Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-almd-2_05-cv-00133/USCOURTS-almd-2_05-cv-00133-0/pdf.json

Parties Involved:
Jo Anne B. Barnhart
Defendant
Laderrick D. Caldwell
Plaintiff

Document Text:

The ALJ accurately described Caldwell’s back surgery as “posterior [iliac] fusion and 1

segmental instrumentation” along his thoracic and lumbar spine and “decompression of [the]

L3" vertebra (R. 18). 

IN THE UNITED STATES DISTRICT COURT

FOR THE MIDDLE DISTRICT OF ALABAMA

NORTHERN DIVISION

LADERRICK D. CALDWELL )

)

Plaintiff, )

)

v. ) CIVIL ACTION NO. 2:05cv133-VPM

) [WO]

JO ANNE B. BARNHART, )

Commissioner of Social Security, )

)

Defendant. )

MEMORANDUM OPINION AND ORDER

Plaintiff LaDerrick D. Caldwell [“Caldwell”] filed this action seeking review of a final

decision of the defendant [“Commissioner”] (Doc. # 1) pursuant to 42 U.S.C. §§ 405(g),

1383(c)(3) (2000). Upon review of the record and the briefs submitted by the parties, the

court concludes that the Commissioner’s decision should be reversed and remanded for

further proceedings.

I. FACTS AND PROCEDURAL HISTORY

Caldwell contends that he is entitled to disability benefits due to traumatic injuries

sustained in multiple vehicle accidents, the first one of which resulted in “massive abdominal

wall disruption, perforated bowel,” and a fractured vertebra that required extensive surgery

(R. 116-229). Then 16 years old, Caldwell, who had been ejected from the vehicle when 1

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Although the court thoroughly reviewed the entire record, the parties’ arguments and, 2

accordingly, the focus of this opinion are limited to the evidence concerning Caldwell’s

mental health (Docs. ## 10, 11, 15). 

2

the seatbelt he was wearing apparently broke from the impact (R. 134), also was diagnosed

with Post Traumatic Stress Disorder [“PTSD”] for which the attending hospital’s “behavioral

medicine team” followed him “closely”(R. 224). 

2

Caldwell’s application was denied initially, and Caldwell requested a hearing before

an Administrative Law Judge [“ALJ”] (R. 23–27; 33). Following the hearing, ALJ Michael

D. Anderson issued an opinion denying benefits (R. 14-22). After receiving additional

evidence the Social Security Administration’s Appeals Council [“AC”] denied Caldwell’s

request for review, rendering the ALJ’s decision the final decision of the Commissioner (R.

6-9). Caldwell then filed this timely lawsuit (Doc. # 1). 

II. STANDARD OF REVIEW

The district court’s review of the Commissioner's decision is a limited one.

Reviewing courts “may not decide the facts anew, reweigh the evidence, or substitute [their]

judgment for that of the [Commissioner].” Miles v. Chater, 84 F. 3d 1397, 1400 (11th Cir.

1996) (citing Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983)). The court

must affirm the Commissioner’s decision “if it is supported by substantial evidence and the

correct legal standards were applied,” Kelley v. Apfel, 185 F.3d 1211 (11th Cir. 1999) (citing

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In Graham v. Apfel, 129 F. 3d at 1422, the Court of Appeals stated that: 3

Substantial evidence is described as more than a

scintilla, and means such relevant evidence as a

reasonable mind might accept as adequate to

support a conclusion. See Richardson v. Perales,

402 U.S. 389, 401, 91 S.Ct. 1420, 1427, 28

L.Ed.2d 842 (1971). 

3

Graham v. Apfel, 129 F. 3d 1420, 1422 (11th Cir. 1997)). This is true despite the existence 3

of substantial evidence “contrary to the findings of the ALJ.” Barron v. Sullivan, 924 F.2d

227, 230 (11th Cir. 1991). “There is no presumption, however, that the Commissioner

followed the appropriate legal standards in deciding a claim for benefits or that the legal

conclusions reached were valid.” Miles, 84 F. 3d at 1400 (citations omitted).

III. DISCUSSION

A. Standard for Determining Disability

An individual who files an application for Social Security disability benefits must

prove that she is disabled, which means that she 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.” 42 U.S.C. § 423(d)(1)(A) (2004); see also

20 C.F.R. §§ 404.1512(a), 416.912(a) (2004). 

The regulations governing disability determinations provide a five-step sequential

evaluation process that the ALJ must follow to determine whether a claimant has proven that

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4

he is disabled. See 20 C.F.R. §§ 404.1520, 416.920; see also Ambers v. Heckler, 736 F.2d

1467, 1469 (11th Cir. 1984); Williams v. Barnhart, 186 F. Supp. 2d 1192, 1195 (M.D. Ala.

