Opinion
No. C98-2112 MJM
February 7, 2001
OPINION and ORDER
INTRODUCTION
Claimant Ronald Saffold's action for judicial review of an administrative decision on his application for disability insurance and for supplemental security income (SSI) benefits comes before the court pursuant to the Report and Recommendation of United States Magistrate Judge John A. Jarvey, filed on August 23, 2000. In his report, Judge Jarvey recommended that the court affirm the decision of the Administrative Law Judge (ALJ) denying benefits because he found that the ALJ's determination that Mr. Saffold was not disabled during the relevant period was supported by substantial evidence. Specifically, Judge Jarvey found substantial evidence on the record as a whole to support the ALJ's finding that Mr. Saffold did not have a "listed" disorder precluding substantial gainful activity under the regulations and that the Commissioner had demonstrated that Mr. Saffold retained the residual functional capacity (RFC) to perform a significant number of other jobs in the national economy that are consistent with his impairments and vocational abilities.
On September 5, 2000, Mr. Saffold filed objections to Judge Jarvey's Report and Recommendation, to which the Commissioner filed a brief response stating its opinion that the ALJ's decision was supported by substantial evidence and that all of Mr. Saffold's objections had been adequately addressed and resolved by Judge Jarvey. The standard of review to be applied by the district court to a report and recommendation of a magistrate judge is established by statute:
A judge of the court shall make a de novo determination of those portions of the report or specified proposed findings or recommendations to which objection is made. A judge of the court may accept, reject, or modify, in whole or in part, the findings or recommendations made by the magistrate [judge].
28 U.S.C. § 636(b)(1); see also Hosna v. Groose, 80 F.3d 298, 306 (8th Cir.), cert. denied, 519 U.S. 860 (1996) (reiterating that it is reversible error for the district court to fail to conduct a de novo review of a magistrate judge's report where such review is required).
Because objections have been filed in this case, the court has reviewed the record as a whole in light of Mr. Saffold's objections. On so doing, the court concludes that the ALJ's decision denying benefits to Mr. Saffold is not supported by substantial evidence on the record as a whole and accordingly declines to adopt Judge Jarvey's recommendation in favor of the Commissioner.
FACTUAL BACKGROUND
At the time of his disability hearing, Ronald Saffold was 42 years old, unmarried, stood six-feet, six-inches tall and weighed 300 pounds. (Tr. 92-93). He has a tenth-grade education and earned his general equivalency diploma (GED). (Tr. 93). He took classes for auto mechanics at a community college, but never worked as an auto mechanic. (Tr. 94). He was involved in a motor vehicle accident on May 30, 1995, which he claims resulted in his inability to work. (T. 95). Before the accident, he worked for a moving company where his duties included packing goods and lifting appliances and furniture. (Tr. 95-96). Mr. Saffold had previous work experience as a janitor, as a de-boner in a chicken plant, as an assistant manager at a rent-to-own store, and as a squeeze molder in a foundry. (Tr. 97-100).
Mr. Saffold was admitted to the hospital on May 31, 1995, following his accident. (Tr. 282-84). He was not knocked unconscious, but believed he had struck his head on the windshield. (Tr. 282). When first brought into the emergency room, he complained of neck and shoulder pain and the inability to move his right arm. (Tr. 282). He initially had numbness and paralysis in the legs, but it improved to almost normal. (Tr. 282, 284). No evidence of trauma to the extremities was observed. (Tr. 283). He experienced a flaccid paralysis of the left hand which was diagnosed as a nerve stretch-type injury. (Tr. 284).
The following day, Mr. Saffold was seen by Muhammad E. Dughly, M.D. (Tr. 286). Dr. Dughly made the following diagnosis:
1. Possible mild headache with possible cerebral concussion.
2. Cervical trauma without any evidence of myelopathy.
3. Weakness in the right arm suggestive for possible stretching injury of the brachioplexus on the right side.
4. Weakness in the left arm and both legs, probably functional and nonorganic.
5. This patient showed a tremendous psychological overly in his symptoms and it is very difficult for the examiner to be able to determine what for sure is of true organic origin and which is not.
(Tr. 286). Dr. Dughly recommended physical therapy, (Tr. 286), and Mr. Saffold was evaluated by a physical therapist on August 24, 1995. (Tr. 309).
On May 7, 1996, Mr. Saffold sought treatment at the Black Hawk-Grundy Mental Health Center, Inc., complaining of moodiness, depression and an aversion to being around people. (Tr. 17). At Black Hawk-Grundy, Mr. Saffold was initially evaluated by Richard Davenport, a clinical psychiatric counselor, (Tr. 362-66), and then, on June 14, 1996, by psychiatrist Robert E. Pucelik, M.D., who diagnosed anxiety and depressive disorder, schizoid personality traits and a probable learning disorder. (Tr. 368). Mr. Saffold returned to Black Hawk-Grundy on a monthly basis for ongoing treatment with Dr. Pucelik and Mr. Davenport. (Tr. 115).
In conjunction with his treatment, Mr. Saffold was prescribed medication for depression and anxiety, including imipramine, elavil and vistaril. (Tr. 368 and 400).
On May 23, 1996, Luis Barrios, M.D., and L. D. Furlong, M.D., treated Mr. Saffold after he complained of difficulty in swallowing. (Tr. 370-73). Nothing abnormal was discovered upon evaluation. (Tr. 370, 373). On June 18, 1996, Susan L. Woo, M.D., an orthopedist, evaluated Mr. Saffold. (Tr. 374-75). Dr. Woo concluded that Mr. Saffold could not lift or carry over 10 pounds, but that he could sit for longer hours. (Tr. 375). She stated his shortness of breath was "more due to lack of exercise and increase of body weight rather than environmental changes with dust, fumes or temperatures." (Tr. 375). Furthermore, she stated: "I am not sure what problem the patient has, but his muscular pain and weakness seem to be out of proportion to his stature and general physique. . . . [T]he physical findings do not match the physical examination." (Tr. 375).
