Robinson v. Berryhill

Filing 22

MEMORANDUM OPINION AND ORDER entered that the decision of the Commissioner of Social Security denying Plaintiff benefits be AFFIRMED. Signed by Magistrate Judge P. Bradley Murray on 2/8/2018. (eec)

IN  THE  UNITED  STATES  DISTRICT  COURT  
FOR  THE  SOUTHERN  DISTRICT  OF  ALABAMA  
SOUTHERN  DIVISION  

FLETCHER  K.  ROBINSON,  

Plaintiff,    

v.  

NANCY  A.  BERRYHILL,    
Acting  Commissioner  of  Social  
Security,  

Defendant.    

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)        CIVIL  ACTION  NO.  17-­0173-­MU    
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MEMORANDUM  OPINION  AND  ORDER  

Plaintiff  Fletcher  K.  Robinson  brings  this  action,  pursuant  to  42  U.S.C.  §§  
405(g)  and  1383(c)(3),  seeking  judicial  review  of  a  final  decision  of  the  
Commissioner  of  Social  Security  (“the  Commissioner”)  denying  his  claim  for  
Disability  Insurance  Benefits  (“DIB”),  and  Supplemental  Security  Income  (“SSI”),  
based  on  disability.  The  parties  have  consented  to  the  exercise  of  jurisdiction  by  
the  Magistrate  Judge,  pursuant  to  28  U.S.C.  §  636(c),  for  all  proceedings  in  this  
Court.  (Doc.  19  (“In  accordance  with  the  provisions  of  28  U.S.C.  636(c)  and  Fed.  
R.  Civ.  P.  73,  the  parties  in  this  case  consent  to  have  a  United  States  Magistrate  
Judge  conduct  any  and  all  proceedings  in  this  case,  …  order  the  entry  of  a  final  
judgment,  and  conduct  all  post-­judgment  proceedings.”)).  See  also  Doc.  21.  Upon  
consideration  of  the  administrative  record,  Robinson’s  brief,  the  Commissioner’s  

brief,  all  other  documents  of  record,  and  oral  argument,  it  is  determined  that  the  
Commissioner’s  decision  denying  benefits  should  be  affirmed.1        
I.    PROCEDURAL  HISTORY  
On  April  24,  2014,  Robinson  applied  for  a  Period  of  Disability  and  DIB,  
under  Title  II  of  the  Social  Security  Act,  and  for  SSI,  based  on  disability,  under  
Title  XVI  of  the  Social  Security  Act  (“the  Act”),  42  U.S.C.  §§  1381-­1383d,  alleging  
disability  beginning  on  March  25,  2014.  (Tr.  235-­46).  After  his  application  was  
denied  at  the  initial  level  of  administrative  review  on  August  1,  2014,  Robinson  
requested  a  hearing  by  an  Administrative  Law  Judge  (ALJ).  (Tr.  136-­42).  After  an  
initial  hearing  was  held  on  October  16,  2015,  and  a  supplemental  hearing  was  
held  on  February  24,  2016,  the  ALJ  issued  an  unfavorable  decision  finding  that  
Robinson  was  not  under  a  disability  from  the  date  the  application  was  filed  
through  the  date  of  the  decision,  April  21,  2016.  (Tr.  33-­107).  Robinson  appealed  
the  ALJ’s  decision  to  the  Appeals  Council,  which  denied  his  request  for  review  on  
March  13,  2017.  (Tr.  1-­6).                
After  exhausting  his  administrative  remedies,  Robinson  sought  judicial  
review  in  this  Court,  pursuant  to  42  U.S.C.  §§  405(g)  and  1383(c).  (Doc.  1).  The  
Commissioner  filed  an  answer  and  the  social  security  transcript  on  July  20,  2017.  
(Docs.  7,  8).  On  August  18,  2017,  Robinson  filed  a  brief  in  support  of  his  claim.  
(Doc.  9).  The  Commissioner  filed  her  brief  on  December  4,  2017.  (Doc.  16).  Oral  

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 Any  appeal  taken  from  this  Order  and  Judgment  shall  be  made  to  the  Eleventh  
Circuit  Court  of  Appeals.  See  Doc.  19  (“An  appeal  from  a  judgment  entered  by  a  
Magistrate  Judge  shall  be  taken  directly  to  the  United  States  Court  of  Appeals  for  
the  judicial  circuit  in  the  same  manner  as  an  appeal  from  any  other  judgment  of  
this  district  court.”).          

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argument  was  held  before  the  undersigned  Magistrate  Judge  on  January  30,  
2018.  (Doc.  20).  The  case  is  now  ripe  for  decision.  
II.    CLAIM  ON  APPEAL  
Robinson  alleges  that  the  ALJ’s  decision  to  deny  him  benefits  is  in  error  
because  the  ALJ’s  Residual  Functional  Capacity  (RFC)  assessment  was  not  
supported  by  substantial  evidence.  (Doc.  9  at  pp.  1-­  2).  
III.  BACKGROUND  FACTS  
Robinson  was  born  on  July  27,  1965,  making  him  48  years  old  at  the  time  
he  filed  his  claim  for  benefits.  (Tr.  296).  Robinson  alleged  disability  due  to  PTSD,  
prostate  cancer,  diabetes,  depression,  high  blood  pressure,  and  back  pain.  (Tr.  
279).  He  graduated  from  high  school  on  June  3,  1983,  attending  regular  education  
classes.  (Tr.  280).  After  high  school  he  joined  the  Army  and  served  for  almost  ten  
years,  including  a  deployment  in  the  Gulf  War.  (Tr.  94).  He  worked  from  1994  to  
2014  as  a  parts  manager  for  the  Mobile  County  sheriff’s  garage.  (Tr.  280-­81).  He  
takes  care  of  his  own  personal  care,  although  his  wife  does  remind  him  to  take  his  
medicine  because  he  has  focus  issues.  (Tr.  289-­90).  He  is  able  to  iron,  do  
laundry,  and  some  minor  cleaning  chores.  (Tr.  290).  He  can  pay  bills,  count  
change,  handle  a  savings  account,  and  use  a  checkbook/money  orders  with  his  
wife’s  help.  (Tr.  291).  He  only  drives  short  distances  with  someone  with  him  
because  he  does  not  know  when  his  PTSD  will  be  triggered.  (Tr.  291).  He  goes  
outside  at  his  home  on  a  daily  basis.  (Tr.  291).  He  spends  his  time  at  home  with  
his  family  or  at  church,  going  to  PTSD  therapy,  and  going  to  doctor’s  
appointments.  (Tr.  292).  He  enjoys  watching  television  and  fishing,  but  says  he  

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cannot  fish  alone  anymore.  (Tr.  292).    He  testified  at  the  first  hearing  that  he  had  
to  retire  from  his  employment  due  to  the  symptoms  caused  by  his  PTSD  and  
having  to  miss  work  to  attend  sessions  for  treatment  of  his  PTSD.  (Tr.  98-­100).  
After  conducting  the  hearings,  the  ALJ  made  a  determination  that  Robinson  had  
not  been  under  a  disability  during  the  relevant  time  period,  and  thus,  was  not  
entitled  to  benefits.  (Tr.  36-­65).    
IV.  ALJ’S  DECISION  
The  ALJ  made  the  following  relevant  findings  in  her  April  26,  2016  decision:  
3.     The  claimant  has  the  following  severe  impairments:  
Prostate  cancer,  obesity,  diabetes   mellitus,  osteoarthrosis,  
essential  hypertension,  anxiety  disorders,  and  affective  
disorders.  (20  CFR  404.1520(c)  and  416.920(c)).  
The  medical   evidence  of  record  documents  that  the  claimant  has  
received  mental  health  treatment  through  the  Veteran's  Administration  
Health  Care  System  (VA)  since  at  least  May  2010.  A  document  dated  
May   5,  2010  indicates  that  the  claimant  was  scheduled  for  admission  
to   the  Psychosocial   Rehabilitation  Residential  Treatment  Program  
(PRRTP)  at  the  VA  Gulf  Coast   Veterans  Health  Care  System  in  Biloxi,  
Mississippi   on  May   17,  2010.  (Exhibit  1F).  The   evidentiary  record  
contains  no  other  documentation  regarding  this  admission.  (Exhibit  
18E).The  record   does  contain  a  “Certificate  of  Completion”   dated  July  
9,  2010,  signed  by   a  psychologist,   two  social  workers,  a  recreation  
therapist,  and  a  chaplain,  indicating  that  the   claimant   successfully  
completed  the  “PTSD  Intensive   Outpatient  program”  through  the  
PRRTP.   (Exhibit   2F).  

