FREEZE v. KIJAKAZI

IN THE UNITED STATES DISTRICT COURT

FOR THE MIDDLE DISTRICT OF NORTH CAROLINA

KIMBERLY FREEZE, )

)

Plaintiff, )

)

v. ) 1:21CV275

)

KILOLO KIJAKAZI, )

Acting Commissioner of Social Security,! )

)

Defendant. )

MEMORANDUM OPINION AND RECOMMENDATION

OF UNITED STATES MAGISTRATE JUDGE

Plaintiff Kimberly Freeze (“Plaintiff”) brought this action pursuant to Sections 205(g)

and 1631(c)(3) of the Social Security Act (the “Act”), as amended (42 U.S.C. §§ 405(g) and

1383(c)(3)), to obtain judicial review of a final decision of the Commissioner of Social Security

denying her claims for Disability Insurance Benefits and Supplemental Security Income under,

respectively, Titles II and XVI of the Act. The parties have filed cross-motions for judgment,

and the administrative record has been certified to the Court for review.

I. PROCEDURAL HISTORY

Plaintiff protectively filed applications for Disability Insurance Benefits and

Supplemental Security Income Benefits on February 20, 2019 and February 5, 2019,

respectively, alleging a disability onset date of July 25, 2018 in both applications. (I'r. at 17,

1 Kilolo Kijakazi was appointed as the Acting Commissioner of Social Security on July 9, 2021. Pursuant to

Rule 25(d) of the Federal Rules of Civil Procedure, Kilolo Kijakazi should be substituted for Andrew M. Saul

as the Defendant in this suit. Neither the Court nor the parties need take any further action to continue this

suit by reason of the last sentence of section 205(g) of the Social Security Act, 42 U.S.C. § 405(g).

301-09.) Her applications were denied initially (Tr. at 94-125, 206-10) and upon

reconsideration (T'r. at 126-205, 217-30). Thereafter, Plaintiff requested an administrative

hearing de novo before an Administrative Law Judge (“ALJ”). (Tr. at 235-36.) Plaintiff, along

with her attorney and an impartial vocational expert, attended the subsequent telephonic

heating on April 27, 2020. (Ir. at 17.) The AL] ultimately concluded that Plaintiff was not

disabled within the meaning of the Act (Ir. at 27), and, on February 4, 2021, the Appeals

Council denied Plaintiffs request for review of the decision, thereby making the AL]’s

conclusion the Commissionet’s final decision for purposes of judicial review. (I'r. at 1-6.)

II. LEGAL STANDARD

Federal law “authorizes judicial review of the Social Security Commissionet’s denial of

social secutity benefits.” Hines v. Barnhart, 453 F.3d 559, 561 (4th Cir. 2006). However, the

scope of teview of such a decision is “extremely limited.” Frady v. Harris, 646 F.2d 143, 144

(4th Cir. 1981). “The courts ate not to try the case de novo.” Oppenheim v. Finch, 495 F.2d

396, 397 (4th Cir. 1974). Instead, “a reviewing court must uphold the factual findings of the

AL] if they are supported by substantial evidence and were reached through application of the

correct legal standard.” Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012) (internal

quotation omitted).

“Substantial evidence means ‘such relevant evidence as a reasonable mind might accept

as adequate to support a conclusion.”’ Hunter v. Sullivan, 993 F.2d 31, 34 (4th Cir. 1993)

(quoting Richardson v. Perales, 402 U.S. 389, 390 (1971)). “It consists of more than a mete

* Transcript citations refer to the Sealed Administrative Record [Doc. #8].

scintilla of evidence but may be somewhat less than a preponderance.” Mastro v. Apfel, 270

F.3d 171, 176 (4th Cir. 2001) (internal citations and quotation matks omitted). “If there is

evidence to justify a refusal to direct a verdict were the case before a juty, then there is

substantial evidence.” Hunter, 993 F.2d at 34 (internal quotation marks omitted).

“In reviewing for substantial evidence, the court should not undertake to te-weigh

conflicting evidence, make credibility determinations, or substitute its judgment for that of the

[ALJ].” Mastro, 270 F.3d at 176 (internal brackets and quotation marks omitted). “Where

conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled, the

responsibility for that decision falls on the ALJ.” Hancock, 667 F.3d at 472. “The issue before

[the reviewing court], therefore, is not whether [the claimant] is disabled, but whether the

AL)’s finding that [the claimant] is not disabled is supported by substantial evidence and was

reached based upon a correct application of the relevant law.” Craig v. Chater, 76 F.3d 585,

589 (4th Cir. 1996).

