Debara DeCamp v. Nancy A. Berryhill, Acting Commissioner, Social Security Administration

Debara DeCamp, a 55-year old woman, challenges

the denial of her applications for Disability Insurance

Benefits and Supplemental Security Income, in which she

claimed disability based on a benign brain tumor, neck and

back issues, and bipolar disorder. DeCamp argues that the administrative

law judge erred by failing to (1) evaluate

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properly DeCamp’s limits with concentration, persistence, or

pace, (2) support her decision to limit DeCamp to 10 percent

off-task time for purposes of assessing residual functional capacity

(“RFC”), and (3) support her adverse credibility determination.

We agree that the ALJ did not properly address De-

Camp’s limitations in concentration, persistence, or pace, and

on that basis we remand.

I. BACKGROUND

DeCamp has a history of depression, drug overdoses, and

suicidal thoughts. She overdosed on medication three times

in October 2007. She admitted to doctors that she had attempted

suicide and had been cutting her legs. Her treatment

notes also reflect a history of alcohol abuse.

In 2010 DeCamp complained of headaches, and an MRI

revealed a tumor in her pineal gland, which secretes hormones

that regulate sleep cycles. A neurosurgeon noted that

the mass was benign and directed DeCamp to follow up about

her migraines with her primary-care doctor, Dr. Jane Walloch,

and repeat the MRI in six months. DeCamp did so, and Dr.

Walloch—noting an improvement in DeCamp’s headaches—

increased her dosage for Cymbalta (an antidepressant). De-

Camp also told Dr. Walloch of her plans to travel, and the doctor

told DeCamp to follow up upon her return.

DeCamp returned to Dr. Walloch in 2011 and reported

feeling depressed. She no longer had health insurance, De-

Camp said, so Cymbalta was too expensive. DeCamp told Dr.

Walloch that her headaches had returned and that she was

“cutting again” in connection with her depression. Dr. Walloch

changed DeCamp’s medication and referred DeCamp to

psychiatric counseling.

No. 18-2105 3

In August 2011 Dr. Esther Lefevre, a psychologist, reviewed

DeCamp’s medical records and completed two questionnaires—

a Psychiatric Review Technique (“PRT”) Form

and a Mental Residual Functional Capacity Assessment

(“MRFC”). On the PRT form, Dr. Lefevre checked a box noting

that DeCamp had “moderate” limitations in maintaining

concentration, persistence, or pace. The doctor also designated

on the MRFC form that DeCamp was “moderately limited”

in two more ways—her ability (1) “to perform activities

within a schedule, maintain regular attendance, and be punctual

within customary tolerances” and (2) “to complete a normal

workday and workweek without interruptions from psychologically

based symptoms and to perform at a consistent

pace without an unreasonable number and length of rest periods.”

In a supplemental narrative explanation, Dr. Lefevre

elaborated that DeCamp “may have some difficulty with concentration

and persistence at times but she is able to meet the

demands of basic unskilled work.”

DeCamp told Dr. Walloch in November 2011 that her

headaches were worse. She added that she was not harming

herself and had no suicidal thoughts. Dr. Walloch changed

DeCamp’s medication for her migraines and encouraged her

to follow up with her primary care doctor for an MRI of her

head.

Agency psychologist Michael Goldstein, Ph.D., examined

DeCamp in March 2012 and prepared a report that described

mental limitations similar to those found by Dr. Lefevre. Dr.

Goldstein noted that DeCamp had “mild” limitations in understanding,

remembering, and carrying out simple instructions,

and “moderate” limitations in maintaining concentration,

attention, and work pace, and in adapting to change.

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And DeCamp had “extreme” limitations in withstanding routine

work stresses and responding appropriately to co-workers

and supervisors.

Dr. Deborah Pape, another state-agency doctor, opined

that DeCamp was more limited than Dr. Lefevre found. On a

MRFC form, Dr. Pape specified that DeCamp was “markedly”

limited in her abilities “to understand and remember detailed

instructions” and “to carry out detailed instructions.” She also

was “moderately” limited in her ability to sustain concentration

and persistence. Dr. Pape made “no severe findings of

diff[iculty] getting along [with] others, supervisors or

coworkers,” but she added that DeCamp was “capable of

withstanding the demands of unskilled as defined by SSA”

with moderate limitations.

At a hearing in December 2012 before an ALJ, DeCamp described

how pain in her back, leg, and hands limited her daily

activities. Her pain made it difficult to stand, walk, sleep, or

grip things. She added that she cared for a dog and a bird and

was able to make simple meals, like soup or microwaved

meals. And she said that she was able to walk to her mailbox

and back.

At another hearing in 2015,1 DeCamp testified that she

had migraines four times a week that lasted all day. On a typical

day, she would watch television, read, use social media,

and lie down. Her medications also made her tired, so she

preferred to sleep when she felt “super depressed.” But her

drug and alcohol problems were under control, she added.

