United States District Court, S.D. New York
PAMELA R. WASHINGTON, Plaintiff,
CAROLYN W. COLVIN Acting Commissioner of Social Security, Defendant.
REPORT AND RECOMMENDATION
DEBRA FREEMAN, Magistrate Judge.
TO THE HONORABLE COLLEEN MCMAHON, U.S.D.J.
Plaintiff Pamela Washington ("Plaintiff") seeks review of the final decision of the Acting Commissioner of Social Security ("Defendant" or the "Commissioner"), denying Plaintiff Supplemental Security Income ("SSI") under the Social Security Act (the "Act") on the ground that Plaintiff's impairments did not constitute a disability for the purposes of the Act. Plaintiff has moved, pursuant to Rule 12(c) of the Federal Rules of Civil Procedure, for judgment on the pleadings reversing the decision of the Commissioner (Dkt. 12), and Defendant has cross-moved for judgment on the pleadings affirming that decision (Dkt. 16).
For the reasons set forth below, I respectfully recommend (a) that Plaintiff's motion be granted, to the extent that Plaintiff requests that her claim be remanded for further consideration of her mental impairments, and (b) that Defendant's cross-motion be denied.
Plaintiff applied for SSI on April 28, 2010 ( see R. at 161-67), alleging that she was disabled due to bipolar disorder with psychotic features, post-traumatic stress disorder and cocaine and alcohol dependence ( id. at 187). In the course of her administrative proceedings, she also seemed to claim disability based on certain physical conditions, most specifically alleged pain and numbness in her hands. ( See id. at 41.)
The background facts set forth herein are taken from the administrative record (referred to herein as "R."), which includes, inter alia, Plaintiff's medical records and the transcript of the May 18, 2011 hearing held before Administrative Law Judge Glenn G. Meyers (the "ALJ"), at which Plaintiff testified.
A. Medical Evidence
The relevant medical evidence in the administrative Record may be summarized as follows:
1. Treatment Records
a. North General Hospital (July 13-22, 2009)
Plaintiff was admitted to North General Hospital from July 13 through 22, 2009. ( See id. 234-61.) It appears from the medical records that she first presented to the hospital's Emergency Department with complaints of depression and hearing voices, and that she was suffering from "vague suicidal ideations, " "mild dizziness, " and headaches. (Id. at 236, 239.) The hospital records indicate a medical diagnosis of "substance induced mood/Psychotic Disorder" and note that major depressive or bipolar disorder with psychotic features would need to be ruled out. (Id. at 241.) The same records also reference "methadone maintenance, alcohol dependence, [and] cocaine abuse" ( id. ), although it is unclear whether these were confirmed or suspected ( see id.; see also id. at 245 ("substance induced psychotic disorder vs. major depressive disorder [with] psychotic features vs. bipolar disorder [with] psychotic features")).
Plaintiff appears to have been discharged on July 22, 2009 with a referral to a walk-in clinic and "no restrictions" with respect to activities. (Id. at 235.)
b. St. Barnabas Hospital (August 3-4, 2009)
On August 3, 2009, Plaintiff was taken to the Emergency Department at St. Barnabas Hospital, after reportedly threatening her neighbor. (Id. at 262-63.) According to the physician's notes, Plaintiff stated that she had been drinking alcohol constantly for several days prior, and complained that she was uncomfortable because something out of the ordinary was "happening to her body" and she was "hearing voices." (Id. at 263.) The physician diagnosed Plaintiff with schizophrenia ( id. at 265; see also id. at 263), and discharged Plaintiff on August 4, 2009 ( id. at 264).
c. Bronx-Lebanon Hospital (September 2009-June 2011)
The Record reflects that, on various dates between September 2009 and April 2010, possibly in connection with a drug treatment program (although this is not clear), Plaintiff underwent a number of screening tests for cocaine, opiates, and other illegal drugs, at the Martin Luther King Jr. Health Center of Bronx-Lebanon Hospital ("Bronx-Lebanon") ( see id. at 282-303); these tests consistently showed negative results ( see id. ).