2002). If the claimant is not currently engaged in substantial gainful activity, the ALJ must

determine whether he suffers from a severe impairment that has lasted or is expected to last

12 months or more. §§ 404.1509, 416.909, 404.1520(a)(4)(I)-(ii), 416.920(a)(4)(I)-(ii). If

so, and the impairment(s) is of such severity as to meet or medically equal a condition

described in the SSA’s “Listing of Impairments,” then the claimant will be found to be

disabled. §§ 404.1520(a)(4)(iii); 404, subpt. P, app. 1; 416.920(a)(4)(iii). 

If the claimant’s severe impairment(s) does not automatically qualify him for

disability benefits, the ALJ must then assess his residual functional capacity [“RFC”], which

represents “the most [a claimant] can still do despite [his] limitations.” §§ 404.1545(a),

416.945(a). Considering his RFC, the ALJ must determine whether the claimant is able to

perform the physical and mental demands of his past relevant work. §§ 404.1520(a)(4)(iv),

416.920(a)(4)(iv). If not, the ALJ must determine whether, considering his RFC, age,

education, and past work experience, the claimant is capable of performing other jobs

available in significant numbers in the national economy. §§ 404.1520(a)(4)(v), 404.1560(c),

416.920(a)(4)(v), 416.960(c). 

B. Application of the Standard: The ALJ’s Findings

After discussing the legal standards and most of the evidence in the record, the ALJ

concluded that Caldwell’s severe impairments included only his “status post fusion at L2

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5

with Harrington Rod insertion and status post laparotomy secondary to motor vehicle

accident trauma” (R. 21). He ultimately concluded that Caldwell could perform jobs

available in significant numbers in the national and regional economies (R. 22). 

Caldwell disagrees and contends that the ALJ erred by ignoring evidence of his mental

impairment(s), failing to order a consultative psychological examination, and failing to obtain

existing records pertaining to his mental impairment(s) (Docs. # 10, 15). Although

Caldwell’s legal arguments seem somewhat misdirected, the court agrees that the ALJ’s

failure to consider the evidence of his mental impairment(s) and evaluate the severity of

condition(s) warrant reversal and remand for further proceedings. The court further

concludes that the record, as currently constructed, is an insufficient basis for the requisite

evaluation.

C. Analysis

When diagnosing Caldwell with PTSD and noting the concern of the behavioral

medicine team, William Rogers, M.D., also noted that Caldwell, upon discharge from the

hospital following the first accident, was to continue with “behavior medicine” (R. 224). 

In addition, Dr. Rogers prescribed Restoril, a “benzodiazepine hypnotic agent” and “central

nervous system . . . depressant[]” designed to relieve anxiety and aid sleep. PHYSICIANS’

DESK REFERENCE 1874 (58th ed. 2004); National Institutes of Health, Medline Plus, at

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Whether Dr. Rogers prescribed Restoril for Caldewell’s PTSD is not clear from the 4

record. It is nevertheless reasonable to make that assumption, and the ALJ’s failure to offer

an opinion on the subject leaves the court no reason to assume otherwise.

The court notes that the ALJ found Caldwell’s allegations only partially credible 5

because they were not supported by the evidence in the record (R. 20). Caldwell does not

challenge this aspect of the ALJ’s decision, and the court does not explore the issue other

than to note that the record portrays Caldwell as one not inclined to exaggerate his condition.

Indeed, the evidence suggests that he may be inclined to minimize the significance of the

residual effects of an extremely serious accident. The court therefore encourages the

Commissioner to revisit this issue to ensure that the ALJ’s conclusion is supportable. 

The ALJ’s description of Caldwell’s testimony as alleging “disabling pain and

functional restrictions” (R. 20) appears disingenuous in light of the VE’s testimony that

Caldwell’s allegations would not change his conclusion that Caldwell was able to perform

jobs available in significant numbers. In other words, Caldwell’s testimony was not as

exaggerated as the ALJ suggests. Notably, the ALJ did not attempt to illicit information

regarding Caldwell’s mental status (R. 310-30). 

