Shivers v. Commissioner of Social Security

IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
DALLAS DIVISION
DEANDRE S., §
PLAINTIFF, §
§
V. § CASE NO. 3:24-CV-3151-BK
§
COMMISSIONER, SOCIAL SECURITY §
ADMINISTRATION, §
DEFENDANT. §
MEMORANDUM OPINION AND ORDER
Pursuant to 28 U.S.C. § 636(b) and the parties’ consent to proceed before the undersigned
United magistrate judge, Doc. 3, the Court now considers this appeal of the denial of Plaintiff’s
application for Social Security disability benefits. As detailed here, the Commissioner’s decision
is REVERSED, and this case is REMANDED for further proceedings.
I. BACKGROUND
A. Procedural History
Plaintiff seeks judicial review of the final decision of Commissioner of the Social
Security Administration (“Commissioner”) denying his application for disability insurance
benefits (“DIB”) and supplemental security income (“SSI”) under the Social Security Act (the
“Act”). Doc. 1.
In March 2022, Plaintiff filed his application for DIB and SSI, alleging a period of
disability beginning in June 2021 due to post traumatic stress disorder (“PTSD”), neuropathy in
the right arm, and anxiety. Doc. 11-1 at 74. Plaintiff’s claim was denied at all administrative
levels, and he now appeals to this Court pursuant to 42 U.S.C. § 405(g). Doc. 1 at 1.
Case 3:24-cv-03151-BK Document 20 Filed 03/30/26 Page 1 of 13 PageID <pageID>

2
B. Factual History
Plaintiff, who was 41 years old at the alleged onset of her disability, has at least some
college education and past relevant work as a construction equipment mechanic. Doc. 11-1 at
53, 65, 113. Plaintiff’s relevant medical history, dating from 2021 to 2024, reflects diagnoses of
PTSD, anxiety, depression, and insomnia.1 Doc. 11-1 at 456-58, 480, 503. The records further
show that Plaintiff began exhibiting psychiatric symptoms after he was robbed and shot in June
2021 by a stranger posing as someone wanting to sell a car to him. Doc. 11-1 at 422, 480.
C. Medical Opinion Evidence
In February 2022, Plaintiff began psychiatric care with Dr. Meitra Leigh Doty. Doc. 11-1
at 462. Plaintiff reported experiencing intrusive thoughts, nightmares, flashbacks, and
dissociative reactions due to the robbery and shooting. Doc. 11-1 at 462. He further reported
irritability, reckless or self-destructive behavior, sleep disturbance, poor concentration, and
feelings of isolation and distrust of others. Doc. 11-1 at 462. Plaintiff was prescribed an
antidepressant and Prazosin for his nightmares. Doc. 11-1 at 463.
In March 2022, Plaintiff reported to Dr. Doty that his panic attacks had decreased since
starting medication, but that he was thrashing around in his sleep. Doc. 11-1 at 456. Dr. Doty
prescribed Plaintiff Trazodone instead of Prazosin to help him sleep. Doc. 11-1 at 458.
In April 2022, Plaintiff reported that his anxiety was through the roof and that he had
been feeling “really overwhelmed.” Doc. 11-1 at 443. Plaintiff began psychotherapy and was
1 Although Plaintiff alleged additional physical impairments related to neuropathy resulting from
the gunshot wounds to his upper extremity, he challenges only the ALJ’s evaluation of his
mental impairments. See Doc. 14 at 1. Accordingly, the Court focuses on the medical records
and evidence pertaining to Plaintiff’s alleged mental impairments.
Case 3:24-cv-03151-BK Document 20 Filed 03/30/26 Page 2 of 13 PageID <pageID>

