The Honor able Samuel H. Ma y s, J r., United States District Judge f or the Western * District of Tenne ssee, sitting by desig nation. NO T R EC OM M EN DE D F OR F UL L- TEX T P UB LIC AT ION F ile Nam e: 10a0452n.06 No. 09-6192 UN ITED STA TES C OU RT OF AP P EA LS F OR THE SI XT H C IR CU IT
AN G ELA K

AYCA RRELLI , Plaintif f-Appellant , v. CO M M ISSI ON ER

OF SOC IA L SEC URITY , Defendant-

Appellee
. ) ) ) ) ) ) ) ) ) ON APPEALFROM THE UN I TE D ST AT ES D I STR I CT CO UR T F OR

TH E E AST ERN DI STRI CT OF TEN

NESSEE O P I N I O N

BEFORE: COLE an d MCK EAGU E, Circuit Judges; MAYS, Distr ict Judge. * COLE, Circuit Jud ge . Plaintiff-Appellant Ang ela Car relli seeks r eview of

a district cour

t’s decision af

firming the dec ision of an administrative law judge (“A L J ”) who denied her re quest for
so c ia l s e c u r it

y d is a b il it y b e n e f it s . B e c a u s e s u b s ta n ti a l e v id e n c e s u

p p o rts th e A L J’ s d e c is io n , we AF F IRM
. I. BACKG ROUND A. F ac tu al b ac kgr ound Carre lli is a hig h school g raduate wit h an assoc iate deg ree in nursing w ho previously worke d
as a r eg istered nur se. In Aug ust 2004, she applied for disability insurance benef

its and supplemental
se c ur ity inc ome un de r T itl e s I I and XV I of the Soc ia l Se c ur ity Ac t, a lle g ingtha

t sh e ha d b e e n una

bleNo. 09-6192

An ge la C arre lliv . Co mm iss ion e r o f So c ial Se c ur ity

- 2 - to w or k s inc e Au g us t 25 , 2 00 1, be c a us e of ri g ht pir if

or mis sy nd ro me , sho uld e r pr ob le ms, c hr on ic pa in, he a da c he s, dig e sti ve tr a c t pr ob le ms, de pr e ssi on , anxie ty , and dif fi c ult y sle e ping. T he sta te ag ency denied he r application init ially and on re consideration. She then re quested a n administrative hear ing. A t the time of the hea ring , she wa s fifty

y ear s old, and she wa s fifty -one y ear s old when the AL J issued his decision. 1. Medic al evidenc e I n Aug ust 2001, Carrelli soug ht treatment for pain in her r ight hip and w as g iven a c ortisone injection. The injec tion gave her temporar y relief , but her pa in persisted, and, in Septe mber 2001, she soug ht medical assistanc e fr om Dr. David Haug e. Dr Haug e per formed a

neurol og ical evaluation, found “a ve ry

miniscule disc bulge at the L 5-S1 level on the l eft which [was] very , very subtle.” (Administrative Rec ord (“ AR”) 187.) Dr Ha ug e suspec ted that Carr elli suffered fr om piriformis sy

ndrome—a

neuromuscula

r disorder that occur s when the pirif ormis muscle, a na

rrow
mus c le lo c a te d in

the bu tto c ks , c omp re sse s o r i rr itate s th e sc ia tic ne rv e . T he fo llo wi ngmon th, in November

2001, Carre lli rece ived another corti s o n e in

je c ti on. Be fore the proc edure , an examination sh ow e d n or

ma l stre ng th, se ns a tio n, and de e p te nd on re fl e xes i n b oth le g s. Pos t- pr oc e dure , Ca rr e lli repor ted positive results and wa s instructed to retur n for injec tions as neede d. I n April 2002 , s t i l l h aving hip pain, Carre lli underwent a n elec trony og ram a

nd a nervec ondu cti on st ud y . T he te sts re su lts we re no rm a l. T wo mon ths la te r, Carr e lli c on su lte d a pa in specia list, Dr. Dennis Har ris. His examination reveale d that Carre lli had full rang e of moti on and str e ng th i n h e r low e r extr e mit ie s, no rm a l tone and mov e me nt, and the a bil ity to w a lk o n h e r h e e ls and toes without difficulty . I n addition, she had normal mood and a ffe ct as we ll as normal thoug htNo. 09-6192

An ge la C arre lliv . Co mm iss ion e r o f So c ial Se c ur ity

- 3 - content an d

th o u g h t p r o c e s s . D r . H ar r is d ia g n o s e d

c h r o n ic mu s c le p a in

an d r e c o mm e nded ag g ressive phy sical thera

py and epidur al infusion. I n Aug ust of that same y ear , Carre lli aga in saw Dr. Ha rris who a dminist ere d an epidur al infusion for her rig ht hip. After the injection, she re ported “g ood relief