On July 11, 1996, Steven B. Mayhew, Ph.D., a psychologist, evaluated Mr. Saffold. (Tr. 376-77). Dr. Mayhew administered the Wechsler Adult Intelligence Scale — Revised ("WAIS-R"). (Tr. 377). Mr. Saffold scored at 52, placing him in the moderate range of mental retardation, although Dr. Mayhew noted that "[o]bserving his performance and effort during the test, [it] clearly indicated that he had low motivation and purposely did not put forth a reasonable degree of effort." (Tr. 377). Dr. Mayhew concluded that Mr. Saffold had borderline intellectual functioning, although "[m]alingering [was] suspected based upon observed performance during psychological testing." (Tr. 377).
Dr. Mayhew evaluated Mr. Saffold again on March 24, 1997. (Tr. 413-14). Dr. Mayhew stated that Mr. Saffold had "a preoccupation with physical health and an apparent fear of physical illness." (Tr. 414). Dr. Mayhew determined that his symptomatic distress levels were within the clinical range. (Tr. 414). He was diagnosed with a major depressive disorder and borderline intellectual functioning. (Tr. 414). Dr. Mayhew concluded that Mr. Saffold would have difficulty with unskilled work, including remembering and understanding instructions and procedures, and maintaining attention and concentration. (Tr. 414). Furthermore, he stated that Mr. Saffold would not be able to "interact appropriately with supervisors and coworkers in light of his symptoms of Schizotypal Personality Disorder." (Tr. 414).
Mr. Saffold was evaluated May 8, 1997, by Michael D. Voigt, M.D. (Tr. 463-64). Dr. Voigt concluded that Mr. Saffold had Hepatitis C. (Tr. 464). He also concluded that Mr. Saffold's chronic fatigue syndrome was unrelated to Hepatitis C. (Tr. 464). No physical reason for his chronic fatigue syndrome was found. (Tr. 464).
Mr. Saffold has not worked since the May 30, 1995 accident. Prior to the accident, he had been in excellent health and had not seen a physician in many years. (Tr. 100-02). Since the accident, he experiences difficulty sleeping, is very short-tempered, and does not like to be around people, (Tr. 103-04; 107). He claims he has difficulty concentrating and remembering things. (Tr. 104-05). He also claims his ankles and feet are weak and swell when he does any walking or standing. (Tr. 103). He claims he can sit approximately five to ten minutes without experiencing pain and can walk approximately one block before having to stop to rest. (Tr. 104-05). He claims he cannot do any stooping or bending, or repetitive use of his hands or arms. (Tr. 104-06).
PROCEDURAL BACKGROUND
Mr. Saffold applied for Title II and Title XVI Social Security disability benefits on June 22, 1995, alleging an inability to work because of limited use of his arms and fingers, swollen feet and general pain. His application was denied on initial review and again on reconsideration. On September 23, 1997, following a video hearing held on March 3, 1997, Administrative Law Judge John P. Johnson found Mr. Saffold not entitled to disability insurance benefits or SSI benefits. In his decision, the ALJ made the following findings:
1. The claimant met the disability insured status requirements of the Act on May 30, 1995, the date the claimant stated he became unable to work, and continues to meet them through the date of this decision.
2. The claimant has not engaged in substantial activity since May 30, 1995.
3. The medical evidence establishes that the claimant has residuals of a motor vehicle accident resulting in medically determinable impairments causing complaints of numbness, severe muscle and joint pain, generalized muscle weakness, bilateral carpal tunnel syndrome, degenerative changes of the lumbosacral spine, borderline intelligence, personality trait disorder, anxiety, and depression, but that he does not have an impairment or combination of impairments listed in, or medically equal to one listed in Appendix 1, Subpart P, Regulations No. 4.
4. The claimant's subjective complaints are not fully credible, and his symptoms are not as limiting as alleged.
5. The claimant has the residual functional capacity to perform the physical exertion and nonexertional requirements of work except for being limited to occasionally lifting 20 pounds and frequently lifting 10 pounds. He can do no continuous bending, stooping, squatting, kneeling, crawling, or climbing. His ability to grip and do fine manipulation is intact but he should avoid continuous, repetitive use of the hands. He should not work at unprotected heights or in the presence of excessive vibrations. He can do simple, routine, repetitive work which does not require very close attention to detail, he requires occasional supervision, and should not have to work at more than a regular pace ( 20 C.F.R. § 404.1545 and 416.945).
6. The claimant is unable to perform his past relevant work as a foundry worker, a cleaner, a truck driver helper, and an iron worker.
7. The claimant is 42 years old, which is defined as a younger individual ( 20 C.F.R. § 404.1563 and 416.963).
8. The claimant has a G.E.D. ( 20 C.F.R. § 404.1564 and 416.964).
9. The claimant does not have any acquired work skills which are transferable to the skilled or semiskilled work functions of other work ( 20 C.F.R. § 404.1568 and 416.968).
10. Although the claimant's additional nonexertional limitations do not allow him to perform the full range of light work, there are a significant number of jobs in the national economy which he could perform. Examples of such jobs are: A housekeeping/ cleaner, a sorter/inspector, and an outside deliverer.
11. The claimant was not under a "disability," as defined in the Social Security Act, at any time through the date of this decision ( 20 C.F.R. § 404.1520(f) and 416.920(f)).
(Tr. 25-26). On December 7, 1998, the Appeals Council of the Social Security Administration denied Mr. Saffold's request for review. Mr. Saffold petitioned for review in federal court on December 30, 1998.
STANDARD OF REVIEW
The Eighth Circuit Court of Appeals has explained the standard for judicial review of an ALJ's denial of Social Security benefits as follows:
We must uphold the ALJ's decision if it is supported by substantial evidence. See Metz v. Shalala, 49 F.3d 374, 376 (8th Cir. 1995). Our task is not to reweigh the evidence, and we may not reverse the Commissioner's decision merely because substantial evidence would have supported an opposite conclusion or merely because we would have decided the case differently. See Woolf v. Shalala, 3 F.3d 1210, 1213 (8th Cir. 1993); Smith v. Shalala, 987 F.2d 1371, 1374 (8th Cir. 1993). In determining whether substantial evidence supports the ALJ's decision, we must consider evidence in the record that supports the ALJ's decision as well as evidence that detracts from it. See Brockman v. Sullivan, 987 F.2d 1344, 1346 (8th Cir. 1993).
