Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alsd-1_04-cv-00290/USCOURTS-alsd-1_04-cv-00290-0/pdf.json

Parties Involved:
Jo Anne B. Barnhart
Defendant
Cletis J. Ryan
Plaintiff

Document Text:

IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

CLETIS J. RYAN, ) 

)

Plaintiff, )

)

vs. )CIVIL ACTION NO. 04-00290-WS-B

)

JO ANNE B. BARNHART, )

Commissioner of )

Social Security, )

)

Defendant. )

REPORT AND RECOMMENDATION

Plaintiff Cletis J. Ryan (“Plaintiff”) brings this action

seeking judicial review of a final decision of the Commissioner

denying his claim for period of disability, disability insurance

and supplemental security income benefits, under Titles II and

XVI of the Social Security Act (“the Act”), 42 U.S.C. §§ 401-433

and 1381-1383(c). This action was referred to the undersigned

Magistrate Judge for report and recommendation pursuant to 28

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

careful consideration of the record, the undersigned

respectfully recommends that the decision of the Commissioner be

AFFIRMED.

I. Procedural History

On February 25, 2002 and March 5, 2002, Plaintiff

protectively filed applications for supplemental security income

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benefits and disability insurance benefits, alleging that he has

been disabled since February 15, 2002 due to emphysema, diabetes

mellitus, depression, anxiety, foot pain, and restricted

shoulder movement. (Tr. 10-11, 46-47, 77-89, 302-303, 310-316).

Plaintiff’s initial applications were denied and he filed a

Request for Hearing before an Administrative Law Judge (“ALJ”).

(Id. at 54-71 and 317-321). ALJ William L. Ragland (“ALJ

Ragland”) conducted a hearing on March 25, 2003, which was

attended by Plaintiff and his counsel. (Id. at 27-42). 

On July 18, 2003, ALJ Ragland entered a decision wherein he

found that Plaintiff has the severe impairments of chronic

obstructive pulmonary disease, diabetes mellitus and morbid

obesity. (Id. at 20, Finding 3). The ALJ also concluded that

the evidence was not sufficient to establish that Plaintiff’s

other alleged impairments, namely depression, general anxiety

disorder, emphysema, shoulder problems, high blood pressure,

congestive heart failure and foot pain, rose to the level of a

severe impairment. (Id., Finding 5). The ALJ determined that

Plaintiff’s severe impairments do not meet or medically equal

the listings and that he retains the residual functional

capacity to perform work activities at the medium level of

exertion. (Id., Finding 4). The ALJ then concluded that

Plaintiff can return to his past relevant work as a truck washer

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or painter as he described the jobs and as described in the

Dictionary of Occupational Titles, (hereinafter “DOT”). (Tr.

20, Findings 7-9). On March 5, 2004, the Appeals Council denied

Plaintiff’s request for review of the ALJ’s decision, making it

the final decision of the Commissioner. (Id. at 2-6). See 20

C.F.R. §§ 404.981, 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), 1383(c)(3).

II. Background Facts

Plaintiff was born on May 11, 1943 and was 59 years old at

the time of the administrative hearing. (Tr. 30-31). Plaintiff

is 5'11" and weighed 305 pounds at the time of the hearing.

(Id. at 31). Plaintiff testified that he is divorced, and that

his son and daughter-in-law live with him. (Id.) Plaintiff has

an 11th grade education, and past relevant work as a painter,

laborer, carpet cleaner and truck washer. (Id. at 30-32, 38).

Plaintiff testified that he became unable to work at his

most recent job, washing trucks, on February 15, 2002, due to

physical problems from emphysema, diabetes mellitus, depression,

anxiety, foot pain and restricted shoulder movement (shoulder

pain). (Id. at 32-34, 38-39). He also testified that he has

congestive heart failure and high blood pressure. (Id.)

According to Plaintiff, he lost his last truck washing job

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The ALJ mistakenly referenced Plaintiff’s physician at the Loxley

Medical Center as “Dr. Berec.” (Tr. 11). 

4

because the company hired a permanent worker in his place. (Tr.

32, 35, 38-39). Plaintiff explained that he was placed on his

last truck washing job by Labor Finders, but after he lost that

assignment, Labor Finders would not send him out on any more

jobs due to his health problems. (Id. at 38-39). Plaintiff

testified that he has a driver’s license, but limits his driving

to 100 miles or less. (Id. at 31-32). 

Regarding his ailments, Plaintiff testified that both his

shoulders have an AC separation which pulls the collarbone out

of the socket, but he has not had surgery to correct it because

he thinks he may “end up worse.” (Id. at 36). Additionally,

Plaintiff testified that Dr. Rouse, of the Baldwin County Mental

Health Center, currently treats him for his general anxiety

disorder. (Id. at 34). Plaintiff also indicated that he sees

Dr. Beck1 at the Loxley Medical Clinic, a division of Franklin

Primary Healthcare Center, for his diabetes, and “everything

medical,” and that Dr. Beck cautions him about his weight and

his diabetes, but does not treat him for obesity. (Id. at 34-

35). According to Plaintiff, because of his physical problems:

he can lift up to about the waist but then has to stop due to

shoulder pain; his feet and legs hurt from diabetes if he stands

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Plaintiff testified that his emphysema, diabetes and other physical

conditions seem to have declined over the past nine months: “I was talking to

my psychiatrist, and he stated that the mental health seem to have a lot to do

with the physical health.” (Tr. 35).

