Tucker v. Berryhill
| Decision Date | 15 April 2019 |
| Docket Number | C/A No.: 1:18-592-SVH |
| Court | U.S. District Court — District of South Carolina |
| Parties | Jeannette Tucker, Plaintiff, v. Nancy A. Berryhill, Acting Commissioner of Social Security Administration, Defendant. |
This appeal from a denial of social security benefits is before the court for a final order pursuant to 28 U.S.C. § 636(c), Local Civ. Rule 73.01(B) (D.S.C.), and the order of Honorable Margaret B. Seymour, Senior United States District Judge, dated March 15, 2018, referring this matter for disposition. [ECF No. 5.] The parties consented to the undersigned United States Magistrate Judge's disposition of this case, with any appeal directly to the Fourth Circuit Court of Appeals. [ECF No. 4.]
Plaintiff files this appeal pursuant to 42 U.S.C. § 405(g) of the Social Security Act ("the Act") to obtain judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying her claim for disability insurance benefits ("DIB") and Supplemental Security Income ("SSI"). The two issues before the court are whether the Commissioner's findings of fact are supported by substantial evidence and whether she applied the proper legal standards. For the reasons that follow, the court affirms the Commissioner's decision.
On August 6 and September 17, 2014, Plaintiff protectively filed applications for DIB and for SSI in which she alleged her disability began July 15, 2002. Tr. at 285-310. Her applications were denied initially and upon reconsideration. Tr. at 168-77, 139, 153. On May 10, 2017, Plaintiff had a hearing by video before Administrative Law Judge ("ALJ") William Wallis. Tr. at 89-114 (Hr'g Tr.). At the hearing, Plaintiff amended her alleged onset date to December 21, 2013. Tr. at 91. As a result, the ALJ found Plaintiff forfeited her DIB claim, as her amended alleged onset date of disability was subsequent to her date last insured of June 30, 2010. Tr. at 91-92. The ALJ dismissed Plaintiff's DIB application and addressed her remaining claim for SSI. Tr. at 73. The ALJ issued an unfavorable decision on August 9, 2017, finding that Plaintiff was not disabled within the meaning of the Act. Tr. at 70-88. 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 1-7. Thereafter, Plaintiff brought this action seeking judicial review of the Commissioner's decision in a complaint filed on March 1, 2018. [ECF No. 1.]
Plaintiff was 60 years old at the time of the hearing. Tr. at 95. She completed high school. Id. She last worked part time as a housekeeper, which the ALJ found did not meet the standards for Substantial Gainful Activity ("SGA"). Tr. at 96. She alleges she has been unable to work since December 21, 2013. Tr. at 97.
On February 20, 2014, Plaintiff presented for a follow-up psychiatric medical assessment at Columbia Area Mental Health Center ("CAMHC") with her psychiatrist, Dr. Patrick Butterfield. Tr. at 468-69. Plaintiff reported she had been living with a friend for the prior year and stated she had applied for disability. Tr. at 468. Dr. Butterfield noted he had decreased Plaintiff's Latuda in October due to postural hypotension. Id. Plaintiff stated she had been out of Latuda for one week and noticed increased depression, but was taking the medication again and felt better. Id. Dr. Butterfield performed a mental status examination ("MSE"), which was unremarkable. Tr. at 468-69. He continued Plaintiff's diagnoses of major depressive disorder, recurrent, severe with psychotic features; alcohol dependence; and cannabis dependence and refilled her prescriptions for Paxil, Trazodone, and Latuda. Tr. at 469.
On March 19, 2014, Plaintiff presented to Dr. Butterfield for an emergency appointment due to increased depression and suicidal ideation. Tr. at 465-66. Plaintiff reported increased irritability and losing her temper with her two toddler grandchildren whom she cared for during the day. Tr. at 465. On MSE, Dr. Butterfield indicated Plaintiff exhibited sad faces, silent tears, and mild slowing of psychomotor functions; she spoke at a low rate of speed and volume and had no spontaneous speech; and she showed depressed mood, constricted affect, and distractible thought process. Tr. at 465-66. Dr. Butterfield increased Plaintiff's Latuda prescription and indicated she would continue with individual and group therapy. Tr. at 465.
