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Bradley Earl Wallace v. Michael J. Astrue

August 20, 2012


The opinion of the court was delivered by: Magistrate Judge Young B. Kim


Bradley Wallace challenges the Commissioner of Social Security's ("Commissioner") denials of his applications for social security disability ("DIB") and supplemental security income ("SSI") benefits under Title II of the Social Security Act, 42 U.S.C. § 423(d) and Title XVI of the Social Security Act, 42 U.S.C. § 1382(c). Wallace's motion for summary judgment is granted to the extent that this matter is remanded for further proceedings consistent with this opinion. For the foregoing reasons, the court finds that the presiding administrative law judge ("ALJ") deviated from the "treating physician rule" and erred in assessing Wallace's credibility:

Procedural History

Wallace applied for DIB and SSI benefits in July 2008 claiming that he became disabled in March 2007 by anxiety, depression, and mood disorders. (Administrative Record "A.R." 145-157.) His claims were denied initially and on reconsideration. (Id. at 64-67, 71-78.) Following a hearing in June 2010, the presiding ALJ found Wallace not disabled as defined by the Social Security Act and denied his claims for DIB and SSI benefits. (Id. at 13-26.) When the Appeals Council denied review, (id. at 5-10), the ALJ's decision became the final decision of the Commissioner, see Schmidt v. Astrue, 496 F.3d 833, 841 (7th Cir. 2007). Wallace then filed the current suit seeking judicial review of the ALJ's decision. See 42 U.S.C. §§ 405(g), 1383(c)(3). The parties have consented to the jurisdiction of this court. See 28 U.S.C. § 636(c).


Wallace was born in 1972 (A.R. 145) and was 35 years old when he allegedly became disabled. He had worked as a production assembler and building maintenance worker. (Id. at 56.) Before the ALJ, he testified that he had lost about four or five jobs because of problems stemming from his rapid cycling bipolar disorder (id. at 38-39), and explained that his last job ended in 2007 when he was not called back to work (id. at 36).

A. Medical Evidence

Wallace claims an onset date of March 25, 2007. (A.R. 145.) It appears from the record that he first sought treatment for depression in 2000-the record contains an evaluation submitted by Dr. Thomas Michalsen in April 2009 that states that he diagnosed Wallace with depression and bipolar disorder in 2000, and opined that he is "unable to work due to highs and lows." (Id. at 342.) Dr. Michalsen also noted that Wallace had not been on medication for approximately four years. (Id.) Apart from this record, the first medical evidence in the record is from Wallace's visit on September 5, 2008, to David NieKamp, Psy.D., for a mental status evaluation requested by the state disability agency. (Id. at 295- 298.) After spending 45 minutes with Wallace, Dr. NieKamp opined that Wallace suffers from "overt anxiety and depression that inhibits his ability to effectively find and maintain gainful employment." (Id. at 297.) Dr. NieKamp diagnosed Wallace to be suffering from moderate to severe anxiety and depression with a Global Assessment of Functioning ("GAF") score of 45.*fn1 (Id. at 298.) Around that time, an employee of the state disability agency interviewed Wallace on the phone and noted that Wallace was "[c]ooperative but there were a lot of background distractions. Also, [claimant] was randomly laughing at some questions and stating 'How stupid that you would ask that question to me.'" (Id. at 207.) Later that month, Carl Hermsmeyer, Ph.D, a state agency psychologist, assessed Wallace's mental residual functional capacity ("RFC") and opined that he has "problems with understanding, remembering and the ability to carry out detailed instructions, but the claimant retains the mental capacity to perform simple one and two-step tasks at a consistent pace." (Id. at 299-315.)

About a month later, Wallace sought treatment from Dr. Pocock, a practitioner of family medicine, on November 8, 2008. (Id. at 321-323.) Wallace related his history of eight years of bipolar disorder to Dr. Pocock, with no treatment for the last two years. He explained that he did not have health insurance. (Id. at 321.) Wallace claimed that he had just emerged from a manic cycle, which he experienced as being extremely talkative, having racing thoughts, crazy dreams, an inability to sleep, and obsessive cleaning. (Id. at 323.) He also described that when he is depressed he hides in his room, has crying episodes, guilty thoughts, and poor appetite, and lies in bed without sleeping. (Id.) Dr. Pocock described Wallace as "jittery and nervous." (Id.) He diagnosed Wallace with bipolar disorder but did not prescribe medication at that time. (Id.)

The following month, on December 17, 2008, Dr. Pocock evaluated Wallace again. (Id. at 325-326.) He observed Wallace to be "happier but speech pressured," and noted that Wallace was sleeping only four hours a night. (Id.) He urged Wallace to seek treatment at the Ben-Gordon Center, prescribed Abilify, and directed Wallace to return in two weeks. (Id.) Wallace returned to Dr. Pocock on February 28, 2009. (Id. at 327.) Wallace had stopped taking Abilify because it had given him palpitations. (Id.) Dr. Pocock observed Wallace to be "in depressive phase of Bipolar disorder." (Id. at 328.) He prescribed Fluoxetine and directed Wallace to return in two weeks. (Id.)

