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Gargano v. Commissioner of Social Security

United States District Court, N.D. Ohio, Eastern Division

March 13, 2017

CARMINE JOSHUWA GARGANO, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          MEMORANDUM OPINION & ORDER

          KATHLEEN B. BURKE, UNITED STATES MAGISTRATE JUDGE

         Plaintiff Carmine Joshuwa Gargano (“Plaintiff” or “Gargano”) seeks judicial review of the final decision of Defendant Commissioner of Social Security (“Defendant” or “Commissioner”) denying his applications for social security disability benefits. Doc. 1. This Court has jurisdiction pursuant to 42 U.S.C. § 405(g). This case is before the undersigned Magistrate Judge pursuant to the consent of the parties. Doc. 15. As explained more fully below, the ALJ's analysis of the medical opinion evidence is insufficient to allow the Court to assess whether the decision is supported by substantial evidence. Accordingly, the Court REVERSES and REMANDS the Commissioner's decision for further proceedings consistent with this opinion.

         I. Procedural History

         Gargano protectively filed applications for Disability Insurance Benefits (“DIB”) and Supplemental Security Income (“SSI”) on July 23, 2013.[1] Tr. 22, 85-86, 177-180, 181-186. Gargano alleged a disability onset date of May 15, 2013. Tr. 22, 177, 181, 202, 226. He alleged disability due to memory problems, bipolar disorder, cannabis dependence, schizoaffective disorder, and back problems. Tr. 64, 87, 117, 133, 202. Gargano's applications were denied initially (Tr. 117-130) and upon reconsideration by the state agency (Tr. 133-137). Thereafter, he requested an administrative hearing. Tr. 143-144. On April 28, 2015, Administrative Law Judge Eric Westley (“ALJ”) conducted an administrative hearing. Tr. 36-63.

         In his May 19, 2015, decision (Tr. 19-35), the ALJ determined that Gargano had not been under a disability within the meaning of the Social Security Act from May 15, 2013, through the date of the decision. Tr. 22, 30. Gargano requested review of the ALJ's decision by the Appeals Council. Tr. 14-18. On February 11, 2016, the Appeals Council denied Gargano's request for review, making the ALJ's decision the final decision of the Commissioner. Tr. 1-6.

         II. Evidence

         A. Personal, vocational and educational evidence

         Gargano was born in 1983. Tr. 42, 177. He was 31 years old at the time of the administrative hearing. Tr. 42. Gargano lives alone in a house that he and his father own. Tr. 41. He is not married and has no children. Tr. 43. He completed school through the 12th grade and started working right after high school. Tr. 42-43. He worked at a coffee/donut shop owned by his father. Tr. 45-46. The shop sold other items such as tobacco and lottery. Tr. 45. Gargano stocked shelves and performed janitorial work. Tr. 45-46. Gargano had some minimal supervisory responsibilities. Tr. 45-46. For example, if someone did not show up for work, he would call them or try to find out why they were not at work. Tr. 46. Ultimately, his father fired him because he had made some female co-workers cry and was showing up late or not showing up for work. Tr. 46-47. Gargano was not told and he does not know what he did to make his co-workers cry. Tr. 47. Gargano worked for a painting company doing outdoor painting when he was in high school. Tr. 47-48. Gargano's most recent work attempt was in the fall of 2014. Tr. 43. He worked at a zombie paintball attraction at Mapleside, an apple farm. Tr. 43-45. His friends were responsible for running the paintball attraction so his schedule was pretty much whatever he wanted it to be. Tr. 44. Gargano was not fired from the job; the job just ended. Tr. 45.

