United States District Court, N.D. Illinois, Eastern Division
RICHARD H. RINEHART, Plaintiff,
NANCY A. BERRYHILL,  Acting Commissioner of Social Security, Defendant.
MEMORANDUM OPINION AND ORDER
E. Cox, Magistrate Judge.
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.
Procedural History and Plaintiff's Background
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].
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).
medical records begin in August of 2012 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).
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).
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).
from Dr. Mark Gindi, M.D. on November 12, 2013 indicated
Plaintiff had a current Global Assessment of Function
(“GAF”) score of 65. (R. 441). Dr. Gindi also
recommended that Plaintiff continue taking Seroquel,
Trazodone, Cymbalta, and start psychotherapy. (Id.)
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.)
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.)
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.
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.
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).
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.)
The ALJ's Decision
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).
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.)
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 ...