United States District Court, D. South Carolina, Greenville Division
REPORT OF MAGISTRATE JUDGE
F. MCDONALD, UNITED STATES MAGISTRATE JUDGE
case is before the court for a report and recommendation
pursuant to Local Civ. Rule 73.02(B)(2)(a) (D.S.C.),
concerning the disposition of Social Security cases in this
District, and Title 28, United States Code, Section
plaintiff brought this action pursuant to Section 1631(c)(3)
of the Social Security Act, as amended (42 U.S.C.
1383(c)(3)), to obtain judicial review of a final decision of
the Commissioner of Social Security denying her claim for
supplemental security income benefits under Title XVI of the
Social Security Act.
plaintiff filed an application for supplemental security
income (“SSI”) benefits on July 11, 2012,
alleging disability since September 1, 1997. The application
was denied initially and on reconsideration by the Social
Security Administration. On June 11, 2013, the plaintiff
requested a hearing. The administrative law judge
(“ALJ”), before whom the plaintiff, her attorney,
and Karl S. Weldon, an impartial vocational expert, appeared
on August 12, 2014, considered the case de novo, and
on November 24, 2014, found that the plaintiff was not under
a disability as defined in the Social Security Act, as
amended. The ALJ's finding became the final decision of
the Commissioner of Social Security when the Appeals Council
denied the plaintiff's request for review on December 21,
2015. The plaintiff then filed this action for judicial
making the determination that the plaintiff is not entitled
to benefits, the Commissioner has adopted the following
findings of the ALJ:
(1) The claimant has not engaged in substantial gainful
activity since July 11, 2012, the application date (20 C.F.R.
§ 416.971 et. seq.).
(2) The claimant has the following severe impairments:
anxiety disorder, affective disorder, schizophrenia (residual
type), and peptic ulcer (20 C.F.R. § 416.920(c)).
(3) The claimant does not have an impairment or combination
of impairments that meets or medically equals the the
severity of one of the listed impairments in 20 C.F.R. Part
404, Subpart P, Appendix 1 (20 C.F.R. §§
416.920(d), 416.925 and 416.926).
(4) After careful consideration of the entire record, the
undersigned finds that the claimant has the residual
functional capacity to perform medium work as defined in 20
C.F.R. 416.967(c) except she should have
less-than-occasional, if any, exposure to hazards associated
with unprotected dangerous machinery or unprotected heights.
She is able to understand, remember, and carry out simple,
routine, repetitive tasks in a low-stress work environment
that is free of fast-paced or team-dependant production
requirements, with clearly defined performance expectations,
and occasional, if any, job changes. Her work must be
performed with less-than-occasional interaction with the
general public and only occasional interaction with
(5) The claimant has no past relevant work (20 C.F.R. §
(6) The claimant was born on September 18, 1991, and was 20
years old, which is defined as a younger individual age
18-49, on the date the application was filed (20 C.F.R.
(7) The claimant has at least a high school education and is
able to communicate in English (20 C.F.R. § 416.964)
(8) Transferability of job skills is not an issue because the
claimant does not have past relevant work (20 C.F.R. §
(9) Considering the claimant's age, education, work
experience, and residual functional capacity, there are jobs
in the national economy that the claimant can perform (20
C.F.R. § 416.969 and 416.969(a)).
(10) The claimant has not been under a disability, as defined
in the Social Security Act, since July 11, 2012, the date the
application was filed (20 C.F.R. § 416.920(g)).
only issues before the court are whether proper legal
standards were applied and whether the final decision of the
Commissioner is supported by substantial evidence.
Social Security Act provides that disability benefits shall
be available to those persons insured for benefits, who are
not of retirement age, who properly apply, and who are under
a “disability.” 42 U.S.C. § 423(a).
“Disability” is defined in 42 U.S.C. §
the inability to engage in any substantial gainful activity
by reason of any medically determinable physical or mental
impairment which can be expected to result in death or which
has lasted or can be expected to last for at least 12
facilitate a uniform and efficient processing of disability
claims, the Social Security Act has by regulation reduced the
statutory definition of “disability” to a series
of five sequential questions. An examiner must consider
whether the claimant (1) is engaged in substantial gainful
activity, (2) has a severe impairment, (3) has an impairment
that equals an illness contained in the Social Security
Administration's Official Listings of Impairments found
at 20 C.F.R. Part 4, Subpart P, App. 1, (4) has an impairment
that prevents past relevant work, and (5) has an impairment
that prevents him from doing substantial gainful employment.
20 C.F.R. § 416.920. If an individual is found not
disabled at any step, further inquiry is unnecessary.