The  evidentiary  record  further  documents  that,  since  January  2011,  the  
claimant  has  received   mental  health  treatment  through  the  Gulf  Coast  
VA  Health  Care  System  for  diagnoses  of  post-­traumatic  stress  disorder  
(PTSD),  Chronic  Depression,   and  OCD.  (Exhibits  3F,  4F,  7F,  and  10F).  
The  treatment  records  reflect  Global  Assessment  of  Functioning  (GAF)  
scores  of  45  to  50   since  2012.  (Exhibits  4F  at  pages   123  and  232,  10F  
at  pages  64,  69,  71,  and   109,  and  21F  at   page  6).  The  claimant  has  
been  followed  medically  at  the  VA  by  staff  psychiatrist   Douglas  Ewing,  
M.D.,   since  February   2011.   A  treatment  note  from  Dr.  Ewing  dated  

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February   6,  2014,   approximately   one  month  prior  to  the  claimant's  
alleged   onset   date,  reflects  that  the  claimant  presented   with  worries  
about  the  responsiveness   of  his  prostate  cancer  to  treatment.  The  
claimant  reported  having  no  medication   side  effects,  and  his  mental  
status  examination  (MSE)  revealed  that  he  reported  his  mood  was  
“down”  and  that  his  affect  was   subdued,  but  appropriate  to  topic.  Dr.  
Ewing  further  noted  at  that  time  that  the  claimant  was  oriented  to  
person,  place,  time,  and  situation,  that  he  denied  current   suicidal  or  
homicidal   ideation,  plan,   or  intent,  that  his   thoughts  were  logical  and  
goal-­directed   without  evidence  of  thought  disorder  or  delusion,  that  
feelings  of  hopelessness   were  not  elicited,  and  that  the  claimant   did  
not  appear  to  be  responding  to  auditory/visual  hallucinations.   Dr.  Ewing  
diagnosed  the  claimant  with  PTSD.  A  psychiatric  outpatient  note  a  little  
over  six  weeks   later,   on  the  claimant's  alleged   onset  date,   March  25,  
2014,   indicates  that  the  claimant  complained  to  Dr.  Ewing  of  symptoms  
of  weekly   intrusive  thoughts,  weekly  dreams/nightmares,   weekly  
flashbacks,  psychological   distress,  psychological  reactivity,  efforts  to  
avoid  thoughts,  feelings,  people,  places ,  and  events,  markedly  
diminished   interest  in   activities,  social  isolation  from  others,  loss  of  
ability  to  feel  emotions,   sleep  disturbances,  anger   outbursts,  poor  
concentration,  hypervigilance ,  and  exaggerated   startle  response.    The  
claimant  further  reported  having  “chronic  persistent   dysphoria  and  
anxiety  and   social   and  interpersonal  restriction.”  The  claimant  denied  
current  suicidal  ideation,  plan,  or  intent  and  he  denied     persistent  
morbid  thoughts.    However,  Dr.  Ewing  noted  that  the  claimant's  MSE  
on  March  25,  2014  was  remarkable   only  for  “low”  mood  and  “mild  to  
moderately   glum”  affect.  All  other  aspects  of  the  claimant's  MSE  on  
that  date  were  within   normal  limits.  The  claimant's  diagnosis  on  that  
date  was  chronic  PTSD.  (Exhibit  3F  at  pages  1-­11).  

A  review   of  the  claimant's  mental   health  treatment  records   from  the  VA  
Medical   Center  from   2014  and  2015  reflects  Dr.  Ewing,  and  VA  staff  
psychologist   Susan  K.  Rhodes,   Ph.D.,  treated  the  claimant  for  PTSD  
and  depression  with  psychotropic  medications  and  individual  therapy  
on  a  regular  basis.   The  records  indicate  that,  although  the  claimant  
continued  to  complain  of  symptoms  of  “self-­injurious  thoughts,”  
recurrent ,  involuntary,  and  intrusive  distressing  memories  of  events  
that  occurred  during  his  military  service,  psychological  distress,  and  
avoidance  of  distressing  memories,  thoughts,   or  feelings  associated  
with  events  that  occurred   during  his  military  service,  he  consistently  
denied  having  active  suicidal  intent,  and  he  also  consistently  denied  
having  feelings  of  hopelessness.     The  treatment  records   do  not  reflect  
that  the  claimant's  mental  health  treatment  providers,   Dr.  Ewing  and  

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Dr.  Rhodes,   documented  any  significantly   abnormal  mental  status  
examination  findings  during  their  office  visits  with  the  claimant.  For  
example,   at  the  claimant's  July  2014  visit  with  Dr.  Ewing,  the  
claimant's  MSE   appeared  normal,   and  the   claimant's   mood  was  
reported   as  “IT'S  GOOD”  and  his   affect   was   subdued  but  appropriate  
to  topic.  Dr.  Ewing  further  noted  that  the  claimant  “smiled  broadly  at  
times.”  (Exhibit  7F  at  page  37).  On  October  22,  2014,  Dr.  Ewing  
recorded   very  similar  MSE   findings,  and  noted  that  the  claimant  
reported   that  his  mood  was  “ALRIGHT”   and  that  his  affect  was  
subdued  but  appropriate  to  topic.  Dr.  Ewing  again  observed  that  the  
claimant  “smiled  broadly.”   (Exhibit  10F  at  page  79).    At  his  visit  with  
the  claimant  on  May  20,  2015,  Dr.  Ewing  again  noted  no  abnormalities  
in  the  claimant's  MSE  and  he  noted  that  the  claimant  reported  that  his  
mood  was   “ GOOD,”  and  he   observed   that  the   claimant's  affect  was  
“ smiling,   friendly   and   engaging”  and  appropriate  to  topic.     (Exhibit  10F  
at  page  116).  
On  mental   status  examination   of  the  claimant  on  October  20,  2014,  Dr.  
Rhodes  observed  that  the   claimant  demonstrated  agitated  psychomotor  
behavior  and  stated  that  his  mood  was  depressed  (with  congruent  
affect),  but  she  further  noted  that  the  claimant  was  alert  and  oriented  to  
person,   place,  time,  and  purpose,  that  his  grooming  and  hygiene   were  
properly  maintained,  that  his  speech  was  average  in  rate   and  tone,  that  
his  thoughts   were  logical  and  goal-­directed,  that  there  was  no  evidence  
of  psychosis,  and  that  his  attention,  concentration,  and  memory  
appeared  adequate.  The  claimant  reported  having  suicidal  thoughts,  but  
he  denied  any  intent  to  act  upon  it.  Dr.  Rhodes  diagnosed  the  claimant  
with  PTSD  and  Depression  NOS.  (Exhibit  10F  at  pages  83-­84).  
The  claimant  was  admitted  to  the  PTSD  Intensive  Outpatient  Program,  
PRRTP,  in  the  Gulf  Coast  Veterans   Health  Care  System,  from  March  
31,  2015  to  May   19,  2015.  The  record   indicates  that   the  claimant  
successfully  completed  the  program.  (Exhibit  10F  at  pages   112;;  Exhibit  
11F).  
On  June  11,  2015,  Dr.  Rhodes   observed  that  the  claimant's  mood  
appeared  depressed   with  congruent  flat  affect,  but  he  was  alert  and  fully  
oriented,  that  he  was  well-­groomed   with  good  hygiene,  that  his  speech  
was  normal,  that  his  thoughts   were  logical   and  goal-­directed,  that  there  
was  no  evidence  of  psychosis,  and  that  he  denied  suicidal  or  homicidal  
ideation  and  did  not  endorse  any  factors  interfering  with  continued  
maintenance   of  safety  from  harm  to  self  or  others.   Dr.  Rhodes  noted  
very  similar  findings  at  her  visit  with  the  claimant  on  June  30,  2015.    Dr.  
Rhodes  diagnosed  the  claimant  with  PTSD  and  Depressive  Disorder,  

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NOS.  (Exhibit  10F  at  page  109).   On  September  2,  2015,  Dr.   Ewing  
noted  that  the  claimant  reported  that  he  was  less  
anxious/irritable/reactive  and  that  his  sleep  and  mood  were  improved.    
The  claimant's  mental  status  examination  on  that  date  was  essentially  
normal,  with  no  suicidal  or  homicidal   ideation,   plan,   or  intent,  and  no  
feelings  of  hopelessness.  (Exhibit   14F  at  pages  8-­9).  
Dr.  Ewing  wrote  a  letter   on  April  9,  2014  in  support  of  the  claimant  's  
VA  compensation  and  pension   claim  based   on  PTSD.  In  that  letter,  Dr.  
Ewing  indicated  that  the  claimant  continued  to  experience   “ significant  
distress  related  to  his  PTSD,”  despite  treatment  with  psychotropic  
medications  and  individual  psychotherapy.   Dr.  Ewing  listed  the  
claimant's   daily  to  weekly  symptoms  and  he  stated  that  the  claimant's  
symptoms  were   significant  and,  in  his  opinion,  the  claimant  was  not  
“cognitively,  interpersonally   or  affectively   capable  of  functioning  in  the  
workplace”  at  that  time  due  to  his  PTSD.  (Exhibit  4F  at  pages  94-­95).  
Dr.  Ewing  also   completed  disability  forms  on  the  claimant's  behalf  for  
the  Retirement   Systems  of  Alabama  (RSA)  on  April   28,  2014  and  July  
8,  2015.  (Exhibits   12E,  5F,  and  9F).   In  both  forms,  Dr.  Ewing  opined  
that  the  claimant  was  “totally  incapacitated”  from  duty  due  to  PTSD,  
depressed  mood,  chronic  anxiety,  low  frustration  tolerance,  and  
emotional  reactivity,  and  that  his  employer  could  not  make  any  
accommodations  which  would  allow  the  claimant  to  be  capable  of  
employability.  In  the  April  28,  2014  form,  Dr.  Ewing  also  noted  that  the  
claimant's  “anxiety/agitation”  precluded  tolerance  of  the  workplace,  
and  in  the  July  8,  2015  form,  he  stated  that  the  claimant  was  
“intolerant  of  social  demands  of  workplace  settings.”  
The  record  documents  that  the  claimant  was  granted  disability  
retirement  from  The  Retirement  Systems  of  Alabama  effective  June  
1,  2014.   (Exhibit  5D).  
On  June  19,  2014,  clinical  psychologist   Jennifer   M.  Jackson,  Psy.  D.,  
completed  an  Initial  PTSD  Disability   Benefits  Questionnaire   on  the  claimant  
for  “internal   VA  or  DoD  use   only.”    Dr.  Jackson  indicated  that  the  claimant  's  
diagnoses  were  PTSD  and  Unspecified  Depressive  Disorder,  and  that  he  had  
overlapping  symptoms  with  one  condition  exacerbating  the  other.  Dr.  
Jackson  opined  that  the  claimant  had  “occupational  and  social  impairment  
with  reduced   reliability  and  productivity.”  (Exhibit  7F  at  pages  39-­46).  
The  claimant  received  a  VA  rating  decision  on  July  25,  2014  which  
found  that  he  had  a  50   percent   disability  rating  effective   August  24,  
2009  due  to  PTSD  with  unspecified   depressive  disorder   based   on  the  
claimant's  difficulty   in  adapting  to  a  work  like  setting,  disturbance   of  
motivation  and  mood,  difficulty  in  establishing  and  maintaining  

