Padin v. Colvin

Filing 28

ORDER: Plaintiff Valerie Padin seeks to overturn the Administrative Law Judge's final decision denying her application for Disability Insurance Benefits under Title II of the Social Security Act. Plaintiff's Motion for Summary Judgment is g ranted [dkt. 18] and Defendant's Motion for Summary Judgment is denied [dkt. 25]. This case is remanded to the Social Security Administration for further proceedings consistent with this opinion. Signed by the Honorable Susan E. Cox on 7/11/2014. Mailed notice (np, )

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF ILLINOIS

VALERIE PADIN
Plaintiff,
No.13-cv-03501
v.
Magistrate Judge Susan E. Cox
CAROLINE W. COLVIN, Acting
Commissioner of Social Security,
Defendant.

ORDER

Plaintiff Valerie Padin seeks to overturn the Administrative Law Judge’s final decision
denying her application for Disability Insurance Benefits under Title II of the Social Security
Act. Plaintiff’s Motion for Summary Judgment is granted [dkt. 18] and Defendant’s Motion for
Summary Judgment is denied [dkt. 25]. This case is remanded to the Social Security
Administration for further proceedings consistent with this opinion.

STATEMENT
Plaintiff Valerie Padin (“plaintiff”) seeks to overturn the Administrative Law Judge’s
(“ALJ”) final decision denying her application for Disability Insurance Benefits (“DIB”) under
Title II of the Social Security Act. 1 The parties consented to the jurisdiction of United States
Magistrate Judge pursuant to 28 U.S.C. § 636(c). After careful review of the record, the Court
now remands the case for further proceedings.

1

42 U.S.C. §§ 405(g), 416(i), 423(d).

1

I.

FACTUAL BACKGROUND
Plaintiff completed her application for DIB June 8, 2010, alleging disability as of January

21, 2009 as a result of slipping on ice while at work. 2 Plaintiff lists a lower back injury,
hypothyroidism, depression, PTSD, and nerve damage to her left leg as the conditions impacting
her ability to work. 3
First, plaintiff alleges physical disability due to severe back pain and pain in her left leg.
A brief history of plaintiff’s back problems reveals diffuse disc bulging and degenerative disc
disease at L5-S1 consistent with disc desiccation. 4 Plaintiff began seeing Richard D. Lim, M.D.,
as her orthopedic physician in March 2007. 5 During the course of his treatment, Dr. Lim found
plaintiff’s symptoms consistent with Radiculopathy and recorded a positive left sided straight leg
raise in March 2007, and in May and December 2010. 6 While Dr. Lim did not see plaintiff from
January 2008 to May 2010, at the request of her attorney, plaintiff followed up with Dr. Lim on
May 18, 2010 and received an x-ray showing the disk space at L5-S1 had collapsed leaving the
vertebrae virtually bone-on-bone. 7 In May 2010, Dr. Lim noted plaintiff was not a candidate for
disk replacement since she had greater than 50% disc height collapse, and in December 2010, Dr.
Lim ordered injections for plaintiff’s back. 8 In February 2011, Dr. Lim concluded that plaintiff
had not improved despite physical therapy and injections. 9 In addition to Dr. Lim’s findings,
plaintiff’s primary physician, Jose Rodriguez, M.D., described her back pain as a chronic
problem, one that waxes and wanes. 10 Plaintiff reported that her back pain affects her ability to

