United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
SHEILA FINNEGAN, Magistrate Judge.
Plaintiff Carlonda Keewana Exson seeks to overturn the final decision of the Commissioner of Social Security ("Commissioner" or "Defendant") denying her application for Supplemental Security Income ("SSI") under Title XVI of the Social Security Act. 42 U.S.C. § 1381a. The parties consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c), and Plaintiff moved for summary judgment. After careful review of the record, the Court now affirms the Commissioner's decision.
Plaintiff, at 36 years of age, applied for SSI benefits on January 26, 2009, three days after she had been released from prison, having served a sentence of over 17 years for a murder conviction. (R. 81, 193, 196). Her application stated that she is disabled due to "learning problems, " and she alleged her disability began on the day she became incarcerated for that crime, on October 25, 1991, at age 18. (R. 193, 205-06). She further explained to the interviewer at the field office at the time she made her application that "I have been incarcerated from 1991 through the present. I have severe learning problems and cannot do any type of job in the national economy now. I cannot do anything." (R. 206). In the most recent Disability Report, dated August 25, 2010, Plaintiff stated that since about January 1, 2010, she has problems standing for a long time; has outbursts when she feels uncomfortable; is diagnosed with diabetes; falls asleep while completing tasks due to sleep apnea; is obese; has stress incontinence; cannot concentrate on tasks or instructions and forgets things; has an eating disorder; breaks out in boils; has recurring skin infections; and has high cholesterol. (R. 236).
The Social Security Administration ("SSA") denied Plaintiff's application initially on April 8, 2009, and again upon reconsideration on May 19, 2010. (R. 81-82). Plaintiff filed a timely request for hearing and appeared before Administrative Law Judge James D. Wascher (the "ALJ") on May 11, 2012. (R. 13). The ALJ heard testimony from Plaintiff, who was represented by counsel, as well as from vocational expert Michael L. Blankenship (the "VE"). After leaving the record open for additional evidence that Plaintiff failed to submit (or to request more time to submit), the ALJ issued his decision on August 13, 2012. (R. 13-29). He determined that Plaintiff is not disabled because she is capable of performing certain light jobs that exist in significant numbers in the national economy. ( Id. ). The Appeals Council denied review of the ALJ's decision, making the ALJ's determination the final decision of the Commissioner. (R. 1-5). Plaintiff now seeks judicial review.
In support of her motion, Plaintiff argues that the ALJ erred (a) in finding that her impairments did not meet or equal the requirements of Listing 12.04; (b) in misevaluating the opinion evidence from her mental health treatment providers and the opinions from two consultative examiners; (c) in over-emphasizing her activities of daily living; (d) in discounting her credibility due to her treatment history; and (e) by failing to fully develop the record. As discussed below, the Court finds no merit to any of these arguments.
Plaintiff completed her GED and earned some credits towards a college degree while she was incarcerated. (R. 56, 210, 303). After leaving prison, she worked for about a month around the holidays doing bell ringing for the Salvation Army. (R. 57-58, 199). She engaged in no other post-imprisonment employment. Plaintiff first lived with her sister upon her release from prison, until her sister put her out. (R. 69, 196). She was living in a shelter called Matthew House at the time of the May 11, 2012 hearing. (R. 56-57).
A. Medical History
1. 1990s through January 2009
Plaintiff's health records from her period of incarceration (October 1991 to January 2009) are mostly irrelevant to her disability claim, but a few bear mention. Regarding her mental health, on August 21, 1992, she complained of depression, presented with a flat affect, and stated she wanted to cut her wrists. (R. 559-70). She was admitted to Cermak Hospital for evaluation, was administered the anti-depressant Sinequan, and was diagnosed with a depressed mood. (R. 564). Plaintiff was released from Cermak on August 24, 1992 after she continuously displayed normal behavior. (R. 564-65). At discharge, she denied ever being suicidal. (R. 565).
A couple of months later, on October 1, 1992, Plaintiff was evaluated by Dr. Dale Hoke, a psychologist at the prison. (R. 302). Plaintiff reported a history of drug abuse, including heroin and cocaine, as well as occasional alcohol use. Plaintiff told Dr. Hoke that she had received drug abuse treatment while she had been held in the Cook County Jail prior to her imprisonment, but no alcohol abuse treatment. ( Id. ). She also reported previous work in sales, fast food, and computer work, and was interested in a work assignment and schooling. ( Id. ). Dr. Hoke diagnosed Plaintiff with opioid and cocaine dependence. ( Id. ).
