Court Opinion

ID: 4736678
Source: CourtListenerOpinion
Date Created: 2021-08-12 17:01:06.836438+00
Date Added: 2024-06-11T08:08:18.827012
License: Public Domain

USCA11 Case: 19-14682   Date Filed: 08/12/2021   Page: 1 of 33

                                                                 [PUBLISH]

            IN THE UNITED STATES COURT OF APPEALS

                    FOR THE ELEVENTH CIRCUIT
                      ________________________

                            No. 19-14682
                      ________________________

                   D.C. Docket No. 1:18-cv-24013-UU

ARTURO O. SIMON,

                                                          Plaintiff-Appellant,

                                  versus

COMMISSIONER, SOCIAL SECURITY ADMINISTRATION,

                                                         Defendant-Appellee.

                      ________________________

               Appeal from the United States District Court
                   for the Southern District of Florida
                     ________________________

                            (August 12, 2021)

                   ON PETITION FOR REHEARING

Before LAGOA, ANDERSON, and MARCUS, Circuit Judges.
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ANDERSON, Circuit Judge:

      The Petition for Panel Rehearing filed by the Commissioner, Social Security

Administration, is GRANTED. The opinion previously issued as 1 F.4th 908 (11th

Cir. 2021), is withdrawn and the following opinion is issued in its stead.

      This appeal requires us to decide whether the Social Security Administration

(“SSA”) properly evaluated the evidence supporting Arturo Simon’s claim for

disability benefits under Title II of the Social Security Act. In his application,

Simon stated that he was no longer able to work due to various psychiatric

conditions, which included chronic depression, anxiety, and bipolar disorder.

Simon received a hearing before an administrative law judge (“ALJ”), who

ultimately found that he was not disabled and denied his claim for benefits.

      In reaching that decision, the ALJ gave little or no weight to three pieces of

evidence in the record indicating that Simon’s mental illness prevents him from

maintaining a job: (1) the opinions of Simon’s treating psychiatrist, (2) the

opinions of a consulting psychologist who examined Simon at the request of the

SSA, and (3) Simon’s own testimony as to the severity of his symptoms. Because

we conclude that the ALJ did not articulate adequate reasons for discounting this

evidence, which provided support for a finding of disability, we will remand to the

agency for further proceedings.

                                I.     BACKGROUND

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      Simon filed his current application for disability benefits in March of 2015,

claiming to be disabled due to his deteriorating mental health. He previously had

filed another such application in May of 2014, which was denied later that year.

This appeal relates solely to Simon’s 2015 application.

      The SSA denied Simon’s application after an initial review, at which point

Simon requested and received a formal hearing before an ALJ, which took place

on July 24, 2017. Below, we begin with a description of the medical evidence and

testimony that was submitted to the ALJ, before moving on to discuss the ALJ’s

disability decision, and finally to discuss our reasons for concluding that a remand

is required.

      A. Summary of the SSA Record

               1. Dr. Turner’s Opinions

      Dr. Rosa Turner was Simon’s treating psychiatrist from 2013 to 2017.

During that period, she met with him approximately thirty-two times and kept

regular notes on his mental condition. Thus, Dr. Turner’s treatment notes offered

an extensive and detailed account of Simon’s psychiatric history.

      At his initial evaluation with Dr. Turner in May of 2013, Simon reported

symptoms of insecurity, losing sight of reality, physical and mental exhaustion,

poor self-esteem, lack of sex drive, road rage, poor memory, loss of focus and

concentration, severe mood swings, and instances of obsessive-compulsive

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behavior. Simon stated that he had been experiencing these problems as long as he

could remember, even in childhood, and he had been taking mental-health

medication for around twenty years. Dr. Turner recorded in her notes that Simon

displayed slowed activity, depression, anxiety, irritability, decreased motivation,

low energy, auditory hallucinations, and suicidal ideation. She also wrote that his

short-term memory, concentration, and attention span were impaired. Dr. Turner

ultimately diagnosed Simon with bipolar disorder, described him as having severe

psychosocial or environmental problems, and started him on a course of

psychiatric treatment with medication.

      Some entries in Dr. Turner’s notes suggested that, at times, this treatment

helped Simon to a degree. In December of 2013, for example, Dr. Turner recorded

that Simon was “very stable” and had improved. Her notes made similar

references to Simon being “stable on medication” in June of 2014, July of 2014,

November of 2014, April of 2015, and June of 2016. In nearly all of these

instances, however, Dr. Turner also wrote that Simon continued to suffer from

significant symptoms of mental illness—such as panic attacks, racing thoughts,

and episodes of anger. Indeed, several of the notations in which Dr. Turner

described Simon as “stable on his medication” went on to say that he was “not

coping well.”

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      On many other occasions, meanwhile, Dr. Turner indicated that Simon’s

overall condition was quite serious, and that it was worsening rather than

improving. In September of 2014, Dr. Turner wrote that Simon was extremely

depressed, having difficulty concentrating, suffering from panic attacks, and

refusing to leave his house out of fear. In January of 2015, she wrote that Simon

was paranoid to the point that he would not go out unless absolutely necessary, and

that he was unable to function, maintain his train of thought, or process

information. In July of 2015, she wrote that Simon was experiencing anger spells

and mood swings, to the point that his wife was growing worried because he would

“change personalities very easily” and sometimes would lose touch with reality. In

August of 2015, she wrote that Simon displayed slowed speech and motor skills,

that he could not focus or concentrate, and that he was isolating himself from

others.

