Ford-Williams v. Colvin
MEMORANDUM AND ORDER: IT IS HEREBY ORDERED that the decision of the Commissioner is AFFIRMED, and Plaintiffs Complaint is DISMISSED with prejudice. Signed by Magistrate Judge Noelle C. Collins on 09/25/2017. (KCB)
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
NANCY A. BERRYHILL,1
Acting Commissioner of Social Security
Case No. 4:16-CV-1272-NCC
MEMORANDUM AND ORDER
This is an action under Title 42 U.S.C. § 405(g) for judicial review of the final decision
of the Commissioner denying the application of Jeanie Ford-Williams (“Plaintiff”) for Disability
Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) under Titles II and XVI
of the Social Security Act, 42 U.S.C. §§ 401, et. seq. and §§ 1381, et. seq. Plaintiff has filed a
brief in support of the Complaint (Doc. 17), Defendant has filed a brief in support of the Answer
(Doc. 23), and Plaintiff has filed a reply to the Answer (Doc. 25). The parties have consented to
the jurisdiction of the undersigned United States Magistrate Judge pursuant to Title 28 U.S.C. §
636(c). (Doc. 10).
Nancy A. Berryhill is now the Acting Commissioner of Social Security. Pursuant to Rule 25(d)
of the Federal Rules of Civil Procedure, Nancy A. Berryhill should be substituted for Acting
Commissioner Carolyn W. Colvin as the defendant in this suit. No further action needs to be
taken to continue this suit by reason of the last sentence of section 205(g) of the Social Security
Act, 42 U.S.C. § 405(g).
I. PROCEDURAL HISTORY
Plaintiff filed her application for DIB on December 12, 2013, alleging an onset date of
November 22, 2013. (Tr. 169-77). Plaintiff was initially denied for DIB on February 14, 2014,
and she filed a Request for Hearing before an Administrative Law Judge (“ALJ”) on March 4,
2014. (Tr. 79-85). Plaintiff also applied for SSI on April 21, 2015 and her application was
escalated to the ALJ level with Plaintiff’s application for DIB. (Tr. 33, 193-98, 273). The ALJ
conducted a hearing on April 23, 2015. (Tr. 30-64). After the hearing, by decision dated May 4,
2015, the ALJ found Plaintiff not disabled. (Tr. 12-29). On June 3, 2016, the Appeals Council
denied Plaintiff’s request for review. (Tr. 1-6). As such, the ALJ’s decision stands as the final
decision of the Commissioner.
II. DECISION OF THE ALJ
The ALJ found Plaintiff has not engaged in substantial gainful activity since November
22, 2013, the alleged onset date. (Tr. 17). The ALJ found Plaintiff has the severe impairments
of migraines and anxiety disorder, but that no impairment or combination of impairments meets
or medically equals the severity of one of the listed impairments in 20 C.F.R. Part 404, Subpart
P, Appendix 1. (Tr. 17-18).
After considering the entire record, the ALJ determined Plaintiff has the Residual
Functional Capacity (“RFC”) to perform light work with the following limitations. (Tr. 19).
Plaintiff is limited to lifting up to 20 pounds occasionally and 10 pounds frequently. (Id.). She
is limited to standing or walking for up to six hours of an eight hour workday and to sitting for
up to six hours of an eight hour workday. (Id.). Plaintiff cannot climb ropes, ladders, or
scaffolds. (Id.). She should avoid exposure to work hazards like unprotected heights or
dangerous moving machinery. (Id.). Plaintiff is able to understand, remember, and carry out
short, simple instructions consistent with unskilled work. (Id.). She can tolerate brief,
occasional contact with coworkers and supervisors, and minimal, superficial contact with the
general public. (Id.). The ALJ determined that Plaintiff is not able to perform any of her past
relevant work, that there are jobs that exist in significant numbers in the national economy that
Plaintiff can perform, including folding machine operator, garment sorter, and collator operator.
