Armstrong v. Social Security Administration, Commissioner

Filing 12

MEMORANDUM OPINION AND ORDER DISMISSING CASE that the decision of the Commissioner is REVERSED and this action is REMANDED to the Commissioner of the Social Security Administration for further proceedings consistent with this memorandum opinion and order as more fully set out in order. Signed by Judge C Lynwood Smith, Jr on 12/21/2015. (AHI)

FILED
2015 Dec-21 AM 09:29
U.S. DISTRICT COURT
N.D. OF ALABAMA

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF ALABAMA
WESTERN DIVISION
NICOLE ARMSTRONG,
Claimant,
vs.
CAROLYN W. COLVIN, Acting
Commissioner, Social Security
Administration,
Defendant.

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Civil Action No. 6:15-cv-309-CLS

MEMORANDUM OPINION AND ORDER OF REMAND
Claimant, Nicole Armstrong, commenced this action on February 20, 2015,
pursuant to 42 U.S.C. § 405(g), seeking judicial review of a final adverse decision of
the Commissioner, affirming the decision of the Administrative Law Judge (“ALJ”),
and thereby denying her claim for a period of disability, disability insurance, and
supplementary security income benefits. For the reasons stated herein, the court finds
that the Commissioner’s ruling is due to be reversed, and this case remanded to the
Commissioner for further proceedings.
The court’s role in reviewing claims brought under the Social Security Act is
a narrow one. The scope of review is limited to determining whether there is
substantial evidence in the record as a whole to support the findings of the
Commissioner, and whether correct legal standards were applied. See Lamb v.

Bowen, 847 F.2d 698, 701 (11th Cir. 1988); Tieniber v. Heckler, 720 F.2d 1251, 1253
(11th Cir. 1983).
Claimant contends that the Commissioner’s decision is neither supported by
substantial evidence nor in accordance with applicable legal standards. Specifically,
claimant asserts that the ALJ failed to consider her depression to be “severe” under
the meaning of the Social Security Act, improperly considered her subjective
complaints of pain, failed to consider all of her impairments in combination, and
failed to fully and fairly develop the administrative record. Upon review of the
record, the court finds merit in claimant’s first argument.
A “severe” impairment as one that “significantly limits [a claimant’s] physical
or mental ability to do basic work activities.” 20 C.F.R. § 404.1520(c) (alteration
supplied). The ALJ found that claimant’s depression was not severe because it did
not cause “more than minimal work-related limitations.”1 According to the ALJ,
claimant had only mild restriction of activities of daily living; mild difficulties in
maintaining social functioning; mild difficulties in maintaining concentration,
persistence, and pace; and no episodes of decompensation. The ALJ also stated:
The fact that claimant’s depression is non-severe is confirmed by
the objective medical evidence of record, which shows that her
depression is well controlled with medications . . . . Furthermore, the
1

Tr. 11.

2

claimant has lived alone for the past two years and has performed all of
her own household chores. She requires no assistance to run her
household, as evidenced by the medical evidence of record. Dr.
Brovender [the medical expert who testified during the administrative
hearing] also testified that the claimant’s depression was not a severe
impairment.2
Finally, the ALJ noted that claimant had not been diagnosed with any residual disease
process that would cause decompensation with only minimal increases in mental
demands, that she had no history of requiring a highly supportive living environment,
and she had not displayed an inability to function outside of her home.3 Those
findings are not supported by the record.
Dr. Brovender testified that claimant did not suffer from any “severe
medical[ly] determinable impairment.”4 He did not specifically address claimant’s
depression, even though the ALJ asked him to address any type of medical
impairments, including those resulting from a “psychological abnormality.”5 Instead,
Dr. Brovender addressed claimant’s foot x-ray, left shoulder pain, range of motion in
upper and lower extremities, and gait. He stated that claimant’s “motor, neurological,
and sensory examination is normal,” but he did not address her mental status.6 Dr.

2

Id. (alteration supplied, citation to the record omitted).

3

Id.

4

Tr. 27 (alteration supplied).

5

Tr. 26.

6

Id.

3

Brovender’s focus on claimant’s physical ailments is to be expected, because his area
of specialty is orthopedic surgery, not psychiatry.7 Considering Dr. Brovender’s
specialty, and looking at his testimony as a whole, it cannot be said that Dr.
Brovender offered a definitive opinion that claimant’s depression was not severe. If
he did offer such an opinion, it is not entitled to controlling weight, because Dr.
Brovender is neither a psychiatrist nor a treating physician, and his opinion is
inconsistent with the medical evidence as a whole, as will be discussed more fully in
the following paragraphs.
Specifically, the record does not support Dr. Brovender’s conclusion that
claimant’s depression was well controlled with medication. Viewed as a whole,
claimant’s mental health records indicate that her medications may have helped some,
but they did not ameliorate her condition completely, or even reduce its impact on
plaintiff’s life to a minimal level. On claimant’s first visit to Northwest Alabama
Mental Health Center on September 9, 2011, she reported experiencing flashbacks
to childhood sexual abuse by her stepfather and physical abuse as an adult by two
different domestic partners. She reported feeling hopelessness, sadness, inability to
sleep, visual hallucinations, fatigue, diminished interest in activities, inability to
handle stressors, and periods of irritability. Claimant denied any thoughts of hurting
7

See Tr. 25.

