IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

JOSHUA R. MILLER, *

*

 Plaintiff, * CIVIL ACTION NO. 15-00323-B

 *

vs. *

*

CAROLYN W. COLVIN, *

Commissioner of Social *

Security, *

 *

Defendant. *

ORDER

Plaintiff Joshua R. Miller (hereinafter “Plaintiff”) seeks 

judicial review of a final decision of the Commissioner of 

Social Security denying his claim for a period of disability, 

disability insurance benefits, and supplemental security income 

under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 

401, et seq., and 1381, et seq. On June 13, 2016, the parties 

consented to have the undersigned conduct any and all 

proceedings in this case. (Doc. 23). Thus, the action was 

referred to the undersigned to conduct all proceedings and order 

the entry of judgment in accordance with 28 U.S.C. § 636(c) and 

Federal Rule of Civil Procedure 73. Upon careful consideration 

of the administrative record and the memoranda of the parties, 

it is hereby ORDERED that the decision of the Commissioner be 

AFFIRMED.

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I. Procedural History

Plaintiff filed his applications for benefits in December 

2013. (Tr. 258, 262). Plaintiff alleged that he has been 

disabled since May 11, 2011, based on “PTSD, TBI [traumatic 

brain injury], neck, back, injuries, shoulder, migraines.”1 (Id.

at 287).

Plaintiff’s applications were denied and upon timely 

request, he was granted administrative hearings before 

Administrative Law Judge Katie H. Pierce (hereinafter “ALJ”) on 

June 17, 2014, and October 14, 2012. (Id. at 37, 63). 

Plaintiff attended both hearings with his counsel and provided 

testimony related to his claims. (Id. at 39, 67). Also 

appearing and testifying at the second hearing was a vocational 

expert (“VE”) and a medical expert (“ME”). (Id. at 75, 89). On 

December 19, 2014, the ALJ issued an unfavorable decision 

finding that Plaintiff is not disabled. (Id. at 32). The 

Appeals Council denied Plaintiff’s request for review on June 3, 

2015. (Id. at 1). Therefore, the ALJ’s decision dated December 

19, 2014, became the final decision of the Commissioner. 

Having exhausted his administrative remedies, Plaintiff 

timely filed the present civil action. (Doc. 1). The parties 

 1 Plaintiff has raised no issue on appeal regarding the ALJ’s 

findings related to any of his physical impairments. (Doc. 13). 

Therefore, the Court’s discussion is limited to Plaintiff’s 

mental impairments. 

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waived oral argument on June 13, 2016 (Doc. 22), and agree that 

this case is now ripe for judicial review and is properly before 

this Court pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3).

II. Issues on Appeal

1. Whether the ALJ erred in rejecting the 

opinion of one-time examining 

psychiatrist, Dr. Anita Nusbaum, M.D., 

while assigning great weight to the 

opinions of non-examining psychological 

experts, Dr. John Davis, Ph.D., and Dr. 

Donald E. Hinton, Ph.D.?

2. Whether substantial evidence supports the 

ALJ’s mental RFC assessment for a range 

of medium work with the stated 

nonexertional restrictions?

3. Whether the ALJ erred in failing to find 

Plaintiff’s PTSD to be a severe 

impairment?

III. Factual Background

Plaintiff was born on March 18, 1980, and was thirty-three 

years of age at the time of his second administrative hearing on 

October 14, 2014. (Tr. 63, 282). Plaintiff graduated from high 

school and attended two years of college. (Id. at 288). While 

in the military from 2006 to 2013, Plaintiff worked as a truck 

driver. (Id. at 68). Prior to serving in the military, 

Plaintiff worked as a truck driver and car salesman in 2001 and 

as an iron worker rigger in 2000. (Id. at 68-69). 

At his hearing, Plaintiff testified that he was involved in 

an explosion in Afghanistan in 2011 when an IED exploded 

Case 1:15-cv-00323-B Document 26 Filed 08/02/16 Page 3 of 35
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underneath his truck. (Id. at 51). Plaintiff claims that as a 

result of the explosion, he has the severe impairments of PTSD,

traumatic brain injury, injuries to the neck, back, and 

shoulder, and migraine headaches. (Id. at 73). At his hearing, 

Plaintiff testified that his “biggest problem” is headaches, 

which he has daily, and that he also has pain, problems with his 

back, and trouble concentrating. (Id. at 51-52, 71-72).

According to Plaintiff, he goes to the VA for mental health 

treatment about once a month. (Id. at 69). On March 28, 2014, 

Plaintiff reported that he was taking no medications for his 

conditions. (Id. at 316). 

Plaintiff testified that he lives with his mother. (Id. at 

55). In a Function Report dated January 27, 2014, Plaintiff 

stated that he takes care of his mother (id. at 306); he has no 

problems with personal care, nor does he need reminders for 

personal care (id.); he has a pill planner to remind him to take 

his medicine (id. at 307); he prepares his own meals (id.); he 

does laundry and small chores (id.); he goes out alone and 

drives 2 (id. at 308); and he shops and handles all of his own 

finances (id.). Plaintiff also reported that he avoids 

 2 At the hearing, Plaintiff testified that his drivers license is 

currently suspended. (Id. at 53, 71, 1030). According to 

Plaintiff, he has had three DUI’s; he last drank alcohol in 

January of 2014; and he last used marijuana in March of 2014. 

(Id. at 47-48).

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authority figures and that he was released from the Army because 

of problems getting along with people (id. at 311). Plaintiff 

also indicated that stress makes him angry and depressed. 

(Id.).

IV. Analysis

A. Standard of Review 

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

role is a limited one. The 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. 3 Martin v. Sullivan, 894 F.2d 

1520, 1529 (11th Cir. 1990). 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. 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) (holding 

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 

 3 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).

Case 1:15-cv-00323-B Document 26 Filed 08/02/16 Page 5 of 35
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evidence exists, a court 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, *4

(S.D. Ala. June 14, 1999).

B. Discussion

An individual who applies for Social Security disability 

benefits must prove his or her disability. 20 C.F.R. §§ 

404.1512, 416.912. Disability is defined as the “inability 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); see also 20 C.F.R. §§ 

404.1505(a), 416.905(a). The Social Security regulations 

provide a five-step sequential evaluation process for 

determining if a claimant has proven his disability.4 20 C.F.R. 

