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Gomez v. Commissioner of Social Security

United States District Court, S.D. New York

March 30, 2017

TAMMY LEE GOMEZ, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          OPINION AND ORDER

          BARBARA MOSES, United States Magistrate Judge

         Pro se plaintiff Tammy Lee Gomez seeks review of a final determination of the Commissioner of Social Security (the Commissioner) denying her application for Supplemental Security Income (SSI) under the Social Security Act, 42 U.S.C. § 1381, et seq. (the Act). Gomez moves pursuant to Fed.R.Civ.P. 12(c) for an order reversing the Commissioner's decision or remanding to a different Administrative Law Judge (ALJ). The Commissioner cross-moves pursuant to Fed.R.Civ.P. 12(c) for an order affirming her decision. The parties have consented to this Court's jurisdiction for all purposes pursuant to 28 U.S.C. § 636(c). For the reasons set forth below, plaintiff's motion is GRANTED in part and this case is REMANDED to the Commissioner for further proceedings.

         I. BACKGROUND

         A. Procedural Background

         Gomez applied for SSI benefits on March 7, 2011, alleging that she became disabled on January 1, 2009. See Cert. Tr. of Record of Proceedings (Dkt. Nos. 12 through 12-11, 21), 111, 208 (hereinafter “R.”). The application was denied on July 27, 2011. (R. 29, 112.) Thereafter, Gomez requested a hearing (R. 131), and on June 4, 2012, she appeared, with counsel, before ALJ Seth Grossman. (R. 131.) On March 18, 2013, Gomez appeared again, with counsel, for a supplemental hearing before ALJ Grossman. (R. 29, 164.) Dr. Edward Halperin, a psychiatrist, and Dr. Yaakov Taitz, a vocational expert, also appeared at the 2013 hearing. (R. 47.) However, as described in more detail below, the hearing was concluded abruptly, before Dr. Halperin completed his testimony, and Dr. Taitz did not testify at all. (R. 63-73.)

         After the 2013 hearing, ALJ Grossman scheduled Gomez for a second consultative psychiatric examination. However, it appears that she never received the appointment letters, which were addressed to an inpatient treatment program from which she had graduated prior to that hearing. (R. 1267-68.) Gomez did not appear for the post-hearing appointment, and on September 17, 2013, the ALJ issued a decision - without the benefit of the second consultative exam or any medical or vocational expert testimony - finding that she was not disabled within the meaning of the Act. (R. 26.) The decision became final on November 6, 2014, when the Appeals Council denied Gomez's request for review. (R. 1.) This action followed.

         B. Relevant Personal and Medical Background

         Gomez was born on April 18, 1968. (R. 208.) She was 42 years old when she applied for SSI benefits in March 2011. She reports suffering from a number of mental and physical ailments, beginning in childhood; however, her March 2011 application for SSI was based solely on her mental impairments. (R. 212.)[1]

         Gomez has a sixth-grade education. (R. 49, 278, 484.) As a child she attended a so-called Six Hundred School for children with disciplinary problems. (R. 49.)[2] She testified both that she has “never worked” (R. 77, 101) and that she had not worked in “quite some time.” (R. 50.) The record suggests some intermittent prior employment, including work as a cashier (R. 803), a job stacking in a supermarket (R. 830), work at the laundry facility in her drug treatment program in 2012, and a waitressing job at her uncle's business. (R. 30, 787, 790, 1031, 1034, 1195.) Other than working at the laundry, it is unclear from the record when Gomez held any of these jobs. The ALJ found that she had no “past relevant work” for purposes of his disability analysis. (R. 35.)

         Gomez has a long history of homelessness, legal troubles, and substance abuse. (See R. 258, 315, 1203, 1216.) She has reported ten non-violent misdemeanors (R. 1203) and two felony convictions for drug sales. (R. 278, 1203.) She was incarcerated on several occasions for vagrancy and trespassing. (R. 315.) In addition, she was incarcerated twice in connection with her drug convictions, most recently from 2004 until 2007. (R. 102.) It appears that she was on parole until November or December 2011. (R. 314, 485, 771, 1015.) While incarcerated, Gomez attempted to obtain a G.E.D., but failed. (R. 315.)

