Coleman v. Social Security Administration

Filing 18

MEMORANDUM AND ORDER: IT IS HEREBY ORDERED that the decision of the Commissioner is reversed and the case is remanded to the Commissioner pursuant to sentence four of 42 U.S.C. § 405(g) for further proceedings consistent with this Memorandum and Order. A separate judgment in accord with this Memorandum and Order is entered this date. Signed by District Judge Catherine D. Perry on February 25, 2013. (BRP)

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
EASTERN DIVISION
SANDRA COLEMAN,
Plaintiff,
vs.
MICHAEL J. ASTRUE,
Commissioner of Social Security,
Defendant.

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Case No. 4:11CV2131 CDP

MEMORANDUM AND ORDER
This is an action under 42 U.S.C. § 405(g) for judicial review of the
Commissioner‟s final decision denying Sandra Coleman‟s application for supplemental
security income benefits under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381 et
seq. Coleman claims she is disabled, listing her conditions as “epilepsy, psychological,
and borderline personality.” The Administrative Law Judge concluded, however, that
Coleman is not disabled, and Coleman now appeals that decision. Because I find the
decision denying benefits was not supported by substantial evidence, I will reverse the
decision of the Commissioner and remand for further consideration.
Procedural History
On January 8, 2009, Sandra Coleman filed for supplemental security income
payments alleging disability beginning in 1998. The Social Security Administration
denied Coleman‟s application at the initial level. Missouri is one of several states

participating in modifications to the disability determination procedures, which include
the elimination of the reconsideration step in the administrative appeals process. 20
C.F.R. § 416.1406, 416.1466 (2011). Coleman‟s appeal in this case therefore proceeded
directly from this initial denial to the administrative law judge level. Coleman appeared
and testified at a hearing on July 21, 2010.1 The ALJ issued an opinion on September 21,
2010 upholding the denial of benefits. Coleman filed a request for review with the
Appeals Council on October 8, 2010. The Appeals Council denied Coleman‟s request for
review on November 18, 2011. Accordingly, the ALJ‟s determination stands as the
Commissioner‟s final determination. Coleman filed this request for review on December
8, 2011.
Testimony Before the ALJ
At the time of the administrative hearing, Coleman was forty-eight years old and
lived with her fiancé. They lived in a single level apartment, but were about to move to a
two-story apartment. Coleman was a high school graduate and testified that she had been
held back one year, possibly between the second and third grades. Coleman stated that
she was primarily in special education classes in school. After high school she had also
participated in vocational rehabilitation.
Coleman testified that she suffered from epilepsy. She stated that when she had an

1

Coleman appeared for a hearing on February 11, 2010, but was not represented at that time. No
testimony was taken during the February 11, 2010 proceedings, and the hearing was delayed so that
Coleman could procure representation.
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epileptic event, she was generally unaware of it but it was observable by other people.
She also testified that she did not lose consciousness during seizures, and she could
sometimes see her legs and arms twitch. She stated that her neck would sometimes
“tweak” as if someone was grabbing and shaking her. Coleman testified that she had
experienced a seizure earlier that month, which she felt and her fiancé observed. She had
tried Dilantin to control her seizures, but had stopped because it caused an allergic
reaction. Coleman testified that she was currently taking Phenobarbital twice daily, as
prescribed.
In addition to her epilepsy, Coleman testified about various mental health issues.
She stated that she was “a borderline personality,” and that she was presently seeing Dr.
Nawaz for depression. Coleman recalled her depression beginning around the time her
son passed away, in 1988. Coleman had been seeing Dr. Nawaz since May of 2010. She
testified that she began seeing Dr. Nawaz at the urging of both her fiancé and her
attorney, and visited her every month or so for about 5 to 10 minutes each visit. Coleman
stated that Dr. Nawaz prescribed Lexapro, which helped her “calm her brain down.” The
Lexapro also helped control Coleman‟s crying spells. She testified that since beginning
the Lexapro, she sometimes felt like not doing anything, and would have trouble
controlling her anger.
Coleman also testified about various physical ailments, including problems with
her eyes, wrists, knees, and back. She stated that she was nearsighted and had an