 4 The claimant must first prove that he or she has not engaged in 

substantial gainful activity. The second step requires the 

claimant to prove that he or she has a severe impairment or 

combination of impairments. If, at the third step, the claimant 

proves that the impairment or combination of impairments meets 

or equals a listed impairment, then the claimant is 

automatically found disabled regardless of age, education, or 

work experience. If the claimant cannot prevail at the third 

step, he or she must proceed to the fourth step where the 

claimant must prove an inability to perform their past relevant 

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

evaluating whether the claimant has met this burden, the 

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§§ 404.1520, 416.920. 

In the case sub judice, the ALJ determined that Plaintiff 

has not engaged in substantial gainful activity since May 11, 

2011, the alleged onset date, and that he has the severe 

impairments of cervical spondylosis, degenerative joint disease 

of the right shoulder, late effects of traumatic brain injury 

vs. psychotic disorder including speech difficulties, headaches, 

anxiety, attention deficit hyperactivity disorder, memory loss, 

and alcohol dependence.5 (Tr. 21). The ALJ further found that 

Plaintiff does not have an impairment or combination of 

impairments that meets or medically equals any of the listed 

impairments6 contained in 20 C.F.R. Part 404, Subpart P, Appendix 

 

examiner must consider the following four factors: (1) objective 

medical facts and clinical findings; (2) diagnoses of examining 

physicians; (3) evidence of pain; and (4) the claimant’s age, 

education and work history. Id. Once a claimant meets this 

burden, it becomes the Commissioner’s burden to prove at the 

fifth step that the claimant is capable of engaging in another 

kind of substantial gainful employment which exists in 

significant numbers in the national economy, given the 

claimant’s residual functional capacity, age, education, and 

work history. Sryock v. Heckler, 764 F.2d 834, 836 (11th Cir. 

1985). If the Commissioner can demonstrate that there are such 

jobs the claimant can perform, the claimant must prove inability 

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

Apfel, 190 F.3d 1224, 1228 (11th Cir. 1999). See also Hale v. 

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

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

5 The ALJ found Plaintiff’s PTSD to be non-severe. (Tr. 21-22).

6 The ALJ found that Plaintiff has only a “mild” restriction in 

activities of daily living; “moderate” restrictions in social 

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1. (Id. at 22).

The ALJ concluded that Plaintiff retains the residual 

functional capacity (hereinafter “RFC”) to perform a range of 

medium work, with the following nonexertional restrictions:

Plaintiff “is able to understand to carry out ‘detailed but 

involved’7 written or oral instructions involving a few concrete 

variables in or from standardized situations; can maintain 

attention/concentration for up to 2 hours at a time; can never 

have contact with the public and only occasional contact with 

coworkers and supervisors; can occasionally adapt to minimal 

changes in the work setting or routine; can perform goal 

oriented work, but not production paced work.” 8 (Id. at 24).

 

functioning and concentration, persistence, or pace; and no 

episodes of decompensation. (Tr. 23-24).

7 The Court notes that, at Plaintiff’s hearing, the ALJ posed a 

hypothetical to the vocational expert describing an individual 

who would be able to understand, to carry out “detailed but 

uninvolved written or oral instructions” involving a few 

concrete variables in or from standardized situations. (Tr. 90) 

(emphasis added). Yet, in her RFC assessment, the ALJ stated 

that Plaintiff could perform work involving “detailed but 

involved written or oral instructions. . . .” (Id. at 

24)(emphasis added). Whether the ALJ’s use of the term 

“involved,” as opposed to “uninvolved,” was a typographical 

error is of no moment. The Court has determined that the ALJ’s 

RFC assessment for detailed work (whether including “involved” 

or “uninvolved” written and oral instructions) constitutes 

error; however, for the reasons explained herein, that error is 

harmless. 

8 The ALJ also assigned certain exertional limitations that are 

not at issue here. (Tr. 24).

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The ALJ also determined that while Plaintiff’s medically 

determinable impairments could reasonably be expected to produce 

the alleged symptoms, his statements concerning the intensity, 

persistence and limiting effects of the alleged symptoms were

not entirely credible for the reasons explained in the decision. 

(Id. at 25).

The ALJ found that Plaintiff is unable to perform his past 

relevant work. (Id. at 30). However, utilizing the testimony

of a VE, the ALJ concluded that Plaintiff is able to perform 

jobs such as “hand packager,” “kitchen helper,” and “poultry 

farm laborer” all of which are classified as medium and 

unskilled. (Id. at 31). Thus, the ALJ concluded that Plaintiff 

is not disabled. (Id. at 32).

The Court now considers the foregoing in light of the 

record in this case and the issues on appeal. 

1. Issues

A. Whether the ALJ erred in rejecting the 

opinion of one-time examining 

psychiatrist, Dr. Anita Nusbaum, M.D., 

while assigning great weight to the 

opinions of non-examining psychological

experts, Dr. John Davis, Ph.D., and Dr. 

Donald E. Hinton, Ph.D., and whether 

substantial evidence supports the ALJ’s 

mental RFC assessment for a range of 

medium work with the stated nonexertional 

restrictions?9

 9 Because these two issues are so closely related, the Court 

considers them together. 

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In this case, Plaintiff argues that the ALJ erred in 

rejecting the opinion of one-time examining psychiatrist, Dr. 

Anita Nusbaum, M.D., in a Mental Disorders Questionnaire form 

dated March 7, 2014, that Plaintiff has a “total occupational 

and social impairment” based exclusively on an “unspecified”

“psychotic disorder.” (Tr. 1091-92; Doc. 13 at 12-13). 

Plaintiff further argues that the ALJ erred in giving great 

weight to the opinions of non-examining State Agency 

psychologist, Dr. Donald E. Hinton, Ph.D., and non-examining 

medical expert, Dr. John Davis, Ph.D. (Tr. 75-78, 96, 104-09, 

1091-92; Doc. 13 at 10-13). Plaintiff also argues that the ALJ 

erred in finding that Plaintiff has the RFC to perform a range 

of medium work, including work involving “‘detailed but 

involved’ written or oral instructions.” (Doc. 13 at 2-6). 

