# U ni te d S ta te s Co ur t of A pp ea ls

For the Eig hth Circu it

__ __ __ __ __ __ __ __ __ __ __ __ __ _

No. 1 4- 21 70

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Kim be rly Anne Nowl in g

ll ll ll ll ll ll ll ll ll ll l Pla in ti

ff - App el la nt

v.

Caro lyn W . Col vi n, Act in g C om m is si on er o f So ci al Secu rit y

ll ll ll ll ll ll ll ll ll ll l Defe nd

an t - Ap pe ll ee

__ __ __ __ __ __

App eal fro m

Uni te d S ta te s Di st ric t Co ur t

fo r th e Weste rn Dis tri ct of M is so ur i - St . Jo se ph

__ __ __ __ __ __

Su bm it te d: Jan ua ry

16 , 20 15

Fil ed : Fe br

ua ry 22 , 20 16

__ __ __ __ __ __

Befo re LOKEN, MELLOY , and GRUENDER, Circu it Ju dg es

.

__ __ __ __ __ __

MELLOY, Circu it Ju dg e.

K i mb e r l y Ann e Nowl in g ap pl ie d fo r di sa bi li ty be ne fit s un de r Tit le II of th e

So ci al Secu rit y Act (th e "Act "), 4 2 U.S.C. § 40 1, et seq

., an d su pp le m en ta l secu rit y

in co m e be ne fit s un de r Tit le XVI of th e Act, 42 U.S.C. § 13 81

, et se q. An ALJ de ni ed

he r ap pl ic at io n, an d th e Co m m is si on e r de cl in ed fu rth er rev ie w. Nowl in g

un su cces sf

ul ly ch al le ng ed he r de ni al of be ne fit s in th e di st ric t co ur t. W e rem an d to

th e ag en cy

for fur th er p ro ceed in gs

.I.

Nowl in g su ffer s fro m co n v e rs io n di so rd er m an ife st in g it se lf as so m at of or m
,

no n- ep il ep ti c "p se ud o- se iz ur es ." In ad di ti on
, sh e is ob es e an d su ffer s fro m m ig rai ne

he ad ach es , m oo d d is or de r, an xi et y di so rd er, an d p ers on al it y di so rd er.

Befo re tu rn in g to th e de ta il s of Nowl in g's m ed ic al an d ad m in is tra ti ve hi st or y ,

we de sc rib e br ie fly th e ph en om en on of co nv ers ion di so rd er an d th e so m at of or m
, no nep il ep ti c "p se ud o- se iz ur es " t h a t f or m th e co re of Nowl in g's m ed ic al is su es an d

al le ge d di sa bi li ty. Co nv ers io n di so rd er is a ph en om en on in whi ch a pe rs on act ua ll y

an d su bjec ti ve ly ex pe rie nc es sym pt om s wit ho ut a kn own un de rlyin g m ed ic al cau se

. East er v. Bo wen
, 86 7 F.2 d 11 28

, 11 29 (8 th Ci r. 19 89 ). It is be li ev ed th e sym pt om s,

s u c h a s no n- ep il ep ti c se iz ur es
, res ul t fro m an un co ns ci ou s, in vo lu nt ary co nv ers io n

of m en ta l st res s in to a ph y si ol og ic al sym pt om

. I d

. ; s e e al so Mi ll er v. Co lv in

, No.

12 –2 29 3, 20 14 W L 64 17 14 at *3 (W. D. Ark

. Feb

. 19

, 20 14 ) ( " P se ud os ei zu res
, or

ps y ch og en ic no n- ep il ep ti c se iz ur es

. . . are be li ev ed to oc cu r as a pa rt of a co nv ers io n

di so rd er in whi ch t he pa ti en t un co ns ci ou sl y co nv ert s em ot io na l dysfu nc ti on in to

ph y si cal sym

pt om s." (ci ti ng Ro na ld P. Less er an d S. Mar c Te s t a
, Sy m pt om s Tha t

Mi m ic Epi le ps y Lin ke d to St res s, Po or Co pi ng Sk il ls

, ht tp :/ /www.h op ki ns m ed ic in e.

o r g / n e w s / med i a / r e l eas es /s y m pt om s_ th at

_m im ic _e pi le ps y

_l in ke d

_ t o

_ s t r e s s

_ p o o r

_

co pi ng _s ki ll s (la st acce ss ed Ja n u a r y 26

, 20 16 ))). In pr io r op in io ns
, we rev ie wed

th es e o r s im il ar di so rd ers an d no te d th e di ffi cu lt y of as se ss in g ho w su ch di so rd ers

l i mi t a pe rs on 's act iv it ie s. Met z v. Sh al al a, 49 F.3 d 37 4, 37 7 (8 th Ci r. 19 95 ). I n 1

See al so
, East er, 86 7 F.2 d at 11 29

. Th e r e
, whe n face d wit h an ap pl ic an t 1

pr es en ti ng a lo ng li st of sym pt om s an d a di ag no si s of so m at of or m or co nv ers io n di so rd er, we s ta te d:

W hil e th e ob jecti ve m ed ic al da ta su pp or ti ng th is li st of ph y si cal ai lm ents

are of va ry in g de gr ees of cert ai nt y an d sp eci fic it y , t he ALJ ha d be fo re
hi m un co nt rad ic te d di ag no se s . . . th at sh e su ffer s fr om a . . . co nd it io n

-2

-pa rti cu la r, we no te d th at a pr im e feat ur e of co nv ers io n di so rd er m ay be a di sc on ne ct

be twee n th e act ua l sev eri ty of sym pt om s d em on st rat ed by cl in ic al ev id en ce and th e

way th e ap pl ic an t su bjec ti ve ly p erce iv es th e sym pt om s. See, e.g ., Eas te r, 8 67 F.2 d

at 11 30 ("[ H] er pr im ary di so rd er, as cl in ic al ly di ag no se d, cau se s he r to ex ag ge rat e he r
ph y si cal pr ob le m s in he r m in d be y on d wha t th e m ed ic al da ta in di cat e."). Tha t is no t

to sa y th is ex ag ge rat ed ex pe rie nc e of sym pt om s am ou nt s to m al in ge rin g. Id

. Rat he r,

th e ap pl ic an t act ua ll y be li ev es he rs el f to be ex pe rie nc in g sym pt om s at a gr eat er le ve l

of sev eri ty tha n c li ni cal ev id en ce ca n s up po rt.

Giv en th is di sc on ne ct

, an ob vi ou s di ffi cu lt y ari se s whe n it be co m es ne ces sa ry

to m ak e cred ib il it y as se ss m en ts in cas es in vo lv in g so m at of or m ph en ome n a

. Su bjec ti ve pe rcep ti on s of so m at of or m effe ct s m ay
, in fact

, be de bi li ta ti ng ev en whe n

cl in ic al or di ag no st ic m ed ic al ev id en ce do es no t fu ll y su pp or t th e cl ai m ed sym pt om s.

It ne v e rth el es s rem ai ns ne ces sa ry to m ak e cred ib il it y as se ss m en ts in th es e se tt in gs
,

an d "[i ]n cas es in vo lv in g s o mat o fo rm di so rd er

. . . an ALJ is no t free to reject

su bjec ti ve ex pe rie nc es wit ho ut an ex pr es s fin di ng th at th e cl ai m an t's te st im on y is no t

cred ib le ." Met z, 49 F.3 d at 37 7. W he re su ch a fin di ng ha s be en m ad e, "[w]e wil l no t

di st ur b th e de ci si on of an ALJ who co ns id ers
, bu t fo r go od cau se ex pr es sl y di sc red it s,

a cl ai m an t's co m

pl ai nt s

. . . eve n in cas es in vo lv in g so m at of or m di so rd er." Gowel l

v. Ap fel , 24 2 F .3d 79 3, 7 96 (8t h C ir. 2 00 1)

.

kn own as so m at of

or m or co nv ers io n di so rd er. Thi s m en ta l di st ur ba nc e

cau se s he r to be li ev e th at he r ph y si cal ai lm en ts are m or e se rio us th an th e

c l in ic al da ta wou ld su gg es t. As de sc rib ed in th e Diag no st ic an d

St at is ti cal Man ua l of Men ta l Dis or de rs (Thi rd Edi ti on ) at pa ge s 24 4 an d

24 7, co nv ers io n di so rd er is no t u nd er a pa ti en t's vo lu nt ary co nt ro l. In

o t h er wor ds

, Mrs

. East er ex pe rie nc es he r ph y si cal pr ob le m s as wo r s e
th an th ey m ay in fact be , and is un ab le to co nt ro l t hi s re sp on se

.

