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Smith v. Colvin

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

February 16, 2017

LOUISE R. SMITH, Plaintiff,
CAROLYN W. COLVIN, Commissioner of Social Security, Defendant.


          M. David Weisman Magistrate Judge

         Plaintiff Louise Smith filed this action seeking reversal of the Commissioner's denial of her application for disability insurance benefits under Title II of the Social Security Act (“Act”). 42 U.S.C. §§ 405(g) et seq. The parties consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 638(c). (Dkt. 9.). For the reasons set forth below, the Court grants Plaintiff's motion and remands the case for proceedings consistent with this opinion.

         The Sequential Evaluation Process for Determining Disability

         A claimant must show a disability under the Act in order to obtain disability insurance benefits. York v. Massanari, 155 F.Supp.2d 973, 978 (N.D. Ill. 2001). To do so, a claimant must establish the “inability 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). The Social Security regulations provide a five-step, sequential inquiry to determine whether a claimant suffers from a disability: (1) whether the claimant has performed any substantial gainful activity during the period for which she claims disability; (2) if not, whether she has a severe impairment or combination of impairments; (3) if so, whether her impairment meets or equals any impairment enumerated in the regulations; (4) if not, whether she has the residual functional capacity to perform her past relevant work; and (5) if not, whether she can perform any other work existing in significant numbers in the national economy. 20 C.F.R. § 404.1520; see Zurawski v. Halter, 245 F.3d 881, 885 (7th Cir. 2001). “The burden of proof is on the claimant through step four; only at step five does the burden shift to the Commissioner.” Clifford v. Apfel, 227 F.3d 863, 868 (7th Cir. 2000).

         Procedural History

         Plaintiff filed for disability insurance benefits on May 4, 2011, alleging that she suffered from bipolar disorder. (R. 148, 186.) Her application was initially denied on July 15, 2011, and again after reconsideration on September 22, 2011. (Id. at 90, 96.) Subsequently, Plaintiff requested a hearing, which was held before an Administrative Law Judge (“ALJ”) on May 29, 2012. (See R. 16-29.) Plaintiff, represented by counsel, testified at the hearing, and the ALJ also heard testimony from Richard J. Hamersma, a vocational expert (“VE”). (Id. at 19, 38-83.)

         On July 14, 2012, the ALJ denied Plaintiff's application, finding that Plaintiff was not disabled for purposes of the Social Security Act. (Id. at 16, 29.) Applying the five-step analysis, the ALJ first determined that Plaintiff did not engage in substantial gainful activity from the alleged onset date through the date she was last insured. (Id. at 21.) At step two, the ALJ found Plaintiff's psychiatric symptoms indeed constituted a severe impairment. (Id. at 22.) At step three, the ALJ found that Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of one of the listed impairments. (Id. at 24.)

         The ALJ next evaluated Plaintiff's residual functional capacity (“RFC”)[1] and determined Plaintiff can perform a full range of work at all exertional levels with the nonexertional limitations of understanding, remembering, and carrying out detailed and complex job tasks. (Id. at 25.) The ALJ further concluded Plaintiff is not suited for work that requires extended intense focus and concentration, can only have casual interaction with the general public, and would be expected to be off task 5% of an eight-hour workday. (Id.) On consideration of Plaintiff's RFC and the VE's testimony, the ALJ found at step four that Plaintiff cannot perform any past relevant work. (Id. at 27.) At the final step, the ALJ concluded that, based on age, education, work experience, and RFC, the national economy contained jobs in significant numbers that Plaintiff can perform. (Id. at 28.) Accordingly, the ALJ held that Plaintiff lacked a cognizable disability as delineated by the Act. (Id. at 28-29.)

         The Appeals Council declined Plaintiff's request for review of the ALJ's decision. (Id. at 1-6, 15). Plaintiff now seeks judicial review of the ALJ's decision, which stands as the Commissioner's final decision. Schmidt v. Astrue, 496 F.3d 833, 841 (7th Cir. 2007).

