Court Opinion

ID: 2997441
Source: CourtListenerOpinion
Date Created: 2015-09-24 19:36:24.964578+00
Date Added: 2024-06-11T15:02:49.750324
License: Public Domain

In the
 United States Court of Appeals
              For the Seventh Circuit
                        ____________

No. 04-2227
LORETTA BOILES,
                                           Plaintiff-Appellant,
                               v.

JO ANNE B. BARNHART, Commissioner
of Social Security,
                                           Defendant-Appellee.

                        ____________
       Appeal from the United States District Court for the
       Southern District of Indiana, Indianapolis Division.
      No. 1:02-CV-1112—Larry J. McKinney, Chief Judge.
                        ____________
 ARGUED NOVEMBER 17, 2004—DECIDED JANUARY 20, 2005
                   ____________

 Before COFFEY, MANION, and ROVNER, Circuit Judges.
  ROVNER, Circuit Judge. Loretta Boiles applied for Supple-
mental Security Income (SSI) in March 2000, claiming that
she was disabled because she suffered from several mala-
dies, including pseudoseizures. Her claim was denied
initially, upon reconsideration, and after a hearing before
an administrative law judge. The ALJ found that although
Boiles had a severe impairment, it did not equal a listed
impairment, and that she was capable of working with
certain restrictions. Because the ALJ did not adequately
2                                                No. 04-2227

support his decision that Boiles’s condition was not equal in
severity to a listed impairment, we vacate the decision and
remand for further factfinding.
  At the time of her hearing, Boiles was 34 years old. She
has a ninth-grade education and has been employed as a
fast food worker/assistant manager, a house cleaner, and a
babysitter. None of these jobs lasted more than a few months,
and in 1998 she stopped working because she “couldn’t keep
[a] job because of my mental illness.” Two years later, after
her disability claim had been denied initially, she worked
briefly as a meat packer but left the job because she was
“having blackouts and nerve problems.”
  Boiles’s medical history reveals treatment for a number
of physical and psychological problems. In the past decade,
she has been treated for conditions including pseudoseizures,
severe depression, anxiety, post-traumatic stress disorder,
heartburn, high blood pressure, back pain, thyroid disease,
and migraines. In addition, Boiles was treated for alcohol-
ism in 1990 and for prescription drug abuse as late as 1999.
The psychological effects of being sexually abused as a child
have been cited frequently as a cause or an exacerbating
factor of many of Boiles’s health problems. Because Boiles
appeals solely on the ground that her pseudoseizures are
medically equivalent to a listed impairment, only her
history of treatment for that condition is discussed in detail.
  Pseudoseizures, also known as psychogenic seizures, non-
epileptic seizures, and paraoxysmal nonepileptic episodes
(PNES), resemble epileptic seizures but are not attributable
to epilepsy or abnormal electric activity in the brain. Ronald
P. Lesser, Treatment and Outcome of Psychogenic
Nonepileptic Seizures, Epilepsy Currents, Nov. 2003, at 198.
No single cause of psychogenic seizures has been identified,
but they are typically attributed to an underlying psycholog-
ical disturbance. Id. Those who have been victims of phy-
sical or sexual abuse seem to be at greater risk for develop-
No. 04-2227                                                 3

ing pseudoseizures. Id. Some symptoms of a pseudoseizure
disorder can be treated with medication, but psychological
therapy, not medication, appears to be the preferred course
of treatment. Id.
  According to her testimony and reports to her neurologist,
Boiles experienced her first seizure sometime in early 2000,
when she arrived at work to find the right side of her car
damaged and could not recall how it happened. Not long
after, she had a seizure at work and an ambulance had to
be called. Boiles also described a seizure that occurred while
she was riding in her sister’s car; her sister rushed her to
the hospital after her eyes rolled back, “foam” came out of
her mouth, and she began to bang her head against the car
window. After this incident, Boiles was put on Dilantin, an
anti-epileptic drug. Then in June 2001, Boiles had another
seizure that prompted her boyfriend to call an ambulance.
In addition to these daytime incidents, Boiles reported fre-
quent seizures at night.
  In the summer of 2001, Boiles sought treatment for her
seizures and was referred to a neurologist, Dr. Matthew
Wallack. She reported experiencing seizures at night that
sometimes woke her up or caused bowel or bladder inconti-
nence. After his initial consultation with Boiles, Dr. Wallack
opined that pseudoseizures were a “significant possibility.”
He prescribed Depakote ER “as a seizure medication.” In
October 2001 Dr. Wallack saw Boiles again and noted that
she reported only four daytime incidents in the prior two
months, but that she continued to experience nighttime
pseudoseizures, after which she woke up sore and tired.
Dr. Wallack prescribed Topamax and noted that if the medi-
cation did not alleviate the seizures, he wanted to admit her
to an epilepsy monitoring unit. After an appointment in
November 2001, Dr. Wallack reported that Boiles had not
experienced any daytime seizures since her last appoint-
ment, but that she was still having pseudoseizures at night.
Dr. Wallack increased the dosage of Topamax but noted
4                                                No. 04-2227

