Henderson v. Social Security Administration, Commissioner

Filing 11

MEMORANDUM OPINION Signed by Judge Madeline Hughes Haikala on 8/31/2015. (KMG)

FILED
2015 Aug-31 PM 05:04
U.S. DISTRICT COURT
N.D. OF ALABAMA

UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
SOUTHERN DIVISION

LESLIE HENDERSON,
Plaintiff,
v.
CAROLYN W. COLVIN,
Commissioner of the
Social Security Administration,
Defendant.

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Case No.: 2:14-cv-01269-MHH

MEMORANDUM OPINION
Pursuant to 42 U.S.C. § 1383(c)(3), plaintiff Leslie Henderson seeks judicial
review of a final adverse decision of the Commissioner of Social Security. The
Commissioner denied Mr. Henderson’s claim for supplemental security income.1
For the reasons stated below, the Court reverses and remands this case to the
Commissioner for further consideration.
PROCEDURAL HISTORY
On January 13, 2010, Mr. Henderson applied for supplemental security
income. (Doc. 7-3, p. 22). In his application, Mr. Henderson alleged that his
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Initially, Mr. Henderson applied for a period of disability and disability insurance benefits and
supplemental security income. Mr. Henderson asserted that his disability began in March 2005.
Before his hearing before the Administrative Law Judge, Mr. Henderson amended his onset date
to January 31, 2010. In doing so, Mr. Henderson acknowledged that he would be eligible for
only supplemental security income. (Doc. 7-3, p. 22).

