Arturo O. Simon v. Commissioner, Social Security Administration ( 2021 )

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[PUBLISH]
IN THE UNITED STATES COURT OF APPEALS
FOR THE ELEVENTH CIRCUIT
________________________
No. 19-14682
________________________
D.C. Docket No. 1:18-cv-24013-UU
ARTURO O. SIMON,
Plaintiff-Appellant,
versus
COMMISSIONER, SOCIAL SECURITY ADMINISTRATION,
Defendant-Appellee.
________________________
Appeal from the United States District Court
for the Southern District of Florida
________________________
(June 9, 2021)
Before LAGOA, ANDERSON, and MARCUS, Circuit Judges.
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ANDERSON, Circuit Judge:
This appeal requires us to decide whether the Social Security Administration
(“SSA”) properly evaluated the evidence supporting Arturo Simon’s claim for
disability benefits under Title II of the Social Security Act. In his application,
Simon stated that he was no longer able to work due to various psychiatric
conditions, which included chronic depression, anxiety, and bipolar disorder.
Simon received a hearing before an administrative law judge (“ALJ”), who
ultimately found that he was not disabled and denied his claim for benefits.
In reaching that decision, the ALJ gave little or no weight to three pieces of
evidence in the record indicating that Simon’s mental illness prevents him from
maintaining a job: (1) the opinions of Simon’s treating psychiatrist, (2) the
opinions of a consulting psychologist who examined Simon at the request of the
SSA, and (3) Simon’s own testimony as to the severity of his symptoms. Because
we conclude that the ALJ did not articulate adequate reasons for discounting this
evidence, which provided support for a finding of disability, we will remand to the
agency for further proceedings.
I. BACKGROUND
Simon filed his current application for disability benefits in March of 2015,
claiming to be disabled due to his deteriorating mental health. He previously had
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filed another such application in May of 2014, which was denied later that year.
This appeal relates solely to Simon’s 2015 application.
The SSA denied Simon’s application after an initial review, at which point
Simon requested and received a formal hearing before an ALJ, which took place
on July 24, 2017. Below, we begin with a description of the medical evidence and
testimony that was submitted to the ALJ, before moving on to discuss the ALJ’s
disability decision, and finally to discuss our reasons for concluding that a remand
is required.
A. Summary of the SSA Record
1. Dr. Turner’s Opinions
Dr. Rosa Turner was Simon’s treating psychiatrist from 2013 to 2017.
During that period, she met with him approximately thirty-two times and kept
regular notes on his mental condition. Thus, Dr. Turner’s treatment notes offered
an extensive and detailed account of Simon’s psychiatric history.
At his initial evaluation with Dr. Turner in May of 2013, Simon reported
symptoms of insecurity, losing sight of reality, physical and mental exhaustion,
poor self-esteem, lack of sex drive, road rage, poor memory, loss of focus and
concentration, severe mood swings, and instances of obsessive-compulsive
behavior. Simon stated that he had been experiencing these problems as long as he
could remember, even in childhood, and he had been taking mental-health
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medication for around twenty years. Dr. Turner recorded in her notes that Simon
displayed slowed activity, depression, anxiety, irritability, decreased motivation,
low energy, auditory hallucinations, and suicidal ideation. She also wrote that his
short-term memory, concentration, and attention span were impaired. Dr. Turner
ultimately diagnosed Simon with bipolar disorder, described him as having severe
psychosocial or environmental problems, and started him on a course of
psychiatric treatment with medication.
Some entries in Dr. Turner’s notes suggested that, at times, this treatment
helped Simon to a degree. In December of 2013, for example, Dr. Turner recorded
that Simon was “very stable” and had improved. Her notes made similar
references to Simon being “stable on medication” in June of 2014, July of 2014,
November of 2014, April of 2015, and June of 2016. In nearly all of these
instances, however, Dr. Turner also wrote that Simon continued to suffer from
significant symptoms of mental illness—such as panic attacks, racing thoughts,
and episodes of anger. Indeed, several of the notations in which Dr. Turner
described Simon as “stable on his medication” went on to say that he was “not
coping well.”
On many other occasions, meanwhile, Dr. Turner indicated that Simon’s
overall condition was quite serious, and that it was worsening rather than
improving. In September of 2014, Dr. Turner wrote that Simon was extremely
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depressed, having difficulty concentrating, suffering from panic attacks, and
refusing to leave his house out of fear. In January of 2015, she wrote that Simon
was paranoid to the point that he would not go out unless absolutely necessary, and
that he was unable to function, maintain his train of thought, or process
information. In July of 2015, she wrote that Simon was experiencing anger spells
and mood swings, to the point that his wife was growing worried because he would
“change personalities very easily” and sometimes would lose touch with reality. In
August of 2015, she wrote that Simon displayed slowed speech and motor skills,
that he could not focus or concentrate, and that he was isolating himself from
others.
