Davis v. Colvin

Filing 21

Order that the decision of the Commissioner of Social Security denying Plaintiffs claim for a period of disability, disability insurance benefits, and supplemental security income be AFFIRMED. Signed by Magistrate Judge Sonja F. Bivins on 3/24/2016. Copies to parties. (mpp)

IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ALABAMA
SOUTHERN DIVISION
DERRICK A. DAVIS,

*
*
*
*
*
*
*
*
*
*
*

Plaintiff,
vs.
CAROLYN W. COLVIN,
Commissioner of Social
Security,
Defendant.

CIVIL ACTION NO. 14-00582-B

ORDER
Plaintiff Derrick A. Davis (hereinafter “Plaintiff”) seeks
judicial

review

of

a

final

decision

of

the

Commissioner

of

Social Security denying his claim for a period of disability,
disability insurance benefits, and supplemental security income
under Titles II and XVI of the Social Security Act, 42 U.S.C. §§
401, et

seq.,

and

1381, et

seq.

On October 15,

2015, the

parties consented to have the undersigned conduct any and all
proceedings in this case.

(Doc. 15).

Thus, the action was

referred to the undersigned to conduct all proceedings and order
the entry of judgment in accordance with 28 U.S.C. § 636(c) and
Federal Rule of Civil Procedure 73.

Upon careful consideration

of the administrative record and the memoranda of the parties,
it is hereby ORDERED that the decision of the Commissioner be
AFFIRMED.

I.

Procedural History
Plaintiff protectively filed his applications for benefits

on October 12, 2011.

(Tr. 162).

Plaintiff alleged that he has

been disabled since September 1, 2009, due to degenerative disc
disease,

lumbar

depression,
(“PTSD”).

cholesterol,

and

hypertension,

post

traumatic

flat

stress

feet,

disorder

(Id. at 162, 168).

Plaintiff’s
request,

radiculopathy,

he

was

applications
granted

were

an

denied

and

administrative

upon

timely

hearing

before

Administrative Law Judge Katie H. Pierce (hereinafter “ALJ”) on
April 24, 2013.

(Id. at 44).

Plaintiff attended the hearing

with his counsel and provided testimony related to his claims.
(Id. at 47).

A vocational expert (“VE”) also appeared at the

hearing and provided testimony.

(Id. at 58).

On May 21, 2013,

the ALJ issued an unfavorable decision finding that Plaintiff is
not

disabled.

(Id.

at

37).

The

Appeals

Council

Plaintiff’s request for review on November 7, 2014.
2).

denied

(Id. at 1-

Therefore, the ALJ’s decision dated May 21, 2013, became

the final decision of the Commissioner.
Having

exhausted

his

administrative

timely filed the present civil action.

remedies,

(Doc. 1).

Plaintiff

The parties

waived oral argument on October 15, 2015 (Doc. 14), and agree
that this case is now ripe for judicial review and is properly

2

before

this

Court

pursuant

to

42

U.S.C.

§§

405(g)

and

1383(c)(3).
II.

Issue on Appeal
1. Whether the ALJ erred in rejecting the
opinions and findings of Plaintiff’s
examining psychologist, Dr. Joseph G.
Law, Jr.?

III. Factual Background
Plaintiff was born on March 28, 1984, and was twenty-nine
years of age at the time of his administrative hearing on April
24, 2013.

(Tr. 42, 162).

Plaintiff testified that he graduated

from high school and attended college.

(Id. at 47-48).

served in the military from 2002 to 2009. 1
2010,

following

his

military

barber in a barber shop.
ship fitter helper.
At

his

service,

(Id.).

He also

(Id. at 48).

Plaintiff

worked

In
as

a

He also worked in 2009 as a

(Id. at 49, 205).

hearing,

Plaintiff

testified

that

the

“primary

problems” that interfere with him working now are PTSD, back
pain, and the side effects of his medication (drowsiness).
at 49-50).
he

had

(Id.

According to Plaintiff, at the time of his hearing,

been

receiving

mental

health

treatment

for

his

PTSD

through the VA and had been seeing a therapist about once a week
for about a year and a half.

(Id. at 49).

1

With respect to his

In the military, Plaintiff served as a fuels propulsions mate,
refueling aircraft and boats. (Tr. 48).