that he was “not convinced that these are seizures.” Boiles
had another appointment with Dr. Wallack the following
month, after which he reported that her seizures had become
less frequent (about two seizures per week), and typically
occurred while she was asleep. In January 2002 Boiles was
admitted to the hospital for observation for five days, during
which time she had one pseudoseizure. Shortly afterward,
Dr. Wallack concluded that she need not be treated with
anti-epileptic drugs for her pseudoseizures.
  Boiles applied for SSI in March 2000. She claimed that
she was disabled due to unspecified “mental disorders,” ar-
thritis, depression, “nerve problems,” memory loss, asthma,
and bronchitis. Her claim was denied, and later that year
she sought reconsideration, reporting that her condition had
grown worse because she had started having “blackouts/
seizures.” In February 2001 her claim was denied upon re-
consideration, and Boiles requested a hearing before an ALJ.
  In February 2002 Boiles had a hearing before an ALJ at
which she testified about her condition. Boiles described
being disoriented and sore after seizures, and testified that
she had been hospitalized “a few times.” Her boyfriend also
testified, describing the seizure that led him to call an am-
bulance. He also corroborated Boiles’s testimony that she
sometimes experienced bladder and bowel incontinence in
bed during seizures.
  In response to a request from the ALJ, Dr. Wallack pro-
vided a written evaluation of her condition and answered
interrogatories regarding the frequency of Boiles’s pseudo-
seizures and her prognosis. He stated that Boiles “suffers
from pseudoseizures and chronic pain which are secondary
to a history of abuse.” He noted that although the cause of
pseudoseizures cannot be identified, they result in genuine
suffering and are often accompanied by “other debilitating
symptoms.” Dr. Wallack estimated that the seizures occurred
twice per week, and characterized her prognosis as “terri-
No. 04-2227                                                    5

ble.” He stated that Boiles’s condition was “untreatable,”
that it was his “firm belief” that Boiles could not work, and
that he “strongly” supported the disability application. He
added that the reason for her disability was not the seizures
in particular but rather the “underlying cause of the sei-
zures,” namely her sexual abuse as a child, which had
“devastated her life.”
   Two non-treating physicians consulted by the ALJ testi-
fied at the hearing. Dr. Stump, an internist, distinguished
pseudoseizures from epilepsy. An epileptic seizure can be
diagnosed by an EEG, he explained, but a pseudoseizure is
“another form of seizure altogether,” and thus a negative
EEG does not mean that no seizure took place. He added
that patients who experience pseudoseizures cannot be
treated with anti-seizure medication and therefore benefit
little from going to the hospital during an episode. Dr. Stump
also testified that it would be unfair to “penalize” someone
suffering from pseudoseizures by not finding her disabled,
because like epileptics, “it’s very difficult for these people to
get jobs.” Dr. Stump emphasized that while pseudoseizures
are not caused by epilepsy, they are “real.”
  The consulting psychologist, Dr. Pitcher, agreed with
Dr. Stump, noting that the cause of Boiles’s pseudoseizures
was unknown, but “there is nothing at all to suggest that
she is malingering or faking any seizure.” In response to a
question from the ALJ, Dr. Pitcher testified that alcohol or
drug use did not appear to be a material factor in Boiles’s
“current position,” although “there may have been a period
of time when it was.” Dr. Pitcher also stated that based on
Boiles’s testimony and the toxicology reports in the record,
there did not appear to be any current substance abuse. Both
Dr. Pitcher and Dr. Stump testified that pseudoseizures
could occur in the absence of drugs or alcohol.
  The ALJ then asked a vocational expert (VE) to determine
whether there were jobs in the national economy that Boiles
could perform. The ALJ asked the VE to consider an indi-
6                                                 No. 04-2227

