Adams v. Social Security Administration, Commissioner
MEMORANDUM OPINION as more fully set out in order. Signed by Magistrate Judge Harwell G Davis, III on 12/11/14. (SPT )
2014 Dec-11 PM 02:22
U.S. DISTRICT COURT
N.D. OF ALABAMA
UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF ALABAMA
COMMISSIONER, SOCIAL SECURITY
) Case No. 6:13-cv-01681-HGD
The parties have filed written consent and this action has been assigned to the
undersigned Magistrate Judge to conduct all proceedings and order the entry of
judgment in accordance with 28 U.S.C. § 636(c) and Fed.R.Civ.P. 73. (See Doc. 13).
Plaintiff, Jason Adams, filed an application for disability benefits on July 6, 2010.
He also filed a Title XVI application for supplemental security income that same date.
These claims were initially denied on October 19, 2010. Mr. Adams filed a request
for a hearing before an Administrative Law Judge (ALJ). He appeared and testified
at a hearing on November 17, 2011. Supplemental hearings were also held on March
Page 1 of 19
21 and July 6, 2012. Plaintiff was represented by attorney Don Bevill in these
On August 10, 2012, the ALJ issued an unfavorable decision finding plaintiff
was not entitled to disability benefits. Plaintiff requested further review by the
Appeals Council. The Appeals Counsel denied plaintiff’s request for review on
August 27, 2013. This case is now ripe for review under 42 U.S.C. §§ 405(g) and
1383(c)(3). Upon consideration of the administrative record and the memoranda of
the parties, the court finds that the decision of the Commissioner is due to be affirmed
and this action dismissed.
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. 20 C.F.R. § 404.1520(a)(4)(i). “Substantial work
activity” is work 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. § 404.1520(b). Second, the ALJ must determine whether the claimant has
a medically determinable impairment or a combination of medical 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.
Page 2 of 19
Id. Third, the ALJ must determine whether the claimant’s impairment meets or
medically equals the criteria 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 first must determine the claimant’s residual functional
capacity (RFC), which refers to the claimant’s ability to work despite his
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 deemed not disabled. Id. If the ALJ finds that the
claimant is 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 his RFC, age, education and work experience. 20 C.F.R.
§ 404.1520(g). Here, the burden of proof shifts from the claimant to the ALJ to prove
the existence in significant numbers of jobs in the national economy that the claimant
Page 3 of 19
can do given the RFC, age, education and work experience.
§§ 404.1520(g) and 404.1560(c).
At the time of the ALJ’s decision, plaintiff was 32 years old. (Tr. 259, 263).
He has a high school education and past relevant work as a logger, construction
laborer and landscape laborer. (Tr. 20, 45, 271-74, 295-97). He alleges the onset
date of his disability to have been September 1, 2009. (Tr. 259, 263). Plaintiff is 6'
tall and weighs 263 pounds.
The ALJ found that plaintiff has the severe impairments of bipolar I disorder,
opioid dependence with recurrent abuse, and degenerative disc disease of the lumbar
spine. (Tr. 11). He also has a number of non-severe impairments. (Tr. 11-14).
The ALJ also found that plaintiff did not suffer from certain impairments that
he claimed. For instance, plaintiff alleged that he had considerable limitations
associated with congestive heart failure that he alleges he was diagnosed in 2008.
However, at his September 2010 claims-related consultative examination, he admitted
to the examiner, Dr. Samia Moizauddin, M.D., that he has had numerous cardiac
evaluations, including cardiac catheterization, and that all results had been normal.
Plaintiff also alleged that he suffers from severe headaches. In October 2011,
he saw Dr. Lorn Miller, M.D., a neurology consultant, for evaluation of severe
Page 4 of 19
headaches with associated photophobia, phonophobis, osmophobia, nausea and
vomiting. (Ex. 13F). He told Dr. Miller that he had headaches with photophobia and
phonophobia as a teenager but that they occurred infrequently and were relieved with
Tylenol until age 21 when a tree fell on his head (in late 2000 or 2001). He reported
that he had been having headaches three to four times a week since the head injury
with no change in severity or frequency and that only Lortab was of any help.
The ALJ found that there was no evidence in plaintiff’s medical records to
support those reports. The ALJ noted that plaintiff did not report a history of
migraines or severe headaches when he saw Dr. Moizuddin in September 2010. (Ex.
5F). Also, the ALJ stated that plaintiff has been seeing his primary care physician,
Dr. Brasfield, once a month on average, since April 2007, and has consistently denied
headaches at those visits. Furthermore, the medical history of plaintiff as documented
by his primary care physician’s records do not include migraine headaches.
