United States District Court, D. South Carolina
REPORT AND RECOMMENDATION
V. HODGES UNITED STATES MAGISTRATE JUDGE
appeal from a denial of social security benefits is before
the court for a Report and Recommendation
(“Report”) pursuant to Local Civ. 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 his claim 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 undersigned
recommends the Commissioner's decision be reversed and
remanded for further proceedings as set forth herein.
about September 24, 2014, Plaintiff filed applications for
DIB and SSI in which he alleged his disability began on
January 2, 1995. Tr. at 205-16. His applications were denied
initially and upon reconsideration. Tr. at 103, 117-33. On
March 17, 2017, Plaintiff had a hearing before Administrative
Law Judge (“ALJ”) James M. Martin. Tr. at 50-98
(Hr'g Tr.). The ALJ issued an unfavorable decision on
June 1, 2017, finding Plaintiff was not disabled within the
meaning of the Act. Tr. at 27-49. 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 1-6. Thereafter,
Plaintiff brought this action seeking judicial review of the
Commissioner's decision in a complaint filed on June 7,
2018. [ECF No. 1].
Plaintiff's Background and Medical History
was 45 years old at the time of the hearing. Tr. at 57. He
attended the seventh grade and obtained a high school
equivalency or general education development
(“GED”) diploma to be released from
prison. Tr. at 60. He has no past relevant work
(“PRW”) for Social Security purposes. Tr. at 43.
He alleges he has been unable to work since January 2, 1995.
Tr. at 30.
Medical Evidence Submitted to the ALJ
15, 1999, Plaintiff presented to the mental health clinic at
the South Carolina Department of Corrections
(“SCDC”), and the attending physician noted he
was talking excessively, continuously moving his extremities,
and complained of anxiety or depression. Tr. at 347.
21, 1999, Plaintiff presented to the mental health clinic at
SCDC, and the attending physician noted:
During today's assessment [Plaintiff] displayed
appropriate affect and mood with only minimal anxiety. He
reported feeling much better than when he arrived [two weeks
ago]. He attributed his initial anxiety to just coming off
alcohol and adjusting to prison for the first time. He
related improved sleep and [denied depression]. . . .
[Plaintiff] voiced belief that most of his problems have
resulted from his alcohol abuse. He expressed hope for his
future and plans to participate in substance abuse
[treatment] as well as obtaining a job assignment at his
assigned institution. [Plaintiff] was alert, oriented , and
[his] thought processes were rational. His anxiety has
decreased significantly and he appears to be adjusting well
to his incarceration at this time. He does not appear
depressed or in need of further mental health [treatment] at
the current time.
Tr. at 346-47. Plaintiff's global assessment of
functioning (“GAF”) score was 68. Tr. at 347.
12, 1999, Plaintiff presented to the mental health clinic at
SCDC, and the attending physician noted he was frustrated,
but in no acute distress, had no psychosis, and was oriented,
calm, coherent, and cooperative. Tr. at 346.
19, 1999, Plaintiff presented to the mental health clinic at
SCDC, and the attending physician noted he was doing
“tolerably well though there is some
anger/anxiety.” Tr. at 345.
August 30, 1999, Plaintiff presented to the mental health
clinic at SCDC and reported anxiety, depression, headaches,
and nervousness, but stated, “I am not mentally ill, I
am just nervous and just want to straighten my life
out.” Tr. at 343. The attending physician noted
Plaintiff maintained good eye contact, was well oriented, and
had appropriate mood and affect. Id.
September 22, 2000, the attending physician at SCDC noted
Plaintiff had panic attacks, depression, and psychiatric
abnormalities with a history of anxiety and sleep disorders,
and took Ativan. Tr. at 368.
October 24, 2000, Plaintiff presented to the mental health
clinic at SCDC. Tr. at 366. He denied a mental health
history, had a low violence risk, with anger that had
improved. Id. The attending physician noted
Plaintiff had an elated affect, logical thought process,
normal speech, good eye contact and attention span, and no
memory deficits. Id. The attending physician
concluded Plaintiff appeared mentally stable. Id.
October 2, 2001, after approximately five months of treatment
in group therapy and counseling, Plaintiff reported
improvement. Tr. at 360-63.
