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Porter v. Berryhill

United States District Court, N.D. Alabama, Middle Division

December 10, 2018

JAMAL PORTER, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Plaintiff Jamal Porter (“Plaintiff” or “Porter”) brings this action pursuant to Section 205(g) of the Social Security Act (the “Act”), seeking review of the decision of the Commissioner of Social Security (“Commissioner”) denying his claims for a period of disability and disability insurance benefits (“DIB”). See 42 U.S.C. § 405(g). Based on the court's review of the record and the briefs submitted by the parties, the court finds that the decision of the Commissioner is due to be affirmed.

         I. Proceedings Below

         On April 17, 2014, Plaintiff filed an application for supplemental security income (“SSI”) alleging disability as of December 31, 2008. (Tr. 20, 39, 71). Plaintiff later amended her alleged onset date and he now contends that it is June 24, 2014. (Tr. 20, 39, 163). Plaintiff's initial application was denied by the Social Security Administration (“SSA”) on July 14, 2014. (Tr. 87-89). On July 29, 2014, Plaintiff filed a request for a hearing by an Administrative Law Judge (“ALJ”). (Tr. 92). That request was granted (Tr. 95-97), and Plaintiff received a hearing before ALJ Denise Copeland (“the ALJ”) on February 8, 2016. (Tr. 39-65, 105-10). In her decision dated April 20, 2016, the ALJ determined that Plaintiff has not been under a disability, as defined by the Act, since his amended disability onset date of June 24, 2014. (Tr. 20-32). After the Appeals Council (“AC”) denied Plaintiff's request for review of the ALJ's decision (Tr. 1-3), that decision became final and a proper subject for this court's review.

         II. Statement of Facts

         Plaintiff was born on November 15, 1975 and was 38 years old on his amended disability onset date. (Tr. 47, 174). He alleges disability due to back problems, bipolar disorder, depression, bad nerves, and attention deficit disorder (“ADD”). (Tr. 66, 71). Plaintiff last worked at Quality Grinding doing machine work from July 2008 until October 2008. (Tr. 72, 186). Prior to that, Plaintiff worked for Goodyear as a tire loader. (Id.). Plaintiff has not worked since 2008. (Tr. 178). Plaintiff was incarcerated from 2000-2006, and he associates his current mental condition with his experience during that time, although he says he has always tended to keep to himself. (Tr. 54, 207, 318).

         Plaintiff had not seen a medical professional prior to filing his disability claim, and the record does not reflect any medical evidence prior to 2014. However, Plaintiff saw Dr. Sathyan Iyer on June 7, 2014 at the request of Disability Determination Services (“DDS”). (Tr. 71, 275-78). Dr. Iyer described Plaintiff as alert with no acute distress and noted a smell of alcohol on his breath. (Id.). Dr. Iyer found Plaintiff to have a history of depression probably caused and aggravated by excess alcohol consumption, as well as uncontrolled hypertension. (Tr. 278). Dr. Iyer found Plaintiff to have no significant physical limitations, but that “continued excess alcohol use could impair many functions.” (Id.).

         Approximately two weeks later June Nichols, a licensed psychologist with Gadsden Psychological Services, LLC, examined and evaluated Plaintiff at the request of DDS. (Tr. 280). Dr. Nichols described Plaintiff as neat and clean with a clear stream of consciousness and orientation to person, place, time, and situation. (Tr. 281). She noted that Plaintiff was “visibly shaking during the interview with a tremulous voice” and that while Plaintiff's speed of mental processing was slowed, his recent memory functions were grossly intact. (Id.). There was no evidence of confusion in his thought processes. (Tr. 282). Dr. Nichols diagnosed Plaintiff with alcohol dependence, post-traumatic stress disorder (“PTSD”), major depressive disorder, panic disorder without agoraphobia, generalized anxiety disorder, and specific reading disorder. (Tr. 282-83). Dr. Nichols found the chance for significant improvement over next twelve months was “poor without intense intervention regarding alcohol abuse and other symptoms.” (Tr. 283). Dr. Nichols explained that Plaintiff's ability to relate interpersonally and his ability to withstand the pressures of everyday work were compromised based on his current symptoms. (Id.). Further, Plaintiff was found to have deficits that would interfere with his ability to remember, understand, and carry out work related instructions. (Id.). Although she did not think that Plaintiff would be able to handle his own funds, Dr. Nichols said Plaintiff could live independently with assistance. (Id.).

         Later that same year, on October 7, 2014, Plaintiff went to Cherokee, Etowah, Dekalb Mental Health Center (“CED”) complaining of auditory hallucinations, paranoia, and depression. (Tr. 302). Plaintiff reported the auditory hallucinations were not commands but statements of his worthlessness. (Tr. 312). In the intake assessment Plaintiff was described as appearing appropriate but with a dysphoric mood and blunted affect. (Tr. 303-04). Plaintiff was unable to sit still, reported that he did not like crowds, and was unable to be alone. (Tr. 304, 312). Plaintiff reported his symptoms started while he was incarcerated but that he has always had social issues. (Tr. 312). Notes indicate that a treatment plan would be formulated. (Tr. 303).

         Plaintiff visited Quality Life Health Services on October 14, 2014 complaining of hypertension, back pain, and headache. (Tr. 284). Dr. Ochuko Odjebda prescribed Plaintiff Flexeril, lisinopril, and meloxicam, yet noted that Plaintiff had a normal physical exam. (Tr. 287). The prescriptions were filled at a Walmart pharmacy in Gadsden. (Tr. 237, 301).

