Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alsd-1_15-cv-00504/USCOURTS-alsd-1_15-cv-00504-0/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 (DIWW)

---

IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

ALYSON E. RIOS, :

Plaintiff, :

vs. : CA 15-0504-C

CAROLYN W. COLVIN, :

Acting Commissioner of Social Security,

:

Defendant.

MEMORANDUM OPINION AND ORDER

Plaintiff brings this action, pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), seeking 

judicial review of a final decision of the Commissioner of Social Security denying her

claims for disability insurance benefits and supplemental security income. The parties 

have consented to the exercise of jurisdiction by the Magistrate Judge, pursuant to 28 

U.S.C. § 636(c), for all proceedings in this Court. (Docs. 18 & 20 (“In accordance with the 

provisions of 28 U.S.C. 636(c) and Fed.R.Civ.P. 73, the parties in this case consent to 

have a United States Magistrate Judge conduct any and all proceedings in this case, . . . 

order the entry of a final judgment, and conduct all post-judgment proceedings.”).) 

Upon consideration of the administrative record, plaintiff’s brief, the Commissioner’s 

brief, and the arguments of counsel at the August 18, 2016 hearing before the Court, it is 

determined that the Commissioner’s decision denying benefits should be reversed and

remanded for further proceedings not inconsistent with this decision.

1

 

 1 Any appeal taken from this memorandum opinion and order and judgment shall 

be made to the Eleventh Circuit Court of Appeals. (See Docs. 18 & 20 (“An appeal from a 

judgment entered by a Magistrate Judge shall be taken directly to the United States Court of 

(Continued)

Case 1:15-cv-00504-C Document 21 Filed 09/08/16 Page 1 of 20
2

Plaintiff alleges disability due to intermittent explosive disorder and cognitive 

disorder secondary to organic brain disease. The Administrative Law Judge (ALJ) made 

the following relevant findings:

1. The claimant meets the insured status requirements of the Social 

Security Act through December 31, 2014.

2. The claimant has not engaged in substantial gainful activity since 

April 3, 2010, the alleged onset date (20 CFR 404.1571 et seq., and 416.971 

et seq.).

. . .

3. The claimant has the following severe impairments: intermittent 

explosive disorder and cognitive disorder (20 CFR 404.1520(c) and 

416.920(c)).

. . .

4. The claimant does not have an impairment or combination of 

impairments that meets or medically equals the severity of one of the 

listed impairments in 20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 

404.1520(d), 404.1525, 404.1526, 416.920(d), 416.925 and 416.926).

. . .

5. After careful consideration of the entire record, the undersigned

finds that the claimant has the residual functional capacity to perform a 

full range work at all exertional levels but with the following 

nonexertional limitations: The claimant is limited to simple tasks; and 

short, simple instructions. Further, the claimant can occasionally have 

casual contact with coworkers and supervisors. In addition, the claimant 

reported she could occasionally respond appropriately to co-workers 

and the public.

In making this finding, the undersigned has considered all symptoms and 

the extent to which these symptoms can reasonably be accepted as 

consistent with the objective medical evidence and other evidence, based 

on the requirements of 20 CFR 404.1529 and 416.929 and SSRs 96-4p and 

96-7p. The undersigned has also considered opinion evidence in 

 

Appeals for this judicial circuit in the same manner as an appeal from any other judgment of 

this district court.”))

Case 1:15-cv-00504-C Document 21 Filed 09/08/16 Page 2 of 20
3

accordance with the requirements of 20 CFR 404.1527 and 416.927 and 

SSRs 96-2p, 96-5p, 96-6p and 06-3p.

In considering the claimant’s symptoms, the undersigned must follow a 

two-step process in which it must first be determined whether there is an 

underlying medically determinable physical or mental impairment(s)—

i.e., an impairment(s) that can be shown by medically acceptable clinical 

and laboratory diagnostic techniques—that could reasonably be expected 

to produce the claimant’s pain or other symptoms.

Second, once an underlying physical or mental impairment(s) that could 

reasonably be expected to produce the claimant’s pain or other symptoms 

has been shown, the undersigned must evaluate the intensity, persistence, 

and limiting effects of the claimant’s symptoms to determine the extent to 

which they limit the claimant’s functioning. For this purpose, whenever 

statements about the intensity, persistence, or functionally limiting effects 

of pain or other symptoms are not substantiated by objective medical 

evidence, the undersigned must make a finding on the credibility of the 

statements based on a consideration of the entire case record. 

The claimant is a 36-year-old woman, with a 12th grade education, who 

alleges disability due to the above-listed impairments. At the hearing, the 

claimant testified that she lives in a trailer with her two daughters, ages 7 

and 9. Further, the claimant testified that her parents pay her bills. As to 

her explosive disorder, the claimant testified that she sustained a severe 

head injury []; this condition makes it impossible for her to keep a job; and 

she is not on medication and she is not receiving therapy or treatment. 

Further, the claimant testified that, when she was on her medication, 

people could not tell she had any problems. The claimant testified that she 

has issues with getting along with coworkers[, and] she loses her temper 

quickly[.] As to her functional limitations, the claimant testified she can 

sit, walk, and stand; her ability to lift and carry is affected by her lower 

back pain; and she could stoop, bend, climb stairs, and grip. In addition, 

the claimant testified that she could take care of her personal care; she 

could do housework; and she visits with family twice a week. As to the 

claimant’s activities of daily living, the claimant reported she gets her kids 

ready for school[,] and she does chores.

