Tolbert v. Chater ( 1997 )

F I L E D
United States Court of Appeals
Tenth Circuit
UNITED STATES COURT OF APPEALS
FEB 11 1997
FOR THE TENTH CIRCUIT
PATRICK FISHER
Clerk
CHERYL TOLBERT,
Plaintiff-Appellant,
v. No. 96-5120
(D.C. No. 94-C-1001-W)
SHIRLEY S. CHATER, (N.D. Okla.)
Commissioner, Social Security
Administration, *
Defendant-Appellee.
ORDER AND JUDGMENT **
Before ANDERSON, KELLY, and LUCERO, Circuit Judges.
Plaintiff Cheryl Tolbert appeals from the district court’s order affirming the
Secretary’s decision denying her application for disability benefits and
*
Effective March 31, 1995, the functions of the Secretary of Health and
Human Services in social security cases were transferred to the Commissioner of
Social Security. P.L. No. 103-296. In the text we continue to refer to the
Secretary because she was the appropriate party at the time of the underlying
administrative decision.
**
This order and judgment is not binding precedent, except under the
doctrines of law of the case, res judicata, and collateral estoppel. The court
generally disfavors the citation of orders and judgments; nevertheless, an order
and judgment may be cited under the terms and conditions of 10th Cir. R. 36.3.
supplemental security income. 1 Ms. Tolbert claimed disability due to pain in her
back and legs, and to depression. The administrative law judge (ALJ) determined
at step five of the five-step sequential process, see Williams v. Bowen, 844 F.2d
748, 750-52 (10th Cir. 1988), that Ms. Tolbert retained the residual functional
capacity (RFC) to perform sedentary work. On appeal, Ms. Tolbert asserts that
substantial evidence does not support the ALJ’s determination that she is not
disabled due to her mental impairments because the ALJ failed to consider and
accord proper weight to documented evidence of her mental impairments. We
agree, and reverse and remand.
We review the Secretary's decision to determine whether her factual
findings are supported by substantial evidence in the record viewed as a whole
and whether she applied the correct legal standards. Andrade v. Secretary of
Health & Human Servs., 985 F.2d 1045, 1047 (10th Cir. 1993). Substantial
evidence is such relevant evidence as a reasonable mind might accept as adequate
to support a conclusion. Castellano v. Secretary of Health & Human Servs., 26
F.3d 1027, 1028 (10th Cir. 1994) (citations and quotation omitted).
1
After examining the briefs and appellate record, this panel has determined
unanimously to grant the parties’ request for a decision on the briefs without oral
argument. See Fed. R. App. P. 34(f) and 10th Cir. R. 34.1.9. The case is
therefore ordered submitted without oral argument.
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Ms. Tolbert injured her back in a work-related accident in 1987. She
testified at her administrative hearing that her back pain prevents her from lifting,
concentrating, doing any housework, driving, shopping, exercising, or engaging in
social activities. Appellant’s App. Vol. II, at 94-97, 102, 114, 116, 140-45. She
testified she sleeps twelve to fifteen hours a day, and spends her day lying in bed
or on the couch. Id. at 95, 104, 115-16, 142-43. Physical examinations of
Ms. Tolbert performed in 1988 through 1992 indicated there was no objective
medical support for many of Ms. Tolbert’s subjective complaints of pain. Id. at
261, 271-76, 289-90, 293-94. Several of these reports indicated that Ms. Tolbert
overstated her complaints, and made unnecessary moans, groans and complaints
of pain. Id. at 274-75, 293, 352.
In January 1993, Ms. Tolbert went to Dr. Hickman for a consultative
psychological examination. Dr. Hickman administered the Weschler Adult
Intelligence Scale - Revised (WAIS-R) test, the Shipley Test, and the Minnesota
Multiphasic Personality Inventory (MMPI). Dr. Hickman reported that
Ms. Tolbert’s IQ was 66 as measured by WAIS-R, although her IQ as measured
by the Shipley test was 81. Id. at 345. Dr. Hickman also diagnosed Ms. Tolbert
with somatoform pain disorder, 2 explaining that Ms. Tolbert’s MMPI results were
2
A somatoform disorder exists when there are “[p]hysical symptoms for
which there are no demonstrable organic findings or known physiological
(continued...)
