Reed v. Social Security Administration, Commissioner
Filing
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MEMORANDUM OPINION. Signed by Judge R David Proctor on 10/13/2020. (KAM)
FILED
2020 Oct-13 PM 04:41
U.S. DISTRICT COURT
N.D. OF ALABAMA
UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
JASPER DIVISION
ANGELA M. REED,
Plaintiff,
v.
ANDREW SAUL,
Commissioner of Social Security,
Defendant.
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Case No.: 6:19-CV-01762-RDP
MEMORANDUM OF DECISION
Angela Reed (“Plaintiff”) brings this action pursuant to §§ 205(g) and 1631(c)(3) of the
Social Security Act (the “Act”), seeking review of the decision by the Commissioner of Social
Security (“Commissioner”) denying claims for a period of disability, disability insurance benefits
(“DIB”), and Supplemental Security Income (“SSI”). 42 U.S.C. §§ 405(g), 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
On July 25, 2016, Plaintiff filed applications for DIB, disability, and SSI, alleging a period
of disability beginning on June 1, 2016.1 (R. 87-88, 162, 194). Plaintiff’s applications were
initially denied by the Social Security Administration on December 6, 2016. (R. 87-88). Plaintiff
then requested a hearing before an Administrative Law Judge (“ALJ”), which was granted. (R.
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An individual cannot receive SSI for any period prior to the month in which she filed her application. See
20 C.F.R. §§ 416.330, 416.335. Thus, the relevant period for deciding Plaintiff’s case is the month in which she filed
her SSI application (here, July 2016) through the date of the ALJ’s decision, and not from her alleged onset date to
the date of the ALJ’s decision. Id.
119-47). On September 6, 2018, ALJ Steven M. Rachal, presided over the video hearing from
Birmingham, Alabama, along with vocational expert (“VE”), Robert D. Mosely, and also with
Plaintiff and her counsel appearing from Jasper, Alabama. (R. 39, 64). On November 21, 2018,
the ALJ entered his decision denying Plaintiff’s applications for disability and SSI benefits. (R.
7-27). The ALJ determined that Plaintiff had not been disabled within the meaning of §§ 216(i),
223(d), and 1614(a)(3)(A) of the Act from June 1, 2016, through the date of the decision. (R. 23).
The Appeals Counsel denied Plaintiff’s request for review of the ALJ’s decision (R. 1-6), making
the ALJ’s decision the final decision of the Commissioner and ripe for judicial review under 42
U.S.C. §§ 405(g) and 1383(c).
II.
FACTS
At the time of the hearing, Plaintiff was 51 years old, had acquired a high school diploma,
and completed one year of vocational training in cosmetology. (R. 45, 162). In her hearing
testimony, Plaintiff testified that she has previous work experience as a cashier, home attendant,
florist supplies salesperson, salesclerk, and receptionist. (R. 45-51, 62). Plaintiff also testified that
she lives alone and that on a typical day she is able to watch television, prepare simple meals, care
for her emotional support dogs, and drive herself to the store to shop. (R. 53-61). In her written
report, dated August 27, 2016, Plaintiff asserts that she is not only capable of completing the
aforementioned activities but can also manage her personal care, manage her finances, attend
church, do laundry, maintain concentration for a few minutes, and follow written and spoken
instructions. (R. 219-226).
Plaintiff claims that she has been disabled since June 1, 2016. (R. 162). According to
Plaintiff, she suffers from physical and mental impairments that affect her ability to work. (R. 5152, 199). Plaintiff alleges that scoliosis, which was the result of an automobile accident she had
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in her twenties, is a physical ailment that prevents her from working. (R. 52-53). Since her
automobile accident, Plaintiff alleges that she experiences pain after standing or sitting for long
periods of time; however, Plaintiff has not received medication, treatment, or surgical intervention
for her scoliosis. (Id.). Additionally, Plaintiff alleges she suffers from the following severe mental
impairments: bipolar, anxiety, depression, and panic attacks. (R. 51-52, 162, 199). Plaintiff has
also identified social anxiety and panic attacks as the primary problems that adversely affect her
ability to work. (R. 52-53).
