Powell v. Commissioner of Social Security et al

Filing 26

MEMORANDUM AND OPINION. The Commissioner's final decision denying Plaintiff's application for Disability Insurance Benefits is REVERSED and REMANDED pursuant to sentence four of 42 U.S.C. § 405(g).The Clerk of Court is directed to enter judgment in favor of Plaintiff. Signed by Magistrate Judge Clifford J. Proud on 7/23/2018. (jmt)

IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ILLINOIS
TINA L. P. 1

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Plaintiff,
vs.
ACTING COMMISSIONER OF SOCIAL
SECURITY,
Defendant.

Case No. 17-cv-00938-CJP 2

MEMORANDUM and ORDER
In accordance with 42 U.S.C. § 405(g), plaintiff Tina L. P. (Plaintiff) seeks
judicial review of the final agency decision denying her application for Disability
Insurance Benefits (DIB) pursuant to 42 U.S.C. § 423.
Procedural History
Plaintiff applied for DIB on November 4, 2013, alleging a disability onset date
of July 30, 2013. (Tr. 162-63). Plaintiff’s application was denied at the initial
level and again upon reconsideration.

(Tr. 81, 99).

Plaintiff requested an

evidentiary hearing, (Tr. 159), which Administrative Law Judge (ALJ) Stephen
Hanekamp conducted on May 25, 2016, (Tr. 41-65).

The ALJ reached an

unfavorable determination on October 3, 2016. (Tr. 8-30). The Appeals Council
denied Plaintiff’s request for review, rendering the ALJ’s decision the final agency

The Court will not use plaintiff’s full name in this Memorandum and Order in order to protect
his privacy. See FED. R. CIV. P. 5.2(c) and the Advisory Committee Notes thereto.
2
This case was assigned to the undersigned for final disposition upon consent of the parties
pursuant to 28 U.S.C. § 636(c). See Doc. 25.
1

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decision. (Tr. 1-7). Plaintiff exhausted her administrative remedies and filed a
timey complaint with this Court. (Doc. 1).
Issues Raised by Plaintiff
Plaintiff contends the ALJ erroneously determined what impairments were
“severe” and improperly considered the evidence in determining her residual
functional capacity.
Applicable Legal Standards
To qualify for DIB, a claimant must be disabled, which means the “inability to
engage in any substantial gainful activity by reason of any medically determinable
physical or mental impairment which can be expected to result in death or which
has lasted or can be expected to last for a continuous period of not less than 12
months.” 42 U.S.C. § 423(d)(1)(A).
A “physical or mental impairment” is an impairment resulting from
anatomical, physiological, or psychological abnormalities which are demonstrable
by medically acceptable clinical and laboratory diagnostic techniques. 42 U.S.C. §
423(d)(3).

“Substantial gainful activity” is work activity that involves doing

significant physical or mental activities, and that is done for pay or profit. 20
C.F.R. § 404.1572.
Social Security regulations set forth a sequential five-step inquiry to determine
whether a claimant is disabled.

The Seventh Circuit Court of Appeals has

explained this process as follows:
The first step considers whether the applicant is engaging in
substantial gainful activity. The second step evaluates whether an
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alleged physical or mental impairment is severe, medically
determinable, and meets a durational requirement. The third step
compares the impairment to a list of impairments that are
considered conclusively disabling. If the impairment meets or equals
one of the listed impairments, then the applicant is considered
disabled; if the impairment does not meet or equal a listed
impairment, then the evaluation continues. The fourth step assesses
an applicant's residual functional capacity (RFC) and ability to engage
in past relevant work. If an applicant can engage in past relevant
work, he is not disabled. The fifth step assesses the applicant's RFC,
as well as his age, education, and work experience to determine
whether the applicant can engage in other work. If the applicant can
engage in other work, he is not disabled.
Weatherbee v. Astrue, 649 F.3d 565, 568-569 (7th Cir. 2011).
Stated another way, it must be determined: (1) whether the claimant is
presently unemployed; (2) whether the claimant has an impairment or
combination of impairments that is serious; (3) whether the impairments meet or
equal one of the listed impairments acknowledged to be conclusively disabling; (4)
whether the claimant can perform past relevant work; and (5) whether the
claimant is capable of performing any work within the economy, given his or her
age, education and work experience. 20 C.F.R. § 404.1520; Simila v. Astrue, 573
F.3d 503, 512-513 (7th Cir. 2009); Schroeter v. Sullivan, 977 F.2d 391, 393 (7th
Cir. 1992).
If the answer at steps one and two is “yes,” the claimant will automatically be
found disabled if he or she suffers from a listed impairment, determined at step
three. If the claimant does not have a listed impairment at step three, and cannot
perform his or her past work (step four), the burden shifts to the Commissioner
at step five to show that the claimant can perform some other job. Rhoderick v.

