Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alsd-1_04-cv-00193/USCOURTS-alsd-1_04-cv-00193-0/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (405(g))
Cause of Action: 42:405 Review of HHS Decision (SSID)

---

IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

ANNIE B. CLAUSELL, *

 *

Plaintiff, *

 *

vs. * Civil Action No.04-00193-BH-B

 *

JO ANNE B. BARNHART, *

Commissioner of * 

Social Security, *

 *

Defendant. *

REPORT AND RECOMMENDATION

Plaintiff Annie B. Clausell (“Plaintiff”) brings this action

seeking judicial review of a final decision of the Commissioner

of Social Security denying her claim for supplemental security

income benefits under Title XVI of the Social Security Act

(“Act”), 42 U.S.C. §§ 1381-1383c. This action was referred to

the undersigned for report and recommendation pursuant to 28

U.S.C. § 636(b)(1)(B). The parties waived oral argument. Upon

consideration of the administrative record and memoranda of the

parties, it is recommended that the decision of the Commissioner

be AFFIRMED. 

I. Procedural History

On October 9, 2002, Plaintiff protectively filed an

application for supplemental security income benefits, alleging

that she has been disabled since March 1, 2002 due to severe,

recurrent, major depressive disorder, with psychotic features

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 1 of 27
1Plaintiff’s application was treated as a prototype case and

thus, the reconsideration step was eliminated. 20 C.F.R. § 416.1406.

2

(including “hearing voices”), diabetes mellitus and high blood

pressure. (Tr. 11, 20, 24-25, 42-44). Plaintiff’s initial

application was denied and she filed a Request For Hearing

before an Administrative Law Judge (“ALJ”).1 (Id. at 24-31).

ALJ James D. Smith conducted a hearing on May 6, 2003, which was

attended by Plaintiff and her counsel. (Id. at 194-208). On

October 16, 2003, the ALJ entered a decision, (id. at 11-21),

wherein he found that while Plaintiff has the severe impairments

of diabetes mellitus, hypertension and major depressive

disorder, she retains the residual functional capacity to

perform work requiring medium exertion such that she can return

to her past relevant work as a laundry presser/laundry machine

operator and cleaner/housekeeper, as those jobs are customarily

performed in the national economy. (Id. at 20, Findings 2, 4,

7-8). Plaintiff sought review before the Appeals Council, which

denied same on March 4, 2004, making it the final decision of

the Commissioner of Social Security. (Id. at 4-7, 189-193).

See 20 C.F.R. § 404.981; 20 C.F.R. § 416.1481. The parties

agree that this case is now ripe for judicial review and is

properly before this Court pursuant to 42 U.S.C. § 405(g).

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 2 of 27
2According to Plaintiff, she has been separated from her husband

for 18 years. (Tr. 198).

3

II. Background Facts 

Plaintiff was born on March 6, 1947 and was approximately

56 years old at the time of the administrative hearing. (Tr.

198). Plaintiff testified that she lives alone,2 and has no

income source other than food stamps. (Id.) Plaintiff further

testified that she has an 11th grade education, that she has been

unemployed for 5 years, and that she last worked for a cleaners.

(Id. at 198-199). According to Plaintiff, she stopped working

because of her health. (Id. at 199). Plaintiff claims problems

with depression, diabetes and hypertension. (Id. at 200-207).

According to Plaintiff, she hears voices all the time when she

is awake, the voices are “very annoying” and they result in her

being unable to perform the duties of her job. (Id. at 203-

204). 

Plaintiff testified that she has been treated by Dr. Charles

Smith at the Mobile Mental Health Center for over one year and

that she has been prescribed Zyprexa and Seroquel, but that the

medicine has not stopped the voices. (Tr. at 201-202).

Plaintiff also indicated that the medicine causes drowsiness,

and that at one point, Dr. Smith reduced her Zyprexa dosage

because she was “doz[ing] off”. (Id. at 203). Plaintiff

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 3 of 27
4

further testified that because of “the voices,” she has problems

concentrating and has memory lapses. (Id. at 203-204).

Additionally, Plaintiff testified that her doctors have

prescribed medication for her diabetes, and placed her on a

special diet, with which she complies. (Id. at 204-205).

Plaintiff also testified that she has been prescribed Norvasc

for her hypertension, and that it keeps her blood pressure under

control unless she eats something that she is not supposed to

eat. (Id.) 

As to her daily activities, Plaintiff testified that she

cooks, cleans house, goes to the grocery store (with a friend

who helps her see the prices), and attends bingo twice a week.

(Id. at 204, 206). Plaintiff also testified that she knows how

to drive, but has become too nervous to do so. (Tr. 198, 205).

She further testified that she smokes one-half of a pack of

cigarettes per day, has not used alcoholic beverages in over 3

years (that she stopped drinking when she started hearing

voices), and that while she has used marijuana in the past, has

not done so in 10 years. (Id. at 199-200).