Dr. Turner continued to describe these types of symptoms throughout her
four years of treating Simon. In September, October, and December of 2015, she
recorded that Simon was depressed, paranoid, and refused to see others. In
February and March of 2016, she wrote that Simon’s symptoms remained serious,
that he was unable to concentrate, that he would not talk, and that he could not
control his racing thoughts. In August of 2016, she wrote that Simon was
depressed, severely anxious, and could not concentrate or maintain his train of
thought. In March and April of 2017, she wrote that Simon was unable to
concentrate and suffered from slowed motor skills. In July of 2017, she recorded
that Simon had isolated himself completely from others.
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As early as October of 2014, Dr. Turner opined that Simon’s psychological
impairments rendered him entirely unable to work or handle any type of stress.
She described him at that time as being in a “complete state of depression” with
racing thoughts, frequent panic attacks, and paranoia. Her treatment notes
reiterated that conclusion in March and May of 2015, both times stating that Simon
was unable to work in any role because of his inability to focus or process
information.
In July of 2017, Dr. Turner submitted a “mental capacities evaluation” to the
SSA in connection with Simon’s disability claim. In her evaluation, she again
diagnosed Simon as suffering from bipolar disorder, mixed with severe anxiety and
panic attacks. She opined that Simon had “extreme” limitations 1 in his abilities to:
• understand, remember, or apply information;
• interact with others;
• concentrate, persist, or maintain pace; and
• adapt or manage himself.
1
The SSA considers a claimant to have an “extreme” limitation in an area of mental
functioning if he or she is “not able to function in [that] area independently, appropriately,
effectively, and on a sustained basis.” 20 C.F.R. § 404, Subpart P, Appendix I.
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She also opined that Simon had “marked” limitations 2 in numerous other areas,
including:
• his ability to perform simple tasks on a full-time basis;
• his ability to perform work requiring regular contact with others; and
• his ability to respond appropriately to the stress of customary work
pressures.
According to Dr. Turner’s assessment, Simon “has been in a critical state of mind
for several years now,” and his condition “will only get worse” with time. She
wrote that Simon “is stable at present time—but we must maintain him this way to
avoid severe decompensation.”
Viewed as a whole, Dr. Turner’s comprehensive clinical records portray
Simon as a person living with a severe combination of bipolar disorder, depression,
and anxiety that significantly impairs his mental and social functioning.
2. Dr. Marban’s Opinions
During its evaluation of Simon’s 2014 claim for disability benefits, the SSA
arranged for Simon to meet with Dr. Elsa Marban for a consultive mental
examination. Dr. Marban recorded that Simon drove himself to the exam and
arrived half an hour early. She described Simon as cooperative, coherent, and
2
The SSA considers a claimant to have a “marked” limitation in an area of mental
functioning if his or her “functioning in [that] area independently, appropriately, effectively, and
on a sustained basis is seriously limited.” 20 C.F.R. § 404, Subpart P, Appendix I.
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loquacious, though he had to be redirected often. She also noted that Simon was
appropriately groomed and displayed normal “psychomotor activity.”
Simon reported to Dr. Marban that he had been suffering from—among
other things—low energy, panic attacks, an inability to control his aggression,
mood swings, racing thoughts, and difficulty concentrating. He explained that he
began experiencing concentration problems at his previous job and would give
unrelated responses when his supervisor asked him questions. Simon also
informed Dr. Marban that he had resigned from another job several years before,
following an angry outburst in which he threatened to push his supervisor through
a balcony.
Dr. Marban recorded that Simon was alert during their examination and
oriented to place, time, and situation. She rated his remote memory as “good,” his
immediate memory as “fair,” and his recent memory as “poor.” She rated his
abstract-reasoning capabilities as “good” because he could interpret basic proverbs
and describe how two things were similar. She also wrote that he had a good fund
of information, such as being able to identify the direction in which the sun rises,
the number of weeks in a year, the capital of Italy, and the continental location of
Brazil. She stated that he displayed good judgment and fair insight into his
psychological issues—such as recognizing that, to improve his condition, he
needed to be on the right medication.
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Dr. Marban diagnosed Simon with Persistent Depressive Disorder,
Generalized Anxiety Disorder, Panic Disorder, and Intermittent Explosive
Disorder. She recorded that Simon could handle his own finances as well as
groom himself and bathe on his own, though there were days that he chose not to
bathe because he lacked motivation. She noted that his socialization was limited to
occasionally meeting friends for dinner. Regarding his ability to work, Dr. Marban
concluded that Simon would have difficulties concentrating, completing tasks,
accepting instructions, and responding to criticism from supervisors.
3. Other Agency Consultants
In addition to Dr. Marban, a number of other medical professionals also
evaluated Simon on behalf of the SSA. Shortly before his psychiatric evaluation
by Dr. Marban in 2014, Simon also met with Dr. Miesha Merati for a physical
examination. At that time, he reported suffering from depression, short-term
memory loss, and panic attacks. He also reported attempting to hang himself
several months before and having thoughts of harming others, particularly while
driving. He stated that he was able to dress himself and shop on his own, though
he did not do household chores.