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Heckler, 737 F.2d 714, 715 (7th Cir. 1984). See also Zurawski v. Halter, 245
F.3d 881, 886 (7th Cir. 2001) (Under the five-step evaluation, an “affirmative
answer leads either to the next step, or, on Steps 3 and 5, to a finding that the
claimant is disabled. . . . If a claimant reaches step 5, the burden shifts to the ALJ
to establish that the claimant is capable of performing work in the national
economy.”).
This Court reviews the Commissioner’s decision to ensure that the decision is
supported by substantial evidence and that no mistakes of law were made. It is
important to recognize that the scope of review is limited. “The findings of the
Commissioner of Social Security as to any fact, if supported by substantial
evidence, shall be conclusive . . . .” 42 U.S.C. § 405(g). Thus, this Court must
determine not whether plaintiff was, in fact, disabled at the relevant time, but
whether the ALJ’s findings were supported by substantial evidence and whether
any errors of law were made. See Books v. Chater, 91 F.3d 972, 977-78 (7th Cir.
1996) (citing Diaz v. Chater, 55 F.3d 300, 306 (7th Cir. 1995)). This Court uses
the Supreme Court’s definition of substantial evidence, i.e., “such relevant
evidence as a reasonable mind might accept as adequate to support a conclusion.”
Richardson v. Perales, 402 U.S. 389, 401 (1971).
In reviewing for “substantial evidence,” the entire administrative record is
taken into consideration, but this Court does not reweigh evidence, resolve
conflicts, decide questions of credibility, or substitute its own judgment for that of
the ALJ.

Brewer v. Chater, 103 F.3d 1384, 1390 (7th Cir. 1997); Moore v.

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Colvin, 743 F.3d 1118, 1121 (7th Cir. 2014). However, while judicial review is
deferential, it is not abject; this Court does not act as a rubber stamp for the
Commissioner. See Parker v. Astrue, 597 F.3d 920, 921 (7th Cir. 2010), and
cases cited therein.
The ALJ’s Decision
ALJ Hanekamp found Plaintiff met the insured status requirements through
December 31, 2019 and had not engaged in substantial gainful activity since July
30, 2013, the alleged onset date. (Tr. 13). Plaintiff had severe impairments of
degenerative disc disease, meniscal tear of the left knee, fibromyalgia, depression,
anxiety, and personality disorder. (Tr. 14). The ALJ opined Plaintiff had the RFC
to perform light work with several additional limitations. (Tr. 17). Plaintiff’s RFC
precluded her from performing past relevant work, buts she was not disabled
because other jobs existed that Plaintiff could perform. (Tr. 23-24).
The Evidentiary Record
The Court has reviewed and considered the entire evidentiary record in
formulating this Memorandum and Order. The following summary of the record
is directed to the points raised by Plaintiff.
1. Agency Forms
In her agency forms, Plaintiff indicated that the following conditions limited
her ability to work: fibromyalgia; chronic depression; insomnia; a thyroid
condition; head, back, and neck injuries; irritable bowel syndrome; high blood
pressure; and anxiety. (Tr. 188). She experienced constant pain “from head to
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toe” and took prescription pain medications, including, Roxicodone, Tramadol,
and Diclofenac.

