The opinion of the court was delivered by: Magistrate Judge Martin Ashman
MEMORANDUM OPINION AND ORDER
Plaintiff Theresa Amey ("Plaintiff" or "Ms. Amey") seeks judicial review of a final decision of Defendant, Michael J. Astrue, Commissioner of Social Security ("Commissioner"), denying her application for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") under Title II of the Social Security Act. Before this Court is Plaintiff's Motion for Summary Judgment and the Commissioner's Motion for Summary Judgment. The parties have consented to have this Court conduct any and all proceedings in this case, including entry of final judgment. 28 U.S.C. § 636(e); N.D. Ill. R. 73.1(c). For the reasons discussed below, the Court finds that both motions are granted in part and denied in part.
In order to qualify for SSI or DIB, a claimant must demonstrate that he is disabled. An individual is considered to be disabled when he is unable to "engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." 42 U.S.C. § 423(d)(1)(A). An individual is under a disability if he is unable to do his previous work and cannot, considering his age, education, and work experience, partake in any gainful employment that exists in the national economy. Id. Gainful employment is defined as "the kind of work usually done for pay or profit, whether or not a profit is realized."
A claim of disability is determined under a five-step analysis. See 20 C.F.R. § 404.1520; 20 C.F.R. § 416.920. First, the SSA considers whether the claimant is engaged in substantial gainful activity. 20 C.F.R. § 404.1520(4)(I). Second, the SSA examines if the physical or mental impairment is severe, medically determinable, and meets the durational requirement.
20 C.F.R. § 404.1520(4)(ii). Third, the SSA compares the impairment to a list of impairments that are considered conclusively disabling. 20 C.F.R. § 404.1520(4)(iii). If the impairment meets or equals one of the listed impairments, then the applicant is considered disabled; if the impairment does not meet or equal a listed impairment, then the evaluation proceeds to step four. Id. Fourth, the SSA assesses the applicant's RFC and ability to engage in past relevant work.
20 C.F.R. § 404.1520(4)(iv). In the final step, the SSA assesses whether the claimant can engage in other work in light of his RFC, age, education and work experience. 20 C.F.R. § 404.1520(4)(v).
Judicial review of the ALJ's decision is governed by 42 U.S.C. § 405(g), which provides that "[t]he 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." Richardson v. Perales, 402 U.S. 389, 401 (1971). The court reviews the entire record, but does not displace the ALJ's judgment by reweighing the facts or by making independent credibility determinations. Elder v. Astrue, 529 F.3d 408, 413 (7th Cir. 2008). Instead, the court looks at whether the ALJ articulated an "accurate and logical bridge" from the evidence to her conclusions. Craft v. Astrue, 539 F.3d 668, 673 (7th Cir. 2008). Thus, even if reasonable minds could differ whether the Plaintiff is disabled, courts will affirm a decision if the ALJ's decision has adequate support. Elder, 529 F.3d at 413 (citing Schmidt v. Astrue, 496 F.3d 833, 842 (7th Cir. 2007)).
Plaintiff filed an application for disability benefits on February 15, 2005, alleging that she became disabled as of October 2, 2003. The Social Security Administration ("SSA") denied the claim initially and again on reconsideration, following which a hearing was held before administrative law judge ("ALJ") John Mondi on November 14, 2006. Ms. Amey was represented by counsel. On February 23, 2007, the ALJ denied Ms. Amey's claim. However, the Appeals Council vacated the decision on the grounds that the ALJ: (1) failed to adequately assess Plaintiff's obesity; (2) did not properly consider her depression; (3) did not include a function-by-function assessment of Plaintiff's ability to work; and, (4) failed to address all the factors required in assessing her credibility. The case was remanded to the ALJ, who held a supplemental hearing on June 5, 2008. On January 8, 2009, the ALJ issued his second decision finding that Ms. Amey was not disabled. This time, Plaintiff's request for review was denied by the Appeals Council, and the ALJ's opinion became the Commissioner's final decision.
Ms. Amey filed the instant action on May 4, 2009.
Plaintiff was given seven extensions of time to file this motion, which she submitted nearly two-and-a-half years after her initial filing. Despite this exceptional length of time, neither Plaintiff nor the Commissioner has provided any account of Ms. Amey's medical history or of critical portions of the record, such as the reports of various state agency physicians or her own treating physicians. The omission of such a discussion is especially problematic in this case because Plaintiff submitted medical records to the ALJ that extend as far back as July 12, 1987.
(R. 318). The relevance of much of this material is unclear, as Ms. Amey alleges that her onset date was October 2, 2003. The Court limits its discussion primarily to those records after October 2, 2003 that concern Ms. Amey's obesity, asthma, depression, and Arnold-Chiari malformation ("Chiari malformation"), which the ALJ found at Step 2 constituted a severe impairment when considered in combination with one another.