-3

-Giv en th e di ffi cu lt y in th is area
, if an ALJ ex pr es sl y acce pt s t h a t a c l ai m an t

su ffer s fro m a so m at of

or m di so rd er, bu t al so fin ds th e cl ai m an t at le as t pa rti al ly no ncred ib le

, th e ALJ id eal ly sh ou ld se t fo rth th e cred ib il it y de te rm in at io n wit h su ffi ci en t

de ta il t o e x p r e ss ly in fo rm th e rev ie win g co ur t as to th e fact ua l de ta il s of th e

pe ti ti on er's li m it at io ns as acce pt ed or be li ev ed by th e ALJ. And in th is type of cas e,

ev en m or e so th an in ot he r cas es
, co rro bo rat in g te st im on y fro m act ua l wit ne ss es su ch

a s fam il y m em

be rs or fo rm er em

pl oyers reg ard in g th e na tu re of th e sym pt om s may

ho ld pa rti cu la r va lu e fo r a fac t fi nd er.

W it h th is ba ck gr ou nd in m in d, we tu r n t o t h e reco rd

. Nowl in g be ga n

ex pe rie nc in g se iz ur e-l i k e ep is od es pr io r to 20 07

. Sh e wor ke d as a nu rs es ai d an d

ba th in g as si st an t. Ove r ti m e, he r emp l o ye r c ut he r ho ur s an d du ti es be cau se it was

no t sa fe fo r he r to be al on e wit h pa ti en ts or li ft or ba th pa ti en ts gi ve n he r po te nt ia l fo r

se iz ur e-l ik e ep is od es

. I n D e c em be r 20 07

, fo ll owi ng an ep is od e of se iz ur e-l ik e

s ym pt om s, he r em

pl oyer as ke d he r to se e a ne ur ol og is t an d in st ru ct ed h e r n o t t o

ret ur n to wor k un ti l sh e di d. Nowl in g vi si te d ne ur ol o g i st s, who id en ti fie d no

ne ur ol og ic al cau se fo r he r sym pt om s an d id e n t i fie d no si gn s of br ai n act iv it y

su gg es ti ve of act ua l ep il ep sy. Sh e ret ur ne d to wor k on a red uc ed ba si s. Eve nt ua ll y , in Aug us t 2 00 8, s he qu it he r job du e to an in ab il it y to work alo ne wit h p at ie nt s.

On Mar ch 6, 20 09

, sh e ap pl ie d fo r Tit le II a n d Ti t l e XVI be ne fit s. Sh e

or ig in al ly al le ge d an on se t da te of Mar ch 6, 20 09

. Her ap pl ic at io ns were de ni ed

, an d

at a he ari ng be fo re an ALJ on Mar ch 16 , 2 01 1, sh e am en de d he r al le ge d on se t d at e

to Feb ru ary 28

, 20 08

. Sh e di d no t al le ge he r co nd it io n m at eri al ly wor se ne d in la te

Feb ru ary 20 08

. Rat he r, Feb ru ary 28

, 20 08

, is a da te whe n sh e as ke d fo r an d rece iv ed

a d o c t o r 's no te reco m

m en di ng th at sh e res tri ct he r wor ki ng ho ur s to 7 1⁄2 ho ur s p e r

da y , th ree d ay s p er week

. 2

The reco rd is cl ear th at Nowl in g su gg es te d th es e pa rti cu la r res tri ct io ns to he r 2

do ct or . The rec or d a ls o i s cl ear th at he r em pl oyer red uc ed he r du ti es du e to pa ti en t

-4

-Me dic al ev ide nc e fr om tr ea tin g phy sic ia

ns w as la rg el y co ns is te nt be twee n 20 07

an d 20 11

. Nowl in g sa w n eu ro lo gi st Mi g n o n Mak os in 20 07

. Dr. Mak os fo un d no

ev id en ce of ep il eptic se iz ur es

. N owli ng ex pe rie nc ed a se iz ur e-l ik e ep is od e du rin g he r

ex am
, an d Dr. Mak os in di cat ed th at Nowl in g was ab le to si t bu t a n u r s e n e e de d to

ho ld he r he ad an d ne ck

. Dr. Mak os al so in di cat ed t h a t Nowl in g's ey es ap pe ared to

reac t vo lu nt ari ly to st im

ul us du rin g th e ps eu do -s ei zu re an d th at sh e ap pe ared to reco il

vo lu nt ari ly i n r e s p on se to di sc om fo rt. Sh e reco ve red qu ic kl y aft er he r se iz ur e an d

ex pe rie nc ed li tt le ph y si cal ch an ge ot he r th an te m po rari ly sl ig ht ly el ev at ed bl oo d

pr es su re. Dr. Mak os di ag no se d he r wit h co nv ers io n di so rd er/ so m at of or m ps eu do

se iz ur es an d to ok he r of

f se iz ur e m ed ic at io n. Nowl in g rep or te d to Dr. Mak os th at sh e
freq ue nt ly su ffer ed m ig rai ne he ad ach es an d th at he r he ad ach e s o f t e n pr eced ed he r

m or e se ve re se iz ur es

. Dr. Mak os pl aced he r on m ed ic at io n to tre at he r he ad ach es in

an effo rt t o c on tro l t he ps eu do -s ei zu res

.

Nowl in g rece i v ed tre at m en t fro m ge ne ral pr act it io ne r Edu ard o Fern an de z,

M.D., fro m Octo be r 20 07 th ro ug h Ju ly 20 10 ; ps y ch ia tri st Jo se Men en de z, M.D., fro m
Aug us t 20 06 th ro ug h Ja nu ary 20 11 (at le as t 29 of fic e vi si ts ); an d li cen se d so c i a l

wor ke r Nan cy Mi ll er fro m Apr il 2 0 0 9 th ro ug h Ja nu ary 20 11 (at le as t 38 vi si ts or

th erap y se ss io ns ). The se care pr ov id ers co ns is te nt ly di ag no se d an d tre at ed Nowl in g

wit h co nv ers io n di so rd er m an ife st in g as no n- ep il ep ti c/ ps eu do -s ei zu res

. Dur in g

tre at m en t, Mi ll er co ns is te nt ly de sc rib ed Nowl in g wit h a GAF sc or e of 45 or 50 ;

an d Dr. Men en de z de sc rib ed a GAF sc or e of 50

. No care pr ov id er d i a g n o s e d h er 3

sa fet y co nc ern s. It is un cl e a r whe th er Nowl in g he rs el f or he r em pl oyer or ig in al ly

fo rm ul at ed th es e res tri ct io ns as p res en te d fo r ap pr ov al fro m he r ph y si ci an

.

In Pat e-Fi res v. Ast ru e, 56 4 F

. 3 d 93 5, 93 7– 38 n.1 –3 (8 th Ci r. 20 09 ), we 3

ex pl ai ne d:

The GAF is a nu m eri c sc al e ran gi ng fro m zero to on e hu nd red us ed to

rat e so ci al

, oc cu pa ti on al an d ps yc h ol og ic al fu nc ti on in g "o n a hypo th e ti cal co nt in uu m of m en ta l he al th -il ln es s." Diag no st ic an d

-5

-wit h ep il ep ti c se iz ur es no r id en ti fie d a ph y si cal ly id en ti fia bl e cau se fo r he r se iz ur es

.

No care pr ov id er as si gn ed a GAF sc or e gr eat er th an 50 ot he r th an Dr. Men en de z who

, in a "m ed ic al so ur ce st at em en t fo rm " co m pl et ed on Nov em

be r 30

, 20 10

, li st ed a GAF

sc or e of 56 as bo th he r cu rren t le ve l of fu nc ti on in g an d as th e h i gh es t le ve l of

fu nc ti on in g in th e p r e c e d i n g y ear. In th e sa m e fo rm
, Dr. Men en de z de sc rib ed

Nowl in g's im

pa irments as se ve re, no te d th at sh e was no t a m al in ge rer, an d st at ed th at

he r im pa irments wou ld cau se he r to be ab se nt f r o m wor k "m or e th an fo ur da y s pe r

m on th ." Eve n th ou gh he de sc rib ed he r im pa irments in th is fas hi on , th e GAF sc or e

of 56 ge ne ral ly reflec ts on ly a m od erat e le ve l o f im pa irments

.