Id. § 416.920(a)(4).
plaintiff is not disabled within the meaning of the Act if he
can return to past relevant work as it is customarily
performed in the economy or as the claimant actually
performed the work. SSR 82-62, 1982 WL 31386, at *3. The
plaintiff bears the burden of establishing his inability to
work within the meaning of the Act. 42 U.S.C. §
423(d)(5). He must make a prima facie showing of disability
by showing he is unable to return to his past relevant work.
Grant v. Schweiker, 699 F.2d 189, 191
(4th Cir. 1983).
individual has established an inability to return to his past
relevant work, the burden is on the Commissioner to come
forward with evidence that the plaintiff can perform
alternative work and that such work exists in the regional
economy. The Commissioner may carry the burden of
demonstrating the existence of jobs available in the national
economy which the plaintiff can perform despite the existence
of impairments which prevent the return to past relevant work
by obtaining testimony from a vocational expert. Id.
scope of judicial review by the federal courts in disability
cases is narrowly tailored to determine whether the findings
of the Commissioner are supported by substantial evidence and
whether the correct law was applied. Hays v.
Sullivan, 907 F.2d 1453, 1456 (4th Cir.
1990). Consequently, the Act precludes a de novo
review of the evidence and requires the court to uphold the
Commissioner's decision as long as it is supported by
substantial evidence. See Pyles v. Bowen, 849 F.2d
846, 848 (4th Cir. 1988) (citing Smith
v. Schweiker, 795 F.2d 343, 345 (4th Cir.
1986)). The phrase “supported by substantial
evidence” is defined as:
evidence which a reasoning mind would accept as sufficient to
support a particular conclusion. It consists of more than a
mere scintilla of evidence but may be somewhat less than a
preponderance. If there is evidence to justify a refusal to
direct a verdict were the case before a jury, then there is
Laws v. Celebrezze, 368 F.2d 640, 642
(4th Cir. 1966) (citation omitted).
it is the duty of this court to give careful scrutiny to the
whole record to assure that there is a sound foundation for
the Commissioner's findings and that the conclusion is
rational. Thomas v. Celebrezze, 331 F.2d 541, 543
(4th Cir. 1964). If there is substantial evidence
to support the decision of the Commissioner, that decision
must be affirmed. Blalock v. Richardson, 483 F.2d
773, 775 (4th Cir. 1972).
February 15, 2005, the plaintiff had an initial clinical
assessment at Spartanburg Area Mental Health Clinic
(“SAMHC”). She was noted to have some social
anxiety that was affecting her self-esteem and had caused a
significant decline in her school grades. The plaintiff had
been adopted by her grandparents. She was noted to have no
relationship with her biological father and had never
“bonded” with her mother. Following a mental
status examination, the plaintiff was diagnosed with
generalized social anxiety disorder and a Global Assessment
of Functioning (“GAF”) score of 50 (Tr. 255-60).
April 27, 2005, Ann Marie Menendez-Caldwell, M.D., of SAMHC,
initially evaluated the plaintiff. The plaintiff's
grandmother was also present and was noted to have custody of
the plaintiff since birth. The plaintiff reported worrying
excessively “about everything.” She indicated
that she gets palpitations and feels sick to her stomach when
she gets nervous. Dr. Menendez-Caldwell indicated that the
plaintiff endorsed decreased energy, feeling sad, and being a
little angry. The plaintiff's affect appeared to be shy
with some dysphoria. Dr. Menendez-Caldwell diagnosed social
anxiety disorder; generalized anxiety disorder and depressive
disorder, not otherwise specified (“NOS”); school
problems; and a GAF score of 50. Dr. Menendez-Caldwell
prescribed Lexapro and recommended school-based therapy (Tr.
335-36). Dr. Menendez-Caldwell also treated the plaintiff and
adjusted her medications on May 18, 2005 (Tr. 334), June 29,
2005 (Tr. 333), and August 10, 2005 (Tr. 331-32).
13, 2005, Camille Bramhall, MA, of SAMHC, indicated that the
plaintiff was hesitant in therapy and difficult to engage
(Tr. 254). On August 1, 2005, Ms. Bramhall indicated that the
plaintiff and her grandmother reported progress with being
more talkative, less irritable, and having more energy. The
plaintiff had a much brighter affect, but she had continued
anxiousness about starting school (Tr. 254).
October 13, 2005, Lori Barwick, M.D., of SAMHC, noted that
the plaintiff's grandmother reported that the plaintiff
was unmotivated, had a lack of energy, isolated herself
frequently, and had difficulty getting along with peers. Dr.