Prior to the alleged onset date, Plaintiff was admitted to Walker Baptist Medical Center on
April 25, 2015, after a visit to the emergency department where she complained of worsening
anxiety and panic attacks. (R. 279). During that visit, examination findings indicated that Plaintiff
was in a depressed and anxious mood, had scratches along her left forearm, and had suicidal
ideations; however, the findings also noted that Plaintiff exercised normal behavior and judgment.
(R. 279-81). Plaintiff was discharged one week later on May 1, 2015, with symptoms congruent
of a mood disorder. (R. 289-90). Plaintiff’s mental treatment regimen began with Prozac and
Ativan but after she expressed concerns, Plaintiff was taken off Prozac and started on Remeron
and Lithium. (R. 290). Plaintiff was subsequently referred to Northwest Alabama Mental Health
Center for continuation of care. (Id.).
On June 3, 2015, Plaintiff presented at Northwest Alabama Mental Health Center reporting
feelings of guilt, sleep disturbance, decreased energy levels, decreased interest in activities,
anxiety, and panic attacks. (R. 293). Mental examination findings during her visit showed that
she was in a depressed and anxious mood, she was easily distractible, and displayed obsessions
and compulsions; however, Plaintiff’s affect was appropriate, her appearance was appropriate, she
had normal orientation, adequate insight, logical thoughts, undisturbed psychomotor activity and
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memory, and expressed no hallucinations or suicidal thoughts. (R. 296). Plaintiff was diagnosed
with bipolar, affective disorder and panic disorder, attention deficit disorder, and was assigned a
Global Assessment of Function (“GAF”) score of 45. (R. 297). Plaintiff’s medication levels were
adjusted accordingly, and she was referred to the facility for further treatment. (Id.). In the
following months, progress notes from Northwest Alabama Mental Health Center indicate that
Plaintiff’s mental state improved, and that she reported that her “mood was pretty good.” (R. 301,
303).
On November 23, 2016, Dr. Joseph W. Dixon, a treating physician, conducted a
psychological evaluation of Plaintiff, noting that “based upon records reviewed, results of the
clinic interview, reported history, and observations”, Plaintiff’s symptoms are indicative of a
“Generalized Anxiety Disorder.” (R. 306, 309). Dr. Dixon noted that “[Plaintiff’s] mental status
was clear . . . . [and] there were no signs or symptoms of serious thought disorder, behavioral
disorder, or mood disorder” despite Plaintiff appearing “somewhat anxious and fidgety.” (R. 309).
Dr. Dixon further noted that “there is no other mental impairment present other than the anxiety
disorder” and that “[Plaintiff] presented [ ] nicely dressed and groomed, she demonstrated a normal
range of interests, and she exhibited good conversational and social skills.” (Id.). Finally, Dr.
Dixon concluded his psychological evaluation stating that “[Plaintiff] was very polite and friendly”
and that “[s]he has the ability to function independently.” (Id.).
From February 2016 through October 2017, Plaintiff presented at Northwest Alabama
Mental Health Center seeking treatment for her mental conditions. (R. 310-69). Throughout these
visits, Plaintiff was reported to be appropriately groomed, exhibited average demeanor, exhibited
average and appropriate eye contact, normal orientation, undisturbed memory, average
intelligence, cooperative behavior and rapport, and had logical thoughts despite a distractible
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attention span, expressed a depressed and anxious mood and affect, and there was concern for her
poor insights and judgment. (R. 319, 334, 337, 341, 347, 350, 352). Further, the progress notes
indicated that Plaintiff was able to retain a capacity to perform activities of daily life (R. 319, 32324, 326, 329, 337, 340-41, 347, 350, 352), and reflect an updated diagnosis of additional mental
disorders such as: major depressive disorder, recurrent episodes of depression, as well as severe
and generalized anxiety disorder (R. 318, 332, 345). In March 2016, Plaintiff reported that she no
longer took her prescribed medications, with the exception of Risperdal, because the medications
made her feel as if she had no energy, no emotions, and no desire to get out of bed. (R. 332).
Plaintiff’s progress notes through the remainder of 2017 report that Plaintiff had an improvement
in sleep and that she did not experience a panic attack; however, the progress notes also state that
Plaintiff expressed concern regarding her financial situation. (R. 351).
From September 2017 through August 2018, primary care provider records from Magic
Wellness Center show routine visits by Plaintiff for anxiety and minor illnesses. (R. 371-444, 451463). Plaintiff’s prescription history related to these visits indicate that several prescriptions were
filled for her throughout this time period, including Paxil, Ativan, Valium, and Wellburtin. (R.
