United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
E. Cox United States Magistrate Judge
Robin Alma (“Plaintiff”) seeks to overturn the
final decision of the Commissioner of Social Security
(“Commissioner” or “Defendant”)
denying his application for Disability Insurance Benefits
(“DIB”) and Supplemental Security Income
(“SSI”) under Titles II and XVI of the Social
Security Act. The parties consented to the jurisdiction of
the United States Magistrate Judge pursuant to 28 U.S.C.
§ 636(c), and Plaintiff filed a motion for summary
judgment. After careful review of the record, the Court now
grants Plaintiff's motion and remands the case for
applied for DIB and SSI on December 13, 2010, alleging that
he became disabled on October 1, 2008. (R. 319). After the
request was denied initially and upon reconsideration,
Administrative Law Judge Jose Anglada (the “ALJ”)
held a hearing on August 31, 2012 at which Plaintiff and a
vocational expert (“VE”) testified. (R. 122-62).
On October 26, 2012, the ALJ issued a written decision
finding found that Plaintiff was not disabled. (R. 188-204).
The Appeals Council remanded the case on February 11, 2014
and instructed the ALJ to evaluate a third-party report
submitted by Plaintiff's wife, reconsider Plaintiff's
residual functional capacity (“RFC”) with
specific references to the record, and pose more
carefully-constructed hypothetical questions to the VE. (R.
210-23). The ALJ then held a supplemental hearing on
September 22, 2014. (R. 43-82). Plaintiff and a VE again
provided testimony. The ALJ issued a second written decision
on October 31, 2014, once again finding that Plaintiff is not
disabled. (R. 15-35). The Appeals Council denied review on
December 30, 2015, making the ALJ's decision the
Commissioner's final decision. (R. 1-5). Plaintiff now
seeks judicial review of the ALJ's denial of benefits.
was 46 years old at the time of the second administrative
hearing. He last worked as the manager of a hotel food and
bar service department before quitting due to his mental
impairments. Plaintiff, who is obese and has a long history
of alcohol and cocaine use, described his primary
restrictions as severe neck pain and difficulties stemming
from bipolar disorder.
sporadically complained of spasms in his neck muscles and
related pain to his treating physician Dr. Syed Akhter in
2009 and 2010. A February 23, 2012 radiology report revealed
multilevel degenerative disc changes in Plaintiff's neck,
including facet and uncinated arthritis. (R. 787). On July
14, 2012, an MRI of the cervical spine showed diffuse
spondylosis and degenerative changes with an osteophyte
complex at all levels from C2-C3 through C6-C7. (R. 789). Dr.
Akhter prescribed the narcotic pain medication Vicodin and
the anti-inflammatory meloxicam to treat Plaintiff's
pain. He also recommended an orthopedic consultation, but
Plaintiff reported that he could not find a specialist who
would accept his Medicaid insurance. (R. 791). The record
does not reflect Plaintiff's condition from the fall of
2012 through 2013, but by January 2014 Dr. Akhter noted
chronic neck pain that radiated through Plaintiff's left
arm at a level of seven out of ten with medication and nine
out of ten without medication. (R. 1047). Dr. Akhter
continued to prescribe both Vicodin and meloxicam, though
Vicodin was no longer covered by Plaintiff's insurance.
(R. 1046). Dr. Akhter therefore added the pain medication
Norco to Plaintiff's medication regimen. (R. 1045). By
the time of Dr. Akhter's last treatment notes in March
and May 2014, Plaintiff reported that his pain levels
continued to be seven to eight out of ten and that he was
still unable to find an orthopedic surgeon who would accept
Medicaid. (R. 1041).
great majority of the medical record concerns Plaintiff's
mental health history. Plaintiff was admitted to St.
Joseph's Hospital in February 2008 for outpatient
treatment after drinking alcohol and taking cocaine for the
past seven months. (R. 437). He reported that he had been off
psychiatric medication for the past two years and had been
experiencing panic attacks since 2000. After his release,
Plaintiff continued to receive treatment from his primary
care physician Dr. Akhter, who described “very
severe” panic attacks in August 2008 and noted ongoing
anxiety throughout his treatment notes. (R. 593). Dr. Akhter
treated Plaintiff with the tranquilizer Xanax, which he
continued to prescribe throughout 2008. (R. 586-96). Despite
that treatment, however, Plaintiff presented at St.
Elizabeth's Hospital in September 2008 complaining that
he was hearing voices and feeling depressed. (R. 452). He was
subsequently admitted for six days of psychiatric treatment
for mood swings, hostility, and noncompliant medication
management. Plaintiff was diagnosed with bipolar disorder
without psychosis and alcohol abuse and was treated with
Depakote, Seroquel, Ativan, Zoloft, Xanax and various
non-psychotropic medications. (R. 449).
record does not show what follow-up care Plaintiff received,
but by August 2009 he began individual therapy at the
Community Counseling Centers of Chicago (“Community
Counseling”). His intake form reflects that Plaintiff
continued to take Depakote, Seroquel, Xanax, and Zoloft. (R.
