Court Opinion

ID: 4356279
Source: CourtListenerOpinion
Date Created: 2019-01-04 23:00:18.96467+00
Date Added: 2024-06-11T14:46:23.170316
License: Public Domain

NONPRECEDENTIAL DISPOSITION
                To be cited only in accordance with Fed. R. App. P. 32.1

                United States Court of Appeals
                                For the Seventh Circuit
                                Chicago, Illinois 60604

                              Argued December 11, 2018
                               Decided January 4, 2019

                                        Before

                            DIANE P. WOOD, Chief Judge

                            KENNETH F. RIPPLE, Circuit Judge

                            AMY C. BARRETT, Circuit Judge

No. 18-1654

JACQUELYEN DERRY,                              Appeal from the United States District
     Plaintiff-Appellant,                      Court for the Northern District of
                                               Illinois, Eastern Division.
      v.
                                               No. 16-cv-11434
NANCY A. BERRYHILL, Acting
Commissioner of Social Security                Susan E. Cox,
    Defendant-Appellee.                        Magistrate Judge.

                                      ORDER

       Jacquelyen Derry is a 49-year-old woman who suffers from several trauma-
related mental health conditions—posttraumatic stress disorder (PTSD), generalized
anxiety disorder, military sexual trauma, panic disorder, and major depressive
disorder—as well as severe migraines. She is seeking disability insurance benefits from
the Social Security Administration. Thus far, however, her efforts have failed. An
administrative law judge held a hearing and rejected her claim, and the Appeals
Council declined to intervene. Derry contends that the ALJ improperly disregarded
both key physician assessments and the finding of the Veterans’ Administration that
No. 18-1654                                                                         Page 2

she is disabled. We agree with her that substantial evidence does not support the
agency’s conclusion, and so we remand for further proceedings.
                                             I
        Derry served in the U.S. Navy from 1988 until September 30, 2010, achieving the
rank of E-7, Dental Tech Chief Petty Officer. In 2007, her supervising officer at the Great
Lakes Naval Station began sexually harassing her. After she rejected his advances and
reported his conduct, she was moved to another work area. But she struggled to adjust
to the culture there. As a result of her problems in the workplace, she developed
migraines and had trouble sleeping. In June 2009, her new supervisor accused her of
dereliction of duty for leaving her post to get feminine hygiene products for her
irregular menstrual bleeding. She was brought to a conduct board of six “master chiefs”
who verbally abused and humiliated her. Shortly after, in August 2009 (just before her
alleged disability-onset date), Derry was admitted to a psychiatric hospital for five days.
Doctors there diagnosed her with depressive disorder and migraines related to her
work environment.
       In September 2010, Derry accepted an honorable discharge from the Navy
because of her medical conditions. After her discharge, a VA doctor diagnosed her with
major depressive disorder, recurrent; PTSD; and military sexual trauma. Dr. Laura Sunn
treated Derry for her mental illnesses from March 2011 to November 2012, when Dr.
Sunn left the VA clinic. Dr. Sunn noted that Derry had trouble concentrating and
limited short-term memory. Although Derry was coherent, logical, and cooperative, Dr.
Sunn documented the following impairments: depression; errors on serial sevens (i.e.
counting backward from 100 by sevens); slow speech; psychomotor retardation; and a
downtrodden and subdued appearance. Dr. Sunn stated that Derry was “so[] impaired
that she cannot seek work and it is unlikely that she could concentrate long enough to
complete tasks.” Dr. Sunn continuously reported that Derry’s mental status and ability
to function were unchanged.
        Derry also began seeing a VA therapist, Lisa Storie, in early 2011. Storie noted
later that year that Derry was doing better. But in September 2011, Derry was isolating
herself and was not taking care of herself; this continued into December. Storie, Dr.
Sunn, and other providers continued throughout 2012 to report similar findings: such
reports appear at no less than 15 places in the record. (Administrative Record 330, 405,
433–34, 441, 553, 649, 846, 849, 858, 893, 914, 929, 931, 985, 992.) At times Derry showed
improvements, but at other times she missed appointments because, according to Dr.
Sunn, her mental conditions made it hard for her to leave the house. Derry’s new
No. 18-1654                                                                        Page 3