2

R. at 139, 142.
R. at 174.
4
R. at 373.
5
R. at 178.
6
R. at 359.
7
R. at 360.
8
Id.
9
R. at 454.
10
R. at 398.
3

2

walk or run (her former hobbies), prevents her from showering alone in case of back spasms, and
prevents her from holding her child. 11 Plaintiff further explained all activities are limited to her
house, and that her son is often with her father-in-law when she is unable to care for him. 12
For purposes of her disability application, two State agency physicians examined
plaintiff. During her Physical Residual Functional Capacity assessment, Victoria Dow, M.D.
found plaintiff could occasionally lift and carry 20 pounds, frequently lift and carry ten pounds,
stand, walk, and sit about six hours during the workday, and push or pull unlimitedly. 13 Dr. Dow
also concluded plaintiff could never climb ladders, ropes, or scaffolds and could occasionally
stoop. 14 David Bitzer, M.D. affirmed Dr. Dow’s assessment after reviewing the evidence in the
file. 15
In her disability application, plaintiff also argues depression and PTSD affect her ability
to work. However, these problems do not appear in the record until 2010, a year after her alleged
onset of disability. Plaintiff began treating with psychiatrist Sudhir M. Gokhale, M.D., and Mr.
Hurley, a social worker, in September 2010 and May 2011 respectively. 16 Dr. Hurley’s
summation of plaintiff’s condition is that she has had a limited response to treatment despite her
compliance with treatment. 17 He found plaintiff suffers from major depression and PTSD, and
that she is irritable and anxious around others, which affects her ability to cope with
supervisors. 18 Mr. Hurley listed that plaintiff suffers from recurrent panic attacks manifesting
from sudden, unpredictable onset of apprehension and fear, as well as recurrent and intrusive

11

R. at 185, 217, 222.
R. at 182-83.
13
R. at 331.
14
Id.
15
R. at 394.
16
R. at 560, 564.
17
R. at 560-61.
18
R. at 560.
12

3

recollections of a traumatic experience. 19 In a separate analysis, Dr. Gokhale also diagnosed
plaintiff with depression and PTSD with similar findings to Mr. Hurley. 20 After numerous
sessions with plaintiff from September 2010 to May 2011, Dr. Gokhale submitted these
determinations for the purpose of her disability application noting she suffered from nightmares,
insomnia, hyper vigilance, and trust issues. 21 Dr. Gokhale concluded that these issues stem from
an abusive past and the trauma of her boyfriend beating her son to death in 2003. 22 Dr. Gokhale
assessed plaintiff’s GAF score at 50, which rates an adult’s ability to function as seriously
impaired 23 and noted that plaintiff reported taking Xanax in the past. 24
With respect to plaintiff’s mental health, the two State agency doctors concluded that
plaintiff does not suffer from marked limitations or episodes of decompensation. B. Johnson,
PhD, performed a psychiatric review on September 20, 2010 and concluded there were no
limitations after evaluating plaintiff. 25 Additionally, on August 16, 2010, M. S. Patil, M.D.,
performed an Internal Medicine Consultative Examination and concluded plaintiff’s orientation,
memory, and ability to relate were within normal limits.26 However, this examination only lasted
35 minutes and Dr. Patil noted that due to plaintiff’s disruptive child it was not possible to gather
a “detailed history and perform [a] satisfactory evaluation.” 27
After considering the evidence, the ALJ concluded the following: (1) plaintiff suffers
from mild restrictions of daily living, moderate restrictions in social functioning and
19

R. at 563.
R. at 464-65.
21
R. at 569, 572, 574.
22
R. at 572.
23
Global Assessment of Functioning (GAF) scores are a scale used to rate an adult’s overall ability to function. See
Craft v. Astrue, 539 F.3d 668, 676 n.7 (7th Cir. 2008) (“A GAF score of 50 indicates serious symptoms”); Farrell v.
Astrue, 692 F.3d 767, 769 (7th Cir. 2012) (explaining plaintiff had received a score of 51 which is on the border of
moderate and serious symptoms).
24
R. at 578.
25
R. at 314-28.
26
R. at 311-12.
27
R. at 311.
20

4

concentration, persistence, and pace, and has experienced no episodes of decompensation, and
(2) plaintiff has the Residual Functional Capacity (“RFC”) to perform light work except she
cannot climb ladders, ropes, or scaffolds. 28 The ALJ found plaintiff was not disabled. 29
II.

STANDARD OF REVIEW
Section 405(g) of the Social Security Act authorizes judicial review of the

Commissioner’s final decision. In reviewing this case, the Court’s task is not to “displace the
ALJ’s judgment by reconsidering facts or making credibility determinations.” 30 The Court’s task
is to determine whether the ALJ’s decision is “supported by reasonable evidence, meaning
evidence a reasonable person would accept as adequate to support the decision.” 31 The ALJ does
not have to “address every piece of evidence or testimony presented, but must provide a logical
bridge between the evidence and her conclusion that a claimant is not disabled.” 32 If the
Commissioner’s decision “‘lacks evidentiary support or is so poorly articulated as to prevent
meaningful review,’ a remand is required.” 33
III.