In undertaking this limited review, the Court notes that “[a] claimant for disability

benefits bears the burden of proving a disability.” Hall v. Harris, 658 F.2d 260, 264 (4th Cir.

1981). In this context, “disability” means the ““inability to engage in any substantial gainful

activity by reason of any medically determinable physical or mental impairment which can be

expected to result in death or which has lasted or can be expected to last for a continuous

of not less than 12 months.” Id. (quoting 42 U.S.C. § 423(d)(1)(A)).3

3 “The Social Security Act comprises two disability benefits programs. The Social Security Disability Insurance

Program (SSDI), established by Title II of the Act as amended, 42 U.S.C. § 401 et seq,, provides benefits to

disabled petsons who have contributed to the program while employed. The Supplemental Security Income

Program (SSI), established by Title XVI of the Act as amended, 42 U.S.C. § 1381 et seq., provides benefits to

indigent disabled persons. The statutory definitions and the regulations promulgated by the Secretary for

“The Commissioner uses a five-step process to evaluate disability claims.” Hancock,

667 F.3d at 472 (citing 20 C.F.R. §§ 404.1520(a)(4); 416.920(a)(4)). “Under this process, the

Commissioner asks, in sequence, whether the claimant: (1) worked during the alleged period

of disability; (2) had a severe impairment; (3) had an impairment that met or equaled the

requirements of a listed impairment; (4) could return to her past relevant work; and (5) if not,

could perform any other work in the national economy.” Id.

A finding adverse to the claimant at any of several points in this five-step sequence

forecloses a disability designation and ends the inquiry. For example, “[t]he first step

determines whether the claimant is engaged in ‘substantial gainful activity.’ If the claimant is

working, benefits are denied. The second step determines if the claimant is ‘severely’ disabled.

If not, benefits are denied.” Bennett v. Sullivan, 917 F.2d 157, 159 (4th Cir. 1990).

On the other hand, if a claimant catries his or her burden at the first two steps, and if

the claimant’s impairment meets or equals a “listed impairment” at step three, “the claimant

is disabled.” Mastro, 270 F.3d at 177. Alternatively, if a clatmant cleats steps one and two,

but falters at step three, te., “[i]f a claimant’s tmpairment is not sufficiently severe to equal or

exceed a listed impairment,” then “the ALJ must assess the claimant’s residual functional

capacity (RFC’).” Id. at 179.4 Step four then requires the AL] to assess whether, based on

determining disability, see 20 C.F.R. pt. 404 (SSDI); 20 C-F.R. pt. 416 (SSI), governing these two programs ate,

in all aspects relevant here, substantively identical.” Craig, 76 F.3d at 589 n.1.

4 “RFC is a measurement of the most a claimant can do despite [the claimant’s] limitations.” Hines, 453 F.3d

at 562 (noting that administrative regulations requite RFC to reflect claimant’s “ability to do sustained work-

related physical and mental activities tn a work setting on a regular and continuing basis . . . [which] means 8

hours a day, for 5 days a week, or an equivalent work schedule” (internal emphasis and quotation marks

omitted)). The RFC includes both a “physical exertional or strength limitation” that assesses the claimant’s

“ability to do sedentary, light, medium, heavy, or very heavy work,” as well as “nonexertional limitations

(mental, sensory, or skin impaitments).” Hall, 658 F.2d at 265. “RFC is to be determined by the AL] only after

that RFC, the claimant can “perform past relevant work”; if so, the claimant does not qualify

as disabled. Id. at 179-80. However, if the claimant establishes an inability to return to prior

wotk, the analysis proceeds to the fifth step, which “requires the [Government] to prove that

a significant number of jobs exist which the claimant could perform, despite the claimant’s

impairments.” Hines, 453 F.3d at 563. In making this determination, the ALJ must decide

“whether the claimant is able to perform other work considering both [the clatmant’s RFC]

and [the claimant’s] vocational capabilities (age, education, and past work experience) to adjust

to a new job.” Hall, 658 F.2d at 264-65. If, at this step, the Government cannot catty its

“evidentiary burden of proving that [the claimant] remains able to work other jobs available

in the community,” the claimant qualifies as disabled. Hines, 453 F.3d at 567.

Ill. DISCUSSION

In the present case, the AL] found that Plaintiff had not engaged in “substantial gainful

activity” since her alleged onset date. The ALJ therefore concluded that Plaintiff met her

burden at step one of the sequential evaluation process. (Tr. at 19-20.)° At step two, the ALJ

further determined that Plaintiff suffered from the following severe impairments:

histoty of migtaine headaches; degenerative disc disease; osteoarthritis; and

obesity|[-]

(Ir. at 20-22.) The AL] found at step three that none of these impairments, individually or in

combination, met ot equaled a disability listing. (Tr. at 22.) Therefore, the ALJ assessed

[the ALJ] considers all relevant evidence of a claimant’s impairments and any related symptoms (¢.g., pain).”

