United States District Court, W.D. Virginia, Roanoke Division
LYDIA I. CALDWELL, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
GLEN E. CONRAD SENIOR UNITED STATES DISTRICT JUDGE.
has filed this action challenging the final decision of the
Commissioner of Social Security denying plaintiffs claims for
disability insurance benefits and supplemental security
income benefits under the Social Security Act, as amended, 42
U.S.C. §§ 416(i) and 423, and 42 U.S.C. § 1381
et seq., respectively. Jurisdiction of this court is pursuant
to 42 U.S.C. § 405(g) and 42 U.S.C. § 1383(c)(3).
This court's review is limited to a determination as to
whether there is substantial evidence to support the
Commissioner's conclusion that plaintiff failed to meet
the requirements for entitlement to benefits under the Act.
If such substantial evidence exists, the final decision of
the Commissioner must be affirmed. Laws v.
Celebrezze, 368 F.2d 640 (4th Cir. 1966). Stated
briefly, substantial evidence has been defined 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).
plaintiff, Lydia I. Caldwell, was born on March 19, 1970, and
has received some college education. Ms. Caldwell was
previously married and did not work during her marriage.
After her divorce, she worked as a waitress and a dishwasher
at a restaurant. However, the Law Judge concluded that the
plaintiff has no past relevant work for purposes of her
applications for benefits. (Tr. 26). The Law Judge found that
Ms. Caldwell last worked on a regular and sustained basis in
2011 based on Ms. Caldwell's alleged onset date of April
1, 2011. On September 11, 2012, Ms. Caldwell filed an
application for a period of disability and disability
insurance benefits, and on October 15, 2012, she filed an
application for supplemental security income benefits. Ms.
Caldwell alleged disability based on fibromyalgia,
osteoporosis, Graves disease, arthritis, incontinence, lower
back pain, severe fatigue and weakness, carpal tunnel
syndrome, migraines, depression, anxiety disorder, and panic
attacks. She now maintains that she has remained disabled to
the present time. As to her application for a period of
disability and disability insurance benefits, the Law Judge
found that Ms. Caldwell met the insured status requirements
of the Act at all relevant times. (Tr. 19); see,
gen., 42 U.S.C §§ 416(i) and 423(a).
Caldwell's applications were denied upon initial
consideration and reconsideration. She then requested and
received a de novo hearing and review before an
Administrative Law Judge. In an opinion dated March 1, 2016,
the Law Judge applied the five-step sequential process for
evaluating disability claims. 20 C.F.R. §§ 404.1520
and 416.920. The Law Judge found that Ms. Caldwell has not
engaged in substantial gainful activity since her alleged
onset date of April 1, 2011,  and that she suffers from severe
impairments including fibromyalgia, Graves ophthalmopathy,
degenerative disc disease, osteoporosis, hypothyroidism,
stress incontinence, history of bilateral carpal tunnel
syndrome, headaches, history of edema, bipolar disorder, and
anxiety. The Law Judge then assessed Ms. Caldwell's
residual functional capacity as follows:
After careful consideration of the entire record, the
undersigned finds that the claimant has the residual
functional capacity to perform light work as defined in 20
CFR 404.1567(b) and 416.967(b) except the claimant can
occasionally climb, stoop, kneel, crouch, and crawl. She can
perform frequent (but not constant) handling. She could have
occasional exposure to excessive noise and vibrations. She
would be able to perform simple, routine, unskilled work
tasks, which do not require exposure to hazards, allow for
regularly scheduled breaks, and have no more than occasional
changes in the work setting. She would require no more than
occasional interaction with the public.