3

back pain, Plaintiff testified that the pain in his lower back
was a seven or eight on a ten-point pain scale, after taking his
medication.

(Id.

at

55).

Plaintiff

testified

that

his

treatment has consisted of a cortisone injection in his back and
medications, including Lortab (for pain) and Baclofen (a muscle
relaxer).2

(Id. at 53-54, 57-58).

Plaintiff

testified

that

he

lives

with

his

wife,

children (ages eight, five, and two), and his sister.
51).

three

(Id. at

He does not help with the children or the house work.

(Id.).

His routine consists of getting up in the morning after

not sleeping well, brushing his teeth, taking a shower,
staying in his room.

(Id.).

Plaintiff testified that he can

lift approximately five pounds regularly.
cannot bend.

(Id.).

(Id. at 52).

53-54).

He

He

He can stand for about fifteen minutes and

can only walk about fifteen feet before needing to stop.
at

and

uses

a

cane

issued

by

the

(Id.

Veterans

Administration, and he has a wheelchair and a walker as well.
(Id. at 53, 190).
In his Function Report, Plaintiff stated that he needs help

2

Plaintiff’s medication list submitted to the Agency also
included aspirin, Ketorolac Tromethamine (pain), Lidocaine patch
(pain),
Lisinopril
(high
blood
pressure),
Lovastatin
(cholesterol), Meloxicam (pain), Methocarbamol (muscle relaxer),
Methylprednisolone
(anti-inflammatory),
Omeprazole
(reflux),
Prazosin (nightmares), Sertraline (depression), and Trazodone
(insomnia). (Tr. 171).

4

with his personal needs such as dressing, bathing, grooming, and
using the toilet.

(Id. at 185).

In addition, he does not drive

and cannot go out alone because he needs assistance getting in
and out of the car.

(Id. at 187).

He can count change but does

not shop and cannot handle a bank account or pay bills.

(Id.).

In addition, Plaintiff reported that he has a short attention
span, lacks focus, is forgetful, and has mood swings.
187-88).

He

no

longer

enjoys

hobbies

or

(Id. at

interests

occasionally socializes with family.

(Id. at 188).

problems

because

getting

irritability.

along

with

others

(Id. at 189).

of

but

He has

anger

and

However, he can interact with

authority figures “when need be” and has never been fired from a
job because of problems getting along with other people.
at 190).
to

Plaintiff does not handle stress well, but he is able

follow

written

activity involved.”
IV.

(Id.

and

spoken

instructions

“within

limits

of

(Id. at 189-90).

Analysis
A.

Standard of Review

In reviewing claims brought under the Act, this Court’s
role

is

a

determining

limited
1)

one.

whether

The
the

Court’s
decision

review
of

the

is

limited

to

Secretary

is

supported by substantial evidence and 2) whether the correct

5

legal standards were applied.
1520, 1529 (11th Cir. 1990).

3

Martin v. Sullivan, 894 F.2d

A court may not decide the facts

anew, reweigh the evidence, or substitute its judgment for that
of the Commissioner.
Cir.

1986).

The

Sewell v. Bowen, 792 F.2d 1065, 1067 (11th
Commissioner’s

findings

of

fact

affirmed if they are based upon substantial evidence.

must

be

Brown v.

Sullivan, 921 F.2d 1233, 1235 (11th Cir. 1991); Bloodsworth v.
Heckler,

703

F.2d

1233,

1239

(11th

Cir.

1983)

(holding

substantial evidence is defined as “more than a scintilla, but
less

than

a

preponderance”

and

consists

evidence as a reasonable person would
support

a

conclusion.”).

In

of

“such

relevant

accept as adequate to

determining

whether

substantial

evidence exists, a court must view the record as a whole, taking
into account evidence favorable, as well as unfavorable, to the
Commissioner’s decision.

Chester v. Bowen, 792 F. 2d 129, 131

(11th Cir. 1986); Short v. Apfel, 1999 U.S. Dist. LEXIS 10163, *4
(S.D. Ala. June 14, 1999).
B.

Discussion

An individual who applies for Social Security disability
benefits

must

prove

404.1512, 416.912.

his

or

her

disability.

20

C.F.R.

§§

Disability is defined as the “inability to

engage in any substantial gainful activity by reason of any
3

This Court’s review of the Commissioner’s application of legal
principles is plenary. Walker v. Bowen, 826 F.2d 996, 999 (11th
Cir. 1987).
6

medically determinable physical or mental impairment which can
be expected to result in death or which has lasted or can be
expected to last for a continuous period of not less than 12
months.”