         B. Medical evidence

         1.Treatment history

         On May 15, 2013, Gargano presented to the emergency room at Lutheran Hospital with complaints of hallucinations. Doc. Tr. 268-271. Gargano's mother was present with him. Tr. 238. Gargano's mother relayed that, over the prior two weeks, her son had been wandering around and acting strange. Tr. 268. Gargano considered jumping off a bridge, thinking it was part of a quarry with water. Tr. 268. Gargano admitted to abusing marijuana and opiates but denied using for about a week. Tr. 268. However, the lab results on admission were positive for marijuana. Tr. 249. Gargano had never been diagnosed with a mental health issue. Tr. 268. He denied any exacerbating or alleviating factors and denied any suicidal or homicidal ideations. Tr. 268. On physical examination, Gargano was observed to have a normal mood and affect; his thought content was normal; his speech was rapid and/or pressured and tangential; he was actively hallucinating; his thought content was not paranoid and not delusional; his cognition and memory were normal; he expressed impulsivity; and he expressed no homicidal or suicidal plans or ideation. Tr. 269. Gargano was initially diagnosed with hallucinations and schizophrenia. Tr. 270. His GAF score on admission was 39.[2] Tr. 252. He was admitted to North Coast Behavioral Center from May 17, 2013, through May 31, 2013. Tr. 248, 272.

         During his admission at North Coast Behavioral Center, Gargano reported that he did not trust anyone except his mother; he had neglected his personal hygiene, he had periods of over activity and periods of sleeping just a few hours; he lost almost 50 pounds over several months; his spending behavior was reckless; he felt that people were out to get him; and he had very impulsive behavior. Tr. 248. Gargano had a history of skeletal pain that led to OxyContin abuse and he almost ended up in trouble for drug trafficking. Tr. 248. Gargano also had a past history of using steroids for bodybuilding. Tr. 248. When he used steroids, he had racing thoughts. Tr. 248. At discharge, Gargano's diagnoses were bipolar I, hypomanic with psychotic features and marijuana dependence. Tr. 248. His GAF score was 56 at discharge.[3] Tr. 252. At discharge, Gargano was in control; not psychotic; not suicidal; had no auditory or visual hallucinations; his mood was even; and his judgment and insight had improved. Tr. 251. Dr. Manual Gordillo, M.D., the discharging physician, recommended that Gargano return home, look for a job, and proceed with outpatient psychiatric follow up at Center for Families and Children Service. Tr. 252. Gargano's prognosis was guarded. Tr. 252.

         On July 18, 2013, Gargano began receiving outpatient services at Center for Families and Children Service. Tr. 301-306. Gargano saw Maureen Sweeney, NP, for a Psychiatric Evaluation. Tr. 301-306. Gargano reported that he was seeking treatment because he was not feeling mentally stable. Tr. 301. Gargano's mother was present for the evaluation. Tr. 301. Gargano and his mother indicated that his symptoms started when he was 16 or 17 years old. Tr. 301. Gargano reported psychomotor agitation (shaking legs) and sleep disturbance. Tr. 301. Gargano was sleeping 2 hours a night. Tr. 301. He reported daily audio hallucinations, visual hallucinations, manic periods lasting for weeks to months, and depressive periods that last for days. Tr. 301. Nurse Sweeney observed that Gargano appeared hypomanic during the evaluation. Tr. 301. Gargano reported using marijuana a couple times per week and drinking alcohol only occasionally. Tr. 301. Gargano felt that the marijuana helped with the pain in his body. Tr. 301. Gargano indicated that he had been working with his father but his father did not want him to work at the donut/coffee shop because of his mental illness. Tr. 302. Gargano indicated that he had a lot of debt from being in business with his father. Tr. 302. Nurse Sweeney diagnosed bipolar I disorder, with psychotic features but rule out schizoaffective disorder, noting that it was unclear whether Gargano's psychotic features go away when Gargano is not manic. Tr. 303. Nurse Sweeney assigned a GAF score of 40. Tr. 304. Gargano was taking Gedeon and Depakote ER but reported having more days of severe depression. Tr. 303. Nurse Sweeney modified Gargano's medications. Tr. 303. She added Seroquel XR, continued Depakote, and decreased the Gedeon dosage. Tr. 303.

