United States Court of Appeals
For the Seventh Circuit
Chicago, Illinois 60604
Argued January 23, 2019
Decided February 15, 2019
Before
DIANE P. WOOD, Chief Judge
MICHAEL S. KANNE, Circuit Judge
AMY J. ST. EVE, Circuit Judge
No. 18‐2180
CARRIE ANN PAUL, Appeal from the United States District
Plaintiff‐Appellant, Court for the Southern District
of Indiana, Terra Haute Division.
v. No. 2:17‐cv‐00235‐MJD‐WTL
NANCY A. BERRYHILL, Mark J. Dinsmore,
Acting Commissioner of Social Security, Magistrate Judge.
Defendant‐Appellee.
O R D E R
Carrie Paul suffers from several mental impairments. She applied for
supplemental security income claiming disability based on a seizure disorder, anxiety,
and polysubstance dependence, among other things. An administrative law judge
concluded that she had moderate mental difficulties, but that she could work with
certain limitations. The district court upheld that decision. She now contends that the
No. 18‐2180 Page 2
ALJ improperly rejected the opinion of an agency psychologist and failed adequately to
account for her mental impairments. We agree that the substantial evidence does not
support the ALJ’s findings, and so we remand this case to the agency for further
proceedings.
I
Paul was 39 years old when she filed her application for benefits, alleging an
onset date of February 1, 2013. She identified several ailments that prevented her from
working: a spinal‐fusion surgery in 1983 with lumbar spondylolisthesis, scoliosis,
schizoaffective disorder, seizure disorder, anxiety, and polysubstance dependence.
Because Paul contests only the ALJ’s conclusions regarding her mental conditions, we
limit our analysis to those conditions.
In connection with her application, Paul had a psychological consultative
examination in April 2013 with Dr. Leah Powell, who concluded that Paul’s difficulties
managing her behavior hindered her ability to work. Dr. Powell opined that “[s]he is
impulsive, has difficulty making good decisions, and has difficulty controlling her own
behavior” and that “[t]hese symptoms are contraindicated with work related activities.”
Dr. Powell diagnosed schizoaffective disorder–bipolar type, generalized anxiety
disorder, and alcohol abuse. Dr. Powell assigned a “Global Assessment of Function,” or
GAF, of 51,1 indicating moderate symptoms or moderate difficulty in social or
occupational functioning. AM. PSYCHIATRIC ASS’N, DIAGNOSTIC AND STATISTICAL
MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994). She also observed that Paul’s mood
was “tense,” and that she was “compromised” in managing her mood, anger, and her
responsibilities in interpersonal relationships. During the exam, Paul discussed her
depressed mood, irritability, difficulty concentrating and remembering, and sleep
disturbances. She stated that she began treatment for her depression 20 years ago and
experiences bipolar symptoms. Paul also said that she experienced daily panic attacks,
chronic crying episodes, and visual hallucinations, delusions, and suicidal ideations.
Though Paul showed “no evidence of distractibility,” Dr. Powell also reported Paul’s
“difficulty with immediate memory and in her attending skills” and that her social
judgment was compromised.
1 This is a measure that is no longer recognized in the American Psychiatric Association’s DIAGNOSTIC
AND STATISTICAL MANUAL OF MENTAL DISORDERS, but it was used regularly in social security disability
hearings at the time of Paul’s proceedings. See Price v. Colvin, 794 F.3d 836, 839 (7th Cir. 2015).
No. 18‐2180 Page 3
Agency psychologist Dr. Joseph Pressner reviewed Dr. Powell’s report and
treatment records in July 2013. He noted Paul’s difficulties maintaining concentration,
persistence, or pace, but he concluded that she could work. He identified four areas in
his mental residual‐capacity assessment in which Paul has moderate limitations: the
ability to (1) understand and remember detailed instructions; (2) respond to detailed
instructions; (3) maintain attention and concentration for long periods; and (4) perform
activities within a schedule and maintain regular attendance. Yet he reported that
despite her limitations in immediate memory and sustained attention, Paul “is
cognitively capable of performing simple, repetitive work‐like tasks on a sustained
basis at a reasonable pace without special considerations.”
After a referral from probation following a DUI charge, Paul began counseling in
June 2014 with a behavioral health therapist. The therapist diagnosed polysubstance
dependence and noted the possibility of bipolar disorder based on Paul’s history of
manic behavior and depressive symptoms. She further recommended that Paul attend
intensive outpatient therapy for substance abuse three times a week. The therapist
observed that Paul’s mood was depressed and anxious but that her memory,
orientation, and intellect were within normal limits. Paul is “often impulsive,” the
therapist noted, and fails to think through consequences easily. At her first session, Paul
stated that she cannot sleep because of her anxiety and feels sad daily, is constantly
fatigued, and struggles getting out of bed, concentrating, and remaining focused. Paul
lacks friends, the therapist said, because she does not trust others. The therapist also
assessed a GAF of 60, demonstrating moderate difficulty in social or occupational
functioning. AM. PSYCHIATRIC ASS’N, supra. Although Paul did not attend therapy
regularly, the therapist observed that she was “highly distractible” and had difficulty
maintaining focus.
