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[DO NOT PUBLISH]
IN THE UNITED STATES COURT OF APPEALS
FOR THE ELEVENTH CIRCUIT
________________________
No. 14-10597
Non-Argument Calendar
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D.C. Docket No. 8:12-cv-02476-JSM-TGW
CATHY MCMAHON,
Plaintiff-Appellant,
versus
COMMISSIONER, SOCIAL SECURITY ADMINISTRATION,
Defendant-Appellee.
________________________
Appeal from the United States District Court
for the Middle District of Florida
________________________
(September 24, 2014)
Before HULL, MARCUS and FAY, Circuit Judges.
PER CURIAM:
Cathy McMahon appeals the district court’s order affirming the Social
Security Administration’s denial of her application for disability insurance
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benefits, 42 U.S.C. § 405(g), and disabled widow’s benefits, 42 U.S.C. § 402(e)(1).
Although the Administrative Law Judge (“ALJ”) found that McMahon was
disabled due to several mental impairments, the ALJ also found that McMahon’s
alcohol use was a contributing factor material to her disability determination, and
thus McMahon could not be considered disabled for purposes of Social Security
benefits. After review, we affirm. 1
I. FIVE-STEP SEQUENTIAL EVALUATION
A claimant for Social Security benefits must prove that she is disabled.
Moore v. Barnhart, 405 F.3d 1208, 1211 (11th Cir. 2005); 42 U.S.C. §§ 402(e)(1),
423(a)(1)(a). 20 C.F.R. § 404.1520(a)(2), (a)(4). To determine whether the
claimant is disabled, the ALJ employs a five-step process. 20 C.F.R.
§ 404.1520(a)(2), (a)(4).
Under the first step, the claimant has the burden to show that she is not
currently engaged in substantial gainful activity. Id. § 404.1520(a)(4)(i). At the
second step, the claimant must show she has a severe impairment. Id.
§ 404.1520(a)(4)(ii). A severe impairment is an “impairment or combination of
1
Our review is limited to whether the ALJ’s decision is supported by substantial evidence
and based on proper legal standards. Winschel v. Comm’r of Soc. 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 quotation
marks omitted). Under this limited standard of review, we do not make findings of fact, reweigh
the evidence, or substitute our judgment for that of the Commissioner. Id.
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impairments which significantly limit[ ] [the claimant’s] physical or mental ability
to do basic work activities.” Id. § 404.1520(c). Step two is a threshold inquiry,
and the ALJ does not go on to step three if the claimant fails to meet step two, but
rather determines that the claimant is “not disabled.” McDaniel v. Bowen, 800
F.2d 1026, 1032 (11th Cir. 1986); 20 C.F.R. § 404.1520(a)(4)(ii). At step three,
the claimant must show that her severe impairment meets or equals the criteria in
the Listings of Impairments. 20 C.F.R. § 404.1520(a)(4)(iii). At step four, if the
claimant cannot meet or equal one of the Listings, the ALJ considers whether the
claimant has the residual functional capacity (“RFC”) to perform her past relevant
work. Id. § 404.1520(a)(4)(iv). Finally, if the claimant establishes she cannot
perform her past relevant work, the burden shifts to the Commissioner to show that
significant numbers of jobs exist in the national economy that the claimant can
perform in light of her RFC, age, education, and work experience. Id.
§ 404.1520(a)(4)(v); Jones v. Apfel, 190 F.3d 1224, 1228 (11th Cir. 1999).
In evaluating the severity of the claimant’s mental impairments at step two,
the ALJ first evaluates the signs, symptoms, and laboratory findings to determine
whether the claimant has a medically determinable mental impairment (called the
“paragraph A criteria”) and then rates the degree of functional limitation from the
mental impairments in four areas: activities of daily living; social functioning;
concentration, persistence, or pace; and episodes of decompensation (called the
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“paragraph B criteria”). 20 C.F.R. § 404.1520a(a)-(d). If the ALJ rates the
claimant’s limitations as “none” or “mild” in the areas of activities of daily living,
social functioning, and concentration, persistence, or pace, and “none” in the area
of episodes of decompensation, the claimant’s mental impairments will be found to
be “not severe.” Id. § 404.1520a(c)(3), (d)(1).
II. DISABILITY WHERE THERE IS EVIDENCE OF ALCOHOLISM
If the ALJ finds at step three that the claimant is disabled, and there is
medical evidence of alcoholism, the ALJ must then determine whether the
alcoholism was a material contributing factor to the disability determination. Id.