      Dr. Turner continued to describe these types of symptoms throughout her

four years of treating Simon. In September, October, and December of 2015, she

recorded that Simon was depressed, paranoid, and refused to see others. In

February and March of 2016, she wrote that Simon’s symptoms remained serious,

that he was unable to concentrate, that he would not talk, and that he could not

control his racing thoughts. In August of 2016, she wrote that Simon was

depressed, severely anxious, and could not concentrate or maintain his train of

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thought. In March and April of 2017, she wrote that Simon was unable to

concentrate and suffered from slowed motor skills. In July of 2017, she recorded

that Simon had isolated himself completely from others.

       As early as October of 2014, Dr. Turner opined that Simon’s psychological

impairments rendered him entirely unable to work or handle any type of stress.

She described him at that time as being in a “complete state of depression” with

racing thoughts, frequent panic attacks, and paranoia. Her treatment notes

reiterated that conclusion in March and May of 2015, both times stating that Simon

was unable to work in any role because of his inability to focus or process

information.

       In July of 2017, Dr. Turner submitted a “mental capacities evaluation” to the

SSA in connection with Simon’s disability claim. In her evaluation, she again

diagnosed Simon as suffering from bipolar disorder, mixed with severe anxiety and

panic attacks. She opined that Simon had “extreme” limitations 1 in his abilities to:

    • understand, remember, or apply information;

    • interact with others;

    • concentrate, persist, or maintain pace; and

1
        The SSA considers a claimant to have an “extreme” limitation in an area of mental
functioning if he or she is “not able to function in [that] area independently, appropriately,
effectively, and on a sustained basis.” 20 C.F.R. § 404, Subpart P, Appendix I.

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    • adapt or manage himself.

She also opined that Simon had “marked” limitations 2 in numerous other areas,

including:

    • his ability to perform simple tasks on a full-time basis;

    • his ability to perform work requiring regular contact with others; and

    • his ability to respond appropriately to the stress of customary work
      pressures.

According to Dr. Turner’s assessment, Simon “has been in a critical state of mind

for several years now,” and his condition “will only get worse” with time. She

wrote that Simon “is stable at present time—but we must maintain him this way to

avoid severe decompensation.”

       Viewed as a whole, Dr. Turner’s comprehensive clinical records portray

Simon as a person living with a severe combination of bipolar disorder, depression,

and anxiety that significantly impairs his mental and social functioning.

               2. Dr. Marban’s Opinions

       During its evaluation of Simon’s 2014 claim for disability benefits, the SSA

arranged for Simon to meet with Dr. Elsa Marban for a consultive mental

examination. Dr. Marban recorded that Simon drove himself to the exam and

2
       The SSA considers a claimant to have a “marked” limitation in an area of mental
functioning if his or her “functioning in [that] area independently, appropriately, effectively, and
on a sustained basis is seriously limited.” 20 C.F.R. § 404, Subpart P, Appendix I.
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arrived half an hour early. She described Simon as cooperative, coherent, and

loquacious, though he had to be redirected often. She also noted that Simon was

appropriately groomed and displayed normal “psychomotor activity.”

      Simon reported to Dr. Marban that he had been suffering from—among

other things—low energy, panic attacks, an inability to control his aggression,

mood swings, racing thoughts, and difficulty concentrating. He explained that he

began experiencing concentration problems at his previous job and would give

unrelated responses when his supervisor asked him questions. Simon also

informed Dr. Marban that he had resigned from another job several years before,

following an angry outburst in which he threatened to push his supervisor through

a balcony.

      Dr. Marban recorded that Simon was alert during their examination and

oriented to place, time, and situation. She rated his remote memory as “good,” his

immediate memory as “fair,” and his recent memory as “poor.” She rated his

abstract-reasoning capabilities as “good” because he could interpret basic proverbs

and describe how two things were similar. She also wrote that he had a good fund

of information, such as being able to identify the direction in which the sun rises,

the number of weeks in a year, the capital of Italy, and the continental location of

Brazil. She stated that he displayed good judgment and fair insight into his

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psychological issues—such as recognizing that, to improve his condition, he

needed to be on the right medication.

      Dr. Marban diagnosed Simon with Persistent Depressive Disorder,

Generalized Anxiety Disorder, Panic Disorder, and Intermittent Explosive

Disorder. She recorded that Simon could handle his own finances as well as

groom himself and bathe on his own, though there were days that he chose not to

bathe because he lacked motivation. She noted that his socialization was limited to

occasionally meeting friends for dinner. Regarding his ability to work, Dr. Marban

concluded that Simon would have difficulties concentrating, completing tasks,

accepting instructions, and responding to criticism from supervisors.

            3. Other Agency Consultants

      In addition to Dr. Marban, a number of other medical professionals also

evaluated Simon on behalf of the SSA. Shortly before his psychiatric evaluation

by Dr. Marban in 2014, Simon also met with Dr. Miesha Merati for a physical

examination. At that time, he reported suffering from depression, short-term

memory loss, and panic attacks. He also reported attempting to hang himself

several months before and having thoughts of harming others, particularly while

driving. He stated that he was able to dress himself and shop on his own, though

he did not do household chores.

