Stewart v. Commissioner of Social Security

Filing 22

OPINION AND ORDER GRANTING the relief sought in the Plaintiffs Brief[ECF No. 15] and REVERSES the decision of the Commissioner. The Court REMANDS this matter for further proceedings consistent with this Opinion. Signed by Judge Theresa L Springmann on 11/18/21. (mlc)

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF INDIANA
FORT WAYNE DIVISION
TYQUAN T. STEWART,
Plaintiff,
v.

CAUSE NO.: 1:20-CV-44-TLS

KILOLO KIJAKAZI, Acting Commissioner
of the Social Security Administration,
Defendant.
OPINION AND ORDER
The Plaintiff Tyquan T. Stewart seeks review of the final decision of the Commissioner
of the Social Security Administration denying his application for supplemental security income.
The Plaintiff argues that the Administrative Law Judge (ALJ) failed to properly evaluate the
medical opinion evidence of record in formulating the Plaintiff’s residual functional capacity
(RFC). For the reasons set forth below, the Court finds that reversal and remand is required for
further proceedings.
PROCEDURAL BACKGROUND
On June 30, 2017, the Plaintiff filed an application for supplemental security income,
alleging disability beginning on March 8, 2016. See AR 251, ECF No. 10. The claim was denied
initially and on reconsideration, and the Plaintiff requested a hearing, which was held before an
ALJ on June 4, 2018. Id. On September 20, 2018, the ALJ issued a written decision and found
the Plaintiff not disabled. Id. at 251–60. The Plaintiff filed a request for review, and, on October
29, 2018, the Appeal Council remanded the case to the ALJ for further proceedings. Id. at 267. A
hearing was held on March 7, 2019, and a supplemental hearing was held on September 16,
2019. Id. at 65, 148. A different ALJ issued an unfavorable decision on October 17, 2019. Id. at

17–28. On November 26, 2019, the Appeals Council denied the Plaintiff’s request for review, id.
at 1–3, thereby rendering the ALJ’s decision the final decision of the Commissioner. See Jozefyk
v. Berryhill, 923 F.3d 492, 496 (7th Cir. 2019). The Plaintiff now seeks judicial review under 42
U.S.C. § 405(g). On January 24, 2020, the Plaintiff filed his Complaint [ECF No. 1] in this
Court, seeking reversal of the Commissioner’s final decision. The Plaintiff filed an opening brief
[ECF No. 14], the Commissioner filed a response brief [ECF No. 17], and the Plaintiff filed a
reply brief [ECF No. 18].
THE ALJ’S DECISION
For purposes of disability insurance benefits and supplemental security income, a
claimant is “disabled” if he is unable “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
twelve months.” 42 U.S.C. § 1382c(a)(3)(A); see also 20 C.F.R. § 416.905(a). To be found
disabled, a claimant must have a severe physical or mental impairment that prevents him from
doing not only his previous work, but also any other kind of gainful employment that exists in
the national economy, considering his age, education, and work experience. 42 U.S.C.
§ 1382c(a)(3)(B); 20 C.F.R. § 416.905(a). An ALJ conducts a five-step inquiry to determine
whether a claimant is disabled. 20 C.F.R. § 416.920.
The first step is to determine whether the claimant is no longer engaged in substantial
gainful activity. Id. § 416.920(a)(4)(i), (b). In this case, the ALJ found that the Plaintiff had not
engaged in substantial gainful activity since June 30, 2017, the application date. AR 19.
At step two, the ALJ determines whether the claimant has a “severe impairment.” 20
C.F.R. § 416.920(a)(4)(ii), (c). Here, the ALJ determined that the Plaintiff has the severe

