United States District Court, S.D. Ohio, Eastern Division
L. Graham, Judge
REPORT AND RECOMMENDATION
KIMBERLY A. JOLSON, UNITED STATES MAGISTRATE JUDGE
Garry Farrell, brings this action under 42 U.S.C. §
405(g) seeking review of a final decision of the Commissioner
of Social Security (“Commissioner”) denying his
applications for Disability Insurance Benefits
(“DIB”) and Supplemental Security Income Benefits
(“SSI”). For the reasons set forth below, it is
RECOMMENDED that the Court
REVERSE the Commissioner's
non-disability finding and REMAND this case
to the Commissioner and Administrative Law Judge under
Sentence Four of § 405(g).
filed his applications for DIB and SSI on June 4, 2015,
alleging that he was disabled beginning April 14, 2014. (Doc.
9, Tr. 228-38). After his application was denied initially
and on reconsideration, the Administrative Law Judge (the
“ALJ”) held a hearing on March 22, 2018. (Tr.
31-61). On July 13, 2018, the ALJ issued a decision denying
Plaintiff's application for benefits. (Tr. 9-30). The
Appeals Council denied Plaintiff's request for review,
making the ALJ's decision the final decision of the
Commissioner. (Tr. 1-6).
filed the instant case seeking a review of the Appeals
Council's decision on May 22, 2019 (Doc. 1), and the
Commissioner filed the administrative record on August 19,
2019, (Doc. 9). This matter is now ripe for review.
(See Docs. 10, 11, 12).
decision, the ALJ found that Plaintiff met the insured status
requirements of the Social Security act through September 30,
2017, (Tr. 14), and had not engaged in substantial gainful
activity since April 14, 2014, the alleged onset date, (Tr.
15). He found that Plaintiff suffers from the following
severe impairments: degenerative joint disease of the right
ankle, status post-surgical repair of torn ligaments;
obesity; anxiety disorder with panic attacks and agoraphobia;
obsessive compulsive disorder (“OCD”);
post-traumatic stress disorder (“PTSD”).
(Id.). The ALJ, however, found that none of
Plaintiff's impairments, either singly or in combination,
met or medically equaled a listed impairment. (Tr. 18).
Plaintiff's residual functional capacity
(“RFC”), the ALJ opined:
[T]he claimant has the residual functional capacity to
perform medium work as defined in 20 CFR 404.1567(c) and
416.967(c) except: frequently climb ramps/stairs, balance,
and stoop; occasionally climb ladders/ropes/scaffolds,
crouch, crawl, and work around hazards such as dangerous
machinery and unprotected heights. Additionally, the claimant
is limited to simple, routine tasks with no fast production
pace. He can occasionally interact with others but not
perform tandem tasks or be involved in teamwork positions, in
conflict resolution, in persuading others, or in customer
service positions. And there can be only occasional changes
in the work setting.
Relevant Hearing Testimony
hearing, Plaintiff testified that he generally does not leave
the house. (See, e.g., Tr. 43). He stated that his
previous job ended because he was missing days and leaving
work early with panic attacks. (Tr. 35). He also testified
that he has not looked for work since moving to Ohio because
of his anxiety. (Id.). Plaintiff testified that, on
good days, his anxiety is a four or five; on most days,
however, his anxiety is an eight or nine. (Tr. 40). He also
testified that he has difficulty being in public places with
noise and commotion and that he suffers from short attention.
at the hearing, Michael Lace, Psy.D., a medical expert,
testified that Plaintiff suffers from panic disorder,
agoraphobia, generalized anxiety disorder, and
obsessive-compulsive disorder. (Tr. 49). He testified that
the mental status exams in the record “suggest a fairly
high level of anxiety, constrictive affect, somewhat
compromised at times.” (Tr. 50). He further stated that
it is “difficult to lend a lot of credibility”
to the reports of Plaintiff's therapists because they
were not provided by an acceptable medical source.