Treat m en t n o te s fro m al l care gi ve rs refl ect th at Nowl in g de sc rib ed th e
freq ue nc y of he r se iz ur es as wax in g an d wan in g ov er th e y ears

. Sh e de sc rib ed th em

as oc cu rri ng as of

te n as two or th ree pe r week an d as in freq ue nt ly as two to th ree pe r

m on th

. Nowl i n g r e p or te d th at he ad ach es of va ry in g in te ns it y , in cl ud in g m ig rai ne

he ad ach es
, of

te n pr eced ed he r se iz ur es

. Sh e rece iv ed m ed ic in e fo r an xi et y an d

pe rs on al it y di so rd er as well as m ed ic in e to co nt ro l he ad ach es

. Ove r th e co ur se of he r

tre at m en t h er ph y si ci an s freq ue nt ly ch an ge d her dr ug s and do sa ge s in an at te m pt to

be tt er co nt ro l h er h ead ach es an d se iz ur es . Alth ou gh m an y tre at m en t n ot es in di cat e

St at is ti cal Man ua l of Men ta l Di so rd ers
, 32 (4 th ed

. Am

. Ps y ch ia tri c
Ass 'n 19 94 ) (DSM– IV).

. . . A GAF of 41 to 50 in di cat es th e in di vi du al

ha s "[s ]erio us sym

pt om s

. . . or an y se rio us imp ai rm en t in so ci al

,

oc cu pa ti on al

, or sc ho ol fu nc ti on in g.

. . ." DSM– IV at 32

. A GAF of 51

to 60 in di cat es th e in di vi du al ha s "[m ]ode rat e sym pt om s

. . . or m od erat e di f f i c u lt y in so ci al

, oc cu pa ti on al

, or sc ho ol fu nc ti on in g.

. ." DSM– IV

at 32

.

In rece nt y ears
, th e ag en cy ha s reco gn iz ed

, an d we ha ve no te d, th at GAF sc or es ha ve
li m it ed im

po rta n c e

. J on es v. Ast ru e, 61 9 F.3 d 96 3, 97 3– 74 (8 th Ci r. 20 10 ) ("M or eo ve r, th e Co m

m is si on er ha s de cl in ed to en do rs e th e [GAF] sc or e fo r us e in th e
So ci al Secu rit y an d [Su pp le m en ta l Secu rit y In co m e] di sa b i l i t y p ro gr am s an d ha s
in di cat ed th at [GAF] sc or es ha ve no di rect co rrel at io n to th e se ve rit y req ui rem en ts of

th e m en ta l d is or de rs li st in gs ." (i nt ern al cit at io ns om it te d) ).

-6

-m il d im

pr ov em en t, read as a who le th ey sh ow he r sym pt om s wax ed an d wan ed wit h

s o me sh or t te rm im

pr ov em en t bu t wit ho ut su bs ta nt ia l lo ng -te rm wor se ni ng or

im pr ov em en t d ur in g t he 20 08 to 20 11 ti m e fra m e.

In tre at m en t no te s, Dr. Fern an de z, Dr. Men en de z, an d Ms

. Mi ll er of te n reci te d

Nowl in g's rep or ts of he r sym pt om s as well as he r rep or ts of ho w sh e ha d be en

sp en di ng he r ti m e. The se rep or ts were larg el y co ns is te nt wit h a la te r de sc rip ti on of

da il y act iv it ie s No wli ng pro vi de d d ur in g h er ALJ h eari ng . She di d no t d riv e, ot he r

th an a on e-m il e ro ut e to he r br ot he r's ho m e, fo r fear of ha vi ng an ep is od e an d cau si ng

an acci de nt

. Sh e di d no t sh op or ge ne ral ly go ou t in pu bl ic al on e. Her fath er or her

si st er-i n- la w ge ne ral ly dr ov e he r whe n ne ed ed

. Sh e co ul d do y ard wor k "at he r own

pa ce," di d he r own la un dr y , an d co ok ed fo r he rs el f an d he r fat he r twi ce pe r week

. On e d a y p e r week

, he r fat he r wou ld dr iv e he r to he r si st er's ho m e in th e m or ni ng

whe re she wou ld he lp he r si st er's ch il dr en pre pa re fo r sc ho ol an d g et on a bu s. Sh e
typic al ly w ou ld watc h t el ev is io n fo r on e to on e an d a ha lf h ou rs pe r da y . She li ke d

to read an d wor k on th e co m pu te r, bu t sh e co ul d on ly wor k on th e co m pu te r fo r ab ou t

fif te en to twen ty m in ut es or read fo r ab ou t ha lf an ho ur be fo re h ead ach es m ad e he r

st op

.

In ad di ti o n, Nowl in g de sc rib ed se ve ral va cat io ns an d fam il y ev en ts sh e

at te nd ed : at le as t on e in st an ce of cam pi ng ; an ev en t whe re sh e he lp ed to ho st a la rg e

gr ou p of fam il y ; m on th ly tri ps to se e he r br ot he r in Neb ras ka ; at te nd in g an d he lp in g

wit h ch il dr en 's sp or ti ng ev en ts ; an d va cat io ni ng on ce in wes te rn Neb ras ka an d on ce

in Nor th Caro li na

. Fo ll owi ng th e tri p to wes te rn Neb ras ka

, Nowl in g rep or te d to Dr.

Men en de z th at sh e fel t rel ax ed an d ha d no t su ffer ed a se iz ur e-l ik e e pi so de at al l

du rin g he r tri p. Dr. Me n e n d e z ' s no te s fro m th at of fic e vi si t in di cat e th at Nowl in g

"d id no t ap pe ar t o h av e an y sym pt om s i n t he ab se nc e o f st res s."

To he r do ct or s, t o Ms

. Mi ll er, an d to th e ALJ, sh e de sc rib ed he r se iz ur e-l ik e

ep is od es as va ry in g in in te ns it y an d effe ct

. So m e ep is od es in vo lv ed co m pl et e lo ss of

-7

-co ns ci ou sn es s, so m e in vo lv ed tre m or s an d sh ak in g, an d st il l ot he rs in vo lv ed an

in ab il it y to fo rm wor ds an d art ic ul at e th o u g h t s

. The du rat io ns va rie d fro m fiv e

m in ut es or le ss to m or e th an twen ty m in ut es
, an d reco ve ry ti m es fo ll owi ng ep is od es

va rie d fro m m in ut es to a who le da y

. In he r he ari ng te st im on y , Nowl in g de sc rib ed he r

se iz ur es as oc cu rri ng "i n sp ur ts " whe re sh e m ig ht ha ve two or th ree in th e sa m e da y

bu t th en go a m on th wit ho ut ha vi ng on e. No tre at in g ph y si ci an su gg es te d an y be li ef

or su sp ic io n t ha t No wli ng was m al in ge rin g o r ex ag ge rat in g h er s y m pt om s.

In th e m ed ic al so ur ce st at em en t fo rm pr ep ared on No v em be r 30

, 20 10

, Dr.

Men en de z de sc rib ed Nowl in g as se rio us ly li m it ed or un ab le to m eet co m pe ti ti ve

st an da rd s in se ve ral res pe ct s, in cl ud in g an in ab il it y to "[m ]ain ta in reg ul ar at te nd an ce

an d be pu nc tu al wit hi n cu st om ary, us ua ll y st ric t to le ran ces ," "[c ]om pl et e a no rm al

wor kd ay an d wor kwe ek wit ho ut in te rru pt io ns fro m ps yc ho lo gi cal ly ba se d

sym pt om s," "[r ]esp on d ap pr op ria te ly to ch an ge s in a ro ut in e wor k se tt in g," or "[d ]eal

wit h s tre ss of s em is ki ll ed an d s ki ll ed work ."