         Gargano saw Nurse Sweeney again on August 1, 2013. Tr. 308-309. Gargano indicated that he was depressed and irritable. Tr. 308. He was feeling isolated because his father and sister were judgmental about him seeking mental health treatment. Tr. 308. Gargano was continuing to have audio hallucinations but only at night. Tr. 308. Nurse Sweeney observed that Gargano appeared euthymic during the appointment and discussed with Gargano that his feelings of depression could be the effect of returning to euthymia following a period of hypomania. Tr. 308. Gargano reported medication side effects of sedation and muscle tightness. Tr. 309. Nurse Sweeney continued Gargano on Depakote, discontinued Gedeon, increased Seroquel, and added Cogentin to address Gargano's muscle tightness. Tr. 309. On August 13, 2013, Gargano saw Nurse Sweeney and reported “still feeling really depressed.” Tr. 310. Gargano was sleeping about 10 hours each day and still feeling fatigued during the day. Tr. 310. Gargano was continuing to have audio hallucinations but only at night. Tr. 310. Nurse Sweeney ordered Wellbutrin to address Gargano's depression but advised that there was a risk that the new medication could cause mania. Tr. 311. Gargano expressed his understanding of the risks and felt that the possible benefits outweighed the risks. Tr. 311. Nurse Sweeney indicated she would see Gargano again in 2 weeks to start him on Wellbutrin. Tr. 311. On August 27, 2013, Gargano saw Nurse Sweeney and reported the he was “still feeling pretty down.” Tr. 312. Nurse Sweeney started Gargano on Wellbutrin. Tr. 313.

         On September 23, 2013, Gargano saw Nurse Sweeney. Tr. 315-316. Gargano indicated that his mood was “normal.” Tr. 315. During that month, Gargano had a decreased need for sleep and he was having paranoid delusions. Tr. 315. He felt “like there was a conspiracy to get [him]” and “thought that the government was watching [him] and that other people's animals were watching [him.]” Tr. 315. Since starting on Wellbutrin, Gargano indicated that he felt less depressed and did not think that the Wellbutrin was causing his manic symptoms. Tr. 315. He relayed that, prior to having the manic symptoms, he had an increase in stressors - he had received a number of shut off notices from the city. Tr. 315. Gargano reported that he was continuing to have audio hallucinations. Tr. 315. He explained that, “[he] zone[s] out and [doesn't] hear the t.v. and . . . hear[s] old friend's that are no longer with [him], in a good way[.]” Tr. 315. Nurse Sweeney noted that Gargano was not manic or hypomanic. Tr. 315. Also, she indicated that Gargano's mood had “gotten better” since starting on Wellbutrin. Tr. 316. Since Gargano was having psychotic symptoms in the absence of mood deregulation, Nurse Sweeney suspected that a more accurate diagnosis might be schizoaffective disorder. Tr. 315-316. Nurse Sweeney increased Gargano's Seroquel to target his psychotic symptoms. Tr. 316.

         On October 7, 2013, Gargano saw his primary care physician Dr. Mudita Bhatia, M.D., for a physical at which time it was noted that Gargano was receiving outpatient treatment for bipolar disorder. Tr. 294. Gargano indicated that his hallucinations/delusions had improved since May 2013 but, at times, his mother observed him talking to himself or unseen people. Tr. 294. Also, it was noted that Gargano had very low attention and concentration and did not do anything at home except read. Tr. 294.