3

The ALJ noted that Plaintiff’s medications also include Glucovance,

Magnesium, Potassium and Remeron. (Tr. 13).

5

for long periods of time (such as for more than 45 minutes); he

is easily out of breath if he walks a short distance due to his

emphysema; his psychiatrist believes that his mental health

condition is related to his physical health;2 squatting is almost

impossible because it causes pain in his legs; and he cannot

stoop or crawl. (Tr. 34-37).

 Plaintiff also testified that while he can not recall all

of the prescription medications he is currently taking, he does

recall Seroquel (anti-psychotic for sleep), Effexor (antidepressant), an occasional Valium, and Glucotrol (for diabetes).

(Id. at 33, 37). According to Plaintiff, he also takes

medication for high blood pressure, high cholesterol, high

triglycerides and for his potassium levels. (Id.) Plaintiff

also indicated that he has an inhaler (for breathing).3 (Id.)

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Although not set forth as an “Issue” in his brief, Plaintiff suggests

that the ALJ “utiliz[es] a more difficult standard for those claimants who are

in some ways less appealing[]” given Plaintiff’s prior conviction for

pedophilia. (Doc. 14 at 11). According to Plaintiff, the ALJ failed to carry

out the Commissioner’s responsibilities without regard to such prejudices.

The undersigned finds that there is no evidence in the record to support

Plaintiff’s suggestion that he was treated in a different manner than other

claimants due to his status as a convicted pedophile. In fact, the ALJ

candidly shared with Plaintiff and his counsel his concerns regarding the

dearth medical documentation for the relevant time period, strongly

encouraging them to submit supporting medical data, and agreeing to hold the

record open to allow them sufficient time in which to submit additional

records for his consideration. (Tr. 39-41). The record does not reflect that

any supporting data was submitted following the hearing. Based upon the

above, Plaintiff’s “bias” argument fails and merits no further discussion.

5

This Court’s review of the Commissioner’s application of legal

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

6

III. Issues On Appeal4

A. Whether the ALJ erred in finding that Plaintiff retains the

residual functional capacity to perform medium work?

B. Whether the ALJ erred in failing to find that Plaintiff

suffers from a severe mental impairment resulting in

significant non-exertional limitations?

IV. Analysis

A. Standard of Review

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

is a limited one. This 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).5 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.

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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) (stating 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

conclusion[]”). In determining whether substantial evidence

exists, courts 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 or supplemental security income must prove their

disability. 20 C.F.R. §§ 404.1512, 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), 416.905(a). The Social Security regulations provide

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First, Plaintiff must prove that he has not engaged in substantial

gainful activity. Second, Plaintiff must prove that he has a severe

impairment or combination of impairments. Third, if Plaintiff proves that the

impairment or combination of impairments meets or equals a listed impairment,

then he is automatically found disabled regardless of age, education, or work

experience. If the Plaintiff cannot prevail at the third step, he must

proceed to the fourth step where he must prove an inability to perform his

past relevant work. Jones v. Bowen, 810 F.2d 1001, 1005 (11th Cir. 1986);

Barnes v. Sullivan, 932 F.2d 1356, 1358 (11th Cir. 1991) (per curiam). 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. Jones, 810 F.2d at 1005. Once

Plaintiff meets this burden, the burden shifts to the Commissioner to prove at

this fifth step that Plaintiff is capable of engaging in another kind of

substantial gainful employment which exists in significant numbers in the

national economy, given his residual functional capacity, age, education, and

work history. Wolfe v. Chater, 86 F.3d 1072, 1077 (11th Cir. 1996). See

generally Sryock v. Heckler, 764 F.2d 834 (11th Cir. 1985). If the

Commissioner can demonstrate that there are such jobs that the Plaintiff can

perform, the burden shifts back to the Plaintiff who must prove an inability

to perform those jobs, in order to be found disabled. Jones v. Apfel, 190

F.3d 1224, 1228 (11th Cir. 1999); Allen v. Sullivan, 880 F.2d 1200, 1201 (11th

Cir. 1989); Hale v. Bowen, 831 F.2d 1007, 1011 (11th Cir. 1987) (citing

Francis v. Heckler, 749 F.2d 1562, 1564 (11th Cir. 1985)).

8

a five-step sequential evaluation process for determining if a

claimant has proven his or her disability.6 20 C.F.R. §§

404.1520, 416.920. In the case sub judice, the ALJ applied the

usual five-step process for evaluating disability claims, finding

that Plaintiff has not engaged in substantial gainful activity

since his alleged onset of disability and that he has the

impairments of chronic obstructive pulmonary disease, diabetes

mellitus and morbid obesity, which are “severe” within the

meaning of the Act. (Tr. 20, Findings 2-3). The ALJ then found

that these impairments, when considered individually, or in

combination, do not meet or equal the criteria listed in 20

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C.F.R. Pt. 404, Subpt. P., App. 1. (Id., Finding 4). 