On March 23, 2010, Plaintiff went to the Emergency Department at Bronx-Lebanon. (Id. at 314.) In the "Emergency Triage" record from that day, Plaintiff's chief complaints were recorded as "pain and numbness to both hands" that had lasted for two weeks, depression, and hearing voices. (Id. at 319.) In the record labeled "Neuro Symptoms" from that day, Plaintiff's chief complaint was recorded as "tingling in [her] fingertips." (Id. at 314.) Plaintiff was diagnosed by Dr. Tania Mariani with "paresthesias" in both hands and discharged with instructions to follow up. (Id. at 318.)
At a follow-up appointment on April 21, 2010, Plaintiff was seen by Dr. James R. Morris. ( See id. at 300.) Plaintiff again complained of numbness and tingling in both hands, stating that she had experienced this for over 10 years, including while detoxing from methadone in 2009. (Id. at 288.) She also reported that she was not on medication for this problem and that it did not cause her to drop things, but that her finger joints were stiff at times. (Id. ) Dr. Morris listed "Arthritis" on Plaintiff's "Problem List, " though he scored Plaintiff's motor function at five out of five in all limbs and noted that she had "no deficits of sensation to touch, temperature, vibration and proprioception." (Id. ) He also noted "no tremor or sign of dystonia, " and a normal "station and gait." (Id. ) Dr. Morris's assessment called for X-rays of Plaintiff's hands, a follow-up appointment one month later, and a trial prescription of Nabumetone (an antiinflammatory medication),  "in an effort to minimize her symptoms." (Id. at 300.) Plaintiff filed her application for SSI about a week after this appointment. ( See id. at 161-67.)
The Record reflects that Plaintiff then had a second follow-up visit to Bronx-Lebanon on June 7, 2010, where it appears that she was again seen by Dr. Morris. (Id. at 283-87.) During that appointment, Plaintiff's "chief complaint" was numbness in her hands, but she apparently reported that the Nabumetone had helped "ease the pain in both of her hands." (Id. at 283.) The X-rays of Plaintiff's hands were found to be "unremarkable, " and Plaintiff's motor function was again described as five out of five in all limbs. (Id. ) The summary signed (electronically) by Dr. Morris stated that Plaintiff was "doing better." (Id. at 286.) He increased her dosage of Nabumetone to ease some discomfort caused by inflammation, and gave her instructions for a follow-up appointment in six or seven weeks. (Id. )
It appears that the Bronx-Lebanon records that were requested by the Social Security Administration, in connection with Plaintiff's claim for benefits, were provided by Bronx-Lebanon on July 11, 2010. ( See id. at 282.) The Record is silent as to whether Plaintiff continued to be seen there, after July 2010.
d. Montifiore Behavioral Care Center (August 2010-May 2011) (Treatment by Psychiatrist Imtiaz Ghumman)
On August 10, 2010, Plaintiff was seen by Dr. Imtiaz Ghumman, a psychiatrist at Montefiore Behavioral Care Center, who outlined an "Initial/Comprehensive Treatment Plan" for her. (Id. at 370.) Dr. Ghumman recorded, inter alia, depression/anxiety, mood swings, disturbed sleep, and "psychosocial stressors" as Plaintiff's "problems." (Id. ) The treatment plan indicated that Plaintiff needed regular psychotherapy and medication management. (Id. ) Dr. Ghumman assigned Plaintiff a global assessment of functioning ("GAF") score of 50.
On December 23, 2010, Plaintiff completed a questionnaire for the Montefiore Sleep-Wake Disorders Center. ( See id. at 359-69.) Plaintiff reported that she had difficulty falling and staying asleep, and a host of other problems related to sleep, including, inter alia, waking up with headaches, waking up choking or gasping for air, nightmares, daytime fatigue, mood changes, anxiety, irritability, and severe pain in her legs at night. ( See id. at 359-63.) Plaintiff also reported feelings of depression and anxiety "nearly every day." (Id. at 365.)