(Tr. 24-25). Therefore, the ALJ found Plaintiff not disabled. (Tr. 25). Plaintiff appeals, arguing
substantial evidence does not support the Commissioner’s decision.
III. LEGAL STANDARD
Under the Social Security Act, the Commissioner has established a five-step process for
determining whether a person is disabled. 20 C.F.R. §§ 416.920, 404.1529. “‘If a claimant fails
to meet the criteria at any step in the evaluation of disability, the process ends and the claimant is
determined to be not disabled.’” Goff v. Barnhart, 421 F.3d 785, 790 (8th Cir. 2005) (quoting
Eichelberger v. Barnhart, 390 F.3d 584, 590-91 (8th Cir. 2004)). In this sequential analysis, the
claimant first cannot be engaged in “substantial gainful activity” to qualify for disability benefits.
20 C.F.R. §§ 416.920(b), 404.1520(b). Second, the claimant must have a severe impairment. 20
C.F.R. §§ 416.920(c), 404.1520(c). The Social Security Act defines “severe impairment” as
“any impairment or combination of impairments which significantly limits [claimant’s] physical
or mental ability to do basic work activities. . . .” Id. “‘The sequential evaluation process may
be terminated at step two only when the claimant’s impairment or combination of impairments
would have no more than a minimal impact on [his or] her ability to work.’” Page v. Astrue, 484
F.3d 1040, 1043 (8th Cir. 2007) (quoting Caviness v. Massanari, 250 F.3d 603, 605 (8th Cir.
2001), citing Nguyen v. Chater, 75 F.3d 429, 430-31 (8th Cir. 1996)).
Third, the ALJ must determine whether the claimant has an impairment which meets or
equals one of the impairments listed in the Regulations. 20 C.F.R. §§ 416.920(d), 404.1520(d).
If the claimant has one of, or the medical equivalent of, these impairments, then the claimant is
per se disabled without consideration of the claimant’s age, education, or work history. Id.
Fourth, the impairment must prevent the claimant from doing past relevant work. 20
C.F.R. §§ 416.920(f), 404.1520(f). The burden rests with the claimant at this fourth step to
establish his or her RFC. Steed v. Astrue, 524 F.3d 872, 874 n.3 (8th Cir. 2008) (“Through step
four of this analysis, the claimant has the burden of showing that she is disabled.”). The ALJ
will review a claimant’s RFC and the physical and mental demands of the work the claimant has
done in the past. 20 C.F.R. § 404.1520(f).
Fifth, the severe impairment must prevent the claimant from doing any other work. 20
C.F.R. §§ 416.920(g), 404.1520(g). At this fifth step of the sequential analysis, the
Commissioner has the burden of production to show evidence of other jobs in the national
economy that can be performed by a person with the claimant’s RFC. Steed, 524 F.3d at 874
n.3. If the claimant meets these standards, the ALJ will find the claimant to be disabled. “The
ultimate burden of persuasion to prove disability, however, remains with the claimant.” Young v.
Apfel, 221 F.3d 1065, 1069 n.5 (8th Cir. 2000). See also Harris v. Barnhart, 356 F.3d 926, 931
n.2 (8th Cir. 2004) (citing 68 Fed. Reg. 51153, 51155 (Aug. 26, 2003)); Stormo v. Barnhart, 377
F.3d 801, 806 (8th Cir. 2004) (“The burden of persuasion to prove disability and to demonstrate
RFC remains on the claimant, even when the burden of production shifts to the Commissioner at
step five.”). Even if a court finds that there is a preponderance of the evidence against the ALJ’s
decision, the decision must be affirmed if it is supported by substantial evidence. Clark v.
Heckler, 733 F.2d 65, 68 (8th Cir. 1984). “Substantial evidence is less than a preponderance but
is enough that a reasonable mind would find it adequate to support the Commissioner’s
conclusion.” Krogmeier v. Barnhart, 294 F.3d 1019, 1022 (8th Cir. 2002). See also Cox v.
