United States District Court, D. South Carolina, Aiken Division
John D. Barrett, Sr., Plaintiff,
Commissioner of Social Security Administration, Defendant.
SHIVA V. HODGES, Magistrate Judge.
This appeal from a denial of social security benefits is before the court for a final order pursuant to 28 U.S.C. § 636(c), Local Civ. Rule 73.01(B) (D.S.C.), and the order of the Honorable Timothy M. Cain dated July 3, 2014, referring this matter for disposition. [ECF No. 13]. The parties consented to the undersigned United States Magistrate Judge's disposition of this case, with any appeal directly to the Fourth Circuit Court of Appeals. [ECF No. 9].
Plaintiff files this appeal pursuant to 42 U.S.C. § 405(g) of the Social Security Act ("the Act") to obtain judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying the claims 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 court reverses and remands the Commissioner's decision for further proceedings as set forth herein.
I. Relevant Background
A. Procedural History
On July 26, 2010, Plaintiff filed applications for DIB and SSI in which he alleged his disability began on February 1, 2010. Tr. at 167-71, 173-93. His applications were denied initially and upon reconsideration. Tr. at 79-83, 86-88, 89-91. On November 8, 2012, Plaintiff had a hearing before Administrative Law Judge ("ALJ") Peggy McFadden-Elmore. Tr. at 41-70 (Hr'g Tr.). The ALJ issued an unfavorable decision on December 7, 2012, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 19-40. 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 5-9. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on June 16, 2014. [ECF No. 1].
B. Plaintiff's Background and Medical History
Plaintiff was 48 years old at the time of the hearing. Tr. at 45. He completed two years of college. Tr. at 47. His past relevant work ("PRW") was as an agricultural commodities inspector. Tr. at 64. He alleges he has been unable to work since February 1, 2010. Tr. at 45.
2. Medical History
Plaintiff was hospitalized at Palmetto Health Baptist from December 22, 1999, to January 3, 2000, with depression and extreme anxiety. Tr. at 430. He was involuntarily committed after assaulting his wife. Id. Psychological testing demonstrated adjustment disorder with mixed emotional features and potential for brief psychotic reactions, as well as alcohol abuse. Tr. at 431. He demonstrated some dependent and avoidant personality traits. Id. Plaintiff's discharge diagnoses included alcohol abuse, brief reactive psychosis, and adjustment disorder with disturbance of mood and conduct. Id.
Plaintiff received intermittent psychiatric treatment with Timothy Malone, M.D., from March 15, 2000, through February 11, 2004. Tr. at 440-49. Notes from these visits are generally illegible.
Plaintiff was hospitalized on the adult psychiatric ward at Palmetto Health Baptist from January 2, 2006, to January 10, 2006, secondary to severe depression with suicidal ideation. Tr. at 434. Plaintiff indicated he was going through a divorce and was unable to see his children. Id. He reported poor sleep, crying spells, helplessness, hopelessness, worthlessness, anhedonia, increased anxiety, and poor appetite. Id. Plaintiff's final diagnoses included major depressive disorder and mixed personality trait. Tr. at 435.
Plaintiff followed up with Dr. Malone on February 6, 2006. Tr. at 439. He reported doing well and did not follow up thereafter. Id.
On January 30, 2010, Plaintiff presented to Kershaw Health Medical Center ("Kershaw Health") with vague complaints of things bothering him. Tr. at 285. He was described as uncooperative, vague, and evasive. Tr. at 286. Plaintiff attempted to leave the emergency department, but he was stopped by a nurse and the police were called. Tr. at 287. Plaintiff was transferred to Palmetto Baptist for inpatient treatment, where he remained until March 2, 2010. Tr. at 288, 289. Plaintiff endorsed paranoid thoughts, was irritable, was guarded in his interaction with staff, and refused to comply with medication orders until he was court-ordered to comply with treatment. Tr. at 292-93. After he became compliant with treatment, he complained that Seroquel made him feel sedated and lightheaded. Tr. at 293. Seroquel was discontinued, but later prescribed again after other medications produced more significant side effects. Id. After resuming use of Seroquel, Plaintiff became more compliant and his mood and affect improved. Id. Jennifer E. Heath, M.D. ("Dr. Heath"), indicated final diagnoses including major depressive disorder with psychotic features, possible paranoid personality disorder traits, pernicious anemia, and hypertension. Tr. at 291. Dr. Heath indicated a global assessment of functioning ("GAF") score of 55 at the time of discharge. Id.