(Tr. 22). Given this residual functional capacity, and after
considering Ms. Caldwell's age, education, and prior work
experience, as well as the testimony of a vocational expert,
the Law Judge determined that Ms. Caldwell retained
sufficient functional capacity to perform certain light work
roles existing in significant number in the national
economy. (Tr. 26). Accordingly, the Law Judge
concluded that Ms. Caldwell has not been disabled since 2011,
is not presently disabled, and is not entitled to either
disability insurance benefits or supplemental security income
benefits. See 20 C.F.R. §§ 404.1520(g) and
416.920(g). The Law Judge's opinion was adopted as the
final decision of the Commissioner by the Social Security
Administration's Appeals Council. Having exhausted all
administrative remedies, Ms. Caldwell has now appealed to
the plaintiff may be disabled for certain forms of
employment, the crucial factual determination is whether the
plaintiff is disabled for all forms of substantial gainful
employment. See 42 U.S.C. §§ 423(d)(2) and
1382c(a). There are four elements of proof which must be
considered in making such an analysis. These elements are
summarized as follows: (1) objective medical facts and
clinical findings; (2) the opinions and conclusions of
treating physicians; (3) subjective evidence of physical
manifestations of impairments, as described through a
claimant's testimony; and (4) 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
review of the record in this case, the court is constrained
to conclude that the Commissioner's final decision is
supported by substantial evidence. The Law Judge's
opinion reflects a thorough evaluation of Ms. Caldwell's
medical records, the relevant medical opinions, Ms.
Caldwell's testimony about her impairments, and Ms.
medical record reveals that Ms. Caldwell received her primary
care from Dr. Caren Aaron from the time of her alleged onset
date in 2011 through mid-2013, and from Dr. Kimberly A.
Dulaney since mid-2013. (Tr. 41). Ms. Caldwell has a history
of treatment for Graves disease, degenerative disc disease,
fibromyalgia, carpal tunnel syndrome, and stress
incontinence. Ms. Caldwell has been advised to treat the
symptoms of her Graves disease, a thyroid eye condition, with
eye drops and ointment (Tr. 718), and has been directed to
take an appropriate dose of her thyroid medication and
Potassium (Tr. 1125). In 2015, Dr. Dulaney determined that
Ms. Caldwell's thyroid was much improved and almost
within the normal range. (Tr. 793). Ms. Caldwell has
complained of back pain, but despite some indication of mild
multilevel degenerative joint disease, her imaging "was
essentially negative." (Tr. 381-83). A 2015 image of Ms.
Caldwell's lumbar spine showed that she has normal
alignment and normal disc heights and facet joints. (Tr.
1000). Ms. Caldwell has reported some improvement in her pain
through the use of pain medication and epidural injections
(Tr. 634), and has been advised to perform lower back
exercises and aquatic therapy to treat her lower back pain
and fibromyalgia (Tr. 967). Ms. Caldwell has also undergone
procedures to correct her bilateral carpal tunnel syndrome
and did not experience any complications with the procedures.
(Tr. 493- 94, 525-26). Additionally, Ms. Caldwell underwent a
bladder sling replacement in 2012 for stress urinary
incontinence. In 2013, Ms. Caldwell requested another
referral to urology because of pain and cramping related to
the sling replacement (Tr. 469), but the record does not
reflect significant later treatment for this problem.
Caldwell's medical record also indicates that she has
been diagnosed with bipolar disorder and has reported
feelings of depression and anxiety. Dr. Aaron noted that Ms.
Caldwell reported an inability to leave her apartment except
to attend medical appointments or go to the grocery store as
well as irritability, panic attacks, and fatigue. (Tr.
628-29). While receiving treatment from Dr. Aaron, Ms.
Caldwell took medication for her anxiety. (See Tr.
622, 626). However, Dr. Aaron's records also reflect
periods in which Ms. Caldwell appeared to have a good mood,
good affect, and no signs of anxiety or depression. (Tr. 616,
630, 633, 694). In 2015, Dr. Dulaney observed that Ms.
Caldwell expressed some difficulty with concentration,
restless sleep, paranoia, and irritability. (Tr. 781, 1020).
Ms. Caldwell also briefly received care at the Center for
Emotional Care in 2015. There, the psychiatrist's report
noted that Ms. Caldwell attended weekly therapy sessions and
had a history of taking medications for anxiety, depression,
and bipolar disorder. (Tr. 1049-50). Although Ms. Caldwell
had described her concentration as "off to Dr. Dulaney
(Tr. 781), the psychiatrist's report described Ms.
Caldwell as having a good affect, good memory, and "good
attention and concentration" (Tr. 1049). Ms. Caldwell
reported to Dr. Dulaney that she experienced some improvement
in her mental health symptoms with medication and counseling.
addition to the medical record, the Law Judge considered the
opinions of the state agency consultants and Ms.