         During an October 21, 2013, appointment with Nurse Sweeney, Gargano indicated that his mood was “okay.” Tr. 318. He was continuing to have a difficult time processing stressors but was gaining insight. Tr. 318. He denied psychotic features. Tr. 318. Nurse Sweeney indicated that Gargano appeared stable on his medications. Tr. 319. On November 18, 2013, Gargano saw Nurse Sweeney. Tr. 320. He indicated that “things [were] okay, a little out of sorts[.]” Tr. 320. He indicated that he was “not feeling up or down.” Tr. 320. Gargano had no major issues to report. Tr. 320. He reported that his sleep was good. Tr. 320. Gargano was somewhat withdrawn but did not seem uncomfortable with that. Tr. 320. Gargano denied psychotic symptoms and, when asked if he thought his medication was helpful, he indicated, “yes . . . I was really out in left field before the meds[.]” Tr. 320. Nurse Sweeney indicated that Gargano's mood was stable. Tr. 320-321.

         On January 2, 2014, Gargano saw Nurse Sweeney reporting, “I am not feeling too good today[.]” Tr. 338. Gargano reported anger and irritability. Tr. 338. Nurse Sweeney was not sure whether Gargano's irritability was related to his depression or to personality issues. Tr. 339. Since Gargano did not report other symptoms of depression, Nurse Sweeney suspected that Gargano's irritability was related to personality issues. Tr. 339. Nurse Sweeney explained that anger is not something that is medicated and she offered Gargano a referral for counseling but Gargano declined. Tr. 338, 339. Gargano denied any hypomanic, manic, or psychotic symptoms. Tr. 338. Nurse Sweeney indicated that Gargano was easily confused. Tr. 338.

         During a February 3, 2014, visit with Nurse Sweeney, Gargano relayed that he was “really hearing a lot of voices all the time[.]” Tr. 340. Gargano's mood was “down.” Tr. 340. Gargano was hearing multiple voices and felt like certain television and radio programs were talking to him. Tr. 340. Gargano had insight into his feelings being abnormal but was continuing to have them. Tr. 340. Gargano's sleep was poor and varied. Tr. 340. At times, he was sleeping 10-12 hours a day and, at other times, he could not sleep. Tr. 340. Gargano reported no mania/hypomania symptoms. Tr. 340. Nurse Sweeney switched Gargano's diagnosis to paranoid schizophrenia due to the presence of psychotic features in the absence of mood issues. Tr. 341. Nurse Sweeney started Gargano on Latuda in place of Seroquel. Tr. 341. Gargano did not think that the Seroquel helped and it made him groggy. Tr. 340.

         On March 3, 2014, Gargano saw Nurse Sweeney and reported that “the [L]atuda works much better than the [S]eroquel[.]” Tr. 342. Gargano was no longer having audio hallucinations but he was having paranoid delusions. Tr. 342. He felt that the government was watching him through his electronic devices. Tr. 342. Nurse Sweeney observed that Gargano appeared less blunted and was pleasant. Tr. 343. Nurse Sweeney noted the possibility of sleep apnea.[4] Tr. 342.

         On April 1, 2014, Gargano saw Nurse Sweeney and reported that his mood had been “up and down” that month but better on Latuda. Tr. 357. Gargano's audio hallucinations and paranoid symptoms were reduced but he continued to believe he was being monitored through his television and computer but recognized that those thoughts were “not normal.” Tr. 357. Gargano was continuing to have difficulty processing information, especially when complicated situations were involved. Tr. 357. Nurse Sweeney observed a change in Gargano's physical appearance over the preceding year, noting that Gargano was dressing very casual and his hair was disheveled and no longer styled. Tr. 357. Nurse Sweeney continued to diagnose paranoid schizophrenia, noting that Gargano's psychotic symptoms had improved on Latuda but he was continuing to suffer negative symptoms of schizophrenia, including cognitive impairments evidenced by difficulty processing information. Tr. 358.

