United States District Court, D. South Carolina
V. Hodges United States Magistrate Judge.
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 Donald C. Coggins, Jr., United States District
Judge, dated March 8, 2018, referring this matter for
disposition. [ECF No. 21]. 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. 19 and 20].
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
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 court affirms the
April 11, 2013, Plaintiff protectively filed an application
for DIB in which he alleged his disability began on July 1,
2012. Tr. at 146-47. His application was denied initially and
upon reconsideration. Tr. at 90-94 and 96-98. On July 28,
2016, Plaintiff had a hearing before Administrative Law Judge
(“ALJ”) Clarence Guthrie. Tr. at 37-62 (Hr'g
Tr.). The ALJ issued an unfavorable decision on September 20,
2016, finding that Plaintiff was not disabled within the
meaning of the Act. Tr. at 21-36. 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 2-8. Thereafter,
Plaintiff brought this action seeking judicial review of the
Commissioner's decision in a complaint filed on October
12, 2017. [ECF No. 1].
Plaintiff's Background and Medical History
was 34 years old at the time of the hearing. Tr. at 46. He
completed high school. Id. His past relevant work
(“PRW”) was as a cashier, a janitor, and a
delivery driver. Tr. at 57. He alleges he has been unable to
work since July 1, 2012. Tr. at 146.
30, 2012 Cooperative Disability Investigations
(“CDI”) report indicates that the Social Security
Administration (“SSA”) had approved
Plaintiff's disability claim in 2002 based on
schizophrenia and that his benefits were subsequently
suspended because of his work activity. Tr at 217.
Plaintiff applied for expedited reinstatement of his benefits
and alleged that he had reduced his work to 22 to 25 hours
per week. Id. The CDI unit initiated an
investigation based on a referral from the state agency.
Id. The investigator interviewed an assistant
manager at Dollar General, who informed him that Plaintiff
had worked for the store for at least five
years; had performed job duties that included
opening and closing the store, making deposits, and
interacting with customers; and was terminated for allegedly
stealing items. Tr. at 218. The assistant manager indicated
Plaintiff continued to shop in the store once a week, could
carry on a conversation, and sometimes drove. Id. An
assistant manager at Rite Aid informed the investigator that
Plaintiff was employed as an assistant manager, had worked 30
to 40 hours per week, and had recently quit because he
claimed he was not being scheduled for enough hours. Tr. at
219. He stated Plaintiff's job duties had included
opening and closing the store, unloading trucks, stocking
shelves, cleaning the building, assisting customers,
operating a cash register and computer, supervising other
employees, and making deposits. Id. He indicated
Plaintiff had problems with attendance, was considered a poor
manager, and performed poor quality work. Id. The
investigator subsequently interviewed the Rite Aid store
manager, who presented a slightly different account.
Id. The store manager specified that Plaintiff was
employed from May 16, 2011, to February 18, 2012, and worked
20 to 30 hours per week. Id. He stated Plaintiff got
along well with staff and other supervisors. Id. He
indicated Plaintiff did well if another manager was in the
store, but not as well if no other manager was present.
Id. He stated Plaintiff had indicated he wanted to
work more hours, but failed to return calls and declined to
work when he was called in at times that he was not scheduled
to work. Id. The investigator parked in front of
Plaintiff's house and observed him sitting on his porch.
Tr. at 220. He noted that over the course of 13 minutes,
Plaintiff spoke to a female, walked up and down the steps,
placed items in a trash can, lifted objects, and talked and
joked with a meter reader. Id.
presented to Trenten A. Prioleau, DPM (“Dr.
Prioleau”), for a three-month history of left heel pain
on May 17, 2012. Tr. at 225. Dr. Prioleau noted tenderness to
palpation of Plaintiff's left heel. Id. He
assessed plantar fasciitis and instructed Plaintiff to engage
in stretching exercises and to use ice massage. Tr. at 226.
On May 31, 2012, Plaintiff reported that he was not in pain,
had been walking more, and had lost 15 pounds. Tr. at 227.
Dr. Prioleau encouraged Plaintiff to continue to use
stretching and icing. Tr. at 228.
reported that he was doing well on June 27, 2012. Tr. at 243.
He indicated his mood and affect were euthymic and denied
psychotic symptoms and side effects from medications.
Id. Edward M. Kendall, M.D. (“Dr.
Kendall”), noted no abnormalities on mental status
examination. Id. He assessed paranoid schizophrenia
and a global assessment of functioning
(“GAF”) score of 60. Tr. at 243-44.
