United States District Court, N.D. Ohio, Eastern Division
Y. PEARSON, MAGISTRATE JUDGE.
REPORT AND RECOMMENDATION OF MAGISTRATE
J. LIMBERT, UNITED STATES MAGISTRATE JUDGE.
Dupont Harris (“Plaintiff”) requests judicial
review of the final decision of the Commissioner of Social
Security Administration (“Defendant”) denying his
application for Supplemental Security Income
(“SSI”). ECF Dkt. #1. In his brief on the merits,
filed on March 7, 2017, Plaintiff asserts that the
administrative law judge (“ALJ”) erred in the
weight assigned to the opinion evidence. ECF Dkt. #12.
Defendant filed a response brief on May 8, 2017. ECF Dkt.
#14. Plaintiff did not file a reply brief.
following reasons, the undersigned RECOMMENDS that the Court
AFFIRM the ALJ's decision and dismiss Plaintiff's
case in its entirety with prejudice.
filed an application for SSI on June 14, 2013. ECF Dkt. #10
(“Tr.”) at 163.The application was denied
initially and upon reconsideration. Id. at 77, 90.
Plaintiff then requested a hearing, which was held on June
23, 2015. Id. at 31. On January 28, 2016, the ALJ
issued a decision denying Plaintiff's claim. Id.
at 10. Subsequently, the Appeals Council denied
Plaintiff's request for review. Id. at 1.
Accordingly, the January 28, 2016, decision issued by the ALJ
stands as the final decision.
instant suit was filed by Plaintiff on November 1, 2016. ECF
Dkt. #1. On March 7, 2017, Plaintiff filed a brief on the
merits. ECF Dkt. #12. Defendant filed a response brief on May
8, 2017. ECF Dkt. #14. Plaintiff did not file a reply brief.
RELEVANT MEDICAL AND TESTIMONIAL EVIDENCE
March 22, 2012, Plaintiff sought treatment for auditory
hallucinations and reported hearing voices instructing him to
kill his mother, others around him, and
himself. Tr. at 271, 289. Plaintiff also reported a
history of drug and alcohol abuse. Id. at 289. At
the time of this treatment, Plaintiff was receiving housing
and recovery services, and indicated that he was experiencing
withdrawal symptoms. Id. at 274, 289.
sought emergency medical treatment on January 1, 2013,
stating that he had been drinking alcohol and smoking
marijuana. Tr. at 436. Treatment notes indicated that
Plaintiff was too intoxicated to provide a coherent history
of his medical condition(s) and that the care provider was
unable to understand most of what Plaintiff was saying due to
severe slurring of his words. Id.
March 8, 2013, Plaintiff underwent a mental health assessment
and complained of feeling anxious around “a lot of
people, ” feeling depressed daily, anhedonia, and
feelings of guilt. Tr. at 278. Plaintiff denied excessive
anger and indicated that he was unsure if he experienced
panic attacks. Id. Additionally, Plaintiff reported
seeing monsters, paranoia, and that he stayed in his house
due to fear. Id. Plaintiff reported that in the past
year he had not had five or more alcoholic drinks on a single
day and that he had not used illegal drugs in the past five
years, however, Plaintiff also reported that he was in an
inpatient treatment program in June 2012 for polysubstance
abuse, including heroin and alcohol. Id. at 279-80.
It was noted that Plaintiff displayed poor hygiene, clear
speech, logical thought processes, fair judgment and insight,
good recent and remote memory, sustained attention span and
concentration, and a dysphoric and overwhelmed mood.
Id. at 281. The licensed social worker interviewing
Plaintiff issued a diagnostic impression of schizophrenia,
paranoid type, rule-out polysubstance dependence, and a
global assessment of functioning (“GAF”) score of
fifty-one to sixty. Id. at 282.
reported experiencing panic attacks on a nearly daily basis,
feeling scared, and hearing voices on March 21, 2013. Tr. at
233. According to Plaintiff, he began having panic attacks
when he was nine years old and started hearing voices when he
was nineteen years old. Id. Plaintiff reported that
his symptoms increased since he stopped using drugs the prior
summer. Id. at 234. On examination, Plaintiff
displayed: some signs of neglect and appeared older than his
stated age; guarded behavior; orientation to time, person,
and place; slow speech; a disorganized thought process;
paranoid ideation; auditory hallucinations; visual
hallucinations; poor judgment and insight; distractible
attention span and concentration; euthymic mood; poor energy
and motivation; fair concentration; and blunted affect.
Id. at 236. Mary Lieder, the certified nurse
practitioner (“CNP”) that performed the
examination, diagnosed schizophrenia, paranoid type, and
assigned a GAF score of thirty-one to forty. Id. at
April 24, 2013, Plaintiff reported that he “felt a lot
better, ” was sleeping better, and felt more at ease.
Tr. at 231. Upon examination, Plaintiff displayed: adequate
grooming; cooperative behavior; orientation to time, person,
and place; spontaneous speech with normal rate and flow;
logical and organized thought processes; euthymic mood; good
appetite; good energy; constricted affect; sustained
concentration and attention; recent and remote memory within
normal limits; and fair judgment and insight. Id.
Plaintiff reported that his paranoid thoughts were
“going down” and that he was experiencing just a
“little bit of hallucinating.” Id.
reported to the emergency room on May 19, 2013, reporting
that he had tripped and hit his head while walking up
concrete steps. Tr. at 391. Plaintiff stated that he had been
drinking alcohol that morning, prior to his fall.
2013, Plaintiff reported that he continued to feel better and
that his family noticed improvement. Tr. at 228. CNP Lieder
examined Plaintiff and noted that he displayed: adequate
grooming; cooperative behavior; orientation to time, person,
and place; spontaneous speech with normal rate and flow;
logical and organized thought processes; eurythmic mood;
“fine” appetite; better energy and motivation;
sustained attention and concentration; recent and remote
memory within normal limits; and fair judgment and insight.