III. Issues on Appeal

Whether the ALJ erred, by failing to properly evaluate

Plaintiff’s mental impairment and develop the record as to the

functional limitations imposed by same by not seeking vocational

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 4 of 27
3This court’s review of the Commissioner’s application of legal

principles is plenary. Walker v. Bowen, 826 F.2d 996, 999 (11th Cir.

1987).

5

expert testimony and by not ordering a consultative examination,

since severe non-exertional impairments were alleged, thus

making it unclear whether she was capable of performing a full

range of medium work?

IV. Analysis

A. Standard of Review

In reviewing claims brought under the Act, this court’s role

is a limited one. The court’s review is limited to determining

1) whether the decision of the Secretary is supported by

substantial evidence, and 2) whether the correct legal standards

were applied. Martin v. Sullivan, 894 F.2d 1520, 1529 (11th Cir.

1990)3. A court may not decide the facts anew, reweigh the

evidence, or substitute its judgment for that of the

Commissioner. Sewell v. Bowen, 792 F.2d 1065, 1067 (11th Cir.

1986). The Commissioner’s findings of fact must be affirmed if

they are based upon substantial evidence. Brown v. Sullivan,

921 F.2d 1233, 1235 (11th Cir. 1991); Bloodsworth v. Heckler, 703

F.2d 1233, 1239 (11th Cir. 1983) (finding that substantial

evidence is defined as “more than a scintilla but less than a

preponderance,” and consists of “such relevant evidence as a

reasonable person would accept as adequate to support a

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 5 of 27
4The claimant must first prove that he or she has not engaged in

substantial gainful activity. The second step requires the claimant

to prove that he or she has a severe impairment or combination of

impairments. If, at the third step, the claimant proves that the

impairment or combination of impairments meets or equals a listed

impairment, then the claimant is automatically found disabled

regardless of age, education, or work experience. If the claimant

cannot prevail at the third step, he or she must proceed to the

fourth step where the claimant must prove inability to perform their

6

conclusion[]”). In determining whether substantial evidence

exists, the court must view the record as a whole, taking into

account evidence favorable as well as unfavorable to the

Commissioner’s decision. Chester v. Bowen, 792 F.2d 129, 131

(11th Cir. 1986); Short v. Apfel, 1999 U.S. Dist. Lexis 10163

(S.D. Ala. 1999). 

B. Discussion

An individual who applies for Social Security disability

benefits must prove her disability. See 20 C.F.R. § 404.1512;

20 C.F.R. § 416.912. Disability is defined as the “inability to

do 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. § 423(d)(1)(A); 20 C.F.R. §§ 404.1505(a) and

416.905(a). The Social Security regulations provide a five-step

sequential evaluation process for determining if a claimant has

proven her disability. 20 C.F.R. §§ 404.1520 and 416.920.4 

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 6 of 27
past relevant work. Jones v. Bowen, 810 F.2d 1001, 1005 (11th Cir.

1986). In evaluating whether the claimant has met this burden, the

examiner must consider the following four factors: (1) objective

medical facts and clinical findings; (2) diagnoses of examining

physicians; (3) evidence of pain; (4) the claimant’s age, education

and work history. Id. at 1005. Once a claimant meets this burden, it

becomes the Commissioner’s burden to prove at the fifth step that the

claimant is capable of engaging in another kind of substantial

gainful employment which exists in significant numbers in the

national economy, given the claimant’s residual functional capacity,

age, education, and work history. Sryock v. Heckler, 764 F.2d 834

(11th Cir. 1985). If the Commissioner can demonstrate that there are

such jobs the claimant can perform, the claimant must prove inability

to perform those jobs in order to be found disabled. Jones v. Apfel,

190 F.3d 1224, 1228 (11th Cir. 1999). See also Hale v. Bowen, 831

F.2d 1007, 1011 (11th Cir. 1987) (citing Francis v. Heckler, 749 F.2d

1562, 1564 (11th Cir. 1985)).

7

In case sub judice, the ALJ applied the five-step process

in evaluating Plaintiff’s claim, and concluded, at steps one and

two, that she has not engaged in substantial gainful activity

since her alleged onset of disability, and that she has the

impairments of diabetes mellitus, hypertension and major

depressive disorder, which are “severe” within the meaning of

the Act. (Tr. 20, Findings 1-3). The ALJ found at step three,

that Plaintiff’s impairments, singly or in combination, do not

meet or equal the listings. (Id., Finding 2). The ALJ also

determined that Plaintiff’s allegations of pain and functional

limitations, to the degree alleged, are not supported by the

evidence in the record. (Id., Finding 3). Next, at step four,

the ALJ found that Plaintiff possesses the residual functional

capacity to perform a full range of work activities at the

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 7 of 27
8

medium exertional level on a regular and sustained basis. (Id.,

Finding 4). The ALJ additionally noted that Plaintiff’s past

relevant work, as a laundry presser/laundry machine operator and

cleaner/housekeeper, is not precluded by this residual

functional capacity as those jobs are customarily performed in

the national economy. (Id., Findings 7-8). As such, the ALJ

determined that Plaintiff was not disabled at step four, as she

could perform her past relevant work, thus terminating the

sequential evaluation process. 

