Walker v. Commissioner of Social Security

Filing 32

MEMORANDUM AND OPINION. The final decision of the Commissioner is reversed and remanded pursuant to sentence four of 42 U.S.C. §405(g). The Clerk of Court is directed to enter judgment in favor of plaintiff. Signed by Magistrate Judge Clifford J. Proud on 3/17/2016. (jmt)

IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ILLINOIS
MICHELE L. WALKER,

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Plaintiff,
vs.
CAROLYN W. COLVIN,
Acting Commissioner of Social
Security,
Defendant.

Civil No. 14-cv-1261-CJP 1

MEMORANDUM and ORDER
PROUD, Magistrate Judge:
In accordance with 42 U.S.C. § 405(g), plaintiff Michele L. Walker,
represented by counsel, seeks judicial review of the final agency decision denying
her Disability Insurance Benefits (DIB) and Supplemental Security Income (SSI)
benefits pursuant to 42 U.S.C. § 423.
Procedural History
Plaintiff applied for benefits in March 2011, alleging disability beginning on
January 1, 2010. (Tr. 22). After holding an evidentiary hearing, ALJ
Anne C. Pritchett denied the application for benefits in a decision dated August 2,
2013. (Tr. 22-37). The Appeals Council denied review, and the decision of the
ALJ became the final agency decision. (Tr. 1). Administrative remedies have been
exhausted and a timely complaint was filed in this Court.
1

This case was referred to the undersigned for final disposition upon consent of the parties,
pursuant to 28 U.S.C. §636(c). See, Doc. 10.

1

Issues Raised by Plaintiff
Plaintiff raises the following points:
1. The ALJ failed to properly consider the opinions of plaintiff’s treating
psychiatrist and physical therapist.
2. The ALJ’s credibility determination was not supported by substantial
evidence.
3. The RFC is conclusory and is not supported by substantial evidence.
4. The ALJ erred in rejecting the state agency psychologist’s and treating
psychiatrist’s opinions as to plaintiff’s abilities in social functioning.
5. The ALJ did not properly consider plaintiff’s impairments in combination.
Applicable Legal Standards
To qualify for DIB or SSI, a claimant must be disabled within the meaning
of the applicable statutes. 2 For these purposes, “disabled” means 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).
A “physical or mental impairment” is an impairment resulting from
anatomical, physiological, or psychological abnormalities which are demonstrable

2

The statutes and regulations pertaining to Disability Insurance Benefits (DIB) are found at 42
U.S.C. § 423, et seq., and 20 C.F.R. pt. 404. The statutes and regulations pertaining to SSI are
found at 42 U.S.C. §§ 1382 and 1382c, et seq., and 20 C.F.R. pt. 416. As is relevant to this case,
the DIB and SSI statutes are identical. Furthermore, 20 C.F.R. § 416.925 detailing medical
considerations relevant to an SSI claim, relies on 20 C.F.R. Pt. 404, Subpt. P, the DIB regulations.
Most citations herein are to the DIB regulations out of convenience.

2

by medically acceptable clinical and laboratory diagnostic techniques. 42 U.S.C.
§423(d)(3).

“Substantial gainful activity” is work activity that involves doing

significant physical or mental activities, and that is done for pay or profit. 20
C.F.R. §§ 404.1572.
Social Security regulations set forth a sequential five-step inquiry to
determine whether a claimant is disabled. The Seventh Circuit Court of Appeals
has explained this process as follows:
The first step considers whether the applicant is engaging in
substantial gainful activity. The second step evaluates whether an
alleged physical or mental impairment is severe, medically
determinable, and meets a durational requirement. The third step
compares the impairment to a list of impairments that are
considered conclusively disabling. If the impairment meets or equals
one of the listed impairments, then the applicant is considered
disabled; if the impairment does not meet or equal a listed
impairment, then the evaluation continues. The fourth step assesses
an applicant's residual functional capacity (RFC) and ability to engage
in past relevant work. If an applicant can engage in past relevant
work, he is not disabled. The fifth step assesses the applicant's RFC,
as well as his age, education, and work experience to determine
whether the applicant can engage in other work. If the applicant can
engage in other work, he is not disabled.
Weatherbee v. Astrue, 649 F.3d 565, 568-569 (7th Cir. 2011).
Stated another way, it must be determined: (1) whether the claimant is
presently unemployed; (2) whether the claimant has an impairment or
combination of impairments that is serious; (3) whether the impairments meet or
equal one of the listed impairments acknowledged to be conclusively disabling; (4)
whether the claimant can perform past relevant work; and (5) whether the
claimant is capable of performing any work within the economy, given his or her

3

age, education and work experience. 20 C.F.R. §§ 404.1520; Simila v. Astrue,
573 F.3d 503, 512-513 (7th Cir. 2009); Schroeter v. Sullivan, 977 F.2d 391,
393 (7th Cir. 1992).
If the answer at steps one and two is “yes,” the claimant will automatically
be found disabled if he or she suffers from a listed impairment, determined at
step three. If the claimant does not have a listed impairment at step three, and
cannot perform his or her past work (step four), the burden shifts to the
Commissioner at step five to show that the claimant can perform some other job.
Rhoderick v. Heckler, 737 F.2d 714, 715 (7th Cir. 1984).