March 10, 2004, Plaintiff reported he would like to speak
with someone about his issues, including being an alcoholic,
finding his parents deceased, and worrying all the time. Tr.
at 356-57. The attending registered nurse noted Plaintiff did
not appear depressed. Tr. at 357.
January 24, 2005, Plaintiff reported increased stress and
anxiety. Tr. at 353.
November 13, 2014, Lisa Clausen, Ph.D. (“Dr.
Clausen”), a state agency psychologist indicated there
was insufficient evidence to complete a psychiatric review
technique (“PRT”) questionnaire or assess
Plaintiffs mental impairments, as there was no medical
evidence in the file. Tr. at 101.
December 14, 2014, James N. Ruffing, Psy.D. (“Dr.
Ruffing”), performed a consultative examination of
Plaintiff due to his allegations of seeing shadows, having
difficulty sleeping, worrying all the time, and hearing
voices. Tr. at 299-302. Dr. Ruffing noted there were no
psychological or medical records available for review and
Plaintiff was not prescribed medications. Tr. at 299.
Plaintiff reported he heard voices telling him to do things
and had severe anxiety and panic attacks. Id.
Plaintiffs activities of daily living (“ADLs”)
included caring for his personal needs, light meal
preparation, cleaning, laundry, and some yard work, but he
did not attend church services, go shopping, pay bills, or
use a computer. Tr. at 299-300. He was unable to drive due to
prior driving under the influence convictions
(“DUIs”), he rarely talked on the phone, and he
occasionally went out to eat, but he had to leave when it got
crowded or loud due to his anxiety. Id. Plaintiff
denied illicit substance abuse or tobacco use, but reported
treatment for alcohol-related issues and two prison sentences
for DUIs and one sentence for violating probation. Tr. at
300. Plaintiff was accompanied by Cynthia Pruitt (“Ms.
Pruitt”), but he fully and accurately completed the
intake questionnaire himself. Id. Plaintiff reported
his history was unremarkable for brain trauma. Id.
Ruffing noted Plaintiff “tended to be rather
intense” and anxious, but managed appropriate levels of
eye contact, calmed down as the session progressed, and
responded with spontaneous speech and linear, logical,
relevant, and coherent thoughts. Id. Dr. Ruffing
noted the following:
EMOTIONAL PRESENTATION: He presented with an appropriate
affect of normal range and intensity and somewhat of an
intense presentation. He was mostly anxious. . . . Despite
rather significant and severe and long-lasting complaints of
severe anxiety, panic attacks, and both auditory and visual
hallucinations, he stated that he has never been treated or
evaluated for mental health related concerns. He has never
been in a psychiatric hospital. He has never received
counseling or medication treatment.
THOUGHT CONTENT: I saw no evidence for psychosis, other than
his complaints of both auditory and visual hallucinations,
which at times seem to represent more of fear and
disconcerting internal dialogue. At times his complaints had
somewhat of a[n] actual hallucinatory quality, but it seemed
rather unusual that he had no other signs or symptoms
consistent with psychosis, such as avolition, disorganized or
catatonic type behavior, disorganized speech, etc.
COGNITION: He attended without distractibility and
demonstrated normal cognitive processing speed. He was able
to recall 3 unrelated words immediately and 2 of 3 after a
five-minute delay with interference task. He could not recall
the 3rdword with forced choice assisted cuing. He
was administered the Folstein Mini-Mental Status Exam
[(“Folstein Exam”)], achieving a raw score of
30/30. A score of 24 [or] higher suggests mental status
functioning is within normal limits.
PSYCHOLOGICAL IMPRESSION: Based on his complaints there is
indication for panic disorder without agoraphobia, severe
anxiety and auditory and visual hallucinations. It is
interesting to note that I saw no other signs or symptoms
consistent with psychosis or lack of reality contact.
CAPACITIES: He is able to understand and respond to the
spoken word. He seems able to manage concentration,
persistence, and pace. Based on his complaints, his greatest
difficulty would be working in close proximity with large
numbers of people. He does appear capable of managing his
finances, if awarded benefits.
Tr. at 300-01.
December 29, 2014, Xanthia Harkness, Ph.D. (“Dr.
Harkness”), a state agency psychologist, completed a
PRT questionnaire and opined Plaintiffs mental impairments
imposed minimal limitations on his ability to perform basic
work-related tasks and functions. Tr. at 107-108, 113-15.