Ms. Amey was a thirty-five year old single mother of three children at the time she allegedly became disabled. Standing five feet and three inches, she weighed 307 pounds at the time of the first hearing. (R. 470). After graduating from high school and cosmetology school, Ms. Amey worked as a hair cutter from approximately 1990 until she allegedly became disabled.
(R. 467). Her only other work during that time included seasonal jobs with United Parcel Service. (R. 468).
Ms. Amey was diagnosed with Chiari malformation as early as October 28, 2002.
(R. 406). Chiari malformations are structural defects in the cerebellum, which controls balance.
Such malformations can cause numbness and other abnormal sensations in the arms and legs, dizziness, vomiting, vision problems, neck pain, balance problems, depression, and headaches. See http://www.ninds.nih.gov/disorders/chiari. Dr. Sam Marzo noted that Ms. Amey had suffered from severe headaches since childhood, often on a weekly basis. She also experienced vomiting, dizziness, and disequilibrium. Dr. Marzo attributed all of these symptoms to Chiari malformation, which was shown by means of a MRI of Ms. Amey's head. (R. 405-06). Subsequent studies confirmed the existence of a Chiari malformation. (R. 186, 189, 341).
On June 10, 2005, Dr. C. J. Wonais concluded that Ms. Amey's disorder accounted for the pain in her back, shoulders, and hands, as well as a temporary blindness that she formerly experienced in both eyes for short periods. (R. 138). Dr. Wonais also noted that Chiari malformation explained Ms. Amey's repeated balance problems, many of which resulted in falls that led to contusions. (Id.). The record shows that on November 7, 2004, Ms. Amey sought emergency treatment for a fall that appeared to result from numbness in her legs. (R. 174). She had earlier sought similar emergency treatment for an incident in 1997, when she fell in her shower. (R. 225, 245). In addition, dizziness and balance problems were noted by physicians in 2004 and 2005. (R. 178, 413).
Ms. Amey was also diagnosed with a syrinx, or syringomylelia, which is often associated with Chiari malformation and involves a fluid buildup in the upper spinal cord, causing numbness, headache, and limb pain. See http://www.ncbi.nlm.nih.gov/pubmedhealth/ PMH0002373. Ms. Amey was prescribed Advil and the muscle relaxant Flexeril to treat the pain and stiffness that resulted from her disorder. (R. 414). She was also prescribed the antidepressant amitriptyline to treat her muscle and headache pain.
In addition to complications stemming from Chiari malformation, Ms. Amey has a history of breathing problems stemming from asthma. She was first diagnosed with asthma in 1995. (R. 138). Although the record contains little information concerning her condition, Dr. Wonais noted that she is required to seek emergency treatment for her asthma five times a year, though she has never been hospitalized for it. (Id.). She was treated in the past with the steroid prednisone, but since 1999 she has been prescribed the bronchodilator Albuterol to control her asthma symptoms. (R. 381).
Ms. Amey also has a documented history of major depression. Although the record evidence is not entirely clear, she appears to have been first diagnosed with this disorder in May 1999, when a treatment note for a gynecology exam stated that she was depressed and experienced suicidal ideation. (R. 384). On November 2, 2005, Dr. Michael Gill noted that Ms. Amey had been on antidepressant medications "for years" but had stopped using Paxil one-and-a-half years prior to their interview. (R. 331). He diagnosed her as depressed and noted that she could start once again on Prozac to remedy her symptoms. (R. 336).
In November 2007, Ms. Amey began treatment with psychiatrist Dr. Huma Pandit through the DuPage, Illinois County Health Department. Dr. Pandit noted that Ms. Amey's mood level averaged a five out of ten, but that it could drop as low as one or two out of ten. (R. 434). Her sleep was erratic, and she had passive suicidal ideation combined with erratic sleep and feelings of worthlessness. (Id.). Dr. Pandit diagnosed her with recurring depression and began treatment with Lexapro, together with Trazadone to help Ms. Amey sleep. (R. 436). By January 2008, she was showing signs of improved mood and sleep. (R. 432). At some point that is not clear in the record, Dr. Pandit switched Ms. Amey's medication from Lexapro to Cymbalta, and she continued to show improvements in her mood by March 2008. (R. 426). It is unclear whether Ms. Amey completed her treatment with Dr. Pandit successfully, as the last medical record dated June 30, 2008 shows that she failed to appear for her appointment with the psychiatrist. (R. 423).
B. Consulting and State Agency Physicians' Reports
The record also contains a number of reports from consulting physicians, as well as state agency reports concerning the limitations imposed by Ms. Amey's impairments. On June 15, 2005, Dr. Madala Vidya issued a physical RFC for the SSA. Dr. Vidya noted that Ms. Amey suffered from a Chiari malformation, syringomylelia, scoliosis, headaches, severe back and arm ...