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 her 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 he applied the proper
legal standards. For the reasons that follow, the undersigned
recommends that the Commissioner's decision be reversed
and remanded for further proceedings as set forth herein.
September 10, 2014, Plaintiff filed an application for DIB in
which she alleged her disability began on August 11, 2014.
Tr. at 188. Her application was denied initially and upon
reconsideration. Tr. at 114-17, 118-22. On May 22, 2017,
Plaintiff had a hearing before Administrative Law Judge
(“ALJ”) Mary Ryerse. Tr. at 48-76 (Hr'g Tr.).
The ALJ issued an unfavorable decision on September 29, 2017,
finding Plaintiff was not disabled within the meaning of the
Act. Tr. at 21-47. 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 December 21, 2018. [ECF No.
1]. On October 4, 2019, the undersigned issued an order
permitting the Commissioner until October 18, 2019, to file a
supplemental brief and advising the parties the court
intended to schedule the case for hearing. [ECF No. 18]. Upon
reviewing the Commissioner's supplemental brief and
notice of supplemental authority (ECF Nos. 19, 20), the
undersigned determined a hearing would not aid the court in
Plaintiff's Background and Medical History
was 58 years old at the time of the hearing. Tr. at 52. She
completed college. Tr. at 189. Her past relevant work
(“PRW”) was as a caregiver, a life enrichment
coordinator, an office assistant, an outreach specialist, and
a staff assistant. Tr. at 189. She alleges she has been
unable to work since August 11, 2014. Tr. at 188.
presented to Michelle B. Nobles, PA-C (“PA
Nobles”), for recurrent episodes of vertigo on August
26, 2014. Tr. at 310-11. PA Nobles indicated she had referred
Plaintiff to a neurologist when she initially presented with
vertigo one year prior. Tr. at 310. She noted blood work, an
electrocardiogram (“EKG”), a computed tomography
(“CT”) scan, magnetic resonance imaging
(“MRI”), and an electroencephalogram
(“EEG”) had all been normal. Id. She
stated Plaintiff's providers ultimately concluded
Plaintiff's anxiety likely caused the vertigo.
Id. She indicated Plaintiff's psychiatrist had
adjusted her medications, and her symptoms had improved until
Plaintiff developed more frequent vertigo over the prior
month. Id. Plaintiff stated she felt dizzy if she
looked up or down or moved her head too quickly. Id.
She endorsed tinnitus and tiredness, but denied syncope and
pre-syncopal episodes. Id. She also reported
decreased cognition. Id. PA Nobles noted some fluid
in Plaintiff's ears and a severely deviated septum, but
indicated no other abnormalities. Id. She assessed
recurrent episodes of vertigo, fatigue, bipolar disorder,
tinnitus, and hearing loss. Id. She referred
Plaintiff to an ear, nose, and throat specialist for
also followed up with psychiatrist Hayne McMeekin, M.D.
(“Dr. McMeekin”), on August 26, 2014. Tr. at 322.
She reported continued decline and difficulty coping.
Id. She endorsed difficulty counting and working
with numbers. Id. Dr. McMeekin indicated
Plaintiff's work ability had declined. Id. He
noted Plaintiff wanted to “go out on disability.”
October 21, 2014, Plaintiff reported she had stopped working.
Tr. at 321. She indicated she had been very suspicious of
others, had scattered thoughts, and was unable to think
through problems. Id. Dr. McMeekin indicated a
mental status exam was abnormal, as Plaintiff demonstrated
racing thoughts and fair attention, concentration, and
comprehension. Id. He noted Plaintiff reported
work-related stressors and an abusive boss. Id. He
assessed a global assessment of functioning
(“GAF”) score of 65. Id. He prescribed
Lorazepam 0.5 mg and increased Plaintiff's dose of
Lamotrigine to 1.5 pills twice a day. Id.