The medications helped her cope with the pain but did not

completely relieve her symptoms. They also made her drowsy and dizzy. Plaintiff
alleged she could not sit or stand very long and felt pain with stretching, bending,
and lifting.

Consequentially, she had difficulty cooking, cleaning, shopping,

sleeping, and taking care of personal needs. She could make microwavable meals
and sandwiches and wash laundry and dishes. Her hobbies and social activities
included reading, watching television, browsing Facebook, talking with friends,
and playing cards. Plaintiff also struggled with mental illness and had suicidal
tendencies. She was always irritable and tired. She handled stress “OK” and was
“good” at handling changes in routines. (Tr. 204, 217-24, 241).
2. Evidentiary Hearing
ALJ Hanekamp conducted an evidentiary hearing in May 2016.

Plaintiff

testified that she engaged in self-harm such as repeatedly punching herself. She
most recently harmed herself two weeks before the hearing.

(Tr. 49).

She

estimated she inflicted injury on herself about 15 or 20 times. She pounded her
head on the wall, hit herself in the head with a piece of metal, burned herself, or
cut herself. She has also run in front of a bus a couple of times and pulled her
hair out. (Tr. 51).
Plaintiff’s mental impairments affected her on a daily basis.

She had

problems focusing, got angry, and thought about harming herself and others. She
previously committed herself to the hospital when she had harmful thoughts.
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About four times each month she isolated herself and did not get out of bed. (Tr.
52). Plaintiff did not notice an improvement in her condition. In fact, she said
that thoughts of hurting herself were getting worse. (Tr. 53).
3. Medical Records
Plaintiff received primary care from Dr. Chris Mbaeri at Family Choice
Medical Clinic during part of the relevant period.

On August 16, 2013, Dr.

Mbaeri diagnosed Plaintiff with anxiety and prescribed her Xanax. (Tr. 457).
On September 3, 2013, Plaintiff followed up with Dr. Mbaeri and reported
increased psych-socioeconomic stressors resulting in homelessness, worsening
anxiety, and a suboptimal appetite. Dr. Mbaeri refilled her Xanax prescription.
(Tr. 456).
Plaintiff presented to Dr. Alka Aggarwal at Belleville Family Health Center on
January 30, 2014. Plaintiff stated she was unemployed, homeless, very anxious,
and using Xanax to get through her days. Dr. Aggarwal wrote the following:
[Patient] wants her Xanax and that is all that she wants; she
threatened suicide when I told her I can’t give it to her until her [drug
screen] is negative; I told her if she is suicidal then I need to call 911
to admit her to the hospital, she rolled her eyes and said she is not
suicidal; she threatened to leave in the middle of the appointment a
few times as well . . .
On psychiatric examination, Plaintiff was oriented to time, place, person,
and situation. She was anxious, had normal knowledge and language, and denied
hallucinations and hopelessness. Dr. Aggarwal noted poor insight and judgment
and pressured speech. Plaintiff did not have suicidal ideations. Dr. Aggarwal
prescribed Plaintiff Xanax with no refills and started her on Celexa. Dr. Aggarwal
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gave Plaintiff hydroxyzine for anxiety and discussed non-pharmaceutical methods
of reducing her anxiety. (Tr. 474-77).
Plaintiff presented to Dr. Mbaeri on February 28, 2014 and reported
anxiety and insomnia. He refilled Plaintiff’s medications. (Tr. 490).
Plaintiff underwent a mental status examination on March 18, 2014 with
state-agency consultant Dr. John Oshodi. Plaintiff told Dr. Oshodi that her father
physically, emotionally, and sexually abused her until she was 13. One of her
sisters had a child by her father and another “sister and him used to have sex.”
She sought counseling in adulthood for the abuse.

Plaintiff reported a long

history of depression resulting from her childhood and a lifestyle consisting of
drug abuse and homelessness.

