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Eric Davis v. Michael J. Astrue

March 21, 2012

ERIC DAVIS, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Magistrate Judge Maria Valdez

MEMORANDUM OPINION AND ORDER

This action was brought under 42 U.S.C. § 405(g) to review the final decision of the Commissioner of Social Security denying Plaintiff Eric Davis's claim for Disability Benefits. The parties have consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons that follow, Davis's motion for summary judgment [Doc. No. 19] is granted in part and denied in part. The Court finds that this matter should be remanded to the Commissioner for further proceedings.

BACKGROUND

I. PROCEDURAL HISTORY

Plaintiff Eric Davis ("Plaintiff," "Claimant," or "Davis") originally filed a Title II application for a period of disability and disability insurance benefits and a Title XVI application for supplemental security income on December 27, 2006. (R. 8.) In both applications, he alleged disability beginning July 1, 2006. (Id.) Plaintiff's claims were denied initially on March 23, 2007, and upon reconsideration on October 9, 2007. (Id.) Plaintiff timely filed a written request for a hearing by an Administrative Law Judge ("ALJ") on November 12, 2007. (Id.) Plaintiff appeared and testified at a hearing held on September 22, 2009, April 6, 2010 and September 10, 2010. (Id.) Also appearing and testifying on the first day of the hearing were impartial medical expert Dr. Julian Freeman ("Dr. Freeman"), impartial psychological expert Dr. Marva Dawkins ("Dr. Dawkins"), impartial vocational expert Michelle Peters, and Plaintiff's girlfriend, Ms. Leslie Bell ("Ms. Bell"). (Id.) Appearing and testifying on the second day of the hearing were impartial medical expert Dr. William Newman ("Dr. Newman"), impartial vocational expert Pamela Tucker, Dr. Dawkins and Plaintiff. (Id.) Appearing and testifying on the third day of the hearing were impartial medical expert Dr. Keenan Ferrell, impartial vocational expert Glee Ann Kehr, Ms. Bell and Plaintiff. (Id.)

On September 20, 2010, the ALJ denied Plaintiff's claim and found him "not disabled" under the Social Security Act. (R. 28.) The Social Security Administration Appeals Council denied Plaintiff's request for review on November 10, 2010. (R. 1.)

The ALJ's decision thus became reviewable by the District Court under 42 U.S.C. § 405(g), see Haynes v. Barnhart, 416 F.3d 621, 626 (7th Cir. 2005), and Plaintiff filed the instant motion on October 3, 2011. [Doc. No. 19.] This matter has been fully briefed since December 5, 2011. {Doc. No. 23.]

II. FACTUAL BACKGROUND

A. Mr. Davis's Background

Mr. Davis was born on March 19, 1972; at the time he claimed that he was unable to work -- July 1, 2006 -- he was thirty-four years old. (R. 239.) Davis alleged that he was unable to work due to his mental condition; specifically, he claimed that he had schizophrenia.*fn1 (R. 268.) In his application for disability insurance benefits, Davis claimed that he worked in 1989, and also worked from 2001 until he was unable to work at Metro Health Care Laundry Services as a linen tech. (R. 240, 269, 1002.) Davis was incarcerated from December 1989 until June 2001. (Id.) The record also indicates that Davis was incarcerated for a short period of time in 2004.

(R. 1048-51.)

