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Weiss v. Berryhill

United States District Court, E.D. North Carolina, Western Division

January 10, 2019

Cynthia Felicia Weiss, Plaintiff,
Nancy A. Berryhill, Acting Commissioner for Operations, Defendant.


          Robert T. Numbers, II United States Magistrate Judge

         Plaintiff Cynthia Felicia Weiss instituted this action in November 2017 to challenge the denial of her application for social security income. Weiss claims that the Administrative Law Judge (“ALJ”) James E. Williams erred in (1) evaluating the medical opinion evidence, (2) failing to properly consider Weiss's testimony, and (3) failing to reconcile inconsistencies between the testimony of the Vocational Expert (“VE”) and the Dictionary of Occupational Titles (“DOT”). Weiss also contends that the Appeals Council failed to appropriately consider new evidence she presented to it. Both Weiss and Defendant Nancy A. Berryhill, Acting Commissioner of Social Security, have filed motions seeking a judgment on the pleadings in their favor. D.E. 12, 14.

         After reviewing the parties' arguments, the court has determined that ALJ Williams reached the appropriate decision. Substantial evidence supports ALJ Williams's evaluation of the medical opinion evidence. And the undersigned cannot conclude that there is a reasonable probability that new evidence submitted to the Appeals Council would change the outcome of the disability determination. And the court finds that ALJ Williams's consideration of Weiss's testimony was proper. Finally, the court holds that there is no conflict in the evidence at step five that required an explanation or resolution. Therefore, the undersigned magistrate judge recommends that the court deny Weiss's motion, grant the Commissioner's motion, and affirm the Commissioner's decision.[1]

         I. Background

         In December 2013, Weiss filed an application for disability insurance benefits, alleging a disability that began that same month.[2] After her claim was denied at the initial level and upon reconsideration, Weiss appeared before ALJ Williams for a hearing to determine whether she was entitled to benefits. ALJ Williams determined Weiss was not entitled to benefits because she was not disabled. Tr. at 21-30.

         ALJ Williams found that Weiss had several severe impairments: affective disorder, anxiety disorder, and obesity. Tr. at 23. ALJ Williams also found that Weiss's impairments, either alone or in combination, did not meet or equal a Listing impairment. Id.

         ALJ Williams then determined that Weiss had the residual functional capacity (“RFC”) to perform medium work with additional limitations. Tr. at 25. Weiss must avoid unprotected heights and moving, mechanical parts. Id. She can perform simple, routine, repetitive tasks that are not performed at a production-rate pace. Id. Weiss is limited to making simple, work-related decisions. Id. While Weiss can have occasional interactions with supervisors and coworkers, she cannot have any job-related contact with the general public. Id.

         ALJ Williams concluded that Weiss could not perform her past relevant work as a legal secretary. Tr. at 28. But considering her age, education, work experience, and RFC, ALJ Williams found that there were jobs existing in significant numbers in the national economy that Weiss could perform. Tr. at 29. These jobs include: laboratory equipment cleaner, hospital cleaner, and industrial cleaner. Id. Thus, ALJ Williams found that Weiss was not disabled. Tr. at 29-30.

         After unsuccessfully seeking review by the Appeals Council, Weiss began this action in November 2017. D.E. 1.

         II. Analysis

         A. Standard for Review of the Acting Commissioner's Final Decision

         When a social security claimant appeals a final decision of the Commissioner, the district court's review is limited to determining whether, based on the entire administrative record, there is substantial evidence to support the Commissioner's findings. 42 U.S.C. § 405(g); Richardson v. Perales, 402 U.S. 389, 401 (1971). Substantial evidence is defined as “evidence which a reasoning mind would accept as sufficient to support a particular conclusion.” Shively v. Heckler, 739 F.2d 987, 989 (4th Cir. 1984) (quoting Laws v. Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966)). The court must affirm the Commissioner's decision if it is supported by substantial evidence. Smith v. Chater, 99 F.3d 635, 638 (4th Cir. 1996).

         B. Standard for Evaluating Disability

         In making a disability determination, the ALJ engages in a five-step evaluation process. 20 C.F.R. § 404.1520; see Johnson v. Barnhart, 434 F.3d 650 (4th Cir. 2005). The ALJ must consider the factors in order. At step one, if the claimant is engaged in substantial gainful activity, the claim is denied. At step two, the claim is denied if the claimant does not have a severe impairment or combination of impairments significantly limiting him or her from performing basic work activities. At step three, the claimant's impairment is compared to those in the Listing of Impairments. See 20 C.F.R. Part 404, Subpart P, App. 1. If the impairment is listed in the Listing of Impairments or if it is equivalent to a listed impairment, disability is conclusively presumed. But if the claimant's impairment does not meet or equal a listed impairment, the ALJ assesses the claimant's RFC to determine, at step four, whether he can perform his past work despite his impairments. If the claimant cannot perform past relevant work, the analysis moves on to step five: establishing whether the claimant, based on his age, work experience, and RFC can perform other substantial gainful work. The burden of proof is on the claimant for the first four steps of this inquiry, but shifts to the Commissioner at the fifth step. Pass v. Chater, 65 F.3d 1200, 1203 (4th Cir. 1995).

         C. Medical Background[3]

         Weiss has diagnoses of bipolar affective disorder and post-traumatic stress disorder (“PTSD”). In July 2014, providers at Monarch noted she displayed guarded behavior, slowed motor activity, distracted attention and concentration, visual hallucinations, paranoia, and fair insight and judgment. Tr. at 343. Weiss mentioned visual hallucinations and paranoia the next month. Tr. at 342. Her mental status examination yielded similar findings to her earlier visit. Id. Providers prescribed her mediations. Id.

