The opinion
IN THE UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF ARKANSAS
FAYETTEVILLE DIVISION
JONATHAN B. EDENS PLAINTIFF
v. CIVIL NO. 22-5067
KILOLO KIJAKAZI, Acting Commissioner
Social Security Administration DEFENDANT
MAGISTRATE JUDGE’S REPORT AND RECOMMENDATION
Plaintiff, Jonathan B. Edens, brings this action pursuant to 42 U.S.C. § 405(g), seeking
judicial review of a decision of the Commissioner of the Social Security Administration
(Commissioner) denying his claims for child disability insurance benefits (CDIB) and
supplemental security income (SSI) benefits under the provisions of Titles II and XVI of the Social
Security Act (Act). In this judicial review, the Court must determine whether there is substantial
evidence in the administrative record to support the Commissioner's decision. See 42 U.S.C. §
405(g).
I. Procedural Background:
Plaintiff protectively filed his current applications for CDIB and SSI on March 9, 2020,
and February 13, 2020, respectively, alleging an inability to work since August 4, 2017, due to
post-traumatic stress disorder, manic depression, trauma-based disorder, paranoid schizophrenia,
and a learning disability. (Tr. 69, 365, 372, 382). An administrative telephonic hearing was held
on March 31, 2021, at which Plaintiff appeared with counsel and testified. (Tr. 29-62).
By written decision dated May 26, 2021, the ALJ found that during the relevant time
period, Plaintiff had an impairment or combination of impairments that were severe. (Tr. 14).
Specifically, the ALJ found Plaintiff had the following severe impairments: anxiety, depression,
dissociative identity disorder, attention deficit/hyperactivity disorder, schizoaffective disorder,
bipolar type, antisocial and borderline personality disorder, and neurodevelopmental disorders.
However, after reviewing all of the evidence presented, the ALJ determined that Plaintiff’s
impairments did not meet or equal the level of severity of any impairment listed in the Listing of
Impairments found in Appendix I, Subpart P, Regulation No. 4. (Tr. 14). The ALJ found Plaintiff
retained the residual functional capacity (RFC) to:
[P]erform a full range of work at all exertional levels but with the following
nonexertional limitations: can understand, carry out, and remember simple
instructions and make commensurate work-related decisions, respond appropriately
to supervision, coworkers, and work situations, deal with routine changes in work
setting, maintain concentration persistence, and pace for up to and including two
hours at a time with normal breaks throughout a normal workday. He is limited to
occasional interaction with coworkers, supervisors, and the general public.
(Tr. 16). With the help of a vocational expert, the ALJ determined Plaintiff could perform work as
a housekeeping cleaner and a power screwdriver operator. (Tr. 20-21).
Plaintiff then requested a review of the hearing decision by the Appeals Council, who
denied that request on February 7, 2022. (Tr. 1-5). Subsequently, Plaintiff filed this action. (ECF
No. 2). Both parties have filed appeal briefs, and the case is before the undersigned for report and
recommendation. (ECF Nos. 13, 15).
II. Applicable Law:
The Court reviews “the ALJ’s decision to deny disability insurance benefits de novo to
ensure that there was no legal error that the findings of fact are supported by substantial evidence
on the record as a whole.” Brown v. Colvin, 825 F. 3d 936, 939 (8th Cir. 2016). Substantial
evidence is less than a preponderance, but it is enough that a reasonable mind would find it
adequate to support the Commissioner’s decision. Biestek v. Berryhill, 139 S.Ct. 1148, 1154
(2019). We must affirm the ALJ’s decision if the record contains substantial evidence to support
it. Lawson v. Colvin, 807 F.3d 962, 964 (8th Cir. 2015). As long as there is substantial evidence
in the record that supports the Commissioner’s decision, the court may not reverse it simply
because substantial evidence exists in the record that would have supported a contrary outcome,
or because the court would have decided the case differently. Miller v. Colvin, 784 F.3d 472, 477
(8th Cir. 2015). In other words, if after reviewing the record it is possible to draw two inconsistent
positions from the evidence and one of those positions represents the findings of the ALJ, we must
affirm the ALJ’s decision. Id.
It is well established that a claimant for Social Security disability benefits has the burden
of proving his disability by establishing a physical or mental disability that has lasted at least one
year and that prevents him from engaging in any substantial gainful activity. Pearsall v.
Massanari, 274 F.3d 1211, 1217 (8th Cir. 2001); see also 42 U.S.C. § 423(d)(1)(A). The Act
defines “physical or mental impairment” as “an impairment that results from anatomical,
physiological, or psychological abnormalities which are demonstrable by medically acceptable
clinical and laboratory diagnostic techniques.” 42 U.S.C. § 423(d)(3). A Plaintiff must show that
his disability, not simply his impairment, has lasted for at least twelve consecutive months.
