MICHAEL A. TELESCA, District Judge.
Rebecca Sharrow, ("Plaintiff"), who is represented by counsel, brings this action pursuant to the Social Security Act ("the Act"), seeking review of the final decision of the Commissioner of Social Security ("the Commissioner") denying her applications for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI"). This Court has jurisdiction over the matter pursuant to 42 U.S.C. § 405(g). Presently before the Court are the parties' motions for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. Dkt. ## 12, 15.
Plaintiff filed an application for DIB and SSI on March 3, 2014, claiming disability since October 31, 2012. T. 177.
The issue before the Court is whether the Commissioner's decision that Plaintiff was not disabled is supported by substantial evidence and free of legal error.
In applying the familiar five-step sequential analysis, as contained in the administrative regulations promulgated by the Social Security Administration ("SSA"),
A federal court should set aside an ALJ decision to deny disability benefits only where it is based on legal error or is not supported by substantial evidence.
Plaintiff challenges the ALJ's decision on the following grounds: (1) the ALJ erred in determining that Plaintiff did not suffer from a severe mental and/or physical impairment; (3) the ALJ failed to attribute controlling weight or any other weight to the opinions of Plaintiff's treating physicians; and (4) the ALJ erred in relying upon the opinion of the consultative examiner. Dkt. #12-1 at 1.
Plaintiff argues that remand is necessary because the ALJ found that she did not suffer from a severe mental and/or physical impairment. Pl. Mem. 15-20.
At step two of the five-step analysis, the ALJ must consider a claimant's medically determinable impairments and decide whether they are "severe." A "severe" impairment is "one that significantly limits a claimant's ability to perform basic work activities," such as "walking, standing, sitting, lifting, [etc.], [c]apacities for seeing, hearing, and speaking, and [u]nderstanding, carrying out, and remembering simple instructions."
Moreover, "[c]ourts have developed a specialized variant of harmless-error analysis with respect to Step 2 severity errors in social security proceedings. . . . [W]hen an administrative law judge identifies some severe impairments at Step 2, and then proceeds through [the] sequential evaluation on the basis of [the] combined effects of all impairments, including those erroneously found to be non severe, an error in failing to identify all severe impairments at Step 2 is harmless."
The record indicates as follows: Plaintiff is a 50-year old female with one year of college education and past relevant work as a sales representative, customer service representative, assistant manager, and customer retention representative. T. 48, 50-57. She testified that she was unable to continue working at her sales job because of the stress of being an aggressive salesperson and meeting quality assurance requirements. T. 51-52. She left her job as an assistant manager at a convenience store after suffering a "crack up" from depression and anxiety. T. 53. Plaintiff suffered depression and anxiety due to, among other things, her husband's unexpected passing, a terminated pregnancy, and body dysmorphic disorder stemming from lifelong obesity. T. 54-65. She had previously weighed 500 pounds, but was down to 336 pounds after gastric bypass surgery. T. 50-51.
On May 23, 2010, Plaintiff complained of depression while being treated at Tuscarora Health Center ("Tuscarora"). She was observed to have a sad expression, flat affect, and she stated she did not like leaving her house. T. 719. She was diagnosed with depression.
Plaintiff was prescribed Lexapro. T. 686. On October 20, 2011, she reported that she did not feel depressed or anxious regarding going to work and when she is away from home for anytime." T. 683.
On July 5, 2012, Plaintiff was upset about her daughters and family issues/relations, that she was under stress and had started a new job. T. 672. Her psychiatric assessment was otherwise normal.
On October 23, 2012, during an appointment at Tuscarora, Plaintiff complained of depressive mood and continued family/financial stressors. T. 637. She reported at that she had stopped taking her Lexapro because she ran out.
Plaintiff was referred by Tuscarora to Niagara Falls Adult Mental Health Clinic ("the Clinic") for managing stress, anxiety, and depression. She appeared on April 11, 2014, for an initial assessment. T. 430. Plaintiff reported having a hard time managing stress which lead to depression and anxiety. She reported an "emotional breakdown" three years prior but did not go to the hospital. T. 431. Justin Walck, LMSW, assessed Plaintiff's impairments in functioning as "severe difficulty maintaining employment, moderate inability to get out of bed, poor personal hygiene and procrastination."