Plaintiff does not take issue with the ALJ’s findings in the

first three steps of the sequential analysis. Rather, Plaintiff

alleges that the ALJ erred in his step four analysis.

Specifically, Plaintiff argues that the ALJ failed to properly

analyze her severe mental impairment, and that the ALJ should

have: 1) obtained VE testimony; and 2) ordered a consultative

examination. (Doc. 14). Based upon a review of the record

evidence, the undersigned finds that the ALJ did not err.

With respect to Plaintiff’s mental impairment, the record

evidence reveals that she received treatment at Franklin Primary

Health Center, Inc. (hereinafter “FPHC”), the University of

South Alabama Medical Center (hereinafter “USA”), and the Mobile

Mental Health Center (hereinafter “MMHC”). The FPHC records

reflect, in pertinent part, that: 

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 8 of 27
9

• May 12, 1999 (Tr. 150): Plaintiff was seen for

complaints of her feet cramping and swelling and

also due to difficulty sleeping. She reported

that she had recently lost her brother, and was

very upset about his death.

• August 4, 2000 (Id. at 138-139): Plaintiff was

seen for a follow-up from a prior hospital visit

for nose bleeding. She was upset over family

problems, and indicated that she was on multiple

medications which she was unable to afford.

Plaintiff was prescribed Zyprexa.

• August 24, 2000 (Id. at 136-137): Plaintiff

reported having an anxiety reaction to her

medication, and was prescribed Prozac and

Zyprexa.

• August 22, 2001 (Id. at 130-131): Plaintiff

appeared depressed, and she reported

restlessness, decreased appetite and the

“shakes.” She expressed worry over the loss of

her house due to a fire, and the deaths of

multiple family members within the last two

years. She also reported an anxiety reaction to

her medication. Her diagnosis included

depression, and her medications were refilled. 

• November 20, 2001 (Id. at 128-129): Plaintiff

reported she was “[d]oing well. No change in

status[,]” except for numbness in her head.

• February 19, 2002 (Id. at 126-127): Plaintiff

complained of being unable to sleep at night and

feeling distressed, nervous and restless.

. March 25, 2002 (Tr. at 124-125): Plaintiff reported

that she was “[d]oing very good” except for complaints

of sleeplessness at night.

• September 30, 2002 (Id. at 120-121): Plaintiff

reported having suffered abuse in the past.

The record also reveals that Plaintiff was treated as an

outpatient at USA from August 21, 2001 through February 19,

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 9 of 27
5There are no mental health records, however, in the evidence of

record which show any mental health treatment at MMHC before March

2002.

10

2002, and the USA records reflect, in relevant part, as follows:

• August 21, 2001 (Id. at 89-94): Plaintiff was

treated for heart fluttering, at which time she

also reported insomnia, anxiety and feeling like

she was going to have a nervous breakdown; she

was diagnosed with anxiety and hypokalemia.

• August 22, 2001 (Id. at 95): Plaintiff was

treated as an outpatient for ams/hearing voices;

she was diagnosed with psychosis, NOS, DM2 and

hypokalemia. 

• August 23, 2001 (Id. at 96): Plaintiff had a

psychiatric consultative exam, at which time she

reported hearing voices telling her that she will

be killed and that her house would be “put under

fire.” Plaintiff stated that the voices started

3 days after heavy drinking. Plaintiff reported

that she does not sleep, feels restless and has

become suspicious. She attributed the condition

to the death of her brother, mother and father in

the past 2 years. Plaintiff stated that she was

seen for a brief time by Dr. Smith at MMHC but

stopped going because she does not have a car.

Plaintiff also admitted that she drinks more than

she should.5 The examination notes reflect that

Plaintiff was anxious, suspicious, coherent and

fluent, and was hearing voices talking to her

about hurting her and burning down her house.

Plaintiff also reported her belief that people

can take away her thoughts or insert theirs into

her head. Plaintiff did not know the name of the

current president. The impression was psychosis

NOS; it was recommended that Plaintiff be sent to

MMHC. 

• October 8, 2001 (Id. at 101-102): Plaintiff was

treated as an outpatient for complaints of side

head numbness with dizziness and blurred vision.

Additionally, an abrasion to her scalp was noted.

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 10 of 27
11

The record also contains treatment records which reflect

that Plaintiff was treated, from March 2002 through May 2003 at

MMHC, for major depressive disorder by psychiatrist Dr. Charles

E. Smith, (hereinafter “Dr. Smith”). The MMHC notes reflect,

in pertinent part, as follows:

• March 28, 2002 (Tr. 114-117): Plaintiff was

initially examined by Dr. Smith for complaints of

an inability to sleep, hearing voices and a

feeling of “I’m at the bottom again[]” and am

“not good.” (Id. at 114). Plaintiff reported

that she lost her job when the restaurant closed

and that in the past year, she suffered the

deaths of her brother and sister, and her house

burned down as well. Plaintiff reported having

been treated intermittently in the past for

depression, “voices,” an alcohol problem, as well

for diabetes mellitus and hypertension with Dr.

