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Patterson v. Astrue

September 29, 2010




On April 5, 2004, Plaintiff Susan M. Patterson ("Plaintiff") filed an application for Disability Insurance Benefits ("DIB") under the Social Security Act ("the Act"). In that application, Plaintiff asserts that she has been disabled since September 29, 2003. The Commissioner of Social Security ("the Commissioner") denied her benefits for lack of disability.

Plaintiff now seeks judicial review of the Commissioner's decision pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3). Compl. (Dkt. No. 1). Both parties have moved for judgment on the pleadings. For the reasons that follow, the Commissioner's determination of no disability is vacated, and the matter is remanded for further administrative proceedings.


A. Procedural History

Plaintiff filed an application for disability benefits on April 5, 2004. R. 42-44.*fn1 That application was denied on July 21, 2004. R. 25-28. Plaintiff timely requested an oral hearing, R. 29, which subsequently took place on August 23, 2005, with Administrative Law Judge ("ALJ") J. Robert Brown presiding. R. 175-204. Plaintiff, represented by counsel, appeared and provided testimony. R. 175-204. Also present was an independent vocation expert ("VE"), Dr. James Ryan, who answered hypotheticals posed by the ALJ and Plaintiff's attorney. R. 199-204. ALJ Brown issued a decision on February 24, 2006, in which he determined that Plaintiff is not "disabled" under the Act. Plaintiff timely requested review of that decision by the Appeals Council. R. 7-10. On June 1, 2006, when the Appeals Council denied review, R. 4-6, the ALJ's determination became the final decision of the Commissioner.

Plaintiff, acting through counsel, commenced this action on July 24, 2006. Compl. (Dkt. No. 1). The Commissioner filed an Answer on August 30, 2006. Dkt. No. 3. Both parties have moved for judgment on the pleadings pursuant to Federal Rule of Civil Procedure 12(c). See Pl.'s Br. (Dkt. No. 5); Def.'s Br. (Dkt. No. 6).

B. Plaintiff's History

Plaintiff was born November 4, 1961. She was 41 years old at the alleged onset date of her disability.R. 42, 178. She has a high school education and one semester of college. R. 182. Plaintiff previously owned and operated a small day care and worked in bookkeeping. R. 63,187. Later, she worked as a sales associate, then in a clerical position, where she was responsible for inventorying merchandise, and finally in human resources, where she was responsible for payroll, interviewing, hiring, and firing, dealing with shortages, and working with the sale associates, managers, and high ranking personnel. R. 54, 63-68, 181-82. She found this last position to be "a very, very stressful job." R. 182. During her tenure in human resources, she claims she experienced chronic pain, and this interfered with her job performance. She left her employment on September 29, 2003 after her physician told her to stop working. R. 54, 189. She alleges that date as the onset of her disability. R. 54.

Plaintiff first began treating with Dr. Richard Handler, a Rheumatology specialist, on April 4, 2001, when she complained of fatigue, pain, and insomnia. R. 106, 171. Dr. Handler referred Plaintiff for evaluations of her knees, hand, pelvis, lumbar spine and back, all of which came back essentially normal for a woman of her age. R. 100-03. A CAT scan of Plaintiff's lumbar spine did show degenerative disc disease at L4-5 and a midline bulge of the annulus fibrosis at L4-5 but no franc disc herniation and intact dural sac and nerve roots. Dr. Handler diagnosed Plaintiff with systemic fibromyalgia, insomnia, and anxiety. R. 106. He referred Plaintiff to psychiatrist Donald Fava, Ph.D. for treatment of her anxiety. R. 107. Dr. Handler treated Plaintiff for approximately three years before advising her that she should leave work. R. 196. He made this recommendation because he considered Plaintiff "unable to function" in the work setting as a result of her pain, fatigue, and inability to deal with stress. R. 111, 107.

In June of 2004, Dr. Handler evaluated Plaintiff's attitude as good, her appearance as neat and healthy, and her behavior appropriate; he found her speech, thought and perception to be clear and normal, but her mood and affect anhedonic and depressive. R. 110. He noted that her insight and judgment, as well as her ability to perform calculations was normal, and that she was able to function at home with help from her husband, but was unable to function in a work setting. R. 111. He assessed Plaintiff as being able to occasionally lift up to twenty pounds; stand and/or walk up to two hours a day; and sit less than six hours per day. He also found her limited by pain. He described her as having no limitation in understanding and memory, sustained concentration and persistence, or social interaction. R. 112-13. He noted that all medications have failed to eliminate Plaintiff's symptoms. R. 107.

On July 19, 2005, Dr. Handler noted that Plaintiff's fibromyalgia was causing her widespread continuous pain, which, in combination with her other symptoms left her able to sit and stand/walk for four hours in an eight hour day, and lift/carry up to twenty pounds. R. 165-67. Dr. Handler concluded that Plaintiff suffered from an "emotional -- not physical handicap." R. 166.He opined that Plaintiff was incapable of handling even low levels of work-related stress and that her symptoms may cause her to miss work more than three times a month. R. 170-2.He found her to have no limit in answering questions or expressing herself. R. 172.

