Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-almd-2_08-cv-00655/USCOURTS-almd-2_08-cv-00655-0/pdf.json

Parties Involved:
Michael J. Astrue
Defendant
Maxie D. Reeves
Plaintiff

Document Text:

IN THE DISTRICT COURT OF THE UNITED STATES

FOR THE MIDDLE DISTRICT OF ALABAMA

NORTHERN DIVISION

MAXIE D. REEVES, )

)

Plaintiff, )

)

v. ) CIVIL ACTION NO. 2:08cv655-CSC

) (WO)

MICHAEL J. ASTRUE, )

Commissioner of Social Security, )

)

Defendant. )

MEMORANDUM OPINION

I. Introduction

The plaintiff challenges the Commissioner’s denial of disability and supplemental

security income benefits for the closed period from April 8, 1995 to February 1, 1999. A

brief recitation of the procedural history of the case is necessary to understand the court’s

resolution of this matter. 

On March 26, 1999, the plaintiff, Maxie D. Reeves (“Reeves”), applied for disability

insurance benefits pursuant to Title II of the Social Security Act, 42 U.S.C. §§ 401 et seq.,

and for supplemental security income benefits under Title XVI of the Social Security Act,

42 U.S.C. § 1381 et seq., alleging that he was unable to work because of a disability. His

application was denied at the initial administrative level. Reeves then requested and received

a hearing before an Administrative Law Judge (“ALJ”). Following the hearing, the ALJ

concluded that the plaintiff has severe impairments of “lumbar radiculitis; sciatica; status

post alcohol abuse; status post polysubstance drug abuse; and recurrent major depression.”

Case 2:08-cv-00655-CSC Document 22 Filed 03/31/10 Page 1 of 28
Pursuant to the Social Security Independence and Program Improvements Act of 1994, Pub.L. No. 1

103-296, 108 Stat. 1464, the functions of the Secretary of Health and Human Services with respect to Social

Security matters were transferred to the Commissioner of Social Security.

2

(R. 19). According to the ALJ, Reeves could not return to his past relevant work as a welder,

iron worker or kitchen worker. On December 21, 2000, the ALJ issued a partially favorable

decision in which the ALJ determined that Reeves was disabled since February 1, 1999 but

not prior to that date. (R. 16). “Since February 1, 1999, the evidence demonstrates that the

claimant has been drug and alcohol free; however, the evidence further demonstrates that

since that time, the claimant has had a severe impairment at Listing level.” (R. 23).

Reeves appealed the ALJ’s decision to the Appeals Council, requesting that the

Appeals Council review the ALJ’s decision. The Appeals Council rejected the request for

reconsideration. The ALJ’s decision consequently became the final decision of the

Commissioner of Social Security (Commissioner). See Chester v. Bowen, 792 F.2d 129, 1

131 (11 Cir. 1986). Reeves then appealed the Commissioner’s partial denial to this court. th

On September 15, 2003, on the motion of the Commissioner, the court remanded the

case pursuant to sentence four of section 205(g) of the Social Security Act, 42 U.S.C. §

405(g), to allow the ALJ to

update the medical records from all treating sources and obtain consultative

examinations, as needed. In addition, a supplemental hearing will be

conducted which will include additional testimony from Plaintiff, testimony

from a medical expert with a speciality in mental disorders, and additional

testimony from a vocational expert which will be based on a hypothetical

which includes all of the limitations established by the record. The ALJ will

issue a new decision for the period at issue, which reevaluates the severity of

each of the impairments established in the record, including diabetes and

Case 2:08-cv-00655-CSC Document 22 Filed 03/31/10 Page 2 of 28
 Reeves alleged that he was disabled beginning on April 5, 1995. 2

3

depression and, if pertinent, determine the issues of drug and alcohol addiction

(DA & A) under the process outlined in 20 C.F.R. § 404.1535 and § 416.935.

(R. 750 & 755).

On June 12, 2004, on the first remand, the Appeals Council affirmed the ALJ’s

finding that Reeves was disabled since February 1, 1999 but vacated the decision as it

applied to the time period before February 1, 1999. (R. 746). The Appeals Council 2

remanded the matter to the ALJ for further proceedings to consider whether Reeves suffers

from a mental impairment; to properly evaluate the severity of his diabetes mellitus and his

subjective complaints; and to properly assess his residual functional capacity. (R. 747).

After a hearing on April 26, 2005, the ALJ concluded that Reeves had severe impairments

of “lumbar radiculitis; sciatica; status post alcohol abuse; status post polysubstance drug

abuse; and recurrent major depression.” (R. 738). The ALJ further concluded that Reeves

could not perform his past relevant work as welder, iron worker, or kitchen worker. (R.

741). Nonetheless, the ALJ concluded that Reeves was not disabled because he “had the

residual functional capacity to perform jobs existing in significant numbers in the national

economy.” (Id.).

The plaintiff appealed the ALJ’s decision to the Appeals Council, requesting the

Appeals Council again review the ALJ’s decision. The Appeals Council rejected the request

for reconsideration, and the ALJ’s decision again became the final decision of the

Commissioner. Reeves then appealed the Commissioner’s denial of benefits for the period

Case 2:08-cv-00655-CSC Document 22 Filed 03/31/10 Page 3 of 28
4

from April 8, 1995 to February 1, 1999, to this court.

On July 28, 2006, on another motion to remand by the Commissioner, the court again

remanded this case pursuant to sentence four of 42 U.S.C. § 405(g) for consideration of the

effects of Reeves’s diabetes on his ability to work. (R. 864-67 & 872-73). On remand from

the court, the Appeals Council directed a different ALJ to

specifically make a determination at step two of the sequential evaluation with

respect to [Reeves’s] diabetes. The Administrative Law Judge will also

specifically consider any limitations resulting from [Reeves’s] diabetes, and

consider this impairment in combination with [Reeves’s] other impairments.

(R. 873-74).

