Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-4_05-cv-04024/USCOURTS-arwd-4_05-cv-04024-0/pdf.json

Nature of Suit Code: 865
Nature of Suit: Social Security - RSI (405(g))
Cause of Action: 42:405g Review of HHS Decision (RSI)

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IN THE UNITED STATES DISTRICT COURT

WESTERN DISTRICT OF ARKANSAS

TEXARKANA DIVISION

MICHAEL WILLIS, JR. PLAINTIFF

VS. CIVIL NO. 05-4024

JO ANNE B. BARNHART,

COMMISSIONER, SOCIAL SECURITY ADMINISTRATION DEFENDANT

MEMORANDUM OPINION

Michael Willis, Jr. (hereinafter “plaintiff”), brings this action pursuant to § 205(g) of the

Social Security Act (“the Act”), 42 U.S.C. § 405(g), seeking judicial review of a final decision of

the Commissioner of the Social Security Administration denying his applications for disability

insurance benefits (“DIB”), and supplemental security income benefits (“SSI”), under Titles II and

XVI of the Act.

Background:

The applications for DIB and SSI now before this court were filed on April 16, 2003, 

alleging an onset date of February 18, 2003, due to an inability to read and write, comprehension

problems, poor memory, tiredness, weakness, and behavior problems. (Tr. 59-61, 80, 99, 179-

180). An administrative hearing was held on September 14, 2003. (Tr. 204-226). Plaintiff was

present and represented by counsel.

At the time of the administrative hearing on September 14, 2003, plaintiff was forty-nine

years old and possessed a high school education. (Tr. 17). The record reveals that he had past

relevant work (“PRW”), as a janitor, hand packer, painter’s helper, and construction laborer. (Tr.

17). 

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On October 4, 2004, the Administrative Law Judge (“ALJ”), found that plaintiff’s

impairments were non-severe. On February 22, 2005, the Appeals Council declined to review

this decision. (Tr. 5-8). Subsequently, plaintiff filed this action. (Doc. # 1). This case is before

the undersigned by consent of the parties. The plaintiff and Commissioner have filed appeal

briefs, and the case is now ready for decision. (Doc. # 9, 10). 

Applicable Law:

This Court’s role is to determine whether the Commissioner’s findings are supported by

substantial evidence on the record as a whole. Ramirez v. Barnhart, 292 F.3d 576, 583 (8th Cir.

2002). Substantial evidence is less than a preponderance but it is enough that a reasonable mind

would find it adequate to support the Commissioner’s decision. The ALJ’s decision must be

affirmed if the record contains substantial evidence to support it. Edwards v. Barnhart, 314 F.3d

964, 966 (8th Cir. 2003). As long as there is substantial evidence in the record that supports the

Commissioner’s decision, the Court may not reverse it simply because substantial evidence exists

in the record that would have supported a contrary outcome, or because the Court would have

decided the case differently. Haley v. Massanari, 258 F.3d 742, 747 (8th Cir. 2001). In other words,

if after reviewing the record it is possible to draw two inconsistent positions from the evidence and

one of those positions represents the findings of the ALJ, the decision of the ALJ must be affirmed.

Young v. Apfel, 221 F.3d 1065, 1068 (8th Cir. 2000).

It is well-established that a claimant for Social Security disability benefits has the burden of

proving his disability by establishing a physical or mental disability that has lasted at least one year

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and that prevents him from engaging in any substantial gainful activity. Pearsall v. Massanari, 274

F.3d 1211, 1217 (8th Cir. 2001); see 42 U.S.C. § § 423(d)(1)(A), 1382c(a)(3)(A). The Act defines

“physical or mental impairment” as “an impairment that results from anatomical, physiological, or

psychological abnormalities which are demonstrable bymedically acceptable clinical and laboratory

diagnostic techniques.” 42 U.S.C. § § 423(d)(3), 1382(3)(c). A plaintiff must show that his

disability, not simply his impairment, has lasted for at least twelve consecutive months. Titus v.

Sullivan, 4 F.3d 590, 594 (8th Cir. 1993).