The Commissioner counters that the medical evidence does 

not support Dr. Nusbaum’s opinion, and, to the contrary, that 

Dr. Nusbaum’s opinion is inconsistent with the substantial 

medical evidence in the case. Thus, her opinion was properly 

discredited. (Doc. 20 at 8-9). The Commissioner further argues 

that the ALJ properly credited the opinions of Dr. Hinton and 

Dr. Davis. (Id.). Finally, the Commissioner argues that 

substantial evidence supports the ALJ’s RFC assessment in this 

case. 

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Having carefully reviewed the record in this case, the 

Court finds, for the reasons discussed herein, that: (1) the ALJ 

had good cause to discredit the opinion of Dr. Nusbaum that 

Plaintiff has a “total occupational and social impairment,” as 

that opinion is inconsistent with the substantial evidence in 

the case; (2) the ALJ properly assigned great weight to the 

opinions of non-examining State Agency psychologist Dr. Hinton, 

as his opinions did not conflict with the opinions of any 

credible examining medical source; (3) the ALJ erred in 

assigning great weight to the opinion of non-examining medical 

expert Dr. Davis that Plaintiff has no more than “mild” 

limitations in any functional area, to the extent that Dr. 

Davis’ opinion conflicts with the opinion of examining 

psychologist Dr. Starkey that Plaintiff is limited to simple 

work; (4) the ALJ erred in assessing Plaintiff’s RFC for a range 

of medium work involving “detailed but involved” written or oral 

instructions, as that assessment is not supported by the 

substantial evidence; and (5) the ALJ’s errors are harmless 

because the substantial evidence in this case supports an RFC 

assessment for simple work, and the vocational expert identified 

unskilled work that the Plaintiff can perform. Therefore, the 

Court finds, for the reasons that follow, that Plaintiff’s 

claims must fail. 

As part of the disability determination process, the ALJ 

Case 1:15-cv-00323-B Document 26 Filed 08/02/16 Page 11 of 35
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is tasked with weighing the opinions and findings of treating, 

examining, and non-examining physicians. In reaching a 

decision, the ALJ must specify the weight given to different 

medical opinions and the reasons for doing so. See Winschel v. 

Commissioner of Soc. Sec., 631 F.3d 1176, 1179 (11th Cir. 2011). 

The failure to do so is reversible error. See Williams v. 

Astrue, 2009 U.S. Dist. LEXIS 12010, *4, 2009 WL 413541, *1 

(M.D. Fla. 2009).

When weighing the opinion of a treating physician, the 

ALJ must give the opinions “substantial weight,” unless good 

cause exists for not doing so. Costigan v. Commissioner, Soc. 

Sec. Admin., 2015 U.S. App. LEXIS 2827, *10, 2015 WL 795089, *4 

(11th Cir. Feb. 26, 2015) (citing Crawford v. Commissioner of 

Soc. Sec., 363 F.3d 1155, 1160 (11th Cir. 2004) and Broughton v. 

Heckler, 776 F.2d 960, 962 (11th Cir. 1985)). The opinion of “a 

one-time examining physician — or psychologist,” on the other 

hand, is not entitled to the same deference as a treating 

physician. Petty v. Astrue, 2010 U.S. Dist. LEXIS 24516, *50, 

2010 WL 989605, *14 (N.D. Fla. Feb. 18, 2010) (citing Crawford, 

363 F.3d at 1160). An ALJ is also “required to consider the 

opinions of non-examining state agency medical and psychological 

consultants because they ‘are highly qualified physicians and 

psychologists who are also experts in Social Security disability 

evaluation.’” Milner v. Barnhart, 275 Fed. Appx. 947, 948 

Case 1:15-cv-00323-B Document 26 Filed 08/02/16 Page 12 of 35
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(11th Cir. 2008) (unpublished) (citing 20 C.F.R. § 

404.1527(f)(2)(i)). “The ALJ may rely on opinions of nonexamining sources when they do not conflict with those of 

examining sources.” Id. (citing Edwards v. Sullivan, 937 F.2d 

580, 584-85 (11th Cir. 1991)). 

Whether considering the opinions of treating, examining, or 

non-examining physicians, good cause exists to discredit the 

testimony of any medical source when it is contrary to or 

unsupported by the evidence of record. Phillips v. Barnhart, 

357 F.3d 1232, 1240 (11th Cir. 2004). “Good cause may also 

exist where a doctor’s opinions are merely conclusory, 

inconsistent with the doctor’s medical records, or unsupported 

by objective medical evidence.” Hogan v. Astrue, 2012 U.S. 

Dist. LEXIS 108512, *8, 2012 WL 3155570, *3 (M.D. Ala. 2012). 

The ALJ is “free to reject the opinion of any physician when the 

evidence supports a contrary conclusion.” Sryock v. Heckler, 

764 F.2d 834, 835 (11th Cir. 1985) (per curiam) (citation 

omitted); Adamo v. Commissioner of Soc. Sec., 365 Fed. Appx. 

209, 212 (11th Cir. 2010) (The ALJ may reject any medical 

opinion if the evidence supports a contrary finding.).

In the present case, the record shows that Plaintiff was 

treated at the VA outpatient clinic from approximately January 

2012 to August 2014, for various physical and mental health 

issues, as well as for substance abuse. (Tr. 367-947, 1071-

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1230). With respect to his mental health treatment, Plaintiff 

was treated at the VA by psychiatrist, Dr. Seth Strauss, M.D., 

and clinical psychologist, Dr. Christine Aiken, Ph.D., for 

anxiety, PTSD, TBI, history of polysubstance abuse, and 

cognitive deficit,10 for which he was given outpatient counseling

and medication. (Id. at 400-01, 412-13, 424-25, 438-39, 460-61, 

477-84, 527-28, 550-56, 605, 675, 716-17, 742-43, 764-71, 783-

84, 794-95, 802, 822). Plaintiff’s medical records reflect a 

significant number of mental status examinations with largely 

normal findings, as well as periods of time during which 

Plaintiff did not seek treatment or was non-compliant with 

appointments and medication. (Id. at 76, 483, 520, 527, 553, 

578, 605, 635, 723, 795, 802-03, 1059, 1078, 1089, 1135, 1213, 

1220, 1227, 1229). At no time did Dr. Strauss or Dr. Aiken 

assign any functional limitations to Plaintiff as a result of 

his mental conditions. 

One notable exception to Plaintiff’s otherwise conservative 

 10 Cognitive testing conducted on May 17, 2012, suggested a lack 

of effort by Plaintiff, as opposed to actual cognitive deficit. 

