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Begic v. Colvin

United States District Court, N.D. Illinois, Eastern Division

January 30, 2017

ADMIRA BEGIC, Plaintiff,
v.
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM OPINION AND ORDER [1]

          SIDNEY I. SCHENKIER United States Magistrate Judge

         In this Social Security appeal, plaintiff Admira Begic moves for reversal or remand of the final decision of the Commissioner of Social Security denying her application for benefits ("Commissioner") (doc. # 19). For the reasons set forth below, we grant Ms. Begic's motion.

         I.

         On April 2, 2012, Ms. Begic filed for disability benefits alleging that she became too disabled to work as of May 1, 2009 (R. 88). Her claim was denied initially and on reconsideration, and after two hearings before an Administrative Law Judge ("ALJ"), the ALJ issued an opinion denying Ms. Begic's request for benefits (R. 18). The Appeals Council denied her request for review (R. 1), making the ALJ's ruling the final decision of the Commissioner. See Loveless v. Colvin, 810 F.3d 502, 506 (7th Cir. 2016).

         In support of her motion, Ms. Begic argues primarily that the ALJ's findings regarding her mental impairments were erroneous and require remand (doc. # 20: PL's Mem. in Supp. of Summ. J. at 8-15). For the reasons that follow, we conclude that remand is necessary on this basis, and we therefore do not reach Ms. Begic's additional arguments for remand. Below, we set forth the evidence relevant to this issue.

         II.

         On October 27, 2010, Ms. Begic began regular psychiatric outpatient treatment with Mussarat Y. Zahid, M.D. (R. 659). Dr. Zahid observed that Ms. Begic showed marked anxiety in her psychomotor activity, had poor concentration, and appeared dysthymic (depressed) and dysphoric (anxious, restless, unhappy) (R. 661). Ms. Begic reported suffering headaches, panic attacks, difficulty sleeping, and off and on feelings of hopelessness, helplessness and guilt (R. 660). Dr. Zahid diagnosed Ms. Begic as suffering from severe major depression, panic disorder and migraines (R. 661). Between November 2010 and April 2011, Dr. Zahid added a diagnosis of insomnia and noted that Ms. Begic remained generally depressed, dysthymic, dysphoric, and at least somewhat anxious (R. 642, 645, 652, 654-59, 804, 816). In May 2011, Dr. Zahid added the diagnosis of post-traumatic stress disorder ("PTSD"), but PTSD did not appear again in Dr. Zahid's notes until April 2012 (R. 640).

         On April 28, 2011, Ms. Begic had a check-up with her primary care physician, Sinisa Boskovic, M.D., who noted that Ms. Begic was "in no acute distress, pleasant, comfortable, cooperative, interacting appropriately" and had a normal affect (R. 696-97). On May 15, 2011, the report from Ms. Begic's visit to Sherman Hospital for an upper respiratory and ear infection stated that she was cooperative and had appropriate mood and affect as well as normal judgment (R. 517-20).

         At her regular appointments with Dr. Zahid from September through December 2011, Dr. Zahid noted that Ms. Begic's concentration remained poor and her psychomotor activity continued to show marked anxiety (R. 650). In addition, in October 2011, Ms. Begic's trouble sleeping and her depression worsened; she reported suffering from nightmares and severe stress (R. 646-49). At Ms. Begic's appointments with Dr. Zahid in February and April 2012, Dr. Zahid's description of Ms. Begic remained largely the same (R. 641, 643-44). However, in February, Dr. Zahid added a prescription for Elavil (for nerve pain and depression), and in April, Dr. Zahid again identified PTSD as a diagnosis for Ms. Begic, along with depression, panic disorder, migraines and insomnia (Id.).

         On May 2, 2012, Dr. Zahid filled out a mental capacity assessment. She wrote that Ms. Begic was severely depressed, had severe social anxiety, and had severe panic attacks (R. 636-37). Dr. Zahid checked boxes indicating that Ms. Begic had extreme limitations (defined as a "major limitation" in an area where the individual has "no useful ability to function") in understanding and memory and sustained concentration and persistence (R. 635-36). Dr. Zahid indicated that Ms. Begic had extreme and marked limitations (defined as a "serious limitation" in an area where the individual cannot generally perform satisfactorily) in social interaction and adaptation (R. 636-37). The same month, Ms. Begic and her nephew filled out function reports stating that she could not cook, clean, or bathe, but she did laundry and drove alone to shop once a week (R. 282-85). They wrote that Ms. Begic spent time with family and friends but she was fearful of noise and being alone (R. 287-88, 298-304).

         From June 2012 through May 2013, Ms. Begic continued to see Dr. Zahid regularly. Dr. Zahid reported that Ms. Begic's depression varied from mild to severe, her mood and affect varied from normal to dysthymic and dysphoric, her concentration varied from poor to good, and her psychomotor activity ranged from within normal limits to showing marked anxiety (R. 639, 782-98). Ms. Begic continued to report having panic attacks and trouble sleeping. Her diagnoses remained major depression (sometimes listed as severe, sometimes not), severe panic disorder, PTSD, insomnia and migraines, and her medications were Elavil, Prozac, Xanax, Topamax (for headache), and at times Remeron (an antidepressant) (Id.). During this time, Ms. Begic continued to see Dr. Boskovic with physical complaints, and she visited the emergency room once complaining of chest pain. Records from those visits reported that her mood and affect were appropriate, and she had no symptoms of anxiety or depression (R. 733-39, 746-48, 759, 853).

         On November 21, 2012, a non-examining state agency medical consultant opined Ms. Begic had mild restrictions in activities of daily living ("ADLs") and social functioning and no difficulties in concentration, persistence or pace (R. 102-03). On March 25, 2013, Dr. Zahid filled out a residual functional capacity ("RFC") questionnaire, stating that Ms. Begic was severely depressed and had panic attacks, nightmares and severe headaches, all of which constantly interfered with her attention and concentration (R. 768).

         On August 15, 2013, at the first hearing before the ALJ, psychologist Kathleen O'Brien, Ph.D., testified as a medical expert (R. 169, 975). She had reviewed Dr. Zahid's reports through June 2012 and found no explanation for why Dr. Zahid diagnosed PTSD or why Dr. Zahid did not change Ms. Begic's treatment plan in light of her continued severe mental impairments (R. 975-76). Dr. O'Brien saw a conflict between Dr. Boskovic's records - which did not indicate that Ms. Begic displayed severe mental impairments - and Dr. Zahid's records (R. 975-76). The ALJ continued the hearing so that Ms. Begic could submit additional records from Dr. Zahid and receive a new psychological consultative examination ("CE") (R. 980).[2]

         On October 2, 2013, Michael E. Stone, Psy.D., performed a psychological CE (R. 834). Ms. Begic reported that she had PTSD after witnessing the war in Bosnia (Id.). Dr. Stone noted that Ms. Begic was "minimally cooperative, " and her behavior was "pained and distracted, but essentially appropriate" (R. 835). She was tearful, her affect was depressed but appropriate, and her mood appeared anxious, dysthymic and dysphoric (Id.). Dr, Stone listed her diagnoses as PTSD, major depression and generalized anxiety disorder with panic attacks (R. 837). He opined that Ms. Begic had moderate restriction in ability to understand, remember and carry out complex instructions; moderate restriction in ability to interact appropriately with supervisors, co-workers and the general public; and moderate ...


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