December 9, 2014, Plaintiff followed up with PA Nobles for
Vitamin B12 deficiency. Tr. at 331. She reported increased
energy, but indicated the injections became less effective
one week prior to the next scheduled injection. Id.
PA Nobles described Plaintiff's affect as normal and
noted no abnormalities. Id. She provided Plaintiff
with a vial of B12 and syringes for at-home administration.
Id. She instructed Plaintiff to continue to take
oral Vitamin D and B12 supplements. Id.
also followed up with Dr. McMeekin on December 9, 2014. Tr.
at 351. She reported she was doing a “lot
better.” Id. She continued to endorse
paranoia, but indicated she was not as obsessive.
Id. She reported she had previously reached a
psychotic level. Id. She stated she had felt like
everyone was against her, but her symptoms had improved since
she stopped working. Id. Dr. McMeekin noted the
following on mental status exam: neat appearance; cooperative
behavior; motor function and speech within normal limits;
full affect; anxious mood; scattered thought form; and linear
thought process. Id. He assessed a GAF score of
December 23, 2014, state agency medical consultant Seham
El-Ibiary, M.D. (“Dr. El-Ibiary”), reviewed the
record and completed a physical residual functional capacity
(“RFC”) assessment. Tr. at 88-90. He provided the
following limitations: occasionally lift and/or carry 50
pounds; frequently lift and/or carry 25 pounds; stand and/or
walk for a total of about six hours in an eight-hour workday;
sit for a total of about six hours in an eight-hour workday;
never climbing ladders/ropes/scaffolds; occasionally
balancing; frequently climbing ramps/stairs, stooping,
kneeling, crouching, and crawling; and avoiding even moderate
exposure to hazards. Id. A second state agency
medical consultant, George Walker, M.D. (“Dr.
Walker”), assessed the same physical RFC on June 3,
2015. Tr. at 105-07.
February 2, 2015, Plaintiff presented to Chad Ritterspach,
Psy. D. (“Dr. Ritterspach”), for a psychological
consultative evaluation. Tr. at 352-54. Dr. Ritterspach noted
Plaintiff was cooperative, informative, demonstrated a
positive attitude, answered questions freely, spoke
articulately, showed normal psychomotor activity, and
“appeared to be an accurate source of information about
her difficulties.” Tr. at 352. Plaintiff reported her
mind raced and she had difficulty remaining “on
track.” Id. She stated she was “almost
always manic.” Id. She endorsed infrequent
depressed mood characterized by self-deprecation.
Id. Dr. Ritterspach noted Plaintiff “ha[d] the
ability to conform to social standards, comply with rules and
regulations, cooperate with authority, and interact with
peers” and could “engage in social
reported a history of termination from employment for
attendance problems related to depression. Id. She
endorsed mild difficulty remembering instructions and stated
she was unable to maintain concentration throughout the
workday or perform tasks independently. Id. She
denied a history of conflict with coworkers and supervisors
and stated she was able to accept constructive feedback from
supervisors. Id. She reported average daily
activities that included reading, writing, cooking, a little
walking, and watching the news. Tr. at 353. She stated mania
affected her ability to drive without getting lost.
Ritterspach noted Plaintiff could read, write, follow
directions, engage in self-care, prepare simple meals, and
engage in social activities. Id. He stated,
“[d]ue to mood impairment, ” Plaintiff was
“easily distressed and fe[lt] overwhelmed and
“d]ue to possible cognitive limitations, ” she
required “help with managing money, driving, managing
finances, and remembering appointments.” Id.
Ritterspach observed the following on mental status exam:
appropriate eye contact; articulate speech at normal volume;
euthymic mood and affect; logical thought processes;
appropriate thought content; ability to follow simple
directions; denial of suicidal and homicidal ideation and
hallucinations; oriented to time, date, place, and situation;
average intellectual functioning; impaired memory for
short-term auditory recall; concentration within normal
limits; and intact judgment and insight. Id.
