United States District Court, M.D. Tennessee, Columbia Division
WILLIAM J. HAYNES, Jr., Senior District Judge.
Plaintiff Chad Eugene Stiles, filed this action under 42 U.S.C. § 405(g), seeking judicial review of the Commissioner's final decision denying Plaintiff's application for benefits under Title II of the Social Security Act ("the Act"). Plaintiff applied for Disability Insurance Benefits ("DIB") on November 3, 2010, asserting his disability since September 7, 2010,  due to alcoholism, anxiety, acute gastrointestinal bleeding, anemia, thrombocytopenia, hyperbilirubinemia, bipolar disorder, depression, loss of concentration, hematemesis, gastric varices, hypertension, peripheral neuropathy, and leg and hip pain. (Docket Entry No. 10, Administrative Record 112-114, 136, 172-174). Plaintiff's application was denied initially and upon reconsideration. Id. at 61-63, 70-71. Plaintiff requested and received a hearing that an Administrative Law Judge ("ALJ") held on June 21, 2012. Id. at 30-58, 73-74, 83-101.
The ALJ concluded that Plaintiff was not disabled within the meaning of the Act, and specifically found that:
1. The claimant meets the insured status requirements of the Social Security Act through December 31, 2015.
2. The claimant has not engaged in substantial gainful activity since April 10, 2011, the amended alleged onset date (20 CFR 404.1571 et seq.).
3. The claimant has the following combination of impairments that is severe: depression, generalized anxiety, panic disorder, bipolar disorder, history of alcohol abuse, gastric varices, peripheral neuropathy, liver disease and right hip pain. (20 CFR 404.1520(c)).
4. The claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525 and 404.1526).
5. After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform a range of light work as defined in 20 CFR 404.1567(b) that is limited to: lifting/carrying up to 20 pounds occasionally, up to 10 pounds frequently; sitting, standing or walking up to or about six hours each in an eight-hour workday with normal breaks; unlimited pushing/pulling; and frequent climbing, balancing, stooping, kneeling, crouching or crawling. The claimant has non-exertional mental limitations, but can understand, remember and carry out short, simple directions; can make judgments on simple work related decisions; can have occasional, superficial contact with the general public, co-workers and supervisors, but is better working with things rather than people; and can adapt to infrequent workplace changes.
6. The claimant is unable to perform any past relevant work (20 CFR 404.1565).
7. The claimant was born on June 18, 1964 and was 46 years old, which is defined as a younger individual age 18-49, on the alleged disability onset date (20 CFR 404.1563).
8. The claimant has a limited education and is able to communicate in English (20 CFR 404.1564).
9. Transferability of job skills is not material to the determination of disability because using the 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 CFR Part 404, Subpart P, Appendix 2).
10. Considering the claimant's age, education, work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that the claimant can perform (20 CFR 404.1569 and 404.1569(a)).
11. The claimant has not been under a disability, as defined in the Social Security Act, from the amended alleged onset [date] April 10, 2011, through the date of this decision (20 CFR 404.1520(g)).
Id. at 12-20. On September 28, 2012, Plaintiff sought review of the ALJ's decision. Id. at 27-28. On November 7, 2013, the Appeals Council declined review that rendered the ALJ's decision the Commissioner's final decision.
Before the Court is Plaintiff's motion for judgement on the Administrative Record (Docket Entry No. 12) to which the Defendant filed a response (Docket Entry No. 13). Plaintiff contends, in essence, that the ALJ erred by: (1) failing to evaluate the opinion of the Plaintiff's treating and/or examining non-acceptable medical source and not considering Plaintiff's mental health records and GAF scores; (2) failing to evaluate properly Plaintiff's credibility; and (3) failing to consider the side effects of Plaintiff's medications and how those effects limit his abilities. The Commissioner argues that the ALJ properly evaluated the proof and the ALJ's decision is supported by substantial evidence.
For the reasons stated below, the Court concludes that the Plaintiff's motion for judgement on the Administrative Record should be denied, as the Commissioner's decision to deny benefits is based upon substantial evidence and is consistent with the Act.
A. Review of the Record
Plaintiff, who was born in 1964, asserts that his disability commenced April 10, 2011,  due to alcoholism and anxiety. (Administrative Record ("AR") at 10, 112, 131, 136). According to the administrative record, Plaintiff was hospitalized for alcohol withdrawal and delirium tremens from August to September 2010. Plaintiff was shaky and nervous after he stopped drinking. Id. at 234. Plaintiff also had elevated liver function test, and leukopenia/thrombocytopenia, secondary to alcohol. Id. at 210-31. Plaintiff had anemia with heme-positive stools and gastritis, secondary to alcohol. An abdominal ultrasound also revealed cholelithiasis with thickened gallbladder and evidence of obstruction. Id. at 210, 219-20. Possible cirrhosis of the liver was noted and a upper endoscopy was deemed necessary to evaluate for varices. Id. at 233-34.
From September 2010, Plaintiff was prescribed Alprazolam for his nerves, but Plaintiff continued to suffer from these symptoms. Id. at 251. In September 2010, Plaintiff was wheezing, and the attending physician recommended pulmonary function testing. Id. at 255. In October 2010, Plaintiff reported that his medications were not working and his Zoloft was causing him to shake. Id. 253. The physician's note reflects that Plaintiff "cannot work currently." Id.
