United States District Court, N.D. Alabama, Jasper Division
MEMORANDUM OPINION
KARON
OWEN BOWDRE CHIEF UNITED STATES DISTRICT JUDGE.
I.
INTRODUCTION
On
December 30, 2014, the claimant protectively applied for
disability and disability insurance benefits under Title II
of the Social Security Act. The claimant initially alleged
disability beginning December 28, 2014, because of
depression, anxiety, obsessive-compulsive disorder, panic
attacks, eating disorder, complex regional pain syndrome,
chronic migraines, social anxiety, and several suicide
attempts. The Commissioner denied the claims on April 2,
2015. The claimant filed a timely request for a hearing
before an Administrative Law Judge, and the ALJ held a
hearing on August 31, 2016. (R. 17, 2071).
In a
decision dated January 24, 2017, the ALJ found that the
claimant was not disabled as defined by the Social Security
Act, rendering her ineligible for Social Security benefits.
On October 5, 2017, the Appeals Council denied the
claimant's request for review. Consequently, the
ALJ's decision became the final decision of the
Commissioner of the Social Security Administration. The
claimant has exhausted her administrative remedies, and this
court has jurisdiction pursuant to 42 U.S.C.
§§405(g) and 1383(c)(3). (R. 1, 14).
Because
substantial evidence does not support the ALJ's findings
regarding the weight he gave the claimant's treating
physician and a consulting examiner, this court REVERSES and
REMANDS the decision of the Commissioner to the ALJ for
reconsideration.
II.
ISSUE PRESENTED
Whether
the ALJ erred in failing to state the weight he gave to the
opinion of the consultative examiner Dr. Susan Corbin and in
his description of the substance of Dr. Corbin's opinion.
III.
STANDARD OF REVIEW
The
standard for reviewing the Commissioner's decision is
limited. This court must affirm the Commissioner's
decision if he applied the correct legal standards and
substantial evidence supports his factual conclusions.
See 42 U.S.C. §405(g); Graham v.
Apfel, 129 F.3d 1420, 1422 (11th Cir. 1997); Walker
v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).
“No
. . . presumption of validity attaches to the
[Commissioner's] legal conclusions, including
determination of the proper standards to be applied in
evaluating claims.” Walker, 826 F.2d at 999.
But this court does not review the Commissioner's factual
determinations de novo. The court will affirm those
factual determinations that are supported by substantial
evidence. “Substantial evidence” is “more
than a mere scintilla. It 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).
The
court must keep in mind that opinions, such as whether a
claimant is disabled, the nature and extent of a
claimant's residual functional capacity, and the
application of vocational factors, “are not medical
opinions, . . . but are, instead, opinions on issues reserved
to the Commissioner because they are administrative findings
that are dispositive of a case; i.e., that would direct the
determination or decision of disability.” 20 C.F.R.
§§ 404.1527(d), 416.927(d). Whether the claimant
meets the listing and is qualified for Social Security
disability benefits is a question reserved for the ALJ, and
the court “may not decide facts anew, reweigh the
evidence, or substitute [its] judgment for that of the
Commissioner.” Dyer v. Barnhart, 395 F.3d
1206, 1210 (11th Cir. 2005). Thus, even if the court were to
disagree with the ALJ about the significance of certain
facts, the court has no power to reverse that finding as long
as substantial evidence in the record supports it.
The
court must “scrutinize the record in its entirety to
determine the reasonableness of the [Commissioner]'s
factual findings.” Walker, 826 F.2d at 999.
And a reviewing court must not only look to those parts of
the record that support the decision of the ALJ, but also
must view the record in its entirety and take account of
evidence that detracts from the evidence relied on by the
ALJ. Hillsman v. Bowen, 804 F.2d 1179, 1180 (11th
Cir. 1986).
IV.
LEGAL STANDARD
The ALJ
“must state with particularity the weight given to
different medical opinions” and the reasons for his
finding; the failure to do so is reversible error. Romeo
v. Comm'r of Social Security, 686 Fed.Appx. 731, 732
(11th Cir. 2017) (citing Winschel v. Comm'r of Social
Security, 631 F.3d 1176, 1179 (11th Cir. 2011)). The
ALJ's stated reasons must be legitimate and supported by
the substantial evidence in the record. See Tavarez v.
Commissioner of Social Security, 638 Fed.Appx. 841, 847
(11th Cir. Jan. 7, 2016) (finding that the “ALJ did not
express a legitimate reason supported by the record for
giving [the consulting physician's] assessment little
weight.”).
V.
FACTS
The
claimant was forty-eight years old at the time of the
ALJ's final decision; has a high school education; has
past relevant work as a physical therapy assistant; and
alleges disability based on major depressive disorder,
anxiety, complex regional pain syndrome, fibromyalgia,
migraine headaches, and chronic and severe pain. (R. 20, 25).