Id. It was also noted that Plaintiff reported that
his paranoid thoughts were “much decreased, ” and
that his visual and auditory hallucinations were very
infrequent. Id. CNP Lieder continued Plaintiff's
medications at the same dose. Id. at 229.
August 23, 2013, Plaintiff underwent a psychological
consultative evaluation with an examining psychologist,
Mitchell Wax, Ph.D. Tr. at 462. Dr. Wax noted that Plaintiff
could not provide clear information about why he could not
work, instead simply stating “I can't work.”
Id. Continuing, Dr. Wax noted memory problems when
Plaintiff could not remember much of his lengthy history of
arrests and incarcerations. Id. at 463. Dr. Wax
noted that Plaintiff indicated that he was a recent alcoholic
and drug abuser, and stated, “I was drinking daily, and
I've been drinking off and on for many years.”
Id. Plaintiff reported that he last used crack
cocaine and phencyclidine (“PCP”) in 2012, and
stated, “I was using drugs off and on for many years
too.” Id. Next, Plaintiff stated that he had
been drug free for the past year.
daily activity, Plaintiff reported that went to bed at 11:00
P.M. and woke at 8:00 A.M. Tr. at 464. Plaintiff stated that
he knew how to cook, but did not cook. Id.
Continuing, Plaintiff indicated that his female friend cooked
for him, washed his laundry, and cleaned his apartment.
Id. Plaintiff stated that on a typical day he
watched television by himself until noon, then took a
two-hour walk to exercise his leg. Id. Following his
walk, Plaintiff would watch television until 5:00 P.M.
Id. Plaintiff stated that his mother and brother
came to his apartment four to five times a week to visit, and
sometimes they would stay for dinner. Id. Regarding
the female friend, Plaintiff stated that she was not a
girlfriend, but that she came over daily. Id.
Plaintiff denied contact with any other friends and stated
that he attended church twice per month. Id.
indicated that Plaintiff presented as a pleasant man who had
intermittent memory problems. Tr. at 464. Continuing, Dr. Wax
noted that Plaintiff appeared confused and distant initially,
but that he was able to focus and become more alert as the
session progressed. Id. Dr. Wax remarked that
Plaintiff displayed intermittent mumbling to himself and that
at times Plaintiff appeared to withdraw into his own
thoughts. Id. Next, Dr. Wax indicated that Plaintiff
stated that he hallucinated and heard voices. Id.
Plaintiff's speech was initially vague and
circumstantial, and Dr. Wax noted that Plaintiff was able to
focus for five to ten minutes before drifting off.
Id. at 465. When Plaintiff drifted off, he had
difficulty providing information about himself and appeared
to be listening to auditory hallucinations. Id.
Plaintiff reported having panic attacks twice per week and
described his mood as depressed. Id. Dr. Wax was
unable to estimate Plaintiff's IQ due to his psychosis,
and indicated that he appeared to be hallucinating during the
evaluation. Id. Following the examination, Dr. Wax
diagnosed Plaintiff with: schizoaffective disorder, bipolar
type, and polysubstance dependence in remission for one year,
and assigned a GAF score of thirty-one. Id. at 466.
Dr. Wax opined that Plaintiff would have difficulty:
understanding, remembering, and carrying out instructions for
a job; maintaining attention and concentration; performing
simple tasks during psychotic episodes; responding
appropriately to coworkers, supervisors, and work pressures
in a work setting; and attending and focusing regularly on a
job. Id. at 466-67.
September 9, 2013, a state agency psychologist, Robelyn
Marlow, Ph.D., reviewed Plaintiff's medical file and
opined that he: would be able to maintain concentration,
attention, persistence, and pace for simple tasks; and
retained the ability to interact superficially with others
and perform routine tasks when sober. Tr. at 85-87. Dr.
Marlow noted that Dr. Wax's opinion appeared to be an
overestimate of Plaintiff's limitations that was based on
a snapshot of his functioning. Id. at 87. On
December 16, 2013, state agency psychologist Karl Voyten,
Ph.D., concurred with Dr. Marlow's assessment.
Id. at 102-103.
was examined by CNP Lieder on September 26, 2013. Tr. at 225.
On examination, Plaintiff reported that he was still feeling
better, but that the “sometimes wakes up feeling he is
dead.” Id. at 225. Plaintiff also stated that
he believed he was “getting along ok with people”
and that he was worried about his mother's declining
health. Id. CNP Lieder noted that Plaintiff
displayed: adequate grooming; cooperative behavior;
orientation to time, person, and place; spontaneous speech
with normal rate and flow; logical and organized thought
processes; a “more depressed” mood;
“fine” appetite; fair energy and motivation;
constricted affect; recent and remote memory within normal
limits; and fair judgment and insight. Id. at 226.
Continuing, CNP Lieder indicated that Plaintiff reported that
his paranoid thoughts had worsened, visual hallucinations
were occurring occasionally, and auditory hallucinations were
“calming down.” Id.
October 9, 2013, CNP Lieder completed a medical source
statement concerning Plaintiff's mental capacity. Tr. at
479. CNP Lieder opined that Plaintiff would have the rare
ability, meaning the activity could not be performed for any
appreciable time, in fifteen of the twenty-two categories
surveyed in the medical source statement, including the
ability to: follow work rules; maintain attention and
concentration for extended periods of two-hour segments;
maintain regular attendance and being punctual with customary
tolerance; deal with work stress; behave in an emotionally
stable manner; and complete a normal workday and workweek
without interruption from psychologically-based symptoms and
perform at a consistent pace without an unreasonable number