Next, the ALJ found that Plaintiff’s non-severe alleged

impairments of depression, general anxiety disorder, shoulder

problems, high blood pressure, congestive heart failure and foot

pain could not be considered credible. (Id., Finding 5). The

ALJ then found that Plaintiff has the residual functional

capacity to perform work activities at the medium level of

exertion and is capable of performing his past relevant work as

a truck washer and painter, as such jobs are not precluded by his

residual functional capacity such that his impairments do not

prevent him from performing his past relevant work as he

described it and under the DOT description. (Id., Findings 7-9).

As such, the ALJ determined that Plaintiff could perform his past

relevant work, thus terminating the sequential evaluation

process. Plaintiff argues that the ALJ erred by finding that he

retains the residual functional capacity to perform medium work,

and by improperly evaluating his mental impairment. (Doc. 14).

Based upon a review of the record evidence, the undersigned finds

that the ALJ did not err. Substantial evidence of record

supports the ALJ’s decision.

The record contains numerous medical records that date back

to 1992, and reflect that Plaintiff has received medical

treatment for a variety of ailments over the years. However, as

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properly noted by the ALJ, the medical records for the period

related to Plaintiff’s February 15, 2002 alleged onset are quite

limited. (Tr. 13). In the year immediately proceeding

Plaintiff’s alleged onset of disability, he was seen by Clyde

Rouse, M.D., (hereinafter “Dr. Rouse”) for a psychiatric

evaluation at the Baldwin County Mental Health Center

(hereinafter “BCMHC”) on February 8, 2001. (Id. at 224-225).

Dr. Rouse noted that: 

• Plaintiff originally presented on October 23, 2000

for symptoms of major depression, but has had no

prior psychiatric treatment. When he presented to

BCMHC, he was extremely tearful and had a blunted

affect, having some difficulties falling asleep and

staying asleep, feeling very anxious, and

experiencing difficulty with concentration and

trouble with recent memory and immediate recall.

He did not have any suicidal ideation. Plaintiff

had just been released from prison for a sexrelated offense and his main concern was wanting to

reconcile with his wife. Plaintiff was started on

Effexor XR 75 m.g. and Seroquel 50 m.g. during his

October visit, and on December 7, 2000, his Effexor

was increased to 150 m.g. 

• During the February 8, 2001 evaluation, Plaintiff

was alert, oriented and cooperative, “obviously

much less depressed than he was when he originally

presented[,]” but “still has a slightly blunted

affect and some psychomotor retardation[,]” yet

“his symptoms have decreased.” His thinking was

clear and goal directed, his speech was

spontaneous, he smiled and laughed several times,

he denied psychotic symptoms or suicidal/homicidal

ideation, his concentration, recent memory and

immediate recall were improved, he denied any mood

swings, and he reported that he had been noticeably

less irritable and was eating/sleeping well, and

his insight and judgment were good.

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• Dr. Rouse diagnosed major depressive disorder

(single episode, moderate) and advised Plaintiff to

continue taking Effexor and Seroquel, noting that

his Effexor may need to be increased “at some point

in the future[.]” 

(Id.)

On July 26, 2001, Plaintiff returned to Dr. Rouse, and it was

noted that:

• he has been doing “relatively well on his current

medication regimen . . . until recently[]”

(Effexor XR 150 m.g. twice daily and Seroquel 25

m.g. twice daily and 100 m.g. at bedtime). 

• Plaintiff reported recently feeling “more

depressed” with an “increase in his anxiety[,]”

difficulty concentrating and “a lot of obsessive

worrying[.]” 

• Plaintiff denied any suicidal ideation, but

continues to be “obsessed with desire to reunite

with his estranged wife who now has another

boyfriend.”

• On examination, Plaintiff was alert, oriented and

cooperative, with clear and goal directed thinking,

moderate psychomotor retardation, but his

concentration was somewhat impaired and his affect

blunted. Plaintiff denied any auditory/visual

hallucinations and no delusions could be detected.

Plaintiff reported that his appetite had decreased,

but that he was sleeping well with Seroquel; his

anxiety had increased but he denied any panic

attacks. Plaintiff denied recent mood swings, but

reported that he had been irritable lately and that

his anergia and anhedonia were worse. Plaintiff’s

insight and judgment were fairly good. 

• Dr. Rouse diagnosed Plaintiff with recurrence of

“significant depressive symptoms[]” and changed

Plaintiff’s medications by adding Remeron 15 m.g.

and Zyprexa 2.5 m.g. at bedtime, “to help stabilize

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his mood[,]” as well as added Valium 5 m.g. every

4-6 hours, “only as needed for severe anxiety.” 

