Smith v. Colvin

Filing 28

MEMORANDUM Opinion and Order Signed by the Honorable M. David Weisman on 7/7/2016. Mailed notice (ao,)

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF ILLINOIS
EASTERN DIVISION
SARAH ELIZABETH SMITH,
Plaintiff,
v.
CAROLYN W. COLVIN,
Commissioner of Social Security,

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No. 14 C 8345

Magistrate Judge M. David Weisman

MEMORANDUM OPINION AND ORDER
Plaintiff Sarah Elizabeth Smith brings this action pursuant to 42 U.S.C. § 405(g) for
judicial review of the decision of the Commissioner of Social Security denying her application
for Disability Insurance Benefits (“DIB”) under the Social Security Act, 42 U.S.C. §§ 421, 423.
(Compl.) Plaintiff filed a motion for summary judgment (Pl.’s Mot.) and a Memorandum in
support of reversing and remanding the decision of the administrative law judge (Pl.’s Mem.).
The Commissioner filed a cross-motion for summary judgment (Def.’s Mot.) and supporting
memorandum (Def.’s Mem.), and Plaintiff replied (Pl.’s Reply.). The parties consented to the
jurisdiction of the Magistrate Judge pursuant to 28 U.S.C. § 636(c).

For the reasons set forth

below, Plaintiff’s motion is granted, and Defendant’s motion is denied.

PROCEDURAL HISTORY
Plaintiff filed her application for benefits on June 28, 2012, alleging a disability onset
date of January 1, 2009. (R. 169.) Her application was denied on August 24, 2012 and again
after reconsideration on January 22, 2013. (R. 110-14.) On February 5, 2013, Plaintiff requested
a hearing before an Administrative Law Judge (“ALJ”). (R. 115-16.) On November 13, 2013,
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Plaintiff, represented by counsel, appeared and testified at the hearing. (R. 36-76.) A vocational
expert also testified. (Id.) On January 31, 2014, the ALJ denied Plaintiff’s application for
benefits. (R. 18-35.) Plaintiff requested review of the ALJ’s decision by the Appeals Council
(R. 13), but her request was denied (R. 1), leaving the ALJ’s decision as the final decision of the
Commissioner, reviewable by this court pursuant to 42 U.S.C. § 405(g). See Villano v. Astrue,
556 F.3d 558, 561-62 (7th Cir. 2009).

BACKGROUND
Plaintiff suffers from bipolar disorder, anxiety, obsessive-compulsive disorder (“OCD”),
and borderline personality disorder. (R. 407-09, 424.) Plaintiff has seen a psychiatrist and
therapist for more than ten years and takes numerous medications to help stabilize her mood. (R.
55-57, 1091.)1 At the time of the hearing, Plaintiff was thirty-two years old and had been living
with her partner for the last four years. (R. 40.) Plaintiff has Associate’s Degrees in Liberal Arts
and Health Management, respectively, and withdrew from Northern Illinois University in 2003
for medical reasons. (R. 40-41.) Plaintiff’s past employment experience included work as a
stocker and as a sales associate. (R.44-46.) At the time of the hearing, Plaintiff was working 13
hours a week as a computer and magazine assistant at the library. (R. 42.)2