Astrue, 495 F.3d 614, 617 (8th Cir. 2007).
It is not the job of the district court to re-weigh the evidence or review the factual record
de novo. Cox, 495 F.3d at 617. Instead, the district court must simply determine whether the
quantity and quality of evidence is enough so that a reasonable mind might find it adequate to
support the ALJ’s conclusion. Davis v. Apfel, 239 F.3d 962, 966 (8th Cir. 2001) (citing
McKinney v. Apfel, 228 F.3d 860, 863 (8th Cir. 2000)). Weighing the evidence is a function of
the ALJ, who is the fact-finder. Masterson v. Barnhart, 363 F.3d 731, 736 (8th Cir. 2004).
Thus, an administrative decision which is supported by substantial evidence is not subject to
reversal merely because substantial evidence may also support an opposite conclusion or because
the reviewing court would have decided differently. Krogmeier, 294 F.3d at 1022.
To determine whether the Commissioner’s final decision is supported by substantial
evidence, the court is required to review the administrative record as a whole and to consider:
(1) Findings of credibility made by the ALJ;
(2) The education, background, work history, and age of the claimant;
(3) The medical evidence given by the claimant’s treating physicians;
(4) The subjective complaints of pain and description of the claimant’s physical activity
(5) The corroboration by third parties of the claimant’s physical impairment;
(6) The testimony of vocational experts based upon proper hypothetical questions which
fairly set forth the claimant’s physical impairment; and
(7) The testimony of consulting physicians.
Brand v. Sec’y of Dep’t of Health, Educ. & Welfare, 623 F.2d 523, 527 (8th Cir. 1980).
In her appeal of the Commissioner’s decision, Plaintiff argues the ALJ erred by failing to
include all of her credible limitations in the RFC. (Doc. 17 at 8). Specifically, Plaintiff argues
the RFC is inconsistent with the Medical Source Statement—Mental (“MSSM”) from Bhaskar
Gowda, M.D., Plaintiff’s treating psychiatrist, even though the ALJ assigned Dr. Gowda’s
opinion significant weight.2 (Doc. 20 at 9). For the following reasons, the Court finds Plaintiff's
arguments without merit and that the ALJ's decision is based on substantial evidence and is
consistent with the Regulations and case law.
The Regulations define RFC as “what [the claimant] can do” despite her “physical or
mental limitations.” 20 C.F.R. § 404.1545(a). “When determining whether a claimant can
engage in substantial employment, an ALJ must consider the combination of the claimant's
mental and physical impairments.” Lauer v. Apfel, 245 F.3d 700, 703 (8th Cir. 2001). “The ALJ
must assess a claimant’s RFC based on all relevant, credible evidence in the record, ‘including
the medical records, observations of treating physicians and others, and an individual’s own
description of [her] limitations.’” Tucker v. Barnhart, 363 F.3d 781, 783 (8th Cir. 2004)
(quoting McKinney, 228 F.3d at 863). See also Myers v. Colvin, 721 F.3d 521, 526 (8th Cir.
