United States District Court, D. Oregon
KATHLEEN A. ROUNSEVELLE, Plaintiff,
CAROLYN W. COLVIN Acting Commissioner of Social Security, Defendant.
FINDINGS AND RECOMMENDATION
PAUL PAPAK, Magistrate Judge.
Plaintiff Kathleen Adele Rounsevelle filed this action November 2, 2012, seeking judicial review of the Commissioner of Social Security's decision denying her application for supplemental security income under Title XVI of the Social Security Act. This court has jurisdiction over plaintiff's action pursuant to 42 U.S.C. § 405(g).
Rounsevelle argues that the Commissioner of Social Security ("Commissioner") erroneously declined to open her prior benefits applications, mischaracterized and failed to consider all of her impairments at the second step of the five-step sequential evaluation process, failed adequately to develop the record, developed an incomplete residual functional capacity ("RFC"), and, in consequence, erred in posing questions to the vocational expert. Furthermore, Rounsevelle argues that the Appeals Council erred by not considering additional evidence she submitted after the Administrative Law Judge ("ALJ") issued his decision. I have considered all of the parties' briefs and all of the evidence in the administrative record. For the reasons set forth below, the Commissioner's final decision should be affirmed.
DISABILITY ANALYSIS FRAMEWORK
To establish disability within the meaning of the Act, a claimant must demonstrate an "inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected... to last for a continuous period of not less than 12 months." 42 U.S.C. § 423(d)(1)(A). The Commissioner has established a five-step sequential process for determining whether a claimant has made the requisite demonstration. See Bowen v. Yuckert, 482 U.S. 137, 140 (1987); see also 20 C.F.R. § 416.920(a)(4). At the first four steps of the process, the burden of proof is on the claimant; only at the fifth and final step does the burden of proof shift to the Commissioner. See Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999).
At the first step, the ALJ considers the claimant's work activity, if any. See Bowen, 482 U.S. at 140; see also 20 C.F.R. § 416.920(a)(4)(i). If the ALJ finds that the claimant is engaged in substantial gainful activity, the claimant will be found not disabled. See Bowen, 482 U.S. at 140; see also 20 C.F.R. §§ 416.920(a)(4)(i), 416.920(b). Otherwise, the evaluation will proceed to the second step.
At the second step, the ALJ considers the medical severity of the claimant's impairments. See Bowen, 482 U.S. at 140-141; see also 20 C.F.R. § 416.920(a)(4)(ii). An impairment is "severe" if it significantly limits the claimant's ability to perform basic work activities and is expected to persist for a period of twelve months or longer. See Bowen, 482 U.S. at 141; see also 20 C.F.R. § 416.920(c). The ability to perform basic work activities is defined as "the abilities and aptitudes necessary to do most jobs." 20 C.F.R. § 416.921(b); see also Bowen, 482 U.S. at 141. If the ALJ finds that the claimant's impairments are not severe or do not meet the duration requirement, the claimant will be found not disabled. See Bowen, 482 U.S. at 141; see also 20 C.F.R. §§ 416.920(a)(4)(ii), 416.920(c). Nevertheless, it is well established that "the step-two inquiry is a de minimis screening device to dispose of groundless claims." Smolen v. Chater, 80 F.3d 1273, 1290 (9th Cir. 1996), citing Bowen, 482. U.S. at 153-154. "An impairment or combination of impairments can be found not severe' only if the evidence establishes a slight abnormality that has no more than a minimal effect on an individual[']s ability to work." Id., quoting SSR 85-28, 1985 WL 56856 (1985).
If the claimant's impairments are severe, the evaluation will proceed to the third step, at which the ALJ determines whether the claimant's impairments meet or equal "one of a number of listed impairments that the [Commissioner] acknowledges are so severe as to preclude substantial gainful activity." Bowen, 482 U.S. at 141; see also 20 C.F.R. §§ 416.920(a)(4)(iii), 416.920(d). If the claimant's impairments are equivalent to one of the impairments enumerated in 20 C.F.R. § 404, subpt. P, app. 1, the claimant will conclusively be found disabled. See Bowen, 482 U.S. at 141; see also 20 C.F.R. §§ 416.920(a)(4)(iii), 416.920(d).
