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Dula A. v. Saul

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

July 26, 2019

DULA A., Plaintiff,
ANDREW M. SAUL, Commissioner of the Social Security Administration[1], Defendant.


          Susan E. Cox, United States Magistrate Judge.

         Plaintiff Dula A.[2] appeals the decision of the Commissioner of the Social Security Administration (“Commissioner”) denying her disability benefits. Plaintiff has filed a motion for summary judgment [11]; 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.

         I. Background

         a. Procedural History

         In 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.

         b. Relevant Medical Background

         Plaintiff 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.

         On 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. [R. 288-89.]

         In 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.

         Dr. 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.[3] Id.

         After 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.

         On 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.]

         On 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. 353-54.]

         On 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 ...

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