See also,

Zurawski v. Halter, 245 F.3d 881, 886 (7th Cir. 2001) (Under the five-step
evaluation, an “affirmative answer leads either to the next step, or, on Steps 3 and
5, to a finding that the claimant is disabled…. If a claimant reaches step 5, the
burden shifts to the ALJ to establish that the claimant is capable of performing
work in the national economy.”).
This Court reviews the Commissioner’s decision to ensure that the decision
is supported by substantial evidence and that no mistakes of law were made. It is
important to recognize that the scope of review is limited. “The findings of the
Commissioner of Social Security as to any fact, if supported by substantial
evidence, shall be conclusive. . . .” 42 U.S.C. § 405(g). Thus, this Court must
determine not whether plaintiff was, in fact, disabled at the relevant time, but
whether the ALJ’s findings were supported by substantial evidence and whether
any errors of law were made. See, Books v. Chater, 91 F.3d 972, 977-78 (7th

4

Cir. 1996) (citing Diaz v. Chater, 55 F.3d 300, 306 (7th Cir. 1995)).
The Supreme Court has defined substantial evidence as “such relevant
evidence as a reasonable mind might accept as adequate to support a conclusion.”
Richardson v. Perales, 402 U.S. 389, 401 (1971).
“substantial

evidence,”

the

entire

administrative

record

In reviewing for
is

taken

into

consideration, but this Court does not reweigh evidence, resolve conflicts, decide
questions of credibility, or substitute its own judgment for that of the ALJ.
Brewer v. Chater, 103 F.3d 1384, 1390 (7th Cir. 1997).

However, while

judicial review is deferential, it is not abject; this Court does not act as a rubber
stamp for the Commissioner. See, Parker v. Astrue, 597 F.3d 920, 921 (7th
Cir. 2010), and cases cited therein.
The Decision of the ALJ
ALJ Pritchett followed the five-step analytical framework described above.
She determined plaintiff had not been engaged in substantial gainful activity since
the date of her application. She found plaintiff had severe impairments of morbid
obesity; degeneration of the lumbar spine, cervical spine, bilateral sacroiliac
joints, and thoracic spine; degeneration of the left shoulder; degeneration of the
bilateral knees and ankles; chronic airway disease with a remote history of
chronic asthmatic bronchitis; adjustment disorder with anxious mood; and
bipolar disorder with depressed mood and dependent personality. The ALJ
determined these impairments do not meet or equal a listed impairment.

5

The ALJ found that plaintiff had the residual functional capacity (RFC) to
perform work at the sedentary level, with physical and mental limitations. Based
on the testimony of a vocational expert (VE), the ALJ found the plaintiff was
unable to perform her past work. However, there were jobs that existed in
significant numbers in the national and local economies that plaintiff could
perform. (Tr. 22-37).
The Evidentiary Record
The Court has reviewed and considered the entire evidentiary record in
formulating this Memorandum and Order. The following summary of the record
is directed to the points raised by plaintiff.
1. Agency Forms
Plaintiff was born on September 6, 1972 and was thirty-seven years old on
the alleged onset date. She was insured for DIB through December 31, 2014. 3 (Tr.
167). Plaintiff was five feet seven inches tall and weighed three hundred and fortytwo pounds. (Tr. 171).
Plaintiff claimed that arthritis in her neck, a reoccurring infection in her
breast, degenerative disc disease, anxiety disorder, a tear in her left knee, a total
knee replacement needed on her right knee, chronic bronchitis and asthma,
thyroid disease, and gastrointestinal reflux disease (GERD) limited her ability to
work. (Tr. 171). She took Albuterol, Advair, Proventil, and Spiriva for breathing
problems; Aspirin for a blood clot, Flexeril as a muscle relaxer; Lasix as a
The date last insured is relevant to the claim for DIB, but not the claim for SSI. See, 42 U.S.C. §§ 423(c) &
1382(a).