Carroll. Plaintiff reported a long history of

alcohol problems and that she drank when

depressed. (Id. at 115). Plaintiff reported

being married for about 35 years to a man who was

physically abusive. (Id. at 116). The treatment

notes reflect that Plaintiff’s mood was

depressed, her affect was appropriate, her memory

appeared good, there was no evidence of a

thinking disorder, and her perception included

“voices.” (Id.) Plaintiff was diagnosed with

major depressive disorder, recurrent and severe,

with psychotic features, alcohol abuse, diabetes

and hypertension. (Id. at 117). Treatment with

Dr. Smith was initiated and Plaintiff was

prescribed an anti-psychotic medication. (Tr.

117). Plaintiff’s GAF was estimated at 65.

(Id.)

• April 3, 2002 (Id. at 113): An interdisciplinary

treatment plan was completed for Plaintiff which

listed her diagnosis as major depressive

disorder, recurrent and severe, with psychotic

features, alcohol and cannabis abuse, that she

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6Under the perceptions category, boxes were provided for WNL

(within normal limits), Auditory hallucinations present, and Visual

hallucinations present. (Tr. 111). There was also a space provided

for a description of any such perceptions. (Id.)

12

was a diabetic, had hypertension, and had a

current GAF 55 with 55 as her highest in the past

year. It was noted that Plaintiff had the

support of friends, was capable of insight into

problems, was motivated for treatment and had a

good social support network.

• June 10, 2002 (Id. at 112): Plaintiff presented

as a walk-in and complained of increased auditory

hallucinations, poor sleep patterns, nervousness

and depression, for which she received a

psychiatric consult and was advised to continue

her medication and decrease her caffeine intake.

The notes reflect that Plaintiff’s appearance was

appropriate, her behavior was normal, her

mood/affect were sad, no speech impairment was

detected, her appetite was good and her sleep was

poor with nightmares. No self injurious

behavior, or suicidal/homicidal thoughts were

noted; however, Plaintiff reported having

auditory hallucinations. Her memory was

forgetful, but no impairments in concentration

were noted.

• June 24, 2002 (Id. at 111): Dr. Smith’s notes

reflect that Plaintiff reported feeling “empty”

due to the loss of relatives during the past year

and complained of “voices.” She also indicated

that she lost her last job due to a

misunderstanding. The notes further reflect that

Plaintiff’s appearance/affect were normal, her

behavior/mood were normal, no speech impairments

were noted and she had good appetite/sleep. No

self injurious behavior or suicidal/homicidal

thoughts were noted. Additionally, the notes

reflect that Plaintiff’s memory was unimpaired

and that her thoughts were logical. Under the

perceptions category, Dr. Smith indicated “None.”6

There was no change in Plaintiff’s diagnosis.

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13

• July 3, 2002 (Id. at 110): The treatment notes

reflect that Plaintiff’s current symptoms were

not assessed during this 90 day review; however,

it was observed that Plaintiff appeared to be

making progress toward most of her goals. It was

also noted that Plaintiff continued to experience

auditory hallucinations and that she would be

encouraged to participate in therapy and continue

her current plan.

• July 31, 2002 (Tr. 109): Dr. Smith’s notes

reflect that Plaintiff continued to report

hearing voices. Plaintiff indicated that she

heard the voice of the same man all the time, and

that he was threatening harm to her. Plaintiff

was described as “very distraught,” and it was

noted that the voice was tormenting her all the

time. Dr. Smith noted that Plaintiff was

understandably discouraged that the three

medications that she had been prescribed were not

working, and discussed with her at length the

need for a “leaner” dosage of medication. He

recommended increasing one of her medications to

600 m.g. Dr. Smith notes reflect that

Plaintiff’s appearance/affect were appropriate,

her behavior/mood were normal, no speech

impairments were noted and that she had good

appetite/sleep. No self injurious behavior or

suicidal/homicidal thoughts were noted.

Additionally, the notes reflect that Plaintiff’s

memory was unimpaired and that her thoughts were

logical. Under the perceptions category, Dr.

Smith indicated that auditory hallucinations

(“always the same man”) were present. Plaintiff

was compliant with her medication and there was

no change in the diagnosis. 

• September 18, 2002 (Id. at 108): Plaintiff was

seen by a nurse and reported that she was “not

doing good,” that her medication was not working,

and that she was still hearing voices. Plaintiff

also complained of difficulty sleeping, and

reported that she was thrown out of her house

recently. Plaintiff resisted an increase in her

anti-psychotic medication because she reported

that it makes her heart flutter. The notes

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14

reflect that her appearance was appropriate, her

mood/affect were sad, her appetite/sleep were

good, she had no self-injurious behavior or

suicidal/homicidal thoughts, and her thoughts

were logical and within normal limits. The notes

reflect that she was to discontinue Seroquel and

began Zeprexa.