Co ns ul ti ng ps y ch ol og is t Jo hn Keo ug h, MA, m et wit h Nowl in g an d co nd uc te d

a p sycho lo gi cal ex am

in May 20 09

. He co nc lu de d No wli ng 's g en eral li fe ac ti vi ti es

an d pre se nt at io n du rin g her ex am in at io n di d no t d em on st rat e se ve re l im it at io ns

. In

pa rti cu la r, Mr. Keo ug h reci te d se ve r a l of Nowl in g's se lf- de sc rib ed act iv it ie s,

di sc us se d he r m an ne ris m s an d ab i l i t y t o res po nd to hi s qu es ti on in g, an d co nc lu de d

sh e co ul d fu nc ti on in a lo w st res s/ lo w dem an d wo rk pl ace.

I n ad di ti on
, co ns ul ti ng ps y ch ol og is t Mar ga ret Su ll iv an
, Ph D, rev ie we d

Nowl in g's reco rd s an d fo un d on ly m il d to m od erat e li m it at io ns
, reac hi ng co nc lu si on s

co ns is te nt wit h t ho se of M r. Keo ug h.

Nowl in g's si st er-i n- la w, Dawn Nowl in g, te st ifi e d e xt en si ve ly ab ou t he r

in te ract io ns wit h Nowl i ng an d he r ob se rv at io ns of Nowl in g's se iz ur es

. Dawn

Nowl in g sp en t at le as t so m e ti m e wit h Nowl in g on a da il y ba si s, so m e da y s sp en di ng

-8

-m os t of th e da y wit h he r. Dawn Nowl in g rep or t e d wit ne ss in g ap pr ox im at el y fo rty

se iz u re-l ik e ev en ts si nc e 20 10

. Sh e de sc rib ed m os t ev en ts as la st in g fiv e to te n 4

m in ut es wit h rel at iv el y sh or t reco ve ry ti m es
, bu t ap pr ox im at el y twen ty-fiv e pe rcen t

of th e ev en ts la st ed fo r fif te en to twen t y mi n u t e s or lo ng er an d req ui red gr eat er

reco ve ry ti m es

. Dawn Nowl in g de sc rib ed Nowl in g's act iv it ie s in a m an ne r co ns is te nt

wit h N o w l i n g's de sc rip ti on : Nowl in g refu se d to dr iv e he rs el f or ap pe ar in pu bl ic

al on e bu t m an ag ed se lf- care
, ho us ek eep in g, an d y ard care o n h e r own pa ce an d

pa rti ci pa te d in fam il y ev en ts an d ot he r ev en ts whe n acco m pa ni ed

. Dawn Nowl in g

de sc rib ed he rs el f or ot he r fam il y m em be rs m ov in g No wli ng to a ch ai r or layin g her

do wn whe n se iz ur e-l ik e sym pt om s wou ld ari s e

. Sh e al so de sc rib ed th e m or e m il d

ep is od es as ak in to so m eo ne who ha s ha d a st ro ke an d can n ot fo rm ul at e wor ds or

fo cu s. Fi na ll y , sh e de sc rib ed th e se iz ur e-l ik e ep is od es as ha vi ng be co m e a f a i rly

ro ut in e o c c u rren ce th at fam il y m em be rs were accu st om ed to de al in g wit h be cau se

th ey ha d be en ha pp en in g fo r a lo ng ti m e an d ph y si ci an s co ul d no t de te rm in e ph y si cal

cau se or o ffer effe ct iv e tr eat m en t.

In a writ te n op in i o n is su ed aft er th e he ari ng
, th e ALJ ap pl ie d th e fiv e-s te p

se qu en ti al an al y si s of 20 C.F.R. § 40 4.1 52 0 an d § 41 6.9 20

. The ALJ fo un d Nowl in g

no n- cred ib le bu t di d no t who ll y reject he r cl ai m ed li m it at io ns or th e ex is te nc e of th e

ps eu do -s ei zu res

. Rat he r, th e ALJ fo un d th at so m e le ve l of li m it at io ns an d m ed ic al ly 5

The he ari ng to ok pl ace on Mar ch 16

, 20 11

. W he n as ke d ho w m an y se iz ur es 4

sh e ha d wit ne ss ed "s in ce 20 10 ," Dawn Nowl in g res po nd ed "p ro ba bl y two or th ree a

m on th ." The ALJ th en no te d th at th is nu m be r wou ld be "ab ou t 40 -s om e." Giv en th is

di al og ue
, it a p pe ars th e ALJ an d Dawn Nowl in g un de rs to od th em se lv es to be

di sc us si ng th e freq ue nc y of se iz ur e-l ik e ep is od es in th e a p p r o x im at el y fo ur te en to

fif te en m on th s p rece di ng th e h eari ng

.

The en ti ret y of th e ALJ's co m m en ta ry on Now l i ng 's cred ib il it y was as 5

fo ll ows :

-9

-su pp or te d sym p t o ms ex is te d bu t at a le ss er se ve rit y th an th at cl ai m ed by Nowl in g.

The ALJ co nc lu de d th e m ed ic al ev id en ce co ul d be ex pe ct ed t o c au se Nowl in g's

ge n e r a l s ym

p to m s. The ALJ, ho wev er, di d no t ad dr es s th e pr im ary feat ur e of

co nv ers io n di so rd er an d so m at of or m sym pt om s, na m el y , th e ex te nt to w hic h Nowl in g

act ua ll y pe rcei ve d sym

pt om s an d th e ex te nt to whi ch co nv ers io n di so rd er rat he r th an

a la ck o f c r e d i b i l it y m ig ht ex pl ai n an ab se nc e of ob jecti ve m ed ic al su pp or t fo r he r

sym pt om s.

In reac hi ng hi s co nc lu si on s, th e ALJ de te rm in ed Dr. Men en de z's op in io n (th e

m ed ic al so ur ce s t a t e ment ) was en ti tl ed to "l it tl e weig ht " be cau se th e op in io n was

in te rn al ly in co ns is te nt in th at i t l i s t e d a GAF sc or e of 56 bu t de sc rib ed Nowl in g's

im pa irments as se ve re. The ALJ no te d th at Dr. Men en de z's op in io n was in co ns is te nt

wit h th e op in io ns of th e co ns ul ti ng ps y ch ol og is ts an d "n ot well su pp or te d." The ALJ

al so st at ed Dr. Men en de z's op in io n wa s i n c o n s i st en t wit h th e ba la nc e of Dr.

Men en de z's own tre at m en t no te s. The ALJ, ho wev er, rel ie d he av il y up on : ( 1 ) th e

co m m en t fro m Dr. Men en de z th at Nowl in g's sym pt om s di d no t ap pe ar to ari se in th e

ab se nc e of st res s, an d (2 ) co m m en ts in Dr. Men e n d e z's tre at m en t no te s in di cat in g

Nowl in g sh owe d "im

pr ov em en t." The ALJ ga ve "g reat es t weig ht " to th e op in io n of

Mr. Keo ug h, th e ps y ch o l o g i s t who ex am in ed Nowl in g on ce. The ALJ al so ga ve
"g reat weig ht " to th e op in io n of Mar ga ret Su ll iv an
, Ph D, th e no n- ex am in in g

ps y ch ol og is t who rev ie wed Nowl in g ' s reco rd s. Fi na ll y , th e ALJ co m m en te d up on

Afte r care fu l co ns id erat io n of th e ev id en ce, th e un de rs ig ne d fin ds th at

th e cl ai m an t's m ed ic al ly de te rm in ab le im pa irments co ul d reas on ab ly be

ex pe ct ed to cau se th e al le ge d sym pt om s; ho wev er, th e c l a i m an t's

st at em en ts co nc ern in g th e in te ns it y , pe rs is te nc e an d l im it in g e ffec ts of

th es e sym pt om s are no t cred ib le to th e ex te nt th ey are in co ns is te nt wit h

th e . . . resi du al fun ct io na l ca pa ci ty ass es sm en t.

