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Rinehart v. Berryhill

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

February 6, 2018

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


          Susan E. Cox, Magistrate Judge.

         Plaintiff Richard H. Rinehart (“Plaintiff”) appeals the decision of the Commissioner of the Social Security Administration (“Commissioner”) denying his disability insurance benefits (“DIB”) under Title II of the Social Security Act. Plaintiff filed a brief [dkt. 16] to reverse or remand the decision of the Commissioner of Social Security, and Defendant responded with a motion for summary judgment. [dkt. 23]. We hereby construe Plaintiff's brief in support of reversing the decision of the Commissioner as a motion. For the following reasons the Commissioner's Motion for Summary Judgment is granted and Plaintiff's brief is denied.

         I. Background

         a. Procedural History and Plaintiff's Background

         Plaintiff filed a Title II application for disability and DIB on January 2, 2013. (Administrative Record (“R”) 214-15). Plaintiff alleged an onset date of disability beginning on August 16, 2012. (R. 214). Plaintiff's claim was denied initially on April 19, 2013 and again at the reconsideration stage on September 26, 2013. (R. 126-55, 162-65). Plaintiff timely requested an administrative hearing, which was held on March 12, 2015 before Administrative Law Judge (“ALJ”) Lee Lewin. (R. 40, 166). Plaintiff was represented by counsel, and both a Medical Expert (“ME”) and a Vocational Expert (“VE”) testified during the hearing. (R. 83-124). On April 3, 2015, the ALJ issued a written decision denying Plaintiff disability benefits. (R. 17-35). On August 5, 2016, the Appeals Council denied Plaintiff's appeal, and the ALJ's decision became the final decision of the Commissioner. (R. 1-6). Plaintiff filed the instant action on October 6, 2016. [dkt. 1].

         Plaintiff was born on September 9, 1960, and was 51 years old on his alleged disability onset date. (R. 34). Plaintiff suffers from primarily mental and social limitations. Plaintiff's medical records reveal diagnoses of bipolar II disorder, alcohol dependence, adult ADHD, social phobia and HIV. (R. 434, 27). Plaintiff testified that he has been sober since June 4, 2010. (R. 62).

         Plaintiff's medical records begin in August of 2012[2] when Plaintiff saw Dr. Todd Hargan, M.D. (R. 321). Dr. Hargan noted on August 17, 2012 that Plaintiff had lower energy, decreased mood and anger since he stopped testosterone. (R. 339). Dr. Hargan then started Plaintiff on monthly testosterone injections which continued into 2013. (R. 321-39, 347-68). Dr. Hargan also continued Plaintiff on Celebrex. (R. 339). Soon after, Dr. Hargan referred Plaintiff for a psychological evaluation for anxiety and anger symptoms. (R. 338). Dr. Hargan opined that Plaintiff had lipodystrophy, or fat redistribution, common in HIV patients due to their medications, and he discussed treatment options with Plaintiff. (R. 337, 397, 28). Plaintiff continued to see Dr. Hargan throughout 2013, during which Dr. Hargan indicated that Plaintiff's anxiety was not well controlled on several occasions. (R. 409, 412, 449). Then in April of 2014, Dr. Hargan noted Plaintiff had a headache associated with muscle spasm when he followed up for his HIV. (R. 457-58). In July of 2014 Plaintiff reported the muscle spasm had resolved. (R. 460).

         On March 28, 2013, Plaintiff saw Dr. Robert V. Prescott, Ph.D, for a formal mental status evaluation for the bureau of Disability Determination Services (“DDS”). (R. 386-91). Plaintiff reported to Dr. Prescott that he was not currently receiving any mental health treatment. (R. 387). Dr. Prescott diagnosed Plaintiff with major depression; moderate, intermittent explosive disorder; anxiety disorder; alcohol abuse that is currently in remission according to Plaintiff; and adult antisocial activities. (R. 390). Dr. Prescott opined Plaintiff would be unable to handle funds and performed a “little less well than expected” given his age, educational and work history on the cognitive portion of the evaluation. (Id.) However, Dr. Prescott also noted that Plaintiff lives by himself and is able to dress and bathe himself, use public transportation, and do his own laundry. (Id.) Additionally, Dr. Prescott noted Plaintiff could recall four of five items after a five-minute delay. (R. 389).

         On that same day, Plaintiff reported to Dr. Donald F. Pochyly, M.D., for an internal medicine consultative examination for DDS. (R. 397-400). Plaintiff reported that he had poor memory due to excessive alcohol intake for 30 years and was taking Trazadone, Cymbalta, and Alprazolam for depression and anxiety. (R. 397). On examination, Plaintiff had normal ranges of motion for his joints except for the left shoulder, which had limited ranges of motion and was tender to inspection. (R. 398).

         A note from Dr. Mark Gindi, M.D. on November 12, 2013 indicated Plaintiff had a current Global Assessment of Function (“GAF”)[3] score of 65. (R. 441). Dr. Gindi also recommended that Plaintiff continue taking Seroquel, Trazodone, Cymbalta, and start psychotherapy. (Id.)

         On August 14, 2013, Plaintiff saw Dr. Robert Shulman, M.D., complaining of anxiety, anger and emotional dysregulation. (R. 431). Plaintiff informed Dr. Shulman of his prior alcohol abuse and reported that he used to drink a liter of vodka daily, until a successful recovery three years ago. (Id.) Plaintiff reported that after achieving sobriety, his moods worsened especially after being fired from his job. (Id.) Dr. Shulman also noted that Plaintiff has a long history of social anxiety that was masked by his drinking. (Id.)

