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Hinton v. Astrue

August 17, 2010

DANIEL P. HINTON, PLAINTIFF,
v.
MICHAEL ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Byron G. Cudmore, U.S. Magistrate Judge

OPINION

Plaintiff Daniel Hinton appeals from a final decision of the Social Security Administration (SSA) denying his application for supplemental security income (SSI) under sections 1602 and 1614(a)(3)(A) of the Social Security Act. See 42 U.S.C. §§ 1381 & 1382c(a)(3)(A). Hinton brings this appeal pursuant to 42 U.S.C. § 405(g). The parties have consented to a determination of this case by a United States Magistrate Judge, pursuant to 28 U.S.C. § 636. Order, December 23, 2009 (d/e 12). The parties have filed cross-motions for summary judgment or affirmance pursuant to Local Rule 8.1(D). Brief in Support of Complaint (d/e 11) (Plaintiff's Brief); Motion for Summary Judgment by Defendant Commissioner of Social Security (d/e 13). For the reasons set forth below, Hinton's request for summary judgment is denied, and the SSA's Motion for Summary Judgment is allowed.

STATEMENT OF FACTS

A. Medical History

Hinton was born July 30, 1976. Answer (d/e 10), Attachments 3 - 10, Administrative Record (A.R.) at 23.*fn1 He graduated from high school and began college in August 1995. He attended classes for three years until he was hospitalized for pneumonia and withdrew from classes. After taking several years off, Hinton began taking classes again in August 2002. He generally takes two classes per semester.

Hinton has received medical treatment from the Western Illinois University Beu Health Clinic (Beu) intermittently since December 2002. Richard Iverson, M.D., Hinton's primary care physician, characterizes Hinton's main problems as depression, anxiety, and asthma with occasional visits for allergic rhinitis. A.R. at 227. On September 23, 2004, Dr. Iverson's treatment notes indicate that Hinton had been experiencing a little more depression recently but that the depression was "very, very short lasting" and not severe. A.R. at 323. Hinton reported that he had experienced increased stress in his personal life and in getting back to school. Hinton returned to Beu in October 2004, complaining of allergy problems including intermittent headaches. A.R. at 324, 327. On November 3, 2004, Hinton saw Dr. Iverson for "sort of a flare of his anxiety problems." A.R. at 329. Dr. Iverson increased the dosage of Buspar. At a follow-up appointment on November 30, 2004, Hinton reported a little bit of improvement, noting that he was feeling more motivated since the Buspar increase. A.R. at 330. On December 16, 2004, Hinton returned to see Dr. Iverson, reporting that he felt "really stressed out" due to some appointments, but was generally not doing too badly. A.R. at 331.

By January 21, 2005, Hinton reported that he was doing pretty well and was quite pleased. A.R. at 332. Dr. Iverson noted that Hinton's depression with anxious features was in pretty good remission and that his asthma was pretty well controlled. Id. On February 28, 2005, Hinton reported a little more anxiety than usual and that he was unsure of its cause. A.R. at 333. Dr. Iverson noted that Hinton's asthma was in fairly good control and his anxiety disorder was reasonably well controlled with medications, although Hinton was experiencing insomnia. Id.

In May 2005, Dr. Iverson noted as follows: Hinton "always has kind of a sad look about him but he actually looks pretty good compared to many times . . . in the past." A.R. at 336. Dr. Iverson directed follow up in the fall and encouraged Hinton to seek counseling. On August 1, 2005, Hinton reported that he was not sleeping as well since running out of Trazodone, but that his depression was "ok." A.R. at 337. On September 2, 2005, Dr. Iverson noted that Hinton was "really doing pretty well" and was very positive about school, although he was having a little more trouble breathing. A.R. at 338. On September 12, 2005, Dr. Iverson noted that Hinton had increased asthma symptoms. A.R. at 339.

On November 15, 2005, Hinton had a follow up appointment with a Dr. Karkare at Beu. A.R. at 341. Hinton reported that he was doing well but found it hard to wake up in the morning. Dr. Karkare determined that Hinton was taking two Trazodone pills daily, before bedtime. According to Hinton, he had tried decreasing this amount but was not able to sleep well. Dr. Karkare recommended that Hinton decrease his Trazodone to 1.5 pills daily. Hinton also reported recent asthmatic symptoms. Dr. Karkare characterized Hinton's anxiety, depression, and asthma as "stable." Id.

Hinton returned to Beu on November 30, 2005 and saw Dr. Baker for asthma and sinus problems. A.R. at 342. Dr. Baker noted that he had known Hinton for most of Hinton's life and characterized him as "very mellow at this time." Id. Notes from a follow up appointment on December 21, 2005 indicate that Hinton was doing fairly well overall and his asthma, depression, and anxiety were stable. A.R. at 342.