Harwood v. Apfel, 186 F.3d 1039, 1042 (8th Cir. 1999). "Substantial evidence is relevant evidence which a reasonable mind would accept as adequate to support the [ALJ's] conclusion." Wieler v. Apfel, 179 F.3d 1107, 1109 (8th Cir. 1999) (citing Pierce v. Apfel, 173 F.3d 704, 706 (8th Cir. 1999)); accord, Singh v. Apfel, 222 F.3d 448, 451 (8th Cir. 2000) ("Substantial evidence is less than a preponderance, but is enough so that a reasonable mind would find it adequate to support the ALJ's conclusion." (citation omitted)).
The court's review must look at the record as a whole to determine whether the Commissioner's findings are supported by substantial evidence. See Wieler, 179 F.3d at 1109 (holding that reviewing court "must determine whether the ALJ's findings are supported by substantial evidence on the record as a whole"). The Eighth Circuit has held that reviewing for substantial evidence on the record as a whole "requires a more scrutinizing analysis" than the traditional "substantial evidence" test. Gavin v. Heckler, 811 F.2d 1195, 1199 (8th Cir. 1987). In Gavin, the court explained:
In the review of an administrative decision, `the substantiality of evidence must take into account whatever in the record fairly detracts from its weight.' Universal Camera Corp. v. National Labor Relations Bd., 340 U.S. 474, 488 (1951). Thus, the court must also take into consideration the weight of the evidence in the record and apply a balancing test to evidence which is contradictory. See Steadman v. Securities and Exchange Comm'n, 450 U.S. 91, 99 (1981). It follows that the only way a reviewing court can determine if the entire record was taken into consideration is for the district court to evaluate in detail the evidence it used in making its decision and how any contradictory evidence balances out.
Gavin, 811 F.2d at 1199; accord, Burress v. Apfel, 141 F.3d 875, 878 (8th Cir. 1998).
DISCUSSION
Mr. Saffold was entitled to disability and SSI benefits as of May 30, 1995 if he was disabled within the meaning of the Social Security Act, 42 U.S.C. § 1381a, as of that date. "Disability" is defined as 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 twelve months." 42 U.S.C. § 1382c (a)(3)(A). In determining whether an individual's physical or mental impairments are of sufficient medical severity to establish eligibility under this section, the Commissioner "shall consider the combined effect of all of the individual's impairments without regard to whether any such impairment, if considered separately, would be of such severity." 42 U.S.C. § 1382c(a)(3)(F).
Under the social security regulations, the Commissioner uses a five-step "sequential evaluation process" to determine if a claimant is eligible for benefits. 20 C.F.R. § 404.1520, 404.1520a (2000) (disability) and 416.920, 416.920a (2000) (SSI); see also Singh, 222 F.3d at 451; Baker v. Apfel, 159 F.3d 1140, 1143-44 (8th Cir. 1998); Terrell v. Apfel, 147 F.3d 659, 661 (8th Cir. 1998). Under step one, a claimant is ineligible if he is "doing substantial gainful activity." 20 C.F.R. § 404.1520(b), 416.920(b). Under step two, a claimant is ineligible unless he is suffering a "severe" mental or physical impairment or combination of impairments which will last at least one year. Id. §§ 404.1520(c), 416.920(c). Under step three, a claimant will be found disabled if he suffers from an impairment that is included in the listing of presumptively disabling impairments (the Listing). See 20 C.F.R. § 404, Subpt. P, App. 1. Under step four, if the severe impairments are not included in the Listing, a claimant may still be eligible if he can prove that his impairments prevent him from performing his "past relevant work." 20 C.F.R. § 404.1520(e), 416.920(e). Finally, under step five, even if the claimant shows he cannot perform his past relevant work, he is ineligible if the Commissioner shows he has sufficient "residual functional capacity" to perform available jobs in the national economy. Id. §§ 404.1520(f), 416.920(f); see also Singh, 222 F.3d at 451 ("If the Commissioner finds that the claimant does not meet the Listings but is nevertheless unable to perform his or her past work, the burden of proof shifts to the Commissioner to prove, first, that the claimant retains the residual functional capacity to perform other kinds of work, and, second, that other such work exists in substantial numbers in the national economy." (citation omitted)).
Regulations regarding disability insurance are found in Part 404 of Title 20, chapter III, of the Code of Federal Regulations. Supplemental security income is covered under Part 416 of the same chapter. As relevant to the matter before the court, the disability and SSI regulations are substantively parallel.
In this case, it is undisputed that Mr. Saffold was not engaged in "substantial gainful activity," that his impairments were "severe," and that he did not have any "past relevant work" which he could perform. The disputed issues concern the third and fifth steps: whether Mr. Saffold qualified under the Listing of Impairments, 20 C.F.R. § 404, Subpt. P, App. 1, and, if not, whether he had the residual functional capacity to perform available jobs in the national economy. Under the third step, the ALJ determined that "the claimant's impairments and resultant symptoms, considered singly or in combination do not meet or equal any criteria contained in the Listing of Impairments." (Tr. 15). Under the fifth step, the ALJ determined that Mr. Saffold could perform a significant number of jobs in the national economy, (Tr. 24-25), and accordingly benefits were denied.
The ALJ determined that Mr. Saffold had the following impairments:
Residuals of a motor vehicle accident resulting in allegations of medically determinable impairments causing numbness, muscle and joint pain, generalized muscle weakness, bilateral carpal tunnel syndrome, degenerative changes of the lubosacral spine, borderline intelligence, anxiety, and depression, and a personality disorder.
(Tr. 15).
As to Mr. Saffold's physical impairments, the court agrees with Judge Jarvey that substantial evidence on the record as a whole supports the ALJ's articulation of those impairments. The gravamen of Mr. Saffold's complaint, then, is that the ALJ improperly weighed or disregarded medical evidence regarding mental impairments that, in combination with his physical impairments, preclude him from sustained gainful employment. In its review, the court will carefully scrutinize the record to determine whether, as Judge Jarvey concluded, there is substantial evidence in the record as a whole to support the ALJ's findings and denial of benefits.