2013). To determine a claimant’s RFC, the ALJ must move, analytically, from ascertaining the
true extent of the claimant’s impairments to determining the kind of work the claimant can still
do despite her impairments. Anderson v. Shalala, 51 F.3d. 777, 779 (8th Cir. 1995). “Although
it is the ALJ’s responsibility to determine the claimant’s RFC, the burden is on the claimant to
establish his or her RFC.” Buford v. Colvin, 824 F.3d 793, 796 (8th Cir. 2016) (internal citations
The parties agree that Dr. Gowda is Plaintiff’s treating psychiatrist. (Doc. 17 at 7; Doc. 23 at
Plaintiff does not challenge the ALJ’s assignment of significant weight to Dr. Gowda’s
opinion. Rather, Plaintiff argues the RFC is flawed because it fails to capture all the limitations
in the MSSM. “A treating physician’s opinion regarding an applicant’s impairment will be
granted controlling weight, provided the opinion is well-supported by medically acceptable
clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial
evidence in the record.” Reece v. Colvin, 834 F.3d 904, 908-09 (8th Cir. 2016) (internal
quotations omitted). “Although a treating physician’s opinion is usually entitled to great weight,
it ‘do[es] not automatically control, since the record must be evaluated as a whole.’” Id. at 909
(quoting Prosch v. Apfel, 201 F.3d 1010, 1013 (8th Cir. 2000)). “Whether the ALJ gives the
opinion of a treating physician great or little weight, the ALJ must give good reasons for doing
so.” Id. “The opinion of a consulting physician who examines a claimant once or not at all does
not generally constitute substantial evidence.” Kelley v. Callahan, 133 F.3d 583, 589 (8th Cir.
1998) (citing Metz v. Shalala, 49 F.3d 374, 378 (8th Cir. 1995)). This is especially true when the
consulting physician’s opinion is “contradicted by the evaluation of the claimant’s treating
physician.” Hancock v. Sec’y of Dep’t of Health, Educ. & Welfare, 603 F.2d 739, 740 (8th Cir.
Dr. Gowda completed his MSSM on April 16, 2015. (Tr. 448-49). He stated that
Plaintiff would not miss work because of “bad days,” but would be off-task approximately 10%
of the time due to a lack of focus. (Tr. 448). Dr. Gowda then gave his opinion on Plaintiff’s
limitations in several areas. (Id.). The MSSM form called for Dr. Gowda to choose from among
“mildly limited,” “moderately limited,” “markedly limited,” or “extremely limited” for each
category. 3 (Id.). Dr. Gowda indicated Plaintiff is only mildly limited in her ability to remember
locations and work-like procedures. (Id.). Dr. Gowda further opined that Plaintiff is moderately
limited in her ability to understand, remember, and carry out very short and simple instructions,
and in her ability to understand, remember, and carry out detailed instructions. (Tr. 448-49).
According to Dr. Gowda, Plaintiff is also moderately limited in 19 areas including her ability to
maintain attention and concentration for extended periods, perform activities within a schedule,
sustain an ordinary routine, work in coordination with or proximity to others, complete a normal
workday or work week without interruption from psychologically-based symptoms, accept
instructions and respond appropriately to criticisms from supervisors, adapt to changes in the
work setting, be aware of normal hazards, and work independently. (Tr. 448-49). Dr. Gowda
did not find Plaintiff either “marked limited” or “extremely limited” in any category. (See id.).
The Court finds that the ALJ properly weighed the opinion of Dr. Gowda and
incorporated the credible limitations from Dr. Gowda’s MSSM in the RFC. The ALJ correctly
afforded Dr. Gowda’s opinion significant weight, finding it largely consistent with the moderate
restrictions demonstrated by the overall evidence. (Tr. 22). To the extent Plaintiff argues that
the RFC is inconsistent with Dr. Gowda’s opinions, the Court rejects this argument. On the
MSSM, Dr. Gowda indicates only moderate limitations in social interaction and only moderate
limitations in following instructions. (Tr. 449). The RFC restricts Plaintiff to “occasional
contact with coworkers and supervisors, but in small numbers and for short periods of time,” and
only “minimal, superficial contact with the general public.” (Tr. 19). Plaintiff is also limited to
unskilled work with short, simple instructions. The moderate limitations in the MSSM are not
Relevant to the current analysis, the form does not define the term “mildly limited” but defines
the term “moderately limited” as “comparable with some, but not all, useful functioning.
Considered to be 1 standard deviation below the norm, or 30% overall reduction in
performance.” (Tr. 448).
inconsistent with the ability to perform unskilled work with limited interactions with others. In
light of the restrictive limitations found by the ALJ, the Court finds that the limitations included
in the RFC are consistent with Dr. Gowda’s opinion.