Hines, 453 F.3d at 562-63.

5 Despite this finding, the AL] noted at step one that Plaintiffs intermittent work as a Registered Nurse and

English teacher in 2018 and 2019 “appear[ed] to rise to the level of substantial gainful activity.” (Ir. at 20.)

Nevertheless, the ALJ “continue[d] with the remaining steps of the sequential evaluation for the periods after

[Plaintiff] earned SGA.” (T'r. at 20.)

Plaintiffs RFC and determined that she could perform medium work with further limitations.

Specifically, the AL] found that Plaintiff

can petform frequent, but not constant overhead teaching; and can tolerate

frequent, but not constant, exposure to extteme cold, pulmonary irritants, such

as dust, fumes, odors, and gases, and work place hazards, such as unprotected

heights and dangerous machinery.

(Tr. at 22.) Based on this determination and the testimony of a vocational expert, the ALJ

determined at step four of the analysis that Plaintiff remained capable of performing her past

televant work as a Registered Nurse and as a Hospice Nurse. (Ir. at 25.) In addition, the AL]

made an alternative finding at step five that, given Plaintiffs age, education, work experience,

RFC, and the testimony of the vocational expert as to these factors, she could perform other

jobs available in significant numbers in the national economy. (Tr. at 26-27.) Therefore, the

AL) concluded that Plaintiff was not disabled under the Act. (It. at 27.)

Plaintiff now challenges the ALJ’s decision in two respects. First, she argues that the

AL} failed to “provide a logical bridge between the evidence and her conclusions” regarding

the impact of Plaintiff's migraine headaches on her RFC. (PL’s Br. [Doc. #12] at 5.) Second,

she contends that the ALJ failed to properly consider the effects of Plaintiffs depression and

anxiety. In particular, she argues that the AL] erred in (1) finding these impairments non-

sevete at step two of the sequential analysis and (2) failing to account for limitations from

mental impairments when formulating the RFC assessment. (PL.’s Br. at 16.) After conducting

a thorough review of the record, the Court concludes that the AL] provided sufficient

explanation for her determinations, and that substantial evidence supports the ALJ’s

conclusions.

A. Migtaine headaches

Plaintiff first argues that the ALJ failed to conduct a proper function-by-function

analysis of Plaintiffs migraine symptoms and their effect on her RFC. As Social Security

Ruling (“SSR”) 96-8p instructs, “[t]he RFC assessment must first identify the individual’s

functional limitations or testtictions and assess his or her work-related abilities on a function-

by-function basis,” including the functions listed in the regulations. SSR 96-8p: Policy

Interpretation Ruling Titles I] and XVI: Assessing Residual Functional Capacity in Initial

Claims, 1996 WL 374184, at *1. “Only after such a function-by-function analysis may an ALJ

exptess RFC in terms of the exertional levels of work.” Monroe v. Colvin, 826 F.3d 176, 179

(4th Cir. 2016) (internal quotations and citations omitted). Further, the “RFC assessment must

include a nattative discussion describing how the evidence supports each conclusion, citing

specific medical facts (e.g., laboratory findings) and nonmedical evidence (e.g., daily activities,

obsetvations).” SSR 96-8p, 1996 WL 374184, at *7. An ALJ must “both identify evidence

that supports his conclusion and build an accurate and logical bridge from [that] evidence to

his conclusion.” Woods v. Berryhill, 888 F.3d 686, 694 (4th Cir. 2018) (emphasis omitted).

The Fourth Citcuit has noted that a per se rule requiring remand when the ALJ does not

perform an explicit function-by-function analysis “is inappropriate given that remand would

ptove futile in cases where the AL] does not discuss functions that are ‘irrelevant or

uncontested.”’ Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015) (quoting Cichocki v.

Asttue, 729 F.3d 172, 177 (2d Cir. 2013) (per curiam)). Rather, remand may be appropriate

“whete an ALJ fails to assess a claimant’s capacity to perform relevant functions, despite

conttadictory evidence in the record, or where other inadequacies in the AL]’s analysis

frustrate meaningful review.” Mascio, 780 F.3d at 636 (quoting Cichocki, 729 F.3d at 177).

