United States District Court, D. Delaware
JAMES A. RALSTON, Plaintiff,
MICHAEL J. ASTRUE, Commissioner of Social Security, Defendant.
GREGORY M. SLEET, District Judge.
The plaintiff James Ralston ("Ralston") filed for disability insurance benefits ("DIB") on October 8, 2007, pursuant to Title II of the Social Security Act. (D.1. 13 at 159-64.) This action against defendant Michael J. Astrue-former commissioner of the Social Security Administration ("SSA")-arises from the denial of Ralston's application. ( Id. at 101-11.) The SSA denied Ralston's claim initially and on reconsideration. ( Id. ) Ralston thereafter requested an administrative law judge ("ALJ") rehearing. ( Id. at 112-13.) The hearing took place on October 22, 2008, and June 24, 2009. ( Id. at 63-95.)
The ALJ, Edward J. Banas, issued a written opinion on July 27, 2009, denying Ralston's DIB claim. ( Id. at 14-31.) The Appeals Council denied review of the ALJ's decision on May 8, 2010. ( Id. at 7-13.) Ralston filed a timely appeal with the court on June 22, 2010. (D.1. 2.) Presently before the court are the parties' cross-motions for summary judgment. (D.1. 16, 18.) For the reasons that follow, the court will: (1) deny the Commissioner's motion for summary judgment; and (2) grant in part Ralston's motion for summary judgment. The court remands this matter for further administrative proceedings.
Ralston was born on October 4, 1959. (D.I. 13 at 159.) He has a seventh-grade education. ( Id. at 218.) As of February 2, 2011, Ralston represented that he is homeless and has been homeless most his life. ( Id. at 58-61.) At the time of his application for DIB, Ralston was forty-eight years old.
A. Medical & Employment History
Ralston has primarily worked as an unskilled laborer. ( Id. at 165-68.) As noted below in greater detail, Ralston has an extensive psychiatric history. ( Id. at 334-35.) The documentation in support of this history is not in the record. ( Id. at 334.) Nevertheless, this history appears to include: (1) being hospitalized for psychosis at age thirteen; (2) spending a month in a state hospital for aggression at age seventeen; (3) attempting to commit suicide while incarcerated at age twenty-one; and (4) being hospitalized for and diagnosed with antisocial personality disorder and substance abuse, following a second suicide attempt because he had no place to live or work. ( Id. at 334-35.)
In March 2003, Ralston was diagnosed with colon cancer and underwent bowel resection surgery. ( Id. at 247-302.) After surgery, Ralston reported that his bowel function had improved and that he was tolerating a regular diet. ( Id. at 248.) Although, Ralston was scheduled to continue with post-surgical chemotherapy, he never completed his regimen because of a fear of needles. ( Id. at 77.) In addition to his colon cancer, Ralston was diagnosed with Hepatitis C, anemia, chronic obstructive pulmonary disease, sinus tachycardia, tobacco use, and a history of intravenous drug abuse. ( Id. at 247.)
After his surgery, Ralston began to work at a car wash. ( Id. at 77-78.) Soon thereafter, however, Ralston suffered an injury at work, requiring the traumatic amputation of the tip of his left third finger. ( Id. at 306-11.) Subsequently, beginning around March 2004, Ralston ceased his employment at the car wash and began living in a tent in the woods. ( Id. at 59-60, 85.) It was during this time that Ralston began to survive on fish and road-kill deer. ( Id. )
B. Expert Opinions
1. Physical Opinions
a. Dr. Lifrak
Dr. Lifrak, a state agency physician, performed a physical examination of Ralston on July 27, 2005. (D.I. 13 at 330-33.) Ralston's chief complaints were: (1) pain extending from his mid-to lower-back, with accompanying pain and numbness in the left lower extremity; (2) episodes of abdominal discomfort; and (3) Hepatitis. ( Id. at 330.). Dr. Lifrak found Ralston to exhibit a "mild degree of limp favoring the left lower extremity." ( Id. at 332.) Overall, he found very few limitations. Dr. Lifrak noted that Ralston was unable to walk on either his heels or toes, but nonetheless did not require an assistive device to walk. ( Id. ) He noted that Ralston was adequately developed and nourished, that he was able to perform maneuvers requiring hand dexterity, and that his grip strength and muscle tone were not limited. ( Id. )
As for Ralston's range of motion, Dr. Lifrak found reduced motion in the area of the lumbar spine without evidence of muscle spasm. ( Id. at 333.) Based on the examination and historical information provided, Dr. Lifrak concluded that Ralston-in a typical eight-hour day-would be able to: (1) perform such activities which may require him to walk either outdoors or indoors; (2) climb stairs; (3) sit for a total period of six hours and stand for a period of five to six hours, while taking usual and customary breaks; and (4) lift weight up to ten pounds with either hand on a regular basis. ( Id. )
b. Dr. Borek
Dr. Borek, a non-examining state agency physician, completed a physical Residual Functional Capacity ("RFC") assessment of Ralston in April 2008. ( Id. at 353-60.) Dr. Borek concluded that Ralston could: (1) occasionally lift and/or carry twenty pounds; (2) frequently lift and/or carry ten pounds; (3) stand and/or walk for about six hours in an eight-hour workday; (4) sit for a total of six hours in an eight-hour workday; and (5) perform unlimited pushing and/or pulling. ( Id. at 354.) Ultimately, Dr. Borek opined that Ralston's medical files did not contain sufficient information to establish a disability prior to March 31, 2006. ( Id. at 358.)