vidual with Boiles’s past work experience who required
seizure precautions and limited contact with other people,
and the VE determined that there were jobs, such as as-
sembly work, that such a person could perform. Replying to
questions from Boiles’s attorney, the VE agreed that a
person who missed as much work due to illness as Boiles had
at her last job would have difficulty maintaining employ-
ment.
   The ALJ determined that Boiles was not disabled. Follow-
ing the five-step analysis used to evaluate disability, see 20
C.F.R. § 404.1520(a)-(g), the ALJ found that: (1) Boiles had
not performed substantial work since the onset of her
medical problems; (2) her pseudoseizures were a severe
impairment; (3) her pseudoseizures did not meet or equal a
listed impairment; (4) she could not perform her past
relevant work and had no transferable skills; and (5) there
were jobs available in Indiana that she could perform. Of
significance for this appeal, the ALJ found at step three
that Boiles’s pseudoseizures were not equal in severity to
epilepsy as described in Listing 11.02, which applies to
major-motor seizures, and Listing 11.03, which applies to
minor-motor seizures. When a claimant’s condition does not
meet the criteria of any of the listed impairments that give
rise to a presumption of eligibility for benefits, she may still
establish presumptive disability by showing that her
impairment is accompanied by symptoms that are “at least
equal in severity and duration to the listed findings.” 20
C.F.R. § 416.926(a); see Barnett v. Barnhart, 381 F.3d 664,
668 (7th Cir. 2004). The ALJ also found that Boiles’s
description of her physical limitations was not “totally cre-
dible” and that she had no exertional limitations, but that
she should avoid work at unprotected heights and around
dangerous machinery or open bodies of water or flame, and
have no more than superficial contact with supervisors, co-
workers, and the general public. The Appeals Council de-
clined review, and the ALJ’s decision thus became the final
No. 04-2227                                                   7

decision of the Commissioner of Social Security. The district
court then affirmed the decision, and Boiles appeals.
  Boiles argues that the ALJ erred in finding that her pseu-
doseizures were not equal in severity to a listed impairment
because he substituted his own judgment for that of the
treating and consulting physicians without citing con-
tradictory medical evidence. Listing 11.02 applies to epilepsy
that is “documented by detailed description of a typical
seizure pattern, including all associated phenomena; occur-
ring more frequently than once a month, in spite of at least
3 months of prescribed treatment,” with either daytime epi-
sodes or “nocturnal episodes manifesting residuals which
interfere significantly with activity during the day.” 20 C.F.R.
§ 220, App. 1. The ALJ decided that Boiles’s pseudoseizures
were not severe enough to equal Listing 11.02 because there
was no EEG evidence of an abnormal brain wave pattern,
the frequency of the seizures was “open to question given the
lack of emergency room medical care for such episodes,” and
there was “no evidence” of residual symptoms from night-
time seizures that would interfere with Boiles’s activities
during the day. Boiles asserts that the ALJ improperly
“played doctor” and substituted his own judgment for the
medical evidence that her pseudoseizures prevented her
from being able to work.
  We will uphold the ALJ’s decision if it is supported by
substantial evidence in the record. Barnett, 381 F.3d at 668.
Evidence is “substantial” when it is “sufficient for a reason-
able person to accept as adequate to support the decision.”
Jens v. Barnhart, 347 F.3d 209, 212 (7th Cir. 2003) (internal
quotations omitted). If the findings of the ALJ are sup-
ported by substantial evidence, they are conclusive, and we
will not substitute our judgment for that of the ALJ. Id. The
ALJ is required to “articulate, at some minimum level, [his]
analysis of the evidence.” Dixon v. Massanari, 270 F.3d
1171, 1176 (7th Cir. 2001). An ALJ may not substitute his
own judgment for a physician’s opinion without relying on
8                                                No. 04-2227

other medical evidence or authority in the record. Clifford
v. Apfel, 227 F.3d 863, 870 (7th Cir. 2000).
   In this case, the testimony of Dr. Wallack and the two
non-treating physicians did not support the reasons stated
by the ALJ for finding that the pseudoseizures did not equal
a listed impairment. First, the ALJ did not explain the
relevance of the lack of EEG evidence for his finding that
the pseudoseizures were not severe enough to equal a
listing. The ALJ did not cite any evidence to contradict Dr.
Stump’s opinion that a negative EEG: (1) was perfectly
consistent with Boiles’s type of seizure disorder and (2) did
not mean that her seizures were any less “real” than those
that could be measured by electric output; thus, it was
improper for the ALJ to use the lack of EEG evidence as
support for his decision.
  The ALJ also improperly relied on the lack of emergency
room visits as evidence that Boiles’s seizures were not fre-
quent enough to be equal in severity to impairments described
in Listing 11.02. Again, the ALJ did not point to anything
in the record that contradicted Dr. Stump’s testimony that
hospitalization was futile for someone suffering from pseu-
doseizures, which are essentially untreatable.
  Nor does the record support the ALJ’s third stated reason
for concluding that Boiles’s condition was not severe enough
to equal a listing: that there was “no evidence” that her
daytime functioning was impaired due to nocturnal pseu-
doseizures. In fact, the record contains evidence that Boiles
was severely fatigued and in pain after a pseudoseizure. Dr.
Wallack told the ALJ that Boiles suffered from “chronic pain”
and Dr. Pitcher, the psychologist, testified that Boiles “has
the postictal, too,” referring to the residual symptoms that
follow a seizure or convulsion. Boiles’s cousin, who completed
a third-party questionnaire, described Boiles as confused,
weak, and tired after a pseudoseizure. Boiles testified that
after she has a nighttime episode, “I feel beat, I’m real
No. 04-2227                                                      9

