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Cranmer v. Colvin

United States District Court, W.D. New York

February 7, 2017


          DECISION & ORDER



         Plaintiff Jessica Cranmer (“Cranmer”) brings this action pursuant to Section 205(g) of the Social Security Act, 42 U.S.C. § 405(g), seeking judicial review of a final decision of the Commissioner of Social Security (the “Commissioner”) denying her application for Supplemental Security Income Benefits (“SSI”). Pursuant to 28 U.S.C. § 636(c), the parties have consented to the disposition of this case by a United States magistrate judge. (Docket # 6).

         Currently before the Court are the parties' motions for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. (Docket ## 16, 18). For the reasons set forth below, I hereby vacate the decision of the Commissioner and remand this claim for further administrative proceedings consistent with this decision.


         I. Procedural Background

         Cranmer protectively filed for SSI on February 21, 2012, alleging disability beginning on August 1, 2009, as a result of post-traumatic stress disorder (“PTSD”), major depressive disorder, irritable bowel syndrome, asthma, chronic obstructive pulmonary disorder (“COPD”), osteoarthritis, urinary incontinence, rheumatoid arthritis, fibromyalgia, acid reflux, and anxiety. (Tr. 206, 215).[1] On May 31, 2012, the Social Security Administration (“SSA”) denied Cranmer's claim for benefits, finding that she was not disabled. (Tr. 132). Cranmer requested and was granted a hearing before Administrative Law Judge Jennifer Smith (the “ALJ”). (Tr. 107, 145, 167-71). The ALJ conducted a hearing on April 29, 2013. (Tr. 107-31). In a decision dated July 19, 2013, the ALJ found that Cranmer was not disabled and was not entitled to benefits. (Tr. 87-106).

         On March 31, 2015, the Appeals Council denied Cranmer's request for review of the ALJ's decision. (Tr. 1-7). In the denial, the Appeals Council considered additional medical treatment records predating the ALJ's determination that were not submitted until after the ALJ had rendered her decision. (Tr. 1-2, 5, 610-56). The Appeals Council determined that these records did “not provide a basis for changing the [ALJ's] decision.” (Tr. 2). The Appeals Council also reviewed medical records and a medical source statement postdating the ALJ's decision (Tr. 2, 10-15, 22-86) and concluded that those records related to “a later time.” (Id.). Cranmer commenced this action on May 2, 2015, seeking review of the Commissioner's decision. (Docket # 1).

         II. Relevant Medical Evidence[2]

         A. Treatment Records Predating ALJ Decision

         Cranmer's treatment records suggest that she initially received mental health treatment from her primary care provider, Jan Goossens (“Goossens”), MD, FACP, at the Big Flats Clinic of the Guthrie Medical Group, P.C. (Tr. 490-91). Those records indicate that Cranmer originally complained of depression and stress and was prescribed Lexapro to manage her symptoms. (Id.). On August 4, 2004, Goossens discontinued Lexapro and prescribed Effexor instead to manage Cranmer's ongoing mental health symptoms. (Id.). On October 12, 2005, Cranmer attended another appointment with Goossens complaining of stress and anxiety. (Tr. 488-89). Treatment notes indicate that due to side effects with Lexapro and Effexor, Goossens prescribed Zoloft. (Id.).

         Treatment notes from January 2009 suggest that Cranmer continued to suffer from anxiety and had been prescribed Effexor, which helped to alleviate her symptoms and no longer caused side effects. (Tr. 480-82). Cranmer complained of numbness and loss of feeling in her hands. (Id.). Rodrigro Samodal (“Samodal”), MD, assessed that Cranmer suffered from anxiety disorder and depression. (Id.). He prescribed Xanax and recommended counseling. (Id.).

         Cranmer returned for an appointment with Samodol on February 16, 2009. (Tr. 478-80). Cranmer reported that her dysesthesia and other symptoms had improved with the Xanax. (Id.). On February 23, 2009, Cranmer attended another appointment with Goossens. (Tr. 476-78). She complained of feelings of derealization, which she attributed to Effexor. (Id.). Cranmer reported that her depressive symptoms had improved, although she continued to experience anxiety. (Id.). Goossens prescribed Lexapro. (Id.).