disability began in March 2005. (Doc. 7-3, p. 22). The Commissioner denied Mr.
Henderson’s claim on November 2, 2010, and Mr. Henderson requested a hearing
before an Administrative Law Judge (ALJ). (Doc. 7-3, p. 22). Before the hearing,
Mr. Henderson amended his alleged onset date to January 13, 2010. (Doc. 7-3, p.
22). The ALJ held a hearing on June 1, 2012. (Doc. 7-3, p. 22). The ALJ denied
Mr. Henderson’s claims on August 3, 2012. (Doc. 7-3, p. 35). On April 29, 2014,
the Appeals Council declined Mr. Henderson’s request for review (Doc. 7-3, p. 26), making the Commissioner’s decision final and a proper candidate for this
Court’s judicial review. See 42 U.S.C. § 1383(c).
STANDARD OF REVIEW
The scope of review in this matter is limited. “When, as in this case, the
ALJ denies benefits and the Appeals Council denies review,” the Court “review[s]
the ALJ’s ‘factual findings with deference’ and [his] ‘legal conclusions with close
scrutiny.’” Riggs v. Comm’r of Soc. Sec., 522 Fed. Appx. 509, 510-11 (11th Cir.
2013) (quoting Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001)).
The Court must determine whether there is substantial evidence in the record
to support the ALJ’s findings. “Substantial evidence is more than a scintilla and is
such relevant evidence as a reasonable person would accept as adequate to support
a conclusion.” Crawford v. Comm’r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir.
2004). In making this evaluation, the Court may not “decide the facts anew,
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reweigh the evidence,” or substitute its judgment for that of the ALJ. Winschel v.
Comm’r of Soc. Sec. Admin., 631 F.3d 1176, 1178 (11th Cir. 2011) (internal
quotations and citation omitted). If the ALJ’s decision is supported by substantial
evidence, the Court “must affirm even if the evidence preponderates against the
Commissioner’s findings.” Costigan v. Comm’r, Soc. Sec. Admin., 603 Fed. Appx.
783, 786 (11th Cir. 2015) (citing Crawford, 363 F.3d at 1158).
With respect to the ALJ’s legal conclusions, the Court must determine
whether the ALJ applied the correct legal standards. If the Court finds an error in
the ALJ’s application of the law, or if the Court finds that the ALJ failed to provide
sufficient reasoning to demonstrate that the ALJ conducted a proper legal analysis,
then the Court must reverse the ALJ’s decision. Cornelius v. Sullivan, 936 F. 2d
1143, 1145-46 (11th Cir. 1991).
SUMMARY OF THE ALJ’S DECISION
To determine whether a claimant has proven that he is disabled, an ALJ
follows a five-step sequential evaluation process. The ALJ considers:
(1) whether the claimant is currently engaged in substantial gainful
activity; (2) whether the claimant has a severe impairment or
combination of impairments; (3) whether the impairment meets or
equals the severity of the specified impairments in the Listing of
Impairments; (4) based on a residual functional capacity (“RFC”)
assessment, whether the claimant can perform any of his or her past
relevant work despite the impairment; and (5) whether there are
significant numbers of jobs in the national economy that the claimant
can perform given the claimant’s RFC, age, education, and work
experience.
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Winschel, 631 F.3d at 1178.
The ALJ in this case found that Mr. Henderson has not engaged in
substantial gainful activity since January 13, 2010, the alleged disability onset date.
(Doc. 7-3, p. 24). The ALJ determined that Mr. Henderson suffers from the
following severe impairments: degenerative joint disease, status post total hip
arthropathy, degenerative disc disease, depression, post-traumatic stress disorder,
polysubstance abuse, and adjustment disorder. (Doc. 7-3, p. 24-25). The ALJ also
determined that Mr. Henderson suffers from hypertension, chronic bronchitis,
allergic sinusitis, chronic obstructive pulmonary disease, and furunculosis, but the
ALJ found that these impairments are not severe. (Doc. 7-3, p. 25). Based on his
examination of the medical evidence, the ALJ concluded that Mr. Henderson does
not have an impairment or combination of impairments that meets or medically
equals the severity of any of the impairments listed in 20 C.F.R. Part 404, Subpart
P, Appendix 1. (Doc. 7-3, p. 25).
The ALJ found that in light of his impairments, Mr. Henderson has the
residual functional capacity:
[t]o perform medium work as defined in 20 CFR 416.967(c) except
that he could never climb ladders, ropes, or scaffolds, occasionally
climb ramps or stairs. However, he can occasionally stoop, kneel,
crouch, crawl, and engage in activities requiring balance. He should
avoid concentrated exposure to extreme cold, heat, uneven or slippery
surfaces, extreme noise, and avoid all exposure to the operational
control of moving machinery and unprotected heights. His work is
limited to simple, routine, and repetitive tasks. He should work in a
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low stress environment, defined as having only occasional changes in
the work setting and he can only have occasional interaction with the
public and with coworkers.
(Doc. 7-3, p. 27). Based on this RFC, the ALJ determined that Mr. Henderson is
not able to perform his past relevant work as a garbage man, dishwasher, stocker,
and fishing lure maker. (Doc. 7-3, p. 34). Relying on testimony from a vocational
expert, the ALJ found that jobs exist in the national economy that Mr. Henderson
can perform, including hand packager, poultry worker, and assembler. (Doc. 7-3,
p. 35). Therefore, the ALJ concluded that Mr. Henderson is not disabled under the
Social Security Act. (Doc. 7-3, p. 35).
ANALYSIS
Mr. Henderson asks this Court to either reverse the ALJ’s decision or
remand the case for further consideration. (Doc. 9, p. 12). Mr. Henderson argues
that substantial evidence does not support the ALJ’s decision to give Dr. John
Neville’s opinion only modest weight. (Doc. 9, p. 8). Mr. Henderson highlights
information in his medical records that supports Dr. Neville’s opinion that Mr.
Henderson has “a ‘moderate to severely impaired’ ability to handle ordinary work
pressures, and a severely impaired ability to respond appropriately to co-workers.”
(Doc. 7-3, p. 29; see also Doc. 7-12, p. 70).
Dr. Neville is a one-time consultative state examiner. On April 29, 2010, he
conducted a psychological evaluation of Mr. Henderson.
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(Doc. 7-12, p. 68).

During his interview of Mr. Henderson, Dr. Neville asked Mr. Henderson a series
of questions designed to help Dr. Neville evaluate Mr. Henderson’s mental state.
(Doc. 7-12, p. 68-71). Dr. Neville also reviewed “[t]he medical evidence of record
provided by the DDS” and “considered [those findings] in the overall assessment”
of Mr. Henderson. (Doc. 7-12, p. 71). Based on Dr. Neville’s observations during
the evaluation and his review of the medical evidence of record, Dr. Neville
concluded that Mr. Henderson had impaired cognitive functioning, a conclusion
that the ALJ considered “largely consistent with the evidence.”
Doc. 7-12, pp. 70-71).