In the “Mental Status” section of her evaluation form, Dr. Merati recorded
that Simon had a normal affect, coherent conversation, no hallucinations or
delusions, no overtly suicidal or homicidal ideation, a “grossly intact” memory,
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and normal cognitive functioning. By her assessment, Simon’s cognitive and
executive functions “appear[ed] to be commensurate with [his] age, socioeconomic
status, and claimed education.” She noted that his chronic pain and depression
limited his daily activities, but she did not list the specific areas in which he was
limited or elaborate on the extent of his limitations. Dr. Merati did not express an
opinion on Simon’s capacity to work.
Dr. George Grubbs and Dr. Anne-Marie Bercik both reviewed some of
Simon’s medical records, but did not personally examine Simon themselves.
Dr. Grubbs’ report determined that Simon had no restrictions in his daily activities,
and only mild difficulties in social function, concentration, persistence, and pace.
Dr. Grubbs also opined that, while Simon’s psychological impairments could be
reasonably expected to produce the types of symptoms that Simon had reported,
Simon’s medical records as a whole did not indicate that his symptoms were as
severe as claimed. Dr. Bercik issued a second report several months later, in which
she agreed with Dr. Grubbs’ conclusions.
4. Simon’s Hearing Testimony
At his hearing before the ALJ, Simon testified that he was sixty-two years
old, lived with his wife, had two years of college education, and previously had
worked in sales.
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Simon testified that he had stopped working in March of 2014 because of his
depression and inability to concentrate. Specifically, he explained that his inability
to focus and his memory problems kept him from completing tasks, and that his
depression caused him to isolate himself. As an example, he stated that when his
wife asked him to go to the grocery store nearby and pick up two or three items, he
would forget them before reaching the store. He testified that he had attempted
suicide and no longer cared whether he was alive or dead. He testified that he no
longer got along with his wife and did not socialize with anyone.
Simon went on to report having mood swings nearly every day, as well as
uncontrollable spikes of aggression. He testified that his wife handled the finances
because he would forget to pay bills on time, and that she gave him his
medications. He testified that he would not leave the house except for a handful of
locations, such as the grocery store, because he felt safer at home. He testified that
his medication helped “a little,” but did not make him feel less depressed or
anxious, and he was unsure whether medication actually made his mood swings
less frequent.
5. The Vocational Expert’s Hearing Testimony
Once Simon had testified, the ALJ posed a series of questions to a
vocational expert (“VE”) regarding Simon’s capacity to work.
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First, the ALJ asked the VE to assume a hypothetical person with Simon’s
medical, educational, and vocational profile who could work at all levels of
physical exertion, but was limited to simple tasks, simple decision-making, and
only occasionally interacting with others. The VE testified that those limitations
would prevent someone from performing Simon’s past work—but such a person
still could perform light, unskilled work, such as floor waxer, bartender helper, or
cook helper.
Next, the ALJ asked the VE to assume a hypothetical person with the same
profile as before, but who was limited to only medium levels of exertion. The VE
testified that such a person could perform the same jobs listed above.
Finally, the ALJ asked the VE to assume a hypothetical person who suffered
from extreme limitations in interacting with others, concentrating, understanding,
remembering, or applying information. The ALJ confirmed that this hypothetical
was based on Dr. Turner’s mental capacities evaluation. The VE testified that such
a person could not perform any work in the national economy.
B. The ALJ’s Decision
After reviewing all of the evidence and testimony described above, the ALJ
denied Simon’s claim for disability benefits in a written decision. Consistent with
SSA guidelines, the ALJ followed a five-step analysis to determine whether Simon
was “disabled” within the meaning of the Social Security Act.
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At step one, the ALJ must determine whether the claimant is currently
engaging in “substantial gainful activity.” 20 C.F.R. § 404.1520(a)(4)(i). Activity
is “substantial” if it involves “doing significant physical or mental activities,” and
it is “gainful” if it is “usually done for pay or profit.” Id. § 404.1572(a)-(b). Here,
the ALJ found that Simon had not been engaged in “substantial gainful activity”
since he stopped working in March of 2014.
At step two, the ALJ must determine whether the claimant suffers from a
medically determinable impairment (or a combination of such impairments) that is
“severe.” Id. § 404.1520(a)(4)(ii). The SSA classifies an impairment as “severe”
if it “significantly limits” an individual’s ability to perform “basic work activities.”
Id. § 404.1520(c). Here, the ALJ found that Simon’s anxiety and depression
qualified as severe.
At step three, the ALJ must determine whether the claimant’s impairment
(or combination of impairments) “meets or equals” the severity of an impairment
listed in 20 C.F.R. § 404, Subpart P, Appendix I. Id. § 404.1520(a)(4)(iii). If a
claimant’s impairments reach that level of severity, then he or she automatically
qualifies as “disabled” under SSA regulations. Id. If they do not, then the ALJ
must move on to step four. Here, the ALJ found that Simon’s psychological
impairments did not meet or equal the severity of an impairment listed in SSA
regulations and therefore proceeded to step four.