,” and that she was “able to toler ate phy sical thera py treatments w hich helped improve her r ang e of motion.” (A R 210.) At a follow-up visit with Dr. Ha rris in Octobe r 2002, Carr elli reporte d that she thoug ht she made “ some prog ress” and wa s “slowly prog ressing ” with phy sical thera py three times per we ek. (A R 25 4. ) H ow e ve r, sh e a lso re po rt e d le ft hip pa in and “ e xpre sse d f ru str a tio n” tha

t “ sh e wo uld
never g et better .” (

Id. ) I n addition, she requested another lower-bac k MRI
. I t showed only minor de g e ne rativ e c ha

ng e s and a le ft -s ide dis c bu lg e that w a s unc ha ng e d f ro m pr e vio us MRI s. An MRI of Carr e lli ’s pe lvi s w a s ta

ke n s e ve ra l mo nth s late r i n F e br ua ry 20 03 . T he MR I showed mild hy

pertrophy , or enla

rg ement, of the right piriformis muscle, compared to the left. Dr. Gl e nn Jung , w ho re a d th e MRI , c on c lud e d, ho we ve r, that th e “ c lin ic a l si g nif ic anc e of thi s [w a s]
uncer tain,” and “ [t ]here [were ] no other signific ant finding s.” (AR 520.) An Aug ust 2004 CT-scan of Carr elli’s pelvis showed no abnor malities. I n addition, a bone mineral content exam in September 2003 showed norma l bone density in Carre lli’s lumbar spi n e an d b o rderline ostepenia ( low bone density) in h er l ef

t h i p . The ra diologist rec ommended follow-up in two to thre e y ear s. When Carr e lli ha d th e re c omm e nd e d fo llo w- up in Ma rc h 20 06 , the te st sh ow e d on ly mil d b on e de ns ity

los s in her lef t hip. Durin g this ti me per iod, Carre lli also saw Dr. Paul Na y lor, an orthope dic surg eon. In October 20 04 , D r. Na

y lor wr ote to C arr e lli ’s a tto rn e y , e xpla in in g tha t Ca rr e lli ha d c hr on ic pir if

or misNo. 09-6192

An ge la C arre lliv . Co mm iss ion e r o f So c ial Se c ur ity

- 4 - sy ndrome a nd that he thoug ht it was “not likely to g et better .” (A R 279.) He a lso thought “w ith a
rea sonable de g ree of medica l cer tainty she [was] not going to be able to c arr y on as a n R

N
. . . .” ( Id. ) I n a dd iti on

to hip pa in, Ca

rr e lli be g an re po rt ing le ft sh ou lde r pa in in Apr il 2 00 3. An MRI showed mild hy

pertrophy , which produced mi nimal impingeme nt of her shoulde r, but no evidenc e of a c omplete rotator c uff t ea r. I n Marc h 2004, afte r Carr elli had experienc ed pain in her left shoulder for

more than one y ear , Dr. Na y lor diag nosed her

with chronic shoulder

pain. L ater

that
mon th, he pe rf

or me d a n a rt hr os c op ic surg ic a l pr oc e dure on he r l e ft sh ou lde r. I n Jun e 20 04 , Ca rr e lli repor ted m ar k ed improveme nt. Howeve r, in Dec ember 2004, Carre lli felt a “pop” in her lef t sh ou lde r a ft e r l if

tin g a tw e lve -p ound tur

ke y . De sp ite the inj ur

y , D r. Na y lor c on c lud e d th a t Ca

rr e lli had g ood rang e of motion, and a n MRI showed only

slight irritation. I n J anuar y 2005, Dr. Jeffre y

Summers, a consulting phy sician, e x am i n ed Carre lli. Dr. Summers noted that Carre lli li mped and favor ed her rig ht leg but did not require an aid to walk. She also had mild difficulty

rising f rom a seated posi tion and getting on and off the examination table. Dr
. S u m m er s co n cl u d edt h at b ec au s e o f h er h i p p ai n , C arre l l i wo u l d h av e di ff i cu l t y s i t t i n g, s t an d i n g,
or wa lking f

or m ore than thirty minutes continuously or for more than six hours in a workday and
wo uld h a v e d i f

f i c u l t y s qu a t t i n g , kn e e l i n g , c l i m b i n g , an d s t o o p i n g o n a f r e qu e n t b a s i s . He a lso
c on c lud e d, ho we ve r, that sh e wo uld oth e rw ise be a

ble to t ole rate wo rk -r e la ted a c tiv iti e s in thi s reg ard. B eca

use of he r shoulder injury , Dr. Summers s t at ed t hat Carr elli should avoid working
ov e rh e a d as we ll as re a c hin g , pull ing , pus hin g , lif tin g , or ca rr y ing g re a te r t

ha n tw e nty po un ds wi th her le ft arm, but other

wise, she should tolerate all other w ork-r elated a ctivit i es i n t h i s reg ard.No. 09-6192

An ge la C arre lliv . Co mm iss ion e r o f So c ial Se c ur ity

- 5 - Finally , Dr. Summers found Car relli to be ale rt and oriented to person, place, tim e, and situation; he also found her

cog nitive function and intellig ence to be commensurate with her f ormal educ ation. A fe w months later, in January 2005, Dr. Celia Gulbenk, a state a g ency phy sician, re viewed Carr e lli ’s me dic a l r e c or ds . D r. Gu lbe nk c on c lud e d th a t Ca

rr e lli c ou ld l if

t or c arr y up to t we nty po un ds oc c a sio na lly

and up to t e n p ound s f

re qu e ntl y ; wa s lim ite d in he r a bil ity to pu sh or

pu ll w ith he r l ow e r e xtre mit ie s; c ou ld sta nd or wa lk fo r a

bo ut six ho ur s in

an e ig ht- ho ur

wo rk da y ; c ou ld s it ab o u ts i x h o u r s i n an ei gh t -h o u r w o rk d ay ; an d wa s l i m i t edt o o cc as i o n al cl i m b i n g, b al an ci n g, sto op ing , kne e lin g , cr ou c hin g , an d cr awl ing
. Th e do c tor a lso no te d th a t Ca

