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HALBROOK v. CHATER

April 26, 1996

ROBERT D. HALBROOK, Plaintiff,
v.
SHIRLEY S. CHATER, Commissioner of the Social Security Administration, Defendant.



The opinion of the court was delivered by: CASTILLO

 Pursuant to 42 U.S.C. § 405(g), Robert D. Halbrook appeals the final decision of the Commissioner of Social Security, Shirley S. Chater, denying Halbrook's application for Supplemental Security Income ("SSI") under §§ 1602 and 1614(a)(3)(A) of the Social Security Act, 42 U.S.C. §§ 1381a and 1382c(a)(3)(A). The plaintiff moves for summary judgment pursuant to Rule 56 of the Federal Rules of Civil Procedure. *fn1"

 RELEVANT FACTS

 The Court begins with a broad overview of the facts, and then reviews Halbrook's claims in detail. Halbrook is a 41 year old man who alleges that he has been continuously disabled since March 1, 1993, due to a chronic fatigue disorder. R. 44. Halbrook has a high school education and four years of technical training as a Machinist. *fn2" R. 89. He has a full-scale IQ of 105, which indicates that he is generally functioning in the average range. R. 164.

  Halbrook applied for SSI on August 6, 1993, claiming "chronic fatigue disorder" as his impairment. *fn3" R. 44, 48. Although not mentioned on his application for SSI, Halbrook also suffers from hypertension, obesity, and muscle spasms around the top of his cervical spine. R. 218, 238. While the SSI application notes a March 1, 1993 "onset of impairment date," R. 44, Halbrook claims to have been suffering from "debilitating" fatigue since February 1988, when he fell and hit his head on some ice. R. 70, 253. Ever since that time, Halbrook reports extreme difficulty staying awake, particularly after exerting himself. R. 184, 189, 201, 252, 255. He complains of being in a "mental fog" all the time. R. 184. He reported to one doctor that as a result of his impairments, he lost "another" job. Id.

 One doctor has diagnosed Halbrook as having chronic fatigue of "unclear etiology." R. 184. However, this diagnosis was unsupported by "discernible physical findings." R. 206, 218. Several doctors have concluded that his episodes of "falling asleep" are most consistent with dissociative episodes rather than loss of consciousness. R. 166, 192, 212. Halbrook has had several psychiatric evaluations, which rule out depression but diagnose a narcissistic personality disorder. R. 212, 217. A chiropractor treating Halbrook for muscle spasms around his neck diagnosed Halbrook with mild hypertrophic spurring in the cervical spine, and hypertrophic spurring along the lumbar spine. R. 238. Halbrook's pain improves with diversified adjusting. R. 237-38.

 Halbrook's SSI claim was denied on February 18, 1994, R. 49, and denied again on reconsideration on June 20, 1994. R. 53. Following a hearing on September 15, 1994, Administrative Law Judge Ellen K. Thomas ("ALJ") issued a decision denying SSI benefits on October 25, 1994. R. 23. The ALJ's decision became the final decision of the Commissioner when the Appeals Council denied review. R. 4-5.

 Halbrook has filed a complaint for judicial review pursuant to 42 U.S.C. § 405(g). The Court now considers the record in this case to determine whether the ALJ's decision is "both supported by substantial evidence and based on the proper legal criteria." Ehrhart v. Secretary of Health and Human Servs., 969 F.2d 534, 538 (7th Cir. 1992).

 Halbrook's Testimony

 At the administrative hearing Halbrook testified that he was 40 years old, married, with two children. R. 248-49. He has a two-year diploma from Madison Area Technical College in machine tool techniques. R. 249. His family lives on public aid and the SSI that his son receives. R. 251.