         Standard of Review

          Judicial review of the Commissioner's final decision is authorized by § 405(g) of the SSA. In reviewing this decision, the Court may not engage in its own analysis of whether the plaintiff is severely impaired as defined by the Social Security Regulations. Young v. Barnhart, 362 F.3d 995, 1001 (7th Cir. 2004). Nor may it “reweigh evidence, resolve conflicts in the record, decide questions of credibility, or, in general, substitute [its] own judgment for that of the Commissioner.” Id. The Court's task is “limited to determining whether the ALJ's factual findings are supported by substantial evidence.” Id. (citing 42 U.S.C. § 405(g)). Evidence is considered substantial “if a reasonable person would accept it as adequate to support a conclusion.” Indoranto v. Barnhart, 374 F.3d 470, 473 (7th Cir. 2004); Moore v. Colvin, 743 F.3d 1118, 1120-21 (7th Cir. 2014) (“We will uphold the ALJ's decision if it is supported by substantial evidence, that is, such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”) (citations omitted). “Substantial evidence must be more than a scintilla but may be less than a preponderance.” Skinner v. Astrue, 478 F.3d 836, 841 (7th Cir. 2007) (citations omitted). “In addition to relying on substantial evidence, the ALJ must also explain his analysis of the evidence with enough detail and clarity to permit meaningful appellate review.” Briscoe ex rel. Taylor v. Barnhart, 425 F.3d 345, 351 (7th Cir. 2005) (citation omitted).

         Although this Court accords great deference to the ALJ's determination, it “must do more than merely rubber stamp the ALJ's decision.” Scott v. Barnhart, 297 F.3d 589, 593 (7th Cir. 2002) (citation omitted). “This deferential standard of review is weighted in favor of upholding the ALJ's decision, but it does not mean that we scour the record for supportive evidence or rack our brains for reasons to uphold the ALJ's decision. Rather, the ALJ must identify the relevant evidence and build a ‘logical bridge' between that evidence and the ultimate determination.” Moon v. Colvin, 763 F.3d 718, 721 (7th Cir. 2014). Where the Commissioner's decision “lacks evidentiary support or is so poorly articulated as to prevent meaningful review, the case must be remanded.” Steele v. Barnhart, 290 F.3d 936, 940 (7th Cir. 2002).

         Relevant Medical Evidence

         Plaintiff was hospitalized in October 2007 where she was diagnosed with delusional disorder. (R. 260-61, 22.) During her eight-day hospitalization, Plaintiff exhibited or admitted to myriad symptoms, including the belief she would marry her physician and run away with her minister, poor hygiene, disheveled appearance, hallucinations, and delusions. (Id. at 261-262.) The hospital notes reflect that Plaintiff raised her voice, verbally threatened staff, refused direction, and had to be physically escorted to her room. (Id. at 262, 320.) The hospital admitted Plaintiff to the intensive treatment unit where she partook in individual therapy, group therapy, expressive therapy, milieu therapy, and discharge planning. (Id. at 262.) Despite denying suicidal and homicidal thoughts, the hospital also placed Plaintiff on escape, assault, and self-injury precautions. (Id. at 261-262.) Plaintiff also received Risperdal, [2] a drug used to treat Bipolar Disorder. (Id. at 261); see (last visited September 15, 2016).

         Shortly thereafter, Plaintiff began treatment with Dr. Moises Gaviria and, at Dr. Gaviria's recommendation, counseling with a licensed social worker, Kris Maynard. (R. 403-404.) On initial evaluation, Dr. Gaviria noted a negative psychiatric history, but diagnosed Plaintiff with Major Depressive Disorder after finding Plaintiff displayed symptoms of depressed mood and anxiety. (Id. at 403.) The subsequent record demonstrates Plaintiff's turbulent experience with her mental illness.

         On January 3, 2008, Dr. Gaviria documented Plaintiff's acute psychotic episode, but noted that she had since recovered to a normal mood with no signs of depression or mood elevation. (Id. at 405.) Plaintiff then remained relatively stable with therapy and medication, (see Id. at 405-412), before relapsing with paranoid delusions and depression in July 2008. (Id. at 413.) At the psychiatrist's recommendation, Plaintiff was again hospitalized. (Id. at 413, 456.) She did not sleep for five or six days, took her husband's credit cards to purchase items from the home shopping network, experienced pressured speech, and inappropriately removed her clothing. (Id. at 414.)[3] Dr. Gaviria's notes also indicate Plaintiff had delusions about the Holy Spirit sending messages via television and radio and Plaintiff's denial of such delusions and related mania. (Id.) The hospital placed Plaintiff under precautions for bizarre behavior and suicidality. (Id. at 456.) She experienced delusional preoccupation with her husband, hallucinations, difficulties with thought processing, thought insertion, [4] and paranoid delusions. (See id.) Plaintiff received risperidone, clonazepam, [5] trazadone, [6] Cogentin, [7] and Zoloft.[8] Ultimately, Plaintiff was diagnosed with Schizoaffective Disorder.[9] (Id. 456-57.)

