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Gaddis v. Commissioner of Social Security Administration

United States District Court, D. South Carolina

March 7, 2018

WESLEY CAIN GADDIS, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant.

          REPORT AND RECOMMENDATION

          BRISTOW MARCHANT, UNITED STATES MAGISTRATE JUDGE

         The Plaintiff filed the complaint in this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of the final decision of the Commissioner wherein he was denied disability benefits. This case was referred to the undersigned for a report and recommendation pursuant to Local Civil Rule 73.02(B)(2)(a) (D.S.C.).

         Plaintiff applied for Disability Insurance Benefits (DIB) on January 15, 2013 (protective filing date), alleging disability beginning May 15, 2008 due to social anxiety disorder, obsessive compulsive personality disorder, depression, panic disorder with agoraphobia, lower back pain, and shoulder pain due to arthritis/torn rotator. (R.pp. 19, 179, 213). Plaintiff's claim was denied both initially and upon reconsideration. Plaintiff then requested a hearing before an Administrative Law Judge (ALJ), which was held on May 20, 2015. (R.pp. 41-89). The ALJ thereafter denied Plaintiff's claim in a decision issued July 16, 2015. (R.pp. 19-36). The Appeals Council denied Plaintiff's request for a review of the ALJ's decision, thereby making the determination of the ALJ the final decision of the Commissioner. (R.pp. 1-5).

         Plaintiff then filed this action in United States District Court. Plaintiff asserts that there is not substantial evidence to support the ALJ's decision, and that the decision should be reversed and remanded to the Commissioner for an award of benefits, or alternatively that the case should be remanded for further proceedings. The Commissioner contends that the decision to deny benefits is supported by substantial evidence, and that Plaintiff was properly found not to be disabled.

         Scope of review

         Under 42 U.S.C. § 405(g), the Court's scope of review is limited to (1) whether the Commissioner's decision is supported by substantial evidence, and (2) whether the ultimate conclusions reached by the Commissioner are legally correct under controlling law. Hays v. Sullivan, 907 F.2d 1453, 1456 (4th Cir. 1990); Richardson v. Califano, 574 F.2d 802, 803 (4th Cir. 1978); Myers v. Califano, 611 F.2d 980, 982-983 (4th Cir. 1980). If the record contains substantial evidence to support the Commissioner's decision, it is the court's duty to affirm the decision. Substantial evidence has been 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 refusal to direct a verdict were the case before a jury, then there is “substantial evidence.” [emphasis added].

Hays, 907 F.2d at 1456 (citing Laws v. Celebrezze, 368 F.2d 640 (4th Cir. 1966)); see also Hepp v. Astrue, 511 F.3d 798, 806 (8th Cir. 2008)[Nothing that the substantial evidence standard is even “less demanding than the preponderance of the evidence standard”].

         The Court lacks the authority to substitute its own judgment for that of the Commissioner. Laws, 368 F.2d at 642. “[T]he language of [405(g)] precludes a de novo judicial proceeding and requires that the court uphold the [Commissioner's] decision even should the court disagree with such decision as long as it is supported by substantial evidence.” Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972).

         Medical Records

         Dr. Khizar Khan, a psychiatrist, initially assessed Plaintiff with depression and anxiety on May 28, 2008. Plaintiff reported he had been given “time off” from his job as an assistant manager at Advanced Auto Parts after he verbally assaulted his district manager. Plaintiff reported that he could not control his emotions and threatened people at work, and had problems with sleep, anhedonia, feeling overwhelmed/helpless, low energy, concentration, poor appetite, and mood irritability. He took Paxil without seeing a difference in mood. Dr. Khan diagnosed moderate to severe major depressive disorder, generalized anxiety disorder, and panic disorder. Effexor and Xanax were prescribed. (R.pp. 280-281). On June 11, 2008, Plaintiff told Dr. Khan that he felt a little jittery and avoided social interactions, but was not experiencing as immense an amount of panic attacks as in the past. (R.p. 279). Plaintiff was thereafter seen by Dr. Khan one or twice a month until November 4, 2008. (R.pp. 271-278).

         On September 30, 2009, Plaintiff was treated by Dr. Kimberly Rothman at AnMed Health Family Medicine Center (AnMed) for bilateral shoulder pain and hypertension. Plaintiff reported that his shoulder had been hurting for about eight months after he lifted a heavy transmission. Dr. Rothman noted weakness in Plaintiff's right hand and paresthias in his lateral arm and finger; diagnosed left rotator cuff syndrome, cervical radiculopathy, and anxiety; and prescribed a Medrol dose pack to help reduce inflammation. (R.pp. 324-325).

         Dr. Joseph McElwee, a psychiatrist at AnMed, began treating Plaintiff's anxiety on October 13, 2009. Plaintiff reported he had discontinued previous psychological medications due to side-effects of feeling emotionally numb or drunk. He described having an obsession with order (needing to see things in their right place), compulsions to clean, and washing his hands at length multiple times a day from a young age. This led to conflict at work where he would have issues with others' disorderliness. Plaintiff reported strong anxiety toward being around people and being out in groups to the point of avoiding those situations altogether. He appeared mildly anxious and was tearful at times when talking about his childhood and raising his son, and reported feelings of hopelessness, anxiety, stress, and sadness. Dr. McElwee diagnosed compulsive personality disorder and prescribed Celexa. (R.pp. 295-298).