Caldwell's treating physician, Dr. Aaron. The state
agency consultants opined that Ms. Caldwell could perform
light work with certain conditions and was moderately limited
in her ability to maintain attention and concentration for
extended periods, but "would be able to meet the basic
mental demands of competitive work on a sustained
basis." (Tr. 104-08, 120-28). A state agency consultant
explained that although Ms. Caldwell experiences stress and
worry, her mental status exams fall within normal limits, she
takes medication to manage symptoms, and she has the ability
to complete household activities and go to the store and
medical appointments. (Tr. 127). The consultant opined that
Ms. Caldwell fears crowds but can otherwise maintain socially
appropriate behavior as demonstrated by her socialization
with her daughter and endeavors outside the home. (Tr. 128).
The consultant recognized that Ms. Caldwell had not received
any "significant psychiatric care" since her
initial filing and had "not been hospitalized or
received intensive inpatient or outpatient psychiatric
care." (Tr. 128). The consultant concluded that Ms.
Caldwell "remains capable of simple, routine work."
(Tr. 128). However, one of the plaintiffs treating
physicians, Dr. Aaron, opined that Ms. Caldwell is disabled
due to a combination of physical and emotional causes. (Tr.
630, 643, 667, 682). The Law Judge determined that Ms.
Caldwell's complaints and Dr. Aaron's notes based on
those complaints were not entirely consistent with the
overall medical evidence, which was reviewed by the state
agency consultants. The court believes that substantial
evidence supports the Law Judge's reliance on the state
agency consultants' opinions, inasmuch as the court
agrees that these opinions are consistent with the objective
findings in the record.
his consideration of the state agency reports, the court
believes that the Law Judge was able to properly consider the
synergistic effect of all of plaintiffs physical and
emotional problems. Stated differently, the court believes
that, in this case, the state agency reports provide
substantial evidence for the Law Judge's disposition.
Judge did not give significant weight to Dr. Aaron's
opinions that Ms. Caldwell was unable to seek or maintain
employment because of back pain, reduced stamina, depression,
and incontinence; that Ms. Caldwell was disabled; or that Ms.
Caldwell's activities of daily living were markedly
limited because of Ms. Caldwell's difficulty with
completing tasks. (Tr. 630, 643, 667, 682). Dr. Aaron assumed
that Ms. Caldwell was "medically compliant." (Tr.
630). To the extent Dr. Aaron opined that Ms. Caldwell was
disabled, the Law Judge rejected the opinion as encroaching
on a judgment reserved for the Commissioner. (Tr. 25). The
Law Judge accorded reduced weight to the remainder of Dr.
Aaron's opinions because she largely relied on Ms.
Caldwell's subjective complaints, which the Law Judge did
not find entirely credible, and her opinions conflicted with
the objective medical evidence in the record. (Tr. 25).
Judge did not fully credit the subjective complaints of Ms.
Caldwell because of her limited work history and history of
drug and alcohol abuse. (Tr. 25). Ms. Caldwell testified at
the administrative hearing that she experiences approximately
three migraines a month, joint pain, pain in her hands,
nausea, diarrhea, difficulty sitting for more than 15 to 20
minutes, difficulty standing for more than 10 to 15 minutes,
feelings of fatigue due to her thyroid condition and
medication, blurred vision, trouble holding objects,
difficulty concentrating, and three to four panic attacks a
week. (Tr. 50-62). In finding Ms. Caldwell's statements
to be of limited credibility, the Law Judge observed that Ms.
Caldwell filed for disability as early as 2005, but continued
to work for several years after 2005 and even continued to
work in an informal manner after the alleged onset date for
her instant applications for benefits. (Tr. 25). The Law
Judge further observed that Ms. Caldwell did not use her
prescription drugs as prescribed, took non-prescribed and
illegal drugs, and has not yet secured treatment for her drug
use. (Tr. 45, 48, 60, 731). A few weeks after being
confronted about her use of controlled and illegal drugs (Tr.
731), Ms. Caldwell arrived at the emergency room and was
found to be intoxicated following a night of drinking with
her boyfriend (Tr. ...