After careful consideration of the evidence, the undersigned finds that the 

claimant’s medically determinable impairments could reasonably be 

expected to cause the alleged symptoms; however, the claimant’s 

statements concerning the intensity, persistence and limiting effects of 

these symptoms are not entirely credible for the reasons explained in this 

decision.

Overall, while the record supports some level of functional limitation as a 

result of her impairments, it does not support such significant limitations 

as alleged by the claimant. The undersigned specifically considered the 

effects of the claimant’s impairments, both separately and in combination, 

Case 1:15-cv-00504-C Document 21 Filed 09/08/16 Page 3 of 20
4

and found that the record only supports functional limitations to a degree 

that is consistent with the above residual functional capacity. Further, the 

undersigned has specifically tailored the residual functional capacity 

above to take into account all of the claimant’s functional limitations for 

which there was support in the record.

In terms of the claimant’s mental impairments, while she does suffer from 

intermittent explosive disorder and cognitive disorder, which are severe 

impairments, the record does not support such severe functional 

limitations as alleged by the claimant. The record shows the claimant was 

diagnosed with these conditions. However, the record shows the claimant 

has not received any treatment; she has been noncompliant with 

medications; and she has not had any inpatient psychiatric 

hospitalizations.

During a remote neuropsychological evaluation on February 17, 2003 with 

Dr. Melissa Ogden, it was noted that the claimant sustained a traumatic 

brain injury in a motor vehicle accident when she was 18 months old. . . .

The diagnostic impression was late effects of intracranial injury. Dr. 

Ogden opined the claimant’s difficulties with executive functions and 

social interactions were likely to pose the greatest obstacles to her ability 

to obtain and maintain an employment position. Further, Dr. Ogden 

opined the claimant’s independent thinking skills were quite limited and 

she should not be placed in a job that required her to make decisions 

independently. Dr. Ogden opined the claimant would need a great deal of 

structure and supervision on a job site in order to help her overcome her 

problems with executive functions; and her attention and concentration 

were areas of relative strength and she appeared able to maintain an 

extended period of focus without difficulty. Dr. Ogden noted the 

claimant’s ability to learn and remember new information was an area of 

relative strength; and while she is able to learn and retain new 

information, she would have difficult[y] applying it flexibly across 

situations. Dr. Ogden opined the claimant might be at somewhat of a 

disadvantage in job settings that had strict deadlines or time pressures. 

During an initial assessment on March 17, 2004, the claimant complained 

that she has a bad attitude. Specifically, the claimant described a recent 

incident at work in which the claimant became irritated with the assistant 

manager and reported confronting her. The claimant’s mother reported 

the claimant had a long history of exploding. Further, the claimant 

attributed some of her difficulties at work to problems at home between 

her boyfriend and another woman that he was seeing. On the Shedler 

QPD, it was noted that the claimant had mildly elevated symptom scores 

on depression, anxiety, and obsessive-compulsive disorder. However, the 

claimant denied chronic problems with sleep, energy, or concentration. As 

to the claimant’s psychiatric history, it was noted that the claimant had 

mental health treatment through the years. The claimant was diagnosed 

with intermittent explosive disorder[,] and cognitive disorder, secondary 

to a closed head injury.

Case 1:15-cv-00504-C Document 21 Filed 09/08/16 Page 4 of 20
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During a mental examination on August 18, 2008 with Dr. Lucile 

Williams, the claimant reported she was unable to work due to 

intermittent explosive disorder. However, it was further noted that the 

claimant had no history of psychiatric hospitalization; she was not [being] 

treated by a physician; and she was not on any medication. A mental 

status examination revealed the claimant’s concentration, immediate 

memory, recent memory, and remote memory were normal. This supports 

the [determination that] claimant has the capacity to perform unskilled 

work. As to her daily activities, the claimant reported she could go to the 

store, cook, do laundry, play with the kids, watch television, listen to 

music, clean the house, play games on the computer, and play video 

games. These activities are inconsistent with the claimant’s allegations of 

inability to pay attention for long periods. Dr. Williams opined the 

claimant would likely have favorable response to treatment, including 

psychotherapy, within the next six to twelve months.

During a neurological evaluation on November 11, 2008, it was noted that 

the claimant was referred by Ms. Lisa Jones with the Mobile County 

Department of Human Resources. Specifically, Ms. Jones needed to know 

if the claimant’s failure to protect her children, poor decisions, and 

inability to retain employment was due to her mental capabilities or poor 

decision-making skills. As to the claimant’s activities of daily living, the 

claimant reported she could complete all personal and simple domestic 

activities of daily living independently. Further, the claimant reported she 

could cook and do the laundry; she could drive; and she could count 

money and shop independently. A mental status examination revealed the 

claimant was properly oriented; her mood and affect were appropriate; 

she did not appear anxious; and she described her usual mood as 

depressed. It was noted that the claimant did not appear highly 

motivated. However, the claimant did not appear to have trouble 

concentrating[] and her effort and persistence seemed adequate for testing 

purposes. The claimant appeared to have cognitive deficits, which limit 

her ability to parent effectively and minimize her ability to perceive 

threatening and dangerous situations accurately. However, Dr. Jack 

Carney opined the claimant’s cognitive deficits should not necessarily 

limit her ability to maintain employment. Further, Dr. Carney opined that, 

while the claimant may appear socially awkward, given her inability to 

read social situations accurately, her overall cognitive functions to attend 

to task, remember her duties, and articulate were intact. In addition, Dr. 

Carney opined the claimant needed a work environment that was highly 

structured, minimally demanding, and required minimal interaction with 

the public. The claimant was diagnosed with cognitive disorder.

