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Arriaga v. Berryhill

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

April 24, 2018

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


          Sidney I. Schenkier Magistrate Judge

         Plaintiff, Manuel Arriaga, seeks reversal and remand of the Commissioner's decision denying his application for Social Security benefits (doc. # 23: PL's Mot. for Summ, J.). An administrative law judge ("ALJ") denied Mr, Arriaga's application for benefits after a hearing, and the Appeals Council denied his request for review of that decision, making the ALJ's decision the final decision of the Commissioner (R. 1). The Commissioner has filed a cross-motion asking the Court to affirm its decision (doc. # 26: Def, 's Mot. for Summ. J.). For the reasons that follow, we grant Mr. Arriaga's motion.


         At the time of his alleged onset date of November 6, 2012, Mr. Arriaga was 43 years old and a known diabetic with high cholesterol (R. 326). On October 1, 2013, Mr. Arriaga was evaluated by a psychiatrist, Laron Phillips, M.D., for the Bureau of Disability Determination Services ("DDS") (R. 359). Dr. Phillips noted Mr. Arriaga reported that he had developed depression and anxiety due to health and family problems, and his primary care physician had prescribed Lexapro for depression and anxiety and Ambien for insomnia (R. 359-60). During the examination, Mr. Arriaga was cooperative and behaved appropriately, but he was tearful and had a depressed mood and saddened affect (R. 360). Dr. Phillips concluded that Mr. Arriaga had major depressive disorder (moderate) and anxiety which resulted in "moderate impairments in social, occupational and interpersonal functioning" (Id.).

         From May through September 2014, Mr. Arriaga's primary care physician, Dilip Patel, M.D., treated Mr, Arriaga for diabetes, hypertension, and peripheral neuropathy (nerve pain) related to his diabetes (R. 401-05). In addition, Dr, Patel prescribed Trazadone (a sedative and antidepressant) (R. 402-03). In September 2014, Mr. Arriaga began seeing a podiatrist, Ronald Hugar, M.D., who treated him for bilateral leg and foot pain and numbness with various medications, including gabapentin, Lyrica (nerve pain medication), and large doses of ibuprofen, as well as with physical therapy (R. 387-97). On October 9, 2014, Deepti Shivakumar, M.D., Mr. Arriaga's new primary care physician, restarted Mr. Arriaga's prescription for Lexapro in response to his complaints of increased depression and frequent crying spells, and increased his dosage of gabapentin to address his peripheral neuropathy (R. 407-09). On January 29, 2015, Dr. Shivakumar referred Mr. Arriaga to a psychiatrist (R. 406-07).

         On March 17, 2015, Mr. Arriaga began treatment with psychiatrist, Evan Deranja, M, D., (R. 443). Dr. Deranja wrote that Mr. Arriaga's reported symptoms of "depressed mood, insomnia, anhedonia, feelings of guilt and worthlessness, poor energy, poor concentration, decreased [a]ppetite, and psychomotor retardation" met the criteria for a "major depressive episode" (Id.). Dr, Deranja noted that Mr, Arriaga was taking Lexapro and Ambien daily, but with no benefit (R. 445). Dr. Deranja found Mr. Arriaga had psychomotor retardation (slowing down of thought and physical movements), depressed mood with a constricted affect, and cognitive difficulties; the remainder of the examination was normal (R. 445-46). Dr. Deranja opined Mr. Arriaga had a single major depressive episode which had been slowly worsening over the previous one to two years, as well as a cognitive disorder (R. 446). Dr, Deranja increased Mr. Arriaga's prescription for Lexapro for depression and Trazodone for insomnia, and referred him for cognitive testing (Id.). The following month, on April 28, 2015, Mr. Arriaga told Dr. Deranja that, overall, he felt "a little better, " but that he still became anxious easily and continued to have trouble sleeping (R. 448). Mr. Arriaga's mental status examination was unchanged from the previous appointment (R. 448-49). Dr. Deranja increased Mr. Arriaga's dosage of Trazadone and maintained the same dosage of Lexapro (R. 449).

         On August 18, 2015, Mr. Arriaga reported to Dr. Deranja that the use of Lexapro had not diminished his depressive symptoms, and that he continued to have insomnia despite taking Trazadone (R. 451). Mr, Arriaga's mental status exam was unchanged (R. 452). Dr, Deranja increased Mr. Arriaga's prescription for Trazadone, discontinued Lexapro, and prescribed Effexor (nerve pain medication and antidepressant) (R. 452-53). On September 28, 2015, Dr. Deranja's progress notes stated that Mr, Arriaga "[c]ontinues to meet criteria for major depressive episode" (R, 454). On Effexor, Mr. Arriaga's motivation increased "a little bit, " his drive to do things "somewhat increased, " and his irritability decreased "some;" however, he continued to have "depressed mood, anhedonia, low concentration, low energy, feelings of worthlessness, [and] insomnia, " and he "continue[d] to struggle with cognitive symptoms" (Id.). Dr. Deranja also performed a cognitive assessment of Mr, Arriaga, which showed cognitive impairment (R. 455). Dr. Deranja doubled Mr, Arriaga's Effexor prescription and referred Mr. Arriaga for a neuropsychological examination (R. 456), which was not performed because it was not covered by Mr. Arriaga's insurance.