         On November 3, 2014, Plaintiff saw Dr. Richard Grant at CED Mental Health Center (“CED”). (Tr. 301). Dr. Grant noted Plaintiff's depressed mood and affect with reports of hallucinations, delusions, and inadequate attention and concentration. (Tr. 301). Plaintiff's insight and judgment were fair and thought process was logical. (Tr. 301). Dr. Grant prescribed Plaintiff Seroquel for depression. (Tr. 301). That prescription was again filled at the Walmart pharmacy in Gadsden. (Tr. 237, 301).

         Plaintiff followed up with Dr. Odjegba on November 6, 2014. (Tr. 284, 289). In addition to following-up on complaints of back pain and hypertension, Plaintiff was experiencing a cough from allergies. (Tr. 289). Lab reports indicate that Plaintiff returned on November 25, 2014 for blood work. (Tr. 296).

         Medical evidence indicates that Plaintiff continued to seek therapy from CED. On November 18, 2014, Plaintiff reported that the Seroquel made him sleepy. (Tr. 300). Plaintiff also reported isolating himself and being afraid of letting people down. (Id.). His mood was dysphoric and his affect was constricted, yet his GAF score increased from 40 to 45. (Id.). Therapy notes from February 13, 2015 indicate that depression coping skills were discussed with Plaintiff and that his GAF remained at 45. (Tr. 299). Therapy notes from March 27, 2015 indicate that Plaintiff's depression had improved but that he continued to isolate himself, though he walked his daughter to the bus approximately two times per week. (Tr. 323). Plaintiff was encouraged to try to visit Dollar General one time a week to help with isolation. (Id.). About two months later, on May 19, 2015, Plaintiff saw Dr. Grant. (Tr. 325). His mood was described as euthymic, and he stated that he was feeling more depressed. (Id.). Around the same time Plaintiff was given another prescription for Seroquel, but it does not appear Plaintiff ever filled that prescription. (Tr. 237, 324).

         At a therapy session on May 20, 2015, Plaintiff noted an increase in depression symptoms due to an injury to his leg. (Tr. 325). However, Plaintiff also noted that he was motivated by his relationship with his daughter. (Id.). On August 17, 2015, Plaintiff reported to the therapist that he was feeling down because he was unable to walk his daughter to the bus that day. (Tr. 326). He stated that he continued to isolate himself. (Id.). A therapy note from November 12, 2015 indicates that Plaintiff felt overwhelmed with stress and having not had his medication for over a month. (Tr. 328). On December 1, 2015, Plaintiff reported hearing voices. (Tr. 330). Notes indicate that “Patient has relapsed due to not taking the Seroquel for several months. Not compliant with process of obtaining medication. Plan is to resume medication.” (Tr. 330).

         On January 26, 2016, about two months after Plaintiff's last reported visit to CED, Plaintiff's counsel referred him to Dr. David Wilson at Gadsden Psychological Services who performed a psychological evaluation. (Tr. 317-21). During the interview, Plaintiff said he felt depressed 95% of the time, but that he felt better when he saw his daughter. (Tr. 320). He said he saw his daughter two to three times a week and took her to the park. (Id.). According to Dr. Wilson, Plaintiff had problems with mental control and attention, problems with short term and working memory, and severe problems with mood disturbance. (Id.). Plaintiff's interview with Dr. Wilson also indicated that he was still taking Seroquel, although the pharmacy records show the last time he filled a prescription was on November 3, 2014, and during his last visit to CED, which was about two months before his interview, he had been off his medication for several months. (Tr. 237, 321, 330). Dr. Wilson diagnosed Plaintiff with major depressive disorder, recurrent (severe with psychotic features), post-traumatic stress disorder, panic disorder, history of alcohol abuse, estimated borderline intelligence, chest pain, problems with back and legs, acid reflux, and severe hypertension. (Tr. 321). Dr. Wilson opined that Plaintiff could not (1) sustain an ordinary routine without special supervision, (2) interact appropriately with co-workers, or (3) adhere to basic standards of neatness and cleanliness. (Tr. 322). Dr. Wilson further estimated Plaintiff would be expected to fail to report to work twenty-eight out of thirty days. (Id.).

         III. ALJ Decision

         Disability under the Act is determined using a five-step test. 20 C.F.R. § 404.1520. First, the ALJ must determine whether the claimant is engaging in substantial gainful activity. 20 C.F.R. § 404.1520(a)(4)(i). “Substantial gainful activity” is work activity that involves doing significant physical or mental activities for pay or profit. 20 C.F.R. § 404.1572. Work activity may be considered substantial even if it is part-time or if the claimant does less, gets paid less, or has less responsibility than when he worked before. 20 C.F.R. § 404.1572(a). Even if no profit is realized, work activity may still be considered gainful so long as it is the kind of work usually done for pay or profit. 20 C.F.R. § 404.1572(b). If the ALJ finds that the claimant is engaging in substantial gainful activity, then the claimant cannot claim disability. 20 C.F.R. § 404.1520(b).

         Second, the ALJ must determine whether the claimant has a severe medical impairment or a combination of impairments that is severe. 20 C.F.R. § 404.1520(a)(4)(ii). If the claimant does not have a severe impairment or combination of impairments, then he may not claim disability. (Id.). If the impairment is not expected to result in death, the claimant must also meet the 12-month duration requirement. 20 C.F.R. § 404.1509.

         Third, the ALJ must determine whether the claimant's impairment meets or medically equals the criteria of an impairment listed in 20 C.F.R. § 404, Subpart P, Appendix 1. See 20 C.F.R. ยงยง 404.1520(a)(4)(iii), 404.1525, and 404.1526. If the claimant meets or equals a listed impairment and meets the duration requirement, he will ...

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