Archibald v. Bisignano

UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF TEXAS
VICTORIA DIVISION
BENJAMIN A.,
Plaintiff,
VS.
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CIVIL ACTION NO. 6:25-CV-00045
FRANK BISIGNANO,
Defendant.
MEMORANDUM AND RECOMMENDATION
Plaintiff Benjamin A.1 filed this action pursuant to 42 U.S.C. § 405(g) to review the
decision of the Commissioner of Social Security (“the Commissioner”) to deny his
application for Social Security disability benefits. Now pending are Benjamin’s and the
Commissioner’s construed cross-motions for summary judgment. (D.E.s 7, 10). Benjamin
contends that substantial evidence did not support the Administrative Law Judge’s (“ALJ”)
conclusion that Dr. Chelsea Wooley’s opinion was unsupported and inconsistent with the
objective findings. For the reasons discussed further below, it is recommended that
Benjamin’s motion (D.E. 7) be DENIED, the Commissioner’s motion (D.E. 10) be
GRANTED, and this cause of action be DISMISSED.
1 Pursuant to the May 1, 2018, “Memorandum Re: Privacy Concern Regarding
Social Security and Immigration Opinions” issued by the Committee on Court
Administration and Case Management of the Judicial Conference of the United States, this
order uses only Plaintiff’s first name and last initial.
United States District Court
Southern District of Texas
ENTERED
July 17, 2026
Nathan Ochsner, Clerk
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I. JURISDICTION
This Court has jurisdiction under 42 U.S.C. § 405(g) to review a final decision of
the Commissioner of Social Security and venue is appropriate because Benjamin resides
in DeWitt County, Texas. 42 U.S.C. § 405(g); 28 U.S.C. § 124(b)(5).
II. BACKGROUND & ADMINISTRATIVE RECORD
a. Application and Hearing
In May 2022, Benjamin filed applications for disability insurance benefits and
supplemental security income, alleging a disability commencing on March 3, 2022. (D.E.
5-6 at 2-6, 9-10). Benjamin claimed the following disabling conditions: (1) major
depressive disorder – recurrent episode, moderate; (2) borderline personality disorder;
(3) posttraumatic stress disorder – childhood trauma (“PTSD”); (4) unspecified disruptive
impulse control – conduct disorder; (5) chronic back pain; (6) chronic neck pain;
(7) degenerative disc disease; (8) high blood pressure; and (9) gout. (D.E. 5-7 at 26). The
Commissioner denied Benjamin’s application both initially and on reconsideration. (D.E.
5-4 at 2, 24).
In the Disability Determination Explanation at the initial stage, state medical
consultant Dr. Leslie Postovoit concluded that Benjamin had severe impairments
consisting of: (1) personality disorders; (2) substance addiction disorders (alcohol);
(3) depressive, bipolar, and related disorders; (4) anxiety and obsessive-compulsive
disorders; (5) trauma-and-stressor-related disorders; (6) impulse control disorders; and
(7) disorders of the skeletal spine. (Id. at D.E. 5-4 at 6). In considering the Paragraph B
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criteria, Dr. Postovoit concluded that Benjamin had moderate impairments in his abilities
to interact with others and concentrate, persist, and maintain pace, and a mild limitation in
his ability to adapt or manage himself. (Id.). Dr. Postovoit noted that Benjamin had
symptoms “very indicative of Borderline Personality [Disorder]” and that it seemed that
his mental health “providers gave him sound guidance and set some boundaries he didn’t
like.” (Id. at 7). When evaluating Benjamin’s mental RFC, Dr. Postovoit found that he
had several moderate limitations throughout the more specific criteria considered. (Id. at
10-11). She stated that Benjamin struggled with adaptive coping strategies and would have
some episodes of anxiety and mood dysregulation that interfered with his ability to focus
on productive activities. (Id. at 10). However, Dr. Postovoit did not believe this
interference would preclude him from participation in a normal routine by 12 months after
his alleged onset date. (Id.). Similarly, within 12 months of his alleged onset date, Dr.
Postovoit believed Benjamin would be able to maintain adequate levels of social
functioning in work settings that limited contact with the general public and where
feedback was given respectfully. (Id. at 11).
In the Disability Determination Explanation at the reconsideration stage, state
medical consultant Dr. Matthew Long concluded that Benjamin had severe impairments
consisting of: (1) personality disorders; (2) substance addiction disorders (alcohol);
(3) depressive, bipolar, and related disorders; (4) anxiety and obsessive-compulsive
disorders; (5) trauma and stressor-related disorders; (6) impulse control disorders; and
(7) disorders of the skeletal spine. (Id. at 28). He also concluded that Benjamin had
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moderate impairments in all four areas of mental functioning in the Paragraph B criteria.
(Id.). Dr. Long concluded that Benjamin had symptoms that would “restrict but … not
preclude basic work activity.” (Id. at 29). When evaluating Benjamin’s mental RFC, Dr.
Long found that he had several moderate limitations throughout the more specific criteria
considered. (Id. at 33-34). Dr. Long concluded that Benjamin had the ability to:
(1) understand and remember simple instructions; (2) maintain attention and concentration
on simple tasks for extended periods over two hours in duration; (3) complete a normal
workday and workweek without an unreasonable number and length of rest periods;
(4) relate to the public on a limited basis, and relate to co-workers and supervisors in non-
confrontational situations; (5) accept respectful supervision and constructive criticism; and
(6) adapt to simple changes in a routine work setting. (Id. at 34).
The ALJ held a hearing on May 1, 2024, at which Benjamin testified to the
following. (D.E. 503 at 175-93). He was seeing a psychiatrist for his mental health issues
and taking five medications. (Id. at 181). He had been hospitalized three previous times
for his mental health issues, most recently in 2017. (Id. at 181-82). He was still having
struggles despite the medications. (Id. at 182). He did not have a social life outside of his
aunt and her husband, who he lived with. (Id.). He had suicidal ideation once a day and
had issues with cutting. (Id. at 183). He had also experienced hallucinations. (Id. at 183-
84). Benjamin could not explain exactly how often these hallucinations happened, but
noted that they seemed to happen more often when he had increased stress. (Id. at 184).
Past trauma made it difficult for him to sleep, and he slept only around 10 hours per week.
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(Id.). His mental health issues made it so he could not work due to lack of patience,
attention span, and memory. (Id. at 188).
A vocational expert identified Benjamin’s past relevant work as a management
trainee. (Id. at 189). The ALJ asked the vocational expert whether there was work in the
national economy for a person with the same age, educational history, and work history as
Benjamin who could: (1) perform light work; (2) have no exposure to fumes or gases and
only occasional exposure to dust or poor ventilation; (3) have no exposure to unprotected
heights or moving mechanical parts; (4) understand, remember, and carry out simple tasks
involving simple work-related instructions; (5) have no interaction with the general public
and only occasional interaction with coworkers and supervisors; and (6) have only
occasional workplace changes. (Id.). The vocational expert testified that such a person
could not complete Benjamin’s previous work, but could perform jobs such as office
helper, shipping and receiving weigher, and laundry sorter. (Id. at 190). In response to an
additional hypothetical from the ALJ, the vocational expert testified that no work would
be available if the person would have two to three absences per month, required 30 minute
breaks every two hours, or could have no interaction with coworkers and supervisors. (Id.).
b. Medical Records and Function Reports
On April 14, 2020, Benjamin had an appointment for psychiatric care with Dr.