The Court also rejects Plaintiff’s argument that the ALJ must include all the limitations
indicated in Dr. Gowda’s opinion. The ALJ may decline to assign a treating source controlling
weight if the ALJ cites good reasons for doing so. See Reece, 834 F.3d at 906. Here, the ALJ
did not give the opinion of Dr. Gowda controlling weight and, therefore, did not need to adopt
every limitation identified by Dr. Gowda. Instead, she assigned the MSSM “significant weight”
because she found Dr. Gowda’s opinion “generally consistent with the moderate restrictions
demonstrated by the overall evidence” and because his opinion is consistent with a finding that
Plaintiff is not disabled despite her reduced focus. (Tr. 22). However, the ALJ properly
included limitations found in Dr. Gowda’s opinion to the extent she found the opinion consistent
with the record.
In fact, in determining Plaintiff’s RFC, the ALJ conducted a thorough review of the
medical evidence and found that the objective medical evidence establishes diagnoses of
migraines and generalized anxiety disorder, but that the evidence was inconsistent as to the
alleged severity of Plaintiff’s limitations. (Tr. 20). The Court finds that the record supports this
analysis. The earliest medical evidence of Plaintiff’s mental impairments is from Thomas
Spencer, Psy.D, who performed a consultative examination on June 13, 2013. (Tr. 276-279).
Dr. Spencer opined that Plaintiff was able to “understand moderately complex instructions” and
“complete moderately complex tasks,” although she demonstrated “moderate impairment[s]” in
interacting socially and adapting to changes in the workplace. (Tr. 279).
Further medical evidence shows that Plaintiff’s mental health has mostly been managed
by her primary care physician through conservative treatment. Failure to seek aggressive
treatment from a mental health professional is a relevant consideration when assessing mental
impairments. See Kirby v. Astrue, 500 F.3d 705, 708-09 (8th Cir. 2007) (affirming ALJ's
finding that claimant did not suffer significant impairment due to psychiatric illness when
claimant had never had any formal treatment by psychiatrist, psychologist, or other mental health
professional on a long-term basis); Vanlue v. Astrue, No. 4:11CV595 TIA, 2012 WL 4464797, at
*12 (E.D. Mo. Sept. 26, 2012) (affirming the ALJ's finding that depression was not a severe
impairment where the claimant had sought only minimal and conservative treatment and the
claimant never required more aggressive forms of mental health treatment than medication).
Plaintiff first saw her primary care physician, Kimberly Bohlmann, M.D., regarding her
anxiety and crying spells on March 19, 2014. (Tr. 365-68). Dr. Bohlmann prescribed Zoloft for
daily use and Valium for use in extreme situations. (Tr. 367). In follow-up visits dated March
31, 2014 and April 23, 2014, Dr. Bohlmann noted that Plaintiff’s symptoms were improving on
the medication. (Tr. 357-63). In July 2014, Dr. Bohlmann increased Plaintiff’s Zoloft dosage
after Plaintiff reported increased depression and crying spells after her husband was diagnosed
with terminal cancer. (Tr. 349-52). Plaintiff saw Dr. Bohlmann again in September 2014 with
depressed mood and crying spells, and her Zoloft was increased. (Tr. 337-40). Plaintiff returned
for a follow-up a week later and reported her mood had improved. (Tr. 333-36). In October
2014, Plaintiff reported that she continued to improve. (Tr. 330). Plaintiff then sought treatment
in February 2015 upon having difficulties coping with anxiety and the death of her husband. (Tr.
408-11, 417-20). Dr. Bohlmann switched Plaintiff from Zoloft to Lexapro, and referred her for
counseling at Pathways Community Health. (Id.). Plaintiff met with counselors at Pathways
numerous times in February and March 2015 until Dr. Gowda completed his MSSM in April
2015. (Tr. 422-50).