7

effective  work  and  social  relationships,   occupational   and  social  
impairment  with  reduced  reliability   and  productivity,   chronic  sleep  
impairment,  weekly  panic  attacks,  anxiety,  and  depressed   mood.    
(Exhibit  10D).  
In  the  most  recent  VA  rating  decision  dated  May  16,  2015,  the  claimant  
received   a  temporary  100  percent   disability  rating  from  the  VA  based  
on  his  admission  to  the  PTSD  Intensive  Outpatient  Program,  PRRTP  
from  March  31,  2015  through  May  19,  2015  for  PTSD.   The  rating  
decision  explained  that  an  evaluation  of  50  percent  was  assigned  from  
August   1,  2010;;  an   evaluation  of  100  percent  was  assigned  from  
March  31,  2015;;  and  an  evaluation  of  50  percent  was  assigned  from  
June   1,  2015.  The  claimant's  overall  combined  rating  was  50  percent  
for  occupational   and  social  impairment  with  reduced  reliability   and  
productivity   due  to  specific   symptom  [sic]  such  as  flattened  affect,  
circumstantial,   circumlocutory,   or  stereotyped  speech;;  panic   attacks  
more  than  once  a  week;;  difficulty  in  understanding   complex  
commands;;  impairment   of    short  and   long-­term  memory;;   impaired  
judgment;;   impaired   abstract  thinking;;  disturbances  of  motivation  and  
mood;;  difficulty  in  establishing  and  maintain   effective  work  and  social  
relationships.  (Exhibit   13F).  
On  December  9,  2015,  the  claimant  underwent  a  psychiatric  
evaluation  by  VA  psychiatrist  Gregory  W.  Cummings,   M.D.  It  is  
noteworthy  that,   in  the  record  of  the  evaluation,  Dr.  Cummings  wrote  
that  the  claimant  identified  with  every  symptom  noted,  i.e.,  sleep  
disturbance,  loss  of  interest,  guilty  ruminations,  poor  energy  level,  
decreased  concentration,  anhedonia,  psychomotor   retardation,  
change  in  appetite,  and  suicidal  thinking.  However,  on  mental  status  
examination  of  the  claimant  Dr.  Cummings  wrote  that  the  claimant  was  
alert  and  oriented  in  all  spheres,  that  he  maintained  adequate  eye  
contact,  that  there  was  no  obvious  psychomotor  abnormality,  that  the  
claimant's  thought  processes  were  logical  and  goal-­directed   and  
without  evidence   of  thought  disorder  or  perceptual  disturbances,  that  
his  cognition   was  grossly  intact  in  terms   of  immediate,  recent,  and  
remote  memory   functioning,  that  his  insight  was   good,   and  that   his  
judgment  and  impulse  control  were  adequate.   The  only  abnormalities  
Dr.  Cummings  noted   were  that  of  a  depressed  mood   with  a  sad  and  
tearful  affect.  Dr.  Cummings  diagnosed  the   claimant  with  chronic  
PTSD  and  Major  Depressive  Disorder,  recurrent,  moderate.  (Exhibit  
21F).  
The  record  contains  correspondence  from  the  Department  of  Veterans  
Affairs,  Central  Arkansas   Veterans   Healthcare   System,  dated  
February  1,  2016,  which   indicates  that  the   claimant 's  mental  health  

8

provider  submitted   an  application   for  the  claimant  for  the  PTSD  
Domiciliary   Program   at   Central  Arkansas  Veterans  Healthcare  System  
in  North  Little  Rock,  Arkansas.   (Exhibit   18E).  
The  State  agency  psychological  consultant,   M.  Hope  Jackson,   Ph.D.,  
who  examined  the  evidentiary  record  on  August   1,  2014,  concluded  that  
the  claimant  possessed  the  severe   impairments   of  Affective   Disorders  
and  Anxiety  Disorders.   With  respect  to  the  “B”  criteria,  Dr.  Jackson  
opined  that  the  claimant  had  moderate  restriction   of  activities  of  daily  
living,  moderate   difficulties  in  maintaining  social  functioning  and  in  
maintaining   concentration,  persistence,  or  pace,  and  no  repeated  
episodes  of  decompensation.  In  the  Mental   Residual  Functional  Capacity  
Assessment   dated   August   1,  2014,  Dr.   Jackson   opined  that  the  claimant  
was   able  to  understand,   remember,   and  carry  out  short  and  simple  
instructions,  that  he  was  able  to  concentrate  and  attend   for  two-­hour  
periods,  that  his  contact  with  the  general  public  should  not  be  a  usual  job  
duty,  that   supervision  should  be  direct  and  non-­confrontational,  and  that  
his  work  setting  changes  should  be  minimal,  gradual,  and  fully  
explained.   (Exhibits  2A  and  4A).  
The  undersigned  propounded   medical   expert  interrogatories  to  clinical  
psychologist  John  W.   Davis,  Ph.D.,  on  October  16,  2015.   In  his  
responses   to  the  interrogatories  on  October   31,  2015,   Dr.  Davis  stated  
that,  some  20  years   after  his  discharge  from  the  Army,  the  claimant  
became   aware  that  he  had   PTSD.  Dr.  Davis  indicated  that  this  
diagnosis  seemed  to  be  based   on  the   opinion  of  one  main  treatment  
provider.  Dr.  Davis  pointed  out  that  the  claimant  admitted  to   essentially  
every  PTSD  symptom  that  he  was  asked  about,  and  that  he  had  also  
periodically  been   diagnosed  with   OCD  and  Depression.   Dr.  Davis  
noted  that  the  claimant  had   seldom  been   hospitalized   for  issues,  and  
that   a  review  of  the  records  revealed  that  mental  status  examinations  
were  essentially  within  normal   limits.    (See  Exhibit  3F  at  page  4  and  89;;  
4F  at  pages  92,   102,   131,  and   155;;  10F  at  pages  25,  71,   84,  and   109;;  
14F  at  pages   5,  9,  11,  and   13).    Dr.   Davis  further   noted  that  the  claimant  
worked  for  many  years  after  his  discharge.  Dr.  Davis  stated  that  he  
considered   Listings   12.04  and   12.05,  but  he  was  unable  to  find  support  
for  meeting  or   equaling  a  listing.  Dr.  Davis  further  opined  that  the  
claimant  had  mild  restriction   of  activities  of  daily  living,  mild  difficulties  in  
maintaining  social   functioning,  mild  difficulties  in  maintaining  
concentration ,  persistence,  or  pace,  and  no  repeated   episodes  of  
decompensation.   Finally,  Dr.  Davis  opined  that  the  claimant  was  
capable  of  returning  to  previously  held  jobs  or  any  one  step  or  two  step  
repeat  jobs.  (Exhibits  17F  and  18F).  
In  conjunction  with  his  interrogatory  responses,  Dr.  Davis  completed  a  

