Court Opinion

ID: 2994853
Source: CourtListenerOpinion
Date Created: 2015-09-24 19:17:00.320801+00
Date Added: 2024-06-11T11:45:22.557780
License: Public Domain

In the
United States Court of Appeals
For the Seventh Circuit

No. 00-1307

LINDA GODBEY,

Plaintiff-Appellant,

v.

KENNETH S. APFEL, Commissioner
of Social Security,

Defendant-Appellee.

Appeal from the United States District Court
for the Northern District of Illinois, Eastern Division.
No. 99 C 2690--William J. Hibbler, Judge.

Argued October 4, 2000--Decided December 15, 2000
Published March 21, 2001/*

  Before MANION, EVANS, and WILLIAMS, Circuit Judges.

  PER CURIAM. In 1985 Linda Godbey was hospitalized
for major depression with psychotic features and
viral syndrome, which doctors diagnosed as
probable viral encephalitis or an acute
inflammation of the brain. More than ten years
later, Godbey applied for disability insurance
benefits ("DIB") from the Social Security
Administration ("SSA"), complaining that between
1985 and 1990 (the date she was last insured) she
experienced memory loss, psychotic episodes,
dementia, confusion and loss of concentration.
After a hearing before an administrative law
judge ("ALJ"), who denied her claim, the Appeals
Council denied Godbey’s request for review. She
then filed a timely complaint in the district
court, and the district court affirmed the denial
of DIB. Godbey now appeals, arguing that the ALJ
failed to consider evidence in support of her
claim. We vacate and remand.

Background

  On May 15, 1985, Godbey was admitted to Mercy
Center Hospital in Aurora, Illinois because she
was disoriented, confused and had a fever. She
was transferred on May 21 to the hospital’s
psychiatric division, and was discharged on June
28. Dr. Richard Gallagher, who treated Godbey
during her stay in the psychiatric ward, composed
a discharge summary upon her departure. In the
summary, Dr. Gallagher discussed an abnormal
electroencephalography ("EEG"), stating that
"sharp waves now are seen on the . . . left
temporal area . . . in addition to moderate to
marked degree of slow wave abnormality seen on
the left temporal area, indicating a significant
neurophysiological disturbance within that
region." Dr. Gallagher also reported that
although Godbey had taken the medications
Etrafon, Tylenol, Vistaril, Halcion and Haldol
during her hospital stay, she did not take
medication in the days before her discharge, and
she was not prescribed medication upon discharge.
He further stated that Godbey had "functioned
well in the community while on therapeutic pass."
Dr. Gallagher noted that Godbey was experiencing
considerable stress arising from her loss of
legal custody of her children, who at that time
lived with her first husband, and the doctor
scheduled a follow up appointment for a
psychiatric consultation. In addition, Dr.
Gallagher wrote that Godbey was advised to
schedule an appointment with her primary
attending physician. Dr. Gallagher’s final
diagnosis of Godbey was that she suffered from
dementia, "[a]djustment reaction of adult life,"
and "[p]robable viral encephalitis." He concluded
that her condition was, "[s]atisfactory--
improved, stabilized," and he noted that his
final prognosis of her was "[g]ood."

  Godbey did not keep her scheduled appointment
with Dr. Gallagher. Further, the record does not
reflect that she sought any medical treatment
until eight years later, in 1993, when she went
to an urgent care center to have a foreign object
removed from her eye. She visited physicians
several times after 1993 for routine examinations
and for various ailments, but did not report any
symptoms relating to her encephalitis until March
1, 1996. On that day, Godbey complained to her
primary treating physician, Dr. Alan Haan, that
she had been experiencing stress because her
second husband was leaving her. Dr. Haan noted
that her situation was complicated by the fact
that she had an "[a]ltered mental status"
deriving from her probable encephalitis in 1985.
Dr. Haan concluded that Godbey was experiencing
"[a]ltered mental status secondary to previous
encephalitis," and referred her to a neurologist
named Dr. Brian O’Shaughnessy for a disability
evaluation.

