United States District Court, W.D. New York
DECISION & ORDER
JONATHAN W. FELDMAN, United States Magistrate Judge
Mandy Nicole Lathrop ("plaintiff" or
"Lathrop") brings this action pursuant to Title II
and Title XVI of the Social Security Act seeking review of
the final decision of the Commissioner of Social Security
(the "Commissioner") denying her application for
disability insurance benefits. See Complaint (Docket
# 1). Presently before the Court are competing motions for
judgment on the pleadings. See Docket ##9, 13. For
the reasons that follow, the plaintiff's motion (Docket #
9) is granted, and the defendant's motion (Docket # 13)
and Procedural History
applied for disability benefits on July 16, 2012, alleging a
disability beginning November 15, 2012 of depression,
anxiety, Crohn's disease, scoliosis, PTSD, and back pain.
AR at 174. These claims were initially denied on November 23,
2012. AR at 90-103. Plaintiff timely filed a request for a
hearing. AR at 12. Plaintiff, represented by counsel, '
testified at the hearing before Administrative Law Judge
Brian Kane (thenALJ") on July 11, 2014.
Vocational Expert Peter Manzi (the "VE") also
testified. AR at 48-84.
issued an unfavorable decision on August 25, 20.14. AR at
16-38. Plaintiff exhausted her administrative remedies by
requesting review by the Appeals Council, which review was
denied on October 22, 2015. AR at 1. She then filed this
civil action on December 21, 2015. Docket # 1. The parties
made competing motions for judgment oh the pleadings
(see Docket ## 9, 13), and I heard oral
argument on January 18, 2017 (see Docket # 18).
health has been mired by substance abuse, mental impairments,
back pain, and abdominal pain. Most of the medical evidence
pertains to her mental impairments and substance abuse.
Because reports of her back and abdominal pain are often
found together with mental health reports, I address all
medical evidence chronologically below.
questionnaire, plaintiff reported that she cooks, cleans, and
takes her children to school. AR at 216, 221. She stated that
she has trouble sleeping and can no longer stand for long
periods of time. AR at 216. Plaintiff reported not being able
to go out because of anxiety attacks and fear of people. AR
at 218. She has a driver's license but does not go out
alone or often. AR at 218. Plaintiff does not spend time with
others. She reported not having any problems following
instructions or paying attention. AR at 222.
indicated that she first experienced pain stomach and back
pain five years ago. AR at 223. Her anxiety began about ten
years ago, and is brought on by stress, crowds, memories, or
specific events. AR at 225. During these attacks, which
occurred daily, plaintiff's heart beats fast, and she
sweats and shakes. AR at 225.
August 16, 2010, plaintiff reported to English Road
Psychotherapy Practice, complaining of stress, anxiety, and
depression. AR at 290. She reported that her biological
father was in jail for murder, that her step father raised
her, and that she has a history of being sexually and
physically abused. AR at 290-91. She also reported using
marijuana, nicotine, and occasionally using alcohol, but
never using cocaine. AR at 2 91. Plaintiff reported only
sleeping a few hours per night. AR at 291. Therapist Gail
Peterson, LCSW,  diagnosed plaintiff with depressive
disorder. AR at 293.
returned to Therapist Peterson with reports that her
"anxiety is bad." AR at 294. She was oriented times
three, but was depressed, and reported sleep problems. AR at
294. She also noted that Xanax was making her sleepy, and
that she had a diminished appetite and weight loss. AR at
October 4, 2010, plaintiff again presented to Therapist
Peterson as oriented times three, but depressed and in pain.
AR at 295. Later that month, on October 26, 2010, plaintiff
was oriented times three and felt "up/down." AR at
295. She had a flattened affect. AR at 296. The following
month, on November 9, 2010, plaintiff told Therapist Peterson
that she had "kind of Walked out of [her] job" due
to statements made by her boss. AR at 296. Plaintiff was
oriented times three but anxious and focused on her problems.