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astigmatism, making it difficult to see at night. She wore glasses, which helped with her
nearsightedness. Coleman also testified that she had tendinitis in her wrists, making it
difficult to pick anything up. She stated that she could not pick up her granddaughter
who weighed around forty pounds, and struggled to lift anything of five pounds or less.
Coleman claimed that her knees were “shot,” and that she could walk for about an hour
before she felt discomfort. She also stated that her back bothered her, and she could only
stand for ten or fifteen minutes without a problem. Coleman testified to having a heart
murmur which sometimes felt like someone beating her chest. She stated that she was
not taking medication for her heart, nor had she gone to the hospital the last time she
experienced a heart event.
Coleman did not work at the time of the hearing. Her most recent job was as a
woodmill operator. Coleman did not know what products were handled at the mill. Her
duties consisted of pulling wood through the mill, stacking it, sweeping floors, and other
similar activities. Coleman testified that she stopped working at the mill because of her
heart pain. Prior to the woodmill, she worked doing laundry in a nursing home.
Coleman stated that both jobs were obtained through vocational rehabilitation programs
in Oregon.
Coleman testified that at various times she lived with her parents, in housing, with
friends, or with boyfriends. In total, she believed she lived about four or five years on her
own. Coleman stated that she currently lived with her fiancé, who was legally blind and

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diabetic. She testified that her fiancé handled their finances and cooked, and she did the
laundry, dishes, and kept the house clean. They went grocery shopping together.
Coleman stated she had a driver‟s license and that she was capable of using money and
knew what the different bills and coins were worth. Regarding her normal day, she stated
that she spent her time sitting at home and watching television. Coleman stated that
although she had many friends in the past, she currently had none and did not go out
often. She also testified that she liked to read mystery books, but had difficulty
concentrating if there were any distractions such as television.
The ALJ called a vocational expert, Brenda Young, who had been provided with
and reviewed Coleman‟s file, including her past work history. The ALJ described a
hypothetical individual for Young of Coleman‟s age, education, and work experience;
who was limited to the full range of medium work except her posturals were at
occasional; who needed to avoid all exposure to operational control of moving machinery
and unprotected heights, and all exposure to hazardous machinery; who was limited to a
job that was simple, routine, and repetitive in a low-stress environment; who was limited
to a job with only occasional decision making or occasional changes in the work setting;
and who was limited to a job that had only occasional interaction with the public and coworkers. The ALJ then asked Young whether this hypothetical person could perform any
jobs in the regional or national economy. Young replied that such an individual could
work as a hand packer or packager or in a janitorial job.

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The ALJ then asked about a hypothetical individual with the same characteristics,
except this person‟s exertional limits went from medium to light, who must avoid all
exposure to operational control of moving machinery and unprotected heights and all
exposure to hazardous machinery. Young replied that this individual could perform
housekeeping jobs, some light assembly jobs, and dining room jobs such as cafeteria
helpers. The ALJ then asked Young whether any jobs existed for either hypothetical
individual with the added condition that she would miss work three or more days a month
because of mental health restrictions. Young replied that this would eliminate all jobs for
either individual.
Finally, Coleman‟s attorney described a hypothetical individual of Coleman‟s age,
education, and work experience, who was limited to the most simple one-step directions.
Young testified that such an individual could not perform any of the jobs she had listed,
or any other jobs.

Medical Records
Coleman‟s high school records indicate that she was enrolled in special education
classes. On April 9, 1980, Coleman took the Wechsler Adult Intelligence Scale (WAIS)
IQ test. She was eighteen years old at the time, and the test revealed a verbal IQ of 87, a
performance IQ of 97, and a full scale IQ of 91.
On August 17, 2006, Paul W. Rexroat, Ph.D., conducted a psychological

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examination of Coleman. Dr. Rexroat felt that Coleman was attempting to malinger but
was afraid to do so, and he considered her “somewhat reliable.” Dr. Rexroat noted that
Coleman‟s dress, emotional responsiveness, affect, energy level, alertness, gait, and
posture were all normal. He also noted that her speech was coherent, with no
abnormalities that would indicate a thought disorder. Coleman reported to Dr. Rexroat
that she had occasional mood swings. Dr. Rexroat also noted that Coleman was welloriented and could perform addition, subtraction, and multiplication. Dr. Rexroat‟s notes
evidence that Coleman responded appropriately to tests of verbal judgment and verbal
reasoning. She had difficulty naming the current president, large cities in the United
States, and could not perform division. Dr. Rexroat estimated an IQ in the borderline
range.
Regarding Coleman‟s limitations, Dr. Rexroat concluded that she was able to
understand and remember simple instructions, could sustain concentration and
persistence with simple tasks, and could interact socially and adapt to her environment.
He noted that there were few limitations in daily living activities, social functioning, and
ability to manage her own funds. He also noted that her memory functioning appeared to
be in the borderline range. He assigned her a GAF of 75.
Dave A. Rengachary, M.D., reported on May 22, 2006 that Coleman presented
with episodes concerning for seizures, but was unable to undergo further testing because
she lacked insurance. Dr. Rengachary prescribed Dilantin for the seizures. He also noted