The record shows the claimant did not have any office visits until January 

13, 2011, when she presented for a consultative examination with Dr. 

Kenneth Starkey. During this visit, the claimant reported her problems 

were getting along with people and anger problems. It was noted that the 

claimant could feed, bathe, groom, and dress herself without assistance; 

Case 1:15-cv-00504-C Document 21 Filed 09/08/16 Page 5 of 20
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she could prepare simple meals; she could shop for small items; and she 

could use a phone and drive without assistance. Further, the claimant 

reported she worked full-time as a cashier/cook for a fast food restaurant 

from 2008 until April 2010 until she quit because “it was Easter weekend” 

and she wanted to stay home with her girls. This is inconsistent with the 

claimant’s testimony that she could not maintain employment because of 

her impairments. A mental status examination revealed the claimant was 

able to focus and sustain attention with no significant distraction from 

extraneous stimuli. Further, the claimant’s thinking was rational, but there 

was evidence of at least mild deficits for reasoning and judgment; and 

intellectual functioning was estimated to be in the low average to 

borderline range of functioning. The claimant’s ability to focus and sustain 

attention and for immediate memory appeared adequate. In addition, the 

claimant’s mood was euthymic; her affect was congruent with mood; and 

her insight and judgment appeared somewhat limited. As to the 

claimant’s daily activities, she reported she got her children up and took 

them to school and daycare after feeding them; she sometimes washed 

dishes and clothes; and she cooked sometimes. Further, the claimant 

reported she liked to get on the computer and visit with friends; and she 

sometimes went to the grocery store, post office, or McDonalds. These 

extensive activities are inconsistent with the claimant’s allegations of 

severe functional limitations. The claimant was diagnosed with cognitive 

disorder. Dr. Starkey opined the claimant’s ability to understand, 

remember, and carry out simple/concrete instructions appeared adequate, 

although she would likely have difficulty with more complex instructions 

or with those requiring other than basic literacy skills. Further, the 

claimant’s ability to work independently appeared marginal; her ability to 

work with supervisors, co-workers, and the general public appeared 

marginal; and her ability to work with pressures common to most 

everyday work settings appeared marginal.

A mental status examination with Dr. Thomas Bennett [on January 30, 

2013] revealed the claimant’s mood was average and she demonstrated a 

normal range of affect. The claimant’s concentration and attention 

appeared to be slightly below average; and her short-term and long-term 

memories appeared to be average. The claimant’s social judgment was 

mildly impaired; her judgment for interacting with family members was 

impaired; and she had no plans for future employment. In addition, the 

claimant’s insight about her difficulties and what could be done about 

them was poor. The claimant was diagnosed with cognitive disorder due 

to head trauma by history. As to her prognosis, Dr. Bennett opined the 

claimant could probably make significant improvement with appropriate 

mental health intervention. Dr. Bennett opined the claimant’s ability to 

relate to others was mildly impaired; her ability to function independently 

was slightly below average, but not impaired; and her ability to 

understand and carry out instructions was slightly below average, but not 

impaired. Dr. Bennett opined the claimant’s ability to respond 

appropriately to supervisors and coworkers was mildly impaired[] and 

Case 1:15-cv-00504-C Document 21 Filed 09/08/16 Page 6 of 20
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she would probably respond to work pressures with some inappropriate 

behavior unless she had some assistance in developing better skills. 

The claimant’s activities of daily living are inconsistent with her 

allegations of such significant functional limitations, but are fully 

consistent with the residual functional capacity described above. The 

evidence of record indicates that, despite the claimant’s complaints and 

allegations, she has admitted that she was able to perform her own 

personal care, drive, and talk on the phone. Further, the claimant reported 

she could cook and do laundry, and she could shop independently. In 

addition, the claimant reported she could play with her kids, watch 

television, listen to music, play games on the computer, and play video 

games. Furthermore, the claimant reported she could care for her children 

and take them to school; she visits with friends; and she goes to the 

grocery store, post office, and McDonalds sometimes. These activities, 

when viewed in conjunction with the other inconsistencies regarding the 

claimant’s allegations of pain and dysfunction, further limit the claimant’s 

credibility in discussing her pain. Of note, her description of her daily 

activities is representative of a fairly active and varied lifestyle and is not 

indicative of a significant restriction of activities or constriction of 

interests.

Also of note, there is an inconsistency between the claimant’s testimony 

and the record. Specifically, at the hearing, the claimant testified that her 

impairments made it impossible for her to keep a job. However, during an 

examination on January 13, 2011, the claimant reported she work full-time 

as a cashier/cook from 2008 through April 2010, but quit because it was 

Easter weekend and she wanted to stay home with her children. While 

this inconsistency may not have been the product of a conscious attempt 

to mislead on the part of the claimant, it nonetheless negatively affects her 

credibility in discussing her activities of daily living and functional 

limitations.

In summary, based on the totality of the evidence as comprehensively 

discussed above, the undersigned finds the claimant only partially 

credible regarding the nature and extent of her functional limitations. The 

undersigned also finds considerable medical evidence to conclude that the 

claimant’s impairments do not prevent the performance of substantial 

gainful activity within the assessed residual functional capacity. Total 

disability from all work activity is not established in this case.

