Court Opinion

ID: 4433810
Source: CourtListenerOpinion
Date Created: 2019-08-27 21:00:38.442884+00
Date Added: 2024-06-11T07:50:00.437449
License: Public Domain

Case: 17-14992      Date Filed: 08/27/2019     Page: 1 of 44

                                                                                [PUBLISH]

                 IN THE UNITED STATES COURT OF APPEALS

                          FOR THE ELEVENTH CIRCUIT
                            ________________________

                                   No. 17-14992
                             ________________________

                         D.C. Docket No. 2:16-cv-00610-CM

HANS SCHINK,

                                                       Plaintiff - Appellant,

versus

COMMISSIONER OF SOCIAL SECURITY,

                                                       Defendant - Appellee.

                             ________________________

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

                                   (August 27, 2019)

Before WILLIAM PRYOR and ROSENBAUM, Circuit Judges, and MOORE, *
District Judge.

         *
          Honorable Kevin Michael Moore, United States District Chief Judge for the Southern
District of Florida, sitting by designation.
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PER CURIAM:

      Appellant Hans Schink applied for Social Security disability benefits based

on various physical impairments and the fact that he suffered from bipolar disorder.

The matter proceeded to a hearing before an administrative law judge (“ALJ”), who

denied benefits. Schink appealed the decision and the Appeals Council remanded

the matter to the ALJ for further proceedings. Schink fared no better the second time

the ALJ considered his case.

      Following the second denial by the ALJ, Schink again appealed. But this time

the Appeals Council affirmed the denial of benefits. Schink then filed a complaint

with the district court, which affirmed the decision to deny benefits. Schink now

asks us to find that the ALJ erred by (1) discounting his treating physicians’ opinions

and (2) concluding that his bipolar disorder was not a severe impairment. Schink

also contends that remand to a different ALJ is warranted because of a high risk that

the ALJ who considered his claims was biased against him.

      After careful review, we conclude that Schink’s claim of bias was forfeited,

but we also conclude that the ALJ’s decision contains errors that must be addressed.

Specifically, we find that the ALJ failed to articulate good cause for discounting two

treating physicians’ opinions, that substantial evidence does not support the finding

that Schink’s bipolar disorder was non-severe, and that the ALJ failed to consider

Schink’s mental impairments when assessing his residual functional capacity. We

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therefore affirm in part and reverse in part the order of the district court affirming

the denial of benefits, and we remand with instructions to vacate the Commissioner’s

decision and to remand to the Commissioner for further proceedings.

                                      I. Facts

A.    Background

      Schink applied for disability insurance benefits in February 2010, alleging an

onset date of October 1, 2004. He claimed disability due to bipolar disorder, type-2

diabetes, and various physical impairments. Schink remained insured through

September 30, 2011, so he was required to establish disability on or before this date

to be entitled to benefits. As for other relevant characteristics, Schink has a high

school education and past relevant work as a car salesman.

B.    Medical Evidence

      In setting forth a summary of the relevant medical evidence, we focus on only

Schink’s mental impairments, since those are at issue in this appeal.

      1. Schink’s Initial Treatment

      Although Schink produced extensive medical records, we do not discuss every

detail relating to Schink’s mental health. Nevertheless, we note that records indicate

Schink had a history of bipolar disorder and a family history of depression. In June

2008, when we pick up Schink’s more recent medical history, doctors believed that

antidepressant therapy would be beneficial, and Schink began taking Lexapro.

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       Notes from psychotherapy sessions in the Spring of 2009 indicate that

Schink’s speech was pressured, his mood was agitated, his affect was limited, his

judgment was poor, and his relationships were isolated. During this timeframe,

Schink met regularly with psychotherapist Nicholas Anthony, Ph.D., who diagnosed

Schink with bipolar disorder.         Dr. Anthony determined that Schink displayed

symptoms of aggression, anger, and agitation, as well as scattered concentration. At

times, Schink’s condition improved, though he continuously suffered from bipolar

disorder. Dr. Anthony also found Schink’s affect to be “blunted” and his energy to

be low, and he concluded that Schink had “marginal social and interpersonal

involvement.”

       In 2010, Schink met with other doctors who similarly documented Schink’s

chronic mood swings, depression, anger, and anxiety. During this timeframe, Schink

revealed that his father had committed suicide by jumping off a bridge, his mother

had died at age 48 (and suffered from depression), and his brother had been

murdered.      Psychiatrist Raymond Johnson, M.D., recorded that Schink was

“extremely hyperverbal and angry” as he fantasized about “get[ting] back at people”

who upset him. Schink was consistently diagnosed with bipolar disorder and in mid-

2010 was assigned a global assessment of functioning (“GAF”) 1 score of 55. Id.

       1
         The GAF is a numeric scale intended to rate the psychological, social, and occupational
functioning of adults. Am. Psychiatric Ass’n, Diagnostic and Statistical Manual of Mental

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Dr. Johnson also noted that Schink had intermixed manic and depressive episodes,

racing thoughts, and rapid cycling manic and depressive episodes.

       2. State Doctors’ Assessment of Schink

       Because he filed for disability benefits in February 2010, Schink was referred

for a consultative psychological examination with J.L. Bernard, Ph.D., on June 30,

2010. During the examination, Schink reported that he was agitated, felt like he

could kill someone, was very depressed, had memory problems, and had passive

suicidal thoughts. Dr. Bernard noted that Schink was talkative, but on several

occasions, Schink could not offer details on how he spent portions of his life. Schink

reported that he discontinued work because he could “no longer deal with people.”

He further told Dr. Bernard that he spent most of his time watching television,

walking the dog, doing very little housework, napping, playing on his computer, and

going for drives. And he told Dr. Bernard that he cooked “minimally” and “read

once in a while.”

       Dr. Bernard indicated that Schink’s attitude at the interview was “brusque,

arrogant, flippant, and abrasive,” with “a harshness and domineering aspect to his

personality” and an “irritable” affect, although his mood was stable. The doctor also

Disorders 32, 34 (4th ed. 2000) [hereinafter DSM-IV-TR]. Scores between 51 and 60 indicate
moderate difficulty in functioning, whereas scores between 61 and 70 indicate mild difficulty. Id.

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reported that Schink had decreased memory skills, pressured speech, and felt like

“killing people most of the time.” Dr. Bernard diagnosed Schink with mood

disorder, personality disorder not otherwise specified with cluster B features,

problems dealing with the social environment, and occupational limitations. Dr.

Bernard assigned Schink a GAF score of 59 and indicated that his prognosis was

chronic.

      In furtherance of the disability claim, state agency consulting psychologist

Anne-Marie Bercik, Ph.D., conducted a review of Schink’s psychiatric medical

history on August 30, 2010. She did not meet with Schink in person. Using a

checklist and a scale of “mild,” “moderate,” “marked,” and “extreme,” Dr. Bercik

concluded that Schink had only mild limitations of daily living, maintaining social

functioning, and maintaining concentration, persistence, or pace, and had no

episodes of decompensation. Dr. Bercik’s overall impression after reviewing Dr.

Bernard’s notes was that while Schink had some mental deficits, his impairments

were not severe and did not currently meet or equal a mental listing.

      3. Additional Treatment by Schink’s Doctors

      Schink returned to see Dr. Anthony in the Fall of 2010, at which point he had

been taking Klonopin for anxiety and Celexa for depression for approximately two-

to-three months. Dr. Anthony completed a formal assessment of Schink and, on a

scale that included “mild,” “moderate,” and “severe,” Dr. Anthony concluded that

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Schink had “moderate” symptoms of loss of interest or pleasure, sleep disturbance,

loss of energy, irritable mood, and cognitive impairment. Dr. Anthony found

moderate improvement in reduction of agitation and minimal improvement in

Schink’s mood, and he assigned a GAF score of 50.