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consistent with those found among individuals experiencing significant
depression, lowered activity levels, apathy, and helplessness, those who try to use
histrionic defense mechanisms, and those whose physical complaints have
hysterical qualities. Id. at 344, 346. Dr. Hickman also completed a “Medical
Assessment of Ability to do Work-Related Activities (Mental)” form, in which he
rated as either “fair” or “poor” Ms. Tolbert’s ability to follow work rules, relate
to coworkers, deal with the public, use judgment with the public, interact with
supervisors, deal with work stresses, function independently, maintain attention
and concentration, follow complex or detailed job instructions, behave in an
emotionally stable manner, relate predictably in social situations, or demonstrate
reliability. Id. at 350-51. Use of the term ‘fair’ (or ‘poor’) on this form is
evidence of disability. See Cruse v. United States Dep't of Health & Human
Servs., 49 F.3d 614, 618 (10th Cir. 1995).
2
(...continued)
mechanisms.” 20 C.F.R. Pt. 404, Subpt. P, App. 1, 12.07. The disorder causes a
claimant to exaggerate her physical problems in her mind beyond what the
medical data indicate. Easter v. Bowen, 867 F.2d 1128, 1130 (8th Cir. 1989).
Such a disorder may itself be disabling. Id. Ms. Tolbert was diagnosed with a
subgroup of somatoform disorder called somatoform pain disorder, which is
indicated where pain is the predominant complaint, the pain is of sufficient
severity to warrant clinical attention, causes significant impairment in social or
occupational functions, and is not better accounted for by a mood, anxiety or
psychotic disorder. American Psychiatric Assoc., Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV), (4th ed. 1994), pp. 458-462. Assuming
the diagnosis of somatoform pain disorder is correct, the pain symptoms are not
intentionally produced or feigned. Id. at 461.
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In determining that Ms. Tolbert was not disabled, the ALJ found that her
testimony and, particularly, complaints of pain were not credible because they
lacked objective medical support and because the medical evidence showed that
Ms. Tolbert exaggerated her complaints. The ALJ’s findings made no reference
to Dr. Hickman’s diagnosis of somatoform pain disorder, and did not consider
whether Ms. Tolbert’s exaggerated complaints were a manifestation of this
disorder, affecting her perception of pain. See Winfrey v. Chater, 92 F.3d 1017,
1021 (10th Cir. 1996) (holding that the ALJ must consider whether a diagnosis of
somatoform disorder affected claimant’s perception of pain). The ALJ did not
include any mental limitations in his hypothetical inquiries to the vocational
expert at plaintiff’s hearing.
The ALJ completed a psychiatric review technique (PRT) form, finding that
Ms. Tolbert did not have somatoform disorder, but did have affective disorders
and mental retardation, although the ALJ stated that Ms. Tolbert’s IQ as measured
by WAIS-R was “lower than [it] should be because of [Ms. Tolbert’s] lack of
credibility.” Appellant’s App. Vol. II, at 27-28. In evaluating what functional
limitations these mental impairments imposed, the ALJ found only slight
restrictions on Ms. Tolbert’s daily activities and social functioning, and found
that Ms. Tolbert seldom experienced deficiencies of concentration, persistence or
pace, and never experienced episodes of deterioration or decompensation in work
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or work-like settings. Id. at 28. These findings were contrary to those of Dr.
Hickman’s, as well as to Ms. Tolbert’s testimony.
When a claimant for disability benefits or supplemental security income
presents evidence of a mental impairment that allegedly prevents a claimant from
working, the Secretary must follow the procedure for evaluating mental
impairments set forth in 20 C.F.R. §§ 404.1520a and 416.920a, and the Listing of
Impairments and document the procedure accordingly. Cruse, 49 F.3d at 617.
Documentation is made by completing a PRT form, which the ALJ must attach to
his written decision. “[T]he record must contain substantial competent evidence
to support the conclusions reached on the PRT form[, and] if the ALJ prepares the
form himself, he must ‘discuss in his opinion the evidence he considered in
reaching the conclusions expressed on the form.’” Id. at 617-18 (quoting
Washington v. Shalala, 37 F.3d 1437, 1442 (10th Cir. 1994)).
