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Tucker v. Berryhill

United States District Court, D. South Carolina

April 15, 2019

Jeannette Tucker, Plaintiff,
v.
Nancy A. Berryhill, Acting Commissioner of Social Security Administration, Defendant.

          ORDER

          SHIVA V. HODGES UNITED STATES 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 Honorable Margaret B. Seymour, Senior United States District Judge, dated March 15, 2018, referring this matter for disposition. [ECF No. 5.] 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. 4.]

         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 her 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 court affirms the Commissioner's decision.

         I. Relevant Background

         A. Procedural History

         On August 6 and September 17, 2014, Plaintiff protectively filed applications for DIB and for SSI in which she alleged her disability began July 15, 2002. Tr. at 285-310. Her applications were denied initially and upon reconsideration. Tr. at 168-77, 139, 153. On May 10, 2017, Plaintiff had a hearing by video before Administrative Law Judge (“ALJ”) William Wallis. Tr. at 89-114 (Hr'g Tr.). At the hearing, Plaintiff amended her alleged onset date to December 21, 2013. Tr. at 91. As a result, the ALJ found Plaintiff forfeited her DIB claim, as her amended alleged onset date of disability was subsequent to her date last insured of June 30, 2010. Tr. at 91-92. The ALJ dismissed Plaintiff's DIB application and addressed her remaining claim for SSI. Tr. at 73. The ALJ issued an unfavorable decision on August 9, 2017, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 70-88. 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 1-7. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on March 1, 2018. [ECF No. 1.]

         B. Plaintiff's Background and Medical History

         1. Background Plaintiff was 60 years old at the time of the hearing. Tr. at 95. She completed high school. Id. She last worked part time as a housekeeper, which the ALJ found did not meet the standards for Substantial Gainful Activity (“SGA”). Tr. at 96. She alleges she has been unable to work since December 21, 2013. Tr. at 97.

         2. Medical History

         On February 20, 2014, Plaintiff presented for a follow-up psychiatric medical assessment at Columbia Area Mental Health Center (“CAMHC”) with her psychiatrist, Dr. Patrick Butterfield. Tr. at 468-69. Plaintiff reported she had been living with a friend for the prior year and stated she had applied for disability. Tr. at 468. Dr. Butterfield noted he had decreased Plaintiff's Latuda in October due to postural hypotension. Id. Plaintiff stated she had been out of Latuda for one week and noticed increased depression, but was taking the medication again and felt better. Id. Dr. Butterfield performed a mental status examination (“MSE”), which was unremarkable. Tr. at 468-69. He continued Plaintiff's diagnoses of major depressive disorder, recurrent, severe with psychotic features; alcohol dependence; and cannabis dependence and refilled her prescriptions for Paxil, Trazodone, and Latuda. Tr. at 469.

         On March 19, 2014, Plaintiff presented to Dr. Butterfield for an emergency appointment due to increased depression and suicidal ideation. Tr. at 465-66. Plaintiff reported increased irritability and losing her temper with her two toddler grandchildren whom she cared for during the day. Tr. at 465. On MSE, Dr. Butterfield indicated Plaintiff exhibited sad faces, silent tears, and mild slowing of psychomotor functions; she spoke at a low rate of speed and volume and had no spontaneous speech; and she showed depressed mood, constricted affect, and distractible thought process. Tr. at 465-66. Dr. Butterfield increased Plaintiff's Latuda prescription and indicated she would continue with individual and group therapy. Tr. at 465.

         On March 24, 2014, Plaintiff's CAMHC case manager, Anna House, summarized Plaintiff's progress from December 23, 2013, to March 23, 2014. Tr. at 435. Ms. House noted Plaintiff lived independently with her daughter and two of her grandchildren. Id. Plaintiff had been compliant in attending her prescribed therapy services and taking her medication. Id. However, Plaintiff had experienced an escalation of symptoms, including increased suicidal ideation and command hallucinations. Id. Ms. House indicated Plaintiff planned to meet her goal of feeling better by continuing to attend therapy sessions and to reduce her tendency to isolate herself by interacting with peers at least once per day. Id. Plaintiff reported a desire to stop avoiding her family and friends. Id. Ms. House noted Plaintiff expressed increased confidence interacting with others until family turmoil three weeks prior that increased her desire to withdraw. Id. In addition, Ms. House stated Plaintiff continued to use marijuana five or more days per week. Id. Plaintiff reported difficulty controlling her anxiety without the use of marijuana. Id. Ms. House noted Plaintiff would begin attending a weekly substance abuse group to better understand how her marijuana use interacted with her mental health. Id.