AR at 296. Therapist Peterson filled out a Psychological
Assessment for Determination of Employability that same day.
Therapist Peterson noted that plaintiff was anxious and
depressed. AR at 373. She opined that plaintiff was
moderately impaired (unable to function 10-25% of the time)
in his capacity to follow instructions, perform simple tasks,
maintain attention, attend to a routine, and perform low
stress, simple tasks. AR at 373. Therapist Peterson concluded
that plaintiff could work for 2 0 hours per week with
accommodations such as a pre-planned schedule and ability to
avoid crowds. AR at 374. Therapist Peterson expected these
limitations to be necessary for three months. AR at 374.
Plaintiff reported to the emergency department at Unity
Health System on December 27, 2010 with sharp, intermittent
abdominal pain, which was not consistent with her typical
Crohn's pain. AR at 283.
returned to Therapist Peterson on February 9, 2011, where she
was oriented times three, but depressed and focused on her
problems. She explained she had a lot going on, including
being six months pregnant and having increased anxiety due to
lack of sleep and appetite. AR at 297.
15, 2011, plaintiff presented to Sandra Boehlert, M.D., at
the Monroe County Department of Social. Services for a
Physical Assessment for Determination. of Employ ability.
Plaintiff reported anxiety, depression, PTSD, Crohn's
disease, and blackouts, although she was then pregnant and
had not had a blackout in a year. AR at 376. Dr. Boehlert
found that plaintiff had moderate to marked scoliosis, as
well as Crohn's disease, and a * [p] sychology
disorder." AR at 377. She opined that plaintiff had
moderate limitations (2-4 hours} in walking, standing,
pushing, and climbing the stairs. AR at 378-79. Dr. Boehlert
concluded that plaintiff could work for up to 4 0 hours, with
limitations such as avoiding heavy lifting (due to pregnancy
or scoliosis), and frequent breaks for diarrheal episodes. AR
at 379. She expected these limitations to last four months.
AR at 3 78.
while pregnant, plaintiff underwent an Assessment for
Determination of Employability, this time by Jennifer
Mariani, RPA-C. Physician Assitant Miriani similarly
estimated plaintiff's limitations, but opined that she
could work for up to 4 0 hours per week. AR at 38 5.
16, 2012, plaintiff self-reported to Genesee Mental Health
Center for a pre-admission screen. AR at 311. She reported
PTSD, recurrent major depression, and anxiety disorder, with
flashbacks and nightmares of past abuse (including being
beaten up and raped). AR at 311. Plaintiff reported feeling
isolated and tearful, and having difficulty leaving the house
due to decreased energy. AR at 311. She reported excessive
worry and panic, especially in social situations. AR at 311.
Plaintiff also indicated that she consumes two two-liter
bottles of Mountain Dew daily. The examiner noted that this
consumption probably contributed to her anxiety. She
presented with slowed speech and decreased motor activity. AR
at 312. Although her thought process was organized, plaintiff
reported occasional racing thoughts. AR at 312. Her affect
was flat and she exhibited depression and anxiety, although
her memory was intact. Plaintiff reported a suicide attempt
when she was 15. AR at 311. Charlene Reeves, LMHC diagnosed
plaintiff with PTSD, major depression, anxiety, and a GAF of
48. AR at 311-13. Her Crohn's disease was also referenced
in this report. AR at 312.
days later, on May 23, 2012, plaintiff saw Lynn McDonald at
Genesee Mental Health Center. Plaintiff appeared to be
restless, agitated, depressed, and anxious, with a flat
affect, but oriented times three, with fair eye contact and
intact memory. AR at 314. Plaintiff again presented on June
13, 2012, with slowed speech, a flat, affect, and an
otherwise depressed and anxious mood. AR at 316.
evaluation, Therapist Reeves completed a Psychological
Assessment for Determination of Employability. Therapist
Reeves opined that plaintiff would be very limited (unable to
perform 25% of time) in capacity to perform simple and
complex tasks independently, maintain attention, stick to a
routine, and perform low stress simple tasks. AR at 390.