         On June 15, 2009, Cranmer returned for another appointment with Goossens and reported improved symptoms. (Tr. 474-75). Cranmer indicated that she had not taken the prescribed Lexapro, but that her derealization symptoms had improved with a lower dose of Effexor. (Id.). Treatment notes from an August 12, 2010, appointment with Goossens indicate that Cranmer had obtained an order of protection against her spouse as a result of an incident in which he had held a gun to her head. (Tr. 460-64). Goossens assessed insomnia and panic anxiety syndrome and prescribed Ambien and Ativan. (Id.).

         Cranmer returned on September 13, 2010, complaining of increased anxiety, panic attacks, and insomnia. (Tr. 457-59). Goossens assessed depression, anxiety disorder, and insomnia and prescribed Effexor and Ambien. (Id.). Cranmer returned on November 30, 2010, complaining of continued symptoms of anxiety and depression. (Tr. 446-49). The treatment notes indicate that Cranmer was taking Effexor and Ambien. (Id.). Goossens advised Cranmer to consult with a psychiatrist. (Id.).

         On September 16, 2010, John Deines (“Deines”), MD, a psychiatrist at Family Services of Chemung County Mental Health Services (“FSCC”), conducted a psychiatric evaluation of Cranmer. (Tr. 330-31). Deines diagnosed Cranmer with PTSD and depressive disorder, not otherwise specified. (Id.). According to Deines, Cranmer's primary stressor was her increasingly abusive relationship with her husband, which had recently involved an incident in which he had put a gun to her head. (Id.). At the time of the evaluation, Cranmer was taking Effexor, Ativan, and Ambien, as prescribed by her primary care physician, and Deines continued her medication and advised her to return in one month. (Id.). Cranmer did not return for appointments with Deines or her therapist Barb Stager (“Stager”), MSW, and her case was closed. (Id.).

         On January 18, 2011, Cranmer returned to FSCC for an intake evaluation with Lezlie Namaste (“Namaste”), LMSW. (Tr. 322-26). Cranmer reported that she had been referred for evaluation by her primary care physician due to depressed feelings, anxiety, panic attacks, and nightmares. (Id.). According to Cranmer, she had been a victim of physical abuse perpetrated by her husband in July 2010. (Id.). She also reported having suffered verbal abuse for the previous ten years. (Id.). Cranmer reported feelings of fear, panic, anxiety, nightmares, insomnia, low energy, stress, and a decreased desire to leave her house. (Id.). At the time of the appointment, Cranmer was living in an apartment with her two teenage sons. (Id.).

         Cranmer reported that she had been married three times, twice to her current husband. (Id.). She had recently left her husband after he had put a gun to her head and she had an order of protection against him. (Id.). Her husband was facing criminal charges resulting from the incident. (Id.). Cranmer explained that her husband harassed her and had other men stalk her. (Id.). She reported feeling fearful all the time and experienced high levels of anxiety and panic attacks, characterized by chest pain, palpitations, and profuse sweating. (Id.). She reported poor concentration, difficulty sleeping, low energy, sadness, and low self-esteem. (Id.).

         Upon examination, Cranmer presented as alert, with full orientation, constricted affect, depressed mood, good eye contact, unspontaneous speech, normal memory, normal psychomotor activity, no evidence of conceptual disorganization or hallucinations, preoccupied thought content, guarded attitude, minimal insight, poor judgment, and distractible concentration. (Id.). According to Namaste, Cranmer cried throughout the interview, and although she was pleasant and cooperative, she was slow to answer questions. (Id.). Namaste assessed that Cranmer suffered from PTSD, depressive disorder not otherwise specified and rule out panic disorder with agoraphobia. (Id.). She assessed a Global Assessment of Functioning (“GAF”) of 52. (Id.). She recommended individual therapy, a medication assessment, and a domestic violence survivors group. (Id.).

         Cranmer attended a therapy session with Stager on January 26, 2011. (Tr. 351-52). The treatment notes indicate that Cranmer reported being harassed by her husband's friends and suffering from panic attacks and nightmares. (Id.). Stager recommended that Cranmer participate in a domestic violence group. (Id.).

         In February 2011, Cranmer attended appointments with Stager and Deines. (Tr. 327-32). During her appointment with Stager, Cranmer reported that her estranged husband had an upcoming court appearance, which was causing her anxiety. (Id.). Cranmer presented with symptoms of anxiety, depression, and panic, and Stager discussed coping mechanisms to help relieve Cranmer's symptoms. (Id.). Cranmer also reported that she was less comfortable going outside because of concerns for her safety. (Id.).