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At the hearing before the ALJ, Plaintiff listed several of the medications she was taking which
were prescribed by her psychiatrist. (R. 56.) They include: Oxcarbazephine (an anticonvulsant
used to treat seizures), Divalproex ER (used in the treatment of manic episodes associated with
bipolar disorder), Venlafaxine ER (an antidepressant), Lorazepam (used to treat anxiety
disorders) Trazodone (an antidepressant used to treat major depressive episodes), Benztropine
(used for control of drug-induced extrapyramidal reactions), and Risperidone (an antipsychotic).
(Id.) Dorland’s Illustrated Medical Dictionary 209, 558, 1074, 1355, 1650, 1957, 2046 (32nd
ed. Elsevier Saunders 2012) [hereinafter Dorland’s].
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Per a doctor’s note, Plaintiff was restricted to working no more than 17 hours per week. (R.
43.)
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THE DISABILITY DETERMINATION PROCESS
Under the Social Security Act, disability is defined as 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). The
regulations prescribe a five-part sequential test for determining whether a claimant is disabled.
See 20 C.F.R. § 404.1520. Under the regulations, the Commissioner must consider: (1) whether
the claimant has performed any substantial gainful activity during the period for which she
claims disability; (2) if she has not performed any substantial gainful activity, whether the
claimant has a severe impairment or combination of impairments; (3) if the claimant has a severe
impairment, whether the claimant’s impairment meets or equals any impairment listed in the
regulations as being so severe and of such duration as to preclude substantial gainful activity; (4)
if the impairment does not meet or equal a listed impairment, whether the claimant retains the
residual functional capacity to perform her past relevant work; and (5) if the claimant cannot
perform her past relevant work, whether she is able to perform any other work existing in
significant numbers in the national economy. Id.; Zurawski v. Halter, 245 F.3d 881, 885 (7th
Cir. 2001).
An affirmative answer at steps one, two, or four leads to the next step. Zurawski, 245
F.3d at 886. An affirmative answer at steps three or five requires a finding of disability, whereas
a negative answer at any step other than step three precludes a finding of disability. Id. The
claimant bears the burden of proof at steps one through four. 20 C.F.R. § 404.1560(c)(2);
Zurawski, 245 F.3d at 886.

If that burden is met, at step five, the burden shifts to the

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Commissioner to establish that the claimant is capable of performing work existing in significant
numbers in the national economy. Id.

THE ALJ’S DECISION
At step one, the ALJ found that Plaintiff has not engaged in substantial gainful activity
since January 1, 2009, noting that earning records from Plaintiff’s part-time job show less than
substantial gainful activity. (R. 20.) At step two, the ALJ determined that Plaintiff has the
severe impairments of bipolar disorder, OCD, anxiety, and borderline personality disorder. (Id.)
At step three, however, the ALJ found that Plaintiff did not have an impairment or combination
of impairments that meets or medically equals the severity of one of the listed impairments in 20
C.F.R. part 404, Subpart P, Appendix 1 (20 C.F.R. §§ 416.920(d)) of the regulations. (R. 21-22.)
At step four, the ALJ found that Plaintiff retains the residual functional capacity (RFC) to
“perform a full range of work at all exertional levels,” except that she can only understand,
remember, and carry out simple, routine, repetitive tasks; can endure only occasional interaction
with supervisors and non-collaborative interaction with co-workers; can have no direct contact
with the public; and must avoid all work requiring a fast pace or strict production quotas. (R. 2228.) At step five, the ALJ determined that Plaintiff is unable to perform any of her past relevant
work, but that there are jobs in the national economy that she can perform.

(R. 28-30.)

Accordingly, the ALJ concluded that Plaintiff is not disabled under the Social Security Act. (R.
30.)

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STANDARD OF REVIEW
The Social Security Act provides for limited judicial review of a final decision of the
Commissioner. See 42 U.S.C. § 405(g). Where the Appeals Council declines a requested review
of an ALJ’s decision, the ALJ’s decision constitutes the Commissioner’s final decision. Villano,
556 F.3d at 561-62. While an ALJ’s legal conclusions are reviewed de novo, her factual
determinations are reviewed deferentially and are affirmed if they are supported by substantial
evidence in the record. Jones v. Astrue, 623 F.3d 1155, 1160 (7th Cir. 2010); Craft v. Astrue,
539 F.3d 668, 673 (7th Cir. 2008). Evidence is substantial if it is sufficient for a reasonable
person to accept it as adequate to support the decision. Jones, 623 F.3d at 1160; Craft, 539 F.3d
at 673. “Although this standard is generous, it is not entirely uncritical,” and the case must be
remanded if the decision lacks evidentiary support. Steele v. Barnhart, 290 F.3d 936, 940 (7th
Cir. 2002).
When evaluating a disability claim, the ALJ must consider all relevant evidence and may
not select and discuss only the evidence that favors her ultimate conclusion. See Murphy v.
Astrue, 496 F.3d 630, 634-35 (7th Cir. 2007); Herron v. Shalala, 19 F.3d 329, 333 (7th Cir.
1994). Although the ALJ is not required to discuss every piece of evidence, the ALJ must
provide an accurate and logical bridge between the evidence and the conclusion, so that a
reviewing court may assess the validity of the agency’s ultimate findings and afford the claimant
meaningful judicial review. Craft, 539 F.3d at 673. “If the Commissioner’s decision lacks
adequate discussion of the issues, it will be remanded.” Villano, 556 F.3d at 562.