psychiatrist, Dr. Corrine Belsky, diagnosed Derry with panic disorder in December
2012.
       Derry’s migraines with aura continued after she left the Navy; by early 2011, she
reported having them twice a week. She continued to receive treatment for them
throughout 2012. In July 2012, neurologist Dr. Hien Dang documented that most
medications did not help Derry’s migraines. Dr. Dang ordered an MRI. The initial and
follow-up MRIs showed signs of lesions “consistent with migraine headaches.” Derry
began therapeutic botulinum toxin injection treatment. Dr. Dang noted that this
treatment helped but that additional medicine also was needed. In November 2012, Dr.
Dang found Derry too dizzy and lightheaded to undergo her scheduled treatment and
sent her to the emergency department instead.
       From February to June 2013, the medical records showed a gap in treatment. In
June, Derry saw her doctors for worsening migraines. In July 2013, Dr. Belsky wrote
that Derry had been in Florida “caring for her mom” for six months and felt “better.”
(When the ALJ asked Derry about this, she testified that her family had brought her
home, and her mother was sick with bronchitis while she was there.) Dr. Belsky also
reported, however, that Derry was still having panic attacks twice a week and frequent
nightmares. Several times, Derry’s family members in Florida drove to Illinois to bring
her home and care for her, at one time because she had suicidal thoughts.
        Derry applied for social security disability benefits in 2013. She underwent state-
agency evaluations in connection with her application. Dr. Julia Kogan diagnosed Derry
with depression. Dr. Gregory Rudolph found that she experienced PTSD symptoms;
presented vegetative symptoms; was oriented to reality; had intact memory skills; was
able to use judgment and reasoning skills; exhibited a depressed mood level; and had a
limited prognosis and insight. Dr. Russell Taylor completed a remote consultative
examination by video feed. He concluded that Derry could understand simple and
detailed instructions; sustain concentration and persist well enough to carry out simple
tasks for a normal work period; make work-related decisions; interact and communicate
sufficiently in a work setting with reduced social/interpersonal demands; could not
continuously interact with the public; and could adapt to simple, routine changes and
pressures. In May 2014, Dr. Thomas Low performed a remote consultative examination
and agreed with Dr. Taylor’s findings.
       In October 2013, Derry underwent evaluations to determine her Navy pension
and benefits. Neurologist Dr. Robert Hazelrigg examined Derry in person and found
that she had “very frequent characteristic prostrating and prolonged attacks of migraine
headache pain,” citing her medical records and the two MRIs. He concluded that her
No. 18-1654                                                                        Page 4

