United States Court of Appeals
                             For the Eighth Circuit
                         ___________________________

                                 No. 16-2191
                         ___________________________

                                     Janet Chesser

                        lllllllllllllllllllll Plaintiff - Appellant

                                            v.

           Nancy A. Berryhill1, Acting Commissioner of Social Security

                       lllllllllllllllllllll Defendant - Appellee
                                      ____________

                     Appeal from United States District Court
                  for the Eastern District of Arkansas - Jonesboro
                                   ____________

                            Submitted: January 12, 2017
                               Filed: June 9, 2017
                                 ____________

Before COLLOTON, GRUENDER, and KELLY, Circuit Judges.
                        ____________

KELLY, Circuit Judge.




      1
       Nancy A. Berryhill has been appointed to serve as Acting Commissioner of
Social Security, and is substituted as appellee pursuant to Federal Rule of Appellate
Procedure 43(c).
       Janet Chesser appeals the district court’s2 order affirming the Social Security
Administration’s (SSA) denial of social security disability benefits. Chesser argues
that the Administrative Law Judge’s (ALJ) determination of the severity of her mental
limitations is not supported by substantial evidence in the record as a whole.

                                   I. Background

      Chesser, born in 1986, protectively filed social security disability applications
on April 26, 2012. She alleged a disability onset date of December 15, 2011,
stemming from anxiety, depression, nightmares, paranoia, auditory and visual
hallucinations, panic attacks, carpal tunnel syndrome,3 and migraine headaches.

        On September 3, 2013, the ALJ held a hearing on Chesser’s claims. Chesser
presented evidence of the above conditions, including documentary evidence from
several medical sources. Chesser testified that she left her most recent job because
she moved to another state following a divorce. She testified that she was unable to
secure employment because she could not “comprehend anything” and did not
“understand what people tell” her. Chesser explained that she spent her time
watching television and sleeping, that she preferred to be alone, and that her
boyfriend managed the household and cooked meals. She said that mental health
treatment and medication improved her symptoms, but that she was unable to afford
all of the medications prescribed to her. Chesser’s written surveys and application
for benefits echoed these complaints regarding depression, anxiety, and mood swings.


      2
       The Honorable Brian S. Miller, Chief Judge, United States District Court for
the Eastern District of Arkansas, adopting the report and recommendation of the
Honorable Beth M. Deere, United States Magistrate Judge for the Eastern District of
Arkansas.
      3
        Chesser does not challenge the ALJ’s determination of her physical limitations
resulting from carpal tunnel syndrome.

                                         -2-
       The ALJ considered the entirety of the record and applied the familiar five-step
process prescribed by the social security regulations. See 20 C.F.R. § 404.1520(a);
Bowen v. Yuckert, 

, 140–42 (1987). The ALJ ultimately determined that
Chesser had the Residual Functional Capacity (RFC) to perform “light work,” as that
term is defined in 20 C.F.R. §§ 404.1567(b) and 416.967(b),

      except the claimant cannot perform rapid repetitive flexion or extension of
      the wrists bilaterally. The claimant is able to perform work where
      interpersonal contact is incidental to the work performed, where
      “incidental” is defined as interpersonal contact requiring a limited degree
      of interaction such as meeting and greeting the public, answering simple
      questions, accepting payment and making change. The claimant is able to
      perform work where the complexity of tasks can be learned by
      demonstration or repetition within thirty days with few variables, little
      judgment, and the supervision required is simple, direct, and concrete.

In arriving at this RFC determination, the ALJ found that Chesser’s testimony about
the severity of her limitations was not fully credible, and as a result, afforded little
weight to the observations of Chesser’s caseworker and Mental Health
Paraprofessional (MHPP), because those opinions were based on Chesser’s subjective
complaints. Likewise, the ALJ assigned little weight to the opinion of Chesser’s
treating physician, finding his opinions were internally inconsistent and inconsistent
with the record as a whole. Relying on testimony from a vocational expert, the ALJ
held that Chesser was able to perform work existing in significant numbers in the
national economy. The ALJ concluded that Chesser was not disabled and denied her
request for benefits.