She began using alcohol, opium, marijuana,

cocaine, mushrooms, acid, and hashish between the ages of 8 and 12. Around
the age of 45, she began abusing crack cocaine and molly. She most recently used
cocaine about one and a half weeks prior to the examination and crack cocaine
and molly about six months prior to the examination. She also reported a long
history of hearing voices and seeing things. Plaintiff was involuntarily committed
in the past and, as early as July 2012, expressed suicidal thoughts. (Tr. 484).
On examination, Plaintiff maintained adequate eye contact and was oriented
to place, person, and time.

She displayed facial expressions and emotions of

anger, worry, and sadness. She exhibited signs of frustration and stated, “Nobody
wants to hire me because I’m overqualified.

I should not have been born.”

Plaintiff’s overall affect was irritable and congruent with her depressed mood.

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She had a clear and coherent speech pattern and quality of thinking, but an angry
intonation.

She denied suicidal and homicidal ideations but reported ongoing

hallucinatory experiences. Her overall thought process and content were logical.
She responded to questions in a goal-directed manner.

Plaintiff had poor

concentration and attention. Her angry emotions and behaviors easily distracted
her. Plaintiff was only able to repeat five digits forward and four digits backward.
She could perform calculations. Her recent memory was poor and she could only
recall two of six words after a five-minute interval.

Her remote memory was

adequate, her insight and judgment were fair, and her overall attitude was
cooperative. (Tr. 486).
Dr. Oshodi diagnosed Plaintiff with polysubstance dependence; mood
disorder due to medical conditions, with depressive features; impulse control
disorder NOS; psychotic disorder NOS; and coping and residential difficulties.
Plaintiff’s GAF score was 53. (Tr. 486-87).
Dr. Oshodi opined Plaintiff’s ability to perform domestic activities of daily
living was fair but her ability to adequately perform work activities and fully
function under pressure was “highly limited as evidenced by her indicated
difficulties marked with irritability, low frustration tolerance, angry emotions, and
drug abuse.”

He opined Plaintiff would benefit from financial management

assistance. (Tr. 487).
On March 25, 2014, state-agency consultant Dr. Ellen Shapiro conducted a
records review and opined Plaintiff had mild restrictions in her ability to perform

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activities of daily living and moderate difficulties maintaining social functioning,
concentration, persistence, and pace. (Tr. 71-73).
On March 27, 2014, Plaintiff followed-up with Dr. Mbaeri and complained
of anxiety and depression. He advised Plaintiff to continue taking Xanax. (Tr.
489).
On May 15, 2014, state-agency consultant Dr. James Brown conducted a
records review and opined Plaintiff had mild restrictions in her ability to perform
activities of daily living and moderate difficulties maintaining social functioning,
concentration, persistence, and pace. (Tr. 88-90).
Plaintiff presented to Dr. Sarah Gebauer at Belleville Family Health Center
on September 12, 2014 for a drug screen.

Dr. Gebauer noted that Plaintiff’s

anxiety and depression were “very poorly controlled on a questionable regimen.”
Plaintiff reported difficulty with functioning and concentrating, anxious and fearful
thoughts, problems falling and staying asleep, depressed mood, fatigue, feelings of
guilt, restlessness, thoughts of death and suicide, excessive worry, and paranoia.
On examination, Plaintiff was oriented to time, place, person, and situation and
demonstrated an appropriate mood and affect. Dr. Gebauer started Plaintiff on
Zoloft and Temazepam and referred her to counseling. (Tr. 719-22).
Plaintiff received primary care from Dr. Jacqueline Aregood at Belleville
Family Health Center, beginning on January 6, 2015. Plaintiff reported trouble
with sleep and impulse control and experiencing low mood, irritability, and
emotionally lability. On mental status examination, Dr. Aregood noted Plaintiff

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was well groomed, clean, and of normal weight. She was cooperative, calm, and
made eye contact. Plaintiff’s speech was fluent, clear, and of normal volume. She
did not have any hallucinations. Plaintiff was oriented to situation, time, place,
and person and her memory was intact.
intelligence and euthymic mood.