(Tr. 683-84). The tester noted that on the easy subtests, 

Plaintiff’s score was worse than what is typically seen in 

persons institutionalized with dementia; yet, he scored much 

better than such individuals on the hardest subtest. (Id. at

684). Subsequent cognitive testing conducted in January 2014 

revealed problems in the areas of immediate and delayed memory 

and attention; however, the tester noted that Plaintiff’s 

episodes of dysfluencies (stuttering) were much improved and 

that his prognosis was “fair-good” with consistent attendance at 

therapy sessions. (Id. at 1160-61). 

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treatment history occurred on February 28, 2014, when Plaintiff 

was admitted to an acute stabilization unit for treatment after 

an episode described as a “brief psychotic disorder.” (Id. at 

1039, 1154). Plaintiff’s medical records indicate that he 

became agitated while in the process of obtaining a compensation 

and pension examination and was taken by the police to the 

hospital. (Id. at 1039, 1080-81, 1152-55). Upon admission, 

Plaintiff was diagnosed with PTSD and opioid dependency and

prescribed Zoloft. (Id. at 1039, 1151). He was discharged the 

same weekend, on March 2, 2014, with instructions to follow up 

with the VA.11 (Id.).

Three days later, on March 5, 2014, VA psychologist, Dr. 

Jennifer Jackson, Psy.D., examined Plaintiff and noted his

recent diagnosis of psychotic disorder. Dr. Jackson’s notes 

indicate that Plaintiff was rambling and making nonsensical 

remarks during her examination and that she was “unclear as to 

the reason for his current psychosis.” (Id. at 1144, 1147-48). 

Dr. Jackson opined that Plaintiff’s current psychosis resulted 

in a “total occupational and social impairment.” (Id. at 1144).

The following day, March 6, 2014, another VA physician, Dr. 

 11 The record shows that one day prior to his psychotic episode, 

Plaintiff was seen at the VA by his treating psychologist, Dr. 

Aiken, who expressly noted that Plaintiff participated in his 

session and that “psychotic symptoms were not present.” (Tr. 

1155-56). 

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Neela Mani, M.D., examined Plaintiff for purposes of evaluating 

his TBI, and her examination findings indicated that Plaintiff 

was able to communicate by spoken and written language, that he 

was able to comprehend spoken and written language, that he had 

no neurobehavioral effects, that his orientation was normal, 

that his motor activity was normal, that his social interaction 

was appropriate, that his judgment was normal, and that his 

memory, concentration, and attention were normal. (Id. at 1097, 

1135-37). 

Interestingly, the next day, March 7, 2014, VA 

psychiatrist, Dr. Anita Nusbaum, M.D., examined Plaintiff,12 and 

in her mental status examination findings, she noted looseness 

of associations, rapid speech, and poor insight, judgment, and 

impulse control, but no observable impairment in attention or 

concentration. (Id. at 1095). Dr. Nusbaum diagnosed Plaintiff 

with mild “resolved” TBI, resulting in no functional limitations

and no impact on his ability to work. Dr. Nusbaum also opined 

that Plaintiff had no diagnosable PTSD. (Id. at 1090, 1096).

Dr. Nusbaum completed a Mental Disorders Questionnaire form 

wherein she noted Plaintiff’s psychotic episode a few days 

earlier and opined that Plaintiff’s unspecified “psychotic 

disorder” resulted in a “total occupational and social 

 12 From a review of the record, it appears that this was the only 

instance in which Plaintiff was seen by Dr. Nusbaum. 

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impairment.” (Id. at 1091-92). Dr. Nusbaum further opined that 

Plaintiff’s unspecified psychotic disorder was not caused by 

military service but possibly was the result of “exposure to 

illicit substances,” referencing his “post-military drug binge”

and his untruthfulness about his substance abuse. (Id. at 1094-

96).

One week later, on March 14, 2014, Plaintiff was examined 

at the request of the Agency by Dr. Kenneth Starkey, Psy.D. 

(Id. at 1029). From the outset, Dr. Starkey noted that 

Plaintiff smelled strongly of alcohol, although Plaintiff denied 

any history of alcohol use problems.13 (Id. at 1030). Plaintiff

reported his “presenting problem” as “brief psychotic disorders” 

because of PTSD and stated that he was also receiving treatment 

for back and neck problems related to disc problems.14 (Id. at 

1030-31). Plaintiff reported that he could manage all personal 

care needs without assistance, that he could manage his money, 

 13 Dr. Starkey noted that Plaintiff’s medical records revealed 

three prior DUI arrests and an arrest for public intoxication 

resulting in a reduction in rank in the Army and that Plaintiff 

had been required to attend a mandatory substance abuse 

treatment program while in the Army. (Tr. 1030). 

14 Plaintiff reported taking Alprazolam (for anxiety), Baclofen (a 

muscle relaxer), Cetirizine (an antihistamine), Divalproex (for 

migraines), Sulindac (an anti-inflammatory), Sumatriptan 

Succinate (for migraines), Tramadol (for pain), and Trazodone 

(an antidepressant). (Tr. 1030). Plaintiff reported that his 

medications were providing some relief of symptoms, and he 

denied having any undesirable side effects. (Id.).

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prepare simple meals, shop, use a telephone, and meet his basic 

transportation needs (although his license was suspended for a 

DUI arrest in 2013). (Id.). Plaintiff reported receiving an 

honorable discharge from the Army.15 (Id.). 

Dr. Starkey’s mental status examination revealed that 

Plaintiff had poor hygiene, bloodshot eyes, and that he smelled 

strongly of alcohol; Plaintiff’s mood was irritable, and his 

motivation for completing the examination tasks was marginal; he 

was ambulatory without assistance; he was alert and oriented to 

person, place, time, day, date and purpose of the meeting; he 

was able to focus and sustain attention with no significant 

distraction; he accurately completed serial 3s and simple math 

problems and spelled “WORLD” backwards; his speech was clear and 

coherent and appropriate; his thinking was rational, with no 

deficits in reasoning or judgment, no delusional thoughts or 

paranoia, no tangential thinking, flight of ideas, or loosening 

of associations, and no anxiety; his estimated intelligence was 

average; he had an adequate ability to focus and sustain 

attention, although his short term memory appeared mildly 

impaired; and he had accurate recall, adequate fund of 

knowledge, and adequate insight and judgment. (Id.)