         In memorializing this manic episode, Dr. Gaviria's notes reflect a Bipolar I diagnosis.[10](Id. at 414.) Dr. Gaviria and Ms. Maynard continued to treat Plaintiff, including medication management. (Id. at 416-38, 464-98.) In addition to, or in conjunction with, the medications set forth above, Dr. Gaviria at times prescribed Lamictal, [11] Lunesta, [12] Abilify, [13] Synthroid, [14] Seroquel, [15] and melatonin.[16] (See generally id.) Plaintiff exhibited symptoms of anxiety, depression, or both interspersed with entirely normal days absent symptoms of depression or mood elevation throughout her treatment. (See id.)

         In January 2011, Plaintiff suffered another major breakdown requiring hospitalization. (See Id. at 439-59.) Plaintiff's family indicated she had not slept in four days and had not eaten in three days. (Id. at 443, 445.) The Emergency Department noted, inter alia, Plaintiff's four-year history of bipolar disorder, [17] sleep and appetite disturbances, poor impulse control, poor judgment, a lack of insight into Plaintiff's own behavior, and Plaintiff's irritable mood. (Id. at 445.) The notes also reflect Plaintiff's attempt to exit a moving vehicle in order see a doctor who treated her several years prior. (Id.) Plaintiff had a history of noncompliance with her medication regimen. (Id. at 448.) The hospital titrated Plaintiff's Risperdal, but due to lack of progress, started Plaintiff on Zyprexa.[18] (Id. at 458.) She was discharged after fourteen days. (Id.)

         Dr. Gaviria and Ms. Maynard assessed Plaintiff with a mental impairment questionnaire on May 6, 2011. (Id. at 459-61, 531-33.) They concluded that, as a result of Plaintiff's bipolar disease, she suffered from sleep disturbance, emotional lability, mood disturbance, perceptual disturbances, and difficulty thinking or concentrating. (Id. at 459, 531) According to the assessment, Plaintiff lacked the ability to work. (Id. at 459, 531) Dr. Gaviria and Ms. Maynard noted Plaintiff's multiple hospitalizations, the side effects associated with her medications, and that stress triggers Plaintiff's psychotic or manic episodes. (Id. at 459, 531) They anticipated Plaintiff would miss work more than three times per week - the highest designation available - and added a note stating “unable to work.” (Id. at 460, 532.) Moreover, Dr. Gaviria and Ms. Maynard did not rank any category of Plaintiff's mental abilities and aptitude in the highest category of “Unlimited/Very Good.” (Id.) They ranked as “Poor/None, ” the lowest category, Plaintiff's ability to remember work-like procedures; maintain attention for two-hour segments, maintain regular attendance and be punctual within customary, usually strict, tolerances; complete a normal workday and work week without interruptions from psychologically-based symptoms; perform at a consistent pace without an unreasonable number and length of rest periods, and deal with normal work stress. (Id.) They further remarked that Plaintiff's medications undermine her concentration and stress induces her psychotic and manic symptoms. (Id.) They opined Plaintiff would constantly have deficiencies of concentration, persistence, or pace, resulting in a failure to complete tasks in a timely manner. (Id. at 461, 533.) Finally, Dr. Gaviria and Ms. Maynard indicated Plaintiff would have continual episodes of deterioration or decompensation in work or work-like settings causing her to withdraw from the situation or experience exacerbation of symptoms. (Id.)


         Plaintiff asserts that the ALJ's decision is not supported by substantial evidence because the ALJ (1) impermissibly rejected the treating psychiatrist's opinion; (2) improperly analyzed Plaintiff's credibility; and (3) improperly evaluated Plaintiff's RFC. ...

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