Williams v. Social Security Administration, Commissioner

Filing 11

MEMORANDUM OF DECISION. Signed by Judge R David Proctor on 1/6/2016. (AVC)

FILED
2016 Jan-06 PM 01:56
U.S. DISTRICT COURT
N.D. OF ALABAMA

IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
SOUTHERN DIVISION
RHONDA LAINE WILLIAMS,
Plaintiff,
v.
CAROLYN W. COLVIN,
Acting Commissioner of Social Security

Defendant.

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Case No. 2:14-cv-01760-RDP

MEMORANDUM OF DECISION
Plaintiff Rhonda Laine Williams brings this action pursuant to Sections 205(g) and
1631(c)(3) of the Social Security Act (the “Act”), seeking review of the decision of the
Commissioner of Social Security (“Commissioner”) denying her claims for a period of disability,
disability insurance benefits (“DIB”), and Supplemental Security Income (“SSI”). See 42 U.S.C.
§§ 405(g) and 1383(c). Based on the court’s review of the record and the briefs submitted by the
parties, the court finds that the decision of the Commissioner is due to be affirmed.
I.

Proceedings Below
Plaintiff filed her applications for disability, DIB, and SSI on March 3, 2011 in which she

alleged that disability began December 1, 2010. (R. 165-74). Plaintiff’s applications were
initially denied by the Social Security Administration on June 24, 2011. (R. 70). Plaintiff then
requested a hearing before an Administrative Law Judge. Plaintiff’s request was granted and a
hearing was held before Administrative Law Judge Paul W. Johnson (“ALJ”) on January 7,
2013. (R. 28-65).
The ALJ’s decision, dated January 29, 2013, found that Plaintiff had not been under a
disability within the meaning of the Act since the date of her alleged onset date. (R. 22). See 20

C.F.R. §§ 404.1520(g), 416.920(g). The ALJ found that Plaintiff had the following severe
impairments: (1) Status Post Remote Subacute Infarcts of the Right Brain; (2) Hypertension; (3)
Major Depression; (4) Cluster B Personality Features; (5) Alcohol dependence, in remission; and
(6) Iron and B-Vitamin Deficiency, Status Post Gastric Bypass. (R. 14). However, the ALJ
concluded that Plaintiff did not have an impairment or a combination of impairments that met or
medically equaled the severity of the listed impairments in 20 C.F.R. Part 404, Subpart P,
Appendix 1. (R. 15-16).
Plaintiff appealed the ALJ’s decision to the Appeals Council. (R. 6). The Appeals
Council denied Plaintiff’s request for review, thereby making the decision the final decision of
the Commissioner and a proper subject of this court’s appellate review. (R. 1).
II.

Facts
Plaintiff was 42 years old at the time of the hearing. (R. 57). Plaintiff testified that she

had completed high school and had taken some college courses. (R. 58). Plaintiff’s work history
includes employment in the service industry and clerical work in the trucking industry. (R. 21118). In the service industry, Plaintiff worked as a waitress, cook, and bartender. (R. 211). In the
trucking industry, Plaintiff calculated fuel taxes, prepared logs and reports, and entered mileage
records. (R. 215-17). Plaintiff alleges she has difficulty concentrating and states that she can no
longer carry out her previous employment duties. (R. 218).
Plaintiff contends that her disability began on December 1, 2010, and was caused by (1)
mental problems and (2) a stroke which lead to numbness in her left hand. (R. 165, 169, 202).
In addition to her mental issues, Plaintiff also complains of constant headaches, alleged to be a
result of her stroke. (R. 37, 387, 392, 404). During the hearing, Plaintiff testified she had had a
headache for nine months straight. (R. 37). Plaintiff further testified that her headaches would