 Halbrook testified that he has chronic fatigue syndrome, which causes him to sleep extreme amounts of time--from eight hours per day to three days at a time. R. 252, 255-56, 258. The amount of time he sleeps correlates with the level of exertion he maintains R. 255, so that a 5- or 3-day per week work schedule could put him in bed for 1-3 days. R. 258. In July 1994, he had to leave his last job after five weeks because he started having muscle spasms that paralyzed his right arm. R. 250. He described feeling so tired the last week he worked that after sleeping the weekend, he was unable to get out of bed for work on Monday and had to stay in bed for five days. R. 252, 256. Prior to that he worked for about five weeks in the fall of 1992 as a tool and die machinist. R. 251. He claims that he was fired because he could not stay awake on the job and "maintain an alert mental state." Id.

 Halbrook testified that he has been diagnosed with sleep apnea. R. 255. He stated that the doctor treating him had told him that a breathing machine could work to alleviate the problem, but the only thing that would "positively work" would be a "tube being placed here on a respirator and [that would] be a permanent implant . . .." Id. He also jammed his neck on a short doorway in 1988 and has had to receive chiropractic therapy ever since. R. 254. He testified that when the top bone in his neck "gets out" he has increased fatigue. R. 253-54. Halbrook also described recurring sinus problems, and high blood pressure which is now under control. R. 256-57. He has had psychiatric evaluations which did not show depression. R. 257.

 His problems with fatigue became particularly troublesome in the winter of 1988 after hitting his head on ice. R. 252-53. Describing himself as a "workaholic" prior to the 1988 accident, Halbrook testified that he worked as a mechanic and a salesman from 1978 to February 1988. R. 258. However, he did not make enough money to file income taxes between 1982 and 1991. Id.

 His daily activities consist of eating, riding his lawn mower or working in his workshop for about one to two hours. R. 260-261. He does no household chores. R. 268-69. He drives when accompanied by another person. R. 267. He can write without difficulty, but falls asleep after reading a few paragraphs. R. 269. He can no longer play his trumpet or play computer games. R. 259. In addition, he has leg cramps and spasms which restrict the amount of time he can spend on his feet. R. 262-63. He can stand for about 1-2 hours before he begins getting mentally confused or gets leg spasms, at which point he must sit for about 2 hours. R. 264.

 Halbrook's Medical Records

 A. Neck and Back Muscle Spasms

 Dr. Rodney Stanfield of the Stanfield Chiropractic Center treated Halbrook between February and October 1994. R. 237-38. Halbrook came in complaining of neck and lower back pain, mid-back and right sided scapular discomfort, with a loss of feeling in his right upper extremity. R. 238. The lumbar and cervical spine MRI series showed "some mild hypertrophic spurring" in the cervical spine as well as "some hypertrophic spurring" in the lumbar spine region. Id. On examining Halbrook, Dr. Stanfield also noted paravertebral muscular spasm in his right trapezius and cervical spine, "some mild location of malpositioning" and restricted range of motion in the lower lumbar spine, and some mild range of motion loss on the cervical spine. Id. Otherwise, Halbrook appeared to be "a healthy, middle-aged man." Id. Dr. Stanfield treated him chiropractically with diversified adjusting. Id.

 Halbrook saw Dr. Stanfield at least once per month, each time receiving diversified adjusting. R. 237-38. Halbrook continued to complain of pain in his cervical spine which improved with treatment but returned to the paresthesia state in between treatments. Id. The records indicate that Halbrook was much improved after the diversified adjusting treatment, and his range of motion improved by at least 70%. R. 237. Dr. Stanfield regularly recommended that Halbrook take vitamin supplements, eat a good diet and get some exercise in response to the excessive fatigue. R. 237-38.

 In June and July 1994, Dr. Kendall Stephens, Halbrook's primary treating physician, R. 253, found a fair amount of spasm and trigger point tenderness in the mid-portion of Halbrook's trapezius. R. 234. He prescribed Oruvail and gave Halbrook an injection of Kenalog and Marcaine without epinephrine. Id. On a later visit, Dr. Stephens noted that the pain in Halbrook's upper shoulder resolved after the trigger point injection. Id.