1 The Commissioner had agreed to a new hearing after the ALJ issued

an unfavorable decision without explaining how Dr. Pape’s opinion was

used in crafting DeCamp’s mental RFC.

No. 18-2105 5

The ALJ then questioned the vocational expert about jobs

a hypothetical claimant with similar limitations to DeCamp

could perform. The ALJ asked the vocational expert whether

jobs existed for a hypothetical claimant who, as relevant here,

was:

limited to unskilled work involving [Specific Vocational

Preparation (“SVP”)]: 2 or less; no fast paced

production line or tandem tasks; few if any changes

in the work setting, meaning that the work place and

tasks change no more than occasionally and only

one or two times per month at most; no more than

occasional interaction with coworkers, supervisors,

and the public; she may be off task or off pace up to

10 percent of the work day in addition to regular

breaks.

The vocational expert, who testified that she had reviewed

an unspecified “E file”2 in preparation for the hearing, responded

that jobs existed for such a person. But if the hypothetical

claimant might “be off pace or off task more than 15

percent of the work day” or “need additional unscheduled

breaks,” then no competitive work would be available.

The ALJ applied the required five-step analysis for assessing

disability, see 20 C.F.R. §§ 404.1520(a)(4),

416.920(a)(4), and concluded that DeCamp was not disabled.

The ALJ determined that DeCamp had not engaged in substantial

gainful employment since her alleged onset date in

February 2009 (step one); that her conditions (“history of

2 We asked the parties at oral argument to clarify what was in De-

Camp’s “E file.” They agreed that the “E file” is a subset of the administrative

record, namely, those files designated with the letter “E” at the end

of the exhibit number.

6 No. 18-2105

cervical discectomy in 2003; right carpal tunnel release in

2004; L5-S1 lumbar fusion in 2010; chronic back pain;

longstanding neoplasm of the pineal gland; headaches; history

of substance abuse; and affective and anxiety disorders”)

were severe impairments (step two); that these conditions did

not equal a listed impairment (step three); that she had the

residual functional capacity to perform light work, except that

she was limited to “unskilled work … with no fast-paced production

line or tandem tasks,” and she could “occasionally interact

with coworkers, supervisors, and the public,” and she

“may be off task up to 10 percent of the workday, in addition

to normal breaks” (step four); and that she could work as a

machine tender, sorter, or office helper (step five).

In determining that DeCamp’s conditions did not equal a

listed impairment at step three, the ALJ applied a so-called

“special technique” to evaluate mental impairments.

See 20 C.F.R. §§ 404.1520a, 416.920a. That method requires an

ALJ to consider “pertinent symptoms, signs, and laboratory

findings” to determine whether a claimant suffers from a

medically determinable mental impairment.

Id. §§ 404.1520a(b), 416.920a(b). Although the ALJ determined

that DeCamp did not have a listed impairment, the ALJ concluded

that DeCamp had “moderate” restrictions in social

functioning and concentration, persistence, or pace, and

“mild” limitations in her activities of daily living.

In determining DeCamp’s RFC, the ALJ gave some weight

to the mental limitations identified by Drs. Lefevre, Pape, and

Goldstein. Those doctors’ opinions supported “moderate” restrictions

in concentration, persistence, or pace, and “mild”

restrictions in understanding, remembering, and carrying out

simple instructions. The ALJ therefore limited DeCamp to

No. 18-2105 7

“unskilled work with an SVP of 2 or less, with no fast-paced

production line or tandem tasks, at a job that allows her to be

off task up to 10% of the workday.” The ALJ also referred to

the opinions of Dr. Lefevre and Dr. Pape, who regarded De-

Camp’s limitations not to be disabling.

The ALJ found that DeCamp’s account of her symptoms

was “not entirely credible” for four reasons. First, DeCamp

had decided to take a vacation after her alleged onset date.

The ALJ recognized that “a vacation and a disability are not

necessarily mutually exclusive,” but DeCamp’s willingness to

travel suggested that she had overstated her symptoms. Next,

DeCamp regularly walked her dog, an activity that conflicted

with her reports of disabling leg pain. Third, DeCamp’s appearance

at her mental-status evaluations and hearings, as

documented by the examining doctors, suggested that she

was not as disabled as she alleged. Last, DeCamp’s medical

records did not reflect that she had complained of pain or

other disabling symptoms from her conditions.

DeCamp sought judicial review, but a district judge upheld

the ALJ’s decision. The judge explained that the ALJ’s

credibility assessment was sound because “the ALJ thoroughly

discussed the substantial evidence that supports her

decision.” Moreover, the ALJ properly oriented the vocational

expert through hypothetical questions that adopted the doctors’

narrative explanations of DeCamp’s mental limitations.

