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Fuller v. Astrue

January 15, 2010


The opinion of the court was delivered by: Jeanne E. Scott, U.S. District Judge


Plaintiff Dawn T. Fuller appeals from a final Decision of the Social Security Administration (SSA) denying her application for Supplemental Social Security Income (SSI) under Chapters II and XVI of the Social Security Act, 42 U.S.C. §§ 423, 1381a. Plaintiff brings this appeal pursuant to 42 U.S.C. § 405(g). Plaintiff filed Plaintiff's Motion for Summary Judgment or Remand (d/e 9) and Plaintiff's Memorandum in Support of Motion for Summary Judgment or Remand (d/e 10). Defendant has filed a Motion for Summary Affirmance (d/e 13) and Commissioner's Memorandum in Support of Motion for Summary Affirmance (d/e 14).

Plaintiff then filed Plaintiff's Reply in Support of her Motion for Summary Judgment or Remand (d/e 15).

For the reasons set forth below, the Court determines that the SSA's Decision is not supported by the evidence. Plaintiff's Motion is granted, and the Commissioner's Motion is denied. The Commissioner's Decision is reversed, and this case is remanded pursuant to 42 U.S.C. § 405(g), Sentence 4, for further proceedings consistent with this Opinion.


Plaintiff Dawn T. Fuller is a 41-year-old woman who has previous work experience as a mail clerk, data entry clerk, retail cashier, machine operator, assembler, and hand packager. Answer (d/e 7), Ex. A, Social Security Transcript (Tr.), at 160. She alleges a disability onset date of January 15, 1994.


The medical records in this case date back to December 29, 2002, when Plaintiff was admitted to the emergency room at Decatur Memorial Hospital in Decatur, Illinois, with chest pain. Tr. at 325. She admitted to physicians that she had been consuming alcohol and smoking marijuana laced with cocaine. Tr. at 325. Examinations revealed that Plaintiff also had a sprained foot and broken toe. Tr. at 329.

On November 27, 2003, Plaintiff was taken to St. Mary's Hospital in Decatur, Illinois, via ambulance after she was found non-responsive at her home. Tr. at 564. She was diagnosed with depression and a drug overdose. Plaintiff stated that she injected heroin and cocaine because "the holiday time [] overwhelmed her." Tr. at 564. Plaintiff later stated to physicians that she was not trying to commit suicide, and doctors recommended that she obtain psychiatric treatment. Tr. at 565.

Plaintiff sought mental health treatment at Heritage Behavioral Health Center in March 2005. Tr. at 511. She was diagnosed with major depression, cocaine dependency, and opiate dependency. Her treating doctor assessed her a Global Assessment of Functioning (GAF) score of 50, noting that Plaintiff felt "down, angry and isolate[d] from others."*fn1 Tr. at 512. Heritage created a comprehensive treatment plan to help Plaintiff deal with her depression and overcome her drug addictions.

On April 2, 2005, Plaintiff was admitted to Decatur Memorial Hospital after she tried to commit suicide by overdosing on Xanax and Klonopin. Tr. at 313. Plaintiff later denied that she had tried to commit suicide. Laboratory testing discovered that she had cocaine and opiates in her system in addition to alcohol and prescription drugs. Tr. at 316.

Plaintiff was transferred to McFarland Mental Heath Center on April 6, 2005. Tr. at 504. She remained there until April 11, 2005, and was diagnosed with major depressive disorder, a possible substance-induced mood disorder, and alcohol, cocaine, and heroin abuse disorder. Tr. at 506. Plaintiff told doctors that she had been sexually abused by her brother when she was 11 years old. Tr. at 504. She was assigned a GAF score of 40. Tr. at 506. Ultimately, Plaintiff was released to an outpatient substance abuse treatment program.

On April 20, 2005, Plaintiff returned to Heritage, where she was diagnosed with major depressive disorder with psychotic features. Tr. at 525. She told doctors that she felt paranoid, and that people were out to get her. Plaintiff was prescribed Effexor, and assigned a GAF score of 45. She returned to Heritage on May 18, 2005, and was again diagnosed with major depressive disorder; this time, she was assigned a GAF score of 53. Tr. at 527.

