Collins v. Commissioner of Social Security

Filing 45

ORDER AFFIRMING the Commissioner of Social Security's benefits decision and DIRECTING the Clerk of Court to ENTER JUDGMENT. Signed by Judge J. Phil Gilbert on 11/3/2020. (cab).

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IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ILLINOIS

KENYA YVONNIA COLLINS,
Plaintiff,
v.

Case No. 18–CV–00643–JPG

COMMISSIONER OF SOCIAL SECURITY,
Defendant.
MEMORANDUM OPINION AND ORDER
This is a Social Security disability appeal. Before the Court is Plaintiff Kenya Yvonnia
Collins’s Brief. (ECF No. 37). Defendant Commissioner of Social Security (“Commissioner”)
responded. (ECF No. 43). For the reasons below, the Court AFFIRMS the Commissioner’s
disability decision and DIRECTS the Clerk of Court to ENTER JUDGMENT.
I.

PROCEDURAL & FACTUAL HISTORY
In January 2014, Collins applied for Social Security disability insurance benefits and

supplemental security income. (Decision 1, ECF No. 31-2). She alleged an onset date—when she
first became disabled—of September 2012. (Id.). The Social Security Administration (“SSA”)
denied her claims in June 2014 and again on reconsideration in April 2015. (Id.). Dissatisfied with
the SSA’s decision, Collins requested a hearing before an administrative-law judge (“ALJ”) under
20 C.F.R. § 404.929. (Id.). And in April 2017, Collins appeared before an ALJ and got the chance
to “submit new evidence . . ., examine the evidence used in making the determination or decision
under review, and present and question witnesses.” § 404.929. (Decision at 1). The ALJ was then
tasked with issuing “a decision based on the preponderance of the evidence in the hearing record.”
§ 404.929.

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During the hearing, Collins testified about her vocational and medical histories. In the past
decade, she worked as a courier for a transportation company; a file clerk for a bank; an accounts
officer for another bank; a unit clerk for a hospital; a call-center representative for a major retailer;
and a dispatcher for a security company. (See Tr. 10–17, ECF No. 31-2).
Collins stopped working in 2012 after developing type 2 diabetes. (See id. at 11). At the
time, she was working as a courier while “taking classes online for medical billing and coding.”
(Id. at 8). She testified, “[O]nce I got sick with diabetes . . . I couldn’t remember everything and I
was in a lot of pain so I couldn’t pass my tests.” (Id. at 10). It took her “[p]robably a good six to
eight months” to get it “under control”; and she began taking insulin in 2017. (See id. at 23).
Collins has also not returned to work “[d]ue to the fibromyalgia and chronic arthritis.” (Id.
at 18). She told the ALJ that she experiences “sharp pains” and “very bad muscle spasm and pain
in [her] arms and . . . legs.” (Id. at 18–19). The pain was once so bad that she thought she was
having a heart attack and went to the emergency room: It was the fibromyalgia. (Id. at 22).
Although she spent some time in physical therapy, Collins testified that she experiences too much
pain to stretch. (See id. at 22–26).
On top of the diabetes, fibromyalgia, and chronic arthritis, Collins testified that she also
suffers from “very painful . . . irritable bowel syndrome,” migraines, and obesity. (See id. at 23–
26). She has “at least 10” migraines per month. (Id. at 29). Although she takes prescription
medication (Percocet and Lyrica), she usually must “lay down because [the] the pain medicine
doesn’t take away [her] migraine.” (Id. at 25, 30).
Collins also discussed how her medical conditions affect her day-to-day life. She testified
that she can walk for five-to-ten minutes before needing a twenty-to-thirty-minute rest; she can
walk up and down stairs, though slowly; and she can sit in a desk chair for at least an hour, though

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it causes “a lot of sharp pain,” muscle spasms, and hand cramps when typing. (Id. at 26–27). The
same could be said for routine chores like sweeping, cleaning dishes, and grocery shopping, which
require frequent breaks and assistance: “[I]f I’m doing something like as simple as cutting fruit or
something [], my fingers will get jammed where they stuck [sic] for a while.” (See id. at 29).
After the hearing, the ALJ applied the five-step analysis used to determine whether an
applicant is disabled and determined that Collins is not disabled. (Decision at 1). During this
“sequential evaluation,” findings made at each step affect later steps. See 20 C.F.R. § 404.1520(a).
At Step 1, the ALJ determined that Collins has not engaged in substantial gainful activity
since her alleged onset date in 2012. (Decision at 3).
At Step 2, the ALJ evaluated Collins’s medical conditions and concluded that she suffers
from the following “severe impairments”: lumbar degenerative disc disease, arthritis, type 2
diabetes, and obesity. (Id. at 3). That said, the ALJ noted that her anemia, hypertension, irritable
bowel syndrome, migraines, and fibromyalgia do not rise to the level of “severe impairments,”
finding “little evidence to suggest that there were significant anemic symptoms”; “no significant
symptoms of hypertensive crisis”; no “significant clinical signs of inflammatory bowel disease”;
only “intermittent” migraines with “no outpatient or emergency department visits associated with
them”; and no clinical “diagnosis of fibromyalgia” consistent with accepted practices. (See id.
at 4–6).
At Step 3, the ALJ concluded that “[t]here is insufficient objective medical evidence”
showing that Collins has “an impairment or combination of impairments that meets or medically
equals the severity of one of the listed impairments in” the Code of Federal Regulations. (Id. (citing
§ 404.1520)). In doing so, he noted the appliable regulation and explained why Collins’s four
severe impairments do not rise to the level of “presumptive disability.” (See id. at 6–7).