If the claimant's impairments are not equivalent to one of the enumerated impairments, between the third and the fourth steps the ALJ is required to assess the claimant's RFC, based on all the relevant medical and other evidence in the claimant's case record. See 20 C.F.R. § 416.920(e). The RFC is an estimate of the claimant's capacity to perform sustained, work-related physical and/or mental activities on a regular and continuing basis,  despite the limitations imposed by the claimant's impairments. See 20 C.F.R. § 416.945(a); see also SSR 96-8p, 1996 WL 374184 (July 2, 1996).
At the fourth step of the evaluation process, the ALJ considers the RFC in relation to the claimant's past relevant work. See Bowen, 482 U.S. at 141; see also 20 C.F.R. § 416.920(a)(4)(iv). If, in light of the claimant's RFC, the ALJ determines that the claimant can still perform his or her past relevant work, the claimant will be found not disabled. See Bowen, 482 U.S. at 141; see also 20 C.F.R. §§ 416.920(a)(4)(iv), 416.920(f). In the event the claimant is no longer capable of performing his or her past relevant work, the evaluation will proceed to the fifth and final step, at which the burden of proof shifts, for the first time, to the Commissioner.
At the fifth step of the evaluation process, the ALJ considers the RFC in relation to the claimant's age, education, and work experience to determine whether a person with those characteristics and RFC could perform any jobs that exist in significant numbers in the national economy. See Bowen, 482 U.S. at 142; see also 20 C.F.R. §§ 416.920(a)(4)(v), 416.920(g), 416.960(c), 416.966. If the Commissioner meets her burden to demonstrate the existence in significant numbers in the national economy of jobs capable of being performed by a person with the RFC assessed by the ALJ between the third and fourth steps of the five-step process, the claimant is found not to be disabled. See Bowen, 482 U.S. at 142; see also 20 C.F.R. §§ 416.920(a)(4)(v), 416.920(g), 416.960(c), 416.966. A claimant will be found entitled to benefits if the Commissioner fails to meet that burden at the fifth step. See Bowen, 482 U.S. at 142; see also 20 C.F.R. §§ 416.920(a)(4)(v), 416.920(g).
A reviewing court must affirm an Administrative Law Judge's decision if the ALJ applied proper legal standards and his or her findings are supported by substantial evidence in the record. See 42 U.S.C. § 405(g); see also Batson v. Comm'r of Soc. Sec. Admin., 359 F.3d 1190, 1193 (9th Cir. 2004). "Substantial evidence' means more than a mere scintilla, but less than a preponderance; it is such relevant evidence as a reasonable person might accept as adequate to support a conclusion." Lingenfelter v. Astrue, 504 F.3d 1028, 1035 (9th Cir. 2007), citing Robbins v. Soc. Sec. Admin., 466 F.3d 880, 882 (9th Cir. 2006).
The court must review the record as a whole, "weighing both the evidence that supports and the evidence that detracts from the Commissioner's conclusion." Id., quoting Reddick v. Chater, 157 F.3d 715, 720 (9th Cir. 1998). The court may not substitute its judgment for that of the Commissioner. See id., citing Robbins v. Soc. Sec. Admin., 466 F.3d at 882; see also Edlund v. Massanari, 253 F.3d 1152, 1156 (9th Cir. 2001). If the ALJ's interpretation of the evidence is rational, it is immaterial that the evidence may be "susceptible [of] more than one rational interpretation." Magallanes v. Bowen, 881 F.2d 747, 750 (9th Cir. 1989), citing Gallant v. Heckler, 753 F.2d 1450, 1453 (9th Cir. 1984).
