United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER
MAGISTRATE JUDGE JEFFREY COLE
Plaintiff
applied for Disability Insurance Benefits (“DIB”)
and Supplemental Security Income (“SSI”) under
Titles II and XVI of the Social Security Act
(“Act”), 42 U.S.C. §§ 416(i), 423,
1381a, 1382c, about four years ago. (Administrative Record
(R.) 190-202). She claimed that she became disabled as of
December 25, 2014, due to severe depression. (R. 218). Over
the ensuing three years, plaintiff’s application was
denied at every level of administrative review: initial,
reconsideration, administrative law judge (ALJ), and appeals
council. It is the ALJ’s decision that is before the
court for review. See 20 C.F.R. §§404.955; 404.981.
Plaintiff filed suit under 42 U.S.C. § 405(g), and the
parties consented to the jurisdiction of a Magistrate Judge
pursuant to 28 U.S.C. § 636( c) on June 7, 2018. [Dkt.
#6]. The case was reassigned to me six months later, on
January 10, 2019. [Dkt. # 21]. Plaintiff asks the court to
reverse and remand the Commissioner’s decision, while
the Commissioner seeks an order affirming the decision.
I.
Plaintiff
was born on October 16, 1980 (R. 192), and was just 34 when
she claims she became unable to ever work again. (R. 192).
She has a high school education, and work experience as a
retail store supervisor, inventory counter and, most
recently, as massage therapist. (R. 232). She says left that
job at Christmastime in 2014 when she had a nervous breakdown
and attempted suicide. (R. 48). She had stopped taking her
medication, inflicted “two very superficial lacerations
on her left wrist”, and was hospitalized for a couple
of weeks. (R. 364). At the time it was noted that her
symptoms were not consistent with a diagnosis of PTSD. (R.
447). She later explained she thought her depression had a
“seasonal component.” (R. 452). Four days later
she felt “great.” (R. 416). She told the ALJ that
she had been using cocaine once a week at the time, but
stopped in May 2015. (R. 42). Conversely, she told her mental
healthcare providers that she hadn’t been using drugs
at all or had used cocaine a single time. (R. 444, 455, 572).
Plaintiff
also thought her problems had to do with her brothers not
appreciating her and disliking her boyfriend of that time,
who was a drug abuser. (R. 475, 556). Plaintiff left that
relationship about four months later (R. 590). More recently,
she had a boyfriend who was stable and reliable, although she
complained that he was boring. (R. 644). Stress over finances
also contributed to her problems, although she reported
having a “steady income” but not a “working
income.” (R. 475, 567). As a result, she said she
planned on seeking disability and unemployment insurance. (R.
475, 567). She was also angry she was not getting a tax
refund in 2015 because she had not repaid her student loans.
(R. 473, 565).
The
medical record in this case is relatively small, as these
cases go, covering about two and a half years of therapy
following plaintiff’s hospitalization. While consisting
of 400 pages or so, records are duplicated two and three
times throughout. (R. 330-736). The records are in the usual
jumble, and this may have led to some confusion. Both the ALJ
(R. 21) and the plaintiff [Dkt. # 10, at 3] refer to
treatment records from a Dr. Peggy Chou, but the records they
cite appear to be from Dr. Castelino (R. 455-57). Dr. Chou
does report that she saw plaintiff every two months from May
2015 through November 2016 (R. 594), but the only other
mention of the doctor comes in a note from another mental
healthcare provider in January 2017. (R. 613, 623). The
record appears to include no treatment notes from Dr. Chou;
there are treatment notes from Dr. Castelino (R. 454-58), and
therapists, Daniel Sasuta (R. 439-53), Sha-Ron Frizzle (R.
459-95), and Daniel Jean (R. 608-735).
As is
generally the case with plaintiffs claiming disability based
on psychological issues like depression or anxiety, page
after page of therapists’ notes show that plaintiff is
sometimes depressed, sometimes better, sometimes fine.
Invariably, a plaintiff – like many people – will
have issues with family, spouses, and significant others.
There’s not much in records like these to suggest
whether a plaintiff can work or cannot. A perfect example of
this is a note from March 9, 2015, where Therapist Frizzle
reported that plaintiff “seemed to be in good spirits
but still seemed to be very depressed.” (R. 480). What
an ALJ, or a reviewing court, is supposed to make of
contradictory entries like that is a puzzle.
But,
aside from the usual, it should be noted that throughout her
treatment, based on the GAF scores various mental health
professionals assigned her, from January 8, 2015 on,
plaintiff was stable. Every session, month after month and
sometimes week after week, her GAF score was at least 55. (R.
466, 469, 475, 480, 503, 505, 576, 578, 582, 594, 613). A GAF
between 51 and 60 reflects “‘Moderate symptoms
(e.g., flat affect and circumstantial speech, occasional
panic attacks) OR moderate difficulty in social,
occupational, or school functioning (e.g., few friends,
conflicts with peers or co-workers).’”
Jelinek v. Astrue, 662 F.3d 805, 807 (7th Cir.
