The opinion
IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF NORTH CAROLINA
CATHERINE P., )
Plaintiff,
v. 1:23CV950
LELAND DUDEK,
Acting Commissioner of Social Security, )
Defendant.
MEMORANDUM OPINION AND ORDER
OF UNITED STATES MAGISTRATE JUDGE
Plaintiff Catherine P. (“Plaintiff”) brought this action pursuant to Section 205(g) of the
Social Security Act (the “Act”), as amended (42 U.S.C. § 405(g)), to obtain judicial review of a
final decision of the Commissioner of Social Security denying her claim for Disability
Insurance Benefits (“DIB”) under Title II 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 her application for DIB on December 7, 2020, alleging a
disability onset date of June 12, 2020. (Tr. at 10, 190-94.)! Her application was denied initially
(Tr. at 103-11, 121-25) and upon reconsideration (Tr. at 112-20, 132-36). Thereafter, Plaintiff
requested an administrative hearing de novo before an Administrative Law Judge (“ALJ”).
(Tr. at 137-38.) On July 27, 2022, Plaintiff, along with her attorney, attended the subsequent
‘ Transcript citations refer to the Sealed Administrative Record [Doc. #5].
telephone hearing, at which Plaintiff and an impartial vocational expert testified. (Tr. at 10,
40-102.) Following the hearing, the ALJ concluded that Plaintiff was not disabled within the
meaning of the Act (Ir. at 23), and, on September 1, 2023, the Appeals Council denied
Plaintiffs request for review, thereby making the AL]’s ruling the Commissionet’s final
decision for purposes of judicial review (Tr. at 1-6).
II. LEGAL STANDARD
Federal law “authorizes judicial review of the Social Security Commissionet’s denial of
social security benefits.” Hines v. Barnhart, 453 F.3d 559, 561 (4th Cir. 2006). However, the
scope of review of such a decision is “extremely limited.” Frady v. Harris, 646 F.2d 143, 144
(4th Cir. 1981). “The courts are 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. Asttue, 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. 1992)
(quoting Richardson v. Perales, 402 U.S. 389, 390 (1971)). “It consists of more than a mere
scintilla of evidence but may be somewhat less than a preponderance.” Mastro v. Apfel, 270
F.3d 171, 176 (4th Cir. 2001) G@nternal citations and quotation marks omitted). “If there is
evidence to justify a refusal to direct a verdict were the case before a jury, 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 re-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 Cit.
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
period of not less than 12 months.” Id. (quoting 42 U.S.C. § 423(d)(1)(A)).?
“The Commissioner uses a five-step ptocess 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, 1n sequence, whether the claimant: (1) worked during the alleged period
2 “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 persons 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
determining disability, see 20 C.F.R. pt. 404 (SSDI); 20 C.F.R. pt. 416 (SSD), governing these two programs are,
in all aspects relevant here, substantively identical.” Craig, 76 F.3d at 589 1.1.
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 carries 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 claimant cleats steps one and two,
but falters at step three, Le., “[i]f a claimant’s impairment 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.° Step four then requires the ALJ to assess whether, based on
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
work, the analysis proceeds to the fifth step, which “requires the [Government] to prove that
3 “REC 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 require RFC to reflect claimant’s “ability to do sustained work-
telated physical and mental activities in a work setting on a regular and continuing basis . . . [which] means 8
houts 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
[the ALJ] considers all relevant evidence of a clatmant’s impairments and any related symptoms (¢.g., pain).”
Hines, 453 F.3d at 562-63.
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 claimant’s RFC]
and [the clatmant’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 carty 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 ALJ found that Plaintiff had not engaged in “substantial gainful
activity” since her alleged onset date. Plaintiff therefore met her burden at step one of the
sequential evaluation process. (Ir. at 13.) At step two, the ALJ further determined that
Plaintiff suffered from the following severe impairments:
systematic lupus erythematosus (SLE), trigger finger, tendonitis, osteoarthritis,
and obesity[-]
(Tr. at 13.) The AL] found at step three that none of these impairments, individually or in
combination, met or equaled a disability listing. (Ir. at 15-16.) Therefore, the AL] assessed
Plaintiffs RFC and determined that she could perform light work with further limitations,
described as follows:
[Plaintiff] is limited to lifting, carrying, pushing, and/or pulling twenty pounds
occasionally, and ten pounds frequently. She can sit for six hours in an eight-
hour workday and can stand and/or walk for six hours in an eight-hour
workday. Further, she is limited to frequent handling and fingering with the
bilateral upper extremities.