Plaintiff presented to Robert K. Hotchkiss, M.D. ("Dr. Hotchkiss"), at Kershaw County Mental Health Center ("Kershaw Mental Health") for an initial physician's assessment on March 29, 2010. Tr. at 335-37. Dr. Hotchkiss described Plaintiff's insight as poor, but indicated no other abnormalities on the mental status examination. Tr. at 336. He assessed a GAF score of 50. Id.
Plaintiff presented to Kershaw Health on May 18, 2010, for a psychiatric evaluation after becoming aggressive with his mother. Tr. at 301. Plaintiff reported that his mother "came to his door banging on the door" and told him that he had an appointment. Tr. at 301. Plaintiff reported that he had rescheduled the appointment earlier in the week and was frustrated. Tr. at 301, 304. He was not exhibiting symptoms of psychosis and denied suicidal or homicidal ideations. Tr. at 304. He was discharged and instructed to follow up with mental health. Tr. at 303.
Plaintiff was involuntarily committed to Palmetto Health Baptist from June 29, 2010, to August 27, 2010, for psychosis. Tr. at 313. Upon admission, he was slightly agitated and his affect was irritable and constricted. Tr. at 313. He had some difficulty with attention and concentration and his thoughts were disorganized. Id. He had "very significant paranoid delusions." Id. His insight and judgment were poor. Tr. at 313-14. Plaintiff's medications were adjusted several times during his hospitalization. Tr. at 314. His thoughts and mood improved by the end of July, but his symptoms were exacerbated when he had contact with his family. Tr. at 315. Finally, after a family meeting on August 19, plans were made for Plaintiff's discharge. Tr. at 316. Dr. Heath indicated a final diagnosis of schizophrenia, paranoid type. Tr. at 313. Plaintiff was also diagnosed with chronic obstructive pulmonary disease ("COPD") and was prescribed bronchodilators. Tr. at 311.
On September 9, 2010, Plaintiff presented to Michael Kulungowski, M.D. ("Dr. Kulungowski"), at Kershaw Mental Health. Tr. at 332-34. His target symptoms for treatment included anxiety, delusions/paranoia, and legal problems. Tr. at 333. He indicated that his mother was "the problem." Id. Although Plaintiff's mental status examination was normal, Dr. Kulungowski assessed a GAF score of 40. Tr. at 334. Plaintiff was instructed to "[g]et on meds." Id.
Plaintiff presented to Leon Hunt, M.D. ("Dr. Hunt"), at Caresouth Carolina on September 30, 2010, for a refill of his blood pressure medication. Tr. at 398. His oxygen saturation was 98 percent. Id. He complained of no pain and indicated he exercised three times per week. Id. Dr. Hunt refilled Plaintiff's prescription for Lotensin. Id.
On October 4, 2010, Kevin King, Ph. D. ("Dr. King"), completed a psychiatric review technique in which he indicated Plaintiff's impairment was severe, but not expected to last 12 months. Tr. at 338. He considered Listings 12.04 and 12.08. Id. He indicated Plaintiff had major depressive disorder with psychotic features and paranoid personality traits. Tr. at 341, 345. Dr. King assessed moderate restriction of activities of daily living, moderate difficulties in maintaining social functioning, marked difficulties in maintaining concentration, persistence, or pace, and one or two episodes of decompensation, each of extended duration. Tr. at 348. Dr. King also completed a mental residual functional capacity assessment in which he indicated Plaintiff was moderately limited with respect to the following abilities: to carry out detailed instructions; to maintain attention and concentration for extended periods; to perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances; to sustain an ordinary routine without special supervision; to work in coordination with or proximity to others without being distracted by them; to make simple work-related decisions; to complete a normal workday and workweek without interruptions from psychologically-based symptoms; to perform at a consistent pace without an unreasonable number and length of rest periods; to interact appropriately with the general public; to ask simple questions or request assistance; to accept instructions and respond appropriately to criticism from supervisors; to get along with coworkers or peers without distracting them or exhibiting behavioral extremes; to maintain socially-appropriate behavior; to adhere to basic standards of neatness and cleanliness; to respond appropriately to changes in the work setting; to be aware of normal hazards and take appropriate precautions; to travel in unfamiliar places or use public transportation; and to set realistic goals or make plans independently of others. Tr. at 352-53. He further indicated the following:
[T]he cl demonstrates good tx response, and although he is currently tx for MDD with psych fx and paranoid personality traits, it is expected that within 12 months of onset he will be able to have the capacity to understand, remember, and carry out simple instructions. The cl will be able to attend to a simple task without special supervision. The cl will be able to maintain personal hygiene, and make simple work-related decisions. The cl will be able to work best with limited contact with the general public. The cl will be able to respond best to supportive supervision. The cl will be able to recognize and avoid normal workplace hazards, and use public transportation.
