United States District Court, D. South Carolina, Aiken Division
Valerie L. Reaves, Plaintiff,
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 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 her claim for Disability Insurance Benefits ("DIB"). 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 reversed and remanded for further proceedings as set forth herein.
I. Relevant Background
A. Procedural History
On August 26, 2008, Plaintiff filed an application for DIB in which she alleged her disability began on August 10, 2007. Tr. at 230-32. Plaintiff later amended her disability onset date to June 26, 2008. Tr. at 20, 347. Her application was denied initially and upon reconsideration. Tr. at 85-88. On July 8, 2010, Plaintiff had a hearing before Administrative Law Judge ("ALJ") Edward T. Morriss. Tr. at 31-56 (Hr'g Tr.). The ALJ issued an unfavorable decision on September 24, 2010, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 89-105. On November 4, 2011, the Appeals Council granted Plaintiff's request for review of the ALJ's decision, remanded the case to the ALJ, and ordered him to: (1) give further consideration to Plaintiff's self-reported earnings during the relevant period; (2) give further consideration to the residual functional capacity ("RFC"), evaluate treating and non-treating source opinions, and request additional information when necessary; and (3) obtain testimony from a vocational expert. Tr. at 106-09.
The ALJ held a second hearing on May 25, 2012. Tr. at 57-84. In a decision dated July 17, 2012, the ALJ again found that Plaintiff was not disabled under the Act. Tr. at 20-30. On December 7, 2012, the Appeals Council granted Plaintiff's request for review. Tr. at 9-12. The Appeals Council issued an unfavorable decision on January 28, 2013. Tr. at 1-6. In its decision, the Appeals Council agreed with the ALJ's findings, but noted that he erred in failing to consider the deposition of vocational expert ("VE") Benson Hecker. Tr. at 5. The Appeals Council accorded Dr. Hecker's opinion no weight and affirmed the ALJ's finding of non-disability. Tr. at 5-6. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on March 8, 2013. [Entry #1].
B. Plaintiff's Background and Medical History
Plaintiff was 38 years old at the time of the second hearing. Tr. at 60. She completed high school and three years of college. Tr. at 34. Her past relevant work ("PRW") was as an operations supervisor at a transportation company. Tr. at 79. She alleges she has been unable to work since June 26, 2008. Tr. at 20, 347.
2. Medical History
Plaintiff stopped working in June 2008. Tr. at 489. On July 11, 2008, Plaintiff's primary care physician Keith W. Lackey M.D., noted that Plaintiff was suffering from mood swings, depressed mood, and problems sleeping. Tr. at 478.
Plaintiff first saw treating psychiatrist, Susan S. Crocker, M.D., on August 6, 2008. Tr. at 489-91. Plaintiff reported leaving a stressful job working with her family and staying in bed for one week after quitting. Tr. at 489. She felt like she had a physical and mental breakdown in June 2008. Id. Dr. Crocker noted that Plaintiff had fair concentration, intact memory, appropriate thought content and process, and normal speech, but was fidgety and exhibited a depressed and anxious mood. Tr. at 490. Dr. Crocker prescribed medications to treat anxiety, a mood disorder, recurrent depression, sleep difficulties, and mood swings. Tr. at 491.
On September 8, 2008, Plaintiff reported low energy, feelings of fatigue, and worsening anxiety. Tr. at 486. On September 24, 2008, Dr. Crocker noted that Plaintiff's mood was mildly dysthymic, she continued to have moderate anxiety around people, her mood cycling was better, but still present, and she was sleeping better. Tr. at 494.
Plaintiff returned to Dr. Crocker on October 23, 2008. Tr. at 560. She reported low energy, jaw clenching, frequent panic attacks, no mood swings, and mild depression. Id. Dr. Crocker diagnosed bipolar disorder. Id. On November 17, 2008, Plaintiff reported feeling sluggish and sedated. Tr. at 558.
On December 4, 2008, Plaintiff reported to Dr. Crocker that her mood swings were worse and that, she was more depressed and anxious. Tr. at 557. Dr. Crocker noted that Plaintiff had gotten medication directions wrong on several occasions. Id. A few days later, Plaintiff reported that her mood swings had decreased, her depression symptoms were mild, and her anxiety symptoms had improved, but she was still avoiding social interactions. Tr. at 556.
By letter dated January 6, 2009, Dr. Crocker explained that Plaintiff's anxiety symptoms were still problematic given her mood disorder and psychosocial stressors despite treatment with benzodiazepines. Tr. at 629. She stated that she treated Plaintiff as having anxiety and bipolar disorders. Id. Dr. Crocker described Plaintiff's medication regimen as being complex and including a mood stabilizer, two antidepressants, one antipsychotic, and one anxiolytic medicine. Id. Dr. Crocker ultimately concluded that "[d]ue to ongoing instability of her mood, moderate anxiety symptoms, and periodic adverse medication side effects, [Plaintiff] is not stable enough to work at this time." Id.