         On March 27, 2014, Plaintiff returned to Dr. Butterfield and reported the increased dosage of Latuda had decreased her hallucinations. Tr. at 461. However, Plaintiff indicated she had been taking more than Dr. Butterfield had prescribed and complained of lightheadedness and increased blood pressure. Id. On MSE, Dr. Butterfield noted Plaintiff exhibited only mildly-depressed mood, did not cry during the appointment, and endorsed decreased auditory hallucinations. Tr. at 462.

         On April 24, 2014, Plaintiff followed up with Dr. Butterfield and reported feeling much better. Tr. at 457. She stated she left the house some, but that she still did not feel like herself. Id. She also indicated she was no longer experiencing dizziness or lightheadedness. Id. Plaintiff informed Dr. Butterfield she had not seen her primary care physician in over six months and had been off her hypertension medication. Id. On MSE, Dr. Butterfield noted Plaintiff's mildly-depressed mood. Tr. at 458. He advised Plaintiff to continue her medications and therapy. Id.

         On June 19, 2014, Ms. House summarized Plaintiff's progress from March 23, 2014, to June 21, 2014. Tr. at 436. Ms. House stated Plaintiff attended psychosocial rehabilitation programming two times per week and was living independently in the community with friends. Id. Ms. House indicated Plaintiff had shown improvement with medication compliance over the review period, but continued to struggle with a tendency to isolate herself. Id. Ms. House did not recommend any changes to Plaintiff's plan of care. Id.

         On June 26, 2014, Plaintiff returned to Dr. Butterfield for a medication check and reported continued improvement. Tr. at 454-55. Dr. Butterfield noted a normal MSE. Id.

         On September 19, 2014, Ms. House summarized Plaintiff's progress from June 21, 2014, to September 19, 2014. Tr. at 437. Ms. House noted Plaintiff continued to live independently in the community with friends, had recently received Medicaid benefits, and had complied with her treatment program. Id. Ms. House stated Plaintiff had improved in her ability to manage her symptoms, had not reported increased depression, and had not experienced command hallucinations during the review period. Id. However, Ms. House noted Plaintiff continued to use marijuana four or more times per week. Id. Ms. House stated Plaintiff had shown progress in her ability to tolerate being with others and her communication skills and had less frequently reported feeling unsafe. Id. Ms. House suggested placing more emphasis on addressing Plaintiff's drug abuse in the upcoming treatment plan. Id.

         On September 24, 2014, Plaintiff reported to Dr. Butterfield that she felt “great” and had been babysitting her grandchildren seven days a week. Tr. at 450. Dr. Butterfield noted a normal MSE. Id.

         On December 3, 2014, Plaintiff complained of frequent headaches and requested a blood pressure check by a nurse at CAMHC. Tr. at 887. The nurse recorded Plaintiff's blood pressure as 160/100 and advised Plaintiff to make an appointment with the Eastover Clinic. Id.

         On December 15, 2014, Plaintiff presented for a blood pressure check at Eastover Family Practice. Tr. at 896-97. Plaintiff reported having been out of blood pressure medication for over a year and complained of headaches, but denied blurred vision or chest pain. Tr. at 896. Plaintiff also reported more frequent urination. Id. The examining nurse recorded the following diagnoses: cardiovascular disorder, heart disease, with unsure diagnosis; hypertension; asthma; depression; and history of inappropriate sinus tachycardia, neurally medicated syncope, and heavy caffeine use. Id. Plaintiff reported she lived alone, smoked less than half a pack of cigarettes per day, drank two cans of beer every other week, and occasionally used marijuana. Id. Plaintiff's blood pressure measured 141/94. Tr. at 897. The examining nurse assessed essential hypertension, ordered labs, restarted Plaintiff on Metoprolol, and instructed Plaintiff to monitor her sodium intake. Id.