Following a third administrative hearing before a different ALJ, the ALJ concluded

that, between April 8, 1995 and February 1, 1999, Reeves had the following severe

impairments: “drug and alcohol abuse, spondylolisthesis, gastroesophageal reflux disease

with acute episodes of pancreatitis, diabetes mellitus with poor medical compliance, and

major depressive disorder with psychosis.” (R. 834). The ALJ further concluded that Reeves

could not perform his past relevant work as an iron worker. (R. 849-50). Nonetheless, the

ALJ concluded that Reeves was not disabled because “when the effects of alcohol and drug

abuse are factored out for the period between April 8, 1995, to February 1, 1999, [he] was

capable of making a successful adjustment to other work in that exists in significant numbers

in the national economy.” (R. 851). Reeves appealed the ALJ’s decision to the Appeals

Council, requesting the Appeals Council review the ALJ’s decision. The Appeals Council

rejected the request for reconsideration, and the ALJ’s decision consequently became the

Case 2:08-cv-00655-CSC Document 22 Filed 03/31/10 Page 4 of 28
 A “physical or mental impairment” is one resulting from anatomical, physiological, or 3

psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory

diagnostic techniques.

5

final decision of the Commissioner.

The case is now before the court for review pursuant to 42 U.S.C. §§ 405 (g) and

1631(c)(3). Pursuant to 28 U.S.C. § 636(c)(1) and M.D. Ala. LR 73.1, the parties have

consented to the United States Magistrate Judge conducting all proceedings in this case and

ordering the entry of final judgment. Based on the court’s review of the record in this case

and the briefs of the parties, the court concludes that the decision of the Commissioner

should be reversed and this case remanded for an award of benefits.

II. Standard of Review

Under 42 U.S.C. § 423(d)(1)(A), a person is entitled to disability benefits when the

person is unable to

engage in 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 12 months . . . 

To make this determination, the Commissioner employs a five-step, sequential 3

evaluation process. See 20 C.F.R. §§ 404.1520, 416.920.

(1) Is the person presently unemployed?

(2) Is the person’s impairment severe?

(3) Does the person’s impairment meet or equal one of the specific

impairments set forth in 20 C.F.R. Pt. 404, Subpt. P, App. 1?

(4) Is the person unable to perform his or her former occupation?

(5) Is the person unable to perform any other work within the economy?

Case 2:08-cv-00655-CSC Document 22 Filed 03/31/10 Page 5 of 28
 McDaniel v. Bowen, 800 F.2d 1026 (11 Cir. 1986), is a supplemental security income case (SSI). 4 th

The same sequence applies to disability insurance benefits. Cases arising under Title II are appropriately

cited as authority in Title XVI cases. See e.g. Ware v. Schweiker, 651 F.2d 408 (5 Cir. 1981) (Unit A). th

6

An affirmative answer to any of the above questions leads either to the next

question, or, on steps three and five, to a finding of disability. A negative

answer to any question, other than step three, leads to a determination of “not

disabled.”

McDaniel v. Bowen, 800 F.2d 1026, 1030 (11 Cir. 1986). th 4

The standard of review of the Commissioner’s decision is a limited one. This court

must find the Commissioner’s decision conclusive if it is supported by substantial evidence.

42 U.S.C. § 405(g); Graham v. Apfel, 129 F.3d 1420, 1422 (11 Cir. 1997). “Substantial th

evidence is more than a scintilla, but less than a preponderance. It is such relevant evidence

as a reasonable person would accept as adequate to support a conclusion.” Richardson v.

Perales, 402 U.S. 389, 401 (1971). A reviewing court may not look only to those parts of

the record which support the decision of the ALJ but instead must view the record in its

entirety and take account of evidence which detracts from the evidence relied on by the ALJ.

Hillsman v. Bowen, 804 F.2d 1179 (11 Cir. 1986). th

[The court must] . . . scrutinize the record in its entirety to determine the

reasonableness of the [Commissioner’s] . . . factual findings . . . No similar

presumption of validity attaches to the [Commissioner’s] . . . legal conclusions,

including determination of the proper standards to be applied in evaluating

claims.

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

Case 2:08-cv-00655-CSC Document 22 Filed 03/31/10 Page 6 of 28
7

III. Procedural History

A. Introduction

Reeves was 41 years old at the time of onset and 54 years old at the time of the third

decision of the ALJ. (R. 850-51). He completed the eighth grade and can read, write and do

simple mathematics. (R. 34). Reeves’s prior experience includes work as an iron worker,

welder and kitchen worker. (R. 61). 

B. Plaintiff’s Claims

As stated by Reeves, he presents the following two issues for the Court’s review:

I. Whether the Commissioner’s ALJs applied improper legal

standards in concluding that Mr. Reeves did not meet Listing

12.04 before February 1999.

II. Whether the ALJ improperly failed to give controlling weight to

the opinion evidence of Mr. Reeves’ treating physician.

(Pl’s Mem. Br., doc. # 11, at 8).

IV. Discussion

The court conducts a de novo review of the Commissioner’s legal conclusions. See

Lewis v. Barnhart, 285 F.3d 1329, 1330 (11 Cir. 2002). “Further, on review, there is no th

presumption “that the Commissioner followed the appropriate legal standards in deciding a

claim for benefits or that legal conclusions reached were valid. Instead, we conduct an

exacting examination of these factors.”” Davis v. Astrue, 287 Fed. Appx. 748, 752 (11 Cir.

th

2008) quoting Miles v. Chater, 84 F.3d 1397, 1400 (11 Cir.1996). th

Case 2:08-cv-00655-CSC Document 22 Filed 03/31/10 Page 7 of 28
 The Global Assessment Functioning Scale considers the psychological, social, and occupational 5

functioning of an individual suffering from mental illness. A score of between 41 and 50 indicates serious

symptoms or serious impairments in social, occupational, or school functioning. American Psychiatric

Association: Diagnostic and Statistical Manual of Mental Disorders (4 ed. 1994). 

th

 Zoloft is an antidepressant used to treat major depressive disorder in adults. 6

 Trazodone is an antidepressant used to treat major depressive episodes. 7

8

A. Relevant Medical Treatment during the time period at issue

On July 22, 1994, Reeves was admitted to the Veterans Administration (“VA”)

hospital for drug and alcohol treatment. He was diagnosed with “drug dependence, crack

cocaine, continuous” use, “alcohol dependence, continuous” use, and “chronic low back

pain.” (R. 183). He was discharged on September 2, 1994. (Id.). At that time, a treatment

note indicated that Reeves was “employable[, but to a]void back strain.” (R. 184).

