“If the ALJ finds that a claimant has not satisfied any step of the process, review does not proceed to the next step.”
How later courts described this case
- “If the ALJ finds that a claimant has not satisfied any step of the process, review does not proceed to the next step.”
- holding that “the ALJ need only review medical evidence once in his decision”
Written by the judges who cited it.
The opinion
IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF NORTH CAROLINA
LAQUITA M. R., )
)
Plaintiff, )
)
v. ) 1:24CV604
)
FRANK J. BISIGNANO, )
Commissioner of Social )
Security, )
)
Defendant.1 )
MEMORANDUM OPINION AND ORDER
OF UNITED STATES MAGISTRATE JUDGE
Plaintiff, Laquita M. R., brought this action pursuant to the
Social Security Act (the “Act”) to obtain judicial review of a
final decision of Defendant, the Commissioner of Social Security
(the “Commissioner”), denying Plaintiff’s claims for Disability
Insurance Benefits (“DIB”) and Supplemental Security Income
(“SSI”). (Docket Entry 2.) The Commissioner has filed the
certified administrative record (Docket Entry 5 (cited herein as
“Tr. __”)), and both parties have submitted dispositive briefs in
accordance with Rule 5 of the Supplemental Rules for Social
Security Actions under 42 U.S.C. § 405(g) (Docket Entry 10
(Plaintiff’s Brief); Docket Entry 12 (Commissioner’s Brief); Docket
1 The United States Senate confirmed Frank J. Bisignano as the Commissioner
of the Social Security Administration on May 6, 2025, and he took the oath of
office on May 7, 2025. Pursuant to Rule 25(d) of the Federal Rules of Civil
Procedure, Frank J. Bisignano should substitute for Leland C. Dudek as the
defendant in this suit. No further action need be taken 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).
Entry 13 (Plaintiff’s Reply)). For the reasons that follow, the
Court will enter judgment for the Commissioner.2
I. PROCEDURAL HISTORY
Plaintiff applied for DIB and SSI (Tr. 201-14), alleging a
disability onset date of March 13, 2022 (see Tr. 201, 213). Upon
denial of those applications initially (Tr. 80-95, 112-16) and on
reconsideration (Tr. 96-111, 123-31), Plaintiff requested a hearing
de novo before an Administrative Law Judge (“ALJ”) (Tr. 132).
Plaintiff, her attorney, and a vocational expert (“VE”) attended
the hearing. (Tr. 45-79.) The ALJ subsequently ruled that
Plaintiff did not qualify as disabled under the Act. (Tr. 21-44.)
The Appeals Council thereafter denied Plaintiff’s request for
review (Tr. 1-6, 195-200), thereby making the ALJ’s ruling the
Commissioner’s final decision for purposes of judicial review.
In rendering that decision, the ALJ made the following
findings later adopted by the Commissioner:
1. [Plaintiff] meets the insured status requirements of
the . . . Act through March 31, 2026.
2. [Plaintiff] has not engaged in substantial gainful
activity since March 13, 2022, the alleged onset date.
3. [Plaintiff] has the following severe impairments:
bipolar disorder; anxiety; and post-traumatic stress
disorder (PTSD).
. . .
2 On consent of the parties, this “case [wa]s referred to [the undersigned]
United States Magistrate Judge . . . to conduct all proceedings . . ., to order
the entry of judgment, and to conduct all post-judgment proceedings []herein.”
(Docket Entry 8 at 1.)
2
4. [Plaintiff] 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.
. . .
5. . . . [Plaintiff] has the residual functional
capacity to perform a full range of work at all
exertional levels but with the following nonexertional
limitations: [she] is limited to understanding,
remembering, and carrying out simple instructions, can
use judgment to make simple work-related decisions; and
can sustain concentration, attention, and pace sufficient
to carry out simple, routine, repetitive tasks for two-
hour intervals over the course of an eight-hour work day;
limited to work in occupations that require no more than
occasional contact with co-workers and supervisors and no
contact with the general public as an essential function
of the job; limited to work in a low stress setting,
which is defined to mean work involving: no paced
production requirements, such as on an assembly line,
where the worker does not control the pace of production,
occasional changes in the work setting or routine, and no
dealing with crisis situations as an essential function
of the job.
. . .
6. [Plaintiff] is unable to perform any past relevant
work.
. . .
10. Considering [Plaintiff]’s age, education, work
experience, and residual functional capacity, there are
jobs that exist in significant numbers in the national
economy that [she] can perform.
. . .
3
11. [Plaintiff] has not been under a disability, as
defined in the . . . Act, from March 13, 2022, through
the date of th[e ALJ’s] decision.
(Tr. 27-38 (bold font and internal parenthetical citations
omitted).)
II. DISCUSSION
Federal law “authorizes judicial review of the Social Security
Commissioner’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). Plaintiff has
not established entitlement to relief under the extremely limited
review standard.
A. Standard of Review
“[C]ourts are not to try [a Social Security] 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 ALJ
[underlying the denial of benefits] if they are supported by
substantial evidence and were reached through application of the
correct legal standard.” Hines, 453 F.3d at 561 (internal brackets
and quotation marks 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
4
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) (internal brackets 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 [C]ourt should not
undertake to re-weigh conflicting evidence, make credibility
determinations, or substitute its judgment for that of the [ALJ, as
adopted by the Commissioner].” 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
[Commissioner] (or the ALJ).” Id. at 179 (internal quotation marks
omitted). “The issue before [the Court], therefore, is not whether
[the claimant] is disabled, but whether the ALJ’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).
When confronting that issue, the Court must take note that
“[a] claimant for disability benefits bears the burden of proving
a disability,” Hall v. Harris, 658 F.2d 260, 264 (4th Cir. 1981),
and that, in this context, “disability” means the “‘inability to
engage in any substantial gainful activity by reason of any
5
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)).3 “To regularize the
adjudicative process, the Social Security Administration [(‘SSA’)]
has . . . promulgated . . . detailed regulations incorporating
longstanding medical-vocational evaluation policies that take into
account a claimant’s age, education, and work experience in
addition to [the claimant’s] medical condition.” Id. “These
regulations establish a ‘sequential evaluation process’ to
determine whether a claimant is disabled.” Id. (internal citations
omitted).
This sequential evaluation process (“SEP”) has up to five
steps: “The claimant (1) must not be engaged in ‘substantial
gainful activity,’ i.e., currently working; and (2) must have a
‘severe’ impairment that (3) meets or exceeds the ‘listings’ of
specified impairments, or is otherwise incapacitating to the extent
that the claimant does not possess the residual functional capacity
[(‘RFC’)] to (4) perform [the claimant’s] past work or (5) any
other work.” Albright v. Commissioner of Soc. Sec. Admin., 174
3 The Act “comprises two disability benefits programs. [DIB] . . .
provides benefits to disabled persons who have contributed to the program while
employed. [SSI] . . . provides benefits to indigent disabled persons. The
statutory definitions and the regulations . . . for determining disability
governing these two programs are, in all aspects relevant here, substantively
identical.” Craig, 76 F.3d at 589 n.1 (internal citations omitted).