         On January 6, 2015, Dr. Butterfield noted Plaintiff had been attending therapy sessions four times per week since December and continued to babysit three of her young grandchildren. Tr. at 888. He indicated a normal MSE. Id.

         On January 8, 2015, Ms. House summarized Plaintiff's progress from September 24, 2014, to December 23, 2014 and noted Plaintiff attended psychosocial rehabilitative services four days per week and received individual therapy approximately once per month. Tr. at 908. Ms. House indicated Plaintiff had been more interactive with peers and reported less isolation. Id. She opined this improvement was due to increased medication compliance related to Medicaid approval. Id. Ms. House stated Plaintiff continued to use marijuana three to five days per week, despite consistently attending her weekly co-occurring disorders group and submitting to random drug testing. Id.

         On January 16, 2015, Dr. Jody Lenrow conducted a consultative mental RFC assessment. Tr. at 130-34. After reviewing Plaintiff's medical records, Dr. Lenrow concluded Plaintiff had the following medically determinable impairments: Affective Disorder, primary, severe; and Alcohol, Substance, and Addiction Disorder, secondary, non-severe. Tr. at 130. Dr. Lenrow opined Plaintiff's affective disorder did not restrict her activities of daily living (“ADLs”); resulted in moderate difficulties in maintaining social function and concentration, persistence, or pace; and had resulted in one or two episodes of decompensation of extended duration. Id. Dr. Lenrow found Plaintiff's allegations credible and that Plaintiff was doing well, but experienced some increased symptoms when not compliant with her medications. Tr. at 131. She noted Plaintiff continued to use marijuana and indicated that could increase her symptoms. Id. Dr. Lenrow found Plaintiff's function intact based in part on her babysitting her grandchildren several days a week. Id. In sum, Dr. Lenrow found Plaintiff suffered from severe mental impairments, but appeared to be stable on medication and should be capable of at least simple tasks with limited public interaction. Id.

         Dr. Lenrow's assessment specifically noted Plaintiff's sustained concentration and persistence limitations included moderate limitations in her ability to carry out detailed instructions; maintain attention and concentration for extended periods; perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances; and complete a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods. Tr. at 133. In addition, Plaintiff's social limitations included moderate limitations in her ability to interact appropriately with the general public and get along with coworkers or peers without distracting them or exhibiting behavioral extremes. Id. Dr. Lenrow explained that, due to Plaintiff's mental conditions, she may have difficulty sustaining her concentration and pace on complex tasks and detailed instructions. Tr. at 134. However, Dr. Lenrow found Plaintiff could understand and remember instructions and should be able to attend to and perform simple tasks without special supervision. Id. Dr. Lenrow found Plaintiff could attend work regularly, but may miss a day occasionally due to her mental condition. Id. Dr. Lenrow indicated Plaintiff could relate appropriately to supervisors and coworkers, but may be better suited for a job that did not require regular work with the general public. Id. In addition, Dr. Lenrow found Plaintiff could make simple, work-related decisions and occupational adjustments; adhere to basic standards for hygiene and behavior; request assistance from others; protect herself from normal workplace safety hazards; and use public transportation. Id.

         On January 29, 2015, Plaintiff followed up with Eastover Family Practice regarding her hypertension. Tr. at 898-99. Plaintiff reported doing well with medication and denied any new concerns or complaints. Tr. at 898. Her blood pressure measured 122/81. Id. The examining nurse indicated Plaintiff had reached her goal blood pressure and directed her to continue taking her medicine. Id.

         On March 20, 2015, Ms. House summarized Plaintiff's progress from December 23, 2014, to March 23, 2015. Tr. at 1005. Ms. House noted Plaintiff had become more active in initiating interactions with peers, but was still reporting some isolation, especially at home and when around strangers. Id. Ms. House reported Plaintiff continued to use marijuana regularly, demonstrate thinking errors, and make excuses about her drug use. Id.