Paul’s claim for disability benefits was denied initially and upon reconsideration,
and so she proceeded to a hearing before an administrative law judge. Paul first
testified about her daily activities, recounting that her husband and teenage children
vacuum and do the laundry because those activities cause her pain. She primarily cooks
microwaved meals for her family because she cannot stand at the stove. She then
testified about her mental‐health limitations, particularly her difficulties with
interpersonal relationships and maintaining focus. She said that she does not have any
friends and her social interactions are limited to her family because being around others
causes her stress. She also struggles to concentrate and gets off task easily. On days
when she experiences bipolar episodes, she does not get up at all and remains in her
room for days at a time without leaving or showering.
No. 18‐2180 Page 4
A vocational expert (“VE”) testified that Paul had the capacity to work if the
work adhered to specific mental‐health limitations. The ALJ asked the expert to
consider a hypothetical claimant with Paul’s vocational background and education who
had the mental capacity to perform “simple, routine, repetitive tasks” that do not
require directing others, abstract thought, or planning; and would involve only “simple,
work related decisions, and routine workplace changes.” The ALJ added that the
claimant would require work that could be performed at a “flexible pace,” meaning that
it is “free of production rate pace where there are no tandem tasks or teamwork or one
production step that’s dependent upon the prior step.” And the job must entail only
occasional interaction with the public, coworkers, or supervisors. The expert testified
that, with these limitations and the relevant physical limitations, the person could work
as a housekeeping cleaner, marker, routing clerk, microfilm document preparer, ampule
sealer, and para‐mutual ticket checker.
Appling the familiar five‐step analysis, see 20 C.F.R. § 416.920(a), the ALJ
concluded that Paul was not disabled. At Step 1, the ALJ determined that Paul had not
engaged in substantial gainful employment since her onset date. At Step 2, the ALJ
found that Paul’s remote spinal fusion with lumbar spondylolisthesis, scoliosis,
schizoaffective disorder, seizure disorder, anxiety, and polysubstance disorder were
severe impairments. At Step 3, he acknowledged that she had moderate difficulties in
social functioning and concentration, persistence or pace because of her compromised
memory, attention, thought processes, and judgment. But he found that she did not
meet any of the agency’s listings for a presumptively disabling impairment. Between
Steps 3 and 4, the ALJ then assigned a residual functional capacity (“RFC”) consistent
with that of the hypothetical claimant he described to the VE. The ALJ attributed some
of Paul’s symptoms to her medically determinable impairments, but found she
overstated the intensity, persistence, and limiting effects of the symptoms. And the ALJ
decided that the opinion evidence of the agency’s psychologist, Dr. Powell, warranted
“little weight,” because it was a one‐time examination, not specific in terms of
functioning, and was inconsistent with Paul’s daily activities and treatment records.
Finally, at Step 5, the ALJ determined that Paul could not perform any past relevant
work but could find other work in the national economy.
After the Appeals Council denied review, Paul sought judicial review. The
parties agreed to have the case adjudicated by a magistrate judge, see 28 U.S.C. § 636(c),
and he in turn upheld the ALJ’s decision. The judge concluded that the ALJ reasonably
discounted Dr. Powell’s opinion because it was vague and conclusive, and that the
No. 18‐2180 Page 5
ALJ’s RFC assessment appropriately incorporated Paul’s mental‐health limitations,
given Dr. Pressner’s opinion that Paul could perform simple tasks at a “reasonable pace
without special considerations.”
II
A. Dr. Powell
Paul first contends that the ALJ improperly evaluated the opinion of the agency’s
examining psychologist, Dr. Powell. She challenges each of the ALJ’s reasons for
discounting Dr. Powell’s opinion (i.e., that it was a one‐time examination, was not
specific in terms of functioning, and was inconsistent with Paul’s daily activities and
treatment records). If fully credited, Dr. Powell’s opinion—that Paul’s mood disorder,
impulsivity, and difficulties in interpersonal relationships are “contraindicated with
work related activities”—suggests that Paul required a more restrictive RFC.
The ALJ’s decision to afford Dr. Powell’s opinion “little weight” is perplexing
because, although an ALJ may discount the opinion of the agency’s examining
physician when contrary evidence exists, see Beardsley v. Colvin, 758 F.3d 834, 839
(7th Cir. 2014), Dr. Powell’s examining notes are consistent with Paul’s treatment
records. Both Paul’s therapist and Dr. Powell reported that Paul had a depressed mood,
experienced sleep disturbances because of anxiety, had difficulty with interpersonal
relationships, concentration, and focus, and was impulsive, failing to think through the
consequences. Both providers assigned GAF scores that indicated moderate difficulty in
social or occupational functioning.
An ALJ may not discount the opinion of an examining physician without a valid
explanation, see Beardsley, 758 F.3d at 839, and here the ALJ failed to support his
decision. First, the ALJ wrongly discounted Dr. Powell’s opinion for being based on a
one‐time examination when he gave “great weight” to non‐examining physician
Dr. Pressner, whose opinion was based on a one‐time review of Paul’s mental‐health
records (including a review of Dr. Powell’s own examining notes). Further, the agency’s
regulations instruct that the medical opinion of an examining source, such as Dr.