         Gomez testified that she has used marijuana, heroin, and crack cocaine at various times, and her records show that she also has struggled with alcohol abuse. (R. 53, 766, 1010.) In November 2010, while on parole, Gomez relapsed on drugs and entered Serendipity II (Serendipity), a residential drug rehabilitation and re-entry program, pursuant to a court order. (R. 79, 207, 334.) In August 2011, she began a methadone-to-abstinence residential program (MTAR) at Basics/Promesa Inc. (Promesa), a “health, human services and community development organization” in the Bronx. (R. 314, 732-35.)

         In early 2011, while Gomez was in the Serendipity program, she received medical treatment at the Postgraduate Center for Mental Health (Postgraduate Center). (R. 259-59.) Later that year, while at Promesa, Gomez received treatment at the Clay Avenue Health Center (Clay Avenue). Medical records in Gomez's file, including records from the Postgraduate Center and Clay Avenue, reflect a long-standing diagnosis of bipolar disorder. (See, e.g., R. 258-59, 308, 314, 319, 321.) In addition, Gomez has, at various times, reported suffering from schizophrenia, depression, seizure disorder, and anxiety disorder. (See, e.g., R. 33, 115.) On her SSI application, she listed the conditions that limited her ability to work as schizophrenia, anxiety, seizure disorder, depression, “bi-polar, ” and “severe depression.” (R. 212.) The primary and secondary diagnoses listed on her Disability Determination, however, are Affective Disorder (a term that can encompass both bipolar disorder and major depressive disorder) and Substance Addiction Disorder (alcohol). (R. 111.)[3]

         Gomez has been prescribed and has taken numerous medications over the years. On April 11, 2011, shortly after she applied for benefits, her medication regimen included, among other things, Topamax (an anticonvulsant), Neurontin (an anticonvulsant also used to treat neuropathic pain), and Abilify (an antipsychotic medication used to treat schizophrenia, bipolar disorder, and major depressive disorder). (R. 8.)

         1. Treatment at Postgraduate Center for Mental Health (March - April 2011)

         On February 4, 2011, Dr. S. Appel, M.D. conducted a psychiatric evaluation of Gomez at the Postgraduate Center. (R. 258-59.) Dr. Appel diagnosed Gomez with bipolar disorder and gave her a Global Assessment of Functioning (GAF) score of 30. (R. 260-63.)[4]

         On March 11, 2011, shortly after Gomez filed her SSI application, Dr. Appel saw her again at the Postgraduate Center. (R. 261.) Dr. Appel noted that Gomez reported progress in her rehabilitation program at Serendipity: her therapist had helped her “rephrase” her statements; she had less animosity; and she was better able to stay calm in confrontational situations. (R. 261.) Gomez had two more appointments with Dr. Appel in April 2011. (R. 260, 261.) At both appointments, she indicated that she was making progress in her program. Dr. Appel noted on April 15, 2011 that Gomez's affect was intense and her thinking was circumstantial. However, her mood was somewhat improved, to the point where she was “unstable, but manageable.” (R. 260.)

         2. Consultative Psychiatric Evaluation by Dr. Michelle Bornstein (May 27, 2011)

         On May 27, 2011, Michelle Bornstein, Psy.D. conducted a consultative psychiatric examination in connection with Gomez's SSI application. (R. 278.) Gomez was “cooperative” during the evaluation. (R. 279.) Dr. Bornstein observed that plaintiff was “unkempt and poorly groomed, ” but her eye contact was “appropriate, ” she “spoke fluently in a clear voice, ” and her “expressive and receptive languages were adequate.” Id. Her manner of relating, social skills, and overall presentation were “adequate.” Id. Although Dr. Bornstein found Gomez's affect to be mildly dysphoric and her mood mildly dysthymic, she described Gomez's thought processes as “[c]oherent and goal directed, ” and her sensorium was clear. Id. Dr. Bornstein found that Gomez's recent and remote memory skills were intact, but her attention and concentration were mildly impaired, and her cognitive functioning was “[e]stimated to fall in the low average range.” (R. 280.) Dr. Bornstein deemed Gomez's insight and judgment “fair.” (R. 280.) Gomez told Dr. Bornstein that she could not work because of mental illness, including “anger issues.” (R. 278.)

