Lisa S. v. Saul

LISA S., Plaintiff, v. ANDREW SAUL, Commissioner of Social Security, Defendant.

No. 19 C 862

UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

September 4, 2020

Magistrate Judge Jeffrey Cummings

MEMORANDUM OPINION AND ORDER

Claimant Lisa S. ("Claimant")¹ brings a motion for summary judgment to reverse the final decision of the Commissioner of Social Security ("Commissioner") that denied her application for a period of disability and Disability Insurance Benefits ("DIBs") under the Social Security Act. 42 U.S.C. §§416(i), 402(e), and 423. The Commissioner has filed a cross-motion. 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 1383(c)(3). For the reasons stated below, Claimant's motion for summary judgment [14] is denied, and the Commissioner's motion for summary judgment [20] is granted.

I. BACKGROUND

A. Procedural History

On February 18, 2015, Claimant filed a disability application alleging a disability onset date of February 11, 2015. Her claim was denied initially and upon reconsideration. OnDecember 14, 2017, an Administrative Law Judge ("ALJ") issued a written decision denying benefits to Claimant. The Appeals Council denied review on December 13, 2018, making the ALJ's decision the Commissioner's final decision. 20 C.F.R. §404.985(d); see also Zurawski v. Halter, 245 F.3d 881, 883 (7th Cir. 2001). Claimant subsequently filed this action in District Court on February 11, 2019.

B. Medical Evidence

1. Evidence From Claimant's Treatment History

The medical record shows a treatment history for physical conditions such as asthma, heart disease that includes a myocardial infarction, and a number of other minor complaints. Claimant, however, challenges the ALJ's consideration of her mental condition and not her severe physical impairments.² The Court therefore only reviews the parts of the medical record and Claimant's testimony that concern her mental health.

Claimant experienced various traumas in her childhood in Cambodia, including having to live in a jungle for a period of time before escaping to Thailand and eventually to the United States. Prior to her alleged onset date, she was hospitalized in September 2012 after she attempted to commit suicide by cutting herself with a knife. She required 22 stitches but refused to take the antidepressant medication that was recommended to her. (R. 600). After she was released from the hospital, Claimant was periodically treated by psychiatrist Dr. Aqeel Khan until May 2014. Dr. Khan's last treatment note of May 10, 2014 states that her depressive disorder was in partial remission and directed Claimant to continue taking the antidepressant medication Prozac. (R. 324). Dr. Kahn noted no suicidal ideation, a euthymic mood, logicalthought processes, and intact concentration and memory. (Id.). Claimant discontinued treatment with Dr. Khan after he asked her to go out with him socially. (R. 493).

Claimant next sought psychiatric treatment on October 1, 2015 with Dr. Gregory Hawley. Dr. Hawley stated that Claimant had stopped taking Prozac after she terminated her treatment with Dr. Khan. Claimant was experiencing tearfulness, anhedonia, and mild irritability at her initial consultation and expressed feelings of hopelessness, despair, and passive suicidal ideation. (R. 493). Dr. Hawley diagnosed her with a mood disorder, non-specific anxiety, post-traumatic stress disorder ("PTSD"), and assigned a GAF score of 50.³ He prescribed Lexapro (sertraline) for depression, Zolpidem to improve her sporadic sleep, and recommended that she begin weekly psychotherapy sessions. (R. 496).

Claimant was somewhat improved at her next consultation on November 25, 2015. In particular, her suicidal ideation was "significantly reduced" and she had "no despair or agitation." (R. 487). Dr. Hawley increased the dosage of Lexapro, and Claimant reported on January 20, 2016 that her anxiety and mood symptoms were better controlled. (R. 970). Dr. Hawley stated that she was only at a "low" risk for suicide. (R. 971). These improvements continued to be present at the next session on May 5, 2016, and her irritability had been slightly diminished as well. (R. 967).

Claimant's symptoms, however, were not always progressively improved. She reported increased anxiety and mood problems in several subsequent consultations, and Dr. Hawley added the medication Abilify to her Lexapro on July 14, 2016. (R. 961-63). Claimant reported in August 2016 that her symptoms had "significantly improved" with this new medication. (R.958). She was more active at home and was better able to tolerate stress. Those improvements continued throughout the rest of 2016. (R. 952-60). Dr. Hawley increased dosages of Abilify and Lamotragine, and Claimant reported on February 23, 2017 that she had additional improvements with "irritability, sleep, and reactivity." (R. 946). Dr. Hawley noted in his last treatment note of June 2, 2017 that Claimant continued to experience those improvements. (R. 940).