1. Did the ALJ disregard or improperly weigh the evidence regarding Mr. Saffold's mental impairments?
In this case, Mr. Saffold offered the medical opinions of his treating psychiatrist, Dr. Robert Pucelik, and treating clinical psychiatric counselor, Mr. Richard Davenport, to substantiate his mental impairments as those impairments would affect a determination of disability. Also in the record are two reports by psychologist Dr. Stephen Mayhew, to whom Mr. Saffold was referred for consultation by DDS. Dr. Mayhew first evaluated Mr. Saffold in July, 1996, and then again in March, 1997.
After reviewing the record in its entirety, the court agrees with Mr. Saffold that the ALJ improperly weighed the medical evidence regarding Mr. Saffold's mental impairments. Specifically, the court finds that the ALJ gave insufficient weight to the opinion of Dr. Pucelik, Mr. Saffold's treating psychiatrist. The ALJ also improperly weighed the opinions of Dr. Mayhew by heavily relying on Dr. Mayhew's initial evaluation even though his second report clearly implies that he had revised his earlier opinion. Because resolution of the present dispute turns largely on proper evaluation of the mental health evidence in the record, the court will review that evidence in some detail prior to discussion of the applicable law.
a) Mr. Saffold's treating psychiatrist
Mr. Saffold sought treatment at the Black Hawk-Grundy Mental Health Center, Inc., on May 7, 1996, complaining of moodiness, depression and an aversion to being around people. (Tr. 17). In that initial meeting, Mr. Davenport performed an extensive clinical interview and noted the following potential diagnoses: pain disorder associated with both psychological factors and a general medical condition, and schizoid personality disorder. (Tr. 362-66). Dr. Pucelik evaluated Mr. Saffold on June 14, 1996, and diagnosed anxiety disorder not otherwise specified, depressive disorder not otherwise specified, rule out residuals of attentional deficit hyperactivity disorder, schizoid personality traits, probable learning disability, and residual pain from the prior automobile accident. (Tr. 367-68). Mr. Saffold continued to see Dr. Pucelik and Mr. Davenport on a regular basis for nearly a year prior to the administrative hearing. (Tr. 115). In January 1997, Dr. Pucelik and Mr. Davenport submitted a joint-opinion letter detailing Mr. Saffold's current treatment plan, including Elavil to control depressive symptoms and Vistaril as needed for anxiety, and concluding the following:
[Mr. Saffold's] quick temper, lack of patience, and indifference to social relationships would interfere with his ability to function in a work setting and interact appropriately with coworkers. He also has difficulty paying attention and concentrating, which would interfere with his ability to follow instructions, maintain pace in the workplace, and respond appropriately to changes in the workplace. . . . In our opinion, Mr. Saffold meets the criteria for mental impairments listed under affective disorders, A and B, and anxiety related disorders.
(Tr. 400). The record also includes a January 28, 1998 note by Dr. Pucelik, hand-written on a prescription pad, that states in total: "Ron Saffold is unable to work."
In his decision, the ALJ briefly notes the diagnoses made by Dr. Pucelik in the June, 1996 evaluation but makes no mention of Dr. Pucelik's January 30, 1997 opinion letter nor any other documentation from Mr. Saffold's ongoing treatment relationship with the Black Hawk-Grundy Mental Health Center. (Tr. 17). At no time does the ALJ explain his disregard of Dr. Pucelik's opinion that Mr. Saffold meets the Listing criteria for affective disorders and anxiety related disorders as defined in 20 C.F.R. § 404, Subpart P, Appendix 1, at §§ 12.04 and 12.06. Nor does he discuss Dr. Pucelik's substantive opinions regarding Mr. Saffold's ability to function in a work setting, or the handwritten declaration that Mr. Saffold is "unable to work."
b) The consulting psychologist: Dr. Mayhew's first and second reports
Dr. Mayhew evaluated Mr. Saffold on July 11, 1996, and again on March 24, 1997. (Tr. 376-77; 413-23). At his initial evaluation, Mr. Saffold alleged difficulties with poor concentration, memory, and avoidance of people, as well as poor physical health due to general body pain, joint pain, and sleep disturbance. (Tr. 376). After evaluation, Dr. Mayhew found Mr. Saffold to have borderline intellectual functioning based on the clinical interview and history. Dr. Mayhew attempted to implement standardized psychological tests such as the WAIS-R intelligence test and the Wechsler Memory Scale but deemed the results invalid because Mr. Saffold's "performance and effort during the testing clearly indicated that he had low motivation and purposely did not put forth a reasonable degree of effort." In summarizing his findings and recommendations, Dr. Mayhew again noted Mr. Saffold's "low motivation to put forth his best effort" and concluded the following:
[Mr. Saffold's] ability to maintain attention and concentration is believed to be fair, however, his test performance suggest [sic] that this is a significant difficulty for him. His ability to interact appropriately with supervisors and coworkers is estimated to be poor. His use of good judgment and responding appropriately to changes in the workplace is also estimated to be quite poor. Further documentation such as educational records and other medical records are recommended for review. Other medical examinations may be helpful in determining whether there is any genuine medical factors which might account for his alleged symptoms. In addition, the psychiatric records from Black Hawk Grundy Mental Health Center are also important to obtain in considering his eligibility for benefits.
(Tr. 377).
At his second evaluation, in March 1997, Mr. Saffold again reported memory problems and general body pain, as well as being "quick tempered." (Tr. 413). His demeanor during the exam was "negativistic and uncooperative," (Tr. 414), and his mood was observed to be "a mixture of depression and agitation." (Tr. 413). Dr. Mayhew further observed that "[w]orry and anxiety were prominent emotional features at various moments during the exam," and "[h]is thought processes were confused and, at times, disconnected." (Tr. 414). For the most part, formal psychological testing measures could not be implemented due to Mr. Saffold's "mental attitude and irritable demeanor." (Tr. 414). However, completion of a symptoms checklist suggested symptomatic distress levels "clearly in the clinical range" as the "intensity of his distress was found to be extremely high and he endorsed a large number of clinical symptoms." (Tr. 414). "Clinically significant elevations were found in depression and mood disorders, anxiety, suspiciousness and interpersonal oversensitivity, obsessive and compulsive features, paranoid ideation, and hostility." (Tr. 414).