Rounsevelle was born April 16, 1962. (Tr. 114). She "was raised by her parents in an intact family" (Tr. 312), and graduated from Milwaukie high school in 1980. (Tr. 114, 551). She has a brother and sister who are 15 and 19 years older. (Tr. 312, 551). According to Rounsevelle's records of wages earned, prior to her claimed disability onset date of September 30, 2001, Rounsevelle worked as a data processing analyst for Priestley Oil & Chemical from 1983-1990 (earning $1, 560 per month), an accounts receivable bookkeeper for Empire Rubber & Supply Co. from 1984-1990 (earning $1, 300 per month), an assistant manager for Hawkeye Construction from 1991-1992 (earning $1, 300 per month), a receptionist and clerk for Rapid Bind, Inc., from 1993-1995 (earning $1, 300 per month), a cashier for 7-11 from 1996-1999 and in 2001 (earning $8.00 per hour), a gas station attendant at Space Age Fuel in 2000 (earning $6.00 per hour), a cashier for Plaid Pantries, Inc., in 2000 (earnings not specified), a cashier for Fred Meyer, Inc., in 2000 (earnings not specified), and a receptionist and file clerk for General Tool & Supply Co. at an unspecified date (earning $8.00 per hour). (Tr. 233-242, 280-281).
In 1988, when Rounsevelle was 26, she married Scott, with whom she had two children. (Tr. 312). Rounsevelle and Scott divorced in 1991. (Tr. 312, 552). At the time of the divorce, Rounsevelle "had been using alcohol, but this increased, and she was not able to care for the children, " who were subsequently raised by Scott after he was given full custody of them. (Tr. 312, 552).
After her divorce, Rounsevelle began a "stormy relationship" with Rob (Tr. 312),  one in which "drinking and later drug use were an issue." (Tr. 312). Rounsevelle reported that Rob was extremely violent, and would beat, smother, and rape her. (Tr. 402). At least ten police reports were filed from June 1993 to October 1995 in connection with such incidents. (Tr. 550). Sometime in or around 1992, Rounsevelle and Rob had a child together. (Tr. 312). In November 1995, their child, then age three, was taken into custody by the State Office of Services for Children and Families ("SCF") "because of the domestic violence between [his] parents and [Rounsevelle's] persistent reconciliations with the father/abuser." (Tr. 312, 550). Rounsevelle was unable to regain custody of Donovan, who was raised by Rounsevelle's brother. (Tr. 312). Many of the physical and mental impairments referenced in Rounsevelle's supplemental security income ("SSI") application stem from the extensive violent physical abuse that she endured during her relationship with Rob.
Rounsevelle has an extensively documented medical history, primarily concerning carpal tunnel syndrome ("CTS"), degenerative disk disease ("DDD") of the cervical spine, and post traumatic stress disorder ("PTSD") (symptoms of anxiety and depression). The earliest medical report in the record is from 1996, when Rounsevelle underwent two comprehensive psychological evaluations. The first evaluation was performed over two days, January 29, 1996 and March 25, 1996 (Tr. 550), and the second on October 14, 1996 (Tr. 542), both by clinical psychologist Luahna Ude, Ph.D., to whom Rounsevelle was referred by her State Office of Services for Children and Families caseworker, in connection with her loss of custody of her son Donovan in November 1995. (Tr. 550).
Following Dr. Ude's 1996 evaluations, the next medical report of record dates from November 30, 2004, more than three years after Rounsevelle's alleged disability onset date of September 30, 2001.
On November 30, 2004, Rounsevelle consulted Dr. Huey Meeker, her primary care physician, to address her complaints of depression and chronic wrist pain. (Tr. 430-431). Dr. Meeker reported that Rounsevelle had been dealing with wrist pain for at least four years, but had not followed his treatment recommendations to that point. (Tr. 430-431). Dr. Meeker further reported that while Rounsevelle's depression had improved, she suffered from chronic arthritis, and was experiencing neck pain, though not from any specific injury. (Tr. 430-431).