The court in Mascio concluded that remand was appropriate because it was “left to guess

about how the ALJ arrived at his conclusions on [the claimant’s| ability to perform relevant

functions” because the AL] had “said nothing about [the claimant’s] ability to perform them

for a full workday,” despite conflicting evidence as to the claimant’s RFC that the ALJ did not

address. Mascio, 780 F.3d at 637.

Here, Plaintiff argues that the ALJ’s failure to properly explain how the RFC

assessment adequately addresses limitations relating to her migraine headaches renders her

decision unsupported by substantial evidence. In her decision, the ALJ discusses at length the

evidence in the record, including the evidence regarding Plaintiff's migraines, and concludes

that, “[iJn limiting the [Plaintiff] to medium work, with additional environmental limitations,

the [ALJ] has adequately accounted for the Plaintiffs history of migraine headaches.” (Tr. at

24.) ‘Those environmental limitations include limited exposure to extreme cold, pulmonary

irritants, and workplace hazards. In reaching this conclusion, the ALJ relied on various factors

including the record’s failure to substantiate Plaintiffs subjective complaints regarding the

impact of her migraines on her RFC.

With respect to the ALJ’s evaluation of Plaintiffs allegations regarding her symptoms,

under the applicable regulations the ALJ’s decision must “contain specific reasons for the

weight given to the individual’s symptoms, be consistent with and supported by the evidence,

and be clearly articulated so the individual and any subsequent reviewer can assess how the

adjudicator evaluated the individual’s symptoms.” Social Security Ruling 16-3p, Titles I] and

XVI: Evaluation of Symptoms in Disability Claims, SSR 16-3p, 2017 WL 5180304, at *10

(Oct. 25, 2017) (“SSR 16-3p”); see also 20 C.F.R. § 404.1529. Moreover, in Arakas v. Comm’

of Soc. Sec., 983 F.3d 83 (4th Cir. 2020), the Fourth Circuit recently clarified the procedure an

ALJ must follow when assessing a clatmant’s statements:

When evaluating a claimant’s symptoms, ALJs must use the two-step

framework set forth in 20 C.F.R. § 404.1529 and SSR 16-3p, 2016 WL 1119029

(Mar. 16, 2016). First, the ALJ must determine whether objective medical

evidence presents a “medically determinable impairment” that could reasonably

be expected to produce the claimant’s alleged symptoms. 20 C.F .R.

§ 404.1529(b); SSR 16-3p, 2016 WL 1119029, at *3.

Second, after finding a medically determinable impairment, the AL] must assess

the intensity and persistence of the alleged symptoms to determine how they

affect the claimant’s ability to work and whether the claimant is disabled. See 20

C.F.R. § 404.1529(c); SSR 16-3p, 2016 WL 1119029, at *4. At this step,

objective evidence is mot requited to find the claimant disabled. SSR 16-3p, 2016

WL 1119029, at *4-5. SSR 16-3p recognizes that “[s]ymptoms cannot always

be measuted objectively through clinical or laboratory diagnostic

techniques.” Id. at *4. Thus, the ALJ must consider the entire case record and

may “not disregard an individual’s statements about the intensity, persistence,

and limiting effects of symptoms solely because the objective medical evidence

does not substantiate” them. Id. at *5.

Arakas, 983 F.3d at 95-96. Thus, the second part of the test requires the ALJ to consider all

available evidence in order to evaluate “the intensity and persistence of the claimant’s

[symptoms], and the extent to which [they] affects [her] ability to work.” Craig, 76 F.3d at

595. ‘This approach facilitates the AL]’s ultimate goal, which is to accurately determine the

extent to which PlaintifPs pain or other symptoms limit her ability to perform basic work

activities. Relevant evidence for this inquiry includes Plaintiffs “medical history, medical signs,

and laboratory findings,” Craig, 76 F.3d at 595, as well as the following factors set out in 20

C.F.R. § 416.929(c)(3) and 20 C.F.R. § 404.1529:

(1) [Plaintiffs] daily activities;

(11) The location, duration, frequency, and intensity of [Plaintiffs] pain or

other symptoms;

(iii) Precipitating and ageravating factors;

(iv) The type, dosage, effectiveness, and side effects of any medication

[Plaintiff] take[s] or [has] taken to alleviate [her] pain or other symptoms;

(v) Treatment, other than medication, [Plaintiff] receives] or [has] received

for relief of [her] pain or other symptoms;

(vi) | Any measures [Plaintiff] use[s] or [has] used to relieve [her] pain or other

symptoms (e.g., lying flat on [her] back, standing for 15 to 20 minutes

every hour, sleeping on a board, etc.); and

(vit) Other factors concerning [Plaintiffs] functional limitations and

resttictions due to pain or other symptoms.