Plaintiff performed digits correctly up to five digits,
remembered recent and remote events, spelled
“world” backward, completed serial threes,
performed simple math, and interpreted proverbs correctly,
but had difficulty recalling three words she had repeated
earlier without prompts. Id.
Ritterspach diagnosed unspecified mood disorder and indicated
“there may be another underlying problem, such as
ADHD.” Id. He noted Plaintiff reported mania
interfered with her activities of daily living
(“ADLs”), causing forgetfulness and
disorientation while driving. Id. He stated
Plaintiff “would have the ability to interact
appropriately with co-workers, supervisors, and the
public” in the workplace. Id. He indicated
Plaintiff “may have trouble retaining new information
as she performs work tasks, ” “may have some
problems tolerating work-related stressors, ” and
“may be somewhat easily distracted from work tasks,
particularly if they are detailed and complex.”
Id. He added “[t]he extent of limitations
based on racing thoughts and distractibility suggests she
would have difficulty in most work settings.”
Id. However, he noted Plaintiff's medication was
“not helpful at [that] time, ” and stated
“she ha[d] the general cognitive/psychological capacity
for employment” if she obtained appropriate treatment.
Id. He indicated Plaintiff needed assistance to
manage her finances in her own best interest. Tr. at 354.
February 6, 2015, state agency consultant Craig Horn, Ph.D.
(“Dr. Horn”), reviewed the record and completed a
psychiatric review technique (“PRT”). Tr. at
85-87. He considered Listing 12.04 for affective disorders
and assessed the following degree of functional limitation:
mild restriction of ADLs; moderate difficulties in
maintaining social functioning; moderate difficulties in
maintaining concentration, persistence, or pace; and no
repeated episodes of decompensation, each of extended
duration. Tr. at 85. He determined Plaintiff had the ability
to perform “simple routine tasks away from
public.” Id. Dr. Horn also completed a mental
RFC assessment. Tr. at 90-91. He found Plaintiff was
moderately limited in the following abilities: to carry out
detailed instructions; to maintain attention and
concentration for extended periods; to work in coordination
with or proximity to others without being distracted by them;
and to interact appropriately with the general public.
April 20, 2015, Plaintiff indicated she had become delusional
and paranoid within five days of applying for jobs. Tr. at
359. She indicated she would attempt to work as a
telemarketer. Id. Dr. McMeekin described
Plaintiff's mental status as “fragile.”
Id. He noted the following observations on mental
status exam: neat appearance; appropriately oriented;
positive eye contact; cooperative behavior; normal motor
activity; normal speech; labile affect; anxious mood;
scattered thought form; racing thoughts; delusional thought
content; startled; and good attention, concentration, recent
and past memory, language, insight, and judgment.
Id. He indicated Plaintiff was having a delusional
episode, as she had become paranoid and delusional while
working in a cleaning job and felt like her coworkers did not
like her and were stealing her supplies. Id. He
prescribed two additional medications and assessed a GAF
score of 70. Id.
3, 2015, a second state agency consultant, Douglas Robbins,
Ph.D. (“Dr. Robbins”), completed a PRT and mental
RFC assessment. Tr. at 102-04, 107-09. He considered Listing
12.04 and assessed no episodes of decompensation, mild
restriction of ADLs, and moderate difficulties in maintaining
social functioning and concentration, persistence, or pace.
Tr. at 102. He concluded the additional evidence supported a
severe, but not listing- level impairment “with
moderate functional limitations.” Tr. at 104. In the
RFC assessment, he indicated Plaintiff had moderate
limitations with respect to the following abilities: to carry
out detailed instructions; to maintain attention and
concentration for extended periods; to work in coordination
with or in proximity to others without being distracted by
them; and to interact appropriately with the general public.