  Dr. O’Shaughnessy saw Godbey on March 6, 1996
and recorded Godbey’s complaints of poor short-
term memory, inability to drive because she would
become lost and disoriented, forgetfulness, and
confusion. According to the report, she also
claimed that she would forget to turn off the
stove, would lose objects, and that her husband
handled all of her finances. After reporting the
results of his examination, Dr. O’Shaughnessy
noted that "this patient has a moderate
deficiency in her cognitive ability which is
secondary to injury from encephalitis. Her
biggest problems appear to be mainly in
concentration and short-term memory but also in
other intellectual functions such as ability to
do arithmetic." He then stated that he did not
believe she was employable due to her cognitive
deficiencies. Further, he opined that Godbey was
"in some danger of independent living. Sadly, I
do not have any medication or treatment for her
problem. I feel the prognosis for improvement in
her mentation is 0 since she has not improved in
ten years." Godbey filed for DIB on or about
March 11, 1996. Her application and subsequent
motion for reconsideration were denied.

  Also in March 1996, the Illinois disability
determination service (which makes disability
determinations for SSA) contacted Dr. Gallagher
to obtain further information about Godbey’s
hospitalization back in 1985. In this March 22,
1996 report, Dr. Gallagher generally repeated the
findings of his 1985 report, but added that
Godbey had experienced "dementia which was
resolved as well as adjustment reaction of adult
life and probable viral encephalitis." (emphasis
added). He also concluded that he believed Godbey
could perform "some work related activities such
as understand[ing], carry[ing] out and
remember[ing] instructions; and . . .
respond[ing] appropriately to supervision, co-
workers, and customary work pressures."

  Godbey testified to her condition at a hearing
before an ALJ. Godbey testified that she had
worked as a word processor/secretary until 1985
(before her hospitalization), but stopped because
her employer relocated to Arizona, and she did
not want to move away. With regards to her
medical complaints, Godbey stated that after her
1985 hospitalization, she could not recall past
events and her "whole past was wiped out." She
reported that she did not leave the house alone
because if she walked further than a block or two
from her home, she would become disoriented and
lost. Godbey testified that her husband took care
of her, adding that he even took away her car
keys for fear that she would get lost and wreck
the car.

  Godbey’s sister, Shirley Jaehrling, also
appeared at the hearing, and testified that when
Godbey returned from the hospital in 1985 "she
was still not better" and "literally did not know
she had children." When Jaehrling visited Godbey
on a weekly basis after her hospitalization, she
found her to be "very disoriented for a long time
. . . like she really wasn’t aware of her
surroundings." Jaehrling believed that Godbey’s
second husband was "domineering," but took care
of her because Godbey "was very insecure about
doing anything on her own." According to
Jaehrling, Godbey’s family was not aware that
Godbey’s "situation was so bad until her husband
left her last year and he said I’m tired of
taking care of her, she can’t find her way
around." Jaehrling further testified that Godbey
now lived by herself, with a brother and a nephew
living nearby.

  After Godbey and Jaehrling testified, the ALJ
ordered that additional neurological and
psychological consulting evaluations be made. On
June 24, 1997, Godbey received a neurological
examination from Dr. Claude Hamilton, who
concluded that Godbey’s memory problems were
"mild" although Godbey did appear to have a "mild
decrease in her activities of daily living." He
also observed that Godbey seemed to be capable of
managing money in her own interest and that
despite "some mild difficulty" with short-term
memory, Godbey’s "mini-mental status was
unremarkable." Dr. Hamilton examined Godbey’s
exertional capabilities and reported that she was
able to sit and stand without difficulty, could
walk two blocks and could lift at least 20
pounds. Dr. Hamilton concluded that Godbey’s
prognosis was "stable" and opined that there
would be "no further neurological improvement" at
that time.

  Godbey received two post-hearing psychological
evaluations, one from William Hilger, Ph.D., and
one from Dr. Kimberly Merenkov. Dr. Hilger
concluded that Godbey was "a fairly intelligent
woman who does not appear to have a serious
memory disturbance as she has alleged." Although
Dr. Hilger reported "some mild memory loss and
confusion," he determined that Godbey had "very
good vocabulary and conceptual reasoning skills,
and a fair level of short term as well as long
term memory." Objective personality testing
showed Godbey to be a chronically depressed,
anxious and dependent person "who was struggling
to maintain independence and self-sufficiency."
Nonetheless, Dr. Hilger believed that if Godbey
received psychiatric treatment, she would have
"good mental potential to pursue and maintain
typical work related activities, follow
instructions, and respond appropriately to co-
workers, supervisors, and customers and work
pressures."