A. Lay Testimony

1. Davis's Testimony and Reports

In his Activities of Daily Living Questionnaire, Plaintiff reported that he rarely goes out, attends to personal hygiene once a week, and does not drive. (R. 299-300.) When asked to explain activities he once did but can no longer do, Davis said the following: "I use to be able to walk before my knew (sic) operation and before the warriors of mazon took over my Temple. Now I'm a servant of durah." (R. 301.) Plaintiff also reported that he lived with his girlfriend, Ms. Bell and his daughter, Jemyria Davis. (R. 302.) In terms of household chores that he performed, Davis reported that he "keep[s] evil out my temple." (Id.) He also indicated that he did not go shopping. (Id.) Plaintiff indicated that his condition had affected his bathing, hair care or dressing, and said, "I hide cause people see me washing up so I do it probably 1 time." (R. 303.) Plaintiff also indicated that he needed help remembering to take medicine or keep appointments, and the Ms. Bell helped him do so. (Id.) Plaintiff reported that he had problems concentrating or thinking, and said that there are "to many other people in my head with me." (Id.) Plaintiff also reported that he had problems finishing things that he starts, and said, "I'm scared to do something." (Id.) Plaintiff also reported that he hears voices and sees people who are not around "all the time." (Id.) Plaintiff indicated that the voices and people interfered with his activities, and said that "they don't believe I'm the boss." (Id.) Plaintiff indicated that someone was watching him or trying to harm him, and identified them as "the evil soldiers of durah." (R. 304.) Plaintiff reported that he left home "once" and goes "everywhere." (Id.) Plaintiff indicated that he could not leave home alone because "[Ms. Bell] don't let me go. She say I'm crazy." (Id.) Plaintiff reported that he did not enjoy people or being around them, and indicated that he feels afraid of people. (Id.)

In a separate Activities of Daily Living Questionnaire, Plaintiff reported that his mom and friends cooked his meals, and that he did no household chores. (R. 281.) Plaintiff also reported that he "smoke[d] a lot of reefer" and that he needed help remembering to take medicine or keep appointments. (R. 282.) He indicated that he had problems with concentrating or thinking, and explained that there were "too many things in my brain thats talking to me with different things and telling me what to do." (Id.) He also indicated that he was forgetful, and explained that "if I put something down my fish steals it." (Id.) Plaintiff reported that he heard voices and saw people who were not around, and indicated that they interfered with his activities. (Id.) Plaintiff said, "I don't leave my room if I don't have too cause they and my fish follows me around." (Id.) In response to a question asking whether he feels as if someone is watching him or trying to harm him, Plaintiff explained that "everybody want all of my golden riches." (R. 283.) Plaintiff reported that he leaves home "about three times a week or sometimes 20." (Id.) He indicated that he could not leave home alone, but then said that he goes by himself sometimes or goes with his mom. (Id.) Plaintiff also reported that he was not able to sleep well because he was "paranoid cause somebody is watching me and stealing my pillow." (Id.) Plaintiff indicated that he does not enjoy people; he said, "I don't trust people. They trying to steal my riches golden that is. Plaintiff indicated that he is afraid of people because "they don't like [his] fish." (Id.)

On the first day of the hearing, Plaintiff testified that he had a seventh or eighth grade education, and discontinued his schooling because he was "in the streets." (R. 969.) Plaintiff also explained that he was abused by his father. (R. 972.) When the ALJ asked Plaintiff to describe how his mental or physical impairments limited him from working, and then asked if Plaintiff was distracted, Plaintiff said, "People be staring at me all the time." (R. 974.) When the ALJ asked Plaintiff with whom he lived, Plaintiff said, "My friend [Ms. Bell]." (Id.) When the ALJ asked if he lived with anyone else, Plaintiff said, "And her kids." (R. 975.) When the ALJ asked whether Plaintiff's stuffed shark stares at him, Plaintiff said, "who told you that?" (Id.) After the ALJ explained that he had read about the stuffed shark in the record and asked Plaintiff if he had any interaction with the shark, Plaintiff said that "[i]t used to be my friend, but I don't talk to it no more." (Id.) When the ALJ asked Plaintiff if he thought that anyone else was staring at him, Plaintiff said, "[i]t's just like, it's like people always think something funny. You know." (R. 976.) After the ALJ asked if Plaintiff thought that people were laughing at him, Plaintiff said that he hears them laughing at him. (Id.) Plaintiff testified that he spends most of his day in his room and that he sleeps a lot. (R. 983.) Plaintiff said that he hears voices and that he communicates with his dead sisters. (R. 985.) He also said that he sees things that are not there, and the medicine does not help all of the time. (R. 986.) Plaintiff testified that he tried to hang himself while incarcerated. (R. 1009.) Plaintiff explained that his stepfather got him his job with Metro Health Care Laundry Services, but that he was not actually working: "He just put me on payroll." (R. 1013.) Plaintiff explained further: "The time that I did go to work, because he said something about that there was [inaudible] he going to have to, like, pick me up and bring me, like, to work for a couple of times so that I could be [inaudible] seen, like, on the hospital site." (R. 1014.) Plaintiff expressed concern that his stepfather might get into trouble. (Id.) After the ALJ assured him that his stepfather would not get in trouble, the ALJ asked if Plaintiff was still in contact with his stepfather; Plaintiff said that he had died. (R. 1015.)