rr e lli ’s a lle g a tio ns of

pa in
wer e not “wholly

cre dible.” (A R 350.) During that same month, at the state a g ency ’s request, psy cholog ist Trac y Allred e x amined Carre lli. Dr. Allre d noted that Carr elli suffer ed a “ mix ture of de pression and a nx iety sy mptoms due to c ir c ums tant ial str e sse s in he r l if e .” (A R 34 0. ) A s a

re su lt, Dr . A llr e d f

ound it d if fi c ult to differ entiate menta l health sy mptoms from medical sy

mptoms. I n addition, when questioned about prior mental he alth treatment, Carre lli was “not intereste d,” denie d curr ent treatment, and de n ied taking an y

me d ic a ti o nf

o r me n ta l h e a lt

h s y mp to ms . ( A R 3 3 8
. ) D r . A ll r e d an d Ca r r e ll i d is cussed Carre lli’s use of L orazepam, b u t C arr elli insist ed that it was pre scribed f or “othe r medica l uses versus de pression or a

nx iety .” (A R 339.) Ultimately , Dr. Allre d diag nosed anxiety and opined that Carre lli wa s moderately limit ed in he r ability to unde rstand and re member, to sustain conc entration
and pe rs ist e nc e , to int e ra c t so c ia lly , a nd to a da pt a nd tol e rate wo rk -r e la te d s tr e ss. During the next mont h, Fe bruar y 2 005, Dr. L arr

y Welch, a state a g ency

revie wing psy cholog ist, ag ree d with Dr. Allred’ s conclusions and fur ther opined that Carre lli could u n d e rstand,No. 09-6192

An ge la C arre lliv . Co mm iss ion e r o f So c ial Se c ur ity

- 6 - re me mbe r, and

c omp le te de ta ile d ta sk s on a re g ula r a nd c on tin ua l ba sis wi th o c c a sio na l di ff ic ult y
su sta ini ngc on c e ntr a tio n, pe rs ist e nc e , a nd pace. He als o c on c lud e d th a t sh e c ou ld i nte ra c t w ith oth e rs wi tho ut d if

fi c ult y , c ou ld a da

pt t o a ro uti ne bu t no t to fr e qu e nt o r f a st- pa c e d c ha

ng e , a nd c ou ld set and a chieve most long-r ang e g oals with only occa sional assistance. That summer, in Jul y 2005, neurolog ist Dr. J ack Scariano ex amined C arr elli. He noted that she wa s oriented to per son, place , and time and that he r mood and a ffe ct wer e appr opriate to the situation. Her spee ch wa s appropr iate and her rec ent and remote memory wer e intact. Her attention sp an and c on c e ntr a tio n we re g oo d a s we re he r vo c a bu lary , awa

re ne ss of c ur

re nt e ve nts , and past his tor y . Ca rr e lli ’s tou c h, pin , a

nd vib rator y se ns a tio ns wer e no rm a l; s he ha d f ull str e ng th i n a ll extremiti es; her ba lance was normal; and she ha d a norma l ga it, with normal heel-toe a nd tandem walking . She did, however , show marke d spasms in her rig ht piriformis muscles. Dr. Sca riano diag nosed piriformis sy

ndrome a nd rec ommended injections to relieve the pain. The ne x t y ear , in March 2007, Ca rre lli underwen

t piriformis-rele ase sur g ery with Dr. Na

y lor. Pir if or mis -r e le a se su

rg e ry inv olv e s c utt ingthe te nd on of the mus c le to re la x it. A t a fo llo w- up vis it two wee ks later, Dr . Naylor noted that Carr elli’s wound was healing and that she was “ambulating well.” ( AR 675.) Prior to the proc edure , Dr. Na y lor had c ompleted a “ Medica l Source Statement of Ab ili ty to D o Wo rk -R e la te d A c tiv iti e s, ” in w hic h h e op ine d tha t Car re lli c ou ld not lif

t any we ig ht; could not stand or wa lk at all; could not sit at all; was limited in her ability to push and pull her lower extremiti es; and c ould never climb, balance , kneel, c rouch, c raw l, or stoop. I n addition to specialists, Carrelli saw a general pra ctitioner, Dr. Ma ncel Wakham, f

rom Se pte mbe r 2 00 1 unti l N ov e mbe r 2 00 6. Duri ng that pe ri od , Dr
. Wak ham tr e a te d Carr e lli fo r h e r h ipNo. 09-6192

An ge la C arre lliv . Co mm iss ion e r o f So c ial Se c ur ity

- 7 - and sh ou lde r i nj uries a s w e ll a s o the r m e dic a l is su e s n ot r e la te d to thi s a pp e a l. H e re fe rr e d h e r t o specia lists, reg ularly

presc ribed pa in medications, and pre scribed sle ep aids and medications used to treat a nx iety . I n Dec ember

