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Carolyn L. Gibson v. Michael Astrue Comissioner of Social Security

March 18, 2013


The opinion of the court was delivered by: Kugler, United States District Judge:


This matter comes before the Court upon the appeal of Carolyn L. Gibson ("Gibson") for the review of a final determination of the Commissioner of Social Security ("Commissioner") denying her application for Supplemental Security Income ("SSI"), under Title XVI of the Social Security Act ("SSA"). For the reasons set forth below, the decision of the Commissioner is vacated and remanded to the Administrative Law Judge ("ALJ") for further consideration.


Gibson, a 36 year old woman, submitted an application for SSI on March 18, 2009. In the application, Gibson alleged that she has been plagued by various disabilities since January 5, 2005. Specifically, Gibson alleged to have suffered from Bi-Polar Disorder, chronic pain in her leg, neck and back, Post-Traumatic Stress Disorder ("PTSD"), and Depression. Gibson's prior work history includes working as a cashier and a waitress. Gibson alleges that she is unable to continue working in her previous positions, or any other position, because her physical and mental conditions are likely to cause recurring absences, a need for daily naps, and regular breaks, difficulty driving, loss of various "specific work activities," a limited range of motion in her neck, and frequent headaches.

A.Alleged Physical Limitations

On November 15, 2003, Gibson was admitted to the Virtua Memorial Hospital. She was discharged on November 20, 2003, with a physical diagnosis of neck pain as a result of a motor vehicle accident. (Admin. Rec. ("Rec.") at 206). On December 13, 2003, she was admitted to Lourdes Medical Center, complaining of pelvic and joint pain, and unspecified "chronic pain and multiple traumas." (Rec. at 233).

In May of 2008, Gibson was seen by Alan Dennison, M.D., of Cooper Family Medicine. After examining Gibson for an ear ache, Dr. Dennison prescribed Percocet to treat her "chronic neck and leg pain." (Rec. at 295). In October of 2008, Gibson was seen by Dr. Dennison's partner, Anjali Ray, M.D. Dr. Ray assessed Gibson following a motor-vehicle collision, and observed neck pain, limited range of motion, and bilateral neck tenderness. Dr. Ray also noted that the pain extended to Gibson's mid-back. (Rec. at 291). Gibson followed-up with Dr. Dennison five days later. In the follow-up examination, Dr. Dennison observed neck pain and decreased neck motion to the right. He further noted "muscle spasm and tenderness" in the right trapezius area, extending to the base of the skull on the right. (Rec. at 290). Gibson again followed-up with Dr. Dennison on February 3, 2009, with no change in her neck pain. (Rec. at 288).

On February 24, 2009, Gibson was seen by Marie Louis, M.D. for abdominal pain, which the doctor noted was "a new problem." After the examination, Dr. Louis made a note that Gibson's neck had normal range of motion and was supple. (Rec. at 285). On March 31, 2009, Hampton Counseling Center recommended an outpatient program for "chronic pain . . . herniated disks, secondary to a motor vehicle accident." (Rec. at 279). Gibson was discharged from the outpatient care in late April of 2009. (Rec. at 278). After one week, Gibson returned to Dr. Dennison, who observed neck pain and spasm, as well as tenderness in the right trapezius. (Rec. at 280).

On September 30, 2009, Nithyashuba Khona, M.D., of Best Med Consultants, PA, performed an orthopedic evaluation of Gibson, at the request of the State of New Jersey's Department of Labor and Work Force Development. (Rec. at 305). During the examination, Dr. Khona observed that Gibson's gait and station were normal, that she could walk on heels and toes, and could perform a squat. (Rec. at 306). She was also able to climb onto the operating table and change her clothes without requiring assistance. Id. She demonstrated no problems with her hand strength and dexterity. Id. Gibson displayed full range of motion of her shoulders bilaterally, elbows, forearms, wrists, fingers, hips, ankles, and knees. Id. Dr. Khona also noted that her cervical spine showed "full flexion, extension, and lateral flexion bilaterally." Id. Gibson also demonstrated "full rotary movement bilaterally, and no cervical or paracervical pain, spasm or trigger points." Id. As for Gibson's spine, thoracic and lumbar regions, Dr. Khona found 75% flexion and extension, as well as full later flexion bilaterally. (Rec. at 307). He found full rotary movement bilaterally. Id. He found no SI joint or sciatic tenderness. Id. He found no spasms, scoliosis, or kyphosis. Id. Ultimately, Dr. Khona's evaluation concluded that there were "no physical findings except for [Gibson's] subjective complaints of pain." Id.

