Sandra Diaz v. KILOLO KIJAKAZI, Acting Commissioner of Social Security

United States Court of Appeals
For the Seventh Circuit
Chicago, Illinois 60604
Argued July 12, 2023
Decided August 16, 2023
Before
DIANE S. SYKES, Chief Judge
ILANA DIAMOND ROVNER, Circuit Judge
DIANE P. WOOD, Circuit Judge
No. 22-2904
SANDRA DIAZ,
Plaintiff-Appellant,
v.
KILOLO KIJAKAZI,
Acting Commissioner of Social Security,
Defendant-Appellee.
Appeal from the United States District Court
for the Eastern District of Wisconsin.
No. 21-CV-810
William E. Duffin,
Magistrate Judge.
O R D E R
Sandra Diaz, who suffers from several physical and mental impairments
(including bipolar disorder) that limit her ability to work, appeals the district court’s
decision affirming the Social Security Administration’s denial of her application for
supplemental security income. This case has had an extremely protracted history. Diaz
filed her application in 2006 and has had six hearings with various administrative law
judges. She was found to be disabled as of June 1, 2016. At issue here is the ten-year
period between her alleged onset date of October 10, 2006, and May 31, 2016. A
magistrate judge, who previously remanded the action because the ALJ did not
NONPRECEDENTIAL DISPOSITION
To be cited only in accordance with FED. R. A PP. P. 32.1

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adequately justify discounting the opinion of the agency’s consultative examiner,
upheld the ALJ’s decision. This is a close case, but we affirm.
Background
We assume familiarity with the extensive procedural history in this case, so we
confine our summary of the background to the evidence of Diaz’s mental impairments
from 2006 to 2016.
In 2006, Diaz was being treated for bipolar disorder by Dr. Michael Eis, a
psychiatrist. Dr. Eis noted that Diaz was often tearful or depressed during their visits.
He prescribed several medications, including an antidepressant and antipsychotic, as
well as psychotherapy. Later that year, Diaz reported auditory hallucinations, although
these improved and “essentially disappeared” in later months. Dr. Eis noted that Diaz
had “some borderline personality traits,” which may have been related to the
hallucinations.
At the end of 2006, a state agency psychological consultant reviewed Diaz’s
records and determined that she had mild difficulties with social functioning and
moderate difficulties in concentration, persistence, and pace. A second state agency
physician affirmed that determination.
The severity of Diaz’s symptoms generally waned over the next few years and
her bipolar disorder was deemed less severe, though she had a few periods of decline.
For example, in early 2007, she reported feeling “down” after missing several
psychotherapy appointments. But a few months later, Dr. Eis described Diaz as “doing
much better” with a “bright, cheerful, pleasant” affect. But in mid-2009, he noted that
she was not doing as well and had a “down” mood.
In connection with Diaz’s application for SSI, Dr. Eis twice wrote to Diaz’s
attorney about Diaz’s limited ability to work. In 2009, he wrote that her “ability to
handle competitive workplace stress” was “extremely limited and would lead to a
significant relapse of symptoms.” In 2010, he reiterated that Diaz’s ability to engage in
competitive employment was “extremely limited.”
In late 2010, the agency asked Dr. Roland Manos, a psychologist (since deceased),
to perform a consultative examination of Diaz. Dr. Manos, who examined Diaz and
reviewed her prior medical records, described her as “tearful” and in “mild-to-
moderate distress.” Diaz described herself, in turn, as highly irritable. She told Dr.
Manos that she “hear[s] voices” and was “a wreck” but said that medication helped.
She said that her daughter performed many household tasks for her. Dr. Manos wrote
that Diaz’s reported symptoms were consistent with her bipolar disorder diagnosis as

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well as borderline personality disorder. As relevant to this appeal, Dr. Manos concluded
that Diaz was markedly restricted in her ability to interact appropriately with
supervisors and coworkers. Additionally, he concluded that she seemed “to be
intolerant of routine stress” but “capable of adapting to changes.”
In late 2011, Diaz gave birth, after which she developed postpartum depression.
Her primary care physician noted that she had a depressed mood and thoughts of self-
harm. Diaz was encouraged to attend a day-treatment program but declined because,
she said, she lacked childcare. Over the next two years, Diaz saw two psychiatrists, who
characterized her symptoms as severe or observed a low mood and tearful affect.
Diaz apparently did not receive further mental-health treatment until late 2016,
when she seems to have experienced worsening symptoms and restarted treatment.
(Diaz says she did not seek further care during that period because she lacked medical
insurance, but it is not clear when and for how long she was uninsured.) Diaz continued
treatment into 2018.
Between 2006 and 2016, Diaz had many other medical visits that did not involve
her mental impairments (i.e., diabetes or a sinus infection), and practitioners
consistently noted that she appeared “oriented,” “pleasant,” or “cooperative.” Diaz at
times reported to her non-mental health providers that her bipolar disorder symptoms
were well-controlled and denied depression or anxiety, even when she was not
receiving mental-health treatment.
We pick up the story with the ALJ’s partially favorable decision in 2018. The ALJ
concluded—without explanation—that Dr. Manos’s sober assessment of Diaz’s stress
tolerance conflicted with “her improvement with medication, her generally good
mental status examinations, and the absence of more intensive and highly structured
mental health care.” In addition, the ALJ ascribed little weight to Dr. Manos’s opinion
of Diaz’s ability to interact with coworkers, stating that it relied on Diaz’s subjective
reports and was inconsistent with the record.
Diaz appealed, and a magistrate judge reversed the Commissioner’s
determination that Diaz was not disabled before June 1, 2016. The magistrate judge
concluded that the ALJ “failed to provide good reasons for discounting the opinions of
the consultative examiner regarding Diaz’s limitations with respect to work-related
stress and interactions with coworkers and supervisors.”
On remand, a new ALJ held a sixth administrative hearing and again concluded
that between 2006 and 2016, Diaz was not disabled. Applying the five-step disability
analysis, see 20 C.F.R. § 416.920(a)(4), the ALJ determined that (step 1) Diaz had not