Reeves was admitted to the VA hospital again on April 8, 1995. (R. 185). He was

diagnosed with “Dythymia, Alcohol dependence, Crack cocaine dependence, Personality

disorder, Chronic back pain bilateral S1 radiculopathy.” (Id.) His conditions were severe

and his GAF score was 50. (Id.). He was prescribed Feldene for back pain, Zoloft for 5 6

depression, and Trazodone for depression and insomnia. (R. 185). Reeves was discharged 7

from the VA on May 10, 1995. (Id.). At that time, his depression was responding to

medication, and his condition was stabilized. (R. 186-87). “[D]epression gradually

improved with a combination of chemotherapy, hospital milieu and abstinence from

substance abuse.” (Id.) 

Between 1995 and 1998, while living in Tennessee, Reeves received treatment for

Case 2:08-cv-00655-CSC Document 22 Filed 03/31/10 Page 8 of 28
 These records were not included in the 1328-page record provided to the court. 8

9

depression for two years. (R. 253). Reeves was hospitalized again on January 27, 1998 for 8

“Major depression, recurrent” and “Dysthymic disorder.” (R. 191). At that time, it was

noted that he had a “history of polysubstance abuse.” (Id.) On admission, Reeves

acknowledged that he had stopped taking his anti-depressant medication. (Id.). He was

depressed, his motor skills were slow, and his affect “was flat, somewhat tearful and

depressed. . . . His insight and judgment were impaired” (R. 191-92). Although Reeves

stated that he last used cocaine and marijuana a month before his admission, his major

problem was depression. (R. 254, 256). Reeves admitted that he used cocaine “to get relief

from the depression.” (R. 247). Reeves denied alcohol use. (R. 252). A urinalysis test for

drugs was negative. (R. 192). 

His initial diagnoses included “major depression, alcohol abuse, in present remission,

and cocaine abuse, last [use] 1 mo[nth] ago.” (R. 247). A treatment note indicates “[h]istory

of long term treatment for depression and one suicide attempt by overdose of medication.”

(R. 251). At the time of his admission, Reeves’s GAF score was between 41 and 50. (R.

249). He was experiencing severe psychiatric stressors including chronic pain, unsafe living

conditions and unemployment. (Id.). His dominant complaints were depression, back pain,

and insomnia. (Id.). He was diagnosed with major depression “with preoccupation with

somatic problems.” (R. 246). Reeves was prescribed Trazodone and Zoloft. (R. 247).

Reeves remained hospitalized and received treatment until March 18, 1998. (R. 257).

Case 2:08-cv-00655-CSC Document 22 Filed 03/31/10 Page 9 of 28
 The record does not disclose why Reeves was assigned work before he was approved to do that 9

work.

10

During treatment, it was noted that Reeves was attempting to mask his depression. (R. 239).

After a week of treatment on anti-depressants, psychological testing revealed the following.

The veteran was administered the Minnesota Multiphasic Personality

Inventory–II, the Million Clinical Multiaxial Inventory-II, the Beck Depression

Inventory, the Beck Anxiety Scale, and the Beck Hopelessness Scale. Results

of the MMPI-2 indicate that the veteran endorsed items in an extremely

defensive fashion. We refer to this attempt to look better off psychologically

than is in fact the case “faking good.” The results of the clinical scales

indicate a person who is likely to present with somatic complaints. Rather than

being grossly incapacitated in functioning he is likely to continue functioning

but at a reduced level of efficiency. He may make excessive use of denial,

projection, and rationalization, and blame others for his difficulties. He is

likely to prefer medical explanations for his symptoms and lack insight into

psychological factors underlying his symptoms. He may have a strong need

for attention, affection, and sympathy. Social relationships are likely to be

shallow and superficial. A compliant attitude towards authority and a tendency

to be controlling with everyone else is likely. He tends to keep his emotions

in check. Beck scores indicate mild to moderate levels of anxiety and

depression and hopelessness scale score falls within the normal range.

Psychosis is not supported by this assessment.

(R. 233).

Reeves was assigned to work in the Print Clinic on February 11, 1998. (R. 216). He 9

began work on February 18, 1998. (Id.). On February 19, 1998, Reeves formally sought

admission to the VA’s supported employment program. (R. 223-24). On February 20, 1998,

the doctors refused medical clearance. (R. 224).

 Received results of the EMG from Dr. Umakantha. His comments indicate

that vet may be in a work setting as tolerated except prolonged standing, no

bending or stooping, no prolonged sitting and may need rest breaks to stand

and stretch.

Case 2:08-cv-00655-CSC Document 22 Filed 03/31/10 Page 10 of 28
 The Genesis Day Program appears to be an intensive community based care psychiatric day 10

program to help veterans integrate into the community.

11

Discussed the above with Dr. Kitchner and feel that considering these medical

precautions, that it is not advisable to accept Mr. Reeves in the supported

employment program since the treatment activities that are available have the

physical requirements which Dr. Umakantha advises against. If Mr. Reeve’s

(sic) medical problems can be resolved, reconsideration will be given to

accepting him into the supported employment program.

(R. 224). 

Reeves was discharged from the Print Clinic on March 11, 1998 due to his physical

inability to handle the work. (Id.). 

On March 5, 1998, Reeves was screened and admitted into the VA’s thirty day

Genesis Day Program. (R. 220-21). Reeves began the Genesis program on March 10, 10

1998. (R. 218). On March 13, 1998, Reeves took the Beck Depression Inventory again. (R.