• Plaintiff was scheduled to return to Dr. Rouse in

three weeks; however, the record does not reflect

that Plaintiff sought any further treatment from

Dr. Rouse for his allegedly disabling mental

impairment.

(Id. at 223).

Plaintiff was also treated from August 2, 2000 through

February 1, 2002, by Gregory S. Funk, D.O., (hereinafter “Dr.

Funk”), at the Gulf Shores General Practice Center. (Id. at 254-

259). While Plaintiff was treated by Dr. Funk on five occasions

during 2000 for high blood pressure, high blood sugar, anxiety and

depression, the record does not reflect any visits to Dr. Funk

during 2001. (Id.) On February 1, 2002, Plaintiff was prescribed

Glucovane by Dr. Funk’s office due to high hemoglobin and high

blood sugar following a January 30, 2002 visit. (Tr. 251-255).

On March 11, 2002, Plaintiff was seen by John Houston, M.D.,

(hereinafter “Dr. Houston”), at the Loxley Family Medical Center,

for complaints of head pressure and slight hypertension. (Id. at

262-263). Plaintiff indicated that he was not diabetic, but that

he wanted to confirm his belief. (Id.) Blood work was performed,

and it was noted that Plaintiff was taking Effexor, Glucovane,

Magnesium K, Seroquel, Remeron and Valium. (Id.) Plaintiff

reported that his occupation was a painter, and indicated that he

had “put in for [d]isability.” (Id. at 260). Plaintiff denied

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any mental disease, and received an intensity pain score of zero.

(Id. at 261).

On May 16, 2002, psychiatrist Charles H. Smith, M.D.,

(hereinafter “Dr. Smith”), performed a consultative disability

evaluation of Plaintiff (Tr. 264-267) and noted the following: 

• (Id. at 264): Upon presentation, Plaintiff had

shortness of breath, normal motor skills,

speech/language consistent with average intellect

and his mannerisms suggested pedophilia, nicotine

dependence, single major depression (mild) and a

mixed personality disorder. 

• (Id. at 265): Plaintiff denied suicidal ideations

and reported that he has gone to BCMHC since

November 2000 when he was released from prison; he

takes Seroquel, Effexor, Remeron and Valium, as

prescribed by Dr. Rouse.

• (Id.): Plaintiff reported that he was formerly an

alcoholic but no longer drinks, and that despite

having emphysema, he still smokes 3 1⁄2 packs per

day. 

• (Id. at 265): Plaintiff is treated at the Loxley

Medical Clinic for general medications and for his

emphysema, high blood pressure and elevated

cholesterol. 

• (Id. at 265-266): The mental status examination

showed that Plaintiff was able to meet his own

needs and is capable of working; he is fully

oriented; he is able to quickly do serial seven

subtractions; he had intact and functional

immediate, recent and remote memory; and could

interpret proverbs (“doctor noted that [i]t is rare

that a person is able to do both proverbs[]”).

Plaintiff’s thought processes were normal; his

conversation was well-articulated; and his affect,

mood, insight and judgment were normal. While

there appeared to be documentation of a major

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depressive disorder, it was noted that Plaintiff

was receiving appropriate medications and there

were no psychotic features, adding that his

depression “appears to be clearly linked to his

last divorce.” 

• (Tr. 266): While Plaintiff was diagnosed with

pedophilia, personality disorder (NOS with

borderline and antisocial features), major

depressive disorder (single episode, mild),

nicotine dependence and generalized anxiety

disorder, Dr. Smith concluded that “this does not

prevent him from working.” It was noted that

Plaintiff’s thought content and processes were

normal (while some reports of depression, etc.,

“[n]o abnormal features noted as part of thought

content which would restrict vocational

endeavors[]”); his affect was normal (no anxiety,

nervousness, dysphoria, depression, psychomotor

retardation/agitation, tearfulness/crying); and his

mood was normal (while he reports depression,

anhedonia and no energy, he did not report crying

spells and “his mood is more stable than he gives

himself credit for[]”). 

• (Id.): Plaintiff’s insight and judgment should not

impair vocational endeavors as he is currently

receiving psychiatric services, appropriate

medications, and medical services, as well as is

under the scrutiny of a probation officer: “I think

he is capable of working. . . . [and] of managing

funds.”

• (Id. at 266-267): Dr. Smith concluded that “I think

this claimant is employable[,]” and he “is

sufficiently stable to pursue vocational endeavors.

. . . He has a history of doing manual labor and

has worked as recently as this year and only

stopped working when he decided to apply for

disability benefits. He appears to be able to meet

his own needs independently and has independent

ADL’s, self-care, and hygiene skills.”

On June 28, 2002, Huguette Douyon, D.O., (hereinafter “Dr.

Douyon”), of Gulf Coast Accumed Systems, LLC, performed a

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Dr. Harris referenced Dr. Douyon’s June 28, 2002 examination of

Plaintiff as support for his conclusions. 