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engaged in substantial gainful activity during the relevant period; (step 2) her bipolar
disorder, asthma, obesity, postpartum depression, diabetes mellitus, and diabetic
neuropathy were severe impairments; but (step 3) none of these equaled a listed
impairment; (step 4) she could perform medium work until July 2015 and light work
until May 2016 (subject to the restrictions described to the vocational expert); and
(step 5) there were a significant number of jobs in the national economy that Diaz could
perform.
The ALJ gave Dr. Manos’s opinion partial weight but did not adopt his
assessment of Diaz’s stress intolerance. Like the prior ALJ, she found this assessment
inconsistent with Diaz’s improved symptoms while taking medication, generally good
mental status examinations, and relatively conservative treatment (she had not needed
to be hospitalized). The ALJ also gave little weight to Dr. Manos’s opinion about Diaz’s
social interactions, an opinion she found unsupported:
Moreover, Dr. Manos’s conclusions are not consistent with the overall
evidence of record, as there is little in the objective treatment records (other
than the claimant’s subjective complaints) to support prominent or
significant social limitations. As noted consistently throughout the previous
Administrative Law Judge’s decision, the record consistently establishes
that the claimant regularly interacts appropriately with treating and
examining providers and demonstrates some ability to engage in activities
requiring her to go out into the community and interact well with others.
Diaz sought review in the district court, arguing primarily that the ALJ failed to
adequately support her decision to disregard Dr. Manos’s opinions. This time, the
magistrate judge upheld the ALJ’s determination. He concluded that although the ALJ
cited many of the same reasons identified as insufficient in the remand order, the ALJ
offered “a more detailed explanation” and “additional evidence” that satisfied the
agency’s burden. For example, the magistrate judge stated that the ALJ went beyond
noting merely that Diaz’s symptoms had improved; the ALJ pointed to evidence that
undermined Dr. Manos’s opinion that Diaz was intolerant of stress. And the magistrate
judge explained that the ALJ rightly afforded little weight to Dr. Manos’s view that
Diaz had marked impairments in her social functioning; the ALJ pointed out that
Dr. Manos failed to identify the factors supporting his assessment despite being asked
to do so. And the ALJ, according to the magistrate judge, supported her conclusion that
Diaz could interact with others “with a lengthy discussion of specific evidence.”

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Analysis
On appeal, Diaz challenges only the ALJ’s treatment of Dr. Manos’s opinions
about her ability to handle routine stress and workplace interactions. Our review is
deferential. We will uphold the ALJ’s determination if it is supported by substantial
evidence. Biestek v. Berryhill, 139 S. Ct. 1148, 1153 (2019). Substantial evidence is merely
“such relevant evidence as a reasonable mind might accept as adequate to support a
conclusion”; it is not a high bar. Id. at 1154. There is an additional wrinkle here because
Dr. Manos not only was an examining physician, meaning that his opinions generally
receive greater weight than non-examining physicians, see 20 C.F.R. § 416.927(c)(1)
(2017), but he was the agency’s physician. We will expect a “good explanation” for the
agency’s “unusual step” of discounting the opinion of its own doctor. Beardsley v.
Colvin, 758 F.3d 834, 839 (7th Cir. 2014).
Diaz generally argues that the ALJ did not provide sufficient reasons for
discounting Dr. Manos’s opinion about her stress tolerance. She raises many fact-
specific challenges to the ALJ’s decision: For instance, she argues that the ALJ did not
afford Dr. Manos appropriate deference as an examining physician, relied on “rote”
observations by non-mental health providers, and “played doctor” by relying on
findings unrelated to Diaz’s stress tolerance (such as Diaz’s consistently appropriate
judgment and appearance).
Although the question is close, we conclude that substantial evidence supports
the ALJ’s determination that Diaz was not as intolerant of stress as Dr. Manos stated.
The ALJ permissibly weighed the medical evidence, including that from non-mental
health providers, and concluded that it conflicted with Dr. Manos’s assessment. As the
magistrate judge appropriately noted, “[t]he gist of the ALJ’s conclusion was that, if
Diaz really was as sensitive to stress as Manos believed, there would be more evidence
of her symptoms being exacerbated by stress.”
Although the ALJ might have made her reasoning more explicit, substantial
evidence supports her determination that Dr. Manos’s opinion of Diaz’s stress tolerance
was inconsistent with the record. For example, the ALJ emphasized that even when
Diaz was “under extreme stress,” she reported to Dr. Eis that she experienced
comparatively minimal symptoms—faint auditory hallucinations that were not
bothersome. Additionally, the ALJ observed that Diaz’s non-mental health providers
consistently noted no psychological issues or abnormalities in Diaz’s appearance. The
ALJ also permissibly noted that Diaz did not require more intensive care, see SSR 16-3p,
2017 WL 5180304 (Oct. 25, 2017), and that her symptoms improved with medication.
See Schmidt v. Barnhart, 395 F.3d 737, 745 (7th Cir. 2005).