In the present case, as instructed by the regulations, the ALJ considered the entire case

record and explained the reasons for deviating from Plaintiff's statements regarding the impact

of her headache symptoms on her ability to work. The AL] reviewed the medical evidence,

Plaintiffs testimony, and other record evidence, such as Plaintiffs activities, in considering

Plaintiffs subjective complaints. She then concluded that the extent to which Plaintiff's

migraine symptoms limited her ability to work was not as extensive as Plaintiff alleged. In

particular, the ALJ found as follows:

[Plaintiff] has . .. been diagnosed with a history of migraine headaches. [She]

has reported migraines since she was 18-years old. [Plaintiff] alleged daily

migraines for a month after a motor vehicle accident in July 2018. She noted

that they tapered off after the first 30 days. She has also reported doing

extensive research into her conditions. She did not receive physical therapy or

vestibular therapy after her accident. A head CT and brain MRI wete

notmal....

On examination, [Plaintiff] generally presents with the following mostly normal

findings: intact cranial nerves, intact processing speed, attention within normal

ranges, intact sensation, alert, answer[s] questions appropriately, and oriented

.... [She] has received mostly conservative treatment, including prescribed

Botox, melatonin, Zonisamide, bulabital, cambia, and hydrocodone. [Plaintiff]

has been noted as practicing yoga. [She] has also been noted as cating for her

mother. [Plaintiff] has reported improvement in her headaches with Botox

injections, including a greater than 50% reduction in her headaches. In March

2019, [Plaintiff] reported that her headaches were becoming less frequent.

10

Neutopsychological testing suggested possible symptom exaggeration.

Additionally, [Plaintiff] has failed to report at additional neurological

appointments. Ryan Conrad, M.D., noted in September 2019, that he did not

“really understand why she is seeing me. She has filed for disability twice and

has been tutned down, seems to want to be on disability from what I can gather

and it seems she has been seeing doctors for this.” In limiting [Plaintiff] to

medium work, with additional environmental limitations, the undersigned has

adequately accounted for [Plaintiffs] history of migraine headaches.

(Tr. at 23-24) (citing Tr. at 437, 730, 731, 2451). More generally, the ALJ noted that “[t]here

ate many inconsistencies throughout the record. For example, [Plaintiff's] neuropsychological

exam... suggested that she was exaggerating her symptoms and that her self-reported mood

disorder should be interpreted with caution. [Treatment records] further noted that [Plaintiff]

‘wanted to be on disability.” (Tr. at 23) (citing Tr. at 731, 2451). Overall, the AL] concluded

that Plaintiffs impairments were “less limiting than alleged.” (Tr. at 23.)

Thus, the AL] here gave multiple reasons for finding Plaintiffs migraines less limiting

that Plaintiff alleged. First, the AL) noted significant credibility issues regarding Plaintiffs

claims, based on the inconsistencies in the record and the assessment of both Dr. Harris and

Dr. Contad. On this point, the ALJ noted that Dr. Hartis’s “[n]europsychological testing

suggested possible symptom exaggeration.” (Ir. at 24, 729-34.) Specifically, Dr. Harris

included a symptom validity test as part of the neuropsychological testing, and Plaintiffs

“performance actoss a stand-alone symptom validity measute was well below expectation and

suggestive of possible symptoms exaggeration.” (Tr. at 731.) In addition, the ALJ also noted

that “Ryan Conrad, M.D. noted in September 2019, that he did not ‘really understand why she

is seeing me. She has filed for disability twice and has been turned down, seems to want to be

on disability from what I can gather and it seems she has been seeing doctors for this.”” (Ir.

at 24, 2451). The AL] expressly telied on these assessments in evaluating the credibility of

11

Plaintiff's claims of debilitating symptoms from migraines, and in concluding that Plaintiffs

“4mpairments ate less limiting than alleged.” (T'r. at 23-24.)

Second, the ALJ noted that the evidence in the medical records did not support

Plaintiffs claims of disabling symptoms. The AL] noted that “[a] head CT’ and a brain MRI

were notmal” and the examinations generally reflect “mostly normal findings: intact cranial

netves, intact processing speed, attention within normal ranges, intact sensation, alert, answer

questions appropriately, and oriented.” (Tr. at 24, 438, 446, 515, 609, 651, 731-32, 736, 748,

2463.) Third, the AL} noted that Plaintiff received mostly conservative treatment, which is

not consistent with the degtee of debilitating symptoms Plaintiff alleged. (Ir. at 24, 494, 748.)