         Upon examination, Dr. Shulman noted normal findings, including concentration within normal limits and coherent thoughts. (R. 434). Plaintiff was cooperative and alert, but his mood was anxious and depressed. (Id.) Dr. Shulman diagnosed bipolar II disorder, alcohol dependence, adult attention deficit disorder, and social phobia. (Id.) Dr. Shulman gave a current GAF score of 51-60, indicating moderate symptoms or moderate difficulty in social, occupational, or school functioning. (Id.)

         Plaintiff continued to see Dr. Shulman over the next few months upon which various medications were tried. (R. 558, 552, 545, 539). Then, on March 10, 2014, Plaintiff reported that he felt like he was “at an even keel” and despite some persisting inattention and poor concentration, he felt much better overall. (R. 528). The following month, Dr. Shulman again adjusted Plaintiff's medication to help with Plaintiff's continuing difficulty with concentration. (R. 521). In June of 2014, Plaintiff had better focus and concentration and stable a mood. (R. 515). Then, in August of 2014, Dr. Shulman noted Plaintiff as being stable and benefiting from Nuvigil, along with better concentration. (R. 501). Dr. Shulman also noted that Plaintiff had become very involved with running Dual Diagnosis Anonymous (“DDA”) groups. (Id.)

         In September of 2014, Plaintiff reported that he developed side effects to Nuvigil and was back to the baseline in terms of focus and concentration. (R. 496.) The following month Dr. Shulman noted that Plaintiff had no overt irritability and mood was much more stable. (R. 489). Dr. Shulman also noted that Plaintiff had not tried Deplin medication yet due to cost. (Id.) Upon mental status examination, Dr. Shulman indicated Plaintiff was within normal limits. (R. 490).

         Plaintiff also saw Dr. Hargan twice in October of 2014 and Dr. Hargan indicated there was some setback in Plaintiff's HIV treatment. (R. 467, 470). Dr. Hargan noted that Plaintiff's non-compliance caused the last regimen to fail, but that now Plaintiff reported he fixed the issue that caused the non-compliance. (R. 470). Dr. Hargan also continued to treat the neuropathy in Plaintiff's feet with Cymbalta. (R. 471).

         On January 21, 2015 Dr. Shulman completed a mental impairment questionnaire. (R. 473-78). Dr. Shulman gave a current GAF score of 65 and stated Plaintiff had no overt abnormalities on mental exam. (R. 473). Dr. Shulman also noted however, Plaintiff can still experience impulsivity, some irritability, impatience and distractibility. (Id.) Dr. Shulman indicated Plaintiff had marked limitations in difficulties in maintaining social functioning and deficiencies of concentration, persistence or pace. (R. 477). Dr. Shulman also opined that there had been one or two episodes of decompensation. (Id.)

         b. The ALJ's Decision

         The ALJ issued a written decision on April 3, 2015 following the five-step analytical process required by 20 C.F.R. 404.1520. (R. 20-35). As an initial matter, the ALJ found that Plaintiff met the insured status requirements of the Act through December 31, 2016. (R. 22). At step one, the ALJ found Plaintiff had not engaged in substantial gainful activity from the alleged onset date of August 16, 2012 through the date last insured of December 31, 2016. (Id.) At step two, the ALJ concluded that Plaintiff had the severe impairments of bipolar disorder II (BP II), personality disorder, generalized anxiety disorder (GAD)(also diagnosed as social phobia and panic disorder), attention deficit disorder (ADHD), human immunodeficiency virus (HIV) infection, and left shoulder arthritis (DJD). (Id.) Other impairments were to determined to be non-severe. (R. 22-23). At step three, the ALJ concluded Plaintiff did not have an impairment or combination of impairments that met or medically equaled the severity of a listed impairment. (R. 23-26). Prior to step four, the ALJ found that through the date of last insured, Plaintiff maintained the residual function capacity (“RFC”) to perform light work, except that he could perform simple, routine, repetitive tasks; can have occasional, brief, and superficial contact with co-workers, supervisors, and the general public; can tolerate proximity to co-workers but cannot perform conjoined tasks, teamwork, or group work; can make independent decisions and can tolerate routine workplace changes, but cannot tolerate fast-paced production rate or strict quota requirements. (R. 26).

         In making this finding, the ALJ determined Plaintiff's general credibility to be undermined and his allegations to be “exaggerated because they are not well supported by the medical evidence of record.” (R. 30). Factors considered by the ALJ included that there was no significant progression of Plaintiff's HIV or manifestations or mental impairments, and extensive range of daily activities which were inconsistent with alleged levels of social phobia, memory loss or pain. (Id.)

         Second, the ALJ gave little weight to the medical opinion of Plaintiff's treating physician, Dr. Shulman, and the mental impairment questionnaire he completed on January 21, 2015. (R. 30). The ALJ determined Dr. Schulman's opinion to be inconsistent with the record and that there was insufficient explanation or support for his opinion. (R. 31). The ALJ also explained that Dr. Schulman's opinions were not supported by the evidence to show one or two episodes of decompensation. (Id.) The ALJ stated that ...

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