Physical
and Mental Impairments
In
November 2007, the claimant was involved in an automobile
accident and suffered a broken right hand. Consequently, the
claimant underwent surgery at Alabama Outpatient Surgery, in
which Dr. Gary Russell placed two pins in her hand and casted
it. Between January 3 and January 30, 2008, the claimant had
follow-up appointments with Dr. Russell at Southern
Orthopedics and Sports Medicine Associates. At each visit,
Dr. Russell noted that the claimant's hand was stiff and
weak, eventually diagnosing her with reflex sympathetic
dystrophy (RSD) and referring her to physical therapy. On
January 21, Dr. Russell removed the pins in the
claimant's hands and scheduled an anesthetic injection
into the nerves in her neck on February 5 to prevent pain.
(R. 47, 241-43).
From
that point, the record contains no relevant medical evidence
until February 1, 2011, when the claimant presented to the
Northwest Alabama Mental Health Center. She noted she had
been a client over 20 years prior and sought to re-establish
herself as a patient. The claimant told therapist Sondra
Wightman that her symptoms of depression, anxiety, and panic
attacks had increased; that simple activities such as walking
down the sidewalk or stopping at a red light cause her to
have panic attacks because she “thinks people are
staring at her”; that she previously attempted suicide
in 1990 and was hospitalized as a result; and that she
thought of suicide again “two months ago, after a
really bad day at work.” (R. 260).
Regarding
her interests, the claimant told Ms. Wightman that she
“does not have a lot of interest or energy, ”
aside from watching television at home. Ms. Wightman noted
that the claimant's current depressive state, along with
her anxiety and panic attacks, cause emotional discomfort and
impairs her ability to “enjoy daily activities to the
fullest and perform appropriately at work.” (R. 260).
Between
August 26, 2011 and September 24, 2013, the claimant
continued her therapy sessions with Ms. Wightman at the
Northwest Alabama Mental Health Center. Based on Ms.
Wightman's notes, the psychiatrist diagnosed the claimant
with “severe” major depressive disorder and
prescribed her Paroxetine and Bupropion for depression and
anxiety.[1] (R. 254-94, 348-50).
The
claimant visited Dr. Arthur Patton, an internal medicine
doctor at Norwood Clinic, for the first time on September 24,
2013, complaining of a severe migraine headache “like
her usual migraines, only worse.” During his physical
examination of the claimant, Dr. Patton noted that the
claimant demonstrated “moderate pain behavior with
vomiting.” Dr. Patton diagnosed the claimant with a
migraine headache and ordered injections of Phenergan and
Toradol, and prescribed acetaminophen. (R. 246-47).
Between
September 24, 2013 and December 3, 2014, the claimant
continued meeting with Ms. Wightman who noted that her
conditions remained the same. The claimant repeatedly stated
that she was depressed and lacked energy. (R. 252, 269, 299,
301-02, 304, 306-07, 309, 311-12, 314-19, 321-22, 324, 326,
330).
On
December 3, 2014, the claimant saw Dr. John Cantrell, an
internal medicine doctor at St. Vincent's Gardendale
Clinic, seeking to become a patient. She explained her
history with depression and anxiety and stated that her
migraines had worsened in the past two months. Dr. Cantrell
noted the claimant's anxiety and depression as
“abnormal, ” and further noted a finding of pain
and RPS in her right hand. Dr. Cantrell diagnosed the
claimant with obsessive compulsive disorder (OCD), migraines,
joint pain, insomnia, chronic pain syndrome, and depression.
He prescribed acetaminophen for her migraines, Lyrica and
Zanaflex for chronic pain, and Paxil and Wellbutrin for
depression and OCD. (R 404-07).
One
month later, on January 2, 2015, the claimant returned to Dr.
Cantrell. She stated that she could not afford Lyrica; had an
eating disorder, chronic pain syndrome, and depression; and
wanted to know if she could be tested for fibromyalgia. She
further informed Dr. Cantrell that she was filing for
disability because she could not work. During his physical
examination, Dr. Cantrell noted the same findings as the
prior appointment. Dr. Cantrell advised the claimant to stop
taking Lyrica and continue taking Zanaflex for chronic pain.
(R. 400-02, 508-10).
At the
request of the Social Security Administration, the claimant
completed a “Function Report-Adult” on January 8,
2015. In that report, the claimant stated that, because of
her pain and OCD, she “takes longer” to dress and
bathe. The claimant further stated that the “pain and
stiffness” of her right hand does not allow her to use
utensils while eating and causes difficulty when shaving. She
never cooks; she just prepares “easy microwave meals
and sandwiches”; can clean the house; can do laundry
once a week with the help of her mother; cannot do yard work
because of “anxiety and panic attacks, severe fatigue
and pain”; can drive alone, but only for ...