Tr. at 354.
On October 13, 2010, state agency medical consultant G. Hampton Smith, M.D., reviewed Plaintiff's medical records and determined he had no severe physical impairments. Tr. at 356.
Plaintiff followed up with Dr. Kulungowski on November 1, 2010. Tr. at 361-62. Dr. Kulungowski noted no abnormalities on Plaintiff's mental status examination. Tr. at 361. Plaintiff's diagnoses included psychotic disorder, NOS, and depressive disorder, NOS. Tr. at 362. Dr. Kulungowski assessed a GAF score of 60 and noted Plaintiff had "no symptoms." Id. He recommended Plaintiff participate in outside activities, exercise, and stay in counseling. Id.
Plaintiff presented to Dr. Kulungowski for follow up on December 30, 2010. Tr. at 427-28. Plaintiff reported symptoms of depression and complained that Zoloft was too strong. Tr. at 428. Dr. Kulungowski indicated Plaintiff had not filled his prescription for Celexa. Id. Dr. Kulungowski instructed Plaintiff to remain on his medications and to continue with counseling. Id.
On January 6, 2011, Dr. Kulungowski indicated Plaintiff's prescription for Celexa was "problematic, " and that he was replacing it with Remeron. Tr. at 426. Plaintiff denied suicidal and homicidal ideations and his mental status examination was normal. Tr. at 425. Dr. Kulungowski assessed a GAF score of 60. Tr. at 426.
Plaintiff followed up with Dr. Kulungowski on February 3, 2011. Tr. at 423-24. Plaintiff reported some tiredness from Remeron. Tr. at 424. He requested that his Invega dosage be decreased, but Dr. Kulungowski was reluctant to lower it. Id. Plaintiff's mental status examination was normal, and Dr. Kulungowski assessed a GAF score of 65. Tr. at 423-24.
On March 22, 2011, Plaintiff presented to Douglas R. Ritz, Ph. D. ("Dr. Ritz"), for a consultative mental status examination. Tr. at 363-66. Plaintiff reported depression, confusion, paranoid thoughts, and social withdrawal. Tr. at 363. He reported thoughts of self-harm, but no specific plan. Id. He indicated his medications made him "sleepy." Id. He described his mood as "kind of blank." Id. Plaintiff maintained eye contact with Dr. Ritz and his speech was normal. Tr. at 364-65. His grooming and hygiene were good. Tr. at 365. His was calm, logical, coherent, alert, responsive, and in no distress. Id. His judgment was good. Id. His affect was flat and his insight was fair. Id. Plaintiff was able to perform serial threes, but he was unable to interpret a proverb. Id. His remote memory was good and he was able to remember three of four objects after a five-minute delay. Id. Dr. Ritz estimated Plaintiff's cognitive abilities to be average. Id. He indicated that Plaintiff "may be able to handle an unskilled type work setting." Id. He diagnosed major depressive disorder, single episode, moderate and psychotic disorder, NOS and assessed a GAF score of 55. Id.
Plaintiff presented to Chioma R. Ekechukwu, M.D. ("Dr. Ekechukwu") at Kershaw Mental Health, on March 31, 2011. Tr. at 421-22. He reported he was stable on his medication regimen. Tr. at 421. Dr. Ekechukwu assessed a GAF score of 60. Tr. at 422.
State agency consultant Gary E. Calhoun, Ph. D. ("Dr. Calhoun"), completed a psychiatric review technique on April 5, 2011, in which he considered Listing 12.03 for schizophrenic, paranoid, and other psychotic disorders, Listing 12.04 for affective disorders, and Listing 12.08 for personality disorders. Tr. at 369. He determined Plaintiff's impairments included psychotic disorder, NOS, major depressive disorder without psychotic features, moderate major depressive disorder (single episode), and paranoid personality traits. Tr. at 371, 372, 376. He assessed mild restriction of activities of daily living, moderate difficulties in maintaining social functioning, moderate difficulties in maintaining concentration, persistence, or pace, and no episodes of decompensation of extended duration. Tr. at 379. Dr. Calhoun indicated Plaintiff was moderately limited with respect to the following abilities: to understand and remember detailed instructions; to carry out detailed instructions; to maintain attention and concentration for extended periods; and to interact appropriately with the general public. Tr. at 383-84. Dr. Calhoun indicated "[o]verall, claimant's symptoms and impairments are severe but would not preclude the performance of simple, repetitive work tasks in a setting that does not require on-going interaction with the public." Tr. at 385.