The Court finds that a longitudinal review of the medical records supports the limitations
in the RFC. Although Plaintiff has some impairments, Plaintiff has only received conservative
treatment over a relatively short period of time. The ALJ properly incorporated Dr. Gowda’s
opinion into the RFC to the extent the MSSM was consistent with the moderate findings in the
medical evidence. The ALJ is not required to include limitations greater than those
demonstrated in the medical record.
The ALJ also declined to include greater limitations in the RFC in part because
nonmedical evidence diminished Plaintiff’s credibility. The credibility of a claimant’s
allegations is weakened by evidence she left stopped working for nonmedical reasons.
Medihaug v. Astrue, 578 F.3d 805, 816-17 (8th Cir. 2009). Here, Plaintiff testified that she quit
her last job after a change in ownership, not because of a medical reason. (Tr. 40-42).
Furthermore, the ALJ found Plaintiff’s daily activities inconsistent with severe limitations. (Tr.
21). The ALJ may discount a claimant’s allegations if they are inconsistent with the claimant’s
daily activities. See Cruze v. Chater, 85 F.3d 1320, 1325 (8th Cir. 1996) (plaintiff’s complaints
were inconsistent with testimony that he cared for chickens and cows, and made weekly trips
into town). Plaintiff testified that she was able to drive, go grocery shopping, prepare her own
meals, perform household chores, and attend a weekly church service. (Tr. 45-47, 234).
Plaintiff also cares for several animals, including chickens, a rabbit, and a dog. (Tr. 387). The
ALJ properly determined that Plaintiff’s daily activities contradicted her allegations of severe
The ALJ also gave “significant weight” to the opinion of state agency psychiatric
consultant Mark Altomari, Ph.D. (Tr. 21-22). State agency medical consultants are highly
qualified experts in Social Security disability assessment, and the ALJ must therefore consider
their findings. 20 C.F.R. §§ 404.1527(f)(2)(i); Kamann v. Colvin, 721 F.3d 945, 951 (8th Cir.
2013) (state agency psychologist’s opinion supported ALJ’s finding that claimant could work
despite his mental impairments). After an extensive review of the evidence, Dr. Altomari opined
that Plaintiff has moderate limitations in social interaction and carrying out detailed instructions.
(Tr. 71-72). However, he ultimately determined that Plaintiff is able to perform unskilled work
despite her limitations, and is therefore not disabled. (Tr. 73-75). The ALJ properly relied upon
Dr. Altomari’s opinion because it he is a highly qualified medical source, and because his
opinion is consistent with the medical evidence in the record, as discussed in detail above.
In sum, the ALJ did not err in assessing Dr. Gowda’s MSSM. The ALJ properly
articulated why she gave significant weight to some of Dr. Gowda’s findings and why she
incorporated them into the RFC. To the extent Dr. Gowda opined Plaintiff has more severe
limitations than set out in the RFC, the ALJ explained that she relied on the MSSM only insofar
as it was consistent with other credible evidence in the record. The ALJ is not required to adopt
a medical opinion wholesale, nor is she required to adopt limitations that are inconsistent with
the record as a whole. Furthermore, the RFC is supported by substantial evidence in that the
ALJ properly gave weight to the objective medical evidence, nonmedical evidence, and the
medical opinions of Dr. Gowda and Dr. Altomari.
For the reasons set forth above, the court finds that substantial evidence on the record as a
whole supports the Commissioner’s decision that Plaintiff is not disabled.
IT IS HEREBY ORDERED that the decision of the Commissioner is AFFIRMED, and
Plaintiff’s Complaint is DISMISSED with prejudice.
A separate judgment shall be entered incorporating this Memorandum and Order.
Dated this 25th day of September, 2017.
/s/ Noelle C. Collins
NOELLE C. COLLINS
UNITED STATES MAGISTRATE JUDGE
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