2003, Dr. Wakham wrote a brief letter opining that Carre lli’s “medical dis a bil iti e s are pe rm ane nt in na tur e . He r phy sic a l limitatio ns ke e p he r fr om pe rf or min g du tie s a s a reg istered nur se or any other ga inful employ ment.” (AR 65.) Three y ear s later, in Dece mber 2006, Dr. Wakham c ompleted a “ Medica l Source Statement of A bility to Do Work-Related Activiti es,”
and op ine d th a t Ca

rr e lli c ou ld n ot l if

t any we ig ht; c ou ld n ot s tand

or wa lk at a ll; c ou ld n ot s it at a ll; was limited in he r ability

to push or pull in her lower e x tremities; and could neve r climb, balanc e, kneel, c rouch, c raw l, or stoop. 2. Physical therapy Carre lli attende d a series of phy sical thera py sessions f

or her rig ht hip and left shoulder f rom May 2002 throug h November

2006. During these sessions, she se t goa ls for her self and c harte d her prog ress. At a

n initial evaluation in April 2003, for instance, Carre lli’s g oals for the next four weeks of thera p y in c lu d e d to le r a ti n g w a lk in g g r e a te r th an 1
. 5 h o u r s w it h d e c r e a s e d p a in me d ic a ti on and incre asing “over all functional status to allow her to drive a ca r and e ventually

return to wor

k.” (A R 600.) At a November 2004 initial eva luation, Ca rre lli re ported that she wa s doing “ fairly well” a fter her r otator cuf

f surg ery . (AR 563.) S he also re ported c ontinued pain in her r ight buttock, whic h left he r u na ble to d ri ve fo r l on g pe ri od s o f t ime . D e sp ite the pa in, ho we ve r, sh e c on tin ue d to wa lk at

a loc a l tr a c k. At

a n in iti a l e va luatio n in F e br ua ry 20 06 , Carr e lli re po rt e d that sh e wa s h a vin g dif fi c ult y sittin g or sta nd ingfo r l on g pe ri od s o f ti me and that sh e c ou ld n ot s it f

or lon g e r t ha n o ne min

ute wi tho ut h a ve to s hif

t po sit ion s.No. 09-6192

An ge la C arre lliv . Co mm iss ion e r o f So c ial Se c ur ity

- 8 - B. P roce dural h istory 1. Administrati ve he aring An administrative hea

ring was held in Ma

y 2007. At the hear ing, Carre lli testified that he r hip was her

most significa

nt medical proble m. She expl ained t h at s h e experience d spasms in her back, buttocks, a

nd leg ; had to chang e positions frequ en t l y ; an d could not sit for more than f ive min ute s at a tim e . Sh e fu

rt he r e xpla ine d th a t sh e c ou ld sta nd fo r an ho ur or tw o bu t the n n e e de d to rest. S he described her second most serious problem as concentration, explaining that her lack of focus wa s relate d to how much attention she ha d to pay t o t h e p ai n and the dosa g e of me dication neede d to control the pain. When a sked by the AL J if she had a

nx iety or depr ession, she testified that sh e ha d mo re anxie ty tha n d epre ssi on

bu t w a s n ot s e e kin g tr e a tme nt f or he r a nxie ty . Ca

rr e lli also testified that she ha d been taking c ontinuing educat i o n courses for nursing ; had a dr iver’s license a nd had driven in the past month; liked to r ead; did stretching exercises e very morning ; and tr ie d to w alk at a

tr a c k thre e tim e s p e r w e e k. F ina lly , s he state d th a t sh e too k a n h our- lon g bath
e ve ry nig ht t o r e la x he r m

us c le s. Next, the AL J asked a

vocational e x p ert (“VE” ) what work wa s available for a person of Carr e lli ’s a g e , e du c a tio n, and vo c a tio na l bac kg ro un d, wh o wa s abl e to pe rf or m li g ht w or

k w itha sit

stand option; no pushing or pulling or legcontrols with the r i gh t l eg; only occa sional lifting and
car rying w ith the left arm; no climbing or cra wling; and only

occa sional stopping or be nding. T he VE re sponded that such a p erson could not perfor m Carre lli’s past work as a reg istered nur se but could per form other jobs such as a medical unit cler k, a medical companion, or a g ener al cler

k. The VE explained that medica l companion jobs involve no lifting but entail sitting w i t h an ill person,No. 09-6192

An ge la C arre lliv . Co mm iss ion e r o f So c ial Se c ur ity

- 9 - monitoring he r position, and no t i fy i n g o ther pe rsonnel if a ssistance is re quired. L ater , Carre lli’s
a tto rn e y a sk e d w he the r a

pe rs on c ou ld p e rf

or m me dic a l un it c le rk wo rk if the pe rs on ha d d if fi c ult y
rema ining a lert or wa s easily distracted. T he VE responde d that it would depend on the se verity of t h o s e l i m i t a t i o n s . C ar

r e l l i ’ s a t t o r

n e y a l s o a s k e d t h e V E i f

a p e r s o nw h o m i s s e d

m o r e t h ant w o d a ys of wo rk pe r m on th w a s emp lo y abl e; the VE re sp on de d th a t “ [g ]en e ra lly , o ve r t wo a bs e nc e s, consistently , per month, is the cutoff point.” (AR 755.) I n addition to the testimony offe red dur ing the administrative hea ring , a surve illance tape of Carr e lli wa s a dmi tte d a s p art of the re c or d. Th e ta

pe is a lso e vid e nc e in l iti g a tio n b e tw e e n Ca rr e lli
and a pr ivate dis a

bil ity ins ur e r. Th e ta

pe wa s su bmi tte d at th e AL J’s r e qu e st. 2. The ALJ’s dec ision Th e AL J f

ound that Carr e lli ha d se ve re imp a ir me nts of ri g ht pir if

or mis sy nd ro me , with piriformis-re lease surg ery in March 2007; history of left shoulder

impingeme nt sy

ndrome, with left shoulder ar

throscopy and rotator cuff

repa ir in Marc h 2004; and minimal disc bulging in her lowe r back. The AL J also found t hat C arr elli does not have a sever e mental impairme nt. The AL J then
c on c lud e d th a t Ca