(Tr. at 16.) At step four of the analysis, the AL] determined that Plaintiffs past relevant work
did not exceed her RFC. Specifically, the AL] found that Plaintiff remained capable of
performing her past relevant work as a teacher for the emotionally impaired. (I't. at 23.)
Therefore, the ALJ concluded that Plaintiff was not disabled under the Act. (Tr. at 23.)
Plaintiff now contends that the ALJ “erred by failing to consider Plaintiffs depression,
anxiety, and posttraumatic stress disorder (“PTSD”) to be severe impairments and include
resulting limitations in the [RFC assessment].” (PL’s Br. [Doc. #12] at 1.) As an initial matter,
Plaintiff acknowledges that the AL]’s omission of a severe impairment at step two does not,
without mote, necessitate remand. “As long as the ALJ determines that the claimant has at
least one sevete impairment and proceeds to discuss all of the medical evidence, any error
regarding failure to list a specific impairment as severe at step two is harmless.” McClain v.
Colvin, No. 1:12CV1374, 2014 WL 2167832, at *4 (M.D.N.C. May 23, 2014) (citations
omitted).4 However, in the present case, Plaintiff contends that the ALJ’s subsequent analysis
also failed to account for the effects of her mental impairments on her ability to work.
At step two, the ALJ included depression, anxiety, and PTSD when listing Plaintiffs
non-severe impairments. In doing so, the AL noted that “[t]reatment and other records show
these conditions are generally well-controlled and have not caused more than minimal or brief
+ Step two is a threshold determination of whether claimants have a severe impairment (or combination of
impairments) that meets the twelve-month duration requirement and significantly limits their ability to do basic
work activities. 20 C-F.R. §§ 404.1520(a) (4) (4), 416.920(a)(4) (it) (2010). If the Commissioner finds no severe
impairments, the claimant is not disabled and the analysis does not proceed to the other steps. Id. However,
if a claimant does have a severe impairment or combination of impairments, the ALJ must consider the effects
of both the severe and non-severe impairments at the subsequent steps of the process, including in the
determination of RFC. See 20 C.F.R. § 404.1523 (2010); Social Security Ruling 96—8p, Policy Interpretation
Ruling Titles IT and XVI: Assessing Residual Functional Capacity in Initial Claims, 1996 WL 374184, at * 5
(July 2, 1996). If the ALJ proceeds to discuss and consider the non-severe impairment at subsequent steps,
there is no prejudice to the clatmant. See Thomas v. Commissioner, Soc. Sec. Admin., No. SAG—11—3587,
2013 WL 210626, at *2 (D. Md. Jan. 17, 2013) (finding harmless error where ALJ continued with sequential
evaluation process and considered both severe and non-severe impairments); Kenney v. Astrue, No. CBD—10—
1506, 2011 WL 5025014, at *5 (D. Md. Oct. 20, 2011) (declining to remand for failure to classify an impairment
as severe because it would not change the result).
limitation in [Plaintiffs] ability to perform work-related activities.” (Tr. at 13.) While this
explanation applied to all of Plaintiffs non-severe impairments, both mental and physical, the
ALJ went on to provide an additional, lengthy explanation regarding her treatment of the
mental health evidence in this case:
In terms of [Plaintiffs] mental impairments, the record shows [Plaintiff] only
sought limited and conservative, routine mental health treatment (Exhibit 5F,
11F, 16F, 17F, 19F), and the record reflects multiple situational stressors,
including her finances, her son’s legal issues, and the pandemic (Exhibits
12F/19, 16F/21, 19F/1-2, 7), with improvement noted once her finances
stabilized (Exhibit 16F/21, 20F/25). [Plaintiffs] allegations as to the limiting
effects of her mental impairments are not consistent with treatment sought,
treatment provided when treatment was sought, findings on examination when
treatment was sought, and her ongoing, albeit part-time, work activity. When
she presented for an initial evaluation with a mental health provider at The Neil
Group in April 2021 for evaluation of depression and anxiety and to have a
disability form signed, she was advised the provider would not sign the form,
because [Plaintiff] had said she felt her physical problems were leading to her
disability (Exhibits 11F/2, 17F/1). Despite some reported symptoms, mental
status examination was benign other than for an anxious mood or affect
(Exhibits 11F/3, 17F/2). She returned to The Neil Group for an assessment
in October 2021, and some distractibility, preoccupied thought content, anxious
and depressed mood and only fair judgment, insight, concentration, and
reasoning were noted at that time (Exhibit 19F/1- 4). On her only two
subsequent appointments with The Neil Group, in November 2021 and then
not again until April 2022, mental status examination findings were almost
entirely benign (Exhibit 19F). Notably, at the April 2022 visit, she reported
doing well on het medication but having some anxiety due to lack of income
(Exhibit 19F/7).