• October 4, 2002 (Id. at 107): Plaintiff’s 90 day

treatment plan was reviewed and it was noted that

she had made good progress, attended all of

schedule appointments, but that she continued to

experience auditory hallucinations daily. She

denied suicidal/homicidal ideations or manic

symptoms or the need for individual therapy. 

• October 16, 2002 (Id. at 106): Dr. Smith noted

that Plaintiff looked good, “well turned out,”

but just “down on her luck.” His notes also

reflect that her appearance/affect were

appropriate, her behavior/mood were normal, no

speech impairment was noted, her appetite/sleep

were good, no self-injurious behavior or

suicidal/homicidal thoughts were reported, her

memory was unimpaired and her thoughts were

logical and coherent. Under the perceptions

category, Dr. Smith indicated “None.” There was

no change in Plaintiff’s diagnosis.

• November 20, 2002 (Id. at 187): Dr. Smith noted

that Plaintiff seemed down and out. She reported

that she was living with a friend and collecting

food stamps. Plaintiff also insisted that the

medicine has not helped her much. She reported

that the voices were still there, but only

“dimmer,” and that she had applied for disability

because she cannot work anymore. Dr. Smith’s

notes reflect that Plaintiff’s appearance/affect

were appropriate, her mood/behavior were normal,

her appetite was good, her sleep was fair, her

memory and concentration were unimpaired, her

thoughts were logical/coherent/within normal

limits, she had no self injurious, suicidal or

homicidal thoughts, and she was compliant with

her Zyprexa medications. Under the perceptions

category, Dr. Smith indicated “None.” There was

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15

no change in Plaintiff’s diagnosis.

• January 3, 2003 (Id. at 186): Plaintiff’s

symptoms were not assessed during her 90 day plan

review. The notes reflect that she appeared to

make progress toward her treatment goals during

the past 90 days. Plaintiff had attended all

appointments and complied with medications;

however, she continued to experience auditory

hallucinations every day of the week. She

reported that the voices “are dimmer,” and that

she was experiencing stressors such as no

permanent housing, limited income and inability

to work.

• February 4, 2003 (Tr. 185): Plaintiff was seen as

a walk-in at which time Dr. Smith noted she

reported that she was sleeping better but was

still hearing voices. The notes also reflect

that she was compliant with medications, her

appearance/affect were appropriate, her

mood/behavior were normal, her appetite/sleep

were good, her memory and concentration were

unimpaired, her thoughts were

logical/coherent/within normal limits, she had no

self injurious behavior or suicidal/homicidal

thoughts, and her perceptions were within normal

limits.

• May 13, 2003 (Id. at 184): Plaintiff was seen as

a walk-in at which time she reported that she was

still feeling depressed, was still hearing voices

(but no commands) and did not believe that the

medication was working. She denied any other

medical problems other than hypertension and

NIDDM. It was noted that Plaintiff had missed her

last two scheduled appointments with Dr. Smith

and that she reported that she needed to have him

complete her disability paperwork. The notes

also reflect that Plaintiff’s appearance/affect

were appropriate, her mood was not gooddepressed, no speech impairment was noted, her

appetite was fair, she reported difficulty

falling asleep and nightmares, she denied self

injurious behavior or suicidal/homicidal

thoughts, she reported auditory hallucinations

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 15 of 27
16

(hearing voices), and her memory was impaired.

It was further noted that Plaintiff was compliant

with her medication (Zyprexa). 

• May 14, 2003 (Id. at 183): Dr. Smith saw

Plaintiff the following day, and noted that she

made an “excellent presentation as she comes in

to seek papers for disability.” He observed that

Plaintiff’s appearance/affect were appropriate,

her behavior/mood were normal, no speech

impairment was noted, her sleep/appetite were

good, she did not have any self injurious

behavior or suicidal/homicidal thoughts, her

perceptions were within normal limits, her memory

was unimpaired, her thoughts were logical, she

had no concentration impairments and she was

compliant with her medication. There was no

change in her diagnosis.

The foregoing constitutes the substance of the medical

records regarding Plaintiff’s mental impairments. A review of

the ALJ’s decision reflects that he reviewed the pertinent

portions of said records, as well as information provided by

Plaintiff regarding her daily activities and her past relevant

work. As noted supra, the ALJ determined, at step four of the

sequential evaluation process, that Plaintiff retained the

residual functional capacity to perform her past work. In her

brief, Plaintiff argues that “[r]egardless of whether her

physical limitations would allow . . . [her] to function at the

stated exertional level, the mental limitations would not.”

(Doc. 14 at 5). At step four of the analysis, the burden is on

the claimant to show that she can no longer perform her former

work because of her impairments. Jones v. Bowen, 810 F.2d 1001

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 16 of 27
17

(11th Cir. 1986). In evaluating whether the claimant has met

this burden, the examiner must consider the following factors:

1) objective medical facts and clinical findings; 2) diagnoses

of examining physicians; 3) evidence of pain; and 4) the

claimant’s age, education and work history. Id at 1005.