Tr. at 107-09. He concluded Plaintiff was able to perform
“simple routine tasks away from public.” Tr. at
22, 2015, Dr. McMeekin noted the following on mental status
exam: neat appearance; cooperative behavior; motor activity
within normal limits; speech within normal limits; full
affect; euthymic mood; linear thought process and form;
thought content within normal limits; and no perceptual
disturbances. Tr. at 372. He indicated Plaintiff's
inability to work increased her stressors. Id. He
changed Plaintiff medications. Id.
23, 2015, Plaintiff presented to a Marsha D. Jackson, LMSW,
LPCS (“Counselor Jackson”), for counseling. Tr.
at 367. She complained of increased depressive symptoms,
including hopelessness, isolation, and paranoia of being
avoided by others. Id. Counselor Jackson indicated
Plaintiff's symptoms were precipitated by a diagnosis of
bipolar disorder, loss of her job, foreclosure of her home,
and a recent visit to the neurologist. Id. Plaintiff
requested intensive treatment for increased negative
thoughts. Tr. at 368. She reported a history of suicide
attempt years prior and endorsed fleeting thoughts that
others would be better off without her, but denied suicidal
ideation and plan. Id. Counselor Jackson noted
Plaintiff was accompanied to the visit by her husband, who
was concerned about her isolation and tearfulness.
Id. She assessed a GAF score of 50 and indicated
Plaintiff was willing to attend a day treatment program.
followed up with Dr. McMeekin on July 28, 2015. Tr. at 371.
Dr. McMeekin noted the following on mental status exam:
cooperative behavior; tense and agitated motor activity;
depressed, anxious, and angry mood; and scattered thought
form characterized by racing thoughts and flight of ideas.
Id. He adjusted Plaintiff's medications.
presented to Carolinas Medical Center Randolph Adult Partial
Hospitalization Program (“Partial Hospitalization
Program”) for intake on August 3, 2015. Tr. at 390.
Lisa Winn, RN (“Nurse Winn”), observed Plaintiff
to have appropriate grooming and hygiene and anxious and
depressed affect. Id. Plaintiff endorsed depression
with increased sleep, binge eating, decreased motivation and
interest, lack of energy, poor concentration and focus, and
short-term memory loss. Id. She stated she had
visited a neurologist, who had diagnosed her with
depression-induced dementia, and was scheduled for an
upcoming evaluation for possible sleep apnea. Id.
Plaintiff endorsed thoughts that “people would be
better off without [her]” and a history of two suicide
attempts years prior, but denied suicidal intent or plan. Tr.
at 390-91. She reported constant paranoia that “people
[were] out to get [her]” and were following her. Tr. at
391. She feared being chastised by others. Id.
Plaintiff indicated she had been diagnosed with bipolar
disorder and had a history of manic behavior characterized by
constant movement and talking and impulsive spending.
August 5, 2015, Plaintiff presented to the Partial
Hospitalization Program for intake with Rodney A. Villanueva,
M.D. (“Dr. Villanueva”). Tr. at 391. She reported
financial difficulty and hopelessness and expressed
“not wanting to be [there]” for the appointment.
Id. She endorsed ruminating thoughts prior to
falling asleep, decreased interest in activities, feelings of
guilt, poor energy level, binge eating, and poor
concentration. Id. She reported being followed by
others, having her patients' family members accuse her of
stealing things, and feeling as if others were annoyed by and
jealous of her. Tr. at 392. Dr. Villanueva stated he was not
sure if Plaintiff had bipolar disorder. Id. He noted
Plaintiff's medications and indicated use of “an
antidepressant in the possible setting of bipolar disorder
[was] somewhat problematic as it could switch her over into a
manic episode.” Id. He indicated “an
antipsychotic might be a better choice if she is having
mania” and “may be helpful for what may be
paranoid delusions.” Id.
on Plaintiff's report that she sometimes lacked money for
medication because of irresponsible spending, Dr. Villaneuva
stated “[o]f note, is that the patient can sometimes go
1-2 weeks without medicines because of financial
reasons.” Tr. at 393. He acknowledged “[t]he
patient may not be consistent with her medications.”