rr e lli ’s ph y sic a l imp a ir

me nts lim ite d he r t o a

re str ic te d r ang e of

lig ht w or k w ith
a sit -s tand op tio n. Th e AL J f

ur the r fo un d, ba se d on the VE ’s te sti mony , th a t th e re we re job s Ca rr e lli could per form, such a s medical unit cler k, medical c ompanion, and g ener al cler k. 3. District court’s decision Pursuant to 42 U.S.C. §§ 405(g) and 1383(c )(3) , Carre lli ti mely filed a c ivil action in the United States District Court for the Ea stern Dist rict of Tenne ssee f or re view of the AL J ’s dec ision. The mag istrate judg e found the re w as substantial evidenc e for the AL J ’s dec ision and rec ommendedNo. 09-6192

An ge la C arre lliv . Co mm iss ion e r o f So c ial Se c ur ity

- 10 - aff irming. The district court ag ree d and adopted the mag istrate judge ’s re port and re commendation. Carre lli ti mely

appea led. II. AN AL YSI S A. Stand ard of review Un de r 4 2 U .S. C. § 40 5( g ), our r e vie w o f t he Com mis sio ne r’ s d e c isi on is l imi te d to deter mining whe ther the f

actua l findings a

re suppor ted by substantial evidence and whe ther the
corr ect leg al standar ds wer e applied. See Cutlip v. Sec 'y of Health & Human Serv s ., 25 F.3d 284, 286 (6th Cir. 1994)
. Substantial e vidence means “more than a scintilla of evidenc e but le ss than a preponde ranc e; it is such releva nt evidenc e as a reasonable mind might acc ept as a dequate to support
a c o n clusion.” Id
. We ma y n o t t r y th e c a s e d e n o v o , r e s o lv e c o n f li c ts in e v id e n c e , o r

decide questions of cr ed i b i l i t y . W alters v. Comm’r of Soc. Se c . , 1 2 7 F
. 3 d 5 2 5 , 5 2 8 ( 6 t h C i r . 1 9 9 7 )
. If supported by

substantial e vidence and dec ided under the cor rec t leg al standar d, the Commiss ioner’s de c is i o nm u s tb e a f

f i r m e d e v e ni f t h i s C o u rtw o u l d

d e c i d e t h e m a t t e r

d i f f e r e n t l y , an d

e v e nif substantial evidence also supports the claimant’s position. Mullen v. Bowe n , 8 00 F .2 d 5 35 , 5 45 (6 th Cir. 1986) (en ba

nc). B . L eg a l f

ra mew o rkf

o r e v a l u a ti n g d i s a b i l i ty cl a i ms “The plaintiff has the ulti mate burde n to establish an entitlement to benef its by proving the exis tence of a disability

. . . .” W yatt v. Sec ’y of He alth & Human Serv s ., 974 F.2d 680, 683 ( 6th Cir. 1992). The Socia l Security Administration de fines a “disability ” as an “inability to e ng ag e in any substantial ga inful activity by rea son of any

medically

deter minable phy sical or menta l impairment which ca n be expected to r es u l t i n d ea t h or which ha s lasted or c an be e x pecte d to last for aNo. 09-6192

An ge la C arre lliv . Co mm iss ion e r o f So c ial Se c ur ity

- 11 - continuous period of not less than 12 months.” 42 U.S.C. § 423(d)( 1)(A)
. To make a deter mination as t o disability , an AL J undertakes a f ive-step se quential eva luation mandated by regulation. W

ilson v. Comm’r of Soc . Sec. , 378 F.3d 541, 548 ( 6th Cir. 2004). First, the claimant must demonstrate that sh e ha s n ot e ng a g e d in su

bs tanti a l g a inf

ul a c tiv ity du

ri ng the c la ime d p e ri od

of dis a bil ity . 2 0 C. F .R. § 4 04 .1 52 0( a )( 4) (i ). Se c on d, the c la ima nt m us t sh owthat sh e suffers fro m a se ve re me dic a lly deter minable phy sical or menta l impairment. § 404.1520(a) (4)( ii). Third, if the claimant shows that he r i mpa ir

me nt m e e ts o r m e dic a lly

e qu a ls one of

the imp a ir

me nts lis te d in

20 C.F .R. pt. 40 4, Sub pt. P, App. 1, she is de emed disabled. § 404.1520(a) (4)( iii). I f not, the AL J fourth dete rmines whethe r, ba se d o n th e c la ima

nt’ s r e sid ua l f un c tio nin g c a

pa c ity (“ RF C” ), th e cla im ant c an p e rf or m he r p a st
re le va nt w or k, in w hic h c a se the c la ima nt i s n ot d isa

ble d. § 40 4. 15 20 (a )( 4) (i v)
. I f s o, the AL J fif th deter mines whether , based on the claimant’s RFC, as well as her ag e, educ ation, and wor k exp er i en ce, the claimant ca n make a n adjustment to other work, in whic h case the claimant is not dis a ble d. § 4 04 .1 52 0( a )( 4) (v ). Th e c la ima nt b e ars the burd e n of pr oo f duri ng the fi rs t f our s te ps , but the burden shifts to the Commissi oner at step five. W ilson , 3 7 8 F. 3 d

at 5 4 8 (c i t i n g W

alt e rs , 127 F.3d at 529). To preva il at step five, the Commissioner must identify a sig nificant number

of jobs in the economy

that acc ommodate the cla imant’s RFC and vocational profile. Jones v . Comm’r of Soc. Sec ., 336 F.3d 469, 474 ( 6th Cir. 2003). Carre lli arg ues that the AL J err ed in two way s. First, she c laims the AL J err ed at step two b y f i n d i n g t h a th e r

an x i e t y d i s o r d e r w a s n o t a s e v e r e i mp a i r

m e n t
. S e c o n d , s h e ar g u e s t h a tt h e A LJ
err ed at step f

ive by concludingthat she wa s capa ble of makinga su cc essful adjustment to other work a nd that such work is available.No. 09-6192