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herself or others, but she did experience ongoing medical issues that negatively
impacted her mood and behavior. She also was embarrassed because her hair was
falling out. She was assessed with major depression, single episode, severe, with
psychotic features, and she was assigned a GAF Score of 45, indicating serious
symptoms.8
On October 11, 2011, claimant described her mood as “sad,” and her affect was
constricted. She had a long history of seeing shadows and hearing her name being
called. She was unable to sleep without a light on and sometimes felt scared with no
known cause. She slept only three hours at night, but got more sleep during the day.
Her feelings of paranoia were worse during the night hours. She denied suicidal or
homicidal ideations, but she did have “vague thoughts.”

Claimant received

prescription medications.9
On October 25, 2011, claimant reported continued auditory hallucinations and
flashbacks to prior abuse. She experienced episodes of feeling sad every three weeks.
The nurse practitioner described claimant as being “emotionally and psychiatrically
fragile.” Plaintiff continued to deny suicidal or homicidal ideations. Her medications
were adjusted.10
8

Tr. 358-59.

9

Tr. 356.

10

Tr. 444.

5

On November 15, 2011, claimant rated her level of depression and anxiety as
a “7” on a scale of 1 to 10. She experienced “episodes of acute paranoia, particularly
at night,” and an increasing number of visual and auditory hallucinations. She was
again noted to be “psychiatrically fragile,” and her medications were adjusted.11
On December 13, 2011, claimant reported increased anxiety and depression but
no auditory or visual hallucinations.12
On January 18, 2012, claimant reported that her medication was effective at
controlling her auditory hallucinations, but she did endorse episodes of feeling sad
and irritable. Her affect was anxious and constricted, and she was noted to be
psychiatrically, financially, and emotionally fragile.13
On February 19, 2012, claimant reported “doing well” because her medications
were effective. She was sleeping well and had a good appetite. She was fully
oriented and experienced no psychomotor agitation or retardation. Her thought
processes were logical and coherent. She experienced moderate stress related to her
daughter being in the military, but she denied suicidal ideations, homicidal ideations,
and hallucinations. Her speech was coherent and appropriate, and she was continued

11

Tr. 442.

12

Tr. 439.

13

Tr. 436.

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on her current medications.14
On April 13, 2012, claimant’s treatment plan was reevaluated. Her assessment
remained major depressive disorder, single episode, severe, with psychotic features.
She also was assessed with post-traumatic stress disorder. She received a GAF score
of 50, still indicating serious symptoms.15
On May 31, 2012, claimant reported frequent nightmares, depressed mood, and
situational stress.16
On June 20, 2012, claimant denied suicidal or homicidal ideations, but she did
report nightmares and auditory and visual hallucinations. Her affected was blunted,
and she described her mood as frustrated and overwhelmed. She exhibited no
psychomotor agitation or retardation. Her thought processes were goal directed and
logical. The effectiveness of her medications was “fair.”17
On August 31, 2012, claimant reported to her therapist that she continued to
feel depressed.18
On September 19, 2012, she reported continued audio and visual hallucinations
during times of acute stress, although the number of episodes had decreased to one
14

Tr. 433.

15

Tr. 428.

16

Tr. 425.

17

Tr. 424.

18

Tr. 422.

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or two each week. Her paranoia had decreased and she did not feel scared anymore.
Her medications caused hypersomnia and daytime sleep, but she also sometimes
experienced episodes of acute insomnia.19
Claimant’s treatment plan was reevaluated once again on December 14, 2012.
She continued to receive diagnoses of major depressive disorder, single episode,
severe, with psychotic features, and post-traumatic stress disorder. Her GAF score
on that day was 60, indicating moderate symptoms.20
In light of all of this evidence, the ALJ’s finding that claimant did not suffer
more than minimal work-related limitations is not supported by substantial evidence.
It is reasonable to expect that the repeated hallucinations, paranoia, sadness, and
anxiety claimant experienced would have a significant effect on her ability to perform
work-related activities, even if she did sometimes experience relief with medication.
Thus, the ALJ should have found claimant’s depression and other psychological
impairments to be “severe.”
That does not necessarily mean, however, that claimant is entitled to benefits.
Instead, further development of the record is warranted with regard to claimant’s
mental impairments and their effect on her ability to perform work-related activities.

19

Tr. 423.

20

Tr. 417.

8

Accordingly, the decision of the Commissioner is reversed, and this action is
REMANDED to the Commissioner of the Social Security Administration for further
proceedings consistent with this memorandum opinion and order.
The clerk is directed to close this file.
DONE this 21st day of December, 2015.

______________________________
United States District Judge

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