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Before advancing to Step 4, the ALJ evaluated Collins’s residual functional capacity
(“RFC”) and determined that she “has the residual functional capacity to perform sedentary
work . . . except that [she] cannot climb ladders, ropes or scaffolds.” (Id. at 7). The RFC
assessment identifies limitations that an applicant’s impairments impose on their ability to work.
§ 404.1520(e). It is “based on all the relevant medical and other evidence in . . . the case record.”
Id. Here, the ALJ found that Collins’s testimony about “widespread body pain, arthritis and low
back pain—including statements about “weakness, muscle spasms, headaches and diabetes”—was
unsubstantiated by objective medical evidence:
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“In terms of [Collins]’s alleged degenerative disc disease,. . . she was noted to be taking
narcotic pain relievers, but her gait was observed to be normal and on at least one
occasion, she denied having back pain altogether.” (Decision at 8 (citing Ex. 19F at 22–
25, ECF No. 31-16)). In other words, she “has minimal degenerative disc disease,
which is in contrast to the subjective complaints of low back pain offered in testimony.”
(Id.).

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“In terms of [Collins]’s alleged arthritis, it has been listed as a problem on most her
treatment records, though imaging of the extremities was infrequent and not conclusive
of any specific joint disease.” (Id.). In short, “[t]here was no imaging evidence in the
file that supports [her] complaints of pain.” (Id.).

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“In terms of [Collins]’s diabetes,” the ALJ noted that Collins was diagnosed with
diabetes “before the alleged onset date” and experienced “elevated blood glucose
levels.” (Id. at 9 (citing Exs. 19F at 43; 3F at 27–31, ECF No. 31-7)). That said, she
received “dietary and exercise recommendations” that “she has not always followed,”
suggestive of “intermittent poor control of diabetes.” (Id.). Even with her “history of
fluctuating blood glucose levels,. . . she has not been hospitalized for hypoglycemia,
hyperglycemia or diabetic crisis since the alleged onset date.” Put differently, although
Collins’s “diabetes is severe, based on her medications and blood glucose readings,
there is no evidence to suggest that she would be unable to perform sedentary work
duties.” (Id.).

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“In terms of [Collins]’s obesity,” which “is clearly in the ‘severe’ functional range
based on the BMI values of 30 kg/m2, . . . the available record does not reveal any
symptoms that would result in the inability to perform a significant range of sedentary
work.” (Id.).

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The ALJ gave “some weight” to the opinions of state physicians Dr. Lenore Gonzalez
and Dr. Julio Pardo, who found that Collins’s “chronic pain issues . .. limited [her] to
the ability to sit for six to eight hours per day; stand and walk for six of eight hours per
day; to life and carry 20 pounds occasionally and ten pounds frequently; to occasionally
climb ladders, ropes or scaffolds; could occasionally climb stairs and ramps, could
frequently stoop and would have unlimited capacity to balance kneel, crouch and
crawl.” (See id. at 9–10). Though those opinions were “generally supported by the
evidence, . . . subsequent medical records found greater limitations of function.” (See
id.).

•

The ALJ gave “significant weight” to the opinion of Collins’s treating physician, Dr
Anthony Truong, a “key support for the finding that [she] retains the ability to perform
the type of sedentary work described in the residual functional capacity.” (Id. at 10).
“Dr. Truong stated that it appeared [Collins] was malingered and that she had a very
poor outlook and attitude. He also noted that [Collins] admitted that she did not do any
home therapy, and that when she did go [to] therapy sessions, she was not motivated
or involved. Finally, he noted that she refused a referral for other services he thought
could be beneficial. These findings by a treating source, indicating that [Collins] was
likely exaggerating her symptoms and do not appear motivated to do what was
necessary to elevate her problems, [are] strong evidence that [she] is not as limited as
she has alleged.” (Id. (citing Ex. 6F at 25, ECF No. 31-8)).