212). His score was “indicative of moderate depressive symptoms,” notwithstanding his two

months of in-patient psychiatric treatment. (Id.) “The results indicate that [Reeves] is

reporting moderate emotional distress or depression with recent thoughts of suicide.

However, he denies current thoughts of self-harm.” (Id.). 

On March 16, 1998, Reeves reported continued depression. (R. 210). By March 23,

1998, the staff was reporting Reeves as being manipulative “to gain attention and

medications.” (R. 198). On March 24, 1998, although Reeves “[wa]s not looking forward

to discharge and desire[d] to remain hospitalized,” he met with his treatment team to discuss

his discharge. (R. 195-96). He was reminded of his need to be compliant with medication,

Case 2:08-cv-00655-CSC Document 22 Filed 03/31/10 Page 11 of 28
 Glipizide is a medication used to treat diabetes. 11

 Diphenhydramine is the generic name for Benadryl and is used to treat allergies. 12

 Propantheline is a medication used to treat ulcers. 13

 Chlorzoxazone is a muscle relaxant.

14

 Levothyroxine is a replacement thyroid hormone used to treat hypothyroidism. 

15

 On his second admission to the VA, the staff apparently realized their error of discharging him 16

without medication because Reeves’s medications were promptly restarted. (R. 259). 

12

and to attend his follow up appointments. (R. 195). It was noted that “he will require much

redirection and frequent reminders as to why he can no longer do things “his own way.” (Id.)

Reeves was discharged on March 25, 1998. (R. 193). His medications at the time of

discharge included Glipizide, Diphenhydramine Hydrochloride, Propantheline, 11 12 13

Chlorzoxazone, Levothyroxine, and Motrin. (Id.). Although Reeves was treated with 14 15

Trazadone and Zoloft while hospitalized and warned to continue compliance with his

medication regime, astoundingly he was not prescribed anti-depressant medication when he

was discharged. (Id.; R. 288-89). 16

Not surprisingly, Reeves was admitted to the VA hospital on July 7, 1998 with

“[r]ecurrent depression with suicidal ideas.” (R. 258). At that time, he complained that he

could not “live with the pain and depression.” (Id.). His mood and affect were depressed

and his insight and judgment were impaired. (Id.). He denied “abusing any alcohol.” (Id.)

His GAF was 40. (Id.). Although his drug screen on admission was positive for benzos, (R.

259), it was noted that “[h]e commendably has not resumed the abuse of alcohol or other

mood-altering substances.” (R. 288). His polysubstance abuse was in remission. (R. 284).

Case 2:08-cv-00655-CSC Document 22 Filed 03/31/10 Page 12 of 28
 This time would correspond to his attempt to work in the VA print shop while hospitalized for

17

depression.

13

On July 16, 1998, during a psychological evaluation, Reeves took the MMPI-II,

MCMI-II, Beck Depression Scale, Beck Anxiety Index, State-Trait Anxiety Inventory and

the Beck Hopelessness Scale. (R. 266). 

Mr. Reeves has a long history of drug abuse. He reportedly used drugs in the

service and began using cocaine in 1982. He started smoking crack cocaine

at least 5 years ago and says that cocaine is his “drug of choice” but that he

will use anything that he can get his hands on. According to the patient, he

completed the substance abuse program at the Tuscaloosa VAMC twice with

his most recent treatment here in 1994. He claims that he has been mostly free

of drugs and alcohol for 9 months, but he admitted to one episode of drug use

and one period of alcohol abuse.

Mr. Reeves was also hospitalized at the Tuscaloosa VAMC in 5/95 and 3/98

on acute psychiatry for complaints of depression. He has had psychiatric

diagnoses of dysthymic disorder and major depression as well as personality

disorder, NOS. The patient reports a suicide attempt by overdose about 10

years ago.

Mr. Reeves said that he was a steel worker when he hurt his back about 8 years

ago, and he has subsequently been employed in a fabrication shop. His last

attempt at working was 6 months ago. In addition to back problems, Mr. 17

Reeves has diabetes and diverticulosis.

* * *

Mr. Reeves seemed manipulative and evasive in interview, but he was not

hostile or unfriendly. He did not appear depressed or anxious, and affect was

appropriately animated. There was no evidence of delusional or disordered

thinking, and the patient did not spontaneously report feelings of paranoia or

undue suspiciousness.

Test results were of limited validity because of a strong tendency to overstate

his symptoms. Responses to the Minnesota Multiphasic Personality Inventory2 were indicative of very high levels of emotional distress and somatic

preoccupation, and the patient reported very severe psychotic symptoms. Mr.

Case 2:08-cv-00655-CSC Document 22 Filed 03/31/10 Page 13 of 28
14

Reeves endorsed 32 out of 33 items on the Depression content scale and 22 of

23 items on the Anxiety content scale. He also endorsed a large proportion of

items on the Hypochondriasis, Paranoia, and Schizophrenia scales. He

reported ideas of reference and feelings of persecution, and he described

himself as an extremely hostile, angry, and immature person with very severe

family problems.

Axis II symptoms on the Million Clinical Multiaxial Inventory-II were less

over-reported, so that the results were not technically invalid. The patient

described himself as an emotionally unstable person who is impulsive and selfdestructive, and who is prone to chronic emotional distress with possible

suicidal or self-injurious behaviors. He is likely to be irresponsible, shallow,

and very self-centered. The patient may also be manipulative and immature

with little capacity for empathy.

Very high levels of emotional distress were reported on the Beck scales. Mr.

Reeves endorsed all 20 items on the Beck Hopelessness Scale, which would

indicate severe hopelessness and despondency if test results were valid. He

also endorsed severe depression on the Beck Depression Scale and severe

anxiety on the Beck Anxiety Inventory. He indicated that he would like to kill

himself on the Beck Depression Scale.