Dr. Meeker referred Rounsevelle to neurologist Gajanan Nilaver, M.D. (Tr. 430-431, 470), with whom she consulted on December 13, 2004. (Tr. 533-536). Dr. Nilaver opined that Rounsevelle was likely suffering DD. the cervical spine (Tr. 470, 533-536), CTS, and dysesthesia. (Tr. 533-536). Dr. Nilaver reported that Rounsevelle might require carpal tunnel decompression surgery, and that an electrodiagnostic examination would help determine the existence and extent of her CTS. (Tr. 535).
Dr. Nilaver referred Rounsevelle to Kevin Jamison, M.D., at Oregon Neurology for the recommended electrodiagnostic examination. On January 3, 2005, Dr. Jamison reported that Rounsevelle had moderate to severe right CTS, but "[o]n the left side, the situation [was] not as clear. She appear[ed] to have an ulnar hand' with innervation of the thenar eminence from the ulnar nerve, [which] eliminates the possibility of entrapment at the transverse carpal ligament." (Tr. 537-538). On January 10, 2005, Rounsevelle followed up with Dr. Nilaver, who concurred with the right CTS diagnosis and referred her "for surgical intervention for right [CTS]." (Tr. 532).
On February 16, 2005, Rounsevelle consulted with John Hardiman, M.D., a physician and surgeon who specialized in orthopedic and fracture surgery. (Tr. 531). After examining Rounsevelle and Dr. Jamison's notes and examination results, Dr. Hardiman concurred with the diagnosis of right CTS and concluded that surgery would be appropriate, stating, "I think that we can offer her a surgical approach. We would start with the more clear side, the right side, with a carpal tunnel release." (Tr. 531). At Rounsevelle's March 2, 2005 follow-up appointment, after learning that Rounsevelle's insurance would not cover the right CTS surgery, Dr. Hardiman administered a Depo-Medrol injection to her right wrist to see if she would obtain any benefit from it. (Tr. 531). On March 29, 2005, she received the same injection in her left wrist along with Xylocaine (Tr. 531), and on May 5, 2005, a second injection in her right wrist, again with Xylocaine. (Tr. 531).
On June 7, 2005, Rounsevelle met with Dr. Meeker complaining of left hand pain and swelling. (Tr. 429). At that time, Dr. Meeker learned that Rounsevelle was being prescribed Vicodin by both Dr. Hardiman and himself, each without the other's knowledge, a fact subsequently confirmed by Dr. Hardiman. (Tr. 531). As a result, Dr. Meeker declined to issue her a Vicodin refill. (Tr. 429).
Rounsevelle began individual therapy and group counseling at Clackamas County Mental Health ("CCMH") in 2005. At her August 10, 2005, individual therapy session with Barbara Breck, a licensed psychologist at CCMH, Rounsevelle complained of wrist pain and fear of her physically and emotionally abusive ex-boyfriend. (Tr. 408).
In 2005, Rounsevelle submitted applications for disability insurance benefits ("DIB") and SSI under Titles II and XVI of the Act. In connection with those applications, the Social Security Administration (the "Administration") conducted a mental and physical residual functional capacity assessment ("RFCA") and a psychiatric review technique ("PRT"). The RFCAs and PRT, dated August 18, 2005, assessed a period of September 1, 2001 to August 15, 2005. (Tr. 506-530).
