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Butler v. Berryhill

United States District Court, N.D. Indiana, South Bend Division

August 30, 2018

NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant.



         Antwonita Butler appeals the Social Security Administration's decision to deny her application for disability benefits. An administrative law judge found that Butler was not disabled within the meaning of the Social Security Act, and Butler challenges that decision on two grounds - one concerning the residual functional capacity (RFC) assigned to Butler and the other relating to a credibility decision made by the ALJ. Neither issue is grounds for reversal.

         It certainly seems that Butler has a host of medical problems. The ALJ found that Butler has several severe impairments including lumbar degenerative disc disease, plantar fasciitis, an obese body habitus, a depressive disorder and anxiety disorder. [A.R. 18.] The ALJ also found that Butler has a number of non-severe impairments. [Id. at 18-19.] The ALJ provided a comprehensive description of the medical evidence in the record which need not be repeated here. [See A.R. at 16-39.]

         Before getting into the guts of the arguments, let's start with some basics on what my role is in this process. It is not to determine from scratch whether or not Butler is disabled and entitled to benefits. Instead, my review of the ALJ's findings is deferential, to determine whether the ALJ applied the correct legal standards and whether the decision is supported by substantial evidence. Shideler v. Astrue, 688 F.3d 306, 310 (7th Cir. 2012); Castile v. Astrue, 617 F.3d 923, 926 (7th Cir. 2010); Overman v. Astrue, 546 F.3d 456, 462 (7th Cir. 2008). If substantial evidence supports the Commissioner's factual findings, they are conclusive. 42 U.S.C. §405(g). “Evidence is substantial if a reasonable person would accept it as adequate to support the conclusion.” Young v. Barnhart, 362 F.3d 995, 1001 (7th Cir. 2004). “Substantial evidence” is more than a “scintilla” of evidence, but it's less than a preponderance of the evidence. Richardson v. Perales, 402 U.S. 389, 401 (1971). So the review is a light one. But of course, I cannot “simply rubber-stamp the Commissioner's decision without a critical review of the evidence.” Clifford v. Apfel, 227 F.3d 863, 869 (7th Cir. 2000).

         Butler raises two issues with the ALJ's decision. The first issue concerns the RFC assigned to Butler by the ALJ. The RFC is a measure of the work that someone is capable of performing despite their severe and non-severe impairments. In other words, the RFC must take into account all of the applicant's impairments to determine whether there is any work that the person is capable of doing. Butler claims that the RFC assigned to her by the ALJ failed to adequately take into account the evidence of her ongoing anxiety, depression, and psychotic features. The second issue is the ALJ's credibility findings. The ALJ looked askance at some of Butler's testimony, and the issue is whether those credibility findings are supported by substantial evidence. I'll take up each of these issues in turn.

         The RFC Determination

         Butler first challenges the ALJ's determination of Butler's RFC, which Butler says did not include certain well-supported limitations urged by Butler, including her severe anxiety, depression, and psychotic features such as hallucinations. The ALJ found that Butler suffered from the severe impairments of a depressive disorder and an anxiety disorder, in addition to other severe physical impairments. The ALJ determined that Butler had the RFC to perform sedentary work and that she could follow simple, but not detailed, instructions and could perform simple, routine tasks but not always at a production-rate pace. [A.R. at 25.] In spite of this, Butler argues that the ALJ's RFC limitation is insufficient to address her deficits in attention and concentration. Butler is essentially arguing that the ALJ erred in her interpretation of the medical evidence in reaching her conclusion that additional limitations should not be included in Butler's RFC.

         The ALJ considered the medical evidence as a whole and determined that her psychological limitations were not as severe as alleged. As to her hallucinations, the ALJ noted that she had denied hallucinations on several occasions and importantly, no clinician had ever noted responses to internal stimuli. The ALJ also relied in part on the fact that Butler had been non-compliant with her care and medications and had not decompensated after long periods of noncompliance. [A.R. at 31.]