* * *

Conclusions & Recommendations

The results of this assessment suggest symptom exaggeration in a patient with

severe personality problems. Antisocial, passive-aggressive, and possible

borderline personality characteristics are suggested. The patient has a longstanding drug and alcohol addiction, although he reports some degree of

sobriety during the last 9 months. There is also a significant problem with

chronic pain, which may be exacerbated by substance abuse, and the patient

has been diagnosed with major depression in the past. The extent to which

pain is disabling and the current degree of emotional distress are difficult to

evaluate because of symptom exaggeration. The patient does not seem very

depressed at present, and he did not appear to be in constant pain, though it is

quite possible that his back injury and pain may prevent him from performing

many types of activities. Anger may be a serious problem for the patient.

There appear to be numerous stressors in the life of the patient, including

family problems and vocational limitations, and he appears to be immature

Case 2:08-cv-00655-CSC Document 22 Filed 03/31/10 Page 14 of 28
 Propoxyphene/APAP is a narcotic analgesic used to treat chronic pain.

18

 Daypro is an anti-inflammatory medication used to treat chronic pain. 19

 Griseofulvin is an antibiotic used to treat different fungi. 20

 Metformin is a medication used to treat diabetes. 21

 Paroxetine is the generic name for the medication Paxil and is used to treat depression. 22

 Desyrel is the brand name for the medication Trazodone and is also used to treat depression. 23

 Dimetapp is used to treat allergies and sinus congestion. 24

15

and self-centered and to have very poor coping skills. Although there may be

minimal distress when hospitalized, emotional disturbances may become much

more evident when he returns home to his old problems. Consequently,

regular outpatient counseling following discharge might be beneficial. The

patient does not appear to be suicidal at the present time, but under stress and

the influence of alcohol or drugs, there is the potential for self-destructive

gestures or attempts.

(R. 264-65) (emphasis and footnote added).

Reeves was discharged on July 16, 1998 with the following medications:

Propoxyphene/APAP, Daypro, Griseofulvin, Glipizide, Metformin, Paroxetine, 18 19 20 21 22

Desyrel, and Dimetapp. (R. 259-60). 23 24

Reeves was admitted to the VA hospital again on February 9, 1999. At that time, he

was diagnosed with “[m]ajor depression, recurrent, moderate,” diabetes, and lumbar

spondylolysis. (R. 326). His GAF score was 50. There was no indication of drug or alcohol

abuse, and he denied any drug or alcohol use for a year. (R. 353). His “mood was dysthymic

and affect was flat and depressed.” (R. 326). Reeves remained hospitalized until February

17, 1999. (R. 326-54).

Case 2:08-cv-00655-CSC Document 22 Filed 03/31/10 Page 15 of 28
16

B. Drug and Alcoholism

Reeves attempts to challenge adverse findings in all three determinations for the

closed period at issue. However, the only findings properly before the court are those made

by the ALJ in the third decision rendered on April 15, 2008. The court must determine

whether the ALJ applied the proper legal standards and whether his determination is

supported by substantial evidence. The crux of Reeves’s arguments is that the ALJ

misapplied the law when he concluded that Reeves did not meet or equal Listing 12.04

before February 1999. 

The ALJ concluded that Reeves was not disabled during the period between April 8,

1995 and February 1, 1999. (R. 832). The ALJ determined that “the occupational base was

so severely eroded during the period at issue that [Reeves] was unable to perform other jobs

existing in significant numbers in the national economy when engaged in alcohol and drug

abuse.” (R. 850). Nonetheless, relying on the testimony of a medical expert, the ALJ

concluded that “[w]hen the effects of polysubstance abuse are disregarded, [Reeves’] mental

impairments considered singly and in combination, did not meet or medically equal the

criteria of listings 12.04 or 12.09.” (R. 844-45). For the reasons that follow, the court

concludes that the ALJ did not apply the appropriate legal standards, and that his

determination is not supported by substantial evidence.

Listing 12.04 deals with affective disorders and depressive syndromes. Listing 12.09

deals with substance and addiction disorders. Listing 12.08 deals with personality disorders.

Case 2:08-cv-00655-CSC Document 22 Filed 03/31/10 Page 16 of 28
17

In the initial disability determination, the ALJ found that Reeves was disabled since February

1, 1999.

Since February 1, 1999, the evidence demonstrates that the claimant has been

drug and alcohol free; however, the evidence further demonstrates that since

that time, the claimant has had a severe impairment at Listing level. However,

I am persuaded by the record and testimony, that subsequent to February 1,

1999, the claimant has remained symptomatic of mental impairments (nonalcohol and non-drug related) which are attended with findings that meet the

criteria of § 12.04 of the Listing of Impairments set forth at 20 C.F.R. Part 404,

Subpart P, Appendix 1. To be met Medical Listing 12.04 requires an affective

disorder characterized by a disturbance of mood, accompanied by a full or

partial manic or depressive syndrome. In this case, the claimant has a

depressive syndrome. This syndrome must be characterized by at least four of

certain enumerated features. In this case the enumerated features which meet

this requirement are anhedonia or pervasive loss of interest in activities, sleep

disturbance, psychomotor agitation or retardation, decreased energy, difficulty

concentrating or thinking, thoughts of suicide, and hallucinations, delusions

or paranoid thinking. These features result in marked difficulties in

maintaining social functioning and deficiencies of concentration, persistence,

or pace resulting in frequent failure to complete tasks in a timely manner. I

conclude, therefor, that since February 1, 1999, the claimant’s impairment is

attended with the same findings as Medical Listing 12.04, 20 CFR Part 404,

Appendix 1 to Subpart P.

(R. 23-24). The ALJ’s finding rests on the fact that Reeves had a negative drug test in

February 1999. (R. 19).

In the determination before the court, the ALJ concluded that Reeves did not meet the

Listing 12.04, Affective Disorders, or 12.09, Substance Addiction Disorders, during the

applicable time period because of his on-going polysubstance abuse. (R. 843). The ALJ did

not consider whether Reeves met Listing 12.08, Personality Disorders despite the fact that

he had been diagnosed as suffering from a personality disorder. (R. 185, 264, 300, 355, 378).