The Commissioner’s regulations require her to apply a five-step sequential evaluation process

to each claim for disability benefits: (1) whether the claimant has engaged in substantial gainful

activity since filing his claim; (2) whether the claimant has a severe physical and/or mental

impairment or combination of impairments; (3) whether the impairment(s) meet or equal an

impairment in the listings; (4) whether the impairment(s) prevent the claimant from doing past

relevant work; and, (5) whether the claimant is able to perform other work in the national economy

given his age, education, and experience. See 20 C.F.R. § § 404.1520(a)- (f)(2003). Only if the final

stage is reached does the fact finder consider the plaintiff’s age, education, and work experience in

light of his or her residual functional capacity. See McCoy v. Schweiker, 683 F.2d 1138, 1141-42

(8th Cir. 1982); 20 C .F.R. § § 404.1520, 416.920 (2003).

Discussion:

In the present case, the ALJ concluded that plaintiff’s impairments were non-severe. An ALJ

may consider an impairment to be non-severe only if a claimant’s medical impairments are so slight

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that it is unlikely he or she would be found to be disabled even if their age, education, and work

experience were taken into account. See Bowen v. Yuckert, 482 U.S. 137, 153 (1987). “Only those

claimants with slight abnormalities that do not significantly limit any ‘basic work activity’ can be

denied benefits without undertaking the vocational analysis.” Id. at 158.

The relevant medical evidence reveals as follows. On June 2, 2003, plaintiff underwent a

psychological examination by Dr. C. Yates Morgan. (Tr. 127-130). Plaintiff complained of blurred

vision and occasional shortness of breath. (Tr. 128). He reported that he was applying for disability

benefits because a friend told him that people who could not read or write were able to receive

financial assistance. (Tr. 127). Dr. Morgan noted that plaintiff was not overtly uncooperative, but

that he put little effort into responding to test items. The results of his I.Q. test were inconsistent

with plaintiff’s reported education and work history. As such, they were not considered valid.

Further, his mental status examination revealed an individual who did not suffer from depression,

psychosis, or undue anxiety. (Tr. 130). 

Plaintiff told Dr. Morgan that he had dropped out of school his senior year because he was

failing. (Tr. 127). However, he reported taking regular classes and getting along with his teachers

and peers. In spite of his education, plaintiff stated that he could not read, and was unable to write

anything beyond his name. Further, plaintiff told Dr. Morgan that his past employment consisted

of work at a paper mill, a tire plant, and driving a cement truck. (Tr. 127-128). He indicated that

he had been fired from the paper mill and tire plant due to conflicts with supervisors and/or fellow

employees. (Tr. 128). 

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Dr. Morgan noted that plaintiff possessed clear thoughts and an intact memory. (Tr. 130).

Further, plaintiff did not appear to be suspicious of the motives and intentions of others. Dr. Morgan

concluded that plaintiff seemed to possess the ability to understand, remember, and carry out

instructions, as well as deal with a reasonable amount of work pressure. However, plaintiff did seem

to have difficulty in responding appropriately to co-workers and supervision. Dr. Morgan then

assessed plaintiff as having a global assessment of functioning score (“GAF”), of sixty-two, which

is indicative of only mild symptoms. DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL

DISORDERS IV-TR, p. 34 (4th ed. 2000). (Tr. 130).

On August 4, 2003, plaintiff underwent a general physical examination. (Tr. 131-137).

Although no physical abnormalities or evidence of psychosis were noted, the doctor did report that

plaintiff could not remember the month or the year. (Tr. 136).

On October 13, 2003, plaintiff underwent an initial clinical interview at Southwest Arkansas

Counseling and Mental Health Center. (Tr. 140-145). Records indicate that he complained of low

mood; feelings of sadness; and, loss of interest, energy and enthusiasm. (Tr. 140). He stated that,

at times, he was explosive and experienced uncontrollable outbursts. However, plaintiff reported

that he was not taking any medications. (Tr. 142). Warren Smith, a licensed social worker, noted

that plaintiff’s motor behavior was slow and lethargic, he had rapid/pressured speech, his mood was

irritable, his affect/attitude was angry/hostile, his thought content was preoccupied, his attention was

distracted, and his memory was impaired. (Tr. 143). He estimated plaintiff’s I.Q. to be below

average. As such, Mr. Smith diagnosed him with mood disorder, not otherwise specified, rule out

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malingering. Further, he assessed plaintiff with a GAF of forty-eight. (Tr. 144). A GAF of fortyeight indicates the presence of serious symptoms or a serious impairment in social, occupational, or

school functioning. DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS IV-TR, p. 34

(4th ed. 2000)

On November 3, 2003, Mr. Smith reported no change in plaintiff’s condition. (Tr. 152).

Plaintiff reported an inability to find work, and stated that he continued to experience dizzy spells.

