Punzio v. Astrue

• Decision Date: 21 January 2011
• Docket Number: No. 09–3064.,09–3064.
• Citation: Punzio v. Astrue, 630 F.3d 704 (7th Cir. 2011)
• Parties: Patricia PUNZIO, Plaintiff–Appellant,v.Michael J. ASTRUE, Commissioner of Social Security, Defendant–Appellee.
• Court: U.S. Court of Appeals — Seventh Circuit

630 F.3d 704

162 Soc.Sec.Rep.Serv. 383

Patricia PUNZIO, Plaintiff–Appellant,

v.Michael J. ASTRUE, Commissioner of Social Security, Defendant–Appellee.

No. 09–3064.

United States Court of Appeals, Seventh Circuit.

Argued March 30, 2010.Decided Jan. 21, 2011.

Ashley S. Rose (argued), Attorney, Glen Ellyn, IL, for Plaintiff–Appellant.John L. Martin (argued), Attorney, Social Security Administration, Office of the Regional Chief Counsel, Region V, Chicago, IL, for Defendant–Appellee.Before POSNER, ROVNER, and TINDER, Circuit Judges.ROVNER, Circuit Judge.

Patricia Punzio has suffered from mental illness for most of her adult life, but an administrative law judge rejected her application for disability benefits on the ground that her treating psychiatrist's opinion about her mental limitations conflicts with the other medical evidence. To the contrary, however, the treating psychiatrist's opinion is well supported not only by her own observations of Punzio but also by the record as a whole. And because a vocational expert confirmed that the mental limitations identified by the psychiatrist would preclude Punzio from working at any job, the only possible outcome was a finding that she is disabled. We reverse the district court's judgment in favor of the Commissioner of Social Security and remand the case to the agency for an award of benefits.

I.

By any measure Punzio has led a difficult life. Her parents were alcoholics who treated her harshly. In the fifth grade she was sexually assaulted by her friend's grandfather and afterward attempted suicide. When she was in the sixth grade she started sneaking alcohol. In the classroom her progress was derailed by dyslexia, but her mother, afraid of the stigma, refused to let her be placed in a special-education program. Punzio dropped out of school after completing the eighth grade, although at some point she earned a GED. She drank heavily as a young adult until, at the age of 26, she stopped abusing alcohol after joining Alcoholics Anonymous, where she developed her most meaningful relationships. Still she possessed few marketable skills and had difficulty holding down a job. Her longest tenure was the four years she worked as a school custodian between 1994 and 1998.

Punzio's medical records pick up in April 1998 when, at the age of 40, she checked herself into a psychiatric facility in Illinois. She had struggled with depression her whole life, she told her treating doctor, and recently had been seeing a counselor at the YWCA. When she arrived at the facility she already was taking the antidepressant Prozac and the mood stabilizer Depakote. But still her mental illness was unbearable, she said, and now she was afraid she might harm herself. She felt increasingly hopeless, she explained, and thought that perhaps she was “supposed to be dead.” At first she made little progress, and during therapy sessions she was withdrawn and disclosed little about her feelings. Within a week, however, her suicidal thoughts subsided. Her doctors diagnosed her with major depression and, after determining that she was no longer a danger to herself, decided to transition her into a partial-hospitalization program, which would allow her to continue receiving intensive treatment during the day while spending the night at her home. They kept her on Depakote but switched her antidepressant to Effexor.

Over the next three weeks, Punzio participated in individual and group therapy sessions at the psychiatric facility. Her doctors observed that she appeared depressed and lethargic, but they also complimented her on her coherence and insight. She shared more details about the origins of her depression, explaining that her parents made her feel inadequate as a child and that now she worried about being a good mother to her son, who was then 11 years old and living with his father because Punzio was too depressed to take care of him. During this time a friend in Maryland offered Punzio a job and a place to stay, and she decided to take advantage of the opportunity to make a fresh start. Her doctors approved and told her that her prognosis was good so long as she continued taking her medications and sought follow-up treatment in Maryland.

