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Jolene Hennenfent v. Michael J. Astrue

October 31, 2011

JOLENE HENNENFENT, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Joe Billy McDADE United States Senior District Judge

E-FILED

Tuesday, 01 November, 2011 09:35:09 AM Clerk, U.S. District Court, ILCD

ORDER & OPINION

This matter is before the Court on Plaintiff's Motion for Summary Judgment and Defendant's Motion for Summary Affirmance. (Docs. 15 & 17). For the reasons stated below, Plaintiff's Motion for Summary Judgment is denied, and Defendant's Motion for Summary Affirmance is granted.

STANDARD OF REVIEW

To be entitled to disability benefits under the Social Security Act, a claimant must prove that she is unable to "engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment." 42 U.S.C. § 423(d)(1)(A). To determine if the claimant is unable to engage in any substantial gainful activity, the Commissioner of Social Security engages in a factual determination. See McNeil v. Califano, 614 F.2d 142, 143 (7th Cir. 1980). That factual determination is made by using a five-step sequential analysis. 20 C.F.R. §§ 404.1520, 416.920; see also Maggard v. Apfel, 167 F.3d 376, 378 (7th Cir. 1999).

In the first step, a threshold determination is made to decide whether the claimant is presently involved in a substantially gainful activity. 20 C.F.R. §§ 404.1520(a)(i), 416.920(a)(i). If the claimant is not under such employment, the Commissioner of Social Security proceeds to the next step. At the second step, the Commissioner evaluates the severity and duration of the impairment. 20 C.F.R. §§ 404.1520(a)(iii), 416.920(a)(iii). If the claimant has an impairment that significantly limits her physical or mental ability to do basic work activities, the Commissioner will proceed to the next step. At the third step, the Commissioner compares the claimant's impairments to a list of impairments considered severe enough to preclude any gainful work; and, if the elements of one of the Listings are met or equaled, he declares the claimant eligible for benefits. 20 C.F.R. §§ 404.1520(a)(iv), 416.920(a)(iv); 20 C.F.R. Part 404, Subpart P, Appendix 1.

If the claimant does not qualify under one of the listed impairments, the Commissioner proceeds to the fourth and fifth steps. At the fourth step, the claimant's residual functional capacity ("RFC") is evaluated to determine whether the claimant can pursue her past work. 20 C.F.R. §§ 404.1520(a)(iv), 416.920(a)(iv). If she cannot, then, at step five, the Commissioner evaluates the claimant's ability to perform other work available in the economy. 20 C.F.R. §§ 404.1520(a)(v), 416.920(a)(v). If the claimant is disabled, but there is evidence of drug or alcohol abuse, the Commissioner must consider whether the claimant would still be considered disabled if she stopped using drugs and/or alcohol; if not, she cannot receive benefits. 42 U.S.C. § 423(d)(2)(C); 20 C.F.R. § 404.1535.

The claimant has the burden to prove disability through step four of the analysis, i.e., she must demonstrate an impairment that is of sufficient severity to preclude her from pursuing her past work. McNeil, 614 F.2d at 145. However, once the claimant shows an inability to perform her past work, the burden shifts to the Commissioner, at step five, to show the claimant is able to engage in some other type of substantial gainful employment. Id.

Once a case reaches a federal district court, the court's review is governed by 42 U.S.C. § 405(g), which provides, in relevant part, "The findings of the Commissioner of Social Security as to any fact, if supported by substantial evidence, shall be conclusive." Substantial evidence is "such evidence as a reasonable mind might accept as adequate to support a conclusion." Maggard, 167 F.3d at 379 (quoting Richardson v. Perales, 402 U.S. 389, 401 (1971)). In a substantial evidence determination, the Court will review the entire administrative record, but it will "not reweigh the evidence, resolve conflicts, decide questions of credibility, or substitute [its] own judgment for that of the Commissioner." Clifford v. Apfel, 227 F.3d 863, 869 (7th Cir. 2000). The Court must ensure that the administrative law judge ("ALJ") "build[s] an accurate and logical bridge from the evidence to [her] conclusion," even though she need not have addressed every piece of evidence. Id. at 872.