         Based on her consultative examination, Dr. Bornstein concluded that Gomez “can dress, bathe, groom, cook, clean, do laundry, shop, manage her money, and take public transportation.” (R. 280.) Dr. Bornstein also opined that Gomez “can follow and understand simple directions and instructions, and perform simple tasks independently. She has some difficulty maintaining attention and concentration. She can maintain a regular schedule and learn new tasks. She may need supervision performing complex tasks. She can make appropriate decisions, relate adequately with others, and appropriately deal with stress.” Id. It is not clear on what basis Dr. Bornstein evaluated Gomez's ability to “relate adequately with others.” Dr. Bornstein's diagnosis was depressive disorder, opiate dependence in early stages of remission, and cocaine abuse in remission. Id.

         3. Woodhull Medical and Mental Health Center (May 31 - June 23, 2011)

         On May 31, 2011, four days after Dr. Bornstein conducted her evaluation, Gomez was involuntarily admitted to Woodhull Medical and Mental Health Center (Woodhull) as the result of an incident of “impulsive/unpredictable behavior.” (R. 331, 356, 358, 360, 369, 480, 481.) The precise nature of the incident is unclear from the record, but there are indications that Gomez was not fully compliant with her medication and behaved aggressively, and possibly violently, at Serendipity. (R. 482, 486, 489, 545.) Gomez remained hospitalized at Woodhull for approximately three and a half weeks, until June 23, 2011. (R. 724, 334.) While there she was medicated and attended group and individual therapy. (R. 402, 536, 539.)

         Throughout her hospitalization, Gomez was under “intensive observation” by nurses and other staff, who kept notes on her behavior. (See e.g., R. 530, 531, 553.) The notes reveal that Gomez was often calm, cooperative, and neat, but also had outbursts of agitation and bizarre or aggressive behavior. (R. 569-702.) For example, on June 11, 2011, Gomez was “screaming, banging the doors, banging on the counter, ” and “not listening” to verbal intervention efforts by the staff. (R. 624.) She was given an injection of Lorezepam (an anti-anxiety drug) and Haldol (an anti-psychotic). Id. By June 17, Gomez showed “steady improvement, ” but was still “tangential and unpredictable at times.” (R. 343.) She frequently failed to attend group classes or therapy sessions, or left within a few minutes of arriving. (See R. 645, 647.) On June 23, 2011, Gomez was discharged to Serendipity. (R. 672, 724, 334.) A discharge form by Dr. Michel D. Joseph, M.D. and social worker Carmen Robles shows that her GAF score was assessed at 50. (R. 334.)

         4. Consultative Review by Dr. Robert F. Lopez (June 21, 2011)

         On June 21, 2011, while Gomez was still at Woodhull, Dr. Robert F. Lopez, a state agency psychologist, completed a Psychiatric Review Technique Form (PRTF), which is a “standard document” typically completed by a medical or psychological consultant. Petrie v. Astrue, 412 Fed. App'x 401, 408 (2d Cir. 2011). The questions on the form are the same questions that must be considered at the second and third steps of the ALJ's sequential analysis for determining disability (see infra at pp. 21-23).

         Dr. Lopez did not meet or evaluate Gomez in person. He completed the PRTF based on the medical records available to him, including Dr. Bornstein's consultative report. There is no indication that Dr. Lopez reviewed Gomez's records from Woodhull or was even aware, at the time he completed his report, that Gomez was an involuntary psychiatric inpatient.

         In considering Gomez's potential mental disorders, Dr. Lopez addressed the criteria for Affective Disorders (Listing 12.04) and Substance Addiction Disorders (Listing 12.09). (R. 283.) He did not consider whether she met the criteria for any other disorders, such as Schizophrenia (Listing 12.03) or Anxiety-Related Disorders (Listing 12.06). Id. With regard to Affective Disorders, Dr. Lopez checked the box for a single symptom: “sleep disturbance.” (R. 286.) The PRTF made no note of any other symptom of any other mental disorder. Moving on to the so-called “paragraph B” criteria (see infra at pp. 22-23), Dr. Lopez found that Gomez experienced “mild” restriction in in her activities of daily living; “moderate” difficulties in maintaining social functioning; “mild” difficulties in maintaining concentration, persistence, or pace; and had experienced “one or two episodes” of “deterioration, each of extended duration.” (R. 293.) Dr. Lopez concluded that Gomez's impairments did not meet or medically equal Listings 12.04 or 12.09. Similarly, Dr. Lopez checked a box indicating that Gomez did not meet the “paragraph C” criteria. (R. 294.)[5]

         Although Dr. Lopez found that Gomez was “not significantly limited” with respect to most of the subcategories in the assessment, he concluded that she was “moderately limited” in certain subcategories, including her ability to understand and remember detailed instructions; carry out detailed instructions; work in coordination with or proximity to others without being distracted by them; interact appropriately with the general public; accept instructions and respond appropriately to criticism from supervisors; get along with coworkers or peers without distracting them or exhibiting behavioral extremes; maintain socially appropriate behavior; adhere to basic standards of neatness and cleanliness; and set realistic goals or make plans independently. (R. 297-98.)