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At step four, the ALJ must determine whether a claimant possesses the
“residual functional capacity” to perform the job requirements of his or her past
work. Id. § 404.1520(a)(4)(iv). SSA guidelines define the term “residual
functional capacity” to mean “the most [a person] can still do despite [his or her]
limitations.” Id. § 404.1545(a)(1). Here, the ALJ found that Simon lacked the
residual functional capacity to perform his past work in sales.
At step five, the ALJ must determine whether a claimant can still adjust to
any other type of work that exists in substantial numbers in the national economy,
given his or her residual functional capacity, age, education, and work experience.
Id. §§ 404.1520(a)(4)(v), 404.1560(c)(1). Here, the ALJ found that Simon retained
the residual functional capacity to perform “medium work,”3 provided that his job
role was “limited to performing simple routine tasks, making simple work[-]related
decision[s], and [only] occasionally interacting with co-workers, supervisors, and
the public.” Accordingly, the ALJ concluded that Simon was not disabled.
In reaching that determination, the ALJ gave “little weight” to Dr. Turner’s
opinions, on the grounds that they were “inconsistent with the longitudinal
history.” The ALJ then went on to list several portions of the administrative record
3
The SSA defines “medium work” as work that requires “lifting no more than 50 pounds
at a time with frequent lifting or carrying of objects weighing up to 25 pounds.” 20 C.F.R.
§ 404.1567(c).
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that he found to be inconsistent with Dr. Turner’s opinions, including Simon’s own
testimony that he could dress himself, feed himself, and go shopping, and
including several observations made by Dr. Marban and Dr. Merati during their
consultive examinations of Simon. The ALJ relied on notations by Dr. Marban
and Dr. Merati like the following:
• that his communication, cooperation, participation, and eye contact were
satisfactory;
• that his cognitive functions, abstract reasoning, and executive functions
appeared commensurate with his age, socioeconomic status, and education;
• that he exhibited a good fund of information;
• that his ability to solve basic mathematical computations was fair; and
• that he demonstrated fair insight and good judgment.
Based on such observations by the SSA’s consulting physicians, the ALJ rejected
Dr. Turner’s opinion that Simon was unable to handle work-related stress.
The ALJ also gave “little weight” to Dr. Marban’s opinions that Simon
likely would have trouble with concentration in the workplace, task persistence,
and responding appropriately to supervisors. In the ALJ’s view, these conclusions
were “inconsistent with the doctor’s own clinical findings,” as well as “other
clinical findings . . . showing the claimant is capable of performing unskilled
work.” The ALJ’s decision did not state which of Dr. Marban’s findings,
specifically, contradicted her overall conclusions. In the preceding paragraph,
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however, the ALJ had summarized Dr. Marban’s evaluation notes and in doing so
emphasized the following observations that she made about Simon:
• that his thought processes were goal oriented with no signs of psychosis;
• that he was alert and oriented to person, time, place, and situation;
• that his remote memory was good, his recent memory was poor, and his
immediate memory was fair;
• that he exhibited a good fund of information, such as being able to identify
the direction that the sun rises, the number of weeks in a year, the capital of
Italy, and the continental location of Brazil;
• that he demonstrated good calculation abilities when tested with serial
sevens;
• that his abstract reasoning was good;
• that he demonstrated good judgment and insight into his psychological
deficits; and
• that he demonstrated sufficient concentration and attention to follow two-
step instructions.
As for the “other clinical findings” in the record that purportedly were inconsistent
with Dr. Marban’s opinions, the ALJ never clarified what those findings were or
why they were at odds with Dr. Marban’s ultimate assessment.
With respect to Simon’s hearing testimony, the ALJ stated that “the
claimant’s statements concerning the intensity, persistence, and limiting effects of
[his] symptoms are not entirely consistent with the medical evidence and other
evidence in the record for the reasons explained in this decision.” But here also,
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the ALJ’s decision never specified which evidence was inconsistent with Simon’s
description of his symptoms, nor did it explain the inconsistency.
Simon appealed the ALJ’s decision to the Appeals Council of the SSA,
which denied his request for review.
C. Proceedings in the District Court
Simon promptly sought judicial review of the SSA’s adverse decision in the
United States District Court for the Southern District of Florida. He contended that
the ALJ’s reasons for denying his disability claim were not supported by
substantial evidence, nor were they adequately explained. Simon’s case was
referred to a magistrate judge, who recommended affirming the agency’s decision.
The District Court agreed and awarded judgment to the SSA.
Simon timely appealed.
II. STANDARD OF REVIEW
When the Appeals Council of the SSA declines to review an ALJ’s decision
to deny disability benefits, as occurred here, we review that ALJ’s decision as the
final decision of the SSA’s Commissioner. Doughty v. Apfel, 245 F.3d 1274,
1278 (11th Cir. 2001). We review de novo the legal principles on which the ALJ’s
decision was based. Moore v. Barnhart, 405 F.3d 1208, 1211 (11th Cir. 2005).
But we review the ALJ’s factual findings—including the disability determination
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itself—only to ensure that they are supported by “substantial evidence.” Henry v.