In March 2009, Wallace visited the Ben Gordon Center for a comprehensive assessment with a psychiatrist, Dr. Samar Mahmood, and a therapist. (Id. at 334-338.) During a 53-minute consultation, Wallace described his experience of rapid cycling between manic and depressive episodes. (Id. at 334.) He described the following symptoms of mania: "extreme adrenaline, racing thoughts, decreased need for sleep, more talkative than usual, and an increase in goal-directed behavior (e.g., cleaning)." He reported that during manic periods, he does not sleep for three to four days. (Id.) He described his depressive cycles to include: "depressed mood, markedly diminished interest in all activities, insomnia, fatigue, and feelings of worthlessness." (Id.) Wallace reported that he has had difficulty maintaining employment. (Id. at 335.) Dr. Mahmood characterized Wallace as being in a euphoric mood, with hyperactive motor activity and rapid speech, a normal attention span and clear thought process. (Id. at 335-336.) Dr. Mahmood concluded that "Brad currently meets criteria for Bipolar I Disorder, [m]ost recent episode mixed." (Id. at 336.) She noted that "Brad's symptoms of mania appear to have caused him to have difficulty sustaining employment." (Id. at 337.) She assessed his GAF score as 45. (Id.)

Wallace returned to see Dr. Mahmood on May 1, 2009, for a 50-minute appointment. (Id. at 367.) Wallace complained of rapid cycling of moods, extreme anxiety and panic attacks in social situations. (Id.) Dr. Mahmood described his mental status as very anxious, ill at ease, and noted that he sweated profusely during his session. (Id.) She described his thought processes as disorganized and his behavior as impatient. (Id.) She noted no change in his GAF score of 45. (Id.) In her treatment plan, Dr. Mahmood suggested Lamictal for his anxiety and Propanalol for "physical symptoms of anxiety such as tremulousness, stuttering, palpitations, sweating, etc." (Id. at 368.)

Dr. Mahmood again treated Wallace on June 5, 2009. (Id. at 369-370.) In a progress note, she described Wallace's mood as "anxious," but commented that Wallace believed that the Lamictal and Propanalol were helping him. (Id. at 369.) He requested stronger prescriptions for both medications, and Dr. Mahmood increased his Lamictal prescription. (Id. at 370.) On that date, she hand-wrote on a prescription notepad that "Brad is my patient and he is unable to work at this time. He has been unstable and not able to work for the last one year." (Id. at 349.)

In July 2009, Dr. Mahmood completed a "psychiatric/psychological impairment questionnaire," which detailed her clinical findings and her assessment of Wallace's mental health. (Id. at 352-59.) She noted that she treats Wallace every four weeks, and that his current GAF score was 50, an improvement from his lowest GAF score of 40 for the past year. (Id. at 352.) Her diagnosis was that Wallace was suffering from bipolar disorder with a "guarded" prognosis. (Id.) Clinical findings included poor memory, sleep disturbance, mood disturbance, psychomotor agitation or retardation, feelings of guilt/worthlessness, social withdrawal or isolation, decreased energy, and generalized persistent anxiety. (Id. at 353.) Dr. Mahmood described Wallace's primary symptoms as mood swings and anxiety. (Id. at 354.) In rating Wallace's mental abilities, Dr. Mahmood noted that Wallace was moderately limited, meaning "significantly affect[ed] but . . . not totally preclude[d]" in the following abilities: understanding, remembering, and carrying out detailed instructions, maintaining concentration and attention for extended periods, performing activities within a schedule, maintaining regular attendance, sustaining routine without supervision, working in coordination or proximity with others without being distracted, completing a normal workweek without interruptions from psychologically based symptoms and performing in a consistent pace, accepting instructions and responding appropriately to criticism, getting along with co-workers or peers, maintaining socially appropriate behavior, responding appropriately to changes in the work setting, and traveling to unfamiliar places or using public transportation. (Id. at 354-57.) Dr. Mahmood evaluated Wallace as being markedly limited, meaning "effectively preclude[d] . . . from performing the activity in a meaningful manner" for the following abilities: interacting appropriately with others and setting realistic goals or making plans independently. (Id.) She opined that Wallace experiences episodes of deterioration or decompensation in work-like settings that cause him to withdraw or experience exacerbation of symptoms. (Id. at 357.) She listed Prozac and Lamictal as his medications. (Id.) Dr. Mahmood opined that Wallace is not a malinger, that his symptoms are ongoing, that he has "good days" and "bad days," and that he is incapable of even low stress due to severe anxiety and unpredictable mood swings. (Id. at 358.) She estimated that Wallace would be absent from work more than three times a month as a result of his impairments. (Id. at 359.)

The next month, in August 2009, Dr. Mahmood met with Wallace for 20 minutes. (Id. at 410.) She characterized his affect as elevated and his mood as anxious. (Id.) Wallace told Dr. Mahmood that he felt better on the medication but still experienced hyperactivity and anxiety. (Id.) Dr. Mahmood increased his doses of Lamictal and Propranolol. (Id. at 411.)

She assessed Wallace's condition as improved but not in remission. (Id.) Dr. Mahmood's notes from a medical monitoring session on October 23, 2009, included the same findings. (Id. at 413-415.) When Wallace returned on January 25, 2010, he complained of heightened anxiety due to an experience testifying in court. (Id. at 416.) Again, Dr. Mahmood described his mood as anxious, his affect as elevated, and assessed his condition as ...

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