15

disability examination of Plaintiff (id. at 268-269) and found as

follows:

• (Id. at 268): Plaintiff reported that he was

applying for disability secondary to chronic

obstructive pulmonary disease. Plaintiff reported

that he was told he has COPD twelve years ago and

was told to stop smoking, but has not (still smokes

3 1⁄2 packs per day); he complains that he is “not

able to do much secondary to shortness of breath.”

Plaintiff denied any use of inhalers for his COPD

and was in no acute distress.

• (Id.): On exam, Plaintiff weighed 315 pounds, lungs

clear to auscultation with no rales, rhonci or

wheezing, extremities had no clubbing, cyanosis or

edema, distal pulses intact, gait normal and no

focal neurological deficits. 

• (Id. at 269): Dr. Douyon diagnosed diabetes

mellitus type II, morbid obesity, chronic

obstructive pulmonary disease, tobacco abuse and

physical deconditioning.

• (Tr. 270): Dr. Douyon completed a Range of Motion

report in which he found that Plaintiff’s range of

motion was unlimited in his cervical spine,

shoulders, elbows, wrists and ankles and slight

limitations were noted in his lumbar spine, hip and

left hand. 

On July 18, 2002, State Agency physician Robert O. Harris,

M.D., (hereinafter “Dr. Harris”),7 reviewed the medical records

and completed a residual functional capacity assessment for

Plaintiff. (Id. at 276-283). He found as follows: 

• (Id. at 277): Plaintiff retains the residual

functional capacity to lift and carry 10 pounds

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occasionally and 10 pounds frequently; to stand

and/or walk about 6 hours in an 8 hour work day; to

sit about 6 hours in an 8 hour work day; an

unlimited push/pull ability; and the ability to

climb, balance, stoop, kneel, crouch and crawl

frequently. 

• (Id. at 278-282): Plaintiff has no manipulative,

visual, communicative or environmental limitations

and no treating/examining source statements about

his physical capacities were found in the file.

On July 26, 2002, State Agency psychologist William H.

Simpson, Ph.D., (hereinafter “Dr. Simpson”), reviewed the records

and completed a psychiatric review technique form, assessing

Plaintiff’s Affective Disorder, Anxiety-Related Disorder and

Personality Disorder (id. at 288-301), as follows: 

• (Id.): Plaintiff’s major depression, generalized

anxiety disorder and personality disorder resulted

in mild restrictions of his activities of daily

living; mild difficulties in maintaining social

functioning; and moderate difficulties in

maintaining concentration, persistence or pace. 

• (Id. at 298): There was insufficient evidence to

determine if Plaintiff had repeated episodes of

decompensation. 

• (Tr. 288-301): Plaintiff does not satisfy the

diagnostic criteria for Listing 12.04 Affective

Disorders, Listing 12.06 Anxiety-Related

Disorders, or Listing 12.08 Personality Disorders.

Dr. Simpson also completed a mental residual functional

capacity assessment of Plaintiff. (Id. at 284-287). He concluded

that Plaintiff is not significantly limited in his ability to:

• remember locations and work-like procedures

• understand, remember and carry out short and simple

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instructions

• perform activities within a schedule

• maintain regular attendance and be punctual

• sustain an ordinary routine without supervision

• work in coordination or proximity with others

without distraction

• make simple work-related decisions

• complete a normal work-day and work week

• interact appropriately with the general public

• ask simple questions or request assistance

• accept instructions and respond appropriately to

supervisors

• get along with co-workers and peers

• maintain socially appropriate behavior

• respond appropriately to changes in the work

setting

• be aware of normal hazards

• travel in unfamiliar places or use public

transportation

• set realistic goals or make plans independently of

others. 

(Id.) Dr. Simpson opined that Plaintiff is moderately limited in

his ability to understand, remember, and carry out detailed

instructions and maintain attention and concentration for extended

periods. (Id.) Dr. Simpson found that with regard to

understanding, memory, sustained concentration and persistence,

Plaintiff could understand, remember and carry out short, simple

instructions as well as attend for 2 hour periods. (Id. at 286).

Dr. Simpson also found no significant limitations in Plaintiff’s

social interaction and adaptation. (Id.)

In addition to the above-referenced medical evidence,

Plaintiff, on June 5, 2002, completed a daily activities

questionnaire, (Tr. 145-149), wherein he reported as follows: 

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• (Id. at 145-147): He described his average day as

sitting around and trying to stay cool and that he

takes Seroquel to help him sleep. He also reported

that he is able to care for his personal needs

without assistance, and that he prepares and cooks

meals, shops for his personal needs, performs

household chores (cleans kitchen and washes

clothes) without assistance, watches television and

can remember what he watches, but does not read.

Plaintiff leaves his house twice per day and

generally goes to the store or to visit his sister,

without assistance. 

• (Id. at 148): Plaintiff reported problems

concentrating as he is distracted by other thoughts

when he works, takes many breaks and “star gazes.”

Plaintiff reported that he performs a task/chore

for 15 minutes before needing a break, and that

most tasks are not finished but “put on the back

burner[.]” Plaintiff reported that he has no

problems with cooking meals, cleaning, shopping,

taking public transportation, paying bills, taking

care of the house or using the phone.