      In April 2011, Schink began to see psychiatrist Nelson A. Hernandez, M.D.

Schink complained of racing thoughts, depression, poor sleep, and increased anxiety.

Dr. Hernandez completed a Mental Status Examination form, which set forth his

opinion that Schink’s affect was labile and his anxiety was moderate, and that he

exhibited depression with anhedonia. Dr. Hernandez also indicated that Schink’s

mood was dysthymic, his recent memory was impaired, his judgment was fair, and

his thought organization was circumstantial. Dr. Hernandez diagnosed Schink with

bipolar disorder and anxiety disorder and assigned a GAF score of 60.            Dr.

Hernandez recommended that Schink begin taking Zoloft and referred him for

treatment by Dr. Charles Assad.

      Schink returned to see Dr. Hernandez twice in September 2011. At the first

meeting, Schink reported having fair energy level, less depression and fewer mood

swings, but he noted he still had some racing thoughts. At the second meeting,

Schink stated that he was feeling better with less agitation and better sleep.

      Based on Dr. Hernandez’s recommendation, Schink began mental-health

treatment with psychologist Charles Assad, Ph.D., in June 2011. At that time, Dr.

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Assad noted that Schink was poorly groomed and that he had pressured speech. Dr.

Assad also described Schink as having a cooperative attitude, elevated anxiety and

depression, and hypomanic affect.           Dr. Assad diagnosed Schink with bipolar

disorder and depression, and assigned a GAF score of 55. During a follow-up visit

later that month, Dr. Assad found that Schink continued to present with similar

symptoms. The next month, however, Dr. Assad found Schink’s thought processes

were “clearer and more logical” and that he had less pressured speech, but his

“bipolar lability [was clearly] continuing.” During an appointment in late July 2011,

Dr. Assad again noted rapid speech and tangential thought processes. Schink met

with Dr. Assad several more times through October 2011. During these visits, Dr.

Assad determined Schink had a depressed mood and affect as well as anger and

resentfulness.

       Schink returned to see Dr. Assad various times from October 2011 through

2012 and 2013, on a biweekly basis. Dr. Assad’s records reflect that Schink’s

impulsiveness and irascibility caused him continuing trouble with relationships and

interactions with strangers, that he suffered from financial problems, and that he

struggled to follow through on scheduling medical appointments and dealing with

other logistic issues in his life.

       4. Questionnaires Completed by Drs. Assad and Hernandez

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      On October 11, 2011, Dr. Assad completed a questionnaire concerning

Schink’s mental residual functional capacity, in which he assessed Schink’s ability

to engage in work-related activities on a day-to-day basis. According to Dr. Assad,

Schink had “marked” limitations in his abilities to (1) accept instruction from or

respond appropriately to criticism from supervisors or superiors, (2) work in

coordination with or in proximity to others without distracting them or exhibiting

behavioral extremes, (3) respond appropriately to coworkers or peers, (4) relate to

the general public and maintain socially appropriate behavior, (5) maintain attention

and concentration for more than brief periods, (6) perform at production levels

expected by most employers, (7) respond appropriately to changes in work setting,

(8) maintain personal appearance and hygiene, and (9) tolerate customary work

pressures. Dr. Assad also opined that Schink had “extreme” limitations in his ability

to behave predictably, reliably, and in an emotionally stable manner. Finally, Dr.

Assad estimated that Schink had “mild” limitations in other areas. The questionnaire

defined the terms “mild,” “marked,” and “extreme” as used by Dr. Assad.

      In late September 2011, Dr. Hernandez filled out a similar questionnaire. He

did not indicate any “extreme” limitations, but he reported “marked” limitations in

the areas of Schink’s ability to behave in a predictable, reliable, and emotionally

stable manner, and in his ability to tolerate customary work pressures. In all other

areas, Dr. Hernandez found Schink to have “moderate” limitations. Dr. Hernandez

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also indicated that if Schink were placed under stress, Schink’s condition would

likely deteriorate. Dr. Hernandez based this assessment on the fact that Schink had

showed multiple “flare-ups.”

       5. Schink’s Voluntary Hospitalization

       Schink was voluntarily hospitalized for one week at Park Royal Hospital from

December 13, 2013, through December 20, 2013. A discharge summary explains

that upon admission, Schink was in distress, had mood swings, was depressed, and

was placed on supervision every fifteen minutes to ensure his safety. 2 Schink was

given lithium, Wellbutrin, and Ativan. The lithium was later replaced with Trileptal,

and Schink was started on Abilify. Upon discharge from the hospital, Schink fared

better, denying depression, anxiety, or suicidal plans. The discharge summary listed

bipolar disorder, type 2, most recent episode depressed, and mood disorder.

C.     ALJ, Appeals Council, and District Court Decisions

       In late October 2011, Schink appeared before the ALJ for a hearing on his

disability claim. On December 30, 2011, the ALJ issued an unfavorable decision.

       2
          The hospital-intake form indicates that Schink denied suicidal ideations, but it qualifies
the statement by recording that “he described feeling overwhelmed and stating to his wife that at
times he felt like giving up.” When the ALJ asked him at the hearing why he had gone to the
hospital, Schink testified that his wife had urged him to do so because she was “very concerned”
about the “really, really bad way” he was in, which included “suicidal thoughts” and “thinking
about ways to do it.” Notes from Dr. Assad dated one week following the hospital discharge also
indicate that Schink was hospitalized because of “intense thoughts of suicide [and] depression.”

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Schink filed a request for review of the ALJ’s decision, and the Appeals Council

remanded the claim by Order dated June 18, 2013.

      The ALJ held a de novo hearing on January 28, 2014, as a result of the Appeals

Council’s remand order. Schink testified at the hearing that two different employers

had fired him after less than three days of employment due to his difficulty

controlling his anger and the way he spoke to customers. He testified that it was

“really hard for [him] to deal with people” because “sometimes they really

aggravate[d] [him] very bad.” He also stated that he “[didn’t] really cook or

anything” and that he no longer drove much because he “g[o]t very, very angry at

people driving.” At one point, the ALJ remarked that Schink had cried “a couple of

times during the hearing” and asked if that was “normal” for him. Schink replied

that he was “upset” and “embarrassed” to be at the hearing, that he “want[ed] to be

able to do something,” and that he felt like he was “falling apart.” He added, “I used

to be okay. I don’t know what happened to me, you know.”

      The ALJ issued another unfavorable decision on March 16, 2015, concluding

Schink was not under a disability within the meaning of the Social Security Act from

October 1, 2004 (the alleged date of onset of disability), through September 30, 2011

(the date of last insured).

      Although the ALJ determined that Schink suffered from various physical

impairments that were severe, he found that Schink’s bipolar disorder was not

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severe. In making this determination, the ALJ discussed Schink’s treatment with

Drs. Anthony, Hernandez, and Assad, as well as the questionnaires regarding

Schink’s Mental Residual Functional Capacity completed by Drs. Hernandez and

Assad. He also acknowledged the psychological evaluation completed by Dr.

Bernard on June 30, 2010.

      The ALJ accorded minimal weight to Dr. Hernandez’s and Dr. Assad’s

opinions as set forth in their respective questionnaires. He explained that he did so,

among other reasons, because the questionnaires used terms—including “mild,”

“extreme,” and “unable to function”—that either did not appear in official forms

used by the Social Security Administration or struck the ALJ as vague or ill-defined.