A few years later, on August 23, 1996, Plaintiff underwent another mental health evaluation by Dr. Cary Haywood, a psychiatrist. (R. 303-04). Plaintiff told Dr. Haywood that she had taken a substance abuse course in the summer of 1994, and that she had earned 12 to 15 credits so far towards her college degree. ( Id. ). The psychiatrist also noted Plaintiff had a history of fighting, anger, drug abuse, and some treatment with Sinequan, which had caused weight gain. ( Id. ). Plaintiff is 5'10" tall and weighed approximately 260 pounds at the time of this evaluation, making her about 100 pounds overweight by Dr. Haywood's estimate. (R. 304). The psychiatrist diagnosed Plaintiff with a history of chemical dependence and a current adjustment disorder with a depressed mood. ( Id. ). He recommended further substance abuse counseling and the anti-depressant Nortriptyline. ( Id. ). The record does not reflect whether Plaintiff took any Notriptyline, or underwent any substance abuse counseling.
Plaintiff's next mental health records are from October 2, 2000, when she was placed in segregation, but was observed to be in no unusual distress and did not require therapeutic services. (R. 305). On October 20, 2001, Plaintiff underwent anger management therapy, and on November 27, 2008, she underwent codependency group therapy. (R. 306-08). Notes from both therapy sessions state that she was an active participant, appeared alert and oriented, and displayed an appropriate affect. ( Id. ).
Plaintiff's physical health records show that on January 8, 2001, she complained of foot callouses, and her feet showed "structural problems." (R. 350). Plaintiff underwent foot x-rays and was diagnosed with moderate hammer toe deformities and bunions in both feet, with a minimal heel spur on the right foot. (R. 349). Several years later, on October 6, 2007, Plaintiff complained of foot callouses and toenail fungus that made it hard to walk and painful to wear shoes. (R. 327). As a result, Plaintiff received monthly treatments at a foot clinic, where her callouses were scraped, toenails were clipped, and she was provided foot hygiene products. (R. 332, 334-41). This treatment continued until she was released from prison. ( Id. ). Plaintiff's records also show she was advised on a few occasions to exercise and watch her diet due to obesity. (R. 317, 592).
A January 15, 2009 health status report prepared in advance of Plaintiff's discharge noted her medical history was significant for obesity, drug abuse, psychological issues and psychological medication use, but stated she was taking no psychotropic medications or receiving other treatments at that time. (R. 288). Plaintiff was released from prison on January 23, 2009, and she applied for benefits three days later, on January 26, 2009. (R. 81, 196).
2. March 2009 through December 2009
On March 9, 2009, Plaintiff underwent psychological testing by Dr. William N. Hilger, a clinical psychologist, for the purpose of evaluating her disability claim. (R. 378-83). She was casually dressed and appeared to be extremely obese, but had a normal gait and posture. (R. 378). She reported no previous psychiatric treatment "in her life, " no psychiatric hospitalizations, no serious health problems, and was not taking any medications. (R. 379). Plaintiff's sister brought her to the examination, and Plaintiff demanded that her sister be present during the examination. (R. 378). Despite Dr. Hilger's repeated admonishments, at times Plaintiff's sister answered questions for and coached Plaintiff. ( Id. ).
Dr. Hilger found that Plaintiff put forth an extremely poor effort, was evasive, and acted inappropriately throughout his examination. (R. 378). When the psychologist approached Plaintiff in the waiting room, she began screaming, "Don't put me in jail, don't put me in jail! What did I do wrong, what did I do wrong?" ( Id. ). She also laughed at herself in a childlike, immature, and exaggerated manner. ( Id. ). Plaintiff stated her full name and age, but then refused to answer questions about where she was living, the current date, or about why she had been in prison. (R. 378-79). When asked whether she was living in an apartment or a house with her sister, Plaintiff described the place as "a box." ( Id. ). When asked about cooking, she described the stove as "no touch, hot, no touch, " and when asked about driving, she said "I like cars, rum-rum, " as if she were a young child. ( Id. ). Plaintiff also said she plays with leaves outside, referred to the leaves as her friends, and tried to pull off her bra during the examination. (R. 379-80). On the other hand, she reported going to church and socializing there, shopping with her sister, bathing herself, and making sandwiches for herself. (R. 379-81). Her sister also admitted that prior to her imprisonment, Plaintiff had completed schooling through the 10th grade. (R. 380).
