Opinion
Case No. 03-4145-RDR.
June 3, 2004
MEMORANDUM AND ORDER
This is an action to review the defendant's decision to deny plaintiff's application for supplemental security income benefits. Plaintiff filed her application on December 10, 1999, alleging a disability onset date of July 5, 1997. A hearing before an Administrative Law Judge (ALJ was held on April 21, 2001. On August 23, 2001 he rendered a decision against the plaintiff's application. This decision was affirmed by the Appeals Council and adopted by defendant.
Legal Standards
We review defendant's decision "to determine whether the factual findings are supported by substantial evidence in the record and whether the correct legal standards were applied."Doyal v. Barnhart, 331 F.3d 758, 760 (10th Cir. 2003). "Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Id. (quotations and citation omitted). However, "[a] decision is not based on substantial evidence if it is overwhelmed by other evidence in the record or if there is a mere scintilla of evidence supporting it." Bernal v. Bowen, 851 F.2d 297, 299 (10th Cir. 1988). A failure to apply the correct legal standards or demonstrate it was done is also grounds for reversal. Winfrey v. Chater, 92 F.3d 1017, 1019 (10th Cir. 1996).
The ALJ's decision
The ALJ concluded that plaintiff had the following "severe" impairments: asthma, arthralgias, and irritable bowel syndrome. (Tr. 29). He determined that: plaintiff had the capacity to lift and/or carry 20 pounds occasionally, 10 pounds frequently; she could sit, stand and/or walk for about 6 hours in an 8-hour workday; and that she was unlimited in her ability to push and/or pull. (Tr. 29). This residual functional capacity was sufficient in the ALJ's judgment to allow plaintiff to perform a significant number of light and sedentary jobs which exist in the regional and national economy. (Tr. 30). The ALJ cited testimony from a vocational expert to support this conclusion.
The ALJ noted that plaintiff had not alleged disability due to an emotional/mental impairment. But, he considered a consultative mental status evaluation by Stanley Mintz, Ph.D. (Tr. 26). The ALJ commented:
During this examination, the claimant reported she was disabled due to rheumatoid arthritis. She denied any basis of an emotional/mental impairment. Her medical history, however, was reported positive for the diagnoses of conversion reaction disorder. Dr. Mintz's findings on examination revealed the claimant to be alert and oriented to time, place, person and situation. The Claimant's form and flow of ideation, as well as her speech processes, were noted to appear adequate. Content of the claimant's thoughts was reported negative for evidence of psychosis. There were no reports of hallucinations, delusions, loose associations or tangential or circumstantial thinking. As regards cognitive processes, the claimant's overall level of intellectual functioning was informally assessed as falling within the average to high average range. As regards mood, the claimant is noted to have denied symptoms of depression, anxiety, of phobia or obsessive compulsive disorder. Following this examination and considering the claimant's history, the record documents the claimant was provisionally provided the diagnoses of conversion disorder.
(Tr. 26). After this summation of Dr. Mintz's evaluation, the ALJ concluded that "the record fails to support a finding of any severe emotional/mental impairment." (Tr. 26).
Evidence in the record
Plaintiff was born on September 13, 1981. She was 19 years old at the time of the administrative hearing. She has no employment history. Her high school education was interrupted by the problems causing her alleged disability. But, she has obtained a GED.
In 1997, she saw Dr. Haug and Dr. Kumar with complaints of back and leg pain and sluggishness. (Tr. 280-83). She was also treated at the KU Medical Center for similar symptoms. (Tr. 278). Dr. Olson of the KU Medical Center wrote that plaintiff had complained of intermittent fatigue, intermittent rash, alopecia, chest pain with palpitations, and intermittent hip and hand pain. (Tr. 268). At that time, October 14, 1997, she was being absent from school and used a wheelchair when she did attend. (Tr. 268). Plaintiff was prescribed several medications in 1997.