Many of Dr. Hawley's notes show that Claimant was also receiving individual therapy with psychologist Dr. Brittany Snow. A letter signed by Dr. Snow states that she began treating Claimant on May 3, 2016, but the record does not contain any of her treatment notes. Prior to that, Claimant was also treated by psychologist Dr. Kelley Hird from August 2015 through the start of treatment with Dr. Snow in May 2016. Unfortunately, Dr. Hird's treatment notes are also missing from the record.

2. Evidence From the State Agency Experts

On July 1, 2015, Dr. Howard Tin issued a report for the Commissioner on Claimant's mental impairments. He found that her affective disorders under listing 12.04 were severe and that they created mild limitations in Claimant's activities of daily living ("ADLs") and social functioning; a moderate restriction in maintaining concentration, persistence, or pace; and that no episodes of decompensation had occurred. Dr. Tin found that Claimant would experience a number of additional limitations in her functioning. These included moderate restrictions in carrying out detailed instructions, maintaining regular attendance, and setting realistic goals on her own. Dr. Tin concluded that Claimant could carry out unskilled work and interact appropriately with the public, work with supervisors, and respond appropriately to changes in her work setting. (R. 74-75). Dr. Darrell Snyder confirmed these findings on reconsideration onJanuary 4, 2016, though he added a severe anxiety disorder under listing 12.06 to Claimant's mental impairments. (R. 88, 93).

On June 19, 2015, consulting expert Dr. John Brauer examined Claimant and issued a report. Dr. Brauer noted that Claimant told him that she was stressed because her son had dropped out of school; she believed her husband had been unfaithful; and she had suffered a heart attack. Claimant stated that she had tried to commit suicide in 2012 and had also attempted to do so in 2015. Claimant stated that she had no hobbies and was not socially active. Dr. Brauer noted that she was calm and alert, was well oriented to place and time, and her affect was generally appropriate. Claimant had not experienced any recent suicidal ideation and did not have homicidal thoughts. Her concentration was within normal limits, and she could perform digit span tests, and serial sevens with a slow response. However, Claimant's "general fund of knowledge" was poor, as was her capacity for abstraction. Claimant told Dr. Brauer that she did not believe she could manage her funds, and he agreed with that conclusion. Dr. Brauer found that Claimant's presentation of her condition largely reflected her real condition, which he diagnosed as an adjustment disorder with a depressed mood. (R. 413-16).

3. Evidence From Treating Physicians

Three treating psychological experts submitted statements about Claimant's condition. Two were merely brief statements that the ALJ considered as medical opinions. On October 1, 2015, Dr. Gregory Hawley undertook an initial mental evaluation of Claimant. He noted that she claimed to be suffering from "hopelessness, despair, and intermittent passive suicidal ideation." (R. 493). Dr. Hawley diagnosed Claimant with a mood disorder and anxiety and assessed a GAF score of 50. (R. 495-96).

On June 29, 2017, Dr. Brittany Snow issued a short "To Whom It May Concern" letter. Dr. Snow stated that she had treated Claimant for a major depressive disorder weekly since May 3, 2016. Claimant had experienced symptoms such as suicidal ideation, depression, and anhedonia and was recommended to continue with therapy.

Treating psychologist Dr. Kelly Hird examined Claimant on August 18, 2015 and issued a mental health evaluation. Dr. Hird stated that she was unable to use standard testing instruments on Claimant - who is of Cambodian origin - because her reading skills were too undeveloped to permit such tests. Dr. Hird's evaluation consisted largely of a summary of Claimant's statements. These include self-reports of a history of cutting and hitting herself; a depressed and irritable mood; feelings of helplessness and hopelessness; and a high level of anxiety in work settings. Dr. Hird diagnosed Claimant with a major depressive disorder but did not make any functional assessments.

On June 16, 2016, however, Dr. Hird issued a formal mental functional assessment for Claimant. Dr. Hird noted that she was "often suicidal" and was "very dependent on others for basic self care and decision making." (R. 561). Dr. Hird also assessed far greater mental restrictions than the state-agency experts had done. She found that Claimant had an "extreme" restriction in her ADLs and "marked" limitations in both social functioning and in her ability to maintain concentration, persistence, or pace. (R. 563). Accordingly, Dr. Hird found that Claim...