On the second day of the hearing, Plaintiff testified that he saw his doctor every week for his mental problems. (R. 1046.) When the ALJ asked if Plaintiff was taking any medication for his mental problems in prison, Plaintiff said, "[t]hey didn't do nothing in jail, they didn't care none about none of that." (R. 1047.) Plaintiff explained that he started living with Ms. Bell after he got out of prison in 2001. (R. 1048.)

On the third day of the hearing, when the ALJ asked whether Plaintiff took care of his daughter, Plaintiff said "I see her." (R. 44.) The ALJ then asked Plaitniff if his daughter lived with him, and Plaintiff said, "[y]eah." (Id.) Plaintiff testified that Ms. Bell helped him take care of his daughter, and that his daughter's maternal grandmother helped as well. (R. 44-45.) Plaintiff said that his daughter attended school during the day, and that during the week her maternal grandmother picked her up from school, kept her, and brought her home in the morning. (Id.) Plaintiff said that the maternal grandmother takes care of his daughter on the weekend as well. (R. 45.)

2. Ms. Bell's Testimony and Reports

Ms. Bell completed a "Function Report" on August 10, 2007 and indicated that she had known Plaintiff for six years. (R. 307.) Ms. Bell reported that Plaintiff doesn't do anything during the day. (Id.) She also reported that Plaintiff takes care of his child and that she helps him. (R. 308.) Ms. Bell explained that when she met Plaintiff, "he was already mental." (Id.) Ms. Bell indicated that she helps Plaintiff with almost all of his personal care, and that she reminds him to take care of his personal needs and grooming. (Id.) Ms. Bell also indicated that Plaintiff does not prepare his own meals or do any household chores. (R. 309.) She reported that Plaintiff goes outside twice per month, and that he walks when he goes out. (Id.) Ms. Bell explained that Plaintiff cannot go out alone, and that Plaintiff does not drive because "he will crash." (Id.) Ms. Bell reported that Plaintiff does not shop, and that he cannot pay bills, handle a savings account, or use checkbooks or money orders. (R. 310.) In terms of hobbies and interests, Ms. Bell reported that Plaintiff "chew[s] on his tongue" and that de does not do it well. (Id.) She also reported that Plaintiff talks to his mother once a week, and that there is nowhere that Plaintiff went on a regular basis. (Id.) Ms. Bell indicated that Plaintiff's illness, injuries or conditions affect his ability to talk, understand, follow instructions, see, complete tasks, remember, concentrate, and get along with others. (R. 311.) Ms. Bell reported that Plaintiff is paranoid, that he can only pay attention for ten minutes, and that he does not finish what he starts. (Id.) Ms. Bell also indicated that Plaintiff has trouble following written instructions and spoken instructions, and that he does not get along with authority figures. (Id.) Ms. Bell reported that Plaintiff does not handle stress or changes in routine well. (R. 312.)

In a different report, Ms. Bell stated that "some days it's hard for him to walk and he talks to imaginary voices all day." (R. 294.) She also said that Plaintiff "thinks he is a fish and other times he plays in his feces." (Id.) Ms. Bell explained that Plaintiff's mental and physical impairments make him "incapable of functioning in society. He constantly talks to imaginary voices. He uses the bathroom on himself. He rarely leaves the house. He believes he is the 'wish master.' He goes to doctors but runs out. I'm trying to get him admitted, but I can only do so much for him." (R. 297.)