42

U.S.C.

§§

404.1505(a),

416.905(a).

provide

five-step

a

423(d)(1)(A);
The

see

Social

sequential

also

20

Security

evaluation

C.F.R.

§§

regulations
process

determining if a claimant has proven his disability. 4

for

20 C.F.R.

§§ 404.1520, 416.920.
In the case sub judice, the ALJ determined that Plaintiff
4

The claimant must first prove that he or she has not engaged in
substantial gainful activity.
The second step requires the
claimant to prove that he or she has a severe impairment or
combination of impairments. If, at the third step, the claimant
proves that the impairment or combination of impairments meets
or
equals
a
listed
impairment,
then
the
claimant
is
automatically found disabled regardless of age, education, or
work experience.
If the claimant cannot prevail at the third
step, he or she must proceed to the fourth step where the
claimant must prove an inability to perform their past relevant
work. Jones v. Bowen, 810 F.2d 1001, 1005 (11th Cir. 1986). In
evaluating whether the claimant has met this burden, the
examiner must consider the following four factors: (1) objective
medical facts and clinical findings; (2) diagnoses of examining
physicians; (3) evidence of pain; and (4) the claimant’s age,
education and work history.
Id.
Once a claimant meets this
burden, it becomes the Commissioner’s burden to prove at the
fifth step that the claimant is capable of engaging in another
kind
of
substantial
gainful
employment
which
exists
in
significant
numbers
in
the
national
economy,
given
the
claimant’s residual functional capacity, age, education, and
work history.
Sryock v. Heckler, 764 F.2d 834, 836 (11th Cir.
1985). If the Commissioner can demonstrate that there are such
jobs the claimant can perform, the claimant must prove inability
to perform those jobs in order to be found disabled. Jones v.
Apfel, 190 F.3d 1224, 1228 (11th Cir. 1999). See also Hale v.
Bowen, 831 F.2d 1007, 1011 (11th Cir. 1987) (citing Francis v.
Heckler, 749 F.2d 1562, 1564 (11th Cir. 1985)).

7

has not engaged in substantial gainful activity since May 2010, 5
and that he has the severe impairments of degenerative disc
disease

of

stenosis,

the

lumbar

spine,

posttraumatic

lumbar

stress

radiculopathy,

disorder

depressive disorder, and insomnia.

lumbar

(“PTSD”),

(Tr. 24).

major

The ALJ further

found that Plaintiff does not have an impairment or combination
of impairments that meets or medically equals any of the listed
impairments contained in 20 C.F.R. Part 404, Subpart P, Appendix
1.

(Id. at 25).
The

ALJ

concluded

that

Plaintiff

retains

the

residual

functional capacity (hereinafter “RFC”) to perform a range of
light work, except that Plaintiff “can sit for 6 hours in an 8hour workday and stand or walk for 6 hours in an 8-hour workday.
The claimant can lift and carry 10 pounds frequently, 20 pounds
occasionally.

The

crouch,

balance,

crawl,

claimant

claimant

can

claimant

cannot

climb

claimant

cannot

operate

and

occasionally

dangerous machinery.

can

occasionally

climb

push

ropes,

and

ramps
pull

ladders,

automotive

and
leg

or

equipment

stoop,

kneel,

stairs.

The

controls.

The

scaffolds.
or

work

The
around

The claimant can understand, remember, and

5

The ALJ found that Plaintiff had engaged in substantial gainful
activity working as a barber from December 2009 through May
2010, after his alleged onset date of September 1, 2009.
(Tr.
23). However, Plaintiff had not engaged in substantial gainful
activity since May 2010, when he stopped working as a barber.
(Id.).

8

carry out simple, routine, repetitive tasks.

The claimant can

understand to carry out detailed but uninvolved written or oral
instructions

involving

a

standardized situations.
with the public.

few

concrete

variables

in

or

from

The claimant cannot tolerate contact

The claimant needs to work independently but

can work in close proximity to coworkers and supervisors.

The

claimant can maintain concentration and attention for up to 2
hours at a time.