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that a cardiovascular examination revealed a regular rate and rhythm, that Coleman was
alert and oriented, and that motor sensory, coordination, and reflexes were normal. Dr.
Rengachary noted a slight cognitive delay with Coleman‟s verbal responses.
Coleman visited Dan Frissell, M.D., on January 4, 2008, with back and shoulder
pain, and for follow up on a skin lesion on her nose that had previously been treated with
freezing. Dr. Frissell noted that she had lower back pain, poor dental health, and was
anxious. Coleman‟s heart, respiratory effort, and lung auscultation were all normal. Dr.
Frissell retreated Coleman‟s nose lesion with freezing.
Coleman returned to Dr. Frissell on January 18, 2008 complaining of pain in her
hips, shoulders, and right ankle. Dr. Frissell noted that Coleman‟s teeth were in poor
repair, she had tenderness in her upper right extremity, she had diminished lung
auscultation, and was anxious. He noted that her right ankle was not swollen or red,
despite having previously been broken. Coleman was also negative for chest pain,
abdominal pain, and joint pain.
On February 7, 2008, Coleman had x-rays taken of her right ankle, lumbar spine,
and right shoulder. Her right ankle x-ray was normal, with no sign of fracture, osseous
erosion, or right ankle joint effusion. The lumbar spine x-ray revealed bilateral
lumbarization of the S1 segment. There was also slight decrease in diskal height at L5S1, but the report noted that this could be normal variation. The right shoulder x-ray
showed that the right acromiohumeral distance was mildly narrowed, but there was no

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fracture, joint separation, or glenohumeral dislocation.
Lauretta V. Walker, Ph.D., conducted a psychological examination of Coleman on
February 18, 2009. Dr. Walker diagnosed Coleman with anxiety disorder NOS, probable
mild mental retardation, epilepsy, asthma, and a GAF of 58. She noted that Coleman‟s
speech was understandable, but she had difficulty expressing herself at times. Dr. Walker
noted that Coleman did not know the date, year, or day of the week, or who the current
president was. Dr. Walker opined that Coleman was mentally retarded, and found it hard
to understand how her IQ scores from 1980 were possible. Dr. Walker did not see any
borderline personality symptoms. She noted that Coleman functioned at a low level,
would have a difficult time being able to understand and follow any but the most simple
one step directions, and had problems concentrating, focusing, and attending.
Coleman returned to Dr. Rengachary on February 23, 2009, over two years after
her previous visit. At that time Dr. Rengachary noted that there had been no generalized
events on her Phenobarbital, although she reported some occasional myoclonic jerks, as
well as a rash associated with her Dilantin. Coleman visited Dr. Rengachary once more,
in August 2009.
On August 26, 2009, Coleman had an MRI at the St. Genevieve County Memorial
Hospital. Kenneth Miller, M.D., noted that the exam showed diffuse multilevel
degenerative disc disease without significant gross cord impingement or definite
neuroforaminal stenosis.

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Coleman visited Nirmal Antonio, MD, on February 18, 2010 to establish care. Dr.
Antonio noted that she had no heart murmur. He continued her Phenobarbital
prescription, and noted an iron deficiency.

Coleman returned to Dr. Antonio on

March 12, 2010 complaining of knee, back, and neck pain. Dr. Antonio noted that
Coleman‟s vitals were stable and there was no heart murmur. He noted paraspinal spasm
in the cervical region and tenderness in the neck, as well as paraspinal spasm in her back.
Dr. Antonio also noted tenderness in the knee, which he thought to be arthritis. He
ordered various X-rays and prescribed muscle relaxants.
On March 23, 2010, Coleman had x-rays of her cervical spine, lumbar spine, and
knees. The cervical spine series showed no acute osseous abnormalities, nominal
retrolisthesis of C3 and C4 with loss of the normal lordotic curvature of the cervical
spine, and degenerative changes with loss of the intervertebral disc space seen at C4-5,
C5-6, C6-7, and C3-4. The lumbar spine series showed no acute osseous abnormality
and no significant interval change. X-rays of her left knee showed some minimal loss of
the joint space in the medial compartment, but no acute osseous abnormalities. X-rays of
her right knee showed no joint effusion and no acute osseous abnormalities.
On April 9, 2010, Coleman underwent psychiatric intake with counselors for
Shajitha Nawaz, M.D. Coleman reported depression, daily crying episodes, and anger
management problems. The counselors noted that Coleman had normal speech, was alert
and calm, and had appropriate affect and logical thought processes. They reported that