         On April 1, 2015, Dr. M. Jane Yates conducted a consultative mental RFC assessment in conjunction with the reconsideration of Plaintiff's initial denial. Tr. at 159-64. Dr. Yates considered some of Plaintiff's more recent medical records and Plaintiff's self-reported ADLs. Tr. at 160. Regarding her ADLs, Plaintiff indicated her condition limited her ability to work because she could not stay focused and experienced forgetfulness. Id. Plaintiff reported regularly caring for her grandchildren and her two pets. Id. She indicated she spent most mornings at the CAMHC “clubhouse, ” attending group therapy sessions. Id. She denied problems with personal grooming. Id. She stated she did not prepare meals; did some household chores; went outside daily; was not comfortable going out alone; only drove to group meetings; shopped in stores; could count change, handle a savings account, and use a checkbook or money order; read and did crossword puzzles; spent time with groups at the clubhouse; regularly attended church; needed reminders to go places and someone to accompany her; and had no trouble getting along with family and friends. Id. In addition, Plaintiff reported she could pay attention for fifteen minutes; had problems completing tasks; did not follow written instructions well, but could follow simple, spoken instructions fairly well; got along with authority figures; could not handle stress or changes in her routine well; and did not like being around people. Id.

         Dr. Yates concluded Plaintiff had limitations in understanding and memory, sustained concentration and persistence, social interaction, and adaptation. Tr. at 162-64. Specifically, regarding Plaintiff's understanding and memory, Dr. Yates found Plaintiff had the ability to understand and remember simple and detailed work locations and procedures and would only need infrequent reminders of some of the detailed instructions due to intermittent difficulties in maintaining focus. Tr. at 164.

         Regarding Plaintiff's sustained concentration and persistence, Dr. Yates noted moderate limitations in Plaintiff's ability to carry out detailed instructions; maintain attention and concentration for extended periods; perform activities with a schedule, maintain regular attendance, and be punctual within customary tolerances; and complete a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods. Tr. at 162-63. Dr. Yates concluded Plaintiff could maintain attention and concentration sufficient to perform simple, and a few detailed, tasks at an acceptable pace and quality for two-hour periods, over eight-hour workdays and forty-hour workweeks, under ordinary supervision, with no more than an infrequent missed day during the work months due to her mental impairment. Tr. at 164. In addition, Dr. Yates found Plaintiff could make simple decisions. Id.

         Regarding social interaction, Dr. Yates noted Plaintiff exhibited moderate limitations in her ability to interact with the general public and to get along with coworkers or peers without distracting them or exhibiting behavioral extremes. Tr. at 163. Dr. Yates found Plaintiff could relate appropriately on a casual and limited basis with the general public, accept ordinary supervision, and relate appropriately to coworkers without being unduly distracted by them, or vice versa. Tr. at 164. In addition, she found Plaintiff could maintain acceptable behavior, hygiene, and dress in the workplace. Id.

         Regarding adaptation, Dr. Yates noted Plaintiff was moderately limited in her ability to respond appropriately to changes in the work setting. Tr. at 163. Dr. Yates found Plaintiff could adapt to the demands of a routine work setting, and respond appropriately to changes in such settings, protect herself from normal workplace safety hazards, and use public transportation. Tr. at 164. In addition, she found Plaintiff could set reasonable goals and initiate action to carry them out and that she would benefit from infrequent encouragement. Id.

         On July 29, 2015, Plaintiff attended a medication monitoring appointment with nurse Penny Reynolds at CAMHC. Tr. at 1155-56. Plaintiff reported the following medication side effects: fatigue, frequent urination, visual problems, diarrhea, and dry mouth. Tr. at 1155. Plaintiff stated she smoked one quarter pack of cigarettes, drank four to five Mountain Dews, and smoked two marijuana cigarettes per day. Id. Plaintiff reported living with her daughter in a trailer on her family's property and caring for her grandchildren. Tr. at 1156. Plaintiff stated she had been taking her medications as prescribed and benefitting from them and denied any side effects. Id. Plaintiff reported continued problems with her anxiety, including restlessness, disorganized thinking, and increased irritability. Id. Plaintiff reported a good appetite and denied sleeping problems. Id. However, she endorsed continued auditory hallucinations telling her to harm her grandchildren. Id.