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DISCUSSION
Plaintiff argues that the ALJ erred in: (1) ruling that Plaintiff’s impairments do not meet
or equal a listing; (2) establishing Plaintiff’s RFC; (3) determining Plaintiff’s credibility; and (4)
in eliciting testimony from the vocational expert. (Pl.’s Mem. at 6-15.) Plaintiff alleges that
these errors flow in part from the ALJ’s failure to give controlling weight to the opinions of her
treating psychiatrist, Dr. Anjum Khatoon. (Pl.’s Mem. at 11-12.) Defendant responds by stating
that substantial evidence supports: (1) the ALJ’s determination that Plaintiff’s impairments do
not meet a listing; (2) the ALJ’s RFC finding; (3) the ALJ’s credibility determination; and (4) the
hypotheticals the ALJ posed to the vocational expert. (Def.’s Mem. at 2-14.) An examination of
the parties’ briefs and the available records reveals that the ALJ erred in her evaluation of the
medical source opinion evidence. Therefore, the case is remanded with instructions.
Treating Physician’s Opinion
Plaintiff asserts that the ALJ’s assessment of her RFC is flawed, in part because the ALJ
failed to provide “substantial evidence” and “good reasons” for giving less than controlling
weight to the opinions of Plaintiff’s treating psychiatrist, Dr. Anjum Khatoon. (Pl.’s Mem. at 1112.) Defendant argues that the ALJ did not reject Dr. Khatoon’s opinion solely because of the
opinions of the non-examining medical consultants, but also because Plaintiff’s activities and Dr.
Khatoon’s treatment notes did not support the limitations in Dr. Khatoon’s assessment. (Def.’s
Mem. at 10.)
The treating physician rule dictates that, in Social Security disability claims, the opinion
of a treating physician is afforded controlling weight if it is both “well-supported” by clinical and
diagnostic evidence and “not inconsistent with the other substantial evidence” in the case record.
20 C.F.R. § 404.1527(c)(2); see Scott v. Astrue, 647 F.3d 734, 739 (7th Cir. 2011). Because of a

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treating doctor’s “greater familiarity with the claimant’s condition and circumstances,” Gudgel v.
Barnhart, 345 F.3d 467, 470 (7th Cir. 2003) an ALJ must “offer good reasons for discounting a
treating physician’s opinion.” Campbell v. Astrue, 627 F.3d 299, 306 (7th Cir. 2010) (citations
omitted). Those reasons must be “supported by substantial evidence in the record; a contrary
opinion of a non-examining source does not, by itself, suffice.” Gudgel, 345 F.3d at 470.
Social Security Regulations require an ALJ to evaluate every medical opinion she
receives. 20 C.F.R. § 404.1527(c). If the opinion of a treating physician is not afforded
controlling weight, the ALJ must then decide what weight to give to each available medical
opinion, considering such factors as the length, nature, and extent of the treatment relationship;
the frequency of examination; the physician’s specialty; the type of tests performed; and the
consistency and support for the physician’s opinion. See 20 C.F.R. § 404.1527(c); Scott, 647
F.3d at 740. The ALJ must then provide a “sound explanation” for that decision. Punzio v.
Astrue, 630 F.3d 704, 710 (7th Cir. 2011). Further, the opinions of non-examining sources
generally do not carry significant weight in comparison to those of treating sources. 20 C.F.R. §
404.1527(c)(2); see McKinzey v. Astrue, 641 F.3d 884, 892 (7th Cir. 2011).
The record shows that, since 2005, Plaintiff has received ongoing mental health treatment
through the DuPage County Health Department’s Southeast Public Health Center (“Center”).
(R. 860, 1091.) Since 2008, Plaintiff’s course of treatment has included approximately monthly
visits with a doctor or psychiatric nurse for evaluation and medication management. (See, e.g.,
R. 328-29, 346-47, 386, 352, 544.) Most recently, Plaintiff’s treating psychiatrist has been Dr.
Anjum Khatoon, who has seen Plaintiff approximately monthly since December 2011. (R. 376,
381, 386, 391, 396, 401, 738, 743, 748, 753, 758, 910, 915, 920, 925, 935.) In addition to her
ongoing psychiatric care and medication management, Plaintiff also receives counseling at the