Barwick noted social problems and grade problems. The
plaintiff and her grandmother reported episodes of
sleepwalking and hypnopompic or hypnogogic hallucinations at
night. Dr. Barwick indicated that the plaintiff had a flat
affect and a quiet tone but did warm up as the interview
continued. Dr. Barwick recommended continued therapy and
increased the plaintiff's dose of Celexa (Tr. 329-30).
October 31, 2005, Ms. Bramhall indicated that the plaintiff
denied significant problems with anxiety but was struggling
with social issues. The plaintiff was disheveled and was
noted to have become more defiant and more irritable. The
plaintiff had difficulty staying on task in therapy sessions.
Continued therapy services at school were recommended (Tr.
December 28, 2006, Dr. Barwick noted that the plaintiff's
grandmother was frustrated over the plaintiff's lack of
motivation and lack of energy. Dr. Barwick indicated that the
plaintiff was quiet and had a flat affect. Dr. Barwick noted
the plaintiff's difficulty tolerating medications. She
started the plaintiff on a trial of Prozac (Tr. 328). On
January 26, 2006, Dr. Barwick evaluated the plaintiff in the
presence of her grandmother, who reported that the
plaintiff's motivation seemed better, and Ms. Bramhall
noted that the plaintiff had progressed in therapy but
continued to have social anxiety. Dr. Barwick increased the
plaintiff's dose of Prozac (Tr. 327).
January 30, 2006, Ms. Bramhall noted that the plaintiff had
become more outgoing verbally, but was having problems with
her grades due to her depressive symptoms and anxiety (Tr.
April 13, 2006, Dr. Barwick noted that the plaintiff's
grandmother reported that Prozac wasn't helping any more
and noted that the plaintiff seemed very lethargic and
difficult to engage. Dr. Barwick started the plaintiff on a
trial of Effexor (Tr. 326).
1, 2006, Ms. Bramhall indicated that the plaintiff still had
a bright affect and mood. She had relationship issues with
her grandmother and was “sluggish.” On June 14,
2006, Dr. Barwick noted that the plaintiff and her
grandmother reported no significant difference with Effexor.
Dr. Barwick indicated that the plaintiff was quiet but
responsive with no reported psychosis. Dr. Barwick increased
the plaintiff's Effexor dose (Tr. 325). On August 16,
2006, Dr. Barwick noted that the plaintiff couldn't
tolerate the increased dose of Effexor. The plaintiff
reported she was anxious about starting school. Dr. Barwick
switched the plaintiff back to Celexa (Tr. 324). On October
11, 2006, the plaintiff denied problems at school, but her
grandmother reported continued frustration over the
plaintiff's motivation. Dr. Barwick joined in the
grandmother's concerns about her lack of socialization.
Dr. Barwick indicated that the plaintiff might have a
personality disorder. Dr. Barwick continued the plaintiff on
Celexa and advised continued therapy (Tr. 323).
October 25, 2006, Susan Henderson, MA, of SAMHC, indicated
that the plaintiff was anxious about beginning school but was
only having major anxiety one to two times per week. Ms.
Henderson recommended continued therapy (Tr. 251).
November 30, 2006, Dr. Barwick noted reports of improvement
and suggested testing to determine what part of the
plaintiff's symptoms involved personality disorders
verses anxiety and depression. Dr. Barwick diagnosed social
anxiety disorder with some depression, NOS, rule out some
underlying schizoid or avoidant personality. She continued
the plaintiff on Celexa, advised continued therapy, and
ordered testing with Dr. Burns (Tr. 322).
January 12, 2007, Ms. Henderson indicated that the plaintiff
had been compliant at home and that her anxiety was decreased
because of Christmas break (Tr. 251). On May 15, 2007, Ms.
Henderson noted continued but diminished anxiety at school
(Tr. 249). On August 10, 2007, Ms. Henderson indicated that
the plaintiff had displayed extreme anxiety before starting
camp. Ms. Henderson indicated that the plaintiff still needed
to work on self-confidence (Tr. 249).
September 26, 2007, Dr. Barwick noted multiple medication
trials. Dr. Barwick noted that the plaintiff had tried to do
a summer camp program with Susan Henderson, which resulted in
a “full-blown panic attack, completely overwhelmed,
hyperventilating.” The plaintiff reported continuing
anxiety and nervousness, especially around crowds, but
reported that she was doing fairly well with her schoolwork.
Dr. Barwick indicated that the plaintiff reported pretty
significant panic attacks, with increased heart rate,
sweatiness, clamminess, and hyperventilation. Dr. Barwick
noted that the plaintiff's symptoms might result from an
avoidant personality. Dr. Barwick indicated that the