Comm’r of Soc. Sec., 802 F.3d 1264, 1266-67 (11th Cir. 2015).
In the Social Security context, “substantial evidence” means “such relevant
evidence as a reasonable person would accept as adequate to support a
conclusion.” Moore, 405 F.3d at 1211. Substantial evidence is “less than a
preponderance,” and thus we must affirm an ALJ’s decision even in cases where a
greater portion of the record seems to weigh against it. Id.; see also Crawford v.
Comm’r of Soc. Sec., 363 F.3d 1155, 1158–59 (11th Cir. 2004) (“Even if the
evidence preponderates against the Commissioner’s findings, we must affirm if the
decision reached is supported by substantial evidence.”). Substantial-evidence
review does not permit us to “decide the facts anew, reweigh the evidence, or
substitute our judgment for that of the [Commissioner].” Phillips v. Barnhart, 357
F.3d 1232, 1240 n.8 (11th Cir. 2004) (alteration in original) (quoting Bloodsworth
v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983)).
Within this narrowly limited role, however, the federal courts “do not act as
automatons.” MacGregor v. Bowen, 786 F.2d 1050, 1053 (11th Cir. 1986). We
retain an important duty to “scrutinize the record as a whole” and determine
whether the agency’s decision was reasonable. Id.18
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III. DISCUSSION
The Social Security Act provides various types of insurance benefits to
individuals who cannot find work because of a disability. See 42 U.S.C. § 423(a).
The Act defines the term “disability” to mean “[an] 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.” Id.§ 423(d)(1)(A).
As described above, the SSA uses a five-step process to decide whether a
benefits claimant is disabled. See 20 C.F.R. § 404.1520. We are concerned here
with the final step, where an ALJ must determine whether the claimant can—
despite any physical or mental impairments—obtain and perform any type of work
that exists in substantial numbers in the national economy. Id.§§ 404.1520(a)(4)(v), 404.1560(c)(1).
When making this assessment, the ALJ must give special attention to the
opinions of a claimant’s treating physician. Indeed, SSA regulations in force at the
time Simon filed his application required an ALJ to give “controlling weight” to a
treating physician’s opinions if they were “well-supported by medically acceptable
clinical and laboratory diagnostic techniques” and “not inconsistent with the other
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substantial evidence in [the] case record.” 20 C.F.R. § 404.1527(c)(2).4 And our
own case law is clear that a treating physician’s conclusions must be given
“substantial or considerable weight” unless there is “good cause” to discount them.
Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997). “Good cause” exists
where “(1) [the] treating physician’s opinion was not bolstered by the evidence; (2)
evidence supported a contrary finding; or (3) [the] treating physician’s opinion was
conclusory or inconsistent with the doctor’s own medical records.” Phillips, 357
F.3d at 1241.
While an ALJ may choose to reject a treating physician’s findings when
there is good cause, “he ‘must clearly articulate [the] reasons’ for doing so.”
Winschel v. Comm’r of Soc. Sec., 631 F.3d 1176, 1179 (11th Cir. 2011) (alteration
in original) (quoting Phillips, 357 F.3d at 1240–41). If the ALJ fails to state
reasonable grounds for discounting such evidence, we will not affirm “simply
because some rationale might have supported the ALJ’s conclusion.” Id. (quoting
Owens v. Heckler, 748 F.2d 1511, 1516 (11th Cir. 1984)). It is the responsibility
of the agency, not the reviewing court, to supply the justification for its decision
4
The SSA amended its rules in 2017 to remove this “controlling weight” requirement. See
20 C.F.R. § 404.1520c. But the current version of the regulation still instructs an ALJ to weigh
all medical opinions in light of the “[l]ength of the treatment relationship,” the “[f]requency of
examinations,” the “[p]urpose of the treatment relationship,” and the “[e]xtent of the treatment
relationship.” Id. These factors continue to indicate the importance of treating physicians’
opinions—especially where the physician has maintained a longstanding and consistent
relationship with the claimant.
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and to sufficiently explain “the weight [it] has given to obviously probative
exhibits.” Cowart v. Schweiker, 662 F.2d 731, 735 (11th Cir. 1981) (quoting
Stawls v. Califano, 596 F.2d 1209, 1213 (4th Cir. 1979)).
Simon’s primary argument on appeal is that the ALJ failed to state good
cause to discount the opinions of his treating psychiatrist, Dr. Turner. We agree,
and that error alone is enough to require that we remand. See Lewis, 125 F.3d at
1440 (“The ALJ must clearly articulate the reasons for giving less weight to the
opinion of a treating physician, and the failure to do so is reversible error.”). We
therefore address that issue first.
A. The ALJ’s Rejection of Dr. Turner’s Opinions
As described in more detail above, Dr. Turner’s treatment notes were
extensive, spanning more than thirty meetings with Simon across four years.
Throughout that considerable length of time, Dr. Turner regularly wrote that Simon
was displaying severe symptoms of mental illness, such as frequent panic attacks,
uncontrollable racing thoughts, volatile mood swings, paranoia about leaving his
home, and self-isolation from friends and family. On the whole, Dr. Turner’s
records indicate that Simon suffers from very serious psychiatric disorders, ones
that she concluded would significantly impair his ability to function under stress,
maintain focus, or interact appropriately with others in a work setting.