Dr. Mayhew's clinical impression was that Mr. Saffold suffered from major depressive disorder, schizotypal personality disorder, and borderline intellectual functioning. His summary and recommendations concluded as follows:
Review of records available for this evaluation had been quite extensive and include various medical and psychiatric documents from Allen and Covenant Hospital's [sic], Black Hawk-Grundy Mental Health Center, and various other physicians, physical therapists, radiology, etc. since May, 1995. There does appear to be fairly good consistency in the observations and findings by a number of mental health providers regarding Ron's mental status and level of functioning. It is my opinion that Ron would have a difficult time remembering and understanding work related instructions and procedures in unskilled work. His ability to carry out instructions, as well as, maintain attention, concentration and pace is expected to be quite poor. He will not be expected to interact appropriately with supervisors and coworkers in light stresses and problems within the work place. Unless there are other contraindicating information which was not available for this exam, it is recommended that he be considered eligible for disability benefits. There does appear to be a mental impairment which is well documented and has lasted for at least twelve consecutive months since onset. These symptoms and mental difficulties would effect work related mental activities. Ron Saffold would not be expected to meet the demands of simple, unskilled work on a sustained basis.
(Tr. 414).
The ALJ briefly summarized both reports in his decision, (Tr. 19, 20-21), but at no point did he address Dr. Mayhew's clinical impressions regarding Mr. Saffold's mental status and functioning or his final opinion that Mr. Saffold could not sustain even simple, unskilled work. Instead, it appears that the ALJ used Dr. Mayhew's reports only to bolster his conclusion that Mr. Saffold's subjective complaints were not fully credible. (Tr. 22). To that effect, the ALJ cites Mr. Saffold's failure to put forth effort in his psychological testing and Dr. Mayhew's 1996 diagnosis of suspected malingering. (Tr. 22).
c) Treatment of medical opinion evidence under the regulations
The Social Security regulations contain detailed instructions for evaluation of medical evidence, including medical opinions. See 20 C.F.R. § 404.1527, 416.927. "Medical opinions are statements from physicians and psychologists or other acceptable medical sources that reflect judgments about the nature and severity of [the claimant's] impairment(s), including . . . symptoms, diagnosis and prognosis, what [the claimant] can still do despite impairment(s), and . . . physical or mental restrictions." 20 C.F.R. § 404.1527(a)(2), 416.927(a)(2). Generally, more weight is given to treating sources, "since these sources are likely to be the medical professionals most able to provide a detailed, longitudinal picture of [the claimant's] medical impairment(s)." 20 C.F.R. § 404.1527(d)(2), 416.927(d)(2). If the treating source's opinion is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record," it will be given controlling weight. 20 C.F.R. § 404.1527(d)(2), 416.927(d)(2); see also Branson v. Callahan, 14 F. Supp.2d 1089, 1095 (N.D.Iowa 1998) ("In determining a plaintiff's disability status, the opinion of a plaintiff's treating physician is entitled to substantial weight, unless it is unsupported by medical or diagnostic data, or if it is merely conclusory.") (citing Trossauer v. Chater, 121 F.3d 341, 343 (8th Cir. 1997); Ghant v. Bowen, 813 F.2d 633, 639 (8th Cir. 1991); Turpin v. Bowen, 813 F.2d 165, 170 (8th Cir. 1987); Janka v. Secretary of HEW, 589 F.2d 365, 369 (8th Cir. 1978); and Ward v. Heckler, 786 F.2d 844, 846 (8th Cir. 1986)). If not given controlling weight, the ALJ will evaluate the opinion by applying various factors to determine how much weight it should be afforded, including, inter alia: the length of the treatment relationship and the frequency of examination; the nature and extent of the treatment relationship; the supporting evidence underlying the opinion; the opinion's consistency with the record as a whole; and whether the opinion is offered by a specialist in the relevant field. 20 C.F.R. § 404.1527(d)(2), 416.927(d)(2). The ALJ must "always give good reasons in [its] notice of determination or decision for the weight [given to the] treating source's opinion." 20 C.F.R. § 404.1527(d)(2), 416.927(d)(2); see also Singh, 222 F.3d at 452 (holding that ALJ's failure to give "good reasons" for the weight given to treating physician's opinion was error); Branson, 14 F. Supp.2d at 1096 (ALJ must provide reasons for rejecting or discrediting opinion of treating physician).
Opinions by non-treating health care providers are also to be evaluated, regardless of the source. 20 C.F.R. § 404.1527(d), 416.927(d). The weight to be given consultative evaluations and opinions is determined using the same factors as used for treating physician opinions. See id. §§ 404.1527(d), 416.927(d). And finally, "the Commissioner is encouraged to give more weight to the opinion of a specialist about medical issues related to his or her area of specialty than to the opinion of a source who is not a specialist." Singh, 222 F.3d at 452 (citing Metz v. Shalala, 49 F.3d 374, 377 (8th Cir. 1995)); see also 20 C.F.R. § 404.1527(d)(5), 416.927(d)(5).
