Clem v. Social Security Administration, Commissioner

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF ALABAMA

NORTHEASTERN DIVISION

TINA MARIE CLEM, §

§

Plaintiffs, §

§

v. §

§ Case No. 5:23-cv-00003-LCB

KILOLO KIJAKAZI, Acting §

Commissioner Social Security §

Administration, §

§

Defendant. §

OPINION & ORDER

Tina Clem seeks judicial review of the final decision of the Commissioner of

the Social Security Administration denying her claim for disability benefits. (Doc. 7

at 1.) Specifically, Clem challenges the administrative law judge’s evaluation of

Clem’s subjective testimony regarding the symptoms and limitations of her mental

impairments. (Doc. 7 at 11−12.) The Court carefully considered the record, and for

the reasons expressed herein, it AFFIRMS the Commissioner’s decision.

I. BACKGROUND

A. Statutory Framework

The Social Security Act defines disability, in relevant part, as the “inability

to engage in any substantial gainful activity by reason of any medically determinable

physical or mental impairment . . . expected to last for a continuous period of not

less than 12 months.” 42 U.S.C. § 423(d)(1). To establish an entitlement to disability

benefits, a claimant must provide evidence of a “physical or mental impairment” that

is the result of “anatomical, physiological, or psychological abnormalities which are

demonstrable by medically acceptable clinical and laboratory diagnostic

techniques.” 42 U.S.C. § 423(d)(3). An individual is deemed disabled only if the

impairment is “of such severity that he is not only unable to do his previous work

but cannot, considering his age, education, and work experience, engage in any other

kind of substantial gainful work which exists in the national economy.” 42 U.S.C. §

423(d)(2).

In light of that framework, an administrative law judge (“ALJ”) reaches a

disability determination pursuant to a sequential, five-step analysis:

(1) Is the claimant engaged in substantial gainful activity?

(2) Does the claimant have a severe impairment?

(3) Does the claimant have an impairment or combination of

impairments that meets or medically equals an impairment listed

in 20 C.F.R. Part 404, Subpart P, Appendix 1?

(4) Is the claimant able to perform former relevant work?

(5) Is the claimant able to perform any other work within the

national economy?

20 C.F.R. § 404.1520(a), 416.920(a); McDaniel v. Bowen, 800 F.2d 1026, 1030

(11th Cir. 1986). The steps are progressive; for example, an ALJ reaches step 4 only

if a claimant is not engaged in substantial gainful activity (“SGA”) (step 1), has a

severe impairment (step 2), and does not have an impairment or combination of

impairments that meets or medically equals a listed impairment (step 3). See

McDaniel, 800 F.2d at 1030; see also Wolfe v. Chater, 86 F.3d 1072, 1077 (11th

Cir. 1996) (noting that claimant bears burden of proof through step four, and

Commissioner bears burden of proof at step five).

If the claimant is able to perform former relevant work (step 4), then she is

not disabled. McDaniel, 800 F.2d at 1030 (citing 20 C.F.R. § 416.920). To determine

a claimant’s ability to perform prior work, the ALJ must first determine the

claimant’s residual functional capacity (“RFC”). 20 C.F.R. § 404.1520(e); Phillips

v. Barnhart, 357 F.3d 1232, 1238 (11th Cir. 2004) (superseded by statute on other

grounds, Jones v. Soc. Sec. Admin, 2022 WL 3448090, at *1 (11th Cir. Aug. 17,

2022)). RFC is “the most [the claimant] can still do despite [his] limitations.” 20

C.F.R. § 404.1545(a)(1). And “the task of determining a claimant’s [RFC] and

ability to work rests with the [ALJ], not a doctor.” Moore v. Soc. Sec. Admin., 649

F. App’x 941, 945 (11th Cir. 2016) (citing 20 C.F.R. § 404.1546(c)).

B. Statement of Facts

Pursuant to Title II of the Social Security Act, Clem filed an application for

disability benefits in December 2020. (Doc. 5-7 at 5.) In her application, she alleged

that she suffers from several impairments including depression, post-traumatic stress

disorder, anxiety, and back problems, and she claimed that her disability onset date

was September 27, 2019. (Doc. 5-8 at 6−7.) Her date last insured was September 30,