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sometimes be so severe as to prevent her from getting out of bed, and that she would typically be
bedridden four out of five days. (R. 42, 43).
Plaintiff was diagnosed with morbid obesity in early 2004 and underwent gastric bypass
surgery on February 4, 2004. (R. 267-70). Dr. Clifford Black performed the gastric bypass
procedure. (R. 267). In addition to morbid obesity, Dr. Black also diagnosed Plaintiff with
depression and hypertension. (R. 268).
Plaintiff was admitted to Stringfellow Memorial Hospital (“SMH”) in May 2008 for
suicidal thoughts and anemia. She was treated by Dr. Lloyd James. (R. 307-314). Dr. James
noted that Plaintiff has experienced chronic iron deficiency since the date of her gastric bypass
surgery and had been noncompliant with seeing a physician for the past several years. (R. 307).
Dr. James further noted that Plaintiff had previously taken Celexa for depression, but was unable
to determine why Plaintiff had stopped taking the medication. (R. 307-08). Upon discharge
from SMH on May 12, 2008, Plaintiff was prescribed iron sulfate, Bactrim, Cardizem, Lortab,
Celexa, and Diflucan. (Id.). Plaintiff was again admitted to SMH in June 2008 following
complaints of generalized weakness. (R. 287). At SMH, it was determined that Plaintiff’s
symptoms were exacerbated by anemia. (Id.).
Plaintiff was treated at the Cheaha Mental Health Center (“CMHC”) from February 2008
to March 2010. (R. 380-83). Plaintiff was diagnosed with major depressive disorder, alcohol
dependence, and a personality disorder. (R. 383). Plaintiff was assessed a Global Assessment of
Functioning (“GAF”) score of 50 by CMHC. (Id.). While at CMHC, the goals of Plaintiff’s
treatment were to decrease and control her symptoms of depression. (Id.). CMHC noted that a
barrier to achieving this goal was Plaintiff’s history of non-compliance with treatment. (Id.).

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Plaintiff was admitted to Citizens Baptist Medical Center (“CBMC”) on December 20,
2010, where she complained of a headache that had lasted for three months. (R. 387). The
clinical impression was that Plaintiff had experienced subacute infarcts. (R. 388). CBMC noted
Plaintiff’s history of unilateral and extremity numbness. (R. 389). Plaintiff had a CT scan
performed while at CBMC, which found evidence of remote infarctions. (R. 392). The CT scan
further found no convincing evidence of acute intracranial process. (R. 392).
Dr. Renee Myers, a psychological consultative examiner, conducted an evaluation of
Plaintiff on May 20, 2011. (R. 397-400). Dr. Myers’ assessment included: (1) major depression,
recurrent; (2) cluster B personality features; and (3) a GAF score of 60. (R. 400). However, Dr.
Myers concluded that Plaintiff had been able to work despite these issues in the past, and
concluded her left hand was the primary factor affecting her ability to work. (R. 400).
Dr. Ledet, a physical consultative examiner for the Alabama disability office, found that
Plaintiff was positive for a previous history of stroke during an examination dated May 21, 2011.
(R. 402-04). Additionally, Dr. Ledet noted that Plaintiff’s left-hand grip strength was weaker
than her right hand, measuring at 3/5. (R. 405). As indicated in a Disability Report, Plaintiff
reported that the issue with her hand had progressively gotten worse over time, and claimed that
she “can’t hold anything anymore.” (R. 235).
Dr. Robert Heilpern conducted a physical residual functional capacity (“RFC”)
assessment of Plaintiff on June 24, 2011. (R. 424-31). Dr. Heilpern’s primary diagnosis was
remote subacute infarcts of the right brain, with a secondary diagnosis of hypertension. (R. 424).
Dr. Heilpern found that Plaintiff could sit or stand for six hours in a typical workday. (R. 425).
Dr. Heilpern concluded that Plaintiff’s allegations of problems with lifting, completing tasks, and
using her hands were only partially credible. (R. 429). But Dr. Heilpern noted that Plaintiff’s

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limitations prevented her from ever climbing a ladder and that she should only occasionally be
required to crawl. (R. 426). Dr. Heilpern further noted that Plaintiff was limited in gross
manipulation and fine manipulation with her hands, but was only limited with her left hand. (R.
427). Plaintiff’s grip strength was measured at 5/5 with her right hand, and 3/5 with her left
hand. (R. 427). Dr. Heilpern noted that Plaintiff had difficulty picking up small objects and
buttoning garments with her left hand, but reported that sensation was intact. (R. 427).
Dr. Robert Estock conducted a mental RFC assessment on Plaintiff the same day. (R.
432-35). Dr. Estock evaluated Plaintiff in the areas of understanding and memory, sustained
concentration and persistence, social interaction, and adaptation. Dr. Estock concluded that
Plaintiff had moderate limitations in ten out of twenty mental activities. (R. 432-33). Dr. Estock
further concluded that Plaintiff had no significant limitations in the other ten mental activities.
(R. 432-33). Dr. Estock’s functional capacity assessment was that Plaintiff could understand and
remember simple instructions, and could attend and concentrate on simple tasks for two hour
periods during a regular work day. (R. 434). Dr. Estock noted that Plaintiff may miss one to
two days per month due to symptoms of major depressive disorder, could have casual contact
with the public, and that workplace changes should be infrequent and gradually introduced. (R.
434).
Plaintiff was hospitalized again at SMH in September 2012. She presented with chest
pain and headaches as her main complaints. (R. 468). Plaintiff was diagnosed with anemia. (R.
468). The physician who evaluated Plaintiff, Dr. Muzamil Babiker, concluded that Plaintiff’s
anemia was most likely caused by her previous gastric bypass surgery. (R. 471). Plaintiff had a
CT scan performed while hospitalized at SMH, with findings consistent with old strokes. (R.
468).