2. Psychiatric Opinions
a. Dr. Chester
Dr. Chester, a state agency consultative psychologist, examined Ralston on August 16, 2005. (D.I. 13 at 334-37:) Upon arrival, Dr. Chester noted that Ralston looked disheveled and poorly groomed, and that he sat with a slumped posture and walked with a limp. ( Id. at 336.) Ralston stated, "I have the blues." ( Id. ) Dr. Chester reported that Ralston had no delusion and no disorder of formal thought. ( Id. )
In her report, Dr. Chester noted that much of the history contained within her report was "gathered from paperwork" sent from the state agency physicians. ( Id. at 334.) In light of the parties' arguments, the court excerpts a portion of Dr. Chester's summary below:
The claimant is a 45-year-old single white male. He reports that he has a psychiatric history notable for substance abuse and notable for substance dependence and antisocial personality which dates back to the age of 13 or earlier. At the age of 13 he was admitted to Friends Hospital in Philadelphia and was misdiagnosed with schizophrenia when he presented in a psychotic state. It was later determined that psychosis was secondary to hallucinogens. He was hospitalized at the Delaware State Hospital at the age of 17 and spent one month there. His discharge diagnosis reflected his tendency to be aggressive, a diagnosis that is no longer in use. At the age of 32 he was readmitted to Delaware State Hospital for 24 hours and discharged with diagnosis of substance abuse and antisocial personality disorder. He was admitted because he had had a fight with his employer who was also his landlord. He was accused of sleeping on the job. He left the job precipitously and got intoxicated. He was then left with no place to live or work. In response to that he took an overdose of pills. The discharge summaries... note... an extensive history of alcohol and substance abuse dating back to the age of 15. His drug of choice was apparently barbiturates and he also used cocaine, marijuana, other hallucinogens, amphetamines, and intravenous heroin. During the interview the claimant only reports use of alcohol and PCP. He reports that he stopped drinking some time in his 30s which is consistent with the paperwork that was sent for review. He denied ever having been treated in a rehabilitation facility or in a detoxification facility. Paperwork sent for review shows that at the age of 29 he was treated as an outpatient in a community mental health center and prescribed amitriptyline. He did not recall this during the interview.
There is no history of mania. There is a history of psychosis as previously noted (secondary to substance abuse).
( Id. at 334-35.)
Dr. Chester defined Ralston's mood as "euthymic, " and that he was alert and oriented. ( Id. at 336.) Dr. Chester assessed Raison with a GAF score of 55, indicating moderate limitations and symptoms. ( Id. at 337.)
b. Dr. Fugate
On January 2, 2008, Dr. Fugate, a non-examining state consultant, reviewed Ralston's health records and completed a psychiatric review technique form and a mental RFC assessment form. ( Id. at 338-48, 349-51) In his Psychiatric Review Technique Form, Dr. Fugate concluded that Ralston had experienced one or two episodes of decompensation and possessed moderate limitations for: (1) activities of daily living; (2) social functioning; and (3) concentration, persistence, or pace. ( Id. at 346.) In his mental RFC assessment form, Dr. Fugate concluded Ralston was markedly limited in his ability to interact with others and that Ralston was unable to meet the basic mental demands of ...