Plaintiff also reported to having seizures since a head injury he suffered in
1998, 2000 or 2001, in either, depending upon the account, a logging accident or a
motor vehicle accident. At his October 2011 neurology evaluation, plaintiff told Dr.
Miller that he began having seizures a short time after he sustained a severe head
injury from the falling trees. He also told Dr. Miller that he had three or four seizures
per year with the last one occurring in August 2011. However, in a report to
Page 5 of 19
emergency room personnel in July 2010, plaintiff stated that he had not had a seizure
since 2003. However, his testimony in this case is that he is currently suffering two
grand mal seizures a month. (Tr. 13). Furthermore, he advised Dr. Miller that he was
given Depakote for the seizures when they began, that he has taken the same 125 mg.
dosage, that this medicine manages the seizures well, and that he did not want any
other seizure medications. (Tr. 13).
Dr. Brasfield’s records reflect no reported history of seizure disorder and no
reports of seizure activity. Despite his claim of having been on Dekapote for over
five years, records reflect that plaintiff was not prescribed Dekapote until October 10,
2010, just ten days before he saw Dr. Miller. His psychiatrist, Dr. Armand Schachter,
M.D., prescribed the medication to plaintiff in answer to plaintiff’s complaints of
increased bipolar symptoms, not for seizures. The ALJ concluded that the record
evidence failed to establish this as a medically determinable seizure disorder. (Tr.
At the hearing, plaintiff also claimed that he was being treated for
schizophrenia. The ALJ found that the record evidence also failed to support this
claim. The ALJ noted that plaintiff has been treated at the Northwest Alabama
Mental Health Center off and on since 2003 and that those records reflect no
diagnosis of schizophrenia. Likewise, plaintiff has been evaluated by a number of
Page 6 of 19
other mental health professionals outside the Mental Health Center, and there is no
evidence that any of the examiners has observed any signs suggestive of
schizophrenia. Consequently, the ALJ found that the evidence failed to establish the
medically determinable impairment of schizophrenia. (Tr. 14).
While plaintiff attributes his alleged mental and physical disability to head and
back injuries, he has given inconsistent accounts regarding the injuries themselves as
well as how they occurred. According to the ALJ, the record evidence reflects that
plaintiff reported 1998, 2000 and 2001 as the year he sustained the injuries.
However, there is no reference to the incident(s) or injuries until July 2008 when he
was admitted to the hospital after overusing methadone, Lortab and Panax. (Exs. 17F
and 30F). Plaintiff told Kaycia Vansickle, M.D., that he had sustained a head injury,
multiple spinal and spinal cord injuries, and injuries to his hand, back and right knee
in a 1998 motor vehicle accident and had undergone multiple surgeries, including a
craniotomy. He presented in a wheelchair and reported that he had experienced
difficulty ambulating without assistance because of the accident.
Previously, when plaintiff saw Muhammad Ali, M.D., a neurologist, in June
2007, he reported no specific precipitating event for his pain and reported having had
only hand and right leg surgery. (Ex. 4F). Later, when admitted to Brookwood
Hospital’s Psychiatric floor in April 2010, plaintiff reported chronic pain from a 2001
Page 7 of 19
“crush” injury that required back, knee, hand and skull surgery and a 30-day hospital
stay, but he reported the injuries occurred when a tree fell on him while he was
logging. (Ex. lF). At his September 2010 consultative physical examination, plaintiff
reported that his back had been broken and the back of his skull crushed in 2001
when he was crushed between two trees and had subsequently had surgery on his
back and his right knee. (Ex. SF).
In addition, plaintiff told Dr. Jerry Gragg, Psy.D., that he had suffered a broken
back, a head injury, and a crushed right arm in a logging accident several years earlier
and had surgery on his back and knee. (Ex. 6F). He told Dr. Miller that he had
suffered severe injuries to his head, neck, back and right knee in 2000 when a tree fell
on his head while he was logging and that he had been hospitalized for 90 days. (Ex.
13F). He reported his other pertinent medical history as a left ACL repair, a fractured
right ankle, and a fractured left hand–all in the 1990s and the result of football
Records from Dr. Brasfield, plaintiff’s primary care physician since 2007,
include no references to back, head, neck or knee injuries until the July 2008
hospitalization. (Exs. 16F-18F). Thereafter, his notes reference the 1998 motor
vehicle accident as the causative factor for plaintiff’s pain, but there is no mention of
any logging accident in his treatment notes. Dr. Brasfield also adopted plaintiff’s
Page 8 of 19
account of having had back surgery–specifically, a laminectomy–following the
accident; however, objective tests show no evidence of surgery. In fact, those tests
reveal little evidence of a back impairment at all.