§ 404.1535(a); see also 42 U.S.C. § 423(d)(2)(C) (providing that “[a]n individual
shall not be considered to be disabled . . . if alcoholism or drug addiction would
(but for this subparagraph) be a contributing factor material to the Commissioner's
determination that the individual is disabled”). The “key factor” in determining
whether alcoholism is a material contributing factor to the disability determination
is whether the claimant would still be found disabled if she stopped using alcohol.
20 C.F.R. § 404.1535(b)(1). “In making this determination, [the ALJ evaluates]
which of [the claimant’s] current physical and mental limitations, upon which [the
ALJ] based [her] current disability determination, would remain if [the claimant]
stopped using drugs or alcohol and then determine[s] whether any or all of [the
claimant’s] remaining limitations would be disabling.” Id. § 404.1535(b)(2). If
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the ALJ determines that the claimant’s remaining limitations would not be
disabling if she stopped using alcohol, then the ALJ will find that the alcoholism is
a contributing factor material to the determination of disability. Id.
§ 404.1535(b)(2)(i). If that determination is made, the claimant is not considered
disabled under the Social Security Act. 42 U.S.C. § 423(d)(2)(C). The claimant
bears the burden to prove that she would be disabled if she stopped using alcohol.
Doughty v. Apfel, 245 F.3d 1274, 1275-76 (11th Cir. 2001).
III. ALJ’S DECISION
At steps one and two, the ALJ determined that McMahon had not engaged in
substantial gainful activity since June 1, 1992, her alleged onset date, 2 and had the
severe impairments of depression, anxiety, dependent personality traits, and
alcohol dependence. At step three, the ALJ found that McMahon’s severe mental
impairments, including her substance use disorder, met Listings 12.04 (affective
disorders), 12.06 (anxiety-related disorders), 12.08 (personality disorders), and
12.09 (substance addiction disorders). In addressing the paragraph B criteria at
step 2, the ALJ noted that: (1) the medical evidence showed that McMahon had
“significant issues with alcohol dependence”; and (2) McMahon had “resided in
2
McMahon appears to argue that the ALJ erred in using the onset date of June 1, 1992,
alleged in her applications for benefits, rather than September 24, 1997, the date McMahon’s
attorney cited in a pre-hearing memorandum. We note that McMahon did not object at the
disability hearing when the ALJ indicated her disability onset date was 1992. In any event,
McMahon has not shown prejudice from the ALJ’s use of the earlier onset date.
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residential treatment facilities on more than one occasion” and “when [McMahon
was] under the influence of alcohol she has exhibited suicidal ideation, poor insight
and judgment, confusion, psychomotor retardation, etc.” As a result, the ALJ
found “marked restriction in activities of daily living, moderate difficulties in
maintaining social functioning, marked difficulties in maintaining concentration,
persistence, or pace, and at least one to two episodes of decompensation of
extended duration.” Thus, McMahon’s mental impairments, including the
substance use disorder, met the paragraph B criteria.
Because the disability finding included McMahon’s alcohol use, the ALJ
then considered whether McMahon’s remaining limitations would have caused
more than minimal impact on her ability to perform basic work activities during
the periods at issue if McMahon had stopped using alcohol. The ALJ determined
that McMahon’s other limitations would not have significantly limited her ability
to perform basic work activities.
In making this determination, the ALJ applied the two-part “pain standard”
for evaluating a claimant’s subjective symptoms and concluded that, if McMahon
stopped her alcohol use: (1) her medically determinable impairments could
reasonably be expected to produce the alleged symptoms; but (2) her statements
about the intensity, persistence, and limiting effects of her symptoms were not
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credible “to the extent they are inconsistent with finding that [McMahon] has no
severe impairment or combination of impairments” absent her alcohol abuse.
The ALJ explained that McMahon had provided little evidence to support a
finding that she was disabled prior to either September 30, 1997 (for disability
insurance benefits), or March 13, 2003 (for disabled widow’s benefits). Noting
that McMahon was in an inpatient facility for alcohol dependence in 1983, in
alcohol rehabilitation in 1984, and arrested for marijuana possession in 1998, the
ALJ stated that McMahon’s file suggested that McMahon’s “history is that of
chronic alcoholic dependence and, perhaps, drug abuse issues.”
McMahon’s file showed no medical treatment activity until 1994, when
McMahon began drinking again and was discharged from nursing school. At that
time, McMahon appeared older then her age and exhibited impaired insight and
judgment, but was cooperative and did not display evidence of paranoia,
hallucinations, or delusions, and had intact recent and remote memory. McMahon
underwent a mental status exam and was diagnosed with adjustment reaction with
depressed mood and anxiety, dependent personality traits, and alcohol dependence.