Plaintiff also had an MRI and MRA performed, with findings that were fairly

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unremarkable. (R. 468). Dr. Babiker noted that Plaintiff was not taking any medication at the
time of hospitalization. (R. 468). The discharge diagnoses included persistent headache, a
history of cerebrovascular accident, hypertension, and deficiencies in iron and vitamin B12. (R.
468).

Upon discharge, Plaintiff received prescriptions for B12 pills, iron, blood pressure

medication, and Fioricet for her headaches. (R. 468).
In treatment notes from Plaintiff’s September 2012 hospitalization at SMH, Dr. Babiker
noted that Plaintiff resided in rehabilitation. (R. 468). Plaintiff stated during the hearing that the
Fioricet was effective at treating her headaches, but that she had not taken the medication while
in rehab because the facility prohibited its usage. (R. 44-45). Plaintiff indicated that she would
be willing to continue treatment of her headaches with Fioricet after she was released from the
rehab facility. (R. 44, 45).
During the hearing, Dr. Michael McClanahan testified as the vocational expert (“VE”).
(R. 55-64). The VE classified Plaintiff’s past work as server, short order cook, payroll clerk, and
receptionist. (R. 56-57). The VE stated that Plaintiff would be unable to find employment in her
former capacity in those four job areas. (R. 58). However, the VE testified that there would be
other jobs available to Plaintiff, which included employment as a stock checker, bakery worker,
or hand presser. (R. 58-61). Thus, while finding that Plaintiff would not be able to engage in her
past relevant work, the ALJ found that there were significant numbers of jobs available that
Plaintiff would be able to perform. (R. 20-21). Based on this testimony, the ALJ concluded that
Plaintiff was not disabled because she would be able to successfully find work in other areas of
employment. (R. 21).
III.

ALJ Decision
Disability under the Act is determined under a five-step test. 20 C.F.R. § 404.1520.

First, the ALJ must determine whether the claimant is engaging in substantial gainful activity.
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20 C.F.R. § 404.1520(a)(4)(i). “Substantial work activity” is work activity that involves doing
significant physical or mental activities. 20 C.F.R. § 404.1572(a). “Gainful work activity” is
work that is done for pay or profit. 20 C.F.R. § 404.1572(b). If the ALJ finds that the claimant
engages in substantial gainful activity, then the claimant cannot claim disability. 20 C.F.R. §
404.1520(b).
Second, the ALJ must determine whether the claimant has a medically determinable
impairment or a combination of impairments that significantly limits the claimant’s ability to
perform basic work activities. 20 C.F.R. § 404.1520(a)(4)(ii). Absent such impairment, the
claimant may not claim disability. Id. Third, the ALJ must determine whether the claimant’s
impairment meets or medically equals the criteria of an impairment listed in 20 C.F.R. § 404,
Subpart P, Appendix 1. See 20 C.F.R. §§ 404.1520(d), 404.1525, and 404.1526. If such criteria
are met, the claimant is declared disabled. 20 C.F.R. § 404.1520(a)(4)(iii).
If the claimant does not fulfill the requirements necessary to be declared disabled under
the third step, the ALJ may still find disability under the next two steps of the analysis. The ALJ
must first determine the claimant’s residual functional capacity (“RFC”), which refers to the
claimant’s ability to work despite her impairments. 20 C.F.R. § 404.1520(e). In the fourth step,
the ALJ determines whether the claimant has the RFC to perform past relevant work. 20 C.F.R.
§ 404.1520(a)(4)(iv). If the claimant is determined to be capable of performing past relevant
work, then the claimant is not disabled. Id. If the ALJ finds the claimant unable to perform past
relevant work, then the analysis proceeds to the fifth and final step.

20 C.F.R. §

404.1520(a)(4)(v). In the last part of the analysis, the ALJ must determine whether the claimant
is able to perform any other work commensurate with her RFC, age, education, and work
experience. 20 C.F.R. § 404.1520(g). Here, the burden of proof shifts from the claimant to the

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ALJ to prove the existence, in significant numbers, of jobs in the national economy that the
claimant can do given her RFC, age, education, and work experience. 20 C.F.R. §§ 404.1520(g),
404.1560(c).
IV.

