alleging disability from depression, anxiety, inability to perform minimum tasks and other mental illness, with an alleged onset date of December 1, 2012. (R. at 173, 177.) Plaintiffs appeal to this Court alleges that the ALJ erred in (1) assigning too little weight to the opinion of the consultative examiner, James O'Keefe, Psy.D., and to Plaintiffs GAF scores; (2) failing to conduct a proper analysis of Plaintiff s symptoms; and, (3) failing to account for Plaintiffs anger in formulating his RFC. (Pl's Mem. at 4-12.) For the reasons set forth below, the ALJ did not err in his decision.

         A. Substantial Evidence Supports the ALJ's Assignment of Weight.

         Plaintiff argues that the ALJ should have afforded more weight to the opinion of the consultative examiner, Dr. O'Keefe, and to Plaintiffs GAF scores. (Pl's Mem. at 4-6, 8-10.) In response, Defendant argues that substantial evidence supports the evaluation of the opinion evidence by the ALJ. (Def.'s Mot. for Summ. J. and Br. in Supp. Thereof ("Def.'s Mem.") (ECFNo. 12) at 9-15.)

         During the sequential analysis, when the ALJ determines whether the claimant has a medically determinable severe impairment, or combination of impairments, which would significantly limit the claimant's physical or mental ability to do basic work activities, the ALJ must analyze the claimant's medical records that are provided and any medical evidence resulting from consultative examinations or medical expert evaluation that have been ordered. 20 C.F.R. §§ 404.1512, 404.1527. When the record contains a number of different medical opinions, including those from the claimant's treating physicians, consultative examiners or other sources that are consistent with each other, then the ALJ makes a determination based on that evidence. §§ 404.1527(c). If, however, the medical opinions are inconsistent internally with each other, or other evidence, the ALJ must evaluate the opinions and assign them respective weight to analyze properly the evidence involved. § 4O4.l527(c)(1)-(6).

         1. Dr. O'Keefe's Opinion.

         Plaintiff argues that the ALJ erred in affording little weight to the opinion of Dr. O'Keefe, the consultative examiner. (Pl's Mem. at 4-7). Specifically, Plaintiff alleges that the record supports Dr. O'Keefe's opinion that Plaintiff could not perform even simple, routine tasks nor complete a normal workday. (Pl's Mem. at 4-7.) Defendant responds that substantial evidence supports the ALJ's assignment of weight. (Def.'s Mem. at 9-12.) Defendant argues that Dr. O'Keefe examined Plaintiff only once - when Plaintiff had not taken his medications for approximately one month - and based his opinion largely on Plaintiffs subjective statements. (Def.'s Mem. at 9-10.)

         On July 21, 2014, Dr. O'Keefe examined Plaintiffs mental status. (R. at 528.) Four days later, Dr. O'Keefe issued a psychology report detailing his observations, conclusions and opinions about Plaintiffs mental ability. (R. at 528-32.) In addition to his interview and examination of Plaintiff, Dr. O'Keefe also reviewed one Department of Disability Services field office report from March 2014, a discharge summary from Poplar Springs Hospital ("Poplar Springs") from August 2013, Plaintiffs treatment notes from Manjit K. Vohra, M.D., on January 7, 2014, and a discharge summary from Southside Community Services Board ("Southside CSB") from February 2014. (R. at 476, 528.)

         Upon examination, Dr. O'Keefe described Plaintiff as overweight, depressed and distressed, with monotone speech and a '"poor me' attitude." (R. at 528.) Plaintiff had fair insight and judgment, and Dr. O'Keefe observed no evidence of a formal thought disorder. (R. at 528.) Plaintiff recounted being abused as a child by his father and brother. (R. at 529.) Plaintiff became depressed from his divorce, loss of visitation rights with his children, and the loss of his house and job. (R. at 529.) He had not taken "a number" of his medications for at least one month, because he could not afford them. (R. at 529.) Plaintiff claimed that he had two or three "violent outbursts" per day. (R. at 531.) Dr. O'Keefe found Plaintiff to be alert and fully oriented, and Plaintiff successfully completed tests assessing his recall, concentration, intermediate memory, fund of knowledge, judgment and reasoning ability. (R. at 530.) Dr. O'Keefe recorded diagnostic impressions of bipolar disorder, panic disorder, borderline personality disorder and mild alcohol abuse disorder. (R. at 531.)