Case 2:08-cv-00655-CSC Document 22 Filed 03/31/10 Page 17 of 28
18

A review of the medical records demonstrates that the ALJ culled the record for selective

entries and ignored evidence that did not support his conclusions. For example, the ALJ does

not consider any of Reeves’s testimony regarding his depression prior to February 1, 1999

because of his “alcohol/drug dependence and abuse.” (R. 848). The ALJ refers to Reeves’s

1998 stint in a drug rehabilitation program. (Id.). However, Reeves was not hospitalized in

1998 for drug treatment. Reeves was hospitalized on July 22, 1994 for detoxification and

drug treatment, which was the last drug rehabilitation program he completed. (R. 183, 901).

Although Reeves confessed to using crack cocaine and alcohol when he was

hospitalized in April 1995, he was admitted for treatment of depression, not drug addiction.

(R. 185). Reeves remained hospitalized for treatment of his depression until May 10, 1995.

(Id.). Reeves was hospitalized again on January 27, 1998 for major depression and

dysthymic disorder. (R. 191). While he had a ‘history’ of polysubstance abuse, his drug

screen was negative. (R. 192). He remained hospitalized until March 18, 1998 when he was

transferred into the Genesis Intensive Day Program. (R. 257, 220-21). 

Reeves was hospitalized again on July 7, 1998 with “[r]ecurrent depression and

suicidal ideas.” (R. 258). It was noted that his polysubstance abuse was in remission. (R.

284). Reeves remained hospitalized until July 16, 1998. At that time, a psychological

assessment noted that Reeves had some “severe personality problems,” including

“[a]ntisocial, passive-aggressive, and possible borderline personality characteristics.” (R.

264-65). The assessment indicated that Reeves was “immature and self-centered,” and had

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19

“very poor coping skills.” (Id.). Anger was also an issue for him. (Id.). “Although there

may be minimal distress when hospitalized, emotional disturbances may become much more

evident he returns home to his old problems.” (Id.). 

Reeves was hospitalized at least two more times for treatment of his depression in

February 1999 and June 1999. Consequently, Reeves’s hospitalizations were for treatment

of his recurrent major depression and not for on-going substance abuse. Moreover, the ALJ

relied on Reeves’s negative drug test in February 1999 to conclude that he was no longer

using drugs. The court notes that Reeves had a negative drug screen in January 1998, (R.

192), March 1998 (R. 896-97) and February 1999. (R. 892). 

The ALJ is not free to simply ignore medical evidence, nor may he pick and choose

between the records selecting those portions which support his ultimate conclusion. The

ALJ’s failure to mention or consider contrary medical records, let alone articulate reasons

for disregarding them, is reversible error. Broughton v. Heckler, 776 F.2d 960, 961 (11 Cir.

th

1985). 

The ALJ compounds his error by relying on the testimony of the medical expert,

Sydney H. Garner. Dr. Garner testified that Reeves only had two mental impairments during

the time period at issue – major depressive disorder with psychosis and “an ongoing

polysubstance abuse diagnosis.” (R. 1308-09). The medical expert testified that the only

other mental limitation Reeves had during this period was major depression. (R. 1311). The

medical expert is simply wrong. First, contrary to Dr. Garner’s assertion, Reeves was not

Case 2:08-cv-00655-CSC Document 22 Filed 03/31/10 Page 19 of 28
 The ALJ relies on a single treatment note on Reeves’s discharge summary in May 1995 that 25

Reeves was “able to work.” (R. 186). The ALJ overemphasizes the importance of this note. There is no

further explanation of the notation, and no way to tell who made the note. Without more, the ALJ’s reliance

on the single notation is misplaced.

20

diagnosed with or treated for ongoing polysubstance abuse during the applicable time period.

It is undisputed that Reeves had a history of polysubstance abuse. However, the evidence

does not support the finding that Reeves’s substance abuse continued unabated from 1995

until February 1, 1999. 

 The ALJ also relied on the medical expert’s testimony that Reeves’s “major

depressive disorder was less severe after February 1999. His depression would not meet or

medically equal section 12.04 of the listing of impairments.” (R. 843). This conclusion

makes no sense in light of the fact that Reeves was found disabled on February 1, 1999,

because he met Listing 12.04. (R. 24). Moreover, during the relevant period, Reeves was

also diagnosed with a personality disorder (R. 185, 264-65). The medical expert clearly did

not consider the effects of Reeves’s personality disorder, either singly or in combination,

with Reeves’ other mental impairments. Thus, the ALJ erred as a matter of law when he

relied on Dr. Garner’s flawed testimony. 

Throughout the ALJ’s opinion, he relies on selective recitation of the evidence,

referring only to those records which support his decision. For example, the ALJ points to

VA records that Reeves “was considered employable.” (R. 848). While the records indicate

that Reeves was considered employable in 1994, the ALJignores evidence that Reeves was 25

considered unemployable in 1998. On February 20, 1998, the VA doctors refused medical

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21

clearance to Reeves to participate in the VA’s own supported employment program. (R.

224). Thus, the mere fact that Reeves may have been employable in 1994 does not translate

into an ability to work in 1998, particularly considering that he was denied permission to

work in the VA’s own work program. 

Additionally, although the ALJ refers to Reeves’s GAF scores, he does not consider

the relevance of these scores. A GAF score of between 41 and 50 indicates serious

symptoms or serious impairments in social, occupational, or school functioning. American

Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4 ed. th

1994). A rating of 31-40 indicates “some impairment in reality testing or communication .

. . OR major impairment in several areas, such as work or school, family relations, judgment,

thinking, or mood.” Haag v. Barnhart, 333 F.Supp.2d 1210, 1214 (N.D. Ala. 2004) (quoting

DSM-IV-TR at 34). A GAF of 35 is strong evidence of an inability to work. Haag, supra

(citing Lloyd v. Barnhart, 7 F.Appx. 135, 2002 WL 31111988 at *1, n. 2 (3 Cir. 2002)). rd

On April 8, 1995, Reeves was admitted to the VA hospital with a GAF score of 50.