Specifically, Dr. Harkness found Plaintiff had mild
difficulties in social functioning and his anxiety was
non-severe for his SSI claim. Id. However, Dr.
Harkness opined there was no medical evidence in the file to
evaluate whether they existed prior to his date last insured
for his DIB claim. Id.
March 12, 2015, Jerome Aya-ay, M.D., (“Dr.
Aya-ay”) evaluated Plaintiff as a new patient. Tr. at
337. Plaintiff reported he was nervous all the time, his
symptoms were worsening, and he could not control his bowel
movements, function, or leave his home at times. Id.
Plaintiff also reported a history of being bullied and
teased. Id. Plaintiff stated he was “not a
normal person” and his girlfriend, Ms. Pruitt, brought
him to the doctor because she cared about him. Id.
Dr. Aya-ay assessed anxiety and depressive disorder, noted
concern regarding post-traumatic stress disorder
(“PTSD”), and prescribed Citalopram and Vistaril.
4, 2015, Plaintiff presented Dr. Aya-ay's office, saw
Christopher McCarthy, M.D. (“Dr. McCarthy”), and
reported the medication had not helped much and he continued
to have depression and anxiety with visual and auditory
hallucinations. Tr. at 336. Dr. McCarthy noted Plaintiff may
have bipolar disorder or severe anxiety and depression with
psychotic features, recommended counseling, discontinued
Vistaril and Citalopram, and prescribed Risperidone and
8, 2015, Plaintiff presented to Dr. McCarthy and reported
medication compliance with no side effects and an improved
mood. Tr. at 335. Plaintiff also reported his dosages did not
need to be adjusted and the voices had decreased, but he
wanted to take Diazepam twice a day. Id. Dr.
McCarthy refilled Diazepam and Risperidone. Id.
8, 2015, Plaintiff presented to Dr. McCarthy and reported
reduced alcohol consumption, but he experienced pain in old
wounds and felt stiff with increased anxiety. Tr. at 334. Dr.
McCarthy encouraged counseling, prescribed Mobic, and
refilled Diazepam and Risperidone. Id.
August 7, 2015, Plaintiff presented to Dr. McCarthy and
reported he had low blood pressure, reduced his alcohol
consumption, and felt well. Tr. at 333. However, Plaintiff
requested increased anxiety medication. Id. Dr.
McCarthy assessed anxiety state and depressive disorder,
increased Diazepam, modified Valium, and refilled Risperidone
and Mobic. Id.
November 16, 2015, Plaintiff presented to Dr. Aya-ay and
reported having taken an extra Diazepam tablet daily due to a
difficult month and requested a refill. Tr. at 322. Plaintiff
also reported Risperidone had helped, but “things are
crazy, ” as he still saw images of people coming out of
the walls and he wrapped himself in plastic at home so he was
not touched. Id. Dr. Aya-ay prescribed Atenolol and
Diclofenac Sodium, modified Risperidone, and refilled
December 14, 2015, Plaintiff presented to Dr. Aya-ay and
reported Risperidone helped and his hallucinations had
improved. Tr. at 331. However, Plaintiff also reported pain
throughout his body, muscle aches, and a back ache.
Id. Dr. Aya-ay refilled Diazepam and Risperidone and
prescribed Norco. Id.
March 21, 2016, Plaintiff presented to Dr. Aya-ay and
reported “he [was] doing okay” and
“Risperidone [was] a lifesaver” because it slowed
down his mind at night. Tr. at 330. Plaintiff also reported
his twelve-year-old cat had died and he missed talking to it.
Id. Plaintiff requested additional medication to
address his pain, as it was more severe since he stopped
consuming alcohol. Id. Plaintiff reported he had cut
his pain medication into thirds and made it last three
months. Id. Dr. Aya-ay assessed stable anxiety,
depressive disorder, and psychosis and refilled Diazepam,
Risperidone, and Norco. Id.
April 5, 2016, Dr. Aya-ay noted Plaintiffs issues as anxiety
state, depressive disorder, psychosis, and hypertension, and
his permanent prescriptions included Diazepam, Mobic, Norco,
and Risperidone. Tr. at 303, 305. Dr. Aya-ay also noted
Plaintiff seldom drank alcohol. Id. Similar notes
were recorded on June 1, 2016, and November 4, 2016. Tr. at
10, 2016, Plaintiff presented to Dr. Aya-ay and reported
increased hallucinations and anxiety. Tr. at 326-29.