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her judgment was limited due to potential borderline intellectual functioning, and that she
likely had below average intelligence.
On May 12, 2010, Coleman saw Dr. Frissell complaining of hot flashes, chest pain,
and acid reflux pain. Dr. Frissell noted that Coleman complained of anxiety. Dr. Frissell
showed Coleman her ECG, which was normal, and discussed her need to lose weight and
to see a dentist for dental care.
On May 26, 2010, Dr. Nawaz conducted a psychiatric evaluation of Coleman.
Coleman reported to Dr. Nawaz that she got angry easily, felt down at times, and had
difficulty sleeping. Dr. Nawaz diagnosed Coleman with mood disorder NOS, borderline
personality disorder, seizure disorder, and overweight. Dr. Nawaz noted that Coleman
had a GAF of 60, and that her borderline personality disorder was her “main” issue. Dr.
Nawaz prescribed Lexapro and recommended psychotherapy.
After the evaluation, Dr. Nawaz completed a questionnaire at the request of
Coleman‟s attorney. Dr. Nawaz reported the diagnoses of mood disorder NOS,
borderline personality disorder, seizures, and past substance abuse. Dr. Nawaz noted that
Coleman‟s disorders manifested in relationship problems, mood swings, poor selfesteem, difficulty controlling anger, and impulse control problems. Regarding the
abilities needed to do unskilled work, Dr. Nawaz marked Coleman as “limited but
satisfactory” in most categories. Dr. Nawaz marked Coleman as “seriously limited but
not precluded” in the following categories: working in coordination with or proximity to

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others without being unduly distracted, accepting instructions and responding
appropriately to criticism from supervisors, getting along with co-workers or peers
without unduly distracting them or exhibiting behavioral extremes, dealing with stress of
semiskilled and skilled work, and maintaining socially appropriate behavior.
Legal Standard
A court‟s role on review is to determine whether the Commissioner‟s findings are
supported by substantial evidence on the record as a whole. Gowell v. Apfel, 242 F.3d
793, 796 (8th Cir. 2001). Substantial evidence is less than a preponderance, but is
enough that a reasonable mind would find it adequate to support the ALJ‟s conclusion.
Prosch v. Apfel, 201 F.3d 1010, 1012 (8th Cir. 2000). As long as there is substantial
evidence on the record as a whole to support the Commissioner‟s decision, a court may
not reverse it because substantial evidence exists in the record that would have supported
a contrary outcome, id., or because the court would have decided the case differently.
Browning v. Sullivan, 958 F.2d 817, 822 (8th Cir. 1992). In determining whether existing
evidence is substantial, a court considers “evidence that detracts from the
Commissioner‟s decision as well as evidence that supports it.” Singh v. Apfel, 222 F.3d
448, 451 (8th Cir. 200) (citation omitted).
To determine whether the decision is supported by substantial evidence, the Court
is required to review the administrative record as a whole to consider:
(1)

the credibility findings made by the Administrative Law Judge;

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(2)

the education, background, work history, and age of the claimant;

(3)

the medical evidence from treating and consulting physicians;

(4)

the plaintiff‟s subjective complaints relating to exertional and nonexertional impairments;

(5)

any corroboration by third parties of the plaintiff‟s impairments; and

(6)

the testimony of vocational experts when required which is based
upon a proper hypothetical question.

Brand v. Secretary of Dep’t of Health, Educ. & Welfare, 623 F.2d 523, 527 (8th Cir.
1980).
Disability is defined in the social security regulations as the inability to engage in
any substantial gainful activity by reason of any medically determinable physical or
mental impairment which can be expected to result in death or which has lasted or can be
expected to last for a continuous period of not less than twelve months. 42 U.S.C. §
416(i)(l); 42 U.S.C. § 1382c(a)(3)(A); 20 C.F.R. §§ 404.1505(a) and 416.905(a). In
determining whether a claimant is disabled, the Commissioner must evaluate the claim
using a five-step procedure.
First, the Commissioner must decide if the claimant is engaging in substantial
gainful activity. If the claimant is engaging in substantial gainful activity, he is not
disabled.
Next, the Commissioner determines if the claimant has a severe impairment which
significantly limits the claimant‟s physical or mental ability to do basic work activities.