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The ALJ ultimately chose to give little weight to Dr. Turner’s opinions, on
the grounds that they were inconsistent with: (1) Simon’s “longitudinal history,”
(2) certain observations made by the SSA consultants who examined Simon, and
(3) Simon’s testimony that he was able to carry out certain daily tasks such as
grooming himself and grocery shopping. In our view, however, the ALJ’s decision
did not adequately explain how any of these pieces of evidence were inconsistent
with Dr. Turner’s opinions or otherwise constituted good cause to disregard her
conclusions.
As an initial point, it is not immediately clear to us what the ALJ meant
when referring to Simon’s “longitudinal history.” SSA guidelines do not
specifically define that term. Instead, the agency simply advises claimants that it
“will request longitudinal evidence of your mental disorder when your medical
providers have records concerning you and your mental disorder over a period of
months or perhaps years.” 20 C.F.R. § 404, Subpart P, Appendix I (emphasis
added). This suggests that, in Simon’s case, the ALJ’s reference to the
“longitudinal history” was intended to refer to Dr. Turner’s treatment notes,5 and
the parties both seem to agree. We therefore read the ALJ’s decision as concluding
5
Dr. Turner was the only physician who kept records of Simon’s mental disorders over an
extended period of time.
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that Dr. Turner’s opinions as to the severity of Simon’s impairments were
inconsistent with her own treatment notes.
However, after scrutinizing Dr. Turner’s treatment notes and examining the
ALJ’s reasons for finding them inconsistent with her overall opinions, we find no
obvious inconsistency. To the contrary, Dr. Turner’s records stated time and again
that Simon was experiencing intense symptoms from his conditions. Yet any
mention of Simon’s most serious symptoms is conspicuously missing from the
ALJ’s decision, which summarized Dr. Turner’s findings as follows:
[T]he claimant received treatment from Rosa Fernandez Turner, M.D. []
He has reported feeling anxious and depressed, and having difficulty
concentrating. His symptoms included anhedonia, decreased energy,
decreased motivation, decreased sleep, and feelings of hopelessness and
helplessness. On June 12, 2014, July 14, 2014, November 13, 2014,
April 27, 2015, and June 20, 2016, it was noted that the claimant was
doing well on his medications and did not report any side effects [].
Nowhere in this paragraph, which was the only part of the decision that discussed
Dr. Turner’s treatment notes at all, did the ALJ address Simon’s panic attacks,
racing thoughts, mood swings, outbursts of anger, memory problems, paranoia, or
his shutting himself off from others. Instead, the ALJ only listed Simon’s
relatively minor symptoms, while at the same time emphasizing the sections of
Dr. Turner’s notes that described Simon as stable on his medications. This
complete failure to engage with significant portions of Dr. Turner’s clinical
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findings, which verges on a blatant mischaracterization of Simon’s medical
records, was error.
It was also error to conclude that Dr. Turner’s occasional references to
Simon being “stable on medication” were inconsistent with a finding of
debilitating mental illness. Many mental disorders—and bipolar disorder in
particular—are characterized by the unpredictable fluctuation of their symptoms,
and thus it is not surprising that even a highly unstable patient will have good days
or possibly good months. See Scott v. Astrue, 647 F.3d 734, 740 (7th Cir. 2011)
(“The very nature of bipolar disorder is that people with the disease experience
fluctuations in their symptoms, so any single notation that a patient is feeling better
or has had a ‘good day’ does not imply that the condition has been treated.”).
Indeed, in another case also involving a claimant diagnosed with bipolar disorder,
we explicitly “agree[d] with our sister [c]ircuits that people with chronic diseases
can experience good and bad days.” Schink v. Comm’r of Soc. Sec., 935 F.3d
1245, 1267 (11th Cir. 2019). For those who suffer from such disorders, “a
snapshot of any single moment says little about [a person’s] overall condition,” and
an ALJ who relies on such snapshots to discredit the remainder of a psychiatrist’s
findings demonstrates a “fundamental, but regrettably all-too-common,
misunderstanding of mental illness.” Punzio v. Astrue, 630 F.3d 704, 710 (7th Cir.
2011). Accordingly, this Court has held that it was improper for an ALJ to dismiss
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a psychiatrist’s treatment notes as “indicat[ing] only mild limitations . . . at best”
simply because “some of [the claimant’s] mental-status examinations were better
than others.” Schink, 935 F.3d at 1262.