James Dotter, at which he sought to switch his anxiety medication. (D.E. 5-10 at 4). His
illness history included depression, PTSD, impulse control disorder with anger outbursts,
alcohol dependence, and personality disorder. (Id.). His depression was rated at moderate
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severity and had been ongoing for over three months, but was stable. (Id. at 4-5). His
mental status examination was normal, and he had fair insight and judgment. (Id. at 6-8).
Dr. Dotter continued Benjamin’s prescriptions for Cymbalta and Trazodone, but prescribed
Xanax in place of a previous prescription for Ativan. (Id. at 8).
On May 11, 2020, Benjamin had a follow-up appointment related to his back pain.
(D.E. 5-14 at 175). He was noted to be anxious but cooperative. (Id. at 176). The same
was true in June and November 2020. (Id. at 160, 170).
On July 17, 2020, Benjamin completed a mental health recovery plan. (D.E. 5-10
at 29). His presenting problems included: (1) depression that caused him to always be sad,
not leave his room, stay in the dark, and isolate; (2) limited sleep of 2-3 hours; (3) self-
injury including cutting himself twice in the previous month; (4) anxiety that resulted in
him not liking being around other people, being unable to catch his breath, and having a
racing mind; (5) alcohol use; and (6) self-care limitations including a decrease in showers.
(Id.).
At a follow-up with Dr. Dotter on July 31, 2020, Benjamin sought new medications
for depression and anxiety. (Id. at 35). His mental status examination was normal, and he
had fair insight and judgment. (Id. at 37-39).
At an August 13, 2020, mental health appointment, Benjamin’s affect was tearful
and depressed, and he had been cutting himself as a form of self-harm. (Id. at 54). He
denied any suicidal ideation. (Id.). At an August 20, 2020, appointment, Benjamin’s
mood/affect and behavior/functioning had both improved to be unremarkable. (Id. at 59).
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He noted he had stopped taking Abilify. (Id.). The same was true on August 27, 2020,
although Benjamin’s case manager noted that he was not making progress on his goals due
to increasing depression, medical issues, and legal issues. (Id. at 62).
At a September 4, 2020, medical appointment for back pain, Dr. Sarah Lewis noted
that Benjamin was “extremely anxious, and [was] sweating profusely.” (D.E. 5-8 at 172).
She also noted that he had “multiple deep and long gashes to bilateral upper extremities in
various states of healing for what he calls ‘cutting.’” Benjamin informed her that he was
often anxious meeting new people, especially for medical appointments. (Id.).
At a September 10, 2020, mental health appointment, Benjamin reported that he had
stayed up over 55 hours straight the previous weekend and had “lost touch with reality,”
including a belief that he was a target of the Romanian mafia. (D.E. 5-10 at 65). He
became tearful when discussing how he wanted to protect Romanian girls he knew online.
Benjamin stated that he no longer had any perception of time. (Id.). At a September 24,
2020, appointment, Benjamin “was tearful throughout [the] session due to continued
depression and physical pain.” (Id. at 68). At a September 30, 2020, appointment,
Benjamin admitted to cutting himself, but stated that he was not doing it to kill himself.
(Id. at 71). He was upset throughout the call. (Id.).
At an October 6, 2020, appointment, Benjamin reported that he had not cut himself
since the previous appointment, and he felt “like things are finally starting to look up got
him.” (Id. at 74). At an October 8, 2020, appointment, however, Benjamin’s case manager
again found that his response to intervention was negative and he did not wish to refrain
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from consuming alcohol with his medications. (Id. at 77). Benjamin was feeling better at
an October 14, 2020, appointment, in part due to an appointment with a new mental health
provider the next day. (Id. at 80).
On October 15, 2020, Benjamin had an appointment with Advanced Practice Nurse
(“APN”) Angela Covarrubias for a psychiatric evaluation. (Id. at 82). He reported that he
was not taking Abilify, but was taking Ativan, and that he wanted “someone to fix me and
give me meds to make me happy.” (Id.). Benjamin further reported that his medications
stopped working, so he had started drinking again. (Id. at 83). He felt that his life sucked
every day and that he had been depressed his entire life, although it worsened when he
moved to Texas two years earlier. He felt worthless, hopeless, and did not sleep well. His
anxiety caused him to worry constantly, and the only way to stop was to drink and pass
out. (Id.). His PTSD arose from sexual abuse as a child and witnessing a friend’s suicide.
(Id. at 84). He also experienced angry outbursts and impulsive behavior. (Id.). Benjamin
reported drinking 4-5 beers or a bottle of wine per day on average. (Id. at 85). During a
mental status examination, APN Covarrubias noted that Benjamin’s mood was sad and
anxious, and his affect was dysphoric and anxious. (Id. at 86). He had thought content
abnormalities including feelings of worthlessness, loneliness, guilt, hopelessness, and
helplessness. (Id. at 87). His insight and judgment were poor. (Id.). The examination was
otherwise normal. (Id. at 86-88). APN Covarrubias continued prescriptions for Cymbalta
and Ativan for depression and anxiety, stopped a prescription for Abilify, started a
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prescription for Latuda for mood instability, and continued a prescription for trazodone for
insomnia. (Id. at 89).
At an October 27, 2020, appointment with his case manager, Benjamin reported that
his depression had shifted more towards anger than sadness. (Id. at 104). His response to
intervention was negative as he was highly agitated, and barriers included medication
noncompliance, continued drinking of alcohol, and increasing depression, among others.
(Id.). Benjamin was angry at a November 11, 2020, appointment. (Id. at 108). He felt that
a nurse with his mental health provider never returned his calls, that his medication was
making him worse, and that just wanted to die. He was cutting himself again. He admitted
to suicidal ideation, but stated that he did not want to do it. (Id.). At a December 9, 2020,
appointment, Benjamin reported he was doing great after having surgery on his back. (Id.
at 111). The felt that the decrease in back pain had also improved his mood and mental
health. He reported that he had not cut or had alcohol since his surgery. (Id.).
At a February 1, 2021, appointment with APN Covarrubias, Benjamin reported that
he was compliant with his medications. (Id. at 125). He reported that his depression was
about the same with good and bad days and he still was not sleeping well. (Id. at 126). His
anxiety was still bad because he was out of Ativan, but he had not had alcohol since his
surgery. (Id.). APN Covarrubias continued his prescriptions, and also added a prescription
for Remeron for treatment-resistant depression. (Id. at 132).
On February 19, 2021, Benjamin called a mental health crisis line and reported that
he cut his throat that night to self-harm. (D.E. 5-12 at 135). He reported that it was only a
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scratch and had stopped bleeding. After talking with a crisis case manager, Benjamin
agreed to put a knife away and stated that he was done cutting for the night. (Id. at 136).