3

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diuretic; Klonopin and Lamictal for anxiety; Ranitidine for acid reflux;
Hydrocodone for pain relief; Diclofen as an anti-inflammatory; Singulair for
allergies; Sumatriptan for migraines; Synthriod for thyroid disease; Trazadone for
insomnia; and Augmentin as an antibiotic. (Tr. 206).
She completed one year of college and had a certified nursing assistant
license as well as a food and sanitation license. (Tr. 172). She previously worked
as a cook in a restaurant, at the deli counter at Walmart, and a scorer at a
shooting complex. (Tr. 172).
Plaintiff completed function reports in March and September 2011. (Tr.
182-190, 212-22). She stated that she could not stand or walk for long periods of
time because her knees buckled and her feet swelled. Plaintiff stated that she had
shortness of breath, mood swings, and difficulty concentrating. Her left arm went
numb down to her fingers as a result of degenerative disc disease. (Tr. 182).
On a daily basis, plaintiff stated that she made sure her daughter was
bathed and dressed but her daughter did many things for herself. (Tr. 183, 213).
Plaintiff enjoyed reading and spending time with her daughter. (Tr. 186). She
made frozen dinners and did laundry once a week. (Tr. 184, 214). However, she
needed a friend to help her clean and perform household repairs because her
chronic pain prevented her from performing these tasks. (Tr. 184-85). She did
not drive often because it was too painful. (Tr. 185). One of her friends did her
grocery shopping for her. (Tr. 215). She also had insomnia and awoke every two
hours as a result. (Tr. 183).

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Plaintiff said she had trouble lifting, squatting, bending, standing, reaching,
walking, kneeling, hearing, seeing, remembering, climbing stairs, completing
tasks, concentrating, using her hands, and getting along with others. (Tr. 187,
217). She was able to walk twenty feet before she needed to stop and rest for ten
minutes. (Tr. 187, 217). She used a cane and wore a neck brace. (Tr. 188, 218).
2. Evidentiary Hearing
Plaintiff was represented by an attorney at the evidentiary hearing on June
20, 2013. (Tr. 53). She was five feet seven inches tall and weighed three hundred
and thirty pounds. (Tr. 67). She lived with her mother, father, and five year-old
daughter at her parents’ house. (Tr. 63). She stated that the environment in her
parents’ home was hectic and often filled with tension. (Tr. 65-66).
Plaintiff was fired from her last job at the deli counter at Walmart because
she missed too much work. (Tr. 56). She testified that she had a nervous
breakdown about her daughter’s father that made her unable to work. (Tr. 57).
She saw a counselor to help deal with these problems. (Tr. 58). She stated that
her anxiety made her sweat profusely and at times made her unable to speak. (Tr.
65). She smoked half a pack of cigarettes a day to calm her nerves. (Tr. 70).
Plaintiff testified that she was unable to work because on a daily basis she
had pain in her shoulders, her neck, both knees, her left arm, her ankles, and her
feet. She occasionally used a cane to prevent her from falling. (Tr. 69). She also
wore a neck brace every afternoon to help alleviate her neck pain. (Tr. 77).
Plaintiff stated that she had a migraine at least once a week. (Tr. 78). She testified

8

that she often lost the ability to grip with her hands. (Tr. 75). If plaintiff sat for
long periods of time she needed to prop her legs up to reduce pain. (Tr. 73-74).
Plaintiff could perform a housekeeping activity for fifteen to twenty-five minutes
before needing a break. (Tr. 74). She did not think she could sit at a table and
perform any work due to the pain in her arms and legs. (Tr. 75).
On a typical day during the summer, plaintiff and her daughter woke up
around noon. Plaintiff kept her daughter up later at night so they did not have to
wake up early. (Tr. 70). She testified that she had insomnia and slept two or three
hours a night. Plaintiff cooked breakfast for her daughter every morning. She had
to sit on a stool while she cooked because of her leg pain. (Tr. 71). Plaintiff went
swimming with her daughter in the summer because the water helped her back
pain. (Tr. 79).
During the school year, she made sure her daughter made it to school and
then went back to bed. Some mornings she would go to McDonalds with a friend
and drink coffee for a few hours. (Tr. 72). When her daughter returned from
school plaintiff would sit in her backyard and watch her daughter play. (Tr. 73).
She stated that her daughter was typically with her but she stayed with her
parents when plaintiff would go to the store with a friend. (Tr. 67).
Plaintiff had a history of shoplifting. She testified that she wanted to give
her daughter everything she wanted and she did not have the funds. The record
indicated that plaintiff was arrested twice in one week for stealing from Walmart,
and was also charged with shoplifting from a Dollar General and a craft store. (Tr.