(R. 185). When he was admitted to the hospital in January 1998, his GAF score was between

41 and 50. (R. 249). In July 1998, Reeves’s GAF score was 40. (R. 258). When Reeves

was hospitalized in February 1999, his GAF score was 50. (R. 326). Interestingly, Reeves’s

GAF score in February 1999 was higher than his scores during the time period at issue.

While the Commissioner has declined to endorse the GAF scale for “use in the Social

Security and SSI disability programs,” and has indicated that GAF scores have no “direct

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22

correlation to the severity requirements of the mental disorders listings,” See 65 Fed.Reg.

50746, 50764-65 (Aug. 21, 2000), the scores emphasize the inherent contradictions in the

ALJ’s determination. Reeves’s recurrent major depression and dysthymia were worse prior

to February 1, 1999. Even the medical expert testified that Reeves’s depression decreased

in severity after February 1, 1999, the date he was deemed disabled due to his depression.

(R. 1311-12). It follows that if, on February 1, 1999, Reeves met the Listing 12.04 for

depression, and his condition was more severe prior to that date, then he must have also met

Listing 12.04 before February 1, 1999. Inexplicably, the ALJ concluded that Reeves did not

meet Listing 12.04 prior to February 1999. 

The ALJ concluded that “[w]hen the effects of alcohol and drug abuse are factored

out for the period between April 8, 1995, to February 1, 1999, [Reeves] was capable of

making a successful adjustment to other work that exists in significant numbers in the

national economy.” (R. 851). However, the ALJ failed to properly apply the law when he

did not follow the sequential analysis before considering whether the plaintiff’s drug

addiction was a contributing factor to the disability determination. See Doughty v. Apfel, 245

F.3d 1274, 1279 (11 Cir. 2001); Bustamante v. Massanari, 262 F.3d 949, 955 (9 Cir.

th th

2001); Drapeau v. Massanari, 255 F.3d 1211, 1214 (10 Cir. 2001). The governing th

regulations require the Commissioner to first determine whether the plaintiff is disabled

before considering whether his drug addiction or alcoholism is a contributing factor material

to disability. See 20 C.F.R. § 404.1535. See also POMS Section DI 90070.050B1 (“Follow

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23

the general disability case development and evaluation process . . . to decide whether the

individual is disabled.”) 

The implementing regulations make clear that a finding of disability is a

condition precedent to an application of § 423(d)(2)(C). 20 C.F.R. §

416.935(a). The Commissioner must first make a determination that the

claimant is disabled. Id. 

Drapeau, 255 F.3d at 1215 (emphasis added). 

If a claimant is disabled, but has evidence of drug addiction or alcoholism, the

ALJ must determine whether the drug addiction or alcoholism is a contributing

factor material to the determination of the finding of disability. 20 C.F.R. §

404.1535(a). In making this determination, the ALJ considers whether the

claimant is disabled without the drug addiction or alcoholism. 20 C.F.R.

404.1535(b)(1). The ALJ considers which of the disabling conditions would

remain should the claimant stop using drugs or alcohol. 20 C.F.R. §

404.1535(b)(2). If the ALJ determines that the claimant’s remaining

limitations would not be disabling, the ALJ will find that the drug usage or

alcoholism is a contributing factor material to the determination of disability.

20 C.F.R. § 404.1535(b)(2)(i). Drugs and alcohol are a contributing factor

material to the determination of disability when they form the exclusive basis

for the finding of disability. If there are other grounds for finding the claimant

disabled, then drugs and alcohol are not a contributing factor material to the

determination of disability. 20 C.F.R. § 404.1535(b)(2)(ii).

Englert v. Apfel, Case No. 97-1526-CIV-ORL-18C, 1999 WL 1289472, at *8, n.3 (M.D. Fla.

June 16, 1999) (emphasis added). See also, Deters v. Commissioner of Social Sec., 301

Fed.Appx. 886, *1 (11 Cir. 2008). th

Only after the ALJ concludes that the plaintiff is disabled, should the ALJ consider

whether the plaintiff’s drug addiction is a contributing factor material to the disability

determination. In this case, the ALJ focused on Reeves’s polysubstance abuse to discredit

him, and improperly conflated the disability finding with the materiality finding. At no point

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24

did the ALJ determine whether Reeves was disabled without consideration of his drug

addiction. Because the ALJ did not consider whether Reeves was first disabled, his finding

that Reeves’s polysubstance abuse was a contributing factor material to disability is simply

wrong. Consequently, the court concludes that the ALJ improperly interjected Reeves’s drug

addiction into the sequential analysis. Thus, the ALJ failed to properly apply the law, and

his finding that Reeves was not disabled before February 1, 1999 because of his drug abuse

is not supported by substantial evidence.

Moreover, if the ALJ had properly applied the law and conducted the appropriate

analysis, Reeves would have perforce been found disabled under Section 12.04 of the Listing

of Impairments during the applicable time period. See 20 C.F.R. Subpart P, Appendix 1.

The Listing provides, in pertinent part, that a claimant is disabled if he meets the following

criteria:

§ 12.04. Affective Disorders: Characterized by a disturbance of mood,

accompanied by a full or partial manic or depressive syndrome. Mood refers

to a prolonged emotion that colors the whole psychic life; it generally involves

either depression or elation.

The required level of severity for these disorders is met when the

requirements in both A and B are satisfied, or when the requirements of C are

satisfied.

A. Medically documented persistence, either continuous or

intermittent, of one of the following:

1. Depressive syndrome characterized by at least four of

the following:

a. Anhedonia or pervasive loss of interest in almost all

activities; or

b. Appetite disturbance with change in weight; or 

c. Sleep disturbance; or

Case 2:08-cv-00655-CSC Document 22 Filed 03/31/10 Page 24 of 28
25

d. Psychomotor agitation or retardation; or

e. Decreased energy; or

f. Feelings of guilt or worthlessness; or

g. Difficulty concentrating or thinking; or

h. Thoughts of suicide; or

i. Hallucinations, delusions, or paranoid thinking; . . .