                                    II. Discussion

     We review de novo whether substantial evidence in the record as a whole
supports the ALJ’s decision. See Milam v. Colvin, 

, 983 (8th Cir. 2015).

                                          -3-
“Substantial evidence is less than a preponderance, but is enough that a reasonable
mind would find it adequate to support the Commissioner’s conclusion.” Prosch v.
Apfel, 

, 1012 (8th Cir. 2000). While we must consider both evidence
that supports and evidence that detracts from the ALJ’s determination, we “may not
reverse the Commissioner’s decision merely because substantial evidence supports
a contrary outcome.” 

v. Apfel, 

, 1050 (8th Cir.
1999)). “[I]f it is possible to draw two inconsistent positions from the evidence and
one of those positions represents the agency’s findings, we must affirm the decision.”
Cruze v. Chater, 

, 1323 (8th Cir. 1996) (quoting Oberst v. Shalala, 

, 250 (8th Cir. 1993)).

       First, Chesser argues that the ALJ erred by assigning little weight to the
opinion of her treating psychiatrist, Dr. Miguel Casillas. The opinion of a treating
physician is generally afforded “controlling weight if that opinion is well-supported
by medically acceptable clinical and laboratory diagnostic techniques and is not
inconsistent with the other substantial evidence in the record.” Wildman v. Astrue,

, 964 (8th Cir. 2010) (quoting Brown v. Barnhart, 

, 540
(8th Cir. 2004)). Where an ALJ assigns less than controlling weight to the opinion
of a treating source, the ALJ must “give good reasons” for doing so. Anderson v.
Astrue, 

, 793 (8th Cir. 2012) (quoting 20 C.F.R. § 404.1527(c)(2)).
Good reasons for assigning lesser weight to the opinion of a treating source exist
where “the treating physician’s opinions are themselves inconsistent,” 

, or where “other medical assessments ‘are supported by better or more
thorough medical evidence,’” 

(quoting Rogers v. Chater,

, 602 (8th Cir. 1997)).

       In assigning little weight to Dr. Casillas’ opinion, the ALJ reasonably
concluded that it was internally inconsistent. As an initial matter, although he is
described as Chesser’s treating physician, Dr. Casillas examined Chesser only once;
that visit constitutes the only instance of mental health treatment by an accepted

                                         -4-
medical source in Chesser’s record aside from evaluations conducted pursuant to
these proceedings. See 20 C.F.R. § 404.1527(c)(2)(i) (“Generally, the longer a
treating source has treated [a claimant] and the more times [a claimant] has been seen
by a treating source, the more weight [the ALJ] will give to the source’s medical
opinion.”); 

416.927(c) (detailing rules for claims filed before March 27,
2017). Chesser sought treatment with Dr. Casillas on April 18, 2012, approximately
four months after her alleged disability onset date and approximately one week before
filing for social security benefits. Dr. Casillas’ treatment notes from this visit
explained that Chesser was experiencing multiple life stressors—unstable
relationships, financial problems, and possible homelessness—and that she suffered
from “paroia [sic], can’t trust, difficulty talking about her problem, [and] severe
anxiety to panic.” However, Dr. Casillas observed that Chesser remained alert, had
appropriate affect, fairly good judgment, and was in “good health, . . . motivated,
[and] intelligent.” Dr. Casillas diagnosed Chesser with bipolar disorder, anxiety
disorder, post-traumatic stress disorder (PTSD), and borderline personality disorder.
He opined that Chesser’s symptoms rendered her “unable to secure or maintain
employment,” but concluded that Chesser’s prognosis was “good.”

       In contrast, Dr. Casillas’ medical source statement—completed two weeks
later—concluded that Chesser had either marked or extreme limitations4 in almost
every area of functioning. Dr. Casillas’ medical source statement concluded with the
remark that Chesser was “very pathologically impaired,” but contained no
explanation for this escalation in the described severity of Chesser’s symptoms from
the time of her appointment two weeks earlier. See Julin v. Colvin, 

,
1089 (8th Cir. 2016) (treating physician’s conclusory opinion entitled to less weight).


      4
        According to the medical source statement form, an individual has a “marked”
limitation when her “ability to function is limited to a point that would seriously
interfere with performance of work activity.” An individual has an “extreme”
limitation when she has “no useful ability to function in this area.”