3
reported as seeming extremely nervous during the session. Doc. 11-1 at 444. However,
Plaintiff’s counselor also observed that Plaintiff appeared to be motivated for treatment to
address his existing mental health issues that “seem to impact day-to-day functioning.” Doc. 11-
1 at 443.
In June 2022, Plaintiff reported that his anxiety had been high and that he continued to
experience panic attacks while on his medication. Doc. 11-1 at 425. In the fall of 2022, Plaintiff
reported that he was experiencing panic attacks and hypervigilance every day, especially upon
leaving the house. Doc. 11-1 at 478, 555. Plaintiff was started on Propranolol for the panic
attacks. Doc. 11-1 at 547.
In November 2022, State Agency Psychological Consultant Sonya Adamo, Psy.D.,
reviewed Plaintiff’s claim and opined that Plaintiff had no limitations in understanding,
remembering, or applying information; mild limitations in interacting with others and
concentrating, persisting or maintaining pace; and moderate limitations in adapting or managing
oneself. Doc. 11-1 at 76. Dr. Adamo also opined that Plaintiff was moderately limited in his
ability to respond appropriately to changes in the work setting, but that he “can adapt to low
stress work.” Doc. 11-1 at 80.
In January 2023, Plaintiff reported improvements in his mood and anxiety, and was
continued on his medications. Doc. 11-1 at 537-39. In August and September 2023, Plaintiff
indicated he was having difficulty refilling his medications due to his insurance. Doc. 11-1 at
493, 497. He further reported that he had gotten a job at a fast-food restaurant and that his
anxiety worsened due to the customer-facing activities involved. Doc. 11-1 at 497. He stated
Case 3:24-cv-03151-BK Document 20 Filed 03/30/26 Page 3 of 13 PageID <pageID>

4
that he had lost the job because he could no longer afford the commute, but that he was looking
for a “work from home customer service job.” Doc. 11-1 at 493.
In December 2023, State Agency Psychological Consultant David Strand, Ph.D.,
reviewed Plaintiff’s claim upon reconsideration found limitations consistent with Dr. Adamo’s
opinion. Doc. 11-1 at 96. Dr. Strand’s opinion differed only in that he noted a moderate
limitation in Plaintiff’s ability to complete a normal workday and workweek without
psychological interruptions and to perform at a consistent pace without an unreasonable number
and length of rest periods. Doc. 11-1 at 100. However, in the narrative portion of his analysis,
Dr. Strand described mild vocational limitations in all areas except adaptation and concluded that
Plaintiff could adapt to a low stress environment. Doc. 11-1 at 101.
D. Hearing Testimony
i. Plaintiff’s Testimony
At the 2024 administrative hearing, Plaintiff testified that he stopped working as a
mechanic after he was robbed and shot in the right arm. Doc. 11-1 at 52. Plaintiff further
testified that he has PTSD and depression as a result of the shooting and is currently on ten
medications to address his anxiety, nerve pain, and sleep disorder. Doc. 11-1 at 57. He averred
that the combination of medications makes him feel groggy, like a zombie, and results in mood
swings. Doc. 11-1 at 60. Plaintiff stated that he lives with friends and family and that, while he
does not do laundry because of the lifting, he tries to do other chores such as vacuuming. Doc.
11-1 at 59.
Plaintiff additionally testified that he tried working as a fast-food manager in 2022 or
2023 for approximately a week, but that his medications and anxiety prevented him from being
Case 3:24-cv-03151-BK Document 20 Filed 03/30/26 Page 4 of 13 PageID <pageID>