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      In the “Mental Status” section of her evaluation form, Dr. Merati recorded

that Simon had a normal affect, coherent conversation, no hallucinations or

delusions, no overtly suicidal or homicidal ideation, a “grossly intact” memory,

and normal cognitive functioning. By her assessment, Simon’s cognitive and

executive functions “appear[ed] to be commensurate with [his] age, socioeconomic

status, and claimed education.” She noted that his chronic pain and depression

limited his daily activities, but she did not list the specific areas in which he was

limited or elaborate on the extent of his limitations. Dr. Merati did not express an

opinion on Simon’s capacity to work.

      Dr. George Grubbs and Dr. Anne-Marie Bercik both reviewed some of

Simon’s medical records, but did not personally examine Simon themselves.

Dr. Grubbs’ report determined that Simon had no restrictions in his daily activities,

and only mild difficulties in social function, concentration, persistence, and pace.

Dr. Grubbs also opined that, while Simon’s psychological impairments could be

reasonably expected to produce the types of symptoms that Simon had reported,

Simon’s medical records as a whole did not indicate that his symptoms were as

severe as claimed. Dr. Bercik issued a second report several months later, in which

she agreed with Dr. Grubbs’ conclusions.

             4. Simon’s Hearing Testimony

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      At his hearing before the ALJ, Simon testified that he was sixty-two years

old, lived with his wife, had two years of college education, and previously had

worked in sales.

      Simon testified that he had stopped working in March of 2014 because of his

depression and inability to concentrate. Specifically, he explained that his inability

to focus and his memory problems kept him from completing tasks, and that his

depression caused him to isolate himself. As an example, he stated that when his

wife asked him to go to the grocery store nearby and pick up two or three items, he

would forget them before reaching the store. He testified that he had attempted

suicide and no longer cared whether he was alive or dead. He testified that he no

longer got along with his wife and did not socialize with anyone.

      Simon went on to report having mood swings nearly every day, as well as

uncontrollable spikes of aggression. He testified that his wife handled the finances

because he would forget to pay bills on time, and that she gave him his

medications. He testified that he would not leave the house except for a handful of

locations, such as the grocery store, because he felt safer at home. He testified that

his medication helped “a little,” but did not make him feel less depressed or

anxious, and he was unsure whether medication actually made his mood swings

less frequent.

             5. The Vocational Expert’s Hearing Testimony

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      Once Simon had testified, the ALJ posed a series of questions to a

vocational expert (“VE”) regarding Simon’s capacity to work.

      First, the ALJ asked the VE to assume a hypothetical person with Simon’s

medical, educational, and vocational profile who could work at all levels of

physical exertion, but was limited to simple tasks, simple decision-making, and

only occasionally interacting with others. The VE testified that those limitations

would prevent someone from performing Simon’s past work—but such a person

still could perform light, unskilled work, such as floor waxer, bartender helper, or

cook helper.

      Next, the ALJ asked the VE to assume a hypothetical person with the same

profile as before, but who was limited to only medium levels of exertion. The VE

testified that such a person could perform the same jobs listed above.

      Finally, the ALJ asked the VE to assume a hypothetical person who suffered

from extreme limitations in interacting with others, concentrating, understanding,

remembering, or applying information. The ALJ confirmed that this hypothetical

was based on Dr. Turner’s mental capacities evaluation. The VE testified that such

a person could not perform any work in the national economy.

      B. The ALJ’s Decision

      After reviewing all of the evidence and testimony described above, the ALJ

denied Simon’s claim for disability benefits in a written decision. Consistent with

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SSA guidelines, the ALJ followed a five-step analysis to determine whether Simon

was “disabled” within the meaning of the Social Security Act.

      At step one, the ALJ must determine whether the claimant is currently

engaging in “substantial gainful activity.” 20 C.F.R. § 404.1520(a)(4)(i). Activity

is “substantial” if it involves “doing significant physical or mental activities,” and

it is “gainful” if it is “usually done for pay or profit.” Id. § 404.1572(a)-(b). Here,

the ALJ found that Simon had not been engaged in “substantial gainful activity”

since he stopped working in March of 2014.

      At step two, the ALJ must determine whether the claimant suffers from a

medically determinable impairment (or a combination of such impairments) that is

“severe.” Id. § 404.1520(a)(4)(ii). The SSA classifies an impairment as “severe”

if it “significantly limits” an individual’s ability to perform “basic work activities.”

Id. § 404.1520(c). Here, the ALJ found that Simon’s anxiety and depression

qualified as severe.

      At step three, the ALJ must determine whether the claimant’s impairment

(or combination of impairments) “meets or equals” the severity of an impairment

listed in 20 C.F.R. § 404, Subpart P, Appendix I. Id. § 404.1520(a)(4)(iii). If a

claimant’s impairments reach that level of severity, then he or she automatically

qualifies as “disabled” under SSA regulations. Id. If they do not, then the ALJ

must move on to step four. Here, the ALJ found that Simon’s psychological

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impairments did not meet or equal the severity of an impairment listed in SSA

regulations and therefore proceeded to step four.