-1 0-Nan cy Mi ll er on ly t o i nd ic at e th at Nanc y Mi ll er rep eat ed th e GAF sc or e of 50 , a nd

th e ALJ d id no t m en ti on th e te st im on y fro m Dawn No wli ng

. 6

The ALJ de te rm in ed

, pu rs ua nt to 20 C.F.R. §§ 40 4.1 52 0( a)(4 ) an d

41 6.9 20 (a)( 4) th at : (i) Nowl in g ha d no t en ga ge d in su bs ta nt ia l ga in fu l act iv it y si nc e

th e am en de d on se t da te ; (ii ) sh e su ffer ed fro m th e fo ll owi ng im pa irments th at

, at le as t

in co m bi na ti on
, were sev ere: co nv ers io n d is or de r wit h p se ud o- se iz ur es
, he ad ach es
, mild ob es it y , m oo d di so rd er, an xi et y di so rd er (n ot ot he rwis e sp eci fie d)

, an d

pe rs o n a li ty di so rd er (n ot ot he rwis e sp eci fie d)

, bu t m ed ic al ev id en ce di d no t sh ow

th em to be so se ve re as to pr ecl ud e wor k fo r 12 m on th s; (ii i) sh e di d no t ha ve a li st ed

im pa irment or a co m

bi na ti on of im

pa irments th at m et or m ed ic al ly eq ua le d a li st ed

im pa irment; (iv ) sh e co ul d no t pe rfo r m h e r pa st rel ev an t wor k; bu t (v ) sh e ret ai ne d

th e res id ua l fu nc ti on al cap aci ty to:

pe rfo rm li gh t wor k as de fin ed in 20 C.F.R. 40 4.1 56 7( b) an d 41 6.9 67 (b )

ex cep t [s he ] m

us t ha ve li m it ed co nt act wit h th e pu bl ic an d sh e can on ly

pe rfo rm si m

pl e, rep et it iv e, ro ut in e ta sk s no hi gh er th an [ta sk s req ui rin g be twe e n 1 an d 3 m on th s to le arn ] an d on ly in a st res s- free wor k

e n v i r o nm en t; sh e can no t wor k at un pr ot ect ed he ig ht s or wor k aro u n d

da n g e ro us or m ov in g m ach in ery, sh e can oc cas io na ll y be nd bu t ne ve r crawl

, kn eel

, cro uc h, or sq ua t; sh e can no t be ex po se d to ex tre m e ho t or

Reg ard in g Nan cy

Mi ll er, t he ALJ st at ed in hi s wri tt en op in io n a t 1 7: 6

Tha t GAF nu m

be r is th en rep eat ed in th e tre at m en t no te s of Nan cy
Mi ll er, a li cen se d cl in ic al so ci al wor ke r, ov er t h e c o u r s e of 2 y ears of

t r e a t m en t. Thi s wou ld in di cat e th at de sp it e 2 y ears of m ed ic at io n a n d

th erap y , th e cl ai m an t di d no t im pr ov e at al l, whi ch is hi gh ly in co ns is te nt

wit h Dr. Men en de z's no te s, hi s op in io n a s t o th e cl ai m an t's GAF, an d

al so wit h Ms

. Mi ll er's no te s, who h e rs el f no te d "i m pr ov em en t"

rep eat ed ly.

-1 1-co ld an d sh e can no t dr iv e m ot or iz ed v eh ic le s as pa rt of he r job

res po ns ib il it ie s.

At th e he ari ng
, th e ALJ pr es en te d th is res id ua l fu nc ti on al cap aci ty to a

qu al ifi ed vo cat io na l ex pe rt in th ree se pa rat e hypo th et ic al sc en a rio s. In a fir st

sc en ari o, th e ALJ de sc rib ed Nowl in g's res tri ct io ns ex act ly as qu ot ed

. Wit h th es e

res tri ct io ns
, th e vo cat io na l ex pe rt op in ed th at Nowl in g co ul d wor k as a pr ic e m ark er,

a ro ut er, or a m ai l fo ld in g m achine ope ra to r—DOT li st ed po si ti on s de em ed co ns is te nt

wit h t he se li m it at io ns an d a va il ab le in su bs ta nt ia l n um be rs in th e st at e an d n at io na l

eco no m ie s. 2 0 C .F.R. §§ 40 4.1 52 0( e), (g ); i d. § § 4 16 .92 0( e), (g ).

In a se co nd sc en ari o, th e ALJ ag ai n as ke d th e vo cat io na l ex pe rt to co ns id er th e

li m it s de sc rib e d in th e res id ua l fu nc ti on al cap aci ty as se ss m en t bu t ad de d se iz ur es

wit h su bs eq ue nt reco ve ry pe rio ds th at wou ld m ak e Nowl in g un ab le to wor k fo r ha lfda y pe rio ds on an un pr ed ic ta bl e ba si s, wit h su ch pe rio ds ari si ng on ce pe r week

. And

in a th ird sc en ari o, th e ALJ de sc rib ed a si m il ar, pe rio di c in ab il it y to pe rfo rm an y wor k

bu t with th e in ab il it y to wor k cau se d by he ad ach es rat he r th an ps eu do -s ei zu res

. As

to bo th of th e la tt er sc en ari os (h er ba se li ne res tri ct io ns as qu ot ed ab ov e co up le d wit h

a pe rio di c an d un pr ed ic ta bl e who le sa le in ab il it y to wor k d u e to ei th er se iz ur es or

he ad ach es ), t h e v oc at io na l ex pe rt op in ed th at th e res ul ti ng ab se nt eei sm wou ld be

u n a c c e p t ab le to an y em

pl oyer su ch th at th ere were no job s Nowl in g co ul d pe rfo rm

if sh e ha d th os e li m it at io ns

. The ALJ co nc lu de d Nowl in g was no t di sa bl ed

, acce pt in g

th e vo cat io na l ex pe rt' s res po ns e to th e fir s t h yp o th et ic al si tu at io n an d fin di ng

Nowl in g co ul d pe rfo rm th e ci te d job s. The Co m m is si on er de ni ed fu rth er rev ie w, an d

th e ALJ's op in io n i s t he fin al ad m in is tra ti ve ord er. The di st ric t co ur t af fir m ed

.

II.

W e rev ie w de no vo th e di st ric t co ur t's jud gm en t affi rm in g th e ALJ's de ni al of

be ne fit s. Grab le v. Co lv in

, 77 0 F.3 d 11 96

, 12 01 (8 th Ci r. 20 14 ). W e owe su bs ta nt ia l

-1 2-de fere nc e to th e ag en cy
, ho wev er, an d wil l "af fir m if th e ALJ m ad e no le ga l erro r an d

th e ALJ's de ci si on is su pp or te d by su bs ta nt ia l ev id en ce in th e reco rd as a who le ." Id

. "Su bs ta nt ia l ev id en ce is le ss th an a pr ep on de ran ce o f t h e e v i d en ce, bu t is 'su ch

r el ev an t ev id en ce as a reas on ab le m in d wou ld fin d ad eq ua te to su pp or t t h e

co m m is si on er's co nc lu si on .'" Id

. (q uo ti ng Dav is v. Apf el

, 23 9 F.3 d 96 2, 96 6 (8 th Ci r.

20 01 )). "In de te rm in in g whe th er ex is ti ng ev id en ce is su bs ta nt ia l, th is co ur t lo ok s at

b ot h ev id en ce th at su pp or ts an d ev id en ce th at de tra ct s fro m th e Co m m is si on e r ' s

de ci si on ." Berg m an n v. Apf el , 20 7 F .3d 10 65 , 10 68 (8t h C ir. 2 00 0) . "W e m ay no t

rev ers e si m

pl y be cau se we wou ld ha ve de ci de d di ffer en tl y or be cau se su b s t a nt ia l

ev id en ce s up po rts a co nt rary out co m e." Grab le , 77 0 F .3d at 1 20 1.

S e v e r al m at te rs
, as de te rm in ed by th e ALJ, are un di sp ut ed at th is t i me:

Nowl in g su ffer s fro m co nv ers io n di so rd er m an ife st in g it se lf as so m at of or m
, no nep il ep ti c "p se ud o- se iz ur es ." In ad di ti on
, sh e is o b e s e an d su ffer s fro m m ig rai ne

he ad ach es
, m oo d di so rd er, an xi et y di so rd er, an d pe rs on al it y di so rd er. Sh e can no t

co nt in ue he r pa st wor k, an d sh e is su bjec t to ph y s i c al an d wor k- en vi ro nm en t

li m it at io ns du e to he r co nd it io ns

.

Not wit hs ta nd in g th es e de te rm in at io ns
, se ve ral m at te rs rem ai n un cl ear. The

ALJ st at ed Nowl in g was no n- cred ib le in pa rt, fin di ng sh e ex ag ge rat ed he r sym pt om s.