Fourth, the ALJ further noted that Plaintiff failed to take advantage of other available and

recommended treatment, including by failing to report for additional neurological

appointments and failing to seek out physical therapy or vestibular treatment that was

recommended by Dr. Harttis. (Tr. at 23-24, 732.) Fifth, the AL] noted that the medical records

teflected a significant improvement in her migraines with medication, with a substantial

reduction in frequency. (Tr. at 24, 702-04, 734, 741, 743.)

Sixth, the AL] noted Plaintiffs activities despite her claim of disabling migraines,

including practicing yoga, driving long distances, using the internet including for doing

extensive reseatch into her conditions, vatious crafts, and caring for her family. Medical

records reflect that Plaintiff told providers she took care of her elderly mother, disabled sister,

and schizophrenic son. (Tt. at 23-24, 516.) In addition, the ALJ noted that Plaintiff worked

as a nutse from November 2018 to January 2019 at Cabarrus Gastroenterology, during the

petiod of claimed disability, but left to file for unemployment, and she continued to take

12

Continuing Education to renew her RN license in 2019. (Tr. at 20, 23-24.) Plaintiff contends

that the ALJ failed to include or consider qualifying statements regarding her activities.

However, as noted by Defendant, the ALJ did consider and include the qualifying statements

regarding her activities, including her alleged difficulties remembering and concentrating, panic

attacks while driving, and difficulties with dizziness (Ir. at 23), but still found that Plaintiffs

activities wete inconsistent with her claim of disabling migraines.

The ALJ also considered the opinion evidence of the State Agency physicians, who

opined that Plaintiff was capable of medium work with environmental limitations. (It. at 24.)

Plaintiff does not point to any contrary opinion evidence from her physicians that her

migtaines ate disabling or otherwise cause work-related limitations.° Although Plaintiff

contends that the AL] should have included limitations in the RFC to account for work breaks

ot absences related to her migtaines, the AL] gave multiple reasons to conclude that the

evidence did not support the severity of symptoms claimed by Plaintiff, as set out above. The

AL} ultimately concluded that Plaintiffs history of migraine headaches was adequately

accounted fot with the limitation to medium work with additional environmental limitations.

Those environmental limitations include limitations on exposure to extreme cold, pulmonary

irritants including odors, and workplace hazards such as unprotected heights and dangerous

machinety, which is consistent with Plaintiffs testimony that her migraines varied depending

on “the weather” and “scents,” as well as her concerns of dizziness. (Tr. at 22, 70.)

® Plaintiff does point to a family leave form covering a brief two-week period from July 26, 2018 to August 6,

2018, immediately after her vehicle accident. (Tr. at 601-02.) However, soon after, her doctor signed a “return

to work” form on August 23, 2018, opining that Plaintiff could be released to work at “full, unrestricted duty.”

(Tt. at 625.)

13

Thus, the ALJ explained the basis for the decision sufficiently to allow the Court to

follow the reasoning, and substantial evidence supports that determination. Whether the ALJ

could have reached a different conclusion based on the evidence is irrelevant. The sole issue

before the Court is whether substantial evidence supports the ALJ’s decision. See Blalock v.

Richardson, 483 F.2d 773, 775 (4th Cir. 1972) (“[I]he language of § 205(g) precludes a de novo

judicial proceeding and requires that the court uphold the Secretaty’s decision even should the

coutt disagree with such decision as long as it is supported by ‘substantial evidence.”’).

B. Anxiety and Depression

Plaintiff next contends that the AL]’s erred at step two of the sequential analysis in

finding that Plaintiff's anxiety and depression wete non-sevete impairments. (Pl.’s Br. at 16.)

She futther contends that the AL]’s failure to account for these impairments at later steps

tenders the RFC unsupported by substantial evidence. At step two, the ALJ identified four

sevete impairments: “history of migraine headaches; degenerative disc disease; osteoarthritis;

and obesity.” (Ir. at 20.) The AL] further identified six additional physical impairments as

non-severe, along with the two mental impairments now in question. (Tr. at 20.) In finding

that Plaintiffs depression and anxiety did not cause more than minimal limitations in her

ability to perform basic work activities, the ALJ noted that, while Plaintiff presented with

“anxious affect and abnormal mood” at times, her examinations revealed “mostly normal

findings,” and her treatment has been conservative, “including psychotherapy and prescribed

alprazolam, Xanax, Lamictal, and Cymbalta,” and she had “significant activities of daily living.”

(Tr. at 24.)