A February 2009 lumbar spine MRI showed degenerative disc disease and
multilevel disc bulges, worse at L5-Sl, but no significant central canal narrowing.
(Ex. 18F at 13). A July 2009 lumbar spine CT revealed no traumatic osseous
abnormality and found a widely patent canal, normal disc space and vertebral body
height throughout, and no malalignment. (Ex. 33F). Lumbar spine x-rays taken in
October 2010 were normal aside from mild chronic wedging in the thoracolumbar
junction and a mild rotary scoliotic deformity of the upper lumbar spine. (Ex. 7F).
A February 2012 lumbar spine MRI revealed only mild multi-level degenerative disc
disease. (Ex. 22F).
According to the ALJ, examinations support plaintiff’s allegations of a back
impairment but not the severe debility he alleges. Dr. Moizuddin’s examination was
remarkable for decreased lumbar range of motion, and Dr. Brasfield’s notes reflect
findings of 1+ or 2+ muscle spasms from time to time and positive straight leg raising
on occasion. Despite such findings, and the occasional right knee effusion, Dr.
Brasfield’s notes consistently find that plaintiff retains normal gait and station.
Physical examinations performed in emergency rooms and during hospitalizations
Page 9 of 19
have also been benign in terms of musculoskeletal complaints. Finally, as late as
October 2011, Dr. Miller found that plaintiff retains 5/5 muscle strength throughout
with no evidence of atrophy evidence–evidence that he has remained active
physically and inconsistent with his allegations of little to no physical activities.
The ALJ also noted that plaintiff’s work history further belies the severe
injuries he has alleged. His earnings record establishes that he was still working as
a logger as recently as 2006 and, as discussed above, ran his own lawn care business
into 2010. Based on plaintiff’s own report, he cut grass and used a weed eater in the
course of running that business.
The ALJ also found that the severity of depression and anxiety plaintiff alleges
is unsupported. There is no question that he has a significant history of mental health
treatment with multiple inpatient psychiatric stays; however, there is also no question
that his substance abuse and noncompliance has exacerbated the effects of the
affective and anxiety disorders reflected in those records. Even so, mental status
examination results as reflected in Northwest Alabama Mental Health Center records
fail to show the persistent severe depression and frequent panic attacks plaintiff
alleges and non-mental health examiners–including Dr. Brasfield–generally find his
mood and affect to be normal when he presents for treatment. According to the ALJ,
plaintiff’s rapid improvement during inpatient treatment once psychotropic
Page 10 of 19
medications are resumed is further evidence of the exacerbating role his
noncompliance plays. Although his record might suggest severe depression at first
glance, given the multiple inpatient stays and references to suicide attempts, plaintiff
vehemently denied any suicidal intent. Plaintiff replied that some overdoses were
accidental and has admitted to staging at least one alleged attempt to avoid being
As noted, plaintiff testified that he did not have to take pain medication, did not
have seizures, and did not have as many mental problems until he sustained severe
head trauma in a 2001 on-the-job accident. However, as noted above, plaintiff
previously reported that he began having headaches as a teenager. His records also
date his drug abuse to his teenage years and he has admitted that he was a “junkie”
who abused opiates and graduated to IV oxycontin well before 1998, the earliest date
he has provided for the motor vehicle accident or logging incident. His use of
methadone began as part of his substance abuse treatment, but he was discharged
from the treatment program due to his continued use of illicit drugs. (Ex. 1lF).
The ALJ also stated that he considered the limiting effects of plaintiff’s
degenerative disc disease and hypertension as well as the additional and cumulative
effects of his obesity and his non-severe impairments in finding that he is limited to
sedentary work activities. The effects of his bipolar disorder and anxiety disorder
Page 11 of 19
were considered by limiting him to simple, non-complex tasks. The ALJ found that
the evidence is not persuasive that work within these limitations would cause any
significant exacerbation of plaintiff’s physical or mental impairments so long as he
remains compliant in taking his medications as prescribed. According to the ALJ, his
allegations otherwise are not credible.
As for the opinion evidence, the ALJ stated that he accorded little evidence to
Dr. Brasfield’s opinions regarding diagnoses and the severity of plaintiff’s pain for
the lack of any objective evidence in support thereof. The ALJ accorded considerable
weight to Dr. Sylvia Colon’s opinions as reflected in her report of evaluation, as those
opinions are supp1ied by her mental status examination results and are consistent
with Mental Health Center records and Dr. Gragg’s earlier findings on evaluation.