Section 404.1520(e) of the Commissioner’s regulations

require a review and consideration of a plaintiff’s residual

functional capacity and the physical and mental demands of the

past work before a determination can be made that the claimant

can perform her past relevant work. Residual functional

capacity is a measure of what a claimant can do despite

limitations. 20 C.F.R. § 404.1545. It is the function of the

ALJ to determine the claimant’s residual functional capacity

through examination of the evidence and resolution of conflicts

in the evidence. Wolfe v. Chater, 86 F.3d 1072, 1079 (11th Cir.

1996). An ALJ must base the assessment upon all of the relevant

evidence of a claimant’s remaining ability to do work,

notwithstanding her impairments. Lewis v. Callahan, 125 F.3d

1436, 1440 (11th Cir. 1997); 20 C.F.R. §§ 404.1546 and 404.1527.

In finding that a claimant has the capacity to perform a

past relevant job, the decision of the Commissioner must contain

among the finding, a finding of fact as to the claimant’s

residual functional capacity, a finding of fact as to the

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 17 of 27
18

physical and mental demands of the past job occupation, and a

finding of fact that the claimant’s residual functional capacity

would permit a return to the past job or occupation. In this

case, the ALJ concluded that there was “no evidence that the

claimant’s mental impairment, which appears to be relatively

well controlled with medication, causes her any significant

mental functional limitation that would prohibit her performance

of semi-skilled work activities.” (Tr. 16). In reaching this

conclusion, the ALJ found that:

The evidence establishes that the claimant’s

impairment has not prevented her from performing her

activities of daily living independently, from

shopping, or from engaging in social activities. In

fact, the evidence documents the relative success of

claimant’s treatment for her major depression and her

major complaint of auditory hallucinations, and it

shows that the claimant’s mental health symptomatology

has responded well to medications, which have proven

successful in maintaining control of her condition and

mitigating the accompanying symptomology. It is

noteworthy that, at the time of the claimant’s last

visit with Dr. Smith in May, 2003, he noted that she

made “excellent presentation,” and he further noted no

abnormalities in his assessment of the claimant’s

current symptoms. . . . 

(Id. at 17). Utilizing the special technique required for

evaluating mental impairments under 20 C.F.R. § 416.920a(e), the

ALJ’s decision included a specific finding as to the degree of

limitation in each of the functional areas. 

Specifically, the ALJ determined that there is no evidence

that Plaintiff suffers from any significant degree of limitation

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 18 of 27
19

in her activities of daily living as she is able to care for her

own personal needs without assistance, do routine household

chores, do her own shopping and prepare and cook meals. (Tr.

17). With respect to Plaintiff’s social functioning, the ALJ

noted that the “claimant has demonstrated the ability to

interact appropriately with others inasmuch as she is able to

attend ‘bingo’ twice weekly and maintain friendships.” (Id.)

According to the ALJ, Plaintiff has not reported any

difficulties getting along with others, nor do Dr. Smith’s

treatment records reflect any such limitations. (Id.) As such,

the ALJ concluded that the evidence does not establish that

Plaintiff possesses more than a mild degree of impairment in her

ability to maintain social functioning. (Id.) With respect to

concentration, persistence or pace, the ALJ found that Dr.

Smith’s treatment notes, during the relevant period,

consistently reflect that Plaintiff had no impairment in her

memory or concentration and that her thoughts were logical,

coherent and within normal limits. (Id.) The ALJ also

acknowledged that while Plaintiff’s reports of auditory

hallucinations would inhibit her ability to effectively maintain

concentration and attention, Dr. Smith’s treatment notes reflect

that this symptom improved with treatment, and that she had not

had any perceptual disturbances since November 2002. (Id.)

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 19 of 27
20

Additionally, the ALJ determined that the treatment notes were

devoid of any evidence that Plaintiff experienced any episodes

of deterioration or decompensation. (Id. at 17-18).

Based upon a careful review of the record evidence,

including Dr. Smith’s treatment notes and Plaintiff’s testimony

at the hearing, the undersigned finds that substantial evidence

supports the ALJ’s determination that Plaintiff’s mental

impairment does not impose any significant work-related

limitations. Simply put, neither the medical evidence, nor

Plaintiff’s testimony regarding her daily activities,

contradicts the ALJ’s findings. In fact, during Plaintiff’s

final May 2003 visit to Dr. Smith, he did not impose any

restrictions on her, notwithstanding the fact that she advised

him that she was seeking disability. Instead, Dr. Smith noted

that Plaintiff made an “excellent presentation,” and found that

her perception was within normal limits, her memory and

concentration were unimpaired, and her thoughts were logical and

coherent. (Tr. 183). Accordingly, the undersigned finds no

error in the ALJ’s determination.