Plaintiff went to the emergency room at St. Mary's Hospital on June 6, 2005, and was admitted to the psychiatric ward on June 14, 2005. Plaintiff complained of hallucinations, paranoia, delusions, and verbalized suicidal thoughts. Tr. at 529. A drug test was positive for cocaine and cannabis. Doctors diagnosed her with bipolar disorder, and chemical dependency. Tr. at 529. She told doctors that she was hearing voices that were telling her to hurt herself, and that her prescription medication was making her tired. Tr. at 531. Treatment notes indicate that Plaintiff was depressed, and that she believed that her overdose was caused by someone putting Xanax in her drink. Tr. at 541. Plaintiff continued to have hallucinations and said that she saw spiders. Tr. at 542.

From August 18, 2005, to December 23, 2005, Plaintiff was incarcerated at the Dwight Correctional Center after she was convicted of retail theft and criminal trespass of a residence. Tr. at 618. She continued to receive psychiatric treatment, and was diagnosed with poly-substance dependence, psychotic disorder, and bipolar disorder. The psychologist noted that Plaintiff was happy and cooperative, and that her affect was appropriate. Tr. at 623. She tested positive for Hepatitis C. Tr. at 607. On October 17, 2005, she was diagnosed with major depressive disorder and cocaine dependence. Tr. at 625. Plaintiff told her doctors that she had not received her psychiatric medication since she was imprisoned in August 2005. Tr. at 607.

Plaintiff returned on January 20, 2006, to Heritage for treatment relating to her depression and hallucinations. Tr. at 633. She was paranoid and verbalized suicidal ideations. The counselor noted that Plaintiff had been imprisoned and had not been taking her medication. Plaintiff again reported physical and sexual abuse by her brother. Tr. at 633. Treatment notes indicate that Plaintiff had not used heroin or cocaine for 7 months, and that her substance abuse disorder was in remission. Tr. at 634. She was diagnosed with major depression, and assigned a GAF score of 52. Tr. at 636.

On April 4, 2006, Plaintiff was again admitted to the psychiatric ward at St. Mary's Hospital after she tried to kill herself by overdosing on Risperdal, cocaine, and alcohol. Tr. at 642. She was diagnosed with bipolar disorder and chemical dependency. Tr. at 643. She told doctors that she had trouble trusting people, but that she was able to gain strength through her religious beliefs. Tr. at 647. Plaintiff indicated that she was attending Narcotics Anonymous and Alcoholics Anonymous while in the hospital, and stated that she would continue to attend after she was discharged. Tr. at 650.

Plaintiff saw Dr. Stephen Vincent for a mental status assessment and psychological evaluation on April 24, 2006. Tr. at 692. Plaintiff told Dr. Vincent that she had worked one day two months earlier, but that she had walked off the job because she "couldn't be around other people." Tr. at 692. She noted that she distrusted others, was paranoid, and had experienced abuse as a child. Plaintiff discussed nightmares, mood swings, and difficulty bonding with others. Dr. Vincent noted that Plaintiff had been hospitalized for psychiatric issues in the past, and that she was diagnosed with Hepatitis C. Plaintiff complained of trouble sleeping and depression, but denied hallucinations. She also told Dr. Vincent that she was living with an uncle, but had previously been homeless. Tr. at 693. Dr. Vincent diagnosed her with major depression, posttraumatic stress disorder (PTSD), and poly-substance abuse and dependence, which was in remission. Tr. at 695. Dr. Vincent commented that Plaintiff was "rather hypervigilant and easily startled. . ., as well as easily distracted." Tr. at 692.

On May 16, 2006, the state agency conducted a Psychiatric Review Technique. Dr. Howard Tin found that Plaintiff satisfied the Paragraph A criteria under Listing 12.04 Affective Disorders, Listing 12.06 Anxiety-Related Disorders, and Listing 12.09 Substance Abuse Disorders. Tr. at 696. However, under the Paragraph B criteria Dr. Tin found that Plaintiff was only mildly or moderately limited in activities of daily living, social functioning, maintaining concentration, persistence, or pace, and had only had one or two episodes of decompensation. Tr. at 706. He found that she did not satisfy the Paragraph C criteria. Tr. at 707.

The state agency also performed a Mental Residual Functional Capacity Assessment (RFC). Plaintiff was found to be only moderately limited in her ability to follow short instructions and concentrate for an extended period of time. Tr. at 710. Dr. Tin determined that her ability to interact socially was moderately limited, but found that she was not significantly psychologically limited in her ability to complete a work day and a work week. Tr. at 711.

In September 2006, Plaintiff went to the Capitol Community Health Center, complaining that she had been off of her medication for months and stating that she wanted to resume taking it. Tr. at 774. Plaintiff reported that she was hallucinating, hearing voices, and having paranoid thoughts.