Id. He observed the following on mental status exam:
neatly dressed; calm and cooperative behavior; good eye
contact; no abnormal movements; normal rate and volume of
speech; euthymic mood; no suicidal or homicidal ideation; no
auditory or visual hallucinations; questionable paranoid
delusions; fair insight and judgment; and linear and
goal-directed thought process without evidence of loosening
of associations or flight of ideas. Tr. at 394. Dr.
Villanueva assessed (1) unspecified bipolar and related
disorder, by history and (2) unspecified psychotic disorder,
consider delusional disorder. Id. He also indicated
“[t]here may be some narcissism on the patient's
part.” Id. He discontinued Prozac, decreased
Lorazepam, prescribed Abilify 10 mg, and continued Lamictal.
reported she was “much better” on August 13,
2015. Tr. at 364. She endorsed decreased paranoia and stated
she had recently reached out to friends. Id. She
continued to report racing thoughts that occurred at night,
but stated she was able to stop them. Id. Dr.
Villaneuva probed Plaintiff's history of paranoid
beliefs. Id. He questioned the diagnosis of bipolar
disorder because he did not believe Plaintiff had described
any true manic episodes. Tr. at 365. He noted the following
observations on mental status exam: neatly dressed and
well-groomed; cooperative and pleasant; good eye contact; no
evidence of psychomotor agitation; speech at normal rate and
volume; euthymic mood; affect marked by appropriate smiling;
no suicidal or homicidal ideation or auditory or visual
hallucinations; paranoid delusions present; linear and
goal-directed thought process; no evidence of flight of ideas
or loosening of associations; fair insight; and adequate
judgment. Id. He continued Plaintiff's
medications. Tr. at 366.
reported “doing really well” during a visit with
Dr. Villanueva on August 20, 2015. Tr. at 361. She reported
she had declined a job with an afterschool program because
she shared a car with her husband and would not have
transportation. Id. She indicated she had applied
for jobs within walking distance of her home. Id.
She reported “a lot less” paranoia. Id.
Dr. Villanueva assessed delusional disorder and explained to
Plaintiff that people with her diagnosis were often capable
of normal functioning. Tr. at 361-62. He noted the following
on mental status exam: neatly dressed; calm, cooperative, and
pleasant; no evidence of psychomotor agitation; good eye
contact; normal rate and volume of speech; euthymic mood;
appropriate and smiling affect; no suicidal or homicidal
ideation; paranoid delusions present, but occurring “a
lot less” often; thought process linear and
goal-directed without evidence of flight of ideas or
loosening of associations; and adequate insight and judgment.
Tr. at 362. Dr. Villanueva continued Abilify and Lamictal,
discontinued Ativan, and instructed Plaintiff to use
Melatonin for sleep.
September 21, 2015, Dr. McMeekin noted the following on
mental status exam: neat appearance; cooperative behavior;
motor function within normal limits; speech within normal
limits; full affect; anxious mood; and scattered thought form
characterized by flight of ideas. Tr. at 370. He assessed a
GAF score of 65, continued Plaintiff's prescriptions for
Ativan and Fluoxetine, and increased Abilify. Id.
January 4, 2016, Dr. McMeekin indicated Plaintiff was doing
well. Tr. at 369. A mental status exam was within normal
February 15, 2016, Plaintiff reported she was no longer
delusional. Tr. at 376. She indicated she recently worked in
an office, as a cleaner, and as a caretaker. Id. She
stated she initially did well in the jobs, but subsequently
began to worry about her job performance and others'
thoughts of her to the point she became suspicious of her
coworkers. Id. She reported she remained at home
most of the time, but sometimes left her home to engage in
activities like shopping. Id. Plaintiff indicated
she was unable to read well because of her short attention
span. Id. She reported a sense of dread, anxiety,
and failure, but denied being delusional and indicated she
could recognize her abnormal thoughts. Id. She
stated her medications were working. Id. Dr.