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If the claimant‟s impairment is not severe, he is not disabled.
If the claimant has a severe impairment, the Commissioner evaluates whether the
impairment meets or exceeds a listed impairment found in 20 C.F.R. Part 404, Subpart P,
Appendix 1. If the impairment satisfies a listing in Appendix 1, the Commissioner will
find the claimant disabled.
If the Commissioner cannot make a decision based on the claimant‟s current work
activity or medical facts alone, and the claimant has a severe impairment, the
Commissioner reviews whether the claimant can perform his past relevant work. If the
claimant can perform his past relevant work, he is not disabled.
If the claimant cannot perform his past relevant work, the Commissioner must
evaluate whether the claimant can perform other work in the national economy. If not,
the Commissioner declares the claimant disabled. 20 C.F.R. §§ 404.1520 and 416.920.
When evaluating evidence of subjective complaints, the ALJ is never free to ignore
the subjective testimony of the claimant, even if it is uncorroborated by objective medical
evidence. Basinger v. Heckler, 725 F.2d 1166, 1169 (8th Cir. 1984). The ALJ may,
however, disbelieve a claimant‟s subjective complaints when they are inconsistent with
the record as a whole. See, e.g., Battles v. Sullivan, 992 F.2d 657, 660 (8th Cir. 1990). In
considering the subjective complaints, the ALJ is required to consider the factors set out
by Polaski v. Hecler, 739 F.2d 1320 (8th Cir. 1984), which include:
claimant‟s prior work record, and observations by third parties and treating
and examining physicians relating to such matters as:
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1.

the claimant‟s daily activities;

2.

the duration, frequency, and intensity of the pain;

3.

precipitating and aggravating factors;

4.

dosage, effectiveness and side effects of
medication;

5.

functional restrictions.

Id. at 1322.
The ALJ’s Findings
The ALJ found that Coleman did not suffer from a disability within the meaning of
the Social Security Act at any time through the date of the decision. He issued the
following specific findings:
1.

The claimant has not engaged in substantial gainful activity since January 8,
2009, the application date (20 CFR 416.971 eq seq.).

2.

The claimant has the following severe impairments: epilepsy, mood
disorder not otherwise specified, borderline personality disorder and obesity
(20 CFR 416.920(c)).

3.

The claimant does not have an impairment or combination of impairments
that meets or medically equals one of the listed impairments in 20 CFR Part
404, Subpart P, Appendix 1 (20 CFR 416.920(d), 416.925 and 416.926).

4.

After careful consideration of the entire record, I find that the claimant has
the residual functional capacity to perform medium work as defined in 20
CFR 416.967(c) except the claimant could occasionally perform postural
activities (i.e. climbing, crawling, kneeling, stooping, crouching, etc); must
avoid all exposure to moving machinery, unprotected heights and hazardous
machinery; limited to simple routine tasks in a low stress environment with
only occasional interaction with public or coworkers.
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5.

The claimant has no past relevant work (20 CFR 416.965).

6.

The claimant was born on January 27, 1962 and was 46 years old, which is
defined as a younger individual age 18-49, on the date the application was
filed (20 CFR 416.963).

7.

The claimant has a limited education and is able to communicate in English
(20 CFR 416.964).

8.

Transferability of job skills is not an issue because the claimant does not
have past relevant work (20 CFR 416.968).

9.

Considering the claimant‟s age, education, work experience, and residual
functional capacity, there are jobs that exist in significant numbers in the
national economy that the claimant can perform (20 CFR 416.969 and
416.969(a)).

10.

The claimant has not been under a disability, as defined in the Social
Security Act, since January 8, 2009, the date the application was filed (20
CFR 416.920(g)).