5
able to do the job. Doc. 11-1 at 61. He stated that his panic attacks and anxiety go from “zero to
100” and that he tries to stay in the house to avoid triggering symptoms of his PTSD. Doc. 11-1
at 61-62. He further averred that his depression impacts him significantly on daily basis and that,
at times, it feels as if he is being held down by an anchor. Doc. 11-1 at 62.
ii. Vocational Expert Testimony
A vocational expert (“VE”) testified at the administrative hearing that an individual with
Plaintiff’s education and work experience who is limited to light work and to understanding,
remembering, and carrying out simple and routine instructions and tasks; occasional interaction
with coworkers and supervisors; and limited or incidental contact with the general public, could
perform jobs in the national economy, including cleaner or housekeeper, routing clerk, and
inspector or hand packager. Doc. 11-1 at 67, 70.
E. The ALJ’s Findings
Following the administrative hearing, the ALJ issued his Hearing Decision utilizing the
five-step sequential evaluation set forth in 20 C.F.R. § 416.920 in determining whether Plaintiff
was disabled. At step one, the ALJ found that Plaintiff met the insured status requirements of the
Social Security Act through June 30, 2026, and had not engaged in substantial gainful activity
since June 18, 2021. Doc. 11-1 at 24. At step two, the ALJ determined that Plaintiff had severe
impairments of major depressive disorder, post-traumatic stress disorder with anxiety, and
insomnia. Doc. 11-1 at 25. However, the ALJ further found that none of Plaintiff’s
impairments, singularly or in combination, met or medically equaled any listed impairment in 20
C.F.R. Part 404, Subpart P, Appendix 1. Doc. 11-1 at 25.
Case 3:24-cv-03151-BK Document 20 Filed 03/30/26 Page 5 of 13 PageID <pageID>

6
At step three, the ALJ found that Plaintiff had the Residual Functional Capacity (“RFC”)
to perform “light work as defined in 20 CFR 404.1567(b) and 416.967(b),” with the mental
limitations that he can understand, remember, and carry out simple and routine instructions and
tasks, but “can have no interaction with the public” and only “occasional interaction with
coworkers and supervisors.” Doc. 11-1 at 30.
At step four, the ALJ found that Plaintiff did not have the RFC to perform any of his past
relevant work. Doc. 11-1 at 39. At step five, relying chiefly on the vocational expert’s
testimony, the ALJ determined that there were a significant number of jobs in the national
economy that Plaintiff could perform. Doc. 11-1 at 40-41. Thus, the ALJ concluded that
Plaintiff was not disabled under the Act. Doc. 11-1 at 41.
II. APPLICABLE LAW
The definition of disability under the Act is the “inability to engage in any substantial
gainful activity by reason of any medically determinable physical or mental impairment which
can be expected to result in death or which has lasted or can be expected to last for a continuous
period of not less than 12 months . . . .” 42 U.S.C. § 423(d)(1)(A). To determine whether a
claimant is disabled, the Commissioner utilizes a sequential five-step inquiry: (1) whether the
claimant is engaged in substantial gainful activity; (2) whether the claimant’s impairments are
“severe”; (3) whether the claimant’s impairment “meets or equals” one of the listings in the
relevant regulations; (4) whether the claimant can still do his past relevant work; and (5) whether
the impairment prevents the claimant from doing any other available work. Webster v. Kijakazi,
19 F.4th 715, 718 (5th Cir. 2021) (citing 20 C.F.R. § 404.1520(a)(4)). The claimant bears the
Case 3:24-cv-03151-BK Document 20 Filed 03/30/26 Page 6 of 13 PageID <pageID>

7
burden on the first four steps. Id. (citation omitted). If the claimant meets his burden, the burden
then shifts to the Commissioner to “prove the claimant’s employability.” Id. (citation omitted).
The Court’s review “is exceedingly deferential and limited to two inquiries: whether
substantial evidence supports the ALJ’s decision, and whether the ALJ applied the proper legal
standards when evaluating the evidence.” Taylor v. Astrue, 706 F.3d 600, 602 (5th Cir. 2012).
“And whatever the meaning of ‘substantial’ in other contexts, the threshold for such evidentiary
sufficiency is not high. Substantial evidence, [the Supreme] Court has said, is more than a mere
scintilla. It means—and means only—such relevant evidence as a reasonable mind might accept
as adequate to support a conclusion.” Biestek v. Berryhill, 587 U.S. 97, 103 (2019) (internal
citations and quotation marks omitted). The Court can neither “reweigh the evidence or
substitute its judgment for the Commissioner’s.” Perez v. Barnhart, 415 F.3d 457, 461 (5th Cir.
2005). A finding that substantial evidence does not exist “is appropriate only if no credible
evidentiary choices or medical findings support the decision.” Whitehead v. Colvin, 820 F.3d
776, 779 (5th Cir. 2016) (cleaned up).
III. ANALYSIS
On appeal, Plaintiff argues that the ALJ’s RFC finding relating to his mental limitations
is not supported by substantial evidence. Specifically, Plaintiff contends that (1) the ALJ
impermissibly relied on his own lay interpretation of the medical evidence in determining
Plaintiff’s mental RFC; and (2) the ALJ failed to adequately evaluate the opinion of Dr. Strand.
Doc. 14 at 1.
Because the Court concludes that remand is required on the first issue, it need not reach
Plaintiff’s second argument.
Case 3:24-cv-03151-BK Document 20 Filed 03/30/26 Page 7 of 13 PageID <pageID>