September 21, 2012, Ada Stewart, M.D. (“Dr.
Stewart”), indicated Plaintiff had a history of
diabetes, obesity, and schizophrenia. Tr. at 223. She noted
that Plaintiff had decreased his weight from 328 to 282
pounds and should continue with diet and exercise. Tr. at
224. She stated Plaintiff's diabetes was well-controlled
and recommended that he continue his current treatment.
Id. She added a prescription for Lisinopril for
October 17, 2012, Plaintiff reported that he had lost over 60
pounds and indicated that Dr. Stewart would consider taking
him off Metformin if he lost an additional 60 pounds. Tr. at
247. He indicated he had experienced no paranoia during the
prior month and was doing well overall. Id.
January 29, 2013, Plaintiff reported that when did not take
his medication he got angry, wanted to fight, had outbursts
with family members, heard voices, had difficulty sleeping,
and was unable to shut off his thoughts. Tr. at 249. He
stated that when he took his medication, he felt calm, heard
no voices, and did well. Id. He stated he continued
to feel somewhat irritable, easily provoked, moody, and
socially withdrawn at times while taking medication.
Id. He indicated he could likely work part-time, but
would be unable to work on some days on an unpredictable
basis. Id. Dr. Kendall indicated Plaintiff's
mental status was normal, aside from fair judgment and
insight, occasional irritability, and occasional auditory
hallucinations. Tr. at 249-50. He assessed paranoid
schizophrenia and a GAF score of 55. Tr. at 250. He continued
Plaintiff on six milligrams of Risperdal per day.
April 23, 2013, Plaintiff indicated that frequent worry was
preventing him from sleeping well. Tr. at 254. He denied
auditory and visual hallucinations. Id. He informed
Linda Smith, R.N. (“Ms. Smith”), that he had
worked full-time for a while without realizing that it would
affect his disability, but had decompensated and had lost
both his job and his disability benefits. Id. Aziz
Mohiuddin, M.D. (“Dr. Mohiuddin”), refilled
Plaintiff's prescription for Risperdal. Tr. at 256.
11, 2013, Plaintiff complained of intermittent depression,
poor energy, low motivation, and social withdrawal. Tr. at
238. He reported that he had attempted suicide through
strangulation a few months prior, but had aborted the
attempt. Id. He denied current suicidal ideation.
Id. He stated his grandmother had recently passed
away and that he was having difficulty processing his grief.
Id. Dr. Kendall noted that Plaintiff was
“clearly bereaved” and “near tears.”
Id. He described Plaintiff as having poor judgment
and insight, labile and bereaved mood, and a full range of
emotion. Tr. at 239. He also noted that Plaintiff
demonstrated cooperative behavior, no psychomotor
abnormalities, intact cognition, normal speech, no
hallucinations, no delusions, no suicidal or homicidal
ideation, and a logical and goal-directed thought process.
Id. He assessed paranoid schizophrenia and
bereavement and a GAF score of 50. Id. He noted that
no changes in Plaintiff's medication were needed.
Id. He stated he believed that Plaintiff was
disabled and would support his claim for disability benefits.
presented to Thomas J. Motycka, M.D. (“Dr.
Motycka”), for a consultative examination on August 28,
2013. Tr. at 257. He reported that he had been diagnosed with
paranoid schizophrenia that caused him to hallucinate,
experience rage, and become violent. Id. Dr. Motycka
stated Plaintiff did “not appear to have paranoid
schizophrenia, or depression.” Id. He noted
that Plaintiff put forth “a poor effort” and was
“very, very unconvincing.” Id. Plaintiff
claimed to have neuropathy, but Dr. Motycka noted that his
records showed only plantar faciitis and diabetes that was
treated with Metformin. Id. Dr. Motycka observed
Plaintiff to walk with a normal gait and to demonstrate
“feeble efforts” on range of motion
(“ROM”) testing. Id. Plaintiff held his
right hand in a claw-like manner and claimed that his wrist
was injured, but Dr. Motycka found his claim to be
“incredible” and “unbelievable.”
Id. Dr. Motycka indicated Plaintiff's blood
pressure was 129/83 mm/Hg. Tr. at 259. He noted Plaintiff was
5'8” tall and weighed 321 pounds with a body mass
index (“BMI”) of 48. Id. He stated
Plaintiff's poor effort was obvious and his presentation
was “rife with concerns about his credibility.”