She demonstrated an average

Her affect was pleasant and congruent to

thought content. Her insight, judgment, and though processes were intact. She
had no suicidal or homicidal ideations or psychosis. Her thought content was
unremarkable and her motor activity was intact. Dr. Aregood assessed Plaintiff
with depressive disorder and prescribed her Remeron for sleep, anxiety, and
mood. (Tr. 598-601).
Plaintiff followed-up with Dr. Aregood on February 3, 2015. She continued
to experience chronic symptoms of depression. Plaintiff stated she had crying
spells and anxiety attacks. She had passive suicidal ideations the previous few
weeks and was still not sleeping well. Plaintiff’s mental status examination was
unremarkable.

Dr. Aregood increased Plaintiff’s Remeron and Effexor and

encouraged her to participate in therapy. (Tr. 594-97).
Plaintiff saw Dr. Aregood on March 3, 2015.

She stated she had some

passive suicidal ideations after her boyfriend recently assaulted her. She was “a
little better” at the time of the appointment but still had chronic symptoms of
depression. Plaintiff was sleeping well. Plaintiff’s mental status examination was
unremarkable. Dr. Aregood increased Plaintiff’s Effexor dosage. (Tr. 591-93).

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Plaintiff began seeing licensed clinical professional counselor Amanda
Woollard on March 25, 2015. Plaintiff reported moderate depression, difficulty
concentrating, fatigue, dramatic changes in her appetite, weight loss, suicidal
ideations, and sleep disturbances. She denied hallucinations and delusions. She
felt like she was not benefitting much from her medications.

Ms. Woollard

identified treatment goals, including increasing day-to-day functioning and
compliance with her medication regimen. (Tr. 588-90).
Plaintiff followed-up with Dr. Aregood on April 1, 2015. Her depression
was in partial remission but she was still troubled by some chronic symptoms,
including a depressed mood, irritability, anhedonia, sleep disturbances, and
emotional lability/mood swings.
unremarkable.

Plaintiff’s mental status examination was

Dr. Aregood switched Plaintiff from Effexor to Cymbalta and

advised her to continue therapy. (Tr. 584-87).
Plaintiff saw her counselor, Ms. Woollard, on April 8, 2015 and discussed
her goals. She was experiencing stress and had difficulty relaxing. (Tr. 581-83).
Plaintiff followed-up with Ms. Woollard on April 22, 2015. She said things
were not going very well for her. She felt discouraged and experienced stress.
She admitted to hitting herself in the head when she was frustrated and getting
into physical altercations with her boyfriend. (Tr. 578-79).
On May 5, 2015, Plaintiff told Ms. Woollard she was still having panic
attacks. She presented with a bruise under her left eye but said she was working
on efforts to reduce conflict with her boyfriend. (Tr. 576-77).

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Plaintiff saw Dr. Aregood on May 5, 2015. She felt chronic symptoms of
depression and anxiety, such as irritability, sleep disturbances, suicidal thoughts,
and mood swings. However, she felt like Cymbalta was helping. Plaintiff’s mental
status examination revealed a flat affect but was otherwise unremarkable. Dr.
Aregood increased Plaintiff’s dosage of Cymbalta. (Tr. 572-75).
Plaintiff called Dr. Aregood’s office on May 6, 2015 and stated she was
having panic attacks all day. She requested Dr. Aregood prescribe her Xanax.
(Tr. 533).
Plaintiff participated in therapy with Ms. Woollard on May 19, 2015. She
continued to feel stress and was tearful as she described her feelings. On mental
status examination, Plaintiff’s mood was sad and her affect was sad, tearful, and
flat.

Plaintiff and Ms. Woollard discussed ways for Plaintiff to handle her

problems through assertive communications and reaching out to social service
agencies. (Tr. 569-71).
Plaintiff saw Dr. Aregood on June 10, 2015. She was sleeping better but
still reported sleep disturbances. She presented with physical injuries on her face
and knee, which resulted from a fight with her boyfriend. She punched herself in
the face during the altercation.