The claimant can occasionally adapt to changes

in the work setting.
criticism,

or

The claimant can tolerate supervision,

instructions

nonthreatening manner.

when

that

in

a

positive,

The claimant can perform goal oriented

work but not production pace work.”
determined

given

while

(Id. at 26).

Plaintiff’s

The ALJ also

medically

determinable

impairments could reasonably be expected to produce the alleged
symptoms, his statements concerning the intensity, persistence
and limiting effects of the alleged symptoms were only partially
credible for the reasons explained in the decision.

(Id. at

27).
Given Plaintiff’s RFC, the ALJ found that Plaintiff is not
capable

of

aircraft
testimony

performing

technician.
of

a

VE,

his

past

(Id.

at

the

ALJ

work
35).

as

a

ship

However,

concluded

fitter

and

utilizing

the

that

considering

Plaintiff’s residual functional capacity for a range of light
work, as well as his age, education and work experience, there

9

are other jobs existing in the national economy that Plaintiff
is

able

to

perform,

such

as

“garment

folder,”

“housekeeper/cleaner,” and “garment bagger,” all of which are
classified as light and unskilled.

(Id. at 36).

concluded that Plaintiff is not disabled.
The

Court

now

considers

the

Thus, the ALJ

(Id. at 36-37 ).

foregoing

in

light

of

the

record in this case and the issues on appeal.
1.

Issues

A. Whether the ALJ erred in rejecting the
opinions and findings of Plaintiff’s
examining psychologist, Dr. Joseph G.
Law, Jr.?
In

this

rejecting

case,

the

Plaintiff

opinions

argues

and

that

findings

the
of

ALJ

erred

his

in

examining

psychologist, Dr. Joseph G. Law, Jr., contained in a mental
status evaluation performed on April 17, 2013.

Specifically,

Plaintiff claims that the ALJ erred in assigning “little weight”
to

Dr.

Law’s

opinions

that

Plaintiff

is

unable

to

maintain

gainful employment as a result of marked limitations in social
and occupational functioning and in assigning “great weight” to
the opinions of consulting psychologist, Dr. Jennifer L. Adams,
Ph.D., that Plaintiff’s PTSD and depression cause only moderate
symptoms

and

instructions.

that

he

(Doc.

is
9

at

able

to

2;

Tr.

understand
32,

34,

and

447,

carry
610).

out
The

Commissioner counters that the ALJ properly weighed all of the

10

medical opinions in this case and that Dr. Law’s opinions are
inconsistent

with

the

substantial

thus, were properly discredited.

evidence

in

the

case

(Doc. 12 at 7).

and,

Defendant

further argues that the opinions of Dr. Adams are consistent
with

the

substantial

properly

afforded

reviewed

the

evidence

great

record

in

weight.

in

this

the

case

(Id.).

case,

the

and,

thus,

Having
Court

were

carefully

agrees

that

Plaintiff’s claim is without merit.
As part of the disability determination process, the ALJ is
tasked

with

examining,

weighing
and

the

opinions

non-examining

and

findings

physicians.

In

of

treating,

reaching

a

decision, the ALJ must specify the weight given to different
medical opinions and the reasons for doing so.

See Winschel v.

Commissioner of Soc. Sec., 631 F.3d 1176, 1179 (11th Cir. 2011).
The failure to do so is reversible error.

See Williams v.

Astrue, 2009 U.S. Dist. LEXIS 12010, *4, 2009 WL 413541, *1
(M.D. Fla. 2009).
When
ALJ

weighing

the

opinion

of

a

treating

physician,

the

must give the opinions “substantial weight,” unless good

cause exists for not doing so.

Costigan v. Commissioner, Soc.

Sec. Admin., 2015 U.S. App. LEXIS 2827, *10, 2015 WL 795089, *4
(11th Cir. Feb. 26, 2015) (citing Crawford v. Commissioner of
Soc. Sec., 363 F.3d 1155, 1160 (11th Cir. 2004) and Broughton v.
Heckler, 776 F.2d 960, 962 (11th Cir. 1985)).

11

The opinion of “a

one-time examining physician — or psychologist,” on the other
hand,

is

not

physician.

entitled

to

the

same

deference

as

a

treating

Petty v. Astrue, 2010 U.S. Dist. LEXIS 24516, *50,

2010 WL 989605, *14 (N.D. Fla. Feb. 18, 2010) (citing Crawford,
363 F.3d at 1160).

An ALJ is also “required to consider the

opinions of non-examining state agency medical and psychological
consultants because they ‘are highly qualified physicians and
psychologists who are also experts in Social Security disability
evaluation.’”
(11th

Cir.