drained for like two or three days, I feel like I just cannot
get up.” She also stated that she knows she has had a night-
time seizure when “it feels like somebody that’s beating me
real hard. . . . I hurt.” Boiles reported that she could not drive,
take baths by herself, or “stay alone” due to her seizures. The
ALJ’s conclusion that there was “no evidence” that Boiles
was impaired during the day was thus unsupported by the
record.
  Boiles also argues that the ALJ improperly rejected the
opinion of her treating physician, Dr. Wallack, who believed
that Boiles was “devastated” by the psychological effects of
her child abuse and thus disabled. The ALJ stated that he
discounted this opinion because Dr. Wallack had no creden-
tials as a psychologist or psychiatrist, and lacked the
longitudinal view of Boiles’s medical history that the ALJ
possessed. Boiles also asserts that the ALJ did not explain
why he discredited Dr. Wallack’s opinion that Boiles had
two pseudoseizures per week, stating instead that the
frequency of the seizures was “open to question.”
  The opinion of a treating physician concerning a patient’s
condition is “entitled to controlling weight if it is well sup-
ported by medical findings and not inconsistent with other
substantial evidence in the record.” Clifford, 227 F.3d at
870. Here, the ALJ did not explain how other evidence in
the record contradicted Dr. Wallack’s opinion about the fre-
quency of Boiles’s pseudoseizures. See Gudgel v. Barnhart,
345 F.3d 467, 470 (7th Cir. 2003). Aside from the puzzling
statement that Dr. Wallack “failed to explain the type of
seizure involved,” the ALJ did not explain why Dr. Wallack’s
opinion about the frequency of the seizures was not “well
supported by medical findings.” Dr. Stump, the non-treating
medical expert, estimated that Boiles had seizures at least
once per month. Although this more conservative estimate
(which the ALJ did not mention) might be viewed as
evidence that contradicts Dr. Wallack’s opinion, it still
supports a level of frequency that is commensurate with
10                                               No. 04-2227

Listing 11.02. At the very least, the ALJ was obligated to
solicit more evidence if he believed that the frequency of the
seizures, as reflected in the record, was unclear. See Smith
v. Apfel, 231 F.3d 433, 437-38 (7th Cir. 2000).
  Finally, Boiles challenges the ALJ’s consideration of her
past drug abuse, arguing specifically that the ALJ “has
taken upon himself to decide that Ms. Boiles was abusing
her medications.” This concern is somewhat borne out by
the record. At the hearing, when Boiles’s attorney was ques-
tioning Dr. Stump about whether her condition was equi-
valent to the epilepsy listing, the ALJ interjected, “I’ll be
honest with you Counsel, with the history of drug and alco-
hol abuse, I would never grant something on a listing on
this . . . there’s no way I’d do it.” And later, in his written
ruling, the ALJ suggested that he was “more fully aware of
the extent of her prescription drug use,” and thus his
opinion was more informed than Dr. Wallack’s.
  It is true that the testifying physicians recognized that
drug abuse had impacted Boiles’s health in the past, yet
neither attributed Boiles’s pseudoseizures to drug abuse.
Moreover, the results of the drug tests in the record support
Boiles’s testimony that she was not abusing her medications.
The ALJ did not acknowledge the drug tests or the physi-
cians’ opinions that substance abuse did not cause Boiles’s
pseudoseizures, nor did he cite evidence to contradict their
opinions, see Clifford, 227 F.3d at 870, and therefore he did
not properly support his conclusion that Boiles’s history of
substance abuse was relevant to his determination.
   Because of the shortcomings in the ALJ’s order, Boiles
urges the court to simply reverse the ALJ and award bene-
fits. But the record does not yet support a finding that
Boiles’s condition is “at least equal in severity and duration”
to epilepsy as described in Listing 11.02. In particular, the
ALJ made no finding about the frequency of Boiles’s seizures.
Whether Boiles’s pseudoseizures are of equal medical sig-
No. 04-2227                                            11

nificance to epilepsy will depend in part upon how fre-
quently they occur; thus the record must be more developed
on this point. Alternatively, pseudoseizures may be more
analogous to an impairment described in a listing other
than 11.02, such as one that describes a psychological
impairment.
  For the reasons stated above, we VACATE the decision
of the district court and REMAND to the Social Security
Administration for further proceedings.

A true Copy:
      Teste:

                       ________________________________
                       Clerk of the United States Court of
                         Appeals for the Seventh Circuit

                  USCA-02-C-0072—1-20-05