The ALJ concluded that although Coleman had severe impairments, the medical
records did not support her allegations about the severity of her limitations. The ALJ
found that Coleman‟s treatment for epilepsy was sporadic and inconsistent, that her
medications effectively controlled her symptoms, and that her testimony regarding daily
activities was inconsistent with her alleged limitations. He found that there was no
medical evidence to confirm whether her obesity would limit her ability to sustain
activity on a regular and continuing basis. The ALJ found that Coleman would have mild
limitations because of her mental impairments and deficiencies in social functioning, and
moderate limitations in concentration, persistence, and pace. He found that Coleman was

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not fully credible, particularly given her limited work history and the contradictions
between her allegations about the severity of her symptoms as compared with her
medical records and ability to perform daily activities.
Discussion
When reviewing a denial of Social Security benefits, a court cannot reverse an
ALJ‟s decision simply because the court may have reached a different outcome, or
because substantial evidence might support a different outcome. Jones ex rel. Morris v.
Barnhard, 315 F.3d 974, 977 (8th Cir. 2003); Woolf v. Shalala, 3 F.3d 1210, 1213 (8th
Cir. 1993). Instead, the court‟s task is a narrow one: to determine whether there is
substantial evidence on the record as a whole to support the ALJ‟s decision. 42 U.S.C. §
405(g); Estes v. Barnhard, 275 F.3d 722, 724 (8th Cir. 2002). On appeal, Coleman raises
three issues. She argues that the ALJ failed to fully develop the record by refusing to
order a new IQ test, that the ALJ failed to properly consider all of the opinion evidence,
and that the ALJ failed to properly consider all of her severe medically determinable
impairments in determining her residual functional capacity. Because I find that the
ALJ‟s decision is not supported by substantial evidence in the medical record, I will
reverse and remand for further proceedings.
The ALJ Erred in Failing to Discuss Coleman‟s IQ
Coleman argues that the ALJ erred in failing to grant her request to order a WAIS
IQ test. An ALJ has a duty to develop the record fairly and fully. See, e.g., Watkins v.

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Astrue, 414 Fed. App‟x 894, 897 (8th Cir. 2011). “The ALJ is required to order medical
examinations and tests only if the medical records presented to him do not give sufficient
medical evidence to determine whether the claimant is disabled.” McCoy v. Astrue, 648
F.3d 605, 612 (8th Cir. 2011). Even if the ALJ fails to properly develop the record,
reversal is only warranted where such failure is unfair or prejudicial. Ellis v. Barnhart,
392 F.3d 988, 994 (8th Cir. 2005) (citing Shannon v. Chater, 54 F.3d 484, 488 (8th Cir.
1995)). According to the social security regulations, the results of IQ tests tend to
stabilize by the age of 16, and therefore, test results obtained after 16 are considered valid
so long as they are compatible with the claimant‟s current behavior. 20 C.F.R. pt. 404,
subpt. P, app. 1, § 112.00D(10); Winfrey v. Astrue, No. 4:11CV231 TCM, 2012 WL
946824, at *14 (E.D. Mo. Mar. 20, 2012).
The record contains Coleman‟s results from a WAIS test she took at the age of
eighteen. She scored a verbal IQ of 87, a performance IQ of 97, and a full scale IQ of 91.
This places Coleman in the “average” range. Coleman argues that because substantial
evidence in the record supports a finding that she has decreased cognitive functioning, a
new WAIS test was warranted. Coleman cites her placement in special education during
high school, as well as observations from various doctors regarding her cognitive
abilities.
The actual record is inconsistent with regard to Coleman‟s cognitive abilities. Dr.
Rengachary noted “slight cognitive delay” with Coleman‟s verbal responses. Dr. Rexroat

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estimated Coleman‟s IQ was in the borderline range. Although he believed that Coleman
was attempting to malinger, he also noted that she was afraid to actually do so. Dr.
Nawaz‟s intake counselors noted that Coleman‟s judgment was limited “due to some
potential borderline intellectual functioning,” although Dr. Nawaz concluded that
Coleman had average intellectual ability. Dr. Walker believed Coleman was mentally
retarded and could perform only simple, one-step tasks. Coleman‟s own testimony
revealed that her daily activities included caring for her blind fiancé, grocery shopping,
and housework.
The ALJ discussed Coleman‟s mental abilities to a limited degree. He noted Dr.
Walker‟s conclusion of probable mild mental retardation, and her limiting Coleman to
simple one-step tasks. He also noted that Dr. Walker reported Coleman had problems
concentrating, focusing, and attending. The ALJ partially discounted Dr. Walker‟s
conclusions to the extent he found them to be inconsistent with Coleman‟s own testimony
regarding her daily activities. The ALJ also noted Dr. Nawaz‟s evaluation of Coleman.
Dr. Nawaz found that Coleman had average intellectual ability, and “fairly ok” attention,
concentration, and memory. In a questionnaire, Dr. Nawaz notated several areas in
which Coleman would be “seriously limited but not precluded:” working in coordination
with or proximity to others without being unduly distracted, accepting instructions and
responding appropriately to criticism from supervisors, getting along with co-workers or
peers without unduly distracting them or exhibiting behavioral extremes, dealing with