At a February 22, 2021, appointment with his case manager, Benjamin explained
that a disability judge had denied his claim because he had returned to work. (D.E. 5-10 at
141). He also was upset that his mental health provider stated that he was stable and
apologized for having left his case manager an “ugly” voice message about it. His back
pain had returned and worsened since he began working. His anxiety had also worsened.
Benjamin reported that he did not believe he was suicidal when he cut his neck, but was
merely angry and overwhelmed with everything happening. His case manager attempted
to discuss coping skills, but Benjamin responded that cutting was his coping skill and he
would not use healthier coping skills. (Id.).
At a March 23, 2021, appointment with APN Covarrubias, Benjamin reported that
he was compliant with his medications. (Id. at 145). He reported that his depression was
not good and that he had called the suicide hotline. (Id. at 146). His sleep had improved a
little. (Id.). He was still suffering from anxiety, particularly regarding unknowns related
to his back problems and work. (Id. at 147). His mental status examination was normal,
although his insight and judgment were poor. (Id. at 149-51). APN Covarrubias continued
all of his prescriptions, and increased his dosage of Remeron. (Id. at 152).
At a March 30, 2021, appointment with his case manager, Benjamin reported that
he was having an anxiety attack. (Id. at 167). His case manager gave him strategies to
help him relax. She observed that he was receptive and engaged throughout the
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appointment, and noted some progress because he was taking his medication and had not
cut for several weeks. (Id.). The same was true on April 21, 2021. (Id. at 170).
At a September 22, 2021, appointment with APN Covarrubias, Benjamin reported
that he was compliant with his medications. (Id. at 176). He further reported that his
depression had been bad since he returned to work, he had been awake for 72 straight hours,
and he also had not been eating. (Id. at 177). He thought about suicide at times, but did
not act on it. (Id.). He also reported anxiety that made him afraid to sleep. (Id. at 178).
During a mental status examination, his mood was sad and anxious, his affect was
dysphoric and anxious, his insight and judgment were poor, and all other areas were
normal. (Id. at 180-82). APN Covarrubias continued Benjamin’s prescriptions for
Cymbalta, Ativan, and trazodone, and increased his dosage of Remeron. (Id. at 183).
On September 23, 2021, Benjamin visited Dr. Gary P. Willers and reported memory
loss. (D.E. 5-14 at 145). Benjamin reported that the onset of the memory loss was sudden,
had been occurring for two days, and was gradually worsening. Other symptoms included
excessively sweating, getting bad cramps in his lower extremities, and difficulty getting
words out. (Id.). His mood and affect were anxious. (Id. at 146). Dr. Willers directed
him to visit the emergency room. (Id.).
In the emergency room, Benjamin was noted to be somewhat anxious. (D.E. 5-9 at
46). He reported that he had been stressed at work and felt like he was having a panic
attack the previous day. (Id.). The doctor recommended that he stay for monitoring, but
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Benjamin stated that he felt fine and was emphatic that he wanted to be discharged. (Id. at
49). He was diagnosed with hypertension. (Id. at 51).
In a December 8, 2021, safety/crisis plan developed with his case manager,
Benjamin stated that drinking and cutting were his only coping strategies, and he refused
to get rid of alcohol or sharps. (D.E. 5-10 at 192). At a December 10, 2021, appointment,
Benjamin reported that he had not cut himself since last speaking to his case manager, but
had continued to drink alcohol. (Id. at 199). He had experienced suicidal ideation, but had
no method, plan, or intent. (Id.).
At a December 14, 2021, appointment with APN Covarrubias, Benjamin reported
that he was compliant with his medications. (D.E. 5-11 at 4). He stated that his depression
was the same or worse, he had quit his job, he had suicidal ideation every day, and he had
not slept in three days. (Id. at 5). He also reported that his anxiety was worse. (Id. at 6).
During a mental status examination, Benjamin’s mood was sad and anxious, his affect was
dysphoric, anxious, and irritable/angry, he had thought content abnormalities including
hopelessness, he had suicidal ideation and a plan, and he had poor insight and judgment.
(Id. at 9-10). The remaining areas of the examination were normal. (Id.). APN
Covarrubias noted that Benjamin was not taking responsibility for his care, was angry that
his Ativan had not been increased between appointments, and blamed his mental health
providers for his decision to quit his job. (Id. at 11). He reiterated that he had suicidal
ideation with a new plan every day, but stated that this had been true for 30 years. He was
upset because he had never actually seen APN Covarrubias due to COVID protocols
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requiring telehealth visits. Benjamin stated that no one helped him and that APN
Covarrubias had previously said she could not help him and medication would not help
him. APN Covarrubias disagreed with this characterization and reminded Benjamin that
medication may not take away all symptoms and that coping skills, therapy, and daily
exercise were also needed. She called the crisis department to perform a crisis evaluation.
(Id. at 11).
At a December 27, 2021, appointment with his case manager, Benjamin was tearful
and angry. (Id. at 23). He reported that he was feeling better because his case manager
called him. (Id. at 24). He was upset that the crisis team was sent to his home, but
understood why they were called. Benjamin reported that he had not looked for work
because he did not want to be around people. His case manager suggested looking for
customer service jobs that could be done from home or overnight stocking shifts, and
Benjamin felt better after looking at job listings. (Id.). At a January 20, 2022, appointment,
Benjamin reported that he had not had alcohol in two days and was feeling withdrawal
symptoms. (D.E. 5-13 at 34). He remained resistant to his case manager’s attempts to
teach him coping skills and “continuously present[ed] as help-rejecting and victim
stance[d].” He stated that nothing worked but cutting, and he had not cut in a while. His
case manager attempted to praise him for not cutting, but he responded that it was not good.
He was resistant to learning coping skills and only semi-engaged throughout the session.
(Id.). At a January 24, 2022, appointment, Benjamin had a labile mood and went from
laughing to crying. (Id. at 38). He was tearful because he had increased gout symptoms
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that made it difficult to move. (Id. at 39). He reported that he had not cut and had not been
drinking, and the gout was flaring up due to not drinking. He had not been eating, sleeping,
or drinking anything. (Id.).
On January 26, 2022, Benjamin had a doctor’s appointment for his gout where he
was described as anxious. (D.E. 5-14 at 138). At a February 1, 2022, appointment,
Benjamin noted that he had been drinking two 12-packs of alcoholic seltzers a day since
the previous November, and attempting to stop caused the gout flare-up. (Id. at 134). He
also reported multiple instances in which he had “seizures” and woke up with a bitten
tongue and sore muscles. (Id. at 135). His mood and affect were anxious. (Id.).