Plaintiff initially admitted prior drug use consisting of "everything imaginable, " but then denied she ever injected any drugs, drank alcohol or smoked. (R. 380). Despite Plaintiff's denials, Dr. Hilger detected an obvious odor of alcohol on her. (R. 379). Plaintiff also admitted to some drug abuse treatment in jail, but refused to elaborate. (R. 380).
Dr. Hilger reported that his testing of Plaintiff's knowledge, calculation ability, reasoning, and judgment produced invalid results due to her blatant malingering. (R. 381). For example, Plaintiff said that 2=5. ( Id. ). But Plaintiff's sister admitted that Plaintiff previously worked as a cashier at K-Mart, which Dr. Hilger found inconsistent with Plaintiff's alleged inability to do simple mathematics. (R. 381-82).
Overall, Dr. Hilger concluded that Plaintiff "has applied for disability benefits attempting to put on quite a show of serious emotional disturbance, but was not at all convincing." (R. 382). He diagnosed her with admitted past poly-substance abuse and probable ongoing alcohol abuse, and with extremely exaggerated symptomatology, blatant disingenuous effort, and malingering. ( Id. ). Dr. Hilger estimated Plaintiff had low-average intellectual functioning with fair mental potential, but no motivation to pursue work activities. ( Id. ). He also felt Plaintiff was capable of unskilled work activities such as in fast food preparation or housekeeping, if she was inclined, but she could not manage any benefit payments while abusing alcohol. (R. 383).
On April 7, 2009, state agency psychological consultant Dr. J.V. Rizzo, Ph.D, completed a psychiatric review for evaluating Plaintiff's disability claim, in which he determined her file presented no evidence she has a medically determinable mental impairment. (R. 384-97). The next day, on April 8, 2009, the SSA denied Plaintiff's claim, and on April 15, 2009, she filed for reconsideration. (R. 81-82).
In early 2010, the SSA sought to arrange another mental health consultative examination of Plaintiff for use in reconsidering her disability claim. (R. 419). However, Plaintiff missed her appointment and did not respond to attempts to reach her. ( Id. ). Regarding her health care during this time, the record contains a March 31, 2010 prescription note for physical therapy, but no related treatment notes or any physical therapy records. (R. 516).
On May 17, 2010, state agency consulting psychologist Dr. Keith Burton, Ph.D., prepared a psychiatric review for reconsidering Plaintiff's disability claim. (R. 420-33). Noting that the only consultative examination in the file was over a year old, Dr. Burton determined there was insufficient evidence that Plaintiff had any impairment. ( Id. ). On May 19, 2010, the SSA again denied Plaintiff's claim. (R. 82).
A May 26, 2010 prescription note in the file shows Plaintiff was referred for a nocturnal polysonogram due to sleep apnea, but there are no related treatment notes or any records showing Plaintiff underwent this procedure. (R. 517). A few months later, on August 19, 2010, Plaintiff applied for an administrative hearing regarding her disability claim. (R. 92).
By September 2010, Plaintiff was again incarcerated for reasons which are not explained in the record. (R. 485). On September 16, 2010, she underwent a medical evaluation at the Dwight Correctional Center. ( Id. ). Plaintiff reported a history of treatment with anti-depressant medications, and the nurse evaluator noted Plaintiff weighed 308 pounds, was tearful and anxious, and required a low bunk due to a slow walk. ( Id. ).
A couple of weeks later, on October 1, 2010, Plaintiff was admitted to the prison's infirmary, complaining of right shoulder pain after being handcuffed. (R. 489, 491). She was hysterical, tearful and uncooperative during the examination, but was later observed relaxing and moving her right arm and shoulder when the examiner left the room. ( Id. ). The next day, a nurse noted Plaintiff said she was hearing voices, and recommended she see the psychologist, but there are no notes concerning any psychiatric treatment at this ...