2

impairments of post-traumatic stress disorder (“PTSD”), depression, schizoaffective disorder,
personality disorder, a history of gunshot to the abdomen, and diabetes. AR 19.
Step three requires the ALJ to consider whether the claimant’s impairment(s) “meets or
equals one of [the] listings in appendix 1 to subpart P of part 404 of this chapter.” 20 C.F.R.
§ 416.920(a)(4)(iii), (d). If a claimant’s impairment(s), considered singly or in combination with
other impairments, meets or equals a listed impairment, the claimant will be found disabled
without considering age, education, and work experience. Id. § 416.920(a)(4)(iii), (d). Here, the
ALJ found that the Plaintiff does not have an impairment or combination of impairments that
meets or medically equals a listing. AR 20.
When a claimant’s impairment(s) does not meet or equal a listing, the ALJ determines the
claimant’s RFC, which “is an administrative assessment of what work-related activities an
individual can perform despite [the individual’s] limitations.” Dixon v. Massanari, 270 F.3d
1171, 1178 (7th Cir. 2001); see also 20 C.F.R. § 416.920(e). In this case, the ALJ assessed the
following RFC:
After careful consideration of the entire record, the undersigned finds that the
claimant has the residual functional capacity to perform light work as defined in 20
CFR 416.967(b) except the claimant can occasionally climb ramps and stairs, he
can never climb ladders, ropes, or scaffolds, he can occasionally balance, stoop,
kneel, crouch and crawl. The claimant can understand, remember and carry out
simple instructions and tasks, he can make judgments on simple work related
decisions, he can respond appropriately to occasional interactions with coworkers
and supervisors, he should avoid work activity requiring interactions with the
general public, he can respond appropriately to usual work situations, and he can
deal with routine changes in a routine work setting.
AR 22.
The ALJ then moves to step four and determines whether the claimant can do his past
relevant work in light of the RFC. 20 C.F.R. § 416.920(a)(4)(iv), (f). In this case, the ALJ found
that the Plaintiff “is capable of performing past relevant work as an assembler, production,
3

706.687-010, SVP 2, light per DOT and as performed.” AR 27. And, as a result, the ALJ found
that the Plaintiff had not been under a disability since June 30, 2017. Id. Thus, the ALJ did not
reach step five, which is applicable if the claimant is unable to perform his past relevant work
and the ALJ determines whether the claimant can “make an adjustment to other work.” 20 C.F.R.
§ 416.920(a)(4)(v), (g). The claimant bears the burden of proving steps one through four,
whereas the burden at step five is on the ALJ. Zurawski v. Halter, 245 F.3d 881, 885–86 (7th Cir.
2001); see also 20 C.F.R. § 416.912.
STANDARD OF REVIEW
The Social Security Act authorizes judicial review of the agency’s final decision. 42
U.S.C. § 405(g). On review, a court considers whether the ALJ applied the correct legal standard
and the decision is supported by substantial evidence. See Summers v. Berryhill, 864 F.3d 523,
526 (7th Cir. 2017); 42 U.S.C. § 405(g). A court will affirm the Commissioner’s findings of fact
and denial of disability benefits if they are supported by substantial evidence. Craft v. Astrue,
539 F.3d 668, 673 (7th Cir. 2008). Substantial evidence is “such relevant evidence as a
reasonable mind might accept as adequate to support a conclusion.” Biestek v. Berryhill, 139 S.
Ct. 1148, 1154 (2019) (citations omitted). Even if “reasonable minds could differ” about the
disability status of the claimant, the court must affirm the Commissioner’s decision as long as it
is adequately supported. Elder v. Astrue, 529 F.3d 408, 413 (7th Cir. 2008) (quoting Schmidt v.
Astrue, 496 F.3d 833, 842 (7th Cir. 2007)).
The court considers the entire administrative record but does not “reweigh evidence,
resolve conflicts, decide questions of credibility, or substitute [the court’s] own judgment for that
of the Commissioner.” McKinzey v. Astrue, 641 F.3d 884, 889 (7th Cir. 2011) (quoting Lopez ex
rel. Lopez v. Barnhart, 336 F.3d 535, 539 (7th Cir. 2003)). Nevertheless, the court conducts a