On March 2, 2022, Benjamin called a crisis hotline and was crying. (Id. at 59). He
stated that he did not see a better tomorrow and had no reason to go on, and reported that
he had been cutting himself for several days and that his chest was a bloody mess. He
reported that he did not need medical attention. He sounded as though he was in pain and
reported that he was bleeding a lot, but the cutting was not a suicide attempt. Benjamin
further stated that he had stopped eating and sleeping, he suffered from not knowing what
was real, and he had been drinking all day. He did not want any assistance sent to his
home. (Id.). He reported suicidal ideation, but no plan. (Id. at 60). Benjamin reported
that he would stay safe that night and was going to drink until he passed out. (Id. at 61).
At a March 7, 2022, appointment with his case manager, Benjamin reported
continued alcohol use and depressive symptoms. (Id. at 65). He stated that he was not in
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a crisis and did not want anyone sent to his home, and ended the call when his case manager
attempted to schedule a home visit. (Id.).
At a March 9, 2022, appointment with APN Covarrubias, Benjamin reported that he
was compliant with his medications, but that his symptoms had not improved. (D.E. 5-11
at 59). He reported that he stayed in his room all day, peed in bottles, was sleep and food-
deprived, and had suicidal thoughts every day. (Id. at 60). During a mental status
examination, Benjamin’s mood was sad and anxious, his affect was dysphoric, anxious,
irritable/angry, tearful, and help rejecting/sarcastic, he had thought content abnormalities
including hopelessness, he had current suicide ideation, and his insight and judgment were
poor. (Id. at 63-64). APN Covarrubias noted that Benjamin continued “to have help-
rejecting/victim stancing behaviors” and did not take responsibility for his part in the
treatment plan. (Id. at 66). She continued his prescriptions, but held his Ativan prescription
due to his daily suicidal ideation. (Id.).
At a March 14, 2022, appointment with his case manager, Benjamin reported that
he woke up that weekend and “actually saw daylight.” (D.E. 5-13 at 88). He realized he
was slowly committing suicide by drinking alcohol and not eating, so he began eating
more, drinking water, and taking his meds because he wanted “to do more with my life.”
His case manager discussed coping skills and noted that it was important to be active
instead of staying alone with his thoughts. (Id.). However, this was not the case on March
21, 2022. (D.E. 5-11 at 83). Benjamin reported that he had been sick all weekend and was
happy because he was sure he was going to die, but he did not. He did not participate when
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his case manager tried to discuss coping skills, and he became tearful and ended the call.
(Id.). On March 30, 2022, Benjamin reported that he had been in bed for several days and
still had not been eating or drinking water. (Id. at 87).
At an April 4, 2022, appointment with his case manager, Benjamin reported that he
had been extremely depressed, but cleaned his room and did laundry over the weekend.
(Id. at 91). He also reported a seizure over the weekend and had a doctor’s appointment
scheduled. (Id.).
On April 7, 2022, Benjamin visited Dr. Willers regarding his seizure. (D.E. 5-14 at
128). He reported that the seizures had been ongoing for seven months and were preceded
by a loss of awareness and visual hallucinations. They were followed by confusion,
lethargy, weakness, and loss of consciousness. Benjamin’s aunt confirmed that she had
seen him have “a full blown seizure” the previous week and that he slept for almost two
days afterwards. (Id.). Benjamin was able to make an appointment with neurology in June,
but was prescribed medication in the meantime. (Id. at 130).
At an April 11, 2022, appointment with his case manager, Benjamin reported that
he drank beer instead of eating or drinking water. (D.E. 5-11 at 95). His case manager
attempted to discuss how using alcohol could worsen symptoms and decrease the
effectiveness of coping skills, but Benjamin responded that he had no positive coping skills
anyway. He was not receptive to using coping skills. (Id.). On April 19, 2022, Benjamin
reported that he felt like he was losing time because he did not remember doing things. (Id.
at 99). On April 23, 2022, he again reported losing time, stating that he was discovering
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online purchases and conversations during times he thought he was asleep. (Id. at 104).
He then stated that he had determined a method to commit suicide. He refused to change
to more frequent appointments with his case manager or to sending an officer for a wellness
check. His case manager encouraged him to call to schedule an earlier appointment with
APN Covarrubias, but Benjamin stated that APN Covarrubias told him she could not help
him. His case manager pushed back on this interpretation of what he had been told. (Id.).
On May 4, 2022, Benjamin reported that he still felt as though he was disassociating, and
he was seeing messages online where he was speaking Russian even though he did not
know Russian. (Id. at 111). He wanted an appointment with APN Covarrubias, but he also
stated that she hated him and told him that she could not help him. (Id.).
On May 6, 2022, Benjamin had a follow-up with Dr. Willers regarding his seizures.
(D.E. 5-14 at 125). His mood was anxious, depressed, and labile. (Id. at 126). He had
been apparently seizure-free until the day before, when there was a period of time he did
not remember. (Id. at 127). When he had a seizure, Benjamin saw an orb of light and then
blacked out. Dr. Willers adjusted his medication. (Id.).
At a May 9, 2022, appointment with his case manager, Benjamin reported that his
doctor was concerned about his kidneys, and Benjamin hoped this was what killed him.
(D.E. 5-13 at 112). He reported symptoms of mania including staying awake for days and
then sleeping for days afterwards. He also reported continued disassociation. On May 16,
2022, Benjamin presented as “manic, paranoid, and delusional.” (D.E. 5-11 at 120). He
reported that he had been awake for four days without sleep. He reported a dispute with a
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cam girl from Colombia, but he did not know if any of it was real. (Id.). On May 19, 2022,
Benjamin again presented as manic, delusional, and paranoid. (Id. at 137). He again
reported that he had probably not taken his medication. (Id.). At a May 27, 2022,
appointment with his case manager, Benjamin presented as calm and coherent and reported
that he had been sleeping more. (Id. at 141). He stated that he had an old girlfriend coming
to visit and had been taking his medications more often. (Id.).
On June 6, 2022, Benjamin visited Dr. Willers for a follow-up on his seizures. (D.E.
5-14 at 121). He reported that he felt like he had split personalities, and he was still having
blackouts every other day even when taking seizure medication. He also reported that he
went through manic states where he did not sleep for days at a time and hallucinated.
Benjamin stated that he had not slept for five days. (Id.). Dr. Willers noted that his mood
and affect were anxious, hypomanic, and labile. (Id. at 122). He continued Benjamin’s
seizure medication, and also recommended that Benjamin take lithium carbonate to
manage his bipolar disease. (Id. at 123).
Benjamin reported the following in a June 9, 2022, function report. (D.E. 5-7 at
38). He spent his time in his room online or watching TV. (Id. at 39). He went days
without sleeping due to PTSD. He went days without bathing due to depression. (Id.). He
needed reminders to take medication and to shower. (Id. at 40). He did not prepare food.
(Id.). He did not go outside of the home alone because he would “rather choke [people]
than say hello.” (Id. at 41). He could not drive due to his blackouts. He could not pay
bills, handle a savings account, or use a checkbook/money orders. He became impulsive
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when manic and spent his money. (Id.). His only hobby was watching TV. (Id. at 42).
He used porn websites to spend time with others. He did not go anywhere because he hated
people and it caused anxiety. (Id.). He did not follow written or spoken instructions well,
did not get along with authority figures, and quit his previous job due to issues getting
along with others. (Id. at 43). He did not handle stress well and reacted by cutting himself.