Plaintiff reported symptoms of anxiety,

depression, and panic, including suicidal thoughts, more than 15 panic attacks in
the previous three months, palpitations, fears of dying, and sweating. Plaintiff’s
affect was flat but the mental status examination was otherwise unremarkable.
(Tr. 565-68).

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Plaintiff followed-up with Ms. Woollard on June 12, 2015 and said things
had been stressful. Her affect was sad, tearful, and flat. She thought about going
to the hospital. (Tr. 660-62).
Plaintiff saw Ms. Woollard on June 26, 2015 and reported things were
“calmer.” Her mental status examination was normal. She denied thoughts of
self-harm and reported a better mood. (Tr. 658-60).
Plaintiff saw Ms. Woollard on June 12, 2015. She had a sad, tearful, and
flat affect. (Tr. 562-64).
Plaintiff followed-up with Dr. Aregood on July 7, 2015.

She thought

Cymbalta was helping her mood, but she was still troubled by chronic symptoms
of depression and anxiety. Her mental status examination was normal. (Tr. 65356).
Plaintiff followed-up with Dr. Aregood on August 26, 2015.

She felt

Cymbalta was helping her mood but she continued to experience chronic
symptoms of anxiety and depression. For instance, Plaintiff was fearful,
depressed, anxious, nervous, and had sleep disturbances and panic attacks. The
mental status examination revealed a flat and constricted affect.

Dr. Aregood

changed Plaintiff’s prescription for Ativan to Klonapin because Plaintiff felt Ativan
was not strong enough. (Tr. 547-51).
Plaintiff saw Ms. Woollard on August 26, 2015. She reported that things
had been more difficult and stressful over the past several weeks. On mental
status examination, Plaintiff’s affect was flat and constricted.

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She missed the

previous therapy session because she was hospitalized for having thoughts about
harming herself and her boyfriend. (Tr. 544-46).
Plaintiff followed-up with Dr. Aregood on September 23, 2015.

She

reported having suicidal ideations the previous month. She felt like Cymbalta was
helping but she still experienced symptoms of depression and anxiety. Plaintiff
also felt like the Ativan was not strong enough.

Plaintiff’s affect was flat and

constricted on mental status examination. Dr. Aregood switched her to Klonopin,
started her on Seroquel, and discontinued her Vistaril.

Dr. Aregood also

diagnosed Plaintiff with personality disorder. (Tr. 539-43).
Plaintiff switched therapists on September 23, 2015 and began seeing
Jessica Epperson.

Plaintiff reported symptoms of anxiety and depression,

including panic attacks, irritability, restless thoughts, worry, problems sleeping,
depressed mood, fatigue, feelings of worthlessness, feelings of hopelessness and
suicidal thoughts. She said she hit herself and hit her head into a wall since the
last visit, out of anger. She felt like “she would like to no longer be here but has
no plans or intent on ending her life.” On mental status examination, Plaintiff was
agitated, her mood was irritable, and her affect was anxious and sad. (Tr. 64043).
Plaintiff saw Ms. Epperson on January 8, 2016. Plaintiff reported things
had been more difficult over the past several weeks with an increase in symptoms.
She had some episodes of self-harm due to inappropriate guilt and feelings of
loneliness. She denied suicidal and homicidal ideations. She struggled with daily

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chronic pain. On mental status examination, Plaintiff had an anxious affect. Ms.
Epperson discussed strategies to manage distress, including engaging in positive
activities. (Tr. 633-36).
Plaintiff followed-up with Dr. Aregood on January 13, 2016. She had not
sought treatment for a while because she lost her insurance. Plaintiff reported
feeling better, calmer, and content. She did not have thoughts of self-harm since
starting her medications but still had trouble sleeping at night. Plaintiff continued
to report symptoms of depression and anxiety, including panic attacks, sleep
disturbances, irritability, and anticipatory fears.