         On October 20, 2009, Plaintiff reported to Dr. Rothman that he had improvement of his shoulder and neck pain with medication and three physical therapy sessions. (R.pp. 311-314).

         On October 28, 2009, Plaintiff told Dr. McElwee that he had a slight decrease in his anxiety in social situations, but no change in his obsessive-compulsive symptoms. Dr. McElwee wrote that Plaintiff had “long standing difficulty with cleanliness issues, superstitious behaviors, intrusive thoughts and other issues.” He noted that Plaintiff's prior medications had not worked well, diagnosed obsessive compulsive disorder (OCD), directed Plaintiff to begin work in an anxiety workbook and continue individual therapy, and prescribed Celexa. (R.pp. 291-294). Plaintiff returned to Dr. McElwee in January 2010 and again in February 2010, at which time Plaintiff reported being better able to control some of his compulsions. No depression and decreased anxiety were noted. (R.pp. 286-290).

         In July 2010, Dr. Rothman completed a mental impairment questionnaire in which she stated that Plaintiff was diagnosed with OCD and depression for which he was taking Celexa and Xanax, and that she had referred Plaintiff to Dr. McElwee. She indicated that Plaintiff was oriented x4 and had obsessive thought content, a worried/anxious mood/affect, adequate attention/concentration, and good memory. Dr. Rothman opined that Plaintiff had a slight work-related limitation in function due to his mental condition, consisting of outbursts of anger with coworkers, OCD behaviors, and exhibiting significant anxiety. She thought he was capable of managing his funds. (R.p. 356).

         Dr. Brian Keith, a psychologist, performed a consultative examination on the Plaintiff on November 18, 2010. Plaintiff told Dr. Keith that he experienced panic attacks and had trouble being with people. He complained of nervousness, depression, no motivation, trouble failing asleep, feeling fatigued, and feeling hopeless. Plaintiff stated that people made him feel nervous, he was scared of people, and that he was unable to work because he could not deal with people and was afraid of hurting somebody. For activities, Plaintiff reported driving his son to school three or four times a week, rarely doing grocery shopping, occasionally going to Wal-Mart at midnight, and getting food from a drive-through restaurant. On examination Plaintiff was found to be oriented in all spheres; he had appropriate eye contact, a broad (normal) affect, and a nervous mood; his psychomotor functioning was normal, although he appeared at times somewhat nervous and fidgety and rubbed his hands in a nervous manner; and his remote memory appeared generally intact and he was able to correctly repeat five numbers after immediate presentation and two of three items after a five-minute delay with interference. Dr. Keith diagnosed Plaintiff with bipolar disorder and generalized anxiety disorder, and opined that Plaintiff should be able to complete moderately complex tasks, follow moderately detailed directions, and complete two to three-step activities. (R.pp. 357-360).

         On December 2, 2010, State agency psychologist Dr. Robbie Ronin opined after a review of Plaintiff's records that Plaintiff could maintain attention and concentration for extended periods, ask simple questions and request assistance, interact appropriately with coworkers and supervisors, adapt to basic workplace demands, perform simple unskilled tasks, but could not work with the public. (R.pp.362-379).

         On April 13, 2012, Plaintiff returned to AnMed to reestablish primary care and resume treatment with Dr. McElwee (he had not had treatment for approximately two years due to lack of insurance). Dr. McElwee reviewed the case with primary care physician Dr. Jason Perey, who diagnosed plantar fasciitis, OCD, depression, left rotator cuff syndrome, hypertension, and hyperlipidemia, and prescribed Medrol, Xanax, Celexa, and Lisinopril-Hydrochlorothiazide. (R.pp. 384-388). On May 14, 2012, Plaintiff reported that his feet were better, that exercises and medication had diminished his shoulder pain some, but that he had had an episode of severe pain when working in the yard the prior weekend. (R.pp. 396-399). On May 16, 2012, Plaintiff reported to Dr. McElwee that he was still living with his father and that he had his son 75% of the time. He also reported that he had broken up with his girlfriend because his OCD was bothering her, and that he continued to have a lot of social anxiety. Dr. McElwee noted that Plaintiff had a very obsessive thought process, was anxious, and was sweating at times; assessed OCD; increased Plaintiff's Celexa dosage, and continued Xanax. (R.pp. 542-544).

         In May 2012, an x-ray of Plaintiff's left shoulder was normal, an x-ray of his cervical spine showed normal alignment with no tissue swelling or evidence of atlanto-axial dislocation. and an x-ray of his right shoulder revealed a “well circumscribed sclerotic density in the right humeral head most consistent with a bone island” and a degenerative change of the right acromioclavicular joint. (R.pp. 400-405).

         On June 14, 2012, Plaintiff reported to Dr. McElwee that his anxiety was “some” better and that he did “ok” attending his son's school program. Plaintiff's affect was more reactive with improved mood and less anxiousness. Celexa was continued. (R.pp. 539-541). On July 9, 2012, Plaintiff reported some success as to his excessive handwashing, but still had difficulty turning off repetitive thoughts when he tried to sleep. Dr. McElwee noted that Plaintiff had an anxious, obsessive, and passive mood and diagnosed social phobia and OCD. (R.pp. 534-536). On August 15, 2012, Plaintiff reported to Dr. McElwee some progress in checking ...


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