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stress of semiskilled and skilled work, and maintaining socially appropriate behavior.
The ALJ claimed to “grant the claimant the benefit of the doubt,” and included
some mental limitations based on the reports of both Dr. Walker and Dr. Nawaz. He
limited her to working jobs that require only simple repetitive tasks and working in a low
stress environment with only occasional interaction with the public and coworkers. The
ALJ concluded that Coleman had mild limitations in social functioning, and moderate
limitations in concentration, persistence, and pace.
However, the ALJ did not articulate his reasons for refusing to order a new IQ test.
In fact, he failed to mention Coleman‟s IQ at all. This failure to discuss Coleman‟s IQ
score requires a remand. See Allen v. Astrue, No. 4:09CV1281 HEA TCM, 2010 WL
2710494, at *14 (E.D. Mo. June 22, 2010) (citing Scott ex. Rel. Scott, 529 F.3d 818, 824
(8th Cir. 2008). While acknowledging some of the inconsistencies in the record, he
failed to address whether the IQ score already on record were compatible with Coleman‟s
current behavior, even though several of the providers estimated that her IQ was lower
than shown by the 1980 test.

20 C.F.R. pt. 404, subpt. P, app. 1, § 112.00D(10). The

ALJ also failed to address whether the score on record influenced his weighing of the
medical evidence, and in particular, the discounted weight he gave to Dr. Walker‟s
assessment. Finally, he failed to discuss how the IQ score on the record impacted
Coleman‟s RFC, and he did not include the IQ score in his hypotheticals posed to the
vocational expert. The case is therefore remanded for the ALJ to address the question of

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Coleman‟s IQ score, including, if necessary, referring her for a consultative examination
and including her IQ or its concrete consequences in a hypothetical to a vocational
expert. Allen, 2010 WL 2710494, at *15.
Coleman also argues that the ALJ failed to properly consider the opinion evidence
of Dr. Walker and Dr. Nawaz. Because the ALJ will need to readdress the weighing of
the evidence in light of a discussion of Coleman‟s IQ, including new testing if necessary,
I need not address that argument in this memorandum.
The ALJ Erred in Failing to Discuss or Consider Coleman‟s Back Pain
Coleman argues that the ALJ failed to consider her back pain as a severe
impairment at step two of his analysis, and accordingly, failed to consider the effects of
her back pain when determining her RFC. “Step two [of the five-step] evaluation states
that a claimant is not disabled if his impairments are not „severe.‟” Kirby v. Astrue, 500
F.3d 705, 707 (8th Cir. 2007) (citing Simmons v. Massanari, 264 F.3d 751, 754 (8th Cir.
2001); 20 C.F.R. § 416.920(a)(4)). “An impairment is not severe if it amounts only to a
slight abnormality that would not significantly limit the claimant's physical or mental
ability to do basic work activities.” Id. at 707. “If the impairment would have no more
than a minimal effect on the claimant's ability to work, then it does not satisfy the
requirement of step two.” Id. (citing Page v. Astrue, 484 F.3d 1040, 1043 (8th Cir.
2007)). “It is the claimant's burden to establish that his impairment or combination of
impairments are severe.” Id. (citing Mittlestedt v. Apfel, 204 F.3d 847, 852 (8th Cir.