(Id. at 44). He also did not handle changes in routine well. (Id.).
Benjamin completed a second function report on June 10, 2022, and reported the
following. (Id. at 54). He could not drive due to dizziness and blackouts, and at one point
he lost two days with no memory of what he did. (Id.). He spent his days sitting in a chair,
eating dinner, and on the computer. (Id. at 55). His conditions affected his sleep and his
mania caused him to go five days without sleep sometimes. He needed reminders to
shower. (Id.). He also needed reminders to take medication. (Id. at 56). He did not prepare
his own food or do any housework. (Id.). He rarely went outside and did not drive. (Id.
at 57). He sometimes went shopping with his aunt to get out of the house, but only rarely
because he hated people. He could not handle money and overspent during manic episodes.
(Id.). His hobby was visiting cam websites for companionship, but he did not handle this
well, had hallucinations, and created alternate realities. (Id. at 58). Visiting cam sites and
talking to cam models was his only social activity. He had difficulty getting along with
people because they “are evil.” (Id.). He could follow written instructions if he was not
interrupted and could follow spoken instructions as long as they were slow. (Id. at 59). He
did not get along with authority figures and had lost a job because of issues getting along
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with other people. (Id.). Stress caused him to freak out, have anxiety, and cry, and changes
in routine annoyed him. (Id. at 60). He had noticed unusual behaviors and fears, including
that other people were in his house or hacking his computer. (Id.). He was experiencing
different realities and thought that he had a second personality that functioned during his
blackouts. (Id. at 61).
At a June 13, 2022, appointment with his case manager, Benjamin reported that he
was not feeling better and was upset because he spent extra emergency money his aunt
gave him on alcohol and cam girls. (D.E. 5-13 at 138). He stated that if he made it to 50
years old, he would kill himself the next day. (Id.).
On June 15, 2022, Benjamin visited neurologist Dr. Andrew J. Cichowski regarding
his seizures. (D.E. 5-11 at 155). He recounted his experiences with the seizures. He noted
that his PTSD from witnessing his friend commit suicide was why he could not sleep and
caused him to drink until he blacked out. (Id.). He stated that he had cut back significantly
on his alcohol intake and only had a couple of beers most days. (Id. at 156). Dr. Cichowski
prescribed Lamotrigine and recommended further testing, dependent on Benjamin’s
insurance coverage and anxiety. (Id. at 159-60).
On June 17, 2022, Benjamin visited APN Covarrubias. (D.E. 5-13 at 139). His
mental status examination was normal with the exception of feelings of hopelessness. (Id.
at 142-44). APN Covarrubias noted that Benjamin was now receiving mental health
treatment through Dr. Willers, who had referred him to another psychiatric provider that
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Benjamin wanted to see. (Id. at 148). APN Covarrubias would no longer handle his
medication management. (Id.).
On June 29, 2022, Benjamin visited psychiatrist Dr. Fazila Siddiqi. (D.E. 5-9 at
171). He reported that he had not slept for four days. His medical history report was
consistent with previous explanations. (Id.). His general appearance and manner were
anxious and restless, but cooperative with good eye contact. (Id. at 172). His judgment
and insight were fair to good, his memory was fair but not good after seizures, his
attention/concentration were distracted and intrusive, and his mood was anxious and
depressed. (Id. at 174). Dr. Siddiqi continued his medications. (Id. at 174-75).
At a June 30, 2022, appointment with his case manager, Benjamin was fidgety and
had difficulty sitting still due to mania and frustration. (D.E. 5-13 at 165). He reported
having angry outbursts. He was resistant to practicing positive coping skills. (Id.). On
July 14, 2022, Benjamin’s mood was labile and switched from crying to laughing to being
belligerent. (Id. at 171). He was actively intoxicated and drinking alcohol during the
session. (Id.). His case manager attempted to discuss coping skills and calm Benjamin
down, but he continually hit the table with his fist, and his aunt indicated that he had broken
his hand. (Id. at 172). His aunt reported that she would take him to the emergency room
when he became sober. (Id.).
At a July 21, 2022, appointment, Benjamin was shaky and unsteady. (Id. at 176).
He reported that he was shaky because he had not had any alcohol, and his case manager
observed him drinking a seltzer. He apologized for the previous week, stated he got upset
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over things he should not, and reported that he had been cutting himself. (Id.). On August
4, 2022, Benjamin reported that he was on a road trip with his family and presented as
upbeat. (Id. at 179). He reported no instances of cutting or punching since he trip began.
(Id.). The same was true on August 15, 2022. (Id. at 181).
On August 17, 2022, Benjamin visited Dr. Siddiqi and reported that he was doing
okay. (D.E. 5-14 at 248). He reported that he was feeling better, sleeping better, his
nightmares had decreased, he was compliant with his medication, his depression was a 5
out of 10, his anxiety was under control, and he had no psychosis or suicidal ideation. (Id.).
Dr. Siddiqi noted that he was not a danger to himself or others, but was high risk. (Id. at
250). Dr. Siddiqi increased his lithium and continued his other medications. (Id. at 251).
At an August 18, 2022, appointment with his case manager, Benjamin reported no
instances of self-injury. (D.E. 5-13 at 184). His case manager attempted to discuss other
positive coping skills, but he was not receptive. (Id.). On August 24, 2022, Benjamin
reported continued medication compliance, but also continued alcohol usage, and was not
concerned about mixing medication with alcohol. (Id. at 188). On September 8, 2022,
Benjamin reported that he continued to drink alcohol and had not had water in a month.
(Id. at 192). He stated that he knew he needed to stop but had no other coping skills, but
he also was resistant to learning other coping skills. (Id.).
On September 16, 2022, Benjamin had a labile mood and went from crying to angry.
(Id. at 197). He had slurred speech, punched a counter and injured his hand, and was
intoxicated. (Id.). He reported that he had not slept in a few days. (Id. at 198). He reported
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that he had taken 15 to 20 Tramadol with alcohol, but denied trying to commit suicide. He
began slurring his speech more, his breathing became labored, and he continually tried to
prevent himself from vomiting. His case manager called 911. (Id.). On September 22,
2022, Benjamin reported that he was initially angry that his case manager called 911, but
understood that she was doing her job and knew that leaving the program would not be
good for him. (Id. at 203). On October 6, 2022, Benjamin presented with increased
depression and anger, stating that after he received disability backpay, he would go to
Colombia to “look for some people and take them out.” (Id. at 216). His case manager
noted that he “remain[ed] malingering and help-rejecting.” (Id.).
At an October 13, 2022, appointment, Dr. Cichowski concluded that Benjamin’s
recent “black out spells” where he chatted with women online while thinking he was asleep
were likely related to his psychiatric conditions. (D.E. 5-11 at 173). Dr. Cichowski
recommend a 72-hour ambulatory EEG, continued Benjamin’s Lamotrigine, and
prescribed a tapered decrease of his other seizure medication. (Id.).