8
A. The ALJ Impermissibly Relied on his Own Interpretation of Medical
Evidence in Assessing Plaintiff’s Mental RFC.
Relying on Ripley v. Charter, 67 F.3d 552 (5th Cir. 1995), Plaintiff contends that,
because the ALJ rejected the only medical opinion evidence addressing the functional effect of
his mental impairments, the ALJ erred in relying on his own interpretation of the remaining
evidence to formulate the RFC. Doc. 14 at 9. Defendant responds that the ALJ properly based
Plaintiff’s mental RFC on his interpretation of the entire record, including both medical and non-
medical evidence. Doc. 18 at 6-7.
“It is the responsibility of the ALJ to interpret ‘the medical evidence to determine [a
claimant's] capacity for work.’” Fontenot v. Colvin, 661 F. App'x 274, 277 (5th Cir. 2016)
(quoting Taylor v. Astrue, 706 F.3d 600, 603 (5th Cir. 2012)). “The ALJ makes an RFC
determination based on all the relevant medical and other evidence in the record,” Gonzales v.
Colvin, No. 3:15-cv-685-D, 2016 WL 107843, at *9 (N.D. Tex. Jan. 11, 2016) (citing 20 C.F.R.
§ 404.1545(a)(1)), and “is entitled to determine the credibility of medical experts as well as lay
witnesses and to weigh their opinions and testimony accordingly.” Fontenot, 661 F. App'x at
277 (quoting Moore v. Sullivan, 919 F.2d 901, 905 (5th Cir. 1990)).
While an ALJ usually “should request a medical source statement describing the types of
work that the applicant is still capable of performing,” the absence of such a statement does not
automatically render the record incomplete. Ripley, 67 F.3d at 557 (citing 20 C.F.R. §
404.1513(b)(6)). Where no medical statement exists, the inquiry focuses on whether the ALJ’s
decision is supported by substantial evidence in existing record. Id.; accord Gutierrez v.
Barnhart, No. 04-11025, 2005 WL 1994289, at *7 (5th Cir. Aug. 19, 2005) (citation omitted).
However, evidence describing the claimant’s medical conditions is alone insufficient to support
Case 3:24-cv-03151-BK Document 20 Filed 03/30/26 Page 8 of 13 PageID <pageID>