         In October 2015, Dr. Deranja filled out a Mental Impairment Report for Mr. Arriaga (R. 427). Dr. Deranja diagnosed him with major depressive disorder and cognitive disorder and listed his symptoms as depressed mood, anhedonia, insomnia, impaired concentration, daily headaches, easily overwhelmed, decreased appetite, decreased energy, feelings of guilt and worthlessness, and psychomotor retardation (Id.). Dr. Deranga opined that these symptoms restricted Mr, Arriaga's daily activities and capacity to function in "multiple realms, " and they had lasted or could be expected to last for more than 12 months (Id.). Dr. Deranja also stated that based on Mr. Arriaga's reports, his illness would affect his ability to sustain concentration and attention and result in the failure to complete tasks (R. 428). He opined that Mr. Arriaga had moderate limitations in activities of daily living ("ADLs") and maintaining social functioning and marked limitations on maintaining concentration, persistence or pace (R. 429). Dr. Deranja also wrote that Mr. Arriaga had specific cognitive impairments, including memory impairment, disturbance in mood, and potential loss of intellectual ability (R. 432). Dr. Deranja opined that depending on the circumstances, Mr. Arriaga's cognitive impairments could cause moderate to marked limitations in ADLs, maintaining social functioning and maintaining concentration, persistence or pace (Id.). He suspected that Mr. Arriaga's cognitive deficits extended beyond that which he had seen thus far (Id.).


         On November 2, 2015, at his hearing before the ALJ, Mr. Arriaga testified that he had pain, numbness, and stiffness in his legs and feet, swelling in both ankles, sharp pains in his back, and numbness and stiffness in his hands which limited his functional abilities (R. 48-52). In addition, Mr. Arriaga testified that he had suffered from psychiatric impairments for the past two years, including depression, insomnia, headaches and anxiety attacks (R. 52, 57-58). His impairments made him sad, and he cried daily (Id.). Mr. Arriaga also had problems with concentration and memory; his wife had to remind him to take his medication (R. 52-55).

         The ALJ presented the vocational expert ("VE") with several hypothetical, including an individual who was limited to sedentary work with frequent or constant bilateral handling, and whose mental impairments limited him to "mild activities of daily living, moderate social functioning, moderate concentration, persistence, or pace, " simple routine work, occasional interaction with coworkers and supervisors, no interaction with the public, and work at a variable rate with no fast-paced production line work (R. 70-71). The VE opined that there were unskilled, sedentary employment options for this individual, but no work would be available if the individual was limited to occasional handling or had marked limitations in concentration, persistence or pace (R. 71-73).


         On December 9, 2015, the ALJ issued a written decision concluding that Mr. Arriaga was not disabled from November 6, 2012 through the date of the decision (R. 32). The ALJ determined that Mr. Arriaga had the severe impairments of diabetes mellitus, peripheral neuropathy, depression, cocaine abuse, insomnia, and degenerative disc disease of the lumbar spine, none of which - alone or in combination - met a listed impairment (R, 18-19). The ALJ specified that Mr. Arriaga's mental impairments did not satisfy the "paragraph B" criteria because he experienced only mild restrictions in ADLs, moderate difficulties in social functioning, moderate difficulties in concentration, persistence or pace, and no episodes of decompensation of extended duration (R. 19-20). The ALJ found that Mr. Arriaga had primarily physical limitations in ADLs, but he was able to perform personal care, manage funds and shop, although he had trouble remembering where items were in the store and his wife had to write down his chores for him (R. 20). Further, the ALJ noted that Mr. Arriaga was fully oriented and demonstrated adequate memory at the consultative psychological evaluation, although examinations with Dr, Deranja showed limitations in delayed recall (Id.).

         The ALJ next determined Mr, Arriaga had a residual functional capacity ("RFC") to perform sedentary work with frequent bilateral handling, and he was limited to simple, routine tasks, no interaction with the public, occasional interaction with coworkers and supervisors, and no fast-paced production line work (R. 21). In making this determination, the ALJ reviewed Mr. Arriaga's testimony and the medical reports in the record, including Dr. Patel's and Dr. Shivakumar's decisions in 2014 to prescribe him Trazadone and Lexapro (R. 25-27), Nevertheless, the ALJ wrote that "[a]s to the claimant's mental ...

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