At an October 27, 2022, appointment with his case manager, Benjamin reported that
he had spoken with the devil and helped him kill people. (D.E. 5-13 at 222). He was not
receptive to coping skills, medications, or other resources. (Id.).
On November 2, 2022, Benjamin visited Dr. Siddiqi and reported having blackouts
once a week. (D.E. 5-14 at 258). He stated that he lost two days and did not remember
anything. He stated that his sleep was off and on, reported feeling low most of the time
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but finding it manageable, and denied suicidal ideation, mania, and alcohol use. (Id.). Dr.
Siddiqi continued his prescriptions. (Id. at 260).
At a November 3, 2022, appointment with his case manager, Benjamin reported that
he continued to drink and was happy with his depression, but had not been cutting or
punching. (D.E. 5-13 at 225). However, on November 17, 2022, Benjamin was more
positive and had an eagerness for the session his case manager had never seen. (Id. at 227).
He had spoken to a friend who had been sober for a year and was interested in becoming
sober himself. Benjamin reported drinking less and his case manager observed less shaking
and uncontrollable movements. (Id.). On November 23, 2022, Benjamin reported that he
was still decreasing alcohol intake, but was unsure about attending any recovery group.
(Id. at 230). On January 5, 2023, he reported that he did want to attend an Alcoholics
Anonymous meeting. (Id. at 232). However, on January 19, 2023, Benjamin reported he
had no interest in attending the meeting anymore and that he would die at 11:59pm on the
night before his fiftieth birthday, which was under a month away. (D.E. 5-14 at 2). He
refused to discuss coping skills. (Id.).
On January 26, 2023, Benjamin was actively drinking during the session and
reported that he had been awake for three days. (Id. at 5). He refused to engage in a
discussion about the importance of sleep and reported an increased urge to begin cutting.
He also refused to review his safety plan. (Id.). On February 2, 2023, Benjamin reported
he still had the urge to cut, but he had not acted on this urge. (Id. at 8). He again refused
to discuss his safety plan. (Id.). On February 6, 2023, Benjamin reported that he did not
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have an urge to cut. (Id. at 12). However, stated that he had not been taking his medication
or attending psychiatric appointments, and he rejected any discussion of coping skills,
doctors, or medication because “[n]one of it works.” (Id.).
On February 8, 2023, Benjamin visited Dr. Siddiqi, who noted that he had missed
appointments. (Id. at 263). Benjamin reported depression and anxiety the previous 1-2
weeks and thoughts of cutting himself. He was drinking 12-15 cans of beer per day. He
stated that drinking slowed his brain down and allowed him to sleep. (Id.). Dr. Siddiqi
continued his medications, prescribed new medications to help with sleep and alcohol use,
and explained that Benjamin could not drink alcohol with his medications. (Id. at 266).
At a February 13, 2023, appointment with his case manager, Benjamin presented
with fresh cuts on his chest. (Id. at 14). He did not use coping skills when he had the urge
to cut and was actively drinking alcohol during the session. (Id.).
On April 26, 2023, Benjamin visited Dr. Siddiqi and reported having ups and downs,
decreased cognitive functioning, and increasing memory problems. (Id. at 273). Dr.
Siddiqi noted that Benjamin was still drinking alcohol and had not taken the medication
prescribed to help with alcohol use. (Id. at 275). Dr. Siddiqi again discussed the risks of
drinking alcohol with medication and the effects of alcohol on cognitive functioning. (Id.
at 275-76). He continued Benjamin’s prescriptions. (Id. at 276). At a July 12, 2023,
appointment, Benjamin reported decreasing his alcohol intake. (Id. at 279). Since his last
appointment, he had cut himself once. (Id.). His memory was not good, he was at times
distracted, and his mood was anxious. (Id. at 281).
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On October 26, 2023, Benjamin visited psychologist Dr. Chelsea Wooley for a
clinical interview and mental status examination. (Id. at 284-89). Benjamin reported
symptoms of depression including crying a lot, getting sad for no reason, becoming moody
when there is a full moon, and disliking other people. (Id. at 284). As to borderline
personality disorder, Benjamin stated that he did not know much about it, but that he had
been diagnosed many times because of his self-mutilation. (Id.). He reported PTSD
symptoms including nightmares and being afraid to sleep. (Id. at 285). He reported anxiety
symptoms including shaking, hating other people and being unable to be around them,
being unable to go shopping for groceries, among other symptoms. (Id.). His depression,
borderline personality disorder, PTSD, and anxiety were not well-controlled. (Id. at 284-
85). His mental health conditions negatively affected his employment, and his last job
“paid [him] not to come back.” (Id. at 285). He was compliant with his medication and it
was somewhat effective at reducing his symptoms. Benjamin reported that he had
depression and anxiety his entire life. He reported both suicidal and homicidal ideation,
although he denied current homicidal ideation because he was not around other people
anymore. He reported both auditory and visual hallucinations beginning within the
previous two years. (Id.). Benjamin further reported that he had difficulties with
concentration, memory, and sleep. (Id. at 286). While he could manage a bank account
and handle bill payments, his understanding of budgeting for daily needs and expenses was
impaired. He reported alcohol use beginning when he was 13 and continuing through the
present day, now consisting of a case of beer daily. Benjamin performed his activities of
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daily living independently, but required maximum assistance for community outings
because he disliked other people and needed help lifting things. He primarily watched TV
and did not have friends or participate in social events. (Id.). He endorsed declining daily
function due to both mental and physical limitations, and his psychological problems
affected his interpersonal relationships and occupational functioning. (Id. at 287).
During a mental status examination, Dr. Wooley observed that Benjamin displayed
a restless attitude, but his eye contact was fair and his responses appeared forthcoming.
(Id.). His speech was angry. His mood appeared dysphoric. He endorsed suicidal ideation
without a plan, but there were no notable hallucinations or other special preoccupations
during the exam. His thought process was logical and he showed no evidence of thought
disturbances. His IQ appeared to be average, his fund of information was adequate, and
he was oriented to person, place, time, and event. As to his memory, Benjamin recalled
his age, date of birth, current date, current president, and a previous predicant, but could
not recall the day of the week and recalled 1 of 3 words after a four minute delay. As to
concentration and attention, he repeated 3 of 5 digits forward and 2 of 5 digits backward,
spelled “world” backwards, and repeated a simple sentence with an error. (Id.). When
asked to interpret idiomatic expressions, Benjamin stated that: (1) “the grass is greener on
the other side” meant that “[s]omething is better than what you already have;” and
(2) “people in glass houses shouldn’t throw stones” meant that “[t]hey are just as messed
up as the rest of us.” (Id. at 287-88). Benjamin stated that if he saw smoke coming from
the windows of a home, he would run and hide, and if he found a wallet on the street, he
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would pick it up. (Id. at 288). His insight into his psychological concerns and judgment
were adequate. (Id.).