14

At step two, the ALJ also included a discussion of the four broad functional ateas of

mental functioning set out in the regulations for evaluating mental impairments, commonly

known as “patagraph B” criteria. These functional areas are understanding, remembering and

applying instructions; interacting with others; concentrating, persisting, or maintaining pace;

and adapting ot managing oneself. In the present case, the AL] concluded that Plaintiff had

mild limitations in each of these areas. The AL] included the following explanation of her

findings regarding Plaintiffs mental functioning:

[Plaintiff] alleged that she has difficulties remembering and concentrating.

However, on mental status examination, [Plaintiff] generally presents with

mostly normal findings, including alert, oriented, cooperative, normal judgment,

appropriately dressed, well-groomed, good hygiene, good eye contact, intact

absttact reasoning, good insight, normal gait, normal behavior, normal mood,

and normal affect. Additionally, [Plaintiff] reports that she is able to live with

her family, use the internet, use social media, reseatch medical treatment, craft,

take care of plants, basket weave, make jewelty, vacuum for shott periods, read,

and drive a car. [Plaintiff] also reported working after the alleged onset date, as

well as attempting to work as an English as a second language instructor. She

noted that she helps take care of her son who has been diagnosed with

schizophrenia. In addition, [Plaintiff] took her continuing education courses

for her RN license in early 2019, and then renewed het RN license in November

of 2019.

(Tr. at 21) (citing Tr. at 438, 470, 507, 515, 518, 593, 660, 667, 736, 748, 763, 2373, 2435, 2436,

2444, 2454, 2456, 2462). The ALJ, citing 20 C.F.R. §§ 404.1520a(d)(1) and 416.920a(d)(1),

concluded that “[b]ecause [Plaintiffs] medically detetminable mental impaitments cause no

more than ‘mild’ limitation in any of the functional ateas and the evidence does not otherwise

indicate that there is more than a minimal limitation in [her] ability to do basic work activities,

they are nonseverte.” (Tr. at 21.)

In making these findings, the AL] further noted that “[t]he limitations identified in the

“paragraph B” criteria are not [an RFC] assessment,” and that the mental RFC “assessment

15

used at steps 4 and 5 of the sequential analysis requires a more detailed assessment.” (I't. at

21.) The ALJ then further discussed Plaintiffs mental impairments in setting the RFC, and

set out het reasons for discounting Plaintiffs statements concerning the limiting effects of her

symptoms. (See Tr. at 23.)

Plaintiff contends that the ALJ erred by finding Plaintiffs mental impairments non-

sevete and by failing to include them in the RFC. Plaintiff notes that the ALJ relied on

Plaintiffs activities but failed to consider Plaintiffs testimony qualifying her abilities to engage

in those activities. Plaintiff also contends that it was error for the AL] to rely on the normal

examination findings, without considering the contraty findings including in particular the

assessments and neuropsychological testing by Dr. Harris. Finally, the ALJ points to the

opinions of the State Agency psychological consultants, who found moderate limitations in

some ateas and limited Plaintiff to “simple work.” Plaintiff argues that including these

limitations would have precluded her teturn to past work and/or transferability of skills

resulting in a finding of disability.

However, the AL] provided multiple reasons and extensive explanation for reaching

her conclusions. First, the AL] noted significant credibility issues regarding Plaintiffs claims,

based on the inconsistencies in the record and the assessments of both Dr. Harris and Dr.

Conrad. On this point, the ALJ noted that Plaintiffs “neuropshychological exam indicated

that it was suggested that she was exaggerating her symptoms and that her self-reported mood

disorder should be interpreted with caution.” (I'r. at 23, 729-34.) Specifically, as noted above,

Dr. Hattis included a symptom validity test as part of the neutropsychological testing, and

Plaintiffs “performance across a stand-along symptom validity measure was well below

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expectation and suggestive of possible symptoms exaggeration.” (Ir. at 731.) Plaintiffs

depression and anxiety findings were based on “self-reported mood measures” to be

“fnterpreted with caution.” (Tr. at 731.) The ALJ also relied on Dr. Conrad’s assessment that

Plaintiff was seeing doctors because she “seems to want to be on disability.” (Tr. at 23, 2451.)

In addition, the ALJ noted specific instances that reflected a lack of credibility, such as Plaintiff

reporting “spending an entire month in bed,” when the remainder of the evidence in the

tecotd showed otherwise, including medical appointments scheduled during that time. (I'r. at

21.)

