United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
E. Cox, United States Magistrate Judge.
Dula A. appeals the decision of the Commissioner
of the Social Security Administration
(“Commissioner”) denying her disability benefits.
Plaintiff has filed a motion for summary judgment ; the
Commissioner has filed a cross-motion for summary judgment
[dkt. 24]. As detailed below, the Court grants
Plaintiff's motion for summary judgment [dkt. 11], denies
the Commissioner's motion for summary judgment [dkt. 24],
and remands this matter for further proceedings consistent
with this Memorandum Opinion and Order.
December 2014, Plaintiff protectively filed for Disability
Insurance Benefits (“DIB”) under Title II of the
Social Security Act, 42 U.S.C. §§ 416(i), 423(d),
alleging disability beginning June 20, 2014. [Administrative
Record (“R.”) 12.] After her applications were
denied initially and on reconsideration, Plaintiff requested
an administrative hearing. [R. 12, 101-02.] On March 1, 2017,
Plaintiff appeared with counsel and testified at a hearing
before Administrative Law Judge (“ALJ”) Janice
Bruning. [R. 33-51.] A vocational expert (“VE”)
also testified. Id. On May 30, 2017, the ALJ
determined that Plaintiff was not disabled. [R. 12-23.] On
April 18, 2018, after a review of the ALJ's decision, the
Appeals Council issued a decision affirming that Plaintiff
had not been under a disability from his alleged onset date
to the date of the ALJ's decision. [R. 1-6.] Thus, the
Decision of the Appeals Council is the final decision of the
Commissioner. Plaintiff filed an action in this court on June
19, 2018, seeking review of the Commissioner's decision.
Relevant Medical Background
was born in 1967 and was 47 years old on her alleged
disability onset date. [R. 52.] Plaintiff came to the United
States from Bosnia in August 1997, after living through the
Bosnian War. [R. 315.] During the war, soldiers broke in to
Plaintiff's home and threatened to kill her if she did
not disclose where her husband was. [R. 231, 365-84.]
Plaintiff's husband was later taken to a concentration
camp, where he was tortured. [R. 315.] Since that time,
Plaintiff has experienced symptoms of depression, anxiety,
and PTSD. Id.
January 18, 2014, Dr. Jasminka Kostic, M.D., diagnosed
Plaintiff with chronic fatigue syndrome and fibromyalgia, and
prescribed Lyrica. [R. 292.] In May 2014, when Plaintiff
presented to Dr. Kostic with headaches, dizziness,
palpitations, as well as pain in her neck, upper back, arms,
elbows, lower back, buttocks, thighs, and knees, Dr. Kostic
increased Plaintiff's dosage of Lyrica. [R. 291.] After
two and a half weeks of little improvement, Dr. Kostic again
increased her dosage of Lyrica. [R. 290.] Plaintiff's
complaints of pain and fatigue continued into March of 2015.
addition to her chronic fatigue syndrome and fibromyalgia,
Plaintiff suffers from multiple psychiatric impairments, and
has been receiving psychiatric care since prior to her onset
date. In November 2013, Dr. Lucyna Puszkarska, M.D., a
psychiatrist, conducted a complete psychiatric evaluation of
Plaintiff. [R. 315-17.] Dr. Puszkarska noted that Plaintiff
has symptoms of anxiety several times a week, including
apprehensiveness, shortness of breath, increased heart rate,
cold hands, and other indicators of autonomic instability.
[R. 315.] Dr. Puszkarska also noted Plaintiff's
difficulties concentrating, episodes of dizziness, and fears
of losing control or dying. Id.
Puszkarska noted that as a result of PTSD arising out of
traumatic events involving actual or threatened death or
serious injury during the Bosnian War, Plaintiff experienced
feelings of intense fear and helplessness. Id. She
experiences recurring, intrusive, and distressing
recollections of the traumatic incident, recurring
distressing dreams of the incident, and flashbacks.
Id. She exhibits diminished interest in important
affairs. Id. Dr. Puszkarska treated Plaintiff for
anxiety, major depressive disorder with psychotic features,
and PTSD. [R. 316-17.] She was prescribed three psychotropic
medications: Pristiq, Clonazepam, and Abilify. Id.
She was assessed with a Global Assessment of Functioning
(GAF) score of 45. Id.
three follow up visits, Plaintiff reported slight improvement
in some of her symptoms. [R. 318-322.] In May 2014, Dr.
Puszkarska noted that Plaintiff had only a slight response to
treatment, and assessed her with a GAF score of 50. [R.
322-23.] On October 23, 2014, Plaintiff returned to Dr.
Puszkarska complaining of excessive worry, decreased
sociability, recurrent recollections of trauma, and
flashbacks. [R. 324-25.] At that time, Dr. Puszkarska again
assessed a GAF score of 45. Id.
December 5, 2014, a mental status examination revealed soft
and slow speech, constricted affect, poor eye contact, and
signs of anxiety. [R. 326-27.] Although Plaintiff noted her
medications made her drowsy, her dosage of Pristiq was
increased, and her GAF score was slightly raised to 50.
Id. In January 2015, Plaintiff's dosage of
Clonazepam was increased because of her ongoing signs of
anxiety. [R. 328-29.] Dr. Puszkarska noted that Plaintiff
needed assistance with activities of daily living.
Id. The following month, it was noted that
Plaintiff's treatment response had been inadequate, and
her ability to perform self care had been reduced. [R. 330.]
On March 6, 2015, Plaintiff's dosage of Abilify was
increased. [R. 332-33.] In Dr. Puszkarska's April 7, 2015
treatment note, he indicated that Plaintiff “has had an
inadequate response to treatment” and that
Plaintiff's GAF score remained at 50. [R. 334.]
April 28, 2015, Plaintiff's GAF score still remained at
50, and her medications were again adjusted, with the
Clonazepam increased, Abilify stopped, and Zolpidem and
Seroquel initiated. [R. 336-37.] In October 2015, Dr.
Puszkarska noted that Plaintiff's symptoms had
stabilized, and treatment with the medications was continued
with some adjustments. [R. 349-50.] Her GAF score was
assessed at 55. Id. The following month, however,
Dr. Puszkarska noted that Plaintiff's symptoms seemed
worse, and he added several medications. [R. 352.] He did,
however, assess Plaintiff at a GAF score of 60. Id.
In December of 2015, Plaintiff's symptoms again seemed to
stabilize, but Dr. Puszkarska increased dosages of various
medications and kept Plaintiff's GAF score at 60. [R.
February 10, 2016, Plaintiff's psychiatric care was
transferred to Dr. Cezary Dudzinski, M.D., a board-certified
psychiatrist. [R. 361.] Dr. Dudzinski confirmed the diagnoses
of major depression, PTSD, and anxiety disorder, but noted
Plaintiff indicated she currently felt more stable than she
had in the past. Id. Notes from an examination on
April 6, 2016 indicate widely varying sleep patterns (ranging
from four to ...