         On August 8, 2015, Plaintiff presented for a follow-up psychiatric medical assessment with Dr. Butterfield. Tr. at 1205-06. Dr. Butterfield noted Plaintiff had tested positive for marijuana on February 3, May 21, and July 7, and was then-attending a drug treatment group three days a week. Tr. at 1205. Dr. Butterfield indicated a normal MSE and continued Plaintiff on her medication and therapy regimen. Id.

         On September 16, 2015, Plaintiff's case manager administered a required functional assessment (DLA-20). Tr. at 1196-97. Plaintiff's responses to the questionnaire indicated she: dreamt about using marijuana, but denied urges or cravings; lived with an ex-boyfriend because she did not have anywhere else to go; did not pay rent, but contributed food to the house using her food stamps and performed chores; attempted suicide twice and was hospitalized after both attempts; slept a sufficient number of hours; only ate one meal per day and reported a poor appetite; received money from her children when needed, but had no other source of income; did well with independent problem solving; talked to her daughter and sister almost every day; enjoyed crossword puzzles, spending time with her grandchildren, and watching television; preferred to stay home and experienced anxiety around crowds; bathed and brushed her teeth daily; kept up her appearance and maintained grooming habits; and dressed appropriately for the weather in clean clothing. Tr. at 1196.

         On November 19, 2015, Plaintiff had a follow-up psychiatric medical assessment with Dr. Butterfield. Tr. at 1186-87. Dr. Butterfield noted Plaintiff graduated from her alcohol abuse and drug treatment program that day and expressed a desire to resume psychosocial rehabilitative services two days per week. Tr. at 1186. Dr. Butterfield noted Plaintiff appeared disheveled, but otherwise indicated a normal MSE. Id.

         On January 11, 2017, one of Plaintiff's therapists noted she continued to exhibit isolating behaviors, persistent signs of anxiety, and hypervigilance. Tr. at 1147.

         On January 18, 2017, in an individual therapy session with Veronica Johnson, Plaintiff reported running out of her medication for two days and described difficulties maintaining medication compliance since her Medicaid benefits were canceled. Tr. at 1143. Ms. Johnson recommended Plaintiff seek employment and Plaintiff indicated she earned money for her medications by babysitting her grandchildren four days per week. Id.

         On February 3, 2017, Plaintiff had a follow-up psychiatric medical assessment with CAMHC psychiatrist Dr. John Billinsky. Tr. at 1139-40. Plaintiff indicated she was looking for work. Tr. at 1139. She reported a “pretty good” mood and that she was sleeping well, but endorsed a poor appetite. Id. Plaintiff declined any problems with her medication and stated she planned to resume attending church. Id. Dr. Billinsky performed an MSE and noted Plaintiff reported experiencing daily auditory hallucinations, but described them as “not as bad” as her prior hallucinations. Id. He also noted Plaintiff exhibited mildly impaired attention and concentration. Id.

         On February 22, 2017, in an individual therapy session with Jennifer Dunbar, Plaintiff explained her roommate paid the bills and she provided food. Tr. at 1129. She indicated she spent most of her time at home, but also visited with her children and grandchildren. Id. She stated if she had a car, she would get out more. Id. Ms. Dunbar noted Plaintiff presented with a flat affect and exhibited some anxious behavior, but that she had a positive and peaceful attitude. Id.

         On March 16, 2017, Ms. Johnson assessed Plaintiff's ADLs using a DLA-20. Tr. at 1152. Plaintiff reported a “happy” mood, good sleep, but poor appetite. Id. Ms. Johnson noted a normal MSE, except that Plaintiff endorsed occasional auditory hallucinations telling her to harm herself. Id. Plaintiff indicated she performed daily chores and other tasks without concern. Id. Ms. Johnson explained Plaintiff's score of 51 on the DLA-20 indicated mild impairments with independent strengths and that Plaintiff often required some help and routine support. Id. Specifically, Ms. Johnson noted ...


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