Dr. Wooley concluded that Benjamin’s prognosis was poor based on his history of
substance abuse, persistent self-harm behaviors, and unwillingness to seek therapy services
that created significant barriers to stability, recovery, and well-being. (Id.). Dr. Wooley
believed that consistent therapy could help Benjamin discover problem-solving skills and
coping strategies. She concluded that he was capable of managing benefits. When
considering Benjamin’s functional capacity, Dr. Wooley concluded that he had a poor
ability: (1) to understand, remember, and apply information, recall and utilize information,
follow multi-step oral instructions, and use reasoning and judgment for work-related
decision-making; (2) to relate and work with supervisors, co-workers, and the public; (3) to
concentrate, persist, and maintain pace, including staying focused on work activities and
sustaining productivity; and (4) to adapt and manage himself, regulate emotions, control
behavior, and maintain his overall well-being in a work setting. (Id.).
At a February 13, 2024, appointment with Dr. Willers, Benjamin reported suicidal
ideation, loss of interest, depressed mood, poor concentration, appetite change, weight loss,
and poor sleep. (Id. at 312). The symptoms were constant, severe, and worsening. He
reported an upcoming appointment with Dr. Siddiqi, and stated that he used to have a
mental health case worker, but they stopped showing up. (Id.).
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c. ALJ Decision
On August 23, 2024, the ALJ issued an opinion, concluding that Benjamin was not
under a disability since March 3, 2022. (D.E. 5-3 at 107-20). At the first step of the
sequential evaluation process, the ALJ concluded that Benjamin had not engaged in
substantial gainful activity since the onset date. (Id. at 109). At the second step, the ALJ
concluded that Benjamin had severe impairments consisting of alcohol abuse disorder,
alcohol induced disorder, seizure disorder, bipolar disorder, personality disorder, PTSD,
gout, obesity, and degenerative disc disease. (Id. at 109-10). At the third step, the ALJ
concluded that Benjamin did not have an impairment or combination of impairments that
met or medically equaled one of the listed impairments in 20 C.F.R. § 404, Subpart P,
Appendix 1. (Id. at 110). In considering the Paragraph B criteria, the ALJ concluded that
Benjamin had moderate limitations in all four areas of mental functioning. (Id. at 112).
The ALJ extensively discussed the medical records, including Dr. Wooley’s opinion, in his
analysis of the Paragraph B criteria. (Id.).
The ALJ concluded that Benjamin had the RFC to complete light work, except that
he could: (1) have no exposure to fumes or gases and only occasional exposure to dust or
poor ventilation; (2) have no exposure to unprotected heights or moving mechanical parts;
(3) understand, remember, and carry out only simple tasks involving simple work-related
instructions; (4) have no interaction with the general public and only occasional interaction
with coworkers or supervisors; and (5) have no more than occasional workplace changes.
(Id. at 113). The ALJ stated that, although Benjamin had medically determinable
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impairments that could reasonably have been expected to produce the alleged symptoms,
his statements about the intensity, persistence, and limiting effects of the symptoms were
not entirely consistent with the medical evidence and other evidence in the record. (Id. at
114). The ALJ then summarized the medical evidence and medical opinions in the record,
including the mental health records. (Id. at 114-17). The ALJ stated that Dr. Wooley’s
opinion was unpersuasive because it was inconsistent with the conservative nature of
Benjamin’s treatment and the opinions of the state agency psychological consultants’
opinions. (Id. at 117). Further, the ALJ concluded that the opinion was inconsistent with
and unsupported by the objective findings in the record, including that he managed his own
care, was usually cooperative with treatment, had average intelligence and a good fund of
knowledge, assisted his aunt with the home, performed household chores, and managed his
own finances. (Id.).
At step four, the ALJ concluded that Benjamin could not perform his past relevant
work. (Id. at 118). However, at step five, the ALJ concluded that Benjamin could adjust
to other work and perform other jobs in the national economy, including office helper,
shipping and receiving weigher, and laundry sorter. (Id. at 119). Accordingly, the ALJ
concluded that Benjamin was not under a disability from March 3, 2022, through the date
of the decision. (Id. at 120).
The Appeals Council denied Benjamin’s request for review of the ALJ’s decision.
(Id. at 2-5).
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III. DISCUSSION
In his motion for summary judgment, Benjamin contends that the ALJ’s rejection
of Dr. Wooley’s opinion was not supported by substantial evidence because his conclusion
was inconsistent with the majority of the evidence in the record. (D.E. 7 at 7). Benjamin
argues that the ALJ did not properly consider the supportability factor in reaching this
conclusion, instead focusing only on the consistency of Dr. Wooley’s opinion with the rest
of the record. (Id. at 9-10). As to the consistency factor, Benjamin argues that the ALJ’s
opinion makes it appear as though there were no abnormal mental health findings in the
record, but that this is not consistent with the extensive evidence in the record of suicidal
ideation, self-harm and mutilation, a history of sexual abuse as a child, and repeated
instances of being angry or irritable. (Id. at 10-11). Benjamin argues that the ALJ’s
discussion does not paint an accurate picture of the evidence in the record and does not
properly address the evidence that is contrary to the ALJ’s conclusion. (Id. at 11-12).
The Commissioner responds that the ALJ properly explained the persuasiveness of
each medical opinion in the record in accordance with the regulations. (D.E. 10 at 7-8).
The Commissioner argues that, although the ALJ did not explicitly reference Dr. Wooley’s
examination findings in his supportability analysis, he did discuss the examination findings
earlier in the opinion and it was clear that he considered them. (Id. at 9-10). Further, the
Commissioner argues that substantial evidence supported the ALJ’s conclusion that Dr.
Wooley’s opinion was not supported by her examination findings, which included an
average IQ, adequate fund of information, largely intact memory, fair eye contact,
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forthcoming responses, and logical thought process, among other normal findings. (Id. at
10-11). Similarly, the Commissioner argues that substantial evidence supported the ALJ’s
conclusion that Dr. Wooley’s opinion was inconsistent with the other medical evidence in
the record, including the mental status examinations and the opinions of the state agency
consultants. (Id. at 11-12).
Judicial review of the Commissioner’s decision regarding a claimant’s entitlement
to benefits is limited to two questions: (1) whether substantial evidence supports the
Commissioner’s decision; and (2) whether the decision comports with relevant legal
standards. Perez v. Barnhart, 415 F.3d 457, 461 (5th Cir. 2005). Substantial evidence is
“such relevant evidence as a reasonable mind might accept as adequate to support a
conclusion.” Id. The burden has been described as more than a scintilla, but lower than a
preponderance. Id. On review, the Court may not reweigh the evidence, and it is the ALJ’s
responsibility to resolve conflicts in the evidence, not the Court’s. Martinez v. Chater, 64
F.3d 172, 174 (5th Cir. 1995). “The ALJ's decision must stand or fall with the reasons set
forth in the ALJ's decision, as adopted by the Appeals Council.” Newton v. Apfel, 209 F.3d
448, 455 (5th Cir. 2000).