The ALJ also determined that Plaintiff has past relevant

work experience as a laundry presser/laundry machine operator

and as a cleaner/housekeeper, and noted that according to the

Dictionary of Occupational Titles, (hereinafter “DOT”), the job

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 20 of 27
21

of laundry presser/laundry machine operator is classified as

medium, semi-skilled work, and the job of cleaner/housekeeper is

classified as light unskilled work. (Tr. 19). The ALJ also

expressly referenced the appropriate DOT code numbers, namely

369.684-014 and 323.687-014, which contain the physical and

mental demands for the referenced positions. (Id.) The ALJ

then concluded, “[a]fter carefully considering all of the

evidence, including the claimant’s testimony and the effects of

her impairments . . . the claimant . . . [is] physically and

mentally capable of performing her past relevant work as a

laundry presser/laundry machine operator and a

cleaner/housekeeper, as she actually performed those jobs and as

those jobs are customarily performed in the national economy.”

(Id. at 19-20). 

Based upon a review of the record, the undersigned finds

that Plaintiff’s contention, that the ALJ erred in determining

that she could return to her past relevant work, is without

merit. The substantial record evidence demonstrates that the

ALJ properly considered the duties and responsibilities of

Plaintiff’s past work, and determined that she retains the

residual functional capacity to return to such work.

 Additionally, the undersigned finds that the ALJ did not

err in failing to obtain Vocational Expert testimony at step

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 21 of 27
22

four of the sequential evaluation process. (Doc. 14). In this

Circuit, “[t]he testimony of a vocational expert is only

required to determined whether the claimant’s residual

functional capacity permits . . . [her] to do other work after

the claimant has met . . . [her] initial burden of showing that

. . . [she] cannot do past work.” Schnorr v. Brown, 816 F.2d

578, 582 (11th Cir. 1987). See also Lamb v. Bowen, 847 F.2d 698,

704 (11th Cir. 1988) (same). In the case sub judice, the ALJ

found that Plaintiff retains the residual functional capacity to

perform her past relevant work, and therefore, there was no

legal requirement for the ALJ to procure the testimony of a

vocational expert. See, e.g., Cole v. Chater, 1997 U.S. Dist.

LEXIS 6442, *47-48 (S.D. Ala. Jan. 7, 1997). 

The undersigned also rejects Plaintiff’s contention that the

ALJ erred by failing to order a consultative examination. (Doc.

14). In this case, the ALJ determined that he had all of the

medical evidence necessary to enable him to make a determination

as to Plaintiff’s functional capacity. Although consultative

examinations are not required by statute, the Regulations

provide for them where warranted. 20 C.F.R. §§ 404.1517 and

416.917. Additionally, 20 C.F.R. §§ 404.1519a and 416.919a

provide, in relevant part, as follows:

(a)(1) General. The decision to purchase a

consultative examination for you will be made after we

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 22 of 27
7See also Wind v. Barnhart, 133 Fed. Appx. 684, 693 (11th Cir.

2005) (unpublished opinion); Dixon v. Apfel, 2000 WL 1844689 (S.D.

Ala. Nov. 8, 2000); Holladay v. Bowen, 848 F.2d 1206, 1209 (11th Cir.

1988); Cowart v. Schweiker, 662 F.2d 731, 735-736 (11th Cir. 1981);

Smith v. Schweiker, 677 F.2d 826, 829 (11th Cir. 1982); Nelms v.

Bowen, 803 F.2d 1164, 1165 (11th Cir. 1986); Welch v. Bowen, 854 F.2d

436, 438 (11th Cir. 1988).

23

have given full consideration to whether the

additional information is needed (e.g. clinical

findings, laboratory tests, diagnoses, and prognosis)

is readily available from the records of your medical

sources . . . .

* * *

(b) Situations requiring a consultative examination.

A consultative examination may be purchased when the

evidence as a whole, both medical and non-medical, is

not sufficient to support a decision on your claim.

Other situations listed below, will normally require

a consultative examination: (1) the additional

evidence needed is not contained in the records of

your medical sources; . . . .

20 C.F.R. § 404.1519a. While it is reversible error for an ALJ

not to order a consultative examination when such evaluation is

necessary for him to make an informed decision, Reeves v.

Heckler, 734 F.2d 519, 522 n.1 (11th Cir. 1984), the ALJ is not

required to order a consultative examination unless the record

establishes that such an examination is necessary to enable the

ALJ to render a decision.7 See, e.g., White v. Barnhart, 373 F.

Supp. 2d 1258, 1266 (N.D. Ala. 2005); Cole, 1997 U.S. Dist.

LEXIS 6442, *42-45. Contrary to Plaintiff’s contention, the

instant record does not demonstrate that a consultative

examination was necessary. The ALJ had adequate information to

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 23 of 27
8See, e.g., Moreno v. Barnhart, 2003 WL 22244971, *3 (W.D. Tex.