On the first day of the hearing, Ms. Bell testified that Plaintiff was her boyfriend and that they lived together. (R. 989.) She said that she was not sure how long they had been living together, but thought that they may have been living together since 2003 or 2004. (R. 991, 993.) At one point, the ALJ said, "[Plaintiff is] very non-responsive. And kind of stares straight out a lot of times, and seems to have, like, a fixed view or fixed stare." (Id.) When the ALJ asked if Plaintiff had been like that for a while, Plaintiff said yes, and said that he had been like that "pretty much since I known him for." (Id.) Ms. Bell said that Plaintiff stays in his room when he is at home and does not really go out at all. (R. 993-94.) Ms. Bell explained that Plaintiff got his job with Metro Health Care Laundry Services through his stepfather, but explained that Plaintiff was not actually working because he did not like to be around a lot of people. (R. 994.) Ms. Bell later clarified and said that Plaintiff did not work every day, and that it got to a period where he was not going to work at all. (R. 1012-13.) Ms. Bell said that Plaintiff"s stepfather would take him to work when he went. (Id.) When the ALJ asked whether she knew that Plaintiff's stepfather died, Ms. Bell said that she probably forgot, and that she had "other stuff going on with me also." (R. 1015.) Ms. Bell said that Plaintiff did not drive. (R. 996.) Ms. Bell said that her two kids lived with them, and that no other kids lived with them. (R. 999.) Ms. Bell explained that she cannot leave Plaintiff by himself for very long because he tends to get nervous and impatient. (R. 1004.) Ms. Bell said that Plaintiff talks to himself and converses with imaginary people.

Ms. Bell did not testify on the second day of the hearing. On the third day of the hearing, Ms. Bell testified that she takes care of Plaintiff's daughter, and that the child's maternal grandmother also takes care of her. (R. 48.) During her testimony, the ALJ stated that "the claimant present with a very severe mental impairment. He's not responsive many times in the hearing room, for instance. He looks off to the side, that kind of thing." (Id.) After the ALJ asked her if Plaintiff was like that when she first met him, Ms. Bell said, "[n]ot all the way, but he's like that now." (Id.) When the ALJ asked her at what stage Plaintiff progressed to his current level of dysfunction, Ms. Bell said, "I'm not a doctor. I don't know that difference in stages. I pretty much just know [Plaintiff]." (R. 49.) The ALJ re-articulated his question: "how long ago was he this bad off in mental functioning?"

(Id.) Ms. Bell responded, "[y]ou're saing bad off, to me, I don't know, because I'm around him every day, so, I really wouldn't know how to answer that." (Id.)

3. Ms. Jenkins's Report

Ms. Jenkins, Plaintiff's mother, also completed a function report. (R. 273.) She reported that she saw Plaintiff three or four times per week. (Id.) Ms. Jenkins said that Plaintiff "mostly stay in the house and watch TV. He cooks, take care of his child. He's really anti-sociable." (Id.) Ms. Jenkins reported that Plaintiff was raising his daughter by himself with a little help from her. (R. 274.) Ms. Jenkins indicated that Plaintiff had no problem with his personal care, and that Plaintiff did not need any special reminders to take care of personal needs and grooming, or take his medicine. (Id.) Ms. Jenkins also indicated that Plaintiff prepared his own meals, and took care of household chores like cleaning, laundry and ironing. (R. 275.) Ms. Jenkins reported that Plaintiff went outside five times per week. (Id.) Ms. Jenkins reported that when he went out, he could do so alone, and indicated that he would walk, ride in a car or use public transportation; she indicated that he would not drive a car or ride a bicycle. (Id.) Ms. Jenkins indicated that Plaintiff did drive. (Id.) Ms. Jenkins also indicated that Plaintiff shopped for himself, and was capable of paying bills, handling a savings account, counting change, and using checkbooks and money orders. (R. 276.) In terms of hobbies and interests, Ms. Jenkins reported that Plaintiff watches TV. (Id.) Ms. Jenkins also reported that Plaintiff spends time with family members, and that there are no places Plaintiff visited on a regular basis. (Id.) Ms. Jenkins indicated that Plaintiff sometimes needed to be reminded to go places, but that he did not require someone to go with him. (R. 277.) In response to a question asking whether Plaintiff had problems getting along with family, friends, neighbors or others, Ms. Jenkins marked "no." (Id.) Ms. Jenkins also indicated that Plaintiff's illness, injuries or conditions affect his ability to understand, follow instructions, complete tasks, concentrate and get along with others. (Id.) Ms. Jenkins reported that Plaintiff can pay attention for only two minutes, that he cannot finish what he starts, that he does not follow written or spoken instructions well, and that he does not get along with authority figures. (Id.) Ms. Jenkins also reported that Plaintiff does not handle stress well. (R. 278.)