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2000)). “Severity is not an onerous requirement for the claimant to meet . . . but it is also
not a toothless standard.” Id. at 708.
At step two of the analysis, the ALJ found that Coleman had the following severe
impairments: epilepsy, mood disorder not otherwise specified, borderline personality
disorder, and obesity. He also noted that Coleman alleged depression, but that it resulted
in minimal, if any, limitation on her ability to perform work-related activities when
properly treated. The ALJ did not address Coleman‟s alleged back pain at all in the step
two analysis.
The failure of an ALJ to find an impairment to be severe at step two is harmless if
the ALJ finds the claimant to suffer from another severe impairment, continues in the
evaluation process, and considers the effects of the impairment at the other steps of the
evaluation process. Matlock ex rel. D.S. v. Astrue, No. 4:11CV1322 FRB, 2012 WL
4109292, at *11 (E.D. Mo. Sep. 19, 2012). Although the ALJ found Coleman suffered
other severe impairments and continued in the evaluation process, he never considered
the effects of Coleman‟s back pain in combination with her severe impairments. In
discussing Coleman‟s obesity, the ALJ noted that obesity has potential effects in causing
musculoskeletal and other physical impairments. However, he determined that there was
no medical evidence to “confirm whether [Coleman‟s] obesity would limit her ability to
sustain activity on a regular and continuing basis.” He did not specifically discuss
Coleman‟s allegations of back pain, nor the medical records relevant to those allegations.

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Nonetheless, he reduced the residual functional capacity to account for the cumulative
effect of her obesity and lowered Coleman‟s RFC to the medium exertional level and
limited her to performing occasional postural activities. The ALJ found that her
subjective complaints did not warrant further limitations.
The ALJ generally found Coleman to have poor credibility regarding the intensity,
persistence, and limiting effects of her symptoms, largely due to inconsistencies between
her allegations and the treatment record and objective medical evidence. The ALJ is
given deference on credibility findings if he “explicitly discredits a claimant‟s testimony
and gives a good reason for doing so.” Buckner v. Astrue, 646 F.3d 549, 558 (8th Cir.
2011) (quoting Wildman v. Astrue, 596 F.3d 959, 968 (8th Cir. 2010)). Coleman
complained of back pain both in her hearing with the ALJ, as well as at various medical
appointments. There is also medical evidence on the record that could support her
allegations of back pain.
At a January 18, 2008 visit to Dr. Frissell, Coleman exhibited tenderness in her
upper right extremity and paraspinous muscles. At the same visit, she had negative
straight leg raising, normal strength, intact sensation, and normal gait. A February 7,
2008 lumbar spine x-ray revealed bilateral lumbarization of the S1 segment, but no
lumbar compression and a slight decrease in diskal height that could have been a normal
variation. An MRI from August 26, 2009 showed mild diffuse posterior disc bulges and
spondylotic ridging, and no significant gross cord impingement or definite

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neuroforaminal stenosis. A cervical spine x-ray on March 23, 2010 revealed no acute
osseous abnormalities, minimal retrolisthesis C3 on C4, and loss of the intervertebral disc
space heights at C4-5, C5-6, C6-7, and C3-4.
While the ALJ discussed Coleman‟s credibility generally and in the context of
some of her other impairments, he never discussed her claims of back pain, nor his
reasons for discrediting them. Furthermore, he never mentioned the medical tests
discussed above. It is therefore unclear whether the ALJ included functional limitations
resulting from Coleman‟s back pain in her residual functional capacity. The ALJ‟s
failure to consider Coleman‟s back pain and related limitations removed from his
consideration whether such impairment, when considered in combination with Coleman‟s
other medically determinable impairments, resulted in a decreased ability to perform
work-related functions. Maybearry v. Astrue, No. 4:07CV1873 DJS, 2009 WL 102097,
at *20 (E.D. Mo. Jan. 13, 2009) (citing Pratt v. Sullivan, 956 F.2d 830, 835-36) (8th Cir.
1992)).
In short, substantial evidence does not support the ALJ's determination of nondisability in this case because his failure to discuss the IQ score and Coleman‟s back pain
prevents me from determining whether he gave them any consideration in finding that
Plaintiff was able to sustain regular, full-time employment. Therefore, I reverse and
remand pursuant to sentence four of 42 U.S.C. § 405(g) for further proceedings consistent
with this order. See Buckener v. Apfel, 213 F.3d 1006, 1010 (8th Cir. 2000) (finding that

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remand under sentence four of 42 U.S.C. section 405(g) is proper when the apparent
purpose of the remand was to prompt additional fact-finding and further evaluation of
existing facts).
Accordingly,
IT IS HEREBY ORDERED that the decision of the Commissioner is reversed
and the case is remanded to the Commissioner pursuant to sentence four of 42 U.S.C. §
405(g) for further proceedings consistent with this Memorandum and Order.
A separate judgment in accord with this Memorandum and Order is entered this
date.

CATHERINE D. PERRY
UNITED STATES DISTRICT JUDGE
Dated this 25th day of February, 2013.

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