Milner v. Barnhart,
2008)

404.1527(f)(2)(i)).
examining

sources

(unpublished)
“The

when

examining sources.”

275 Fed. Appx. 947, 948

ALJ

they

may
do

(citing
rely

not

on

20

C.F.R.

opinions

conflict

with

of

§
non-

those

of

Id. (citing Edwards v. Sullivan, 937 F.2d

580, 584-85 (11th Cir. 1991)).
Whether considering the opinions of treating, examining, or
non-examining

physicians,

testimony

any

of

medical

good

cause

source

exists

when

it

to

is

discredit

contrary

to

the
or

unsupported by the evidence of record.

Phillips v. Barnhart,

357 F.3d 1232, 1240 (11th Cir. 2004).

“Good cause may also

exist

where

a

doctor’s

opinions

are

merely

conclusory,

inconsistent with the doctor’s medical records, or unsupported
by objective medical evidence.”

Hogan v. Astrue, 2012 U.S.

Dist. LEXIS 108512, *8, 2012 WL 3155570, *3 (M.D. Ala. 2012).
The ALJ is “free to reject the opinion of any physician when the

12

evidence supports a contrary conclusion.”
764

F.2d

834,

835

(11th

Cir.

1985)

Sryock v. Heckler,

(per

curiam)

(citation

omitted); Adamo v. Commissioner of Soc. Sec., 365 Fed. Appx.
209,

212

(11th

Cir.

2010)

(The

ALJ

may

reject

any

medical

opinion if the evidence supports a contrary finding.).
In the present case, the record shows that at the request
of

Plaintiff’s

attorney,

Dr.

Law

conducted

a

mental

status

examination of Plaintiff on April 17, 2013, and administered
several tests, including the Post Traumatic Checklist, the Beck
Depression Inventory, and the Rey 16 Item Memory Test. 6
605).
and

(Tr.

Upon examination, Dr. Law found that Plaintiff was alert
oriented

to

time,

place,

and

person;

his

speech

was

understandable and coherent; his behavior was appropriate to the
situation; he denied hallucinations and delusions; his long term
memory was in tact; when asked to

follow simple, three-step

instructions, he complied and could remember all three steps;
and his test results did not indicate malingering.
606).

(Id. at

In addition, Dr. Law noted that Plaintiff’s mood was

depressed;

he

disappointment,

readily

admitted

confusion,

anger,

to
fear,

feelings

of

frustration,

anxiety,
tension,

and depression; and he reported having difficulty sleeping and

6

The ALJ initially questioned Dr. Law’s credentials but
ultimately treated Dr. Law as an acceptable medical source.
(Tr. 34-35).

13

horrible nightmares.

(Id.).

Dr. Law diagnosed Plaintiff with

Post Traumatic Stress Disorder (chronic due to military combat)
and Major Depressive Disorder (without psychosis, secondary to
chronic

PTSD

and

pain).

(Id.

at

609).

Dr.

Law

assigned

Plaintiff a GAF score of 457 and opined that Plaintiff’s “ability
to stay on task and to adapt to work settings is impaired by
chronic pain as well as his PTSD/major depression with marked
impairment.”

(Id. at 610).

Dr. Law opined that Plaintiff “is

not adapting well and suffers from depression secondary to both
pain and chronic PTSD.

His PTSD symptoms have worsened since

onset in September 2009 and are debilitating.

. . . [H]e is not

able to maintain gainful employment and has a total loss of
access to the competitive labor market.”

(Id.).

Dr. Law also

completed a Mental RFC Questionnaire, finding that Plaintiff has
7

A GAF score of 45 indicates serious symptoms.
GAF (Global
Assessment of Functioning) is a numeric scale (0 through 100)
used by mental health clinicians that measures a patient’s
overall level of psychological, social, and occupational
functioning on a hypothetical continuum.
A GAF score of 41-50
indicates serious symptoms (e.g., suicidal ideation, severe
obsessional rituals, frequent shoplifting) or serious social
dysfunction (e.g., no friends, unable to keep a job).
A GAF
score of 51-60 suggests moderate symptoms (e.g., flat affect and
circumstantial speech, occasional panic attacks) or moderate
difficulty in social, occupational, or school functioning (e.g.,
few friends, conflicts with peers or co-workers). A GAF score of
61-70 is indicative of mild symptoms (e.g., depressed mood and
mild insomnia) or some difficulty in social, occupational, or
school functioning (e.g., occasional truancy, or theft within
the household), but generally functioning pretty well, has some
meaningful interpersonal relationships. See http://www.gafscore
.com.