       At step four, the ALJ must determine whether a claimant possesses the

“residual functional capacity” to perform the job requirements of his or her past

work. Id. § 404.1520(a)(4)(iv). SSA guidelines define the term “residual

functional capacity” to mean “the most [a person] can still do despite [his or her]

limitations.” Id. § 404.1545(a)(1). Here, the ALJ found that Simon lacked the

residual functional capacity to perform his past work in sales.

       At step five, the ALJ must determine whether a claimant can still adjust to

any other type of work that exists in substantial numbers in the national economy,

given his or her residual functional capacity, age, education, and work experience.

Id. §§ 404.1520(a)(4)(v), 404.1560(c)(1). Here, the ALJ found that Simon retained

the residual functional capacity to perform “medium work,”3 provided that his job

role was “limited to performing simple routine tasks, making simple work[-]related

decision[s], and [only] occasionally interacting with co-workers, supervisors, and

the public.” Accordingly, the ALJ concluded that Simon was not disabled.

3
        The SSA defines “medium work” as work that requires “lifting no more than 50 pounds
at a time with frequent lifting or carrying of objects weighing up to 25 pounds.” 20 C.F.R.
§ 404.1567(c).

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      In reaching that determination, the ALJ gave “little weight” to Dr. Turner’s

opinions, on the grounds that they were “inconsistent with the longitudinal

history.” The ALJ then went on to list several portions of the administrative record

that he found to be inconsistent with Dr. Turner’s opinions, including Simon’s own

testimony that he could dress himself, feed himself, and go shopping, and

including several observations made by Dr. Marban and Dr. Merati during their

consultive examinations of Simon. The ALJ relied on notations by Dr. Marban

and Dr. Merati like the following:

    • that his communication, cooperation, participation, and eye contact were
      satisfactory;

    • that his cognitive functions, abstract reasoning, and executive functions
      appeared commensurate with his age, socioeconomic status, and education;

    • that he exhibited a good fund of information;

    • that his ability to solve basic mathematical computations was fair; and

    • that he demonstrated fair insight and good judgment.

Based on such observations by the SSA’s consulting physicians, the ALJ rejected

Dr. Turner’s opinion that Simon was unable to handle work-related stress.

      The ALJ also gave “little weight” to Dr. Marban’s opinions that Simon

likely would have trouble with concentration in the workplace, task persistence,

and responding appropriately to supervisors. In the ALJ’s view, these conclusions

were “inconsistent with the doctor’s own clinical findings,” as well as “other

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clinical findings . . . showing the claimant is capable of performing unskilled

work.” The ALJ’s decision did not state which of Dr. Marban’s findings,

specifically, contradicted her overall conclusions. In the preceding paragraph,

however, the ALJ had summarized Dr. Marban’s evaluation notes and in doing so

emphasized the following observations that she made about Simon:

   • that his thought processes were goal oriented with no signs of psychosis;

   • that he was alert and oriented to person, time, place, and situation;

   • that his remote memory was good, his recent memory was poor, and his
     immediate memory was fair;

   • that he exhibited a good fund of information, such as being able to identify
     the direction that the sun rises, the number of weeks in a year, the capital of
     Italy, and the continental location of Brazil;

   • that he demonstrated good calculation abilities when tested with serial
     sevens;

   • that his abstract reasoning was good;

   • that he demonstrated good judgment and insight into his psychological
     deficits; and

   • that he demonstrated sufficient concentration and attention to follow two-
     step instructions.

As for the “other clinical findings” in the record that purportedly were inconsistent

with Dr. Marban’s opinions, the ALJ never clarified what those findings were or

why they were at odds with Dr. Marban’s ultimate assessment.

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      With respect to Simon’s hearing testimony, the ALJ stated that “the

claimant’s statements concerning the intensity, persistence, and limiting effects of

[his] symptoms are not entirely consistent with the medical evidence and other

evidence in the record for the reasons explained in this decision.” But here also,

the ALJ’s decision never specified which evidence was inconsistent with Simon’s

description of his symptoms, nor did it explain the inconsistency.

      Simon appealed the ALJ’s decision to the Appeals Council of the SSA,

which denied his request for review.

      C. Proceedings in the District Court

      Simon promptly sought judicial review of the SSA’s adverse decision in the

United States District Court for the Southern District of Florida. He contended that

the ALJ’s reasons for denying his disability claim were not supported by

substantial evidence, nor were they adequately explained. Simon’s case was

referred to a magistrate judge, who recommended affirming the agency’s decision.

The District Court agreed and awarded judgment to the SSA.

      Simon timely appealed.

                          II.    STANDARD OF REVIEW

      When the Appeals Council of the SSA declines to review an ALJ’s decision

to deny disability benefits, as occurred here, we review that ALJ’s decision as the

final decision of the SSA’s Commissioner. Doughty v. Apfel, 245 F.3d 1274,

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1278 (11th Cir. 2001). We review de novo the legal principles on which the ALJ’s

decision was based. Moore v. Barnhart, 405 F.3d 1208, 1211 (11th Cir. 2005).

But we review the ALJ’s factual findings—including the disability determination

itself—only to ensure that they are supported by “substantial evidence.” Henry v.

Comm’r of Soc. Sec., 802 F.3d 1264, 1266-67 (11th Cir. 2015).