         One month later, Weiss again reported visual and auditory hallucinations, and providers noted distractible attention and concentration, anxious speech and mood, and paranoia. Tr. at 350. In October 2014, Weiss claimed she was experiencing poor sleep. Tr. at 349. She again displayed distractibility and paranoia. Id. A December 2014 mental status examination found Weiss had guarded behavior, constricted mood and affect, paranoia, and fair insight and judgment. Tr. at 373. The next month, providers again noted Weiss was anxious. Tr. at 372.

         Treatment notes from April 2015 reflect that Weiss was having difficulty meeting with people because of her anxiety. Tr. at 394. She had slowed motor activity, constricted mood and affect, and fair insight and judgment. Id. Providers prescribed medications for her symptoms. Id. Two months later, Weiss was again assessed as anxious with fair insight and judgment. At her mental health care visits throughout 2015, providers noted no significant changes. Tr. at 390-91, 393, 396.

         In February 2016, Weiss began treatment with Dr. Lance Fuller, a psychiatrist. Tr. at 419. Weiss stated that she had a down and anxious mood, rarely left her home, had trouble sleeping, and experienced visual and auditory hallucinations. Tr. at 420. Dr. Fuller adjusted Weiss's medications. Tr. at 425. Two months later, Weiss again reported she had trouble leaving her home and experienced feelings of persecution. Tr. at 427. Dr. Fuller assessed PTSD and schizoaffective disorder and adjusted her medications. Tr. at 428. One month later, Weiss stated that she was not doing well in her mood or with her sleep and she continued to experience auditory and visual hallucinations Tr. at 430. Dr. Fuller again adjusted Weiss's medications. Tr. at 431. Weiss continued to claim poor sleep, paranoia, and hallucinations at a follow-up visit the next month. Tr. at 435.

         In June 2016, Dr. Fuller summarized Weiss's conditions in a Mental Impairment Questionnaire. Tr. at 407-11. He diagnosed her with PTSD and schizoaffective disorder. Id. He remarked that Weiss displayed depressed mood, illogical thinking, persistent, irrational fears, appetite disturbance with weight changes, delusions, hallucinations, and impaired sleep. Tr. at 408. Dr. Fuller noted that her signs and symptoms had been present since May 2014. Tr. at 411.

         Dr. Fuller opined that Weiss had marked limitations in her ability to complete a normal workday, interact appropriately with the public, and maintain socially appropriate behavior. Tr. at 410. He also opined that Weiss had moderate to marked limitations in her ability to make simple, work-related decisions, accept instructions and respond to criticism appropriately, get along with co-workers and peers, adhere to basic standards of neatness, and respond appropriately to workplace changes. Id. Dr. Fuller concluded that Weiss would be absent from work more than three times per month. Tr. at 411.

         In September 2016, Weiss reported increased hallucinations after she ran out of medication. Tr. at 438. She also noted bad dreams, difficulty leaving her house, and she no longer shopped or attended church. Id. A mental status examination found auditory hallucinations and providers continued her medications. Tr. at 438-39.

         In March 2017, Dr. Fuller completed a second Mental Impairment Questionnaire. Tr. 7- 11. He noted Weiss's diagnoses of schizoaffective disorder, bipolar type, and PTSD. Tr. at 7. Dr. Fuller stated that she displayed depressed mood, maniac syndrome, illogical thinking, poor immediate memory, intrusive recollections of past traumatic experience, paranoia, anhedonia, decreased energy, impulsive and damaging behavior, delusions, hallucinations, paranoia, and impaired sleep. Tr. at 8. Dr. Fuller remarked that Weiss experienced these signs and symptoms since May 2014. Tr. at 11.

         Dr. Fuller opined that Weiss would have marked difficulty in her ability to work in coordination with others; make simple, work-related decisions; complete a normal workday; perform at a consistent pace; interact appropriately with the public; accept instructions and respond appropriately to criticism; get along with co-workers and peers; and respond appropriately to workplace changes. Tr. at 10. He also concluded that Weiss would have moderate to marked difficulty remembering work procedures; performing on a schedule and being punctual; sustaining an ordinary routine; asking questions or requesting assistance; maintaining socially appropriate behavior; adhering to basic standards of neatness; being aware of hazards; and setting realistic goals. Id. Dr. Fuller again found that Weiss would be absent from work more than three days a month. Tr. at 11.

         At the hearing, Weiss testified that she had difficulty getting out of bed, experienced crying spells, anxiety attacks, hallucinations, and episodes of mania. Tr. at 47-51, 60-61. Although she watched television and movies, Weiss stated she often took a break because of problems with her focus. Tr. at 53-54. She performs some household chores but her husband does some as well. Tr. at 54, 61.

         D. Medical Opinion Evidence

         Weiss argues that ALJ Williams erred in assigning only partial weight to the assessment of her treating psychiatrist, Dr. Fuller. The Commissioner contends that ALJ Williams sufficiently explained why this provider's opinion was not entitled to greater weight. The undersigned finds no error with ALJ Williams's consideration of this evidence.

         “Medical opinions are statements from physicians and psychologists or other acceptable medical sources that reflect judgments about the nature and severity of [a claimant's] impairment(s), including [the claimant's] symptoms, diagnosis and prognosis, what [the claimant] can still do despite impairment(s), and [the claimant's] physical or mental restrictions.” 20 C.F.R. §§ 404.1527(a)(2), 416.927(a)(2). An ALJ must consider all medical opinions in a case in determining whether a claimant is disabled. See Id. §§ 404.1527(c), 416.927(c); Nicholson v. Comm'r of Soc. Sec.,600 F.Supp.2d 740, 752 (W.D. Va. ...

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