United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
JEFFREY CUMMINGS, UNITED STATES MAGISTRATE JUDGE
John L. (“Claimant”) brings a motion for summary
judgment to reverse the final decision of the Commissioner of
Social Security (“Commissioner”) that denied
Claimant's claim for a period of disability and
Disability Insurance Benefits (“DIBs”) under 42
U.S.C. §§ 416(i) and 423(d) of the Social Security
Act. The Commissioner has brought a cross-motion for summary
judgment seeking to uphold the Social Security Agency's
decision to deny benefits. The parties have consented to the
jurisdiction of the United States Magistrate Judge pursuant
to 28 U.S.C. § 636(c). This Court has jurisdiction to
hear this matter pursuant to 42 U.S.C. §§ 405(g)
and 138(c)(3). For the reasons stated below, Claimant's
motion for summary judgment  is granted and the
Commissioner's motion for summary judgment  is
March 28, 2012, Claimant filed a Title II application
alleging a disability onset date of December 16, 2010. (R.
133). His claim was denied initially on July 27, 2012 and
upon reconsideration on December 10, 2012. (R. 113, 170-72).
On February 27, 2015, an Administrative Law Judge
(“ALJ”) issued a written decision denying
benefits to Claimant. (R. 133-57). The Appeals Council denied
review on July 27, 2017, making the ALJ's decision the
Commissioner's final decision. (R. 1-5). Zurawski v.
Halter, 245 F.3d 881, 883 (7th Cir. 2001). Claimant
subsequently filed this action in District Court.
suffers from sleep apnea, parasomnia,  degenerative disc
disease of the lumbar spine, anxiety, a mild cognitive
impairment and bilateral hearing loss with tinnitus. Only
Claimant's parasomnia is relevant to the Court's
assessment of the ALJ's decision.
Evidence From Claimant's Treatment History
February 21, 2011, Claimant sought treatment for sleep
problems with sleep specialist Dr. Phyllis Zee. Claimant told
Dr. Zee that he had difficulty falling asleep and staying
asleep. At the time of the consultation, Claimant went to bed
between 11p.m. and 2 a.m. but woke up every two hours, often
from hearing sounds “like a sizzle.” (R. 398-99).
Dr. Zee diagnosed Claimant with “possible exploding
head syndrome (except no exploding sound)” and mild
obstructive sleep apnea. (R. 400). Claimant told Dr. Zee that he
heard sounds when he was sleepy four to five times a day or
when he shifted his attention. (R. 399). Dr. Zee noted that
Claimant had received a sleep apnea diagnosis in 2010 and was
currently using a CPAP machine for it. She added a CPAP
pillow to his sleep protocol and encouraged him to take a low
dose of melatonin before bedtime. (R. 400-01). Claimant
followed up with Dr. Zee one year later on February 13, 2012.
He told her that he fell asleep easily but awoke at 4 a.m.
with tinnitus and could not go back to sleep. (R. 403). Dr.
Zee noted that Claimant was using his CPAP machine without
problems and that he had only had one episode of exploding
head syndrome in the last two months. (R. 407).
met with Dr. Vanessa Kim on November 21, 2013 and told her
that although he used his CPAP machine daily he was often in
bed eight to ten hours with only minimal sleep. (R. 667). Dr.
Kim referred Claimant to a sleep clinic. Before Claimant was
able to comply with Dr. Kim's recommendation, Dr. Carmen
Rosario referred Claimant for a neurological exam after he
complained to her of “crashing” sounds and
“explosions” in his head. (R. 660). A brain MRI
and a head magnetic resonance angiography (“MRA”)
were carried out on April 28, 2014, showing early ischemic
changes without gross abnormalities. (R. 512). On September
3, 2014, neurologist Dr. Rasheed Izad-Yar noted that both
tests were “negative” and
“unremarkable.” (R. 728). Dr. Izad-Yar stated
that no tests or treatment exist for exploding head syndrome
and that he suspected that Claimant's complaints were
hypochondriacal in nature “given [his] multiple
complaints spanning multiple organ systems and frequent
self-referrals for evaluations.” (R. 729).
expanded his complaints about exploding head syndrome on
August 1, 2014 by telling Dr. Elizabeth Apolonio that he was
having three to four dozen episodes each week and that his
symptoms ranged from a sizzling sound to loud explosions. (R.
811). Claimant told Dr. Ward on September 11, 2014 that he
had experienced five to six explosive sounds that day and
that he woke up every hour from it. (R. 803). On October 2,
2014, Claimant met with Dr. James Wyatt at the Rush Hospital
Sleep Disorder Clinic. Dr. Wyatt prescribed a routine during
which Claimant would go to bed at 4 a.m. for the first week
and arise at noon every day “regardless of how you
slept that night.” Claimant was then to sit near a
window or go outside for an hour between noon and 2 p.m. (R.
addition to treatment for exploding head syndrome, Claimant
also pursued a range of treatments for other conditions.
Claimant complained of cognitive difficulties. Neurologist
Dr. Darren Gitelman stated on August 4, 2011 that he had
“a mild deficit” in some aspects of his memory
and “very subtle difficulties” in attention and
executive functions. (R. 440). Dr. Eric Brehem, however,
determined on September 15, 2011 that no cognitive
dysfunction existed and that Claimant's perception that
it did could be attributed to his sleep disorder,
environmental distractions, or his heightened awareness that
sleep problems may cause cognitive difficulties. (R. 451).