9

82). Plaintiff stated that she was only charged with shoplifting once from Walmart
and once from a jewelry store. (Tr. 82-83). The ALJ also questioned plaintiff
about her doctor’s discontinuation of her Xanax prescription after a failed drug
screening. Plaintiff stated that she thought the hospital had used the wrong urine
sample and she never misused her prescriptions. (Tr. 83).
A vocational expert (VE) also testified. The ALJ asked the VE a hypothetical
question which comported with the ultimate RFC assessment, that is, a person of
plaintiff’s age and work history who was able to perform sedentary work, limited
to occasional reaching with her non-dominant upper extremity, constant use of
her dominant hand for all activities, and frequent use of her non-dominant hand.
She could occasionally perform postural activities and could tolerate only
occasional exposure to respiratory irritants. Finally, the person could not tolerate
any stringent speed or production requirements and was limited to unskilled
work. (Tr. 86-88).
The VE testified that the person could not perform any of plaintiff’s
previous work. However, the person could perform jobs that exist in significant
numbers in the national economy. Examples of such jobs are stuffer, surveillance
system monitor, and inspector. Upon questioning from plaintiff’s attorney, the VE
testified that if the person could only perform occasional manipulations with the
hands it would greatly diminish the labor market. (Tr. 89-91)
3. Medical Treatment

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Plaintiff has extensive medical records for both physical and mental health
issues. Her mental health records begin in February 2010 at Human Service
Center where she sought treatment for major depression and generalized anxiety
disorder. (Tr. 254-61). Plaintiff regularly saw a therapist at Human Services
Center for her anxiety and depression through 2013. (Tr. 254-61, 581-93, 799808, 954-65, 1050-67). Plaintiff was diagnosed with major depressive disorder,
generalized anxiety disorder, mood disorder not otherwise specified, bipolar
disorder, and dependent personality while at Human Services Center. (Ex., Tr.
259, 592, 806-07, 1055). She was noted to have questionable insight and
judgment, difficulty getting along with others, mood swings, and increased anxiety
and depression. (Ex., Tr. 259, 582, 589, 804-05, 807, 953, 960, 963, 1061, 1064,
1066).
In 2012, she also began receiving regular treatment from her psychiatrist,
Dr. Terrence Casey. She first presented with increased anxiety and Dr. Casey
started plaintiff on Abilify and Klonopin. (Tr. 791). Dr. Casey frequently changed
plaintiff’s medications thereafter. (Tr. 785, 787, 789, 790, 965, 1027). Plaintiff
admitted to being a kleptomaniac and often presented with mood swings,
difficulty with family, and insomnia. (Ex., Tr. 785, 787, 790-91, 964-65, 102427). Dr. Casey diagnosed plaintiff with bipolar disorder, dependent personality,
depression, and anxiety. (Tr. 785-91, 964-65, 1024-27).
Plaintiff’s has a wide variety of physical health issues on record. Plaintiff’s
treatment notes indicate she has a history of asthma and bronchitis, shortness of

11

breath, and chronic respiratory infections. (Ex., Tr. 288, 322, 322, 372, 497, 502,
695, 878, 910, 1000, 1020-21). For relief, plaintiff had an albuterol inhaler, took
nebulizer treatments, and was prescribed Spiriva, Advair, Singular, steroids, and
Zyrtec. (Ex., Tr. 264, 322, 606, 649, 799, 841, 855, 980, 1000, 1033). She has
medical records for treatment with GERD, hypothyroidism, migraines, and
hypertension. (Ex., Tr. 322, 519, 606, 799, 841, 855, 873, 1019, 1033). She was
prescribed ranitidine for GERD and took increasing dosages of Synthroid for her
thyroid. (Ex., Tr. 372, 606, 799, 855, 873, 893, 1000, 1019, 1033).
Plaintiff was morbidly obese. Her weight at the alleged onset date was two
hundred and was typically around three hundred pounds in her medical records.
(Ex., Tr. 476, 520, 530, 603, 611, 739, 745, 829, 832, 894, 913, 998-99, 1002,
1005, 1069). Plaintiff also had degenerative disc disease, spondylosis, and
arthritis that caused neck and back pain. (Tr. 322-23, 442, 446-47, 453-54, 71718, 890, 912, 946, 1049). She used a surgical collar and a traction device for
neck support. (Tr. 603-04, 842-43, 909). She reported shoulder pain, as well as
pain in her lumbar and thoracic spine. (Tr. 447, 454, 527, 649, 688).
Plaintiff claimed significant pain in her knees and ankles that caused her to
walk with an assistive device for stability. (Ex., Tr. 375, 462, 686, 694, 723, 75859, 764, 809, 836, 878-89, 907, 1030). She was prescribed physical therapy to
help with her neck and lower extremity pain. (Tr. 282, 846, 907). Additionally,
she was prescribed numerous pain medications like Norco, Vicodin, Flexeril, and
Mobic. (Ex., 308, 322, 372, 490, 602, 685, 740, 770, 833, 841, 844-46, 979,