An ge la C arre lliv . Co mm iss ion e r o f So c ial Se c ur ity

- 12 - C. St e p t wo: se ve r e m e nt al i m pai r m e nt At ste p tw o, Carr e lli mus t sh owthat sh e su ff e rs fr om a

se ve re me dic a lly

de te rm inab le phy sical or menta l impairment. 20 C.F.R. § 404.1520(a) (4)( ii). An impairment is not considere d
sever e whe n it “does not signif icant l y l i m i t [ o ne’s] phy sical or menta l ability to do basic work activities.” § 404.1521(a ). Re lyingon

the op ini on s o f D r. Al lr e d a nd Dr . We lc h, Carr e lli argue s that the AL J fa ile d to take a cc o u n t of her se vere mental impairments. As we have disc ussed, Dr. A llred conc luded that Carre lli presented a

“mix ture of depre ssion and anx iety sy mptoms.” (AR 342.) Howeve r, Dr. A llred fo un d it dif fi c ult to d e te rm ine the c a

us e of Carr e lli ’s anxie ty

—wh ether

it w a s c a us e d b y me nta lhealth sy mptoms or medical sy

mptoms—because of the “cir cumstantial stresses” in Carre lli’s life. (AR 342.) I n addition, a lthough Dr. Allre d conclude d that some of Carr elli’s mental abilities were limit ed due to a

nx iety , Dr. Allre d further conclude d that C ar relli was only “moder ately

limit ed.” (AR 34 0
. ) D r . We lc h c a me to a s im il ar c o n c lu s io n . H e o p in e d

th a t C ar r e ll i c o u ld

u n d e r s ta n d,
re me mbe r, and

c omp le te de ta ile d ta sk s o n a re g ula r a nd c on tin ua l ba sis wi th o nly

“ oc c a sio na l” difficulty sustaining c oncentr ation, persistenc e, and pa ce. ( AR 353.) We conseque ntly conclude that, althoug h Dr. Allred’s and Dr. Welch’s diag noses might—with additional evide nce—suppor t the conc lusion that Carrelli suffe rs a sever e mental impairme nt, they do not nece ssarily

lead to that conclusion. Carr e lli a lso re lie s on her his tor y of us ing ps y c ho tr op ic dr ug s, inc lud ingAt iva

n, L or a zep a m, Z oloft, Cymba lta , a

nd Rita lin , a s e vid e nc e of

he r m e nta l im

pa ir me nts . U nf

or tun a te ly fo r h e r, us e of such drug s is not nece ssarily indicative of a severe me ntal impairment. See Thacker v. Sec’ y ofNo. 09-6192

An ge la C arre lliv . Co mm iss ion e r o f So c ial Se c ur ity

- 13 - He alt h &Hu ma n S

e rv s. , No. 90-5546, 1990 U.S. App. L EXI S 21866, at *7 (6th Cir. Dec . 12, 1990) (“The mere fac t that claimant is taking medication to ca lm his ner ves does little to establish mental imp a ir me nt. ” ). Mo re ov e r, the re c or d in dic a te s th a t th e se dr ug s we re pr e sc ri be d f

or se datio n, mus c le sp a sms , a nd sle e pin g . In f

a c t, C arr e lli tol d D r. Al lr e d th a t sh e us e d L or a zep a m ( c omm on ly us e d to treat anxi ety

), not for de pression and anx iety , but for other medical purposes. Thus, her r eliance on he r p sy c ho tr op ic dr

ug -u se fa lls sh or

t of c on c lus ive ly

de mon str a tin g a

se ve re me nta l im

pa ir me nt. Moreove r, there is evidence on the othe r s id e o f th e s cale supporting the AL J ’s deter mination. First, other

doctors re ported that Car

relli suffe red no mental impairments. Neur ologist Dr. Sca riano conclude d that Carre lli had “no si g nificant a ffe ct distress, memory or conc entration problems, or problems with insight and judg ment.” (AR 376-77.) Dr. Summers a lso obse rved that Carre lli was aler t a nd oriented to pe rson, place , time, a nd situation; her cog nitive f unction and intelligenc e we re
comme n s u r a te w it

h h e r f o r ma l e d u c a ti o n ; a

n d s h e in te r a c te d

w e ll w it h h im , w it

h n o a b n o rmal be havio rs or

mann e ri sms . Se c on d, Carr e lli ’s c la ims that sh e ha d d if fi c ult y c on c e ntr a tin g and

c ou ld not follow a new spaper

wer e inconsistent with h e r o wn te s ti mony

that she take s continuing e ducation
c l a s s e s t o m a i n t a i n h e r n u r s i n g l i c e n s e , c ar e s f o r h e r t e e n a g e s o n , p r e p a r e s s i mp l e m e a l s , e n