Evidence From the State Agency Consultants
12, 2012, psychologist Dr. Robert Neufeld examined Claimant
on behalf of the Social Security Administration and issued a
report. Dr. Neufeld noted that Claimant was cooperative and
had normal affect. He could remember eight digits forward and
five digits in reverse with no problem in accessing
“personally meaningful remote memory items.” Dr.
Neufeld determined that Claimant had a mild anxiety disorder
that was focused on his current life situation. (R. 387-89).
agency expert Dr. Young-Ja Kim found on July 26, 2012 that
Claimant suffered from the severe impairments of hearing loss
and an anxiety disorder. Dr. Kim did not find that these
impairments imposed any limitations on Claimant's
physical abilities but stated that restrictions were required
on his ability to hear and to work with hazards such as
machinery and working at heights. (R. 105-08). Psychological
expert Dr. Donna Hudspeth issued a separate report on June
21, 2012 finding that Claimant suffered from an affective
disorder and an organic mental disorder. (R. 120). Dr.
Hudspeth stated that these impairments imposed a mild
restriction on Claimant's activities of daily living
(“ADLs”) and moderate restrictions on his social
functioning and ability to maintain concentration,
persistence, or pace. (R. 120).
Dr. Angelica Ortiz examined Claimant on September 5, 2013 and
issued a report. Dr. Ortiz noted that Claimant had
experienced a significant amount of stress following his
son's suicide in 2006 though the panic attacks that he
experienced at that time had since abated. (R. 463). He
displayed a broad affect during the examination and showed no
evidence of hallucinations or delusions. Claimant could
repeat five digits forward and three backward. Tests that Dr.
Ortiz applied during the examination showed that Claimant had
above-average normal intellectual functioning. Unlike Dr.
Neufeld, however, Dr. Ortiz determined that Claimant had a
poor ability to recall past memories. Dr. Ortiz concluded
that Claimant suffered from an anxiety disorder that imposed,
at most, mild restrictions on his ability to carry out
complex instructions and make judgments about complex work
problems. Claimant had no limitations in his ability to
interact with supervisors, co-workers, or the public. (R.
own motion, the ALJ also submitted interrogatories to
non-examining psychological expert Dr. Mark Oberlander. On
January 5, 2015, Dr. Oberlander issued his opinion concerning
Claimant's ability to carry out work-related tasks. He
found that Claimant suffered from an anxiety disorder and an
organic mental disorder that included sleep apnea, tinnitus,
parasomnia, and a mild cognitive impairment. (R. 979). Dr.
Oberlander determined that Claimant had no restrictions in
understanding simple instructions, had mild limitations in
carrying out complex instructions, and had a moderate
restriction in making complex work-related decisions.
Claimant had a mild limitation in interacting appropriately
with supervisors but had no other restrictions in dealing
with the public or co-workers. (R. 975-77).
Evidence From Claimant's Testimony
appeared at a November 12, 2013 hearing that the ALJ held
after noting that Claimant intended to appear without counsel
or a non-attorney representative. The ALJ advised Claimant of
his right to representation and delayed the hearing to give
him an opportunity to obtain counsel. The ALJ also requested
additional documents from the Veterans Administration
(“VA”) and Northwestern Hospital on
Claimant's behalf. (R. 92-97). A brief second hearing was
held on April 22, 2014. The ALJ continued that hearing,
however, to permit Claimant to complete medical tests that
had already been scheduled at the VA clinic and to give him
additional time to find an attorney to represent him. (R.
appeared at the third hearing on October 9, 2014 without
counsel. He stated that he had contacted an attorney who
declined to represent him and that he wished to proceed
without counsel. Claimant testified about his exploding head
syndrome by telling the ALJ that when he was sleepy he heard
explosions in his head up to 30 times an hour or more. (R.
30). Claimant described the sound as like a shotgun that
wakes him up. He also hears explosions when he shifts his
focus while concentrating on something. (R. 31). He wakes up
ten times a night. (R. 46). Claimant told the ALJ that one
doctor had prescribed a blood pressure medication to treat
his symptoms but he was unable to take it until he completed
his sleep therapy. (R. 32-33). Claimant goes to bed at 4 a.m.
and rises at noon, sits by a window for an hour, then eats
breakfast. (R. 38).
The Medical and Vocational Experts' Testimony
Medical expert Dr. Ronald Semerdjian also testified at the
October 2014 hearing. Dr. Semerdjian described exploding head
syndrome (which he called “exploding headaches”)
was rare and placed it in the same category as migraine
headaches. (R. 55). Based on Claimant's May 2014 hip
x-ray, Dr. Semerdjian testified that he would be limited to
sedentary work. (R. 61).
expert (“VE”) Linda Gels was also present at the
hearing. The ALJ asked her if a hypothetical person with
Claimant's RFC could carry out his past work as a
document preparer. The VE testified that such a person would
be able to perform that task as it is described in the
Dictionary of Occupation Titles. (R. 70-72).