         Cranmer cancelled her appointment with Stager on February 14, 2011, and attended her appointment with Deines on February 24, 2011. (Id.). Cranmer reported an increase in the severity of her symptoms, including hearing gun shots and mice running through her house. (Id.). She also reported periods of derealization during which she was unable to feel pain. (Id.). Cranmer complained of severe anxiety, panic attacks, low energy, poor sleep, poor appetite, and poor concentration. (Id.). Deines noted that Cranmer presented with a “distant” look and frequently paused before responding to questions. (Id.). He diagnosed her with major depressive disorder, single episode, and PTSD. (Id.). He assessed a GAF of 45 and prescribed Seroquel to assist with sleep. (Id.).

         Cranmer attended several appointments with Stager and Deines during March 2011. (Tr. 333-46). On March 1, 2011, Cranmer met with Stager and reported that Seroquel was assisting with sleep, although she continued to hear gunshots inside her home and mice and birds outside her home. (Id.). Cranmer reported not wanting to leave her home and that others followed her and waved at her when she did leave. (Id.). She also reported difficulties with her memory and ability to speak. (Id.). According to Cranmer, she had spoken with the district attorney handling her husband's criminal matter and informed him that she was not mentally capable of testifying against her husband. (Id.). Cranmer also reported that she had begun the process of applying for SSI. (Id.). Stager noted that Cranmer was mildly cooperative during the session, but that she sometimes exhibited a blank stare when Stager was speaking. (Id.).

         On March 10, 2011, Cranmer met with Deines and reported decreased depression, anxiety, episodes of derealization, and difficulty sleeping, although she continued to suffer from auditory hallucinations, feelings of fear, and nightmares. (Id.). She reported that her husband had pled guilty to the criminal charges and she still had an order of protection. (Id.). Deines noted that Cranmer continued to exhibit a “distant” look and frequently paused before responding to questions. (Id.). Deines increased Cranmer's dosage of Seroquel. (Id.).

         Cranmer returned for an appointment with Stager on March 15, 2011. (Id.). During the appointment, Cranmer reported fatigue, although she was sleeping better. (Id.). She also reported continued auditory hallucinations, including gun shots, cars with loud music, a diesel truck, a whining puppy, and people walking upstairs. (Id.). She continued to experience nightmares and was worried because she believed that her husband's family had learned where she was living. (Id.). Cranmer met with Deines the following day and reported improved sleep and calmer thoughts, but continued auditory hallucinations. (Id.). According to Deines, Cranmer continued to pause before speaking, although Cranmer reported that she was doing this less than before. (Id.). Cranmer also complained of feeling itchy or that something was crawling on her after taking Seroquel. (Id.). Deines instructed her to continue her medications, but to return in one week to evaluate whether she continued to experience side effects from Seroquel. (Id.).

         Cranmer returned for an appointment with Deines on March 23, 2011. (Id.). Deines noted that Cranmer appeared more focused and did not exhibit the “distant” look and that the rhythm of her speech was much more normal. (Id.). Cranmer reported that her ability to speak had improved, her depression and anxiety were significantly lessened, and she had experienced minimal episodes of derealization. (Id.). Cranmer also reported that she continued to have feelings of fearfulness and paranoia and continued to have occasional auditory hallucinations of gunshots approximately three or four times per week. (Id.). Cranmer reported that she continued to feel itchiness after taking Seroquel. (Id.). Deines was concerned that Cranmer was allergic to Seroquel and prescribed Abilify instead. (Id.).

         On March 29, 2011, Cranmer attended a therapy session with Stager. (Id.). Cranmer reported that she was feeling better, but that since switching to Abilify she was sleeping poorly and continued to experience auditory hallucinations and chest pain. (Id.). Cranmer also reported that she had called and requested to discontinue Abilify and restart Seroquel. (Id.). According to Cranmer, she continued to experience some itchiness on Seroquel, but that it had diminished. (Id.).

         Two days later, Cranmer attended another appointment with Deines. (Id.). She reported improved sleep since switching back to Seroquel and minimal side effects. (Id.). Cranmer also reported increased anxiety, fearfulness, and paranoia, which she attributed to continued harassment by her estranged husband of her boyfriend and her. (Id.). Deines increased Cranmer's Seroquel dosage and advised her to contact the police if her husband contacted her again. (Id.).