 15 The record indicates that Plaintiff was forced to leave the 

Army after misconduct involving alcohol abuse and a DUI arrest 

but that he received an honorable discharge. (Tr. 100, 1201-

02). 

Case 1:15-cv-00323-B Document 26 Filed 08/02/16 Page 18 of 35
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Tests conducted on his intellectual functioning revealed a 

Full Scale IQ score of 93, reflecting an average range of 

intellectual functioning; and testing showed no clinically 

significant deficits for short term or long term memory. (Id.

at 1032-36). Plaintiff’s mood assessment was inconsistent, 

causing Dr. Starkey to question its validity. For example, Dr. 

Starkey noted that Plaintiff reported symptoms of PTSD but did 

not report any symptoms of depression. (Id. at 1036). 

Plaintiff’s reported daily activities consisted of getting 

dressed, eating, watching television, listening to music, 

washing dishes, washing clothes, watching the dog, going to the 

store, going to the doctor, and going to church. (Id.). 

Dr. Starkey diagnosed Plaintiff with Alcohol Use Disorder, 

Rule out PTSD mild.16 (Id.). He listed Plaintiff’s prognosis 

as “appears guarded” but unable to accurately assess because of 

Plaintiff’s impaired condition (alcohol) and “marginal” 

motivation/lack of effort/cooperation. (Id. at 1037). Dr.

Starkey opined that Plaintiff’s symptoms could improve with more 

effective treatment of alcohol use problems. (Id.). He also 

noted that testing did not confirm any diagnosable 

neurocognitive disorder and opined that Plaintiff’s ability to 

 16 Dr. Starkey opined that it was impossible to evaluate 

Plaintiff’s PTSD because of Plaintiff giving misleading 

information during the evaluation regarding his drinking. (Tr. 

1037).

Case 1:15-cv-00323-B Document 26 Filed 08/02/16 Page 19 of 35
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understand, remember and carry out simple/concrete instructions 

appears “good;” that his ability to work independently appears

adequate especially for simple tasks; and that his ability to 

work with others (supervisors, coworkers, public) and to deal 

with work pressures appears marginal but could improve with 

treatment of his alcohol use problems. (Id.). 

The following week, on March 24, 2014, State Agency 

psychologist, Dr. Donald E. Hinton, Ph.D., reviewed Plaintiff’s 

records and completed a Mental RFC Assessment. In the 

assessment, Dr. Hinton opined that Plaintiff is not 

significantly limited in his ability to understand and remember 

locations or short and simple instructions and procedures, his 

ability to carry out very short and simple instructions, his 

ability to maintain regular attendance, his ability to sustain 

an ordinary routine without special supervision, his ability to 

work with others and to make simple work-related decisions, his 

ability to complete a normal work day and work week, and his 

ability to accept instructions and criticism from supervisors. 

(Id. at 107-09). He also opined that Plaintiff is moderately 

limited in his ability to understand, remember, and carry out

detailed instructions, his ability to maintain attention and 

concentration for extended periods, his ability to interact 

appropriately with the general public, and his ability to 

respond appropriately to changes in the work setting. (Id.).

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21

The record reflects that in the months following 

Plaintiff’s brief (and only) psychotic episode in February 2014, 

he continued to receive routine treatment at the VA for his 

various physical and mental ailments. Although Plaintiff 

continued to complain of anxiety and, on one occasion, exhibited 

incoherent speech, 17 at no time other than February 2014 was 

Plaintiff ever diagnosed with psychosis. To the contrary, after 

February 2014, Plaintiff’s physicians consistently noted 

improvement with medication and no symptoms of psychosis. (Id.

at 1055-61, 1067, 1069, 1071, 1078, 1081, 1220, 1225, 1228-30). 

Specifically, on March 28, 2014, Plaintiff presented to the 

VA mental health clinic for a medication refill and reported

“everything is going fine.” (Id. at 1083). On April 28, 2014, 

Plaintiff reported that his medications were helping his mood. 

(Id. at 1067). On May 1, 2014, Plaintiff’s psychiatric 

examination findings reflected normal affect and mood, less 

anxiety, and improved attention. (Id. at 1059, 1067). On that 

same date, the VA issued Plaintiff an Apple Ipod as part of his 

 17 The Court notes that on one occasion, April 28, 2014, Plaintiff 

presented for counseling with Dr. Aiken, and Dr. Aiken noted 

increased anxiety and rambling speech with “delusional content.” 

(Tr. 1073). Dr. Aiken instructed Plaintiff to see Dr. Strauss 

on that same date to discuss changing his medication. (Id.). 

Dr. Strauss examined Plaintiff and noted that he was “quite 

anxious” and “had difficulty expressing himself clearly (as is 

usual for him),” but that there was “no evidence of psychosis.” 

(Id. at 1071).

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22

therapy, and Plaintiff verbalized understanding of the 

instructions and demonstrated proper use of the device. (Id. at 

1067). On May 28, 2014, and July 14, 2014, Plaintiff reported 

to Dr. Strauss that he had no complaints. (Id. at 1228, 1230). 

On June 19, 2014, Plaintiff’s mother reported “no 

needs/concerns” at that time. (Id. at 1229). After missing his 

appointment with Dr. Aiken on August 11, 2014, Plaintiff 

reported, “I’ve been better, I’ve been worse.” (Id. at 1220). 

The record reflects that Plaintiff was a “no show” for his 

VA appointments on May 15, 2014, June 3, 2014, June 19, 2014, 

July 17, 2014, August 11, 14, and 28, 2014. 18 (Id. at 1220, 

1228-29). These are the last VA treatment notes in the record. 

On May 1, 2014, the VA issued a determination related to 

Plaintiff’s claim for service related compensation. The VA 

assigned Plaintiff a 10% disability rating for degenerative 

joint disease in Plaintiff’s cervical spine, a 10% disability 

rating for degenerative joint disease in Plaintiff’s right 

shoulder, and a 10% disability rating for Plaintiff’s TBI 

(claimed as speech problems, memory loss, headaches, and dizzy 

spells). (Id. at 1040-52). The VA denied Plaintiff’s claim for 

 18 The VA record dated July 18, 2004, reflects that Plaintiff 

exceeded the “no show” limits for the VA Speech Pathology 

Clinic, and as a result, Plaintiff was notified that 

recertification would be required before he would be readmitted. 

