United States District Court, E.D. Arkansas, Western Division
Daniel Hamilton (“Hamilton”) appeals the final
decision of the Commissioner of the Social Security
Administration (defendant “Berryhill”) to deny
his claim for Supplemental Security Income
(“SSI”). Hamilton contends the Administrative Law
Judge (“ALJ”) erred in: (1) assessing his mental
limitations, particularly by failing to appropriately credit
the opinion of treating physician Dr. Clements
(“Clements”); and (2) assessing his physical
limitations. The parties ably summarized the medical records
and the testimony given at the administrative hearing, which
was conducted on March 28, 2016. The Court has carefully
reviewed the record to determine whether there is substantial
evidence to support Berryhill's decision. 42 U.S.C.
§ 405(g). The relevant period to be considered is from
March 18, 2013, Hamilton's alleged onset date, through
May 19, 2016, the date the Commissioner issued her decision.
was 47 years old at the time of the administrative hearing.
He testified he had an eleventh grade education and earned a
GED, though he “sometimes” had trouble reading.
(Tr. 50). Hamilton indicated he lived with his two children,
ages seven and eleven, and his mother-in-law. He stated he
has a driver's license, and smokes about one third of a
pack of cigarettes daily, a significant decrease from a
previous five pack a day habit. According to Hamilton, he no
longer drinks alcohol nor takes drugs, having last used
illegal drugs in 2004. Hamilton described numerous past jobs,
the most recent of which was working as a chicken marinater
for Tyson's in 2006. Hamilton testified that he had never
been fired from employment, and that he quit his most recent
job due to his depression. He described daily activities of
taking care of his children, doing some cooking, laundry, and
grocery shopping, and resting for 2-3 hours daily due to
depression. Hamilton said he attended school functions and
church, and fished from the bank on weekends.
work, Hamilton stated his depression and hearing voices
prevented him from employment. He also described neck and
back pain, and noted prior neck and back surgeries in 2006
and 2007. He indicated he takes only Tylenol for physical
pain, and would have problems being around people on a job
site, as well as problems maintaining his concentration.
Hamilton testified to seeing Clements for about a year prior
to the administrative hearing, to seeing a therapist every
two weeks, and to taking prescription medications with no
side effects for his mental impairments. Hamilton also stated
he has asthma, and has been treated with an inhaler since he
was sixteen years old. According to Hamilton, he sometimes
shakes after using the inhaler and is required to stop and
wait for the shaking to cease. Hamilton estimated he could
stand for five minutes, walk for five minutes, and sit for
thirty minutes or less before back pain would occur. Hamilton
stated he could carry no more than five pounds. (Tr. 49-70).
vocational expert, David Elmore (“Elmore”),
testified Hamilton could not perform any of his past jobs.
The ALJ asked Elmore to assume a hypothetical worker of
Hamilton's age and background, with the ability to do
light work with numerous restrictions. Elmore indicated
such a worker could perform the jobs of production assembler
and sewing machine operator. A second hypothetical question,
assuming the worker would be off task 25% of the time, would
miss work once a week, and would require additional daily
breaks, was posed, and Elmore stated there would be no
available jobs for such a worker. (Tr. 72-76).
May 19, 2016, decision, the ALJ found Hamilton had severe
impairments of degenerative disc disease with residuals of
cervical and lumbar surgery, asthma, post traumatic stress
disorder (“PTSD”), and depression. The ALJ held
Hamilton did not meet a listed impairment. In conjunction
with the analysis regarding a listing, the ALJ considered the
“paragraph B” criteria and found the following:
Hamilton has mild limitations in activities of daily living,
has moderate limitations in social functioning, moderate
difficulties with regard to concentration, persistence or
pace, and had no episodes of decompensation. The ALJ
determined Hamilton had the residual functional capacity
(“RFC”) to perform light work with restrictions
which mirrored those contained in her initial hypothetical
question posed to Elmore and listed in footnote one herein.
thoroughly reviewed the medical findings by both treating and
consulting examiners, and also addressed the findings of the
state agency physicians. In reaching her RFC conclusion, the
ALJ ultimately assigned “great weight” to the
findings of Dr. Wilkins, who performed a 2013 consultative
physical examination, “great weight” to the
findings of Dr. Spataro, who performed a 2012 consultative
physical examination, “great weight” to the
findings of Dr. Faupel, who performed a 2014 consultative
psychological examination, and “little weight” to
the Medical Source Statement of Clements, the treating
psychologist. (Tr. 34-35). The ALJ explained that little
weight was given to Clements' opinion “because such
limitations are inconsistent with the claimant's clinical
presentation and treatment history.” (Tr. 35). The ALJ
also assigned “significant weight” to the
opinions offered by the state agency consultants. (Tr. 35).