PROCEDURAL HISTORY

Plaintiff applied for disability benefits in January 2009, alleging a disability onset date of October 1, 2008. (Tr. 124-28). After her application was denied initially and upon reconsideration, she requested a hearing. (Tr. 68, 74). ALJ Diane Raese Flebbe held a hearing on February 10, 2010, and issued her opinion denying Plaintiff benefits on February 16, 2010. The Appeals Council denied Plaintiff's request for review. (Tr. 1-5). Plaintiff filed her request for judicial review by this Court, pursuant to 42 U.S.C. § 405(g), on December 22, 2010. (Doc. 1).

RELEVANT MEDICAL HISTORY

On March 14, 2008, Plaintiff entered the emergency room on the anniversary of her first husband's and son's deaths, reporting that she wanted to kill herself. Plaintiff reported that she had had 4-5 drinks, and that she had tried to cut her wrist the previous weekend. (Tr. 290-95). Her blood alcohol level upon admission was 178. (Tr. 268). She was transferred to another hospital on March 15, 2008, from which she was discharged on March 20, 2008. (Tr. 210-42).

During the March 2008 hospitalization, Dr. Thena Poteat noted that Plaintiff had "reported numerous stressors including conflict between her husband and family member, continued difficulty dealing with the death of her mother," as well as the deaths of her son and first husband; Plaintiff had also recently quit her job as a CNA for unrelated reasons. (Tr. 211, 213). Plaintiff's family did not support her decision to seek treatment, which was distressing to her. (Tr. 211, 222). Dr. Poteat found that Plaintiff's "mood improved significantly" as she received more support from her husband and children throughout her hospitalization. (Tr. 211, 224). Plaintiff reported that she had tried several different antidepressants, but they had not been fully successful. (Tr. 213). Plaintiff also reported "frequent binges on alcohol," every several weeks, and that when she drank, she frequently did so to get drunk; Dr. Poteat "encouraged her to be honest about the role of alcohol in her depression." (Tr. 214, 224). Plaintiff reported to a social worker at the hospital that she planned to attend a 12-step program and "avoid routines that resulted in her drinking behavior;" Plaintiff believed that "her alcohol consumption contributed to her downward spiral." (Tr. 240). Dr. Poteat diagnosed Plaintiff with recurrent, severe major depressive disorder, without psychotic features. (Tr. 215). When she was discharged, Plaintiff was in a good mood, with a "bright" affect, and no indication of a psychotic process. Plaintiff denied any suicidal or homicidal ideation, and "acknowledged the need to address her alcohol use and to abstain from further alcohol use." (Tr. 212, 219). Plaintiff had a checkup on October 6, 2008, at which it was noted that her medications "are working;" on October 28, she was referred to Dr. Ralph Saintfort. (Tr. 253, 255).

On October 29, 2008, Plaintiff saw Dr. Saintfort. (Tr. 301). She reported that she had "significantly regressed" since her March 2008 hospitalization, and that her physician had been unable to find an appropriate anti-depressant medication. (Tr. 301). She had been feeling more depression and anxiety, and vaguely indicated that she was experiencing flashbacks of childhood molestation, as well as grief over the loss of her first husband, son, and mother, and family conflicts. (Tr. 301). She saw Dr. Saintfort again in December 2008, reporting that she was still feeling depressive symptoms and sleeping through much of the day. (Tr. 300). However, she did "not endorse any suicidal ideation, plans, or intent," and was "in good spirit, spontaneous, organized, and goal-directed." (Tr. 300). Dr. Saintfort reviewed her medications and added a new prescription to address her mood and anxiety. (Tr. 300).

Plaintiff reported to the emergency room on March 16, 2009, having cut her wrists superficially both three days prior and on that date. (Tr. 271-76). She reported to the triage nurse that she had last cut herself two or three months before. (Tr. 271). Plaintiff reported having had five drinks; her alcohol level was 163. (Tr. 271, 278). The next day, Plaintiff saw a social worker, who also noted that Plaintiff was intoxicated when she cut herself and that two or three months previously, she had planned "to use exhaust to kill herself." (Tr. 274). The social worker noted that Plaintiff's current problem was triggered by her son's arrest for drugs and her father having cancer; her husband also had cancer. (Tr. 274). Plaintiff attributed her wishes to die to episodes of drinking. (Tr. 275). Plaintiff reported feeling anxious, but had been working on getting out of the house though she felt panic and anxiety when leaving home. (Tr. 275).