      In the Social Security context, “substantial evidence” means “such relevant

evidence as a reasonable person would accept as adequate to support a

conclusion.” Moore, 405 F.3d at 1211. Substantial evidence is “less than a

preponderance,” and thus we must affirm an ALJ’s decision even in cases where a

greater portion of the record seems to weigh against it. Id.; see also Crawford v.

Comm’r of Soc. Sec., 363 F.3d 1155, 1158–59 (11th Cir. 2004) (“Even if the

evidence preponderates against the Commissioner’s findings, we must affirm if the

decision reached is supported by substantial evidence.”). Substantial-evidence

review does not permit us to “decide the facts anew, reweigh the evidence, or

substitute our judgment for that of the [Commissioner].” Phillips v. Barnhart, 357

F.3d 1232, 1240 n.8 (11th Cir. 2004) (alteration in original) (quoting Bloodsworth

v. Heckler, 703 F.2d 1233, 1239 (11th Cir. 1983)).

      Within this narrowly limited role, however, the federal courts “do not act as

automatons.” MacGregor v. Bowen, 786 F.2d 1050, 1053 (11th Cir. 1986). We

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retain an important duty to “scrutinize the record as a whole” and determine

whether the agency’s decision was reasonable. Id.

                                III. DISCUSSION

      The Social Security Act provides various types of insurance benefits to

individuals who cannot find work because of a disability. See 42 U.S.C. § 423(a).

The Act defines the term “disability” to mean “[an] inability to engage in any

substantial gainful activity by reason of any medically determinable physical or

mental impairment which can be expected to result in death or which has lasted or

can be expected to last for a continuous period of not less than 12 months.” Id.

§ 423(d)(1)(A).

      As described above, the SSA uses a five-step process to decide whether a

benefits claimant is disabled. See 20 C.F.R. § 404.1520. We are concerned here

with the final step, where an ALJ must determine whether the claimant can—

despite any physical or mental impairments—obtain and perform any type of work

that exists in substantial numbers in the national economy. Id.

§§ 404.1520(a)(4)(v), 404.1560(c)(1).

      When making this assessment, the ALJ must give special attention to the

opinions of a claimant’s treating physician. Indeed, SSA regulations in force at the

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time Simon filed his application required an ALJ to give “controlling weight” to a

treating physician’s opinions if they were “well-supported by medically acceptable

clinical and laboratory diagnostic techniques” and “not inconsistent with the other

substantial evidence in [the] case record.” 20 C.F.R. § 404.1527(c)(2).4 And our

own case law is clear that a treating physician’s conclusions must be given

“substantial or considerable weight” unless there is “good cause” to discount them.

Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997). “Good cause” exists

where “(1) [the] treating physician’s opinion was not bolstered by the evidence; (2)

evidence supported a contrary finding; or (3) [the] treating physician’s opinion was

conclusory or inconsistent with the doctor’s own medical records.” Phillips, 357

F.3d at 1241.

       While an ALJ may choose to reject a treating physician’s findings when

there is good cause, “he ‘must clearly articulate [the] reasons’ for doing so.”

Winschel v. Comm’r of Soc. Sec., 631 F.3d 1176, 1179 (11th Cir. 2011) (alteration

in original) (quoting Phillips, 357 F.3d at 1240–41). If the ALJ fails to state

reasonable grounds for discounting such evidence, we will not affirm “simply

4
         The regulation quoted above only applies to disability claims that were filed before
March 27, 2017. Claims filed after that date are governed by a new regulation prescribing a
somewhat different framework for evaluating medical opinions. See 20 C.F.R. § 404.1520c.
Because Simon filed his claim in March of 2015, we need not and do not consider how the new
regulation bears upon our precedents requiring an ALJ to give substantial or considerable weight
to a treating physician’s opinions absent good cause to do otherwise.

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because some rationale might have supported the ALJ’s conclusion.” Id. (quoting

Owens v. Heckler, 748 F.2d 1511, 1516 (11th Cir. 1984)). It is the responsibility

of the agency, not the reviewing court, to supply the justification for its decision

and to sufficiently explain “the weight [it] has given to obviously probative

exhibits.” Cowart v. Schweiker, 662 F.2d 731, 735 (11th Cir. 1981) (quoting

Stawls v. Califano, 596 F.2d 1209, 1213 (4th Cir. 1979)).

      Simon’s primary argument on appeal is that the ALJ failed to state good

cause to discount the opinions of his treating psychiatrist, Dr. Turner. We agree,

and that error alone is enough to require that we remand. See Lewis, 125 F.3d at

1440 (“The ALJ must clearly articulate the reasons for giving less weight to the

opinion of a treating physician, and the failure to do so is reversible error.”). We

therefore address that issue first.

      A. The ALJ’s Rejection of Dr. Turner’s Opinions

      As described in more detail above, Dr. Turner’s treatment notes were

extensive, spanning more than thirty meetings with Simon across four years.

Throughout that considerable length of time, Dr. Turner regularly wrote that Simon

was displaying severe symptoms of mental illness, such as frequent panic attacks,

uncontrollable racing thoughts, volatile mood swings, paranoia about leaving his

home, and self-isolation from friends and family. On the whole, Dr. Turner’s

records indicate that Simon suffers from very serious psychiatric disorders, ones

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that she concluded would significantly impair his ability to function under stress,

maintain focus, or interact appropriately with others in a work setting.