2020. (Doc. 5-3 at 18.) The Social Security Administration denied the application

both initially and upon reconsideration. (Doc. 5-3 at 15.) Clem then filed a written

request for a hearing. (Doc. 5-3 at 15.) On April 12, 2022, ALJ Lori J. Williams held

a video hearing.1 (Doc. 5-3 at 15.) Clem was 48 years old at the time, and she was

represented by counsel at the hearing. (Doc. 5-3 at 15.) Rachel McDaniel, an

impartial vocational expert, also testified at the hearing. (Doc. 5-3 at 15.) Roughly

two months later, the ALJ issued an unfavorable decision. (Doc. 5-3 at 29.) Clem

appealed that decision, and on November 8, 2022, the Appeals Council adopted the

ALJ’s decision as the final decision of the Commissioner. (Doc. 5-3 at 2.) Clem then

initiated a timely civil action in this Court on January 4, 2023. (Doc. 1.)

C. The ALJ’s Decision

The ALJ issued a written opinion explaining her decision that Clem did not

qualify as being disabled under the Social Security Act. (Doc. 5-3 at 15−29.) In her

opinion, the ALJ followed the five-step evaluation process. (Doc. 5-3 at 16.) During

the first three steps, she made the following findings: (1) Clem did not engage in

SGA between her alleged disability onset date of September 27, 2019, and the date

last insured, September 30, 2020 (i.e., the relevant time period); (2) Clem had several

severe impairments—morbid obesity, degenerative joint disease/facet arthropathy of

the lumbar spine at L4-5 and L5-S1, and a major depressive disorder with anxiety;

1 The hearing was virtual due to health concerns presented by the COVID-19 pandemic. (Doc. 5-

3 at 15.)

and (3) Clem did not have an impairment, or combination of impairments, that met

or medically equaled the severity of one of the listed impairments in 20 C.F.R. Part

404, Subpart P, Appendix 1. (Doc. 5-3 at 18−19.)

Before proceeding to step four, the ALJ determined that Clem had the RFC to

perform “light work,”2 subject to some limitations, such as she could not interact

with members of the general public, and she could only handle routine-tasks work,

requiring no more than one- to three-step instructions. (Doc. 5-3 at 21.) At step four,

the ALJ concluded that Clem’s RFC precluded her from performing her past work,

which included working as an electrical assembler, a telephone solicitor, a cashier,

a circuit board assembler, and a chief telephone operator. (Doc. 5-3 at 26.) At step

five, however, the ALJ considered Clem’s age, education, work experience, RFC,

and the testimony from the vocational expert and concluded that there were jobs in

the national economy which Clem could perform. (Doc. 5-3 at 27−28.) Accordingly,

the ALJ determined that Clem did not qualify for disability benefits under the Social

Security Act. (Doc. 5-3 at 28.)

II. LEGAL STANDARD

Once the Commissioner renders a final administrative decision regarding a

claimant’s benefits, the claimant may seek judicial review in federal court. 42 U.S.C.

2 “Light work involves lifting no more than 20 pounds at a time with frequent lifting or carrying

of objects weighing up to 10 pounds.” 20 C.F.R. § 404.1567(b).

§ 405(g). But the scope of judicial review is limited: the role of a federal court is to

determine whether the correct legal standards were applied and whether the

Commissioner’s decision is supported by substantial evidence. Winschel v. Comm'r

of Social Sec., 631 F.3d 1176, 1178 (11th Cir. 2011). “Substantial evidence is more

than a scintilla and is such relevant evidence as a reasonable person would accept as

adequate to support a conclusion.” Id. (internal citation and quotation marks

omitted). The court’s “limited review precludes deciding the facts anew, making

credibility determinations, or re-weighing the evidence.” Moore v. Barnhart, 405

F.3d 1208, 1211 (11th Cir. 2005). Thus, while the court must scrutinize the record

as a whole, it must affirm if the decision is supported by substantial evidence, even

if the evidence preponderates against the Commissioner’s findings. Henry v. Comm'r

of Soc. Sec., 802 F.3d 1264 (11th Cir. 2015); Bloodsworth v. Heckler, 703 F.2d 1233,

1239 (11th Cir. 1983).

