United States District Court, N.D. Ohio, Eastern Division
MEMORANDUM OPINION & ORDER
KATHLEEN B. BURKE, UNITED STATES MAGISTRATE JUDGE
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.
protectively filed applications for Disability Insurance
Benefits (“DIB”) and Supplemental Security Income
(“SSI”) on July 23, 2013. 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.
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.
Personal, vocational and educational evidence
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.
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
Tr. 252. He was admitted to North Coast Behavioral Center
from May 17, 2013, through May 31, 2013. Tr. 248, 272.
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. 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.
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.
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.
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.
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.
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.
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.
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.
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. Tr. 342.
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.
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.
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.
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“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.
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.
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.
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.
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.
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.
Sweeney - January 2, 2014
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
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.
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.
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.
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.”
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.
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.
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.
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.
Sweeney, co-signed by M.D. - March 3, 2014
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.
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.
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.
Kauffman and Dr. Hunt - April 2015
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.
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.
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