9

Medical   Source  Statement  (MSS)  of  the  claimant's  ability  to  do  work-­
related   mental  activities.  In  the  MSS,  Dr.  Davis  opined  that  the  
claimant's  abilities  to  understand,   remember,  and  carry  out  complex  
instructions,  to  make  judgments   on  complex  work-­related   decisions,  to  
interact  appropriately  with  the  public,   supervisors,  and  co-­workers,  and  
to  respond   appropriately  to  usual   work  situations  and  to  changes  in  a  
routine  work  setting  were  only  mildly  impaired.  Dr.  Davis  further  opined  
that  the  claimant's  abilities  to  understand,  remember,  and  carry  out  
simple  instructions   and  to  make  judgments   on  simple  work-­related  
decisions  were  not  impaired.  (Exhibit   18F).  
Based  on  the  claimant's  representative's  objection  to  Dr.  Davis'  
interrogatories  and  the   representative's  request  that  he  be  allowed  to  
cross-­examine  Dr.  Davis  regarding  his  interrogatory  responses,  Dr.  
Davis  appeared  and  testified  as  a  medical  expert  witness  at  a  
supplemental  hearing  held  on  February  24,  2016.  (Exhibit  16E).  Dr.  
Davis  stated  that  he  had  read  the  file  and  had  listened  to  the  
claimant's  testimony  at  the  October  16,  2015  hearing.  In  his  hearing  
testimony,  Dr.  Davis  stated  that  he  knew  Dr.  Douglas  Ewing,  the  
claimant's  VA  psychiatrist,  and  that  he  considered  Dr.  Ewing  to  be  a  
competent  psychiatrist.  However,  Dr.  Davis  testified   that  he  was  
unable  to  give  Dr.  Ewing's   opinion  that  the  severity  of  the  claimant's  
PTSD  rendered  him  unable  to  engage  in  employment   great  weight  for  
two  main  reasons.  First,   Dr.  Davis  pointed  out  that  the  fact  that  the  
claimant  presented   with  severe  symptoms   of  PTSD  after  working  20  
years  was  very  unusual.  Second,  Dr.  Davis  stated  that  throughout  the  
record   in   this  case,  including  the  most  recent  evidence  submitted  in  
Exhibit  21F,  the  notes  consistently  reflect  that  the   claimant's  mental  
status  exam  is  completely  normal.  Dr.  Davis  noted  that  the  claimant  
had  been  seen  and  examined  by  numerous  treatment  providers  who  
found  the  claimant's  mental   status  exam  to  be  completely  normal.  Dr.  
Davis  testified  that  those  are  the  factors  upon  which  he  based  his  
opinions  in  the  medical  expert  interrogatories,  as  well  as  his  conclusion  
that  Dr.  Ewing's  opinions  could  not  be  assigned  much  weight.  
The  undersigned   points  out  that,  in  his  examination   of  Dr.  Davis,  the  
claimant's  representative  endeavored  to  elicit  testimony  from  Dr.  Davis  
on  the  issue  of  whether  “ delayed  onset   PTSD”  is  a   legitimate   disorder  
and,  as  such,  provides  an  explanation  for  the  fact  that  the  claimant  did  
not   present   for  treatment  of  his  disorder  until  17  years  after  his  military  
service  ended.  In  his  February  25,  2016  brief  in  which  he  objected  to  the  
medical  expert  interrogatories   completed  by   Dr.  Davis  on  October  31,  
2015  and  to  the  medical  testimony   given  by  Dr.  Davis  at  the  February  
24,  2016   hearing,  the   claimant's  representative  stated  that  Dr.   Davis  

10

“ refused  to  believe  that  late  onset  PTSD  is  a  legitimate   disorder,  but  
admitted   in  his  hearing  testimony  that  there  was  a  debate  about  that  
issue  within  the  psychiatric   community.”   (Exhibit   19E).  This  assertion  
somewhat   mischaracterizes   Dr.  Davis'  testimony   on  this  issue.  A  review  
of  Dr.  Davis'  testimony  reveals  that  he  did  not  take  a  firm  position   on  
the  issue.  Rather,  he  pointed   out  that  there  was  a  lot  of   disagreement  
about  the  issue  in  the  psychiatric   community  because   some  thought  that  
it  was  possible,  but  others  thought  that  it  was  unusual   not  to  have  any  
symptoms  and  then  20  years  later,  after  a  20-­year  work  history,  to  begin  
having  those  problems.   Dr.  Davis  simply  reiterated  that  this  was  one  of  
the  factors  in  evidence  in  this  case  he  relied  on  in  forming  his  opinions  
regarding  the  severity  of   the  claimant's  mental  impairments  and  
corresponding   functional   limitations.  
The  claimant's  representative   also  questioned   Dr.  Davis  regarding  the  
potential   effects  the  combination  of  several  prescribed   medications  could  have  
on  an  individual.  The  claimant's  representative  pointed   out  that  the  record  
indicated  that  the  claimant  was  currently  being  prescribed   four  different  
medications  for  mental  health  conditions  (Exhibit  21F  at  page   1)  and  asked  Dr.  
Davis  about  the  potential   side  effects  of  those  medications.  Dr.  Davis  testified  
that  those  medications  could  potentially   affect  the  claimant's  energy,   cause  
drowsiness,  and  impair   his  ability  to  operate  an  automobile.     When  asked  
about  the  potential   interaction  and  effects  of  a  combination  of  prescribed  
medications,   Dr.  Davis  testified  that  the  combination  of  six  medications  had  an  
80  percent  probability   of  negative  interaction,  and  a  combination  of  eight  
medications  had   a  100  percent  probability   of  negative  interaction.    Dr.  Davis  
also  testified  that,   since  the  claimant  was  taking  four  medications   for  his  
mental  health  problems,  as  well  as  other  medications   for  diabetes,   it  was  
“probable”  that  the  combination   of  medications   could  have  a  negative  impact  
on  the   claimant's   day  to  day  functioning.   In  his  February  25,  2016  brief,  the  
claimant's  representative  noted  that   Exhibit   21F  reflected  that  the  claimant  is  
currently  taking   more  than   eight  medications.   However,  of  the  numerous  
medications  the   claimant's   representative  listed  from  Exhibit  21F,  only  four  of  
those  medications  are  clearly  prescribed   for  the  claimant's  mental  health  
symptomatology,  while  three  could  be  prescribed   for  either  the   claimant's  
hypertension   or  anxiety,  and  many  are  benign  medications  such  as  aspirin,  
vitamin  D,   a  topical  analgesic  cream,  a  non-­steroidal   anti-­inflammatory   drug,  
and  an  enzyme  for  lactose   intolerance.   Nevertheless,   the  claimant's  
representative   again  mischaracterized   Dr.  Davis'   testimony   when  he  stated  
that  “Dr.  Davis  declined  to  opine  on  how  that  would   impact  the  Claimant."   As  
noted   above,  Dr.   Davis   stated  that  it  was  “probable”  that  the  combination   of  
the   claimant's  medications  could  have   a  negative   impact  on  the   claimant's  
day  to  day  functioning,  and  Dr.  Davis  further  indicated  that  the  opinions  he  
provided   in  his  responses  to  the  ME  interrogatories  remained  unchanged.  The  

11

undersigned   has  considered  all  of  Dr.  Davis'  opinions  and  testimony,  including  
his  statement  at  [sic]  to  the  probability   of  the  negative   impact  of  the   claimant's  
numerous  prescription  medications  on  his  functional   capacity,  and  has  
assigned  Dr.  Davis'  opinions  partial   evidentiary  weight.  
Finally,  the  claimant's  representative   argued  that  Dr.  Davis'   opinions  in  his  
responses  to  the  ME  interrogatories  and  in  his  hearing  testimony   were  not  
consistent  with  “the  other  evidence  of  record.”  The  representative  went  on  to  
list  the  claimant's  subjective  complaints   of  symptoms   recorded  in  the  March  
25,  2014  treatment  note  in  Exhibit  3F  at  pages  2-­3.  While  Dr.  Davis'   opinions  
may  not  be  consistent  with  the  claimant's  subjective  complaints  of  symptoms  
or  with  Dr.  Ewing's  opinions  that  the  claimant's  mental  impairments   prevent  
him  from  being  employable,   his  opinions  are  consistent  with  the  documented  
results  of  mental  status   examinations  performed   by  numerous  mental  health  
treatment  providers  throughout  the  relevant  period  under   consideration.    
Additionally ,  Dr.  Davis'  opinions  do  not  concern  issues  reserved  for   the  
Commissioner,   as  do  Dr.  Ewing's   opinions.  
*  *  *  
In  social  functioning,  the  claimant  has  moderate  difficulties.  The  
claimant  has  alleged  that  he   has  difficulty  getting  along  with  others,  that  
he  is  quick-­tempered,   and  that  he  does  not  like   crowds.     (Exhibits  8E  
and  14F  at  page   8).  The  claimant's  wife  also  reported   that   she  
observed  the  claimant   demonstrate   similar  issues  in  the  past.  (Exhibits  
2E  and  4E).   However,  during  the  claimant's  2015  residential   PTSD  
treatment   program   at  the  VA,  the  mental   health  treatment  providers  
noted  that  the  claimant  progressed   in  increasing  socialization  with  his  
peers.  (Exhibit  12F  at  page  36).  The  claimant  has  also  reported   that  he  
attends  church.  (Exhibit   8E).  There  is   no  direct  evidence  that  the  
claimant  has  demonstrated  an  inability  to  interact  with  others  on  at  
least  a  basic  level  sufficient  to  allow  him  to  shop  for  his  personal   needs,  
drive  an  automobile,  attend  medical  appointments,  and  attend   church.  
Dr.  Jackson,  the  State  agency  psychological  consultant,  opined  that  
the  claimant  had  a  moderate  degree  of  restriction  in  his  ability  to  
maintain  social  functioning.  The  non-­examining  medical  expert  
witness,  Dr.  Davis,  opined  that  the   claimant  had  …    mild  difficulties  in  
maintaining  social  functioning.  (Exhibit  18F).  The  examining   VA  
psychologist,  Dr.  Jennifer  Jackson,  opined  that    the  claimant's  
“occupational  and  social  impairment”  caused  “reduced  reliability  and  
productivity,”    which  indicates  some  degree  of  functional  impairment,  
but  not  severe  or  debilitating  impairment  that  would  totally  preclude  
reliability  and  productivity.  (Exhibits  2A,  4A,  and  7F).  Therefore,  the  
undersigned  concludes  that  the  opinion  of  the  examining   VA  
psychologist   is  consistent  with  a  moderate  degree  of  impairment  in  this  