Thereafter, McMahon received “sporadic treatment” for: (1) alcohol withdrawal in
1995, during which she was “fully aware” that she had a problem, displayed “fairly
good motivation,” was fully alert, oriented, and cooperative, and was discharged
within five days; and (2) six-month substance abuse treatment in March 1996, after
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which she was “successfully discharged” with a “very positive outlook on her
recovery.” In 1996, McMahon completed one college degree and began working
on another. The ALJ found that this evidence did not “support [McMahon’s]
allegations of disabling mental issues.” In 1997, McMahon experienced a “crisis,”
which appeared to be a relapse, and withdrew from her studies. In 1998,
McMahon was admitted to a crisis stabilization unit with suicidal ideations, but the
ALJ noted that this treatment was also tied to her substance abuse.
Based on this evidence, the ALJ found that, for purposes of disability
insurance benefits, from McMahon’s onset date (June 1, 1992), McMahon sought
treatment only sporadically, during which treatment notes showed she was alert,
cooperative, and in no jeopardy of harming herself or others, and up to the point
when her insured status expired (September 30, 1997), she exhibited problems, but
they were all related to her alcoholism.
With respect to disabled widow’s benefits, the ALJ found that McMahon did
not seek further treatment until 2001, when she enrolled in a 60-day detox
program. McMahon was discharged in June 2001 with a GAF score of 80, 3 and
did not receive any follow-up treatment prior to the date of her remarriage (March
13, 2003). In sum, the ALJ found that the medical evidence did not show that the
3
The Global Assessment Functioning (GAF) Scale ranges from 1 to 100, and a score of
80 indicates transient symptoms with no more than slight impairment in social, occupational, or
school functioning. See Diagnostic and Statistical Manual of Mental Disorders, at 34 (4th ed.
text rev. 2000).
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medically determinable impairments, aside from alcoholism, caused more than a
minimal limitation on McMahon’s ability to perform basic work activities. The
ALJ noted that, during the relevant period: (1) McMahon had several intact mental
status exams, “particularly during periods after a detoxification program was
completed”; and (2) there was “little to no evidence” of complaints of panic attacks
and no evidence of alleged physical limitations or medication side effects.
As to opinion evidence, the ALJ gave considerable weight to the State
agency mental assessments, which included a 2009 psychological exam by Dr.
Melissa Trimmer and a 2009 psychiatric review technique completed by Dr. Carol
Deatrick. Dr. Trimmer opined, inter alia, that McMahon was “capable of
understanding and following simple instructions and directions” and appeared
“cognitively capable of performing complex tasks, but had “difficulty dealing with
stress.” Dr. Trimmer diagnosed McMahon with major depression recurrent,
alcohol dependence in full remission, and mix personality features. Dr. Deatrick
opined, inter alia, that McMahon had no restrictions of activities of daily living, no
difficulties in maintaining social functioning, mild difficulties maintaining
concentration, persistence and pace, and no episodes of decompensation and that
McMahon’s mental status was essentially normal.
The ALJ concluded that without McMahon’s alcohol dependence, the
evidence showed only mild restrictions in three of the four “paragraph B”
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functional areas (activities of daily living, social functioning, and concentration,
persistence, or pace) and no episodes of decomposition for an extended period of
time. “Because the remaining mental limitations would cause no more than ‘mild’
limitation in any of the first three functional areas and ‘no’ limitation in the fourth
area, they would be nonsevere if the substance use was stopped.” Accordingly, the
ALJ determined that McMahon’s substance use disorder was a contributing factor
material to the determination of disability and that McMahon was not disabled
within the meaning of the Social Security Act at any time between June 1, 1992
and September 30, 1997 (for disability insurance benefits purposes), or March 13,
2003 (for disabled widow’s benefits purposes).
For these reasons, the ALJ denied McMahon’s applications for benefits.
The Appeals Council denied McMahon’s request for review, making it the
Commissioner’s final decision. The district court affirmed the ALJ’s decision.
IV. MCMAHON’S APPEAL
A. Five-Step Evaluation
McMahon’s argument that the ALJ failed to follow the proper legal
standards lacks merit. The ALJ followed the five-step process and, at steps one
through three, found that McMahon had not engaged in substantial gainful activity
since June 1, 1992, had several severe mental impairments, including her alcohol
dependence, and that these impairments met Listings 12.04, 12.06, 12.08 and
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12.09. Because McMahon met the Listings, there was no need for the ALJ to
determine McMahon’s RFC and proceed to steps four and five.