       The ALJ ultimately chose to give little weight to Dr. Turner’s opinions, on

the grounds that they were inconsistent with: (1) Simon’s “longitudinal history,”

(2) certain observations made by the SSA consultants who examined Simon, and

(3) Simon’s testimony that he was able to carry out certain daily tasks such as

grooming himself and grocery shopping. In our view, however, the ALJ’s decision

did not adequately explain how any of these pieces of evidence were inconsistent

with Dr. Turner’s opinions or otherwise constituted good cause to disregard her

conclusions.

       As an initial point, it is not immediately clear to us what the ALJ meant

when referring to Simon’s “longitudinal history.” SSA guidelines do not

specifically define that term. Instead, the agency simply advises claimants that it

“will request longitudinal evidence of your mental disorder when your medical

providers have records concerning you and your mental disorder over a period of

months or perhaps years.” 20 C.F.R. § 404, Subpart P, Appendix I (emphasis

added). This suggests that, in Simon’s case, the ALJ’s reference to the

“longitudinal history” was intended to refer to Dr. Turner’s treatment notes,5 and

5
       Dr. Turner was the only physician who kept records of Simon’s mental disorders over an
extended period of time.
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the parties both seem to agree. We therefore read the ALJ’s decision as concluding

that Dr. Turner’s opinions as to the severity of Simon’s impairments were

inconsistent with her own treatment notes.

      However, after scrutinizing Dr. Turner’s treatment notes and examining the

ALJ’s reasons for finding them inconsistent with her overall opinions, we find no

obvious inconsistency. To the contrary, Dr. Turner’s records stated time and again

that Simon was experiencing intense symptoms from his conditions. Yet any

mention of Simon’s most serious symptoms is conspicuously missing from the

ALJ’s decision, which summarized Dr. Turner’s findings as follows:

   [T]he claimant received treatment from Rosa Fernandez Turner, M.D. []
   He has reported feeling anxious and depressed, and having difficulty
   concentrating. His symptoms included anhedonia, decreased energy,
   decreased motivation, decreased sleep, and feelings of hopelessness and
   helplessness. On June 12, 2014, July 14, 2014, November 13, 2014,
   April 27, 2015, and June 20, 2016, it was noted that the claimant was
   doing well on his medications and did not report any side effects [].

Nowhere in this paragraph, which was the only part of the decision that discussed

Dr. Turner’s treatment notes at all, did the ALJ address Simon’s panic attacks,

racing thoughts, mood swings, outbursts of anger, memory problems, paranoia, or

his shutting himself off from others. Instead, the ALJ only listed Simon’s

relatively minor symptoms, while at the same time emphasizing the sections of

Dr. Turner’s notes that described Simon as stable on his medications. This

complete failure to engage with significant portions of Dr. Turner’s clinical

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findings, which verges on a blatant mischaracterization of Simon’s medical

records, was error.

      It was also error to conclude that Dr. Turner’s occasional references to

Simon being “stable on medication” were inconsistent with a finding of

debilitating mental illness. Many mental disorders—and bipolar disorder in

particular—are characterized by the unpredictable fluctuation of their symptoms,

and thus it is not surprising that even a highly unstable patient will have good days

or possibly good months. See Scott v. Astrue, 647 F.3d 734, 740 (7th Cir. 2011)

(“The very nature of bipolar disorder is that people with the disease experience

fluctuations in their symptoms, so any single notation that a patient is feeling better

or has had a ‘good day’ does not imply that the condition has been treated.”).

Indeed, in another case also involving a claimant diagnosed with bipolar disorder,

we explicitly “agree[d] with our sister [c]ircuits that people with chronic diseases

can experience good and bad days.” Schink v. Comm’r of Soc. Sec., 935 F.3d

1245, 1267 (11th Cir. 2019). For those who suffer from such disorders, “a

snapshot of any single moment says little about [a person’s] overall condition,” and

an ALJ who relies on such snapshots to discredit the remainder of a psychiatrist’s

findings demonstrates a “fundamental, but regrettably all-too-common,

misunderstanding of mental illness.” Punzio v. Astrue, 630 F.3d 704, 710 (7th Cir.

2011). Accordingly, this Court has held that it was improper for an ALJ to dismiss

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          USCA11 Case: 19-14682          Date Filed: 08/12/2021       Page: 25 of 33

a psychiatrist’s treatment notes as “indicat[ing] only mild limitations . . . at best”

simply because “some of [the claimant’s] mental-status examinations were better

than others.” Schink, 935 F.3d at 1262.

       As noted above, the opinion evidence of Dr. Turner diagnoses Simon with a

severe combination of bipolar disorder, depression, and anxiety, accompanied by

symptoms considerably more serious than those acknowledged by the ALJ. These

conditions, in Dr. Turner’s opinion, imposed significant limitations on Simon’s

mental and social functioning. We conclude that isolated entries in Dr. Turner’s

treatment notes indicating that Simon was at times stable on his meds, without

more, cannot constitute or contribute to good cause to reject Dr. Turner’s

opinions.6

       We now turn to the ALJ’s second basis for discounting Dr. Turner’s

opinions—the ALJ’s belief that several observations made by the SSA’s consulting

doctors were inconsistent with Dr. Turner’s assessment of Simon’s condition. The

ALJ relied on the following notations by Dr. Marban and Dr. Merati:

    • that Simon displayed satisfactory communication, cooperation, participation,
      and eye contact;

    • that Simon had a “grossly intact” memory;

    • that Simon exhibited good calculation abilities when tested with serial
      sevens;

6
        Moreover, as noted above, most of these entries were accompanied by a clarification that
significant symptoms continued.
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   • that Simon had good cognitive function, executive function, thought
     processes, and abstract reasoning;

   • that Simon had a good fund of information; and

   • that Simon displayed fair insight and good judgment.