Powell, generally receives more weight than the medical opinion of a non‐examining
source, such as Dr. Pressner. See 20 C.F.R. § 416.927(c)(1). A conclusion to the contrary
requires a “good explanation for this unusual step,” Beardsley, 758 F.3d at 839, which the
ALJ did not supply here.
No. 18‐2180 Page 6
Second, the ALJ’s finding that Dr. Powell’s opinion “is vague and not specific in
terms of functioning” is unsupported by the evidence. Again, the ALJ did not
substantiate this finding. And Dr. Powell’s opinion was sufficiently specific: the six‐page
narrative report recounted Paul’s performance on her mental‐status exam and included
the doctor’s behavioral observations of Paul; included observations that Paul’s mood
was tense, that she had symptoms associated with bipolar disorder like “mood swings,
depressed mood, irritability, racing thoughts, and difficulty concentrating and
remembering”; and contained explicit findings that Paul had difficulty with her
immediate memory and in her attending skills, had a compromised mood due to her
schizoaffective disorder, and that “work related activities” were “contraindicated” with
her difficulty managing her behavior and her responsibilities in interpersonal
relationships. In any case, if the ALJ believed that Dr. Powell’s opinion was deficient,
the ALJ should have sought additional clarification from Dr. Powell before discounting
it outright. See 20 C.F.R. § 416.919p; Simila v. Astrue, 573 F.3d 503, 516 (7th Cir. 2009).
We are also unimpressed with the final two reasons the ALJ gave for rejecting
Dr. Powell’s opinion—that the opinion deserved little weight because “the claimant was
not consistent with attending her mental health therapy, and she continues to be able to
take care of a household, including her two children.” Regarding the former, the ALJ
does not explain why Paul’s inconsistent attendance at her therapy sessions provides a
reasonable basis to discount the examining physician’s opinion. Moreover, ALJs
assessing mental illness and bipolar disorder must consider possible alternative
explanations before racing to conclusions about noncompliance with medical directives.
See Jelinek v. Astrue, 662 F.3d 805, 814 (7th Cir. 2011) (stating that bipolar disorder is “by
nature episodic and admits to regular fluctuations even under proper treatment” so
ALJs must consider alternative explanations before determining that non‐compliance
supports an adverse credibility inference). And Paul’s ability to maintain her
household, by performing simple chores, does not indicate a capacity to work full‐time.
See Roddy v. Astrue, 705 F.3d 631, 639 (7th Cir. 2013). Paul’s family, including her two
teenage children, do the household chores such as laundry and vacuuming. And even
though Paul sometimes cooks using the microwave, she testified that during bad
periods she does not leave her room for consecutive days.
B. Limitations in concentration, persistence, or pace
In her second argument, Paul contends that the ALJ erred in his RFC assessment
when he failed to account for his own findings of moderate limitations in concentration,
persistence, or pace. This flawed RFC, she adds, tainted the hypothetical question that
No. 18‐2180 Page 7
he posed to the VE. To the extent that the RFC refers to “simple, routine, repetitive
tasks,” Paul says that these limitations are insufficient to encompass her difficulties
maintaining her focus and concentration. Further, she asserts that the reference in the
RFC to “flexible pace”—as tasks that exclude “production rate pace” or “tandem tasks
or teamwork where one production step is dependent on the prior step”—also does not
adequately address her difficulties, because it fails to specify the particular pace at
which she can work.
Paul’s challenge to the RFC is well‐taken. Though an RFC assessment need not
recite the precise phrase “concentration, persistence, or pace,” any alternative phrasing
must clearly exclude those tasks that someone with the claimant’s limitations could not
perform. See Moreno v. Berryhill, 882 F.3d 722, 739 (7th Cir. 2018), as amended on reh’g
(Apr. 13, 2018); O’Connor‐Spinner v. Astrue, 627 F.3d 614, 619 (7th Cir. 2010). Paul’s
ability to learn routine, unskilled tasks does not address whether she can also maintain
the concentration and focus needed to sustain her performance of that task for an
extended period. See Moreno, 882 F.3d at 730. The RFC and the hypothetical question
here exclude complex tasks that require higher‐level thinking but do not acknowledge
Paul’s moderate limitations with following a schedule and sticking to a given task. And
the ALJ’s reference to “flexible pace” is insufficient to account for Paul’s difficulties
maintaining focus and performing activities within a schedule, because the reference
excludes only production‐pace employment. See Varga v. Colvin, 794 F.3d 809, 815 (7th
Cir. 2015). Without more, the VE cannot determine whether someone with Paul’s
limitations could maintain the proposed pace or what the proposed pace even is. See id.
Thus, because the ALJ failed to provide sufficient reasons to discount
Dr. Powell’s opinion, and because the hypothetical questions to the vocational expert
did not capture Paul’s difficulties with attention and concentration, we VACATE the
district court’s judgment and REMAND this case to the Social Security Administration
for further proceedings.