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1024, 1030, 1051). She received facet block injections as well as radiofrequency
ablation treatments for her neck pain. (Tr. 316-17, 319-20, 322-23, 844-46).
4. Treating Medical Specialists’ Opinions
Plaintiff’s treating psychiatrist, Terrance Casey, M.D., submitted two
medical source statements in October 2012. (Tr. 792-95, 945, 1037-40). Dr.
Casey felt plaintiff had moderate limitations in the ability to remember locations
and work-like procedures. He opined that she had marked limitations in her
ability to understand, remember, and carry out short, simple, and detailed
instructions, to perform activities within a schedule, maintain regular attendance,
and be punctual within customary tolerances, to make simple work related
decisions, to complete a normal workday and workweek without interruptions, to
perform at a consistent pace, to get along with coworkers or peers without
distracting them or exhibiting behavioral extremes, to maintain socially
appropriate behavior and adhere to basic standards of neatness and cleanliness,
to travel in unfamiliar places or use public transportation, and to set realistic
goals or make plans independently of others. (Tr. 792-94, 1037-39).
Dr. Casey noted that plaintiff had extreme limitations in her ability to
maintain attention and concentration for extended periods, to sustain an ordinary
routine without special supervision, to work in coordination with or proximity to
others without being distracted by them, to interact appropriately with the general
public, to ask simple questions or request assistance, to accept instructions and
respond appropriately to criticism from supervisors, to respond appropriately to

13

changes in the work setting, and to be aware of normal hazards and take
appropriate precautions. (Tr. 793-94, 1039-40).
Dr. Casey also submitted a letter stating that plaintiff suffered from
depression, anxiety, and mood related issues for which she took medication. He
stated that in addition to her long standing psychiatric history she had several
medical issues that impaired her ability to function on a daily basis. Dr. Casey
stated that in his opinion, plaintiff was a suitable candidate for disability. (Tr.
945).
Plaintiff’s treating physical therapist, Mallori Wilson, completed an
assessment of plaintiff’s capabilities in October 2012. (Tr. 946-50). She felt
plaintiff could occasionally lift or carry up to ten pounds but never anything
heavier. (Tr. 947). Plaintiff could infrequently stand, but could occasionally walk,
or sit. Additionally, she could infrequently push or pull, and occasionally reach,
handle, finger, and feel with her right hand. She could infrequently push, pull, or
reach, and occasionally handle, finger, and feel with her left hand. Ms. Wilson
opined that plaintiff could infrequently operate foot controls, climb stairs and
ramps, balance, and crouch, occasionally stoop, and never climb ladders or
scaffolds, kneel, or crawl. (Tr. 948-49).
Ms. Wilson felt plaintiff should never be near unprotected heights, moving
mechanic parts, or vibrations. Additionally, plaintiff could infrequently operate
motor vehicles, be near dust, odor, fumes, pulmonary irritants, and extreme cold

14

and heat. Ms. Wilson’s final assessment was that plaintiff tested within the
sedentary physical demand level. (Tr. 949-50).
5. Consultative Examinations
Plaintiff underwent a physical consultative examination in June 2011 with
Dr. Vittal Chapa. (Tr. 602-09). Plaintiff listed sixteen different medications she
took on a daily basis. (Tr. 606). On examination, plaintiff could bear weight and
ambulate without aid. She walked with a limp favoring her right knee and was
unable to walk on her toes, walk on her heels, or squat. (Tr. 603). Plaintiff’s
handgrip was 5/5 bilaterally and she could perform both fine and gross
manipulations with both hands. She had a limited range of motion of the cervical
spine and both knees, but her sensory examination was within normal limits. Dr.
Chapa’s diagnostic impressions were osteoarthritis of the right knee and chronic
cervical pain syndrome. Plaintiff wore a cervical collar for her cervical pain though
there was no evidence of cervical radiculopathy. (Tr. 604).
Plaintiff also underwent a psychological consultation in June 2011 with
Harry Deppe, Ph.D. (Tr. 610-14). Plaintiff told Dr. Deppe that she was prescribed
Klonopin and it was helping her a great deal. (Tr. 611). She informed Dr. Deppe
that she last worked in November 2010 and quit due to stress at home. She also
told Dr. Deppe that she shopped, cooked, performed housework, and paid the
bills on her own. (Tr. 612). Dr. Deppe’s clinical impressions were that plaintiff’s
ability to relate to others, including fellow workers and supervisors was fair to
good, and her ability to understand and follow simple instructions, as well as her