headache condition diminished her ability to work. Dr. Brian Lipson also reviewed
medical records and examined Derry, observing that her major depressive disorder and
PTSD symptoms had increased since her previous evaluation in 2010. He opined that
Derry’s depressive disorder, migraine headaches, and PTSD rendered her unable to
secure and maintain substantially gainful employment. Dr. Mark Aghakhan examined
Derry and reviewed her “documentation and reported symptomology”; he found that
she demonstrated average insight, unimpaired judgment, but that she showed
extensive symptoms of PTSD and depression. Dr. Aghakhan opined that Derry’s mental
impairments had increased since her 2010 exam, and her depressive and PTSD
symptoms affected her functioning. The VA determined that Derry was disabled and
unable to secure or follow substantially gainful employment.
       Derry continued to see Dr. Dang for migraines throughout 2013. In November
2013, Dr. Dang again sent Derry to the emergency department for severe symptoms. Dr.
Dang noted that while therapeutic injections helped, her “chronic recurrent
migraine[s]” were “refractory” to medications.
       Throughout 2014, Derry’ new therapist, Andrea Fafford, and psychiatrist
Dr. Patricia Zaror both noted that Derry had full insight and intact judgment but also
documented persistent symptoms of depression, military sexual trauma, and PTSD—
neurovegetative symptoms, distorted thinking and perception of events, psychomotor
retardation and agitation, and sleeping during the day. Fafford noted that Derry still
had difficulty prioritizing specific objectives; her thinking was distorted; and she was
not able to change too many things at once because her low stress tolerance caused
“overwhelming and sabotage”—an assessment that Fafford repeated many times. In
June 2014, Derry told Fafford that she had not moved to Florida to be with her family
only because her trust issues made her fearful of leaving her medical providers and
having to start over.
       In early 2015, Derry went to Florida but kept in touch with Fafford. When she
came back, Dr. Zaror noted that Derry “said that being [with] her family, walking,
biking makes her happy.” Derry was still “sleeping a lot.” The psychiatrist recorded
that Derry exhibited psychomotor retardation and a constricted affect. Throughout
2015, Fafford assessed no improvements in Derry’s mental state.
                                            II
       Derry applied for social security disability benefits on May 14, 2013. Her
application was initially denied, and so she requested a hearing. See 20 C.F.R. § 404.929.
At the hearing, she testified about her physical and mental health problems and the
limitations they caused. Derry denied that she participated in any of her former
No. 18-1654                                                                        Page 5

activities, such as luncheons, walking at the mall, or church. The ALJ asked about a
psychiatrist’s note reporting that Derry liked walking and biking in Florida, but Derry
denied that she had biked in the last four or five years.
       Next, the vocational expert testified that jobs existed in the national economy for
a hypothetical person such as Derry who, according to the ALJ, retained the residual
functional capacity (RFC) to perform light work consistent with mild limitations for
daily functioning and moderate limitations for social functioning and concentration,
persistence, and pace. But he also stated that such a person would not be able to sustain
competitive work if she missed two days a week on account of migraines or difficulties
with motivation, nor if she were off task 15% of the time or needed additional breaks to
lie down.
        The ALJ concluded that although Derry had severe impairments, she was still
able to perform certain work and thus was not disabled. In coming to that conclusion,
the ALJ dismissed the opinions of treating psychiatrists Dr. Sunn and Dr. Zaror and did
not even discuss how she weighed the opinions of other treaters, such as the therapists
and Dr. Dang. The ALJ also disregarded the VA’s disability rating, because she thought
it relied too heavily on subjective reports and was unsupported by the medical records
and gaps in treatment. She said the same of Dr. Lipson’s opinion. As for Drs. Aghakhan
and Hazelrigg, the other two VA pension examiners, the ALJ found overall support for
the former’s opinion but questioned whether Aghakhan had reviewed the entire record,
and considered Hazelrigg’s opinion vague. The ALJ gave the agency’s consultative
examiners’ opinions greater weight because they specifically addressed each of Derry’s
functional capacities and were, in the ALJ’s view, consistent with the medical evidence.
       Last, the ALJ concluded that Derry’s impairments could reasonably be expected
to produce the reported symptoms, but (using language about “credibility” that the
Social Security Administration has eliminated from its regulations, see Social Security
Ruling 16-3P) her statements about their intensity, persistence, and limiting effects were
not “entirely” credible. The ALJ believed that Derry minimized her efforts to go to
college and had not mentioned sleeping during the day to her providers. Derry’s trips
to Florida, the ALJ thought, showed that she was not severely impaired.
                                           III
       This court reviews the ALJ’s decision de novo, upholding it if it is supported by
substantial evidence. Derry contends that the ALJ improperly accorded little weight to
the medical opinions of her VA physicians, who treated her for several years. She
argues that the medical records support those opinions and correspond with the
reported intensity and frequency of her symptoms.
No. 18-1654                                                                          Page 6