On March 25, 2002, Plaintiff completed a work history report

in which he reported past work as 1) a truck washer: worked 8

hours per day 5 days per week using machines, tools and equipment,

used technical knowledge or skills, but did not write reports or

complete forms, spent 31⁄2-4 hours per day walking and sitting,

heaviest weight lifted less than 10 lbs and weight frequently

lifted less than 10 lbs, and did not supervise anyone or hire/fire

anyone; 2) a pipe layer: worked 7 1⁄2 hours per day 5 days per week,

work involved walking and stooping with some crouching and

handling, grabbing or grasping big objects, he would lift/carry

plastic pipe 15-20 times per day, heaviest weight lifted 50 lbs

Case 1:04-cv-00290-WS-B Document 22 Filed 10/25/05 Page 18 of 31
19

and weight frequently lifted 25 lbs, and he did not supervise

others; and 3) painter: worked 8 hours per day 5 days per week,

used tools, did not use any technical knowledge/skills or write

reports/complete forms, work involved walking 30 minutes per day,

standing 6 hrs per day, crouching, crawling and stooping 2 hrs per

day with some climbing, he lifted/carried paint about 31 lbs each

and ladders weighing about 30-40 lbs each, heaviest weight lifted

50 lbs, frequently lifted less than 10 lbs, and he did not

supervise others; and 4) carpet cleaner. (Id. at 136-144).

The foregoing constitutes the substance of the pertinent

records before the ALJ. The ALJ reviewed Plaintiff’s testimony,

his medical records, his alleged symptoms of pain, his credibility

and his activities of daily living, and concluded that Plaintiff

retains the physical residual functional capacity to perform

medium work. (Tr. 11-18). The ALJ further noted Plaintiff’s past

work as a painter, laborer, carpet cleaner, and truck washer, and

after reviewing the record evidence, concluded that Plaintiff

retains the residual functional capacity for medium work, and that

his past relevant work constituted medium work such that he is not

precluded from working as a painter/truck washer. (Id. at 18).

While Plaintiff argues that the ALJ erred in finding that

Plaintiff has the residual functional capacity to perform medium

Case 1:04-cv-00290-WS-B Document 22 Filed 10/25/05 Page 19 of 31
8

Medium work involves lifting no more than 50 pounds at a time with

frequent lifting or carrying of objects weighting up to 25 pounds; if someone

can do medium work, they can also do sedentary and light work. 20 C.F.R. §§

404.1567(c), 416.967(c); SSR 83-10. 

20

work,8 the undersigned finds that substantial evidence supports

the ALJ’s decision. 

As noted supra, at step four of the sequential analysis, the

burden is on the claimant to show that he can no longer perform

his former work because of his impairments. Jones v. Bowen, 810

F.2d 1001 (11th Cir. 1986). Section 404.1520(e) of the

Commissioner’s regulations requires a review and consideration of

a claimant’s residual functional capacity and the physical and

mental demands of past work before a determination can be made

that he or she can perform 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 his

impairments. Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir.

1997); 20 C.F.R. §§ 404.1546, 404.1527. In finding that a claimant

has the capacity to perform a past relevant job, the decision of

Case 1:04-cv-00290-WS-B Document 22 Filed 10/25/05 Page 20 of 31
21

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 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. 

Plaintiff contends that the ALJ’s finding, that he can

perform medium work, is erroneous because the ALJ did not specify

what weight he assigned to the opinion of Dr. Douyon and rejected

his findings regarding Plaintiff’s exertional limitations, and

further rejected Dr. Harris’ opinion that Plaintiff is limited to

light work. A review of the ALJ’s decision evidences that he gave

full weight to Dr. Douyon’s evaluation. Dr. Douyon did not

include any lifting or other work restrictions in his report of

Plaintiff’s physical examination. (Tr. 14, 270). The examination

revealed that Plaintiff has no limitations in the range of motion

in his cervical spine, shoulders, elbows, knees or ankles, and

only slight limitations in his lumbar spine, hips and left leg.

(Id.) Additionally, although Plaintiff complained of shortness

of breath, Dr. Douyon’s examination revealed that he had clear

lungs with no rales, rhonchi or wheezing, his extremities showed

no evidence of clubbing, cyanosis or edema, and his gait was

normal. (Id.) Contrary to Plaintiff’s assertions, these

Case 1:04-cv-00290-WS-B Document 22 Filed 10/25/05 Page 21 of 31
22

findings fail to demonstrate that Plaintiff has any exertional

limitations. In fact, neither Dr. Douyon, nor any other examining

doctor, imposed any lifting or other work restrictions upon

Plaintiff. Accordingly, the ALJ’s findings are consistent with

Dr. Douyon’s report.

The ALJ discussed the physical residual functional capacity

assessment completed by non-examining State Agency Physician Dr.

Harris, and properly rejected his finding that Plaintiff is

limited to lifting/carrying no more than 10 pounds. (Tr. 14, 18).

