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Miller v. Berryhill

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

March 6, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security Defendant,


          Honorable Michael T. Mason

         Claimant Mariana Miller (“Miller” or “claimant”) is seeking judicial review of the final decision of the Commissioner of Social Security (“Commissioner”). The Commissioner denied Miller's applications for supplemental security income (“SSI”) and disability insurance benefits (“DIB”) under §§ 216(i), 223(d) and 1614(a)(3)(A) of the Social Security Act (“the Act”). 42 U.S.C. §§ 416(i), 423(d) and 1382(c). The parties have consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons set forth below, Miller's motion for summary judgment [9] is granted, the Commissioner's cross-motion for summary judgment [16] is denied, and the case is remanded to the ALJ for further consideration.

         I. BACKGROUND

         A. Procedural History

         Miller filed her applications for SSI and DIB on December 27, 2011. (R. 157-69.) In her applications, Miller alleges she has been disabled since January 15, 2010 due to Post Traumatic Stress Disorder (“PTSD”), anxiety, postpartum depression, auditory and visual hallucinations, and Attention Deficit Hyperactivity Disorder (“ADHD”). (R. 171.) Her applications were initially denied on March 22, 2012, and again on September 21, 2012, after a timely request for reconsideration. (R. 92-104.) Claimant filed a request for a hearing before an ALJ. (R. 109-10.) On July 18, 2013, ALJ Jose Anglada held a hearing, and on July 26, 2013, the ALJ issued a decision denying claimant's applications for benefits. (R. 15-35.) Miller then requested review by the Appeals Council, which was denied. (R.1-6.) At this point, the ALJ's decision became the final decision of the Commissioner and Miller then filed this action in the District Court.

         B. Medical Evidence

         1. Treating Physicians

On July 24, 2009, Dr. Romero Mercado, a primary care physician, diagnosed claimant with asthma, depression, and anxiety. (R. 253-57.) In October of 2010, Dr. Milagranos Villalobos, another primary care physician, also diagnosed claimant with asthma, depression, and anxiety. (R. 265-67.) To manage her depression and anxiety, Dr. Villalobos prescribed Fluoxetine. (R. 267.)

         On February 14, 2011, Amanda Lenvin, a mental health counselor, conducted a psychosocial assessment of Miller. (R. 342-59.) During this assessment, Miller stated that for the past two years, her ADHD has caused her to have trouble focusing and finishing tasks, she noted that her emotions are difficult to control and she experienced anxiety and fear of failure. (R. 345.) Miller's thought-process and dress were appropriate, but Lenvin noted that her attention was poor and her speech was rapid. (Id.) Miller disclosed a history of sexual abuse, domestic violence, and one previous psychiatric hospitalization after a suicide attempt. (R. 344-61). She also disclosed that she experienced visual hallucinations at night. (R. 347.) Lenvin conducted a Global Assessment of Functioning Test (“GAF test”), and claimant scored a 62. (R. 344.) Lenvin also diagnosed claimant with Bipolar Disorder Type I. (R. 344). For further psychiatric evaluation, Lenvin referred claimant to Dr. S.J. Puszkarski. (R. 357.)

         On April 27, 2011, Dr. Puszkarski saw claimant for the first time and diagnosed her with ADHD, Inattentive Type and PTSD, for which he prescribed Adderall. (R. 370-71.) Dr. Puszkarski administered a GAF test and claimant scored a 55. (R. 371.) He opined that she had “signs of attentional problems, ” she was “easily distracted and inattentive, ” and she was careless and forgetful. (R. 370.) He noted she had difficultly concentrating, she had recurrent distressing dreams about her past abuse, and she suffered from “intense psychological distress at exposure to...cues...that symbolize or resemble the event.” (Id.) He also noted “markedly diminished interest or significant activities, ” “a restricted range of affect” and “irritability or outbursts of anger.” (Id.) Miller's speech was normal, her thought-process was logical and goal-directed and her insight and judgment were good. (R. 370-71.)

         On June 6, 2011, claimant met with Dr. Puszkarski again and no additional symptoms were noted. (R. 368.) He noted that Miller was experiencing feelings of anxiety but there were no depressive symptoms, hallucinations, delusions or other symptoms of psychotic process, and she denied any thoughts of suicide. (Id.) Again, her insight and judgment were good, she was dressed appropriately and her mood was also appropriate. (Id.) On October 25, 2011, however, Dr. Puszkarski reported that Miller had suffered a set back. (R. 366.) She had not been taking her medications and she displayed signs of psychotic process including anxiety, paranoia, and auditory hallucinations. (Id.) Dr. Puszkarski noted that claimant was “friendly, fully communicative, [and] casually groomed.” (Id.) He also noted cognitive functioning was in the normal range, and he prescribed Paxil and Risperdal. (R. 367.) At this appointment, Miller denied suicidal thoughts. (Id.)