 B. Sleep Disorder, Neurological and Psychological Evaluations

 Several doctors from Dean Medical Center treated Halbrook from February 1988 through September 1993. Dr. Icenogle treated Halbrook on February 1, 1988 when he came into the Dean Urgent Care Center with pain on the right side of his head. R. 204. Halbrook did not remember a 30 minute period of time, but thought he may have slipped on some ice. Id. Dr. Icenogle diagnosed a possible concussion. R. 205.

 In April 1988, Halbrook described his episodes of falling asleep to Dr. David Hahn of Dean Medical Center: the "episodes usually [begin] with drowsiness and then uncontrolled sleepiness and then periods of amnesia. For example he once drove 300 miles and had no recollection of it." R. 202. Dr. Hahn noted that Halbrook possibly sustained a concussion two months earlier. Id. Dr. Hahn diagnosed amnesic spells of uncertain etiology, and recommended a neurology consultation. Id.

 Dr. Mary Dominski, also of the Dean Medical Center, treated Halbrook from April through June 1988. R. 199-202. Halbrook originally saw Dr. Dominski in April 1988, when he came in complaining of uncontrollable lethargy. R. 201. Since February when he hit his head on some ice, he described having several episodes of "falling asleep," in which he could not remember blocks of time lasting several hours. Id. Dr. Dominski opined that he was having dissociative episodes, and wanted to rule out post concussion syndrome. Id. She recommended an EEG, multiple sleep latency tests, and a neuropsychological evaluation. Id.

 In May 1988, Dr. Dominski conducted a multiple sleep latency test. R. 163. The results were "strongly against the occurrence of narcolepsy since no rapid onset of REM is seen. During the only nap opportunity that culminated in sleep, normal progression into stage one and stage two sleep occurred." Id. Dr. Dominski concluded that the test results were normal. Id. In June 1988, Halbrook continued to complain of daytime sleepiness, but was no longer having dissociative episodes. R. 199. Halbrook asked Dr. Dominski for a written excuse saying why he was unable to work or go to school. Id. She explained that she would need to further evaluate his dissociative episodes with a psychiatric evaluation. Id.

 Dr. P. Williamson examined Halbrook in May 1988, running a complete battery of neuropsychological tests "to rule out an organic etiology for his current difficulties," and evaluating Halbrook for disturbances of memory and consciousness at the request of Dr. Dominski. R. 164. The evaluation revealed an IQ of 105, which "indicates that he is generally functioning in the average range." Id. His cognitive testing scores were "compatible with his age, level of education, and occupation." R. 167. Dr. Williamson diagnosed a possible conversion disorder with dissociative features, R. 166, and indicated a concern from a neuropsychological standpoint that Halbrook's "slurred speech, poor fine motor control, and impulsivity and difficulties with verbal learning on the California Verbal Learning Test" could indicate some type of organic dysfunction. R. 167. At that time, however, he felt that "evidence for any extensive organic dysfunction is simply not there." Id. He concluded by suggesting a psychiatric referral if "there is no other compelling evidence of organic brain dysfunction." Id.

 Dr. Benton treated Halbrook at Dean Medical Center from August 1989 through April 1991. R. 193-199. Over the course of three visits, Halbrook complained of excessive sleepiness, R. 195, 197, 199, including that he would fall asleep while reading or playing video games. R. 199. In August 1989, Dr. Benton recommended sleep studies to rule out narcolepsy. Id. In October 1989, Dr. Benton noted the possibility that Halbrook would be thrown out of school and would have to obtain full-time employment. R. 195. He opined that Halbrook was "incapable of handling this at this point in time." Id. Suspecting depression and suppressed violence, Dr. Benton screened Halbrook with the Center for Epidemiologic Studies Depression ("CESD") scale, and the Zung Self-rating Depression Scale ("SDS"), both of which generated ...


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