Bu t it is un cl ear whe th er th is de te rm in at io n was a fin di ng of m al in ge r i n g or an

ex ag ge rat io n rel at ed to th e n a t u r e of co nv ers io n di so rd er. Fu rth er, th e ALJ ne it he r

ex pl ai ne d ho w ex te ns iv e he de te rm in ed Nowl in g's sym pt om s to be no r ad dr es se d th e

effe ct of he r co n v e r s i o n d i so rd er up on he r pe rcep ti on of he r own sym pt om s. It

th eref or e re mai n s un cl ear wha t sym pt om s th e ALJ act ua ll y be li ev ed Nowl in g

ex pe rie nc es an d wha t, if an y , e ffec t he r c o n ve rs io n di so rd er ha s up on he r ab il it y to

wor k.

In th e co nt ex t of th is un cert a i n t y, N o wli ng arg ue s th e ALJ co m m it te d le ga l

erro r in th ree res pe ct s res ul ti ng in a co nc lu si on no t su pp or te d by su bs ta nt ia l ev id en ce

-1 3-on th e reco rd as a who le

. Fi rs t, sh e arg ue s th e ALJ fai le d to co ns id er te st im on y fro m

he r si st er-i n- la w, Dawn Nowl in g, who wit ne ss ed Nowl in g's no n- ep il ep ti c se iz ur es

. Seco nd

, sh e arg ue s th e ALJ im pr op erl y di sc ou nt ed Dr. Men en de z's op in io n. Thi rd

, sh e arg ue s th e ALJ im

pr op erl y di sc ou nt ed Nan cy Mi ll er’s op in io n. W e ad dr es s th es e

arg um en ts be lo w and co nc lu de rem an d i s re qu ire d.

In pa rti cu la r, we co nc lu de th e erro rs id en ti fied by Nowl in g sh ow th e ALJ fai le d

to co ns id er Men ta l Im

pa irment Lis ti ng 12 .07 So m at of or m Dis or de rs (in cl ud in g

Co nv ers io n Dis or de r) whe n as se ss in g No w l i n g's res id ua l fu nc ti on al cap aci ty. The

ALJ’s op in io n as se rts th at he "co ns id ered whe th er th e cl ai m an t's pa th ol og y an d

at te nd in g sym

pt om s m et or eq ua le d" Lis ti ng 12 .07

. The A LJ

, h owe ve r, di d no t

co ns id er th e li st in g in rel at io n to Nowl in g's res id ua l fu nc ti on al cap aci ty in th e m an ne r

req ui red by the reg ul at io ns go ve rn in g M en ta l Di so rd ers , Sub pt . P, App . 1 § 12 .00

.

Sect io n 12 .00 .D.1. ad dr es se s so ur ces of ev id en ce in co ns id eri ng m en ta l

im pa irments

. The ALJ’s co nc lu so ry f in di ng th at Nowl in g was no t cred ib le di d no t

ta ke § 12 .00 .D.1.b

. in to acco un t. The fai lu re to co ns id er Dawn Nowl in g's te st im on y

an d li m it ed co ns id erat io n of Nan cy Mi ll er's tre at m en t reco r d s w a s co nt rary to

§ 12 00 .D.1.c. The fai lu re to co ns id er th e m ed ic al ev id en ce "l on gi tu d i na ll y " was

co nt rary to § 12 .00 .D.2., le ad in g to un warra nt ed em ph as is on th e on e-t im e ev al ua ti on

of Keo gh an d an ev al ua ti on of Dr. Men en de z ba se d on th e Nov em be r 20 10 m ed ic al

so ur ce s ta te m en t ra th er t ha n Dr. Men en de z's en ti re cou rs e of tre at m en t. Furt he r, as

no te d ab ov e, su pr a at n. 3, th e e x c e s s i ve (al m os t ex cl us iv e) rel ia nc e on th e GAF

sc or es was an im

pr op er ba si s up on whi ch to d i s c o un t th e su bs ta nt ia l lo ng it ud in al

tre at m en t reco rd s of Dr. Men en de z. Fi na ll y, t h e A LJ fai le d to co ns id er whe th er

Nowl in g's ch ro ni c im

pa irment res ul te d in a st ru ct ur ed li fe th at m as ke d th e ex te nt to

whi ch sh e is im

pa ire d fr om

work in g, s ee § § 1 20 0.E. an d F

.

W e al so co nc lu de th e ALJ fai le d to ev al u a t e fu ll y th e vo cat io na l ex pe rt' s

te st im on y

. In po si ng th e se co nd an d th ird hypo th et ic al s reg ard in g se iz ur es an d

-1 4-he ad ach es an d reco ve ry ti m es , th e ALJ d es cri be d l es se r im pa irments th an Nowl in g

cl ai m ed

. The vo cat io na l ex pe rt no ne th el es s sa id bo th co nd i t io ns were di sa bl in g

be cau se th ey wou ld cau se un sc he du le d, ex ces si ve ab se nt eei sm —t he ex act reas on Dr.

Men en de z's m ed ic al so ur ce st at em en t co nc lu de d Nowl in g was di sa bl ed

. Yet th e ALJ

m ad e no fin di ng th at Nowl in g's co nv ers io n di so rd er was of le ss se ve rit y th an wha t

he de sc rib ed in hi s h y

po th et ic al s.

A. Dawn Nowl in g

Dawn Nowl in g is no t a m ed ic al so ur ce, bu t he r te st im on y refl ect s on th e

se ve rit y of Nowl in g's im

pa irments an d is ev id en ce th e ALJ is to co ns id er in ap pl y in g

th e fiv e-s te p se qu en ti al an al y si s. See 20 C.F.R. § 40 4.1 51 3( d)

. It is un di sp ut ed th e

ALJ's op in io n fai le d to ad dr es s Dawn Nowl ing ' s te sti m on y ex pr es sl y or de sc rib e wha t

weig ht

, if an y , th e ALJ acco rd ed he r te st im on y

. In ge ne ral su ch an om is si on ne ed no t

le ad ou r co ur t to rev ers e an ALJ's ot he rwis e-s up po rte d de ci si on

. See, e.g
., Bu ck ne r

v. Ast ru e, 6 4 6 F.3 d 54 9, 56 0 (8 th Ci r. 20 11 ) (rejec ti ng an arg um en t th at th e fai lu re

t o ad dr es s a la y -wit ne ss 's de sc rip ti on of sym pt om s req ui red rem an d, st at in g, " t h e

ALJ's 'arg ua bl e de fic ie nc y in o p i n io n- writ in g te ch ni qu e,' ha d no be ari ng on th e

ou tc om e o f [t he ] cas e an d d oe s n ot req ui re rem an d" (q uo ti ng Ro bi ns on v. Su ll iv an
, 95 6 F.2 d 83 6, 84 1 (8 th Ci r. 19 92 ))); W il dm an v. Ast ru e 59 6 F.3 d 95 9 (8 th Ci r. 20 10 )

("Al th ou gh req ui red to de ve lo p th e reco rd fu ll y an d fai rly, an ALJ is no t req ui red to

di sc us s ev ery pi ece of ev id en ce su bm it te d." (q uo ti ng Bl ack

, 14 3 F.3 d at 38 6) ). W he n

co up le d wit h ot he r "er ro rs an d un cert ai nt ie s in th e op in io n," W il lc oc ks on v. Ast ru e,

54 0 F.3d 87 8, 88 0 (8t h Cir. 20 08 ), ho wev er, we h av e rem an de d for reco ns id erat io n

an d cl ari fic at io n by th e ag en cy
, id

. a t 8 8 1

. A nd

, he re th e fai lu re to co ns id er Dawn

Nowl in g's te st im on y was co nt rary to th e go ve rn in g reg ul at io ns

. See 20 C.F.R. P t

. 40 4, Su bp t. P, App

. 1, § 12 00 .D.1.c ("I f ne ces sa ry
, in fo rm at io n s h ou ld al so be

ob ta in ed fro m no nm ed ic al so ur ces
, su ch as fam il y m em be rs an d ot he rs who kn o w

y ou
, to su pp le m en t th e reco rd of y ou r fu nc ti on in g in or de r to es ta bl is h th e co ns is te nc y

of th e m ed ic al ev id en ce an d l on gi tu di na li ty of im pa irment s ev eri ty . . . .").