III. DISCUSSION

In her brief, Clem raises one assignment of error: that the ALJ erred in the

ALJ’s consideration of Clem’s credibility and subjective complaints. (Doc. 7 at

11−12.) She claims that the reasons the ALJ gave for discrediting her allegations as

to her mental health symptoms and limitations are not supported by substantial

evidence, so the Commissioner’s decision is due to be reversed. (Doc. 7 at 11−12.)

As provided in 42 U.S.C. § 423(d)(5)(A), “[a]n individual’s statement as to

pain or other symptoms shall not alone be conclusive evidence of disability.” When

a claimant attempts to establish his disability through subjective testimony, the ALJ

must apply a three-part pain standard: there must be “‘(1) evidence of an underlying

medical condition and either (2) objective medical evidence that confirms the

severity of the alleged pain [or symptoms] arising from that condition or (3) that the

objectively determined medical condition is of such a severity that it can be

reasonably expected to give rise to the alleged pain [or symptoms].’” Foote v.

Chater, 67 F.3d 1553, 1560 (11th Cir. 1995) (quoting Holt v. Sullivan, 921 F.2d

1221, 1223 (11th Cir. 1991)).

If the ALJ concludes that the claimant suffers from a medical condition (i.e.,

an impairment) that could reasonably cause the alleged symptoms, she must evaluate

the intensity and persistence of the symptoms to determine how they limit the

claimant’s capacity for work. 20 C.F.R. §§ 404.1529(c), 416.929(c). When making

that evaluation, the ALJ considers a variety of factors: the objective medical

evidence; the claimant’s daily activities; symptom location, duration, frequency, and

intensity; precipitating and aggravating factors; type, dosage, effectiveness, and side

effects of medication taken to alleviate the symptoms; treatment, other than

medication, received for pain or symptoms; measures used to relieve pain or

symptoms; and other factors concerning functional limitations and restrictions due

to symptoms. Id. The ALJ also considers any inconsistencies between the evidence

and the claimant’s testimony. 20 C.F.R. §§ 404.1529(c)(4), 416.929(c)(4); Social

Security Ruling 16-3p. “The ALJ may discredit the claimant’s testimony regarding

his subjective symptoms, but she ‘must clearly articulate explicit and adequate

reasons’ for doing so.” Taylor v. Acting Comm’r of Soc. Sec., 761 F. App’x 966, 968

(11th Cir. 2019) (citing Dyer v. Barnhart, 395 F.3d 1206, 1210 (11th Cir. 2005)). In

fulfilling that obligation, the ALJ need not “‘specifically refer to every piece of

evidence in his decision,’ so long as the decision is sufficient to allow [the reviewing

court] to conclude the ALJ considered the claimant’s medical condition as a whole.”

Brown v. Barnhart, 158 F. App’x 227, 228 (11th Cir. 2005) (per curiam) (quoting

Dyer, 395 F.3d at 1211). A court will not disturb a clearly articulated finding that

the record evidence is inconsistent with the claimant’s testimony, provided that

finding is supported by substantial evidence. See Taylor v. Comm’r of Soc. Sec.,

2022 WL 1634086, at *6 (11th Cir. May 24, 2022) (“We will not disturb ‘[a] clearly

articulated credibility finding with substantial supporting evidence in the record.”)

(quoting Foote, 67 F.3d at 1561−62). At day’s end, “it is the ALJ’s responsibility to

resolve the conflicts between the evidence and testimony presented.” Loveless v.

Comm’r, Soc. Sec. Admin., 678 F. App’x 866, 868 (11th Cir. 2017) (citing Moore,

405 F.3d at 1212 (noting that “credibility determinations are the province of the

ALJ”)).

In her application for disability benefits, Clem alleged that she suffers from

debilitating depression and anxiety symptoms, and her testimony at the hearing

reiterated those allegations. (Doc. 5-3 at 50−72 and Doc. 5-8 at 24−31.) She testified

that she suffers from manic episodes and severe mood swings that cause her to

isolate herself and inhibit her ability to concentrate, sometimes for the entire day.

(Doc. 5-3 at 52, 55−56.) As part of her mood swings, she stated that she has anger

outbursts and that she has been known to throw and break items. (Doc. 5-3 at 52−53).

