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Riley v. Berryhill

United States District Court, D. Massachusetts

August 30, 2017

NANCY A. BERRYHILL, [1] Acting Commissioner, Social Security Administration, Defendant.



         I. Introduction

         Plaintiff Schyler Riley (“Riley”) filed an application for supplemental security income (“SSI”) with the Social Security Administration (“SSA”). R. 154.[2] Pursuant to the Social Security Act, 42 U.S.C. § 405(g), Riley brings this action for judicial review of the final decision of the Commissioner of the SSA (“Commissioner”), issued by an Administrative Law Judge (“ALJ”) on September 25, 2014. See R. 6, 12. Before the Court is Riley's motion to reverse the ALJ's decision denying SSI, D. 20, and the Commissioner's motion to affirm the decision, D. 24. For the reasons discussed below, the Court DENIES Riley's motion to reverse and GRANTS the Commissioner's motion to affirm.

         II. Factual Background

         Riley was born on January 11, 1967 and was forty-five years old when she filed a claim for SSI on October 19, 2012. R. 99. In her claim, she alleged post-traumatic stress disorder (“PTSD”) as her disability, with an onset date of October 17, 2012. R. 99-100.

         III. Procedural History

         Riley filed an application for SSI on October 19, 2012. R. 99. The SSA determined Riley was not disabled and denied her claim on March 7, 2013. R. 103, 117. Riley filed a request for reconsideration on April 6, 2013 and her claim was again denied. R. 120-21. On June 11, 2013, Riley filed a request for a hearing before an ALJ, R. 124, which was held on August 8, 2014, R. 29. Riley appeared at this hearing in person and was not represented. R. 31. The ALJ found Riley not disabled and denied her application on September 25, 2014. R. 12. Riley filed a request for review of the ALJ's decision on November 11, 2014. R. 10. The Appeals Council denied Riley's request for review on December 31, 2015, rendering the ALJ's decision the final decision of the Commissioner. R. 6. Riley submitted a request, dated February 21, 2016, for an extension to file a civil complaint. R. 2. The Appeals Council granted the request. R. 1.[3]

         IV. Discussion

         A. Legal Standards

         1. Entitlement to SSI

         Entitlement to SSI turns on whether the claimant has a disability, 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 has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. §§ 416(i)(1), 423(d)(1)(A); 20 C.F.R. § 416.905(a). This impairment must be severe, rendering the claimant unable to do his or her previous work or any other gainful activity existing in the national economy for which the claimant is qualified. 20 C.F.R. § 416.905(a).

         There is a five-step process to determine whether a claimant has a disability. Id. § 416.920. The analysis may conclude at any step. Id. § 416.920(a)(4). First, if the claimant is engaged in substantial gainful activity, the Commissioner will find the claimant not disabled. Id. § 416.920(a)(4)(i). Second, if the claimant has not had a severe impairment or combination of impairments during the relevant time period, the Commissioner will find the claimant not disabled. Id. § 416.920(a)(4)(ii). Third, if the severe impairment meets or equals those listed in SSA regulations, the claimant is found disabled. Id. § 416.920(a)(4)(iii). Fourth, the Commissioner determines the claimant's residual functional capacity (“RFC”). Id. § 416.920(a)(4)(iv). If the RFC is such that the claimant can still perform past relevant work, the claimant is found not disabled. Id. Fifth, if the RFC, considered in conjunction with the claimant's age, education and work experience, renders the claimant unable to do any other work in the national economy, the Commissioner will find that the claimant is disabled. Id. § 416.920(a)(4)(v).

         2. Standard of Review

         The Court may affirm, modify or reverse the decision of the Commissioner with or without remanding the case for a rehearing. 42 U.S.C. § 405(g). This review is “limited to determining whether the ALJ used the proper legal standards and found facts upon the proper quantum of evidence.” Ward v. Comm'r of Soc. Sec., 211 F.3d 652, 655 (1st Cir. 2000). The Commissioner's findings of fact are conclusive if supported by substantial evidence, 42 U.S.C. § 405(g); Manso-Pizarro v. Sec'y of Health & Human Servs., 76 F.3d 15, 16 (1st Cir. 1996), which exists when “more than a mere scintilla” supports the conclusion, Richardson v. Perales, 402 U.S. 389, 401 (1971). The Commissioner's findings of fact “are not conclusive when derived by ignoring evidence, misapplying the law, or judging matters entrusted to experts.” Nguyen v. Chater, 172 F.3d 31, 35 (1st Cir. 1999) (citing Da Rosa v. Sec'y of Health & Human Servs., 803 F.2d 24, 26 (1st Cir. 1986)).