                                         -5-
      The ALJ incorporated Dr. Casillas’ diagnoses into his discussion of Chesser’s
impairments. However, because Dr. Casillas examined Chesser only once and
because he provided two descriptions of the severity of Chesser’s symptoms that were
inconsistent, the ALJ did not err in assigning little weight to Dr. Casillas’ opinion.
See id.; Casey v. Astrue, 

, 692 (8th Cir. 2007) (“In considering how
much weight to give a treating physician’s opinion, an ALJ must also consider the
length of the treatment relationship and the frequency of examinations.”); 

(treating source’s opinions assigned lesser weight when the “opinions
have largely been inconsistent and are not fully supported by the objective medical
evidence”).

       “[O]ther evidence in the record also supports the ALJ’s decision not to accord
[Dr. Casillas’] opinion controlling weight.” Reece v. Colvin, 

, 910 (8th
Cir. 2016). The record includes a report from Dr. Suzanne Gibbard, a consultative
psychologist who examined Chesser at the request of the Social Security
Administration. Like Dr. Casillas, Dr. Gibbard diagnosed Chesser with bipolar
disorder, anxiety disorder, and PTSD. Dr. Gibbard described Chesser as depressed
and anxious, but with logical and relevant thought processes. According to Dr.
Gibbard, Chesser could cope with the mental cognitive demands of work-related
activities, although she may have problems completing tasks in a timely manner due
to her volatile mood and anxiety. In the course of the evaluation, Dr. Gibbard
prepared a six-page report detailing Chesser’s personal and employment history.
See Cantrell v. Apfel, 

, 1107 (8th Cir. 2000) (no error in crediting one-
time consultant’s opinion over treating physician when the consultant’s opinion is
“supported by better or more thorough medical evidence” (citation omitted)).
Similarly, two state agency consultants who reviewed the record concluded that
Chesser was capable of unskilled work involving limited interpersonal contact,
simple tasks, few variables, little judgment, and direct and concrete supervision.




                                         -6-
       Chesser complains that the ALJ simply chose the opinion of Dr. Gibbard over
that of Dr. Casillas, without offering sufficient reason. But the ALJ considered all of
evidence in the record—including Chesser’s own responses to agency
questionnaires—to conclude that while Chesser suffered impairments, her resulting
limitations were not as severe as indicated by Dr. Casillas. Viewing the ALJ’s
opinion in light of the record as a whole, substantial evidence supports the ALJ’s
decision to assign little weight to Dr. Casillas’ conclusion that Chesser is “very
pathologically impaired” and unable to work in any capacity. See 

(internal inconsistency and conflict with other evidence on the record
constitute good reasons to assign lesser weight to a treating physician’s opinion).

       Chesser also argues that the ALJ erred in assigning insufficient weight to the
opinions of Chesser’s caseworker and MHPP, Lisa Wilbanks. The parties agree that
Wilbanks constitutes an “other medical source” pursuant to agency regulation. See
20 C.F.R. § 404.1513(a)(3); Social Security Ruling, SSR 06-03p, 

,
at *2 (Aug. 9, 2006). An ALJ may consider the opinion of an other medical source
“to show the severity of [a claimant’s] impairment(s) and how it affects [a claimant’s]
ability to function.” Social Security Ruling, SSR 06-03p, 

, at *2
(Aug. 9, 2006); see also Nowling v. Colvin, 

, 1123 (8th Cir. 2016)
(citing 20 C.F.R. § 416.913). In so doing, the ALJ may consider, among other things,
the length of the treatment relationship, whether the opinion is consistent with other
evidence, the evidence underlying the opinion, and the quality of the opinion’s
explanation. Social Security Ruling, SSR 06-03p, 

, at *4–5 (Aug.
9, 2006). Usually, “[i]n determining what weight to give ‘other medical evidence,’
the ALJ has more discretion and is permitted to consider any inconsistencies found
within the record.” 

(alteration in original) (quoting Raney
v. Barnhart, 

, 1010 (8th Cir. 2005)).