12

area  of  functioning.  
With  regard  to  concentration,  persistence   or  pace,  the  claimant  has  moderate  
difficulties.  The   claimant  reported  that  he  has  difficulty  paying  attention.    
(Exhibit  8E).  During  the   claimant's  2015  residential   PTSD  treatment  program  at  
the  VA,  the  mental  health  treatment  providers   noted   that  the  claimant  was  
mostly  attentive  to  the  group  discussions,   although  he  appeared  to  struggle  
with  wakefulness  at  times.  (Exhibit  12F  at  page   37).   None   of  the  treating  or  
examining  mental  health  providers   observed  that  the  claimant  demonstrated  
any  deficiencies   in  his  ability  to   maintain   concentration   and  attention  during  
mental  status  examination.  For  example,  on  mental  status  examination  of  the  
claimant  on  October  20,  2014,  VA  staff  psychologist   Dr.   Susan  Rhodes  
observed  that  the  claimant's  attention,   concentration,   and  memory  appeared  
adequate.  (Exhibit  10F  at  pages  83-­84).  Dr.  Davis  opined  that  the  claimant  had  
mild  difficulties   in  maintaining  concentration ,  persistence,   or  pace.  (Exhibit  
18F).   The  State  agency  psychological   consultant   opined  that  the  claimant  had  
a  moderate   degree  of  restriction  in  his  ability  to  maintain   concentration,  
persistence,   or  pace.  (Exhibits  2A  and  4A).  
*  *  *  
5.      After  careful  consideration  of  the  entire  record,  the  
undersigned  finds  that  the  claimant  has  the  residual  
functional  capacity  to  perform  medium  work  as  defined  in  20  
CFR  404.1567(c)  and  416.967(c)  except  the  claimant  is  
unable  to  climb  ladders,  ropes,  or  scaffolds;;  the  claimant  can  
occasionally  climb  ramps  or  stairs;;  the  claimant  can  
occasionally  stoop,  kneel,  crouch,  and  crawl;;  the  claimant  
can  have  no  exposure  to   unprotected  heights  or  hazardous  
machinery;;  the  claimant  is  limited  to  simple,  routine  tasks;;  
the  claimant  can  tolerate  occasional  changes  in  a  routine  
work  setting;;  the  claimant  can  have  no  direct  interaction  with  
the  public;;  and  the  claimant  can  work  in  close   proximity  to  
others  but  he  must  work  independently,  not  in  a  team.  

*  *  *  
The  claimant  testified  that  the  primary  problem  that  prevents  him  from  
working  is   that  he  goes  to  mental   health  classes  a  lot.  The  claimant  
also  alleged  that  he  takes  three   medications   for  anxiety  three  times  a  
day,  two   medications  to  help  him   sleep,  and  medications   for  high  
blood  pressure,   diabetes,  cholesterol,  and  for  his  back  and  chest.    The  
claimant  testified   that  the  medications   slow  him  down  and  cause  him  
not  to  be  quick  to  get  angry  and  make  him  calmer.  The   claimant  also  
testified  that  he  was  overwhelmed  by  situational  stressors  related  to  
his  incarceration  for  domestic  violence  and  the  requirement  to  attend  

13

classes  related  to  legal  charges,  as  well  as  to  his  cancer   diagnosis,  
which  was  more  than  he  could  handle.  However,  the   claimant   stated  
that  he  did  not  think  anything  was  wrong  with  him,  that  he  had  issues  
to  deal  with  that  no  one  understood.  

*  *  *  
Additionally,   the  undersigned   finds  that,  in  order  to  accommodate   the  
claimant's  affective  and   anxiety  disorders,  the  claimant  is  limited  to  the  
performance   of  simple,  routine  tasks  and,  although  he   can  tolerate  
occasional  changes  in  a  routine  work   setting,  his  mental  health  
symptomatology  associated  with  his  PTSD  and  depression  requires  
that  he  have  no  direct  interaction  with  the  public.  Moreover,  although  
the  claimant  can  work  in  close  proximity  to  others,  he  must   work  
independently,  not  in  a  team.  
These  non-­exertional   limitations  are  consistent  with  and  supported  by  
the  medical  evidence  of  record,  including  the  documented  results  of  
mental  status  examinations   performed   in  2014  and  2015,  documented  
observations  of  the  claimant's  mental  health  treatment  providers,   the  
opinions   of  the  examining  VA  psychologist,   Dr.  Jennifer  Jackson,  the  
opinions  of  the  non-­examining   State   agency  psychologist ,  Dr.  Hope  
Jackson,  and  the  opinions  of  the  medical   expert  witness,  clinical  
psychologist   Dr.  John  Davis.  Dr.  Jennifer  Jackson  concluded  that  the  
claimant  had  “occupational   and  social  impairment   with  reduced  reliability  
and  productivity”  secondary  to  his  PTSD  and  depression.     While  her  
opinion  reflects  a  reduction   in  the  claimant 's  mental   functional   capacity,  
it  does  not  indicate  that  the  claimant  was  precluded   from  understanding,  
remembering,  and  carrying  out  short  and  simple  instructions  or  from  
concentrating  and  attending  for  two  hour  periods,  which  is  the  mental  
residual  functional   capacity  the  non-­examining  State  agency  
psychologist,   Dr.  Hope  Jackson,   assigned  the  claimant.     Dr.  Hope  
Jackson's  mental  residual  functional   capacity  is  wholly   consistent   with  
Dr.  Jennifer  Jackson's  opinion  of  the  claimant's  mental  capacity  
because   Dr.  Hope  Jackson  also  concluded  that  the  claimant's  contact  
with  the  general  public  should  not  be  a  usual  job   duty  and  work  setting  
changes  should  be  minimal,   gradual,  and  fully  explained,  which  
correlates  to  Dr.  Jennifer  Jackson 's  assessment   of  the  level   of  the  
claimant's  occupational   and  social  impairment.  
In  making  this  finding,  the  undersigned   has  considered   all  symptoms  
and  the  extent  to  which  these  symptoms  can  reasonably  be  accepted  
as  consistent  with  the  objective  medical   evidence  and  other  evidence,  
based  on  the  requirements   of  20  CFR  404.1529   and  416.929  and  SSR  
96-­4p.   The  undersigned   has  also  considered   opinion  evidence  in  

14

accordance  with  the  requirements   of  20   CFR  404.1527  and  416.927  
and  SSRs  96-­2p,  96-­5p,  96-­6p  and  06-­3p.  
In  reaching  a  conclusion  as  to  the  claimant's  degree   of  functional  
limitation   in  the  “B  criteria,”  as  well   as  to  the  claimant's  mental  residual  
functional   capacity,  the  undersigned   carefully  considered  the  correlation  
of  the  objective  medical   evidence   such  as  mental  status  examination  
findings  and  documented   observations   of   the  claimant  by  the  mental  
health  treatment  providers   throughout  the  relevant   period  under  
consideration   with  the  numerous  opinions  from  treating,   examining,  and  
non-­examining   sources  in  the  record.  The  undersigned   has  assigned  
great  weight  to  the  opinions  of  the  non-­examining  State  agency  
psychological   consultant,   Dr.  Hope  Jackson,  in  Exhibits  2A  and  4A.     Dr.  
Jackson's  opinions  regarding  the  claimant's  mental  capacities  and  
limitations  are  generally  consistent   with  the  totality   of  the  medical  
evidence   of  record,  as  well  as   being  consistent  with  the  information  
received   at  the  hearing  level.  Dr.  Jackson's  opinions  of  no  greater  than  
moderate  limitation   in  any  functional  area,  as  well  as  her  opinions  of  the  
claimant's   mental  residual  functional  capacity,  are  consistent  with  and  
supported  by  the  preponderance   of  the  evidence   in  this  case.  
The  undersigned  has  also  assigned  great  weight  to  the  opinion  of  the  
examining  VA   psychologist,  Dr.  Jennifer  Jackson,  who  completed  an  
Initial  PTSD  Disability  Benefits  Questionnaire  on  the  claimant  on  June  
19,  2014  and  opined  that  the  claimant's  PTSD  and  Unspecified  
Depressive  Disorder  caused  “occupational  and  social  impairment  with  
reduced  reliability  and  productivity.”  (Exhibit  7F  at  pages  39-­46).   Dr.  
Jackson's  opinion  is  generally  consistent  with  the  record  as  a  whole  
and  with  the  claimant's  residual  functional  capacity,  as  well  as  being  
supported  by  relevant  evidence  of  record.  

*  *  *  
The  undersigned  has  assigned  partial  weight  to  the  opinions  of  the  non-­
examining  medical  expert  witness,  Dr.  John  Davis,  as  set  out  in  his  
responses  to  the  medical  expert  interrogatories,  which  includes  his  
opinions  in  the  mental  RFC  form,  as  well  as  his  testimony  at  the  
supplemental  hearing.   Dr.  Davis'  opinions  are  based  on  his  review  of  
all  the  medical  evidence  of  record  and  a  summary  of  the  claimant's  
hearing  testimony.   The  additional  mental  limitations  in  the  claimant's  
residual  functional   capacity,  beyond  those  endorsed  by  Davis,  
accommodate  the  claimant's  subjective  complaints  that  are  consistent  
with  the  information  recorded  by  the  VA   mental  health  treatment  
providers  and  the  examining  psychologist,   Dr.  Jackson.  Dr.  Davis'  
assessment  of  the  claimant's  degree  of  functional   limitation   in  the  “B”  