(Id.). He also testified that there “appear[s]
to be some ongoing therapy” and “medication
notes.” (Tr. 50-51). Additionally, he testified that,
based on the record, no listings were met or equaled,
explaining that the record supports “mild”
limitations in Plaintiff's ability to understand and
remember and “moderate” limitations regarding his
ability to interact with others, and noting that
“[t]here is evidence of fairly consistent anxiety,
panic.” (Tr. 51). He also testified that Plaintiff
would have “moderate” limitations in his ability
to concentrate, persist, or maintain pace. (Id.). As
for a residual functional capacity, Dr. Lace testified that,
“[i]f the claimant were to work full-time, there would
be some significant limitation[s].” (Tr. 52).
Specifically, he testified that Plaintiff should “be
limited to brief, superficial, and occasional contact with
all groups, the general public, supervisors, as well as
coworkers” and “to routine tasks, with few, if
any changes in terms of venue” and “no fast-paced
production or high quotas.” (Id.).
Relevant Medical Evidence
received counseling at Mind Springs Health Center in Grand
Junction, Colorado, from December 8, 2014 through July 30,
2015. (Tr. 351-77). Mental status examinations revealed an
anxious mood and racing thoughts but logical and
goal-directed thought process with no signs or symptoms of a
formal thought disorder and no suicidal ideation and normal
speech, memory, and concentration. (See, e.g., Tr.
353, 358-59, 364-65, 372-73). Plaintiff was diagnosed with
generalized anxiety disorder. (Tr. 355). Treatment notes from
January 2015 document Plaintiff's difficulty leaving
home, social anxiety, and generalized anxiety disorder. (Tr.
347). A January 2015 mental status exam revealed poor
hygiene, friendly personality, psychomotor agitation, and
anxious mood. (Tr. 364). In July 2015, Plaintiff stated that
his anxiety had not improved in the last 6 months and rated
his anxiety between a seven and nine throughout the day. (Tr.
352). He reported racing thoughts, anxiousness, shaking,
heart pounding, panic at times, and fear of leaving the
February 2016, Plaintiff reported panic attacks and worsening
anxiety throughout the day. (Tr. 391). In April 2016,
Plaintiff's primary care provider met with
Plaintiff's therapist, who “d[id] not think
[Plaintiff] can make progress on his anxiety as he is
struggling too much.” (Tr. 385). His primary care
provider told his therapist about his
“impression” that Plaintiff “has become
habituated to the Xanax and it has created additional
pathology.” (Id.). In May 2016, Plaintiff
reported tossing and turning and having nightmares but
reported seeing a therapist weekly. (Tr. 383). In July 2016,
Plaintiff expressed having “horrible” anxiety and
that only Xanax provided relief. (Tr. 379). On exam,
Plaintiff appeared agitated, anxious, and distracted, and was
described as “[v]ery tense, agitated, anxious.”
(Id.). In August 2016, Plaintiff described symptoms
of agoraphobia and social anxiety. (Tr. 397). Mental status
exam notes revealed benign findings other than mild avoidant
eye contact, moderately rapid speech, moderately racing
thought process, severely anxious mood, and severely restless
behavior. (Tr. 400).
mental status exam performed by Ms. Baker revealed a
well-groomed appearance, mildly avoidant eye contact, mildly
mistrustful demeanor, severely anxious mood, and moderately
constricted affect. (Tr. 488). Treatment notes throughout
2017 from psychiatric nurse practitioner Maryam Niazi show
limited judgment and insight, racing thoughts, fidgety
behavior, agitation, mistrust, and an unstable condition but
no reports of delusions, self-abuse, aggression, or
hallucinations. (See, e.g., Tr. 566, 568-70).
4, 2017, Plaintiff presented for a psychotherapy intake at
Tru-Rob Counseling and Consulting. (Tr. 494). He appeared
agitated with a constricted affect and anxious mood but had
appropriate thought process and was oriented to person,
place, and time. (Id.). His memory was intact, and
he had good attention and concentration. (Id.). He
had appropriate thought content with normal speech and
unremarkable flow of ...