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Raynes v. Saul

United States District Court, D. South Carolina, Greenville Division

September 17, 2019

Patty S. Raynes, Plaintiff,
v.
Andrew M. Saul, Commissioner of Social Security, Defendant.

          REPORT OF MAGISTRATE JUDGE

          Kevin F. McDonald, United States Magistrate Judge

         This case is before the court for a report and recommendation pursuant to Local Civil Rule 73.02(B)(2)(a) (D.S.C.), concerning the disposition of Social Security cases in this District, and Title 28, United States Code, Section 636(b)(1)(B).[1] The plaintiff brought this action pursuant to Section 205(g) of the Social Security Act, as amended (42 U.S.C. 405(g)) to obtain judicial review of a final decision of the Commissioner of Social Security denying her claim for disability insurance benefits under Title II of the Social Security Act.

         ADMINISTRATIVE PROCEEDINGS

         The plaintiff filed an application for disability insurance benefits (“DIB”) on January 21, 2016, alleging that she became unable to work on December 15, 2015. The application was denied initially and on reconsideration by the Social Security Administration. On October 5, 2016, the plaintiff requested a hearing. On October 4, 2017, an administrative hearing was held at which the plaintiff and Joel D. Leonard, an impartial vocational expert, appeared and testified in Columbia, South Carolina. The plaintiff was represented by an attorney at the hearing (Tr. 38). On December 20, 2017, the ALJ considered the case de novo and found that the plaintiff was not under a disability as defined in the Social Security Act, as amended (Tr. 21-33). On May 2, 2018, the Appeals Council notified the plaintiff and her attorney that it had granted the request for review and proposed to issue a decision finding that the plaintiff was not entitled to benefits under the Social Security Act (Tr. 175-78). On June 19, 2018, the Appeals Council issued its decision, noting that it considered the brief submitted by the plaintiff's attorney and found that it did not provide a basis for changing the decision (Tr. 4, 8; see Tr. 295-96). The Appeals Council adopted the ALJ's statements regarding the Act, the pertinent regulations and rulings, the issues in the case, and the evidentiary facts (Tr. 4). The Appeals Council modified the residual functional capacity (“RFC”) assessment of the ALJ, but adopted all of the other findings contained in the ALJ's decision in finding that the plaintiff was not under a disability as defined in the Social Security Act (Tr. 1-8). The Appeals Council's decision is the final decision of the Commissioner of Social Security (Tr. 1). The plaintiff then filed this action for judicial review.

         In making the determination that the plaintiff is not entitled to benefits, the Commissioner has adopted the following findings of the Appeals Council (Tr. 6-7):

(1) The claimant meets the insured status requirements of the Social Security Act through December 31, 2020.
(2) The claimant has not engaged in substantial gainful activity since December 15, 2015, the alleged onset date (20 C.F.R. § 404.1571 et seq.).
(3) The claimant has the following severe impairments: affective disorder; anxiety disorder; attention-deficit hyperactivity disorder; and borderline personality disorder (20 C.F.R. § 404.1520(c)).
(4) The claimant does not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. §§ 404.1520(d), 404.1525, 404.1526).
(5) The claimant has the maximum capacity to perform a full range of work at all exertional levels but with the following nonexertional limitations: only simple, routine, and repetitive tasks but not a production rate pace (e.g., assembly line work); only simple work-related decisions; occasional interactions with supervisors; no work involving team-type duties; no ability to respond appropriately to the public; and the ability to tolerate only few changes in a routine work setting defined as having only occasional, routine changes in the work setting and duties.
(6) The claimant is unable to perform past relevant work (20 C.F.R. § 404.1565).
(7) The claimant was born on October 9, 1956, and was 59 years old, which is defined as an individual of advanced age, on the alleged disability date (20 C.F.R. § 404.1563).
(8) The claimant has at least a high school education and is able to communicate in English (20 C.F.R. § 404.1564).
(9) Transferability of job skills is not material to the determination of disability because using Medical-Vocational Rules as a framework supports a finding that the claimant is “not disabled, ” whether or not the claimant has transferable job skills (See SSR 82-41 and 20 C.F.R. Part 404, Subpart P, Appendix 2).
(10) Considering the claimant's age, education, work experience, and residual functional capacity, the claimant is capable of making a successful adjustment to other work that exists in significant numbers in the national economy. A finding of “not disabled” is therefore appropriate under the framework of section 204.00 in the Medical-Vocational Guidelines.
(11) The claimant has not been under a disability, as defined in the Social Security Act, from December 15, 2015, through the date of the hearing decision (20 C.F.R. § 404.1520(g)).