In connection with the mental RFCA (Tr. 520-522), Administration medical consultant and clinical psychologist Karen Bates-Smith, Ph.D., conducted a review of Rounsevelle's medical records. Dr. Bates-Smith found Rounsevelle's understanding and memory capabilities not significantly limited (Tr. 520), and her sustained concentration and persistence capabilities not significantly limited, except that her ability to maintain attention and concentration for extended periods was moderately limited. (Tr. 520-521). Dr. Bates-Smith further found Rounsevelle's social interaction capabilities not significantly limited, except that her ability to interact appropriately with the general public was markedly limited. (Tr. 521). Dr. Bates-Smith lastly found Rounsevelle's adaptation capabilities not significantly limited, except that her ability to set realistic goals or make plans independently of others was moderately limited. (Tr. 521). Dr. Bates-Smith concluded that, regarding "understanding and memory" and "sustained concentration and persistence, " Rounsevelle was "able to understand & carry out simple and complex, direction & instruction. [She] is able to complete all tasks adequately & independently... [with] some difficulty concentrating at time." (Tr. 522). Regarding "social interaction" and "adaptation, " Dr. Bates-Smith opined that Rounsevelle "should be precluded from any public contact secondary to her PTSD. There is no evidence that she could not behave appropriately with coworkers or management. [She] will benefit from vocational guidance." (Tr. 522).
In connection with the PRT (Tr. 506-519), Dr. Bates-Smith classified Rounsevelle's mental health symptoms as falling under listings 12.04 (Affective Disorders) and 12.06 (Anxiety-Related Disorders). (Tr. 506). Regarding Affective Disorders, Dr. Bates-Smith found that Rounsevelle suffered from disturbance of mood accompanied by depressive syndrome, characterized by sleep disturbance, decreased energy, difficulty concentrating or thinking, and thoughts of suicide. (Tr. 509). Regarding Anxiety-Related Disorders, Dr. Bates-Smith found that Rounsevelle had "[a]nxiety as the predominant disturbance or anxiety experienced in the attempt to master symptoms, as evidenced by... [r]ecurrent and intrusive recollections of a traumatic experience, which are a source of marked distress." (Tr. 511).
Dr. Bates-Smith further found that Rounsevelle had moderate "restriction of activities of daily living, " moderate "difficulties in maintaining social functioning, " mild "difficulties in maintaining concentration, persistence, or pace, " and no "episodes of decompensation of an extended duration." (Tr. 516). The degree of limitation scale consists of degrees of none, mild, moderate, marked, and extreme, with only the degrees marked and extreme satisfying the functional criterion. (Tr. 516). Lastly, Dr. Bates-Smith found that the evidence did not establish the presence of the "C" criteria in connection with either Affective Disorders or Anxiety-Related Disorders. (Tr. 517).
In connection with the physical RFCA (Tr. 523-530), Administration medical consultant Mary Ann Westfall, M.D., likewise conducted a review of Rounsevelle's medical records. Dr. Westfall found no exertional (Tr. 524) or postural (Tr. 525) limitations. Dr. Westfall found that Rounsevelle should be limited to occasional twisting and turning of her wrists as well as occasional "overhead reaching secondary to her CTS and cervical spine DDD." (Tr. 526). Dr. Westfall found no visual (Tr. 526), communicative (Tr. 527), or environmental (Tr. 527) limitations. Dr. Westfall noted that Rounsevelle stated she had problems "lifting, squatting, bending, stooping, standing, reaching, talking, and hearing, " and that these statements were corroborated by a third party. (Tr. 528). However, Dr. Westfall found Rounsevelle's statements not "fully credible as there [was] no basis for [Rounsevelle's] allegations of [impairments in] standing, and squatting as her MDI's [sic] would not cause these limitations." (Tr. 528).
Rounsevelle's prior applications for DIB and SSI were denied on August 19, 2005. (Tr. 138).
On September 12, 2005, Rounsevelle "had very big news" at individual therapy. (Tr. 408). Rounsevelle reported that her abusive ex-boyfriend Rob had died, "express[ing] relief and excitement that he was gone." (Tr. 408). Rounsevelle went as far as going "to view [his] body at the crematorium before it was cremated... in order to make sure that he was dead." (Tr. 408). Rounsevelle reported that she already felt better about leaving her house and being around other people, and felt "more relaxed and was able to focus enough to read a book, " which was noteworthy given that "she had not been able to sit and read anything for years [and] was pleased that she was able to do that now." (Tr. 408).