Id. He observed Plaintiff to have no clubbing,
cyanosis, or edema; to demonstrate normal dorsalis pedis and
posterior tibial pulses; to have no crepitus, effusions,
redness, warmth, instability, McMurray clicks, or Baker's
cyst in the knees; to have normal radial pulses in his hands;
to show no swelling or crepitus and normal ROM of his wrists;
and to demonstrate normal and non-tender hips and
acromioclavicular joints. Tr. at 260. Dr. Motycka stated the
orthopedic examination was entirely normal. Id. He
assessed features of borderline and antisocial personality
disorders. Id. He indicated that Plaintiff's
weight was “a big problem” and that Plaintiff
needed to lose weight. Tr. at 261. He indicated it seemed as
if Plaintiff was engaging in “a rehearsed effort for
secondary gain” and opined that he was “able to
do any type of work he has done in the past.”
October 2, 2013, state agency psychological consultant Samuel
Goots, Ph.D. (“Dr. Goots”), reviewed the evidence
and completed a psychiatric review technique
(“PRT”). Tr. at 68-69. He considered Listing
12.03 for schizophrenic, paranoid, and other psychotic
disorders and assessed no repeated episodes of
decompensation, mild restriction of activities of daily
living (“ADLs”), moderate difficulties in
maintaining social functioning, and moderate difficulties in
maintaining concentration, persistence, or pace. Id.
He found that Plaintiff had moderate limitations in his
mental residual functional capacity (“RFC”) with
respect to abilities to understand and remember detailed
instructions; 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 work in
coordination with or in proximity to others without being
distracted by them; to complete a normal workday and workweek
without interruption 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 accept instructions and respond
appropriately to criticism from supervisors; and to get along
with coworkers or peers without distracting them or
exhibiting behavioral extremes. Tr. at 69-71. He found
Plaintiff to have “partially credible symptoms”
that were consistent with schizophrenia. Tr. at 68. However,
he noted that Plaintiff's “reasonable adaptive
functioning, ” “good work history, ” the
CDI report, and Dr. Motycka's report suggested
malingering and did not indicate severe limitations as a
result of a mental condition. Id. He stated the
totality of the evidence indicated Plaintiff was
“capable of simple work in a setting with limited
contact with the general public.” Id. He
indicated Plaintiff could understand, retain, and follow
simple instructions; could concentrate well enough to
complete simple tasks with ordinary supervision; would have
moderate difficulty with more detailed instructions and
complex tasks; could complete a normal workweek with an
occasional interruption due to his mental condition; would
function best in a work setting with limited contact with the
general public and minimal interaction with coworkers and
supervisors; and could avoid common work-related dangers. Tr.
January 31, 2014, a second state agency psychological
consultant, Leslie Burke, Ph.D. (“Dr. Burke”),
completed a PRT and assessed the same degree of limitation
and the same mental RFC as Dr. Goots. Compare Tr. at
81-82 and Tr. at 83-85, with Tr. at 68-69 and Tr.
presented to Columbia Area Mental Health Center
(“CAMHC”) for an initial psychiatric assessment
on September 11, 2015. Tr. at 329. He reported anger and
thoughts of harming others. Id. He endorsed paranoid
thoughts and indicated he was only sleeping for an hour or
two at night. Id. Kathy M. Lundvall, M.D.
(“Dr. Lundvall”), noted that Plaintiff's
weight had decreased to 220 pounds. Tr. at 330. She observed
him to demonstrate mild hand tremors. Id. She
indicated the following abnormalities on mental status
examination: hyperactive behavior; poor, anxious, restless,
and avoidant eye contact; circumstantial thought process;
perseveration; persecutory delusions; paranoid thoughts;
homicidal ideation without plan; auditory hallucinations;
anxious, angry, and irritable mood; inappropriate, anxious,
irritable, and restless affect; and fair insight and
judgment. Tr. at 330. She assessed paranoid schizophrenia,
bereavement, and a GAF score of 50. Id. She
prescribed three milligrams of Risperdal twice a day and
provided samples to Plaintiff. Id.
presented to CAMHC for a clinical reassessment on September
24, 2015. Tr. at 287. He reported that he was hearing voices
“all the time” and experiencing “deep
depression.” Id. He stated he felt like being
alone, had no motivation, and had lost everything.