(Doc. 7-3, p. 33;

Dr. Neville reported that, “Mr. Henderson appeared

irritable and his mood was somewhat labile. Developing rapport with him was
difficult.” (Doc. 7-12, p. 70). Dr. Neville concluded that Mr. Henderson had a
“severely” impaired ability to respond to coworkers, and a “moderately to severely
impaired” ability to respond to work pressures. (Doc. 7-12, p. 71). The ALJ
concluded that Dr. Neville’s opinion about Mr. Henderson’s ability to respond to
coworkers and to work pressures was “inconsistent with the weight of the
evidence.” (Doc. 7-3, p. 33). Consequently, the ALJ gave this aspect of Dr.
Neville’s opinion only modest weight. (Doc. 7-3, p. 33).
An ALJ does not have to defer to the opinion of a one-time examining
physician, Crawford, 363 F.3d at 1160 (citing McSwain v. Bowen, 814 F.2d 617,
619 (11th Cir. 1987)), and an ALJ “may reject the opinion of any physician when
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the evidence supports a contrary conclusion.” McCloud v. Barnhart, 166 Fed.
Appx. 410, 418-19 (11th Cir. 2006). When explaining the weight given to a
medical opinion, an ALJ does not have to refer specifically “to each piece of
evidence in the record, but [the ALJ] must sufficiently explain the weight given to
‘obviously probative exhibits.’” Cooper v. Comm. of Social Sec., 521 Fed. Appx.
803, 808 (11th Cir. 2013) (quoting Cowart v. Schweiker, 662 F.2d 731, 735 (11th
Cir. 1981)). The ALJ’s decision should enable “the reviewing court to conclude
that the ALJ considered the claimant’s medical condition as a whole.” Lewen v.
Comm’r of Soc. Sec., 605 Fed. Appx. 967, 968 (11th Cir. 2015). If the record
viewed in its entirety indicates that the ALJ “focus[ed] upon one aspect of the
evidence and ignor[ed] other parts of the record,” then the reviewing court “cannot
properly find that the administrative decision is supported by substantial evidence.
It is not enough to discover a piece of evidence which supports that decision, but to
disregard other contrary evidence. The review must take into account and evaluate
the record as a whole.” McCruter v. Bowen, 791 F.2d 1544, 1548 (11th Cir. 1986).
In discounting Dr. Neville’s opinion regarding Mr. Henderson’s ability to
respond to co-workers and to handle ordinary work pressures, the ALJ
acknowledged that mental health treatment records that post-date Dr. Neville’s
report indicate that Mr. Henderson has “difficult[y] interacting with people” and
that “he ‘[d]istances himself’ from people.” (Doc. 7-3, p. 29). The ALJ found,
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though, that the weight of the evidence indicated that Mr. Henderson’s mental
health symptoms were not severe enough to be disabling. The ALJ noted that Mr.
Henderson has friends and a girlfriend, gets along well with his family members,
and is often pleasant and cooperative with medical personnel. (Doc. 7-3, p. 33). In
addition, the ALJ found that Mr. Henderson’s GAF scores in the range of mid 5060s indicated “moderate” to “mild” symptoms. (Doc. 7-3, p. 33). The ALJ stated
that Mr. Henderson “routinely denies psychotic symptoms and suicidal or
homicidal ideations,” and the ALJ cited a medical record from May 2011 that
states that Mr. Henderson had “‘only mild remaining depressive [symptom[s]],’
which are ‘related to stressors.’” (Doc. 7-3, p. 29). The ALJ concluded that Mr.
Henderson’s GAF scores combined with his ability to live independently suggest
that Mr. Henderson is able to handle stress and pressure at a basic level. (Doc. 7-3,
p. 33).
The ALJ’s opinion does not mention that a brief screening for depression in
January 2006 produced a positive result. (Doc. 7-12, p. 100). Mr. Henderson’s
primary care physician rendered an official diagnosis of depression in April 2010
(Doc. 7-12, pp. 26-28) and made a diagnosis of anxiety one year later. (Doc. 7-16,
p. 82). On April 16, 2010, the V.A. psychiatrist who Mr. Henderson visited noted
that Mr. Henderson complained that he had had trouble sleeping for the previous
seven-to-eight years. (Doc. 7-12, p. 27). Mr. Henderson reported that he slept 1-2
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hours per night while taking the insomnia medication Trazodone. (Doc. 7-12, p.
44). Since 2010, Mr. Henderson’s V.A. mental health records consistently have
reflected that Mr. Henderson sleeps only two-to-three hours per night, and he is
frequently awakened by nightmares. (Doc. 7-12, p. 27; Doc. 7-15, p. 29; Doc. 716, pp. 81, 84; Doc. 7-17, pp. 6, 17).
Information about Mr. Henderson’s nightmares appears frequently in his
mental health records. Mr. Henderson’s V.A. mental health treatment notes from
July 2011 describe Mr. Henderson as an individual suffering with depression and
PTSD who has related symptoms of “labile mood, irritab[ility], [and] overreactive, internalized rage.” The record states that Mr. Henderson was “withdrawn
and detached from others, guarded, [and] hypervigilant,” and he had “dreams and
nightmares that frequently interrupt his sleep.”

(Doc. 7-16, p. 51-52).