6
F.3d 473, 475 n.2 (4th Cir. 1999).4 A finding adverse to the
claimant at any of several points in the SEP forecloses an award
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
each of the first three steps, “the claimant is disabled.” Mastro,
270 F.3d at 177. Alternatively, if a claimant clears steps one and
two, but falters at step three, i.e., “[i]f a claimant’s impairment
is not sufficiently severe to equal or exceed a listed impairment,
the ALJ must assess the claimant’s [RFC].” Id. at 179.5 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
4 “Through the fourth step, the burden of production and proof is on the
claimant. If the claimant reaches step five, the burden shifts to the
[government] . . . .” Hunter, 993 F.2d at 35 (internal citations omitted).
5 “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 require RFC to reflect claimant’s “ability to do sustained work-
related physical and mental activities in 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
impairments).” Hall, 658 F.2d at 265. “RFC is to be determined by the ALJ only
after [the ALJ] considers all relevant evidence of a claimant’s impairments and
any related symptoms (e.g., pain).” Hines, 453 F.3d at 562-63.
7
claimant establishes an inability to return to prior work, the
analysis proceeds to the fifth step, whereupon the ALJ must decide
“whether the claimant is able to perform other work considering
both [the 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
carry 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 567.6
B. Assignment of Error
In Plaintiff’s first and only issue on review, she maintains
that “[t]he RFC determination is not supported by substantial
evidence because the ALJ failed to properly evaluate the opinion
evidence pursuant to 20 C.F.R. §§ 404.1520c(b)(2), 416.920c(b)(2).”
(Docket Entry 10 at 2 (bold font and block formatting omitted); see
also Docket Entry 13 at 1-4.) More specifically, Plaintiff
contends that “three treating providers[, Dr. Ralph Newman, Meaghan
Whitson, LCSW (‘LCSW Whitson’), and Uchenna Nwoko, PA (‘PA
Nwoko’),] offered opinions related to Plaintiff’s ability to work
and quantified limitations that would impact the ability to work on
6 A claimant thus can qualify as disabled via two paths through the SEP.
The first path requires resolution of the questions at steps one, two, and three
in the claimant’s favor, whereas, on the second path, the claimant must prevail
at steps one, two, four, and five. Some short-hand judicial characterizations
of the SEP appear to gloss over the fact that an adverse finding against a
claimant on step three does not terminate the analysis. See, e.g., Hunter, 993
F.2d at 35 (“If the ALJ finds that a claimant has not satisfied any step of the
process, review does not proceed to the next step.”).
8
a regular and continuing basis, eight hours a day, five days a
week . . .[; h]owever, the ALJ rejected all of these opinions
without properly addressing supportability and consistency and
without supporting her conclusions with substantial evidence.”
(Docket Entry 10 at 7 (hyphen omitted).) Plaintiff notes that
“[t]he [VE] testified that an individual who was off task more than
ten percent would be unable to work[,]” and “that more than one
absence a month would preclude work” (id. at 13 (citing Tr. 74-
75)), and further points out that “Dr. Newman, LCSW W[h]itson, and
PA Nwoko all opined Plaintiff would be off-task and absent beyond
employer tolerances.” (Id. (citing Tr. 361, 429, 469).) In
Plaintiff’s view, “the ALJ has frustrated meaningful review with
the legally insufficient evaluations of [those] opinions.” (Id. at
13.) For the reasons explained in more detail below, Plaintiff’s
contentions lack merit.
For benefits applications filed on or after March 27, 2017,
such as Plaintiff’s (see Tr. 201-14), the SSA has enacted
substantial revisions to the regulations governing the evaluation
of opinion evidence. See Revisions to Rules Regarding the
Evaluation of Medical Evidence, 82 Fed. Reg. 5844-01, 2017 WL
168819 (Jan. 18, 2017). Under the new regulations, ALJs need not
assign an evidentiary weight to medical opinions or to accord
special deference to treating source opinions. See 20 C.F.R.
§§ 404.1520c(a), 416.920c(a) (providing that ALJs “will not defer
9
or give any specific evidentiary weight, including controlling
weight, to any medical opinion(s) or prior administrative medical
finding(s), including those from [a claimant’s] medical sources”).7
Instead, an ALJ must determine and “articulate in [the] . . .
decision how persuasive [he or she] find[s] all of the medical
opinions and all of the prior administrative medical findings in [a
claimant’s] case record.” 20 C.F.R. §§ 404.1520c(b), 416.920c(b)
(emphasis added). Moreover, when a medical source provides more
than one opinion or finding, the ALJ will evaluate the
persuasiveness of such opinions or findings “together in a single
analysis” and need not articulate how he or she considered those
opinions or findings “individually.” 20 C.F.R. §§ 404.1520c(b)(1),
416.920c(b)(1).
In evaluating the persuasiveness of an opinion or finding, the
SSA deems supportability and consistency “the most important
factors” and thus the ALJ must address those two factors in
evaluating the persuasiveness of an opinion or a finding. 20
C.F.R. §§ 404.1520c(b)(2), 416.920c(b)(2).8 The ALJ must only
7 The new regulations define a “medical opinion” as “a statement from a
medical source about what you can still do despite your impairment(s) and whether
you have one or more impairment-related limitations or restrictions” in the
abilities to perform the physical, mental, or other demands of work activity or
to adapt to environmental conditions. 20 C.F.R. §§ 404.1513(a)(2), 416.913(a)(2)
(2017). Those regulations also define a “prior administrative medical finding”
as a “finding, other than the ultimate determination about whether [a claimant
is] disabled, about a medical issue made by [the SSA’s] Federal and State agency
medical and psychological consultants at a prior level of review.” 20 C.F.R.
§§ 404.1513(a)(5), 416.913(a)(5) (2017).
8 “Supportability” means “[t]he extent to which a medical source’s opinion
is supported by relevant objective medical evidence and the source’s supporting
explanation.” Revisions to Rules, 82 Fed. Reg. at 5853; see also 20 C.F.R.
10
address the three other persuasiveness factors — the nature and
extent of the medical source’s relationship with the claimant and
area of specialization, as well as the catch-all “other factors
that tend to support or contradict” the opinion/finding, 20 C.F.R.
§§ 404.1520c(c)(3)-(5), 416.920c(c)(3)-(5) — when the ALJ finds two
or more opinions or findings about the same issue “[e]qually
persuasive” in terms of supportability and consistency, 20 C.F.R.
§§ 404.1520c(b)(3), 416.920c(b)3).
1. Dr. Newman’s Opinions
Dr. Newman completed a preprinted form entitled “Mental Health
Medical Source Statement” on May 11, 2022 (“Newman MSS”), on which
he listed Plaintiff’s diagnoses as “Bipolar Depression; Panic
Disorder [with] Agoraphobia; [and] PTSD.” (Tr. 361.) Dr. Newman
noted that Plaintiff experienced “ongoing auditory hallucinations
that only partially respond[ed] to medication” and “[r]ecurrent,
severe panic attacks 3[ times] per day,” along with anhedonia,
decreased energy and fatigue, persistent anxiety, withdrawal,
psychomotor agitation or retardation, difficulty concentrating,
impaired memory, paranoia, and disturbance of mood and sleep.