         On May 1, 2014, Gargano saw Nurse Sweeney reporting that he was “still having up and down days[.]” Tr. 359. Gargano felt that the Latuda was helping with his paranoid thoughts but he was continuing to have delusions about people monitoring him at his home. Tr. 359. Gargano continued to understand that these were abnormal thoughts but they felt very real to him. Tr. 359. Gargano decreased his Depakote on his own because he was sleeping too much. Tr. 359. There was no mania/hypomania present and Gargano's speech was normal. Tr. 359. Gargano's sleep had improved on the CPAP. Tr. 359. Gargano was continuing to isolate himself, which he indicated was due to his mood. Tr. 359. Because Gargano was continuing to have psychotic features, Nurse Sweeney increased Gargano's Latuda. Tr. 360. Also, Nurse Sweeney increased Gargano's Wellbutrin for his mood. Tr. 360. During a May 31, 2014, visit with Nurse Sweeney, Gargano reported that “things are getting better[.]” Tr. 361. Gargano denied audio hallucinations or delusional thinking - he no longer felt that the television was sending him messages. Tr. 361. Gargano was continuing to exhibit a flat affect, which his family was having a difficult time with. Tr. 361. Gargano's sleep was better; he was averaging about 8 hours. Tr. 361. Nurse Sweeney's assessment was that Gargano appeared more stable. Tr. 362. Nurse Sweeney informed Gargano that he would be seeing Kelley Kauffman because Nurse Sweeney was going to be out on leave. Tr. 362.

         On June 30, 2014, Gargano saw Kelley Kauffman, RN, NP. Tr. 363-364. Gargano reported that he had been taking it easy and was compliant with his medication. Tr. 363. He indicated that his audio hallucinations had decreased but he was having visual hallucinations. Tr. 363. He was having “feelings that animals and bugs [were] tracking him and reporting back to someone unknown.” Tr. 363. He said he ignores cameras and reported some paranoia of an unknown threat that he had been trying to discover for over a year. Tr. 363. Gargano stated that when he takes his Latuda he feels he needs to pace. Tr. 363. The Cogentin was not helping with Gargano's restlessness so Gargano requested an increase. Tr. 364. Nurse Kauffman increased Gargano's Cogentin dose and continued his other medication. Tr. 364.

         On July 30, 2014, Gargano saw Nurse Sweeney. Tr. 365. Gargano reported that his mood was “good for the most part[.]” Tr. 365. He was continuing to experience akathisia[5]“mostly at night” due to the Latuda but he was not taking his Cogentin regularly. Tr. 365, 366. Nurse Sweeney discussed this with Gargano and he agreed to increase his medication compliance. Tr. 366. Gargano denied psychotic features. Tr. 365. He was continuing to have some tax issues related to his father's business. Tr. 365. Gargano was no longer taking Depakote but continued with Cogentin, Latuda and Wellbutrin. Tr. 366.

         During an August 27, 2014, visit with Nurse Sweeney, Gargano indicated that his mood was “okay.” Tr. 367. He denied audio hallucinations but continued to have delusional thinking. Tr. 367. He relayed, “I feel like when I see white cars then they are all on the same team or something.” Tr. 367. His sleep was okay except when his akathisia was bad. Tr. 367. His Cogentin was not working. Tr. 367. Nurse Sweeney recommended discontinuing Cogentin because it was not effective and starting Benadryl. Tr. 368.

         On September 25, 2014, Gargano saw Nurse Sweeney reporting that his mood was “okay but stressed[.]” Tr. 369. Gargano relayed that he was working at Mapleside Farm for the season. Tr. 369. He was enjoying the work but was feeling stressed because he was working Monday through Friday 8:30-6 and unable to find time to meet with his case manager to discuss getting assistance with his medical bills. Tr. 369. However, Gargano did indicate that his mom could drop off paperwork with his case manager and Nurse Sweeney encouraged Gargano to set up a phone appointment with his case manager. Tr. 369. Sweeney indicated that his work was seasonal so he would stop working in November. Tr. 369. Gargano indicated that the audio hallucinations were “less on meds” and he was using music as a distraction from baseline symptoms. Tr. 369. Gargano's sleep was “good” - he was averaging 8 hours. Tr. 369. He denied suicidal and homicidal ideation. Tr. 369. Nurse Sweeney assessed Gargano as stable, noting he was able to work part time at a seasonal job and was compliant on medication. Tr. 370. She noted he needed assistance with social stressors and would forward a note to his case manager regarding that need. Tr. 370.

