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McAlister v. Colvin

United States District Court, D. South Carolina, Aiken Division

May 13, 2014

Steven Roy McAlister, Plaintiff,
v.
Carolyn W. Colvin, Acting Commissioner of Social Security Administration, Defendant.

REPORT AND RECOMMENDATION

SHIVA V. HODGES, Magistrate Judge.

This appeal from a denial of social security benefits is before the court for a Report and Recommendation ("Report") pursuant to Local Civil Rule 73.02(B)(2)(a) (D.S.C.). Plaintiff brought this action pro se pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3) to obtain judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying his claim for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI"). The two issues before the court are whether the Commissioner's findings of fact are supported by substantial evidence and whether she applied the proper legal standards. For the reasons that follow, the undersigned recommends that the Commissioner's decision be affirmed.

I. Relevant Background

A. Procedural History

On October 23, 2009, Plaintiff filed applications for DIB and SSI in which he alleged his disability began on December 31, 2001. Tr. at 8. His applications were denied initially and upon reconsideration. Tr. at 79, 81, 83-84. On March 23, 2011, Plaintiff had a hearing before Administrative Law Judge ("ALJ") Ivar E. Avots. Tr. at 35-78 (Hr'g Tr.). The ALJ issued an unfavorable decision on April 27, 2011, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 8-18. Subsequently, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner for purposes of judicial review. Tr. at 1-3. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on November 27, 2012. [Entry #1].

B. Plaintiff's Background and Medical History

1. Background

Plaintiff was 43 years old at the time of the hearing. Tr. at 41. He graduated from high school. Id. His past relevant work ("PRW") was as a stocker. Tr. at 74. He alleges he has been unable to work since December 31, 2001.[1] Tr. at 8.

2. Medical History

Plaintiff began exhibiting symptoms of depression in June 2009, shortly after his wife passed away. Tr. at 256. On September 15, 2009, Plaintiff was hospitalized at Oconee Memorial Hospital ("Oconee Memorial") for three days after he was found with a gun to his head. Tr. at 227, 233-34. On discharge, he was diagnosed with major depressive disorder with a single episode of psychotic features, generalized anxiety disorder, bereavement, possible panic disorder, and hypertension. Tr. at 233. During the course of his hospitalization, his mood improved, but his sometimes joyful and exuberant mood caused the treating physician to wonder whether he would carry out his suicidal plan if released on his own recognizance. Id. Consequently, Plaintiff was discharged to Patrick B. Harris Psychiatric Facility ("Harris Psychiatric") where he remained for another five days. Tr. at 233-34, 244. He was discharged from Harris Psychiatric on September 22, 2009, with a diagnosis of adjustment disorder with depressed mood. Tr. at 245. It was noted that his global assessment functioning ("GAF")[2] score was 39 on admission, but had increased to 65 by the time of his discharge. Id.

On November 14, 2009, Plaintiff was admitted to Oconee Memorial for an episode of syncope that doctors noted might have been some type of seizure event. Tr. at 260. It was noted that his hypertension was well-controlled ( id. ), but that he was morbidly obese. Tr. at 263. An EKG and a CT scan of Plaintiff's head were normal. Tr. at 264, 280-81, 284.

After being discharged from Oconee Memorial, Plaintiff presented to the AnMed Health Emergency Department ("AnMed") on November 17, 2009, complaining of abdominal pain. Tr. at 307. He was diagnosed with unspecified constipation. Tr. at 309.

Plaintiff was again seen in the Oconee Memorial emergency room on December 6, 2009, after experiencing some pseudoseizure-type activity in his extremities. Tr. at 288. His main complaint was left lower quadrant abdominal pain, and he was discharged with diagnoses of constipation and mild diverticulitis. Tr. at 288-89.

On February 17, 2010, Plaintiff returned to AnMed complaining of back pain after tripping over a night stand and falling over a coffee table. Tr. at 311. Examination was negative for headache, dizziness, lightheadedness, syncope, and vertigo. Id. He was noted to have a past seizure disorder for which he was not taking medication. Tr. at 312. He was discharged with a diagnosis of low back pain and prescriptions for narcotic pain medication and muscle relaxants. Tr. at 313.

Plaintiff completed a function report on June 15, 2010, in which he stated that he went to church on Sunday morning, Sunday evening, and Wednesday. Tr. at 159. He noted that he also went fishing and grocery shopping once a month. Id. He stated that he could walk no more than 200 feet before needing to rest and could not pay attention for longer than 30 minutes. Tr. at 160.

On January 26, 2010, Plaintiff's treating physician, Edward H. Booker, M.D., reported that Plaintiff had diagnoses of depression, anxiety, and possible bipolar disorder. Tr. at 303. Dr. Booker noted that Plaintiff's symptoms included slowed thought process, suspicious thought content, flat mood/affect, and poor attention/concentration. Id. Dr. Booker opined that these impairments/symptoms caused Plaintiff to have serious work-related limitation in function. Id.