4

“critical review of the evidence,” and the decision cannot stand if it lacks evidentiary support or
an adequate discussion of the issues. Lopez, 336 F.3d at 539 (citations omitted); see also Moore
v. Colvin, 743 F.3d 1118, 1121 (7th Cir. 2014) (“A decision that lacks adequate discussion of the
issues will be remanded.”). The ALJ is not required to address every piece of evidence or
testimony presented, but the ALJ “has a basic obligation to develop a full and fair record and
must build an accurate and logical bridge between the evidence and the result to afford the
claimant meaningful judicial review of the administrative findings.” Beardsley v. Colvin, 758
F.3d 834, 837 (7th Cir. 2014) (internal citations omitted). However, “if the Commissioner
commits an error of law,” remand is warranted “without regard to the volume of evidence in
support of the factual findings.” White ex rel. Smith v. Apfel, 167 F.3d 369, 373 (7th Cir. 1999)
(citing Binion v. Chater, 108 F.3d 780, 782 (7th Cir. 1997)).
ANALYSIS
In this appeal, the Plaintiff argues that the ALJ erred by failing to address the more
restrictive limitations contained in the opinion of state agency reviewing psychologists, the
testifying medical expert, and the consultative psychological examiner. Remand is required for
proper consideration the opinions.
The mental portion of the residual functional capacity finding assigned by the ALJ
provides:
The claimant can understand, remember and carry out simple instructions and tasks,
he can make judgments on simple work related decisions, he can respond
appropriately to occasional interactions with coworkers and supervisors, he should
avoid work activity requiring interactions with the general public, he can respond
appropriately to usual work situations, and he can deal with routine changes in a
routine work setting.
AR 22.

5

In reviewing a disability claim, an ALJ has an obligation to evaluate every medical
opinion and explain the persuasiveness of the opinion. See 20 C.F.R. § 416.920c(a), (b). Medical
opinions are considered under the following factors: (1) supportability, which means how well
the objective medical evidence and supporting explanations presented by a medical source
support the opinion; (2) consistency, which means how consistent the medical opinion is with the
evidence from other medical sources and nonmedical sources; (3) relationship with the claimant,
which considers the length of a treatment relationship, the frequency of examinations, the
purpose of a treatment relationship, the extent of a treatment relationship, and whether there is an
examining relationship; (4) specialization of the medical source; and (5) any other factors that
tend to support or contradict the medical opinion. 20 C.F.R. § 416.920c(c)(1)–(5).
A.

State Agency Reviewing Psychologists
State agency physicians are deemed, by regulation, to be “highly qualified and experts in

Social Security disability evaluation,” and their opinions must be considered by the ALJ in the
disability determination process. See 20 C.F.R. § 416.913a(b)(1) (citing 20 C.F.R.
§§ 416.920b, 416.920c, 416.927). In this case, the Plaintiff argues that the ALJ erred by failing
to consider the more restrictive limitations in the “check box” or “worksheet” section of the state
agency reviewing psychologists’ opinions. The “worksheet observations” from the state agency
psychological consultants are “medical evidence which cannot just be ignored.” Varga v. Colvin,
794 F.3d 809, 816 (7th Cir. 2015). While an ALJ may rely on a consultative psychologist’s
narrative description, the ALJ “still must adequately account for limitations identified elsewhere
in the record, including specific questions raised in check-box sections of standardized forms
such as the [Psychiatric Review Technique] and [Mental Residual Functional Capacity] forms.”

6

DeCamp v. Berryhill, 916 F.3d 671, 676 (7th Cir. 2019) (citing Yurt v. Colvin, 758 F.3d 850, 859
(7th Cir. 2014)).
In this case, state agency consultative reviewing psychologists Dr. Donna Unversaw and
Dr. Joelle Larson completed a Mental Residual Functional Capacity Assessment form on
September 6, 2017, and November 1, 2017, respectively. See AR 227–29, 242–44. The narrative
portion of the opinions provide that the Plaintiff “appears capable of unskilled tasks on a
sustained basis without special considerations. He would perform best in situations that do not
require constant contact with peers, supervisors, or customers.” Id. at 229, 244. In response to the
more specific functional assessment ratings, both doctors opined, as relevant here, that the
Plaintiff is “moderately limited” in his ability to “carry out detailed instructions,” “maintain
attention and concentration for extended periods,” “complete a normal workday and workweek
without interruptions from psychologically based symptoms and to perform at a consistent pace
without an unreasonable number and length of rest periods,” and “get along with coworkers or
peers without distracting them or exhibiting behavioral extremes.” Id. at 228–29, 243–44
(emphasis added).
Although the ALJ found the state agency determinations to be “somewhat persuasive,”
id. at 27, the ALJ neither discussed these specific functional limitations nor accounted for them
in the RFC assessment. Instead, the ALJ noted generally that the state agency opinion is
“consistent with limitations in all four areas of mental functioning, but not to exactly [the] same
extent noted by the evaluators.” Id. The ALJ’s only specific comment was that the state agency
opinion “is consistent with the claimant performing best when he has reduced interaction with
others.” Id. (emphasis added). Based on the ALJ’s analysis, the Court cannot determine whether
the ALJ accounted for the Plaintiff’s social deficits and propensity for social extremes.