Therapist Reeves determined that plaintiff would not be able
to participate in any activities except for treatment or
rehabilitation for one to three months. AR at 390.
presented many of the same conditions to Ms. McDonald on June
20, 2012. This time, however, Ms. McDonald noted that
plaintiff seemed extremely anxious due to finding out that
her stepfather was terminally ill and that her friend's
daughter was reported missing. AR at 317. A week later, on
June 27, 2012, plaintiff presented to Ms. McDonald trembling,
shaking, crying, and hyperventilating. AR at 318. It took
plaintiff ten minutes to calm down. AR at 318. She reported
feeling more stressed now that her children were home for the
summer. AR at 318. Her speech and thought-process continued
to be slow, and she presented as restless, depressed, and
anxious, though her memory was intact. AR at 318.
13, 2012, plaintiff was seen by Dorota Gardy, M.D., for a
psychiatric evaluation. At this visit, she appeared
distressed, anxious, restless, and became easily tearful. AR
at 323. Dr. Gardy found plaintiff's affect to be
congruent, her attention adequate, and that she was oriented
times three. AR at 3 23.. However, she struggled with
chronological sequencing. AR at 323. She assigned plaintiff a
GAF score of 55. AR at 323. Dr. Gardy recommended that
plaintiff talk to her primary care physician, especially for
her Crohn's disease. Dr. Gardy reinstated plaintiff's
Klonopin prescription. AR at 3 23. Plaintiff denied using
illicit substances, but Dr. Gardy ordered a urine screen. AR
30, 2012, plaintiff returned to Ms. McDonald with panic
attacks, anxiety, and depressed mood. During that session,
plaintiff reported a decreased intensity and frequency of
panic attacks in the last two weeks, during which plaintiff
leaves the room and goes outside for a few minutes. AR at
327. Ms. McDonald noted that plaintiff appeared calmer than
usual, but that she was depressed and had a flat affect.
saw Mohika Quistorf, R.N., on August 9, 2012, where she
appeared to be anxious and depressed, and reported having a
hard time leaving her house. AR at 328. Plaintiff returned to
Ms. McDonald on August 22, 2012, where plaintiff reported
continued anxiety and depression, and increased panic attacks
due to a Child Protective Services investigation. AR at 329.
September 10, 2012, plaintiff's physician Jose E.'
Lopez, M.D., indicated that plaintiff suffered from chronic
back pain and scoliosis, and that she was seeing a specialist
about possible Crohn's disease. AR at 412. He noted that
plaintiff was not to work until she had seen the specialist.
AR at 412. Therapist Annette Lee wrote similar letters in
October and November asking that plaintiff be excused from
tenant accountability class due to her depression, anxiety,
and inability to leave the house. AR at 417.
September 12, 2012, plaintiff again saw Ms. McDonald with
panic disorder and anxiety. On September 20, 2012, plaintiff
returned to Ms. McDonald with continued anxiety and
difficulty managing stress. AR at 438. Ms. McDonald noted
that plaintiff was able to secure an appointment for her
Crohn's disease. AR at 43 8. The following week, on
September 27, 2012, plaintiff came to Ms. McDonald with
decreasing levels of anxiety and desensitivity to stressful
situations. AR at 440. Plaintiff noted that she had gone to a
store but left after 15 minutes due to the stress; the
therapist challenged plaintiff to view this as a positive
step. AR at 440. The mental status exam revealed anxiety,
agitation, and restlessness. AR at 440. On October 4, 2012,
plaintiff appeared to her session with Ms. McDonald with
anxiety, panic, sweating, and shaking. Her mental. status
exam was largely the same. AR at 441.
began to see a new therapist, Annette Lee, on October 12,
2012. During that session, plaintiff reported that her
anxiety had been higher over the previous week because her
children were demanding her attention. The mental status exam
revealed the typical agitation, restlessness, anxiety, and
depression. AR at 443.