On April 24, 2014, Christine Ransom, Ph.D., performed a consultative mental evaluation of Plaintiff. T. 442-45. The psychologist found that Plaintiff was oriented with normal motor behavior, appropriate eye contact, fluent speech, coherent and goal-directed thought process, mildly dysphoric and tense affect, and intact memory, attention, and concentration. T. 443-44. Plaintiff told Dr. Ransom that her daily activities included maintaining her personal care, preparing meals, cleaning, doing laundry, shopping, socializing with her family, watching television, reading, and making crafts. T. 444.
Dr. Ransom opined that Plaintiff could follow and understand simple directions and instructions, perform simple tasks independently, maintain attention and concentration for simple tasks, maintain a simple regular schedule, and learn simple new tasks. T. 444. She indicated that Plaintiff had only mild difficulty performing complex tasks, relating adequately with others, and appropriately dealing with stress. T. 444.
On April 25, 2014, Mr. Walck, LMSW, assessed Plaintiff's prognosis as fair, and she was not referred to a psychiatrist in lieu of conservative measures. T. 791. Although Plaintiff was scheduled to attend counseling sessions every two weeks, she did not return to the Clinic until June 20, 2014, at which time she was again diagnosed with generalized anxiety disorder and depressive disorder. T. 794-95.
Plaintiff returned to the Clinic on August 19, 2014. T. 798-805. The provider noted that "adequate coping skills of yet to be established as client has shown poor attendance." T. 799.
On August 28, 2014, Plaintiff complained of increased difficulty falling/staying asleep and that her thoughts were racing at night. She had episodes of stress-induced anxiety. T. 763-765. On September 9, 2014, Plaintiff was again seen at the Clinic with continuing depression and anxiety. At Plaintiff's September 30, 2014 session, it was noted her condition and complaints were unchanged. T. 808-812.
On February 10, 2015, Plaintiff complained her anxiety and insomnia had increased. She was grieving the loss of her grandmother as well as dealing with longstanding family issues and despite learning to use tools for self-help, these issues were still overwhelming to her. She stated that something was wrong with her and she couldn't seem to get out of the mood she was in. Her diagnosis of depressive disorder remained the same. T. 839.
On March 23, 2015, Plaintiff complained that she was feeling more overwhelmed with worry which interfered with her quality of life, and was having trouble sleeping. Her prior diagnosis of depressive disorder and anxiety remained the same. T. 835-836.
On July 6, 2015, Plaintiff was treated at Tuscarora where her continuing diagnosis of depressive disorder, malaise and fatigue were confirmed. T. 906.
On March 14, 2016, Plaintiff was treated at Tuscarora and complained that her depression was getting worse and medication was not helping enough. T. 919-920.
On May 26, 2016, a Mental Health Report was filled out by the Niagara County Department of Social Services which indicated Plaintiff suffered from major depressive disorder and generalized anxiety disorder in addition to her physical ailments. She also was assessed as having relationship issues with limited social support. She was prescribed Wellbutrin, Lexapro, Klonopin, Celebrex, and Norvasc. The Report states that Plaintiff showed uneven improvement throughout the program. T. 977.
On July 6, 2016, psychologist Dr. Christopher Pino evaluated Plaintiff and stated he would continue treating her for social anxiety disorder and depression. T. 883. At that time he assessed a GAF score of 50.
Plaintiff now requests that the matter be remanded for the ALJ to determine how Plaintiff's severe anxiety and depression affect her RFC. The Court agrees that the ALJ erred in her step two severity analysis in light of her subsequent RFC finding which does not contain any mental limitations. T. 27. Rather, the ALJ found that Plaintiff could perform her past work of telephone sales representative and customer relations complaint clerk, both semiskilled, sedentary jobs, after assessing her RFC with the physical demands of the work only.
Generally, the failure to find an impairment severe at step two may be considered harmless, and the Court would be inclined to find such a failure to be harmless error, since the ALJ found other impairments to be severe and continued with the sequential evaluation. However, the medical, testimonial, and opinion evidence calls into question whether the ALJ properly considered the evidence related to Plaintiff's mental impairments.
In light of the Court's determination it need not reach Plaintiff's remaining arguments.
For the foregoing reasons, Plaintiff's motion is granted to the extent that the matter is remanded to the Commissioner for further administrative proceedings consistent with this Decision and Order and the Commissioner's motion is denied.
ALL OF THE ABOVE IS SO ORDERED.