Plaintiff saw Dr. Saintfort again on March 24, 2009. (Tr. 297-99). She reported to him that she had been doing well avoiding alcohol until her son's 21st birthday, when she went out drinking with him; since then, she had "regressed to having lapses in her abstinence from alcohol." (Tr. 297). She stated that her self-mutilation had been triggered by alcohol intoxication, but that she now self-mutilated when feeling numb or empty; she denied a suicidal intention, explaining that she cut herself as a means of coping. (Tr. 297-98). The hospitalization earlier in the month had been triggered by an intentional binge drinking episode. (Tr. 297). Since then, Plaintiff had not felt the urge to cut herself, and had not binged on alcohol. (Tr. 298). Plaintiff's family physician had recently changed her medications, and Dr. Saintfort suggested other changes. (Tr. 298-99). On April 9, 2009, Plaintiff had a checkup, at which it was noted that her Abilify medication "seem[ed] to be helping," and that she was "getting out, able to work a little bit." (Tr. 257). Plaintiff cut her finger on a can (apparently accidentally) on April 14, 2009, and went to see her doctor about it the next day; she also had had a fever for about a week. (Tr. 347).

On May 14, 2009, Plaintiff was referred for an emergency psychiatric evaluation, as she had cut her wrist while drinking. (Tr. 310-11). She also reported to hospital staff having had eight alcoholic drinks in three hours, and that she had planned to kill herself with her car exhaust; she had called her brother, who took her to the hospital. (Tr. 303). She had not taken her Xanax that day. (Tr. 303). By the end of the day, though, she was "pleasant, laughing, cooperative," and "express[ed] wishes to go to [Alcoholics Anonymous]." (Tr. 305). Plaintiff reported on June 5, 2009 for a follow-up. (Tr. 345).

Dr. Charles Farrar, a licensed clinical psychologist, issued a mental status evaluation of Plaintiff on May 18, 2009, at the request of the state agency. (Tr. 320-22). His evaluation was based on an interview with Plaintiff and on her disability application. (Tr. 320). Dr. Farrar diagnosed Plaintiff with major depressive disorder, post traumatic stress disorder, and alcohol addiction. (Tr. 321). Plaintiff reported to him that she was disabled because she could not leave her house, had started cutting herself, and had planned to commit suicide. (Tr. 320). She reported difficulty keeping jobs due to excessive absences and panicky feelings preventing her leaving the house. (Tr. 320). Plaintiff's husband and stepson prepared the meals and did most of the housework, though Plaintiff did handle the bill-paying. (Tr. 320). She stated that she spent most of her time in bed, and rarely got dressed. (Tr. 320). Dr. Farrar found that Plaintiff's intelligence appeared to be normal, and that her thought processes were normal, though her affect was depressed. (Tr. 321). Neither her short-term nor long-term memory were significantly impaired, but her sustained concentration and persistence were impaired. (Tr. 321). He found that, except for when she was intoxicated, Plaintiff understood and could conform to societal rules and expectations. (Tr. 321).

Dr. Patricia Beers completed a Psychiatric Review Technique form and a Mental RFC Assessment of Plaintiff on June 3, 2009. (Tr. 323-36, 337-40). In the Psychiatric Review Technique, Dr. Beers considered whether Plaintiff met the requirements of Listings 12.04 (Affective Disorders), 12.06 (Anxiety-Related Disorders), 12.08 (Personality Disorders), and 12.09 (Substance Addiction Disorders), and determined that an RFC assessment was necessary. (Tr. 323). Listings 12.04, 12.06, and 12.08 require that a claimant meet the requirements of their paragraphs "A" and "B," or that the requirements of their paragraph "C" are met. Paragraph "B" requires at least two of the following: marked restriction of activities of daily living; marked difficulties in maintaining social functioning; marked difficulties in maintaining concentration, persistence, or pace; or ...


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