(Id.) According to Dr. Newman, Plaintiff’s mental impairments
would cause her to need “about 10 [unscheduled breaks] per shift,”
remain off task “25 [percent] or more” of a typical workday, and
§§ 404.1520c(c)(1), 416.920c(c)(1). “Consistency” denotes “the extent to which
the opinion is consistent with the evidence from other medical sources and
nonmedical sources in the claim.” Revisions to Rules, 82 Fed. Reg. at 5853; see
also 20 C.F.R. §§ 404.1520c(c)(2), 416.920c(c)(2).
11
miss work “[m]ore than four days per month.” (Id.) Dr. Newman
believed that Plaintiff could not handle “even ‘low stress’ work,”
and opined that Plaintiff had “marked” limitation in her ability to
understand, remember, or apply information, “extreme” limitations
in her abilities to interact with others and concentrate, persist,
or maintain pace, and “moderate” limitation in her ability to adapt
and self-manage. (Id.)
The ALJ provided the following evaluation of the
persuasiveness of the Newman MSS:
Th[e Newman MSS] is not persuasive as to the marked and
extreme limitations. This opinion is not well supported,
as it contains almost no narrative explanation for the
opinion. Further, while the opinion was somewhat
supported by [Plaintiff’s] presentation and subjective
report on the visits shortly before Dr. Newman completed
the [MSS] ([Tr. 320-60]), when [Plaintiff] was reportedly
not able to afford all of her medications, the opinion is
not consistent with subsequent records, once [she] had
begun taking all of the prescribed medications only a few
months later ([Tr. 386-427]). Once she was taking those
medications, while she was not without symptoms and still
had some abnormalities on mental status exams, overall
these records do not support more than a moderate
limitation or a need for unscheduled breaks, excessive
time off task or absenteeism.
(Tr. 35.) Plaintiff contests that evaluation by the ALJ on three
grounds (see Docket Entry 10 at 7-8), none of which carry the day.
To begin, Plaintiff objects to the ALJ’s rationale that the
Newman MSS “‘contain[ed] almost no narrative explanation for the
opinion.’” (Id. at 7 (quoting Tr. 35).) According to Plaintiff,
“[t]he regulations include no requirement that a narrative
explanation be provided within the four corners of the opinion
12
itself” but, instead, “require[] a review of the information
contained in the records from the source itself, meaning all the
records from Dr. Newman were to be reviewed and evaluated for
supportability.” (Id. (citing 20 C.F.R. §§ 404.1520c(b)(2),
416.920c(b)(2)).)
Although the regulations do not require a medical source to
include narrative explanations for his or her opinions, those
regulations make clear that “[t]he more relevant the objective
medical evidence and supporting explanations presented by a medical
source are to support his or her medical opinion(s) . . ., the more
persuasive the medical opinions . . . will be.” 20 C.F.R.
§§ 404.1520c(c)(1), 416.920c(c)(1) (emphasis added). Here, Dr.
Newman did not provide any narrative explanation for his opinions
regarding unscheduled breaks, off-task time, low stress work, work
absence, and functional limitations. (See Tr. 361.) District
courts within the Fourth Circuit have long recognized that ALJs may
permissibly discount check-box forms that lack narrative
explanations. See, e.g., Simone v. Saul, No. 5:19CV41, 2020 WL
961431, at *5 (E.D.N.C. Jan. 24, 2020) (unpublished) (“Check-box or
fill-in-the-blank forms are typically considered weak evidence.”),
recommendation adopted sub nom. Simone v. Berryhill, 2020 WL 968361
(E.D.N.C. Feb. 27, 2020) (unpublished); Curtis W. v. Saul, No. CV
18-3037, 2019 WL 6872869, at *3 (D. Md. Dec. 17, 2019)
(unpublished) (“Although it is entirely appropriate for a treating
13
source to indicate their opinion on [] a checkbox form, an ALJ is
permitted to discount such opinions where they do not include
enough narrative explanation to communicate the basis of the
opinion.” (internal quotation marks omitted)); Mullinax v. Saul,
No. 6:18CV690, 2019 WL 4565050, at *3 (D.S.C. Sept. 20, 2019)
(unpublished) (“[T]he ALJ found [the physician’s] opinion was []
entitled to less weight because it was a checkbox form calling for
minimal narrative explanation, which is [] a proper basis for not
giving the opinion of a treating physician controlling weight[.]”
(internal quotation marks and parenthetical citation omitted));
Shelton v. Colvin, No. 7:13CV470, 2015 WL 1276903, at *3 (W.D. Va.
Mar. 20, 2015) (unpublished) (“Notably, [the physician]’s opinion
is simply a checkbox form. Courts in the Fourth Circuit have
recognized the limited probative value of such checkbox opinion
forms.”); Schaller v. Colvin, No. 5:13CV334, 2014 WL 4537184, at
*16 (E.D.N.C. Sept. 11, 2014) (unpublished) (“[S]ince the opinion
is in the form of a questionnaire, the ALJ was entitled to assign
it less weight than a fully explanatory and narrative opinion
because such form opinions do not offer adequate explanation of
their findings.”).9 The ALJ did not err by discounting the Newman
9 Although not relied on by Plaintiff (see Docket Entries 10, 13), in
Easterbrook v. Kijakazi, 88 F.4th 502, 514 (4th Cir. 2023), the United States
Court of Appeal for the Fourth Circuit faulted an ALJ’s decision to discount a
treating physician’s opinions in part because the physician “merely checked off
boxes on a form and did not provide a narrative report containing specific
clinical findings to support all the extreme limitations.” Easterbrook, 88 F.4th
at 514 (internal quotation marks omitted). However, the Fourth Circuit found ALJ
error, because the physician had actually “provided notations in the margins
relevant to [the plaintiff]’s condition” and “submitted a narrative letter . . .
14
MSS, in part, because it lacked narrative explanations. (See Tr.
35.)
Next, Plaintiff contends that the ALJ’s observation that the
Newman MSS “‘was somewhat supported by [Plaintiff’s] presentation
and subjective report on the visits shortly before Dr. Newman
completed the [MSS]’ . . . actually indicates [the Newman MSS] was
supported by [his] examination findings[, and] . . . it should have
been found persuasive.” (Docket Entry 10 at 7 (italics supplied by
Plaintiff) (quoting Tr. 35).) Plaintiff additionally argues that,
although “the ALJ discount[ed] the supportability of [the Newman
MSS] because there appeared to be some improvement after Plaintiff
began taking some medications” (id. (citing Tr. 35)), “the ALJ even
note[d] that ‘[Plaintiff] was not without symptoms and still had
some abnormalities on mental status exams’” (id. at 7-8 (quoting
Tr. 35)). Plaintiff thus faults the ALJ for “actually find[ing]
support for [the Newman MSS] but []not cit[ing] anything specific
that would allow the Court to understand why [the Newman MSS]
should be rejected.” (Id. at 8.) That argument fails for two
reasons.