The evidence in this case also contains medical opinions regarding the 

claimant’s physical and mental functional capabilities. All medical 

opinions are evaluated under 20 CFR 404.1527/20 CFR 416.927. The 

factors considered are: 1) examining relationship; 2) treatment 

relationship; 3) supportability; 4) consistency; 5) specialization; and 6) 

other factors. Opinions on issues reserved to the Commissioner are 

opinions on the ultimate issue of disability, opinions as to whether 

impairments meet or equal a medical listing, opinions about residual 

Case 1:15-cv-00504-C Document 21 Filed 09/08/16 Page 7 of 20
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functional capacity, or opinions concerning the application of vocational 

factors.

The undersigned gives little weight to the opinions of Dr. Melissa Ogden, 

Dr. Lucile Williams, and Dr. Jack Carney, the consultative examiners. 

These opinions are given little weight because the claimant has not seen 

these physicians during the relevant period and has not complied with 

medications prescribed by them since 2004 or 2005.

The undersigned gives significant weight to the opinions of Dr. Kenneth 

Starkey and Dr. Thomas Bennett. In particular, their opinions are 

consistent with their findings on examination; the claimant’s lack of 

inpatient psychiatric treatment and consistent mental health treatment; 

and her extensive activities of daily living.

The undersigned gives little weight to the opinions of Dr. Linda Duke, the 

State Agency Psychological Consultant. In particular, Dr. Duke’s opinions 

are inconsistent with the record showing the claimant is able to take care 

of her personal care independently; her extensive activities of daily living; 

and the lack of inpatient psychiatric hospitalizations or significant mental 

health treatment in the record.

Deborah Rice, M.S.[,] opined the claimant would maybe be appropriate 

for jobs where another adult could work closely with her and offer 

guidance and supervise her. The undersigned considered this opinion; 

however, it should be noted that Ms. Rice is not an “acceptable medical 

source” pursuant to 20 CFR § 404.1513(a) and § 416.913(a).

6. The claimant is unable to perform any past relevant work (20 

CFR 404.1565 and 416.965).

The demands of the claimant’s past relevant word exceed[s] the residual 

functional capacity. The vocational expert, Leslie Gillespie, testified that 

claimant has past relevant work as a Cashier/Checker (211.462-014, SVP3, 

Light). This occupation is characterized in the Dictionary of Occupational 

(DOT) as light, semi-skilled work. As the claimant’s residual functional 

capacity limits her to unskilled work, she is unable to perform her past 

relevant work.

7. The claimant was born on October 28, 1977 and was 32 years old, 

which is defined as a younger individual age 18-49, on the alleged 

disability onset date (20 CFR 404.1563 and 416.963).

8. The claimant has at least a high school education and is able to 

communicate in English (20 CFR 404.1564 and 416.964).

9. Transferability of job skills is not material to the determination 

of disability because using the Medical-Vocational Rules as a 

framework supports a finding that the claimant is “not disabled,” 

Case 1:15-cv-00504-C Document 21 Filed 09/08/16 Page 8 of 20
9

whether or not the claimant has transferable job skills (See SSR 82-41 

and 20 CFR Part 404, Subpart P, Appendix 2).

10. 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 

404.1569, 404.1569(a), 416.969, and 416.969(a)).

. . .

The claimant’s ability to perform work at all exertional levels has been 

compromised by nonexertional limitations. To determine the extent to 

which these limitations erode the occupational base of unskilled work at 

all exertional levels, the Administrative Law Judge asked the vocational 

expert whether jobs exist in the national economy for an individual with 

the claimant’s age, education, work experience, and residual functional 

capacity. The vocational expert testified that given all of these factors the 

individual would be able to perform the requirements of representative 

occupations such as:

JOB DOT# EXERTION

LEVEL

#ALA[] #NAT[]

Comm[.]

Cleaner

381.687-

014

Heavy/SVP2 300 254,000

Laundry

Worker II

361.685-

018

Medium/SVP2 3,000 199,000

Hand

Packager

920.587-

018

Medium/SVP2 9,000 661,000

Pursuant to SSR 00-4p, the undersigned has determined that the 

vocational expert’s testimony is consistent with the information contained 

in the Dictionary of Occupational Titles.

Based on the testimony of the vocational expert, the undersigned 

concludes that, considering the claimant’s age, education, work 

experience, and residual functional capacity, the claimant is capable of 

making a successful adjustment to other work that exists in significant 

numbers in the national economy. A finding of “not disabled” is therefore 

appropriate under the framework of section 204.00 in the MedicalVocational Guidelines.

11. The claimant has not been under a disability, as defined in the 

Social Security Act, from April 3, 2010, through the date of this decision 

(20 CFR 404.1520(g) and 416.920(g)). 

(Tr. 13, 14, 15-17, 17, 17-21, 21 & 22 (internal citations omitted; emphasis in original).) 

The Appeals Council affirmed the ALJ’s decision (Tr. 1-3) and thus, the hearing decision 

became the final decision of the Commissioner of Social Security.

Case 1:15-cv-00504-C Document 21 Filed 09/08/16 Page 9 of 20
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DISCUSSION

In all Social Security cases, an ALJ utilizes a five-step sequential evaluation 

to determine whether the claimant is disabled, which considers: (1) 

whether the claimant is engaged in substantial gainful activity; (2) if not, 

whether the claimant has a severe impairment; (3) if so, whether the 

severe impairment meets or equals an impairment in the Listing of 

Impairments in the regulations; (4) if not, whether the claimant has the 

RFC to perform her past relevant work; and (5) if not, whether, in light of 

the claimant’s RFC, age, education and work experience, there are other 

jobs the claimant can perform.