506). Psychiatrist Dr. Ahmed noted that Plaintiff was only
sleeping two to three hours each night. Plaintiff received
multiple treatment sessions at Community Counseling
throughout late 2009, 2010, and 2011 while, at the same time,
receiving treatment and prescription medications from his
primary physician Dr. Akhter. An entry dated November 12,
2010 states that Plaintiff had been given Seroquel, Zoloft,
and Xanax from Dr. Akhter but had discontinued treatment with
Dr. Ahmad because his depression prevented Plaintiff from
making his appointments. (R. 480). Plaintiff's diagnosis
fluctuated throughout this period to some degree. In October
2010 it was bipolar disorder with severe psychotic features,
including hearing voices, nightmares, mania, and sleep that
was restricted to two to four hours each night. (R. 459-63).
At other times, the diagnosis included instead a mood
disorder with an unspecified psychosis and a panic disorder
without agoraphobia. (R. 458). Plaintiff's psychiatric
symptoms persisted even though the Community Counseling notes
state that his cocaine dependence was in full remission by
June 2010 and his alcohol abuse was in partial remission. (R.
point in late 2010, Plaintiff no longer received Xanax
prescriptions from Dr. Akhter and was given Klonopin instead
from a different treating source. He reported that his
anxiety levels increased as a result. (R. 471). By March
2011, Plaintiff reported that he was not sleeping for up to
three days at a stretch and that he was again hearing voices.
(R. 477). As a result, Plaintiff's counselor sent him to
the emergency room for immediate psychiatric intervention.
(R. 477). Plaintiff was subsequently admitted to St. Mary of
Nazareth Hospital on March 16, 2011 for depression with
suicidal ideation and auditory hallucinations. (R. 666).
Blood tests showed no traces of alcohol or illicit drug use.
(R. 666). Psychiatrist Dr. Shephali Patel diagnosed Plaintiff
with bipolar disorder with severe episodes accompanied by
psychosis and assigned a Global Assessment of Functioning
(“GAF”) score of 20 to 30. (R. 667). Plaintiff
was released after five days of treatment and began to
receive monthly medical consultations at Community Mental
Health Services. The treatment notes from that agency contain
few descriptive entries but report sleeplessness, extreme
agitation, and depression that were treated with Thorazine,
Klonopin, Trazedone, Abilify, and Lithium. (R. 714-25).
mental health treatment in 2012 was primarily with Dr.
Akhter, who continued to note depression, anxiety, and a
bipolar disorder, together with medications to treat those
conditions. (R. 791-801). There are no records for 2013. On
January 7, 2014, however, Plaintiff was admitted to the
Advocate Illinois Masonic Medical Center for suicidal
thoughts, auditory hallucinations, severe depression, and
poor sleep. (R. 928). He was currently taking twenty
medications to treat his physical and psychiatric symptoms.
(R. 869). Psychiatrist Dr. Rajeev Panguluri recommended that
Plaintiff's psychotropic medications should include
Abilify, Trazedone, Xanax, and Lexapro. (R. 869). Plaintiff
subsequently began outpatient treatment at Advocate Illinois
with psychiatrist Dr. Zachary Friedman and other treaters.
Dr. Friedman noted on January 22, 2014 that Plaintiff had not
slept for two days. (R. 916). Consequently, Plaintiff's
medication regimen was changed by February 2014 to include
Abilify, Buspar, Sertraline, Restoril, Xanax, and Trazodone.
(R. 912). Despite these medications, Plaintiff had difficulty
leaving his home for treatment due to ongoing anxiety. (R.
898, 904). In the last treatment note dated May 13, 2014,
however, Plaintiff reported that the recent addition of the
bipolar medication Latuda had reduced his mood swings and
permitted him to sleep up to five hours a night. (R. 896).
THE ALJ'S DECISION
the familiar five-step evaluation procedure for disability
cases, the ALJ found at step one that Plaintiff had not
engaged in substantial gainful activity since his alleged
onset date of October 1, 2008. (R. 18). His severe
impairments at step two were degenerative disc disease of the
cervical spine, obesity, an affective mood disorder, and
polysubstance abuse disorder. (R. 18). At step three, the ALJ
concluded that Plaintiff's obesity and neck impairments
did not meet or medically equal a listed impairment, either
singly or in combination. (R. 19). Plaintiff's mental
impairments, however, met the requirements of listing 12.04
(affective disorders) and listing 12.09 (substance abuse
disorder) because Plaintiff experienced marked restrictions
in his social functioning and concentration, persistence, and
pace when he used drugs and alcohol. (R. 19-20). Because such
a finding meant that Plaintiff would be disabled, the
regulations required the ALJ to determine if Plaintiff would
continue to be disabled if he did not have a substance abuse
disorder. See 20 C.F.R. § 404.1535(b)(1). The
ALJ concluded that substance abuse materially contributed to
Plaintiff's mental functioning and that he would not meet
or equal a listed impairment if he did not use drugs or
alcohol. (R. 20-21). Accordingly, the ALJ continued with the
moving to step four, the ALJ found that Plaintiff's
testimony concerning the severity of his symptoms was not
fully credible. The ALJ also gave only some weight to the
report issued by Plaintiff's wife and to the written
opinion of consulting psychiatrist Dr. Kenneth Levitan. (R.