(Tr. at 14.)
After providing this summary, the ALJ specifically considered the four broad ateas of
mental functioning, also known as the “paragraph B” criteria, set out in the regulations. (Tr.
at 14-15); see also 20 C.F.R., Part 404, Subpart P, Appendix 1, 12.00E. These areas of mental
functioning are (1) understanding, remembering, or applying information; (2) interacting with
others; (3) concentrating, persisting, and maintaining pace; and (4) adapting and managing
oneself. (See Tr. at 14-15.) For each of these areas, the AL] must rate Plaintiffs degree of
limitation as none, mild, moderate, marked, or extreme. 20 C.F.R., Part 404, Subpart P,
Appendix 1, 12.00F(2).
In the present case, the ALJ found that Plaintiff had no limitations in her ability to
understand, remember, ot apply information, and mild limitations in the other three paragraph
Bareas. (Ir. at 14-15.) Plaintiff nevertheless contends that her mental impairment are severe
“because of the degree of poor concentration and stress intolerance she experiences.” (PL.’s
Br. at 8.) Accordingly, she challenges, in part, the ALJ’s mild findings regarding Plaintiffs
ability to maintain concentration, persistence, and pace and her ability to adapt and manage
herself.
In terms of concentration, persistence, and pace, the AL] specifically noted that
[t]he record fails to show any mention of distractibility and an inability to
complete testing that assesses concentration and attention. Although some
distractibility, preoccupied thought content, anxious and depressed mood|,] and
only fair judgment, insight, concentration, and reasoning were noted on an
assessment in October 2021, mental status examinations otherwise mostly
noted no significant abnormality in this area. [Plaintiff] reported [that] her
symptoms wete at times exacerbated by emotional or situational stress, but her
medication generally controlled her symptoms well.
(Tr. at 15) Gnternal citations omitted). Similarly, with respect to understanding, remembering,
ot applying information, the ALJ noted that Plaintiff:
was able to provide information about her health, describe her prior work
history, and respond to questions ftom medical providers. The providers noted
she was alert and oriented. She answered questions clearly. She had good
concentration and memory (Exhibit 11F). Mental status examinations generally
noted no significant abnormality in cognition or memory (Exhibits 18E, 6, 16,
22, 5F/5, 11F/2-3, 12F/18, 16F/19, 17F/2, 19F/2, 8, 20F/4, 10, 14, 24,
21F/30). [Plaintiff] reported her symptoms were at times exacerbated by
emotional or situational stress, but her medication generally controlled her
symptoms well (Exhibits 12F, 16F, 21F/25).
at 14.) In terms of Plaintiffs ability to adapt ot manage herself, the AL] explained that
“the record showed [that Plaintiff] lives alone, has appropriate grooming and hygiene, no
significant problem getting along well with providers and staff, and no problems with temper
control. Treatment records reflect that [Plaintiff] was cooperative, well groomed, well
nourished, and well developed.” (Tr. at 15) (internal citations omitted).
The ALJ specifically noted that she had “considered all of [Plaintiffs] medically
determinable impairments, including those that are not severe, when assessing [Plaintiffs]
residual functional capacity.” (Ir. at 15.) With respect to Plaintiffs mental impairments, the
ALJ concluded that those impairments caused, at most, mild functional problems, as discussed
above, which thus did not cause limitations in Plaintiffs RFC. Moreover, in explaining the
basis for her RFC assessment, the AL] went on to discuss numerous teasons for discounting
Plaintiffs assertions regarding the severity of her mental impairments.
