King v. Barnhart

• Decision Date: 01 June 2004
• Docket Number: Civ.A. No. 02-G-2555-W.
• Court: U.S. District Court — Northern District of Alabama
• Parties: Sharon Latricia KING, Plaintiff, v. Jo Anne B. BARNHART, Commissioner of Social Security, Defendant.

320 F.Supp.2d 1227

Sharon Latricia KING, Plaintiff, v. Jo Anne B. BARNHART, Commissioner of Social Security, Defendant.

Civ.A. No. 02-G-2555-W.

United States District Court, N.D. Alabama, Western Division.

June 1, 2004.

George W. Harris, George W. Harris PC, Tuscaloosa, AL, for plaintiff.

Alice H. Martin, U.S. Attorney, Edward Q. Ragland, U.S. Attorney's Office, Birmingham, AL, Mary Ann Sloan, Doug Wilson, Social Security Administration — Office of General Counsel, Atlanta, GA, for defendant.

MEMORANDUM OPINION

GUIN, District Judge.

Plaintiff brings this action pursuant to the provisions of section 205(g) of the Social Security Act, [hereinafter the Act], 42 U.S.C. § 405(g),¹ seeking judicial review of a final adverse decision of the Commissioner of Social Security [hereinafter Commissioner]. Application for a period of disability and disability insurance benefits under sections 216(i) and 223 of the Social Security Act, as amended, was filed January 5, 2001. These applications were denied initially. Request for a hearing before an administrative law judge [hereinafter ALJ] [Jerry W. Shirley] was granted, and a hearing was held February 5, 2002. The ALJ's decision to deny benefits was handed down March 28, 2002. Plaintiff's request for review by the Appeals Council was denied September 21, 2002. An appeal to this court followed.

Plaintiff is a 51 year old female with a high school education. Past relevant work is as a dentist's receptionist, convenience store cashier, and office manager in a grocery store. She claims disability due to pain and mental impairments.

Ms. King testified she hurts all the time every day. She is unable to work because of the pain. Her legs throb. She is unable to stand for very long — about 15 minutes. Pain prevents her from sleeping. She is unable to walk very far — maybe a block. She has to take a pain pill or sit down. She is able to sit about 30 minutes. At times the pain is so bad she is unable to get out of bed: her legs won't work. She has pain from her hips down. She rates her pain between an eight/nine on a scale of 10. On a better day she rates the pain at about a four. She is able to lift about four pounds maximum.

Daily activities include sitting and lying down. She is unable to do any housework. She is unable to bend. Plaintiff stays in the house most of the time because of panic attacks. She goes out to visit the doctor or her parents. It hurts to ride in a car and she does not drive. She has no friends other than her family. She does not go out to visit friends. She never goes out alone and is rarely alone. Her husband helps her with her personal needs. She reads and watches television. She is no longer able to attend church.

Plaintiff testified she has been having panic attacks about 10 years for which Prozac, Buspar, Valium, and Xanax have been prescribed at different times.

Prescribed medication is Ambien.(sleep medication). She takes Propoxy (?) for pain and Infex (?), a muscle relaxer.

The record shows that plaintiff has suffered with back problems. She was treated initially by orthopedist Dr. H. Chester Boston. X-rays of the lumbar spine showed a marked narrowing at the L5-S1 vertebrae. Dr. Boston sent her to pain specialist Dr. Wesley Spruill for treatment. Dr. Spruill diagnosed low back pain, degenerative disc disease L5-S1, and bilateral lower extremity radiculopathgy. He treated her with lumbar epidural injections (3) and performed a lumbar provocative discogram L3-4, L4-5, and L5-S1 to evaluate her for spinal fusion.

In February 2001 Dr. Boston performed anterior interbody fusion at the L5-S1 vertebrae with BAK cages and autograft. Two days later plaintiff had severe nausea and vomiting. Dr. Naresh Kumar performed a paparatomy with lysis of abdominal lesions.

Although she did well following surgery she continued to report numbness in her left leg in August 2001.² Plaintiff testified she has never been pain free since the surgery. Dr. Boston's notes of August 6, 2001, indicate that as of that date plaintiff was having some dysesthesias (paresthesias)³ involving the left leg.

A consultative evaluation was performed March 27, 2001, one month following surgery, by Dr. Jamal A. Halim. A musculoskeletal examination of the LS-spine showed moderate tenderness and spasm over the lumbosacral region bilaterally. Straight leg raising tested positive on the left at 30 degrees. The doctor's assessment was status-post lumbar surgery in February for degenerative disc at L5-S1 and left lumbar radiculopathy. Dr. Halim concluded his evaluation with the following comments:

DISCUSSION: Based on the history and physical exam I believe that the patient should be restricted to activities in the mild range⁴ including sitting, standing, walking, lifting, carrying objects, bending, pushing and pulling. Travel is limited because of her low back pain. A cane is not medically necessary.