First, Plaintiff’s argument glosses over the modifier
“somewhat” the ALJ placed in front of the word “supported” (Tr.
that provided details about [the plaintiff], her condition, her prior treatment,
the current scope of her disability, and [the physician’s] prognosis for [the
plaintiff]’s condition” and thus found that “[the physician]’s opinions offered
far more than a cursory review of [the plaintiff]’s condition.” Id. Thus,
Easterbrook did not hold that an ALJ errs merely by discounting a check-box
medical opinion as lacking an explanatory narrative. See id.
15
35). (See Docket Entry 10 at 7.) The ALJ’s finding the Newman
MSS’s opinions “somewhat supported” by Dr. Newman’s records (Tr. 35
(emphasis added)) would not, even standing alone, require the ALJ
to find those opinions fully persuasive and/or to adopt those
opinions. Second, and more significantly, Plaintiff interprets the
ALJ’s statement deeming the Newman MSS “somewhat supported” (Tr.
35) outside of its larger context. The ALJ actually stated that,
“while the [Newman MSS] was somewhat supported by [Plaintiff’s]
presentation and subjective report on the visits shortly before Dr.
Newman completed the [MSS], when [Plaintiff] was reportedly not
able to afford all of her medications, the [MSS] is not consistent
with subsequent records, once [she] had begun taking all of the
prescribed medications only a few months later.” (Tr. 35 (emphasis
added) (citing Tr. 386-427).) The full context of the ALJ’s
statement makes clear she found the Newman MSS’s opinions only
“somewhat supported” by Dr. Newman’s records (id. (emphasis
added)}, which covered the brief time frame from March 16, 2022, to
May 11, 2022 (see Tr. 330-61), when Plaintiff experienced an acute
exacerbation of her mental impairments (see Tr. 63), and had not
yet started taking the antipsychotic medication Seroquel (see Tr.
320), but not consistent with subsequent treatment which showed
improvement on medication (see Tr. 35 (citing Tr. 386-427)). In
short, the Court can meaningfully review the ALJ’s supportability
analysis of the Newman MSS.
16
Plaintiff additionally asserts that “the ALJ completely
ignore[d] the regulatory requirement to discuss consistency[,]”
because she “d[id] not acknowledge any medical evidence from any
other provider in the discussion of [the Newman MSS].” (Docket
Entry 10 at 8 (citing 20 C.F.R. §§ 404.1520c(b)(2),
416.920c(b)(2)).) That assertion entirely overlooks the ALJ’s
statement that “the [Newman MSS] is not consistent with subsequent
records, once [Plaintiff] had begun taking all of the prescribed
medications only a few months later.” (Tr. 35 (emphasis added)
(citing Tr. 386-427).) In support of that statement, the ALJ cited
to treatment records from Plaintiff’s primary care provider,
Alvesha Williams, NP (“NP Williams”), from October 20, 2022,
through March 23, 2023. (Id. (citing Tr. 386-427).)10 As the ALJ
had previously observed in the decision, those records reflected
“that [Plaintiff] was grossly oriented to person, place and
time[,] . . . [had] intact judgment and insight,” with “normal”
mood and an “appropriate” affect, reported “[n]o hallucinations and
no delusions[,] . . . and [] was only taking Seroquel.” (Tr. 32.)
The ALJ thus cited to substantial evidence that lacked consistency
with the Newman MSS, allowing for meaningful judicial review.
10 The record contains no treatment between May 11, 2022, the date of the
Newman MSS, and October 20, 2022, the date of Plaintiff’s first visit with NP
Williams in 2022.
17
2. LCSW Whitson’s Opinions
LCSW Whitson filled out the same preprinted form as Dr. Newman
on March 24, 2023 (“Whitson MSS”), diagnosing Plaintiff with
bipolar I disorder, agoraphobia with panic disorder, PTSD, and
insomnia disorder. (Tr. 429.)11 LCSW Whitson stated that Plaintiff
experienced “ongoing hallucinations” and “[r]ecurrent, severe panic
attacks 3[ times per] day,” along with anhedonia, decreased energy
and fatigue, persistent anxiety, withdrawal, difficulty
concentrating, impaired memory, paranoia, hyperactivity/
distractibility, and disturbance of mood and sleep. (Id.) In LCSW
Whitson’s view, Plaintiff’s psychiatric conditions would cause her
to need 12 “brief” unscheduled breaks per shift, remain off-task
“25 [percent] or more” of a typical workday, and miss work “[m]ore
than four days per month.” (Id.)12 LCSW Whitson opined that
Plaintiff had “marked” limitation in her ability to understand,
remember, or apply information, “extreme” limitations in her
abilities to interact with others and concentrate, persist, or
maintain pace, and “moderate” limitation in her ability to adapt
and self-manage. (Id.)
11 LCSW Whitson listed the psychiatric diagnostic codes “296.5, 300.21,
309.81, [and] 780.52[,]” which correspond to bipolar I disorder, agoraphobia with
panic disorder, PTSD, and insomnia disorder, respectively, in the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (“DSM-V”). See DSM-V, 127,
217, 271, 362 (Am. Psychol. Ass’n 5th ed. 2013).
12 LCSW Whitson offered contradictory opinions regarding Plaintiff’s
ability to tolerate work stress, in that she checked both the box that
characterized Plaintiff as “[i]ncapable of even ‘low stress’ work” and the box
that deemed her “[c]apable of moderate stress - normal work.” (Tr. 429.)
18
The ALJ analyzed the persuasiveness of the Whitson MSS as
follows:
Th[e Whitson MSS] is [] not persuasive. It is not well
supported in the body of the opinion itself, and it is
not consistent with overall records once [Plaintiff] had
begun taking all of the prescribed medications ([Tr. 386-
427]). Once she was taking those medications, only a few
months after the alleged onset date, while she was not
without symptoms and still had some abnormalities on
mental status examinations, overall these records do not
support more than a moderate limitation or a need for
unscheduled breaks, excessive time off task or
absenteeism. Notably, this opinion is inconsistent with
findings on mental status examinations shortly after the
[Whitson MSS] ([Tr. 520-61, 589]).
(Tr. 36.) Plaintiff attacks that analysis on three bases (see
Docket Entry 10 at 9-10) but, for the reasons discussed in more
detail below, none of those bases establishes a basis for remand.
Plaintiff first reiterates her objection to the ALJ’s reliance
on the lack of “narrative explanation within the four corners of
the [Whitson MSS].” (Id. at 9 (citing Tr. 36).) As discussed
above, however, the ALJ did not err in discounting the persuasive
value of the Whitson MSS, in part, because it lacked any supporting
explanation for its significant limitations. See, e.g., Simone,
2020 WL 961431, at *5 (“Check-box or fill-in-the-blank forms are
typically considered weak evidence.”); Curtis W., 2019 WL 6872869,
at *3 (“Although it is entirely appropriate for a treating source
to indicate their opinion on [] a checkbox form, an ALJ is
permitted to discount such opinions where they do not include
enough narrative explanation to communicate the basis of the
19
opinion.” (internal quotation marks omitted)); Mullinax, 2019 WL
4565050, at *3 (“[T]he ALJ found [the physician’s] opinion was []
entitled to less weight because it was a checkbox form calling for
minimal narrative explanation, which is [] a proper basis for not
giving the opinion of a treating physician controlling weight[.]”