Sept. 3, 2003) (holding that while the ALJ found the claimant to have

a depressive disorder, the disorder did not restrict his daily

activities and resulted in only "mild" social functioning

difficulties and "moderate” difficulties in maintaining

concentration, persistence, and pace with no episodes of

decompensation, and thus, the claimant failed to raise the requisite

suspicion that a psychiatric consultative examination was necessary

for the ALJ to discharge the duty of full inquiry, particularly

because, in part, the medical records discussing the claimant’s

depression were in the record and the ALJ had explicitly considered

those materials). 

24

assess Plaintiff’s residual functional capacity and

physical/mental impairments properly.8

Indeed, Plaintiff fails to point to any specific “gap” in

the record for which a consultative examination was necessary.

Moreover, the record contains a consultative exam conducted at

USA (Tr. 96), as well as Plaintiff’s treatment records from FPHC

and MMHC. See supra. As noted infra, the ALJ considered this

evidence and relied on such evidence in concluding that

Plaintiff’s impairments were not disabling. Dr. Smith’s

treatment notes reflect that after Plaintiff began treatment at

MMHC, she responded well to medications, her memory and

concentration were unimpaired and her perceptions were within

normal limits. During Plaintiff’s last visit with Dr. Smith in

May 2003, he observed that she had “an excellent presentation,”

and did not note any abnormalities. (Tr. 183). The record does

not contain any evidence that conflicts with Dr. Smith’s

findings, nor does it contain evidence that suggests any

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 24 of 27
25

uncertainty as would require further information to enable the

ALJ to render a decision. See, e.g., Kilcrease v. Barnhart, 347

F. Supp. 2d 1157, 1162 (M.D. Ala. 2004). In the absence of any

conflicting or uncertain evidence, the ALJ acted properly in

rendering a decision based upon the record that was before him.

See, e.g., Street v. Barnhart, 340 F. Supp. 2d 1289, 1293 (M.D.

Ala. 2004), aff’d., 133 Fed. Appx. 621 (2005).

V. Conclusion

For the reasons set forth, and upon consideration of the

administrative record and memoranda of the parties, it is

recommended that the decision of the Commissioner of Social

Security denying Plaintiff’s claim for supplemental security

income benefits is due to be AFFIRMED.

The attached sheet contains important information regarding

objections to this report and recommendation.

DONE this the 26th day of September 2005.

 /s/ Sonja F. Bivins 

UNITED STATES MAGISTRATE JUDGE

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 25 of 27
MAGISTRATE JUDGE’S EXPLANATION OF PROCEDURAL RIGHTS

AND RESPONSIBILITIES FOLLOWING RECOMMENDATION

AND FINDINGS CONCERNING NEED FOR TRANSCRIPT

1. Objection. Any party who objects to this recommendation or

anything in it must, within ten days of the date of service of

this document, file specific written objections with the clerk

of court. Failure to do so will bar a de novo determination by

the district judge of anything in the recommendation and will

bar an attack, on appeal, of the factual findings of the

magistrate judge. See 28 U.S.C. § 636(b)(1)(c); Lewis v. Smith,

855 F.2d 736, 738 (11th Cir. 1988). The procedure for

challenging the findings and recommendations of the magistrate

judge is set out in more detail in SD ALA LR 72.4 (June 1,

1997), which provides, in part, that:

A party may object to a recommendation entered by a

magistrate judge in a dispositive matter, that is, a

matter excepted by 28 U.S.C. § 636(b)(1)(A), by filing

a “Statement of Objection to Magistrate Judge’s

Recommendation” within ten days after being served

with a copy of the recommendation, unless a different

time is established by order. The statement of

objection shall specify those portions of the

recommendation to which objection is made and the

basis for the objection. The objecting party shall

submit to the district judge, at the time of filing

the objection, a brief setting forth the party’s

arguments that the magistrate judge’s recommendation

should be reviewed de novo and a different disposition

made. It is insufficient to submit only a copy of the

original brief submitted to the magistrate judge,

although a copy of the original brief may be submitted

or referred to and incorporated into the brief in

support of the objection. Failure to submit a brief

in support of the objection may be deemed an

abandonment of the objection.

A magistrate judge’s recommendation cannot be appealed to

a Court of Appeals; only the district judge’s order or judgment

can be appealed.

2. Opposing party’s response to the objection. Any opposing

party may submit a brief opposing the objection within ten (10)

days of being served with a copy of the statement of objection.

Fed. R. Civ. P. 72; SD ALA LR 72.4(b). 

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 26 of 27
27

3. Transcript (applicable where proceedings tape recorded).

Pursuant to 28 U.S.C. § 1915 and Fed.R.Civ.P. 72(b), the

magistrate judge finds that the tapes and original records in

this action are adequate for purposes of review. Any party

planning to object to this recommendation, but unable to pay the

fee for a transcript, is advised that a judicial determination

that transcription is necessary is required before the United

States will pay the cost of the transcript.

 /s/ SONJA F. BIVINS 

 UNITED STATES MAGISTRATE JUDGE

Case 1:04-cv-00193-BH-B Document 21 Filed 09/26/05 Page 27 of 27