15

criteria  slightly  understates  the  claimant's  degree  of  limitation  as  
reflected   in  the  treatment  records,  but  his  opinion  that  the  claimant  can  
do  “simple  repeat  jobs,”  is  consistent   with  the  totality  of  the  medical   and  
other   evidence  of  record,  including  the  claimant's   own  reports   of  his  
activities  of  daily  living.  For  these  reasons,   as  well  as  those  previously  
set  forth  above  in  this  decision,  Dr.  Davis'  opinions  can  be  afforded  only  
partial   evidentiary  weight.  
The  undersigned   recognizes  that  20  CFR  404.1527(d)(2),  
416.927(d)(2),   and  Social  Security  Ruling  96-­2p  require  that  a  treating  
source's  medical   opinion   on  the  nature  and   severity   of  a  claimant's  
impairments  must  be  given  controlling  weight  if  it  is  well-­supported  by  
medically  acceptable  clinical  and  laboratory  techniques  and  is  not  
inconsistent  with  other  substantial  evidence  in  the  record.  Substantial  
weight  must  be  given  to  the  opinion,  diagnosis,  and  medical  evidence  
of  a  treating  physician  unless  there  is  good  cause  to  do  otherwise.    
Good  cause  exists  if   the  opinion  is  not  bolstered   by  the  evidence,  the  
evidence   supports  a  contrary  finding,  or  the  opinion  is  conclusory   or  
inconsistent  with  the  physician's  own  medical  records.  (Phillips  v.  
Barnhart,  357  F.3d   1232,  1241,  1242  (11th  Cir.  2004);;  Lewis  v.  
Callahan,  125  F.3d   1436,  1439-­1441  (11th  Cir.  1997).  
The  undersigned   finds  that,  in  the  present   case,  good  cause  exists  to  
justify   not  assigning  controlling  evidentiary   weight  to  Dr.  Ewing's  
opinions  in  Exhibits   12E,  4F,  5F,  and  9F.  In  fact,  the  undersigned  has  
assigned  only  partial   weight  [to]  Dr.  Ewing's   opinions.  Dr.  Ewing's  
opinions  that  the  clamant  is  “totally  incapacitated  for  further  
performance   of  his  duty”  and  is  incapable  of  “functioning   in  the  
workplace”  obviously   indicate  that  the  claimant's  mental   impairments  
cause  him  some  functional   limitations,  but  those  opinions  concern  
issues  reserved  to  the  Commissioner.  Social  Security  Rulings  96-­2p  
and  96-­5p  indicate  that  a  physician's   opinion  on  issues  reserved  to  the  
Commissioner   of  Social  Security  is  never   entitled  to  controlling  weight  
or  special  significance.    Examples  of  opinions  that  may  not  be  given  
controlling  weight  are   opinions  about  what  an  individual 's  residual  
functional   capacity  is  and  whether  an  individual  is   disabled.    
Therefore,  those  opinions  cannot  be  given  controlling  weight.     Although  
Dr.  Ewing's  opinions  in  the  April  9,  2014  letter  and  the   April  2014  and  
July  2015  forms  provide  no   quantifiable  mental  functional  limitations  
and  are  conclusory,  those  opinions  can  be  accepted  only  to  the  extent  
they  reflect   at  most  moderate   limitation.  
The  undersigned  further  finds  that  Dr.  Ewing's  opinions  are  without  
objective  or  persuasive  corroborating  evidence  in  the  longitudinal  
record.  Dr.  Ewing's  statements  that  the  claimant  experiences  

16

“significant  distress  related  to  his  PTSD,”  symptoms  of  “poor  
concentration,”  “persistent  morbid  thoughts,”  and  “chronic  suicidal  
ideation,”  are  not  supported  by  the  information  recorded  in  his  own  
treatment  records,  or  in  the  treatment  records  of   the  claimant's  
treating  psychologist,   Dr.   Susan  Rhodes.  Dr.  Ewing's  and  Dr.  Rhodes'  
treatment  notes  contain  no  significantly  abnormal   mental   status  
examination  findings  or  documentation  of  complaints  of  severe  mental  
health  symptoms.  The  claimant  saw  Dr.  Ewing  on  April  9,  2014  and  
reported  an  exacerbation  of  his  PTSD   symptoms  over  the  previous  
two  weeks.  However,  the  claimant's   MSE  was  within  normal   limits,  
with  the  claimant's  reported   as  being  “better  now.”    (Exhibit  4F  at  
pages  90-­93).     A  VA  mental  health  nursing  note  dated  April  28,  2014  
reflects  that  the  claimant  scored  a  4  on  the  PHQ-­9  depression   screen,  
which  was  suggestive  of  no  depression.     (Exhibit  4F  at  page   89).    On  
July  7,  2014,  Dr.  Ewing  noted  that  the  claimant   was  less  anxious  and  
irritable   and  that  he  reported   overall  better  mood  and  sleep,  even  
though  he  continued  to  experience  nightmares   at  variable  frequency.    
Dr.  Ewing  also  noted  that  the  claimant's   MSE  on  that  date  was  within  
normal  limits.  (Exhibit  7F  at  pages  37-­38).   Although  the  claimant  
reported  having  “self-­injurious  thoughts”  at  his  September  22,  2014  
visit  with  Dr.  Ewing,  no  observations  of  abnormal  behavior  and  no  
abnormal  MSE  findings  were  recorded.  In  fact,  Dr.  Ewing  noted  that  
the  claimant's  mood  brightened  during  the  visit,  that  he  smiled  
broadly,  and  that  he  denied  active  suicidal  intent.   (Exhibit  7F  at  page  
19).  
Statements  made  by  the  claimant's  treating  VA  psychologist,   Dr.  
Rhodes,  in  her  June  30,  2015  treatment  note  bolster   one  of  the  reasons  
that  Dr.  Davis'  gave  as  basis   for  discounting  Dr.  Ewing's  opinions,   i.e,  
that  Dr.  Ewing  assumed  the  role  of  advocate  for  the  claimant.     In  her  
treatment  note,  Dr.  Rhodes  addresses  the  claimant's  concern  that  she  
did  not  complete   a  form  regarding  the  claimant's  Compensation  and  
Pension   claim  because   she  did  not  believe  the  claimant  deserved  or  
needed  the  disability  pension.  Dr.  Rhodes  explained  that  she  had  been  
told  by  her  management  that  completing  the  disability   evaluation  form  
was  a  “conflict  of  interest”  and  was  supposed  to  be  completed  by  his  
C&P  examiners  only.  (Exhibit  10F  at  page   106).  
At  the   supplemental   hearing,   and  in  his  February  25,  2016  post-­hearing  
brief,  the  claimant's   representative   sought  to  discount  Dr.   Davis'  
opinions  alleging  that  Dr.   Davis  “downplayed”  the  claimant's  inpatient  
mental  health  treatment   at  the  VA  facilities,  the  most  recent  of  which  
was  in   March  2015,  with  an  upcoming   admission  scheduled  for  some  
time  in  the  near  future.  However,  the  information  contained   in  the  VA  
treatment   records  bolsters   Dr.   Davis'  opinion  that  the  claimant's  

17

admissions   to  the   VA  PTSD  treatment   programs   did  not  tend  to  support  
Dr.   Ewing's  opinions.  Specifically,  the   VA  treatment  records  document  
that,  prior  to  his  admission  to  the  PRRTP  program   on  March  31,  2015,  
the  claimant  was  initially  denied  acceptance   into  the  residential   program  
in  2014  because  he  had  not  attempted  a  lower  level  of  care.  (Exhibit  10F  
at  page  47).  The  claimant  was  referred  back  to  his  primary  mental  
health  care  provider  to  explore  other  treatment  options.  Next,  the  record  
shows  that  the  claimant  postponed   his  admission  to  the  residential  
treatment  program  for  over  three  months.  The  VA  records  document  that  
the  claimant  was  scheduled  for  admission  to  the  PTSD  clinic  on  
December   19,  2014,  but  the  claimant  requested  a  later  date.  The  
claimant  was  given  a  new  admission  date  of  January  30,  2015,  but  he  
again  postponed  the  admission.   (Exhibit   1OF  at  pages  51,  55,  and  68).  
It  is  more  than  reasonable  to  expect  that  the  claimant  would  not  have  
repeatedly  postponed   his  admission  to  the  PTSD  clinic/program,  and  for  
such  a  prolonged   period   of  time,  if  he,   in  fact,  experienced  the  mental  
health  symptomatology   in  the  severity,  frequency,  and  duration  that  he  
alleged.  The  claimant'  s  allegations   form  the  basis  for  Dr.  Ewing's  
opinions  that  the   claimant  has   significant   and  incapacitating  mental  
health  symptomatology.  Therefore,  the  undersigned   finds  that  the  
claimant's  actions  both  undermine  support  [for]  Dr.  Ewing's  opinions  
and  bolster  those  of  Dr.  Davis.  (Exhibit  10F  at  pages  74-­77).  