9
an RFC determination. Moreno v. Astrue, No. 5:09-CV-123, 2010 WL 3025525, at *3 (N.D.
Tex. June 30, 2010) (Koenig, J.) rep. & rec. adopted, 2010 WL 3025519 (N.D. Tex. Aug. 3,
2010) (citing Ripley, 67 F.3d at 557). Accordingly, an ALJ may not—without medical
opinions—derive a claimant’s RFC solely from the existence of medical conditions and the
claimant’s subjective statements. Williams v. Astrue, 355 F. App’x 828, 832 n. 6 (5th Cir. 2009).
In this case, the ALJ concluded that Plaintiff’s mental RFC limited him to understanding,
remembering, and carrying out simple tasks and instructions, occasional interaction with
coworkers and supervisors, and no interaction with the public. Doc. 11-1 at 39. However, the
ALJ neither identified an acceptable medical opinion supporting these limitations nor adequately
explained how the remaining evidence substantiates them.
Critically, the ALJ rejected the November 2022 and December 2023 opinions of State
agency psychological consultants Dr. Sonya Adamo and Dr. David Strand. Doc. 11-1 at 39.
Both consultants opined that Plaintiff had no limitations in understanding remembering or
applying information, and only mild limitations in interacting with others and in concentrating,
persisting, and maintaining pace. Doc. 11-1 at 39 (citing Doc. 11-1 at 87, 96, 108). The ALJ
found these opinions unpersuasive, explaining—albeit in a conclusory fashion—that “they were
inconsistent with the overall medical record,” that additional evidence had subsequently been
submitted, and that the ALJ adopted “a different interpretation of the medical evidence that was
before them.” Doc. 11-1 at 39. Although the ALJ rejected these opinions, he ultimately assessed
an RFC that included greater limitations than those identified by either Dr. Adamo or Dr. Strand.
Compare Doc. 11-1 at 87, 96, with Doc. 11-1 at 39. According to the ALJ, “[t]he record as a
Case 3:24-cv-03151-BK Document 20 Filed 03/30/26 Page 9 of 13 PageID <pageID>

10
whole shows a broader range of symptoms affecting memory and the ability to interact with
others.” Doc. 11-1 at 39.
Having rejected this opinion evidence, the ALJ relied on his own review of Plaintiff’s
testimony, prior statements, and treatment records in formulating the RFC. See generally, Doc.
11-1 at 26-29. For example, regarding Plaintiff’s ability to interact with others, the ALJ cited
records showing that Plaintiff “has interacted well with his treatment providers,” and has “often
been described as calm and/or cooperative.” Doc. 11-1 at 27. The ALJ also noted that, in an
August 2022 function report, Plaintiff stated that he lived with friends while also reporting that
he had difficulty getting along with others. Doc. 11-1 at 28. Additionally, the ALJ referenced
Plaintiff’s September 2023 statement that he was “looking for a work from home customer
service job.” Doc. 11-1 at 28 (citing Doc. 11-1 at 493). The ALJ ultimately concluded that
“[o]verall, such evidence indicates no more than a moderate limitation in this area.” Doc. 11-1 at
28.
With respect to Plaintiff’s ability to understand, remember, and apply information, the
ALJ’s analysis was similar. The ALJ cited multiple records showing that Plaintiff’s mental
status examinations consistently reflected intact or normal memory, and thought processes that
were intact, normal, logical, and/or well organized. Doc. 11-1 at 27. The ALJ also noted that, in
August 2022 and November 2023 function reports, Plaintiff indicated that he could follow
written instructions “okay” and spoken instructions “okay” or “well.” Doc. 11-1 at 28 (citing
Doc. 11-1 at 278, 301). The ALJ further observed that Plaintiff’s September 2023 statements—
that he had lost his job because he could not afford his commute and was seeking a home
customer service job—suggest that he did not stop working due to any problems understanding,
Case 3:24-cv-03151-BK Document 20 Filed 03/30/26 Page 10 of 13 PageID <pageID>