He also complained of mounting expenses, with no way to pay his bills. Plaintiff stated that he was

at a loss because of his inability to read and write. As such, Mr. Smith encouraged plaintiff to

contact the literacy program. (Tr. 152). 

On January 9, 2004, no significant changes were noted. (Tr. 170). Plaintiff told Mr. Smith

that he had applied for SSI, stating that he had significant medical problems. Records indicate that

his depression continued to be a problem. (Tr. 170). 

On February 26, 2004, plaintiff was treated by Dr. Sanjeev Singhal, a psychiatrist. (Tr. 177-

178). Plaintiff complained of depression, anxiety, auditory hallucinations, low energy, loss of

interest, irritability, and headaches. (Tr. 177). However, when probed further regarding his

symptoms, plaintiff provided no specific information that would validate his symptoms. As such,

Dr. Singhal concluded that plaintiff’s symptoms were “really not convincing.” He noted, however,

that there was a possibility that plaintiff was suffering from psychotic symptoms. (Tr. 178).

Accordingly, Dr. Singhal diagnosed plaintiff with a deferred diagnosis of rule out major depressive

disorder, anxiety, and psychotic disorder. Because his symptoms did not seem legitimate to Dr.

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Singhal, he did not prescribe any medications. Instead, he asked plaintiff to continue seeing Mr.

Smith, and to follow-up with Dr. Singhal’s office in a couple of months. (Tr. 178). 

On March 4, 2004, Mr. Smith again documented no significant change in plaintiff’s

condition. (Tr. 176). Plaintiff reported periodic depression with anger outbursts, and maintained that

he was unable to work, due to his physical and medical problems. Mr. Smith noted that plaintiff

described a “lonely existence.” Further, plaintiff complained of being unable to see a doctor for his

many complaints. However, the record does not indicate why plaintiff was unable to see a doctor.

(Tr. 176). 

On April 22, 2004, plaintiff had his second appointment with Dr. Singhal. (Tr. 175). After

reviewing notes from plaintiff’s session with Mr. Smith, Dr. Singhal noted that plaintiff’s depression

and irritability complaints remained constant. As such, he prescribed Prozac. (Tr. 175). 

On June 24, 2004, plaintiff’s thought process was noted to be logical and resistant. (Tr. 173).

Notes indicate that his depression was evidenced by decreased energy, impaired sleep, and

constricted interaction. As such, there had been no significant change in his condition. Plaintiff

indicated that he could not work because he could not stand being around people. (Tr. 173). 

On July 19, 2004, plaintiff saw Dr. Oladele Adebogun, a psychiatrist. (Tr. 171). Dr.

Adebogun noted that plaintiff had been seeing Dr. Singhal for anxiety and depression. He also

indicated that plaintiff had been diagnosed with high blood pressure, deteriorating vision, dyslexia,

and tension headaches. Plaintiff reported that he had fallen as a child, and continued to have knots

on the back of his head. However, he denied experiencing seizures. Further, plaintiff denied

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experiencing suicidal/homicidal ideations. He acknowledged that he did have “explosive moods,”

and had been involved in multiple altercations. Plaintiff reported feeling anxious when people “act

a fool around him.” Although he had remained compliant with his medication, plaintiff indicated

that it had not really helped him. As such, Dr. Adebogun advised plaintiff to increase his dosage of

Prozac, and prescribed Depakote and Geodon to control his unstable mood. (Tr. 171). Geodon is

a medication used to treat schizophrenia and manic and mixed episodes associated with bipolar

disorder. See PHYSICIAN’S DESK REFERENCE, p. 2515 (60th ed. 2006). Depakote is also used to treat

mania associated with bipolar disorder. See PHYSICIAN’S DESK REFERENCE, p. 429 (60th ed. 2006).

This same date, counseling progress notes indicate that plaintiff continued to report problems

with irritability, impaired sleep, and withdrawn behavior. (Tr. 172). The counselor noted that

plaintiff had difficulty identifying and verbalizing his feelings. (Tr. 172).

On November 4, 2004, plaintiff was evaluated by Dr. John Jamerson. (Tr. 194-196).

Following an interview with plaintiff, Dr. Jamerson concluded that plaintiff’s symptoms indicated

the presence of psychosis with underlying paranoia and delusions of persecution. (Tr. 196). Plaintiff

reported experiencing both auditory and visual hallucinations. (Tr. 194). Dr. Jamerson noted that

chronic and severe health problems, anxiety, illiteracy, and probable dyslexia exacerbated the

delusional elements of plaintiff’s illness, and predisposed him to anger and violence. (Tr. 196).