(Tr. 1227). Plaintiff also exceeded the “no show” limit for the 

VA Radiology department on July 8, 2014. (Id. at 1229). 

Case 1:15-cv-00323-B Document 26 Filed 08/02/16 Page 22 of 35
23

PTSD and noted that Plaintiff sought no mental health treatment 

while in the service and that the cause of any PTSD was likely 

Plaintiff’s “binge use of illicit drugs and abuse of alcohol.” 

(Id. at 1052). 

On October 14, 2014, non-examining medical 

expert/psychologist, Dr. John William Davis, Ph.D., testified at 

Plaintiff’s second administrative hearing that Plaintiff has a 

problem with alcoholism and that, when intoxicated, all of his 

limitations would be “marked” (id. at 75-78); that Plaintiff’s 

TBI, anxiety, and PTSD are not severe (id. at 77, 88); and that 

there is no objective evidence of ADD (id. at 76). Dr. Davis 

opined that in the absence of alcoholism, any limitations on 

Plaintiff’s judgment and his ability to handle routine changes 

in the work place, understand, carry out, and remember 

instructions and respond appropriately to coworkers, 

supervisors, and work pressures are “mild.” (Id. at 77).

Based on the record evidence, the undersigned finds that 

the ALJ had good cause for rejecting the opinion of Dr. Nusbaum. 

The ALJ found, and the record confirms, that the opinion of Dr.

Nusbaum set forth in the Mental Disorders Questionnaire form 

completed on March 7, 2014, that Plaintiff’s unspecified 

psychotic disorder resulted in a “total occupational and social 

impairment” (id. at 1090-92), was based primarily on her review 

of the records of a single medical event that occurred the 

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preceding week 19 and is otherwise inconsistent with the 

substantial medical evidence in this case.20 (Id. at 1135-37). 

As discussed above, the record shows that four days after 

Plaintiff’s February 2014 psychotic episode (and one day before 

Dr. Nusbaum’s examination), VA physician, Dr. Neela Mani, M.D., 

examined Plaintiff for purposes of evaluating any cognitive 

deficits caused by his TBI and found that he was able to 

communicate by spoken and written language, that he was able to 

comprehend spoken and written language, that he had no 

neurobehavioral effects, that his orientation was normal, that 

his motor activity was normal, that his social interaction was 

appropriate, that his judgment was normal, and that his memory, 

concentration, and attention were normal. (Id. at 1097, 1135-

37). 

Dr. Nusbaum’s opinion is also inconsistent with the 

findings of consultative examining psychologist, Dr. Starkey, 

who evaluated Plaintiff twelve days after his psychotic episode 

and reported that Plaintiff was able to focus and sustain 

 19 In fact, Dr. Nusbaum referred to Plaintiff’s psychotic 

disorder as “current” and opined that it was not caused by his 

military service but by exposure to illicit drugs, referencing 

Plaintiff’s “post-military drug binge.” (Tr. 1094-96). 

20 Like Dr. Nusbaum, Dr. Jackson, Psy.D., also examined Plaintiff 

shortly after his single psychotic episode, and she too opined 

that Plaintiff’s “current psychosis” resulted in total 

occupational and social impairment; however, as indicated above, 

this finding is at odds with the substantial record evidence. 

Case 1:15-cv-00323-B Document 26 Filed 08/02/16 Page 24 of 35
25

attention and was alert and oriented, that his speech, thinking, 

reasoning, insight, judgment, focus, attention, language, 

hearing, vision, and motor function were normal, and that he had 

no anxiety. (Id. at 1030-33, 1035-36). Dr. Nusbaum’s opinion 

is inconsistent with Dr. Starkey’s opinion that Plaintiff’s 

ability to understand, remember and carry out simple/concrete 

instructions is “good” and that his ability to work 

independently is adequate especially for simple tasks.21 (Id. at 

1037, 1092).

Dr. Nusbaum’s opinion is also inconsistent with Plaintiff’s 

routine treatment records from the VA. These records reflect 

that at no time other than February 2014 was Plaintiff ever 

diagnosed with psychosis. To the contrary, after February 2014, 

Plaintiff’s physicians consistently noted improvement with 

medication and no symptoms of psychosis. 

In addition, Dr. Nusbaum’s opinion is inconsistent with 

Plaintiff’s reported activities of daily living which include 

taking care of his mother, taking care of his own personal 

needs, preparing meals, doing laundry and small chores, walking 

outdoors “as much as possible,” having social activities “as 

 21 Dr. Nusbaum’s opinion that Plaintiff’s “psychotic disorder” may 

have been caused by a “drug binge” (Tr. 1094-96) supports Dr. 

Starkey’s opinion that Plaintiff’s symptoms could improve with 

substance abuse treatment and contradicts Dr. Nusbaum’s own 

opinion that Plaintiff is unable to work because of a total 

social and occupational impairment. (Id. at 1037). 

Case 1:15-cv-00323-B Document 26 Filed 08/02/16 Page 25 of 35
26

much as possible,” going out alone, going to church, driving,

shopping, handling all of his own finances, and reading 

instructions “easily.” (Id. at 306-09, 1036). Based on the 

foregoing, the ALJ had good cause to reject Dr. Nusbaum’s 

opinion because it was inconsistent with the substantial medical 

evidence in the case.

However, the ALJ’s finding that Plaintiff retains the RFC

to perform a range of medium work which would require him “to 

understand to carry out ‘detailed but involved’ written or oral 

instructions involving a few concrete variables in or from 

standardized situations” is problematic. (Id. at 24). Residual 

functional capacity is a measure of what Plaintiff can do 

despite his or her credible limitations. See 20 C.F.R. § 

404.1545. Determinations of a claimant’s residual functional 

capacity are reserved for the ALJ, and the assessment is to be 

based upon all the relevant evidence of a claimant’s remaining 

ability to work despite his or her impairments, and must be 

supported by substantial evidence. See Beech v. Apfel, 100 F. 

Supp. 2d 1323, 1331 (S.D. Ala. 2000) (citing 20 C.F.R. § 

404.1546 and Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 

1997)); Saunders v. Astrue, 2012 U.S. Dist. LEXIS 39571, *10, 

2012 WL 997222, *4 (M.D. Ala. March 23, 2012). Once the ALJ has 

determined the Plaintiff’s residual functional capacity, the 

claimant bears the burden of demonstrating that the ALJ’s 

Case 1:15-cv-00323-B Document 26 Filed 08/02/16 Page 26 of 35
27

decision is not supported by substantial evidence. See Flynn v. 