Hinton received treatment at Beu for an asthma flare on January 30, 2006. A.R. at 343. Hinton was referred by Beu to the McDonough District Hospital that same day for further evaluation. A.R. at 230-31. Notes from the visit indicate that Hinton was alert and cooperative. A nebulizer treatment was given, after which Hinton seemed to be improved.

On February 10, 2006, Hinton returned to see Dr. Iverson, who noted that Hinton was better following his trip to the emergency room. A.R. at 344. At an appointment on March 29, 2006, Dr. Iverson noted that Hinton's lungs were as clear as he had ever seen them. A.R. at 345. However, Dr. Iverson noted that Hinton had "a lot on his plate," including worries about friends moving away, his mother's health, and the fact that he needed to declare a major by the end of the semester. Id. Hinton reported that he was going to begin counseling, and Dr. Iverson encouraged him to follow through with it.

In March and April 2006, Hinton attended counseling sessions with Ada Macias, M.A., of the Western Illinois University Counseling Center, which focused on addressing the ways in which Hinton's anxiety and depression were affecting his academics. A.R. at 233. Hinton failed to appear for two additional scheduled sessions. Macias recommended that Hinton be referred for a psychiatric evaluation, but Hinton declined due to financial concerns.

In a letter to the Illinois Department of Human Services, dated July 7, 2006, Dr. Iverson opined as follows:

[Hinton] has been able to continue going to school although making slower progress than the average student. He has continued to be gainfully employed at times however it would be my opinion that he would have an extremely difficult if not impossible time holding full time employment. For example he has worked for our food service and working a normal shift has proved to be too stressful for him most of the time because of his anxiety level.

A.R. at 227.

In July 2006, Hinton returned to Beu, complaining of dizziness, with pressure in his neck and at the base of his skull, which made it difficult to sleep. A.R. at 347. Hinton reported that he almost felt as if he would pass out during these spells. In August 2006, Hinton saw Dr. Iverson, who noted possible vertigo. A.R. at 351.

Also in August 2006, Hinton was evaluated by licensed clinical psychologist Alan W. Jacobs, Ph.D. A.R. at 235-37. Hinton reported that he had never slept well, even with medication. Hinton further reported that he did all of his own chores, played video games, and talked with friends. Hinton informed Dr. Jacobs that he had agoraphobia, but after probing the issue, Dr. Jacobs characterized Hinton's problem as "more an issue of motivation than one of panic." A.R. at 236. Dr. Jacobs described Hinton as polite and cooperative to questioning, but rather tentative in his responses. Dr. Jacobs noted that Hinton made only occasional eye contact, spoke in a very soft voice, and flushed facially several times during the interview. In Dr. Jacobs' assessment, Hinton appeared to have chronic problems with personal inadequacy and borderline tendencies, was depressed, and had obsessive tendencies.

On September 9, 2006, Leslie Fyans, Ph.D. conducted a psychiatric review of Hinton's medical records. A.R. at 246-59. Dr. Fyans opined that Hinton failed to meet Listing No. 12.04 or 12.06. According to Dr. Fyans, Hinton displayed no limitation in activities of daily living or his ability to maintain concentration, persistence, and pace. Dr. Fyans noted no episodes of decompensation of extended duration. However, Dr. Fyans concluded that Hinton displayed mild limitation in maintaining social functioning. Also in September 2006, Hinton was examined by Donald Habecker, M.D. A.R. at 242-45. Dr. Habecker described Hinton as a neatly dressed, soft spoken male who related normally to staff and surroundings. Dr. Habecker conducted a physical examination and noted no physical limitations in Hinton's functional capacity.

In October 2006, Ernst Bone, M.D. completed a residual functional capacity evaluation of Hinton. A.R. at 260-67. Dr. Bone concluded that Hinton could lift fifty pounds occasionally and twenty-five pounds frequently, could stand and/or walk approximately six hours in an eight-hour workday, and could sit approximately six hours in an eight-hour workday. According to Dr. Bone, Hinton should avoid concentrated exposure to extreme cold and heat, wetness, humidity, fumes, odors, dusts, gases, and poor ventilation. Dr. Bone noted that Hinton's asthma was showing good control and there were no symptoms of any additional physical impairments. A.R. at 267.

In November 2006, Hinton was seen by Dr. Iverson. A.R. at 354. Hinton reported that his request for SSI had been denied and asked if there was any more information that Dr. Iverson could forward to the SSA. Dr. Iverson reviewed his letter, dated July 7, 2006, but noted that he had nothing to add to it. Id. Hinton reported that he was doing about the same and experiencing some dizziness. Dr. Iverson characterized Hinton's asthma, depression, insomnia, and acid peptic symptoms as stable.

In February 2007, Sandra Bilinsky, M.D. and Phyllis Brister, Ph.D. reviewed Hinton's medical records and affirmed the opinions of Dr. Fyans and Dr. Bone. A.R. at 268-70. Hinton saw Dr. Iverson in February 2007, complaining of increased asthma symptoms. A.R. at 360. In April 2007, Hinton returned to see Dr. Iverson for follow up on depression/anxiety.