In so doing, the ALJ determined that the finding was not supported

by the record evidence, and as the opinion of a non-examining

source, it was entitled to little weight. (Id.) Swindle v.

Sullivan, 914 F.2d 222, 226 (11th Cir. 1990). Indeed, while

Plaintiff testified that he suffers from foot pain if he stands

more than 45 minutes, the ALJ correctly determined that the record

evidence does not contain any evidence of treatment for, or

documented complaints of, this condition, and that Plaintiff had

failed to seek medical treatment of any kind, regarding his

alleged impairments, in over a year. Additionally, Plaintiff’s

activities of daily living do not support a finding of physical

functional limitations. While Plaintiff claimed that all he does

is “sit around and try to stay cool” every day, the record

evidence establishes that he performs household chores, goes out

Case 1:04-cv-00290-WS-B Document 22 Filed 10/25/05 Page 22 of 31
23

of the house to shop and visit with friends, rides the lawn mover,

takes care of his personal needs, and is able to drive and take

public transportation. Moreover, Plaintiff’s shortness of breath

symptom is stable with prescribed medicine and he has not sought

treatment for any exacerbation of that condition in the past year.

In fact, Dr. Douyon’s examination revealed that Plaintiff had

clear lungs with no rales, rhonchi or wheezing. It is also

noteworthy that while Plaintiff has a history of emphysema due to

his extensive history of nicotine abuse, he still smokes despite

his doctor’s advice to quit. (Tr. 176, 268). Plus, during a June

28, 2002 consultative examination, Plaintiff denied the use of any

inhaler to control his chronic obstructive pulmonary disease.

(Id. at 269). Further, none of Plaintiff’s treating or examining

physicians placed any restrictions on his ability to perform workrelated activities or stated that he was disabled. Accordingly,

based on the substantial evidence before the ALJ, he could

reasonably conclude that Plaintiff’s condition was not so limited

that it would preclude medium work. Arnold v. Checkler, 732 F.2d

881, 884 (11th Cir. 1984). Thus, substantial evidence supports the

ALJ’s conclusion that “the evidence indicates the claimant could

return to these occupations [painter/truck washer] as he actually

performed either job or as either job was generally performed in

the national economy.” (Tr. 18). Barnes, 932 F.2d at 1358.

Case 1:04-cv-00290-WS-B Document 22 Filed 10/25/05 Page 23 of 31
24

Plaintiff also contends that the ALJ erred in finding that

he does not suffer from a severe mental impairment (depression and

general anxiety disorder) given the opinions and findings of

health care professionals at BCMHC (including Dr. Rouse), Dr.

Smith’s consultative psychological examination, and Dr. Simpson’s

mental residual functional capacity assessment and psychiatric

review technique form. (Doc. 14 at 7-10). Upon consideration of

the entire administrative record and Plaintiff’s testimony at the

administrative hearing, the undersigned finds that the decision

of the ALJ, that Plaintiff does not suffer from a severe mental

impairment, is supported by substantial evidence.

The undersigned is aware of the standard for a non-severe

impairment as set forth in Brady v. Heckler, 724 F.2d 914, 920

(11th Cir. 1984), which states that an impairment is severe if it

causes more than just a slight abnormality which has such a

minimal effect on the individual that it would not be expected to

interfere with the ability to work without regard to the

plaintiff’s age, education or work experience. However, the

undersigned also recognizes the standard for review, i.e., is

there substantial evidence in the record to support the ALJ’s

finding. Substantial evidence which is defined as “more than a

scintilla but less than a preponderance,” consists of “such

relevant evidence as a reasonable person would accept as adequate

Case 1:04-cv-00290-WS-B Document 22 Filed 10/25/05 Page 24 of 31
25

so support a conclusion.” Richardson v. Perales, 402 U.S. 389,

401 (1971); Bloodsworth, 703 F.2d at 1239. The “reasonable

person” standard dictates that if there is pertinent and adequate

evidence supporting a decision, it must be upheld. Martin v.

Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990). Additionally,

this Court may neither substitute its own judgment for the

Commissioner’s nor reevaluate the evidence unless the decision is

clearly illogical and unsubstantiated. Bloodsworth, 703 F.2d at

1239. See also Powell v. Heckler, 773 F.2d 1572, 1575 (11th Cir.

1985). Therefore, even when the evidence appears to weigh against

the Commissioner’s decision, this Court must affirm the decision

if there is sufficient supporting evidence. Martin, 894 F.2d at

1529; Bloodsworth, 703 F.2d at 1239.

In concluding that Plaintiff’s mental condition does not rise

to the level of a severe impairment, the ALJ found that although

he has been diagnosed with, and treated for, depression and

anxiety, his statements regarding the severity of his mental

impairments are “self-serving,” “wholly unsubstantiated by the

objectively demonstrable evidence or are conditions that have

responded within twelve months to prescribed treatment without any

lasting functional limitations.” (Tr. 16). The ALJ further noted

that evidence of psychiatric treatment, from the alleged

disability onset date of February 15, 2002 forward, was “nonCase 1:04-cv-00290-WS-B Document 22 Filed 10/25/05 Page 25 of 31
9

Dawkins v. Bowen, 848 F.2d 1211, 1213 (11th Cir. 1988) (finding that a

remediable or controllable medical condition is generally not disabling). 