Second, the ALJ telied on the examination records reflected “mostly normal” mental

status examinations including “alert, oriented, cooperative, normal judgment, appropriately

dressed, well-groomed, good hygiene, good eye contact, intact abstract reasoning, good

insight, normal gait, normal behavior, normal mood, and normal affect.” (Ir. at 21.) Plaintiff

points to other records showing depression and anxiety and related symptoms, particularly the

assessments and related limitations from Dr. Harris. However, as noted above, the AL]

specifically addressed Dr. Harris’ assessment and relied on Dr. Harris’ warning that Plaintiffs

“self-reported mood disorder” which included the anxiety and depression assessment, should

be considered with caution and reflected symptom exaggeration.

Third, the ALJ relied on Plaintiffs activities, including living with her family, using the

internet, using social media, researching medical treatment, crafting, taking care of plants,

basket weaving, making jewelry, vacuuming for shore periods, reading, and driving a car. (Tr.

at 21; see also Tr. at 2443.) The AL] also referenced Plaintiffs continued work activity after

the alleged onset date and her ability to care for her son who has been diagnosed with

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schizophrenia, as well as her decision to take continuing education courses and renew her RN

license in September 2019. (Tr. at 21.) The ALJ reasonably relied on the evidence in the

record reflecting that Plaintiff maintained the mental abilities required for these activities. The

AL) also noted Plaintiffs qualifying testimony that she had panic attacks when driving and

difficulty remember and concentrating due to a traumatic brain injury (Tr. at 23), but the ALJ

also noted that there was “no objective medical abnormality related to a traumatic brain

injuty,” with a “negative head CT” and “normal neurological examination findings.” (Tr. at

21-22.) ‘Thus, the ALJ considered Plaintiffs testimony regarding those activities, and

addressed those contentions in the context of the evidence in the record.

Finally, the AL] considered the evidence again in making a determination that the State

agency psychological consultants’ opined mental limitations were unpersuasive (Tr. at 24).

The State agency psychologists found Plaintiff had some moderate limitations in the

“patagtaph B” functional areas and opined that, as a result, she was “limited to understanding

and remembering short and simple instructions, sustaining sufficient attention to complete

simple routine tasks with normal breaks, working in a setting with minimal social demands,

and managing a stable work assignment in a setting with minimal changes in routine.” (Tr. at

24.) The ALJ found that these opinions were not persuasive because they were “inconsistent

with, and unsupported by, [Plaintiffs] mostly normal progtess reports, activities of daily living,

treatment history, and examination findings.” (Tr. at 24-25.) Those findings are further

explained throughout the decision, as discussed at length above, and notably the ALJ relied

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on the reports from Plaintiffs physicians Dr. Harris and Dr. Conrad as part of that

determination and explanation.’

Plaintiff essentially asks the Court to reconsider and re-weigh the evidence presented.

However, it is not the function of this Court to re-weigh the evidence or reconsider the AL]’s

determinations if they are supported by substantial evidence. As noted above, “[w]here

conflicting evidence allows reasonable minds to differ as to whether a claimant is disabled, the

responsibility for that decision falls on the ALJ.” Hancock, 667 F.3d at 472 (quotation

omitted). Thus, the issue before the Court is not whether a different fact-finder could have

drawn a different conclusion, or even “whether [Plaintiff] is disabled,” but rather, “whether

the AL]’s finding that [Plaintiff] is not disabled is supported by substantial evidence and was

reached based upon a correct application of the relevant law.” Craig, 76 F.3d at 589. Hete,

the ALJ reviewed the evidence, explained her decision, and clearly explained the reasons for

her determination. That determination is supported by substantial evidence in the record.

Plaintiff has not identified any errors that require remand, and Plaintiff's Motion to Reverse

the Decision of the Commissioner should therefore be denied.

IT IS THEREFORE RECOMMENDED that the Commissionet’s decision finding

no disability be AFFIRMED, that PlaintifPs Motion for Summary Judgment [Doc. #11] be

To the extent Plaintiff contends that a finding limiting her to simple work would render her disabled because

she could not return to her past work or have transferrable skills, Defendant has noted that such a finding

would not have rendered her disabled under the Grids, and has further noted that the ALJ made an alternative

finding that Plaintiff would be able to perform the requirements of unskilled work such as Store Laborer, Hand

Packager, and Dining Room Attendant. (Ir. at 26-27.) The Court need not consider that issue further, given

that there is substantial evidence supporting the AL]’s determination as discussed above.

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DENIED, that Defendant’s Motion for Judgment on the Pleadings [Doc. #13] be

GRANTED, and that this action be DISMISSED with prejudice.

This, the 1st day of September, 2022.

/s/ Jot Elizabeth Peake

United States Magistrate Judge

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