27-28). Great weight was given to the physical RFC report
issued by non-examining expert Dr. Julio Pardo. (R. 27). The
ALJ assigned moderate weight to an RFC report submitted by
Plaintiff's treating physician Dr. Syed Akhter but
dismissed a mental RFC issued by treating psychiatrist Dr.
Michael Reinstein by giving it slight weight. (R. 28, 31).
The ALJ further adopted and rejected parts of a report given
by treating psychiatrist Dr. Zachary Friedman. (R. 31-32).
then formulated a complex RFC assessment that fell into two
parts. He concluded that if Plaintiff stopped abusing drugs
and alcohol, then prior to July 2012 he would be able to
perform light work with no additional exertional or
non-exertional restrictions. Multiple mental restrictions,
however, would be required. Plaintiff could not focus for
extended periods of time; could only have casual contact with
the general public and co-workers; would be restricted to
“dealing with things as opposed to people”; and
could be off-task for five percent of the time. (R. 22). That
RFC changed, however, as of July 2012 based on the ALJ's
conclusion that Plaintiff's neck condition had worsened
at that time. The ALJ now found that Plaintiff could carry
out what he identified as sedentary work, though he also
concluded that Plaintiff could stand and walk for six hours
during an eight-hour workday. Numerous non-exertional
limitations were also identified. As for the mental RFC, the
ALJ removed the restriction that Plaintiff could be off-task
for five percent of each workday. (R. 28-29). Based on these
findings, the ALJ found at step four that Plaintiff could not
perform his past relevant work as a hotel manager and
bartender. (R. 32). Relying on the testimony of the VE, the
ALJ further found that a significant number of jobs existed
in the national economy that Plaintiff could perform both
before and after July 2012. (R. 32-33). He therefore
concluded that Plaintiff was not disabled.
review of the Commissioner's final decision is authorized
by Section 405(g) of the Social Security Act. See 42
U.S.C. § 405(g). In reviewing this decision, a court may
not engage in its own analysis of whether Plaintiff is
severely impaired as defined by the Social Security
Regulations. Young v. Barnhart, 362 F.3d 995, 1001
(7th Cir. 2004) (citation omitted). Nor may it
“displace the ALJ's judgment by reconsidering facts
or evidence or making credibility determinations.”
Castile v. Astrue, 617 F.3d 923, 926 (7th Cir. 2010)
(quoting Skinner v. Astrue, 478 F.3d 836, 841 (7th
Cir. 2007)). The court's task is to determine whether the
ALJ's decision is supported by substantial evidence,
which is “such relevant evidence as a reasonable mind
might accept as adequate to support a conclusion.”
McKinzey v. Astrue, 641 F.3d 884, 889 (7th Cir.
2011) (quoting Skinner, 478 F.3d at 841)).
making this determination, the court must “look to
whether the ALJ built an ‘accurate and logical
bridge' from the evidence to her conclusion that the
claimant is not disabled.” Simila v. Astrue,
573 F.3d 503, 513 (7th Cir. 2009) (quoting Craft v.
Astrue, 539 F.3d 668, 673 (7th Cir. 2008)). The ALJ need
not, however, “provide a complete written evaluation of
every piece of testimony and evidence.'” Pepper
v. Colvin, 712 F.3d 351, 362 (7th Cir. 2013) (quoting
Schmidt v. Barnhart, 395 F.3d 737, 744 (7th Cir.
2005) (internal citations and quotation marks omitted)).
Where the Commissioner's decision “'lacks
evidentiary support or is so poorly articulated as to prevent
meaningful review, ' a remand is required.”
Hopgood ex rel. L.G. v. Astrue, 578 F.3d 696, 698
(7th Cir. 2009) (quoting Steele v. Barnhart, 290
F.3d 936, 940 (7th Cir. 2002)).
recover DIB or SSI under Titles II and XVI of the Social
Security Act, a claimant must establish that she is disabled
within the meaning of the Act. Keener v. Astrue,
2008 WL 687132, at *1 (S.D. Ill. Mar. 10,
2008). A person is disabled if she is unable to
perform “any substantial gainful activity by reason of
any medically determinable physical or mental impairment
which can be expected to result or which has lasted or can be
expected to last for a continuous period of not less than 12
months.” 20 C.F.R. § 404.1505(a); Crawford v.
Astrue, 633 F.Supp.2d 618, 630 (N.D. Ill. 2009). In
determining whether a claimant suffers from a disability, the
ALJ conducts a standard five-step inquiry, which involves
analyzing “(1) whether the claimant is currently
employed; (2) whether the claimant has a severe impairment;
(3) whether the claimant's impairment is one that the
Commissioner considers conclusively disabling; (4) if the
claimant does not have a conclusively disabling impairment,
whether he can perform his past relevant work; and (5)
whether the claimant is capable of performing any work in the
national economy.” Kastner v. Astrue, 697 F.3d
642, 646 (7th Cir. 2012) (citing 20 C.F.R. § 404.1520).