  Dr. Merenkov’s report, on the other hand,
painted a less optimistic picture of Godbey’s
capabilities. In the "Medical Assessment of
Ability to do Work-Related Activities (Mental)"
form attached to Dr. Merenkov’s report, Dr.
Merenkov rated Godbey’s ability to work in the
majority of delineated categories as "fair"
(meaning that the ability to function in that
occupational area "is seriously limited, but not
precluded"). With respect to the categories of
dealing with work stress and personally and
socially demonstrating reliability, Dr. Merenkov
rated Godbey’s ability as fair to "poor" ("poor"
being defined as no "useful ability to function
in this area"). Finally, Dr. Merenkov rated as
poor Godbey’s ability to understand, remember,
and carry out detailed and complex job
instructions. The doctor also concluded that
based on Godbey’s history, she may need
assistance in managing her money. Yet, the doctor
noted that Godbey’s memory "appeared to be better
during this mental status exam than what would
have been expected per her history." Dr. Merenkov
outlined the final diagnosis, finding that Godbey
had a "[c]ognitive disorder not otherwise
specified," as well as "[p]ersonality disorder
not otherwise specified with dependent and
narcissistic features." Dr. Merenkov then
concluded that the prognosis was "very guarded
for this claimant," and that Godbey "may benefit
from a trial of individual psychotherapy to
further clarify her actual cognitive deficits and
possible need for psychotropic medication."

  On October 29, 1997, the ALJ issued his
decision, concluding that on and before December
31, 1990, Godbey had the residual functional
capacity ("RFC") to perform her past relevant
work as a clerical worker and thus was not
disabled. The ALJ found Godbey’s testimony to be
credible "in certain respects," yet "not
supportive of any disabling impairment." Based on
the reports of Dr. Gallagher, Dr. Hamilton, Dr.
Hilger, and Dr. Merenkov, the ALJ determined that
the medical conditions resulting from Godbey’s
1985 probable encephalitis had been resolved
prior to her release from the hospital, and that
Godbey was "well oriented with only mild memory
impairments." In support of his determination
that Godbey could perform light clerical work,
the ALJ cited Dr. Hamilton’s report that she
could sit and stand without difficulty, could
walk two blocks, and could lift at least 20
pounds. Also, the ALJ repeatedly stated that
Godbey had not followed through with any
psychiatric treatment after her 1985
hospitalization. Notably, the ALJ did not mention
Dr. O’Shaughnessy’s report, nor did the ALJ
discuss Dr. Merenkov’s conclusions doubting
Godbey’s ability to work. After the Appeals
Council denied Godbey’s request for review of the
ALJ decision, Godbey filed a complaint in federal
district court. The district court affirmed the
denial of DIB, concluding that substantial
evidence supported the ALJ’s determination that
Godbey was not disabled on or before December 31,
1990.

Analysis

1. The ALJ’s failure to consider important
evidence in the record

  On appeal, Godbey primarily argues that the ALJ
failed to consider important evidence in the
record that counters the ALJ’s determination that
she was not disabled. In reviewing an ALJ’s
decision that a social security claimant is not
disabled, this court may not "reweigh the
evidence, resolve conflicts, decide questions of
credibility, or substitute [its] own judgment for
that of the Commissioner." Clifford v. Apfel, No.
99-3831, slip op. at 10 (7th Cir. Sept. 14,
2000). Despite the deference accorded to the ALJ,
in considering whether a decision to deny
benefits is supported by substantial evidence,
this court looks to see whether the ALJ built "a
bridge from the evidence to his conclusion."
Green v. Apfel, 204 F.3d 780, 781 (7th Cir.
2000). We believe that the ALJ’s decision does
not adequately consider evidence that supports
Godbey’s claim. Therefore, we are not certain
that the ALJ sufficiently articulated why he
rejected Godbey’s evidence of disability. See
Clifford, No. 99-3831, slip op. at 11.