(internal quotation marks and parenthetical citation omitted));
Shelton, 2015 WL 1276903, at *3 (“Notably, [the physician]’s
opinion is simply a checkbox form. Courts in the Fourth Circuit
have recognized the limited probative value of such checkbox
opinion forms.”); Schaller, 2014 WL 4537184, at *16 (“[S]ince the
opinion is in the form of a questionnaire, the ALJ was entitled to
assign it less weight than a fully explanatory and narrative
opinion because such form opinions do not offer adequate
explanation of their findings.”).
Second, Plaintiff posits that the ALJ’s finding “that
‘overall’ the record only support[ed] moderate
limitations . . . frustrates meaningful review because it is
unclear what evidence from LCSW Whitson’s own records fails to
support [the Whitson MSS].” (Docket Entry 10 at 9 (quoting Tr.
36).) According to Plaintiff, LCSW Whitson’s “examinations noted
anxious mood and auditory hallucinations[,]” and Plaintiff “noted
that it was challenging to alter hallucinations versus reality when
she [wa]s around other people.” (Id. at 10 (citing Tr. 473).)
20
Plaintiff contends that “[t]h[o]se findings were not mentioned by
the ALJ although they support the [Whitson MSS].” (Id.)
As an initial matter, although Plaintiff refers to
“examinations” conducted by LCSW Whitson (see id. (emphasis
added)), the record contains only one treatment record from LCSW
Whitson dated April 27, 2022 (see Tr. 473). Moreover, contrary to
Plaintiff’s assertion that LCSW Whitson’s “findings were not
mentioned by the ALJ” (Docket Entry 10 at 10), previously in the
ALJ’s decision, she discussed that treatment record as follows:
Office treatment records from Triad [Adult and Pediatric
Medicine] dated April 27, 2022, showed [Plaintiff]
presented with anxious mood with an appropriate affect.
She denied suicidal ideation or homicidal ideation. She
reportedly experience[d] auditory hallucinations.
However, [she] reported that she was noticing an
improvement with her panic attacks and anxiety since
taking medication. She expressed that she had not
experienced as many panic attacks and that she had been
trying to go in public more frequently. [She] expressed
that she was able to alter between hallucinations and
reality when alone. She also reported that she had not
purchased antipsychotic medication, but had every other
medication. She stated that she planned to go purchase
antipsychotic medication, as she realized the importance
([Tr. 473]).
(Tr. 32 (emphasis added).) As emphasized above, the ALJ clearly
discussed the findings Plaintiff references, as well as Plaintiff’s
report to LCSW Whitson of improving panic attacks and anxiety. See
McCartney v. Apfel, 28 F. App’x 277, 279 (4th Cir. 2002) (holding
that “the ALJ need only review medical evidence once in his
decision”). Moreover, the ALJ acknowledged the fact that, at the
time of LCSW Whitson’s sole examination of Plaintiff, she had not
21
yet started on Seroquel (see id.), which the ALJ cited as one basis
to discount the Whitson MSS (see Tr. 36). Under such
circumstances, the Court can trace the path of the ALJ’s
supportability analysis.
Third, Plaintiff targets the ALJ’s consistency analysis as a
“blanket finding that ‘th[e Whitson MSS wa]s inconsistent with
findings on mental status examinations,’ [which] point[ed] to a
swath of evidence that d[id] not direct the Court into meaningful
review of why the [Whitson MSS wa]s not persuasive.” (Docket Entry
10 at 10 (quoting Tr. 36).) According to Plaintiff, “[t]he [ALJ’s]
citation to the record . . . contains mixed evidence that fails to
show any genuine inconsistency with [the Whitson MSS]” (id. (citing
Tr. 520-51, 590)), including “objective findings” such as a
“(Generalized Anxiety Disorder (‘GAD’)}]-7 score [of] 18 indicating
severe anxiety, and [a] [Patient Health Questionnaire (‘PHQ’)]-9
score [of] 22 indicating severe depression” (id. (citing Tr. 590)).
As a threshold matter, Plaintiff mischaracterizes her scores
on the PHQ-9 and the GAD-7 as “objective findings.” (Id. (emphasis
added) .) “The [PHQ]-9 is a self-administered scale that helps
clinicians assess for depression. The nine items on the scale
incorporate depression criteria from the [Diagnostic and
Statistical Manual of Mental Disorders (Am. Psychiatric Ass’n 4th
ed. 1994) (‘DSM-IV’)].” Xavier S. v. Saul, No. 1:19CV1195, 2020 WL
1015816, at *16 n.10 (E.D. Va. Mar. 2, 2020) (unpublished)
22
(emphasis added) (internal citations omitted). The PHQ-9 “scores
each of the nine DSM-IV criteria as ‘0’ (not at all) to ‘3’ (nearly
every day). The total of the nine scores is used to rate the
severity of depression. A total score of 0-4 is ‘none,’ 5-9 is
‘mild,’ 10-14 is ‘moderate,’ 15-19 is ‘moderately severe,’ and
20-27 is ‘severe.’” Deboard v. Colvin, No. 3:16CV2661, 2017 WL
510743, at *3 (S.D.W. Va. Jan. 18, 2017) (unpublished),
recommendation adopted sub nom. Deboard v. Berryhill, 2017 WL
510052 (S.D.W. Va. Feb. 7, 2017) (unpublished).
“Like the PHQ-9, the [GAD]-7 is a self-administered diagnostic
instrument to measure anxiety severity. A score of 0-4 represents
a ‘minimal’ level of anxiety; 5-9, ‘mild’; 10-14, ‘moderate’; and
5-21, ‘severe.’” Buechner v. Saul, No. 20CV379, 2021 WL 457610, at
*2 (W.D. Wis. Feb. 9, 2021) (unpublished) (emphasis added)
(internal citations omitted). Thus, Plaintiff’s PHQ-9 and GAD-7
scores did not constitute “objective findings” substantiating the
Whitson MSS. See Facer v. Commissioner of Soc. Sec., No. CV
23-281, 2024 WL 5167714, at *1 n.1 (W.D. Pa. Dec. 19, 2024)
(unpublished) (“[T]he ALJ’s failure to discuss the PHQ-9 and GAD-7
scores in relation to their consistency with [a therapist]’s
opinion is not reversible error as these scores are based on [the
p]laintiff’s subjective reports, not results on objective
examination.”); Nicole M. v. O’Malley, No. 7:22CV600, 2024 WL
1283343, at *5 n.3 (W.D. Va. Mar. 26, 2024) (unpublished) (“The
23
PHQ-9 test appears to calculate a score based entirely on the
subject’s responses to certain questions. As one court put it,
those test scores were ‘based upon claimant’s subjective reports,
rather than [the provider’s] objective assessments.’” (internal
parenthetical citation omitted) (quoting Moffat v. Kijakazi, No.
3:21CV129, 2022 WL 2196311, at *13 (N.D.W. Va. May 23, 2022)
(unpublished), recommendation adopted, 2022 WL 2195764 (N.D.W. Va.