14

frequent deficiencies in concentration, persistence, or pace,
repeated

expected

episodes

of

decompensation,

and

marked

limitations in social functioning, understanding, carrying out,
and

remembering

supervision,

instructions,

co-workers,

responding

and

work

appropriately

pressures,

to

performing

repetitive tasks, and completing work related activities.

(Id.

at 611-12).
As the ALJ found, Dr. Law’s opinions related to Plaintiff’s
mental

impairments,

limitations

in

including

understanding,

that

Plaintiff

carrying

out,

and

has

marked

remembering

instructions, that he cannot concentrate or stay on task, and
that his PTSD symptoms are debilitating, are undermined by his
own findings that Plaintiff was alert and oriented, that his
speech

was

understandable

and

coherent,

that

his

long

term

memory was completely in tact, that he could read and follow a
command in a sentence, that he could remember three words and
repeat them back to the examiner, and that when asked to follow
simple, multi-step instructions, he complied and could remember
all of the steps.
In

addition,

(Id. at 606).
Dr.

Law’s

opinions

related

to

Plaintiff’s

physical impairments, i.e., Plaintiff’s impairment from chronic
pain which contributes significantly to his depression and his
inability to stay on task and to adapt to work settings, are not
based on any physical findings and are inconsistent with his Dr.

15

Law’s

own

acknowledgement

that

Plaintiff’s

treatment

records

showed only lumbar sprain and degenerative disk disease at L4-L5
causing “mild” stenosis.
regarding

the

inconsistent
case.

(Id. at 607, 610).

severity
with

of

the

Plaintiff’s

remaining

Dr. Law’s opinions

chronic

substantial

pain

are

evidence

also

in

the

For example, Dr. Law references the MRI taken in June

2011 which showed degenerative disk disease at L4-5 causing only
“mild”

central

stenosis.

canal

stenosis

and

bilateral

(Id. at 239, 571) (emphasis added).

neuroforaminal
In addition, x-

rays of Plaintiff’s lumbar spine taken in November 2011 show
“normal position and alignment,” “no disc space narrowing,” “no
spondylolysis,” and “normal lumbar spine.”
a

physician’s

complaints
“lumbar

of

assistant
back

strain,

functional

at

pain

VA

further

resolved”

limitation;”

the

with

“DDD

(Id. at 228).

who

evaluated

opined
no

L4-5

that

Plaintiff’s

Plaintiff

radiculopathy
lumbar

spine”

radiculopathy and only “mild functional limitation.”
240-41).
treating

The

ALJ

physicians

correctly
at

the

noted
VA

that
nor

neither

his

Also,

and
with

had
“no
no

(Id. at

Plaintiff’s

non-VA

treating

orthopedist had imposed any functional limitations related to
Plaintiff’s

back.

(Id.

at

34,

594).

To

the

contrary,

Plaintiff’s recommended treatment consisted of physical therapy,
injections, and medications.

(Id. at 553, 566, 573, 580, 594).

Likewise, Dr. Law’s opinions related to Plaintiff’s mental

16

impairments

are

inconsistent

evidence in this case.

with

the

remaining

substantial

The record shows that at the request of

the Agency, Plaintiff was examined by psychological consultant,
Dr. Jennifer L. Adams, Ph.D., on January 10, 2012.
445).

Dr.

Adams

observed

that

Plaintiff

(Id. at

walked

“with

discomfort” and was using a walker, but, otherwise, he appeared
“strong

and

in

good

health,”

and

“his

posture

was

erect.”