Plaintiff’s mental status

examination was normal. Dr. Aregood restarted Plaintiff on Vistaril for insomnia.
(Tr. 629-33).
Plaintiff saw Ms. Epperson on February 5, 2016. She had been doing “OK”
since the last session but continued to struggle with anxiety symptoms. She had a
decrease in panic episodes and was practicing relaxation techniques and avoiding
negative people at work. She continued to be overwhelmed and reported having
thoughts of self-harm, but was able to refrain from cutting. Mental status exam
revealed an irritable mood and an anxious affect. (Tr. 624-26).
Plaintiff presented to Dr. Aregood on March 16, 2016. Plaintiff still had
symptoms of anxiety and depression. Dr. Aregood restarted Plaintiff on Vistaril
for insomnia and made minor adjustments to her other medications. Plaintiff
denied suicidal or homicidal ideations and felt like Cymbalta was helping her

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mood. On mental status examination, Plaintiff’s mood was down and worried.
Her affect was constricted. (Tr. 842-46).
Plaintiff saw Ms. Epperson on April 6, 2016.

Her affect was flat, dull,

angry, and irritable. She reported abnormal sleep with sleep disruptions every
night. Her concentration and attention decreased. She had thoughts of hurting
“anyone who gets on my nerves” with a baseball bat and/or a “knife to the throat.”
She also had thoughts of suicide and was tearful during the session. On mental
status examination, Plaintiff was irritable, anxious, sad, and tearful. (Tr. 838-41).
Plaintiff followed-up with Dr. Aregood on April 27, 2016. She continued to
have chronic symptoms of depression, anxiety, and borderline personality
disorder. Dr. Aregood adjusted Plaintiff’s medications. Plaintiff had no suicidal
or homicidal ideations and felt like Cymbalta was helping her mood. Dr. Aregood
encouraged Plaintiff to continue therapy. On mental status examination, Plaintiff
demonstrated impaired insight and judgment. (Tr. 829-33).
Plaintiff followed-up with Ms. Epperson on April 27, 2016.

She

experienced continued depression and anxiety symptoms. Plaintiff almost had a
panic attack during the session because she was missing a $10 bill from her
wallet. She began pacing the floor and making phone calls in an attempt to locate
the money.

Ms. Epperson noted that Plaintiff had poor planning skills and

difficulties with problem solving.

Plaintiff became tearful and stated she was

going to “put herself in the hospital” because her medications were not working.

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On mental status examination, Plaintiff was irritable, anxious, angry, hostile, sad,
and tearful. She appeared agitated and oppositional. (Tr. 834-37).
Plaintiff saw Ms. Epperson on June 8, 2016.

She appeared agitated,

irritable, and anxious. Plaintiff reported continued symptoms of agitations and
distress. She recently punched herself in the face on two occasions. She denied
any suicidal intent, plan, and/or attempts or recent self-harming behaviors. (Tr.
869-71).
Plaintiff followed-up with Dr. Aregood on June 8, 2016 and continued to be
troubled by chronic symptoms of depression, anxiety, and borderline personality
disorder. Her mood was down and her insight and judgment were impaired. Her
affect was anxious and constricted.

Dr. Aregood made minor adjustments to

Plaintiff’s medications. (Tr. 872-75).
Analysis
Plaintiff

asserts,

inter

alia,

that

the

ALJ

misrepresented

and

mischaracterized the evidence related to her mental conditions. “An ALJ has the
obligation to consider all relevant medical evidence and cannot simply cherry-pick
facts that support a finding of non-disability while ignoring evidence that points to
a disability finding.” Denton v. Astrue, 596 F.3d 419, 426 (7th Cir. 2010). This
does not mean an ALJ must mention every piece of evidence. Golembiewski v.
Barnhart, 322 F.3d 912, 917 (7th Cir. 2003). Rather, the ALJ cannot “ignore an
entire line of evidence that is contrary to the ruling.” Id.

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The ALJ must also provide an accurate summary of the medical evidence.
See Steele v. Barnhart, 290 F.3d 936, 940 (7th Cir. 2002).