     Chesser began seeing Wilbanks one to two times per week in early 2012.
Wilbanks completed a third-party function report on May 28, 2012, after treating

                                         -7-
Chesser for approximately three months. In the report, Wilbanks expressed the view
that Chesser was very unstable, experienced mood swings and outbursts, and was
unable to maintain a savings account or use a checkbook because she “has trouble
comprehending.” Wilbanks indicated that Chesser was capable of following spoken
instructions, preparing simple meals, and maintaining personal care, but spent much
of her day sleeping and watching television. Wilbanks also highlighted Chesser’s
difficulty maintaining social and professional relationships.

       The ALJ acknowledged that Wilbanks’ opinion was relevant to a determination
of the severity of Chesser’s mental limitations. See Social Security Ruling, SSR
06-03p, 

, at *4 (Aug. 9, 2006); cf. Shontos v. Barnhart, 

, 426–27 (8th Cir. 2003) (error to ignore other medical source evidence).
However, the ALJ explained that Wilbanks’ report “does not establish that the
claimant is disabled, and cannot carry her burden of proof” on that issue because it
was based on Chesser’s subjective reports and was not based on medically acceptable
standards. See 

(finding ALJ permissibly declined to give
controlling weight to treating physician on workplace limitations insofar as they
relied on the claimant’s unreliable subjective complaints); Social Security Ruling,
SSR 06-03p, 

, at *5 (Aug. 9, 2006) (“Not every factor for weighing
opinion evidence will apply in every case. The evaluation of an opinion from a
medical source who is not an ‘acceptable medical source’ depends on the particular
facts in each case.”). According to Chesser, the fact that Wilbanks’ opinion was
“based in part on Chesser’s reported symptoms . . . is not a sufficient reason for
discounting the opinion.” We agree that the nature of the relationship between
Chesser and her case worker is such that Wilbanks’ opinion will necessarily be
shaped at least in part by the complaints her client self-reports. But the ALJ
determined that Chesser’s characterization of the severity of her symptoms was not
fully credible—a finding that Chesser does not challenge here. See 

. The ALJ also noted that Wilbanks’ report did not satisfy medical standards



                                        -8-
of any kind. The ALJ appropriately weighed Wilbanks’ opinion along with the other
record evidence in determining the severity of Chesser’s impairments.

       In addition to the reports from Dr. Casillas, Dr. Gibbard, and Wilbanks, two
state agency consultants offered their views. These consultants—who admittedly did
not examine Chesser—agreed that Chesser suffers from bipolar disorder and anxiety
disorder, and that she had some limitations, including mild restrictions in daily living,
moderate difficulties in maintaining social function, and moderate difficulties in
maintaining concentration, persistence, or pace. After reviewing the record, they
recognized that Chesser could not follow detailed instructions or concentrate for an
extended period of time, but believed she was able to follow short and simple
instructions, get along with coworkers, and make simple work-related decisions.
Chesser’s own adult function report, completed on May 28, 2012, supported that
conclusion. Chesser explained that she was able to prepare simple meals, pay bills,
and count change. Chesser said that she was not capable of following written
instructions, but that she was capable of following spoken instructions if they are
repeated slowly. The ALJ’s RFC determination reflected these limitations in
Chesser’s ability to follow instructions, socialize, and maintain concentration.

      The limited treatment records from the emergency room and Chesser’s primary
care doctor also support the ALJ’s conclusion. The records largely document
incidents unrelated to Chesser’s mental condition, including a basketball injury and
appointments related to Chesser’s carpal tunnel syndrome. However, for a visit on
September 10, 2013, the notes indicate that Chesser was unemployed, but “denied
depression.” Records that are silent on mental health cannot be used as substantial
evidence that the person is not disabled, see Pate-Fires v. Astrue, 

,
943–44 (8th Cir. 2009), but these records are not silent. Instead, they include
observations of Chesser’s mood, affect, orientation to time and place, and
psychological history. Chesser’s denial of any depression—one of the bases on
which Chesser filed for benefits—during the period of time for which she seeks

                                          -9-
benefits, and doctors’ observations of Chesser’s mood and affect are relevant to the
assessment of the severity of Chesser’s symptoms.

                                 III. Conclusion

      Because the ALJ’s decision is supported by substantial evidence in the record
as a whole, we affirm.
                       ______________________________




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