However, little weight was accorded the medical source statement of plaintiff’s ability
to do work-related activities that Dr. Colon completed in conjunction with her report,
given the multiple inconsistencies between her responses and her findings on
evaluation set forth above. (Ex. 38F at Tr. 1064-66).
The ALJ also accorded great weight to Dr. Schachter’s opinions as reflected
in Mental Health Center records. Dr. Gragg based his opinion regarding plaintiff’s
diagnoses on a single visit. By nature, the signs of plaintiff’s bipolar disorder wax
and wane in intensity and, based on complete Mental Health Center records and the
Page 12 of 19
other evidence of record, his completely benign presentation on the day he saw Dr.
Gragg is atypical. On the other hand, despite the failure to consider the effects of
plaintiff’s bipolar disorder, Dr. Gragg’s assessment of plaintiff’s mental capabilities
is consistent with Mental Health Center and primary care physician records insofar
as plaintiff’s overall status when he is taking medications as prescribed and attending
counseling as recommended.
The ALJ accorded little weight to the opinion of Leslie Rodrigues, Ph.D., the
State agency psychological consultant, that plaintiff has no severe mental impairment
as it was based on an incomplete treatment record. (Ex. lOF). Mental Health Center
and other records in conjunction with medical expert testimony at the hearing were
persuasive that plaintiff’s affective disorder and anxiety cause more than minimal
limitations in his ability to perform work-related mental activities.
The ALJ accorded little weight to the opinions of plaintiff’s third party
informant as reflected at Exhibit 6E because the severity of limitation reflected was
inconsistent with the other evidence of record. The informant reported, for example,
that plaintiff must be reminded to eat, bathe and groom; that he cannot concentrate
well enough to drive; and that his back severely limits his ability to perform most
physical activities. However, mental status examination results from multiple
examiners show that plaintiff is able to perform personal care tasks independently and
Page 13 of 19
adequately and can maintain concentration sufficiently to perform simple tasks such
as driving, while the x-ray, CT and MRI results and findings on physical examination
noted above belie the significant physical limitations the informant describes.
In sum, the ALJ concluded that the RFC assessment was supported by
objective test results, findings on examination by treating and examining providers,
and plaintiff’s overall presentation and history. (Tr. 11-20).
After a consideration of all the testimony and evidence submitted, the ALJ
found that plaintiff has the RFC to perform sedentary level work that is unskilled and
involves simple, not detailed instructions. (Tr. 17). Relying on testimony from a
vocational expert (VE), the ALJ concluded that plaintiff is able to perform jobs
available in the economy in significant numbers. (Tr. 21).
On appeal, plaintiff challenges the ALJ’s decision only with respect to his
evaluation of the report of consultative examiner Dr. Sylvia Colon. (Tr. 16-17, 19,
1063-71). See Doc. 14, Plaintiff’s Brief, at 11-15. In essence, plaintiff asserts that
the ALJ disregarded Dr. Colon’s rating of plaintiff as having marked impairments in
understanding, remembering and carrying out detailed instructions. (Tr. 1064). She
also noted that plaintiff would have marked difficulties in responding appropriately
to work pressure and to changes in a routine work setting due to his bipolar disorder.
Page 14 of 19
In particular, plaintiff challenges the fact that the ALJ gave little weight to Dr.
Colon’s medical source statement because of “multiple inconsistencies between her
responses and her findings on evaluations.” (Tr. 19). Plaintiff asserts that the ALJ
failed to specify or discuss any of the alleged inconsistencies between Dr. Colon’s
responses to the disability questionnaire and her other narrative reports. (Doc. 14,
Plaintiff’s Brief, at 13).
In evaluating medical opinions, the ALJ considers many factors, including the
examining relationship, the treatment relationship, whether an opinion is amply
supported, whether an opinion is consistent with the record and the doctor’s
specialization. See 20 C.F.R. §§ 404.1527(d) and 416.927(d). Generally, the more
consistent a physician’s opinion is with the record as a whole, the more weight an
ALJ should place on that opinion. Id. §§ 404.1527(d)(4) and 416.927(d)(4).
A review of Dr. Colon’s report supports the findings of the ALJ. In the
medical source statement regarding plaintiff’s ability to do work-related activities, Dr.
Colon noted that plaintiff had moderate restrictions in his ability to understand and
remember short, simple instructions, carry out simple instructions and make
judgments on simple work-related decisions. She further noted marked restrictions
in his ability to understand and remember detailed instructions and to carry out
Page 15 of 19
detailed instructions. (Tr. 1064). She also found that plaintiff had moderate difficulty
in interacting with the public, supervisors and co-workers. She found that he had
marked difficulties in responding to work pressures in a usual work setting and to
changes in a routine work setting. (Tr. 1065). In addition, Dr. Colon noted that
plaintiff could not manage benefits in his own best interests due to his difficulties
with tasks and making decisions. (Tr. 1066).