       We agree with Derry that the ALJ failed properly to explain why she rejected the
opinion of Dr. Sunn, who treated Derry at length. Under the regulations in effect at the
time of the ALJ’s decision, a treating physician’s opinion that is consistent with the
record is generally entitled to “controlling weight.” 20 C.F.R. § 404.1527(c)(2); Jelinek v.
Astrue, 662 F.3d 805, 811 (7th Cir. 2011). An ALJ must give more weight to the opinions
of doctors who have (1) examined a claimant, (2) treated a claimant frequently and for
an extended period of time, (3) specialized in treating the claimant’s condition, (4)
performed appropriate diagnostic tests on the claimant, and (5) offered opinions
consistent with objective medical evidence and the record as a whole. Roddy v. Astrue,
705 F.3d 631, 637 (7th Cir. 2013) (citing 20 C.F.R. § 404.1527(c)(2)(i), (ii)). All of these
factors support giving significant weight to Dr. Sunn’s opinion that Derry was too
impaired to seek work or complete tasks. See id.
       Indeed, the ALJ’s opinion is confusing in its treatment of Dr. Sunn. Although the
ALJ acknowledged that Dr. Sunn was a longitudinal specialist, the ALJ also stated that
Dr. Sunn’s opinion was a “snapshot” of Derry’s functioning rather than a “longitudinal,
function-by-function assessment” supported by the record. The “snapshot” observation
has no basis in the record. In fact, Dr. Sunn’s treatment and examination records for the
period from March 2011 to November 2012 support her assessment of Derry’s
functional limitations. We have described those records in detail above and see no
reason to repeat them here. Dr. Sunn consistently reported that Derry’s mental status
exam was unchanged or worse. The ALJ did not account for objective observations
confirming the severity and persistence of Derry’s depression, PTSD, and military
sexual trauma. Nor did the ALJ explain why or how Dr. Sunn’s assessment was not
“consistent with objective medical evidence and the record as a whole.” See Roddy, 705
F.3d at 637. She also failed to explain why Dr. Sunn’s 20-month course of treatment
deserved less weight than the opinions of consultative examiners who each interacted
with Derry one time over a video feed.
       The ALJ also improperly disregarded Dr. Zaror’s opinion that Derry suffered
“paralyzing” migraines, stating without any elaboration that Dr. Dang’s treatment
records did not support this characterization. The record, once again, is definitively to
the contrary. Dr. Dang twice brought Derry to the emergency room because her
migraines were too acute for him to treat during a regular office visit. His entire
treatment record reflects positive diagnostic testing and aggressive treatment of
migraines. And during the pension review, Dr. Hazelrigg, the VA neurologist, reviewed
Dr. Dang’s treatment records and the MRIs and opined that Derry suffered “very
frequent characteristic prostrating and prolonged attacks of migraine headache pain.”
The ALJ’s failure to address the medical evidence corroborating Derry’s subjective
No. 18-1654                                                                         Page 7