McMeekin noted it had been difficult to find medications that
were consistently effective and recommended Plaintiff
continue her medications. Id.
April 25, 2016, Plaintiff indicated she desired to become
involved in her mother's church. Tr. at 377. Dr. McMeekin
observed Plaintiff to be calm and not as suspicious or
overwhelmed as she was when she was working. Id. He
noted Plaintiff's symptoms were stable and continued her
presented to Anthony W. Bracken, M.D. (“Dr.
Bracken”), for a cardiology consultation on March 29,
2017. Tr. at 379. She reported recent low diastolic blood
pressure readings, but Dr. Bracken indicated a review of her
chart failed to yield any abnormal recordings. Tr. at 379-80.
Plaintiff also complained of falling asleep during the day
and upper right-sided chest discomfort that occurred at rest
and upon exertion. Tr. at 380. Dr. Bracken noted no
abnormalities on physical exam, but indicated an EKG showed
poor R-wave progression, nonspecific T-wave changes, and low
voltage in the precordial leads. Tr at 382. He recommended a
stress echocardiogram based on Plaintiff's risk factors
and advised her to follow up with her primary care physician
for daytime somnolence and a possible sleep apnea evaluation.
Tr. at 379, 382.
April 26, 2017, Counselor Jackson provided a letter
specifying she had begun counseling Plaintiff in 2007. Tr. at
388. She stated Plaintiff was a “model client, ”
who was “motivated and cooperative concerning
recommendations” for treatment. Id. She noted
Plaintiff had worked successfully for many years in a
hospital, but had accepted a new position in 2011 that had
led to increased work stress. Id. She indicated
“[b]y 2014, her psychiatric s[ymptoms] became
full-blown” and included reduced cognitive functioning.
Id. She stated after Plaintiff left the hospital,
she “counseled her through countless other attempts at
employment.” Id. She noted Plaintiff had
attempted and failed many types of jobs. Id. She
stated Plaintiff's “severe paranoid ideation . . .
took its toll socially and in the workplace.”
Id. She indicated Plaintiff “would rather be
gainfully employed, but each attempt t[ook] her further into
a depressed state.” Id.
hearing, Plaintiff testified she was married and lived with
her husband. Tr. at 52. She stated she was 5'
1½” tall and weighed 185 pounds. Tr. at 52-53.
She said she earned a master's degree. Tr. at 53. She
indicated that since August 2016, she had worked three hours
a day, three days a week for Boomerang Transport,
transporting Workers' Compensation patients to their
appointments and earning a minimum of $22 per ride. Tr. at
53-54. She said she had previously worked for Care Partners.
Tr. at 54. She stated she initially worked as a caregiver,
but subsequently worked in the office, handling billing and
payroll matters. Id. She testified she stopped
working as a caregiver because the rushed pace of the job
exacerbated her symptoms. Id. She indicated she left
the office job because she made mistakes with numbers,
causing her to become upset and depressed and to miss work.
Id. She said she worked for Eaeic for one week as a
scanner for $200. Tr. at 55.
testified she previously worked for Charlotte Mecklenburg
Hospital as an outreach specialist and a staff assistant.
Id. She testified she previously worked for Liberty
Mutual Insurance as an office assistant. Tr. at 55-56. She
stated she also previously worked for wholesale distributor
Natural Organics and for chemical distributor Aceto
Corporation as a customer service representative. Tr. at
testified that her medications caused dizziness, vertigo,
drowsiness, and blurred vision. Tr. at 57. She said she
occasionally had problems with high blood pressure and
continually had problems with irritable bowel syndrome
(“IBS”) and gastroesophageal reflux disease
(“GERD”) that were not relieved by medication.
Tr. at 58. She denied having recently followed up with Dr.
Gaspari for ...