Clem claimed she no longer goes anywhere because leaving the house triggers an

anxiety attack. (Doc. 5-3 at 56−57, 61.) Due to her condition, she alleged that she

now has difficulty communicating with other people outside her family. (Doc. 5-3

at 59.) She also reported that she suffered like symptoms when she was still

employed. (Doc. 5-3 at 52−55, 60.) At work, she allegedly experienced manic

episodes daily, and she even occasionally passed out due to an anxiety attack.3 (Doc.

5-3 at 52−55, 60.)

Having considered Clem’s subjective complaints and the rest of the evidence

in the record, the ALJ, in her opinion, applied the pain standard and concluded that

while Clem’s medically determinable mental impairments “could reasonably be

expected to cause some of the alleged symptoms,” Clem’s “statements concerning

the intensity, persistence and limiting effects of [those] symptoms [were] not entirely

3 Clem stopped working in 2017. (Doc. 5-8 at 16.)

consistent with the medical evidence and other evidence in the record.”4 (Doc. 5-3

at 22.) Said differently, the ALJ found that the symptoms caused by Clem’s mental

impairments were not as debilitating as Clem alleged.

The ALJ explained why she discredited Clem’s subjective complaints.

Specifically, the ALJ made the following statements:

The claimant’s testimony alleging while working she had significant

difficulties with her depression, daily manic spells, and routine

absences from work is not consistent with 2016-2017 medical records

that are absent uncontrolled mental illness when working. Rather, the

objective exams repeatedly show the claimant being alert, oriented,

cooperative, and having normal mood, affect, attention span, and

concentration, such as in June 2017 when primary care records include

the use of Zoloft and Abilify (Exhibit C6F/23-24, 34). There are no

records of uncontrolled symptoms physically or mentally to corroborate

the routine absences from work she reports when working.

. . . .

The records of Wellstone Behavioral Health begin in October 2018

when the claimant was seen for major depression, single episode. She

denied being depressed or anxious and reported medications (Zoloft,

Hydroxyzine, Trazadone) work well. The practitioner recommended to

continue medications and follow-up in six months (Exhibit C8F/63-64,

67). The practitioner only follow-ups for 2019 and 2020 have been as

much as six months apart, as recommended, and she continues to be

managed with those same medications with the addition of Vraylar for

mood stability. The Zoloft and Vraylar are daily use and the Trazadone

and Hydroxyzine (aka Vistaril) are “as needed” use. With such

conservative course of care, the objective exams are repeatedly without

abnormal finding and controlling symptoms such that the claimant has

not required ER care, intensive outpatient treatment, or inpatient

psychiatric hospitalization for symptom control. Moreover, she has not

sought or required any urgent care visits at [sic] mental health between

her scheduled follow-ups, which as previously mentioned have been as

4 The ALJ reached the same conclusion with regard to Clem’s physical impairments, but Clem did

not challenge that conclusion in this matter.

much as six months apart. The objective exams include the claimant

alone at visits, independent with giving history and making decisions

about her treatment plan, and routinely showing for recommended

follow-ups, which is indicative of responsible behavior, good

judgment, and good memory functions.

The alleged disability onset date of September 27, 2019, is not

remarkable in these mental health records. At the follow-up before that

date, which was in July 2019, the claimant reported her mood is “ok”

when at home and she recently had dinner out with her son and fiancé’

[sic] at a buffet. Objectively, there was appropriate behavior and affect,

euthymic mood, and normal attention, concentration, and

speech/vocabulary with no hallucinations/delusions or

suicidal/homicidal plan or intent. She did not seek any care again until

her recommended follow-up in November 2019. That visit is 1-2

months after the alleged disability onset date and the same good

objective findings are documented. The practitioner only follow-ups

continue during 2020 and they were two and/or three months apart

when the same medications were continued with the addition of Vraylar

that she reports helps with mood stability. At her three-month follow-

up in April 2020, she denied being bothered by the Covid-19 quarantine

and reported better sleep, energy, and weight loss. The July 2020

follow-up is when she reported having been out of Vraylar for two

weeks recently due to a pharmacy problem, but she has resumed use

and has an “ok” mood. She reported improved eating habits with weight

loss and that she recently got a tattoo. She takes Hydroxyzine only as

needed “occasionally when she has to get out of the house”. Her

objective exams in April and July remained normal, she again denied

thoughts of harm to self or others, and medication management was

continued with mention that Vraylar could be adjusted for

depression/energy if needed. The September 28, 2020 exam remained

normal and she was continued on the same medications with an increase

to Vraylar to target symptoms she reported although not evident on

exam, no change to Zoloft, and instructions to resume as needed use of

Trazadone and Hydroxyzine (aka Vistaril) (Exhibit C8F). She did not

return until her scheduled follow-up in November.