On March 24, 2014, Plaintiff's CAMHC case manager, Anna House, summarized Plaintiff's progress from December 23, 2013, to March 23, 2014. Tr. at 435. Ms. House noted Plaintiff lived independently with her daughter and two of her grandchildren. Id. Plaintiff had been compliant in attending her prescribed therapy services and taking her medication. Id. However, Plaintiff had experienced an escalation of symptoms, including increased suicidal ideation and command hallucinations. Id. Ms. House indicated Plaintiff planned to meet her goal of feeling better by continuing to attend therapy sessions and to reduce her tendency to isolate herself by interacting with peers at least once per day. Id. Plaintiff reported a desire to stop avoiding her family and friends. Id. Ms. House noted Plaintiff expressed increased confidence interacting with others until family turmoil three weeks prior that increased her desire to withdraw. Id. In addition, Ms. House stated Plaintiff continued to use marijuana five or more days per week. Id. Plaintiff reported difficulty controlling her anxiety without the use of marijuana. Id. Ms. House noted Plaintiff would begin attending a weekly substance abuse group to better understand how her marijuana use interacted with her mental health. Id.
On March 27, 2014, Plaintiff returned to Dr. Butterfield and reported the increased dosage of Latuda had decreased her hallucinations. Tr. at 461. However, Plaintiff indicated she had been taking more than Dr. Butterfield had prescribed and complained of lightheadedness and increased blood pressure. Id. On MSE, Dr. Butterfield noted Plaintiff exhibited only mildly-depressed mood, did not cry during the appointment, and endorsed decreased auditory hallucinations. Tr. at 462.
On April 24, 2014, Plaintiff followed up with Dr. Butterfield and reported feeling much better. Tr. at 457. She stated she left the house some, but that she still did not feel like herself. Id. She also indicated she was no longer experiencing dizziness or lightheadedness. Id. Plaintiff informed Dr. Butterfield she had not seen her primary care physician in over six months and had been off her hypertension medication. Id. On MSE, Dr. Butterfield noted Plaintiff's mildly-depressed mood. Tr. at 458. He advised Plaintiff to continue her medications and therapy. Id.
On June 19, 2014, Ms. House summarized Plaintiff's progress from March 23, 2014, to June 21, 2014. Tr. at 436. Ms. House stated Plaintiff attended psychosocial rehabilitation programming two times per week and was living independently in the community with friends. Id. Ms. House indicated Plaintiff had shown improvement with medication compliance over the review period, but continued to struggle with a tendency to isolate herself. Id. Ms. House did not recommend any changes to Plaintiff's plan of care. Id.
On June 26, 2014, Plaintiff returned to Dr. Butterfield for a medication check and reported continued improvement. Tr. at 454-55. Dr. Butterfield noted a normal MSE. Id.
On September 19, 2014, Ms. House summarized Plaintiff's progress from June 21, 2014, to September 19, 2014. Tr. at 437. Ms. House noted Plaintiff continued to live independently in the community with friends, had recently received Medicaid benefits, and had complied with her treatment program. Id. Ms. House stated Plaintiff had improved in her ability to manage her symptoms, had not reported increased depression, and had not experienced command hallucinations during the review period. Id. However, Ms. House noted Plaintiff continued to use marijuana four or more times per week. Id. Ms. House stated Plaintiff had shown progress in her ability to tolerate being with others and her communication skills and had less frequently reported feeling unsafe. Id. Ms. House suggested placing more emphasis on addressing Plaintiff's drug abuse in the upcoming treatment plan. Id.
On September 24, 2014, Plaintiff reported to Dr. Butterfield that she felt "great" and had been babysitting her grandchildren seven days a week. Tr. at 450. Dr. Butterfield noted a normal MSE. Id.
On December 3, 2014, Plaintiff complained of frequent headaches and requested a blood pressure check by a nurse at CAMHC. Tr. at 887. The nurse recorded Plaintiff's blood pressure as 160/100 and advised Plaintiff to make an appointment with the Eastover Clinic. Id.
On December 15, 2014, Plaintiff presented for a blood pressure check at Eastover Family Practice. Tr. at 896-97. Plaintiff reported having been out of blood pressure medication for over a year and complained of headaches, but denied blurred vision or chest pain. Tr. at 896. Plaintiff also reported more frequent urination. Id. The examining nurse recorded the following diagnoses: cardiovascular disorder, heart disease, with unsure diagnosis; hypertension; asthma; depression; and history of inappropriate sinus tachycardia, neurally medicated syncope, and heavy caffeine use. Id. Plaintiff reported she lived alone, smoked less than half a pack of cigarettes per day, drank two cans of beer every other week, and occasionally used marijuana. Id. Plaintiff's blood pressure measured 141/94. Tr. at 897. The examining nurse assessed essential hypertension, ordered labs, restarted Plaintiff on Metoprolol, and instructed Plaintiff to monitor her sodium intake. Id.
On January 6, 2015, Dr. Butterfield noted Plaintiff had been attending therapy...
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