Plaintiff’s Argument for Reversal
Plaintiff presents one argument in support of reversing the decision of the ALJ in denying

disability. (Pl.’s Mem. at 5-11). She contends that the ALJ committed reversible error by failing
to properly consider her symptoms according to the requirements of the Eleventh Circuit’s threepart pain standard. (Pl.’s Mem. at 5-11).
V.

Standard of Review
The only issues before this court are whether the record reveals substantial evidence to

sustain the ALJ’s decision, see 42 U.S.C. § 405(g); Walden v. Schweiker, 672 F.2d 835, 838
(11th Cir. 1982), and whether the correct legal standards were applied. See Lamb v. Bowen, 847
F.2d 698, 701 (11th Cir. 1988); Chester v. Bowen, 792 F.2d 129, 131 (11th Cir. 1986). Title 42
U.S.C. § 405(g) mandates that the Commissioner’s findings are conclusive if supported by
“substantial evidence.” Martin v. Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990). The district
court may not reconsider the facts, reevaluate the evidence, or substitute its judgment for that of
the Commissioner; instead, it must review the final decision as a whole and determine if the
decision is reasonable and supported by substantial evidence. See Id. (citing Bloodsworth v.
Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983)).
Substantial evidence falls somewhere between a scintilla and a preponderance of
evidence; “[i]t is such relevant evidence as a reasonable person would accept as adequate to
support a conclusion.” Martin, 894 F.2d at 1529 (quoting Bloodsworth, 703 F.2d at 1239)(other
citations omitted). If supported by substantial evidence, the Commissioner’s factual findings
must be affirmed even if the evidence preponderates against the Commissioner’s findings. See
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Martin, 894 F.2d at 1529. While the court acknowledges that judicial review of the ALJ’s
findings is limited in scope, the court also notes that review “does not yield automatic
affirmance.” Lamb, 847 F.2d at 701.
VI.

Discussion
Plaintiff argues that the ALJ committed reversible error by failing to apply the three-part

pain standard as required by the Eleventh Circuit. 1 (Pl.’s Mem. at 5-11). Plaintiff claims that the
ALJ erred by failing to “consider and develop the evidence of record.” (Pl.’s Mem. 9). It is
Plaintiff’s position that she should have been found disabled based on her documented medical
symptoms, and that the decision of the Commissioner is not based upon substantial evidence.
(Pl.’s Mem. 10). Plaintiff requests that this court reverse the ALJ’s decision and grant her
benefits. In the alternative, Plaintiff requests her case be remanded to the ALJ for consideration
of the record, which was bolstered by additional evidence. (Pl.’s Mem. 11).
The Eleventh Circuit requires that the above mentioned three-part pain standard be
applied where a claimant attempts to establish disability through her own testimony of pain or
other subjective symptoms. Holt v. Sullivan, 921 F.2d. 1221, 1223 (11th Cir. 1991). The first
requirement of the test is that evidence of an underlying medical condition exists. Id. at 1223.
Following this step, the next requirements can be interchanged. Id. A claimant must either
establish that there is objective medical evidence confirming the severity of the alleged pain from
that condition or that there is an objectively determined medical condition of such severity that it
can reasonably be expected to cause the alleged pain. Id.

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Plaintiff bolsters her argument with Social Security Ruling 96-7p. (Pl.’s Mem. at 5). This ruling requires
that an ALJ first consider whether there is an underlying medically determinable physical or mental impairment that
could reasonably be expected to produce the claimant’s pain or other symptoms. The ALJ must next evaluate the
intensity, persistence, and limiting effects of the claimant’s symptoms to determine the extent to which they limit the
claimant’s functioning.

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There are only two questions that this court must answer in connection with this issue:
whether the decision of the Commissioner is supported by substantial evidence and whether the
correct legal standards were applied. See 42 U.S.C. § 405(g); Lamb v. Bowen, 847 F.2d 698, 701
(11th Cir. 1988). After careful review of the record and the briefs submitted by the parties, the
court finds that the ALJ’s decision was supported by substantial evidence and the correct legal
standards were applied.
In applying for benefits from the Social Security Administration, the burden falls upon a
claimant to prove disability. See 20 C.F.R. §§ 404.1512(a), 416.912(a). The ALJ found that
Plaintiff suffers from several severe impairments, but that her impairments, considered singly
and in combination, do not meet or medically equal the listed impairments in 20 C.F.R. Part 404,
Subpart P, Appendix 1. (R. 14, 15). The ALJ outlined the two-step process required to consider
Plaintiff’s symptoms. (R. 17). The first step was to determine whether there is an underlying
medically determinable physical or mental impairment that could reasonably be expected to
produce Plaintiff’s pain or symptoms; the next step was to evaluate the intensity, persistence, and
limiting effects of Plaintiff’s symptoms to determine the extent to which they limit her
functioning. (R. 17).
Plaintiff contends that the pain standard does not require objective proof of the pain itself.
(Pl.’s Mem. 6). “While both the regulations and the [three-part pain standard] require objective
medical evidence of a condition that could reasonably be expected to cause the pain alleged,
neither requires objective proof of the pain itself.” Elam v. Railroad Retirement Board, 921 F.2d
1210, 1215 (11th Cir. 1991). The court agrees but that does not fully address what an ALJ is
required to determine. A claimant must also provide “objective medical evidence of a condition