On the part of the questionnaire that called for Plaintiff to list all medications that she was then using, Plaintiff listed, inter alia, one medication associated with the treatment of insomnia, Temazepam; three medications that are generally used to treat psychiatric problems, specifically Risperidone,  Seroquel,  and Sertraline; Nabumetone (as described supra, at n.5); and certain other medications of less relevance here. ( See id. at 363.)
A few days later, on December 28, 2010, in connection with Plaintiff's application for SSI, Dr. Ghumman filled out a questionnaire, in which he stated that Plaintiff had been under his care since August 10, 2010. (Id. at 371.) Dr. Ghumman noted that he had seen Plaintiff on December 4, 2010,  although her most recent visit had been on December 28, 2010, the day he completed the form. (Id. ) Dr. Ghumman stated that Plaintiff had been "compliant with her treatment, " and recorded that her medication included Risperdal ( see supra n.8), Seroquel ( see supra n.9), Zoloft ( see supra n.10), and Restoril ( see supra n.7). (R. at 371.)
Dr. Ghumman reported that Plaintiff suffered from "depression, mood swings, psychosis (hearing voices [and] feeling paranoid), sleep disturbances, and difficulty... focus[ing] and concentrat[ing]." (Id. ) He stated that Plaintiff was "relatively clinically stable on treatment, but [did] have emotional and behavioral exacerbations on and off, affecting her baseline routine life." (Id. ) He reported that she still "experience[d] depression [and] anxiety" and that she still "hear[d] voices, " although less in severity and frequency. (Id. ) He also noted that she was "still paranoid" and found it "difficult to focus." (Id. )
Using the multiaxial method of assessment,  Dr. Ghumman diagnosed Plaintiff with "major depression with psychotic features" on Axis I, with a need to rule out "schizoaffective disorder" ( id. at 372), and, for Axis II, he similarly indicated the need to rule out "schizoaffective personality" disorder ( id. ). For Axis III, he recorded an "enlarged thyroid" and "arthritis." (Id. ) As to Axis IV, Dr. Ghumman noted "chronic mental illness, disturbed childhood, [and] no children." (Id. ) Finally, for Axis V, Dr. Ghumman recorded a GAF of 55. (Id. )
Dr. Ghumman's prognosis was that Plaintiff suffered from "chronic mental illness" and seemed to be in need of "long-term Psychiatric Treatment." (Id. ) Also, Dr. Ghumman circled "Yes" in response to the question "Ha[ve] the patient's impairments lasted or can [they] be expect[ed] to last at least twelve months?" (Id. )
On May 14, 2010, Dr. Ghumman completed a "Medical Assessment of [Plaintiff's] Ability To Do Work-Related Activities (Mental)." (Id. at 373-75.) As to limitations in making an occupational adjustment, Dr. Ghumman stated that Plaintiff suffered from "mood swings... hallucinations, depression, [and] difficulty focusing, " which "affect[ed] her baseline functional level." (Id. at 374.) As to limitations in making a performance adjustment, Dr. Ghumman similarly noted that Plaintiff suffered from "paranoia, mood swings, anger issues, hallucinations, sleep difficulty, [and] difficulty focusing and concentrating, " which the doctor again found to "affect her baseline functional level." (Id. ) Dr. Ghumman indicated that any stress, work-related or not, could "deteriorate [Plaintiff's] clinical condition" and that Plaintiff "seem[ed] to suffer from chronic mental illness." (Id. at 375.)
Dr. Ghumman did not, however, fill out the portion of the form regarding Plaintiff's limitations as to ability to transition into a new job, make a performance adjustment, or make personal/social adjustments, as he considered those topics "beyond [the] scope of [his] assessment." (Id. at 373-74.) Dr. Ghumman also declined to give an opinion where the form asked for a description of any limitations Plaintiff had as to personal-social adjustment. (Id. at 374.) As to the medications Plaintiff was taking as of May 14, 2011, Dr. Ghumman listed Risperdal ( see supra n.8), Seroquel ( see supra n.9), Zoloft ( see supra n.10), and Wellbutrin. (R. at 375.)