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Center. She has seen the same therapist, Certified Mental Health Professional Nancy Myers,
approximately twice each month since 2008. (R. 430-31, 888, 1091.)
Dr. Khatoon and Ms. Myers jointly signed opinion letters regarding Plaintiff’s
impairments in August 2012, April 2013, and October 2013. (R. 407-10, 764-65, 1091-92.) The
narrative portion of each letter describes Plaintiff’s symptoms, diagnoses, ongoing treatment
history, treatment side effects, and prognosis. (Id.) In the first opinion letter, the psychiatrist and
therapist characterized Plaintiff’s impairments as “chronic, treatment-resistant, and incurable.”
(R. 409.) With the second letter, the two treatment providers also included a Mental Medical
Source Statement (“MSS”) form which they both signed. (R. 766-68.) On the form, Dr.
Khatoon and Ms. Myers assessed Plaintiff as either “unable to meet competitive standards” or as
having “no useful ability to function” in thirteen of sixteen listed “Mental Abilities and Aptitudes
Needed to Do Unskilled Work.” (R. 766.) They assessed Plaintiff at those same levels for all
four of the listed “Mental Abilities and Aptitudes Needed to Do Semiskilled and Skilled Work”
and found she has “no useful ability to function” in any of the five listed “Mental Abilities and
Aptitudes Needed to Do Particular Types of Jobs.” (R. 767.)
The record contains three additional medical opinions. The first is a report from a
psychological examination performed by a consultative examiner, psychologist John L. Peggau,
Psy.D. on August 17, 2012. (R. 652-56.) Dr. Peggau interviewed Plaintiff for forty minutes and
read two pages of her disability report, but he did not have access to her extensive mental health
treatment records. (R. 652.) After the interview, he concluded that Plaintiff meets the diagnostic
criteria for bipolar disorder type I, an unspecified anxiety disorder, and a personality disorder
with borderline features. (R. 655.) He also reported that Plaintiff demonstrated “below average”

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memory and concentration, despite putting forth her “best effort.” (Id.) Dr. Peggau made no
assessment of Plaintiff’s RFC.
On August 23, 2012, agency reviewing physician Dr. Terry A. Travis reviewed Plaintiff’s
record and completed a Mental Residual Functional Capacity Assessment as part of Plaintiff’s
initial denial of benefits. (R. 77-85.) Dr. Travis’s findings were sharply at odds with the MSS
provided by Plaintiff’s psychiatrist and therapist. (R. 82-83.) For example, Dr. Travis found
Plaintiff “moderately” limited in her ability to “complete a normal workday and workweek
without interruption from psychologically based symptoms and to perform at a consistent pace
without an unreasonable number and length of rest periods.” (R. 83.) On the other hand,
Plaintiff’s treatment providers found that she has “no useful ability” to complete a normal
workday or workweek without interruptions and opined that she is “unable to meet competitive
standards” in performing at a consistent pace without an unreasonable number of rest periods.
(R. 766.) Similarly, Dr. Travis found Plaintiff was “not significantly limited” in her ability to
“maintain socially appropriate behavior and to adhere to basic standards of neatness and
cleanliness,” while her treating providers found Plaintiff has “no useful ability to function” in
those areas. (R. 83, 767.) Dr. Travis rated Plaintiff as “moderately limited” in six of the sixteen
listed work-related mental capacities, and found her “not significantly limited” or showing “no
evidence of limitation” in the remaining ten capacities. (R. 82-83.) On January 13, 2013, Dr.
Donald Henson, Ph.D. completed a similar review and assessment and arrived at findings
identical to those of Dr. Travis. (R. 87-97.)
In her decision, the ALJ referenced Dr. Khatoon’s notes from August 2012 to determine
Plaintiff’s severe impairments. (R. 20.)3 When determining Plaintiff’s RFC later in her decision,
3