         Dr. Lopez also conducted a mental residual functional capacity (RFC) assessment. (R. 297-301.) “Residual functional capacity” refers to “the most [claimant] can still do despite [claimant's] limitations.” 20 C.F.R. § 404.1545(a)(1). The assessment required Dr. Lopez to rate Gomez's degree of limitation in four categories of mental activity: understanding and memory; sustained concentration and persistence; social interaction; and adaptation. Each category, in turn, contains various subcategories, for a total of 20. (R. 297-98.) With regard to each of the 20 subcategories, Dr. Lopez found that Gomez was “not significantly limited” or was “moderately” limited. He did not find her “markedly” limited in any subcategory. Nor did he indicate that he had insufficient evidence to rate Gomez in any of the 20 subcategories. Id. Dr. Lopez concluded that Gomez's allegation of difficulty functioning due to bipolar disorder was “credible, but not to the degree alleged.” (R. 299.) In particular, Dr. Lopez questioned Dr. Bornstein's statement that Gomez “has some difficulty maintaining attention and concentration, ” commenting that Bornstein's statement was “based on a one time evaluation and is not consistent with the findings of the mental status examination that she performed.” (R. 299.)[6] Ultimately, Dr. Lopez concluded that Gomez was “capable of following supervision, relating appropriately to coworkers, and performing substantial gainful activity (SGA), though she “may be precluded from performing tasks requiring a high degree of stress and/or complexity.” Id.

         5. Treatment at Clay Avenue (August 22, 2011 - June 26, 2012)

         On August 22, 2011, approximately one month after she was discharged from Woodhull, Gomez was admitted to Promesa for MTAR. (R. 356, 732, 976.) The intake notes reflect that Gomez was “[c]alm and cooperative, ” felt well, and had “no complaints.” (R. 732, 976.) A psychiatric note, also dated August 22, 2011, stated that Gomez was “oriented to time, place, person, and situation, ” that she had “normal insight” and “normal judgment, ” and that she exhibited “appropriate mood and affect.” (R. 734, 978.)

         On October 14, 2011, Gomez met with Dr. Kingsley Nwokeji, M.D., an attending psychiatrist at Clay Avenue. Dr. Nwokeji became Gomez's treating psychiatrist while she was in the Promesa program. (R. 747, 991.) Gomez presented on October 14 with “mood swings.” (R. 747, 991.) Dr. Nwokeji's notes reflect that Gomez had been “non-compliant with medications” in the past, though she was then compliant. (R. 745, 746, 989, 990.) Dr. Nwokeji evaluated Gomez's mental status, noting:

The patient is not exhibiting signs of psychosis. No signs of mania. Patient's appearance is appropriate. Patient is oriented to person, place, time and situation. Behavior is described as unremarkable. Speech is clear. Patient's affect is appropriate. Patient's mood is euthymic. Memory is intact. Sensorium is clear consciousness. Patient's intellect is average. Attitude is cooperative. Attention is gained. Reasoning is fair. Impulse control is fair. Judgment is fair. Insight is fair. Patient's self-perception is realistic. Thought processes are logical. Thought content is unremarkable. The patient does not express suicidal ideation. The patient does not express homicidal ideation.

(R. 746, 990.) Dr. Nwokeji diagnosed bipolar disorder, assessed a GAF score of 40, and continued Gomez's medications. (R. 746, 990.)

         On November 11, 2011, Gomez had a follow-up appointment with Dr. Nwokeji. (R. 753, 997.) She reported no complaints and stated that she was compliant with her medications. (R. 753, 997.) Dr. Nwokeji noted that Gomez exhibited “[m]oderate improvement” in responding to medications. (R. 754, 998.) The report on her mental status was mostly unchanged. Dr. Nwokeji added only that her “[p]sychomotor behaviors are unremarkable.” (R. 754, 998.)