complaints and Dr. Zaror’s assessment amounts to “cherry picking the medical record.”
See Cole v. Colvin, 831 F.3d 411, 416 (7th Cir. 2016).
       The ALJ also failed to explain why she gave the VA’s disability rating such little
weight. Even though the VA’s evaluation of disability gives the benefit of the doubt to
the claimant, a VA rating that a claimant’s impairments prevent her from engaging in
substantially gainful employment is “practically indistinguishable” from the Social
Security Administration’s disability determination. See Bird v. Berryhill, 847 F.3d 911,
913 (7th Cir. 2016). The ALJ said the VA’s rating was of “limited evidentiary value”
because it was inconsistent with records of “primarily normal objective physical and
mental findings,” but she did not point to any of these “normal” findings, and so there
is no way to know what medical records she believed conflicted with the VA rating.
       Also troubling are some leaps of logic the ALJ made that are difficult to justify.
For example, she discounted Dr. Hazelrigg’s opinion about Derry’s migraines affecting
her ability to work because “her station and gait were normal.” The connection between
those factors and the migraines is nowhere explained. The years of treatment notes
documenting Derry’s severe depression and PTSD meant little to the ALJ because Derry
had “good hygiene, [and was] cooperative, polite and alert.” Again, that supposed
conflict is unexplained. The ALJ’s failure appropriately to account for the VA’s
disability determination and the medical opinions supporting it (e.g., those of Drs.
Aghakhan, Lipson, and Hazelrigg) requires a remand. See Hall v. Colvin, 778 F.3d 688,
691 (7th Cir. 2015).
        Yet another problem lies in the ALJ’s failure logically to connect the evidence in
the record to her determination of Derry’s mental RFC. As discussed above, the ALJ
erroneously analyzed the medical record. She also relied on incorrect information. In
rejecting Derry’s statement that she sleeps most of the day, for example, the ALJ stated
that Derry never reported this degree of impairment to her examiners or treatment
providers. The record is otherwise. Derry told numerous different providers
throughout the years that she stays in bed most of the day. Dr. Zaror also documented
that Derry presented neurovegetative symptoms of trouble sleeping at night. This
evidence could support limitations on daily functioning and concentration, persistence,
and pace, but the ALJ did not consider it.
       The RFC determination was further marred when the ALJ set an impractically
high and legally incorrect bar for establishing disabling mental illness. See Voight v.
Colvin, 781 F.3d 871, 878 (7th Cir. 2015). The ALJ stated that Derry had only moderate
difficulties in social functioning because she had no history of being fired for not getting
along with others and had no history of multiple arrests or incarcerations. Where that
No. 18-1654                                                                          Page 8

standard came from is a mystery. Moreover, the ALJ overlooked evidence that Derry
does have trouble interacting with other people. The treatment records show that Derry
had conflicts with her supervisors resulting in discipline, and her 2009 hospitalization
was partially because of these conflicts. And the ALJ did not discuss any of the medical
evidence showing that Derry has trouble trusting others and processing change, and
that she experienced social anxiety and tended to isolate herself because of her
childhood and military sexual trauma. The ALJ should have explained why this
evidence mattered less than the fact that, in 22 years of Navy service, Derry was never
fired, arrested, or incarcerated and achieved the rank of Chief Petty Officer. See Craft v.
Astrue, 539 F.3d 668, 676–78 (7th Cir. 2008).
        The ALJ also undercut the severity of Derry’s problems with concentration,
persistence, and pace without discussing most of the relevant evidence, primarily from
Derry’s treating physicians. Derry’s providers repeatedly noted her concentration
problems, her difficulty completing tasks and goals, and her distorted thinking and
perception. The ALJ was required properly to reconcile this evidence with her own
thinly supported conclusions about Derry’s residual functional capacity. See Clifford v.
Apfel, 227 F.3d 863, 873–74 (7th Cir. 2000).
        The ALJ’s adverse credibility determination suffers from the same flaws of
overlooking or misstating parts of the medical record and giving, without proper
explanation, dispositive weight to the opinions of consultative doctors over treaters.
Further, the ALJ discounted Derry’s reported mental limitations by stating that Derry
tried to minimize that she went to college, but the ALJ was silent about the fact that
Derry received a disability accommodation and was unable to complete her original
program. Moreover, Derry’s mere “desire to work”—or attend school—“is not
inconsistent with her inability to work because of a disability.” Hill v. Colvin, 807 F.3d
862, 868 (7th Cir. 2015) (emphasis in original). The ALJ also does not explain why she
interpreted Derry’s trips to Florida as evidence that she was capable of work, rather
than as reflecting her family’s belief that she needed to be in their care.
                                             IV
       Because the ALJ provided inadequate explanations for rejecting the VA’s
disability rating and the opinions of Derry’s treating physicians, while neglecting to
address substantial evidence contrary to her conclusion, we VACATE and REMAND
for further proceedings.