On January 7, 2009, Plaintiff reported that her mood swings and depression were better, but that she continued to have sleep problems and moderate to severe anxiety, worried excessively, and avoided the public. Tr. at 554.
On March 24, 2009, Dr. Crocker noted that Plaintiff's mood was primarily euthymic with mild intermittent dysthymia breakthrough and that she was generally sleeping well and had less severe panic attacks about five times per month. Tr. at 628. Plaintiff stated that she felt she was more stable emotionally, but was in physical pain on a daily basis because of her fibromyalgia and degenerative joint disease. Id.
Plaintiff was in a car accident on May 29, 2009. Tr. at 626. On June 25, 2009, Dr. Crocker noted that the accident had traumatized Plaintiff, causing worse sleep and exacerbated anxiety symptoms. Id.
On October 7, 2009, Plaintiff reported feeling more depressed, anxious, and guilty because she could not work. Tr. at 624. Dr. Crocker noted that Plaintiff was easily agitated and felt sluggish and overmedicated. Id. On January 6, 2010, Plaintiff reported that Prozac had helped her mood, but she still had some breakthrough depression. Tr. at 623. She also reported decreased energy, poor sleep, and no significant mood swings. Id. Plaintiff continued to treat with Dr. Crocker through May 2011. Tr. at 690-95. During these visits, Plaintiff continued to report depression, mild to moderate anxiety, variable sleep, and variable energy. Id. Plaintiff's global assessment of functioning ("GAF") scores throughout her treatment with Dr. Crocker ranged from 55 to 65. Tr. at 486-94, 554-60, 623-28, 690-95.
On July 19, 2010, Dr. Crocker denied Plaintiff's counsel's request to complete a Treating Psychiatrist's Statement and Mental Residual Functional Capacity ("RFC") Statement. Tr. at 661. Dr. Crocker noted that she did not do evaluations of functional capacity and suggested Plaintiff seek out a disability evaluator such as Dr. Gordon Teichner. Id.
Dr. Teichner conducted a consultative neuropsychological evaluation in August 2010. Tr. at 662. As part of the evaluation, Dr. Teichner reviewed Plaintiff's psychiatric and medical records, psychiatric medications, psychiatric history, vocational history, and administered a battery of neuropsychological tests. Tr. at 662-64. Plaintiff reported that her only job had been with her family's trucking company and that she probably would have been fired many times over the years if she had been working for someone other than her parents. Tr. at 663. She stated she threw frequent tantrums at work where she would scream, yell, and act out, and that she often had panic attacks. Id. On examination, Dr. Teichner noted that Plaintiff was alert and oriented, organized in her thoughts, fidgety, anxious, depressed, and sad. Tr. at 665. She exhibited intact memory and fair judgment. Id. Testing revealed that Plaintiff demonstrated average intellectual abilities, average language abilities, severe deficits of visual focused attention, inconsistent and erratic reaction time indicative of inattention and problematic information processing speed, and excessive errors of commission indicating problematic impulsivity. Tr. at 668-69.
Based on his evaluation of Plaintiff, Dr. Teichner diagnosed bipolar disorder, generalized anxiety disorder, panic disorder with agoraphobia, social phobia, attention deficit/hyperactivity disorder not otherwise specified, and victim of childhood physical and sexual abuse by history. Tr. at 671. He assessed her with a GAF score of 40, noted that she demonstrated a poorly-controlled bipolar disorder, and stated that her psychological assessment revealed a severe mental illness that involved both affective and anxiety disorders. Id. Dr. Teichner concluded that Plaintiff did not have the capacity to gain and maintain meaningful employment due to the cumulative negative effects of her poorly-controlled psychiatric conditions and personality pathology. Tr. at 672. He agreed with Plaintiff that the only reason that she was able to maintain employment for as long as she did was because she was working for her parents. Id. He noted that any other employer would have certainly fired her years ago. Id.
Dr. Teichner also completed an Examining Psychologist's Statement in which he opined that Plaintiff met the paragraph A, B, and C criteria for Listings 12.04 and 12.06. Tr. at 675-79. He opined that Plaintiff had marked restriction of ADLs; extreme difficulties in maintaining social functioning; marked difficulties in maintaining concentration, persistence, or pace; and four or more episodes of decompensation, each of an extended duration. Tr. at 678.
On December 6, 2010, Dr. Crocker wrote a letter to Plaintiff's counsel stating that Plaintiff's diagnoses were "consistent with those given by Dr. Teichner in his extensive evaluation done in August 2010." Tr. at 689.