FIVE STEP INQUIRY
Claimant is disabled if she is unable to do any substantial gainful activity due to any

“medically determinable physical or mental impairment which can be expected to result in
death” and has lasted or is expected to last continually for no less than twelve months. 34 The
Social Security Act provides a five step evaluation process for determining whether a claimant is
disabled: (1) Is the claimant employed in substantial gainful activity (2) Is the claimant’s

28

R. at 32.
R. at 33.
30
Castile v. Astrue, 617 F.3d 923, 926 (7th Cir. 2010) (quoting Skinner v. Astrue, 478 F.3d 836, 841 (7th Cir.
2007)).
31
Kastner v. Astrue, 697 F.3d 642, 646 (7th Cir. 2012).
32
Id.
33
Hopgood ex rel. L.G. v. Astrue, 578 F.3d 696, 698 (7th Cir. 2009) (quoting Steele v. Barnhart, 290 F.3d 936, 940
(7th Cir. 2002)).
34
See 20 C.F.R. § 404.1505(a)(4)(i-v).
29

5

impairment severe (3) Does the impairment meet or equal one of a list of specific impairments
enumerated in the regulations (4) Can the claimant engage in past relevant work and (5) Is the
claimant capable of performing other work? 35
IV.

DISCUSSION
In support of plaintiff’s request for remand, she raises several issues for review. We will

only focus on whether the ALJ properly evaluated and explained the weight she afforded to the
treating and state physicians, and within this analysis, how the ALJ determined the RFC. We will
also briefly touch on the credibility analysis.
A.

Weight Attributed to the Doctors
The ALJ’s weight evaluations for the treating and state doctors are insufficient. An ALJ

must determine what weight to give a physician’s opinion by considering: (1) the length of the
treatment relationship, frequency of examination, and the nature and extent of the treatment
relationship; (2) the supportability of the opinions by medical signs and laboratory findings; (3)
the consistency of the opinion with the record as a whole; and (4) whether the opinion was from
a specialist. 36 Additionally, the ALJ must explain the weight she gives each doctor. 37 Here, the
ALJ failed to demonstrate full consideration of the regulations, provide a rationale for her
determination, and articulate what weight she gave each doctor.
i.

Mental Health

In her decision, the ALJ gave no weight to Dr. Gokhale because she found his
determination regarding the severity of plaintiff’s mental impairments inconsistent with

35

20 C.F.R. § 404.1520(a)(1).
20 C.F.R. § 404.1527(c)(2)-(5).
37
See Larson v. Astrue, 615 F.3d 744, 751 (7th Cir. 2010) (stating even if the ALJ had articulated good reasons for
rejecting the doctor’s opinion, it was still necessary to determine what weight to give him under the regulations).
36

6

treatment notes. 38 However, an ALJ must explain these inconsistencies in her reasoning. 39 Here,
the ALJ finds that plaintiff “generally exhibited fair to good attention and concentration, and was
otherwise appropriate on examination,” 40 but she does not explain how this detracts from Dr.
Gokhale’s notes, nor is this an adequate reason to find Dr. Gokhale inconsistent with the record
as a whole. 41 Dr. Gokhale’s treatment notes are replete with findings that support plaintiff’s
PTSD. For example, he determined in 2011 that plaintiff continued to “have nightmares [three to
four times] a week” with the “recent break in at neighbor’s house as [a] possible trigger,” 42 and
that she suffered from insomnia and was hyper-vigilant to “noises [and] physical space to
men.” 43 Dr. Gokhale also noted plaintiff received a GAF score of 50 44 which indicates serious
functional impairments to daily life. 45 The ALJ must explain how these findings do not
correspond with the other evidence in the record to properly dismiss Dr. Gokhale’s opinion.
Finally, the ALJ cites plaintiff’s return to work, despite her PTSD, as evidence inconsistent with
Dr. Gokhale’s assessments. This alone, however, is not enough to completely discredit Dr.
Gokhale. The Seventh Circuit recognizes that even persons who are disabled may work long
after they might have been entitled to benefits and their disability actually commences. 46
38