In addition to her physical problems plaintiff has mental problems, as well. Neuropsychologist John Goff performed a "CONFIDENTIAL PSYCHOLOGICAL EVALUATION." He saw plaintiff January 21, 2001, a month prior to her back surgery. Accompanying the request for the evaluation were a "substantial number of records (later supplemented),"⁵ most of which dealt with her physical problems.

In the section of his report entitled "BEHAVIORAL OBSERVATIONS AND MENTAL STATUS" he noted plaintiff described the pain she was experiencing. She admitted to being depressed. The doctor opined she appeared to be quite apprehensive and anxious, being afraid of falling. Her memory was intact.

Dr. Goff made "PSYCHOMETRIC FINDINGS" based on comprehensive psychological assessment administration of multiple tests: Wechsler Abbreviated Scale of Intelligence [WASI]; Reitan-Indiana Aphasia Screening Test; Wide Range Achievement Test [WRAT-III]; Minnesota Multiphasic Personality Inventory [MMPI-2]; and informal clock drawing tasks. Portions of his findings follow:

The clinical profile obtained is suggestive of an individual who exhibits an array of symptoms including depression, anxiety, mental turmoil and social withdrawal. She is plagued by constant worry and self-doubt. She feels inadequate to meet the ordinary demands of everyday life and becomes helplessly overwhelmed by bigger challenges. Her distress and agitation interfere with her concentration and the clarity of her thinking. She finds it difficult to focus on her thoughts and to communicate effectively. She feels estranged, frustrated and misunderstood.

Many types of social situations including employment situations are uncomfortable for her. She may try to avoid them unless they are minimal demands and she receives much support and reassurance. Forming relationships and maintaining comfortable attachments, even with family members, presents a hardship for her. Though finding it difficult to feel accepted, trusting and affectionate she may hold onto relationships with much ambivalence. Episodes of intense distress, confusion and unusual behavior may occur periodically. These may arise in response to situational stress or develop gradually. She increasingly retreats from social interaction and turns to narrow, obsessive belief systems for guidance. She frets over the disparity between her expectations of herself and her actual progress or accomplishment. Some suicidal impulses may ensue during times of spiraling despair and dissatisfaction or when pain becomes an overriding issue.

The patient is very depressed. Mental dullness adds to her considerable subjective feelings of depression. Persistent unhappiness and discouragement sap much of her energy, enthusiasm and initiative.

...

The modal diagnoses suggested by the MMPI-2 computer generated printout include Depressive Disorder NOS, Psychotic Disorder NOS, Anxiety Disorder NOS, Schizoaffective Disorder and Schizotypal Personality Disorder. I should note that I do not think the patient is psychotic....

In his "SUMMARY/IMPRESSIONS" the doctor noted her anxiety is probably related to some elements of posttraumatic stress and opined she needs treatment. When she ventures out of the house she has panic attacks which drive her back in. Plaintiff sees herself as being boxed in by her mental and physical problems. Portions of his "CONCLUSIONS" follow:

Examination of the psychometric test data yields the following conclusions and/or inferences.

...

3. This lady has had significant anxiety symptoms for many years. I think that is her principal psychological presentation. She is also very depressed, but I think her depression is primarily a reactive depression....

4. She does have panic attacks.

5. Diagnosis:

Axis I:⁶ Posttraumatic stress disorder,⁷ probably late onset, moderate with panic attacks⁸ Adjustment disorder with depressed mood,⁹¹⁰ moderate to severe

Axis II:¹¹ I think there are some dependent personality characteristics here which probably exacerbate her problems. I am not sure they exist to the point that a diagnosis is warranted.

Following his diagnosis the doctor concluded his evaluation with a comment to the effect that plaintiff's distress is "rather extreme"¹² and that her "psychological difficulties in and of themselves represent a moderately severe impairment."

No medical evidence contradicts Dr. Goff's diagnoses or opinion. See 20 C.F.R. § 404.1527 Evaluating opinion evidence. More weight is given "to the opinion of a specialist about medical issues related to his or her area of specialty than to the opinion of a source who is not a specialist." 20 C.F.R. § 404.1527(d)(5). Medical opinions supported by data such as testing are also given greater deference. 20 C.F.R. § 404.1527(d)(3). Other factors to be considered are the expert's familiarity with the Social Security's disability programs and familiarity with the complete record.¹³ His opinions are consistent with the other medical evidence on record. 20 C.F.R. § 404.1527(d)(4).¹⁴

Dr. Goff completed a "Medical Source Statement (M...