2. Consultant Reports
a. Psychiatric Consultative Examination (June 1, 2010, by Dr. Joyce Schreiber)
In connection with her application for SSI, Plaintiff underwent a psychiatric examination on June 1, 2010, by a consultant, Dr. Joyce Schreiber. Dr. Schreiber noted that Plaintiff had traveled approximately 12 miles by herself, via public transportation, to the appointment. (Id. at 304.) Plaintiff reported that she was unemployed at the time, had last worked in April of 2008,  and that she had stopped working due to "psychiatric problems." (Id. ) Plaintiff stated that she had previously been hospitalized for psychiatric reasons three times. (Id. ) Plaintiff also acknowledged a history of substance abuse, but stated that she had been sober for five years and attended treatment sessions at the Martin Luther King Jr. Health Center. (Id. at 304-05.)
According to Dr. Schreiber, Plaintiff reported a range of psychiatric symptoms associated with depression and mania, including, inter alia, hopelessness, loss of interests, recurrent thoughts of death or suicide with no suicidal intent, flight of ideas, problems with concentration, distractibility and psychomotor agitation. (Id. at 305.) Plaintiff also stated that she heard voices, which told her "negative things" and made her "angry." (Id. ) Dr. Schreiber noted that Plaintiff was appropriately dressed and spoke fluently, and that her thought processes were "coherent and goal-directed." (Id. at 305-06.) Dr. Schreiber also reported, though, that Plaintiff appeared depressed and sad. (Id. at 306.)
Dr. Schreiber noted that Plaintiff's "attention and concentration [were] intact, " as she was "able to count forward and backwards" and "could do simple calculations and serial 3's." (Id. ) She also reported that Plaintiff's "recent and remote memory skills were fair" and that Plaintiff "appear[ed] [to be] of borderline intellectual functioning, " with "a slightly limited general fund of information." (Id. ) With regard to her mode of living, Plaintiff reported to Dr. Schreiber that she was able to dress, bathe, and groom herself, as well as to do some laundry, cleaning and shopping. (Id. ) Dr. Schreiber concluded that, vocationally, Plaintiff appeared capable "of following, understanding, and remembering simple instructions and directions, " and of performing simple tasks and maintaining a schedule. (Id. at 307.) Dr. Schreiber also noted, however, that Plaintiff had a history of difficulties in making appropriate decisions, dealing with stress, and being able to interact appropriately with others. (Id. ) Dr. Schreiber found that the results of her examination "appear[ed] to be consistent with psychiatric problems... [which] may significantly interfere with [Plaintiff's] ability to function on a daily basis." (Id. )
Using the multiaxial method of assessment ( see supra at n.13), Dr. Schreiber diagnosed Plaintiff, on Axis I, with "Schizoaffective Disorder, " "Bipolar Disorder NOS" (Not Otherwise Specified), and "Polysubstance Dependence in full sustained remission." (Id. ) On Axis II, she diagnosed Plaintiff with "Personality Disorder with Borderline Features" and, on Axis III, with "recurrent muscle/joint pain." (Id. ) Dr. Schreiber recommended that Plaintiff "continue with psychological, psychiatric, and substance abuse treatment" and undergo a medical evaluation to reveal the cause of her physical symptoms. (Id. ) Dr. Schreiber gave Plaintiff a "cautious to guarded" prognosis and stressed the importance of "continued intervention and support." (Id. )
b. Internal Medicine Consultative Examination (June 30, 2010, by Dr. Sharon Revan