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The ALJ also supported her conclusion that Dr. Manos overstated Diaz’s stress
limitations by pointing to evidence that Diaz’s statements, which informed the doctor’s
opinion, were inconsistent with her own reports to other doctors. See Bates v. Colvin,
736 F.3d 1093, 1100 (7th Cir. 2013). For instance, in October 2010, Diaz told Dr. Manos
that she had stopped treatment and run out of medications the previous April because
she lost health insurance; she reported that her psychiatric symptoms had returned and
she was depressed and had mood swings. But in September and November 2010, she
told her primary care physician that her bipolar disorder was well-controlled; that
physician’s records indicate no abnormalities in her appearance or affect.
Diaz raises several similar objections to the ALJ’s treatment of Dr. Manos’s
assessment of her workplace social interactions. She asserts that the ALJ erred by
incorrectly stating that Dr. Manos did not support his findings, cherry picking records
that suggested Diaz was cooperative while ignoring the rest of the record, and giving
too much weight to Diaz’s ability to cooperate with providers and perform some daily
activities.
But the ALJ’s determination that Diaz was not more than moderately limited in
her social abilities was supported by substantial evidence. The ALJ was entitled to give
Dr. Manos’s opinion little weight after concluding that it was inconsistent with the
record. See 20 C.F.R. § 416.927(c)(3)–(4). The ALJ permissibly noted that Diaz regularly
interacted appropriately with her treating physicians, who often described her as
cooperative or pleasant—indeed, Diaz was described as cooperative even when she
otherwise had severe mental-health symptoms. She also rightly observed that Diaz
declined anger management therapy and she was able to work out those issues on her
own. And the ALJ again relied on Diaz’s symptom improvement when she was on
medication. To the extent Diaz argues that the ALJ failed to consider that cooperating
with a doctor is different than cooperating at work, the ALJ accounted for that
difference by limiting Diaz to jobs with only “occasional” workplace interactions.
Diaz also challenges the ALJ’s assertion that Dr. Manos did not adequately
support his assessment that she had marked limitations in her ability to interact with
coworkers and supervisors. She points to Dr. Manos’s statement that her symptoms
were consistent with borderline personality disorder. But even if we accept that Diaz
has borderline personality disorder, she still had the burden to show that the disorder
limited her ability to work. See Schmidt, 395 F.3d at 745–46.
Notwithstanding our conclusion that substantial evidence supports the ALJ’s
decision, we agree with Diaz that some of the evidence the ALJ relied on is weak or
unrelated to the functional areas at issue. For instance, the ALJ did not explain how

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Diaz’s weight loss was "inconsistent with" her inability to handle routine stress. And the
evidence the ALJ relied on (such as Diaz’s appearance, intact judgment, and linear
thinking) did not directly contradict Dr. Manos’s opinions about stress and sociability:
Rather, it suggested that Diaz was generally functioning well. See Bates, 736 F.3d at 1101
(if ALJ thought medical evidence insufficient, it was “her responsibility to recognize the
need for additional evaluations”). Further, Dr. Manos saw from his review of Diaz’s
records that her symptoms improved; despite this, he concluded that Diaz was
intolerant of routine stress and markedly impaired in her social functioning. Finally, the
ALJ at times seems overly concerned that Dr. Manos’s opinion relied on Diaz’s
“subjective reports,” but this court has repeatedly said that an ALJ may not discount a
medical opinion merely because it depends on the claimant’s subjective statements.
See Adaire v. Colvin, 778 F.3d 685, 688 (7th Cir. 2015).
But ultimately, it was Diaz’s burden to prove her disability, Karr v. Saul, 989 F.3d
508, 513 (7th Cir. 2021), and she did not do so here. As the Commissioner argues, Diaz
points to little evidence supporting that she was more than moderately limited in her
stress tolerance and social interactions. Thus, even though “reasonable minds” might
have reached a different outcome, the ALJ’s opinion was supported by substantial
evidence. See id.
AFFIRMED

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