In January 1998 plaintiff was examined by Dr. Short for complaints of back and leg pain and sudden loss of leg function. (Tr. 350-51). She again saw Dr. Kumar while she was hospitalized at Mercy Health Center of Manhattan on January 31, 1998. (Tr. 346-47). She was also hospitalized at the KU Medical Center in February 1998 and in March 1998. Paraplegia or leg weakness was noted during the hospitalizations. (Tr. 230, 249). Plaintiff visited Dr. Short with similar symptoms in May 1998. Plaintiff attended eleven sessions of physical therapy during April 1998 and showed progress. (Tr. 303-04). She also had eight sessions of physical therapy from October 16, 1998 through December 1, 1998. (Tr. 293-94). She saw Dr. Kumar in December 1998 and January 1999 regarding an episode when she blacked out in the shower and lost sensation and movement in her legs. (Tr. 312). Plaintiff also saw doctors in 1998 for shoulder and rib pain. (Tr. 423 and 345).
In July 1999 plaintiff was hospitalized and treated by Dr. Short for lower extremity weakness. (Tr. 321). Dr. Short's discharge summary reads as follows:
HISTORY OF PRESENT ILLNESS: The patient was admitted [for] lower extremity weakness. The patient has had previous known history of lower extremity weakness and in fact had been transferred to KU Medical Center for concerns of transverse myelitis with previously known rheumatoid arthritis. She has had initiation of recent onset of neurologic symptomatology that has occurred over the last 24 hours with no change in her clinical function otherwise. Sed rate was normal. Rheumatologic workup was unremarkable. She has been diagnosed with conversion reaction on previous admissions, previous admission at KU and consultations through Dr. Gilmartin, pediatric neurologist in Wichita. She does though have significant abnormalities of clinical function in regards to what appears to be a juvenile onset of rheumatoid arthritis as well as severe eczema associated with underlying asthma and allergy.
HOSPITAL COURSE: Clinical course in the hospital was such that she was monitored with physical therapy and found to be without strength deficits by physical therapy but was unable to walk and ambulate. She did request wheelchair assistance and moving about within her room as well as in the hall. MRI of the cervicothoracic spine and clinical evaluation revealed there basically to be no clinical concern. In result of significant pathologic abnormalities that seemed to present, psychiatry was consulted and did agree with the potential for conversion reaction. She was discharged to be followed up as an outpatient at Geary County Physical Therapy and to return to the office in one month to see how she has improved clinically.
(Tr. 321). During this hospital stay, Dr. Brian Parsells performed a consultation and diagnosed plaintiff as having a conversion disorder. (Tr. 324).
In November 2000 plaintiff saw Dr. Short who reported that she was in a wheelchair and unable to use her legs. (Tr. 404). During 2000, plaintiff also saw doctors for treatment of abdominal pain, loss of hair, irritable bowel syndrome, headache and fatigue.
Plaintiff missed 45 days of school in the 1997-1998 school year; 57 days in the 1998-1999 school year; and 35 days during the first semester of the 1999-2000 school year and did not return to school. (Tr. 224). As noted earlier, plaintiff ultimately obtained a GED.
Many of the medical records concerning plaintiff indicate that the etiology of the paraplegia or leg weakness is not determined and that conversion disorder is suspected. (Tr. 249, 278, 313, 324, 329, 349, 356, 373, 424, 428). A conversion disorder causes one to believe that physical ailments are more serious than clinical data suggest. Plaintiff has resisted the suggestion that there is a psychological or mental component to her ailments.
In February 1999 plaintiff was evaluated at Pawnee Mental Health Services. The summary of her evaluation states:
Rosalina is a very attractive girl who presents herself in a very contained and reserved manner. She clearly indicated that she did not feel the need to have been brought for [this appointment] and did not feel that she was having any problems. . . . Rosalina was oriented times three. Her affect and mood were mild to moderately depressed and somewhat flat in terms of presentation of affect. Intellectual functioning appears to be in the above average range although no formal testing was completed in this interview. Recent and remote memory are intact. There is no current suicidal or homicidal ideation or plan. Thought content and process were sparse but were logically and goal directed. Sensory and perceptual processes appear normal. Judgment and insight appear to be fair.