As a result, the ALJ deemed the questionnaires ambiguous with respect to both the

questions asked and the providers’ responses.            He also objected that the

questionnaire did not address the category of “Understanding and Memory.” The

ALJ further accorded minimal weight to the treating doctors’ opinions because he

concluded that they were not well-supported by medically acceptable clinical and

laboratory diagnostic techniques and were inconsistent with other evidence in the

record. He also stated that the doctors provided sporadic treatment and their

treatment notes reflected only mild limitations.

      In support of his findings, the ALJ relied on the opinion of Dr. Bercik, who

concluded that Schink’s alleged mental impairments were not severe. The ALJ

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noted that although Dr. Bercik indicated that Schink had mood disorder, bipolar

disorder, and personality disorder, she opined that his impairments caused him only

mild restrictions in his activities of daily living, mild difficulties in maintaining

social functioning, and mild difficulties in maintaining concentration, persistence,

or pace. In the end, the ALJ accorded significant weight to the opinions of Drs.

Bercik and Bernard, and minimal weight to the opinions of treating physicians Drs.

Hernandez and Assad.

      In determining that Schink’s bipolar disorder was a non-severe impairment,

the ALJ concluded that Schink had only mild limitation in the area of activities of

daily living because he could clean, shop, cook, pay bills, maintain a residence, and

care appropriately for his personal hygiene, and he took care of two parrots. In

addition, the ALJ determined that Schink had only mild limitation in social

functioning because he was able to get along with others, such as family, friends,

and neighbors, and he occasionally went to church. Finally, the ALJ found that

Schink had only mild limitation in the area of concentration, persistence, and pace.

The ALJ reasoned that because, in the ALJ’s view, Schink’s mental impairment

caused no more than “mild” limitation in any of these functional areas, and because

Schink had no episodes of decompensation of extended duration, his mental

impairments were not severe.

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      Then the ALJ proceeded to step three of the sequential analysis because he

had found that some of Schink’s physical impairments were severe. At this step, the

ALJ determined that Schink did not have an impairment or combination of

impairments that met or medically equaled any listed impairment.

      At step four, the ALJ found that through the date of last insured Schink “had

the residual functional capacity to perform a full range of light work limited to

lifting/carrying up to 20 pounds occasionally and up to 10 pounds frequently,” could

“sit, stand and/or walk for a total of six hours during an eight-hour workday,” could

“occasionally stoop or crouch,” and could “frequently reach in all directions,

including overhead.” The ALJ did not include any mental capacities or limitations

in the assessment of Schink’s residual functional capacity. In arriving at this ruling,

the ALJ stated that he considered “all symptoms.” The ALJ further narrated, but did

not discuss, Schink’s testimony that he had previously received short-term disability

benefits based on his bipolar-disorder diagnosis, that he could no longer perform

work as a car salesman because he had become argumentative with managers and

customers, and that he was prescribed medication for bipolar disorder.

      Ultimately, the ALJ concluded that Schink could perform his past relevant

work as a car salesman. In the alternative, the ALJ stated without explanation that

even if Schink could not perform his past relevant work, other jobs existed in the

national economy that he could perform.

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      Schink sought review of the denial of benefits by the Appeals Council.

Among other things, Schink argued that the ALJ erred by failing to properly weigh

and analyze the treating physicians’ opinions and by finding Schink’s mental

impairments to be non-severe. Schink also argued for the first time that the ALJ was

biased against him. In support of this contention, Schink alleged that the ALJ had

been disciplined as a result of complaints filed against him by Schink’s counsel.

Under the circumstances, Schink claimed that the ALJ should have recused himself

from the case. The Appeals Council denied Schink’s request for review.

      Schink later filed a complaint with the district court seeking review of the

determination that he was not entitled to disability benefits. The district court

affirmed the Commissioner’s decision to deny Schink disability benefits. The

district court also rejected Schink’s bias claim. Schink timely appealed.

                              II. Standard of Review

      We review this Social Security appeal to determine whether the

Commissioner’s decision is supported by substantial evidence and whether the

correct legal standards were applied. Winschel v. Comm’r of Soc. Sec., 631 F.3d

1176, 1178 (11th Cir. 2011). When the Appeals Council denies review of the ALJ’s

decision, as occurred here, we review the ALJ’s decision as the Commissioner’s

final decision. Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001).

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      Substantial evidence is “such relevant evidence as a reasonable person would

accept as adequate to support a conclusion.” Id. (citation omitted). Under this

standard, we will not “decide the facts anew, reweigh the evidence, or substitute our

judgment for that of the [Commissioner].” Id. (quoting 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)). But nor will we merely rubber-

stamp a decision. We “must scrutinize the record as a whole to determine if the

decision reached is reasonable and supported by substantial evidence.” MacGregor

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

                              III. Schink’s Bias Claim

      Before turning to the merits of the appeal, we address Schink’s contention that

the ALJ exhibited bias and should have recused himself. In the past, we have noted

that “[t]he ALJ plays a crucial role in the disability review process. Not only is he

duty-bound to develop a full and fair record, he must carefully weigh the evidence,

giving individualized consideration to each claim that comes before him.” Miles v.

Chater, 84 F.3d 1397, 1401 (11th Cir. 1996) (per curiam). When the process is

compromised, the claimant is entitled to an unbiased reconsideration of his

application for benefits before a different ALJ. Id.; see also 20 C.F.R. § 404.940.

      The regulations themselves provide a process for disqualification, stating that

an ALJ “shall not conduct a hearing if he or she is prejudiced or partial with respect

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to any party or has any interest in the matter pending for decision.” 20 C.F.R. §

404.940. A claimant may object to the ALJ who is designated to conduct the

hearing, but he must give notice to the ALJ of his objections at the “earliest

opportunity.” Id. The ALJ must then consider the claimant’s objections and decide

whether to proceed or withdraw. Id. If the ALJ does not withdraw, the claimant

may, after the hearing, present objections to the Appeals Council as to why a hearing

decision should be changed or a new hearing held before another ALJ. Id.

       The bulk of Schink’s bias claim stems from his contention that the ALJ

harbored animus against his attorney. According to Schink, the animus is evident

from a lawsuit the ALJ filed against the Commissioner. Schink claims, in that

lawsuit, among other things, the ALJ accused Schink’s attorney of deceptive and

fraudulent behavior. The ALJ alleged he noticed a “pattern” that had developed

among several local attorneys who routinely requested interpreters in an attempt to

bolster the illegitimate contention that the claimants could not “communicate in

English.” See Butler v. Colvin, No. 14-60444-cv-Williams/Turnoff (S.D. Fla. 2014);

Doc. 1 at ¶ 13; Doc 1-2 at 43-44.3 The ALJ further alleged he was issued a reprimand

because he declined to reschedule three cases for hearing using a Spanish interpreter

in which Schink’s attorney represented claimants. Id. at Doc. 1 at ¶ 12; Doc 1-2 at

       3
        The Court may take judicial notice of any fact that is not subject to reasonable dispute
because it “can be accurately and readily determined from sources whose accuracy cannot
reasonably be questioned.” Fed. R. Evid. 201(b)(2).

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43. Based on this, Schink contends the ALJ was “embroiled in a personal dispute

with Schink’s counsel and should have disqualified himself from the case.”