Watkins v. Commissioner of Social Sec., 457 Fed. Appx. 868, 870 (11th Cir. Feb. 9, 2012)2

(per curiam) (citing 20 C.F.R. §§ 404.1520(a)(4), (c)-(f), 416.920(a)(4), (c)-(f); Phillips v. 

Barnhart, 357 F.3d 1232, 1237 (11th Cir. 2004)) (footnote omitted). The claimant bears the 

burden, at the fourth step, of proving that she is unable to perform her previous work. 

Jones v. Bowen, 810 F.2d 1001 (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; and (4) the claimant’s age, education and work history. Id. at 1005. Although “a 

claimant bears the burden of demonstrating an inability to return to her past relevant 

work, the [Commissioner of Social Security] has an obligation to develop a full and fair 

record.” Schnorr v. Bowen, 816 F.2d 578, 581 (11th Cir. 1987) (citations omitted). If a 

plaintiff proves that she cannot do her past relevant work, as here, it then becomes the 

Commissioner’s burden—at the fifth step—to prove that the plaintiff is capable—given 

her age, education, and work history—of engaging in another kind of substantial 

gainful employment that exists in the national economy. Phillips, supra, 357 F.3d at 1237; 

 2 “Unpublished opinions are not considered binding precedent, but they may be 

cited as persuasive authority.” 11th Cir.R. 36-2.

Case 1:15-cv-00504-C Document 21 Filed 09/08/16 Page 10 of 20
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Jones v. Apfel, 190 F.3d 1224, 1228 (11th Cir. 1999), cert. denied, 529 U.S. 1089, 120 S.Ct. 

1723, 146 L.Ed.2d 644 (2000); Sryock v. Heckler, 764 F.2d 834, 836 (11th Cir. 1985). 

The task for the Magistrate Judge is to determine whether the Commissioner’s

decision to deny claimant benefits, on the basis that she can perform those unskilled 

jobs identified by the vocational expert at the administrative hearing, is supported by 

substantial evidence. Substantial evidence is defined as more than a scintilla and means 

such relevant evidence as a reasonable mind might accept as adequate to support a 

conclusion. Richardson v. Perales, 402 U.S. 389, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971). “In 

determining whether substantial evidence exists, we 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).3 Courts are precluded, 

however, from “deciding the facts anew or re-weighing the evidence.” Davison v. 

Astrue, 370 Fed. Appx. 995, 996 (11th Cir. Apr. 1, 2010) (per curiam) (citing Dyer v. 

Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005)). And, “’[e]ven if the evidence 

preponderates against the Commissioner’s findings, [a court] must affirm if the decision 

reached is supported by substantial evidence.’” Id. (quoting Crawford v. Commissioner of 

Social Security, 363 F.3d 1155, 1158-1159 (11th Cir. 2004)).

On appeal to this Court, Rios asserts two reasons why the Commissioner’s 

decision to deny her benefits is in error (i.e., not supported by substantial evidence): (1) 

the ALJ’s decision is not based on substantial evidence as the preponderance of the 

evidence of record supports a finding of disability based on plaintiff’s multiple 

cognitive impairments and personality disorder; and (2) the ALJ failed to pose the 

 3 This Court’s review of the Commissioner’s application of legal principles, 

however, is plenary. Walker v. Bowen, 826 F.2d 996, 999 (11th Cir. 1987).

Case 1:15-cv-00504-C Document 21 Filed 09/08/16 Page 11 of 20
12

vocational expert (“VE”) a hypothetical question that encompassed all of plaintiff’s 

impairments and limitations as established by her residual functional capacity (“RFC”).

Plaintiff specifically describes her primary issue as follows: “The ALJ’s decision 

is not based on substantial evidence as the preponderance of evidence in the file 

supports a finding of disability based on the Plaintiff’s multiple cognitive impairments 

and personality disorder.” (Doc. 13, at 2.) However, plaintiff’s counsel recognizes that 

the law in the Eleventh Circuit is, as previously explained, that “’[e]ven if the evidence 

preponderates against the Commissioner’s findings, [a court] must affirm if the decision 

reached is supported by substantial evidence[,]’” Davison, supra, 370 Fed. Appx. at 996; 

therefore, this Court focuses on plaintiff’s “true” argument, which is that the ALJ’s RFC 

determination is not supported by substantial evidence because absent therefrom is any 

limitation on her abilities to handle ordinary work pressures and to work 

independently (see Doc. 13, at 2-3). 

The undersigned notes that the responsibility for making the residual functional 

capacity determination rests with the ALJ. Compare 20 C.F.R. § 404.1546(c) (“If your case 

is at the administrative law judge hearing level . . ., the administrative law judge . . . is 

responsible for assessing your residual functional capacity.”) with, e.g., Packer v. 

Commissioner, Social Security Admin., 542 Fed. Appx. 890, 891-892 (11th Cir. Oct. 29, 2013) 

(per curiam) (“An RFC determination is an assessment, based on all relevant evidence, 

of a claimant’s remaining ability to do work despite her impairments. There is no rigid 

requirement that the ALJ specifically refer to every piece of evidence, so long as the 

ALJ’s decision is not a broad rejection, i.e., where the ALJ does not provide enough 

reasoning for a reviewing court to conclude that the ALJ considered the claimant’s 

medical condition as a whole.” (internal citation omitted)). A plaintiff’s RFC—which 

“includes physical abilities, such as sitting, standing or walking, and mental abilities, 