Applying the regulations to this case, the court finds that the record as a whole overwhelmingly demonstrates mental impairments that, combined with his physical impairments, preclude Mr. Saffold from sustaining gainful employment. As noted by Dr. Mayhew, there is in this case "fairly good consistency in the observations and findings by a number of mental health providers regarding [Mr. Saffold's] mental status and level of functioning." The record indicates consistent documentation of a psychological aspect to Mr. Saffold's complaints dating back to the 1995 auto accident. Dr. Dughly, examining Mr. Saffold shortly after the accident, noted "a tremendous psychological overlay" in his symptoms. (T. 286). Dr. Woo, an orthopedist who examined Mr. Saffold for "body pain" in May, 1996, stated that "his muscular pain and weakness seem to be out of proportion to his stature and general physique," and that "the physical findings do not match the physical examination." (Tr. 375). While the comments of Drs. Dughly and Woo are certainly not determinative as to Mr. Saffold's mental health status, they do, in this court's opinion, support a strong inference that the opinions of the mental health specialists — namely, Drs. Pucelik and Mayhew — may be extremely relevant to proper disposition of Mr. Saffold's case and need be carefully considered and addressed by the ALJ. See 20 C.F.R. § 404.1527(d)(5), 416.927(d)(5); Metz, 49 F.3d at 377 (encouraging Commissioner to give more weight to opinion of specialists in relevant areas of specialty).
Putting aside the handwritten note by Dr. Pucelik which the court agrees does not warrant substantial weight under the regulations, the court is at a loss as to the ALJ's nearly complete disregard of the substance of Dr. Pucelik's January 30, 1997 opinion letter. In that letter, not only did Dr. Pucelik explicitly lay out numerous clinical impressions that were of potentially significant effect to determination of Mr. Saffold's residual functional capacity, he also stated his opinion that Mr. Saffold met step three Listing criteria for depressive and anxiety related disorders. Dr. Pucelik is clearly a treating physician as that term is understood in the regulations. See 20 C.F.R. § 404.1527(d), 416.927(d) (listing relevant factors including length of treatment relationship and frequency of examination). As of the date of his letter, Dr. Pucelik had been treating Mr. Saffold on a regular basis for over six months. Although no formal psychological testing was done by Dr. Pucelik, (Tr. 400), his opinion was presumably based on the ongoing treatment relationship between Mr. Saffold, Mr. Davenport and himself. Therefore, the opinion of Dr. Pucelik as Mr. Saffold's treating physician, should have been granted controlling weight to the extent the opinion is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with other substantial evidence in the record." Singh, 222 F.3d at 452.
Again, the court is left to speculate as to whether the ALJ properly evaluated Dr. Pucelik's opinion. It may be that without formal psychological testing the ALJ was unwilling to credit Dr. Pucelik's clinical diagnoses, and that the ALJ justified that conclusion by Mr. Saffold's unwillingness or inability to complete such testing. The court, however, agrees with Mr. Saffold that the regulations and case law do not allow for such a restricted definition of relevant medical evidence, and that, in general, inclusion of formal testing results is not a prerequisite to consideration of medical opinion evidence on mental health issues. See 20 C.F.R. § 404.1513(b), 416.913(b) (citing as medical evidence "[c]linical findings (such as the results of . . . mental status examinations)"); see also, e.g., Branson, 14 F. Supp.2d at 1095 (discussing and accepting progress notes as supporting evidence of treating psychiatrist's opinion). Rather, the presence or absence of such testing is merely one of many factors in determining whether the medical opinion is well-supported by acceptable techniques. See id. at 1097 (discussing 8th Circuit rule that disability claimant need not produce objective evidence to corroborate allegations of disabling pain, this court concluded that "because psychiatric problems and pain share the same characteristics and are considered `nonexertional impairments,' plaintiff should not necessarily be required to corroborate her psychiatric problems with objective evidence either").
In finding no disability at step three, the ALJ noted that "the record does not contain medical findings obtained on clinical examination or special study which are the same as or equal to any of those listed in any subsection of the Listing of Impairments." (Tr. 15).
The appropriate analysis, then, is whether the various opinions stated in Dr. Pucelik's January 30, 1997 letter are adequately supported and are not inconsistent with other substantial evidence in the record. With regard to the step three Listing criteria, the court agrees that, despite Dr. Pucelik's opinion to the contrary, substantial evidence on the record as a whole supports the ALJ's decision that Mr. Saffold was not presumptively disabled. The court first notes the conclusory nature of Dr. Pucelik's statement that Mr. Saffold meets those criteria for depressive disorder and anxiety related disorder. Dr. Pucelik did not explain which criteria under the regulations were purportedly met nor why he concluded that they were established. See Marciniak v. Shalala, 49 F.3d 1350, 1353 (8th Cir. 1995) (quoting Sullivan v. Zebley, 493 U.S. 521, 530 (1990)) ("`For a claimant to show that [an] impairment matches a listing, it must meet all of the specified medical criteria.'"). While Dr. Pucelik (and subsequently Dr. Mayhew) diagnosed a depressive disorder, such diagnosis without further explication is not synonymous with a finding at step three that the claimant is disabled. See 20 C.F.R. § 404.1527(e)(1), 416.927(e)(1) ("We [the SSA] are responsible for making the determination or decision about whether you meet the statutory definition of disability."); Qualls, 158 F.3d at 428 (holding that ALJ not compelled to adopt treating physician's opinion on ultimate issue of disability). Thus, the court finds that Dr. Pucelik's opinion of January 30, 1997 is not controlling as to whether Mr. Saffold is presumptively disabled and that the ALJ properly concluded from the record as a whole that, for purposes of step three of the sequential evaluation process, he was not.
For example, to establish presumptive disability status under the Listings criteria for affective disorder, the claimant must show that requirements in both paragraphs A and B are met. As relevant here, paragraph A requires evidence of medically documented persistence, either continuous or intermittent, of depressive syndrome as manifested by one of nine listed characterizations. Under paragraph B, the claimant must again introduce evidence of medically documented persistence, either continuous or intermittent, of two of four listed functional restrictions.