Id. He denied suicide attempts, but endorsed
suicidal thoughts. Id. Loyda C. Stevens, M. Ed.,
R.N. (“Ms. Stevens”), described Plaintiff as
appearing neat and clean; showing appropriate motor activity;
having a cooperative attitude; demonstrating an appropriate
affect; having a happy mood; speaking at a normal rate and
tone; demonstrating a normal thought process; endorsing
paranoid thought content, auditory hallucinations, and
persecutory delusions; being oriented to person, place, time,
and situation; showing poor decision making and judgment;
having poor remote memory; being easily distracted; and
demonstrating an average fund of knowledge. Tr. at 289-90.
She indicated Plaintiff's weight to be 215 pounds. Tr. at
290. Plaintiff reported adequate sleep, appetite, energy
level, and libido. Id. Ms. Stevens noted that
Plaintiff presented as “very happy, friendly and
appropriately engaging.” Id. She indicated
Plaintiff did not talk of “wanting to hurt
people.” Id. She noted that Plaintiff had
resumed use of Risperdal following his appointment with Dr.
Lundvall and considered the medication to be helping with his
mood and thoughts. Id. Plaintiff reported that he
had lost his job as a janitor because he was experiencing
paranoia, but he indicated he was not taking his medication
at the time and acknowledged that he “fe[lt] better and
[did] not get angry easily” when taking his medication.
Tr. at 291. Ms. Stevens provided more samples of Risperdal
and referred Plaintiff to a case manager. Id.
September 30, 2015, Plaintiff endorsed depression and anxiety
and reported he was doing “fair” and taking his
medication daily. Tr. at 326-27. He was proud of his weight
loss and indicated he was taking daily walks for exercise.
Tr. at 327. He stated he became violent and experienced
“terrible” auditory hallucinations when he was
not taking his medication. Id. He denied suicidal
and homicidal ideation. Id. Elizabeth S. Nixon, R.N.
(“Ms. Nixon”), observed Plaintiff to be dressed
nicely and on time for his appointment. Id.
presented to Laurinda Saxon, M.H.P., L.P.C. (“Ms.
Saxon”), on the same day for individual therapy. Tr. at
343. Ms. Saxon described Plaintiff as pleasant, cooperative,
and appropriately dressed and groomed. Id. She noted
Plaintiff had a bright affect, maintained good and direct eye
contact, and was able to articulate his feelings and thoughts
and process information without difficulty. Id.
Plaintiff indicated he had difficulty maintaining employment
because of his symptoms. Id. He stated he spent a
lot of time alone or with family and did not have an active
social life. Id. He indicated his sleep, diet,
depression, and auditory hallucinations had improved since he
restarted his medications. Id. He reported his mood
was “good” and expressed a desire to comply with
medication and treatment. Id.
October 29, 2015, Plaintiff reported that he was “doing
a little bit better.” Tr. at 323. He indicated he was
living with his father, but tended to self-isolate and felt
like he did not fit in. Id. He complained of hearing
voices “from time to time, ” but indicated he
heard them less frequently while taking the medication.
Id. He denied visual hallucinations. Id.
Dr. Mohiuddin indicated that Plaintiff was experiencing
persecutory delusions and auditory hallucinations and had
fair judgment and insight, but otherwise noted normal
findings on mental status examination. Id. He
continued Plaintiff on three milligrams of Risperdal twice a
same day, Plaintiff presented to Ms. Saxon for individual
therapy. Tr. at 342. He reported that his medication helped
him to better control his anger. Id. He continued to
endorse occasional paranoia and auditory hallucinations.
Id. He indicated he did not have a lot of friends,
but talked with some friends on the phone. Id. Ms.
Saxon noted that Plaintiff had limited insight into his
November 18, 2015, Plaintiff reported that he was compliant
with his medications, but did not feel like he needed them.
Tr. at 340. He admitted that he had difficulty controlling
his impulses when he was off his medication. Id. Ms.
Saxon described Plaintiff as appropriately dressed and
groomed. Id. She encouraged him to develop a daily
January 20, 2016, Plaintiff presented to Lan Bonno-Lebozec,
Ed.S., M.H.P. (“Ms. Bonno-Lebozec”), for
individual therapy. Tr. at 338. He indicated his life was
“very stable” and “good” and
expressed a desire to return to work and reengage in the
reported that he was doing well and taking his medication
daily on February 23, 2016. Tr. at 303. He indicated he was
living with his father and had a girlfriend. Id. He
endorsed some irritability and paranoid ...