On June 30, 2010, a consulting internist, Dr. Sharon Revan, conducted an internal medicine examination of Plaintiff, in connection with her application for SSI. ( See id. at 321.) At that examination, Plaintiff reported a history of psychiatric issues, including bipolar disease, anxiety, paranoia, schizophrenia, depression, and hearing voices, and she told Dr. Revan that she had been evaluated by a psychologist several weeks earlier. (Id. at 321.) According to Dr. Revan, Plaintiff also complained of hypothyroidism, hand pain, eye pain, bronchitis, and shortness of breath upon walking three blocks or climbing steps. (Id. ) Dr. Revan listed the medications that Plaintiff was taking, including, inter alia, Ambien,  Seroquel ( see supra n.9), Zoloft ( see supra n.10), Simvastatin ( see supra n.11), and Nabumetone ( see supra n.5). (R. at 322.) Plaintiff also reported a history of drug abuse. (Id. ) Plaintiff stated that she showered, dressed, and cooked for herself, that she was able to do some cleaning and laundry, and that she watched television and followed up with her doctor, but that her hands hurt and the pain sometimes caused her to drop things. (Id. )
Dr. Revan diagnosed Plaintiff with the following: hypothyroidism, eye problems, hand problems, muscle twitching, bronchitis, bipolar disease, anxiety, paranoia, schizophrenia, hearing voices and hallucinating, and depression. (Id. at 324.) She gave Plaintiff a "fair" prognosis. (Id. ) Dr. Revan also stated that, in her opinion, Plaintiff had mild limitations with gross motor activity in the upper extremities due to pain; mild limitations walking distances, climbing stairs and lying down due to shortness of breath; and mild limitations in daily living activities due to hand pain. (Id. )
c. Mental RFC Assessment (July 16, 2010, by Psychologist V. Reddy)
Dr. V. Reddy, apparently a consulting psychologist,  completed a Mental Residual Functional Capacity ("RFC") Assessment of Plaintiff on July 16, 2010, and found that Plaintiff was "Moderately Limited" in the following categories: "ability to understand and remember detailed instructions, " "ability to carry out detailed instructions, " "ability to maintain attention and concentration for extended periods, " and "ability to complete a normal workday without interruptions from psychologically based symptoms and to perform at a consistent pace." (Id. at 309-10.) Dr. Reddy found Plaintiff was "Not Significantly Limited" in each of the remaining categories considered. ( See id. at 309-10.) Dr. Reddy specifically noted that the "treating source did not provide a work related statement" and concluded that Plaintiff appeared "capable of the basic functional requirements of unskilled work in a low stress environment." (Id. at 311.) On the same date, Dr. Reddy filled out a "Psychiatric Review Technique" Form and opined that Plaintiff did not meet or medically equal the listings for Schizophrenic, Paranoid and other Psychotic Disorders (12.03), or Affective Disorders (12.04). ( See id. at 344-45). Dr. Reddy found that Plaintiff had only "mild" limitations in her activities of daily living and social functioning ( id. at 344), that she had "moderate limitations" in maintaining concentration, persistence or pace ( id. ), and that she had experienced "one or two" episodes of decompensation ( id. ).
B. Plaintiff's Statements Regarding Her Claimed Impairments, Made in Connection with Her Application for Benefits
At or about the time that she filed her application for SSI, Plaintiff provided certain reports to the Social Security Administration, in which she described her claimed impairments and provided other information relevant to her claims.
1. Disability Report
On April 28, 2010, the day she filed her application, Plaintiff completed a form
"Disability Report" ( see id. at 186-94), in which she reported that she was "bipolar with psychotic features, " that she had PTSD (post-traumatic stress disorder), and she had cocaine and alcohol dependence issues. (Id. at 187.) Plaintiff also stated that she had stopped working in April of 2009, when she was "fired due to detoxing on methadone and [because] [she] was hearing voices." (Id. at 188.)
Plaintiff further reported that her highest grade of education was the 10th grade. (Id. ) She stated that, in her past work, she had been a home health aide for an elderly client, a job she maintained from 2007 through 2009. (Id. at 189.) Plaintiff also reported that she could "handle large objects, " that she could "write, type or handle small objects" for up to one hour, and that she could "reach" for up to two hours. (Id. at ...