7

The failure to discuss the more specific social limitations contained in the worksheet
section of the opinions is harmful because the ALJ did not include them in the hypothetical to the
vocational expert who subsequently testified to a lack of employer tolerance for any exhibition of
“behavioral extremes” with supervisors or coworkers. Id. at 93–94. In the RFC, the ALJ only
addressed the amount of time the Plaintiff could interact socially in a given day, finding that the
Plaintiff “can respond appropriately to occasional interactions with coworkers and supervisors”
and have no interactions with the general public. Id. at 22 (emphasis added). In this context,
“occasionally” means “from very little up to one third” of an eight-hour workday. SSR 83-10,
1983 WL 31251, at *5 (Jan. 1, 1983). The Plaintiff reasons that this quantitative limitation fails
to address the more specific limitation that the Plaintiff would exhibit inappropriate workplace
behaviors, specifically a limitation in his ability “to get along with coworkers or peers without
distracting them or exhibiting behavioral extremes.” AR 228–29, 243–44. It is unclear how such
a limitation can be addressed by limiting the Plaintiff’s exposure to supervisors and coworkers to
one-third of the day, when the behavioral extremes do not appear to occur only after a specific
amount of contact.
Importantly, the reviewing consultative psychologists are not the only medical sources to
opine on this limitation. Consultative psychologist Dr. Predina, who examined the Plaintiff on
February 20, 2017, opined that the Plaintiff’s anger and anxiety would hinder his ability to get
along with supervisors and coworkers. Id. at 882. At the March 7, 2019 hearing, medical expert
Dr. Hamilton testified that the Plaintiff has moderate limitations in his ability to respond
appropriately to supervision, coworkers, and the general public. Id. at 74. And, more specifically,
Dr. Hamilton testified as to the likelihood of an occurrence of “impulsive behaviors,” explaining
that the Plaintiff would be triggered “when he doesn’t get what he is expected to get either in

8

terms of a verbal response or a service of some sort.” Id. at 83–84. As discussed more in the next
section, Dr. Hamilton gave conflicting testimony in relation to this limitation, stating that the
Plaintiff would be prone to outbursts if criticized by a supervisor in the work context whereas he
would have less conflict with the public, see id. at 83–84, 86, 95, but also opining that Plaintiff
can have only occasional interaction with supervisors and coworkers but frequent interaction
with the general public, see id. at 75–76. Yet, the ALJ found Dr. Hamilton’s hearing testimony to
be “persuasive.” Id. at 26. Notably, the Plaintiff appears to have displayed this very behavior at
the March 2019 hearing when the Plaintiff interrupted Dr. Hamilton’s testimony, describing the
trauma he had suffered in his life and yelling profanities. Id. at 79–81. The Plaintiff was
eventually removed from the proceedings. Id. at 81.
Although the ALJ found the state agency psychologists’ opinions persuasive, their
narrative assessments did not “encapsulate” the worksheet observations discussed above. See
Varga, 794 F.3d at 816. The narrative assessment opines that the Plaintiff “would perform best in
situations that do not require constant contact with peers, supervisors, or customers,” but such a
limitation does not account for conduct demonstrating behavioral extremes as opined in the
worksheet section. AR 229, 244. Importantly, upon questioning by the Plaintiff’s attorney, the
vocational expert testified that exhibitions of such behaviors would not likely be tolerated by
employers more than once. Id. at 93–94. The vocational expert also testified that, if the
individual could not tolerate redirection or instruction, resulting in behavioral extremes, no
positions would be available. Id. at 93. Thus, it appears that, if the ALJ had included such a
limitation regarding behavioral extremes, all work may have been excluded, resulting in a
finding of disability.