Notably, the ALJ acknowledged Plaintiffs allegations “that loud noises and voices
affected her, that she was a “nervous wreck,” that she had IBS and pancreatitis due to stress,
and that she was sometimes so tired she spent the day in bed. Plaintiff further reported having
problems with memory and concentration due to “lupus fog.” (Tr. at 17.) However, she
testified that the “biggest issues that prevented her from working were fatigue and pain.” (Tr.
at 17.) Ultimately, the ALJ found that Plaintiffs “statements concerning the intensity,
persistence[,] and limiting effects of [her] symptoms [were] not entirely consistent with the
medical evidence and other evidence in the record.” (Tr. at 17.) In making this finding, the
ALJ noted that, in the months leading up to her alleged onset date, Plaintiff regularly reported
“hating her job as a teacher,” and that her job dissatisfaction, along with financial stress and
her oldest child’s legal troubles, were the source of her anxiety and depression. (Tr. at 17-18.)
In May 2020, Plaintiff reported to her mental health care provider, Justina Okonkwo, that “her
anxiety and depression had increased ‘more than anything due to her working as a teacher at
home.” (Tr. at 18) (quoting Tr. at 655).
On June 1, 2020, Plaintiff returned to her treating rheumatologist, noting that she was
trying to apply for disability. After a benign mental and physical examination, Dr. Gay advised
Plaintiff that she did not have signs of active lupus and that lupus was unlikely to qualify her
for disability. (Tr. at 18.) Plaintiff “was noted to have responded that she had ‘enough other
medical problems to warrant applying for it[,| and specifically mentioned PTSD, depression,
and anxiety.” (Tr. at 18) (quoting Tr. at 429). However, “[o]n returning to Ms. Okonkwo
three days later regarding her mental health, [Plaintiff] reported [that] her medications were
working and she was having no side effects, and she declined a referral for cognitive behavioral
therapy.” (Ir. at 18, 651.)
As further recounted by the AL],
In August 2020, [Plaintiff] reported to Ms. Okonkwo that her primaty care
physician and rheumatologist had refused to complete FMLA and STDI forms.
She said that she cannot return to work with all of her medical conditions
including lupus and that she is unable to master the virtual system of education.
At that time, [Plaintiff] was provided a work note for two weeks.
(Tr. at 18) (citing Tr. at 648) (internal citations omitted). In that medical record, Ms. Okonkwo
noted that Plaintiff “reports doing well as an Avon rep and has sold over $11,000 worth of
Avon products this month; also excited about [her] son’s progtess academically.” (Tr. at 648.)
Later that month, as noted by the ALJ, Plaintiff established care with a new primaty care
physician, again expressing her desire to pursue disability. (Tr. at 18, 640-42.)
10
In December 2020, Plaintiff “presented to Lauren Tessneer for [her] mental health
concerns and expressed an interest in seeing a therapist, although her mood and affect were
normal at that time, and [Plaintiff] did not want to change her medications.” (Tr. at 19, 610-
12.) Nurse Practitioner Tessneer’s record for that visit reflects that Plaintiff was alert and
otiented with a normal mood and affect, and on review of systems, anxiety and depression
wete “present” but other symptoms were “not present” including impaired cognitive function,
inability to concentrate, and memory loss. (Tr. at 612) (emphasis added). The record also
reflects that Plaintiffs “associated symptoms do not include . . . social difficulties, employment
difficulties, financial difficulties, [or] difficulty with activities of daily living.” (Tr. at 610.) As
noted by the ALJ, PlaintifPs mental status exams were benign. (Tr. at 19.) For example, in
Match 2021, Nurse Practitioner Tessneer performed mental status examinations reflecting that
Plaintiff was
able to articulate well with normal speech/language, rate, volume and
coherence, thought content normal with ability to perform basic computations
and apply abstract reasoning, associations ate intact, no evidence of
hallucinations, delusions, obsession ot homicidal/suicidal ideation,
demonstrates appropriate judgment and insight, displays ability to recall recent
and remote events and fund of knowledge is intact and attention span and ability
to concentrate ate normal.