The Commissioner’s regulations require her to apply a five-step sequential evaluation
process to each claim for disability benefits: (1) whether the claimant has engaged in substantial
gainful activity since filing his claim; (2) whether the claimant has a severe physical and/or mental
impairment or combination of impairments; (3) whether the impairment(s) meet or equal an
impairment in the listings; (4) whether the impairment(s) prevent the claimant from doing past
relevant work; and, (5) whether the claimant is able to perform other work in the national economy
given his age, education, and experience. See 20 C.F.R. §§ 404.1520, 416.920. Only if the final
stage is reached does the fact finder consider the Plaintiff’s age, education, and work experience
in light of his residual functional capacity. Id.
III. Discussion:
Of particular concern to the undersigned is the ALJ’s RFC determination. RFC is the most
a person can do despite that person’s limitations. 20 C.F.R. § 404.1545(a)(1). It is assessed using
all relevant evidence in the record. Id. This includes medical records, observations of treating
physicians and others, and the claimant’s own descriptions of his limitations. Guilliams v.
Barnhart, 393 F.3d 798, 801 (8th Cir. 2005); Eichelberger v. Barnhart, 390 F.3d 584, 591 (8th
Cir. 2004). Limitations resulting from symptoms such as pain are also factored into the assessment.
20 C.F.R. § 404.1545(a)(3). The United States Court of Appeals for the Eighth Circuit has held
that a “claimant’s residual functional capacity is a medical question.” Lauer v. Apfel, 245 F.3d
700, 704 (8th Cir. 2001). Therefore, an ALJ’s determination concerning a claimant’s RFC must
be supported by medical evidence that addresses the claimant’s ability to function in the
workplace. Lewis v. Barnhart, 353 F.3d 642, 646 (8th Cir. 2003). “[T]he ALJ is [also] required
to set forth specifically a claimant’s limitations and to determine how those limitations affect his
RFC.” Id.
The medical evidence establishes Plaintiff has been diagnosed and treated for various
mental impairments to include schizoaffective disorder, bipolar type; attention
deficit/hyperactivity disorder; substance abuse disorder; major depressive disorder; unspecified
anxiety disorder; dissociative identity disorder; and unspecified disruptive, impulse-control and
conduct disorder. A review of the record revealed during the time period in question, Plaintiff
appears to have frequently abused substances which led to him failing to follow his medication
regimen which in turn increased his anxiety and irritability. Due to the abuse of substances and
inability to cope, Plaintiff agreed to in-patient treatment during the time period in question.
In making the disability determination, the ALJ did not discuss the medical evidence
relating to Plaintiff’s delusional thoughts, aggression or use of alcohol and other substances, and
how this impacted Plaintiff’s ability to perform substantial gainful activity. A review of the
medical record revealed that in September of 2017, Plaintiff’s therapist noted Plaintiff continued
to deal with entrenched delusions. (Tr. 937). At that time, there was no indication Plaintiff was
abusing substances. However, in October of 2017, Plaintiff admitted to abusing substances and
agreed to in-patient treatment. While in treatment, the record reveals Plaintiff was moved to a
different facility after having an altercation with another patient. In January of 2019, Dr. Donna
Rocha indicated Plaintiff had chronically impaired judgement. (Tr. 1077). At that time, Plaintiff
denied substance abuse, but Dr. Rocha noted there was suspected abuse. A treatment review dated
January 29, 2019, indicated Plaintiff continued to struggle with irrational thoughts and Plaintiff’s
ability to cope had been overwhelmed by maladaptive substance abuse. (Tr. 1084). In January of
2020, Plaintiff was noted to be addicted to alcohol and other substances. (Tr. 1134). Because the
ALJ failed to address Plaintiff’s delusional thoughts, frequent but not continuous abuse of
substances and irritable/aggressive behavior, the Court is unable to determine if the ALJ’s
determination is supported by substantial evidence. Accordingly, the Court believes remand is
warranted for the ALJ to more fully and fairly develop the record with respect to Plaintiff’s mental
impairments.
On remand, the ALJ is also directed to address interrogatories to a mental health physician
requesting that said physician review Plaintiff's medical records; complete a mental RFC
assessment regarding Plaintiff's capabilities during the time period in question; and give the
objective basis for the opinion so that an informed decision can be made regarding Plaintiff's ability
to perform basic work activities on a sustained basis. With this evidence, the ALJ should then re-
evaluate Plaintiff's RFC and specifically list in a hypothetical to a vocational expert any limitations
that are indicated in the RFC assessment and supported by the evidence.
IV. Conclusion:
Based on the foregoing, the undersigned recommends reversing the decision of the ALJ
and remanding this case to the Commissioner for further consideration pursuant to sentence four
of 42 US.C. § 405(g). The parties have fourteen days from receipt of our report and
recommendation in which to file written objections pursuant to 28 U.S.C. § 636(b)(1). The
failure to file timely objections may result in waiver of the right to appeal questions of fact.
The parties are reminded that objections must be both timely and specific to trigger de novo
review by the district court.
DATED this 5th day of May 2023.
is aca, Comedic
HON. CHRISTY COMSTOCK
UNITED STATES MAGISTRATE JUDGE