(Id.).
Dr. Adams noted that Plaintiff’s speech was normal; his
concentration

and

attention

were

normal;

he

was

alert

and

oriented in all spheres; he was able to count backward from 20
by 2s; he was able to spell the word WORLD backward; he was able
to solve a simple mathematical equation involving change-making;
his memory was normal; he could recall four digits forward and
three digits backward; he could recall three objects immediately
and all three after five minutes; he could recall the events of
the day of the evaluation and the preceding few days; he could
recall

remote

events

as

well;

his

fund

of

information

was

normal; he could recall items in the news; he could name the
current president and the preceding president; his abstraction
was

normal;

he

could

interpret

proverbs

and

do

simple

similarities; his thought processes were normal; there was no
confusion; his thought content was normal; and his judgment and
insight

were

adequate.

(Id.

at

17

445-46).

Dr.

Adams

noted,

however,

that

Plaintiff’s

mood

irritable, and his affect was flat.

was

dysphoric

and

somewhat

(Id.).

Plaintiff reported to Dr. Adams that his activities are
limited.

According to Plaintiff, he largely spends the day in

bed watching television, although he is able to take care of his
activities of daily living with “some help” from his wife.

(Id.

at 446).
Dr.

Adams

diagnosed

Plaintiff

with

PTSD

and

Depressive Disorder and assigned a GAF score of 55. 8
447).

Major
(Id. at

Dr. Adams opined that Plaintiff’s prognosis is “fair” and

that he “would be expected to respond to mental health services,
if he is willing to engage with the therapist.”

(Id.).

Dr.

Adams summarized her evaluation as follows:
[Plaintiff] is a 27 year-old veteran who was
injured in the war in Iraq and Afghanistan.
In addition to physical injuries he seems to
have suffered PTSD.
He also seems to have
developed
some
depression,
likely
in
reaction to the adjustments he is having to
make in his lifestyle as a result of his
physical injuries and PTSD.
[Plaintiff’s]
intellectual functioning is likely in the
Average range and he is able to manage any
benefits he
might obtain.
His memory and
concentration seem to be somewhat impaired,
possibly from anxiety and depression or
8

As previously noted, a GAF score of 55 indicates moderate
symptoms
(e.g.,
flat
affect
and
circumstantial
speech,
occasional panic attacks) or moderate difficulty in social,
occupational,
or
school
functioning
(e.g.,
few
friends,
conflicts with peers or co-workers).
See http://www.gafscore.
com.

18

medication. There is not a reference in the
medical
records
to
a
head
injury.
[Plaintiff] is not functioning as well as he
probably should be and likely will in the
future with mental health treatment.
He is
able
to
understand
and
carry
out
instructions, but he is probably not able to
remember instructions reliably at this time.
[Plaintiff] is probably not able to respond
appropriately to supervision, co-workers and
work stresses at this time.
(Id. at 447) (emphasis in original).9
While both Dr. Law and Dr. Adams diagnosed Plaintiff with
PTSD

and

Major

Plaintiff’s

Depressive

mental

debilitating
inconsistent

impairments

limitations
with

Disorder,

Dr.

that

have

Dr.

resulted

preclude

Adams’

Law’s

him

findings

opinion

in

from
that

that

marked
working

and
is

Plaintiff’s

concentration, attention, memory, fund of information, thought
processes,
adequate;

content,
that

instructions

he

judgment,
is

(although

able
he

and
to

may

insight
understand

not

be

are

normal

and

carry

out

and

able

to

remember

instructions reliably); that his prognosis is fair; that his
symptoms from his PTSD and depression are moderate; and that he
would be expected to respond to mental health services.

(Id. at

446-47).
9

Dr. Adams does not describe the nature of Plaintiff’s injuries
while serving in the military, but, at his hearing, Plaintiff
testified that he was working on a flight deck when a fuel hose
got caught on the deck and snatched him off his feet. Plaintiff
testified that he landed on his back and has been having
problems “ever since then.” (Tr. 50, 506).

19

As

the

ALJ

found,

Dr.

Adams’

opinions

that

Plaintiff’s

symptoms are moderate and that he is able to understand and
carry

out

instructions

treatment

records,

treatment

for

his

are

which
mental

consistent

reflect
health

a

with

Plaintiff’s

conservative

impairments

and

level

VA
of

essentially

normal mental status examinations with only moderate depression
and anxiety.
Patricia

(Id. at 33-34).

Schlottman,

a

social

Indeed, the treatment notes of
worker

who

began

therapy

with

Plaintiff in 2012 for PTSD, repeatedly noted that Plaintiff was
only “moderately” depressed, 10 that his eye contact, insight, and
judgment were good, that his thought processes were clear, and
that his memory was intact.
506,

508,

510,

514,

(Id. at 481, 483, 489, 493-94, 503,

518-19,

522,

525,

531,

554,

734).