Plaintiff applied for SSI benefits on February 23, 2006, alleging a disability onset date of January 15, 1994. Tr. 160. On May 19, 2006, the SSA denied her application. Tr. at 99. Plaintiff requested reconsideration, but the SSA on August 10, 2006, again denied her application. Tr. at 106.

A. First Administrative Hearing

On August 12, 2006, Plaintiff requested a hearing before an administrative law judge (ALJ). Tr. at 112. Plaintiff's hearing was held via video conference on November 9, 2006, before ALJ Alice Jordan. Tr. at 27. Plaintiff appeared with her attorney in Springfield, Illinois, and the ALJ appeared with vocational expert Ronald Malik (Malik) in Peoria, Illinois.

Plaintiff testified at the hearing that she was 38 years old, approximately 5 feet, 4 inches tall, and weighed about 170 pounds. Tr. at 35. She said that she was not and had never been married, and that she had four children, ages 12, 9, 8, and 4. Tr. at 36. Plaintiff told the ALJ that the two youngest children lived with her and her fiancé. Tr. at 37. Plaintiff's 8-year-old daughter received SSI benefits for asthma. Tr. at 37. Plaintiff had a medical card and received food stamps. Tr. at 38. Plaintiff left high school after her sophomore year, but Plaintiff earned her GED in 1987. Tr. at 38.

Plaintiff stated that she had last been employed in 1999, when she worked for six months sorting mail at a bank in Decatur, Illinois. Tr. at 39-40. She testified that she had also worked as a cashier in a grocery store and on an assembly line in a factory; Plaintiff said she was fired from the latter position because she was not "fast enough." Tr. at 40-41. Plaintiff also stated that she had been employed on a temporary basis doing data entry for the State of Tennessee in 1993. Tr. at 58-59.

During the days, Plaintiff testified that she stayed home and watched television. Tr. at 41. Although she liked to read, Plaintiff could not concentrate long enough to do so. She did not do any cooking, but she was responsible for cleaning the apartment, doing laundry, and occasionally washing dishes. Tr. at 41-42. However, she stated that her fiancé did more of the household chores than she did. Tr. at 42. Plaintiff was able to maintain her personal hygiene and play with her children, and stated that she did not have any hobbies. Tr. at 43. Plaintiff stated that the voices in her head prevented her from going to church and from praying. Tr. at 45. She sometimes went to the grocery store with her fiancé, but that they did not go out on dates because Plaintiff felt paranoid when she was around other people. Tr. at 56. Plaintiff's mental-health case worker was responsible for taking her to doctors' appointments for herself and her children. Tr. at 56-57. The case worker also helped Plaintiff maintain and keep a calendar, since Plaintiff had trouble concentrating and was forgetful. Tr. at 57.

Plaintiff testified that she smoked a pack of cigarettes a day, and that, while she had struggled with alcohol and drug abuse in the past, she had not used alcohol or drugs since April of 2006, when she tried to commit suicide by overdosing on cocaine. Tr. at 44-45. She said that she tried to commit suicide because demonic voices in her head told her to do it. Tr. at 45. Plaintiff took Geodon and Lexapro to help "stop the voices and hallucinations." Tr. at 48. Specifically, she said that spirits, such as that of her deceased grandmother, spoke to her. Tr. at 48. In terms of side effects from the medication, Plaintiff said that she shook, bit her tongue, and felt like a "zombie" and "out of it." Tr. at 50. Plaintiff told the ALJ that as a girl she had been forced to attend church, and that she was sexually abused. Tr. at 50.

Plaintiff said that she had been on parole for a year after she was caught shoplifting. Tr. at 46. Prior to that incident, Plaintiff had been in trouble with police on a few occasions for battery. Tr. at 51. She stated that she had started having social and mental problems while in high school, when she started remembering things from her abusive childhood. Tr. at 52. Plaintiff tried to conceal her problems by abusing alcohol and drugs. Tr. at 52. She stated that in addition to the April 2006, suicide attempt, she had tried to kill herself in April 2005, by overdosing on various prescription medications, and in November 2003, by injecting large amounts of cocaine and heroin. Tr. at 53-54. Plaintiff testified that she did not use illegal drugs for recreational purposes. Tr. at 55.

In terms of physical impairments, Plaintiff testified that she had difficulty lifting things because she had injured her back as a young girl when she fell off playground equipment. Tr. at 49. She said that she could not lift 25 pounds, but that she could lift a laundry basket and pick up her 4-year-old ...

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