As noted above, the opinion evidence of Dr. Turner diagnoses Simon with a
severe combination of bipolar disorder, depression, and anxiety, accompanied by
symptoms considerably more serious than those acknowledged by the ALJ. These
conditions, in Dr. Turner’s opinion, imposed significant limitations on Simon’s
mental and social functioning. We conclude that isolated entries in Dr. Turner’s
treatment notes indicating that Simon was at times stable on his meds, without
more, cannot constitute or contribute to good cause to reject Dr. Turner’s
opinions.6
We now turn to the ALJ’s second basis for discounting Dr. Turner’s
opinions—the ALJ’s belief that several observations made by the SSA’s consulting
doctors were inconsistent with Dr. Turner’s assessment of Simon’s condition. The
ALJ relied on the following notations by Dr. Marban and Dr. Merati:
• that Simon displayed satisfactory communication, cooperation, participation,
and eye contact;
• that Simon had a “grossly intact” memory;
• that Simon exhibited good calculation abilities when tested with serial
sevens;
6
Moreover, as noted above, most of these entries were accompanied by a clarification that
significant symptoms continued.
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• that Simon had good cognitive function, executive function, thought
processes, and abstract reasoning;
• that Simon had a good fund of information; and
• that Simon displayed fair insight and good judgment.
The ALJ found that these observations were inconsistent with Dr. Turner’s
findings and warranted giving her opinions “little weight.” We disagree.
Before an ALJ may reject a treating physician’s opinions as inconsistent
with other medical findings in the record, he or she must identify a “genuine”
inconsistency. Id. (citing Lewis, 125 F.3d at 1440). “It is not enough merely to
point to positive or neutral observations that create, at most, a trivial and indirect
tension with the treating physician’s opinion by proving no more than that the
claimant’s impairments are not all-encompassing.” Id. at 1263. Consequently,
when a claimant has been diagnosed with the types of mental and emotional
disorders at issue here, highly generalized statements that the claimant was
“cooperative” during examination, that he exhibited “organized speech” and
“relevant thought content,” or that he showed “fair insight” and “intact cognition,”
ordinarily will not be an adequate basis to reject a treating physician’s opinions.
Id. at 1262. Nor is it enough to say that the claimant is “intelligent enough to
understand and follow orders and to solve problems,” such as serial sevens,
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because “highly intelligent and able people do fall prey to crippling depression.”
MacGregor, 786 F.2d at 1053–54.
Furthermore, when evaluating a claimant’s medical records, an ALJ must
take into account the fundamental differences between the relaxed, controlled
setting of a medical clinic and the more stressful environment of a workplace. As
the Third Circuit has observed, “[f]or a person . . . who suffers from an affective or
personality disorder marked by anxiety, the work environment is completely
different from home or a mental health clinic.” Morales v. Apfel, 225 F.3d 310,
319 (3d Cir. 2000). Thus, “it is not inconsistent—or even that unlikely—that a
patient with a highly disruptive mood disorder, in a structured one-on-one
conversation with a mental-health professional, might be capable of ‘be[ing]
redirected’ from his ‘tangential’ thought processes so as to ‘remain on topic.’”
Schink, 935 F.3d at 1263 (alteration in original); see also Castro v. Acting Comm’r
of Soc. Sec., 783 F. App’x 948, 956 (11th Cir. 2019) (“Without more, we cannot
say that [the treating physician’s] observations of Castro’s judgment, insight,
thought process, and thought content in a treatment environment absent work
stressors were inconsistent with his assessments about the limitations she would
face in a day-to-day work environment.”).
In this case, we cannot discern—and the ALJ did not attempt to explain—
how any of Dr. Marban’s or Dr. Merati’s findings are genuinely inconsistent with
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Dr. Turner’s opinions. For example, Simon’s ability to solve basic math problems
says little to nothing about his ability to perform simple tasks on a full-time basis,
his ability to respond appropriately to the stress of customary work pressures, his
ability to interact with others in the workplace, or his ability to concentrate, persist,
and maintain pace. Similarly, the fact that Simon can communicate, maintain eye
contact, and follow simple instructions during a mental-health evaluation does not
have any obvious bearing on his mood swings, his panic attacks, his outbursts of
anger, or his fear of leaving his home. And while Dr. Merati did describe Simon’s
memory as “grossly intact,” Dr. Marban’s more detailed evaluation rated his
“recent memory” as “poor,” which is consistent with a conclusion that Simon
would have difficulties remembering work-related instructions.7 We therefore
conclude that capabilities like the foregoing observed during consultive
examinations, without more, did not constitute or contribute to good cause to reject
Dr. Turner’s opinions.
For largely the same reasons, the ALJ’s final basis for discounting
Dr. Turner’s opinions was not sufficient. Specifically, the ALJ found it significant
7
We also note that Dr. Merati is not a mental-health professional, which of course bears
significantly on the weight to be accorded to her opinion. See 20 C.F.R. § 404.1520c(c)(3)
(requiring an ALJ to consider a physician’s “area of specialty” and the “[p]urpose of the
treatment relationship”). Dr. Merati’s role in the SSA proceedings was to conduct a physical
examination—not a psychiatric one. Any findings she made regarding Simon’s mental condition
at that time were merely incidental to the main purpose of the exam and were not within her area
of expertise. However, in light of our disposition of this case, we need not comment on the
appropriate weight owed to Dr. Merati’s incidental observations.