On October 6, 2005, Ms. Breck learned that Rounsevelle had been arrested, charged, and ultimately convicted of possession of methamphetamine ("meth") in April of 2005, and was currently on probation. (Tr. 409). According to her probation officer ("PO"), Rounsevelle had turned in four urinary analysis ("UA") tests positive for meth, and failed to keep her last appointment with her PO. (Tr. 409). When her PO made a home visit, Rounsevelle advised her that she was using meth three to four times per week. (Tr. 409). Ms. Breck opined that "[b]ecause of [her] lies and failure to disclose, it is difficult to know what is going on with [Rounsevelle]. (Tr. 409).
At an October 13, 2005, appointment with Dr. Meeker, Rounsevelle reported her medications, including a benzodiazepine, were no longer effective. (Tr. 428).
Rounsevelle's prior drug use is documented more thoroughly in a November 16, 2005, alcohol and drug ("A&D") assessment (Tr. 384-407), which was filled out prior to her starting A&D group counseling at CCMH. The A&D assessment stated that Rounsevelle's use of meth began at age thirty-five and evolved to daily usage. (Tr. 386-387). Rounsevelle stopped using for over four years, but as of November 16, 2005, she was using weekly, if not more frequently, and had used just days earlier. (Tr. 386). The A&D assessment also stated that Rounsevelle correlated her meth use to depression (Tr. 387), and that she had low motivation and poor self esteem. (Tr. 406). Rounsevelle began A&D group counseling on November 18, 2005. (Tr. 410).
At a January 6, 2006, A&D group counseling session, Rounsevelle admitted to relapsing again on January 4, 2006. (Tr. 412). On January 10, 2006, Rounsevelle met with Dr. Meeker, complaining of severe mood swings and irritation. (Tr. 428). At a February 10, 2006, A&D group counseling session, Rounsevelle reported improvement, stating that she was feeling the positive effects of taking her medications and having meth out of her system. (Tr. 413). She reaffirmed this improvement at her February 14, 2006, appointment with Dr. Meeker. (Tr. 427-428). While her CTS still left her in pain, Dr. Meeker reported that Rounsevelle's depression and anxiety symptoms had improved with Zyprexa. (Tr. 427-428).
On August 11, 2006, Rounsevelle protectively filed an application for SSI. (Tr. 138, 191-196). She alleged a disability, beginning on September 30, 2001 (Tr. 138), based on a combination of impairments, the most severe and pertinent being PTSD with agoraphobia/anxiety and depressive/dysthymic disorder, personality disorder, DD. the cervical spine, and CTS. (Tr. 140, 290, 470). She also alleged scoliosis, high cholesterol, and asthma. (Tr. 216).
At an August 14, 2006, individual therapy session, Rounsevelle reported significant improvement since her January 2006 meth relapse (Tr. 412), particularly a healthy weight gain and overall physical and emotional improvement. (Tr. 416). While some PTSD symptoms still persisted, she reported that Dr. Meeker had developed a good medication regimen to help manage her PTSD, and that she was more stable than before. (Tr. 416). While Rounsevelle had considered looking for a part-time job, she reported lacking confidence in her ability to work, complained about her CTS, and was "concerned about losing [her] health insurance if she work[ed]." (Tr. 416).
On October 18 and 19, 2006 (Tr. 444, 460, 469), in connection with Rounsevelle's August 14, 2006, SSI application, the Administration conducted a mental and physical RFCA and a PRT. Unlike the 2005 RFCAs and PRT, which assessed a period from 2001 to 2005, the 2006 assessments were a "Current Evaluation." (Tr. 458, 462).