         The only issues before the court are whether proper legal standards were applied and whether the final decision of the Commissioner is supported by substantial evidence.

         APPLICABLE LAW

         Under 42 U.S.C. § 423(d)(1)(A), (d)(5), as well as pursuant to the regulations formulated by the Commissioner, the plaintiff has the burden of proving disability, which is defined as an “inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 20 C.F.R. § 404.1505(a).

         To facilitate a uniform and efficient processing of disability claims, the Social Security Act has by regulation reduced the statutory definition of “disability” to a series of five sequential questions. An examiner must consider whether the claimant (1) is engaged in substantial gainful activity, (2) has a severe impairment, (3) has an impairment that meets or medically equals an impairment contained in the Listing of Impairments found at 20 C.F.R. Pt. 404, Subpt. P, App. 1, (4) can perform his past relevant work, and (5) can perform other work. Id. § 404.1520. If an individual is found not disabled at any step, further inquiry is unnecessary. Id. § 404.1520(a)(4).

         A claimant must make a prima facie case of disability by showing he is unable to return to his past relevant work because of his impairments. Grant v. Schweiker, 699 F.2d 189, 191 (4th Cir. 1983). Once an individual has established a prima facie case of disability, the burden shifts to the Commissioner to establish that the plaintiff can perform alternative work and that such work exists in the national economy. Id. (citing 42 U.S.C. § 423(d)(2)(A)). The Commissioner may carry this burden by obtaining testimony from a vocational expert. Id. at 192.

         Pursuant to 42 U.S.C. § 405(g), the court may review the Commissioner's denial of benefits. However, this review is limited to considering whether the Commissioner's findings “are supported by substantial evidence and were reached through application of the correct legal standard.” Craig v. Chater, 76 F.3d 585, 589 (4th Cir. 1996). “Substantial evidence” means “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion; it consists of more than a mere scintilla of evidence but may be somewhat less than a preponderance.” Id. In reviewing the evidence, the court may not “undertake to re-weigh conflicting evidence, make credibility determinations, or substitute [its] judgment for that of the [Commissioner].” Id. Consequently, even if the court disagrees with Commissioner's decision, the court must uphold it if it is supported by substantial evidence. Blalock v. Richardson, 483 F.2d 773, 775 (4th Cir. 1972).

         EVIDENCE PRESENTED

         The plaintiff was 59 years old on her alleged disability onset date (December 15, 2015) and 61 years on the date of the ALJ's decision (December 20, 2017). She completed the twelfth grade and has past relevant work as a senate secretary (Tr. 5, 31).

         Medical records from psychiatrist James Kirkland, M.D., covering the period from July 2014 through December 21, 2015, showed that the plaintiff engaged in therapy sessions with Dr. Kirkland at least ten times (Tr. 335-38, 388). Dr. Kirkland recorded in July 2014 that the plaintiff had tried Klonopin and Ativan for her anxiety symptoms, but that Xanax gave her better control and that her migraines were less frequent with use of Imitrex, which was listed among her other medications of Effexor, trazodone, and Neurontin. At her next therapy session on October 1, 2014, the plaintiff presented with a sad, frustrated mood and “limited range” affect, due to the trauma of her ex-husband's suicide (Tr. 388). Dr. Kirkland's subsequent notes indicated that the plaintiff saw “Dr. [Glen] Gerstner every week” for therapy sessions where she was learning coping skills in order to better handle family and work-related matters and that her medications, with some adjustments, were helping her sleep better and stabilized her anxiety symptoms (Tr. 336-38). On June 17, 2015, the plaintiff reported to Dr. Kirkland that Dr. Gerstner suspected that she had “some degree of attention deficit hyperactivity disorder (“ADHD”) and recommended to [her] employer that [she] is likely to be more efficient if she could work in an area [with] less noise.” On July 16, 2015, Dr. Kirkland noted that the plaintiff's employer had “provided a white noise machine that covers up most of the background noise” and that “this along [with] Adderall, has improved her concentration, ” and thus, “she no longer procrastinates and lets things pile up on her desk.” He indicated that the plaintiff was experiencing some increased anxiety and advised adding Vyvanse to her medications (Tr. 337).

