United States District Court, W.D. New York
DECISION & ORDER
W. PAYSON, UNITED STATES MAGISTRATE JUDGE
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).
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.
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). 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).
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).
Relevant Medical Evidence
Treatment Records Predating ALJ Decision
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.
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
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.
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.
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.).
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.
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.
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.).
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.).
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.).
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.).
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
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
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
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.).
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.).
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.).
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.
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.
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.).
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.
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.
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
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
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.).
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.).
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
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.).
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.).
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.).
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.).
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.).
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 ...