         On January 11, 2012, Dr. Puszkarski saw Miller again and he noted that there were signs of improvement and abatement of the symptoms of psychotic process, although she had been admitted to the hospital after a panic attack. (R. 364.) She described no hallucinations, delusions or other symptoms of psychotic process. (Id.) She reported no suicidal thoughts or impulses, and her cognitive functioning, anxiety, insight and social judgment were all noted as good. (Id.)

         On March 7, 2012, Dr. Puszkarski completed a mental impairment questionnaire for the purpose of assisting in the determination of claimant's Residual Functioning Capacity (“RFC”). (R. 437-39.) In the questionnaire, Dr. Puszkarski noted a diagnosis of ADHD, PTSD and Bipolar Disorder Type I. (R. 437.) He noted that she has mood swings, difficulty thinking or concentrating, social withdrawal, delusions and hallucinations, obsessions, feelings of worthlessness, suicidal ideation, hostility and paranoia, among other things. (Id.) In response to a question about clinical findings to support the severity of her mental impairments, he only responded that she “is unable to work, she is isolative [and] unmotivated.” (Id.) He stated she does not have a low I.Q. or reduced intellectual functioning, but he described claimant as not having the ability to: maintain attention for a two-hour segment, maintain regular attendance and be punctual, perform at a consistent pace without unreasonable number and length of rest periods, respond appropriately to changes in a routine work setting, or deal with normal work stress. (R. 438.) In support of these findings, Dr. Puszkarski stated only that “due to her medical conditions, she is unable to work.” (Id.) He did find that she was “good” at understanding and remembering simple instructions, working in coordination with others, asking simple questions and requesting assistance, and being aware of normal hazards and taking appropriate precautions. (Id.) He noted that Miller's ability was “fair” with respect to remembering work-like procedures, carrying out simple instructions, sustaining ordinary routine without special supervision, making simple work-related decisions, completing a normal work day without interruption, accepting instructions and responding appropriately to supervisors, and getting along with co-workers or peers. (Id.) Lastly, he determined that she had a “slight” restriction of activities of daily living, a “moderate” difficulty in maintaining social functioning, “constant deficiencies of concentration, persistence or pace resulting in failure to complete tasks in a timely manner, ” and “continual” episodes of deterioration or decompensation in work or work-like settings that cause her to withdraw or to experience exacerbation of signs or symptoms. (R. 439.)

         Beginning on May 22, 2012, claimant was examined by Dr. Deep Buch for her Bipolar Disorder and PTSD. (R. 471-72.) At the initial consultation, claimant reported mood swings, insomnia, depressive moods, suicide attempts, and issues with self-esteem, among other things. (Id.) On June 12, 2012, Dr. Buch noted a logical thought process, and a sad, angry, guarded and suspicious disposition. (R. 473.) Miller reported that she experienced hallucinations and suicidal thoughts. (R. 474.) Dr. Buch noted that she also had symptoms of severe depression. (Id.)

         On July 10, 2012, Dr. Buch followed up with claimant. (R. 577.) Dr. Buch and his staff created a detailed treatment plan of counseling and prescriptions for Paxil, Risperdal, and Ativan. (Id.) On September 17, 2012, Dr. Buch met with claimant and noticed “much improvement” in her symptoms. (R. 612.) Claimant saw Dr. Buch again on October 15, 2012 and November 12, 2012, and Miller reported that she felt more calm, that she was sleeping better and that she was doing some light exercise daily. (R. 613.) On December 10, 2012, claimant saw Dr. Buch and reported a recent incident, in which her daughter's friend's boyfriend came into their house and beat her. (R. 615.) As a result, claimant reported increased anxiety and paranoia, although she had been doing very well prior to the incident. (Id.) Claimant continued with her original treatment plan after this episode. (R. 578-81.)

         On March 4, 2013, Miller was examined by Dr. Carol Lynn Childers. (R. 618-19.) Miller reported to Dr. Childers that she was a victim of child abuse and sexual abuse as a child and that she had tried to kill herself multiple times. (R. 618.) Miller also reported that she has a daughter who was the product of rape. (Id.) Miller told Dr. Childers that she was sexually harassed at one of her jobs, which had triggered her PTSD. (Id.) Dr. Childers noted that Miller felt hopeless and depressed and she experienced paranoia and audio and visual hallucinations. (Id.) Dr. Childers diagnosed Miller with PTSD and psychotic disorder. (R. 619.)

         Dr. Childers saw claimant again on April 30, 2013. (R. 616.) During this visit, claimant disclosed to Dr. Childers that she had been diagnosed with a brain tumor after she suffered a seizure at age twelve, and she had suffered another seizure while giving birth to her daughter. (Id.) At this appointment, Miller reported that she takes her medications regularly or she hears voices and see visions. (Id.) She described her issues with self-image and body image since she was raped. (Id.) She indicated that she had gained 120 pounds in the 20 years since her rape in order to ...

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