Winchester v. O'Malley

Background

Belinda Winchester applied for disability insurance benefits and supplemental security income under the Social Security Act. She alleged disability beginning January 13, 2016, based on a torn rotator cuff, chronic migraines, depression, anxiety, neck and lower-back problems, and reactive airway disease. After a July 2022 hearing, an administrative law judge (ALJ) found her not disabled. The Appeals Council denied review, and Winchester asked the district court to reverse the decision and remand the case.

The ALJ found several physical conditions severe but found Winchester’s migraines and psychological impairments non-severe at Step Two of the five-step disability analysis. The ALJ then determined that Winchester had the residual functional capacity (RFC)—her remaining ability to work despite her impairments—to perform light work with additional restrictions. The ALJ found she could perform her past work as a clerk and other jobs, including mail room clerk and packer.

The Court’s Analysis

The court held that the ALJ erred in finding Winchester’s migraines non-severe. Step Two is a low-threshold screening step: an impairment is not severe only when the evidence shows it has no more than a minimal effect on the person’s ability to work. The court found substantial evidence of repeated migraine complaints from 2016 through 2022, migraine diagnoses, prescribed medications, changes in medication, and continued symptoms despite generally compliant treatment. Winchester also testified that her migraines occurred two or three times per month and caused pain, dizziness, nausea, light sensitivity, and difficulty concentrating.

The court also held that the ALJ erred in finding Winchester’s psychological impairments non-severe. The record included diagnoses and treatment relating to depression, post-traumatic stress disorder, and other mental-health conditions. The court found that the ALJ improperly relied on Winchester’s limited mental-health treatment without considering whether her mental impairments contributed to that lack of treatment. The court also found that the ALJ relied too heavily on a psychologist’s suggestion that Winchester may have exaggerated her emotional problems, without making an express finding of intentional deception or considering whether any exaggeration could itself be a symptom of her diagnosed conditions.

Because the Step Two errors affected the ALJ’s weighing of medical opinions and the RFC determination, the court did not resolve Winchester’s remaining arguments, including her challenge to the evaluation of her testimony. The court granted Winchester’s motion to remand, reversed the Commissioner’s decision, and remanded for further proceedings. On remand, the ALJ must reconsider the effectiveness and side effects of migraine treatment, any migraine-related work restrictions, the significance of the possible exaggeration noted in the psychological evaluation, the medical opinions, and the severity of Winchester’s mental-health limitations. The court did not decide whether Winchester is entitled to benefits.