a. Dr. Merenkov’s Report

  We first address Dr. Merenkov’s report, which
the ALJ selectively discussed; he does not
address portions of that report which support
Godbey’s claim that she suffered cognitive and
personality disorders. A complete review of the
report reveals that Dr. Merenkov opined that
Godbey had a cognitive disorder, a personality
disorder, as well as a past history of psychotic
symptoms, albeit from an unclear source.
Furthermore, Dr. Merenkov determined that Godbey
would be unable to understand, remember, and
carry out complex and detailed job instructions,
and that her ability to deal with work stresses
and "demonstrate reliability" was between fair
and poor. This report is significant because it
diverges from Dr. Gallagher’s and Dr. Hilger’s
conclusions that Godbey was psychologically
capable of managing typical work activities.
Perhaps the ALJ discounted Dr. Merenkov’s
analysis because the doctor characterized the
conclusions as indecisive, admitted that the
prognosis was "guarded," or because Dr. Merenkov
believed that further clarification of Godbey’s
"actual cognitive deficits" was appropriate.
Nonetheless, the ALJ’s failure to address Dr.
Merenkov’s report in its entirety prevents this
court from tracking the ALJ’s reasons for
discounting it. See Clifford, No. 99-3831, slip
op. at 13 (ALJ must consider "all relevant
evidence" and may not analyze only that
information supporting ALJ’s final conclusion
(emphasis in original)); Green v. Shalala, 51
F.3d 96, 101 (7th Cir. 1995) (ALJ is required to
articulate "his analysis of the evidence" so that
appellate court may "track the ALJ’s reasoning
and be assured that the ALJ considered the
important evidence"). While the ALJ need not
articulate his reasons for rejecting every piece
of evidence, he must at least minimally discuss
a claimant’s evidence that contradicts the
Commissioner’s position. See Green v. Shalala, 51
F.3d at 101. Here, the Commissioner admitted both
in his brief and during oral argument that Dr.
Merenkov’s report is inconsistent with the
conclusions of Dr. Hamilton, Dr. Hilger and Dr.
Gallagher. The ALJ’s decision, however, does not
reflect that he resolved this evidentiary
conflict. See Schmidt v. Apfel, 201 F.3d 970, 972
(7th Cir. 2000).

b. Dr. O’Shaughnessy’s Report

  Also troubling is the ALJ’s failure to mention
Dr. O’Shaughnessy’s report. In the report, Dr.
O’Shaughnessy opined that Godbey was suffering
from a "moderate deficiency" in cognitive ability
and was having problems with concentration,
short-term memory and arithmetic. He also
concluded that she was not employable and that it
may be dangerous for her to live on her own.
Lastly, he stated that her problems were not
treatable and that her condition had not improved
for ten years. As the Commissioner points out,
there are many reasons why the ALJ could have
disregarded Dr. O’Shaughnessy’s report. For
example, the doctor’s opinion that Godbey’s
condition had not improved in ten years relies
entirely on Godbey’s allegations of the duration
of her symptoms, and an ALJ may place less
significance on a claimant’s subjective
complaints. See Diaz v. Chater, 55 F.3d 300, 308
(7th Cir. 1995). But this court cannot evaluate
whether the ALJ properly rejected this evidence
in favor of the other doctors’ reports, or even
ensure that the ALJ examined this report, unless
the ALJ explains his reasoning. See Sarchet v.
Chater, 78 F.3d 305, 307 (7th Cir. 1996).

c. Evidence regarding Godbey’s failure to seek
medical treatment after 1985

  In denying Godbey’s DIB application, the ALJ
repeatedly states that Godbey had not sought
medical treatment for her claimed disability for
almost ten years. Godbey, however, argues that
the ALJ failed to consider evidence that
justified her failure to seek medical treatment.
The record contains considerable evidence that
Godbey depended heavily on the assistance of
others, both emotionally and with respect to her
mobility. Her sister testified that Godbey’s
second husband was domineering and took care of
Godbey’s affairs. Godbey also testified that she
would not leave her immediate neighborhood
without the company of either her former husband,
her sister, or another relative. Additionally,
Dr. Merenkov’s report included Godbey’s
allegation that she did not see a doctor after
her hospitalization because she could not find
the doctor’s office on her own, and because the
medicines were not improving her memory or making
her feel better. Dr. Merenkov concluded that
Godbey suffered from a personality disorder with
dependent and narcissistic features. Although
this evidence of Godbey’s severe dependence on
others may explain why she did not seek medical
treatment after her hospitalization, the ALJ did
not address any of this information.

  To the extent that the ALJ based his decision
to deny benefits on Godbey’s failure to follow
through with prescribed medical or psychiatric
treatment, the record demonstrates another
significant conflict in the evidence which the
ALJ did not adequately resolve. On the one hand,
Dr. Gallagher reported in his discharge summary
that he had not prescribed any medication upon
Godbey’s departure from the hospital, but had
scheduled Godbey for a psychiatric consultation.
Godbey never followed through with Dr.
Gallagher’s prescribed treatment of psychiatric
therapy, and under SSA regulations, to obtain
benefits a claimant "must follow treatment
prescribed by [the claimant’s] physician if this
treatment can restore [the] ability to work," 20
C.F.R. sec. 404.1530(a). Furthermore, the fact
that Dr. Gallagher did not prescribe medication
upon Godbey’s discharge supports the ALJ’s
conclusion that Godbey’s problems relating to the
probable encephalitis had resolved when she left
the hospital in 1985, and that psychiatric
treatment would have assisted her with her
lingering problems relating to stress management.
Finally, Dr. Hamilton concluded that with
psychiatric treatment, Godbey would be able to
return to work, and Dr. Merenkov opined that
further psychiatric evaluation would be helpful.