      We express no judgment about the merits of this contention because Schink

did not raise the bias claim in a timely manner. The ALJ filed his lawsuit against

the Commissioner—which, according to Schink, showed animus toward Schink’s

counsel—on February 21, 2014. See Butler, No. 14-60444-cv-Williams/Turnoff

(S.D. Fla. 2014); Doc. 1. Approximately one year and one month later, on March

16, 2015, the ALJ denied Schink’s claim for Social Security benefits. Schink had

not raised any issue of alleged bias at that point and instead raised the issue of the

ALJ’s alleged bias for the first time on April 17, 2015, when he appealed the ALJ’s

denial of benefits. The failure to raise the bias claim earlier might be forgiven if

Schink’s counsel had been unaware of the lawsuit. But here, Schink’s counsel knew

about the lawsuit before the ALJ issued his March 16, 2015, decision and failed to

raise the bias claim at the “earliest opportunity.” He has therefore forfeited the

claim. See 20 C.F.R. § 404.940; see also McKinney v. Pate, 20 F.3d 1550, 1562

(11th Cir. 1994) (explaining that “a challenger must object to a biased [district] judge

in a motion to recuse before trial or as soon as the alleged bias is discovered,” on

pain of forfeiture).

      In particular, citations in Schink’s Opening Brief reveal this to be the case. In

an attempt to convince this Court of the ALJ’s bias, Schink’s counsel pointed to

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several “factually similar” cases in which he represented clients who also had claims

before the same ALJ and where the district court found a “risk of appearance of

bias.” When we reviewed those cases, it became obvious that counsel for Schink

was aware of the ALJ’s complaint against the Commissioner by, at the latest,

October 27, 2014. See King v. Comm’r of Soc. Sec., Case No. 2:14-cv-341-CM

(M.D. Fla. 2014); Doc. 21. On that date, in another case, counsel for Schink filed a

Memorandum in Opposition to the Commissioner’s Decision in which he attached

as an exhibit the ALJ’s complaint against the Commissioner. Id. Yet Schink did

not allege any claim of bias in the pending matter until April 17, 2015—nearly six

months later. Because Schink did not object to the ALJ’s alleged bias at the “earliest

opportunity,” Schink has forfeited the opportunity to complain of it now, and we

affirm the district court’s order to the extent that it rejects his bias claim.

                          IV. Schink’s Substantive Claims

A.     Treating Physicians’ Opinions

       Much of Schink’s appeal centers on his contention that the ALJ improperly

discounted the opinions of his treating physicians (Drs. Hernandez and Assad), who

found Schink’s mental impairments to be severe and disabling. In Social Security

cases, the opinions of a treating physician are entitled to more weight than those of

a consulting or evaluating health professional. This is because treating physicians

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are more likely to be able to give a more complete picture of the applicant’s health

history. As the Social Security Administration has explained, treating physicians

               are likely to be the medical professionals most able to
               provide a detailed, longitudinal picture of [a claimant's]
               medical impairment(s) and may bring a unique perspective
               to the medical evidence that cannot be obtained from the
               objective medical findings alone or from reports of
               individual    examinations, such        as consultative
               examinations or brief hospitalizations.

20 C.F.R. § 404.1527(c)(2).

       The ALJ must give a treating physician’s opinion “substantial or considerable

weight unless good cause is shown to the contrary.” Phillips, 357 F.3d at 1240

(citation omitted); see also 20 C.F.R. § 404.1527(c)(2).4 Good cause exists when

(1) the treating physician’s opinion was not bolstered by the evidence, (2) the

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

conclusory or inconsistent with his or her own medical records. Winschel, 631 F.3d

at 1179; Phillips, 357 F.3d at 1240-41. We have explained that the ALJ must clearly

articulate the reasons for giving less weight to the opinion of a treating physician.

Winschel, 631 F.3d at 1179; see also 20 C.F.R. § 404.1527(c)(2) (noting that “good

       4
         This regulation applies to claims filed before March 27, 2017. See 20 C.F.R. § 404.1527.
Claims filed on or after that date are governed by a new regulation prescribing somewhat different
standards for the handling of opinions from treating physicians. See id. § 404.1520c. Because
Schink’s claim was filed in February 2010, we need not and do not consider how the new
regulation would interact with our precedents requiring the ALJ to give a treating physician’s
opinion substantial or considerable weight absent an articulation of good cause to do otherwise.

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reasons” must be provided in the decision for the weight given to treating source’s

medical opinion). The failure to do so is reversible error. Lewis v. Callahan, 125

F.3d 1436, 1440 (11th Cir. 1997).

       The ALJ must consider many factors when weighing a medical opinion. See

20 C.F.R. § 404.1527(c). For instance, the Social Security regulations command

that the ALJ consider (1) the examining relationship;5 (2) the treatment relationship,

including the length and nature of the treatment relationship; (3) whether the medical

opinion is amply supported by relevant evidence; (4) whether an opinion is

consistent with the record as a whole; and (5) the doctor’s specialization. Id. Non-

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

opinions of examining physicians and do not alone constitute substantial evidence.

Sharfarz v. Bowen, 825 F.2d 278, 280 (11th Cir. 1987) (per curiam).

       After considering the record and with the benefit of oral argument, we find

that the ALJ failed to articulate good cause for discounting Dr. Hernandez’s and Dr.

Assad’s opinions in favor of the non-examining consultative physician, Dr. Bercik.

First, on this record, the ALJ should not have discounted the treating physicians’

opinions based on what he perceived to be “sporadic” treatment. True, an ALJ is

justified in discounting a physician’s opinion when the doctor has seen the claimant

       5
        More weight is given to the medical opinion of a source who examined the claimant than
one who has not.

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only once; for the purposes of our caselaw, “one-time examiners” are not properly

considered “treating physicians.” McSwain v. Bowen, 814 F.2d 617, 619 (11th Cir.

1987) (per curiam); see also Crawford v. Comm’r of Soc. Sec., 363 F.3d 1155, 1160

(11th Cir. 2004) (per curiam). We have also held that an ALJ was justified in

discounting a treating physician’s opinion when the physician “saw [the claimant]

twice and submitted only sketchy, conclusory notes.” Hudson v. Heckler, 755 F.2d

781, 784 (11th Cir. 1985) (per curiam). But in that case, it was not the low number

of examinations alone that provided good cause to discount the opinion; what

mattered more was that we found the opinion “so brief and conclusory that it lack[ed]

persuasive weight” and that it could not be said to be “[]substantiated by any clinical

or laboratory findings.” Id. (quoting Bloodsworth, 703 F.2d at 1240).

      But here, both doctors administered significant treatment to Schink multiple

times over the course of months before completing the questionnaires that contained

their ultimate opinions on his mental impairments. Dr. Hernandez saw Schink at

least three times over the course of five months before providing his opinion. He

helped to manage Schink’s treatment plan, and he prescribed Schink medications

and altered their doses based on Schink’s response. As for Dr. Assad, he saw Schink

at least eight times before assessing Schink’s mental impairments as indicated on the

questionnaire. He administered cognitive-behavioral therapy to Schink, as reflected

in his detailed notes of their therapy sessions.   Dr. Assad’s notes from Schink’s

                                          22
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intake appointment also record that Dr. Assad coordinated his treatment with Dr.

Hernandez, who had referred Schink to him in the first place. For these reasons, the

ALJ’s decision to discount Dr. Hernandez’s and Dr. Assad’s opinions was not

supported by the suggestion that Schink saw them only infrequently. Both were

undoubtedly treating physicians, and their familiarity with Schink was sufficient to

entitle their opinions to the presumption of substantial or considerable weight that is

ordinarily due to treating physicians’ opinions.

      What is more, the ALJ gave “significant weight” to the opinions of Drs.

Bernard and Bercik, even though Dr. Bernard saw Schink only once and Dr. Bercik

never saw him at all. The ALJ’s failure to apply his sporadic-treatment rationale

across the board—with no explanation given and with no obvious reason for the

inconsistency in sight—makes it impossible for us to consider this rationale “good

cause.” See Lewis, 125 F.3d at 1440–41 (rejecting the ALJ’s decision to discount a

treating physician’s opinion because he was not a cardiologist when the ALJ did not

apply the same criterion to non-treating physicians); cf. Spencer by Spencer v.