A.R. at 362. Hinton reported dropping a class and, as a result, losing his campus job. Hinton told Dr. Iverson that he had an interview at a grocery store later in the week. Dr. Iverson noted that Hinton "always looks sad, but he looks better than usual and does not appear to be acutely distressed." Id.

On July 23, 2007, Hinton presented to Beu for a refill on his prescriptions. A.R. at 357. He saw Dr. Baker. Hinton reported late night/early morning acute anxiety attacks for which Dr. Baker prescribed Xanax. Dr. Baker indicated that Hinton had a history of agoraphobia and at one time felt he needed to get away from his apartment based on a sense of being closed in there. With respect to Hinton's reported dizzy spells, Dr. Baker brought up the possibility of Meniere's disease and suggested a low dose of Valium.

Also in July 2007, Hinton underwent psychological assessment, mental status examination, risk assessment, alcohol and drug assessment, strengths and limitations assessment, and diagnostic review conducted by Licensed Clinical Professional Counselor John Reinert at North Central Behavioral Health Systems, Inc. A.R. at 272-97. Hinton reported symptoms of depression and anxiety. Hinton also reported that he had attempted suicide by overdose two times, once in 1991 and once in 2005. A.R. at 285. Hinton stated that he was hospitalized following the 1991 attempt, but did not seek any treatment, even the emergency room, following the 2005 overdose. Reinert opined that Hinton continued to present symptoms of major depression and anxiety, which appeared to be significant and compromise his life. A.R. at 280. Reinert assigned Hinton a GAF score of 48.*fn2 A.R. at 297.

Hinton had an appointment at North Central Behavioral Health Systems on July 27, 2007 to develop a treatment plan and goals. A.R. at 298. Progress notes reveal the Hinton reported recent increases in his panic attacks and agoraphobic tendencies. Hinton reported that he had a panic attack on the bus on the way to the appointment. Notes indicate that Hinton appeared shaken when he arrived.

Hinton failed to appear for two appointments in August 2007 with North Central Behavioral Health Systems. In August 2007, Hinton underwent an MRI of the brain, which revealed no abnormality to account for his symptoms of vertigo. A.R. at 358. On September 21, 2007, Hinton had an appointment with Sheryl Yoder of North Central Behavioral Health Systems. A.R. at 299. Hinton reported that he had experienced asthma and upper respiratory problems at the beginning of the new semester, which caused him to miss classes. Hinton felt that he may need to drop one class because he was behind. Yoder encouraged Hinton to visit campus disability services.

On October 15, 2007, Hinton saw Dr. Scott Wright, at the recommendation of Dr. Iverson, for a psychiatric evaluation. A.R. at 300. Hinton reported that his mood was poor and he had more bad days than good ones. He reported sleeping nine to ten hours a day and having a chronic problem with memory and focus. Dr. Wright assigned Hinton a GAF of greater than 50. A.R. at 301.

Hinton was a "no show" for therapy sessions with Sheryl Yoder on October 25 and December 4, 2007. A.R. at 302. Hinton saw Dr. Wright on December 12, 2007 for a medicine check. Id. Dr. Wright noted a diagnosis of major depressive disorder, recurrent, moderate; generalized anxiety disorder with panic and agoraphobic features; ADHD; and schizoid personality. Dr. Wright characterized Hinton's mood as down; his memory, concentration, and energy as low; and his sleep as up and down. Dr. Wright adjusted Hinton's medications and ordered follow up in eight to ten weeks. Hinton attended a therapy session with Sheryl Yoder on December 14, 2007. A.R. at 303. Hinton reported that he believed his mood had improved, although it was not as good as he would like it to be.

He was more relaxed now that finals were over, although he was afraid he may have received a D in one of his classes, which would affect his financial aid. Yoder characterized Hinton as more relaxed than in the past, but noted that a recent fight with an old friend had been stressful for Hinton.

Sheryl Yoder completed a diagnostic review and treatment plan for Hinton in January 2008. A.R. at 305-08. She noted that Hinton's attendance at counseling had been poor and he did not make it in for the diagnostic review. She assigned Hinton a GAF of 48. Hinton saw Dr. Wright in February 2008. A.R. at 304. Hinton reported that his dizziness was worsening. Dr. Wright characterized Hinton's mood as anxious, his concentration as fair, his motivation as low, his sleep a problematic, and his energy as low. Dr. Wright encouraged Hinton to try one Xanax at bedtime and ordered follow up in eight to ten weeks. In April 2008, Hinton was discharged from therapy at North Central Behavioral Health Systems due to poor attendance. A.R. at 405-10. However, his case was reopened in June 2008. A.R. at 411-27. On June 10, 2008, Licensed Clinical Professional Counselor Pam Helms noted a belief that Hinton was more concerned with receiving medication than coming to therapy. A.R. at 415. She stressed the need for Hinton to attend his therapy sessions, and he stated that he understood. Helms completed a ...


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