         Issues of credibility and inferences drawn from the facts on record are the responsibility of the Commissioner, who ultimately resolves conflicts in the evidence and determines the disability status of the claimant. Lizotte v. Sec'y of Health & Human Servs., 654 F.2d 127, 128 (1st Cir. 1981). As such, the Court must uphold the Commissioner's decision when “a reasonable mind, reviewing the evidence in the record as a whole, could accept it as adequate to support [the] conclusion, ” even if the record could support multiple decisions. Dedis v. Chater, 956 F.Supp. 45, 49 (D. Mass. 1997) (quoting Ortiz v. Sec'y of Health & Human Servs., 955 F.2d 765, 769 (1st Cir. 1991)); see Evangelista v. Sec'y of Health & Human Servs., 826 F.2d 136, 144 (1st Cir. 1987).

         The Court may liberally construe a pro se plaintiff's allegations. King v. Colvin, 128 F.Supp.3d 421, 439 (D. Mass. 2015); see Tefera v. Colvin, 61 F.Supp.3d 207, 214 (D. Mass. 2014).

         B. Before the ALJ

         1. Medical History

         a. PTSD

         In November 2010, Riley saw a psychologist, David H. Gover, Ed.D., through Massachusetts Rehabilitation Services (“Mass Rehab”) for a mental status examination. R. 315-19. Riley told Dr. Gover she was fired from her job at Best Buy for “vulgar language and threatening behavior” even though she was “doing good work.” R. 315-16. Riley also stated that she had “some problems in the area of verbal comprehension.” R. 316. Dr. Gover did not observe signs of depression or anxiety, R. 315, and noted Riley was “very verbal and personable, ” R. 317. Dr. Gover also reported “a faint paranoid aroma, ” R. 318, but remarked, “[Riley] had a very interesting story for every adversity, but they were all so plausible that I can't say they don't just represent a rather long bad situation, ” R. 316. He further noted that Riley “appear[ed] to have a way of placing blame on a lot of people in her life for things that have gone wrong for her, ” which often happens when someone “whose understanding of emotions is low, but their responsiveness to them is of an exaggerated nature.” R. 317. Dr. Gover noted that Riley “appeared to have the cognitive capacity to learn, understand and perform well in a wide variety of job situations, but she need[ed] to deal with emotional factors that have interfered with her performance on a chronic basis, ” id., which could be treated most successfully with one-on-one psychotherapy, R. 318. He suggested that Riley's presentation was more indicative of a personality disorder than an affective disorder. R. 317. Dr. Gover gave Riley a GAF[4] score of 75.

         Riley began treatment with a psychiatrist, Murtuza Vali, M.D., in October 2012. R. 286. Dr. Vali observed Riley was coherent in speech and thoughts, cooperative, goal directed and had a “congruent” affect, although Riley reported feeling depressed that day. Id. Dr. Vali noted Riley had a “bizarre” paranoia “regarding [a] family member [who] was experimented on in school” and “poor insight into [the] nature of [her own] suspiciousness and paranoia.” Id. Dr. Vali diagnosed Riley with PTSD with “possible persecutory delusions” and prescribed Abilify, giving Riley a GAF score of 40. Id.

         On November 7, 2012, Dr. Vali noted Riley was “pleasant and smiling, ” cooperative and “less distressed.” R. 284. Dr. Vali also observed that Riley was goal directed and coherent in speech and thoughts, assessing a GAF score of 40. Id. Riley told Dr. Vali she had been compliant with Abilify, though her “past trauma still bother[ed] her and she [was] depressed [about] not having her son . . . [who was] currently . . . in [the Department of Children and Families] custody.” Id. Dr. Vali reported that Riley's previous paranoia regarding a family member had decreased in intensity and concluded that Riley had shown overall improvement with Abilify. Id.