-1 5-Dawn Nowl in g te st ifi ed reg ard in g Nowl in g's da il y act iv it ie s i n a mann er

co ns is te nt wit h Nowl in g's te st im on y an d st at em en ts to he r ph y si ci an s. In pa rti cu la r,

Dawn Nowl in g st at ed th at Nowl in g di d no t sh op or ot h e r wis e go ou t pu bl ic ly by

he rs el f fo r fear of h a v i ng a se iz ur e-l ik e ep is od e whe n un acco m pa ni ed

. The ALJ,

ho wev er, reci te d hi s un de rs ta nd in g of Nowl in g's act iv it ie s as in cl ud in g sh op pi ng by

he rs el f. The fai lu re to co ns id er Dawn Nowl in g's te st im on y an d th e m is st at em en t of

7

th e reco rd in th is reg ard de m on st rat es a fai lu re to pr op erl y an al y ze th e effe ct s of a

st ru ct ur ed se tt in g as req ui red by th e r e g u l a t i on s. Id

. § 12 00 .F (d es cri bi ng th e

po te nt ia ll y m it ig at in g effe ct of l i f e in st ru ct ur ed se tt in g, whe th er an in st it ut io n or a

ho m e, up on sym

pt oms)

. Si m

pl y pu t, th e na tu re of th e m ed ic al co nd it io n an d th e 8

na tu re of th e li fe act iv it ie s, in cl ud in g su ch co ns id erat io ns as in de pe nd en ce, sh ou ld be

co ns id ered ag ai ns t t h e ba ck dr op of whe th er su ch act iv it ie s act ua ll y sp eak to

Thi s fin di ng ap pe a r s t o e n jo y no su pp or t in th e reco rd as th e ev id en ce we 7

id en ti fie d in di cat es Nowl in g and Dawn Nowli ng bo th st at ed Nowl in g res tri ct ed he r

pu bl ic act iv it ie s in th is reg ard to si tu at io ns whe re fam il y m em be rs acco m

pa ni ed he r.

20 C.F.R. Pt . 40 4, Su bp t. P, Ap p. 1 § 1 20 0.F pro vi de s: 8

Part i c u l arl y in cas es in vo lv in g ch ro ni c m en ta l di so rd ers
, ov ert

sym pt om at ol og y m ay be co ntr oll ed or at te nua te d by psy ch osocial fact or s

su ch as pl acement in a ho sp it al

, ha lfwa y ho us e, bo ard an d care faci li ty,

or ot he r en vi ro nm en t th at pr ov id es si m il ar st ru ct ur e. Hig hl y st ru ct ur ed

an d su pp or ti ve se tt in gs m ay al so be fo un d in y ou r ho m e. Su ch se tt in gs

m ay gr eat ly red uc e th e m en ta l de m an ds pl aced on y ou

. W it h lo w e r e d

m en ta l de m an ds

, ov ert s y m pt om s an d si gn s of th e un de rlyin g m en ta l

di so rd er m ay be m in im iz ed

. At th e sa m e ti m e, ho wev er, y ou r ab il it y to

fu nc ti on ou ts id e of su ch a st ru ct ur ed or su pp or ti ve se tt in g m ay no t ha ve ch an ge d. If yo u r sym

pt om at ol og y is co nt ro ll ed or at te nu at ed by

ps y ch os oc ia l fact or s, we must co ns id er yo ur ab il it y to fu nc ti on ou ts id

e of su ch hi gh ly st ru ct ur ed

set ti ng s.

(Em ph as is ad de d)

-1 6-cl ai m an t's ab il it y to ho ld a job

. Part ic ip at io n in act iv it ie s wit h fam il y or act iv it ie s at

ho m e an d at "your own pa ce" m ay no t refl ect an ab il it y to pe rfo rm at wor k. And

, "a

cl ai m an t ne ed no t be be dr id de n to qu al ify fo r di sa bi li ty be ne fit s." Hut s e l l v.

Mas sa na ri, 2 59 F.3d 70 7, 7 13 (8t h C ir. 2 00 1)

.

Ci ti ng Bu ck ne r, th e ag en cy arg ue s an y erro r in fai li ng to di sc us s D a w n

Nowl in g's te st im on y do es no t req ui re rem an d be cau se th e sa m e ev id en ce th at

di sc red it s Nowl in g's te st im on y al so di sc red it s Dawn Nowl in g's te st im on y

. Bu ck ne r,

64 6 F.3 d at 55 9– 60 (d en y in g rem an d whe re it was no t po ss ib le to de te rm in e whe th er

th e ALJ ha d co ns id ered la y te st im on y bu t whe re it was cl ear th e sa m e ev id en ce th at

di sc red it ed th e cl ai m an t's te st im on y wou ld al so di sc red it th e la y wit ne ss 's te st im on y ).

The ag en cy 's arg um en t in th is reg ard m is se s th e m ark

. Fi rs t, it is un cl ear wha t ex act ly

th e ALJ fo un d no t c r e d i b l e ab ou t Nowl in g, ot he r th an th e co nc lu si on th at he r

sym pt om s were so m e un art ic ul at ed de gr ee of se ve rit y le ss th an sh e de sc rib ed th em

to be

. In th is se tt in g, ev en wit ho ut ta ki ng in to acco un t th e pe cu li ari ti es of a

som at of or m di so rd er, Dawn Nowl in g's te st im on y is ne it he r red un da nt w ith N ow lin g' s

te st im on y , no r is it di sc red it ed by th e sa m e ev id en ce th at pu rp or te dl y di sc re d it s

Nowl in g's te st im on y

. Rat he r, D a w n N o w li ng 's te st im on y se rv es as a th ird -p art y 's

ob se rv at io n of th e sym

pt om s th e ALJ ap pe ars to ha ve reje c t e d a s no n- cred ib le

s u bjec ti ve co m

pl ai nt s. See W il lc oc ks on , 5 40 F.3 d at 88 1 ("[ W ]e q ue st io n whe th e r

wit ne ss st at em en ts co rro bo rat in g a cl ai m an t's su bjec ti ve co m pl ai nt s can lo gi cal ly be

tre at ed as cu m

ul at iv e by as su m in g th at th e y w ou ld ha ve be en reject ed fo r th e sa m e

reas on s th at th e cl ai m an t st at em en ts were rejecte d, where th e ag en cy it se lf sa y s th at

be cau se su bjec ti ve co m

pl ai nt s are ha rd to d o c u ment

, it wil l 'care fu ll y co ns id er'

ev id en ce from ot he r pe rs on s add res si ng th e ex te nt of th e cl ai m an t's pa in an d ho w it

affe ct s h is or h er ab il it y

to fun ct io n." (qu ot in g 2 0 C .F.R. § 4 04 .15 29 (c)( 3) )).

Fu rth er, th e ALJ's op in io n an d th e ag en cy 's arg um en t on ap pe al ig no re en ti rel y

th e ge ne ral na tu re of so m at of or m di so rd ers

. As in Ea s t e r
, " t h e ALJ's op in io n

. . . ci te s

. . . so m at of

or m di so rd er [b ut ] do es no t ad eq ua te ly con si de r th e effe ct s of th at

-1 7-m en ta l co nd it io n." 86 7 F.2 d at 11 3 0

. Th e ALJ fo un d Nowl in g su ffer ed fro m

co nv ers io n di so rd er bu t at no po in t acco rd ed an y co ns eq ue nc e to th at f a c t o r to th e

nu an ce ou r co ur t reco gn iz ed in East er th at so m at of or m di so rd ers m ay be di sa bl in g

an d m ay res ul t in "a di st or te d pe rcep ti on of

. . . p hysic al ai l men ts ." Id . a t 11 31

. In

th is si tu at io n, an d in li gh t of th e ad di ti on al co nc ern s de ta il ed be lo w, we can no t fin d

th e fai lu re to ad dr es s Dawn Nowl in g's te st im on y ha rm le ss no r ch arac te riz e it m erel y

as an "ar gu ab le de fic ie nc y in op in io n- writ in g te ch ni qu e." Ro bi ns on
, 95 6 F.2 d at 84 1

B. Dr. Men en de z & Nan cy Mi ll er

"A tre at in g ph y si ci an 's op in io n 'sh ou ld be gr an te d co nt r ol li ng weig ht if it is

w el l-s up po rte d by m ed ic al ly acce pt ab le cl in ic al an d la bo rat or y di ag no st ic te ch ni qu es

an d i s no t in co ns is te nt wit h th e o th er s ub st an ti al ev id en ce i n t he reco rd .'" Mi ll er v

. Co lv in

, 78 4 F.3 d 47 2, 47 7 (8 th Ci r. 20 15 ) (q uo ti ng Cu nn in gh am v. Apf el

, 22 2 F.3 d

49 6, 50 2 (8 th Ci r. 20 00 )). A tre at in g p h ys ic ia n's op in io n, ho wev er, "d oe s no t

au to m at ic al ly co nt ro l or o b v ia te th e ne ed to ev al ua te th e reco rd as a who le ."