On April 9, 2011, Plaintiff attended a disability determination examination with Nicole Edwards, D.O. ("Dr. Edwards"). Tr. at 387-91. Plaintiff alleged psychosis, manic depression, hypertension, anemia, COPD, low back pain, and blacking out. Tr. at 387-88. He indicated he could sit and stand for unlimited periods, walk for 10 to 15 minutes at a time on level ground, and lift approximately 20 pounds. Tr. at 388. Plaintiff favored his left hip when he walked. Tr. at 389. He had reduced flexion of his lumbar spine to 80 degrees and bilateral knee crepitus. Tr. at 390. He had paresthesias on the left and low back pain with left straight-leg raise. Id. His left ankle was internally rotated five to 10 degrees at rest. Id. Plaintiff's physical examination was otherwise normal. Tr. at 389-90. Dr. Edwards indicated Plaintiff's "mentation was pleasant, but he did appear nervous." Tr. at 390. She further indicated Plaintiff bounced his legs and wrung his hands throughout the examination. Id. She indicated Plaintiff's "psychosis and manic depression" needed to be "further evaluated through a psychiatric exam to determine his functionality." Id. She indicated Plaintiff's hypertension, anemia, and COPD appeared to be controlled. Id. She indicated he had some abnormalities due to low back pain, but that they did not appear to be functionally limiting. Id. She found no neurological explanation for Plaintiff's blackouts. Id.
Plaintiff presented to Dr. Hunt for a medication refill on April 11, 2011. Tr. at 397. He reported pain that was a seven out of 10. Id. His oxygen saturation was 96 percent. Id. Dr. Hunt indicated diagnoses of hypertension and bipolar disorder. Id.
On April 29, 2011, state agency medical consultant Hugh Clarke, M.D., completed a physical residual functional capacity assessment in which he indicated Plaintiff was limited to occasionally lifting and/or carrying 50 pounds; frequently lifting and/or carrying 25 pounds; standing and/or walking about six hours in an eight-hour workday; sitting for about six hours in an eight-hour workday; pushing and/or pulling without limit; occasionally climbing ramps/stairs; never climbing ladders/ropes/scaffolds; and avoiding concentrated exposure to fumes, odors, dusts, gases, poor ventilation, and hazards. Tr. at 399-406.
Plaintiff followed up with Dr. Ekechukwu on May 24, 2011. Tr. at 419-20. He reported increased emotional bluntedness with an increased dosage of Invega. Tr. at 419. He endorsed depressed mood, and Dr. Ekechukwu indicated she was reluctant to decrease Plaintiff's dosage of Invega without first prescribing an antidepressant. Id. Dr. Ekechukwu assessed a GAF score of 56. Tr. at 420.
Plaintiff followed up with Dr. Ekechukwu on July 5, 2011. Tr. at 416-17. Plaintiff's target symptoms for treatment included anxiety, delusions/paranoia, and legal problems. Tr. at 416. Plaintiff reported increased swelling and blurred vision since starting Wellbutrin SR. Id. He also reported residual paranoia. Id. Dr. Ekechukwu noted Plaintiff "seems particularly sensitive to side effects" of medications. Id. Plaintiff decided to remain on Wellbutrin SR despite its side effects because it had a positive effect on his depressive symptoms. Id. However, Plaintiff complained that Invega caused him to be emotionally blunted. Id. Dr. Ekechukwu prescribed a trial dose of Fanapt to target paranoia. Id.
Plaintiff followed up with Dr. Ekechukwu on September 13, 2011. Tr. at 414-15. His target symptoms for treatment included anxiety and delusions/paranoia. Tr. at 414. Plaintiff reported a negative reaction to Geodon. Id. He reported residual paranoia, but stated that he could cope with it. Id. Dr. Ekechukwu decribed Plaintiff's judgment and insight as fair. Id. She noted that Plaintiff was taking his medication, keeping his appointments, and acknowledged his illness and need for medication. Id. Dr. Ekechukwu indicated diagnoses of psychotic disorder, NOS and depressive disorder, NOS. Tr. at 415. She assessed a GAF score of 55 and discontinued Geodon. Id.
Plaintiff presented to Pamela Wood, APRN ("Ms. Wood"), at Kershaw Mental Health on October 25, 2011. Tr. at 412-13. He reported delusions and moderate-to-severe depression despite compliance with medications. Tr. at 412. He indicated he did not want his dosage of Invega increased because it made his mind feel blank. Id. He reported a 40pound weight gain, which Ms. Wood indicated was possibly caused by Remeron. Id. Ms. Wood increased Plaintiff's Wellbutrin SR dosage to 300 mg. Tr. at 413.