         Beginning in early December 2011, Gomez attended weekly individual therapy sessions with Gustavo A. Checa, a licensed master social worker, at Clay Avenue. (See, e.g., R. 761-62.) On intake, Checa assessed a GAF score of 50. (R. 766-68, 1012.) Gomez reported to Checa that she had been drinking more than five glasses of beer per day as recently as the previous month. (R. 766.) She also reported her past drug abuse, including snorting heroin until July 2, 2011. Checa's mental status evaluation from his first session with Gomez reports that she displayed agitated behavior, hyperactive psychomotor behavior, pressured speech, anxious mood, tangential thought processes, and obsessive thought content. (R. 767.) Gomez told Checa that in order to handle anger she took showers, took her medication, went to sleep, or read a book. In order to handle sadness she cried. Id. Checa's notes from various therapy sessions from January 2012 to May 2012 reveal that Gomez increasingly reported “anxiety” as her chief complaint (see, e.g., R. 893, 907, 910, 940); she and Checa discussed, among other things, Gomez's progress at Promesa (see, e.g., R. 787, 790, 893, 904), her difficulties with a roommate (R. 888), and her attempts to locate housing outside of Promesa. (R. 888, 907, 910, 940.)[7]

         At Clay Avenue, Gomez was also seen occasionally by nurse practitioner (NP) Briana Morrison. (See, e.g., R. 773-76.) On December 16, 2011, when Gomez presented with depression, Morrison stated that her “[r]elated symptoms are fairly controlled, ” and there was “improvement of initial symptoms, ” and that the patient's GAF score was 45. (R. 773, 1017.) Gomez told Morrison that her functioning was “somewhat difficult, ” but she denied any presenting symptoms or aggravating factors, and she reported her medication to be “therapeutic and tolerable.” (R. 773, 1017.) Gomez was compliant with her medication at that time; her medication response was noted as “[s]ymptoms resolved.” (R. 774, 1018.)

         Gomez next saw her treating psychiatrist, Dr. Nwokeji, on January 13, 2012. (R. 793, 1037.) Dr. Nwokeji noted that Gomez was compliant with her medications and that there had been moderate improvement in her medication response. (R. 794, 1038.) Gomez denied experiencing any side effects from her medications. (R. 794, 1038.) Dr. Nwokeji's mental status report dated January 13, 2012 remained unchanged from his prior reports. (R. 794, 1038.)

         That same day, Dr. Nwokeji completed a Medical Source Statement for Gomez in connection with her pending SSI application. (R. 308.) In the Medical Source Statement, Dr. Nwokeji stated that he had first seen Gomez on September 16, 2011 at the Clay Avenue mental health clinic, and monthly thereafter Id.[8] Dr. Nwokeji listed Gomez's symptoms as mood swings, poor sleep, poor appetite, and command auditory hallucinations. (R. 308.)[9] Gomez's mood was depressed, and her affect was labile (indicating rapid shifts in outward emotional expressions), but she denied any suicidal or homicidal ideation. Id. Dr. Nwokeji assessed her insight, judgment, and impulse control as “fair.” Id. He concluded that Gomez's GAF score was 45 and that her impairments lasted, or could be expected to last, at least twelve months. (R. 309.)

         As part of the Medical Source Statement, Dr. Nwokeji checked boxes to indicate that Gomez's mental abilities were “poor” with respect to every category concerning her ability to make an occupation adjustment; every category concerning her ability to make a performance adjustment; and every category concerning her ability to make a personal-social adjustment. (R. 310-12.) However, asked to identify the factors that supported his assessment or any other work-related activities that would be affected by Gomez's impairment, Dr. Nwokeji left those sections of the form blank. Id. He did check a box to indicate that Gomez could manage benefits in her own best interest. (R. 312.)

         On February 16, 2012, Gomez presented to Dr. Nwokeji with mood swings. (R. 1055.) She reported that she had “no complaints, ” that she was compliant with her medications, and that she had not experienced any side effects from her medications. Id. Dr. Nwokeji noted “[m]oderate improvement” with respect to Gomez's response to medication, and her mental status report remained unchanged. (R. 1056-57.)

         On March 1, 2012, Dr. Nwokeji completed a “psychiatric summary” of Gomez, which set forth unremarkable findings concerning her mental status, including “[f]riendly affect and good mood.” (R. 321.) Her GAF score remained unchanged at 45. Id.