R. at 31.
See Bailey v. Barnhart, 473 F. Supp. 2d 822, 838 (N.D. Ill. 2006) (finding that the ALJ erred in giving no weight
to claimant’s treating doctor because of inconsistency when the ALJ failed to explain how she determined different
interpretations of “further”); see also Roddy v. Astrue, 705 F.3d 631, 636 (7th Cir. 2013) (the ALJ must explain what
evidence she found to diminish the value of the treating physician’s opinion). Compare Maziarka v. Colvin, No.
12C5897, 2013 WL 6099328, at *13 (N.D. Ill. 2013) (demonstrating an example of an ALJ articulating specific
inconsistencies by mentioning that one physician found the claimant was improving in 2010, while hospital records
showed claimant was suffering from degenerative disc disease).
40
R. at 31.
41
See Goble v. Astrue, 385 Fed. App’x 588, 592 (7th Cir. 2010) (holding the ALJ’s reasoning improper when she
found the treating physician’s opinion inconsistent because the claimant appeared alert and pleasant during a
physical examination since this does not diminish pain complaints).
42
R. at 569.
43
R. at 572.
44
R. at 578.
45
According to the Diagnostic Statistical Manual IV (DSM-IV), GAF scores of 41-50 indicate “serious symptoms
(e.g. suicidal ideation, severe obsessive rituals, frequent shoplifting) or any serious impairment in social,
occupational, or school functioning (e.g. no friends, unable to keep a job).”
46
Shauger v. Astrue, 675 F.3d 690, 697 (7th Cir. 2012).
39

7

Additionally, the ALJ’s analysis of the 20 C.F.R. § 404.1527(c) criteria is insufficient.
The ALJ mentions the length and frequency of treatment with Dr. Gokhale 47 finding that it did
not start until well after her alleged onset date. 48 This would seem an appropriate reason to
discount his opinion. But the regulations require more. For example, the ALJ states “the claimant
has seen Dr. Gokhale and therapist Hurley for about a year, from October 2010 through
November 2011. The claimant testified that she sees Dr. Gokhale every 90 days and therapist
Hurley twice a month, although this frequency is not reflected in the treatment notes.” 49 The ALJ
does not expound upon this factor but, instead, begins to discuss plaintiff’s mental conditions
after giving birth to her son. 50 So while the ALJ mentions frequency, she gives no explanation as
to how the frequency of this relationship affected her weight determination.
The ALJ’s RFC determination is also confusing because she concluded that plaintiff has
severe mental impairments but relies only on the State’s psychiatrist, Dr. Johnson, who found no
limitations. When the ALJ discusses plaintiff’s mental impairments, she states she has
“considered the opinion of the State agency physician who found no medically determinable
impairment.” 51 The ALJ then states that she gives no weight to either of plaintiff’s treating
physicians, 52 but she concludes that plaintiff has severe mental impairments. 53 The ALJ does not
articulate why she finds plaintiff to have severe mental impairments because she points to no
specific evidence to support her conclusion. It is possible the ALJ is attempting to come out
somewhere in the middle, perhaps giving some credit to plaintiff’s testimony, but her decision
does not tell us where she derives her conclusion. We note that she is also not permitted to
47

R. at 31.
R. at 29.
49
R. at 31.
50
Id.
51
Id.
52
Id.
53
Id.
48

8

construct her own medical determinations. 54 On remand, the ALJ should expound on her weight
assessments for the treating and State doctors to demonstrate her RFC conclusions.
Lastly, the ALJ properly concluded that Dr. Hurley is not an appropriate medical
source. 55 However, Dr. Hurley is still a valuable “other source” for information regarding the
severity of plaintiff’s impairments and how this might impact her ability to function. 56 In other
words, the weight the ALJ affords the therapist is dependent on whether the opinions are
supported by objective evidence. 57 The ALJ stated she found this opinion lacked backing of
objective evidence because she found the impairments accompanying the B and C criteria of
Listing 12.04 inconsistent with plaintiff’s return to work for two years after her son was born (an
event that exacerbated her PTSD) and her normal findings on consultative examinations. 58 We
find given the lower threshold of explanation, where simply noting inconsistencies is sufficient,
the ALJ adequately explained her reasoning for affording no weight to Dr. Hurley.
ii.