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that could reasonably be expected to cause the pain alleged . . . .” Id. In other words, Plaintiff
must put forward sufficient evidence that the alleged condition could cause the pain at issue.
An ALJ is not required to explicitly articulate the pain standard; it is enough if the
language of the ALJ’s opinion indicates that the standard was applied. Davis v. Barnhart, 153
Fed. Appx. 569, 572 (11th Cir. 2005) (stating that an ALJ’s statement may indicate the
application of the pain standard where not explicitly mentioned). Of course, when an ALJ
discredits a claimant’s testimony, he must sufficiently articulate the reasons for doing so,
supported by substantial evidence. Id.
In this case, the ALJ found that the medical evidence did not support Plaintiff’s alleged
limitations with her left hand and the severity of other impairments. (R. 17). Furthermore, the
ALJ found that Plaintiff’s allegations were not credible to the extent they were inconsistent with
her RFC. (R. 19). The court agrees. Dr. Heilpern’s physical RFC assessment found that
Plaintiff’s alleged problems with lifting, completing her tasks, and using her hands were partially
credible. (R. 429). Dr. Heilpern noted that a physical examination of Plaintiff in December
2010 found normal neurological signs and that Plaintiff had a full range of motion in her
extremities. (Id.). Dr. Heilpern further noted that a consultative examination of Plaintiff in May
2011 had normal findings with the exception of a decrease in grip strength in Plaintiff’s left
hand.

(Id.).

Dr. Estock’s mental RFC assessment similarly found that Plaintiff was not

significantly limited in ten evaluated mental activities, finding that Plaintiff could understand,
remember, and carry out simple instructions. (R. 434).
Plaintiff alleged that the limitations involving her left hand had worsened to the point of
total paralysis of the hand. (R. 33). But to the contrary, Plaintiff had a CT scan performed at
Citizens Baptist Medical Center in December 2010, and that CT scan found remote infarction

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changes, but no convincing evidence for acute intracranial process. (R. 392). The ALJ also
noted that Plaintiff testified at the hearing that she had participated in chores while a resident at
the rehabilitation center, such as cleaning, cooking, and making her bed. (R. 40-41).
To be sure, the examination by Dr. Johnathan Ledet revealed that Plaintiff did have some
difficulties using her left hand. (R. 405). Dr. Ledet’s examination, conducted May 21, 2011,
found that Plaintiff’s left hand grip strength had been decreased to 3/5. (R. 405). Dr. Ledet also
noted that Plaintiff’s right hand was the dominant extremity. (R. 406). The medical evidence
shows that Plaintiff was treated for headache at Stringfellow Hospital. (R. 468). While at
Stringfellow, Plaintiff had a CT scan, MRI, and a MRA of her head completed. (R. 518-20).
Neither the CT scan nor the MRI revealed an acute intracranial finding, only showing signs of a
past stroke. (R. 518, 519). The results of the MRA were reported as “otherwise unremarkable.”
(R. 520).
Plaintiff also argues that the ALJ did not consider her history of depression. (Pl.’s Mem.
7). However, the ALJ relied upon the findings of a psychological consultative examiner, Dr.
Renee Myers, who found that Plaintiff did indeed suffer from depression. (R. 18, 20, 397-400).
In addition, Dr. Myers noted that Plaintiff had worked in spite of these limitations in the past,
stating that “[Plaintiff’s] problems with her hand are the primary limiting factor for current
employment.” (R. 400). The ALJ also noted that Plaintiff was not then undergoing therapy or
counseling for her depressive symptoms. (R. 19). Plaintiff testified at the hearing that the
medication was effective in treating the symptoms she complains of. (R. 39, 44).
VII.

Conclusion
The court concludes that the ALJ’s determination that Plaintiff is not disabled is

supported by substantial evidence and proper legal standards were applied in reaching this

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determination. The Commissioner’s final decision is therefore due to be affirmed, and a separate
order in accordance with this memorandum of decision will be entered.
DONE and ORDERED this January 6, 2016.

_________________________________
R. DAVID PROCTOR
UNITED STATES DISTRICT JUDGE

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