         Dr. O'Keefe opined that Plaintiff retained "the cognitive abilities to manage his finances in a reasonable way," but concluded that Plaintiff should have his mother as his payee because of his previous alcohol abuse and impulse spending. (R. at 531.) Dr. O'Keefe opined that Plaintiff could not perform simple, routine tasks or complex, detailed activities. (R. at 532.) Despite having the cognitive ability, Plaintiff lacked the emotional stability to perform in a work environment. (R. at 532.) According to Dr. O'Keefe, Plaintiffs apathy and lethargy likely prevented him from maintaining regular attendance at work. (R. at 532.) Plaintiff could accept directions from supervisors, but his "regular anger outbursts" might preclude his ability to follow instructions. (R. at 532.) Dr. O'Keefe opined that Plaintiff would struggle to interact with coworkers and the public, because he became easily annoyed, had a limited tolerance for frustration and could display passive-aggressive behavior. (R. at 532.)

         The ALJ afforded Dr. O'Keefe's opinion little weight, because it underestimated Plaintiffs functional ability and conflicted with Plaintiffs education, psychiatric history and clinical findings. (R. at 42.) The ALJ also noted that Plaintiff had not taken his medications for a couple of weeks when he presented to Dr. O'Keefe. (R. at 42.)

         Objective medical evidence in the record supports the ALJ's decision to give little weight to Dr. O'Keefe's opinion. On February 28, 2013, Plaintiff first presented to Karen Highlander, F.N.P., for treatment of hypertension and anxiety. (R. at 446-48.) Nurse Highlander found Plaintiff to be pleasant, alert, cooperative and in no acute distress. (R. at 447.) Nurse Highlander altered Plaintiffs prescription for hypertension and refilled his anxiety medication, lorazepam. (R. at 447.)

         On May 7, 2013, Plaintiff began counseling treatment with Elaine Cole, L.C.S.W., at Southside CSB. (R. at 457.) Plaintiff indicated that he had been hospitalized in 2003 for psychiatric treatment. (R. at 457.) His condition improved such that he stopped taking all medications in 2005. (R. at 457.) During his visit with Ms. Cole, he complained of depression, anxiety, moodiness, anger and sadness. (R. at 457.) Plaintiff indicated that a doctor had prescribed Ativan to treat his anxiety attacks. (R. at 457.) Plaintiff also told Ms. Cole that he had lost his job two years ago and wanted to feel better. (R. at 457.) Plaintiff denied any suicidal or homicidal ideations. (R. at 457.)

         On June 3, 2013, Plaintiff returned to Ms. Cole, seeking treatment for bipolar disorder, including medication management and therapy. (R. at 458.) Plaintiff recounted strained relationships with his immediate family - including his parents with whom he lived - and a history of substance abuse. (R. at 459.) Ms. Cole noted Plaintiffs long employment history and that he continued to look for work. (R. at 459.) Plaintiff had no problems with his daily and independent living skills. (R. at 459.) Upon examination, Ms. Cole noted Plaintiffs depressive-like behavior, including anhedonia, feelings of worthlessness and guilt, crying and poor concentration. (R. at 460.) Yet, Plaintiff displayed appropriate attitude and affect, and Ms. Cole described him as "[intelligent" and "[c]reative." (R. at 460.) Plaintiff set goals to remain compliant with his medications and to develop coping skills and eliminate self-destructive behaviors. (R. at 463.)

         On June 7, 2013, Plaintiff returned to Nurse Highlander. (R. at 451.) He complained of nightly anxiety/panic attacks, difficulty sleeping and mildly impaired concentration, but he denied suicidal ideations, hallucinations and paranoia. (R. at 452.) Nurse Highlander noted Plaintiffs anxious appearance and poor eye contact. (R. at 452.) She directed him to visit his primary care physician for medication management, but the record does not contain evidence of such a visit. (R. at 451.)

         On August 2, 2013, Plaintiff presented to Dr. Vohra at Southside CSB for a medication review and psychiatric follow-up examination. (R. at 465-67.) Plaintiff described feeling "guilty, spikes of energy, depression, no ambition, no motivation . . . and angry with [him]self all [d]ay." (R. at 465.) He had smoked marijuana heavily for twenty-five years, and he quit a few months before. (R. at 465.) Plaintiff claimed that his medications did not work, because he felt "guilty[, ] scared and full of negativism." (R. at 465.) Dr. Vohra noted that Plaintiff remained alert and cooperative despite feeling "genuinely frustrated" and sounding "very angry." (R. at 465.) He had normal speech and a depressed mood, as well as fair insight, judgment and fund of knowledge. (R. at 465.) Dr. Vohra found Plaintiffs memory to be "ok" ...


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