Case 1:15-cv-00504-C Document 21 Filed 09/08/16 Page 12 of 20
13

such as the ability to understand, remember and carry out instructions or to respond 

appropriately to supervision, co-workers and work pressure[]”—“is a[n] [] assessment 

of what the claimant can do in a work setting despite any mental, physical or 

environmental limitations caused by the claimant’s impairments and related 

symptoms.” Watkins, supra, 457 Fed. Appx. at 870 n.5 (citing 20 C.F.R. §§ 404.1545(a)-(c), 

416.945(a)-(c)); see also Luterman v. Commissioner of Social Security, 518 Fed.Appx. 683, 689 

(11th Cir. May 2, 2013) (“RFC includes mental abilities, such as the ability to 

understand, remember, and carry out instructions or respond appropriately to

supervision, coworkers, and work pressures.”). Here, the ALJ’s RFC assessment 

consisted of the following: “After careful consideration of the entire record, the 

undersigned finds that the claimant has the residual functional capacity to perform a 

full range work at all exertional levels but with the following nonexertional 

limitations: The claimant is limited to simple tasks; and short, simple instructions. 

Further, the claimant can occasionally have casual contact with coworkers and 

supervisors. In addition, the claimant reported she could occasionally respond 

appropriately to co-workers and the public.” (Tr. 15 (emphasis in original).)

To find that an ALJ’s RFC determination is supported by substantial evidence, it 

must be shown that the ALJ has “’provide[d] a sufficient rationale to link’” substantial 

record evidence “’to the legal conclusions reached.’” Ricks v. Astrue, 2012 WL 1020428, 

*9 (M.D. Fla. Mar. 27, 2012) (quoting Russ v. Barnhart, 363 F. Supp. 2d 1345, 1347 (M.D. 

Fla. 2005)); compare id. with Packer v. Astrue, 2013 WL 593497, *4 (S.D. Ala. Feb. 14, 2013) 

(“’[T]he ALJ must link the RFC assessment to specific evidence in the record bearing 

upon the claimant’s ability to perform the physical, mental, sensory, and other 

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requirements of work.’”), aff’d, 542 Fed. Appx. 890 (11th Cir. Oct. 29, 2013)4; see also 

Hanna v. Astrue, 395 Fed. Appx. 634, 636 (11th Cir. Sept. 9, 2010) (per curiam) (“The ALJ 

must state the grounds for his decision with clarity to enable us to conduct meaningful 

review. . . . Absent such explanation, it is unclear whether substantial evidence 

supported the ALJ’s findings; and the decision does not provide a meaningful basis 

upon which we can review [a plaintiff’s] case.” (internal citation omitted)).5 However, 

in order to find the ALJ’s RFC assessment supported by substantial evidence, it is not 

necessary for the ALJ’s assessment to be supported by the assessment of an examining 

or treating physician. See, e.g., Packer, supra, 2013 WL 593497, at *3 (“[N]umerous court 

have upheld ALJs’ RFC determinations notwithstanding the absence of an assessment 

performed by an examining or treating physician.”); McMillian v. Astrue, 2012 WL 

 4 In affirming the ALJ, the Eleventh Circuit rejected Packer’s substantial evidence 

argument, noting, she “failed to establish that her RFC assessment was not supported by 

substantial evidence[]” in light of the ALJ’s consideration of her credibility and the medical 

evidence. Id. at 892.

5 It is the ALJ’s (or, in some cases, the Appeals Council’s) responsibility, not the 

responsibility of the Commissioner’s counsel on appeal to this Court, to “state with clarity” the 

grounds for an RFC determination. Stated differently, “linkage” may not be manufactured 

speculatively by the Commissioner—using “the record as a whole”—on appeal, but rather, 

must be clearly set forth in the Commissioner’s decision. See, e.g., Durham v. Astrue, 2010 WL 

3825617, *3 (M.D. Ala. Sept. 24, 2010) (rejecting the Commissioner’s request to affirm an ALJ’s 

decision because, according to the Commissioner, overall, the decision was “adequately 

explained and supported by substantial evidence in the record”; holding that affirming that 

decision would require that the court “ignor[e] what the law requires of the ALJ[; t]he court 

‘must reverse [the ALJ’s decision] when the ALJ has failed to provide the reviewing court with 

sufficient reasoning for determining that the proper legal analysis has been conducted’” 

(quoting Hanna, 395 Fed. Appx. at 636 (internal quotation marks omitted))); see also id. at *3 n.4 

(“In his brief, the Commissioner sets forth the evidence on which the ALJ could have relied . . . . 

There may very well be ample reason, supported by the record, for [the ALJ’s ultimate 

conclusion]. However, because the ALJ did not state his reasons, the court cannot evaluate 

them for substantial evidentiary support. Here, the court does not hold that the ALJ’s ultimate 

conclusion is unsupportable on the present record; the court holds only that the ALJ did not 

conduct the analysis that the law requires him to conduct.” (emphasis in original)); Patterson v. 

Bowen, 839 F.2d 221, 225 n.1 (4th Cir. 1988) (“We must . . . affirm the ALJ’s decision only upon 

the reasons he gave.”).

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1565624, *4 n.5 (S.D. Ala. May 1, 2012) (noting that decisions of this Court “in which a 

matter is remanded to the Commissioner because the ALJ’s RFC determination was not 

supported by substantial and tangible evidence still accurately reflect the view of this 

Court, but not to the extent that such decisions are interpreted to require that 

substantial and tangible evidence must—in all cases—include an RFC or PCE from a 

physician” (internal punctuation altered and citation omitted)); but cf. Coleman v. 

Barnhart, 264 F.Supp.2d 1007 (S.D. Ala. 2003).