j o ys
rea ding, a nd drives. Third, the re cord shows that Carre lli has not sought treatment for her alleg ed mental impairments. Althoug h not disposit ive, treatment that a claimant ha s rec eived is a r eleva nt fac tor in evaluating the a lleg ed i n t en s i t y and per sistence of

her sy mptoms. See 20 C.F.R. § 404.1529(c) (3)( v). F inally , Carre lli her self attributes much of he r anxiety to her phy sical condition. Duri ngthe a dmini st rat iv e he ari ng , s he te sti fi e d th a t th e anxie ty and de pr e ssi on

that sh e su ff

e rs is
re la te d to pa in. Th is s e lf -a sse ssm e nt s up po rt s th e AL J’s c on c lus ion that Ca rr ell i’ s anxie ty

wa s aNo. 09-6192

An ge la C arre lliv . Co mm iss ion e r o f So c ial Se c ur ity

- 14 - sy mptom of her phy sical impairment and not a separ ate disorde r. I n the final analy sis, we conclude that substantial evidence suppor ted the AL J ’s conc lusion that Ca rr e lli do e s n ot s uf

fe r f ro m a se ve re me nta l im

pa ir me nt. D. Step fi ve: succ essfu l adjustme nt to other availabl e work Carr e lli a lso c ha lle ng e s th e AL J’s c on c lus ion that th e re were job s ava ila ble that Ca

rr e lli could p e r f

o r m. Sh e la

u n c h e s th is a tt a c k in thr e e w ay s . F ir s t, s h e c la im s th a t the AL J was predisposed to find a g ainst her. In other words, she claims he was biased. Next, she argues that the A LJ i mp r o p e r l y

i g n o r e d t h e o p i n i o n s o f

h e r t r e a t i n g p h y s i c i an s . F i n a l l y , s h e c l a i m s t h a t t h e A LJ de vis e d in a c c ur a te hy

po the tic a l qu e sti on s. 1. Bias We a pp ly the “ pr e su mpt ion

that po lic y

make rs withde c isi on makin g po we r e xer c ise the ir power with honesty

and integ rity ,” and “ any

alleg ed pre

judice mus t be evident from the re cord a nd cannot be based on spe culation or infe renc e.” Navistar Int’l Trans p. Corp. v. U.S. EPA , 941 F.2d 1339, 1360 (6th Cir. 1991). I n addition, any claim of bias must be supporte d by a “ strong showi ng ”
o f b a d faith. C i t

y of Mount C lemens v . U.S. EPA , 917 F.2d 908, 918 ( 6th Cir. 1980) (interna l qu otatio n ma

rk s o mit te d) . Ca

rr e lli ha s o ff

e re d n o e vid e nc e to m e e t th is h ig h s tand ard , a nd we e a sil y reje ct her asser tion. 2. Treating physicians ’ opinions As di s c u s s e d , b o th D r. Wak ham and Dr . N ay lor

wr ote le tte rs and

c omp le te d e va luatio n f

or ms op ini ngthat Ca

rr e lli ’s a bil ity to wo rk wa s hig hly lim ite d. Carr e lli c la ims tha t th e AL J com

ple te ly dis re g ard e d th e se op ini on s, bu t sh e mis re a ds the de c isi on . Con tr ary to h e r a c c us a tio n, the AL J didNo. 09-6192

An ge la C arre lliv . Co mm iss ion e r o f So c ial Se c ur ity

- 15 - no t di sr e g ard th e do ctor s’ op ini on s; i ns te a d, the AL J con c lud e d th a t th e op ini on s “ g ro ssl y exagg erat[ ed]” Carre lli’s lim ita ti o n s , a n d th e “ridiculously

oppressive limitations” wer e inconsistent with the objective evidenc e of the rec ord, clinical exam notes, Carre lli’s r eporte d daily activities, and the AL J ’s ob s er v at i o n s o f her at the administrative hea ring . (AR 18, 21.) Thus, the A L J did not disreg ard the opinions—he simply found them unper suasive. Ca r r e ll i a ls o ar g u e s th a t th e o p in io n s o f h e r tr e a ti n g p h y s ic ia n s s h o u ld h a v e b e e ng iven controlling weig ht. She is corre ct that an AL J g ener ally should give g reater de fer ence to a treating phy sician’s opinion than to a non-tr eatingphy sician’s opinion. See Blakley v. Comm’r of Soc. Se c. , 58 1 F .3 d 3 99 , 4 06 (6 th C ir . 2 00 9) (a pp lyingthe tr e a tin g -p hy sic ian r ule ). Ho we ve r, an A L J “mu st” g ive a tre a tingsource controlling weig ht only if it is “well-supported by

medically

acc eptable c linical and labor atory

diag nostic techniques” and is “not inconsistent with other sub s ta nti a l e v id e n c e in

[t he]
c a se re c or d. ” 20 C.F .R. § 4 04 .1 52 7( d) (2 ); se e als o Blakley , 581 F.3d at 406. I ndeed, “ ‘[i] t is an
err or to g ive an opi n i on controlling weig ht simpl y beca use it is the opinion of a treating sourc e . .