11
remembering, or applying information. Doc. 11-1 at 27. Accordingly, the ALJ concluded that
the evidence indicates no more than a moderate limitation in this area. Doc. 11-1 at 27.
While the ALJ was free to reject the medical opinion evidence of the State’s
psychological consultants, “he cannot then independently decide the effects of Plaintiff’s . . .
impairments on [his] ability to work[.]” Shugart v. Astrue, No. 3:12–CV–1705, 2013 WL
991252, at *5 (N.D.Tex. Mar.13, 2013). After rejecting the only medical opinions addressing
the functional effects of Plaintiff’s mental impairments, the ALJ relied solely on his own
interpretation of treatment notes, mental status examination, and Plaintiff’s subjective reports.
See generally, Doc. 11-1 at 26-29. But, while these sources describe the existence and general
severity of Plaintiff’s symptoms, they did not assess how those symptoms translate into work-
related limitations. By relying on this evidence alone in crafting the RFC, the ALJ
impermissibly substituted his lay judgment for medical expertise in violation of Ripley. See, e.g.,
Medendorp v. Colvin, No. 4:12-CV-687, 2014 WL 308095, at *6 (N.D. Tex. Jan. 28, 2014)
(Means, J.) (ALJ improperly relied on his own medical judgment where the only medical opinion
addressing the functional effects of the impairment on the claimant’s ability to work was
rejected, and no other medical evidence supported the ultimate RFC); Cooper v. Comm’r of Soc.
Sec., No. , 2022 WL 4538460 (N.D. Tex. July 15, 2022) rep. & rec. adopted, 2022 WL 4538460
(N.D. Tex. Sept. 27, 2022) (ALJ committed Ripley error by including limitations in the RFC
despite record containing vast amount of medical evidence of impairments because all opinions
Case 3:24-cv-03151-BK Document 20 Filed 03/30/26 Page 11 of 13 PageID <pageID>

12
addressing functional effect of those impairments were rejected). Consequently, The ALJ’s
mental RFC determination is not supported by substantial evidence.
B. The ALJ’s Error Was Not Harmless.
Nevertheless, the existence of an error does not automatically result in reversal of the
Commissioner’s decision. Rather, “[w]hen an ALJ commits a Ripley error, remand ‘is
appropriate only if [the claimant] shows that he was prejudiced.” Fitzpatrick v, Colvin, No.
3:15-CV-3202, 2016 WL 1258477, at *8 (N.D. Tex. Mar. 31, 2016) (Fitzwater, J.) (quoting
Ripley, 67 F.3d at 557). “Prejudice can be established by shown that additional evidence would
have been produced if the ALJ had fully developed the record, and that the additional evidence
might have led to a different decision.” Ripley, 67 F.3d at 557 n. 22.
Here, the ALJ rejected Dr. Adamo and Dr. Strand’s opinions, in part because additional
evidence was submitted which suggested a broader range of symptoms affecting Plaintiff’s
memory and the ability to interact with others. Doc. 11-1 at 39. However, once the ALJ
determined that these opinions no longer reflected Plaintiff’s mental limitations, “it became
incumbent upon [him] to obtain an expert medical opinion about the types of work activities that
Plaintiff could still perform” in light of the new evidence. Shugart, 2013 WL 991252, at *6;
Alondra E. F. v. Kijakazi, No. 3:20-CV-2787, 2022 WL 605301, at *5 (N.D. Tex. Mar. 1, 2022)
(Horan, J.). Had the ALJ done so, his RFC determination could conceivably have reflected
different or greater limitations. See Alondra, 2022 WL 605301, at *5 (remanding where ALJ
recognized evidence suggesting greater mental limitations than those noted in the medical
opinions of record, because an updated medical opinion accounting for those changes might have
supported greater limitations than those ultimately found). This is particularly true in light of
Case 3:24-cv-03151-BK Document 20 Filed 03/30/26 Page 12 of 13 PageID <pageID>

13
reports post-dating at least one medical opinion which indicate that Plaintiff reported
experiencing panic attacks three times a day. Doc. 11-1 at 504. Because such evidence could
have changed the medical expert’s opinion, and in turn, altered the ALJ’s RFC determination,
the ALJ’s failure to obtain updated medical opinion evidence prejudiced Plaintiff. Alondra,
2022 WL 6055301, at *5. Remand is therefore required on this issue.
IV. CONCLUSION
For the foregoing reasons, the Commissioner’s decision is REVERSED, and this case is
REMANDED to the Social Security Administration for further proceedings consistent with this
opinion.
SO ORDERED on March 30, 2026.
Case 3:24-cv-03151-BK Document 20 Filed 03/30/26 Page 13 of 13 PageID <pageID>