Heckler, 765 F.2d 1090, 1094 (11th Cir. 1985) (per curiam) (rejecting the ALJ’s

inconsistent reliance on one source’s opinion to undermine that of a treating

physician when the ALJ rejected the first source’s opinion about other important

matters on unexplained grounds).

                                          23
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      Next, the ALJ improperly rejected the opinions of the treating physicians

based on the format of the questionnaires completed by Drs. Hernandez and Assad.

The ALJ objected that the questionnaires used vague language, failed to track the

language of the regulatory regime and official forms used by the Social Security

Administration, and failed to “address the category of ‘Understanding and Memory’

at all.”   None of these reasons amounts to good cause for discounting the

questionnaires.

      First, the regulations do not require a doctor’s opinion to take a certain form.

On the contrary, they expressly contemplate that medical sources “may”—but need

not—use terms similar to those used in the regulations and may—but need not—use

them in exactly the same way as the Administration if they do so. See 20 C.F.R. pt.

404, subpt. P., app. 1, § 12.00(F)(3)(a) (“The medical evidence may include

descriptions regarding the diagnostic stage or level of [a claimant’s] disorder, such

as ‘mild’ or ‘moderate.’ Clinicians may use these terms to characterize [a] medical

condition. However, these terms will not always be the same as the degree of [a

claimant’s] limitation in a paragraph B area of mental functioning.”). Where no

other evidence counters the treating physician’s opinion, the ALJ cannot reject that

opinion simply because it is not in a particular format. Instead, the ALJ must address

the merits of the treating physicians’ opinions. Here, although the ALJ found certain

terms, like “mild” and “extreme,” to be vague, the questionnaire defined those

                                         24
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terms. 6    Consequently, how the treating doctors assessed Schink’s mental

impairments should not have been a mystery to the ALJ. As for the phrase “unable

to function,” it has a commonsense meaning and should not have been objectionable

to the ALJ. The same is true of the ALJ’s suggestion that time periods like “50% of

the work day or work week” were difficult to understand.

       Plus, the ALJ’s conclusion that he found the terms Dr. Hernandez’s and Dr.

Assad’s opinions employed to be vague is contradicted by the fact that the state

consultative doctor who opined about Schink’s condition—Dr. Bercik—used the

same terms, and the ALJ had no problem relying on Dr. Bercik’s opinion. Indeed,

when determining Schink’s “degree of limitation,” Dr. Bercik used a check-box

form that similarly employed the terms “mild” and “extreme.” The ALJ’s reliance

on Dr. Bercik’s opinion therefore negates this rationale for discounting the treating

doctors’ questionnaires. See Lewis, 125 F.3d at 1440–41.

       As for the ALJ’s objection that the questionnaire failed to address Schink’s

understanding and memory, we think it is beside the point. Schink’s claim is that

his bipolar disorder disables him primarily by affecting his mood, affect, and

interpersonal relationships—not his cognition or memory. Cf. MacGregor, 786 F.2d

at 1053 (holding that the claimant’s lack of intellectual impairment was not a

       6
         The term “mild” was defined as “unable to function in this area less than 10% of the work
day [or] work week.” The term “extreme” was defined as “unable to function in this area over
50% of the work day or work week.”

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sufficient reason to discount a treating physician’s opinion of his mood impairment).

To be sure, there is considerable evidence that Schink’s conditions affect his

cognition and memory. But the heart of his claim lies elsewhere. And in any event,

a medical opinion’s failure to address all possible functional limitations is not a

logical reason to discount what it says about the limitations that it does address.

         The most that can be said in criticism of the questionnaires’ format is that they

used a “check box” format with limited space for explanation of the assessments.

But that is not a basis, in and of itself, to discount them as conclusory. For one thing,

the same was true of Dr. Bercik’s opinion, which the ALJ relied on heavily, and as

we have explained, a rationale applied inconsistently for no apparent reason is not

good cause.        More importantly, treating-physician opinions “should not be

considered in a vacuum, and instead, the doctors’ earlier reports should be

considered as the bases for their statements.” Wilson v. Heckler, 734 F.2d 513, 518

(11th Cir. 1984) (per curiam). In other words, the ALJ should have interpreted Drs.

Hernandez’s and Assad’s answers to the questionnaires in light of their treatment

notes.

         Here, the doctors’ treatment notes fleshed out and were consistent with their

conclusions regarding Schink’s mental health as set forth on the questionnaires. Dr.

Hernandez’s notes reflected that Schink repeatedly presented with racing thoughts,

depression with dysthymic and anhedonic characteristics, anxiety, and a “labile”—

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that is, unstable or changeable—affect, and that he had a family history of suicide.

Dr. Hernandez also diagnosed Schink with bipolar disorder and anxiety disorder. As

for Dr. Assad, he repeatedly found Schink to have pressured speech, impaired

judgment, elevated anxiety and depression, and hypomanic affect. Dr. Assad

similarly diagnosed Schink with bipolar disorder and depression, and his notes from

before filling out the questionnaire reflect his familiarity with Schink’s interpersonal

and emotional difficulties, including a “repetitive pattern in most relationships” of

“intense anger” and passive aggression. At one of his sessions with Schink, Dr.

Assad wrote, “clearly bipolar lability is continuing.” Without question, the treatment

notes supported the questionnaires filled out by both doctors.

      The ALJ found that Drs. Hernandez’s and Assad’s notes “indicate[d] only

mild limitations in reported mental status examinations, at best,” but the ALJ did not

“clearly articulate” the basis for this conclusion, Lewis, 125 F.3d at 1440, nor do we

see how the record could support it. To be sure, some of Schink’s mental-status

examinations were better than others, and at each visit he appeared better on some

parameters than on others. For instance, as the ALJ narrated in the background

section of his opinion, Dr. Assad recorded at one therapy session that Schink

displayed “tangential” thought processes but “was able to be redirected and remain

on topic,” and Dr. Hernandez recorded at his first appointment with Schink that

Schink was “cooperative” and exhibited “organized” speech, “relevant” thought

                                          27
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content, “fair” insight, and “intact” cognition. But to discount a treating physician’s

opinion because it is “inconsistent with [the source’s] own medical records,” an ALJ

must identify a genuine “inconsisten[cy].” 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. See MacGregor, 786 F.2d at

1053–54 (explaining that there was “no inconsistency whatever” between a treating

physician’s conclusion that the claimant was so depressed “that he could not operate

under pressure nor relate appropriately to supervisors or co-workers” and the same

doctor’s statement that the claimant was “intelligent enough to understand and

follow orders and to solve problems”; after all, “highly intelligent and able people

do fall prey to crippling depression”). And the ALJ’s opinion does not so much as

hint at any real inconsistency between Drs. Assad’s and Hernandez’s treatment notes

and their opinions in the questionnaires. For example, 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.”

      Nor can we accept the ALJ’s finding that Drs. Hernandez’s and Assad’s

opinions in the questionnaires were “inconsistent with other substantial evidence of

                                          28
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record” as a good reason for discounting them, for two reasons. First, once again,

the ALJ failed to clearly articulate what evidence led him to this conclusion. See

Lewis, 125 F.3d at 1440; see also Winschel, 631 F.3d at 1179 (“[T]he ALJ must state

with particularity the weight given to different medical opinions and the reasons

therefor.” (emphases added)); MacGregor, 786 F.2d at 1053 (“The [ALJ] must

specify what weight is given to a treating physician’s opinion and any reason for

giving it no weight . . . .” (emphases added)). Second, once again, we fail to see the

inconsistency.