Contrary to McMahon’s assertions, the fact that the ALJ found that she met
the Listing criteria does not render her immediately entitled to disability benefits
because this determination included consideration of her alcohol abuse disorder.
See 20 C.F.R. § 404.1535(a). Similarly, the ALJ’s determination that McMahon
had the “severe impairments” of depression, anxiety, dependent personality traits,
and alcohol dependence does not mean the ALJ necessarily found that the non-
alcohol impairments were independently severe. See id. § 404.1520(a)(4)(ii), (c)
(explaining that at step two the ALJ considers whether the claimant has an
impairment or combination of impairments that is severe). Because there was
medical evidence of McMahon’s alcoholism, after the ALJ found that she met the
Listings with her alcohol dependence and therefore was disabled, the ALJ was
required to determine whether McMahon’s alcohol dependence was a contributing
factor material to that disability determination. See 42 U.S.C. § 423(d)(2)(C); 20
C.F.R. § 404.1535(b). Thus, the ALJ correctly went on to determine whether
McMahon would be disabled without alcohol use by going back to step two. See
20 C.F.R. § 404.1535(b). Finally, because the ALJ determined that McMahon did
not satisfy the severe impairment requirement at step two without alcohol use, the
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ALJ properly stopped her analysis there and did not proceed on to steps three
through five. See id. § 404.1520(c); McDaniel, 800 F.3d at 1032.
B. Medical Source Evidence
The ALJ also properly evaluated the medical opinion evidence in the record
in concluding that McMahon’s impairments were not severe. See Sharfarz v.
Bowen, 825 F.2d 278, 280-81 (11th Cir. 1987) (explaining that the ALJ is required
to indicate and explain the weight assigned to different medical opinions). The
ALJ specifically addressed the weight given to each doctor’s medical opinion.
Although McMahon contends the ALJ did not give proper weight to her
mental health counselor’s 1997 letters and the nurses’ progress notes from
McMahon’s 2001 inpatient treatment for alcohol dependence, these documents do
not constitute “medical opinions” because they are not statements from physicians
or psychologists that reflect judgment about the nature and severity of McMahon’s
impairments. See 20 C.F.R. § 404.1527(a)(2).4 Thus, the ALJ was not required to
assign and explain the weight given to that evidence. See id.; see also Sharfarz,
825 F.2d at 280-81. Further, while the ALJ must address medical opinions
explicitly, the ALJ is not required to address every piece of evidence in the record.
4
In 1995, while in nursing school, McMahon was forced to withdraw from classes due to
her drinking problem and, in order to remain in the nursing program, agreed to, among other
things, seek counseling. Between 1996 and 1997, Donna Roberts, a licensed mental health
counselor and registered nurse, counseled McMahon and also wrote two letters to McMahon’s
university.
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See Dyer v. Barnhart, 395 F.3d 1206, 1211 (11th Cir. 2005) (stating that “there is
no rigid requirement that the ALJ specifically refer to every piece of evidence in
his decision”); see also Cowart v. Schweiker, 662 F.2d 731, 735 (11th Cir. 1981)
(noting that the ALJ should sufficiently explain the weight given to “obviously
probative” evidence).
As McMahon concedes, the letters and progress notes were not from an
“acceptable medical source” for determining whether McMahon had a medically
determinable impairment. See 20 C.F.R. § 404.1513(a), (d). The ALJ may still
consider evidence from nurses and therapists in determining the severity (rather
than the existence) of medically determinable impairments. Id. § 404.1513(d).
Here, however, neither the mental health counselor’s letters nor the nurses’
progress notes addressed the severity of McMahon’s other mental impairments,
that is, the degree to which those other mental impairments limited her ability to do
basic work activities. See id. § 404.1521(a) & (b) (explaining that an impairment
is non-severe “if it does not significantly limit [the claimant’s] physical or mental
ability to do basic work activities”).
The mental health counselor’s letters did not describe any significant
limitations on McMahon’s mental ability to do basic work activities, except to say
that McMahon found nursing school stressful, that “stress made it difficult for
[McMahon] to continue to concentrate on her class work” and that McMahon had
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“PMS related depression.” The mental health counselor, however, also requested
that McMahon’s university permit her to remain a student in good standing and
later expressed surprise when McMahon was dismissed from the program.
Moreover, the mental health counselor indicated that, although McMahon had
failed a drug test, missed a counseling session, and admitted to drinking, McMahon
had since put her recovery program back in place and understood her alcoholism.