         On November 10, 2014, Gargano saw Nurse Sweeney and reported that his mood was “not great.” Tr. 371. Gargano indicated that performing seasonal work had affected his ability to take his medication so he was having more symptoms. Tr. 371. He was taking Latuda intermittently because of his work schedule. Tr. 371. He reported an increase in audio hallucinations and paranoia. Tr. 371. Gargano was interested in an injectable form of medication. Tr. 371-372. Nurse Sweeney discontinued Latuda and started Gargano on Invega with a plan to work towards Sustenna. Tr. 372.

         On December 1, 2014, Gargano saw Nurse Sweeney and reported that his mood was “okay” since starting on Invega but noted increased sedation and some mild toe cramping. Tr. 373. Gargano no longer believed that he had “vague ‘special powers'” but he was having some paranoia. Tr. 373. He explained “he stares out his window and ‘feels like there is something bad going to happen to him.'” Tr. 373. Gargano remained somewhat social with friends and he had recently had Thanksgiving dinner with his family. Tr. 373. Because of the sedation caused by the Invega, Gargano was interested in switching to a new medication. Tr. 373. Nurse Sweeney changed Gargano's medication from Invega to Abilify. Tr. 374.

         On February 2, 2015, Gargano saw Nurse Kauffman. Tr. 376-377. Gargano was euthymic with a congruent affect. Tr. 376. Gargano reported decreased paranoia and believed that his symptoms were well controlled on his current medication but he was still having instances of increased paranoia when under stress. Tr. 376. Gargano reported drinking to the point of “blacking out” when stressed. Tr. 376. Nurse Kauffman encouraged abstinence and discussed the effects of combining alcohol with medication. Tr. 376. Gargano saw Nurse Kauffman again on February 27, 2015. Tr. 378-379. Gargano reported that the Abilify was causing anxious feelings but did feel that the Abilify was helping manage his psychotic symptoms. Tr. 378. He denied internal restlessness but endorsed feeling that he needed to walk around. Tr. 378. He indicated that his mood was stable with intermittent paranoia that was manageable. Tr. 378. Gargano reported side effects of anxiety and heart burn. Tr. 379. Because side effects made taking his medication “regularly intolerable, ” Gargano requested a decrease in his medication rather than changing medications. Tr. 378. Gargano felt that the benefits of staying on Abilify at a reduced dose outweighed risks at the time. Tr. 379. Per Gargano's request, Nurse Kauffman decreased the Abilify dose to decrease the risk of side effects and continued the treatment of his symptoms of psychosis. Tr. 379.

         2. Opinion evidence

         a. Treating sources

         Nurse Sweeney - January 2, 2014

         On January 2, 2014, Nurse Sweeney completed a “Mental Impairment Questionnaire (RFC & Listings).” Tr. 324-327. Nurse Sweeney indicated in the Questionnaire that she had seen Gargano since July 2013 and that Gargano had a diagnosis of bipolar I disorder and a GAF score of 40. Tr. 324. She offered the following information regarding his “treatment and response:”

On Seroquel & Depakote for mood stabilization & Wellbutrin XL for depression. [N]o recent hypomanic/manic episodes but recent episodes of severe depression marked by anger/irritability.

Tr. 324. Nurse Sweeney indicated that Gargano's medication caused drowsiness, fatigue, and lethargy. Tr. 324. Nurse Sweeney indicated that the following clinical findings demonstrated the severity of Gargano's impairment and symptoms - irritable during appointments; difficult time concentrating; often confused; needs repeated education on medication and mental health; very concrete in his thinking; and unable to cope with stressors. Tr. 324. Nurse Sweeney opined that Gargano was unable to function at a level needed to maintain employment because of his diagnosis of bipolar disorder that was expected to last for more than 12 months. Tr. 324.