In December 2010, Plaintiff complained of increased anxiety and stress due to his divorce, lack of work, and his cessation of drinking. Id. at 250. Due to his stress, Plaintiff resumed drinking that caused gastrointestinal complications. Id. Plaintiff reported Zoloft made him sick and caused him insomnia as well as groin/genital pain. Id. Plaintiff cited right hip pain with intermittent numbness from his hip to his foot. Id. at 250-51. In December 2010, Plaintiff went to the emergency room for gastrointestinal bleeding reflected by blood in his stools. Id. at 236-48. Plaintiff had acute GI bleeding with melena (black, tarry stools). Id.
In January 2011, Plaintiff attended Centerstone for mental health treatment. Id. at 279-82. Plaintiff was assessed as having bad mood swings, impulsivity, recklessness, frequent and extended stay in bed without eating or bathing as well as social isolation, extensive problems with focus, memory, flight of ideas, pressured speech, hyperactive behavior and difficulty adjusting to medical problems and inability to work. Id. at 281-82. Centerstones's diagnosis was bipolar disorder I with the most recent episode described as manic, severe without psychotic features, and generalized anxiety disorder as well as alcohol abuse. Id. at 279, 282.
A Tennessee Clinically Related Group (CRG) form reflects an evaluation of Plaintiff and a list of impairments in several areas of basic mental functioning. Id. at 276-78. Plaintiff had regular or frequent problems with performing daily routine activities and marked limitations in interpersonal/social functioning. Plaintiff's Global Assessment Function ("GAF") was 45, with his highest GAF the prior six months being 55, and his lowest score of 40. Id. at 278. Plaintiff was placed in Group 1 for persons with severe and persistent mental illness.
Centerstone's records reflect that, from December 2010 through April 2011, Plaintiff complained of right hip pain with radiation through his right leg with occasional numbness in his right leg and his right arm. Id. at 385-90. Plaintiff cited increased pain with lifting, sitting for too long, or walking for too long. Id. Plaintiff reported continuing anxiety and side effects from his medications such as nausea and insomnia. Id. at 390. By April 2011, Plaintiff continued experiencing depression, mood swings, social withdrawal, irritability, anxiety, helplessness and worthlessness. Id. at 274-98, 346-84. Plaintiff's GAF score was 45, reflective of serious symptoms or serious impairment in social or occupational functioning despite his ongoing treatment. Id.
In April 2011, Plaintiff was also hospitalized for gastrointestinal bleeding, likely alcoholic liver disease, hepatitis, pancytopenia, peripheral neuropathy, hypokalemia, hypomagnesemia, and hypertension. Id. at 333. According to Dr. Maltz, "[g]iven finding on esophagogastroduodenoscopy, the patient really has bad prognosis, " with "no available treatment for gastric varices." Id. at 335. Dr. Maltz stated that if Plaintiff bleeds again, there would be a very high mortality. Id.
On February 4, 2011, Dr. Darrel Ray Rinehart, a consultant, reviewed Plaintiff's medical records and found that Plaintiff did not have any physical limitations. Id. at 270-72. In April 2011, Dr. John Fahlberg, found that Plaintiff did not have severe physical impairments. Id. at 309. On June 28, 2011, Dr. Frank Pennington performed a residual functional capacity function assessment and opined that Plaintiff had severe physical impairments that limited him to a range of light work. Id. at 393-401. Earlier, in March 2011, Dr. Deborah Doineau, an educational specialist evaluated Plaintiff's records and opined that Plaintiff had mild limitations in performing simple and complex instructions without any limitations in interacting with others. Id. at 299-305.
Dr. Kimberly Tartt-Godbolt, a psychologist, reviewed Plaintiff's mental health treatment, and opined that Plaintiff retained the ability to perform simple and one-to-four-step detailed tasks, to interact effectively with others on a superficial level, and to adapt to infrequent changes, but could not make executive-level independent decisions. Id. at 310-26. Dr. Jenaan Khaleeli, a psychologist concurred. Id. at 391. The psychologists considered Plaintiff's mental health treatment from Centerstone, including the January 2010 intake form and the GAF scores. Id. at 322, 391.
The ALJ found that Plaintiff had a severe combination of impairments of depression, generalized anxiety, panic disorder, bipolar disorder, history of alcohol abuse, gastric varices, peripheral neuropathy, liver disease, and right hip pain. Id. at 12. Yet, the ALJ did not find any of Plaintiff's impairments, alone or in combination, to satisfy any listing for disability under the Act. Id. at 12-14. The ALJ also found that Plaintiff's testimony of his disabling symptoms lacked credibility based on Plaintiff's medical treatment, the medical evidence, and the medical opinions. Id. at 14-18. The ALJ found that Plaintiff retained residual functional capacity to lift 20 pounds frequently and 10 pounds occasionally, sit for 6 hours in an 8-hour workday, and stand/walk for 6 hours in an 8-hour workday. Id. at 14. The ALJ found that Plaintiff could frequently climb, balance, stoop, kneel, crouch, and crawl and could follow simple instructions, make simple work-related decisions as well as have superficial contact with the general public, co-workers, and supervisors. Id. at 14. Citing vocational expert testimony, the ALJ concluded that Plaintiff could perform work that exists in significant numbers in the national economy, including work as a dishwasher, a building cleaner, and a grounds worker. Id. at 19. Consequently, the ALJ found Plaintiff not disabled. Id. at 21.
The ALJ gave the opinion of Dr. Fahlberg, one of Plaintiff's treating physician, little weight as inconsistent with the record. Id. at 18. The ALJ found the other opinions cited above consistent with Plaintiff's medical treatment and ...