In this case, the ALJ accorded significant weight to the opinions of Dr. Kenneth 

Starkey and Dr. Thomas Bennett (Tr. 21), see Luterman, supra, 518 Fed.Appx. at 689 (“In 

assessing the claimant’s RFC, the ALJ must state with particularity the weight given to 

different medical opinions and the reasons therefor.”), and, as a general matter, 

“linked” her RFC findings/limitations to evidence in the record, namely, the opinions 

of Drs. Starkey and Bennett, along with other evidence in the record reflecting a fairly

expansive level of activities of daily living, a lack of consistent mental health treatment, 

and plaintiff “quitting” her full-time work as a cashier/cook in April of 2010 because it 

was Easter weekend and she wanted to stay at home with her girls. However, this 

Court need agree with plaintiff that the ALJ did not complete the necessary linkage 

because she failed to account for the “work pressure” limitations found by Drs. Starkey 

and Bennett.6

 6 In addition, while the plaintiff has not convinced the Court that the ALJ did not 

properly account for Dr. Starkey’s use of the modifier “marginal” by her use of the word 

“occasionally” (compare Tr. 15 (“[T]he claimant can occasionally have casual contact with 

coworkers and supervisors . . . [and] reported she could occasionally respond appropriately 

to co-workers and the public.”) with Tr. 258 (“Her ability to work with supervisors, co-workers 

and general public also appears marginal.”)), the ALJ’s failure to include the noted limitation 

with respect to working independently (see id.) in her RFC determination also inhibits this 

Court’s ability to find proper linkage in this case. In other words, the ALJ should have included 

in her RFC determination some sort of limitation on Rios’ ability to work independently, e.g., 

(Continued)

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It is clear in this case that Dr. Starkey specifically noted that plaintiff’s “ability to 

work with pressures common to most every day work settings also appears 

marginal[,]” (Tr. 258) and that Dr. Bennett noted that “[s]he would probably respond to 

work pressures with some inappropriate behavior unless she had some assistance in 

developing better skills.” (Tr. 262.) While the undersigned would note that nothing 

about either doctor’s comment denotes a wholesale inability to handle ordinary work 

pressures, there can also be little question but that, based on the findings of Drs. Starkey 

and Bennett, plaintiff’s ability to respond appropriately to work pressures is limited. 

Because the ALJ did not reject the “work pressures” findings of these two doctors, 

though this was certainly an option, see Wilson v. Colvin, CA No. 15-0446-C, Doc. 7, 

Transcript, at 22 (“Great weight is given to the opinion of Dr. Starkey that the claimant 

would be limited to simple instructions. His assessment is largely consistent with the 

remainder of the evidence. However, no weight can be given to the statement that the 

claimant would have only marginal ability to handle work pressures. This limitation is 

not borne out in the remainder of the examination or the remainder of the evidence.” 

(emphasis supplied)), and, instead, accorded significant weight to the entirety of their 

opinions (Tr. 21), the failure to include a “work pressures” limitation in her RFC 

determination precludes this Court’s ability to find that the ALJ’s RFC determination is 

supported by substantial evidence because, as aforesaid, RFC includes mental abilities 

 

the claimant can occasionally work independently. And on remand, of course, the ALJ will have 

every opportunity to explain how use of “occasional” is equivalent to “marginal,” etc.

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such as the ability to respond appropriately to work pressures, see Watkins, supra, 457 

Fed.Appx. at 870 n.5.7

Because this Court cannot find that the ALJ’s RFC determination is support by 

substantial evidence, it is obvious that the fifth-step determination in this case, based 

significantly on expert testimony (see Tr. 22), need be reversed and remanded for 

further consideration not inconsistent with this decision. On remand, the ALJ will be 

 7 This Court simply cannot agree with the defendant’s argument that the ALJ’s 

findings—limiting Rios to simple tasks and short, simple instructions, occasional casual contact 

with coworkers and supervisors, and the occasional ability to respond appropriately to coworkers and the public—sufficiently account for the “work pressure” opinions of Drs. Starkey 

and Bennett by limiting claimant to unskilled work conditions that allow her to avoid stressful 

circumstances and work pressures (see Doc. 14, at 6-9), particularly in light of the recognition in 

Watkins, supra, that a claimant’s RFC includes the mental abilities to understand, remember and 

carry out instructions or to respond appropriately to supervision, co-workers and work 

pressures, 457 Fed.Appx. at 870 n.5; see also 20 C.F.R. §§ 404.1545(c) & 416.945(c) (“A limited 

ability to carry out certain mental activities, such as limitations in understanding, remembering, 

and carrying out instructions, and in responding appropriately to supervision, co-workers, and 

work pressures in a work setting, may reduce your ability to do past work and other work.”), 

and there being no citation to any authority by defendant that an RFC determination like the 

one made by the ALJ in this case would inherently be understood to “encompass” a limitation 

with respect to the ability to respond appropriately to work pressures. See Wilson, supra, at Tr. 

18 & 22 (in a case where the claimant could only perform unskilled work, the ALJ took “pains” 

to reject a consulting examiner’s noted “limitation” of “marginal ability to handle work 

pressures”); compare id. with Smith v. Colvin, 2014 WL 4187668, *2 (N.D. Ala. Aug. 15, 2014) (“The 

ALJ further found Smith had moderate limitations in her ability to work with supervisors and 

co-workers in interpersonal interaction and discussion; maintain attention to simple tasks; 

respond appropriately to work pressures; make judgments on simple decisions; and adapt to 

changes in routine work settings.” (emphasis supplied)); Parker v. Colvin, 972 F.Supp.2d 1267, 

1272 (N.D. Ala. 2013) (“After considering the entire record, the ALJ found that Mr. Parker had 

the residual functional capacity [] to perform ‘sedentary work’ as defined in 20 C.F.R. §§ 

404.1567(b) and 416.967(b). He further found that Mr. Parker ‘has moderate restriction in the 

following areas: understanding, carrying out, and remembering simple instructions; using 

judgment; responding appropriately to supervision, co-workers, and usual work situations; 

dealing with changes in a routine work setting; and responding to customary work pressures.” 