(Tr. 373). It was reported that plaintiff did not wish to participate in therapy and adamantly denied having any depression or anxiety about her illness. (Tr. 373). The diagnostic impression was "stress related physiological response affecting juvenile arthritis." (Tr. 373).
On January 29, 2000 plaintiff was evaluated by Dr. John Verstraete. He concluded:
The patient has a history of joint discomforts, diagnosed with rheumatoid arthritis. She complains of pain in the wrists, hands, hips, knees, ankles, and back but full range of motion is noted of all regions. Grip strength and dexterity are preserved. Gait and station are stable. The patient does bend zero inches to the floor. No assistive device required. There is no difficulty of orthopedic maneuvers. X-rays of the lumbar region are enclosed and appear to be within normal limits. The patient has a history of paraparesis x 2, requiring hospitalization. Conversion reaction has been considered.
(Tr. 362).
On January 22, 2001, Dr. Short, plaintiff's treating physician, wrote:
Rosalina has been plagued by chronic rheumatologic functional deficits, which involve myopathy and neurologic impairment, creating sudden transverse myelitis episodes, which limit her ability to ambulate and she is confined to a wheelchair. Associated with this she has severe eczema and high sed rate suggestive of autoimmune process, asthma and functional bowel disorder. She has been followed by dermatology for recurring alopecia and has been seen by numerous neurologists within the Manhattan, Kansas City and Wichita area for her unusual neurologic presentations. Functionally, she has limited capabilities of activity due to recurring neurologic deficits. Based on her complicated degree of medical issues, her functional capacity is limited to the point of disability.
(Tr. 445).
Plaintiff's testimony
Plaintiff testified before the ALJ that she is in constant pain and has been for the last four years. (Tr. 43). She also testified that she has episodes of paralysis approximately three times a year. (Tr. 44). She has had six such episodes from 1999 to 2001. (Tr. 46). The paralysis renders her unable to move without help from someone. She testified that she has used a wheelchair on a daily basis over the last two years. (Tr. 44-45). Family members help her to get dressed. Sometimes she also needs help going to the restroom, bathing and getting into and out of the family van. (Tr. 49-50). Plaintiff lives with her mother and father. She reads and paints plaster figures as a hobby. She attends church regularly and sometimes goes to the mall. (Tr. 53-54). She stated that pain limits her ability to sleep at night and, therefore, she often sleeps three or four hours in the afternoon. (Tr. 57). Her only chore is dusting on days she feels up to it. She testified that she could lift 50 to 80 pounds (Tr. 58), but that she could not stand up, bend over and pick up such a weight and lift it above her head. (Tr. 59). She stated that she was limited to sitting for two hours before having to get up and that she could stand for no more than 15 or 30 minutes at a time. (Tr. 59-60). She said she could walk no further than a block and that she could not bend over from a standing position to pick up a pencil or a pen. (Tr. 60). She testified that she could not perform the job of an information clerk because she would need to lie down for periods of time. (Tr. 63).
Plaintiff's arguments
1. Assessment of conversion disorder. Plaintiff's first argument to reverse the decision to deny benefits is that the ALJ did not accurately assess plaintiff's conversion disorder. Defendant appears to concede that plaintiff has a conversion disorder, but claims that the disorder is not a severe impairment. The court believes that the assessment of the severity of a conversion disorder should be conducted under the regulations discussing somatoform disorders. These regulations state:
Somatoform Disorders: Physical symptoms for which there are no demonstrable organic findings or known physiological mechanisms.
The required level of severity for these disorders is met when the requirements in both A and B are satisfied.
A. Medically documented by evidence of one of the following:
1. A history of multiple physical symptoms of several years duration, beginning before age 30, that have caused the individual to take medicine frequently, see a physician often and alter life patterns significantly; or
2. Persistent nonorganic disturbance of one of the following:
a. Vision; or
b. Speech; or
c. Hearing; or
d. Use of a limb; or
e. Movement and its control (e.g., coordination disturbance, psychogenic seizures, akinesia, dyskinesia; or
f. Sensation (e.g., diminished or heightened).