         On November 7, 2012, Dr. Vali completed a mental health assessment for Riley. See R. 252-55. Dr. Vali stated Riley complained of “grief and feelings of loss related to [her] son being removed” from her home. R. 252. Additionally, Dr. Vali noted that Riley “present[ed] with numerous delusions including thinking that her son has a ‘genetic alteration' and that the school was ‘running experiments' on him” and Riley “report[ed] flashbacks related to [domestic violence] by [her] ex-boyfriend.” Id. Dr. Vali observed that Riley was well groomed, had a “good rapport, ” appeared of average intelligence and “report[ed] no memory or concentration problems, ” while also stating that Riley had “mild tangentiality on thought processes” and a “somewhat incongruent” mood and affect. Id. Dr. Vali noted Riley's PTSD diagnosis and Abilify prescription. R. 253. In regard to Riley's functional capacity, Dr. Vali opined that Riley had an impairment that would affect her ability to work and would last more than a year. R. 255. Dr. Vali observed that Riley's suspiciousness could “affect her ability to work with her colleagues.” R. 254.

         On December 14, 2012, Dr. Vali noted that Riley “appeared pleasant and smiling.” R. 282. Dr. Vali also reported that Riley denied any paranoid concerns and stated her past trauma still bothered her. Id. Additionally, Dr. Vali observed that Riley was cooperative, less distressed, goal directed and coherent in speech and thoughts. Id. Dr. Vali concluded Riley had shown improvement with Abilify, although she still had “poor insight into nature of suspiciousness and paranoia, ” and increased Riley's dosage. Id. Dr. Vali assessed Riley's GAF score at 55. Id.

         On March 7, 2013, Dr. Vali noted Riley “appeared pleasant and smiling this afternoon . . . had been compliant [with] Abilify . . . denied any paranoid concerns . . . stated past trauma still bother[ed] her . . . [and] denied any significant PTSD [symptoms].” R. 295. Dr. Vali also noted that Riley was goal directed and coherent in speech and thoughts and had fair insight and judgment. Id. Dr. Vali assessed that Riley had shown overall improvement with Abilify and gave her a GAF score of 60.

         Steven N. Shapse, Ph.D., a psychologist, saw Riley in March 2013. R. 298. He spoke with Riley and conducted a number of psychological tests. R. 298-307. Dr. Shapse found that Riley was oriented to time, date, place and person, appropriately dressed in casual attire, able to maintain attention, generally able to comprehend instructions and completed all required tasks as directed. R. 302. Dr. Shapse also observed that Riley's range of emotions was “normal with affect consistent with topics discussed, ” there was “no evidence of delusions or hallucinations nor did she appear paranoid” and she had intellectual functioning in the average to high average range. Id. Furthermore, Dr. Shapse determined that Riley's memory function was unimpaired, her interpersonal style was cooperative and her insight and judgment were appropriate. Id. Dr. Shapse stated that Riley “evidenced no special or behavioral needs.” Id.

         Dr. Shapse noted that Riley reported she experienced few symptoms related to PTSD, but “[t]esting reveal[ed] otherwise, ” R. 302, as she “indicate[d] past traumatic stresses: reliving something horrible that has occurred in the past and being long time troubled by memories of a bad experience, ” R. 303. He explained that the “[t]ests showed a defensive response style which limits the utility of these findings” as Riley “did not answer questions in a forthright manner, tending to portray herself as being relatively free of common shortcomings to which most individuals will admit, ” and “was reluctant as well to recognize minor faults in herself.” R. 302. Dr. Shapse noted that this type of defensive response is “actually common in custody and termination of parental rights matters” and stems from “concern about being evaluated unfavorably.” R. 302-03. Furthermore, Riley's “level of defensiveness or ‘look good' responding [was] not necessarily higher than others being evaluated for similar reasons.” R. 303. Dr. Shapse commented that the “reader of this report should therefore note that the following findings may underestimate the level of pathology of any psychological ...

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