       Indeed, the record as a whole strikes us as consistent with the treating

physicians’ opinions. For example, the opinions in the questionnaires comported

with Dr. Anthony’s assessment that Schink’s affect was “blunted,” his energy was

low, and he had “marginal social and interpersonal involvement.” And the treating

physicians’ opinions about Schink’s social functionality are consistent with Dr.

Bernard’s evaluation, to which the ALJ “accorded significant weight.” Dr. Bernard

diagnosed Schink with a mood disorder, a personality disorder with cluster B

features, 7 “[p]roblems dealing with the social environment,” and “occupational

       7
          Cluster B personality disorders include antisocial personality disorder, borderline
personality disorder, histrionic personality disorder, and narcissistic personality disorder. See
generally DSM-IV-TR at 685, 701–17. Antisocial personality disorder is characterized by a
pattern of disregard for and violation of the rights of others. Those with borderline personality
disorder suffer from unstable interpersonal relationships and self-image and often exhibit
impulsive behavior, intense episodes of anger, and reckless behavior, among other things. They
may also display suicidal behaviors. People with histrionic personality disorder exhibit intense

                                               29
              Case: 17-14992       Date Filed: 08/27/2019      Page: 30 of 44

limitations.” He recorded that Schink’s affect was irritable; that his attitude was

“brusque, arrogant, flippant, and abrasive”; and that “[o]verall, he had a harshness

and domineering aspect to his personality.” On their face, these observations by Dr.

Bernard are consistent with the treating physicians’ opinions that Schink’s mental-

health conditions would substantially impair his social interactions and emotional

resilience in the workplace. If the ALJ discounted these observations despite

ostensibly relying on Dr. Bernard’s examination in other respects, he should have

explained why. Cf. Spencer, 765 F.2d at 1094. And if the ALJ gave “significant

weight” to these observations along with the rest of Dr. Bernard’s report, but

nonetheless concluded that the rest of the evidence was inconsistent with the treating

physicians’ opinions in the questionnaires, he should have given his reasons for

reaching that far-from-obvious conclusion.

       We recognize that the ALJ expressed his belief that Schink “was able to

participate in normal activities of daily living.” But the daily activities upon which

the ALJ relied were mostly, if not all, solitary activities such as watching television,

walking the dog, and cooking.           These activities do not discount the treating

physicians’ opinions that Schink suffered significantly from mental impairments,

particularly when he interacted with others.

emotionality and attention-seeking behavior. Individuals with narcissistic personality disorder
behave in ways associated with a sense of entitlement and superiority and may show extreme
sensitivity to criticism and a lack of empathy, among other things.

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      Finally, we reject the government’s suggestion that we affirm based on the

ALJ’s statement that Drs. Hernandez and Assad “did not cite to any medically

acceptable clinical or diagnostic techniques to support their opinions.” Even if the

discounting of their opinions could have been justified on this basis with a proper

explanation—a matter we do not consider—the ALJ provided no explanation for this

statement, leaving it an unadorned echo of a legal standard from the regulations. See

20 C.F.R. § 404.1527(c)(2). So it cannot discharge the ALJ’s duty to “clearly

articulate the reasons for giving less weight to the opinion of a treating physician.”

Lewis, 125 F.3d at 1440.

      For all these reasons, we conclude that the ALJ failed to articulate good cause

for discounting the opinions of Drs. Hernandez and Assad.

B.    Severity of Schink’s Mental Impairments

      The ALJ ultimately denied Schink’s disability claim because he found that

Schink did not suffer from a severe mental impairment and could return to his past

job as a car salesman. We agree with Schink that substantial evidence did not

support the ALJ’s finding that Schink’s mental impairments—most notably his

bipolar disorder—were non-severe as defined by 20 C.F.R. § 404.1521 We also

conclude that the ALJ erred by failing to consider Schink’s mental capabilities and

limitations when he conducted his Residual Functional Capacity (“RFC”)

assessment.

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       The Social Security regulations set forth a five-step, sequential evaluation

process to determine whether a claimant is disabled.8 At the second step of the

sequential evaluation, the ALJ must “consider the medical severity of [the

claimant’s] impairment(s).” Phillips, 357 F.3d at 1237 (alteration in original)

(quoting 20 C.F.R. § 404.1520(a)(4)(ii)). This step is a “threshold inquiry” and

       8
           The five-step sequential evaluation, as set forth in the regulations, is as follows:

                 (i) At the first step, we consider your work activity, if any. If you
                 are doing substantial gainful activity, we will find that you are not
                 disabled. (See paragraph (b) of this section.)
                 (ii) At the second step, we consider the medical severity of your
                 impairment(s). If you do not have a severe medically determinable
                 physical or mental impairment that meets the duration requirement
                 in § 404.1509, or a combination of impairments that is severe and
                 meets the duration requirement, we will find that you are not
                 disabled. (See paragraph (c) of this section.)
                 (iii) At the third step, we also consider the medical severity of your
                 impairment(s). If you have an impairment(s) that meets or equals
                 one of our listings in appendix 1 of this subpart and meets the
                 duration requirement, we will find that you are disabled. (See
                 paragraph (d) of this section.)
                 (iv) At the fourth step, we consider our assessment of your residual
                 functional capacity and your past relevant work. If you can still do
                 your past relevant work, we will find that you are not disabled. See
                 paragraphs (f) and (h) of this section and § 404.1560(b).
                 (v) At the fifth and last step, we consider our assessment of your
                 residual functional capacity and your age, education, and work
                 experience to see if you can make an adjustment to other work. If
                 you can make an adjustment to other work, we will find that you are
                 not disabled. If you cannot make an adjustment to other work, we
                 will find that you are disabled. See paragraphs (g) and (h) of this
                 section and § 404.1560(c).

20 C.F.R. § 404.1520(a)(4).

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“allows only claims based on the most trivial impairments to be rejected.” McDaniel

v. Bowen, 800 F.2d 1026, 1031 (11th Cir. 1986). The burden rests with the claimant,

however, to show that he has a severe impairment or combination of impairments.

Jones v. Apfel, 190 F.3d 1224, 1228 (11th Cir. 1999).

       “An impairment or combination of impairments is not severe if it does not

significantly limit [the claimant’s] physical or mental ability to do basic work

activities.” 20 C.F.R. § 404.1522(a); see also Phillips, 357 F.3d at 1237. Basic work

activities include the following:

             (1) Physical functions such as walking, standing, sitting,
             lifting, pushing, pulling, reaching, carrying, or handling;
             (2) Capacities for seeing, hearing, and speaking; (3)
             Understanding, carrying out, and remembering simple
             instructions; (4) Use of judgment; (5) Responding
             appropriately to supervision, co-workers and usual work
             situations; and (6) Dealing with changes in a routine work
             setting.

20 C.F.R. § 404.1522(b) (emphasis added).

      We have recognized that an “impairment is not severe only if the abnormality

is so slight and its effect so minimal that it would clearly not be expected to interfere

with the individual’s ability to work, irrespective of age, education or work

experience.” McDaniel, 800 F.2d at 1031. A claimant’s burden to establish a severe

impairment at step two is only “mild.” Id.

