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McDonald v. Berryhill

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

August 29, 2017

NANCY A. BERRYHILL, Acting Commissioner of Social Security, [1] Defendant.



         This action was brought under 42 U.S.C. § 405(g) to review the final decision of the Commissioner of the Social Security Administration (the “Commissioner”) denying Plaintiff Michael McDonald's claim for Supplemental Security Income (“SSI”).[2] The parties have consented to the jurisdiction of the United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons that follow, the case is remanded for further proceedings consistent with this Opinion.



         On February 29, 2012, Plaintiff protectively filed a claim for Supplemental Security Income, alleging disability since March 1, 2009. (R. 20.) The claim was denied initially and upon reconsideration, after which Plaintiff timely requested a hearing before an Administrative Law Judge (“ALJ”). (Id.) On February 27, 2014, Plaintiff, represented by counsel, personally appeared and testified at a hearing before ALJ James D. Wascher. (R. 40-79.) Vocational expert (“VE”) Lisa Gagliano testified by phone. (Id.)

         On May 30, 2014, the ALJ denied Plaintiff's claim for Supplemental Security Income, finding him not disabled under the Social Security Act. (R. 20-55.) The Social Security Administration Appeals Council then denied Plaintiff's request for review, leaving the ALJ's decision as the final decision of the Commissioner and, therefore, reviewable by the District Court under 42 U.S.C. § 405(g). See Haynes v. Barnhart, 416 F.3d 621, 626 (7th Cir. 2005).


         Plaintiff was born on October 22, 1960 and was 51 years old at the time his application was filed. (R. 33.)

         A. Medical Evidence

         On March 3, 2011, Plaintiff sought psychiatric medication and treatment from the Stroger Hospital emergency room and was evaluated by Dr. Jessica Weddle, M.D. (R. 233-37.) Plaintiff reported being depressed all the time and having auditory and visual hallucinations. (R. 233.) He stated that he had not been able to afford his medications elsewhere after being released from jail three months earlier. (Id.) Plaintiff expressed feelings of paranoia, thinking that people were always “out to get him.” (R. 234.) He also endorsed recent suicidal ideations. (Id.) His mental status examination was relatively normal, with good insight and judgment, normal affect, and mood slightly down. (R. 235-36.) Dr. Weddle assessed schizoaffective disorder assigned a GAF score of 55.[3] Plaintiff was prescribed Risperdal, [4] Doxepin, [5] and Zoloft, [6] and was instructed to follow-up in one month. (R. 236.)

         On September 16, 2011, Plaintiff presented to Dr. Adedapo Williams, M.D., at the Fantus Clinic for further evaluation and medication management. (R. 241.) Plaintiff reported auditory and visual hallucinations, anxiety, passive suicidal ideation, and depression. (R. 242.) Dr. Williams noted that Plaintiff was appropriately dressed and maintained good eye contact. (R. 244.) He noted mild retardation in psychomotor activity and a slow rate of speech at times with some latency. (Id.) Insight and judgment were poor. (Id.) Dr. Williams diagnosed psychotic disorder NOS. (R. 245.) He increased the dosages of the doxepin, risperidone, and sertraline, and recommended a follow-up visit in two months. (Id.)

         Plaintiff next saw Dr. Williams on December 7, 2011, where he continued to endorse auditory and visual hallucinations. (R. 239.) He still felt depressed, although his symptoms had improved since the previous visit. (Id.) Sleep was poor. (Id.) Plaintiff stated that he felt like there was someone “out to get him” and therefore he did not go out at night. (Id.) Mental status examination was “essentially unremarkable.” (Id.) Dr. Williams noted that Plaintiff was “still depressed and psychotic, ” diagnosed psychotic disorder not otherwise specified (NOS), and assigned a GAF score of 45.[7] (R. 238-40.)