In evaluating a disability claim, the Commissioner follows a five-step sequential
process to determine whether: (1) the claimant is participating in substantial gainful
activity; (2) the claimant’s ability to work is significantly limited by a physical or mental
impairment; (3) the claimant’s impairment meets or equals an impairment listed in the
appendix to the regulations; (4) the impairment prevents the claimant from doing past
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relevant work; and (5) the claimant cannot presently perform other relevant work.
Martinez, 64 F.3d at 173-174; 20 C.F.R. §§ 404.1520(a)(4). The claimant bears the burden
of proof on the first four steps, with the burden shifting to the Commissioner at the fifth
step. Bowling v. Shalala, 36 F.3d 431, 435 (5th Cir. 1994). The ALJ bases his decision on
the preponderance of the evidence in the record. 20 C.F.R. § 404.953(a).
RFC, which is determined between the third and fourth steps, is the most a claimant
can do despite their limitations. 20 C.F.R. § 404.1545(a); Perez, 415 F.3d at 461-62. When
assessing a claimant’s RFC, the ALJ must consider all relevant medical and other evidence,
including statements by the claimant and their family members regarding the limitations
that result from their symptoms. 20 C.F.R. § 404.1545(a)(3). When creating the RFC, the
ALJ must consider all a claimant’s medically determinable impairments. Id.
§ 404.1545(a)(2). “[T]he determination of residual functional capacity is the sole
responsibility of the ALJ.” Taylor v. Astrue, 706 F.3d 600, 602-03 (5th Cir. 2012). When
assessing a claimant’s RFC, the ALJ must consider all relevant medical and other evidence,
including statements by the claimant and their family members regarding the limitations
that result from their symptoms. 20 C.F.R. § 404.1545(a)(3). The “ALJ must consider all
the record evidence and cannot ‘pick and choose’ only the evidence that supports his
position.” Loza v. Apfel, 219 F.3d 378, 393 (5th Cir. 2000).
The ALJ does not defer or give any specific evidentiary weight to any medical
opinion or prior administrative medical finding. 20 C.F.R. § 404.1520c(a). The ALJ
considers several factors when evaluating medical opinions, including: (1) supportability;
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(2) consistency; (3) relationship with the claimant; (4) specialization; and (5) other factors
as applicable. Id. § 404.1520c(c). The most important factors when evaluating
persuasiveness are supportability and consistency. Id. § 404.1520c(a). “Supportability”
means that “[t]he more relevant the objective medical evidence and supporting
explanations presented by a medical source are to support his or her medical opinion(s) or
prior administrative medical finding(s), the more persuasive the medical opinions or prior
administrative medical finding(s) will be.” Id. § 404.1520c(c)(1). “Consistency” means
that “[t]he more consistent a medical opinion(s) or prior administrative medical finding(s)
is with the evidence from other medical sources and nonmedical sources in the claim, the
more persuasive the medical opinion(s) or prior administrative medical finding(s) will be.”
Id. § 404.1520c(c)(2). The ALJ must articulate how persuasive they find all of the medical
opinions and prior administrative medical findings in the record. Id. § 404.1520c(b). The
ALJ must address supportability and consistency, but the other factors are optional. Id.
§ 404.1520c(b)(2).
Here, the ALJ adequately addressed both the supportability and consistency factors,
and substantial evidence supported his conclusion that Dr. Wooley’s opinion was
unpersuasive. First, the ALJ properly considered the supportability factor when evaluating
Dr. Wooley’s opinion. The ALJ stated that Dr. Wooley’s conclusion that Benjamin had a
poor ability to perform in all functional areas was both “unsupported” and “inconsistent”
with, among other things, “the objective findings as described.” (D.E. 5-3 at 117). Earlier
in his opinion, the ALJ extensively discussed Dr. Wooley’s objective findings, including
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noting that she found Benjamin’s intelligence to be average and his fund of knowledge
within normal limits, his thought process logical and relevant with no evidence of thought
disturbance, his memory intact, and his judgment and insight intact. (Id. at 112, 115-16).
The ALJ also acknowledged the parts of Dr. Wooley’s opinion that showed impairments,
including variable concentration and attention. (Id. at 116). Considering the opinion as a
whole and the ALJ’s specific reasoning for finding Dr. Wooley’s opinion unpersuasive,
the record shows that he properly considered the supportability factor.
Second, as to the consistency factor, the ALJ’s opinion accurately noted that records
indicated Benjamin was generally cooperative and that mental status examinations
throughout the record regularly showed normal cognition, memory, fund of knowledge,
concentration, and attention. (See id. at 112, 115-17; D.E. 5-9 at 172, 174; D.E. 5-10 at 6-
8, 37-39, 86-88, 149-51, 180-82; D.E. 5-11 at 9-10; D.E. 5-13 at 142-44; D.E. 5-14 at 287-
88). On the other hand, the record also indicated that Benjamin often endorsed suicidal
ideation, had several instances of self-cutting, and was regularly described as depressed
and anxious with thought content abnormalities including feelings of hopelessness and
worthlessness. (See, e.g., D.E. 5-8 at 172; D.E. 5-9 at 46, 172, 174; D.E. 5-10 at 83, 86-
87, 149-51, 180-82; D.E. 5-11 at 9-10, 63-64; D.E. 5-13 at 142-44; D.E. 5-14 at 122, 126,
135, 138, 146, 160, 170, 176, 281, 287-88). Overall, the record is mixed regarding the type
and extent of Benjamin’s mental limitations, and there is certainly evidence in the record
to support greater limitations than those found by the ALJ. However, it is not this Court's
role to re-weigh the evidence, and considering the record as a whole, the ALJ's conclusion
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that Dr. Wooley’s opinion was unsupported by her examination, inconsistent with the
wider record, and accordingly unpersuasive was supported by more than a scintilla of
evidence. Perez, 415 F.3d at 461; Martinez, 64 F.3d at 174.
IV. RECOMMENDATION
Accordingly, it is recommended that Benjamin’s motion (D.E. 7) be DENIED, the
Commissioner’s motion (D.E. 10) be GRANTED, and this cause of action be
DISMISSED.
Respectfully submitted on July 17, 2026.
____________________________
Julie K. Hampton
United States Magistrate Judge
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NOTICE TO PARTIES
The Clerk will file this Memorandum and Recommendation and transmit a copy to
each party or counsel. Within FOURTEEN (14) DAYS after being served with a copy of
the Memorandum and Recommendation, a party may file with the Clerk and serve on the
United States Magistrate Judge and all parties, written objections, pursuant to Fed. R. Civ.
P. 72(b), 28 U.S.C. § 636(b)(1), General Order No. 2002-13, United States District Court
for the Southern District of Texas.
A party’s failure to file written objections to the proposed findings, conclusions, and
recommendation in a magistrate judge’s report and recommendation within FOURTEEN
(14) DAYS after being served with a copy shall bar that party, except upon grounds of
plain error, from attacking on appeal the unobjected-to proposed factual findings and legal
conclusions accepted by the district court. Douglass v. United Servs. Auto Ass’n, 79 F.3d
1415 (5th Cir. 1996) (en banc); 28 U.S.C § 636(b)(1).
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