      Based on these standards, substantial evidence does not support the ALJ’s

conclusion that Schink’s mental impairments were not severe. On this record,
                                           33
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Schink’s impairments due to his bipolar disorder, anxiety, and mood disorder cannot

be considered only “slight” or “trivial” abnormalities. Schink’s mental-health issues

were serious enough that he was referred to and saw various mental-health

professionals over a period of years. Every doctor who saw Schink diagnosed him

with bipolar disorder or a comparable personality disorder and opined that it

significantly affected his mood, affect, and ability to interact with others. No state

doctor disputed this diagnosis. On the contrary, the only state doctor who examined

Schink, Dr. Bernard, attested to his “brusque, arrogant, flippant, and abrasive”

attitude, his “harshness and domineering aspect,” and his “irritable” affect, among

other traits corroborating a non-trivial personality disorder. The evidence bears out

these remarks by Dr. Bernard.       Here, the evidence showed that Schink was

argumentative and combative with others, regularly harbored revenge fantasies, and

even described wanting to kill his neighbor. Dr. Assad’s psychotherapy notes record

many other instances of Schink’s impulsive and irascible tendencies spurring him

into conflict with the people around him. Anger, mania, depression, and conflicted

interpersonal relationships were present in Schink’s symptomatology and surely

would have had some effect on Schink’s ability to respond to supervision and co-

workers.

      Further, Schink’s GAF scores did not support a finding that Schink’s mental

impairments should be considered “slight.” The known GAF scores ranged from 50

                                         34
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to 60, reinforcing that Schink had at least moderate difficulty in functioning. Even

the state consultative examiner Dr. Bernard, who assessed Schink for his ability to

work, determined a GAF score of 59. We recognize that GAF scores are by no

means dispositive of a claim, but, in this case, Schink’s GAF scores and the more

detailed medical evidence point to the same conclusion: that his mental-health

condition constitutes a severe impairment.

      The ALJ based his finding of non-severity in part on the conclusion that

Schink had only a “mild” limitation in his activities of daily living, stating that he

could clean, shop, cook, pay bills, maintain a residence, and care for his own

grooming needs.     But that conclusion was not substantially supported by the

evidence. Dr. Bernard recorded that Schink “attempt[ed] to cook only minimally”

and “[did] very little housework.” These assessments were consistent with Schink’s

testimony before the ALJ and with a June 2010 function report in which Schink

wrote that he cooked “easy stuff mostly,” like “sandwiches” and “frozen dinners,”

and that he did not “clean much,” resulting in “stuff pil[ing] up.” And while Schink

took care of his grooming needs and could pay bills, this hardly constitutes a full

range of daily activities, and it hardly establishes that Schink’s mental-health issues

were “so slight and [their] effect so minimal that [they] would clearly not be

expected to interfere with [his] ability to work” in any significant way. McDaniel,

800 F.2d at 1031.

                                          35
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      Indeed, Social Security regulations acknowledge that the ability to complete

tasks in settings that are less demanding than a typical work setting “does not

necessarily demonstrate [an applicant’s] ability to complete tasks in the context of

regular employment during a normal workday or work week.” 20 C.F.R. pt. 404,

subpt. P, app. 1, § 12.00(C)(6)(b). That is especially relevant where, as here, an

applicant spends most of his time among familiar (or no) people and a steady

environment, so his behavior does not necessarily show how he would function in a

work setting on a sustained basis. See id. pt. 404, subpt. P, app. 1, § 12.00(D)(3)(b).

So that Schink was able to feed and clothe himself, walk a dog, and watch television

tells us very little about whether he suffered from a severe mental impairment or

about his ability to function in a stressful work setting.

      The ALJ also found that Schink had only mild limitations in social functioning

because he could interact independently, appropriately, and effectively on a

sustained basis with other individuals. Again, no support for this conclusion exists

in the record. Rather, the record shows that Schink leads an isolated life, rarely

engaging in activities outside the home, with few or no friends, and with major and

chronic conflict in his few significant relationships. In fact, the ALJ acknowledged

that Schink spent most of his day watching television, playing on the computer,

napping, and going for long drives. These activities—which do not require or even

involve human interaction—do not establish that Schink is able to function socially.

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Instead, the record painted a picture of a depressed, agitated, frequently angry, and

sometimes tearful person who had a family history of mental illness and who had

for years seen doctors and taken medication to control his disruptive bipolar

disorder.

       The ALJ found that medication helped to manage Schink’s symptoms and that

his “on-going treatment of medication management and therapy (counseling) has

resulted in . . . a level of adaptation adequate for employment on a regular basis.”9

Whether or not Schink’s impairments, when treated, would be compatible with

employment—the question reserved for steps four and five of the sequential

analysis—the effects of treatment on Schink are not substantial evidence that his

mental impairments were non-severe. Schink’s treatment with medication was

intermittent, his prescriptions changed frequently, and he complained that

antidepressants “made him worse” and a mood stabilizer “made him feel weird.”

True, Schink sometimes spoke positively about his medications; notably, he told Dr.

Assad days after his discharge from the hospital that his then-current prescriptions

were helping. (Over the previous fortnight, Schink had been prescribed at least five

different psychotropic medications to control his near-suicidal state.) But a mere

       9
         It is not clear whether the ALJ intended these remarks to describe Schink’s response to
treatment around the time of the hearing in 2014 or his response to treatment during the 2004-2011
period for which Schink claims benefits. But this ambiguity makes no difference to our conclusion
that Schink’s mental impairments were severe.

                                               37
               Case: 17-14992        Date Filed: 08/27/2019       Page: 38 of 44

month later, Schink testified to the ALJ that his doctor was experimenting with

“different medications,” and his mental condition was obviously poor. Considering

the record as a whole, there is little evidence that medication has ever durably

improved Schink’s condition, and there certainly is no substantial evidence that it

has ever made it “so slight and its effect so minimal that it would clearly not be

expected to interfere with [his] ability to work.” McDaniel, 800 F.2d at 1031.10

Similarly, even if psychotherapy has helped Schink to a certain extent, it is obvious

that he still suffers from serious emotional and interpersonal challenges even after

years of counseling sessions with Dr. Assad.

       Nor does the fact that Schink, at times, seemed to be “doing better” support a

finding on this record that Schink’s mental impairments were non-severe. Indeed,

the bulk of the treatment notes support the notion that Schink’s mental impairments

continued well beyond his brief periods of stability. In this respect, the treatment

       10
          The Commissioner points to periods during which Schink did not take medication. In a
similar vein, the ALJ reasoned that gaps in Schink’s treatment suggested that he “had periods when
his mental health conditions were not debilitating or distressing enough to justify seeking medical
assistance.” But the record indicates that Schink’s failure to maintain consistent treatment was
much more a symptom of his disorder—particularly his emotional oscillation between manic and
depressive states, his compromised judgment, and his limited ability to follow through with plans
and to stick to regimens—than a sign of its mildness. Indeed, Dr. Assad’s treatment notes are
replete with instances of Schink complaining about his symptoms, acknowledging that he should
schedule a psychiatric appointment, yet failing to do so. In any event, this fact, weighed against
the other consistent and abundant evidence of Schink’s disruptive mental impairment, cannot on
this record support a finding that Schink’s bipolar disorder was only mild or trivial.

                                                38
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notes reflect the episodic nature of bipolar disorder and refute the lack of a severe

mental impairment.

      We agree with our sister Circuits that people with chronic diseases can

experience good and bad days. And when bad days are extremely bad and occur

with some frequency, they can severely affect a person’s ability to work:

             A person who has a chronic disease, whether physical or
             psychiatric, and is under continuous treatment for it with
             heavy drugs, is likely to have better days and worse days;
             that is true of the plaintiff in this case. Suppose that half
             the time she is well enough that she could work, and half
             the time she is not. Then she could not hold down a full-
             time job. That is likely to be the situation of a person who
             has bipolar disorder that responds erratically to treatment.

