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