Heckler, 768 F.2d 1273, 1274 (11th Cir. 1985). 

Having reviewed the evidence in this case at length, the 

Court finds that the substantial evidence detailed above does 

not support the ALJ’s conclusion that Plaintiff can perform work 

involving “detailed but involved” written and oral instructions. 

Simply put, the ALJ’s finding in this regard conflicts with the 

opinion of examining psychologist Dr. Starkey that Plaintiff is 

limited to work involving only simple instructions and simple 

tasks. The ALJ’s finding also conflicts with the opinion of 

non-examining State Agency psychologist Dr. Hinton that, 

although Plaintiff is not significantly limited in his ability 

to understand and remember locations or short and simple

instructions and procedures, his ability to carry out very short 

and simple instructions, his ability to maintain regular 

attendance, his ability to sustain an ordinary routine without 

special supervision, his ability to work with others and to make 

simple work-related decisions, his ability to complete a normal 

work day and work week, and his ability to accept instructions 

and criticism from supervisors, he is moderately limited in his 

ability to understand, remember, and carry out detailed

instructions, his ability to maintain attention and 

concentration for extended periods, his ability to interact 

appropriately with the general public, and his ability to 

Case 1:15-cv-00323-B Document 26 Filed 08/02/16 Page 27 of 35
28

respond appropriately to changes in the work setting (id. at 

107-09). Thus, the ALJ erred in including “detailed” work in 

Plaintiff’s RFC assessment.22

Nevertheless, although the ALJ erred in including 

“detailed” work in the Plaintiff’s RFC assessment, the Court 

finds the error to be harmless. The record reflects that, at 

the administrative hearing, the ALJ posed a hypothetical 

question to the vocational expert which limited Plaintiff to 

simple work and another hypothetical question which limited 

Plaintiff to “detailed but uninvolved” written or oral 

instructions. In response to both questions, the vocational 

expert identified three unskilled jobs, namely, “hand packager,” 

“kitchen helper,” and “poultry farm laborer,” as jobs which 

Plaintiff is capable of performing. (Id. at 90-92). Although 

in the RFC assessment the ALJ found that Plaintiff could engage 

in “detailed work,” she listed the three unskilled jobs 

identified by the vocational expert in finding that Plaintiff is 

not disabled because there are jobs that exist in significant 

 22 Additionally, the Court finds that, to the extent that the ALJ 

construed the opinion of non-examining medical expert Dr. Davis, 

that Plaintiff has no more than “mild” mental functional 

limitations, as supporting a finding that Plaintiff can 

understand and carry out “detailed but involved” instructions, 

the ALJ erred in relying on that opinion as it conflicts with 

the substantial record evidence, including the opinion of 

examining psychologist Dr. Starkey that Plaintiff is limited to 

work involving only simple instructions and simple tasks. See

Milner, 275 Fed. Appx. at 948.

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29

numbers in the national economy that Plaintiff can perform. 

(Id. at 31). Therefore, the ALJ’s error in including “detailed” 

work in the RFC assessment was harmless. See Jones v. 

Commissioner of Soc. Sec., 492 F. Appx. 70, 73 (11th Cir. 2012) 

(failure to include a driving limitation in the hypothetical 

posed to the VE was harmless where the jobs identified by the VE 

could be performed without driving and, thus, did not affect the 

outcome of Plaintiff’s case); see also Battle v. Astrue, 243 

Fed. Appx. 514, 522 (11th Cir. 2007) (unpublished) (errors are 

harmless if they do not prejudice the claimant); Harper v. 

Colvin, 2015 U.S. Dist. LEXIS 15793, 2015 WL 540079, *6 (N.D. 

Ala. Feb. 10, 2015) (“Assuming arguendo that the ALJ did commit 

error by not including any mental limitations in his RFC 

finding, any such error was harmless because limitations based 

on the Plaintiff’s mental impairment were included in the

hypothetical presented to the VE,” and the ALJ ultimately relied 

upon the jobs identified by the VE at step five of his 

decision); Sheehan v. Colvin, 2014 U.S. Dist. LEXIS 125155, *37

(M.D. Fla. Sept. 8, 2014)(“The Court finds that the ALJ erred in 

discounting the January, 2010 opinion of Dr. Gomes containing 

restrictions, but the error is harmless because there is VE 

testimony identifying other work that a hypothetical individual 

restricted to light work and simple, routine tasks could do, and 

that the work identified exists in significant numbers in the 

Case 1:15-cv-00323-B Document 26 Filed 08/02/16 Page 29 of 35
30

national economy, given Plaintiff’s RFC as corrected, age, 

education and work experience. A remand is not necessary.”). 

Based on the foregoing, the Court finds that Plaintiff’s claim 

is without merit. 

B. Whether the ALJ erred in failing to find 

Plaintiff’s PTSD to be a severe 

impairment?

Last, Plaintiff argues that the ALJ erred in failing to 

find his PTSD to be a severe impairment. (Doc. 13 at 6-10). 

The Commissioner counters that the ALJ’s finding that 

Plaintiff’s PTSD is not severe is supported by substantial 

evidence, and that even if the ALJ erred in not identifying PTSD 

to be a severe impairment at step two of the sequential 

evaluation process, the error is harmless because the ALJ 

considered all of Plaintiff’s impairments, including PTSD, 

during the subsequent steps of the inquiry. (Doc. 20 at 4-8). 

Having carefully reviewed the record in this case, the Court 

agrees that Plaintiff’s claim is without merit. 

In her decision, the ALJ found at step two of the 

sequential evaluation process that Plaintiff has the severe 

impairments of cervical spondylosis, degenerative joint disease 

of the right shoulder, late effects of traumatic brain injury 

vs. psychotic disorder including speech difficulties, headaches, 

anxiety, attention deficit hyperactivity disorder, memory loss, 

and alcohol dependence. (Tr. 21). The ALJ discussed the 

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31

evidence relating to Plaintiff’s PTSD and determined that it was

not a severe impairment. (Id. at 21-22).