At Steps 4 and 5, the ALJ considered Collins’s RFC and concluded that she “is capable of
performing past relevant work as a charge account clerk” or as a “cutter-and-paster” or “telephone
quotation clerk.” (See id. at 10–11 (citing Dictionary of Occupational Titles ## 205.307-014,
249.587-014, 237.367-046, https://occupationalinfo.org/cat2div4_0.html.)). As a result, the ALJ
found that Collins “is not disabled.” (Id. at 12). The Appeals Counsel then denied Collins’s request
for review, so the ALJ’s Decision became “the final decision of the Commissioner of Social
Security.” (Notice of Appeals Council Action 1, ECF No. 31-2).
In 2018, Collins appealed to this Court under 42 U.S.C. § 405(g), which authorizes judicial
review of “any final decision of the Commissioner of Social Security.” (See Compl. 1, ECF No. 2).
II.

LAW & ANALYSIS
“It is well established that judicial review of administrative determinations under the Social

Security Act is severely limited.” Williams v. Califano, 593 F.2d 282, 284 (7th. Cir. 1979). The

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Court must treat the ALJ’s factual findings as conclusive “so long as they are supported by
‘substantial evidence.’ ” Beistek v. Berryhill, 139 S. Ct. 1148, 1152 (2019) (citing 42 U.S.C.
§ 405(g)). “Substantial evidence” means “such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971).
This is a very deferential standard of review. See Elder v. Astrue, 529 F.3d 408, 413 (7th Cir.
2008). “It is the responsibility of the ALJ, not the reviewing court, to resolve conflicting evidence.”
Brewer v. Chater, 103 F.3d 1384 (7th Cir. 1997). In other words, the Court must only determine
“whether the ALJ built an ‘accurate and logical bridge’ from the evidence to her conclusion that
the claimant is not disabled.” Simila v. Astrue, 573 F.3d 503, 513 (7th Cir. 2009) (quoting Craft v.
Astrue, 539 F.3d 668, 673 (7th Cir. 2008)).
Although not stating so explicitly, Collins’s Brief essentially amounts to a challenge to the
RFC assessment. She states that she has “continuous pain every day . . . from the time [she]
wake[s] up” until she goes to sleep. (Collins’s Brief 1, ECF No. 37). She “cannot sit, stand, for
any long periods without” sharp pain in her neck and back. (Id.). She also wakes up with migraines
that are only temporarily relieved by her prescription medication; has “to change positions
constantly and immediately stop what [she is] doing to try to get relief”; “cannot . . . wash dishes
or sweep, mop without getting this sharp pain within ten minutes or less”; “suffer[s] from pain
with when it’s extremely” hot or “cold outside”; experiences leg cramps and hip, arm, shoulder,
chest, pelvic, hand, and finger pain, as well as “diabetic nerve pain from [her] toes up to [her] leg
to [her] knees.” (Id. at 1–3). She also described her (presumably recent) attempt to work at a socialservices office—by the third day, she “was in the emergency room due to sharp pain in [her] hands,
arms, shoulder swelling.” (Id. at 3). She “get[s] sharp pain doing anything physical,” even having
“to take breaks to finish” writing her Brief. (Id. at 4–5).

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An ALJ examines the entire case record when considering the intensity, persistence, and
limiting effects of an individual’s symptoms. SSR 16-3p, 2016 WL 1119029, at *4 (Mar. 16,
2016). 1 This includes the objective medical evidence, the individual’s statements, statements and
other information provided by medical sources and other persons, and any other relevant
information in the individual’s case record. Id. But not every factor is relevant in every case: An
ALJ need only discuss those factors that are “pertinent to the evidence of record.” Id. An ALJ may
also consider the frequency of the claimant’s complaints, the frequency of the claimant’s attempts
to receive treatment, and, if the claimant did not seek treatment, then why not. Id. Ultimately,
“[t]he determination or decision must contain specific reasons for the weight given to the
individual’s symptoms, be consistent with and supported by the evidence, and be clearly
articulated so the individual and any subsequent reviewer can assess how the adjudicator evaluated
the individual’s symptoms.” Id. An ALJ’s failure to adequately explain a credibility finding by
discussing specific reasons supported by the record is therefore grounds for reversal. Terry v.
Astrue, 380 F.3d 471, 477 (7th Cir. 2009).
With that in mind, “because the ALJ is in the best position to determine a witness’s
truthfulness and forthrightness,” Stepp v. Colvin, 795 F.3d 711, 720 (7th Cr. 2015), the Court may
“overturn an ALJ’s decision to discredit a claimant’s alleged symptoms only if the decision is
‘patently wrong,’ meaning it lacks explanation or support,” Cullinan v. Berryhill, 878 F.3d 598,
604 (7th. Cir. 2017). An ALJ is therefore “ ‘free to discount the applicant’s testimony on the basis
of the other evidence in the case’ as ‘[a]pplicants for disability benefits have an incentive to