In

addition, Plaintiff’s treatment records show that he has never
required

in-patient

psychiatric

treatment

treatment for any mental health issue.
Although

Plaintiff

criticizes

or

emergency

room

(Id.).
the

ALJ

for

referencing

Plaintiff’s VA treatment records (including the fact that no

10

Early in the evaluation process at the VA, Plaintiff was
administered the Beck Depression Inventory II test, and he
scored in the “severely depressed” range.
(Tr. 526).
Subsequent to that time and throughout his treatment at the VA,
the staff repeatedly found him to be only “moderately”
depressed.
(Id. at 481, 483, 489, 493-94, 503, 506, 508, 510,
514, 518-19, 522, 525, 531, 554, 665, 672, 699, 708).
On
November 29, 2012, he was observed to be only “mildly”
depressed. (Id. at 674).

20

treatment source at the VA has ever found that Plaintiff is
disabled due to a mental impairment, nor has Plaintiff received
a service connection disability for PTSD or depression), the
fact remains that Plaintiff’s treatment records at the VA are
relevant and do reflect a level of treatment that is consistent
with Dr. Adam’s opinions detailed above and inconsistent with
Dr. Law’s opinions that Plaintiff’s mental health impairment is
debilitating.
Based

on

the

foregoing,

the

Court

finds

that

the

ALJ

assigned the appropriate weight to both Dr. Law’s and Dr. Adams’
opinions.

In addition, the Court finds that the ALJ’s RFC fully

accommodates Plaintiff’s PTSD and depression (specifically, Dr.
Adams’

findings

that

Plaintiff

may

not

be

able

to

reliably

remember instructions or respond appropriately to supervision,
co-workers, or work stresses)

11

by limiting Plaintiff to goal

oriented work with only occasional changes in the work setting,
carrying out uninvolved written or oral instructions with few
concrete

variables,

and

limiting

his

supervisors, co-workers, and the public. 12

11

Interestingly,
problems getting
being terminated
with others. (Tr.

interaction

with

In addition, the

as noted by the ALJ, Plaintiff reported no
along with authority figures and denied ever
from a job because of problems getting along
39, 194).

12

As previously discussed, the ALJ limited Plaintiff’s mental
RFC as follows: “The claimant can understand, remember, and
carry out simple, routine, repetitive tasks;” “can understand to
21

Court finds that the ALJ’s RFC fully accommodates Plaintiff’s
physical impairments related to his back pain. 13

(Id. at 26).

Accordingly, Plaintiff’s claim must fail.
V.

Conclusion
For

the

reasons

set

forth

herein,

and

upon

careful

consideration of the administrative record and memoranda of the
parties,

it

is

hereby

ORDERED

that

the

decision

of

the

Commissioner of Social Security denying Plaintiff’s claim for a
period

of

disability,

disability

insurance

benefits,

and

supplemental security income be AFFIRMED.
DONE this 24th day of March, 2016.
/s/ SONJA F. BIVINS
UNITED STATES MAGISTRATE JUDGE

carry out detailed but uninvolved written or oral instructions
involving a few concrete variables in or from standardized
situations;” “cannot tolerate contact with the public;” “needs
to work independently but can work in close proximity to
coworkers and supervisors;” “can maintain concentration and
attention for up to 2 hours at a time;” “can occasionally adapt
to changes in the work setting;” “can tolerate supervision,
criticism,
or
instructions
when
given
in
a
positive,
nonthreatening manner;” and “can perform goal oriented work but
not production pace work.” (Tr. 26).
13

The ALJ limited Plaintiff’s physical RFC as follows: Plaintiff
“can sit for 6 hours in an 8-hour workday and stand or walk for
6 hours in an 8-hour workday.
The claimant can lift and carry
10 pounds frequently, 20 pounds occasionally. The claimant can
occasionally stoop, kneel, crouch, crawl, balance, and climb
ramps and stairs.
The claimant can occasionally push and pull
leg controls.
The claimant cannot climb ropes, ladders, or
scaffolds. The claimant cannot operate automotive equipment or
work around dangerous machinery.” (Tr. 26).

22