In contrast, during her examination of plaintiff, Dr. Colon established that
plaintiff’s immediate, recent and past memories were intact. (Tr. 16, 1069). She also
noted that his ability to engage in abstract thinking was intact and that his judgment
and insight were good. She stated that he had good control of his symptoms with
medication. (Tr. 1070). During testing, plaintiff was able to complete three-step
commands with some prompting. Dr. Colon observed that plaintiff tended to
exaggerate his difficulties with certain tasks. (Tr. 16, 1069-70). She stated that “[i]t
is difficult to appropriately assess if he is able to handle funds. During the interview
he seems to exaggerate difficulties doing specific tasks. With prompting he is able
to do such tasks.” (Tr. 1071). Neither Dr. Gragg nor Dr. Colon observed any
evidence suggesting that plaintiff was experiencing increased anxiety at the
consultative examinations despite undergoing testing by strangers in an unfamiliar
setting. (Tr. 17). Dr. Colon also observed that plaintiff had a pleasant attitude, good
Page 16 of 19
eye contact, normal speech, and no psychomotor retardation or agitation or tic
gestures. (Tr. 1069).
The ALJ gave considerable weight to Dr. Colon’s opinions reflected in her
interview report. He explained that the opinions in her report are supported by her
examination results and consistent with the earlier findings of consultative examiner
Dr. Gragg, as well as treatment records from the Northwest Alabama Mental Health
According to Dr. Gragg, plaintiff’s presentation was”completely benign,” and
his anxiety and depression appeared to be reasonably controlled. (Tr. 19, 441-43).
In addition, the examination findings in plaintiff’s Mental Health Center treatment
records, including those of treating psychiatrist Dr. Armand Schachter, which the ALJ
gave great weight, failed to show the persistent severe depression or frequent panic
attacks which plaintiff alleged. (Tr. 18-19).
Furthermore, as noted above, Dr. Brasfield generally found plaintiff’s mood
and affect to be normal. (Tr. 18). The ALJ explained that plaintiff’s improvement
was rapid during inpatient treatment because it had been caused by unintentional
medication overdose. (Tr. 18-19). Consequently, substantial evidence supports the
ALJ’s decision to afford considerable weight to Dr. Colon’s examination report while
giving little weight to her medical source statement.
Page 17 of 19
The ALJ was not required to adopt the limitations Dr. Colon indicated in her
medical source statement. During the interview, Dr. Colon noted that plaintiff was
able to complete three-step commands with prompting and had no memory deficits,
and she indicated that he could “perform simple instructions and labor.” In the
medical source statement, she indicated that plaintiff had moderate limitations in
remembering and carrying out short, simple instructions.
During her examination, Dr. Colon observed that plaintiff exhibited good
insight and judgment. In the medical source statement, she found that plaintiff had
moderately limited abilities to make judgments on simple work-related decisions.
She also indicated in her examination that plaintiff exhibited good insight and
judgment, yet in her medical source statement, she found him to be moderately
limited in his ability to make judgments on simple work-related decisions.
Finally, Dr. Colon stated that plaintiff had marked limitations in responding
appropriately to work pressure and changes. This conflicts with her determination
that plaintiff had good control of his symptoms with medication. (Tr. 1070). The
only support that she gives for any of her findings in the medical source statement
was “bipolar disorder.” (Tr. 1064-65).
Dr. Colon’s conflicting interview findings and the medical source statement
support the ALJ’s decision to discount the medical source statement. See 20 C.F.R.
Page 18 of 19
§§ 404.1527(c)(3) and (4), 416.927(c)(3) and (4). Although plaintiff is unhappy that
the ALJ failed to have a medical expert evaluate Dr. Colon’s report, this is not
necessary where, as here, the evidence is sufficient to support the ALJ’s
determination. See Wilson v. Apfel, 179 F.3d 1276, 1278 (11th Cir. 1999).
For the foregoing reasons, substantial evidence supports the ALJ’s
determination that plaintiff is not disabled. This determination is in accord with
applicable law. Therefore, the decision of the Administrative Law Judge is due to be
affirmed. A separate order will be entered.
DONE this 11th day of December, 2014.
HARWELL G. DAVIS, III
UNITED STATES MAGISTRATE JUDGE
Page 19 of 19
Disclaimer: Justia Dockets & Filings provides public litigation records from the federal appellate and district courts. These filings and docket sheets should not be considered findings of fact or liability, nor do they necessarily reflect the view of Justia.
Why Is My Information Online?