(emphasis supplied; internal citation omitted)); and Jones v. Astrue, 2013 WL 5428115, *11 (N.D. 

Ala. Sept. 26, 2013) (“The ALJ determined that the claimant can perform light work, can follow 

1-2 step simple instructions, has mild deficits in his ability to respond appropriately to coworkers and accepting supervision, and has moderate deficits in his ability to respond to work 

pressures.” (emphasis supplied)). Stated somewhat differently, the ALJ’s RFC determination in 

this case simply cannot be regarded as sufficiently “accounting for” a mental ability specifically 

delineated by regulation, see 20 C.F.R. §§ 404.1545(c) & 416.945(c), supra, and mental examiners’ 

evaluations (see, e.g., Tr. 258 & 262), as central to a determination of whether a claimant has the 

ability to perform other work in the national economy. 

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able to pose to the vocational expert (“VE”) a hypothetical question that incorporates all 

of plaintiff’s mental limitations, compare Pendley v. Heckler, 767 F.2d 1561, 1562 (11th Cir. 

1985) (“’[U]nless there [i]s vocational expert testimony concerning the availability of 

jobs for a person with the claimant’s educational level, work skills and experience and 

physical [and mental] limitations, the decision of the ALJ, based significantly on the 

expert testimony, would be unsupported by substantial evidence.’”) with Winschel v. 

Commissioner of Social Sec., 631 F.3d 1176, 1180 (11th Cir. 2011) (“’In order for a 

vocational expert’s testimony to constitute substantial evidence, the ALJ must pose a 

hypothetical question which comprises all of the claimant’s impairments.’” (citation 

omitted)), including the recognized limitation that plaintiff can “occasionally respond 

appropriately to co-workers and the public[]” (Tr. 15), see Watkins, supra, 457 Fed.Appx. 

at 870 n.5 (recognizing that a claimant’s RFC includes the mental abilities to respond 

appropriately to co-workers and supervision). This Court simply cannot find on the 

record before it that the VE “would have answered in a similar manner” had the ALJ 

instructed him to consider all of Rios’ mental limitations, see Pendley, supra, 767 F.2d at 

1563, which would include, in addition to those posed to the VE (see Tr. 49), that Rios 

can only occasionally respond appropriately to co-workers and the general public and 

is limited in her abilities to work independently and in responding appropriately to 

work pressures.8 Cf. Winschel, supra, 631 F.3d at 1180 & 1181 (“Other circuits have [] 

rejected the argument that an ALJ generally accounts for a claimant’s limitations in 

concentration, persistence, and pace by restricting the hypothetical question to simple, 

routine tasks or unskilled work. But when medical evidence demonstrates that a 

 8 It will be for the ALJ on remand to determine whether to utilize Dr. Starkey’s 

modifier—marginal—or another modifier—like “occasionally” or “moderate”—based on the 

credible evidence before her.

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claimant can engage in simple, routine tasks or unskilled work despite limitations in 

concentration, persistence, and pace, courts have concluded that limiting the 

hypothetical to include only unskilled work sufficiently accounts for such limitations. 

Additionally, other circuits have held that hypothetical questions adequately account 

for a claimant’s limitations in concentration, persistence, and pace when the questions 

otherwise implicitly account for these limitations. In this case, the ALJ determined at 

step two that Winschel’s mental impairments caused a moderate limitation in 

maintaining concentration, persistence, and pace. But the ALJ did not indicate that 

medical evidence suggested Winschel’s ability to work was unaffected by this 

limitation, nor did he otherwise implicitly account for the limitation in the hypothetical. 

Consequently, the ALJ should have explicitly included the limitation in his hypothetical 

question to the vocational expert.” (internal citations omitted)). In other words, because 

the ALJ in this case posed to the VE a hypothetical question that failed to include all of 

Rios’ mental limitations, the VE’s testimony is not substantial evidence and cannot 

support the ALJ’s determination that plaintiff could perform unskilled work existing in 

significant numbers in the national economy. Accordingly, the Commissioner’s fifthstep determination is due to be reversed and remanded for further proceedings not 

inconsistent with this decision. 

CONCLUSION

In light of the foregoing, it is ORDERED that the decision of the Commissioner 

of Social Security denying plaintiff benefits be reversed and remanded pursuant to 

sentence four of 42 U.S.C. § 405(g), see Melkonyan v. Sullivan, 501 U.S. 89, 111 S.Ct. 2157, 

115 L.Ed.2d 78 (1991), for further proceedings not inconsistent with this decision. The 

remand pursuant to sentence four of § 405(g) makes plaintiff a prevailing party for 

purposes of the Equal Access to Justice Act, 28 U.S.C. § 2412, see Shalala v. Schaefer, 509 

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U.S. 292, 112 S.Ct. 2625, 125 L.Ed.2d 239 (1993), and terminates this Court’s jurisdiction 

over this matter.

DONE and ORDERED this the 8th day of September, 2016.

s/WILLIAM E. CASSADY

UNITED STATES MAGISTRATE JUDGE

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