June 17, 2022) (unpublished))); Amy R. v. Saul, No. 19CV1508, 2020
WL 3077502, at *1 (D. Minn. June 10, 2020) (unpublished) (rejecting
the plaintiff’s “argu[ment] that the ALJ erred when he failed to
consider [the plaintiff’s] PHQ-9[ and] GAD-7[] scores as objective
evidence of severe depression and anxiety,” because “the PHQ-9 and
the GAD-7 are measurements that are derived solely from the
patient’s report of their own subjective experience” and thus “to
rule that the tests are not subjective would unacceptably blur the
line between subjective and objective tests”).
Moreover, the ALJ here found Plaintiff’s subjective statements
(which would include her PHQ-9 and GAD-7 scores) “not entirely
consistent with the medical evidence and other evidence in the
record” (Tr. 30), a finding which Plaintiff did not challenge (see
Docket Entries 10, 13). See Sheila A. v. Berryhill, No. 17CV2161,
2018 WL 4572982, at *4 (D. Minn. Sept. 24, 2018) (unpublished)
(“Because the content on a PHQ is derived exclusively from the
patient’s subjective complaints, it is subject to being credited or
24
discredited for the same reasons as other subjective complaints.”),
aff’d, 802 F. App’x 228 (8th Cir. 2020)).
Furthermore, the ALJ earlier in her decision discussed in
detail the treatment records she cited as inconsistent with the
Whitson MSS. (See Tr. 33-34; see also Tr. 36 (citing Tr. 520-51,
589).) The ALJ provided the following discussion of those records:
Following the hearing, [Plaintiff]’s representative
submitted office treatment records from Cone Health -
Guilford County Behavioral Health covering April 24, 2023
through June 6, 2023. [Plaintiff] presented on April 24,
2023, to establish care with a new psychiatrist. Her
prior psychiatrist, Dr. Newman, had not been able to see
her for some time due to his own health
problems. [Plaintiff] reported that she was currently on
Alprazolam 1 mg; Seroquel 200 mg, and Trazodone 50 mg.
She was no longer taking phentermine because it made her
anxiety worse. [She] was told she would have to come
back during walk-in hours, and she reported that she
would come back Wednesday after she drop[ped] her
daughter off at school. Other than a mild headache, she
reported no other concerns at present. Mood was anxious
and affect was congruent. Thought processes were
coherent and goal directed. Thought content was logical.
Judgement, insight and concentration were all fair. She
returned on April 26, 2023. [She] related that her
auditory hallucinations kept her safe and reminded her to
be wary of her surroundings. For example, they may tell
her to look both ways before making a turn while driving.
Since taking Seroquel, [she] stated that the voices in
her head had calmed down considerably. [She] reported
that during her manic episodes, she did not like to be
around others. She reported occasionally having racing
thoughts and stated that she also experienced
premonitions. She denied visual hallucinations but
reported auditory hallucinations. [She] reported having
been cyber bullied and harassed through social media.
She reported re-experiencing flashbacks and having
intrusive thoughts and difficulty concentrating when
hyperarousal [sic]. [She] was to continue taking
medications as prescribed. She was to return in six
weeks. [She] was seen on June 6, 2023, for medication
management. She reported that her medications continued
25
to be helpful and denied any issues or concerns regarding
her current regimen. [She] reported being under stress
after being harassed by an individual that nearly missed
her and her daughter with [the individual’s]
vehicle. [Plaintiff] was alert and oriented times four,
calm, cooperative and fully engaged in conversation
during the encounter. Mood was okay. [She] continued to
endorse auditory hallucinations but denied worsening
symptoms. [She] denied visual hallucinations and did not
appear _to be responding to internal/external stimuli.
She reported receiving on average 12 hours of sleep each
night. Assessment showed [Plaintiff] denied any issues
or concerns regarding her current medication regimen. It
appeared [her] current symptoms were attributed to a
verbal altercation she had earlier in the day. [She]
appeared stable and was to continue to take her
medications as prescribed.
(Tr. 33-34 (emphasis added) (internal parenthetical citations
omitted).) As the findings emphasized above make clear, the ALJ
discussed (and then later cited to) medical evidence in the record
inconsistent with the extreme limitations on the Whitson MSS,
permitting the Court to meaningfully review the ALJ’s decision-
making. See McCartney, 28 F. App’x at 279 (holding that “the ALJ
need only review medical evidence once in his decision”).
3. PA Nwoko’s Opinions
PA Nwoko also submitted opinions on the same preprinted form
as Dr. Newman and LCSW Whitson on May 2, 2023 (“Nwoko MSS”), and
provided diagnoses of PTSD, panic disorder with agoraphobia,
insomnia, and bipolar disorder, depressed, with psychotic features.
(Tr. 469.) PA Nwoko stated that Plaintiff’s “stressors” included
“loud noises, enclosed spaces, going outside of [her] home, [and
her] ex-partner,” and listed Plaintiff’s symptoms as anhedonia,
26
decreased energy and fatigue, persistent anxiety, withdrawal,
psychomotor agitation or retardation, difficulty concentrating,
paranoia, hyperactivity/ distractibility, and disturbance of mood
and sleep. (Id.) According to PA Nwoko, Plaintiff’s mental
impairments rendered her “[i]ncapable of even ‘low stress’ work”
and would cause her to remain off-task “25 [percent] or more” of a
typical workday and miss work “[m]ore than four days per month.”
(Id.)13 PA Nwoko further opined that Plaintiff had “none-[to-]mild”
limitation in her ability to understand, remember, or apply
information, “moderate” limitations in her abilities to interact
with others and concentrate, persist, or maintain pace, and
“marked” limitation in her ability to adapt and self-manage. (Id.)
The ALJ evaluated the persuasive value of the Nwoko MSS as
follows:
The [ALJ] finds th[e Nwoko MSS ] is not persuasive.
Although the opinions as to the first three [paragraph]
B criteria are consistent with [Plaintiff]’s treatment
records, the [Nwoko MSS] as a whole is not well
supported, as [PA Nwoko] provided next to no narrative
support for the ratings of functional limitations. The
opinion as to the fourth criterion is not well supported
and is also inconsistent with the [Newman MSS] and
[Whitson MSS} and with the overall treatment record.
Similarly, the opinions as to expected unscheduled
breaks, time off task, capacity to perform low stress
work, and absenteeism are unsupported and are
inconsistent with the overall treatment record. Notably,
[PA Nwoko] completed th[e Nwoko MSS] after the very first
visit with [Plaintiff], and while there were some
abnormal findings on the mental status examination on
13 PA Nwoko described the number of unscheduled breaks Plaintiff would need
during a workday as “indeterminate” due to her status as “currently not working.”
(Tr. 469.)
27
that visit, the [Nwoko MSS] appears to have been
completed largely based on ([Plaintiff]’s subjective
reports. The degree of limitation expressed is also
inconsistent with [Plaintiff]’s election not to make any
adjustments in her medication regime, which suggests an
adequate level of control of symptoms at that time. At
the next appointment six weeks later, findings on mental
status examination were somewhat improved, despite some
recent situational stressors, and medications were again
continued without change.
(Tr. 36 (internal parenthetical citations omitted) Plaintiff
challenges that analysis on multiple fronts (see Docket Entry 10 at
11-13), none of which, for the reasons that follow, have merit.