1

As noted by the Commissioner, the SSA recently “abandon[ed] the use of the term ‘credibility’ and instead focuses
on determining the ‘intensity and persistence of [the claimant’s] symptoms.’ ” (Comm’r’s Brief 8, ECF No. 43
(quoting SSR 16-3p, 2016 WL 1119029, at *4). The Court, however, remains “bound by case law concerning the
same regulatory process under the ‘credibility’ analysis of the former” regulation. Farr v. Colvin, No. 14 C 6319,
2016 WL 3538827, at *5 n.3 (N.D. Ill. June 29, 2016) (collecting cases).

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exaggerate their symptoms.’ ” Stepp, 895 F.3d at 720 (quoting Johnson v. Barnhart, 449 F.3d 804,
805 (7th Cir. 2006)).
The Seventh Circuit confronted a similar question in Stepp, affirming an ALJ’s decision to
discount a claimant’s testimony about the intensity and persistence of her symptoms:
Here, the ALJ made only a partially adverse credibility finding.
Although she determined that Stepp's testimony was not fully
supported by the record, she also discounted opinions from other
physicians that seemed to understate Stepp's condition. For
instance, the ALJ assigned “little weight” to state agency medical
consultant Dr. Dobson's determination that Stepp could perform
“light work” (i.e., that she could lift twenty pounds occasionally
and ten pounds frequently, and that she could stand and/or walk for
up to six hours in an eight-hour workday), concluding that the
record demonstrated that Stepp was “more limited” than Dr.
Dobson determined. The ALJ ultimately found that Stepp could
perform sedentary work—which is less taxing than “light work”—
with a few additional limitations. The ALJ acknowledged that
Stepp continued to report chronic pain throughout the adjudicative
period but concluded that the record demonstrated improvement in
Stepp's condition following surgery, medication changes, and
therapy. While the ALJ credited Stepp's assertion that she still
experienced residual pain, the ALJ determined that such pain “does
not equate to disability.” In light of all of the evidence before her,
we believe that the ALJ's finding that Stepp's testimony was only
partially credible was not patently wrong.
Id. at 720–21 (internal citations omitted).
So too here, the ALJ’s RFC assessment was supported by substantial evidence and not
patently wrong. Although he acknowledged that Collins does in fact have severe impairments, the
ALJ went through each and described why “the objective evidence does not fully support her
testimony” that she experiences “debilitating pain.” (Decision at 8). For example, the ALJ gave
“significant weight” to the opinion of Collins’s treating physician, who noted that Collins asked,
“[H]ow many [times] do I have to do [physical therapy] before I get disability?” (Id. at 10; Ex. 6F
at 25). He also stated that “because of her statement today, it appears she is malingering but I

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cannot prove this. She has a very poor attitude and outlook regarding her diseases and her
prognosis. She admits she does not do any home therapy, and when she does go to the therapy
sessions, she . . . is not motivated and not involved.” (Ex. 6F at 25). What’s more, other medical
reports recounted that Collins did not appear in “acute distress” while personally appearing for an
appointment—a far cry from her assertion that she cannot hold a pen without debilitating pain.
(E.g., Ex. 19F at 52). Even so, like the ALJ in Stepp, the ALJ here acknowledge that Collins does
experience pain and gave less weight to the opinions of two state physicians that found lesser
limitations. (Decision at 9–10). Ultimately, however, the ALJ properly recognized that a claimant
cannot be found disabled based solely on subjective complaints of pain—there must always be
medical evidence. (See id. at 8–10). Punzio v. Astrue, 630 F.3d 704, 712 (7th Cir. 2011) (“The
claimant bears the burden of submitted medical evidence establishing her impairments and her
residual functional capacity.”) And although the Court construed her pro se Brief liberally, Collins
does not point to any medical evidence that the ALJ ignored. In any event, the ALJ specifically
articulated reasons, supported by citations to the record, to discredit Collins’s alleged symptoms.
Put differently, the fact Collins “disagrees with the significance that the ALJ assigned to the
evidence he cited does not mean that substantial evidence does not support his decision.”
(Comm’r’s Brief at 10). Rather, the Court finds that the ALJ’s Decision was adequately supported
and not patently wrong.
III.

CONCLUSION
The Court AFFIRMS the Commissioner’s disability decision and DIRECTS the Clerk of

Court to ENTER JUDGMENT.
IT IS SO ORDERED.
Dated: Tuesday, November 3, 2020

S/J. Phil Gilbert
J. PHIL GILBERT
UNITED STATES DISTRICT JUDGE

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