         On April 12, 2012, Dr. Nwokeji completed another “psychiatric summary, ” in which he described Gomez's presenting problem as:

[A] long History of Dysphoria with persistent sadness, insomnia, social withdrawal, Anhedonia, poor impulse control, religious pre-occupation, anxiety and associated vague Auditory Hallucinations with ideas of reference which lasts for 2 to 3 weeks at a time. She also describes occasions of persistent irritable mood with pressured speech, “flight of ideas” and increased energy which last between 3 to 5 days. She is being followed for medication management monthly and weekly psychotherapy.

(R. 319.) Dr. Nwokeji also noted that Gomez “has been unable to function without medications.” (R. 320.) The mental status report was generally unremarkable. (R. 319.)

         On April 20, 2012, shortly after her application for supportive housing was conditionally approved by the New York City Human Resources Administration (NYC HRA), Gomez was admitted to the St. Barnabas Hospital Emergency Department with a panic attack. She was discharged later that day. (R. 323-24, 328, 1080.)

         On May 9, 2012, Gomez met with NP Esther Aguirre at Clay Avenue for “standard medication management.” Gomez presented as “extremely anxious, tearful, [and] agitated.” (R. 1090.) Ultimately, however, she “agree[d] to refrain from harmful action, ” and she was “able to descale, ” and “went back to MTAR.” (R. 1092-93.) Two days later, on May 11, 2012, Gomez reported to her social worker, Checa, that she was going to a “3/4 housing” in two weeks and that her plan was to move into “supportive housing” eventually. (R. 1095.) It is unclear from the record whether these moves ever occurred. On May 29, 2012, Gomez saw NP Aguirre, reported feeling “less agitated, ” and stated that her medication was helping. (R. 1104.)

         On August 13, 2012, Gomez again saw NP Aguirre for medication management. (R. 1238.) The notes state that Gomez had “graduated” from MTAR the previous month and that she was in the “Narco Freedom” substance abuse and treatment program. (R. 1238.) Gomez reported that she was feeling “less agitated” but was starting to get panic attacks, and that her doctor was not helping. Id. Her mental status report remained generally unremarkable; however, NP Aguirre noted that Gomez's “[t]hought content reveals paranoia.” (R. 1241.) Gomez agreed to continue her current medications and NP Aguirre recommended therapy. (R. 1242.)

         6. Treatment at FEGS (November - December 2012)

         In November and December 2012 Gomez was evaluated at the Institute for Family Health through Federation Employment and Guidance Services (FEGS). (R. 1194, 1214.)[10] It appears that her initial evaluation, on December 4, 2012, was conducted by Dr. Artur Mushyakov, M.D. (R. 1194.) The results of the evaluation are contained in a FEGS Biopsychosocial Report (BPS Report), which states that Gomez's last auditory hallucinations were in May 2011; that she had traveled independently to her FEGS appointment by subway, but was unable to travel during rush hours because of a history of head injury; and that she spent her days seeking housing. (R. 1222.) Gomez received a score of 14 on a Patient Health Questionnaire for depression (PHQ-9), which indicated “moderate” depression. (R. 1206, 1223.) With respect to her daily activities, Gomez reported that she was able to wash dishes and clothes, sweep/mop, vacuum, make beds, shop for groceries, cook meals, get dressed, bathe, and use the toilet. (R. 1223.)

         The BPS Report also noted that Gomez “became tearful” during her evaluation, reporting that “her lack of stable housing for 12 years or longer [was] devastating” and that she “feels often overwhelmed with all of her appointments and lack of assistance.” (R. 1223.) Dr. Mushyakov referred her for a psychiatric examination for anxiety and schizophrenia. (R. 1194.)

         On December 19, 2012, Gomez saw Dr. John Lohrasbi for the psychiatric examination. (R. 1197.) She unable to elaborate on certain aspects of her personal and medical history, (R. 1195), and was “evasive” regarding her drug use. The report indicates that Gomez may have used drugs the previous month. Id. With respect to Gomez's functional impairment, Dr. Lohrasbi stated that her ability to follow work rules, accept supervision, deal with the public, maintain attention, relate to co-workers, adapt to change, and adapt to stressful situations were all “severely impaired.” (R. 1195-96.) Gomez was assessed a GAF score of 45, and diagnosed with Opioid Dependence and Mood Disorder. (R. 1196.) Her “wellness plan” included outpatient psychotherapy rehabilitation, antipsychotic medication, and methadone substance abuse treatment. Id.

         II. ...


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