371-77, 383-85, 387, 453, 455, 456, 461). These progress records also note that Plaintiff exhibited
a worsening of symptoms of depression and anxiety after her father’s passing; however, by August
2018, Plaintiff reported an improvement with her anxiety with agoraphobia symptoms as she had
been getting out of the house. (R. 461, 463).
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 currently engaged in substantial gainful activity.
20 C.F.R. § 404.1520(b). “Substantial work activity” is work activity that involves significant
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physical or mental activities. 20 C.F.R. § 404.1572(a). If the ALJ finds that the claimant is
engaged in substantial gainful activity, 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(c). Absent such impairment, the claimant
may not claim disability. Id. Third, the ALJ must determine whether the claimant meets or
medically equals the criteria of an impairment listed in 20 C.F.R. § 404, Subpart P, Appendix 1.
20 C.F.R. §§ 404.1520(d), 404.1525, and 404.1526. If such criteria are met, then the claimant is
declared disabled. 20 C.F.R. § 404.1520(d).
Even if the claimant cannot be declared disabled under the third step, the ALJ may still
find disability under the next two steps of the analysis. The ALJ must 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 must determine whether the
claimant has the RFC to perform past relevant work. 20 C.F.R. § 404.1520(f). If it is determined
that the claimant is capable of performing past relevant work, then the claimant is not disabled. 20
C.F.R. § 404.1560(b)(3). 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(g)(1). In this
final analytical step, the ALJ must decide whether the claimant is able to perform any other
relevant work corresponding with her RFC, age, education, and work experience. 20 C.F.R. §
404.1560(c). Here, the burden of proof shifts from the claimant to the ALJ in proving the existence
of a significant number of jobs in the national economy that the claimant can perform given her
RFC, age, education, and work experience. 20 C.F.R. §§ 404.1520(g), 404.1560(c).
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In this case, the ALJ found that (1) Plaintiff has not engaged in substantial gainful activity
since her alleged onset date of disability, June 1, 2016, and (2) she suffers from the following
severe impairments that significantly limit her ability to perform basic work activities: panic
disorder with agoraphobia, generalized anxiety disorder, and depression. (R. 12). However, the
ALJ concluded that Plaintiff’s severe impairments did not meet or medically equal one of the listed
impairments in 20 C.F.R. § 404, Subpart P, Appendix 1. (R. 13). After consideration of the entire
record, the ALJ determined that Plaintiff retains the RFC to perform a full range of work at all
exertional levels, within the context of 20 C.F.R. §§ 404.1527, 404.1529, 416.927, 416.929, and
SSR 16-3p, based on her ability: to understand, remember, carry out simple instructions and tasks
within two hour increments; engage in occasional work-required interaction with co-workers,
supervisors, and the public; and also tolerate workplace changes that are infrequent and gradually
introduced. (R. 15-16). Following the testimony of the VE, the ALJ determined that Plaintiff was
precluded from performing her past relevant work as a cashier, home attendant, salesperson,
salesclerk, or receptionist. (R. 21). However, the ALJ determined she could perform other jobs
existing in significant numbers in the national economy, including positions such as marker, router,
and cleaner/housekeeper. (R. 21-22). The ALJ further concluded that Plaintiff was not disabled
as defined by the Act. (R. 23). Finally, the ALJ concluded that Plaintiff had not been under a
disability at any time between June 1, 2016, through the date of the ALJ’s decision, November 21,
2018. (Id.).
IV.
PLAINTIFF’S ARGUMENT FOR REMAND OR REVERSAL
Plaintiff advances two arguments in favor of reversing the ALJ’s decision. First, she claims
that the ALJ improperly applied the Eleventh Circuit’s pain standard by relying exclusively on
objective evidence contained in the record. In particular, Plaintiff’s primary contention is that the
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ALJ failed to consider Plaintiff’s subjective testimony regarding the severity of her ailments.
Second, Plaintiff contends that the ALJ’s decision to deny a period of disability, DIB, and SSI was
not based on substantial evidence because that determination was based on a misapplication of
evidence that could not constitute substantial evidence.
V.
STANDARD OF REVIEW
Judicial review of disability claims under the Act is limited to whether the Commissioner’s
decision is supported by substantial evidence and whether the correct legal standards were applied.