         In April 2011, Cranmer attended two sessions with Stager and one appointment with Deines. (Tr. 347-54). During these appointments, Cranmer reported experiencing crying spells and continued auditory hallucinations, although she reported her feelings of fearfulness, paranoia, and panic attacks had lessened. (Id.). She had commenced divorce proceedings against her husband and was attempting to serve the papers on him without success. (Id.). Deines decided not to alter Cranmer's medications. (Id.).

         Cranmer met twice with both Deines and Stager during May 2011. (Tr. 355-62). In early May, Cranmer reported a decrease in her feelings of fearfulness, paranoia, and panic attacks, but continued frequent auditory hallucinations, depressed feelings, and low energy. (Id.). Cranmer also reported panic attacks after encounters with her husband or his family members. (Id.). Deines recommended that Cranmer participate in domestic violence group therapy and increased her Effexor dosage. (Id.).

         On May 25, 2011, Cranmer attended unscheduled crisis sessions with both Stager and Deines due to an increase in her symptoms. (Id.). According to Cranmer, she was planning to go to the emergency room because she was experiencing increased depression, panic, anxiety, and auditory hallucinations. (Id.). She presented as tearful and upset and reported having been crying for the previous hour while staying in her basement due to fear. (Id.). During the session, Cranmer calmed down and discussed that her panic attacks and anxiety were triggered by an incident with her family members. (Id.). Cranmer reported to Deines that her symptoms were worsening due to increased auditory hallucinations. (Id.). Deines increased Cranmer's Seroquel dosage and decreased her dosage for Ativan and Effexor. (Id.). As an option, Deines offered psychiatric hospitalization to permit Cranmer's medications to be adjusted quickly and aggressively. (Id.).

         Cranmer returned for an appointment with Deines on June 9, 2011. (Tr. 364-65). Cranmer reported that her depression, anxiety, and auditory hallucinations had been alleviated by her medication adjustment. (Id.). She reported sleeping approximately ten hours a night and feeling tired during the day, and Deines advised her that she could decrease her Seroquel dosage to avoid excessive sedation. (Id.). Cranmer also reported going to the emergency room the previous week for chest pain, which she believed was anxiety-related. (Id.). She indicated that she continued to encounter associates of her husband, but that the divorce papers had been served and she expected the divorce to be finalized within the next month. (Id.).

         Cranmer did not attend her scheduled session with Stager on June 30, 2011, but met with Deines on July 7, 2011. (Tr. 366-68). Cranmer reported continued improvement in her depression and anxiety and that she had not experienced any auditory hallucinations. (Id.). She also was sleeping well, although she continued to experience some sedation during the day. (Id.). According to Cranmer, she was driving a new vehicle that was not known to her husband or his friends and she had not experienced any recent incidents involving them. (Id.).

         In August 2011, Cranmer met with both Deines and Stager. (Tr. 369-72). Deines noted that Cranmer had not met with Stager in approximately two months and emphasized the importance of ongoing therapy. (Id.). Cranmer indicated that she had been doing so well that she had delayed contacting Stager. (Id.). According to Cranmer she was not experiencing any auditory hallucinations and her sleep and mood had improved. (Id.). She continued to be drowsy during the day and had experienced a few nightmares. (Id.). She had not experienced any encounters with her husband. (Id.). Cranmer reported that she had befriended a woman who had moved into the apartment above hers and had attended yard sales and demolition derbies with her. (Id.).

         Cranmer returned for an appointment with Deines on September 29, 2011, after cancelling an earlier scheduled appointment. (Tr. 373-74). During the appointment, Cranmer reported increased anxiety and nightmares, which she attributed to her estranged husband, who had started stalking her sister. (Id.). Cranmer had not obtained the bloodwork requested by Deines and had not scheduled any appointments with the therapist who was covering for Stager, who was out on medical leave. (Id.). Deines questioned whether Cranmer was taking more than her prescribed dosage of Ativan and advised her to obtain bloodwork. (Id.).