         As part of the Questionnaire, Nurse Sweeney opined that Gargano had marked restrictions in activities of daily living; marked difficulties in maintaining social functioning; marked difficulties in maintaining concentration, persistence or pace; and three episodes of decompensation within a 12 month period, each of at least two weeks duration. Tr. 327.

         Nurse Sweeney also rated Gargano's functional abilities in specific categories within the areas of “understanding and memory limitations;” “sustained concentration and persistence limitations;” “social interaction limitations;” and “adaptation limitations.” Tr. 325-326. The rating choices were “unlimited or very good, ” “limited but satisfactory, ” “seriously limited, but not precluded, ” “unable to meet competitive standards, ” and “no useful ability to function.” Tr. 325.

         In the area of “understanding and memory, ” Nurse Sweeney rated Gargano's ability to understand and remember very short and simple instructions as “unlimited or very good” and his ability to remember locations and work-like procedures and understand and remember detailed instructions as “seriously limited, but not precluded.” Tr. 325. She explained her ratings, noting that Gargano “has difficulty [with] concentration [and] memory when mood [at] extremes.” Tr. 325.

         In the area of “sustained concentration and persistence, ” Nurse Sweeney rated Gargano's ability to carry out very short and simple instructions as “limited but satisfactory.” Tr. 325. Nurse Sweeney rated Gargano's ability in the following seven categories as “seriously limited, but not precluded” - carry out detailed instructions; maintain attention and concentration for extended periods; perform activities within a schedule; sustain an ordinary routine without special supervision; work in coordination with or in proximity to others without being distracted by them; make simple work-related decision; and perform at a consistent pace without an unreasonable number and length of rest periods. Tr. 325. She rated Gargano as “unable to meet competitive standards” in the following two categories - manage regular attendance and be punctual within customary tolerances and complete a normal workday and workweek without interruptions from psychologically based symptoms. Tr. 325. She explained her ratings by noting that, “due to extreme moods related to bipolar [disorder, ] [Gargano] is extremely limited in ability to handle normal work activities (i.e. concentration, persistence, attention, schedule)[.]” Tr. 325.

         In the area of “social interaction, ” Nurse Sweeney rated Gargano as “seriously limited, but not precluded” in his ability to ask simple questions or request assistance and “unable to meet competitive standards” in the following four categories - 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; and maintain socially appropriate behavior and adhere to basic standards of neatness and cleanliness. Tr. 326. Nurse Sweeney explained her ratings, noting “[due to] bipolar [disorder] [Gargano] is extremely limited in ability to behave appropriately [with] co-workers or general public.” Tr. 326.

         In the area of “adaptation, ” Nurse Sweeney rated Gargano as having “limited but satisfactory” ability to travel in unfamiliar places or use public transportation and she rated Gargano as “seriously limited, but not precluded” in his ability to respond appropriately to changes in the work setting; be aware of normal hazards and take appropriate precautions; and set realistic goals or make plans independently of others. Tr. 326. She explained her ratings, noting “[Gargano] has difficulty processing information [due to] bipolar [disorder.]” Tr. 326.

         Nurse Sweeney indicated that Gargano did not have a low IQ or reduced intellectual functioning. Tr. 326. She opined that Gargano's impairments or treatment would cause him to be absent form work more than four days per month and his symptoms would cause him to be off-task 25% of an 8-hour workday. Tr. 327. Also, she opined that Gargano's symptoms would cause him to be tardy to work more than four times per month. Tr. 327.