Mr. Saffold also argues that the ALJ erred in not finding the presence of somatoform disorders under the regulations. See 20 C.F.R. pt 404, Subpart P, App. 1, § 12.07 (defining somatoform disorders as "physical symptoms for which there are no demonstrable organic findings or known physiological mechanisms"). The court agrees with Judge Jarvey's finding that the ALJ adequately evaluated evidence in the record and concluded that Mr. Saffold did not have a somatoform disorder for purposes of step three of the sequential evaluation process. The record does not indicate that Mr. Saffold was ever diagnosed with a somatoform disorder but merely that several doctors concluded that his statements did not match his physical examination. (E.g., Tr. 286; 370; 373-75). See Marciniak, 49 F.3d at 1353 (quoting Sullivan, 493 U.S. at 530) ("`For a claimant to show that [an] impairment matches a listing, it must meet all of the specified medical criteria.'"). And, as noted by Judge Jarvey, the ALJ specifically found the absence of a somatoform disorder, (Tr. 28), thereby further indicating his consideration and rejection of the disorder in Mr. Saffold's case. The court further notes, however, that absence of a somatoform disorder at step three of the sequential evaluation process does not preclude consideration of evidence regarding such a disorder at step five to determine Mr. Saffold's residual functional capacity.
That said, however, the court finds Dr. Pucelik's opinion extremely relevant to the ALJ's subsequent step five analysis and holds that the ALJ erred in his apparent disregard or discrediting of Dr. Pucelik's opinion when determining Mr. Saffold's residual functional capacity. The regulations require consideration of accepted medical sources' "statements about what [the claimant] can still do." See 20 C.F.R. § 404.1513(c), 416.913(a). In cases of mental impairment, such statements may include "the acceptable medical source's opinion about [the claimant's] ability to understand, to carry out and remember instructions, and to respond appropriately to supervision, coworkers, and work pressures in a work setting." Id. §§ 404.1513(c)(2), 416.913(c)(2). Dr. Pucelik's January 30, 1997 letter includes explicit opinion evidence regarding limitations on Mr. Saffold's ability to function in a work setting. In Dr. Pucelik's opinion, Mr. Saffold's "quick temper, lack of patience, and indifference to social relationships would interfere with his ability to function in a work setting and interact appropriately with coworkers." Further, his "difficulty paying attention and concentrating . . . would interfere with his ability to follow instructions, maintain pace in the workplace, and respond appropriately to changes in the workplace." Dr. Pucelik's opinion is based on and supported by his ongoing treatment relationship with Mr. Saffold and is not substantially contradicted by other evidence in the record. As such, Dr. Pucelik's clinical impressions as to Mr. Saffold's residual functional capacity were entitled to substantial, if not controlling, weight. See 20 C.F.R. § 404.1527(d)(2), 416.927(d)(2) (explaining that where treating source's opinion is "well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in [the] case record," it will be given controlling weight).
The minimal consideration given by the ALJ to Dr. Pucelik's opinion is even more puzzling in light of the corroborating opinion of Dr. Mayhew. In his first report, Dr. Mayhew suspected malingering but explicitly noted the need for further review of Mr. Saffold's medical records and the importance of obtaining the psychiatric records from Black Hawk Grundy Mental Health Center. For the second evaluation approximately nine months later, Dr. Mayhew obtained and reviewed all relevant medical records. Based on review of those records and a second examination, Dr. Mayhew concluded that Mr. Saffold's mental impairments were such that he could not function appropriately in the workplace and could not sustain gainful employment. There is no mention of malingering in the second, more complete report in which Dr. Mayhew explicitly recommends that Mr. Saffold be considered eligible for disability benefits due to "a mental impairment which is well documented and has lasted for at least twelve consecutive months since onset."
Reviewing the record as a whole, the court is hardpressed to understand the ALJ's treatment of Dr. Mayhew's consultative opinions. It appears that the ALJ relied on Dr. Mayhew's first report for purposes of discrediting Mr. Saffold's credibility despite the strong suggestion in Dr. Mayhew's second report that he had abandoned his initial, tentative diagnosis of suspected malingering. Again, it may be that the ALJ discredited the mental health opinion evidence on the grounds that Mr. Saffold was uncooperative with attempted psychological testing. If so, the ALJ erred since a reasonable reading of the record as a whole cannot support such a conclusion. Dr. Mayhew's second report is the result of two evaluations and a thorough review of the physical and mental health history. In his report, Dr. Mayhew explicitly noted Mr. Saffold's negative attitude and refusal to complete formal psychological testing. However, he nevertheless made significant findings and conclusions regarding Mr. Saffold's mental status and the court finds nothing in the record or case law to suggest that the validity of those conclusions should be discredited because of Mr. Saffold's less than cooperative participation. On the contrary, Mr. Saffold's behavior seems wholly consistent with Dr. Mayhew's diagnoses and clinical impressions. Thus, as this court reads the record, the only reasonable conclusion is that Dr. Mayhew's clinical observations as to Mr. Saffold's demeanor were factored into, and are properly reflected in, his second opinion. Moreover, Dr. Mayhew's opinion is corroborated by, and corroborates, the similar clinical findings and conclusions in Dr. Pucelik's opinion letter. Thus, the court concludes that Dr. Mayhew's opinion, as articulated in his second report, was entitled to substantial weight and that the ALJ's use of selective negative findings from both reports distorts the record as a whole which, when properly reviewed, convincingly demonstrates that Mr. Saffold's mental impairments preclude sustained gainful employment.
2. Did the ALJ rely on a flawed hypothetical at step five of the disability analysis?
In view of this court's finding that the ALJ improperly discounted the opinions of Mr. Saffold's treating psychiatrist and consulting psychologist, the court finds that the hypothetical question posed to the vocational expert by the ALJ, and relied upon in his decision, did not adequately reflect Mr. Saffold's mental impairments. That hypothetical purportedly incorporated Mr. Saffold's impairments as follows:
Mr. Saffold also contends that the hypothetical ignored critical physical restrictions — specifically, a statement in the evaluative report of Robert Bedard, a physical therapist who treated Mr. Saffold on August 24, 1995, that "[a]t this time, stooping, climbing, kneeling and crawling would not be possible for him." The court agrees with Judge Jarvey that the ALJ's failure to explicitly mention Mr. Bedard's report in his decision is not reversible error. A physical therapist is not an "acceptable medical source" under the regulations, see 20 C.F.R. § 404.1513(a), although it is an "other source" which may be considered where deemed helpful. See id. § 404.1513(e). And as noted by Judge Jarvey, "[a]lthough required to develop the record fully and fairly, an ALJ is not required to discuss every piece of evidence submitted." Black v. Apfel, 143 F.3d 383, 386 (8th Cir. 1998) (citation omitted). In this case, the "undiscussed" opinion evidence is neither controlling nor particularly persuasive in light of the record as a whole. Mr. Bedard's report was written less than three months after Mr. Saffold's auto accident, there is no evidence in the record that Mr. Bedard treated Mr. Saffold on an ongoing basis, and there is ample evidence in the record to support the ALJ's conclusion that Mr. Saffold's physical impairments are not as restrictive as described by Mr. Bedard.