B. Expert Testimony & Medical Evidence

1. Dr. Castelino Evaluation and Reports

Dr. Castelino is a staff psychiatrist at Beverly Morgan Park Mental Health Center. (R. 924.) He completed an evaluation on April 30, 2010. (R. 925.) Dr. Castelino reported that he had treated Plaintiff for close to two years. He diagnosed Plaintiff with schizoaffective disorder, and noted that Plaintiff had a history of mood swings ranging from depression to irritability, and that Plaintiff expressed psychotic symptoms such as auditory hallucinations. (R. 924.) Dr. Castelino concluded that Plaintiff appeared to have "very poor social and occupational functioning due to chronic course of his illness." (R. 925.) Dr. Castelino determined that Plaintiff's abilities to remember locations and work-like procedures, to understand and remember very short and simple instructions, to understand and remember detailed instructions, to carry out detailed instructions, to maintain attention and concentration for extended periods, to interact qppropriately with the general public, and to maintain socially appropriate behavior and to adhere to basic standards of neatness and cleanliness were markedly limited. (R. 926-27.)

Plaintiff's presenting problems included a history of auditory hallucinations, insomnia and mood swings. (R. 956) Dr. Castelino identified the following mood symptoms: sadness, anxiety, extreme irritability, hopelessness, feeling "empty," tired/slowed down. (Id.) The doctor also identified the following psychotic positive symptoms: Audio and visual hallucinations, and thought disorder. (Id.) Dr. Castelino also indicated that Plaintiff had difficulty with attention, difficulty with concentration, instability in mood, instability in interpersonal relationships, depression, and boredom. (Id.) Dr. Castelino's records indicate that Plaintiff had already been prescribed Invega, Depakote and Seroquel. Dr. Castelino recommended medication education, the continuance of the medication Plaintiff was already using, new medication (Cymbalta), and the continuance of individual psychotherapy and individual counseling. (R. 961.) Dr. Castelino diagnosed Plaintiff with schizoaffective disorder. (Id.)

On August 1, 2008, Dr. Castelino indicated the following symptoms: loss of interest, tired/slowed down, hallucinations, difficulty with attention and concentration, instability in mood and interpersonal relationships, depression and anxiety. (R. 952.) On October 31, 2008, the doctor recognized many of the same symptoms. (R. 948.) On June 12, 2009, Plaintiff reported that he felt alright, but Dr. Castelino identified the following symptoms: anxiety, hallucinations, difficulty with attention and concentration, and depression. (R. 940.) On October 16, 2009, Dr. Castelino identified the following active problems: anxiety and paranoia. (R. 938.) On January 8, 2010, Dr. Castelino identified the same active problems, and also identified the following symptoms: anxiety, difficulty with attention and concentration, and depression. (R. 932, 934.) On April 30, 2010, Dr. Castelino determined that Plaintiff's schizoaffective disorder was in partial remission. (R. 930.) He identified anxiety and paranoia as Plaintiff's active problems, and anxiety, hallucinations, difficulty with attention and concentration, and depression as Plaintiff's current symptoms. (R. 928, 930.)