Plaintiff followed up with Ms. Wood on November 28, 2011. Tr. at 410-11. His target symptoms for treatment included anxiety, delusions/paranoia, depression, legal problems, and sleep/appetite disturbance. Tr. at 410. He reported intermittent and moderate depression, weird and paranoid thoughts, and moderate anxiety. Id. Ms. Wood decreased Plaintiff's Wellbutrin SR dosage to 150 mg and noted that he developed a headache that lasted for two weeks while taking the higher dose. Id. She also prescribed Zoloft and diagnosed schizophrenia, paranoid type, and depressive disorder, NOS. Tr. at 410, 411. She assessed a GAF score of 60. Id.
On January 13, 2012, Plaintiff presented to Donald W. Morgan, M.D., at Kershaw Mental Health. Tr. at 408-09. His target symptoms for treatment included anxiety, delusions/paranoia, depression, legal problems, and sleep/appetite disturbance. Tr. at 408. Dr. Morgan noted Plaintiff was taking Invega 9 mg and Wellbutrin SR 150 mg and that he was doing well with good sleep and appetite. Id. He reported no side effects to his medications. Id. Dr. Morgan assessed schizophrenia, paranoid type and depressive disorder, NOS. Id. He indicated Plaintiff's GAF score to be 70. Tr. at 409.
Plaintiff followed up with Dr. Hotchkiss on February 13, 2012. Tr. at 451-53. He reported rarely taking Remeron and taking Vistaril a couple of times per week for anxiety. Tr. at 451. Plaintiff reported stable mood and denied excessive sedation and major irritability, but endorsed mild paranoia. Id. Dr. Hotchkiss assessed a GAF score of 60. Tr. at 452.
On March 26, 2012, Plaintiff followed up with Dr. Hotchkiss. Tr. at 454-56. Plaintiff reported that he saw his children monthly and went to a friend's garage, but that he was uncomfortable in social settings. Tr. at 454. He reported stable mood and denied sleep and appetite disturbance, suicidal ideations, and homicidal ideations. Id. He denied gross mania, hallucinations, and delusions, but endorsed a "little paranoia" and "slight hypervigilance." Id. He indicated he only used Remeron as needed and stated he had not used Vistaril "much." Id. Dr. Hotchkiss assessed a GAF score of 60. Tr. at 455.
Kelli Barnes, LPC ("Ms. Barnes"), wrote a letter on March 26, 2012, indicating Plaintiff's diagnoses included schizophrenia, paranoid type and depressive disorder, NOS. Tr. at 437. Ms. Barnes wrote that Plaintiff reported depressed mood, anxiety attacks, sleep disturbance, poor energy and concentration, confusion, persecutory delusions, and paranoia. Id. Ms. Barnes indicated "[t]he symptoms reported are, at times, sufficiently severe that his daily life is adversely affected in various ways." Id. She further indicated that Plaintiff had delusions toward his family members and was aggressive with them, that he experienced mild paranoia, that he was confused in the mornings and unable to concentrate on tasks, and that he had a history of wandering when unstable. Id.
Plaintiff followed up with Dr. Hotchkiss on May 15, 2012. Tr. at 457-59. He reported only rarely taking Remeron and Vistaril. Tr. at 457. He denied gross mania, suicidal ideations, homicidal ideations, sustained depression, and sleep disturbance. Id. He endorsed occasional strange thoughts and some sense of hypervigilance. Id. Plaintiff's insight was described as "fair, " but his mental status examination was otherwise normal. Tr. at 457-58. Dr. Hotchkiss assessed a GAF score of 61. Tr. at 458.
Plaintiff again followed up with Dr. Hotchkiss on July 10, 2012. Tr. at 460-62. He reported being depressed and feeling "so-so." Tr. at 460. He indicated that he could not think straight at times, had occasional racing thoughts, and obsessed about the past. Id. He denied suicidal or homicidal ideation, gross mania, hallucinations, delusions, paranoia, and hypervigilance. Id. He reported compliance with medications and denied excess sedation. Id. Dr. Hotchkiss assessed a GAF score of 60. Tr. at 461.
Plaintiff saw Dr. Hotchkiss on September 6, 2012, and reported good sleep and good appetite. Tr. at 463. He indicated he experienced occasional depression when he focused on the past and that he was not very active. Id. Dr. Hotchkiss indicated Plaintiff had fair insight, but the mental status examination was otherwise normal. Tr. at 464. He assessed Plaintiff's GAF score to be 59. Id.
C. The Administrative ...