42 U.S.C. § 405(g); Dyer v. Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005).
“The
Commissioner’s factual findings are conclusive” when “supported by substantial evidence.”
Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001). “Substantial evidence” is more than a
mere 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)
(quoting Lewis v. Callahan, 125 F.3d 1346, 1349 (11th Cir. 1997)). Even if the Commissioner’s
decision is not supported by a preponderance of the evidence, the findings must be affirmed if they
are supported by substantial evidence. Id. at 1158-59; see also Martin v. Sullivan, 894 F.2d 1520,
1529 (11th Cir. 1990). However, the Commissioner’s conclusions of law are not entitled to the
same deference as findings of fact and are reviewed de novo. Ingram v. Comm’r of Soc. Sec.
Admin., 496 F.3d 1253, 1260 (11th Cir. 2007).
VI.
DISCUSSION
a.
The ALJ Properly Applied the Eleventh Circuit Standard for Evaluating
Disability Due to Pain
Plaintiff first contends that the ALJ’s step four RFC determination is not supported by
substantial evidence because the ALJ used the wrong standard for evaluating her mental illness.
Specifically, Plaintiff asserts that the ALJ selectively chose notations in the record that support the
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decision to deny benefits as and failed to account for Plaintiff’s subjective evidence regarding the
severity of her ailments. However, this argument fails because the record makes clear that the ALJ
determined that Plaintiff’s testimony regarding the intensity, persistence, and limiting effects of
her symptoms was not consistent with the evidence contained in the record as a whole. (R. 16).
A claimant’s subjective complaints alone are insufficient to establish disability under the
Act. See 20 C.F.R. §§ 404.1529(a), 416.929(a); Edwards v. Sullivan, 937 F.2d 580, 584 (11th Cir.
1991). In Holt v. Sullivan, the Eleventh Circuit has articulated the “pain standard” that applies
when a claimant seeks to establish disability through her own testimony about pain or other
subjective symptoms. 921 F.2d 1221, 1223 (11th Cir. 1991). Under the standard, a claimant must
show:
(1) evidence of an underlying medical condition and either (2) objective medical
evidence that confirms the severity of the alleged pain arising from that condition
or (3) that the objectively determined medical condition is of such a severity that it
can be reasonably expected to give rise to the alleged pain.
921 F.2d at 1223 (internal citation omitted). The relevant pain standard applies during the fourth
step of the ALJ’s determination of Plaintiff’s RFC. 20 C.F.R. 20 C.F.R. §§ 404.1529(c),
416.929(c)-(d). If a claimant successfully establishes the existence of an underlying medical
condition that could reasonably be expected to produce the alleged symptoms, as Plaintiff did here,
the ALJ may discredit a claimant’s testimony regarding symptoms so long as he “clearly
articulate[s] explicit and adequate reasons” for doing so. Dyer v. Barnhart, 395 F.3d at 1210
(quoting Foote v. Chater, 67 F.3d 1553, 1561-62 (11th Cir. 1995)). Any failure to adequately
express the reasons for discrediting a claimant’s subjective symptomology requires the testimony
to be accepted as true as a matter of law. Holt v. Sullivan, 921 F.2d at 1223. Here, the ALJ
concluded that “[Plaintiff’s] medically determinable impairments could reasonably be expected to
cause some of alleged symptoms; however, [Plaintiff’s] statements concerning the intensity,
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persistence and limiting effects of these symptoms are not entirely consistent with the medical
evidence and other evidence in the record for the reasons explained in [the] decision.” (R. 16).
The ALJ discredited Plaintiff’s pain testimony. (Id.) The court’s task now is to evaluate whether
the ALJ’s stated reasons for doing so are supported by substantial evidence in the record. Dyer,
395 F.3d at 1210. They are.
The ALJ opined that “[Plaintiff’s] allegations are not supported by the objective medical
evidence” and are inconsistent with the level of symptomology of which Plaintiff claims. (R. 16).