In connection with the physical RFCA (Tr. 462-469), Administration medical consultant Martin Kehrli, M.D., conducted a review of Rounsevelle's medical records. Dr. Kehrli found Rounsevelle capable of occasionally lifting and/or carrying 20 pounds, frequently lifting and/or carrying ten pounds, standing and/or walking approximately six hours in an eight-hour workday, and sitting about six hours in an eight-hour workday, and not limited in her ability to push and/or pull. (Tr. 463). Dr. Kehrli then found Rounsevelle capable of occasionally climbing a ladder/rope/scaffold and crawling, and capable of frequently climbing ramps/stairs, balancing, stooping, kneeling, and crouching. (Tr. 464). Dr. Kehrli further found Rounsevelle limited in reaching in all directions (including overhead), handling (gross manipulation), and fingering (fine manipulation), stating that Rounsevelle "has DDD in [cervical] spine and bilat[eral] CTS. She is limited to freq[uent] bilat[eral] overhead reach and frequent bilat[eral] handle/finger/grasp." (Tr. 465). Lastly, Dr. Kehrli found that Rounsevelle had no visual, communicative, or environmental limitations. (Tr. 465-466).
Dr. Kehrli noted that in August of 2006, Rounsevelle reported both mental and physical improvement. (Tr. 416, 469). Furthermore, Dr. Kehrli found Rounsevelle's statements regarding the severity of her limitations to be only partially credible, due in part to Rounsevelle's history of meth abuse and the issue involving her getting Vicodin from two doctors simultaneously. (Tr. 429, 469, 531). Dr. Kehrli concluded that Rounsevelle "is capable of performing light level work on a consistent basis. Therefore, Light RFC." (Tr. 469).
In connection with the mental RFCA (Tr. 458-461), Administration medical consultant Peter LeBray, Ph.D., conducted a review of Rounsevelle's medical records. Dr. LeBray found Rounsevelle's understanding and memory capabilities not significantly limited, except that her ability to understand and remember detailed instructions was moderately limited, and found her sustained concentration and persistence capabilities not significantly limited, except that her ability to carry out detailed instructions and maintain attention and concentration for extended periods was moderately limited. (Tr. 458). Dr. LeBray then found Rounsevelle's social interaction capabilities not significantly limited, except that her ability to interact appropriately with the general public was moderately limited. (Tr. 459). Rounsevelle's moderately limited ability to interact appropriately with the general public was an improvement from her 2005 mental RFCA, where Dr. Bates-Smith found her markedly limited. (Tr. 521). Dr. LeBray lastly found Rounsevelle's adaptation capabilities not significantly limited, except that her ability to set realistic goals or make plans independently of others was moderately limited. (Tr. 459).
In his conclusion, Dr. LeBray opined that, regarding "understanding and memory" and "sustained concentration and persistence, " Rounsevelle could "understand, remember, and complete simpler instructions, infrequently rushed tasks/procedures on [a] routine basis." (Tr. 458-459, 460). Regarding "social interaction, " Dr. LeBray further opined that Rounsevelle was "limited to interactions that require[d] minimal contact [with the] general public as well as limited contact [with] peers/coworkers. [She is] [r]esponsive to supportive lay supervision (not overly harsh, critical style)." (Tr. 459, 460). Lastly, regarding "adaptation, " Dr. LeBray opined that Rounsevelle "will do best given a set routine to follow and help set realistic goals." (Tr. 459, 460).
The last element in this course of assessing Rounsevelle's current condition was the PRT (Tr. 444-457), also conducted by Dr. LeBray. (Tr. 444-457). In Part I, the medical summary, Dr. LeBray classified Rounsevelle's mental impairments as falling under listings 12.04 (Affective Disorders), 12.06 (Anxiety-Related Disorders), and (12.09 Substance Addiction Disorders). (Tr. 444).
Part II consisted of documenting the factors that evidence the three disorders above. (Tr. 445-453). For all three disorders, Dr. LeBray found that "[a] medically determinable impairment is present that does not precisely satisfy the diagnostic criteria above." (Tr. 447, 449, 452). As to Affective Disorders, Dr. LeBray found that the disorder was primarily comprised of "[d]epression/anxiety (on [prescription management with] good response per [her] [primary care physician])." (Tr. 447). As to Anxiety-Related Disorders, Dr. LeBray found that the disorder was primarily comprised of "[a]nxiety/depression (h/o PTSD per MH MEOR [medical evidence of record])." (Tr. 449). Lastly, as to Substance Addiction Disorders, Dr. LeBray found that the disorder was primarily comprised of "mixed DAA in early remission (since [January 20]06 to p[resent])." (Tr. 452).