Plaintiff began treating with Donald Fava, Ph.D. in November 2004, complaining of "immune system disorder, chronic migraine headaches, fibromyalgia, severe sleep disturbance, moderate-severe anxiety, and progressive rheumatoid pain symptoms throughout her body." R. 137.Dr. Fava assessed Plaintiff as being "volatile and unpredictable," "not oriented for time," and "show[ing] fluctuating alertness," and he found her speech disorganized, her recent and remote memory moderately impaired, her thought "characterized by obsessions," and her judgment deteriorating. R. 139. Dr. Fava noted that Plaintiff "experiences episodic depersonalization" and found her attention/concentration to be poor. R. 139. He found her "depressed to anxious and pressured to agitate." R. 139. Dr. Fava diagnosed her as suffering from mood disorder due to immune disorder and fibromyalgia, bipolar disorder, dysthymia, panic disorder with agoraphobia, obsessive compulsive disorder, post-traumatic stress disorder, pain disorder, depersonalization disorder, sleep disorder, stress-related physiological response, self-defeating personality features and obsessive defeating personality features; he found she had a GAF score of 51. R. 140-41. Dr. Fava commented that "[i]n her condition, any type of vocational activity would be impossible." R. 138.

Plaintiff was referred to Dr. Richard Williams by the New York State Office of Disability Determinations for a psychological functioning assessment. Dr. Williams consultatively examined Plaintiff of June 8, 2004. R. 118. Dr. Williams found her "neat, clean and well dressed.... pleasant and cooperative." R. 119. He noted that she "was alert and oriented" and her "[a]ttention and concentration were good" as was her immediate memory, but her "delayed recall was very poor." R. 119. Her abstract thinking, insight, and judgment were good, and her thoughts clear and logical. R. 119. Plaintiff's mood was "somewhat anxious" and her affect appropriate; her speech was in the normal range and thought content unremarkable. R. 119. Plaintiff relayed complaints of migraines, increased anxiety, and a very limited daily routine. R. 119. Dr. Williams diagnosed her with generalized anxiety disorder, dysthymic disorder, self-reported fibromyalgia pain and migraines, health problems; he reported a GAF score of 55. R. 119. Dr. Williams found that Plaintiff "has signs and symptoms of chronic depression and anxiety.... Since she has reportedly tried a large number of medications with no success, [her] prognosis is guarded even with continued treatment." R. 120.

On June 14, 2004, Dr. Sateesh Goswami assessed Plaintiff at the request of the New York State Office of Disability Determinations. R. 121-23. Plaintiff complained of "chronic pain all over and headaches." She also complained of limits on her daily activities, for example carrying laundry baskets or grocery bags. R. 121. Plaintiff related that she did needlework, watches television, reads, and goes to the store for short periods. R. 121. She told Dr. Goswami that she can only walk or stand for approximately 30 minutes at a time. R. 122.

Dr. Goswami's physical examination of Plaintiff found Plaintiff to be "tender all over most of the joints which she has described in all the trigger points of the fibromyalgia." R. 122. The evaluation revealed some decreased range of motion. Plaintiff was also described as "unable to walk on heels and toes. She loses balance. She can squat minimally.... Gait and speech are normal.... [M]otor strength is 4." R. 122.

Dr. Abdul Hameed, a State agency physician, provided a mental RFC assessment of Plaintiff on July 12, 2004. R. 129-31. He opined that there is no evidence of any limitation to Plaintiff's ability to remember locations and work-like procedures; he noted Plaintiff's ability to understand, remember, and carry out short and simple instructions, as well as detailed instructions, were not significantly limited. R. 129. Dr. Hammed also found no significant limitation with regard to Plaintiff's ability to maintain attention for extended periods, sustain an ordinary routine without supervision or work with others. R. 129. He found her only moderately limited with regard to her ability to complete a normal workday and workweek without interruption, and be able to perform at a consistent pace. R. 130. He found Plaintiff's abilities under the heading social interaction to be not significantly limited, and her ability to adapt to changes to be only moderately or not significantly limited. R. 130.

C. The Hearing

At her hearing in front of ALJ Brown, Plaintiff related her symptoms, work history, and limitations in daily functions. R. 178-98. She testified that her daily routine was very limited: she can drive a car on short trips; do some needlework until her pain prevents her from continuing; read until her concentration falters, which it does after only a short duration; do minimal shopping; walk for approximately forty-five minutes before pain forces her to stop; lift small items; and perform certain household tasks, though no heavy chores. She explained that she takes medications, though these often have severe side-effects causing her to withdraw and lack alertness. R. 184-98. She stated that she stopped working on the advice of Dr. Handler. R. 189. She explained that her symptoms, which include pain, severe ...

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