         On August 13 and September 9, 2015, Dr. Kirkland noted that the plaintiff's concentration and functioning appeared to improve with the medication adjustments, but she continued to have “interpersonal problems at work and with family members” (Tr. 336). In December 2015, the plaintiff reported to Dr. Kirkland that she had been “fired for insubordination, ” which increased her “anxiety and mood swings.” Dr. Kirkland described the plaintiff as sad, frustrated, and irritable, with a limited range affect. He continued her medications at current dosages (Tr. 335).

         Dr. Kirkland's office records dated from March 9, 2016, to June 29, 2017, indicate that the plaintiff was seeing a counselor at Lexington County Community Mental Health Center (“LCCMHC”), “however no one at that facility will prescribe Vyvanse or Xanax.” In her notes, dated August 2016, Dr. Kirkland described the plaintiff as “down” with “limited range” affect, and she explained that the Valium that had been prescribed by a nurse practitioner “is not as effective as Xanax, ” and that “Adderall . . . is not as effective as Vyvanse.” The rest of Dr. Kirkland's office notes reflect that the plaintiff continued to demonstrate an “OK” mood and that her affect was limited in range. Dr. Kirkland continued to prescribe her medications, including Xanax and Adderall (Tr. 432-34).

         In her February 2017 and June 2017 office notes, Dr. Kirkland indicated that that the plaintiff was only taking Adderall and Xanax “as needed due to financial limitations.” Dr. Kirkland wrote that the plaintiff “had one appointment with a psychiatrist there [at LCCMHC] who was filling in from another program. The session did not go well” and that she had looked into getting the Vyvanse “from an indigent pt. program” (Tr. 434).

         The plaintiff regularly attended psychotherapy sessions with Glen Gerstner, Psy.D., at Crossroads Counseling Center (Tr. 300-31). Dr. Gerstner's intake notes dated October 9, 2014, reflect the plaintiff's difficulty coping with “family issues, suicide of close friend and ex-husband, brother's murder in 2005.” During the examination, the plaintiff exhibited anxiety and worry, anger, listlessness, irritability, easy distractibility, moderate depression, short attention span, defiant behavior, and poor eye contact. She also expressed feelings of loss, frustration, grief, and sadness, as well as problems in the workplace. Her diagnosis was major depressive disorder, recurrent episode, moderate (DSM 296.32) (Tr. 300-01).

         Dr. Gerstner saw the plaintiff at least 17 more times, through December 2015, in sessions lasting from 45 minutes to an hour. During the sessions she displayed and/or complained of waxing and waning depressive symptoms characterized by “an emotional disorder that interferes with day to day functioning, ” including persistent work-related problems (Tr. 302-11, 313, 314, 316, 318, 320, 324, 326). In October 2015, Dr. Gerstner added generalized anxiety disorder to her diagnoses, and in July 2015, he added ADHD, predominantly inattentive presentation (Tr. 302, 318). On December 29, 2015, the plaintiff reported she had been fired from her job and that she had a “decrease in overall functioning since her previous session” (Tr. 326). In office notes dated January and February 2016, Dr. Gerstner described the plaintiff's mental status as “appears angry, sad looking, irritable, distracted, communicative, casually groomed, underweight, ” and “glum.” He added that the plaintiff's insight into her problems was poor, that her judgement appeared poor, and that she exhibited restlessness and defiant behavior (Tr. 328-30).

         The plaintiff continued treatment at LCCMHC, where she received psychotherapy under the supervision of Myrtle A. Cherry, M.D., over the period from February 2016 through June 2017 (Tr. 389-431). At her intake interview, the plaintiff expressed anxiety and feeling overwhelmed and sad (Tr. 430). On a trauma assessment for adults form, she endorsed experiencing seven types of traumatic incidents (Tr. 431).

         At her initial therapy session at LCCMHC on March 8, 2016, the plaintiff displayed a depressed mood and affect, fair insight and judgment; expressed feelings of worthlessness and hopelessness; reported racing thoughts, increased anxiety, and depression; and she endorsed “symptoms of PTSD and tendency to obsess.” The therapist's notes reflected the plaintiff's stressors related to financial constraints that contributed to persistent depression and habitual procrastination in attending to her goals and objectives as set forth in her plan of care; problematic family relationships; ...


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