On

February 16, 2012, the V.A. psychiatrist who Mr. Henderson visited noted that Mr.
Henderson has a history of PTSD and depression and wrote that Mr. Henderson
“had nightmares in the past four days, about people trying to murder him and him
trying to defend himself. For the last two days, he woke up with his gun in his
hands.” (Doc. 7-17, p. 17; see also Doc. 7-17, p. 21). Mr. Henderson also reported
that he had flashbacks 2-3 times per day. (Doc. 7-17, p. 17).
Beyond the nightmares and flashbacks, Mr. Henderson has experienced
suicidal thoughts. On July 13, 2011, the V.A. psychiatric social worker who Mr.
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Henderson saw noted that Mr. Henderson has impulsive suicidal thoughts when he
feels like he “don’t care anymore.” (Doc. 7-16, p. 52). The February 2012
medical record indicates that Mr. Henderson tried to hurt or kill himself one year
earlier. (Doc. 7-17, p. 20; see also Doc. 7-17, p. 46). His suicide risk was
documented as “mild,” and he reported a “very supporting” romantic relationship.
(Doc. 7-17, pp. 17, 20). Still, virtually all of Mr. Henderson’s mental health
records reflect that V.A. psychiatrists and social workers routinely gave Mr.
Henderson instructions about steps to take if he began to feel hopeless or suicidal,
and Mr. Henderson reported that he relies on his faith when his thoughts become
hopeless. (Doc. 7-12, p. 29; Doc. 7-16, pp. 32, 52, 54, 84; Doc. 7-17, pp. 2, 7, 9,
20, 46).
Mr. Henderson’s mental health records reflect that he has difficulty
interacting with people. A V.A. record from July 15, 2010 states that Mr.
Henderson avoids all people because it seems to him that “‘everybody has it out
for [him].’” (Doc. 7-15, p. 29). On April 11, 2011, the psychiatric social worker
who Mr. Henderson visited reported that Mr. Henderson distances himself from all
people because “people just be aggravating.” (Doc. 7-13, p. 64). Mr. Henderson’s
February 2012 mental health record states that Mr. Henderson was struggling with
“a pervasive emotion of anger” which Mr. Henderson used as a defense
mechanism and that Mr. Henderson has a “generalized distrust of others.” (Doc. 710

17, p. 46). That record continues: “[Mr. Henderson has] some symptoms of PTSD
such as re-experiencing through dreams and intrusive memories; hyperarousal such
as irritability, anger, hypervigilance and distrust; avoidant traits such as
detachment and isolation, suppression of emotions except for anger. . . . [Mr.
Henderson] emphasized the need to be hypervigilant and to defend himself.”
(Doc. 7-17, p. 46).
With respect to Mr. Henderson’s ability to respond to coworkers, Mr.
Henderson reported to Dr. Neville that he stopped working in 2008 in part because
of conflicts with coworkers. (Doc. 7-12, p. 69). A V.A. record from April 2011
states that Mr. Henderson’s “[m]ain source of distress tolerance has been helping
his brother tend to his horses every other day . . .” (Doc. 7-13, p. 64). In addition, a
V.A. record from May 2011 states that Mr. Henderson had conflicts with his
brothers while he cared for his ailing father. (Doc. 7-15, p. 29). A record dated
November 2011 states that cognitively Mr. Henderson may get worse over time
absent efforts toward recovery from trauma. (Doc. 7-17, p. 46).
Mr. Henderson’s mental health records from the V.A. support Dr. Neville’s
opinion. Based on the ALJ’s decision, the Court cannot tell whether the ALJ fully
considered these mental health records or incorporated this information concerning
Mr. Henderson’s mental health at any stage of his analysis of Mr. Henderson’s
case. The ALJ did not state how much weight he gave to records from Mr.
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Henderson’s V.A. psychiatrists and psychiatric social workers. (Doc. 7-3, p. 2435). After reviewing the ALJ’s decision, this Court cannot conclude that the ALJ
considered the claimant’s medical condition as a whole. Therefore, the Court
remands the case to the ALJ to assess the weight to be given to Mr. Henderson’s
V.A. mental health records and the weight to be given to Dr. Neville’s opinion in
light of Mr. Henderson’s V.A. records. The Court finds no error in the ALJ’s
analysis of Mr. Henderson’s physical impairments.
CONCLUSION
For the reasons discussed above, the Court remands this action to the
Commissioner for further proceedings consistent with this memorandum opinion.
The Court will enter a separate final order.
DONE and ORDERED this August 31, 2015.

_________________________________
MADELINE HUGHES HAIKALA
UNITED STATES DISTRICT JUDGE

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