In January and February 2012, Plaintiff began seeing therapist Nancy D. Wington, LPC, and psychiatrist Paul I. Robbins, M.D. Tr. at 711-14. At the initial visit, Plaintiff reported low energy, low sleep, anhedonia, poor concentration, easy distractability, racing thoughts, and high anxiety. Tr. at 713. She was observed to have a depressed and anxious mood, tearfulness, flat or congruent affect, poor insight, and poor judgment. Id. Dr. Robbins's initial assessment of Plaintiff on February 24, 2012, was bipolar affective disorder and panic disorder with agoraphobia, and he wanted to rule out post-traumatic stress disorder. Tr. at 711. Dr. Robbins assigned a GAF score of 50 and adjusted Plaintiff's psychiatric medications. Id. Subsequent treatment and counseling notes through May 2012 continued to show tearfulness on examination and showed that Dr. Robbins continued to adjust Plaintiff's medications. Tr. at 707-10, 715.
At the request of Plaintiff's counsel, Dr. Robbins drafted an opinion letter dated May 22, 2012. Tr. at 717-19. Dr. Robbins noted that he had reviewed Dr. Crocker's letter dated December 6, 2010, and Dr. Teichner's opinions from August 2010. Tr. at 718. Dr. Robbins stated that he agreed with Dr. Teichner's mental RFC assessment and stated that he saw no improvement in Plaintiff's ability to function in a work-related environment. Tr. at 718-19. He noted that Plaintiff was having much difficulty functioning even in her home environment. Tr. at 719.
Over the course of the time period at issue in this appeal, Plaintiff also received treatment, underwent studies, and was prescribed medications for her physical impairments by gastroenterologists (Tr. at 457, 465-76, 496-521, 654-60, 696-700), neurologist Harnid R. Bahadori, M.D. (Tr. at 643-53), and rheumatologist Gregory Niemer, M.D. (Tr. at 564-74, 630-42, 701-06). A gastrointestinal emptying study performed on June 6, 2007, was found abnormal (Tr. at 457, 470) and gastroenterologist Todd E. Dantzler, M.D., diagnosed Plaintiff with gastroparesis (Tr. at 659-60). Dr. Bahadori's notes from July 2009 to January 2010 showed that Plaintiff was treated for complaints of neck and back pain and spasms. Tr. at 643-53. She was assessed with cervical radiculolpathy, neck spasm, neck dystonia, and occipital headache. Tr. at 644, 646, 653. However, MRI and EMG studies came back negative. Tr. at 646, 648-50.
Dr. Niemer wrote two type-written letters to Dr. Crocker. In a letter dated March 3, 2009, Dr. Niemer indicated that Plaintiff's physical examination was notable for multiple trigger points and decreased range of motion. Tr. at 642. He noted that Plaintiff's symptoms seemed to be related to a combination of degenerative disc disease of the lumbar spine and fibromyalgia. Id. In a letter dated August 31, 2009, Dr. Niemer noted that Plaintiff continued to have marked symptoms secondary to her fibromyalgia, along with great difficulty sleeping. Tr. at 632.
C. The Administrative Proceedings
1. The First Administrative Hearing
At the hearing on July 8, 2010, Plaintiff stated that she lived with her husband and two children. Tr. at 35. She reported having a long history of social anxiety (Tr. 53) and that she had been on antidepressant and anti-anxiety medication since her twenties (Tr. at 38). She said that after attending three years of college, she started working at her parents' business. Tr. at 50-51. Plaintiff testified that before she quit working, she was having panic attacks at work, having frequent mood swings, and could not handle stressors in the office. Tr. at 37. She stated that her job was very high stress and that another employer would not have tolerated her flying off the handle, screaming, throwing fits, and walking out of the office. Tr. at 38-39. She said her parents allowed her to go to another room to cool down or go home for the day. Tr. at 39. She stated that she stopped working after getting into what should have been a minor disagreement with her brother, but which escalated into her walking off the job and not speaking to her family for a month. Tr. at 40.
Plaintiff testified that although her medications had improved her mood swings, she continued to have panic attacks. Tr. at 40-41. She said she sometimes had to take extra medication to feel comfortable, but that the medication caused her thinking to become cloudy, slowed her reaction time, and affected her memory. Tr. at 41. She testified that she spent about 80 percent of her time in her bedroom. Tr. at 42. She stated that she left the house once or twice a week to go to dinner or visit family and shopped when the grocery store was not busy. Tr. at 43-44.
Plaintiff testified to gastrointestinal issues as well as difficulty sleeping. Tr. at 46-48. She said she had low energy during the day and spent five or six hours resting during normal work hours. Tr. at 48. She reported being involved in a car accident in May 2009 and stated ...