Physical Limitations

In the ALJ’s opinion, she correctly finds that treatment has been routine and
conservative 59 and that no other physicians have expressed that plaintiff’s limitations exceed
light work. 60 However, the ALJ’s RFC assessment is not complete without an analysis of the
weight she affords Dr. Lim. The regulations provide that the SSA “will always give good reasons
in [their] notice of determination or decision the weight [they] give [a claimant’s] treating
54

See Rohan v. Chater, 98 F.3d 966, 968 (7th Cir. 1996) (“ALJs must not succumb to the temptation to play doctor
and make their own independent medical findings”); Norris v. Astrue, 776 F. Supp. 2d 616, 636 (N.D. Ill.
2011)(stating ALJ’s “are not permitted to construct a middle ground without a proper medical basis,” and should
include a “discussion as to how the evidence supports each conclusion, citing specific medical facts”).
55
See 20 C.F.R. § 404.1513 (explaining that to establish an impairment the claimant needs to provide acceptable
medical sources which include, 1) Licensed physicians (medical or osteopathic doctors), 2) licensed or certified
psychologists, 3) licensed optometrists, 4) licensed podiatrists, and 5) qualified speech-language pathologists).
56
See Eggerson v. Astrue, 581 F. Supp. 2d 961, 966 (N.D. Ill. 2008).
57
Pierce v. Colvin, 739 F.3d 1046, 1051 (7th Cir. 2014).
58
R. at 31.
59
R. at 30.
60
R. at 31.

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source’s opinion.” 61 While the ALJ can afford greater weight to the State doctors, the ALJ errs
when she does not provide any explanation of weight to a treating doctor. 62
Here, the ALJ only mentions Dr. Lim’s findings in 2007, noting that plaintiff returned to
work for two years after these findings. 63 The ALJ does not mention the rest of Dr. Lim’s
treatment of plaintiff following this time period, much of which identifies positive straight leg
raises, 64 MRIs for plaintiff’s degenerative disc disease, 65 and treatment suggestions, nor does she
explain why she chooses to discount this evidence, if indeed she did. While the ALJ recounts
evidence of plaintiff’s impairments in her overall opinion, she does not discuss how this
evidence impacts her weight assessment. For example, the ALJ mentions plaintiff’s gap in
treatment with Dr. Lim and plaintiff’s return to him at her attorney’s suggestion. 66 However, the
ALJ does not discuss how or if this impacts the weight she gave, if any, to Dr. Lim. 67 Without
more, we must remand for a more complete consideration of the record.
B.

Credibility Analysis

`

The ALJ’s decision on credibility was that plaintiff’s medical history generally did “not

support the degree of limitations alleged.” 68 The Court treats the ALJ’s credibility assessment
with deference; however, an ALJ must consider the regulation factors in her reasoning. 69 The
ALJ’s credibility assessment is given special deference because she is best positioned to see and

61

20 C.F.R. § 404.1527(c)(2).
See Larson v. Astrue, at 751 (stating even if the ALJ had articulated good reasons for rejecting the doctor’s
opinion it was still necessary to determine what weight to give him under the regulations).
63
R. at 31.
64
R. at 359-64.
65
R. at 360, 470, 472.
66
R. at 27.
67
See Farrell v. Astrue, 692 F.3d 767, 772 (7th Cir. 2012) (concluding the court could not know the ALJ’s thoughts
when determining the physician’s weight because the ALJ only cited to a handful of pages in the record and did not
provide any serious discussion of the opinions).
68
R. at 29.
69
See Maziarka, 705 F.3d, ?? (citing Elder v. Astrue, 529 F.3d 408, 415 (7th Cir. 2008) (“If an ALJ discounts an
opinion after considering the factors set forth in the regulations, the Court ‘must allow that decision to stand so long
as the ALJ minimally articulated his reasons—a very deferential standard that [the Court has], in fact, deemed lax”).
62