[W]e have an individual who is currently 42 years old. He was 41 years old as of the alleged onset date of disability. He's a male, he has a high school general equivalency diploma, as well as training as an auto mechanic and he has the following impairments. He has residuals of a motor vehicle accident resulting in medically determinable causing complaints of pain, numbness and weakness of various areas of the body, a history of bilateral carpal tunnel syndrome, degenerative changes of the lumbar spine, borderline intelligence, anxiety and depressive disorders and personality trait disorder and as a result of a combination of those impairments, he has the residual functional capacity to perform basic work activities as follows. He should not lift more than twenty pounds, routinely lift ten pounds, with no continuous bending, stooping, squatting, kneeling, crawling or climbing. His gripping and gross find manipulation is intact, but he should avoid continuous repetitive use of the hands. He should not work at unprotected heights or in the presence of excessive vibrations. He is able to do simple routine repetitive work, which does not require a very close attention to detail. He does require occasional supervision and he should not work at more than a regular pace, using three speeds of pace, being fast, regular and slow.
A second hypothetical posed by the ALJ factored in additional physical restrictions that the court deems irrelevant to disposition of this matter.
The ALJ's hypothetical referred to a person with "borderline intelligence, anxiety and depressive disorders and personality trait disorder" but included no concrete manifestations of those diagnoses. In contrast, the hypothetical included detailed description as to how Mr. Saffold's physical impairments restrict his functioning. Based on the hypothetical, the vocational expert testified that Mr. Saffold could perform unskilled work within the light category of physical demands, such as a housekeeper cleaner, a sorter/inspector in the garment industry, and an outside deliverer. When asked to explain the basis for his opinion, the vocational expert cited only the exertional restrictions and made no mention of restrictions imposed by the proposed mental impairments. Because the ALJ failed to adequately incorporate the concrete opinion evidence of Drs. Pucelik and Mayhew into the hypothetical, the vocational expert did not consider Mr. Saffold's recognized mental impairments as they would likely affect or restrict his workplace functioning. See Taylor v. Chater, 118 F.3d 1274, 1278 (8th Cir. 1997), quoted in Roberts v. Apfel, 222 F.3d 466, 471 (8th Cir. 2000) ("Testimony from a vocational expert is substantial evidence only when the testimony is based on a correctly phrased hypothetical question that captures the concrete consequences of a claimant's deficiencies.") (emphasis added). Accordingly, the testimony of the vocational expert that jobs exist for Mr. Saffold cannot constitute substantial evidence on the record as a whole. See Singh, 222 F.3d at 453 (rejecting vocational expert testimony where ALJ had improperly discredited opinion of treating physician); accord, Branson, 14 F. Supp.2d at 1099-1100; Newton v. Chater, 92 F.3d 688, 694-5 (8th Cir. 1996) (holding that hypothetical question must "completely describe" a plaintiff's individual impairments so that vocational expert may accurately assess whether jobs exist for the plaintiff).
Instead, the court finds relevant the expert's subsequent testimony in response to questioning by Mr. Saffold's attorney wherein he proposed an additional restriction for consideration by the vocational expert — that the individual had "marked inability to interact appropriately with coworkers and supervisors, [and] would be allowed to work at jobs that require no significant or frequent contact with the public, limited to jobs with only mild stress." (Tr. 130). So characterized, this proposed restriction adequately captures at least a portion of the opinion evidence of Drs. Pucelik and Mayhew. In response to the modified hypothetical, the vocational expert responded that "the person's inability to appropriately interact while in a work setting would, of course, exclude competitive employment." (Tr. 130). As previously discussed, the court finds that Dr. Pucelik's and Dr. Mayhew's opinions were entitled to substantial weight and, accordingly, testimony by the vocational expert which properly reflects those opinions significantly contributes to this court's conclusion that Mr. Saffold is disabled and eligible for benefits. See, e.g., Wiekamp v. Apfel, 116 F. Supp.2d 1056 (N.D.Iowa 2000) (citing Roberts, 222 F.3d at 471, and finding that vocational expert's response to alternative hypothetical question which "captures the concrete consequences of a claimant's deficiencies" does constitute "substantial evidence" that claimant is disabled).
CONCLUSION
The court sustains Mr. Saffold's objection to Judge Jarvey's finding that the Commissioner met his burden to show jobs in the national economy for which Mr. Saffold was qualified. The well-supported opinion of Mr. Saffold's treating psychiatrist establishes severe mental impairments that are manifested in ways which significantly restrict his ability to appropriately interact and function within the workplace. There is nothing in the record which substantially conflicts with Dr. Pucelik's opinion. To the contrary, the record is replete with evidence supporting his conclusions, including Dr. Mayhew's consultative reports and consistent documentation by numerous physicians suggesting that more than mere physical impairments were at issue. Because the record as a whole convincingly establishes that Mr. Saffold suffers from a combination of mental and physical impairments that precludes him from past relevant work and from any other jobs available in significant numbers in the national economy, the court concludes that Mr. Saffold was disabled for purposes of disability insurance and supplemental security income benefits as of May 30, 1995. Accordingly, the court will reverse and remand to the Commissioner for calculation and payment of benefits. See Taylor, 118 F.3d at 1279 (reversal is appropriate where there is overwhelming evidence of disability).
Having so concluded, the court declines to address Mr. Saffold's remaining objections to Judge Jarvey's Report and Recommendation.
ORDER
For the reasons discussed herein, the ALJ's decision denying benefits is REVERSED and this matter is REMANDED to the Commissioner for the calculation of benefits as of May 30, 1995, in accordance with this ORDER.