2011)(quoting American Psychiatric Association, Diagnostic
and Statistical Manual of Mental Disorders, Text Revision
(DSM–IV–TR) 34 (4th ed. 2000). Compare this to
the general notion that “GAF scores bounce around a
great deal, however, because they depend on how the patient
happens to feel the day he's examined.” Voigt
v. Colvin, 781 F.3d 871, 875 (7th Cir. 2015). This is
the record the ALJ was tasked to consider.
After
an administrative hearing – at which plaintiff,
represented by counsel, and a vocational expert testified
– the ALJ determined plaintiff was not disabled. The
ALJ found that plaintiff had one severe impairment:
depressive disorder. (R. 17). Plaintiff was also obese, but
it was not severe as it caused no more than minimal
limitations to plaintiff’s ability to perform basic
work activities. The ALJ went on to determine that
plaintiff’s psychological impairment caused a mild
limitation in understanding, remembering, or applying
information; a moderate limitation in interacting with
others; a moderate limitation in concentrating, persisting,
or maintaining pace; and a moderate limitation in adapting or
managing herself. (R. 18-19). But, because not one area was
affected to a marked level, the ALJ found that
plaintiff’s psychological impairments, either singly or
in combination, did not meet or equal a listed impairment
assumed to be disabling in the Commissioner’s listings.
(R. 19).
The ALJ
then stated that the plaintiff had the residual functional
capacity to perform work at all extertional levels with the
following nonexertional limitations due to her psychological
impairment: “simple, routine repetitive tasks in a
low-stress environment, defined as having few if any changes
in the work setting and few if any simple work-related
decisions; no contact with the public; only occasional
contact with co-workers but no tandem or team tasks where one
production step depends on another; and would need a
ten-minute break every two hours, which can be accommodated
by routine breaks and lunch.” (R. 19). The ALJ next
noted plaintiff’s laundry list of alleged symptoms:
anxiety attacks, nightmares, irritability, paranoia,
difficulty concentrating/focusing, short attention span,
limited ability to complete tasks or understand instructions,
difficulty getting along with others, week-long manic
episodes every few weeks, and drowsiness for two hours after
taking her medications. (R. 20). She then found that
plaintiff’s “medically determinable impairments
could reasonably be expected to cause the alleged symptoms;
however, [her] statements concerning the intensity,
persistence and limiting effects of these symptoms are not
entirely consistent with the medical evidence and other
evidence in the record for reasons explained in this
decision.” (R. 24).
The ALJ
then carefully and at length discussed the medical evidence,
noting both normal and abnormal findings. (R. 20-25). The ALJ
also assessed the medical opinion evidence. The psychiatrist
that examined plaintiff in connection with her application
for benefits found she could communicate with co-workers and
supervisors, follow and retain most instructions, perform
simple, routine tasks, but would have difficulty handling
moderate work stress. The ALJ accorded significant weight to
this opinion as it came from an experienced psychiatrist with
knowledge of disability standards. (R. 24). Next, the ALJ
noted that plaintiff’s treating therapist found that
she was markedly limited in her ability to concentrate and
unable to function in a competitive work setting. The ALJ
accorded this opinion moderate weight, saying it was not
consistent with the treatment notes, was in response to
prompts on a form, and was the result of a relatively short
treatment relationship. (R. 24). The ALJ also accorded only
moderate weight to the opinion of plaintiff’s
psychiatrist that plaintiff would be disabled due to a number
of significant limitations because these were not congruent
with the psychiatrist’s treatment notes and with other
findings. (R. 25). Finally the ALJ said that the record
generally supported the opinion of the state agency reviewing
physician and firmly supported the opinion of the state
agency reviewing psychologist. (R. 25).
Next,
the ALJ determined that plaintiff could not return to her
past work because is was semiskilled and required more
contact with the public than she was now capable of. (R. 26).
Then, the ALJ – relying on the testimony of the
vocational expert – found that given her residual
functional capacity, plaintiff could perform the following
jobs that exist in significant numbers in the national
economy: laundry laborer (DOT #361.687-018), industrial
cleaner (DOT #381.687-018), and machine packager (DOT
#920.685-078). (R. 27). Accordingly, the ALJ concluded that
plaintiff was not disabled and was not entitled to benefits
under the Act. (R. 29-30).
II.
If the
ALJ’s decision is supported by substantial evidence,
the court on judicial review must uphold that decision even
if the court might have decided the case differently in the
first instance. See 42 U.S.C. § 405(g). Substantial
evidence is “such relevant evidence as a reasonable
mind might accept as adequate to support a conclusion.”
Richardson v. Perales,402 U.S. 389, 401 (1971);
Beardsley v. Colvin, 758 F.3d 834, 836 (7th Cir.
2014). To determine whether substantial evidence exists, the
court reviews the record as a whole but does not attempt to
substitute its judgment for the ALJ's by reweighing the
evidence, resolving material conflicts, or reconsidering
facts or the credibility of witnesses. Beardsley,
758 F.3d at 837. “Where conflicting evidence allows
reasonable minds to differ as to whether a ...