*  *  *  
The  claimant's  allegations  of  severe  functional  limitations  secondary  to  
ongoing  mental   health   symptomatology  are  also  not  fully  supported  by  
the  information   contained  in  the  medical   and   mental  health  treatment  
records.   It  is  well  established  that  the   claimant  has  received  formal  
mental  health  treatment  for  PTSD  and  depression   during  the  relevant  
period  under  consideration,  and  that  treatment   has  consisted  of  up  to  
four  psychotropic   medications,  PTSD   classes,  and  individual  therapy.    
Although  the  claimant  endorses  chronic  symptoms  of  PTSD  and  some  
depression  for  at  least  the  past   10  years,  he  was  able  to  work  
successfully,  without  significant  mental  limitation,  for  over  20  years  after  
he  completed  his  military   service.  The  undersigned's  conclusion  that  the  
claimant's  mental  impairments   cause  him  no  more  than  moderate  
functional  limitations  and  that  he  has  the  residual   functional   capacity   set  
out  above  in  this  decision  is   supported  by  the  opinions  of  the  examining  
psychologist,  Dr.  Jennifer  Jackson,  the  non-­  examining  State  agency  
psychological   consultant,  Dr.  Hope  Jackson,  and  the  non-­examining  
medical  expert,  Dr.  Davis.  
The  undersigned   finds  that  the   claimant's  symptoms  related  to  his  
mental   impairments  cause   moderate   limitations,  but  not  the  extreme  

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limitations  the  claimant  has  alleged  or  cited  by  his   treating  psychiatrist,  
Dr.  Ewing.  This  conclusion  is  supported  not  only  by  the  lack  of  
abnormal   mental   status  examination  findings  since  the  alleged  
disability  onset  date  and  by  the  opinions  of   the  examining   and  non-­
examining   psychologists,  but  also  by  the  claimant's   own   statements  
regarding  his  mental   impairments.  At  his  visit  with  his  psychiatrist  a  
little  over  six  weeks  prior   to  his  AOD,  the  claimant  made  no  complaints  
of  significant  mental  health  symptomatology,  other  than  feeling  a  bit  
depressed  over  his  diagnosis  of  prostate  cancer.  However,  the  next  
time  he  saw  his  psychiatrist,  approximately   seven  weeks  later,  the  
claimant  identified  a  litany  of  mental  health  symptoms,  with  no  obvious  
traumatic  or  triggering  event  reported.  However,   Dr.  Ewing  noted  that  
the  claimant's   MSE   on  March  25,  2014  was  remarkable   only  for  “low”  
mood  and  “mild  to  moderately   glum”  affect.  All  other  aspects  of   the  
claimant's  MSE  on  that  date  were   within  normal  limits.  A  VA  mental  
health  nursing  note  dated  April  28,  2014,  one  month  later,  reflects  that  
the  claimant   scored  a  “4”  on  the  PHQ-­9   depression   screen,  which  was  
suggestive  of  no  depression.  (Exhibits  4F  at  page   89  and  7F  at  page  
49).  
On  April  9,  2014,  the  claimant  reported   an  exacerbation  of  his  PTSD  
symptoms  over  the   previous  two  weeks.     However,  the  claimant's  MSE  
was  within  normal  limits,  with  the  claimant's   mood  reported   as  being  
“better   now.”   (Exhibit  4F  at  pages  90-­93).  At  the  claimant's  regularly  
scheduled  psychiatric   follow-­up  visit  on  July  7,  2014,  Dr.  Ewing  noted  
that  the  claimant  was  less  anxious  and  irritable  and  that  he  reported  
overall  better  mood  and  sleep,  even  though  he  continued  to  
experience  nightmares   at  variable   frequency.  Dr.  Ewing  also  noted  that  
the  claimant's  MSE  on  that  date  was  within  normal   limits.  (Exhibit   7F  
at  pages  37-­38).  Although  the  claimant  reported   having  “self-­injurious  
thoughts”  at  his  September  22,  2014  visit  with  Dr.  Ewing,  no  
observations  of  abnormal  behavior   and  no  abnormal  MSE  findings  
were   recorded.  In  fact,  Dr.  Ewing  noted  that  the  claimant's  mood  
brightened   during  the  visit,  that  he   smiled  broadly,  and  that  he  denied  
active  suicidal   intent.   (Exhibit  7F  at  page   19).  At  the  claimant's  visit  
with  Dr.  Ewing  on  May  20,  2015,  the  claimant  again  reported  that  he  
had  been  discharged  from  PRRTP  and  that  his  mood  and  sleep  were  
better  and  that  he  was  less  anxious/irritable.  Dr.  Ewing  again  noted  no  
abnormal  MSE  findings.  (Exhibit   10F  at  pages   115-­   116).  
At  the  October  16,  2015  hearing,  the  claimant  testified  that,  in  his  
opinion,  he  thought   nothing   was  wrong  with  him  mentally.   The  claimant  
did  not  provide  any  testimony  at  the  hearing  as  to  any  specific  mental  
limitations  or  symptoms,  aside  from  some  situational  anxiety  and  

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depression.  In  fact,  the  claimant's  hearing  testimony   is  generally  
consistent  with  Dr.  Davis'   opinions.  (See  Exhibit  7F  at  page  46).  

(Tr.  38-­44,  50-­51,  52-­60).  

V.    DISCUSSION  
A  claimant  is  entitled  to  an  award  of  SSI  benefits  if  the  claimant  is  unable  to  
engage  in  substantial  gainful  activity  by  reason  of  any  medically  determinable  
physical  or  mental  impairment  which  can  be  expected  to  result  in  death  or  last  for  
a  continuous  period  of  not  less  than  12  months.  See  20  C.F.R.  §  416.905(a).  The  
impairment  must  be  severe,  making  the  claimant  unable  to  do  the  claimant’s  
previous  work  or  any  other  substantial  gainful  activity  that  exists  in  the  national  
economy.  42  U.S.C.  §  423(d)(2);;  20  C.F.R.  §§  404.1505-­11.  “Substantial  gainful  
activity  means  work  that  …  [i]nvolves  doing  significant  and  productive  physical  or  
mental  duties  [that]  [i]s  done  (or  intended)  for  pay  or  profit.”  20  C.F.R.  §  404.1510.  
In  all  Social  Security  cases,  an  ALJ  utilizes  a  five-­step  sequential  
evaluation  in  determining  whether  the  claimant  is  disabled:  
(1)  whether  the  claimant  is  engaged  in  substantial  gainful  activity;;  (2)  
if  not,  whether  the  claimant  has  a  severe  impairment;;  (3)  if  so,  
whether  the  severe  impairment  meets  or  equals  an  impairment  in  
the  Listing  of  Impairment  in  the  regulations;;  (4)  if  not,  whether  the  
claimant  has  the  RFC  to  perform  her  past  relevant  work;;  and  (5)  if  
not,  whether,  in  light  of  the  claimant’s  RFC,  age,  education  and  work  
experience,  there  are  other  jobs  the  claimant  can  perform.        

Watkins  v.  Comm’r  of  Soc.  Sec.,  457  F.  App’x  868,  870  (11th  Cir.  2012)  (per  
curiam)  (citing  20  C.F.R.  §§  404.1520(a)(4),  (c)-­(f),  416.920(a)(4),  (c)-­(f);;  Phillips  
v.  Barnhart,  357  F.3d  1232,  1237  (11th  Cir.  2004))  (footnote  omitted).  The  claimant  
bears  the  burden  of  proving  the  first  four  steps,  and  if  the  claimant  does  so,  the  

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burden  shifts  to  the  Commissioner  to  prove  the  fifth  step.  Jones  v.  Apfel,  190  F.3d  
1224,  1228  (11th  Cir.  1999).    
If  the  claimant  appeals  an  unfavorable  ALJ  decision,  the  reviewing  court  
must  determine  whether  the  Commissioner’s  decision  to  deny  benefits  was  
“supported  by  substantial  evidence  and  based  on  proper  legal  standards.”  
Winschel  v.  Comm’r  of  Soc.  Sec.,  631  F.3d  1176,  1178  (11th  Cir.  2011)  (citations  
omitted);;  see  42  U.S.C.  §  405(g).  “Substantial  evidence  is  more  than  a  scintilla  
and  is  such  relevant  evidence  as  a  reasonable  person  would  accept  as  adequate  
to  support  a  conclusion.”  Id.  (citations  omitted).    “In  determining  whether  
substantial  evidence  exists,  [the  reviewing  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).  
The  reviewing  court  “may  not  decide  the  facts  anew,  reweigh  the  evidence,  or  
substitute  [its]  judgment  for  that  of  the  [Commissioner].”  Id.  When  a  decision  is  
supported  by  substantial  evidence,  the  reviewing  court  must  affirm  “[e]ven  if  [the  
court]  find[s]  that  the  evidence  preponderates  against  the  Secretary’s  decision.”  
MacGregor  v.  Bowen,  786  F.2d  1050,  1053  (11th  Cir.  1986).      

Robinson  asserts  one  ground  in  support  of  his  contention  that  the  ALJ  

erred  in  concluding  that  he  was  not  entitled  to  benefits:  he  argues  that  the  ALJ’s  
residual  functional  capacity  (“RFC”)  assessment  is  not  supported  by  substantial  
evidence  because  she  erred  in  her  evaluation  of  Dr.  Jennifer  Jackson’s  opinion  
regarding  his  mental  functional  limitations.  (Doc.  9  at  p.  3).  Conversely,  the  
Commissioner  asserts  that  the  ALJ  properly  applied  the  five  step  sequential  

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process  in  making  her  determination,  including  her  assessment  of  Robinson’s  
RFC.  After  concluding  that  Robinson  had  the  following  severe  impairments:  
prostate  cancer,  obesity,  diabetes  mellitus,  osteoarthrosis,  essential  hypertension,  
anxiety  disorders,  and  affective  disorders,  the  ALJ  found  Robinson  to  have  the  
RFC  to  perform  medium  work,  with  certain  limitations,  set  forth  as  follows:  
the  Plaintiff  is  limited  to  simple,  routine  tasks;;  the  Plaintiff  can  
tolerate  occasional  changes  in  a  routine  work  setting;;  the  
Plaintiff  can  have  no  direct  interaction  with  the  public;;  and  the  
Plaintiff  can  work  in  close  proximity  to  others  but  he  must  
work  independently,  not  in  a  team.  

(Tr.  52).    