15

ability to maintain attention required to perform simple repetitive tasks, was
intact. He opined that her ability to withstand the stress and pressures associated
with day-to-day work activity, and her overall general prognosis was good. He
diagnosed plaintiff with adjustment disorder with anxious mood. (Tr. 613).
6. RFC Assessments
Dr. Julio Pardo, a state agency consultant, assessed plaintiff’s physical RFC
in June 2011. He reviewed medical records but did not examine plaintiff. He
opined plaintiff was able to do work at the light exertional level, i.e., frequently lift
10 pounds and occasionally lift 20 pounds. He felt plaintiff could stand, walk, or
sit, for six hours out of an eight hour workday. Plaintiff was limited to frequent
pushing and pulling with her upper extremities. (Tr. 634). Dr. Pardo limited
plaintiff to frequent bilateral overhead reaching but provided no further postural
or manipulative limitations. (Tr. 635-36).
In November 2011, state agency physician Dr. Lenore Gonzales completed a
second physical RFC assessment for plaintiff. She also opined that plaintiff could
perform work on the light level and sit for six hours during a normal workday.
However, she stated that she could only stand or walk for two hours out of an
eight hour workday. Dr. Gonzales stated that plaintiff was limited to occasional
usage of her hands bilaterally. Additionally, plaintiff should never climb ladders,
ropes, or scaffolds and could occasionally climb ramps or stairs, balance, stoop,
kneel, crouch, or crawl. Dr. Gonzales stated that plaintiff should avoid
concentrated exposure to fumes, odors, dusts, gases, poor ventilation, and

16

hazards such as machinery and heights. She reasoned that plaintiff had recurring
breast infections, arthritis, a left knee tear, right knee problems, bronchitis,
thyroid disease, and GERD. She felt plaintiff’s statements regarding her inability
to walk for long distances due to her feet swelling and other pain were credible
and consistent with the medical evidence. (Tr. 778-84).
In June 2011, Dr. M.W. DiFonso, another state agency consultant, assessed
plaintiff’s mental RFC. She opined that plaintiff was moderately limited in her
ability to understand, remember, and carry out detailed instructions, maintain
attention and concentration for extended periods, interact appropriately with the
general public, and accept instructions and respond appropriately to criticism
from supervisors. (Tr. 629-30). She based these opinions on plaintiff’s
generalized anxiety disorder and adjustment disorder with anxious mood. Dr.
DiFonso stated that plaintiff’s cognitive and attentional skills were intact and
adequate for simple one or two step work tasks. (Tr. 631).
Analysis
Plaintiff first argues the ALJ erred by failing to properly consider the
opinions of plaintiff’s treating psychiatrist. She contends that the ALJ erred in her
RFC assessment by discounting the state agency psychologist’s and Dr. Casey’s
opinions regarding social functioning. Plaintiff argues that the ALJ erred by
improperly analyzing the opinion of her physical therapist and by failing to
consider plaintiff’s impairments in combination. Plaintiff finally argues that the

17

RFC assessment was not supported by substantial evidence and that the ALJ
erred in forming her credibility determination.
Plaintiff’s first argument is that the ALJ erred in failing to properly consider
the opinions of plaintiff’s treating psychiatrist, Dr. Casey. A treating doctor’s
medical opinion is entitled to controlling weight only where it is supported by
medical evidence and is not inconsistent with other substantial evidence in the
record. Clifford v. Apfel, 227 F.3d 863 (7th Cir. 2000); Zurawski v. Halter,
245 F.3d 881 (7th Cir. 2001). The version of 20 C.F.R. §404.1527(c)(2) in effect
at the time of the ALJ’s decision states:
Generally, we give more weight to opinions from your
treating sources, since these sources are likely to be the
medical professionals most able to provide a detailed,
longitudinal picture of your medical impairment(s) and
may bring a unique perspective to the medical evidence
that cannot be obtained from the objective medical findings
alone or from reports of individual examinations, such as
consultative examinations or brief hospitalizations. If we
find that a treating source's opinion on the issue(s) of the
nature and severity of your impairment(s) is wellsupported by medically acceptable clinical and laboratory
diagnostic techniques and is not inconsistent with the
other substantial evidence in your case record, we will give
it controlling weight. [Emphasis added]
It must be noted that, “while the treating physician’s opinion is important, it
is not the final word on a claimant’s disability.” Books v. Chater, 91 F.3d 972,
979 (7th Cir. 1996)(internal citation omitted). It is the function of the ALJ to
weigh the medical evidence, applying the factors set forth in §404.1527.
Supportability and consistency are two important factors to be considered in
weighing medical opinions. See, 20 C.F.R. §404.1527(c). In a nutshell, “[t]he
18