And DeCamp’s challenge to the ALJ’s determination that De-

Camp would be off-task up to 10 percent of the work day

failed, the judge added, because her “argument assumes a

precision that this kind of limitation does not allow.” Rather,

the ALJ’s finding permissibly was “based on her judgment as

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to the severity of Plaintiff’s impairments, not a mathematical

measurement.”

II. ANALYSIS

DeCamp first argues that the ALJ’s RFC determination

and hypothetical question did not include all her limitations

in concentration, persistence, and pace, and so the vocational

expert could not evaluate whether jobs existed for a claimant

with her limitations. Rather, DeCamp contends, the ALJ included

limitations in the hypothetical question that did not

accurately describe her abilities. The ALJ must explicitly account

for all a claimant’s limitations in her hypothetical, including

limitations in concentration, persistence, or pace, unless

the vocational expert has independently reviewed the

medical record. See Moreno v. Berryhill, 882 F.3d 722, 730 (7th

Cir. 2018); Lanigan v. Berryhill, 865 F.3d 558, 563, 565 (7th Cir.

2017).

We agree that the ALJ erred by not including DeCamp’s

“moderate” limitations in concentration, persistence, and

pace in the hypothetical question to the vocational expert. The

ALJ’s hypothetical to the vocational expert omitted any mention

of DeCamp’s moderate limitations in the four areas identified

by Dr. Pape (whose opinion the ALJ cited to support her

finding): maintaining attention and concentration for extended

periods; performing activities within a schedule,

maintaining regular attendance, and being punctual within

customary tolerances; working in coordination or proximity

to others without being distracted; and completing a normal

workday and workweek without interruptions from psychologically

based symptoms and performing at a consistent

pace. The ALJ opted instead to limit DeCamp to “unskilled

work” with no “fast-paced production line or tandem tasks.”

No. 18-2105 9

We have previously rejected similar formulations of a claimant’s

limitations because there is no basis to suggest that eliminating

jobs with strict production quotas or a fast pace may

serve as a proxy for including a moderate limitation on concentration,

persistence, and pace. See Moreno, 882 F.3d at 730;

O’Connor-Spinner v. Colvin, 832 F.3d 690, 698 (7th Cir. 2016).

The ALJ’s analysis is similarly flawed with respect to De-

Camp’s mild limitations in understanding, remembering, and

carrying out simple instructions and her moderate limitations

in concentration, persistence, and pace as found by Dr. Goldstein.

An ALJ need not use “specific terminology,” but we

have “repeatedly rejected the notion that a hypothetical …

confining the claimant to simple, routine tasks and limited interactions

with others adequately captures temperamental

deficiencies and limitations in concentration, persistence, and

pace.” Yurt v. Colvin, 758 F.3d 850, 858–59 (7th Cir. 2014); see

also Winsted v. Berryhill, No. 18-2228, 2019 WL 494052, at *4

(7th Cir. Feb. 8, 2019); Varga v. Colvin, 794 F.3d 809, 814 (7th

Cir. 2015). Moreover, the vocational expert did not review De-

Camp’s medical records, which could have excused the ALJ

from stating all DeCamp’s limitations. See Varga, 794 F.3d at

814; Yurt, 758 F.3d at 857.

The Commissioner contends that the ALJ adequately accounted

for DeCamp’s limitations in her RFC determination

and in the hypothetical question to the vocational expert by

relying on part of the narrative explanations (the part of the

PRT and MRFC forms where the doctors provide a written

explanation of their findings, rather than the check-box sections)

offered by Dr. Pape and Dr. Goldstein. True, both doctors

offered narrative explanations in addition to the checkboxes

on the assessment forms, and an ALJ may rely on those

descriptions. See Varga, 794 F.3d at 816. But even if an ALJ may

10 No. 18-2105

rely on a narrative explanation, the ALJ still must adequately

account for limitations identified elsewhere in the record, including

specific questions raised in check-box sections of

standardized forms such as the PRT and MRFC forms. See

Yurt, 758 F.3d at 859. In Yurt, a narrative explanation translated

the limitations identified by doctors in the check-box

sections of the forms. See id. at 854–55. We still reversed and

remanded because the ALJ did not adequately account for the

limitations identified by the doctor in the check-box section of

the forms. See id. at 859. Here, the ALJ similarly focused her

analysis on the doctors’ bottom-line conclusion that DeCamp

was not precluded from working without giving the vocational

expert any basis to evaluate all DeCamp’s impairments,

including those in concentration, persistence, and pace.

Because we determine that the ALJ did not properly evaluate

DeCamp’s limitations in concentration, persistence, and

pace, we do not address DeCamp’s other arguments. Accordingly,

we VACATE the judgment and remand this case to the

district court with directions to remand the case to the Social

Security Administration.