I d

. ( q uo ti ng Hog an v. Apf el

, 23 9 F.3 d 95 8, 96 1 (8 th Ci r. 20 01 )). Rat he r, "an A LJ

m ay d i s c o u n t o r ev en di sr eg ard th e op in io n of a tre at in g ph y si ci an whe re ot he r

m ed ic al as se ss m en ts are s up po rte d b y be tt er o r m or e th or ou gh m ed ic al ev id en ce or

whe re a tre at in g ph y si ci an ren de rs in co ns is te nt op in io ns th at un de rm in e th e

cred ib il it y of su ch op in io ns ." Id

. (q uo ti ng W il dm an
, 59 6 F.3 d at 96 4 (fu rth er ci ta ti on

om it te d) ).

The ALJ di sc ou nt ed Dr. Men en de z's op in io n bec au se th e GAF sc or e of 56 in

th e med i c a l so ur ce st at em en t was in co ns is te nt wit h th e ot he r ex pe rts ' op in io ns an d

wit h Dr. Men en de z's ot he r op in io ns an d s ta te m en ts . As st at ed ab ov e, su pr a at n. 3,

h o w e v e r
, G AF sc or es are of li tt le va lu e. As su ch

, it is erro r to di sr eg ard s u c h

su bs ta nt ia l lo ng it ud in al tre at m en t ba se d m erel y up on on e of se ve ral rep or te d GAF

sc or es

.

-1 8-Fu rth er, we no te th e ALJ im pr op erl y acco rd ed gr eat weig ht to st at em en ts in Dr.

Men en de z's tre at m e n t no te s in di cat in g th at Nowl in g de m on st rat ed "i m pr ov em en t"

wit ho ut ack no wled gi ng th at Nowl in g's sym pt om s wax ed an d wan ed th ro ug ho ut th e

s u bs ta nt ia l pe rio d of tre at m en t, wit ho ut ack no wled gi ng th e un pr ed ic ta bl e an d

sp or ad ic na tu re of Nowl in g's sym pt om s, an d w it ho ut as se ss in g th e effe ct of he r

st ru ct ur ed li vi ng en vi ro nm en t. See Hut se ll

, 25 9 F.3 d at 71 2 (s ta ti ng th at an ALJ m ay

ha ve "re li ed to o he av il y on in di cat io ns in th e m ed ic al reco rd th at [th e cl ai m an t] was

'do in g well ,' be cau se do in g well fo r th e pu rp os es of a tre a t men t pr og ram ha s no

ne ces sa ry rel at io n to a cl ai m an t's ab il it y to wor k or to he r wor k- rel at ed fu nc ti on al

cap aci ty"); se e al so 20 C.F.R. Pt

. 40 4

, S u b p t. P, App

. 1, § 12 00 .F ("I f y ou r

sy m pto m at olo gy is co ntro ll ed or at te nu at ed by ps y ch os oc ia l fact or s, we mus t co nside r

y ou r ab il it y to fu nc ti on ou ts id e y ou r hi gh ly st ru ct ur ed se tt in gs ." (em ph as is ad de d) ).

The ALJ's su pe rfi ci al refe ren ces to th e GAF sc or e an d Nowl in g's "i m pr ov em en t" fai l

to sa ti sf y th e reg ul at io ns ' "re qu ire [m en t] th at th e ALJ 'al way s gi ve go od reas on s' fo r

th e weig ht affo rd ed to a tre at in g ph y si ci an 's ev al ua ti on ." Ree d v. Barn ha rt, 39 9 F.3 d

91 7, 92 1 (8t h C ir. 2 00 5) (qu ot in g 2 0 C .F.R. § 4 04 .15 27 (d )(2 )). Here t ho se reas on s

m us t be art ic ul at ed wit h ack n o w l e d g men t of th e na tu re of th e di so rd er at is su e an d

wit h c on si de rat io n g iv en to Dawn No wli ng 's c or ro bo rat in g t es ti m on y

.

Fi na ll y , Nowl in g arg ue s th e ALJ fai le d to co n s i d e r th e ex te ns iv e tre at m en t

reco rd s fro m Nan cy Mi ll er. Nan cy Mi ll er
, th e li cen se d cl in ic al so ci al

wor ke r/t he r a p i st who tre at ed Nowl in g ov er th e co ur se of 38 vi si ts an d who

co ns is te nt ly rat ed Nowl in g's im pa irments as se ve re
, i s n o t an "ac cep ta bl e m ed ic al

so ur ce," 20 C.F.R. § 40 4.1 51 3( a), bu t is an "o th er m ed ic al so ur ce," id

. § 40 4.1 51 3( d)

, who se op in io n t he ALJ is to co ns id er when as se ss in g th e se ve rit y of an im pa irment

an d ho w it affe ct s th e ab il it y to wor k. S e e id

. § 41 6.9 13

. Gen eral ly, "[i ]n

de te rm in in g wha t weig ht to gi ve 'ot he r m ed ic al ev id en ce,' t h e A LJ h as m or e

di sc ret io n an d is pe rm it te d to co ns id er an y in co ns is te nc ie s fo un d wit hi n th e reco rd ."

Ran ey
, 39 6 F.3 d at 1 0 1 0 (q uo ti ng 20 C.F.R. § 41 6.9 27 (d )(4 )). The ag en cy it se lf,

ho wev er, ha s in st ru ct ed th at t h e o p in io n of an "o th er m ed ic al so ur ce" ge ne ral ly

-1 9-sh ou ld be co ns id ered pu rs ua nt to se ve ral pe rti ne nt fact or s, in cl u d i n g t h e le ng th of

tre at m en t. See So ci al Secu rit y Ru li ng (SSR ) 06 –3 p, 71 Fed

. Reg

. 45 ,59 3, 20 06 W L

23 29 93 9, at *6 (Au g. 9, 20 06 ); 20 C.F.R. Pt

. 40 4, Su bp t. P, App

. 1 §1 20 0.C

. ("Ot he r 9

pr of es si on al he al th care pr ov id ers

. . . c a n no rm al ly pr ov id e va lu ab le fu nc ti on al

in fo rm at io n, whi ch sh ou ld be ob ta in ed whe n av ai la bl e an d ne ed ed ."). In li gh t of th e

ex te ns iv e tre at m en t hi st or y be twee n Nan cy Mi ll er an d Nowl in g, an d th e co ns is te nc y

be twee n Nan cy Mi ll er an d Dr. Men en de z's tre at m en t reco rd s, it was erro r to di sr eg ard

Nan cy Mi ll er's te st im on y ba se d so le ly on th e refe ren ce to GAF sc or es

. See su pr a n.

3 & 6.

III. Co nc lu si on

Fo r th e reas on s st at ed

, we rem an d wit h in st ru ct io ns to th e di st ric t co ur t to

rem an d t hi s ca se to th e ag en cy for fur th er co ns id erat io n.

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __

The So ci al Secu rit y

Ru li ng st at es : 9

Alt ho ug h th ere is a di st in ct io n be twee n wha t an ad jud ic at or m

us t

co ns id er an d wha t th e ad jud ic at or m

u s t e x pl ai n in th e di sa bi li ty

de te rm in at io n or de ci si on
, th e ad jud ic at or ge ne ral ly sh ou ld ex pl ai n th e weig ht gi ve n to op in io ns fro m th es e "o th er so ur ces ," or ot he rwis e en su re
th at th e di sc us si on of th e ev id en ce i n t h e de te rm in at io n or de ci si on al lo ws a cl ai m an t or su bs eq ue nt rev i e w e r t o fo ll ow th e ad jud ic at or 's

reas on in g, whe n su ch op in io ns m ay ha ve an effe ct on th e ou tc om e of th e

cas e.

SSR 0 6- 03 P7 1, 2 00 6 WL 23 29 93 9, at *6

.

-2 0-