         Butler claims that the ALJ ignored the diagnosis of Butler's treating physician and impermissibly played doctor. It's not clear to me what treating physician Butler is referring to. But Butler does reference several evaluations that she says support including her mental limitations as alleged in the RFC. First, Butler argues that a report compiled by Warren Sibilla, Jr., Ph.D. supports her claims. But this report was completed in 2008 - six years prior to the alleged onset date. [A.R. at 335.] A report authored six years prior to the alleged onset date is hardly persuasive evidence. And in all events Dr. Sibilla noted that although Butler's mood was depressed, she was alert and engaged, demonstrated a competent orientation to person, place, time, and situation, demonstrated no gross impairment in her speech, and that her thoughts were goal-directed and topic-specific. [Id.] Moreover, Butler “denied any psychotic related symptomatology” and was able to answer some of the simple calculations and recall questions posed to her. [Id. at 336.] It is true that Dr. Sibilla diagnosed Butler with “Major Depressive Episode, Moderate Severity.” [Id. at 337.] But the ALJ made a reasoned decision to discount the report given the fact that it had a thick layer of dust on it and did not support Butler's subjective symptoms in any event.

         Second, Butler points to an examination by Alan Wax, Ph.D., conducted in January of 2015, in which he found that Butler could recall none of the three words after five minutes, failed both trials of six digits forward, failed both trials of five digits backwards, and was unable to complete serial sevens and serial threes. [A.R. at 464-67.] But the ALJ discussed Dr. Wax's report at length and expressly acknowledged that Butler could not complete some of the tasks mentioned above. [A.R. at 27.] The ALJ went on to note portions of Dr. Wax's report that indicated Butler's mathematical skills were preserved, her abstract thought processes were within functional limits, and her judgment and insight were intact. [Id.] Dr. Wax diagnosed Butler with a depressive disorder, but he offered no opinion on what limitations her symptoms would pose for her. [Id.]

         The ALJ reasonably determined that Dr. Wax's opinion supported the conclusion that Butler could perform the demand of unskilled work, which includes following simple but not detailed instructions and performing simple, routine tasks. The ALJ included an additional limitation to address Butler's impaired recall, restricting her to work that did not require a consistent production-rate pace. [A.R. at 25.] For reasons that I will discuss further below, the ALJ reasonably determined that Butler's subjective complaints of symptoms were not entirely credible. Thus, the record did not support any additional limitations based on her mental impairments.

         Butler cites to two additional pieces of evidence that she argues support her claim that additional limitations based on her depression, anxiety, and hallucinations should have been included in her RFC assessment. She claims that Roohi Sualeh, M.D. diagnosed her with PTSD, bipolar disorder, and generalized anxiety. However, on September 14, 2016, this same doctor also observed that Butler was giving lengthy answers with unnecessary details “in order to convince this physician.” [A.R. at 737.] Dr. Sualeh also indicated that Butler “reports that she hears voices, ” but there appears to be nothing in the report that verifies these reports in any way. [Id.] Dr. Sualeh observed that Butler was alert, oriented to time, place, and person, and that her attention was okay. [Id.] As the ALJ noted in her opinion, Dr. Sualeh also noted that Butler “is seen after a year and her presentation is pretty much the same as a year ago.” [Id.] This suggested that, despite not receiving treatment by Dr. Sualeh for a year, her mental state had not decompensated.

         Butler also refers to several examinations conducted by Sandy Imanse, LCSW, in 2016. Imanse noted hallucinations in Butler's record, but this appears to have been based solely on Butler's reports that she heard voices. Indeed, Imanse's assessment on February 12, 2016 indicates that Butler “is able to respond appropriately to questions although she states that she ‘hears voices.'” [A.R. at 691.] Imanse also noted on another visit that “Bipolar disorder [patient] states that this is her diagnosis although she states that she ‘hears voices.'” [A.R. at 679.] Other assessments completed by Imanse in March 2016 noted that Butler's cognitive functioning was not impaired, that her hygiene was good, her appearance was calm, and no behavior abnormalities were demonstrated. [A.R. at 679, 686.]

         The ALJ considered all of the evidence discussed above, but the ALJ also considered evidence from multiple doctors' visits in which Butler denied these same symptoms. For example, at a physical exam conducted by Dr. Curry on September 10, 2014 - immediately prior to the alleged onset date - Butler denied mental illness. [A.R. at 436.] So although Butler reported psychological symptoms at the February 2015 psychological exam, just a few months prior, she had denied all psychological issues. [Id.] Ultimately, despite mixed medical evidence in the record regarding the severity of Butler's mental impairments, the ALJ did include a ...

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