Relying upon the testimony of Elmore, the ALJ concluded
Hamilton was not disabled. (Tr. 27-37).
Evidence During the Relevant Period:
April 2013 Hamilton saw his treating physician, Dr. Citty
(“Citty”), and was diagnosed with chest pain and
cervical fusion (old). (Tr. 921). Hamilton visited Citty
again in October and November 2013, with unremarkable
findings. (Tr. 917, 919). In May 2013 Dr. Wilkins
(“Wilkins”) performed a consultative physical
examination, finding a limited range of motion of the
cervical spine. Wilkins diagnosed Hamilton with cervicalgia
and lumbago, but indicated Hamilton was able to sit, walk,
and/or stand for a full workday, as well as lift/carry
without limitations. (Tr. 867-870).
February and April 2014 Hamilton was treated at local medical
centers for upper respiratory infection, acute bronchitis,
and asthma. (Tr. 875-882, 1093-1096).
consultative mental evaluation was performed by Dr. Ron
Faupel (“Faupel”) in June 2014. Faupel diagnosed
Hamilton with persistent depressive disorder, anxious
distress, and personality disorder (not otherwise specified).
Among other things, Faupel noted Hamilton could drive, shop,
make transactions, handle money, cook, clean house, do
laundry, make and keep appointments with reminders,
communicate effectively, and attend to his activities of
daily living. Faupel indicated Hamilton had problems
following instructions, which should be simple and written,
and that his ability to tolerate normal work related demands
was moderately impaired due to anxiety and low stress
tolerance. Further, Faupel found Hamilton's ability to
sustain attention on tasks and persist with difficult tasks,
and his ability to maintain pace on tasks, was moderately
impaired due to anxiety and poor concentration. (Tr.
September 2014 Hamilton was first seen at Clements'
Wellness Center, where Pam Daniel (“Daniel”),
LCSW, recorded a diagnosis of MDD (major depressive disorder)
without psychotic features, anxiety disorder (NOS), and
chronic PTSD. (Tr. 1120-1122). Hamilton returned for
counseling with Daniel later that month, in October and
December 2014, and in March 2015. (Tr. 1106-1108). Clements,
a psychiatrist, saw Hamilton in October 2014, and changed his
medications. Clements found Hamilton to be dealing with
anxiety symptoms, insomnia, and depression. He stated that
Hamilton was adequately dressed, with adequate eye contact,
regular rate and rhythm of speech, congruent affect, and
goal-directed and linear thought-processes, but feeling
overwhelmed and anxious, with limited insight and judgment.
(Tr. 1118). Clements next saw Hamilton in March 2015, finding
he was “doing better” without panic attacks but
still complaining of anxiety symptoms. (Tr. 1115). Clements
reported Hamilton's ability to cope with stressors was
“fair.” (Tr. 1115). Hamilton reported to Clements
that he was getting along well with his children and having
less mood swings. Clements' plan was to increase
medications and have Hamilton return in three months.
Hamilton saw Clements three more times during the relevant
period - in June and September 2015 and in January 2016. (Tr.
1128-1131, 1144-1147, & 1174-1177). On all three
occasions Clements continued and/or altered Hamilton's
medications. In March 2016, Clements executed a Medical
Source Statement indicating Hamilton was extremely limited in
ten areas of functioning, markedly limited in five areas, and
moderately limited in five areas. There were no areas in
which Clements found Hamilton had no or mild limitations.
(Tr. 1182-1183). Clements also opined Hamilton would be
absent from work more than three days a month due to his
in May 2015, Hamilton frequently was seen by Donald Wilson
(“Wilson”) for his mental issues. Wilson's
treatment notes identify himself as an “LPE, ” a
licensed psychological examiner. In his brief, Hamilton
refers to Wilson as “Dr. Wilson, Ph.D., LPE.”
Docket entry no. 11, page 8. Hamilton also describes Wilson
as his therapist. Docket entry no. 11, page 11. Wilson saw
Hamilton approximately every month in 2015 and approximately
twice a month in 2016 prior to the ALJ's decision. Wilson
treated Hamilton for agoraphobia, anxiety, stress,
depression, and PTSD. Wilson's treatment notes reflect
Hamilton was depressed, but typically his insight was intact
and his thought processes and thought content were not
impaired. There were occasions when Wilson found impaired
insight, such as in December 2015 and January 2016. (Tr.
1162, 1171). Wilson ...