United States District Court, E.D. North Carolina, Western Division
MEMORANDUM & RECOMMENDATION
T. Numbers, II United States Magistrate Judge
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.
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
December 2013, Weiss filed an application for disability
insurance benefits, alleging a disability that began that
same month. 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.
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
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.
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.
unsuccessfully seeking review by the Appeals Council, Weiss
began this action in November 2017. D.E. 1.
Standard for Review of the Acting Commissioner's Final
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).
Standard for Evaluating Disability
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).
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
Medical Opinion Evidence
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.
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.