Plaintiff alleges that she experiences constant panic attacks with palpitations when she interacts
with others; however, Plaintiff’s mental examination records report that she is cooperative and
friendly despite reporting feelings of anxiety and depression. (R. 17, 307-09). Also, Plaintiff’s
testimony at the ALJ hearing—which initially indicated that she was able to manage her own
personal care—directly contrasts with her own statements at the end of the hearing in which she
reported that she could not remember the last time she showered. (R. 54-57, 61). This claim is
also inconsistent with the evidence of record which continuously indicates that Plaintiff was
appropriate, clean, and neatly groomed in appearance. (R. 307, 309, 319, 332, 334, 337, 341, 347,
350, 352). Plaintiff’s statement that she does not take medication is also inconsistent with evidence
in the record that show Plaintiff’s continuous refills of psychotropic medications. (R. 387, 392,
405, 409, 417, 452). The medical prescription records not only show that the refills were
continuous but also indicate that the prescriptions were effective in alleviating Plaintiff’s
symptoms due to a reported improvement in mood by Plaintiff since she had begun the
medications. (R. 408, 417, 461). Furthermore, Plaintiff’s statement that she is willing to attend
therapy but is unable to afford therapy is directly contradicted by Northwest Alabama Mental
Health Center records indicating that she is able to afford therapy but stopped attending counseling
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in October 2016. (R. 18, 332, 340). Finally, Plaintiff’s assertions also clash with her daily
activities, including watching television, preparing simple meals, caring for her dogs, driving
alone, leaving home, shopping in stores, attending church, doing laundry, ability to follow written
and spoken instructions, and paying attention for minutes at a time. (R. 19, 319, 334, 337, 341,
347, 350, 352).
In summary, the ALJ considered Plaintiff’s activities of daily living, the frequency,
intensity, and inhibiting effects of her symptoms, the types and dosages of her medications, and
concluded that Plaintiff’s subjective complaints were inconsistent with her testimony and the
medical records. Thus, the ALJ adequately explained his reasons for discrediting Plaintiff’s
subjective testimony. The court concludes that the ALJ followed the correct legal standards and
that his decision to discredit Plaintiff’s subjective evidence regarding the severity of her pain is
supported by substantial evidence in the record.
b.
Substantial Evidence in the Record Supports the ALJ Decision
Second, Plaintiff contends that the ALJ’s decision is not based on substantial evidence
because the ALJ fails to properly apply the Eleventh Circuit pain standard. After review of the
entire record and for the reasons set forth above, the court concludes that the ALJ’s decision to
deny benefits to Plaintiff is supported by substantial evidence in the record.
The function of this court is to determine whether the decision of the Commissioner is
supported by substantial evidence and whether proper legal standards were applied. 42 U.S.C. §
405(g); Wilson v. Barnhart, 284 F.3d 1219, 1221 (11th Cir. 2002). The court must “scrutinize the
record as a whole to determine if the decision reached is reasonable and supported by substantial
evidence.” Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983). It is “more than a
scintilla, but less than a preponderance.” Id.
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Here, the ALJ fully and fairly developed the record in deciding to deny benefits. The ALJ
is obligated to explore all relevant facts pertaining to a case for the sake of developing a full and
fair record. Welch v. Bowen, 854 F.2d 436, 440 (11th Cir. 1988) (quoting Cowart v. Schwiker,
662 F.2d 731, 735 (11th Cir. 1981)). The ALJ’s decision to deny benefits in this matter was
reached after a comprehensive examination of the entire record based on the considerations given
the evidence at the hearing level, medical opinions given by Plaintiff’s treating physicians, and the
medical record evidence submitted. The ALJ’s discussion of Plaintiff’s subjective pain testimony,
in the context of the entire record, indicates that the ALJ conducted an analysis of the entire
medical record to develop a full and fair record. (R. 40-48). Despite Plaintiff’s allegations to the
contrary, the ALJ did not selectively or arbitrarily choose notations in the record that support the
decision to deny benefits but rather the ALJ was performing his obligation to explore all relevant
facts and evidence for the sake of developing a full and fair record.
It is emphatically Plaintiff’s burden to prove disability. In this case, the Plaintiff failed to
do so. The ALJ’s decision to discredit portions of Plaintiff’s subjective testimony based on
inconsistencies in the record is supported by substantial evidence.
VI.
CONCLUSION
Upon review of the administrative record, and considering all of Plaintiff’s arguments, the
court finds the Commissioner’s decision is supported by substantial evidence and in accord with
the applicable law. A separate order that is consistent with this opinion will be entered.
DONE and ORDERED this October 13, 2020.
_________________________________
R. DAVID PROCTOR
UNITED STATES DISTRICT JUDGE
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