regulations state that an ALJ must give a treating physician's opinion controlling
weight if two conditions are met: (1) the opinion is supported by ‘medically
acceptable clinical and laboratory diagnostic techniques[,]’ and (2) it is ‘not
inconsistent’ with substantial evidence in the record.” Schaaf v. Astrue, 602
F.3d 869, 875 (7th Cir. 2010), citing §404.1527(d).
Thus, the ALJ can properly give less weight to a treating doctor’s medical
opinion if it is inconsistent with the opinion of a consulting physician, internally
inconsistent, or inconsistent with other evidence in the record. Henke v. Astrue,
498 Fed.Appx. 636, 639 (7th Cir. 2012); Schmidt v. Astrue, 496 F.3d 833,
842 (7th Cir. 2007). If the ALJ determines that a treating doctor’s opinion is not
entitled to controlling weight, he must apply the §404.1527(d) factors to
determine what weight to give it. Campbell v. Astrue, 627 F.3d 299, 308 (7th
Cir. 2010). Further, in light of the deferential standard of judicial review, the ALJ
is required only to “minimally articulate” his reasons for accepting or rejecting
evidence, a standard which the Seventh Circuit has characterized as “lax.” Berger
v. Astrue, 516 F.3d 539, 545 (7th Cir. 2008); Elder v. Astrue, 529 F.3d 408,
415 (7th Cir. 2008).
The ALJ noted that Dr. Casey submitted two source statements that
indicated functional limitations that would result in a finding of disability if
adopted fully. The ALJ recites portions of the statements and gave them “little
weight” because “they are inconsistent with the treatment notes indicating
adequate symptom management with medication and the claimant’s own
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subjective reporting showing her routinely engaged in activities consistent with
unskilled work.” (Tr. 34).
Plaintiff contends that the ALJ failed to consider the factors from 20 C.F.R.
§404.1527 in determining how much weight to give Dr. Casey’s opinions. She
states that the ALJ did not acknowledge how long plaintiff was treated by Dr.
Casey, that he is a specialist, or that he prescribed and made frequent
adjustments to plaintiff’s medications. Within these arguments, plaintiff also
contends that the ALJ’s statement that Dr. Casey’s opinions were contradicted by
his treatment notes was unsupported.
The Commissioner argues that the ALJ provided sufficient evidence for
discounting Dr. Casey’s opinions. She states that the ALJ’s determination that
plaintiff never required more than medication and psychotherapy for her mental
illnesses and that her mood was controlled with medications. The Commissioner
claims that the ALJ cited specific evidence that showed plaintiff had adequate
symptom management and that plaintiff’s capabilities and activities were
inconsistent with Dr. Casey’s opinions.
The ALJ failed to note that Dr. Casey was a specialist, that he was one of
plaintiff’s regular treating physicians, and that he prescribed and made frequent
adjustment to plaintiff’s medications. However, the Commissioner is correct in
noting that an ALJ need not apply all of the factors in 20 C.F.R. §404.1527(c).
See, Elder, 529 F. 3d. at 415. The ALJ attempted to apply the factors of
consistency and supportability, which the Seventh Circuit has noted are two of the

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most important factors. Schaaf, 602 F.3d at 875, citing §404.1527(d).
However, this Court agrees with plaintiff that the ALJ’s analysis was inadequate.
The ALJ failed to indicate how Dr. Casey’s opinions were inconsistent with
his treatment notes. Dr. Casey’s notes show consistent changes to plaintiff’s
medication regimen. (Tr. 785-87, 789-90, 964-65, 1024, 1026-27). He repeatedly
noted she had difficulty getting along with her family and could not stop
shoplifting. (Tr. 785-87, 964-65, 1024-25, 1027). As plaintiff points out, her
treatment notes from her therapist corroborate the fact that plaintiff’s mental
impairments were not necessarily well controlled by medication. She repeatedly
noted that plaintiff was not making progress, had questionable insight and
judgment, and had increased anxiety and depression. (Tr. 589, 804-05, 807, 953,
960, 963, 1061, 1063-64, 1066).
Additionally, the ALJ failed to show how plaintiff’s subjective reporting of
her daily activities did not support Dr. Casey’s opinions. The Seventh Circuit has
repeatedly held it is appropriate to consider daily activities but it should be done
with caution. The ability to perform daily tasks “does not necessarily translate
into an ability to work full-time.” Roddy v. Astrue, 705 F.3d 631, 639 (7th Cir.
2013). The Seventh Circuit also held that an ALJ cannot equate caring for a
family member and performing housework with work in the labor market. Gentle
v. Barnhart, 430 F.3d 865, 867 (7th Cir. 2005); Mendez v. Barnhart, 439
F.3d 360, 362 (7th Cir. 2006); Beardsley, 758 F.3d 838.