26

existent[]” and moreover, that Plaintiff has “failed to maintain

a treatment regimen with a mental health professional regarding

his alleged mental impairments . . . [and] [i]nstead . . . has

relied on a general health practitioner to prescribe medication

and ‘counseling.’ The only record available for review in this

respect are those of consultative psychiatric exams.” (Id.) 

At the outset, it should be noted that while the ALJ did not

discuss the records from BCMHC, since they do not pertain to the

period in question, the undersigned’s review of these records

reveals that after Plaintiff was prescribed anxiety/depression

medication in October 2000, he experienced significant relief in

his anxiety and mood by February 2001 (“tremendous relief in

anxiety and mood,” “new outlook on life,” and “obviously much less

depressed”).9 (Id. at 224). Further, while Dr. Rouse advised

Plaintiff, in July 2001, to return to BCMHC for treatment due to

a reported recurrence of depressive symptoms, the record does not

reflect that Plaintiff ever did so. (Id. at 223, 226).

Additionally, while Plaintiff contends that the reports of

Dr. Smith and Dr. Simpson demonstrate that his mental impairment

significantly limits his ability to work, Dr. Smith’s report does

not contain any such limitations. As noted supra, in his May 16,

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27

2002 consultative psychological evaluation of Plaintiff (id. at

264-267), Dr. Smith found that:

• Even though Plaintiff subjectively reported

depression and was diagnosed with pedophilia,

personality disorder (NOS with borderline and

antisocial features), major depressive disorder

(single episode, mild), nicotene dependence and

generalized anxiety disorder, his mood was “more

stable than he gave himself credit for” and his

“insight and judgment should not impair his

vocational endeavors.”

• Plaintiff is able to take care of his own needs

independently and has independent activities of

daily living, self-care and hygiene skills (he

splits the household chores with his wife, does

yard work, socializes with his wife, watches

television, rides the lawnmower outside, takes a

bath, does yard work).

• Plaintiff was fully oriented, he was able to

quickly do serial seven subtractions, his

immediate, recent and remote memory were intact and

functional, he was able to interpret proverbs, he

had normal thought processing, well-articulated

conversation and had a normal affect, mood, insight

and judgment. 

(Tr. 264-267).

There is nothing in Dr. Smith’s report which suggests that

Plaintiff’s mental impairment imposes a significant limitation on

his ability to work. To the contrary, Dr. Smith’s report suggests

that Plaintiff is more stable than he gives himself credit for,

and that his thought processes, insight and judgment are normal.

While Dr. Simpson, who did not examine Plaintiff, opined that he

is moderately limited in his ability to understand, remember, and

Case 1:04-cv-00290-WS-B Document 22 Filed 10/25/05 Page 27 of 31
28

carry out detailed instructions as well as maintain attention and

concentration for extended periods, there is no evidence in the

record which supports his finding. Dr. Smith found no such

limitations. Instead, Dr. Smith found that Plaintiff was capable

of quickly doing serial seven subtractions, and that he could

interpret two proverbs, which is unusual for most people. (Tr.

265-266). Plaintiff also reported that he has no problems

performing tasks such as cooking, taking care of his dog,

shopping, taking public transportation, paying bills, taking care

of the house and using the telephone. (Id. at 145-149).

Moreover, as correctly found by the ALJ, while Plaintiff has had

past episodes of depression, the record clearly reflects that his

condition is stable with prescribed medicine, that he has not

sought treatment for any exacerbation of depression in at least

one year, and that if he had indeed experienced restricted

activities of daily living, the record would reflect a need for

a more intensive medical regimen. (Id. at 17).

Based upon a careful review of the record evidence, 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 his daily

activities, contradict the ALJ’s findings. See supra.

Case 1:04-cv-00290-WS-B Document 22 Filed 10/25/05 Page 28 of 31
29

Accordingly, the undersigned finds no error in the ALJ’s

determination of Plaintiff’s mental residual functional capacity.

V. Conclusion

For the reasons set forth, and upon careful 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 period of disability,

disability insurance benefits and supplemental security income

benefits, be AFFIRMED.

The attached sheet contains important information regarding

objections to this report and recommendation.

DONE this 25th day of October, 2005.

 /s/ SONJA F. BIVINS 

UNITED STATES MAGISTRATE JUDGE

Case 1:04-cv-00290-WS-B Document 22 Filed 10/25/05 Page 29 of 31
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); and 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. See Fed. R. Civ. P. 72; SD ALA LR 72.4(b). 

Case 1:04-cv-00290-WS-B Document 22 Filed 10/25/05 Page 30 of 31
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-00290-WS-B Document 22 Filed 10/25/05 Page 31 of 31