         Cranmer met with both Deines and Stager in October 2011. (Tr. 376-79). Cranmer reported increased anxiety and nightmares caused by encounters with her estranged husband. (Id.). She also reported that her son was experiencing mental health issues and her grandmother had passed away. (Id.). According to Cranmer, she believed her son was having an inappropriate relationship with her sister's partner. (Id.). Cranmer reported that her current psychiatric medication regimen was helping significantly, but that she continued to experience anxiety, particularly when she saw her estranged husband. (Id.). Deines discontinued Cranmer's prescription for Ativan and instead prescribed Klonopin. (Id.). Cranmer missed her appointment with Stager scheduled for October 27, 2011. (Id.).

         Cranmer met with Stager three times during November 2011. (Tr. 380-82). Initially, Cranmer reported a reduction in her anxiety, panic, and nightmares after switching to Klonopin. (Id.). However, in mid-November, Cranmer reported increased stressors in her life. (Id.). According to Cranmer, one of her sons totaled his truck during a traffic accident and a nodule on his lung had been discovered, which Cranmer feared was malignant. (Id.). Additionally, her estranged husband had chased her boyfriend in his vehicle. (Id.). Her youngest son was improving with medication, but continued to have difficulty sleeping. (Id.). Cranmer reported that she continued to experience some relief from Klonopin and had not experienced any chest pain. (Id.). During the next appointment, Cranmer reported that her son's lung nodule was not cancerous and she was experiencing decreased stress and anxiety. (Id.).

         Cranmer did not attend an appointment scheduled with Stager on December 1, 2011, but met with Deines on December 22, 2011. (Tr. 383-84). During the appointment, Cranmer indicated that she was doing better overall on the Klonopin, but that she had experienced a recent increase in anxiety due to an incident involving her estranged husband's family member. (Id.). Cranmer also reported less frequent nightmares. (Id.). Deines advised Cranmer that she could take an additional dose of Klonopin as needed when she experienced increased anxiety. (Id.).

         Cranmer met with Stager once during January 2012. (Tr. 386-87). During the appointment, she reported that she continued to sleep well and had experienced less anxiety. (Id.). Cranmer described her daily routines, and Stager advised her to monitor her caffeine intake. (Id.). Cranmer reported that she was exercising, had started sewing, and had a positive experience with her family during the holidays. (Id.). Cranmer reported some nightmares and some obsessive compulsive disorder symptoms. (Id.).

         In February 2012, Cranmer met with Stager three times. (Tr. 388-91). During the appointments, Cranmer reported some positive occurrences in her life and a slight reduction in anxiety and depression. (Id.). According to Cranmer, she had been taking care of a baby goat, had obtained a new hairstyle, and had assisted the woman who lived above her. (Id.). Cranmer continued her attempt to obtain SSI benefits and reported an onset of physical pain. (Id.). She was being evaluated for rheumatoid arthritis and had been prescribed pain medication. (Id.). Stager counseled her regarding her various prescriptions, and Cranmer reported difficulty with her memory. (Id.). Cranmer also reported that her son continued to struggle with mental health issues, which caused Cranmer to experience increased anxiety. (Id.).

         On March 6, 2012, Cranmer attended another appointment with Stager. (Tr. 392). During the appointment, Cranmer reported increased anxiety and stress and that she continued to have difficulty with her son, who was demonstrating increased aggression and depression. (Id.). Cranmer reported that she also was experiencing difficulty because the anniversary of her mother's death was approaching. (Id.). Cranmer requested another appointment with Stager later that week. (Id.).

         Two days later, on March 8, 2012, Cranmer met with both Stager and Deines. (Tr. 393-97). Cranmer met with Stager first, who described Cranmer as confused and unfocused. (Id.). Cranmer reported ongoing difficulties with her son, who was living with his grandfather, and auditory hallucinations. (Id.). Stager helped Cranmer with her SSI paperwork. (Id.). Stager observed that Cranmer appeared drowsy, overly-controlled and restrained, with a flat affect, empty mood, good eye contact, slowed speech, normal memory, slowed psychomotor activity, a mild degree of conceptual disorganization, and poor attention span. (Id.).

         Later that day Cranmer met with Deines. (Id.). During the appointment, Cranmer reported experiencing varying degrees of depression and anxiety and occasional nightmares. (Id.). She reported ongoing difficulties with her son and with finalizing her divorce. (Id.). She believed that her medication regimen continued to work adequately. (Id.). Deines continued ...

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