In sum, the mental health records include the claimant’s depression

with anxiety is under control with medication management and

practitioner followups months apart without any therapy/counseling or

formal interventions otherwise. The above finding accommodates the

mental impairments with limitations to simple routine tasks work,

simple decision making, no more than 1-3 step instructions, and

infrequent and well-explained workplace changes as well as work

requiring only occasional interaction with coworkers and supervisors

and no interaction with the public. The records are indicative of good

recall/memory functions, as evident by the claimant’s reports of

specifics about medication use, daily activities, etc., between visits, and

even her adherence for years with scheduled visits. The repeatedly

normal/intact/appropriate findings on objective exams are inconsistent

with deficits of mental functioning to find greater limitation. The

objective exams do not identify memory deficit and routinely include

normal attention and concentration. The conservative course of care

2019-2020, including followups months apart with ongoing normal

mental status exams at those visits is not consistent with excessive

absences being a problem for work, as was indicated in hearing

testimony. The are no employer or medical records documenting

passing out from anxiety or daily manic episodes the claimant testified

were a problem at work.

(Doc. 5-3 at 23−25.)

As evidenced in the excerpt above, the ALJ articulated explicit and specific

reasons, supported by the record, for why she discredited, in part, Clem’s subjective

complaints regarding Clem’s mental impairment symptoms. For instance, the ALJ

noted that there was no evidence to explain why Clem’s disability onset date was

September 27, 2019, or to support her allegations that she suffered from severe

symptoms when she was still employed. The ALJ also cited medical evidence of

record to support her conclusions, such as Clem’s “normal” objective psychiatric

examinations from November 2019 and April and July 2020. At each of those

examinations, the practitioner made the same observations: Clem’s mood was

euthymic; she had appropriate affect; she demonstrated good concentration; and she

was coherent, logical, and goal directed. (Doc. 5-11 at 61−62, 66−67, 77.)

This Court, having reviewed the entire record, finds that the ALJ’s reasons

are sufficiently supported by the record because a “reasonable person would accept

[them] as adequate” to support the ALJ’s decision to discount Clem’s subjective

complaints. In other words, the Court finds no basis for concluding that the ALJ’s

reasons lack substantial evidentiary support. The Court emphasizes that the ALJ

gave some credence to Clem’s subjective complaints and that she incorporated

limitations in Clem’s RFC based on Clem’s mental impairments, including routine-

tasks work; simple decision making, no more than 1-3 step instructions; infrequent

and well-explained workplace changes; only occasional interaction with coworkers

and supervisors; and no interaction with the public. (Doc. 5-3 at 21.) As such, it is

clear to the Court that the ALJ “considered [Clem’s] medical condition as a whole,”

and the Court will not second-guess the ALJ’s determination that there were

inconsistencies between Clem’s subjective complaints and the evidence in the record

that undermined Clem’s allegations as to the full extent of her limitations.

Clem offers no meaningful argument to the contrary. Her main argument is

that “the ALJ ignore[d] the actual assessment by the mental health professionals”

because during the relevant time period, the medical evidence shows that Clem’s

mental impairments only worsened. (Doc. 7 at 12.) Clem cites several notations from

her appointments at Wellstone Behavioral Health, such as some from January 2020,

when Clem reported her anxiety was worse, and from November 2019, when the

status for Clem’s “mood/instability” read “Not Controlled,” and the status for her

depression read “Worsening.” (Doc. 7 at 13.) But Clem’s argument merely points to

evidence that supports her preferred outcome—it does not change the fact that the

several reasons the ALJ gave for discounting Clem’s subjective complaints are

supported by substantial evidence in the record.

IV. CONCLUSION

The Court thus AFFIRMS the Commissioner’s decision. A final judgment

will be entered separately.

DONE and ORDERED May 30, 2023.

Ko SZ Sh

LILES C. BURKE

UNITED STATES DISTRICT JUDGE

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