3. Unrealistic interpretation of physical signs or sensations associated with the preoccupation or belief that one has a serious disease or injury;
AND
B. Resulting in at least two of the following:
1. Marked restriction of activities of daily living; or
2. Marked difficulties in maintaining social functioning; or
3. Marked difficulties in maintaining concentration, persistence, or pace; or
4. Repeated episodes of decompensation, each of extended duration.
20 C.F.R. 404, Subpt. P, App.1, § 12.07.
"Episodes of decompensation" are defined as "exacerbations or temporary increases in symptoms or signs accompanied by a loss of adaptive functioning, as manifested by difficulties in performing activities of daily living, maintaining relationships, or maintaining concentration, persistence, or pace." Id. at § 12.00(C)(4). "Repeated episodes of decompensation, each of an extended duration" is defined as "three episodes within 1 year, or an average of once every 4 months, each lasting for at least 2 weeks," although more frequent episodes of shorter duration or less frequent episodes of longer duration may also satisfy the definition in the judgment of the Social Security Administration if the functional effects are of equal severity. Id.
The court does not believe the ALJ measured the severity of plaintiff's conversion disorder against the above-stated regulatory standard. This is contrary to the holding in Clifton v. Chater, 79 F.3d 1007, 1009 (10th Cir. 1996). The ALJ's analysis also appears to ignore the evidence of symptoms reported by treating physicians and their diagnoses of conversion disorder. Instead, the ALJ's order emphasizes the reports of two consultative examinations. In one of those reports there is only one reference to conversion disorder — "conversion reaction has been considered." (Tr. 362). In the other, the author states, "I am not sure I can contribute very much in terms of addressing the issue of Conversion Disorder." (Tr. 356). Therefore, the findings of the ALJ do not appear to be supported by a specific weighing of the evidence. The ALJ's analysis also ignores the episodic nature of plaintiff's alleged paralysis. This is contrary to 20 C.F.R. § 404.1520a(c)(2) which states that in rating the degree of functional limitation, the Social Security Administration will consider "any episodic limitations". For these reasons, we agree that the ALJ did not properly consider the impact of plaintiff's conversion disorder.
2. Credibility determination. Plaintiff's second argument is that the ALJ's credibility determinations are not supported by the record. A proper evaluation of plaintiff's pain symptoms must include a consideration of the conversion disorder and the functional limitations caused by the conversion disorder. SeeCarradine v. Barnhart, 360 F.3d 751 (7th Cir. 2004);Easter v. Bowen, 867 F.2d 1128 (8th Cir. 1989); Teter v. Heckler, 775 F.2d 1104 (10th Cir. 1985); see also, 20 C.F.R. § 404.1529(c)(3). As discussed in relation to plaintiff's first argument, the court finds that the ALJ did not properly evaluate plaintiff's conversion disorder. This led to an improper consideration of the credibility of plaintiff's pain allegations.
3. The ALJ's hypothetical question. Finally, plaintiff asserts that the ALJ's hypothetical question does not accurately portray all of plaintiff's credible mental and physical restrictions. This ties in again to the evaluation of plaintiff's functional limitations in conjunction with an assessment of the severity of plaintiff's conversion disorder. Without a proper evaluation of the severity of the conversion disorder, there can be no confidence in the accuracy of the ALJ's hypothetical question.
Conclusion
The court believes that the ALJ failed to apply the correct standards in this case when he did not analyze the severity of plaintiff's conversion disorder under the above-mentioned regulatory format for somatoform disorders. The ALJ also failed to adequately address the possible episodic nature of plaintiff's functional limitations and appeared to gloss over the substantial number of references from treating physicians and others who seemed to lend credence to the existence and severity of the alleged conversion disorder. For these reasons, the ALJ's conclusions regarding the extent of plaintiff's functional limitations and the severity of plaintiff's pain are not supported by the correct legal and factual analysis. Accordingly, the court shall reverse the decision to deny plaintiff's application for benefits and remand this matter under the fourth sentence of 42 U.S.C. § 405(g) for further proceedings consistent with this opinion.