         Nurse Sweeney, co-signed by M.D. - March 3, 2014

         On March 3, 2014, Nurse Sweeney completed a Mental Status Questionnaire. Tr. 334-336. The March 3, 2014, Questionnaire was co-signed by an M.D. Tr. 336. However, the name of the M.D. is not identifiable from the signature. Tr. 336. Gargano's mental status was described as follows: his appearance was pale and somewhat disheveled; his flow of conversation and speech were normal rate, rhythm and volume; his mood was “good” and his affect was congruent on that date but in the past his affect was appropriate; he had anxiety about his normal life stressors; he had paranoid delusions that the government was watching him through technology, he felt like he was thought projecting and at times felt like the television and radio were talking to him and sending him messages so he was having delusions of reference; he was alert and oriented; he had difficulty with concentration and short term memory because at times he had difficulty telling reality from psychosis; he had impairment with abstract reasoning; he had good insight into psychotic features but only when symptoms are well controlled; his judgment was dependent on the level of psychosis; and there were no substance abuse issues. Tr. 334.

         Nurse Sweeney indicated that Gargano's diagnosis was paranoid schizophrenia. Tr. 335. Gargano's treatment included Latuda to decrease his psychosis but he was still having some delusions of reference and paranoia. Tr. 335. Gargano was also taking Wellbutrin to stabilize his mood. Tr. 335.

         Nurse Sweeney offered her opinion regarding Gargano's functional abilities. Tr. 335. She opined that Gargano had difficulty with memory and comprehension due to psychosis. Tr. 335. He had severe difficulty in maintaining attention due to psychosis. Tr. 335. He had difficulty sustaining concentration or persisting at tasks due to psychosis. Tr. 335. He had difficulty interacting socially due to paranoia and psychosis and difficulty adapting due to psychosis. Tr. 335. In response to an inquiry regarding how Gargano would “react to the pressures, in work settings or elsewhere, involved in simple and routine, or repetitive, tasks, ” Nurse Sweeney stated that Gargano “would react very poorly to any work or life stressors as they would likely [increase] paranoia [and] psychosis.” Tr. 335.

         Nurse Kauffman and Dr. Hunt - April 2015

         In April 2015, Nurse Kauffman and Dr. Andrew Hunt, M.D., completed a “Mental Impairment Questionnaire.” Tr. 384-385. Nurse Kauffman signed the Questionnaire on April 2, 2015, and Dr. Hunt signed the Questionnaire April 9, 2015. Tr. 385. They indicated that Gargano had been with the agency since July 2013 and with Nurse Kauffman in 2015. Tr. 384. Gargano's diagnosis was listed as schizophrenia. Tr. 384. They indicated that Gargano was prescribed Abilify, Wellbutrin XL, and Cogentin, with restlessness listed as a side effect. Tr. 384. The following clinical findings were listed as demonstrating the severity of Gargano's impairment and symptoms - paranoia, disorganization, delusions of “special powers.” Tr. 384. Nurse Kauffman and Dr. Hunt indicated that Gargano's prognosis was “unclear, may be good with continued adherence to medication.” Tr. 384. They opined that Gargano's impairment lasted or was expected to last at least 12 months. Tr. 384.

         Nurse Kauffman and Dr. Hunt also rated Gargano's functional abilities in specific categories within the areas of “sustained concentration and persistence limitations;” “understanding and memory limitations;” “social interaction limitations;” and “adaptation limitations.” Tr. 384-385. The rating choices were “unlimited or very good, ” “limited but satisfactory, ” “seriously limited, but not precluded, ” “unable to meet competitive standards, ” and “no useful ability to function.” Tr. 384.

         In the area of “sustained concentration and persistence, ” Nurse Kauffman and Dr. Hunt rated Gargano's ability to carry out very short and simple instructions; to manage regular attendance and be punctual within customary tolerances; and perform at a consistent pace without an unreasonable number and length of rest periods as “seriously limited, but not precluded.” Tr. 384. They rated Gargano as “unable to meet competitive standards” in the following categories - carry out detailed instructions; maintain attention and concentration for extended periods; perform activities within a schedule; sustain an ordinary routine without special supervision; work in ...


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