Otherwise, it is

impossible to determine whether substantial evidence supports the decision.
The ALJ, here, provided a perfunctory and slanted summary of the medical
evidence related to Plaintiff’s depression, anxiety, and personality disorder. He
ignored virtually all of the evidence that supported Plaintiff’s allegations and
highlighted the few instances where Plaintiff reported experiencing any kind of
improvement in symptoms or demonstrated normal mental status examinations.
For instance, the ALJ noted, “Throughout the summer of 2015 [Plaintiff]
indicated that with use of mediation [sic], she was controlling her mental health
symptoms.

On examination, she was cooperative and calm and maintained

normal eye contact. Her speech was fluent and clear. Her mood was euthymic
and her affect was pleasant and congruent to thought.” (Tr. 20). As an initial
matter, neither Plaintiff nor her treatment providers indicated Plaintiff was
“controlling” her symptoms and the record certainly does not support this
conclusion.

From May 2015 through August 2015, Plaintiff reported frequent

panic attacks, sleep disturbances, suicidal thoughts, mood swings, punching
herself in the face, hitting her head against a wall, and contemplating committing
herself to the hospital. (Tr. 533, 572-75, 576-77, 565-66, 660-62). Plaintiff’s
therapist and doctor also noted that Plaintiff’s affect was tearful, flat, and sad
during mental status examinations. (Tr. 562-64, 660-62). Plaintiff expressed that
“she would like to no longer be here. . .” (Tr. 640-43). The ALJ, however, failed

19

to mention any of this evidence. Instead, he mentioned a single mental status
examination that was not representative of the others from that period.
The ALJ also noted Plaintiff felt like Cymbalta was helping. However, he
failed to mention that Plaintiff felt like some of her medication was not strong
enough.

(Tr. 539-43).

“This sound-bite approach to record evaluation is an

impermissible methodology for evaluating the evidence.”

Scrogham v. Colvin,

765 F.3d 685, 698 (7th Cir. 2014).
The ALJ further opined, “Treatment records [from “early 2016”] indicated
that contrary to her allegations, with use of medication, she had better control of
her symptoms than she asserted.” (Tr. 20). The record does not support this
observation, either.

In January 2016, Plaintiff stated things had been more

difficult and she experienced an increase in symptoms. She reported episodes of
self-harm.

(Tr. 633-36).

Although she had a decrease in panic attacks in

February 2016, she continued to have thoughts of self-harm and a mental status
examination revealed an anxious and irritable mood. (Tr. 624-26).
The ALJ also failed to acknowledge other portions of the record that
corroborate the intensity of Plaintiff’s symptoms resulting from her mental
impairments.

For instance, in September 2014, Dr. Gebauer noted Plaintiff’s

anxiety and depression were “very poorly controlled on a questionable regimen.”
(Tr. 719-22). Plaintiff demonstrated poor insight and judgment on a number of
occasions during mental status examinations, (Tr. 474-77, 829-33, 872-75), along
with irritability, anger, and hostility (Tr. 846, 624-26, 834-37, 838-41, 869-71).

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In April 2016, Plaintiff had thoughts of hurting other people with a baseball bat or
a “knife to the throat.” (Tr. 838-41). She stated she wanted to commit herself to
the hospital because her medications were not working. (Tr. 834-37).
As evidenced above, many of the ALJs conclusions are contrary to the
evidence of record and/or the ALJ provided such a warped review of the record
that it is impossible to tell whether his opinions rest on substantial evidence.
Remand is necessary on this point, alone, so the Court will not address Plaintiff’s
remaining argument.
Conclusion
The Commissioner’s final decision denying Plaintiff’s application for
Disability

Insurance

Benefits

is

REVERSED

and

REMANDED

to

the

Commissioner for rehearing and reconsideration of the evidence, pursuant to
sentence four of 42 U.S.C. § 405(g).
The Clerk of Court is directed to enter judgment in favor of Plaintiff.
IT IS SO ORDERED.
DATE: July 23, 2018.

s/ Clifford J. Proud
CLIFFORD J. PROUD
UNITED STATES MAGISTRATE JUDGE

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