Yet within two months Punzio had returned to Illinois, still crippled by her depression. In July 1998 she was jointly evaluated by a psychiatrist and a social worker on behalf of the DuPage County Health Department. Her medications were ineffective, she told them, and she felt hopeless and worthless and as a result was unable to concentrate or sleep through the night. Nor could she ride her bike, go dancing, or take part in any of the other social activities that she used to enjoy. Instead she found herself overeating and had gained 50 pounds in recent months. Her evaluators opined that she was extremely depressed and probably bipolar. They increased her dosage of Effexor and arranged for her to receive counseling. In the months that followed, Punzio met with a therapist and worked with a psychiatrist to calibrate her dosage of Effexor. In February 1999, however, she quit taking her medications after concluding that the drugs were hindering her concentration and making her drowsy. But she continued to see a therapist at the YWCA on a weekly basis through August 2001.

Meanwhile, Punzio also was seeking treatment for additional ailments. In November 1998 an educational therapist diagnosed her with dyslexia and recommended that she undergo further testing for attention-deficit disorder. The therapist observed a number of dyslexic behaviors, like confusing vowels, reading syllables out of sequence, and omitting the last syllable of some words. The therapist concluded that, although Punzio was intelligent, her potential had been impeded by her learning disability and emotional instability. When Punzio was tested for attention deficit disorder, however, the examining neurologist was unable to provide a conclusive diagnosis, explaining that the symptoms of attention-deficit disorder mimic the symptoms of depression. On top of it all, in October 2001 Punzio was diagnosed with advanced carpal-tunnel syndrome in both hands, and a few months later she had surgery to relieve the pressure on her nerves.

Throughout this time Punzio continued to struggle with her mental illness. For a few months at the end of 2002 she saw a licensed clinical professional counselor, who recommended that she consult a psychiatrist to resume her medications. The psychiatrist suggested the mood stabilizer Lamictal, but Punzio said she was wary of taking any medication because of a bad experience in the past; after doing some research, however, she agreed to give Lamictal a try, gradually increasing her dosage each week. A few weeks later the psychiatrist supplemented the regimen with Adderall to improve Punzio's memory and concentration. By the beginning of 2003, she told her counselor that both medications seemed to be working and that she felt “encouraged” about her progress. But soon thereafter Punzio lost her insurance and was unable to continue her appointments.

In July 2003 Punzio returned to the DuPage County Health Department to consult a psychiatrist. Initially her psychiatrist diagnosed her with bipolar disorder and prescribed the antidepressant Wellbutrin. By August Punzio reported that she was feeling better than she had felt in years. She felt depressed only during tough encounters with her family, she told her psychiatrist, and at worst her symptoms lingered for only a few hours. Her psychiatrist cautioned, however, that Punzio would need to take her medications for the rest of her life. Indeed in October, when Punzio missed an appointment and ran out of her medications, her progress rapidly regressed. Even so, after going back on Adderall, Lamictal, and Wellbutrin, she showed improvement.

For at least four more years, Punzio continued to consult psychiatrists at the DuPage County Health Department, usually monthly. She did show some progress. Her drug regimen was stable, and she told one assigned doctor that she was active and able to function at home and in the community. But the severity of her symptoms continued to wax and wane with the changing seasons. During the fall, she said, she consistently became more depressed and unmotivated, although never to the point of feeling hopeless or suicidal. And there were more missed appointments and lapses in medications, which predictably worsened her condition. During the summer of 2004, Punzio was overwhelmed with worries about her son, by then a teenager, who had attempted suicide a few months earlier and had just been released from a rehabilitation center. To quell Punzio's anxiety, a psychiatrist at the county health department prescribed Buspar. The drug seemed to help, although the psychiatrist had to increase the dosage when Punzio reported that she still felt quite nervous around crowds and sometimes felt daunted even by simple tasks like going to the store. In 2005 she occasionally suffered mood swings triggered by her inability to hold a job, but thanks to her medications these ups-and-downs were less severe than what she had experienced in the past. Yet she still experienced continuous frustration dealing with the limitations imposed by her dyslexia, as well as chronic problems with memory. In April 2006, for example, the county psychiatrist then managing her care observed that Punzio felt depressed because of her “cognitive deficits in areas of comprehension, retention of information, short-term memory, and dyslexia, which leads to spending an excessive amount of time on completing tasks.”

In addition, from October 2005 until October 2006 Punzio returned to the YWCA and received weekly counseling. Her therapist attributed Punzio's psychological problems to the trauma she had experienced throughout her life. The therapist tried to help Punzio cope with those scars by exploring and understanding her past....