(Tr. at 807, 801.) Plaintiff saw Nurse Practitioner Tessneer again several times during the
spting and summer of 2021, and those visits all reflect similar assessments, and also note that
Plaintiffs anxiety and depression were “improved with medication.” (Tr. at 800, 805-07, 799-
801, 787-89, 885-87, 881-83, 877-79.)
11
The ALJ considered these records and noted that Plaintiffs mental health cate going
forward continued to reflect circumstantial stressors, good management with medication, and
a focus on obtaining disability.°
In April 2021, [Plaintiff] presented to the Neil Group for an initial evaluation
of depression and anxiety and asked for a disability form to be completed.
[Plaintiff] reported that her other providers would not fill out the disability
forms. However, she was advised they could not fill out disability forms, as
[Plaintiff] felt her physical problems were leading to her disability. She was
advised that she needed to work with a lawyer and primary care physician.
During 2021, [Plaintiff] continued [treatment] at Bethany Medical for
medication management for her mental health and other concerns and generally
reported that her medication[s] were working well but that her circumstances at
times made things challenging. Both physical and mental status examination
remained mostly benign, other than for obesity, and her provider there, Terri
Wood-Cummings, MD, reported in November 2021 that she was “[s]till
completing monthly disability forms on patient’s behalf.”
[Plaintiff] returned to the Neil Group in April 2022 after not having been seen
in about a year and reported [that] Bethany Medical would not refill her
medication due to not having been in for a visit in a while, and she reported
doing well on her medications but having a lot of anxiety due to lack of income.
at 19) (internal citations omitted).¢ Notably, by June 2022, Plaintiff reported that “she
was doing better now that her finances had stabilized.” (Tr. at 19, 941).
Overall, the ALJ found that Plaintiffs alleged “mental health limitations are not
consistent with her treatment history, with her reported response to medication, with findings
° At around this same time, in Match 2021, Plaintiff underwent a Physical Functional Capacity Evaluation, but
“the evaluator felt she had not put forth a full effort” and “the evaluator noted the test results were ‘heavily
influenced’ by ‘significant self-limiting behavior.”’ (Tr. at 19, 327.)
° These records from the Neil Group reflect that at her first visit in April 2021, the PA noted that Plaintiff
“wants us to sign a disability form... I told her I could not sign her form because she feels her physical
problems ate leading to her disability and she would need to work with her lawyer and [Primary Care
Physician].” (Ir. at 900.) Plaintiff was assessed as “alert and oriented” with “good concentration and memoty.”
(Ir. at 900-01.) The next visit in October 2021 noted “mild impairment” with issues related to financial
struggles and stress related to her son’s legal issues. (Tr. at 907-08.) However, a subsequent visit in April 2022
reflects appropriate mood and affect, cleat speech, intact thought process, intact memory, good insight, good
concentration, and average or above intellectual functioning. (Tr. at 914.)
12
on mental status evaluations, and with her ongoing work as an Avon representative.” (T'r. at
20.) The ALJ further explained that Plaintiffs “alleged limitations are noted to have been
influenced significantly by situational stressors with reported improvement on alleviating those
stresses, such as improvement in her financial situation.” (Tr. at 20.) Along these lines, the
ALJ noted that
[Plaintiff] had clearly experienced some dissatisfaction with the demands of her
job prior to seeking disability, as she had reported to several providers that she
hated her job and she later expressed having an inability to adjust to the virtual
education system during the pandemic. She also recounted considerable and
understandable stress due to her son’s legal troubles and her financial situation.
As detailed herein, she has given varying and inconsistent statements regarding
the reasons she feels she cannot work. Although certainly some variation could
reflect simply [sic] some changes in her condition, the overall record here does
not reflect a strong medical basis for that variation.
(Tr. at 20.)
In further support of her findings, the ALJ relied on medical opinion evidence supplied
by the State agency psychological consultants and the initial and reconsideration levels. At the
initial level, Kendra McCarty, Psy.D., determined from her review of the evidence that Plainuff
had mild limitations in concentration, persistence, and pace, but no limitations in
understanding, remembering, or applying information, no limitations in interacting with
others, and no limitations in adapting or managing oneself. (Tr. at 21, 107.) At the
reconsideration level, Sean Sayers, Ph.D., found Plaintiff mildly limited in three functional
ateas: interacting with others, concentrating, persisting, and maintaining pace, and adapting
ort managing herself. Like Dr. McCarty, Dr. Sayers found no limitations in Plaintiffs ability
to interact with others. (Tr. at 21,116.) Because these opinions support no more than mild
13
limitations in any mental functional area, they also support the ALJ’s ultimate omission of
mental limitations in PlaintifPs RFC assessment, as discussed above.