The ALJ found that these observations were inconsistent with Dr. Turner’s

findings and warranted giving her opinions “little weight.” We disagree.

      Before an ALJ may reject a treating physician’s opinions as inconsistent

with other medical findings in the record, he or she must identify a “genuine”

inconsistency. Id. (citing Lewis, 125 F.3d at 1440). “It is not enough merely to

point to positive or neutral observations that create, at most, a trivial and indirect

tension with the treating physician’s opinion by proving no more than that the

claimant’s impairments are not all-encompassing.” Id. at 1263. Consequently,

when a claimant has been diagnosed with the types of mental and emotional

disorders at issue here, highly generalized statements that the claimant was

“cooperative” during examination, that he exhibited “organized speech” and

“relevant thought content,” or that he showed “fair insight” and “intact cognition,”

ordinarily will not be an adequate basis to reject a treating physician’s opinions.

Id. at 1262. Nor is it enough to say that the claimant is “intelligent enough to

understand and follow orders and to solve problems,” such as serial sevens,

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         USCA11 Case: 19-14682       Date Filed: 08/12/2021   Page: 27 of 33

because “highly intelligent and able people do fall prey to crippling depression.”

MacGregor, 786 F.2d at 1053–54.

      Furthermore, when evaluating a claimant’s medical records, an ALJ must

take into account the fundamental differences between the relaxed, controlled

setting of a medical clinic and the more stressful environment of a workplace. As

the Third Circuit has observed, “[f]or a person . . . who suffers from an affective or

personality disorder marked by anxiety, the work environment is completely

different from home or a mental health clinic.” Morales v. Apfel, 225 F.3d 310,

319 (3d Cir. 2000). Thus, “it is not inconsistent—or even that unlikely—that a

patient with a highly disruptive mood disorder, in a structured one-on-one

conversation with a mental-health professional, might be capable of ‘be[ing]

redirected’ from his ‘tangential’ thought processes so as to ‘remain on topic.’”

Schink, 935 F.3d at 1263 (alteration in original); see also Castro v. Acting Comm’r

of Soc. Sec., 783 F. App’x 948, 956 (11th Cir. 2019) (“Without more, we cannot

say that [the treating physician’s] observations of Castro’s judgment, insight,

thought process, and thought content in a treatment environment absent work

stressors were inconsistent with his assessments about the limitations she would

face in a day-to-day work environment.”).

      In this case, we cannot discern—and the ALJ did not attempt to explain—

how any of Dr. Marban’s or Dr. Merati’s findings are genuinely inconsistent with

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          USCA11 Case: 19-14682           Date Filed: 08/12/2021       Page: 28 of 33

Dr. Turner’s opinions. For example, Simon’s ability to solve basic math problems

says little to nothing about his ability to perform simple tasks on a full-time basis,

his ability to respond appropriately to the stress of customary work pressures, his

ability to interact with others in the workplace, or his ability to concentrate, persist,

and maintain pace. Similarly, the fact that Simon can communicate, maintain eye

contact, and follow simple instructions during a mental-health evaluation does not

have any obvious bearing on his mood swings, his panic attacks, his outbursts of

anger, or his fear of leaving his home. And while Dr. Merati did describe Simon’s

memory as “grossly intact,” Dr. Marban’s more detailed evaluation rated his

“recent memory” as “poor,” which is consistent with a conclusion that Simon

would have difficulties remembering work-related instructions.7 We therefore

conclude that capabilities like the foregoing observed during consultive

examinations, without more, did not constitute or contribute to good cause to reject

Dr. Turner’s opinions.

7
         We also note that Dr. Merati is not a mental-health professional, which of course bears
significantly on the weight to be accorded to her opinion. See 20 C.F.R. § 404.1527(c)(5)
(requiring an ALJ to “generally give more weight to the medical opinion of a specialist about
medical issues related to his or her area of specialty than to the medical opinion of a source who
is not a specialist”).Dr. Merati’s role in the SSA proceedings was to conduct a physical
examination—not a psychiatric one. Any findings she made regarding Simon’s mental condition
at that time were merely incidental to the main purpose of the exam and were not within her area
of expertise. However, in light of our disposition of this case, we need not comment on the
appropriate weight owed to Dr. Merati’s incidental observations.
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         USCA11 Case: 19-14682       Date Filed: 08/12/2021    Page: 29 of 33

      For largely the same reasons, the ALJ’s final basis for discounting

Dr. Turner’s opinions was not sufficient. Specifically, the ALJ found it significant

that Simon could feed himself, dress himself, and shop. But here again, the ALJ

failed to identify any genuine inconsistency with Dr. Turner’s findings. In our

view, it goes almost without saying that many people living with severe mental

illness are still capable of eating, putting on clothes in the morning, and purchasing

basic necessities. None of those activities, however, say much about whether a

person can function in a work environment—with all of its pressures and

obligations—on a sustained basis. Without some reasonable explanation from the

ALJ as to why completing basic household chores is inconsistent with a finding of

disability, this evidence was not sufficient to discredit Dr. Turner.