2. Dr. Friedson's Evaluation

On March 2, 2007, Dr. Friedson conducted a mental status evaluation for the Bureau of Disability Determination Services. (R. 336.) Dr. Friedson reported that Plaintiff "presented as quite hostile and belligerent. He really did not cooperate."

(R. 337.) Dr. Friedson also reported that Plaintiff was extremely vague about his history. (Id.) Dr. Friedson asked Plaintiff about his education. Plaintiff told Dr. Friedson that the only education he ever received was "in the pen." (Id.) When Dr. Friedson asked Plaintiff in what penitentiaries her served, Plaintiff said, "all of them." (Id.)

When Dr. Friedson asked Plaintiff with whom he lived, Plaintiff said, "Me and everybody else." (Id.) When the doctor asked Plaintiff whether he had ever heard voices in his head, Plaintiff said, "I'm not going to answer that question. I hear your voice." (R. 338.) When Dr. Friedson asked Plaintiff to define the word "repair," Plaintiff said, "I'm not answering that. Don't you know the answer to that? Why are you asking me?" (Id.) Dr. Friedson reported that Plaintiff was unable to identify a similarity between a piano and a drum. (Id.) When Dr. Friedson asked Plaintiff to add five and four, Plaintiff correctly stated nine; but when the doctor asked him to subtract four from ten, Plaintiff stated, "negative sixteen." (Id.) When Dr. Friedson asked Plaintiff how many months were in a year, Plaintiff said, "365." (Id.)

Dr. Friedson reported that Plaintiff was unable to tell him what medications he had taken. (Id.) The doctor also reported that Plaintiff claimed that he saw a psychiatrist while in the penitentiary. (Id.) Dr. Friedson stated, "I did get the sense from this claimant's presentation that there may be a long history of antisocial behavior. It was really not clear to me whether there is a truly psychotic process. . . . In the absence of documentation, there may also be validity issues." (Id.) Dr. Friedson diagnosed Plaintiff with "possible psychotic disorder NOS" and "probable antisocial personality disorder by history and presentation -- primary diagnosis." (R. 339.) Dr. Friedson also reported that, based on his evaluation, Plaintiff did not have the capacity to manage his own finances. (Id.)

3. Dr. Heinrich's Evaluation

On March 20, 2007, Dr. Heinrich completed a mental residual functional capacity assessment. (R. 368.) Dr. Heinrich identified possible psychotic disorder, NOS and probable antisocial personality disorder as medically determinable impairments. (R. 348. 353.) Dr. Heinrich found that Plaintiff had moderate limitations in maintaining social functioning and maintaining concentration, persistence or pace. (R. 356.) The doctor also found that Plaintiff was moderately limited in his ability to carry out detailed instructions, the ablilty to maintain attention and concentration for extended periods, the ability to interact with the general public, the ability to get along with co-workers or peers without distracting them or exhibiting behavioral extremes, the ability to maintain socially appropriate behavior and to adhere to basic standards of neatness and cleanliness, and the ability to respond appropriately to changes in the work setting. (R. 368-69.)

Dr. Heinrich reported that there was no longitudinal evidence supporting a schizophrenia diagnosis, and that Plaintiff's presentation was not consistent with a schizophrenia diagnosis. (R. 370.) Dr. Heinrich determined that "[h]is behavioral diagnoses appear to be probable antisocial personality disorder and probable cannabis abuse." (Id.)

4. Dr. Dawkins's Testimony

On the first day of the hearing, Dr. Dawkins testified that Plaintiff had been diagnosed and treated for schizoaffective disorder. (R. 1008). Dr. Dawkins opined that Dr. Friedson would have diagnosed Plaintiff with schizoaffective disorder as well had Dr. Friedson had Plaintiff's treating source records at that time. (Id.) Dr. Dawkins explained the nature and course of schizoaffective disorder and explained that the condition could have gone untreated for years. (Id.) Dr. Dawkins also explained that the personnel at the Illinois Department of Corrections might not have recognized or treated Plaintiff's condition. (R. 1009.) Dr. Dawkins reported that Plaintiff's treating source records provided a good longitudinal ...


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