The Court notes at the outset that the Commissioner is 

correct that, even if Plaintiff’s PTSD were severe, the ALJ’s 

failure to classify it as a severe impairment at step two of the 

sequential evaluation process is not fatal. See Bennett v. 

Astrue, 2013 U.S. Dist. LEXIS 115951, *14, 2013 WL 4433764, *5 

(N.D. Ala. 2013) (“‘[n]othing requires that the ALJ must 

identify, at step two, all of the impairments that should be 

considered severe’ and, even if the ALJ erred by not recognizing 

every severe impairment, the error was harmless since he found 

at least one such impairment.”); Ferguson v. Astrue, 2012 U.S. 

Dist. LEXIS 139135, *25, 2012 WL 4738857, *9 (N.D. Ala. 2012) 

(“[B]ecause step two only acts as a filter to prevent non-severe 

impairments from disability consideration, the ALJ’s finding of 

other severe impairments allowed him to continue to subsequent 

steps of the determination process and his failure to list 

headaches as severe does not constitute reversible error 

because, under the Social Security regulations, the ALJ at later 

steps considers the combined effect of all the claimant’s 

impairments.”) (emphasis in original). 

Here, the ALJ found Plaintiff’s cervical spondylosis, 

degenerative joint disease of the right shoulder, late effects 

of traumatic brain injury vs. psychotic disorder including 

Case 1:15-cv-00323-B Document 26 Filed 08/02/16 Page 31 of 35
32

speech difficulties, headaches, anxiety, ADHD, memory loss, and 

alcohol dependence to be severe at step two and then proceeded 

on to the next steps where she considered all of Plaintiff’s 

impairments in combination, including his PTSD. (Tr. 24-30). 

Thus, the ALJ satisfied the requirements of the regulations. 

Further, in order for an impairment to be severe, it must 

be more than a slight abnormality or a combination of slight 

abnormalities “that causes no more than minimal functional 

limitations.” 20 C.F.R. § 416.924(c). Indeed, it must 

“significantly limit[]” an individual’s “ability to do basic 

work activities.” 20 C.F.R. § 416.920(c). “It is [the] 

Plaintiff’s burden to prove the existence of a severe 

impairment, and she must do that by showing an impact on her 

ability to work.” Marra v. Colvin, 2013 U.S. Dist. LEXIS 

105669, *13-14, 2013 WL 3901655, *5 (M.D. Fla. 2013) (citing 

Bowen v. Yuckert, 482 U.S. 137, 146 (1987)); see also Barnhart 

v. Thomas, 540 U.S. 20, 24 (2003) (“At step two, the SSA will 

find nondisability unless the claimant shows that he has a 

‘severe impairment,’ defined as ‘any impairment or combination 

of impairments which significantly limits [the claimant’s] 

physical or mental ability to do basic work activities.’”) 

(quoting §§ 404.1520(c), 416.920(c)); McDaniel v. Bowen, 800 

F.2d 1026, 1031 (11th Cir. 1986) (“Unless the claimant can 

prove, as early as step two, that she is suffering from a severe 

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33

impairment, she will be denied disability benefits.”). 

Here, Plaintiff has failed to satisfy his burden of proof 

with respect to the alleged severity of his PTSD. Although 

Plaintiff’s medical records document a diagnosis and treatment 

for PTSD, none of his medical records indicates that his PTSD is 

severe and significantly limits his ability to do basic work 

activities. 

To the contrary, Plaintiff’s treatment records show very 

conservative treatment for his PTSD, consisting of medication

and counseling. 23 (Id. at 1058-67, 1071-79, 1166-67, 1172-73, 

1205-09). Plaintiff’s medical records also show periods of no 

treatment whatsoever or non-compliance with treatment (id. at 

76, 316, 1057, 1205, 1207, 1209, 1213, 1220), as well as 

frequent and consistent drug and alcohol abuse. (Id. at 100, 

437, 464, 740, 793, 810, 823, 830, 934, 1030, 1036, 1052, 1164, 

1173, 1202, 1211). Although Plaintiff’s treating VA 

psychiatrist, Dr. Strauss, and treating psychologist, Dr. Aiken, 

diagnosed Plaintiff with PTSD, neither assigned any functional 

limitations from the condition. (Id. at 1071, 1073-74). 

Moreover, VA psychiatrist, Dr. Nusbaum, who examined Plaintiff 

 23 With the exception of Plaintiff’s brief hospitalization in 

February 2014 for the psychotic episode that occurred during his 

compensation and pension examination with the VA (id. at 1039, 

1154), his records reflect no hospitalizations or emergency room 

visits for any mental condition.

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34

on March 7, 2014, after his brief psychotic episode, opined that 

he had no diagnosable PTSD. (Id. at 1090, 1096). In addition, 

the VA denied Plaintiff’s claim for PTSD, noting that he sought 

no mental health treatment during his service and that the cause 

of any PTSD was likely his “binge use of illicit drugs and abuse 

of alcohol.” (Id. at 1052).

Further, consultative examining psychologist, Dr. Starkey,

found Plaintiff’s report of symptoms of PTSD to be inconsistent, 

noting that he did not report any symptoms of depression and 

that he gave misleading information regarding his drinking. 

(Id. at 1036-37). Dr. Starkey diagnosed Plaintiff with Alcohol 

Use Disorder, Rule Out PTSD mild. (Id. at 1036). Also, medical 

expert/psychologist, Dr. Davis, testified at Plaintiff’s 

administrative hearing that, based upon his review of 

Plaintiff’s medical records, Plaintiff’s PTSD was not severe. 

(Id. at 76-77). In sum, none of Plaintiff’s treating or 

examining physicians nor the non-examining psychological expert 

found any functional limitations attributable to Plaintiff’s 

PTSD. 

In light of this evidence, the ALJ did not err in 

determining that Plaintiff’s PTSD did not significantly limit 

his ability to do basic work activities, and thus, is not a 

severe impairment. Thus, Plaintiff’s claim is without merit. 

V. Conclusion 

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35

For the reasons set forth herein, and upon careful 

consideration of the administrative record and memoranda of the 

parties, it is hereby ORDERED that the decision of the 

Commissioner of Social Security denying Plaintiff’s claim for a 

period of disability, disability insurance benefits, and 

supplemental security income be AFFIRMED.

DONE this 2nd day of August, 2016.

 /s/ SONJA F. BIVINS 

 UNITED STATES MAGISTRATE JUDGE

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