      In summary, we hold that the ALJ failed to articulate good cause to reject

the opinions of Simon’s treating physician. The ALJ pointed to no genuine

inconsistencies between Dr. Turner’s opinions and her treatment notes, the other

medical evidence from Dr. Marban and Dr. Merati, or Simon’s own testimony.

Our holding in this regard is sufficient by itself to require remand.

      B. The ALJ’s Rejection of Dr. Marban’s Opinions

      Although the ALJ’s improper treatment of Dr. Turner’s opinions is enough

on its own to necessitate remand, we believe it important to also note our

agreement with Simon that the ALJ erred in giving “little weight” to Dr. Marban’s

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         USCA11 Case: 19-14682         Date Filed: 08/12/2021   Page: 30 of 33

opinions. Dr. Marban concluded that, in a workplace setting, Simon likely would

have trouble with concentration, task persistence, accepting instructions from

others, or responding appropriately to supervisors. The ALJ chose to disregard

those opinions, however, on the grounds that they were “inconsistent with the

doctor’s own clinical findings and other clinical findings discussed further in this

decision showing the claimant is capable of performing unskilled work.” We find

this explanation to be insufficient.

      In discounting Dr. Marban’s opinions, the ALJ relied on the same kinds of

capabilities, observed by Dr. Marban and Dr. Merati in their consultive

examinations of Simon, that he also relied on to discount Dr. Turner’s opinions.

As discussed above, such capabilities—e.g., a good fund of information, fair

insight, good judgment, good calculation abilities, and good abstract reasoning—

say little to nothing about the capacity to work of a person suffering from the types

of mental illnesses with which Simon was diagnosed. And in our view, it scarcely

even needs to be explained that knowing such things as the direction in which the

sun rises has almost no relevance to a person like Simon’s ability to function in a

workplace on a sustained basis. Thus, for the same reasons that these capabilities

did not constitute or contribute to good cause to discount Dr. Turner’s opinions,

they cannot constitute a reasonable basis for discounting Dr. Marban’s opinions.

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          USCA11 Case: 19-14682           Date Filed: 08/12/2021       Page: 31 of 33

       As for the “other clinical findings” that the ALJ found to be inconsistent

with Dr. Marban’s opinions, we cannot say with any certainty what those findings

were because the ALJ’s decision did not list them. We know that the ALJ did not

rely on the opinions of Dr. Grubbs and Dr. Bercik because the ALJ’s decision

explicitly accorded them little weight. But in any event, “[n]on-examining

physicians’ opinions are entitled to little weight when they contradict opinions of

examining physicians and do not alone constitute substantial evidence.” Schink,

935 F.3d at 1260. The ALJ’s decision does not refer to any other medical evidence

relevant to the limitations imposed by Simon’s mental disorders.

       For these reasons, we conclude that the ALJ failed to articulate reasonable

grounds for giving Dr. Marban’s opinions little weight.

       C. The ALJ’s Rejection of Simon’s Testimony

       Third and finally, we conclude that we must vacate the ALJ’s finding that

Simon’s testimony regarding “the intensity, persistence and limiting effects of [his]

symptoms” was “not entirely consistent with the medical evidence and other

evidence in the record.” 8

       At his hearing before the ALJ, Simon testified: (1) that his concentration

issues and memory problems made it difficult for him to complete certain tasks,

8
        Once again, the ALJ did not elaborate on which portions of the medical evidence (or
“other evidence”) were inconsistent with Simon’s statements, thus making it difficult for us to
review this finding.
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         USCA11 Case: 19-14682       Date Filed: 08/12/2021   Page: 32 of 33

such as paying bills or remembering which items to pick up from the grocery store;

(2) that he had attempted suicide and no longer cared whether he was alive or dead;

(3) that he experienced mood swings nearly every day; (4) that his depression

caused him to isolate himself from others; and (5) that he was afraid of going

outside and would not leave his house except for a few select locations. All of

this—and much more—is also recorded in Dr. Turner’s treatment notes, and Simon

reported most of these same symptoms in his examinations with Dr. Marban and

Dr. Merati, both of which occurred several years before his SSA hearing.

      In any event, because we have vacated the ALJ’s decision to discount the

opinions of Dr. Turner and Dr. Marban, the medical evidence considered on

remand may well be different. Accordingly, the ALJ will need to reassess Simon’s

testimony as well. If, after giving each medical opinion in the record appropriate

weight, the ALJ is still inclined to disbelieve Simon’s statements as to the severity

of his symptoms, then the ALJ must support that finding by identifying some

specific portion of the record undermining Simon’s credibility.

                                IV. CONCLUSION

      For the foregoing reasons, we hold that the SSA’s denial of Simon’s

application for disability benefits was not supported by substantial evidence.

Accordingly, we reverse the judgment of the district court with instructions to

remand to the agency for further proceedings consistent with this opinion.

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REVERSED AND REMANDED.

                             33