On March 23, 2010, Plaintiff began receiving treatment at Rosa Clark Clinic for anxiety attacks. Tr. at 334. Records indicate that Plaintiff was assessed with "[p]anic disorder versus seizure, " and was prescribed Effexor and Ativan. Tr. at 334-35.

On April 26, 2010, Plaintiff was transported to Oconee Medical Center for an unintended overdose of Ativan. Tr. at 396. Plaintiff later stated, "I just wanted to calm down and fall asleep; I do not want to kill myself." Id. He was discharged home the same day. Tr. at 397.

On May 25, 2010, psychologist Robin Moody, Ph.D., performed a consultative examination of Plaintiff. Tr. at 337-40. Plaintiff reported numerous symptoms of depression and anxiety, including "depressed mood, fatigue, hopelessness/helplessness, appetite changes, sleep disturbances, suicidal ideations and withdrawal... constant worry, nervousness, restlessness, fatigue, irritability, difficulty concentrating and sleep disturbances." Tr. at 337. Plaintiff reported that he spent most of his day in bed, but could drive, do household chores, cook, and groom himself. Id. He stated that he had been sexually abused at the age of eight or nine years old. Tr. at 338. Dr. Moody examined Plaintiff and noted that his affect was normal even though his mood was slightly depressed, his thought processes were appropriate, his attitude was cooperative, and his memory was intact. Id. She noted that Plaintiff answered questions to the best of his ability and did not appear to be embellishing symptoms or malingering. Id. Dr. Moody noted that Plaintiff had difficulty with delayed recall, serial 7s, and spelling the word "world" backwards. Id. Dr. Moody assessed Plaintiff as having "moderate difficulty maintaining social relationships due to his isolation and depression." Id. However, she opined that Plaintiff could carry out simple instructions, and noted that, despite distracted concentration, Plaintiff had good pace and adequate persistence. Id. Dr. Moody diagnosed Plaintiff with recurrent major depressive disorder with psychotic features, panic disorder with agoraphobia, and generalized anxiety disorder, and assigned him a GAF score of 59. Tr. at 338-39.

On May 27, 2010, state agency medical consultant Gary E. Calhoun, PhD., reviewed the evidence of record and opined that Plaintiff had major depressive disorder with psychotic features, anxiety/panic disorder with agoraphobia, and adjustment disorder with depressed mood. Tr. at 341-48. He opined that Plaintiff had mild restriction of activities of daily living ("ADLs"); moderate difficulties in maintaining social functioning; moderate difficulties in maintaining concentration, persistence, or pace; and no episodes of decompensation. Tr. at 351. Dr. Calhoun opined that Plaintiff could understand and remember simple instructions; could carry out simple tasks and instructions for two hours at a time; would perform best in situations that do not require on-going interaction with the public; and was able to be aware of normal hazards and take appropriate precautions. Tr. at 369-71. He further opined that Plaintiff's impairments did not preclude him from performing simple, repetitive work tasks in a setting that does not require on-going interaction with the public. Tr. at 371.

On June 3, 2010, state agency medical consultant Frank Ferrell reviewed the evidence of record and opined that Plaintiff could lift or carry up to 50 pounds occasionally and 25 pounds frequently; could sit, stand, or walk about six hours each in an eight-hour day; could frequently climb ramps or stairs, balance, stoop, kneel, crouch, and crawl, and occasionally climb ladders, ropes and scaffolds; and must avoid even moderate exposure to hazards such as unprotected heights or dangerous machinery. Tr. at 374-81.

On July 1, 2010, Plaintiff presented to the Oconee Medical Center emergency department complaining of pain in his right shoulder and arm after a verbal altercation with a neighbor. Tr. at 413. He asked to have his blood sugar checked and reported that he was a borderline diabetic. Id. On examination, Plaintiff was in no acute distress and did not have an altered mental status, but was noted to have an odd affect. Tr. at 413-14. He was discharged with diagnoses of resolved hypertension, stress reaction, and paresthesia in his feet. Tr. at 415.

From December 17, 2010, through December 22, 2010, Plaintiff was hospitalized with criteria for admission listed as "[p]otentially dangerous to self, others or property and in need of a controlled environment." Tr. at 466. He exhibited no symptoms of mania or psychosis and expressed concern about writing fraudulent checks. Id. He was discharged in stable condition and advised to follow up with the Anderson Mental Health Center. Tr. at 467. His discharge diagnosis included non-specific depressive disorder, non-insulin dependent diabetes, and hypercholesterolemia. Id. Following discharge, Plaintiff received mental health treatment from the Anderson Mental Health Center. Tr. at 471-83. As of March 1, 2011, target symptoms for treatment included: "Anxiety, Depression, Irritability, SI/HI ideation/attempts." Tr. at 471. Plaintiff reported that he experienced periods of excessive anger ...


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