  On the other hand, the fact that Godbey was not
prescribed medication upon her discharge from the
hospital also supports the opposite conclusion:
that there was no medication or treatment
available to alleviate Godbey’s problems
resulting from her probable encephalitis. Dr.
O’Shaughnessy’s observations that he did not have
any medication or treatment for her symptoms, and
that his "prognosis for improvement in her
mentation is 0 since she has not improved in ten
years" contradicts the determination that
prescribed therapy would enable Godbey to return
to work. As stated before, the ALJ does not
discuss O’Shaugnessy’s report, and an ALJ must
explain the reasoning for rejecting evidence, see
Clifford, No. 99-3831, slip op. at 15. Because
the ALJ did not discuss the competing evidence
regarding Godbey’s reasons for not seeking
medical attention, it is not possible for us to
discern whether the ALJ adequately considered all
of the evidence.

d. Godbey’s and Jaehrling’s testimony regarding
Godbey’s condition after her discharge from the
hospital

  Godbey additionally argues that the ALJ erred
in disregarding testimony given by her and her
sister about Godbey’s memory problems and other
post-hospitalization mental difficulties. This
testimony is relevant to the question of whether
Godbey was disabled between 1985 and 1990,
because it is the only evidence, besides Dr.
Gallagher’s discharge summary, contemporaneous
with Godbey’s condition at that time. But again,
it is not clear from the ALJ’s decision that he
rejected or considered Godbey’s or Jaehrling’s
testimony about Godbey’s ability to function
between 1985 and 1990. The fact that Godbey’s and
Jaehrling’s testimony are lay opinions, as
opposed to medical diagnoses, regarding Godbey’s
alleged mental disorder does not matter. With
respect to lay opinions about the existence of
depression, this court held in Wilder v. Apfel,
153 F.3d 799, 802 (7th Cir. 1998), that "[w]hat
is required is contemporaneous corroboration of
the mental illness . . . not necessarily
contemporaneous medical corroboration."

e. Godbey’s 1985 EEG readings

  The ALJ also failed to address abnormal EEG
readings that were taken before Godbey left the
hospital in 1985. In the 1985 discharge summary,
Dr. Gallagher noted that the EEG reading showed
"marked to moderate degree of slow wave
abnormality . . . indicating a significant
neurophysiological disturbance within that
region." The report, however, does not explain
whether this EEG reading is important or if it
reflects on Godbey’s ability to function
mentally. The abnormal EEG reading could be
considered contemporaneous evidence of a medical
impairment that had not resolved at the time of
her discharge from the hospital, thus
corroborating both Godbey’s and Jaehrling’s
testimony, as well as the retrospective reports
of Dr. Merenkov and Dr. O’Shaughnessy. Or the EEG
report could mean nothing at all. But because the
ALJ’s decision does not discuss the EEG findings,
we can not be sure that the ALJ examined this
evidence or rejected it as insignificant.

2. The absence of a "standard document"

  Finally, Godbey argues that the decision should
be reversed because the ALJ did not complete a
standard document that is required in all cases
involving mental disorders. But under revised
regulations that took effect on September 20,
2000, the ALJ is no longer required to complete
the standard document. See Revised Medical
Criteria for Evaluating Mental Disorders and
Traumatic Brain Injury, 65 Fed. Reg. 50746,
50774-50775 (August 21, 2000) (to be codified at
20 C.F.R. sec. 404.1520a). Therefore, we need not
remand the case so that the ALJ can compile the
standard document and attach it to his decision.

Conclusion

  Because the ALJ’s decision failed to address
significant evidence in the record, we vacate the
district court’s decision with instructions to
remand this case to the Commissioner for further
proceedings consistent with this decision.

VACATED and REMANDED.

/* Although our original disposition of this case
was by an unpublished order under Circuit Rule
53, we have subsequently granted a motion to
reissue this decision as a published opinion.