Plaintiff first repeats her objection to the ALJ’s reliance on
the lack of narrative explanation supporting the Nwoko MSS (see id.
at 11 (citing Tr. 36)) but, as discussed above, the ALJ may
permissibly discount the persuasiveness of an opinion to the extent
the source fails to provide supporting explanations, see, e.g.,
Simone, 2020 WL 961431, at *5; Curtis W., 2019 WL 6872869, at *3;
Mullinax, 2019 WL 4565050, at *3; Shelton, 2015 WL 1276903, at *3;
Schaller, 2014 WL 4537184, at *16.
Plaintiff also faults the ALJ for “discount[ing] the [Nwoko
MSS] because it was [issued] ‘after the very first visit with’
Plaintiff” (Docket Entry 10 at 11 (quoting Tr. 36)), and contends
that such a “rationale makes no logical sense given the RFC is
based completely on the non-examining . . . review completed by
[the reconsideration-level state agency psychological consultant]”
(id. (citing Tr. 35)). To begin, the regulations require the ALJ
to consider the “[l]length,” “[f]requency,” and “[e]xtent” of PA
28
Nwoko’s treatment relationship with Plaintiff, 20 C.F.R.
§§ 404.1520c(c)(3), 416.920c(c)(3). Thus, the fact that PA Nwoko
had treated Plaintiff on only one occasion before completing the
Nwoko MSS held relevance to “whether [PA Nwoko] ha[d] a
longitudinal understanding of [Plaintiff’s] impairments,” 20
C.F.R. §§ 404.1520c(c)(3)(i), (ii), 416.920c(c)(3)(i), (ii).
Furthermore, Plaintiff’s argument that the ALJ relied
“completely” on the reconsideration-level consultant’s opinion to
formulate the RFC (Docket Entry 10 at 11 (emphasis added)) glosses
over the fact that the ALJ found that consultant’s opinion “mostly
persuasive” (Tr. 35 (emphasis added)), finding the consultant’s
paragraph “B criteria [ratings] more consistent with the evidence
and supported by objective medical findings,” but deeming the
consultant’s “functional limitations [] vaguely expressed” (id.;
see also Tr. 100-01, 109-10 (reconsideration-level consultant’s
opinions limiting Plaintiff to “simple tasks,” “minim[al] social
demands,” and “simple changes in routine” and, “[o]verall,” to
“[simple, routine, repetitive tasks (‘SRRTs’)]”).) Consistent with
that analysis, the ALJ included in the RFC non-exertional
limitations to “simple instructions,” “simple work-related
decisions,” “occasional contact with co-workers and supervisors and
no contact with the general public as an essential function of the
job,” and “a low stress setting . . . involving[] no paced
production requirements, . . . occasional changes in the work
29
setting or routine, and no dealing with crisis situations as an
essential function of the job.” (Tr. 29.) In fashioning the RFC,
the ALJ also considered the objective medical evidence (see Tr. 30-
34) and Plaintiff’s subjective symptom reports, which the ALJ found
“not entirely consistent” with the evidence, but did not wholly
dismiss (Tr. 30 (emphasis added)). Accordingly, the ALJ did not
base the RFC “completely” (Docket Entry 10 at 11) on the
reconsideration-level consultant’s opinion.
Next, Plaintiff characterizes the ALJ’s observation that PA
Nwoko completed his MSS “‘based on [Plaintiff]’s subjective
reports’” as “untrue” (id. (quoting Tr. 36)), and argues that
“[t]he pages [of PA Nwoko’s treatment records] cited by the ALJ
note [multiple mental] symptoms” (id. (citing Tr. 556-57)).
Additionally, Plaintiff asserts that “[i]t was not inappropriate
for [PA Nwoko] to rely on Plaintiff’s subjective reports to
establish [PA Nwoko’s] findings” (id. at 12), because “‘a
psychiatrist [or psychologist] must base his or her findings on the
subjective reports of a patient[, as [p]sychology and psychiatry
necessarily rely on such subjective reports because the types of
disorders they deal with are not usually susceptible to direct
physical observation as in other medical areas’” (id. at 11
(quoting Thompson v. Berryhill, No. 4:18CV133, 2019 WL 2980030, at
*12 (E.D.N.C. Apr. 22, 2019) (unpublished), recommendation adopted
30
sub nom Thompson v. Saul, 2019 WL 2932736 (E.D.N.C. July 8, 2019)
(unpublished))).
At the outset, the fact that the diagnosis of certain mental
impairments may depend to a larger degree than physical impairments
on an individual’s subjective symptom reports neither renders
objective medical findings irrelevant nor precludes an ALJ from
discounting a provider’s opinions because the provider over-relied
on those subjective reports. See Vaughn v. Kijakazi, No. 1:21CV1,
2022 WL 604257, at *11 (M.D.N.C. Mar. 1, 2022) (unpublished)
(rejecting the plaintiff’s argument that her mental impairments
“result[ed] in entirely subjective symptoms,” where “[t]he record
contain[ed] numerous mental status examinations by [the
p]laintiff’s treating mental health providers . . . [reflecting]
the objective observations . . . of [those] mental health
professionals,” who “objectively verified through [those ]
examinations whether [the p]laintiff’s [mental impairments]
impacted her orientation, appearance, behavior, speech, thoughts,
affect, concentration, attention, memory, judgment, and insight”),
recommendation adopted, 2022 WL 981181 (M.D.N.C. Mar. 31, 2022)
(Schroeder, C.J.); Fedornak v. Commissioner of Soc. Sec., No.
8:20CV416, 2021 WL 397353, at *5 (M.D. Fla. Jan. 19, 2021)
(unpublished) (classifying “mental status examinations” as “form of
objective evidence” and holding that, “[w]hile psychological
diagnoses will depend in part on the subjective allegations by the
31
patient, there is no precedent for relying solely on a patient's
self-reporting of psychological limitations” (emphasis added)),
recommendation adopted, 2021 WL 391268 (M.D. Fla. Feb. 4, 2021)
(unpublished); Blessing v. Astrue, No. 12CV5275, 2013 WL 316153, *7
(W.D. Wash. 2013) (unpublished) (“Like the physical examination,
the Mental Status Examination is termed the objective portion of
the patient evaluation.” (emphasis added) (quoting Paula T.
Trzepacz and Robert W. Baker, The Psychiatric Mental Status
Examination, 3-4 (Oxford Univ. Press 1993))).
Moreover, pages 556 and 557 of the administrative record
indeed contain a list of mental symptoms (see Tr. 556-57), but
those symptoms do not appear as findings in PA Nwoko’s mental
status examination but rather in the subjective portion of the
treatment record entitled “History of Present Illness” (Tr. 555).
Indeed, on mental status examination, although PA Nwoko recorded an
“[a]nxious, [d]epressed, and [d]ysphoric” mood with a “[c]ongruent
and [d]epressed” affect, PA Nwoko also found Plaintiff “not
hyperactive” and “[w]ell [g]roomed,” with “[g]ood eye contact,
“[c]lear and [c]oherent” speech, “[c]oherent” and “[g]oal
[d]irected” thought process, “[f]ull” orientation, “[f]air”
insight, and “[g]ood” memory and recall, judgment, concentration,
attention span, and fund of knowledge. (Tr. 560.) PA Nwoko
further described Plaintiff’s cognition as within normal limits
32
(see id.) and her activities of daily living (“ADLs”) as “[i]ntact”
(id.).