The only other opinion evidence relating to Plaintiffs mental functioning comes from
Dr. Wood-Cummings, who, as previously mentioned, submitted multiple documents relating
to Plaintiffs long-term disability claim in 2021. Although Dr. Wood-Cummings asserted in
the forms that Plaintiffs major depressive disorder, anxiety, and chronic pain rendered
Plaintiff unable to work, the ALJ correctly notes that only one of Dr. Wood-Cummings’
opinions included any functional limitations. (It. at 22, 210-12, 217-18, 345-47.) In her
December 12, 2021 opinion, Dr. Wood-Cummings
stated that [Plaintiff] was unable to perform “most functions requiring sustained
effort and concentration, all requiring repetitive physical effort,” and she stated
[that Plaintiff] had “demonstrated inability to concentrate/focus on even
sedentary job tasks for months now due to significant anxiety and depression
which ate aggravated by variably recurrent symptoms of her chronic physical
conditions.”
(Ir. at 22) (quoting Tr. at 346-47) G@nternal brackets omitted). The AL] found this opinion
unpersuasive. In particular, she noted that the “extreme limitations” opined by Dr. Wood-
Cummings were “not consistent with [Plaintiffs] treatment records or activities,” as previously
discussed in the administrative decision. (Tr. at 22.) The ALJ also noted that, in Dr. Woods-
Cummings’ most recent treatment notes prior to that form, from November 2021, Plaintiff
exhibited normal mood and affect as well as “essentially benign” physical findings. (Tr. at 22,
864-66.)’
The medical records reflect that in May 2021, Dr. Wood-Cummings noted that Plaintiff had started going to
the Neil Group for counseling and medication management, and Dr. Wood-Cummings explained to Plaintiff
that “she can only see 1 mental health provider for patient safety and symptom management.” (Tr. at 784.)
Dr. Wood-Cummings’ records for Plaintiffs next visits in August 2021 and November 2021 note normal
mental status exam and no psychiatric treatment. (Tr. at 863-66, 870-73.). Subsequent records from Dr. Wood-
14
In sum, substantial evidence clearly supports the AL]’s determination that Plaintiff's
mental impairments were non-severe and required no functional limitations. Notably, this is
not an instance in which the AL] found one or more impaitments non-sevete at step two and
then failed to consider or discuss their impact later in the analysis. The ALJ in this case
discussed Plaintiffs allegations of disabling depression, anxiety, and PTSD throughout her
analysis, including Plaintiffs testimony, treatment notes, activities, and opinion evidence
relating to these impairments, as set out at length above. In addition, the Court notes that
contrary to Plainuffs contentions, this is not a case where the ALJ discounted an examinet’s
findings because they were based solely on subjective complaints, or otherwise relied on the
lack of objective medical evidence.§ Instead, the AL]’s decision reflects that the ALJ relied on
Cummings in June 2022 likewise reflect normal mental status examinations and that Plaintiff is “Followed by
The Neil Group” for her depression. (Tr. at 918-22, 938-41.)
8 When evaluating a claimant’s symptoms, 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 (“SSR”) 16-3p, Titles II 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 CE-R. §§ 404.1529,
416.929. In Arakas v. Comm’r of Soc. Sec., 983 F.3d 83 (4th Cir. 2020), the Fourth Circuit clarified the
procedure an ALJ must follow when assessing a claimant’s statements:
When evaluating a claimant’s symptoms, ALJs must use the two-step framework set forth in 20
CER. § 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 ALJ 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 required to find the claimant disabled. SSR 16-3p, 2016 WL
1119029, at *4-5. SSR 16-3p recognizes that “[s]ymptoms cannot always be measured objectively
through clinical or laboratory diagnostic techniques.” Id. at *4. Thus, the AL] 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.