Thus, the mental health counselor’s letters support, rather than undermine, the
ALJ’s finding that McMahon’s alcoholism was a contributing material factor to her
disability, and, if McMahon stopped using alcohol, her other mental impairments
would not cause more than minimal impact on her ability to perform basic work
activities during the relevant periods.
Likewise, the progress notes for McMahon’s 2001 treatment for alcohol
dependence do not contain any evidence of significant limitations caused by
McMahon’s other mental impairments. These progress notes indicated, inter alia,
that McMahon was sober, sleeping well, and working at a mortgage company and,
importantly, that her alcohol dependence was in early remission and her major
depression recurrent was in full remission. In short, this evidence supported the
ALJ’s finding that, when McMahon was not using alcohol, McMahon’s other
mental impairments were not severe.
C. McMahon’s Subjective Symptoms
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McMahon argues that the ALJ did not properly evaluate her subjective
complaints. We disagree.
When a claimant attempts to establish disability through her own testimony
about her subjective symptoms, a three-part “pain standard” applies. Wilson v.
Barnhart, 284 F.3d 1219, 1225 (11th Cir. 2002). The pain standard requires: “(1)
evidence of an underlying medical condition; and (2) either (a) objective medical
evidence confirming the severity of the alleged pain; or (b) that the objectively
determined medical condition can reasonably be expected to give rise to the
claimed pain.” Id. If the ALJ determined that the claimant has a medically
determinable impairment that could reasonably be expected to produce the pain or
other symptoms, then the ALJ evaluates the extent to which the intensity and
persistence of those symptoms limit her ability to work. 20 C.F.R. § 404.1529(b).
At this stage, the ALJ considers the claimant’s history, the medical signs and
laboratory findings, the claimant’s statements, statements by treating and non-
treating physicians, and other evidence of how the pain affects the claimant’s daily
activities and ability to work. Id. § 404.1529(a).
A claimant’s testimony supported by medical evidence that satisfies the pain
standard is sufficient to support a finding of disability. Foote v. Chater, 67 F.3d
1553, 1561 (11th Cir. 1995). If the ALJ decides not to credit a claimant’s
testimony about her symptoms, the ALJ “must articulate explicit and adequate
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reasons for doing so. Failure to articulate the reasons for discrediting subjective
pain testimony requires . . . that the testimony be accepted as true.” Id. at 1561-62.
Here, the ALJ properly applied the pain standard, found that McMahon had
medically determinable impairments (apart from her alcohol dependence) that
could reasonably be expected to produce the alleged symptoms (primarily panic
attacks and an inability to concentrate), but did not credit McMahon’s statements
about the intensity and persistence of those symptoms. Further, the ALJ
articulated specific reasons for discrediting McMahon’s statements regarding the
intensity, persistence, and limiting effects of her symptoms, explaining that: (1)
McMahon provided minimal evidence regarding her disability; (2) up until
September 30, 1997, the record showed that McMahon had problems, but those
problems were all related to her alcoholism; (3) McMahon not only attended
college during this time period, but also graduated from college; and (4) there was
no evidence to corroborate McMahon’s alleged panic attacks. The ALJ properly
discredited McMahon’s subjective symptom testimony, and that credibility finding
is supported by substantial evidence.5
D. Severity of Other Mental Impairments Without Alcohol
5
McMahon also complains that the ALJ did not consider her husband’s 2009
questionnaire. The ALJ was not required to explicitly address this piece of evidence in her
decision, especially given that it was duplicative of McMahon’s testimony, which the ALJ found
not credible.
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Finally, substantial evidence supports the ALJ’s determination that
McMahon’s remaining mental impairments would have resulted in only mild
limitations in the functional areas of activities of daily living, social functioning,
and concentration, persistence, and pace, as well as no episodes of
decompensation. The record showed that McMahon had intact mental functioning
and improvement during periods when she was not drinking alcohol. During these
times, she also successfully worked and went to school. Thus, the record contains
relevant evidence that a reasonable person would accept as adequate to support a
finding that McMahon’s other mental impairments would not have a more than
minimal impact on her ability to perform basic work activities if she stopped using
alcohol. See Moore, 405 F.3d at 1211.
V. CONCLUSION
For these reasons, substantial evidence supports the ALJ’s determination
that McMahon’s alcohol use disorder was a contributing factor to the
determination of disability and thus that McMahon was not disabled for purposes
of disability insurance benefits or disabled widow’s benefits.
AFFIRMED.
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