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The ALJ did not specify which daily activities of the plaintiff were consistent
with unskilled work in this portion of her opinion. However, in analyzing
plaintiff’s daily activities elsewhere in the opinion, the ALJ stated that plaintiff
shopped, cooked, did housework, watched television, paid bills, and cared for her
daughter. Plaintiff was able to bathe and dress herself. (Tr. 30). The ALJ stated
that one psychotherapy note indicated she was “active.” The ALJ opined that each
of these activities required abilities similar to those required for sedentary
unskilled work. (Tr. 31).
While plaintiff does take care of her daughter and perform minimal
household chores, the ALJ overlooked the limitations she faced in the tasks she
felt made her capable of sustained work. Plaintiff stated that she made frozen
dinners and did laundry once a week. (Tr. 184, 214). She needed a friend to help
her clean, perform household repairs, and take her to the store because her
chronic pain prevented her from performing these tasks alone. (Tr. 184-85).
Plaintiff lived with her parents who helped care for her daughter. (Tr. 67). Even if
plaintiff’s daily activities indicate she is capable of some form of work, the ALJ
fails to articulate how these daily activities are in contrast to Dr. Casey’s opinions.
This is error.
The Commissioner’s reliance on the ALJ’s argument elsewhere in the
opinion that plaintiff never received more than medication and psychotherapy for
her mental illnesses is not well taken. The ALJ did not explain how this course of
treatment was lacking or what would be expected of someone who has a disabling

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mental impairment. The ALJ is not a doctor and it is error for her to assume a
certain course of treatment is less serious when no suggestions to this idea have
been made by medical professionals. The Seventh Circuit has held that an ALJ is
not permitted to “play doctor” and her decision “must be based on testimony and
medical evidence in the record, and not on [her] own ‘independent medical
findings.’” Rohan v. Chater, 98 F.3d 966, 970 (7th Cir. 1996). It seems as
though that is what ALJ Pritchett did in the case at hand when she noted that
plaintiff’s treatment history consisted of “nothing more than medication and
psychotherapy.” (Tr. 34).
The Commissioner argues that the treatment notes that support Dr. Casey’s
opinions do not establish plaintiff is totally disabled. While this may be true, his
records do indicate more limitations than the ALJ acknowledges as the portions
of the record that do support of Dr. Casey’s opinions were entirely excluded from
the ALJ’s opinion. In analyzing the evidence, the ALJ is not permitted to “cherrypick” the evidence, ignoring the parts that conflict with her conclusion. Myles v.
Astrue, 582 F.3d 672, 678 (7th Cir. 2009).

While she is not required to

mention every piece of evidence, “[she] must at least minimally discuss a
claimant's evidence that contradicts the Commissioner's position.” Godbey v.
Apfel, 238 F.3d 803, 808 (7th Cir. 2000). While the ALJ did not have to agree
with Dr. Casey’s opinions, she did need to minimally discuss the portions of the
record that do not support her decision. Her failure to do so makes her
assessment of Dr. Casey’s opinions inadequate.

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The Seventh Circuit has held that discounting the opinion of an examining
physician requires good explanation, which ALJ Pritchett failed to provide in the
case at hand. Beardlsey v. Colvin, 758 F.3d 834, 839 (7th Cir. 2014). The
ALJ is “required to build a logical bridge from the evidence to his conclusions.”
Simila v. Astrue, 573 F.3d 503, 516 (7th Cir. 2009). While the ALJ was not
required to give Dr. Casey’s opinions controlling weight, she needed to adequately
explain why his opinions were discounted. ALJ Pritchett simply failed to do so
here. “If a decision ‘lacks evidentiary support or is so poorly articulated as to
prevent meaningful review,’ a remand is required.” Kastner v. Astrue, 697 F.3d
642, 646 (7th Cir. 2012)., citing Steele v. Barnhart, 290 F.3d 936, 940 (7th
Cir. 2002).
It is not necessary to address plaintiff’s other points at this time. The Court
wishes to stress that this Memorandum and Order should not be construed as an
indication that the Court believes that plaintiff is disabled or that she should be
awarded benefits. On the contrary, the Court has not formed any opinions in that
regard, and leaves those issues to be determined by the Commissioner after
further proceedings.
Conclusion
The Commissioner’s final decision denying Michele Walker’s application for
social security disability benefits is REVERSED and REMANDED to the
Commissioner for rehearing and reconsideration of the evidence, pursuant to
sentence four of 42 U.S.C. §405(g).
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The Clerk of Court is directed to enter judgment in favor of plaintiff.
IT IS SO ORDERED.
DATE: March 17, 2016

s/ Clifford J. Proud
CLIFFORD J. PROUD
UNITED STATES MAGISTRATE JUDGE

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