         On May 15, 2012, Dr. Norton B. Knopf, Ph.D., conducted a mental status examination of Plaintiff and issued a psychological report. (R. 255-60.) Plaintiff's major presenting problem was reported as being, “I can't do the job I used to do, I used to do a lot of lifting and standing, and I can't do it like that anymore.” (R. 256.) He indicated previous treatment had been “somewhat” successful, although he reported experiencing auditory and visual hallucinations. Dr. Knopf noted Plaintiff's manner of dress was casual and his hygiene appeared good. Plaintiff walked with the help of a cane; however, Dr. Knopf indicated Plaintiff's gait seemed normal without the use of the cane. Posture was normal. (Id.)

         Dr. Knopf noted that Plaintiff's level of responsiveness did not show any obvious effects of pain, medications, or drugs; there were no overt signs of distress during the interview. Plaintiff reported current feelings of moderate depression, stating he felt depressed “all the time.” He reported experiencing loss of interest (in swimming), motor retardation, sleep disturbance, fatigue, and loss of sexual interest. (Id.) Plaintiff stated he felt anxious “every day, ” and that his anxiety was severe; however, Dr. Knopf observed to signs of anxiety during the interview. (R. 257.) Plaintiff endorsed anxiety-related symptoms of chest pains, dizziness, faintness, and dry mouth.

         Plaintiff was fully oriented. He remembered five digits forward and four backward. He recalled the name of his elementary school, his birthdate, address, and phone number. Dr. Knopf estimated Plaintiff's intelligence to be in the borderline range. There was no indication of notable decline in intellectual ability. His fund of information was consistent with his background and intellectual level. Plaintiff correctly performed simple addition, subtraction, and division problems. He knew a similarity and a difference between a bush and a tree. There were no signs of aphasia or cognitive deficits typically associated with a brain dysfunction. (Id.)

         Dr. Knopf concluded that based on the character and coherency of Plaintiff's responses, spontaneous comments, and behavior, the information obtained during the interview was believed to be reliable. (R. 259.) Thus, the results of the examination were believed to be reliable and valid. Dr. Knopf opined that Plaintiff's personality was best characterized as “schizoid.” Plaintiff's insight into his own psychological functioning and adjustment and judgment appeared to be fair. Dr. Knopf diagnosed psychotic disorder NOS, and depressive disorder, NOS (by history). He deferred the Axis II diagnoses, but wrote “rule/out borderline intellectual functioning.” (Id.)

         On June 11, 2012, Plaintiff returned to Dr. Williams, again reporting auditory and visual hallucinations, feelings that “someone might be out to get him, ” and fleeting thoughts of suicide. (R. 312.) Plaintiff indicated a loss of interest and stated his concentration and memory were poor. He reported feelings of anxiety, poor sleep, and difficulty getting up in the morning. The risperidone provided very short-lived relief. (Id.) Mental status examination was noted to be unremarkable. (R. 313.) Dr. Williams again described Plaintiff as “still depressed and psychotic, ” increased the risperidone to 3mg, and assigned a GAF score of 45. (R. 311, 313.)

         When Plaintiff next followed up with Dr. Williams in September 2012, he indicated he was “doing better” and felt the medications were helping. (R. 308.) However, he was still experiencing auditory hallucinations, and reported seeing “silly stuff, just off the wall.” Plaintiff also reported occasional paranoia. He was still experiencing depression, but indicated it was only for short periods of time. (Id.) Mental status examination was essentially unremarkable and Dr. Williams continued to describe Plaintiff as “still depressed and psychotic.” (R. 308-09.) Dr. Williams continued Plaintiff's current medications and assigned a GAF score of 45. (R. 307, 309.)

         Plaintiff's final visit of record with Dr. Williams was on November 19, 2013. (R. 334-36.) Plaintiff reported having problems with child support, and stated his mood had been “scared, panicky, worried, and depressed.” (R. 334-35.) He reported fleeting thoughts of suicide and endorsed continuing auditory hallucinations. (R. 335.) Dr. Williams noted that Plaintiff was well-groomed, cooperative, and maintained good eye contact. No psychomotor agitation or retardation was noted; insight and judgment were good. (Id.) Dr. Williams assessed Plaintiff as ‚Äústill depressed and psychotic - maintained by ongoing psychosocial ...

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