Bauer v. Astrue, 532 F.3d 606, 609 (7th Cir. 2008); accord Singletary v. Bowen, 798

F.2d 818, 821 (5th Cir.1986) (noting that although “symptom-free periods may

negate a finding of disability when a physical impairment is alleged, symptom-free

intervals do not necessarily compel such a finding when a mental disorder is the

basis of the claim” (citation omitted)).

      Here, that Schink experiences good days and bad days is to be expected. On

this record, and considering the episodic nature of Schink’s mental impairment, the

ALJ’s citation of the good days as evidence of no disability did not support a finding

that Schink did not suffer from a severe impairment (or that his doctors’ treatment

opinions are inconsistent with the record). Indeed, even Dr. Bernard (the state

consultative doctor) found Schink’s prognosis to be “chronic.” That Schink had to
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be hospitalized for one week due to intense suicidal thoughts and depression is

revealing about the depth of Schink’s condition.11

       Taking everything together, we cannot conclude that substantial evidence

supported the ALJ’s finding that Schink’s mental impairments were non-severe. On

this record, it cannot be said that Schink’s bipolar disorder and mood disorder were

abnormalities so slight and trivial that they would produce minimal effects on

Schink’s ability to work.

C.     The ALJ’s Deficient RFC Assessment

       Our conclusion that substantial evidence does not support the ALJ’s finding

that Schink’s mental impairments were non-severe does not necessarily end the

discussion. That finding could be harmless if the ALJ nevertheless proceeded in the

sequential evaluation, duly considered Schink’s mental impairment when assessing

his RFC, and reached conclusions about Schink’s mental capabilities supported by

substantial evidence. Here, though, the ALJ’s RFC assessment was limited to

Schink’s physical abilities and impairments and erroneously omitted his mental

ones. As a result, we cannot say that the erroneous finding of non-severity was

harmless.

       11
           We recognize that the timeframe during which Schink was hospitalized was after his
date of last insured, but that Schink was hospitalized because of depression—a chronic condition
for him—tends to support a finding that his mental impairments before the date of hospitalization
were severe. It also comports with Schink’s treating doctors’ opinions that Schink was susceptible
to “flare ups” and demonstrates the cyclical and episodic nature of bipolar disorder.

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      At step four of the sequential analysis, the ALJ conducts a residual-functional-

capacity assessment of the claimant, which is “an assessment, based upon all of the

relevant evidence, of a claimant’s remaining ability to do work despite his

impairments.” Lewis, 125 F.3d at 1440 (citing 20 C.F.R. § 404.1545(a)). The ALJ

makes this determination by considering a claimant’s physical, mental, and other

abilities affected by the impairment. See 20 C.F.R. § 404.1545(b)-(d). A limited

ability to carry out certain mental activities, such as limitations which affect

“responding appropriately to supervision, co-workers, and work pressures in a work

setting,” may reduce a claimant’s ability to do past work and other work. Id.

§ 404.1545(c).

      To support his conclusion that Schink was able to return to his past job as a

car salesman, the ALJ was required to consider all the duties of that work and

evaluate Schink’s ability to perform them despite his impairments.          Lucas v.

Sullivan, 918 F.2d 1567, 1574 (11th Cir. 1990). Consideration of all impairments,

severe and non-severe, is required when assessing a claimant’s RFC. Bowen v.

Heckler, 748 F.2d 629, 634-35 (11th Cir. 1984). The ALJ must also consider a

claimant’s medical condition taken as a whole. Mitchell v. Comm’r, Soc. Sec.

Admin., 771 F.3d 780, 782 (11th Cir. 2014); Phillips, 357 F.3d at 1237 (ALJ has a

duty to consider impairments in combination and to determine whether combined

impairments render the claimant disabled); see also 20 C.F.R. § 404.1523(c) and

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Social Security Ruling 96-8p. If an ALJ fails to address the degree of impairment

caused by the combination of physical and mental medical problems, the decision

that the claimant is not disabled cannot be upheld. Bowen, 748 F.2d at 634 (“[I]t is

certain that mental and psychological defects can combine with physical

impairments to create total disability to perform gainful employment.” (quoting

Brenem v. Harris, 621 F.2d 688, 690 (5th Cir.1980))).

      Here, although the ALJ stated he “considered all symptoms” when assessing

Schink’s RFC, the content of his decision demonstrates he did not. Nearly the entire

section of the ALJ’s opinion relating to RFC discusses Schink’s physical

impairments.   For instance, the decision discusses at length Schink’s obesity,

diabetes, right shoulder problems, knee pain, and sleep apnea. And while it mentions

that Schink had bipolar disorder, the decision contains no real discussion of how the

mental condition affected Schink’s RFC. Indeed, most of the references to Schink’s

bipolar disorder in the RFC section are purely biographical or occur within

summaries of medical examinations relating to Schink’s physical conditions. Cf.

Ambers v. Heckler, 736 F.2d 1467, 1470 (11th Cir. 1984) (“[I]t does not appear that

the ALJ considered Ambers’ other psychological impairments. . . . The ALJ made

no findings on these, other than to restate the physicians’ diagnoses of these

impairments.”). In fact, the ALJ’s ultimate conclusions as to RFC do not include

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even a single finding about Schink’s mental capacities. Instead, the ALJ’s findings

concern Schink’s physical capacities exclusively.

      Even the most favorable interpretation of the ALJ’s opinion—namely, that the

ALJ considered Schink’s mental conditions in the RFC assessment sub silentio and

implicitly found that they imposed no significant limitations on his work-related

mental capacities—would not permit us to affirm because, as our precedent holds,

the ALJ’s “failure . . . to provide the reviewing court with sufficient reasoning for

determining that the proper legal analysis has been conducted mandates reversal” in

its own right. Keeton v. Dep’t of Health & Human Servs., 21 F.3d 1064, 1066 (11th

Cir. 1994). We recognize that in finding Schink’s bipolar disorder to be a non-severe

impairment, the ALJ went through the four broad functional areas known as the

“paragraph B” criteria. But the ALJ also explained that the “limitations identified

in the ‘paragraph B’ criteria are not a residual functional capacity assessment but are

used to rate the severity of mental impairments at steps 2 and 3 of the sequential

evaluation process.” As acknowledged by the ALJ in his opinion, the mental RFC

assessment used at steps 4 and 5 of the process “requires a more detailed assessment

by itemizing various functions contained in the broad categories found in paragraph

B of the adult mental disorders listings in 12.00 of the Listing of Impairments.” Even

if we assume the RFC assessment conducted by the ALJ included some silent

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consideration of Schink’s mental impairments, we have no way of knowing whether

it included the “more detailed assessment” required.

      Severe or not, the ALJ was required to consider Schink’s mental impairments

in the RFC assessment but evidently failed to do so. And as a result of this error, we

cannot say that the ALJ’s earlier error in finding Schink’s mental impairments to be

non-severe was harmless. In short, the ALJ provided no real assessment of how

Schink’s mental impairments—including depression, mania, and anger—affected

his ability to work. The assessment was therefore inadequate.

                                   V. Conclusion

      For the foregoing reasons, we find that Schink’s claim of bias was forfeited

but that the ALJ failed to articulate good cause for discounting the opinions of Drs.

Hernandez and Assad, the ALJ’s finding of non-severity is not supported by

substantial evidence, and the ALJ failed to consider Schink’s mental impairments in

assessing his RFC. Accordingly, the judgment of the district court is affirmed in

part and reversed in part, and this case is remanded to the district court with

instructions to vacate the Commissioner’s decision and to remand to the

Commissioner for further proceedings consistent with this opinion.

      AFFIRMED IN PART, REVERSED IN PART, AND REMANDED

WITH INSTRUCTIONS.

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