The ALJ is required to “evaluate every medical opinion” he receives,
20 C.F.R. § 404.1527(d), and to “consider all relevant medical evidence of record
in reaching a conclusion as to disability,” Baker v. Bowen, 886 F.2d 289, 291
(10th Cir. 1989). “[I]n addition to discussing the evidence supporting his
decision, the ALJ also must discuss the uncontroverted evidence he chooses not to
rely upon, as well as significantly probative evidence he rejects.” Clifton v.
Chater, 79 F.3d 1007, 1010 (10th Cir.1996); see also Taylor v. Schweiker, 739
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F.2d 1240, 1243 (7th Cir. 1984)(“[A]n ALJ must weigh all the evidence and may
not ignore evidence that suggests an opposite conclusion.”) (quoting Whitney v.
Schweiker, 695 F.2d 784, 788 (7th Cir. 1982)).
We conclude that the ALJ erred in rejecting Dr. Hickman’s diagnosis of
somatoform pain disorder without providing any explanation for doing so, and
that this error infected his evaluation of Ms. Tolbert’s subjective complaints of
pain and, therefore, his evaluation of her credibility. See Winfrey, 92 F.3d at
1021. Similarly, the ALJ failed to discuss why his conclusions on the PRT form
differed from Dr. Hickman’s findings. See Washington, 37 F.3d at 1442. The
only aspect of Dr. Hickman’s report the ALJ discussed in his decision was
Ms. Tolbert’s low IQ scores, which the ALJ concluded were not representative
because of her history of overstating her problems and lack of credibility.
Appellant’s App., R. Vol. II, at 21, 28. In concluding that Ms. Tolbert’s scores
were depressed, the ALJ noted that a consultative examination of Ms. Tolbert
performed by Dr. Karathanos on behalf of the agency four days after
Dr. Hickman’s examination indicated Ms. Tolbert was overstating her problems
but did not indicate any change in her scores. Id. at 21. However, Dr. Karathanos
is a neurologist, not a psychologist, and there is no indication in his report that he
performed any psychological or intelligence testing of Ms. Tolbert. Dr.
Hickman’s report is the only mental evaluation of Ms. Tolbert in the record, and
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we find no evidence in the record refuting any of his findings. Indeed, the
observations in numerous medical reports that Ms. Tolbert overstates her
problems may well be consistent with his diagnosis of somatoform pain disorder.
The ALJ’s failure to discuss or consider uncontroverted, probative evidence
of disability requires us to reverse and remand for proper consideration of
Ms. Tolbert’s mental impairments. On remand, the ALJ will also need to reassess
the credibility of Ms. Tolbert’s testimony, considering the possible effect of the
diagnosis of somatoform pain disorder. See Luna v. Bowen, 834 F.2d 161,
165-66 (10th Cir.1987) (holding that one of the factors an ALJ should consider in
evaluating allegations of pain is “the possibility that psychological disorders
combine with physical problems”). In turn, because many of the ALJ’s findings,
including those on the PRT form, were predicated on his credibility
determination, the ALJ will need to reconsider these findings as well. Finally, the
ALJ will need to evaluate whether Ms. Tolbert’s mental impairments meet or
equal a listed impairment, or whether the evidence supports the existence of a
severe nonexertional impairment that must be considered as affecting Ms.
Tolbert’s residual functional capacity to perform work. See Hargis v. Sullivan,
945 F.2d 1482, 1491 (10th Cir. 1991). These findings may dictate the need for
additional vocational expert testimony. See Cruse, 49 F.3d at 619 (requiring
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“expert vocational testimony or other similar evidence” when mental impairments
diminish a claimant’s residual functional capacity).
In conclusion, we determine that the ALJ’s decision was not supported by
substantial evidence. Therefore, we REVERSE and REMAND the case to the
district court with directions to REMAND to the Commissioner for further
proceedings consistent with this order and judgment.
ENTERED FOR THE COURT
Carlos F. Lucero
Circuit Judge
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