. if it is inconsistent w ith the other substantial evidenc e in the ca se re cord.’ ” Id. (quoting Soc. Sec. R u l
. 9 6

- 2 p , 1 9 9 6 S S R

LE X IS 9 , a t* 5 ( J u l y

2 , 1 9 9 6 ) ) ( a l t e r a t i o n i n o r i g i n a l )
. If , h o w e v e r , t h e A LJ does not ac cord c ontrolling weig ht to a treating phy sician, t he AL J still must determine how much weig ht is appropriate by

consideringthe re cord a s a whole. W ilson , 37 8 F. 3d at 5 44 ; se e als o 20 C.F.R. § 404.1527(d)( 4) (“G ener ally the more consistent an opinion is the with the rec ord as whole , the more weig ht w e will g ive that opinion.”); 20 C.F.R. § 404.1527(b) (“I n decidingwh et h er y ou
are dis a ble d w e wi ll a lw ay s c on sid e r the me dic a l op ini on s in y our c a se re c or d to g e the r w iththe re st of the re levant evide nce w e re ceive .”).No. 09-6192

An ge la C arre lliv . Co mm iss ion e r o f So c ial Se c ur ity

- 16 - The AL J did th a t h e r e . T h e A L J f ir s t n o te d th a t t h e M RI s s h o w e d

o n ly “ v e r y mi n is c ule” lower ba ck disc bulg ing w ith no nerve root impingeme nt, mild hy pertrophy of the piriformis muscle,
an d a s h o u l d e r s t r a i n a f

t e r h o l d i n g a t w e l v e p o u n d

tu r k e y w i t h o n l y h e r l e f tar m . ( A R 1 8
. ) T h e A LJ then noted that Carr elli’s pain dec rea sed after her pi riformis release surg ery in Marc h 2007, and that afte r her shoulder surg ery

in March 2004, she had g o o d ra n ge o f motion and only minimal t enderness. (

Id. ) T h e A L J f

u rth e r n o te d th e n u me r o u s d ia g n o s ti c te s ts s h o w in g n o p hy sical or neurolog ical abnor

malities, including CT-sc ans, EMGs, MRI s, and nerve -conduc tion studies. ( Id. ) The AL J then re lied on Dr. Summers’s finding that Carre lli had no neurolog ical or musculoske tal
a bn or ma lit ie s, a lon g wi th h is a sse ssm e nt t hat Ca rr e lli c ou ld lif

t tw e nty po un ds and

sit , s tand , o r w a lk for up to six hours, but no more than thirty minutes at a time. (AR 19.) The AL J explained that he g ave “ considera

ble weig ht” to Dr. Summers’s a ssessment beca use the assessment took acc ount of Carre lli’s le ft s houlder a

nd hip pain but also was consistent with the benig n diag nostic tests and Carre lli’s reported a

nd observe d daily

activities. (

Id. ) More over, a s the AL J noted, Dr. G ulbenk, an expert in Social Security disability evaluation, ag ree d with Dr. Summers’ asse ssment. ( Id. ) Consequ en t l y , we c onclude that the opinions of Dr . Wakham and Dr . Nay lor wer e inc on sis te nt w iththe re c or d a s a wh ole , a nd the AL J wa s n ot r e qu ir e d to de fe r t o th e ir op ini on s. 3. Hypothetical que

stions Finally , Carre lli arg ues that the questions the AL J posed to the VE did not accur ately portray her me ntal and phy sical impairments. See Va rle yv . S e c ’y of H e alt h & Hu ma n S

e rv s. , 820 F.2d 777, 779 (6th Cir. 1987). I n particula r, she claims that none of the hy pothetical questions took acc ount of her mental i mpairments requiring the use of psy chotropic dr ug s, the number of

fre quent abse ncesNo. 09-6192

An ge la C arre lliv . Co mm iss ion e r o f So c ial Se c ur ity

- 17 - that her impairme nts would cause, a nd her ne ed to be a

ble to sit and stand at will. Car relli furthe r contends that whe n the VE c onsidered the se a d d i tional limi tations, the VE testified that no jobs
wo uld be a va ila ble fo r C arr e lli
. An AL J ’s hy

pothetical question to a VE must a ccur ately portray a claimant’s phy sical and
me nta l im pa ir me nts , b ut i t is a lso “ we ll e sta bli sh e d tha t an A L J may

po se hy po the tic a l qu e sti on s to
a voca tional expert and is require d to incorporate only those limit ations acc epted a s cre dible by the finder of fac t.” Cas e

y v . Se c ’y of He alt

h a nd Hu ma n S e rv s. , 987 F.2d 1230, 1235 ( 6th Cir. 1993). Her e, our r eview of

the re cord r evea ls that the AL J p ro p er l y incorporated his findings into the deter mination of Carre l l i ’s R FC. The AL J then pre sented Car relli’s RFC, alongwith her a g e, education, and past rele vant work e x perie nce to the V E in hy pothetical questions. The V E subsequently

conclude d that a number of jobs that Carre lli was able to per form existed. Carre lli is c o r

r e c t th a t th e V E te s ti f

ie d th a t th e id e n ti f

ie d jo b s w o u ld b e e li mi n a te d for a pe rs on wh o h a d dif

fi c ult y re ma ini ng a le rt or fo r a p e rs on wh o w a s e a sil y

dis tr a c te d, and

the VE a lso testified that an e mploy ee w ith freque nt absenc es would have trouble maintaining employ ment. But consideration of these additional fa ct o rs i s beside the point. When asked a hy pothetical question encompa ssing the limitations that the AL J found cr edible, the VE testified t h at j o b s ex i sted. The additional limit ations offe red by Carrel l i’s attorney

—limit ations that the AL J found not
cre dible—need not be considere d. We theref ore r ejec t Carre lli’s challeng e. III . C ON CL USI ON For the fore g oing r easons, we AF F IRM the jud g me nt o f t he dis tr ic t c ourt
.