The ALJ describes these notes as a letter “dated April 10, 2012” submitted by Dr. Khatoon. (R.
20.) The record does not contain a letter bearing that date. Based on the pages cited, the ALJ
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the ALJ summarized the providers’ April 2013 letter and MSS stating, “Dr. Khatoon’s opinion is
not given controlling weight, despite his status as a treating physician.” (R. 27.) Instead, she
gave “lesser weight” to the treating physician’s findings. (Id.) As justification, the ALJ cited
“inconsistencies with other opinion evidence in the file,” and noted that Plaintiff’s activities and
Dr. Khatoon’s treatment notes indicated that Plaintiff’s restrictions are not as severe as the doctor
opined. (R. 27-28.) As to the “other opinion evidence in the file,” the ALJ afforded “some
weight” to the opinion of agency reviewing physicians Dr. Travis and Dr. Henson. However, the
ALJ attributed greater limitations to Plaintiff than Drs. Travis and Hanson did, based on the
treatment records. (R. 27.) The ALJ did not weigh the opinion of Dr. Peggau, who provided no
RFC assessment.
Because the opinion of a non-treating source does not, by itself, suffice to discount the
opinion of a treating physician, Gudgel, 345 F.3d at 470, the ALJ was required to provide other
“good reasons” before weighting the conclusions of Drs. Travis and Henson more heavily than
those of Dr. Khatoon. Campbell, 627 F.3d at 306. The reasons provided by the ALJ, however,
do not meet this standard.

The ALJ found that Plaintiff’s activities and her doctor’s

corresponding treatment notes did not support the “degree of dysfunction” alleged in the opinion.
(R. 27.) As evidence, she cites a treatment note from May 2013 when Plaintiff indicated that she
felt “less anxious” and had a “level mood,” and a second treatment note that indicated she had
“no manic symptoms” in July 2013, though she reported feeling “stressed” and was picking at
her nails more. (R. 28 (citing R. 925, 930).) Yet in her next visit to Dr. Khatoon on September
17, 2013, Plaintiff again reported that she was stressed, picking at her nails more, was

appears to be referring to the August 10, 2012 report jointly issued by Dr. Khatoon and Ms.
Myers. (R. 20, citing R. 407-10.)

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experiencing “creepy crawly” sensations on her skin, and had recently been unable to make it
through her four-hour shift at work, needing to leave early because of her symptoms. (R. 935.)
As the Seventh Circuit has repeatedly explained, “a person who suffers from a mental
illness will have better days and worse days, so a snapshot of any single moment says little about
her overall condition.”

Punzio, 630 F.3d at 710 (citations omitted).