9

By failing to discuss the more specific limitations by the state agency reviewing
psychologists that were not otherwise included in their narrative opinions, the ALJ failed to build
a logical and accurate bridge between the evidence and the RFC. See Beardsley, 758 F.3d at 839
(explaining that “rejecting or discounting the opinion of the agency’s own examining physician
that the claimant is disabled, as happened here, can be expected to cause a reviewing court to
take notice and await a good explanation for this unusual step” (citing Gudgel v. Barnhart, 345
F.3d 467, 470 (7th Cir. 2003))). Remand is required for proper consideration of the Plaintiff’s
behavioral extremes and the impact on the Plaintiff’s ability to work.
The Plaintiff also argues that the ALJ should have specifically addressed the state agency
consultative reviewing psychologists’ opinions that the Plaintiff has moderate limitations in the
ability to “maintain attention and concentration for extended periods” and to “complete a normal
workday and workweek without interruptions from psychologically based symptoms and to
perform at a consistent pace without an unreasonable number and length of rest periods.” AR
228, 243. Although the Plaintiff is correct that the ALJ did not specifically discuss these two
limitations, these specific opinions are “encapsulated” in the narrative portion of the state agency
opinions, which provide that the Plaintiff “appears capable of unskilled tasks on a sustained basis
without special considerations.” Id. at 229, 244. Thus, remand is not required on this basis.
B.

Testifying Medical Expert Dr. Hamilton
The Plaintiff next argues that the ALJ erred by rejecting portions of testifying medical

expert Dr. Hamilton’s opinions that were suggestive of disability despite the ALJ’s finding that
Dr. Hamilton’s testimony was persuasive. Id. at 26. “An ALJ cannot rely only on the evidence
that supports her opinion.” Bates v. Colvin, 736 F.3d 1093, 1099 (7th Cir. 2013) (citing Herron
v. Shalala, 19 F.3d 329, 333 (7th Cir. 1994)); see also Denton v. Astrue, 596 F.3d 419, 425 (7th

10

Cir. 2010) (“An ALJ has the obligation to consider all relevant medical evidence and cannot
simply cherry-pick facts that support a finding of non-disability while ignoring evidence that
points to a disability finding.” (citing Myles v. Astrue, 582 F.3d 672, 678 (7th Cir. 2009))).
The Plaintiff identifies several contradictions in the testimony from Dr. Hamilton who
opined that the Plaintiff has moderate limitations in responding appropriately to supervision,
coworkers, and the general public. AR 74. First, the ALJ relied on Dr. Hamilton’s testimony that
the Plaintiff’s behavior was under his own control “99 percent of the time” and could be “very
appropriate” when it benefitted him but failed to reconcile this with Dr. Hamilton’s testimony
that his psychological impairments caused him to be “impulsive.” Id. at 25, 77–78, 83. Second,
the ALJ noted Dr. Hamilton’s testimony that personality disorders can “be treated successfully”
but did not acknowledge Dr. Hamilton’s testimony that the Plaintiff’s “anti-social personality
disorder” would actually be “made worse” by treatment. Id. at 25, 79. The ALJ did not address
Dr. Hamilton’s testimony, discussed above, that the Plaintiff would be prone to explosive
behavioral extremes when “he is hearing things or you know, being asked to do things that he
doesn’t like” or “when he doesn’t get what he is expected to get either in terms of a verbal
response or a service of some sort.” Id. at 83, 84.
Dr. Hamilton testified that the Plaintiff should not interact with the general public but
could respond appropriately to occasional interactions with supervisors and coworkers. Id. at 86.
However, on questioning by the Plaintiff’s attorney about the ability to tolerate communication
with supervisors, coworkers, and the general public, Dr. Hamilton testified:
I do think that [the Plaintiff] is more likely to have problems with people who are
in authority. So, for example, a customer or you know, if he were working in an
environment like that he was pretty, you know, that’s over and done with pretty
quickly. But a supervisor who is in a position to . . . render some criticism might be
more a target of the anger.