10

hear the claimant. 70 Furthermore, the ALJ’s decision must be upheld unless it is “patently
wrong.” 71 On review, the Court’s task is to examine whether the ALJ’s decision was reasoned
and supported. 72
The ALJ found plaintiff’s impairments may not hinder her daily activities as much as she
alleges. First, the ALJ found plaintiff’s testimony that she spends 65-70% of her time laying
down, and hardly doing any chores, conflicting with her statement to Dr. Gokhale that she feels
like a nanny and maid. 73 Specifically, the ALJ concluded that such a statement “indicates that
she was doing more work than alleged.” 74 The ALJ then states plaintiff’s refusal to undergo back
surgery because she was unsure how she would manage a young child also suggested plaintiff is
more active than she alleges. 75 Nonetheless, the ALJ should exercise caution when considering
daily activities in her credibility analysis because a person’s ability to perform daily household
activities does not always mean the ability to work full time. 76
The ALJ also found plaintiff’s conservative care did not corroborate her alleged severity.
For example, the ALJ states the plaintiff only received “two injections and was otherwise just
treated with medications” despite complaining of excruciating pain. 77 Furthermore, the ALJ
notes gaps in plaintiff’s treatment. Plaintiff began treating with Dr. Lim after her initial fall in
2007; however, there is a two year gap in treatment, and the record indicates she followed up
with Dr. Lim at the suggestion of her attorney. 78 Additionally, plaintiff stated her PTSD
worsened after the birth of her son in 2007, yet she did not begin treating with Dr. Gokhale until

70

Powers v. Apfel, 207 F.3d 431, 435 (7th Cir. 2000).
Skarbek v. Barnhart, 390 F.3d 500, 504 (7th Cir. 2004).
72
Elder v. Astrue, 529 F.3d 408, 413 (7th Cir. 2008).
73
R. at 29.
74
Id.
75
Id.
76
Roddy, 705 F.3d at 639.
77
R. at 30.
78
R. at 360.
71

11

2010. 79 Both gaps raise questions as to the seriousness of plaintiff’s impairments and why she
waited until 2010 to seek treatment. However, the ALJ did not ask plaintiff to reconcile these
gaps at the hearing, which she is required to do. 80
Additionally, the ALJ questioned the alleged severity of plaintiff’s physical impairments.
An ALJ may conclude that discrepancies between a claimant’s self-reports and objective
evidence suggests symptom exaggeration 81 and, here, the ALJ found that plaintiff’s statements of
leg swelling are unsupported by the record. 82 It is correct that Dr. Lim’s treatment notes often
state there is no swelling. The ALJ also mentioned plaintiff’s claim of cluster headaches, 83 albeit
in a portion of her discussion unrelated to credibility. This claim supports the ALJ’s credibility
finding because the ALJ noted that plaintiff only “rated the pain as mild at a 4 out of 10
severity,” 84 which is the same rating plaintiff gave to a sinus headache. 85 We note that cluster
headaches are rare and intensely painful (characterized by a burning or boring pain). 86 Overall,
we find that the ALJ properly supported her credibility conclusion with evidence in the record.

79

R. at 576.
See Craft v. Astrue, 539 F.3d 668, 679 (7th Cir. 2008) (stating while infrequent treatment can support an adverse
credibility finding, an ALJ “‘must not draw any inferences’ about a claimant’s condition from this failure unless the
ALJ has explored the claimant’s explanations as to the lack of medical care”).
81
Jones v. Astrue, 623 F.3d 1155, 1161 (7th Cir. 2010).
82
R. at 30.
83
According to the Attorney’s Medical Dictionary, cluster headaches are severe headaches affecting one side of the
head and face, usually accompanied by tearing of the eye on the affected side and watery discharge from the nose.
The headaches are recurrent, with attacks occurring in groups.
84
R. at 29.
85
R. at 515.
86
See AMA Complete Medical Encyclopedia, q.v. “headache” (2003); see also Mayo Clinic,
http://www.mayoclinic.org/diseases-conditions/cluster-headache/basics/definition/con-20031706 (last visited June
30, 2014) (people who experience cluster headaches “say that the pain feels like a hot poker being stuck in the eye
or that the eye is being pushed out of its socket”).
80

12

V.

CONCLUSION
For the reasons stated above, Plaintiff’s Motion for Summary Judgment is granted [dkt.

18], and Defendant’s Motion for Summary Judgment is denied [dkt. 25]. This case is remanded
to the Social Security Administration for further proceedings consistent with this opinion.

ENTER:

DATED: July 11, 2014

/s/ Susan E. Cox___________
Susan E. Cox
United States Magistrate Judge

13