During the interview, plaintiff admitted to having a fairly extensive criminal background, to include

shootings, stabbings, and general assaults. (Tr. 195). 

Dr. Jamerson was of the opinion that plaintiff was an unlikely candidate for psychiatric

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intervention, due to his suspiciousness and history of medical non-compliance. (Tr. 195). Plaintiff

reported an unwillingness to take psychotropic medication for fear that it would hurt his heart.

Therefore, Dr. Jamerson diagnosed plaintiff with schizophrenia, paranoid type; panic disorder with

agoraphobia; and, a reading disorder. (Tr. 196). He then indicated that plaintiff had a GAF of thirtyfive. This score is indicative of “some impairment in reality testing or communication or a major

impairment in several areas, such as work or school, family relations, judgment, thinking, or mood.”

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS IV-TR, p. 34 (4th ed. 2000).

Dr. Jamerson also completed a medical source statement. (Tr. 197-203). He noted that

plaintiff suffered from delusions and hallucinations, emotional withdrawal, marked difficulties in

maintaining social functioning, deficiencies of concentration, repeated episodes of deterioration or

decompensation, generalized anxiety, and recurrent severe panic attacks. He then indicated that

plaintiff had marked restrictions regarding activities of daily living, extreme difficulty maintaining

social functioning, often experienced deficiencies of concentration, and would continually experience

episodes of deterioration or decompensation. (Tr. 203).

While we are aware that initial assessments seemed to indicate that plaintiff was malingering

or over reporting his symptoms, we note that more recent records indicate that plaintiff was actually

suffering from a mental impairment. (Tr. 171, 194-203). Dr. Singhal was hesitant to prescribe any

medication for plaintiff’s condition, but after reviewing several of plaintiff’s counseling progress

notes, he diagnosed plaintiff with depression. (Tr. 175, 178). He noted that depressive and anxiety

symptoms were prevalent and consistent, and prescribed Prozac. Approximately three months later,

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Dr. Adebogun added Depakote and Geodon to plaintiff’s medication regimen. (Tr. 171). As stated

above, these are relatively strong medications used to treat schizophrenia and manic and mixed

episodes associated with bipolar disorder. The records clearly indicate that plaintiff was

experiencing problems with “explosive moods,” and indicated that he had been involved in a number

of altercations. In fact, plaintiff told Dr. Adebogun that he always carried a pocketknife in his hand

or pocket. (Tr. 171). 

We also note that Dr. Jamerson diagnosed plaintiff with paranoid schizophrenia, panic attacks

with agoraphobia, and a learning disorder. (Tr. 203). In addition, he indicated that plaintiff had

marked restrictions in activities of daily living, experienced extreme difficulty maintaining social

functioning, often experienced deficiencies of concentration, and would continually experience

episodes of deterioration or decompensation. (Tr. 203). Given plaintiff’s symptoms and the

medications prescribed to treat his condition, we believe that remand is necessary to allow the ALJ

to reconsider the evidence concerning plaintiff’s mental condition. 

After reviewing the entire record, we are also concerned that the ALJ relied on the

psychological examination of Dr. Morgan to conclude that plaintiff’s impairment was non-severe.

We note that the opinion of a consulting physician who examined the plaintiff once, or not at all,

does not generally constitute substantial evidence. See Jenkins v. Apfel, 196 F.3d 922, 925 (8th Cir.

1999). This is especially true in this instance, where the notes of plaintiff’s treating physicians

indicate that plaintiff was actually suffering from a significant impairment, and the ALJ has failed

to explain his reasons for disregarding this evidence. Whether the ALJ grants a treating physician’s

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opinion substantial or little weight, the regulations provide that the ALJ must “always give good

reasons” for the particular weight given to a treating physician’s evaluation. 20 C.F.R §

404.1527(d)(2); see also SSR 96-2p; See Prosch v. Apfel, 201 F.3d at 1010, 1012-13 (8th Cir. 2000).

Conclusion:

Accordingly, we conclude that the ALJ’s decision is not supported by substantial evidence,

and therefore, the denial of benefits to the plaintiff, should be reversed and this matter should be

remanded to the Commissioner for further consideration pursuant to sentence four of 42 U.S.C. §

405(g). 

DATED this29th day of March 2006.

/s/ Bobby E. Shepherd

HONORABLE BOBBY E. SHEPHERD

UNITED STATES MAGISTRATE JUDGE 

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