Part III consisted of rating Rounsevelle's four functional limitations, from lowest to highest degree of limitation (none, mild, moderate, marked, and extreme), with only marked and extreme satisfying the functional criterion. (Tr. 454-455). Dr. LeBray found Rounsevelle to have (1) a mildly limited "restriction of activities of daily living, " (2) moderately limited "difficulties in maintaining social functioning, " (3) moderately limited "difficulties in maintaining concentration, persistence, or pace, " and (4) no "episodes of decompensation, each of extended duration." (Tr. 454). In Part III.B, the "C" criteria of the listings, Dr. LeBray found that the evidence did not establish presence of the "C" criteria for Affective Disorders or Anxiety-Related Disorders. (Tr. 455).
Lastly, Part IV contained Dr. LeBray's summary of his (1) analysis of current medical and all non-medical evidence and (2) assessment of consistency of the evidence and resolution of material conflicts. (Tr. 456). In his analysis of current medical and non-medical evidence, Dr. LeBray noted Rounsevelle's recent improvement and stabilization. In May of 2006, Rounsevelle reported that Zyprexa was "working very well for [her] depression, " she had been "clean and sober since [January 2006], " and she was "[c]onsidered stable on [her] med[ication]s and [her] home life [was] more stable." (Tr. 456). In August of 2006, Rounsevelle "reported feeling better physically and emotionally and feeling more stable, " that her medication regimen was working well, and that "she was considering getting a [part-time] job but didn't want to lose her health insurance, " and even discussed vocational rehabilitation. (Tr. 456).
In his assessment of consistency of the evidence and resolution of material conflicts, Dr. LeBray noted Rounsevelle "allege[d] severe PTSD and multiple other physical complaints which causes anxiety attacks, " had diagnoses of anxiety and depression, and had a history of meth use. (Tr. 456). Dr. LeBray further noted that, while Rounsevelle reported that she feared running into her abusive ex-boyfriend, she had previously told her therapist that since his death in September of 2005, it had been easier to leave her home and be around others. (Tr. 456). Dr. LeBray concluded that Rounsevelle's statements were only partially credible. (Tr. 456).
On October 20, 2006, a Vocational Decision Worksheet was completed by Disability Analyst Amanda Dinan, who concluded that, while Rounsevelle was incapable of performing any past relevant work, she was "capable of performing other work, " including surveillance system monitor, kosher inspector, and blending tank helper. (Tr. 257-258).
On October 24, 2006, Rounsevelle met with Dr. Meeker, complaining of persistent symptoms of depression. (Tr. 425). Due to her worsening depression, Dr. Meeker increased Rounsevelle's Zyprexa dosage. (Tr. 425). On October 25, 2006, Rounsevelle attended A&D group counseling and was an active group participant. (Tr. 360). She was a "no show" to the following six consecutive A&D group counseling sessions, from November 1 to December 6, 2006. (Tr. 360, 369-374). Rounsevelle did attend her individual therapy session with Ms. Breck on November 7, 2006. (Tr. 361, 368). As Rounsevelle was leaving, she stopped and spoke with Wilma Gardner-Watson, from CCMH's Care Coordination, who reported that Rounsevelle stated she would make an appointment to start the vocational rehabilitation enrollment process. (Tr. 361, 368).
On November 16, 2006, the Administration denied Rounsevelle's application for SSI, finding her not disabled. (Tr. 154-157). On December 18, 2006, Rounsevelle timely filed a request for reconsideration of the adverse decision. (Tr. 158). In response to with Rounsevelle's request for reconsideration, the Administration had Rounsevelle's ...