Bipolar disorder, in

particular, is a chronic and episodic disease; patients frequently respond erratically to treatment.
See Bauer v. Astrue, 532 F.3d 606, 609 (7th Cir. 2008). “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 . . . does not imply that the condition has been treated.” Scott, 647
F.3d at 740 (citations omitted).
Here, Dr. Khatoon’s treatment notes show that both Plaintiff’s mood and her anxiety
symptoms have fluctuated significantly over time. For example, in January 2013 she was “a
little manic” and irritable, in February she was depressed, and in April she was struggling with
anxiety and picking her fingers to the point of bleeding. (R. 910, 915, 920.) The effectiveness of
her medications also seems to wax and wane, as do various side effects from those medications
including grogginess, weight gain, a “crawly” sensation on her skin, and hair growth on her
body. (See, e.g., R. 376, 381, 386, 391, 920, 935.) Therefore, in citing a few days where
Plaintiff reported no symptoms of depression or mania, the ALJ has done little to support her
contention that Plaintiff’s “degree of dysfunction” is less than that described in the opinion
letters. Rather, the ALJ has identified periods of time in which Plaintiff’s symptoms have
“waxed and waned,” which is not inconsistent with the overall diagnosis made by Dr. Khatoon.
Larson v. Astrue, 615 F.3d 744, 751 (7th Cir. 2010).

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Other inconsistencies cited by the ALJ to justify her rejection of Dr. Khatoon’s opinions
similarly fail to persuade. The ALJ wrote that the “consultative examiner did not note any
manifestations of OCD symptoms while examining her for 40 minutes.” (R. 26.) Yet there is
ample medical evidence to support findings of anxiety and OCD symptoms. For example, one of
Plaintiff’s recurrent symptoms, picking her nails and skin, is documented throughout her
treatment records. Plaintiff dealt with periods of this behavior in 2008, when she reportedly
picked at her nails for “emotional release,” leading to “bleeding and scarring,” (R. 495, 523); in
May and June 2010 (R. 518, 562); again in 2011 (R. 413, 603); for several months in 2012, to the
point of picking off five of her fingernails entirely (R. 334-35, 338-39, 349, 396, 743); and again
in 2013 (R. 1062, 1078). The fact that Plaintiff’s picking and other symptoms of anxiety and
OCD sometimes improve, and that she was able to refrain from them during her consultative
exam, does not belie their existence or severity. The ALJ’s reliance on Plaintiff’s behavior
during a single, 40 minute consultative examination to discount the opinion of her treating
physicians constitutes the sort of “sound-bite approach” that is an impermissible means of
evaluating evidence. Scrogham v. Colvin 765 F.3d 685, 698 (7th Cir. 2014); see Yurt v. Colvin,
758 F.3d 850, 859 (7th Cir. 2014) (remanding a denial of benefits based on “cherry-picking of
the medical record”).
The ALJ also discounted Dr. Khatoon’s opinion because she found it to be inconsistent
with Plaintiff’s work history. (R. 27.) The ALJ notes, “Despite Dr. Khatoon’s opinion that the
claimant cannot accept instruction from supervisors or get along with coworkers, the claimant’s
work history supports the ability to do both.” (R. 28.) In arriving at this conclusion, the ALJ
does not explain how she evaluated the evidence from Plaintiff’s employer. On August 21,
2013, the director of the library where Plaintiff worked submitted a letter explaining the

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accommodations Plaintiff received while working for the library which included working a
limited part-time schedule with no morning shifts. (R. 283.) The letter also notes the difficulties
Plaintiff has with her work. (Id.) Some of those challenges were “trouble maintaining basic
social interaction with patrons and staff including approaching her supervisor for instruction and
clarification.” (Id.) The director also stated that Plaintiff was working “to her maximum ability”
and that she would not be successful working more hours. (Id.) The ALJ did not address
Plaintiff’s October 10, 2013 performance review, which indicated that Plaintiff had arrived late
or asked to leave early five times since July. (R. 285-88.) The ALJ also did not explain how she
evaluated Plaintiff’s work abilities in light of the uncontroverted testimony of Plaintiff, her
partner, and her therapist that, while at work, Plaintiff frequently contacts her mother and her
partner for emotional support. (R. 47, 291, 1091.) The ALJ has failed to provide “good reasons”
for her decision to give less than controlling weight to treating physician, Dr. Khatoon.
Even if an ALJ articulates good reasons for giving less than controlling weight to the
opinion of a treating physician, she is required to explain how she weighed that opinion in light
of the prescribed regulatory factors, including the nature, length, and extent of any treatment
relationship; the specialization of the doctor; and consistency with the record as a whole. 20
C.F.R. § 404.1527(c); Larson, 615 F.3d at 751. Here, the ALJ gave scant attention to the
regulatory factors in addressing Dr. Khatoon’s opinion. The ALJ acknowledged the existence of
a treatment relationship, but failed to consider Dr. Khatoon’s specialization as a psychiatrist, the
nature and extent of the doctor’s treatment relationship with Plaintiff as her prescribing
psychiatrist through many medication changes, or the length and frequency of treatment. The
ALJ also overlooked significant evidence that showed consistency between Dr. Khatoon’s
opinions and the record as a whole. See 20 C.F.R. § 404.1527(c)(4). For example, therapy notes