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the assessments by Plaintiffs medical providers of the impact of her impairments on her
mental status and functioning, as well as Plaintiffs reports regarding the effectiveness of
medication and the improvement once her finances stabilized, the lack of impact on her
activities including her work as an Avon representative, the specific assessment of the impacts
in each of the Paragraph B areas of functioning, the limited and conservative nature of her
mental health treatment with her focus on obtaining disability, her inconsistent statements to
her providers regarding the basis for her disability claim, and the opinions of the state agency
psychological consultants. See Clifford E. v. O’Malley, No. 1:23CV704, 2024 WL 3105669,
at *9-10 (M.D.N.C. June 24, 2024); Mary W. v. O’Malley, No. 1:23CV128, 2024 WL 1256268
at *11-12 (M.D.N.C. March 25, 2024); Lasharne W. v. Commissioner, Soc. Sec. Admin., No.
SAG-21-2603, 2023 WL 2414497, at *4 (D. Md. Mar. 8, 2023); Anthony P. v. O’Malley, No.
1:22CV291, 2024 WL 965608, at *3 (E.D. Va. Mar. 6, 2024) (“[T]he ALJ in this case did not
dismiss [the plaintiffs] subjecttve complaints based entirely upon the belief that they were not
corroborated by the medical evidence; nor did the ALJ require that [the plaintiffs] subjective
statements be validated by objective medical support. Rather, in assessing [the plaintiff's]
subjective complaints, the AL] considered [the plaintiff's] ability to complete ... myriad...
983 F.3d at 95. In Arakas, 983 F.3d at 97, the Fourth Circuit further explained that some conditions, such as
fibromyalgia, simply do not manifest themselves in objective signs and symptoms. 983 F.3d at 97. Several
later, in Shelley C. v. Comm’r of Soc. Sec. Admin., 61 F.4th 341, 361-62 (4th Cir. 2023), the court extended
the reasoning in Arakas to include psychological impairments, and depression in particular. Because the
symptoms of both fibromyalgia and depression were ““entitely subjective,” the AL]s in these cases erred by
“requiring that [the claimants’] subjective statements be validated by objective medical support.” Shelley C., 61
F4th at 361-62 (quoting Arakas, 983 F.3d at 96). Plaintiff argues that the ALJ in the present case improperly
telied on objective evidence to discount Plaintiffs subjective statements. However, in this case, the ALJ did
not require that Plaintiffs subjective statements be validated by objective tests or reports. Instead, the AL]’s
decision reflects that the AL) considered all of the testimony and the record as a whole, and concluded that
“statements concerning the intensity, persistence, and limiting effects of [Plaintiffs] symptoms [were] not
entitely consistent with the medical evidence and other evidence in the record.”
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daily activities, [his] own statements about his condition, and [his] treating provider’s
obsetvations of [the plaintiffs] functioning. Fourth Circuit precedent does not suggest that
ALJs should ignore objective evidence such as this; instead, Shelley C. and Arakas prevent
ALJs from requiring claimants to provide medical evidence that would be impossible to
produce given their specific medical conditions. The AL] weighed the [plaintiffs] subjective
complaints appropriately under those holdings and did not impose undue demands.”’).
Contrary to Plaintiffs contentions, the ALJ in the present case did not require that Plaintiffs
complaints of debilitating mental symptoms be validated by objective medical evidence.
Rather, in accordance with 20 C.F.R. §§ 404.1529 and 416.929, SSR 16-3p, and relevant case
law, the ALJ considered the medical evidence, including the assessments by Plaintiffs treating
ptoviders upon examination, as one of many factors when evaluating her subjective
complaints. Further, given the extensive analysis set out in the decision, this is not a scenario
in which the ALJ failed “to assess [the] claimant’s capacity to perform relevant functions,
despite contradictory evidence in the record, or where other inadequacies in the AL]’s analysis
frustrate meaningful review.” Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015). Here, the
AL] teviewed 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.
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IT IS THEREFORE ORDERED that the Commissionet’s decision finding of no
disability is AFFIRMED, that Plaintiffs Dispositive Brief [Doc. #12] is DENIED, that
Defendant’s Dispositive Brief [Doc. #13] is GRANTED, and that this action is DISMISSED
with prejudice.
This, the 26% day of March, 2025.
j [ st Peake
nited States Magistrate Judge
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