Ransom, Ph.D. performed a psychiatric evaluation on plaintiff
on October 17, 2012. Plaintiff told Dr. Ransom that she had
been raped as a child, and her mother was repeatedly
hospitalized for psychiatric issues, leaving plaintiff to
feel emotionally abandoned. AR at 333. Plaintiff reported
irritability, fatigue, wandering thoughts, and difficulty
concentrating, as well as a lack of energy and willpower. AR
at 333. She reported being afraid of leaving the house,
blacking out, and being around people. During the
examination, plaintiff also reported a history of alcohol and
marijuana dependence, but asserted that she stopped using
alcohol two years ago and marijuana in 1999. AR at 333. Dr.
Ransom noted that plaintiff appeared lethargic, but her
thought process was coherent and she was oriented times
three. AR at 334. However, Dr. Ransom indicated that
plaintiff's attention and concentration were mildly
impaired by emotional disturbance and anxiety. Her immediate
memory was mildly impaired. AR at 334. Dr. Ransom opined that
plaintiff could understand and follow simple directions and
instructions and perform simple tasks independently. AR at
335. She could maintain attention and concertation for these
tasks, maintain a regular schedule, and learn simple, new
tasks. However, she would have moderate difficulty performing
complex tasks,, relating to others, and appropriately dealing
with stress. Dr. Ransom diagnosed her with PTS'D, major
depressive disorder, panic disorder, and alcohol and
marijuana dependence. AR at 335. She also referenced
plaintiff's scoliosis and Crohn's disease. AR. at
335. Dr. Ransom listed plaintiff's prognosis as fair.
same day, plaintiff saw Karl Eurenius, M.D., for an internal
medical examination. Plaintiff complained of Crohn's
disease, mental health issues, mild scoliosis, and blackouts.
AR at 337. Dr. Eurenius noted that plaintiff had been
diagnosed with Crohn's disease five years ago after
having intermittent abdominal pain and multiple tests. AR at
337. However, plaintiff admitted that she had not had a
colonoscopy or biopsy since her diagnosis. AR at 33 7.
Without her Prednisone, plaintiff reported having chronic
diarrhea. AR at 337. Plaintiff also reported having
scoliosis, which she said is a stabbing, low back pain, and
blackouts almost weekly. AR at 337. Plaintiff had hot had an
MRI for the scoliosis and she had no neuropathic symptoms. AR
at 3 37. Dr. Eurenius indicated that he could "not
appreciate scoliosis." AR at 339. She denied use of
alcohol or drugs, but acknowledged smoking a pack of
cigarettes a day. AR at 338.
Eurenius diagnosed plaintiff with probable Crohn's
disease, but noted that she lacked a biopsy diagnosis. He
also stated that plaintiff had. chronic back pain and
blackout spells, both with uncertain etiology. AR at 34 0.
Dr. Eurenius found that it was difficult to recommend
limitations without a firm diagnosis, but opined that
plaintiff would be markedly limited in activities where a
blackout spell would injure herself or others. AR at 340. He
also opined that plaintiff would be moderately limited in
bending, lifting, carrying, and kneeling due to chronic low
back pain. AR at 34 0.
reported to Alyce Marks, R.N. for medication management on
October 17, 2012, where plaintiff appeared depressed and
anxious, and had negative ruminations. AR at 444. On November
8, 2012, plaintiff saw Therapist Lee with continued reports
of anxiety, depression, and blackouts. Her affect was
appropriate. AR at 448. She felt largely the same on November
27, 2012. There, plaintiff reported to Therapist Lee that she
felt she could not leave the house to do the Christmas
shopping. AR at 44 9. No mental status exam was performed.
came to Dr. Gardy on December 6, 2012, with reports that she
was not eating or drinking. Dr. Gardy advised plaintiff to
slowly increase intake. AR at 447. On December 11, 2012,
plaintiff reported to therapy feeling sad that she was not
able to take her son to see Santa due to her anxiety. AR at
450. On January 10, 2013, plaintiff reported to Therapist ...