In light of those mostly normal mental status findings, the
ALJ did not err by discounting the Nwoko MSS, in part, because PA
Nwoko over-relied on Plaintiff’s subjective symptom reports. See
Julin v. Colvin, 826 F.3d 1082, 1088-89 (8th Cir. 2016) (holding
that “the ALJ was entitled to discount [the physician]’s opinions
insofar as they relied on [the plaintiff]’s subjective complaints”,
where physician’s opinions that the plaintiff “struggles to
interact with people” and “would have difficulty with pace,
concentration, and completing tasks” relied on materials “that [the
plaintiff] completed[, m]uch of [which wa]s derived from [her]
recitation of her symptoms”); Scottie J. D. v. O’Malley, No.
1:23CV695, 2024 WL 2746799, at *10 (M.D.N.C. May 29, 2024)
(unpublished) (“Consistent with the lack of objective findings
supporting [the consultative psychological examiner]’s opinions,
[the examiner]’s report makes clear he relied heavily on [the
p]laintiff’s subjective statements. . . . Under such
circumstances, the ALJ did not err by discounting [the examiner]’s
opinions, in part, because they over-relied on [the p]laintiff’s
subjective reports.”), recommendation adopted, 2024 WL 3498405
(M.D.N.C. July 22, 2024) (unpublished) (Schroeder, J.); Miller v.
Kijakazi, No. 1:21CV97, 2022 WL 1004582, at *10 (M.D.N.C. Apr. 4,
2022) (unpublished) (“[The consultative psychological examiner]
33
found [the p]laintiff pleasant, friendly and open, with rapport
easily established, and eye contact established and maintained and
thus [the examiner] based his statement that [the p]laintiff had a
history of not getting along with his fellow workers and
supervisors and reported he was easily angered and tended to argue
on [the p]laintiff’s subjective statements rather than any
objective findings. . . . [T]he ALJ did not err in discounting
[the examiner]’s opinions based, in part, on his over-reliance on
[the p]laintiff’s subjective symptom reporting[.]” (internal
quotation marks, parenthetical citations, some brackets, and
ellipsis omitted)), recommendation adopted, slip op. (M.D.N.C. Apr.
20, 2022) (Schroeder, C.J.).
Additionally, Plaintiff objects to “the ALJ[’s] reject[ion of
the Nwoko MSS] based on Plaintiff’s desire to maintain her current
medication regimen.” (Docket Entry 10 at 12 (citing Tr. 36).) In
that regard, Plaintiff contends that, “given the side effects noted
at the time of the [Nwoko MSS] (weight gain, dizziness, sedation[],
diabetes risk, fatigue, depression, dizziness, [] forgetfulness,
confusion, nausea, vomiting, edema, blurred vision, and
hypotension), it appears reasonable that Plaintiff would not want
to adjust or increase any medication.” (Id. (citing Tr. 469).)
Plaintiff’s argument falls short, because PA Nwoko clearly
listed potential (as opposed to actual) side effects of Plaintiff’s
medications on the Nwoko MSS: including “weight gain, dizziness,
34
sedation, diabetes [and] dyslipidemia risk” as possible side
effects of Seroquel, “sedation, fatigue, depression, dizziness, []
forgetfulness, [and] confusion” as potential side effects of
alprazolam (Xanax), and “[n]ausea, vomiting, edema, blurred vision,
dizziness, [and] hypotension” as possible side effects of
Trazodone. (Tr. 469 (emphasis added) Although at different
places in the record, Plaintiff complained of weight gain,
sedation, and blurred vision related to her Seroquel (see Tr. 54-
55, 261, 281-82, 387, 404), PA Nwoko’s records do not reflect that
Plaintiff complained to PA Nwoko of any of the side effects listed
on the Nwoko MSS (see Tr. 517-620), and instead “report[ed] that
her medications continue[d] to be helpful and denie[d] any issues
or concerns regarding her current regimen” (Tr. 585 (emphasis
added)). Thus, the fact that Plaintiff opted not to change her
medication regimen held relevance to the intensity, persistence,
and limiting effects of her mental symptoms, and the ALJ did not
err by relying on that fact (see Tr. 36). See Social Security
Ruling 16-3p, Titles II and XVI: Evaluation of Symptoms in
Disability Claims, 2017 WL 5180304, at *9 (Oct. 25, 2017) (“SSR 16-
3p”) (“Persistent attempts to obtain relief of symptoms, such as
increasing dosages and changing medications, trying a variety of
treatments, referrals to specialists, or changing treatment sources
may be an indication that an individual’s symptoms are a source of
35
distress and may show that they are intense and persistent.”
(emphasis added)).
Lastly, Plaintiff challenges the ALJ’s “state[ment] that [the
Nwoko MSS] is inconsistent with the [Newman MSS] and [the Whitson
MSS]” (Docket Entry 10 at 12 (citing Tr. 36)), deeming it “unclear
why this would matter given the ALJ rejected both of those opinions
as well” (id. at 12-13). Plaintiff further points out that all
three MSSs “opined Plaintiff would need unscheduled breaks during
the workday, would be off-task more than 25 percent of the workday,
would be absent more than four days per month, would be incapable
of even ‘low stress’ work, and would have marked limitations in
adapting and managing herself.” (Id. at 13 (citing Tr. 361, 429,
469).)
Plaintiff misstates the record by asserting that all three
MSSs “opined Plaintiff . . . would have marked limitations in
adapting and managing herself.” (Id. (emphasis added) (citing Tr.
361, 429, 469).) In fact, both the Newman MSS and Whitson MSS
reflect only “moderate” limitations in that functional area (Tr.
361, 429 (emphasis added)), which harmonize with the ALJ’s moderate
finding in adaptation/self-management at step three of the SEP (see
Tr. 28). Thus, in specifically finding the Nwoko MSS’s “marked”
limitation in adaptation/self-management (Tr. 469 (emphasis added))
not persuasive (see Tr. 36), the ALJ noted that the Newman MSS and
Whitson MSS, which reflected greater limitations than the Nwoko MSS
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in the other three paragraph B criteria (compare Tr. 361, 429, with
Tr. 469), provided lesser, i.e., “inconsistent” (Tr. 36),
limitations in adaptation/self-management.
In light of the foregoing analysis, Plaintiff has failed to
demonstrate that the ALJ reversibly erred in evaluating the Newman
MSS, the Whitson MSS, and the Nwoko MSS and thus Plaintiff’s first
and only assignment of error fails as a matter of law.
III. CONCLUSION
Plaintiff has not established an error warranting relief.
IT IS THEREFORE ORDERED that the Commissioner’s decision
finding no disability is AFFIRMED, and that this action is
DISMISSED with prejudice.
/s/ L. Patrick Auld
L. Patrick Auld
United States Magistrate Judge
September 19, 2025
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