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that Simon could feed himself, dress himself, and shop. But here again, the ALJ
failed to identify any genuine inconsistency with Dr. Turner’s findings. In our
view, it goes almost without saying that many people living with severe mental
illness are still capable of eating, putting on clothes in the morning, and purchasing
basic necessities. None of those activities, however, say much about whether a
person can function in a work environment—with all of its pressures and
obligations—on a sustained basis. Without some reasonable explanation from the
ALJ as to why completing basic household chores is inconsistent with a finding of
disability, this evidence was not sufficient to discredit Dr. Turner.
In summary, we hold that the ALJ failed to articulate good cause to reject
the opinions of Simon’s treating physician. The ALJ pointed to no genuine
inconsistencies between Dr. Turner’s opinions and her treatment notes, the other
medical evidence from Dr. Marban and Dr. Merati, or Simon’s own testimony.
Our holding in this regard is sufficient by itself to require remand.
B. The ALJ’s Rejection of Dr. Marban’s Opinions
Although the ALJ’s improper treatment of Dr. Turner’s opinions is enough
on its own to necessitate remand, we believe it important to also note our
agreement with Simon that the ALJ erred in giving “little weight” to Dr. Marban’s
opinions. Dr. Marban concluded that, in a workplace setting, Simon likely would
have trouble with concentration, task persistence, accepting instructions from
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others, or responding appropriately to supervisors. The ALJ chose to disregard
those opinions, however, on the grounds that they were “inconsistent with the
doctor’s own clinical findings and other clinical findings discussed further in this
decision showing the claimant is capable of performing unskilled work.” We find
this explanation to be insufficient.
In discounting Dr. Marban’s opinions, the ALJ relied on the same kinds of
capabilities, observed by Dr. Marban and Dr. Merati in their consultive
examinations of Simon, that he also relied on to discount Dr. Turner’s opinions.
As discussed above, such capabilities—e.g., a good fund of information, fair
insight, good judgment, good calculation abilities, and good abstract reasoning—
say little to nothing about the capacity to work of a person suffering from the types
of mental illnesses with which Simon was diagnosed. And in our view, it scarcely
even needs to be explained that knowing such things as the direction in which the
sun rises has almost no relevance to a person like Simon’s ability to function in a
workplace on a sustained basis. Thus, for the same reasons that these capabilities
did not constitute or contribute to good cause to discount Dr. Turner’s opinions,
they cannot constitute a reasonable basis for discounting Dr. Marban’s opinions.
As for the “other clinical findings” that the ALJ found to be inconsistent
with Dr. Marban’s opinions, we cannot say with any certainty what those findings
were because the ALJ’s decision did not list them. We know that the ALJ did not
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rely on the opinions of Dr. Grubbs and Dr. Bercik because the ALJ’s decision
explicitly accorded them little weight. But in any event, “[n]on-examining
physicians’ opinions are entitled to little weight when they contradict opinions of
examining physicians and do not alone constitute substantial evidence.” Schink,
935 F.3d at 1260. The ALJ’s decision does not refer to any other medical evidence
relevant to the limitations imposed by Simon’s mental disorders.
For these reasons, we conclude that the ALJ failed to articulate reasonable
grounds for giving Dr. Marban’s opinions little weight.
C. The ALJ’s Rejection of Simon’s Testimony
Third and finally, we conclude that we must vacate the ALJ’s finding that
Simon’s testimony regarding “the intensity, persistence and limiting effects of [his]
symptoms” was “not entirely consistent with the medical evidence and other
evidence in the record.” 8
At his hearing before the ALJ, Simon testified: (1) that his concentration
issues and memory problems made it difficult for him to complete certain tasks,
such as paying bills or remembering which items to pick up from the grocery store;
(2) that he had attempted suicide and no longer cared whether he was alive or dead;
(3) that he experienced mood swings nearly every day; (4) that his depression
8
Once again, the ALJ did not elaborate on which portions of the medical evidence (or
“other evidence”) were inconsistent with Simon’s statements, thus making it difficult for us to
review this finding.
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caused him to isolate himself from others; and (5) that he was afraid of going
outside and would not leave his house except for a few select locations. All of
this—and much more—is also recorded in Dr. Turner’s treatment notes, and Simon
reported most of these same symptoms in his examinations with Dr. Marban and
Dr. Merati, both of which occurred several years before his SSA hearing.
In any event, because we have vacated the ALJ’s decision to discount the
opinions of Dr. Turner and Dr. Marban, the medical evidence considered on
remand may well be different. Accordingly, the ALJ will need to reassess Simon’s
testimony as well. If, after giving each medical opinion in the record appropriate
weight, the ALJ is still inclined to disbelieve Simon’s statements as to the severity
of his symptoms, then the ALJ must support that finding by identifying some
specific portion of the record undermining Simon’s credibility.
IV. CONCLUSION
For the foregoing reasons, we hold that the SSA’s denial of Simon’s
application for disability benefits was not supported by substantial evidence.
Accordingly, we reverse the judgment of the district court with instructions to
remand to the agency for further proceedings consistent with this opinion.
REVERSED AND REMANDED.
32