11

Id. at 95. The ALJ does not discuss this testimony and concludes, without explanation and in
apparent contradiction to Dr. Hamilton’s testimony, that the Plaintiff can never interact
appropriately with the general public but can interact with supervisors occasionally.
The Plaintiff notes that, when asked by the ALJ during the hearing how often the Plaintiff
can “respond [appropriately] or tolerate exposure, interactions with say supervisors,” Dr.
Hamilton initially responded, “20% of the time.” Id. at 75. The Plaintiff argues that the RFC for
contact “occasionally” with supervisors and coworkers, which means up to one third-of the
eight-hour workday, is more than twenty percent of the work day and that the ALJ does not
address this inconsistency. However, the ALJ asked Dr. Hamilton to translate the twenty-percent
figure to the scale used for functional ability, and Dr. Hamilton chose “occasionally.” Id. at 75–
76. Although this clarification makes it appear that there is no contradiction in the testimony,
twenty percent of the day is less than “up to one-third” of the day.
Finally, the ALJ stated that the RFC is “even more restrictive than Dr. Hamilton’s
assessment.” Id. at 26. The Plaintiff argues that this incorrect because the ALJ did not account
for any event in which the Plaintiff would exhibit intolerable social behaviors directed at
supervisors or coworkers, such as the very type of event that occurred during the hearing with
the Plaintiff’s outburst during Dr. Hamilton’s testimony and his removal from the building. As
discussed in the previous section, Dr. Hamilton’s testimony, like the state agency psychologists’
opinions, suggests that the Plaintiff would exhibit inappropriate social behaviors in response to
either authority figures or coworkers as a result of his psychological impairments. And, the
vocational expert testified that such a limitation would not be tolerated more than one time by
employers. Id. at 93–94.

12

On remand, the ALJ must address and reconcile, if necessary, these apparent
contradictions in Dr. Hamilton’s testimony.
C.

Consultative Examiner Dr. Predina
Finally, the Plaintiff argues that the ALJ erred by failing to confront the February 2017

opinion of state agency consultative psychological examiner Dr. Predina that the Plaintiff would
have difficulty getting “along with supervisors and coworkers due to his anger, and anxiety.” Id.
at 882. In her decision, the ALJ found Dr. Predina’s opinion to be “somewhat persuasive.” Id. at
26. The ALJ noted Dr. Predina’s opinion that the Plaintiff “would likely struggle to get along
with others,” which the ALJ found to be supported by Dr. Predina’s findings and to be consistent
with the evidence of record. Id. The Plaintiff argues that this opinion is consistent with the
opinions of the state agency reviewing physicians as well as Dr. Hamilton’s testimony, yet the
ALJ failed to incorporate relevant limitations. The Plaintiff reasons that Dr. Predina’s opinion
contains no quantitative restriction on this limitation based on the amount of time spent with
others per workday. The Plaintiff also notes that Dr. Predina observed such behavior during the
consultative examination, where the Plaintiff “became agitated and stated he felt rage coming on
and wanted to leave. He agreed to just a few more questions and then he left.” Id. at 880. The
ALJ observed similar conduct by the Plaintiff at the hearing where he had an outburst during Dr.
Hamilton’s testimony and was eventually asked to leave. Id. at 80–81. On remand, the ALJ will
have an opportunity to include these specific aspects of Dr. Predina’s opinion regarding the
Plaintiff’s mental limitations regarding interactions with supervisors and coworkers.

13

CONCLUSION
For the reasons stated above, the Court GRANTS the relief sought in the Plaintiff’s Brief
[ECF No. 15] and REVERSES the decision of the Commissioner. The Court REMANDS this
matter for further proceedings consistent with this Opinion.
SO ORDERED on November 18, 2021.
s/ Theresa L. Springmann
JUDGE THERESA L. SPRINGMANN
UNITED STATES DISTRICT COURT

14