The court is troubled by what appears to be the ALJ’s conscious decision to ignore 6

the relevant evidence, particularly when Caldwell was not represented by legal counsel prior

to or at the administrative hearing. For example, the ALJ stated, “The claimant was

discharged on August 25, 2000, to the day-hospital program for continue [sic] physical and

6

http://www.nlm.nih.gov/medlineplus/druginfo/drug_Qa.html. 

4

Furthermore, Caldwell’s mother, who completed a third-party daily activities

questionnaire, described Caldwell as sometimes being depressed, due to his inability to play

sports as he once did, and preoccupied with concerns about falling (R. 77-78). Although

Caldwell did not mention depression or fear in his own daily activities questionnaire, he did

acknowledge having a “nervous stomach” (R. 82).5

Despite the Commissioner’s consideration of Caldwell’s PTSD at an earlier stage of

the application review (R. 74), the ALJ’s opinion mentions nothing of the evidence discussed

supra. Consequently, he failed to make the threshold determination regarding the severity 6

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occupational therapy and wound care” (R. 18). The relevant record, however, which is the

same discharge summary containing the PTSD diagnosis, Restoril prescription and the

reference to the hospital’s behavior medicine team, states, “The patient will be discharged

to our day-hospital program and will continue physical occupational behavior medicine” (R.

224) (emphasis added). 

Caldwell has not alleged that the ALJ was biased, and the court does not so conclude

in this opinion. His missteps, however, may well support an argument that he was not

blindly fulfilling his role, and the Commissioner should be aware of this when deciding how

best to proceed on remand. 

7

of Caldwell’s apparent mental impairment(s). This error warrants reversal and remand.

Ashford v. Barnhart, 347 F. Supp. 2d 1189, 1193 (M.D. Ala. 2004) (holding that the ALJ’s

failure to “explain[] how (and why) the weight of the evidence would not support a finding

that bipolar disorder was a severe impairment” in light of evidence that the claimant suffered

from the condition constituted reversible error); Williams v. Barnhart, 186 F. Supp. 2d 1192,

1197-98 (M.D. Ala. 2002) (reversing the Commissioner’s decision when the ALJ failed to

discuss medical conditions evidenced in the record). 

Assuming the ALJ’s opinion could be read as implicitly concluding that the mental

impairment(s) is or was not severe for purposes of step two of the sequential evaluation, this

conclusion is not supported by substantial evidence. Dr. Rogers’s discharge summary

constitutes the only objective evidence of a mental impairment, and it offers no insight into

the severity of the condition or any limiting effect it may have had or may still have on

Caldwell’s ability to work. See, e.g., Ford v. Sec’y of Health & Human Sacs., 659 F.2d 66,

69 (11th Cir. 1981) (holding that the ALJ “failed to fulfill his duty to fully and fairly develop

the facts with regard to [the claimant’s] alleged mental impairment” when the medical record

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Thus, the court does not conclude that the ALJ should have ordered a consultative 7

examination in the first place, and the evidence was insufficient to allow even a psychiatrist

or psychologist to perform the technique required for evaluating mental impairments, though

that likely will not be the case once the record is more fully developed. See 42 U.S.C. §

421(h); 20 C.F.R. 1520a. 

8

indicated the existence of a condition and the ALJ “failed to make an express factual finding

with regard to [its] . . . severity”). 

Caldwell’s mental condition must be more fully developed in the record, but the court

declines to instruct the Commissioner how best to accomplish this objective. It is possible

that sufficient documentary evidence regarding Caldwell’s condition currently exists and can

be obtained, although there is no evidence that the ALJ failed to make every reasonable effort

to obtain Caldwell’s records. Conversely, documentary evidence may be lacking, in which

case the Commissioner more likely than not will need to order a consultative examination.7

42 U.S.C. § 421(j); 20 C.F.R. 1519a. 

The court concludes merely that the ALL’s failure to consider Caldwell’s mental

impairment(s) was reversible error and that, upon remand, the record regarding his mental

impairment(s) must be more fully developed.

IV. CONCLUSION

Therefore, it is hereby 

ORDERED that, pursuant to sentence four of 42 U.S.C. § 405(g), the Commissioner’s

decision is REVERSED and REMANDED for further proceedings not inconsistent with this

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opinion. 

DONE this 22 day of February, 2006. nd

/s/ Vanzetta Penn McPherson

VANZETTA PENN MCPHERSON

UNITED STATES MAGISTRATE JUDGE

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