A  claimant’s  RFC  is  “an  assessment  of  an  individual’s  ability  to  do  

sustained  work-­related  physical  and  mental  activities  in  a  work  setting  on  a  
regular  and  continuing  basis.”  SSR  96-­8p,  1996  WL  374184,  at  *1.  It  is  an  
“administrative  assessment  of  the  extent  to  which  an  individual’s  medically  
determinable  impairment(s),  including  any  related  symptoms,  such  as  pain,  may  
cause  physical  or  mental  limitations  or  restrictions  that  may  affect  his  or  her  
capacity  to  do  work-­related  physical  and  mental  activities.”  SSR  96-­8p,  1996  WL  
374184,  at  *2.  It  represents  the  most,  not  the  least,  a  claimant  can  still  do  
despite  his  or  her  limitations.  20  C.F.R.  §  404.1545;;  SSR  96-­8p,  1996  WL  
374184,  at  *2  (emphasis  added).  The  RFC  assessment  is  based  on  “all  of  the  
relevant  medical  and  other  evidence.”  20  C.F.R.  §  404.1545(a)(3).  In  assessing  a  
claimant’s  RFC,  the  ALJ  must  consider  only  limitations  and  restrictions  attributable  
to  medically  determinable  impairments,  i.e.,  those  which  are  demonstrable  by  
objective  medical  evidence.  SSR  96-­8p,  1996  WL  374184,  at  *2.  Similarly,  if  the  

22

evidence  does  not  show  a  limitation  or  restriction  of  a  specific  functional  capacity,  
the  ALJ  should  consider  the  claimant  to  have  no  limitation  with  respect  to  that  
functional  capacity.  Id.  at  *3.  The  ALJ  is  exclusively  responsible  for  determining  an  
individual’s  RFC.  20  C.F.R.  §  404.1546(c).  
Robinson  asserts  that  the  portion  of  the  RFC  that  addresses  his  mental  
limitations  was  not  supported  by  substantial  evidence  because,  while  according  
great  weight  to  the  opinion  of  Dr.  Jennifer  Jackson,  the  ALJ  did  not  include  all  of  
the  restrictions  she  assigned.  Specifically,  Robinson  argues  that  the  ALJ’s  mental  
RFC  assessment  did  not  properly  take  into  consideration  Dr.  Jennifer  Jackson’s  
opinion  that  he  has  difficulty  in  adapting  to  stressful  circumstances,  including  a  
work-­like  setting,  that  he  has  problems  with  concentration,  and  that  he,  at  times,  
exhibits  irritable  behavior  and  angry  outbursts.  (Doc.  9  at  p.  5).  It  is  well-­settled  
that  the  ultimate  responsibility  for  determining  a  claimant’s  RFC,  in  light  of  the  
evidence  presented,  is  reserved  to  the  ALJ,  not  to  the  claimant’s  physicians  or  
other  experts.  See  20  C.F.R.  §  404.1546.  “[T]he  ALJ  will  evaluate  a  [physician’s]  
statement  [concerning  a  claimant’s  capabilities]  in  light  of  the  other  evidence  
presented  and  the  ultimate  determination  of  disability  is  reserved  for  the  ALJ.”  
Green  v.  Soc.  Sec.  Admin.,  223  F.  App’x  915,  923  (11th  Cir.  2007);;  see  also  
Pritchett  v.  Colvin,  Civ.  A.  No.  12-­0768-­M,  2013  WL  3894960,  at  *5  (S.D.  Ala.  July  
29,  2013)  (holding  that  “the  ALJ  is  responsible  for  determining  a  claimant’s  RFC”).  
“To  find  that  an  ALJ’s  RFC  determination  is  supported  by  substantial  evidence,  it  
must  be  shown  that  the  ALJ  has  ‘provide[d]  a  sufficient  rationale  to  link’  
substantial  record  evidence  ‘to  the  legal  conclusions  reached.’”  Jones  v.  Colvin,  

23

CA  14-­00247-­C,  2015  WL  5737156,  at  *23  (S.D.  Ala.  Sept.  30,  2015)  (quoting  
Ricks  v.  Astrue,  No.  3:10-­cv-­975-­TEM,  2012  WL  1020428,  at  *9  (M.D.  Fla.  Mar.  
27,  2012)  (internal  quotation  marks  and  citations  omitted)).  
A  review  of  the  entire  record  reveals  that  the  ALJ  was  presented  with  
multiple  opinions  regarding  Robinson’s  mental  functional  limitations.  In  this  case,  
as  set  forth  above,  the  ALJ  discussed  the  medical  evidence  in  detail,  including  the  
weight  accorded  to  the  medical  opinion  evidence  and  the  grounds  therefor.  The  
ALJ  also  described  the  information  provided  by  Robinson  in  his  Function  Report  
and  at  the  hearing  concerning  his  limitations  and  activities,  and  she  explained  her  
reasons  for  finding  that  Robinson  was  not  entirely  credible.  Robinson  has  not  
actually  pointed  to  any  specific  finding  in  the  RFC  that  was  not  supported  by  
evidence.  Rather,  he  claims  there  is  evidence  that  supports  a  finding  of  more  
limitations  than  set  forth  in  the  RFC.  He  argues  that  the  mental  limitations  set  forth  
in  the  RFC  do  not  fully  take  into  account  Dr.  Jennifer  Jackson’s  opinion  that  
Robinson’s  PTSD  causes  clinically  significant  distress  or  impairment  in  social,  
occupational,  or  other  important  areas  of  functioning,  including  difficulty  in  
adapting  to  stressful  circumstances,  problems  with  concentration,  and  problems  
with  irritable  behavior  and  angry  outbursts.  (Doc.  9  at  p.  5).  However,  the  Court  
finds  that  the  ALJ’s  decision  demonstrates  that  she  did  take  these  opinions  of  Dr.  
Jennifer  Jackson  into  account  when  formulating  Robinson’s  RFC.  Specifically,  the  
ALJ  found:  
Additionally,   the  undersigned   finds  that,  in  order  to  
accommodate   the   claimant's  affective  and   anxiety  disorders,  the  
claimant  is  limited  to  the  performance   of  simple,  routine  tasks  
and,  although  he   can  tolerate  occasional  changes  in  a  routine  

24

work   setting,  his  mental  health   symptomatology  associated  with  
his  PTSD  and  depression  requires  that  he  have  no  direct  
interaction  with  the  public.  Moreover,  although  the  claimant  can  
work  in  close  proximity  to  others,  he  must   work  independently,  
not  in  a  team.  
These  non-­exertional   limitations  are  consistent  with  and  supported  
by  the  medical  evidence  of  record,  including  the  documented  
results  of  mental  status  examinations   performed   in  2014  and  
2015,  documented   observations  of  the  claimant's  mental  health  
treatment  providers,   the  opinions   of  the  examining  VA  
psychologist,   Dr.  Jennifer  Jackson,  the  opinions  of  the  non-­
examining   State   agency  psychologist ,  Dr.  Hope  Jackson,  and  the  
opinions  of  the  medical   expert  witness,  clinical   psychologist   Dr.  
John  Davis.  Dr.  Jennifer  Jackson  concluded  that  the  claimant  had  
“occupational   and  social  impairment   with  reduced  reliability   and  
productivity”  secondary  to  his  PTSD  and  depression.     While  her  
opinion  reflects  a  reduction   in  the  claimant 's  mental   functional  
capacity,  it  does  not  indicate  that  the  claimant  was  precluded   from  
understanding,   remembering,  and  carrying  out  short  and  simple  
instructions  or  from  concentrating  and  attending  for  two  hour  
periods,  which  is  the  mental  residual  functional   capacity  the  non-­
examining  State  agency  psychologist,   Dr.  Hope  Jackson,  
assigned  the  claimant.     Dr.  Hope  Jackson's  mental  residual  
functional   capacity  is  wholly   consistent   with   Dr.  Jennifer  Jackson's  
opinion  of  the  claimant's  mental  capacity  because   Dr.  Hope  
Jackson  also  concluded  that  the  claimant's  contact  with  the  
general  public  should  not  be  a  usual  job   duty  and  work  setting  
changes  should  be  minimal,   gradual,  and  fully  explained,  which  
correlates  to  Dr.  Jennifer  Jackson 's  assessment   of  the  level   of  the  
claimant's  occupational   and  social  impairment.  

(Tr.  53-­54).    
This  Court’s  role  in  review  of  claims  brought  under  the  Social  Security  Act  
is  a  narrow  one.  Having  reviewed  the  evidence  and  considered  the  arguments  
made  by  Robinson  and  being  mindful  of  the  admonishment  that  the  reviewing  
court  may  not  reweigh  the  evidence  or  substitute  its  judgment  for  that  of  the  
Commissioner,  the  Court  finds  that  the  assessment  made  by  the  ALJ  was  

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supported  by  substantial  evidence.  The  opinions  of  Dr.  Jennifer  Jackson,  Dr.  
Hope  Jackson,  and  Dr.  Davis,  along  with  other  evidence  in  the  record,  constitutes  
substantial  evidence  supporting  the  ALJ’s  RFC  assessment,  as  well  as  her  final  
decision.    
CONCLUSION  
In  light  of  the  foregoing,  it  is  ORDERED  that  the  decision  of  the  
Commissioner  of  Social  Security  denying  Plaintiff  benefits  be  AFFIRMED.  
DONE  and  ORDERED  this  the  8th  day  of  February,  2018.  

s/P.  BRADLEY  MURRAY    

UNITED  STATES  MAGISTRATE  JUDGE  

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