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from August and September 2013 indicate that Plaintiff went ten days without showering, was
not sleeping at night, had been late for work twice, was experiencing anxiety, and had twice
experienced bladder incontinence. (R. 1064, 1078, 1082, 1086, 1091.) In sum, though the ALJ
did explicitly ascribe “less weight” to Dr. Khatoon’s opinions, she failed to provide the required
“sound explanation” for doing so. See Punzio, 630 F.3d at 710.
Additionally, the ALJ ignored that Dr. Khatoon’s opinions were co-signed by Plaintiff’s
therapist, Ms. Myers. Consequently, the ALJ provided no evaluation of those opinions or
Plaintiff’s five-year treatment relationship with Ms. Myers. While the opinions of non-physician
medical sources like therapists do not suffice to establish a diagnosis and do not merit controlling
weight, an ALJ may consider such sources to determine the severity of a claimant’s impairments
and their effects on the claimant’s work capacities. 20 C.F.R. § 404.1513(a), (d); SSR 06-03p,
2006 WL 2329939 at *2; Voigt v. Colvin, 781 F.3d 871, 878 (7th Cir. 2015). The opinions of
non-physician medical sources are weighed using the same regulatory factors applicable to those
of physicians. 20 C.F.R. § 404.1527(c); SSR 06-03p, 2006 WL 2329939 at *4-5; see Williams v.
Colvin, No. 14 C 3222, 2015 WL 9460243 (N.D. Ill. Dec. 28, 2015). Given Ms. Myers’ fiveyear treatment relationship with Plaintiff, encompassing bimonthly visits at which they discussed
the day-to-day impacts of Plaintiff’s impairments and developed strategies for coping with and
minimizing her symptoms, Ms. Myers’ opinions are likely to shed light on the severity of
Plaintiff’s impairments. The ALJ’s failure to explain or even mention her rejection of Ms.
Myers’ opinions in light of that treatment relationship was also erroneous. On remand, the ALJ
should evaluate Ms. Myers as an “other source” as mandated by SSR 06-03p and determine what
weight her opinions deserve in light of the factors set forth in 20 C.F.R. § 404.1527(c). See
Tharpe v. Colvin, No. 14 C 5641, 2015 WL 4653228, at *3, n.42 (N.D. Ill. Aug. 6, 2015).

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Plaintiff’s Additional Arguments
The ALJ’s flawed evaluation of the medical evidence requires remand for a reassessment of Plaintiff’s RFC, as described above. On remand, a proper evaluation of the
medical evidence may also impact the ALJ’s step three listings analysis and her analysis of
Plaintiff’s credibility. In assessing Plaintiff’s credibility, the ALJ is advised to consider the
entire record, including Plaintiff’s longitudinal treatment history and numerous medication
changes, in accordance with SSR 96-7p.

CONCLUSION
For the foregoing reasons, Plaintiff’s motion for summary judgment [11] is granted, and
the Commissioner’s motion for summary judgment [19] is denied. The case is remanded to the
Commissioner pursuant to 42 U.S.C. § 405(g) for further proceedings consistent with this
opinion. Judgment is entered in favor of the Plaintiff and against the Commissioner.
SO ORDERED.

ENTERED: July 7, 2016

_________________________________
M. David Weisman
United States Magistrate Judge

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