* * *

OR

C. Medically documented history of a chronic affective disorder

of at least 2 years duration that has caused more than a minimal

limitation of ability to do basic work activities, with symptoms

or signs currently attenuated by medication or psychosocial

support, and one of the following:

1. Repeated episodes of decompensation, each of

extended duration; . . . 

Section 12.04 of the Listing of Impairments, 20 C.F.R. Subpart P, App. 1.

In December 2000, the ALJ found, and the Appeals Council accepted, that, beginning

February 1, 1999, Reeves met Listing 12.04 due to his depressive syndrome. (R. 24). There

is no indication in the medical records that Reeves’s depression and dysthymia were better

between April 8, 1995 and February 1, 1999. In fact, the medical records support a

conclusion that his depression was worse between those times. Reeves was first hospitalized

on April 8, 1995, for severe depression. (R. 185-86). He was anxious, depressed and

experiencing ruminating thoughts. (R. 187-88). He was prescribed Zoloft and discharged

on May 10, 1995. (R. 187). Reeves received treatment for his depression for two years when

he lived in Tennessee.

On January 27, 1998, Reeves was hospitalized again for recurrent major depression.

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26

(R. 191). He was experiencing insomnia, (R. 249), and he was preoccupied with his somatic

problems. (R. 246). Reeves remained hospitalized until March 25, 1998 when he was

discharged into the Genesis Day Program, an intensive community care psychiatric program.

(R. 293). On July 7, 1998, Reeves was hospitalized for recurrent depression with suicidal

thoughts. His judgment was impaired, and he was experiencing sleeplessness and

hopelessness. (R. 298). He remained hospitalized until July 16, 1999. 

The medical records demonstrate that Reeves has suffered from major depression

since at least April 1995. During his numerous hospitalizations, he has reported episodes of

anhedonia, insomnia, suicidal thoughts, difficulty concentrating, decreased energy, and

feelings of hopelessness and anxiety. His depression spans the time period at issue – from

April 1995 until February 1, 1999. He experienced at least three episodes of

decompensation, requiring extended hospital stays. Consequently, Reeves was disabled. 

Following the appropriate sequential analysis, the ALJ would then have considered

whether Reeves remained disabled if he stopped using drugs or alcohol. 20 C.F.R. §

404.1535(b)(2). In 2000, the ALJ concluded that Reeves’s depression was disabling even

after he stopped using drugs and alcohol. (R. 24). “Since February 1, 1999, the evidence

demonstrates that [Reeves] has been drug and alcohol free; however, the evidence further

demonstrates that since that time, [Reeves] has had a severe mental impairment at Listing

level.” (R. 23). Consequently, as a matter of law, the ALJ found that Reeves’s drug

addiction was not a contributing factor material to the disability determination. “The key

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27

factor . . . in determining whether drug addiction . . . is a contributing factor material to the

determination . . . is whether we would still find you disabled if you stopped using drugs .

. .” 20 C.F.R. § 404.1535(b)(1). Because the ALJ determined that Reeves’s depression was

disabling independent of drug or alcohol addiction, his polysubstance abuse could not be a

contributing factor material to the disability determination. 20 C.F.R. § 404.1535(b)(2)(ii).

Because Reeves meets the requirements of Listing 12.04, and his polysubstance abuse was

not a contributing factor material to his disability, Reeves should have been found disabled

as a matter of law. See McDaniel, 800 F.2d at 1026 (“An affirmative answer . . . leads . . .to

. . . on step three . . . a finding of disability.”)

In reaching this conclusion, the court has carefully considered whether it should

remand this case to the Commissioner for further proceedings, or reverse and remand for an

award of benefits. Reeves originally filed his application for disability benefits in 1999. (R.

831). The ALJ’s final determination was issued on April 15, 2008. (R. 852). As noted

earlier in this opinion, this is the third time this case has come to this court. While Social

Security proceedings are inquisitorial, not adversarial, see Ingram v. Commissioner of Social

Sec. Admin., 496 F.3d 1253 (11 Cir. 2007), courts have long, routinely assigned evidentiary th

burdens to both the claimant and the Commissioner. See, e.g., Johns v. Bowen, 821 F.2d 551

(11 Cir. 1987) (A Social Security claimant bears the initial burden of proving inability to th

perform prior relevant work); Jackson v. Bowen, 801 F.2d 1291 (11 Cir. 1986) (If a th

claimant meets the burden of showing he can no longer do his past relevant work, the burden

Case 2:08-cv-00655-CSC Document 22 Filed 03/31/10 Page 27 of 28
28

shifts to the Commissioner to prove that other work exists in the national economy which the

claimant can perform). Reeves has met his burden of demonstrating that he meets Listing

12.04 and that he is disabled. The Commissioner has failed, three times, to properly apply

the law, and the court concludes that he shouldn’t get another chance to get it right. Enough

is enough. 

Accordingly, the court concludes that it is appropriate to reverse the decision of the

Commissioner so that benefits may be awarded to the plaintiff. See Davis v. Shalala, 985

F.2d 528, 534 (11 Cir. 1993) (reversal with award of benefits appropriate where the th

Commissioner has already considered the essential evidence and it is clear that the evidence

establishes disability without any doubt). See also Lamb v. Bowen, 847 F.2d 698, 701 (11th

Cir. 1988) ( failure to apply the correct legal standards is grounds for reversal and an award

of benefits). 

V. Conclusion

Accordingly, the decision of the Commissioner will be reversed and the case

remanded to the Commissioner with instructions that benefits be awarded to the plaintiff.

A separate order will issue. 

Done this 31 day of March, 2010. st

 /s/Charles S. Coody 

CHARLES S. COODY

UNITED STATES MAGISTRATE JUDGE

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