Plaintiff also reported a lot of stress at home and requested
additional medication. Id. He indicated his
medication helped, but he had been without it for a few days.
Id. Dr. Aya-ay noted Plaintiff needed to see a
psychiatrist and follow up with mental health or a private
doctor. Id. Dr. Aya-ay assessed anxiety, depressive
disorder, psychosis, and hypertension and refilled Diazepam,
Norco, and Risperidone. Id.
August 16, 2016, Joseph Grace, Ph.D. (“Dr.
Grace”) evaluated Plaintiff. Tr. at 308, 314-21. Dr.
Grace based his evaluation on medical records from Dr. Aya-ay
dated June 1, 2016, a plan of care submitted by the South
Carolina Department of Mental Health (“Mental
Health”) dated June 23, 2016, a Personal Inventory for
Psychological Disability Assessment completed on July 29,
2016, extended clinical interviews and cognitive counseling
on July 28, August 5, and August 16, 2016, and a Minnesota
Multiphasic Personality Inventory-2 (“MMPI-2”)
administered on August 3, 2016. Tr. at 314. Dr. Grace noted
Plaintiff completed the seventh grade, obtained a GED while
in prison, and was accompanied to all sessions by Ms. Pruitt
and her daughter, described as Plaintiffs family and
caretakers. Tr. at 314-15. Plaintiff reported having been
homeless for five years before moving in with Ms. Pruitt. Tr.
at 315. Dr. Grace noted Ms. Pruitt and her daughter were
“instrumental in obtaining comprehensive
interviews” and “assisted in stabilizing
[Plaintiff] emotionally when discussing stressful and tragic
issues and providing information [or] clarification regarding
his sometimes vague descriptions and gaps in his
Grace provided a detailed review of Plaintiffs education,
conviction, family, work, marital, medical, emotional, and
psychiatric histories. Tr. at 314-21. Plaintiffs mother was
diagnosed with paranoid schizophrenia and was a harsh
disciplinarian, and his father was abusive. Id.
After harsh beatings, Plaintiffs mother kept him home from
school to avoid investigation. Id. During his
childhood, Plaintiff almost drowned, witnessed his mother
jump from a moving vehicle, lost his best friend in a car
accident, and had frequent fights with gang members for being
in their territory. Tr. at 315-16. When Plaintiff was
twenty-four years old, his father died from a metastatic
disease and his mother starved herself to death the following
year. Tr. at 316. Ms. Pruitt relayed that Plaintiff became
more emotionally unstable with erratic behavior after his
parents' deaths. Id.
had two failed marriages and reported serving prison
sentences that amounted to seven years for domestic violence,
failure to pay child support, DUI, and sexually abusing a
minor. Tr. at 316-17. Plaintiff reported a sporadic work
history that ended due to “work-related injuries,
perceived harassment by co-workers, and extreme discomfort
with the work environment.” Tr. at 317.
had been diagnosed with depressive disorder, panic disorder,
PTSD, psychosis, schizophrenia, paranoia, bipolar disorder,
and schizoaffective disorder, bipolar type, and he currently
received treatment from Dr. Aya-ay. Tr. at 317-18. Plaintiffs
symptoms included depressed mood, increased anhedonia,
excessive worry, frequent anxiety, sleep disturbances,
extreme daytime fatigue with little stamina, decreased
concentration and short-term memory, difficulty making
routine decisions, increased irritability with low
frustration tolerance, hypervigilance and uncomfortableness
around strangers, frequent nightmares, daily panic episodes,
racing thoughts, inability to stay focused on any topic,
alienation, hallucinations, delusions of persecution and
control, and “very confused, disturbed thinking.”
Tr. at 318-19.
was “shabbily dressed and unkempt during all
interviews.” Tr. at 315. Plaintiff “was a
rambling informant, ” “emotionally labile,
” “could generally relate significant events in
his life but struggled with dates, ” “strayed
from issues he had presented, ” and “perseverated
on issues with a tendency to provide much irrelevant
information.” Id. Plaintiff was oriented to
time, person, and place, but indicated he frequently