Dr. Ray examined Gibson again on June 4, 2010, to treat dysuria and a burn on her leg that she allegedly sustained in an unspecified accident involving a motorcycle. (Rec. at 390). Dr. Ray did not report any further physical distress during that examination.On June 23, 2010, Gibson was evaluated by Dr. Ray a third time. Dr. Ray noted that Gibson had a supple neck with normal range of motion. (Rec. at 387). Yet, on July 19, 2010, when Dr. Ray again observed Gibson, she found neck pain and muscular tenderness. (Rec. at 384). Dr. Ray also noted "severe pain in the cervical spine after going on [a] boat." (Rec. at 383). After performing a physical exam, however, Dr. Ray found no tenderness of the spinous processes. (Rec. at 384). On November 12, 2010, Gibson was once more examined by Dr. Ray, after she fell down while on the stairs. (Rec. at 364-5). Dr. Ray noted that the fall "provoked her neck pain." (Rec. at 363-5). Finally, on December 7, 2010, Gibson sought a comprehensive evaluation of her health in connection with her SSI claim. In regards to her physical health, Dr. Dennison reported "chronic neck problems" and a "decreased [range of motion] of the neck and tenderness of the paraspinal muscles." (Rec. at 362).

B.Alleged Mental Impairments

On November 15, 2003, during her hospitalization at Virtua Memorial Hospital, Gibson was diagnosed with bipolar disorder, with mixed and severe episodes. (Rec. at 206). According to the discharge report, Gibson exhibited a variety of "difficulties apparently related to manic symptoms including impulsivity, distractibility, irritability, labile mood and very poor judgment." Id. She was discharged with an "improved condition." Id. Gibson next spent six-days in Lourdes Medical Center, from December 13 to December 19, 2003. While hospitalized, she was diagnosed and treated for bipolar disorder and alcohol abuse.

On November 4, 2004, Gibson was admitted to the Kennedy Health System. Upon admittance, she was diagnosed with "dysthymic disorder, major depressive disorder and PTSD, as well as alcohol dependence." (Rec. at 246). When she was discharged, she was diagnosed with "dysthymic disorder, PTSD, alcohol dependence and rule out ADHD." (Rec. at 247). The observing doctor noted that Gibson displayed "delusions/illusions" and "obsessive/compulsive thoughts." (Rec. at 252). However, the doctor also noted that her affect was "appropriate," her speech was "clear and coherent," her insight was good and her judgment was fair. Gibson was again admitted to the Kennedy Health System, on April 9, 2008. While there, she was diagnosed with Bipolar II Disorder, Major Depressive Disorder (illegible), panic disorder with agoraphobia, and PTSD. (Rec. at 261). On December 16, 2008, Gibson was again diagnosed with PTSD by Cooper Hospital's OB/GYN department. The staff attributed Gibson's PSTD to an alleged history of molestation and rape. (Rec. at 335).

After Gibson's evaluation with Dr. Dennison on February 3, 2009, he determined that she suffered from Bipolar Disorder, which manifested in the form of chronic stress and anxiety. (Rec. at 288). Due to panic attacks and anxiety, Gibson was seen by Dr. Ray on March 17, 2009. (Rec. at 282). She claimed an inability to sleep and auditory and visual hallucinations. Id. Dr. Ray strongly urged her to seek immediate mental healthcare. (Rec. at 283).

Gibson was admitted to Hampton Counseling Center on March 31, 2009. (Rec. at 278). Until she was discharged on April 28, 2009, Gibson participated in a number of group treatments, with the reported goal of decreasing symptoms associated with depression, anxiety, and PTSD. Id. At the time of her discharge, the Center diagnosed Gibson with "Depression, Not Otherwise Specified,"*fn1 as well as PTSD and alcohol abuse. Id. Gibson was readmitted to Hampton on May 12, 2009, again alleging symptoms of PTSD, depression, and anxiety. (Rec. at 296). Her discharge summary again noted the diagnosis of Depressive Disorder, Not Otherwise Specified, and Anxiety Disorder, Not Otherwise Specified. Id.

On September 23, 2009, Gibson met with Wm. Dennis Coffey, PsyD., for a mental status exam. (Rec. at 299). During the examination, Dr. Coffey observed that Gibson was impatient, not-forthcoming and very agitated. (Rec. at 302). He also noted that Gibson did not display any obsessive or compulsive behavior, suicidal or homicidal ideation, or symptoms of a thought disorder. Id. While her insight was poor, Dr. Coffey noted that she did not present with inadequacies in her understanding, memory, concentration, mental pace, and persistence. Id. Ultimately, he diagnosed Gibson with Depressive Disorder, Not Otherwise Specified, and Borderline Personality Disorder. (Rec. at 303). He recommended that Gibson continue with her current treatment, and that she consult with a psychiatrist and therapist. Id.

On October 5, 2009, Robert Eckardt, Ph.D., a state agency psychological consultant, provided a psychiatric review technique based on the existing medical evidence. (Rec. at 312). While Dr. Eckardt noted an unspecified depressive disorder, a substance abuse problem, and a personality disorder affecting her relationships, he determined that Gibson displayed only moderate mental limitations. (Rec. at 315-22).

On June 23, 2010, Gibson was again evaluated by Dr. Ray, who made note of her PTSD. (Rec. at 386). Dr. Ray repeated this evaluation on November 11, 2010, finding that Gibson suffered from panic attacks, bipolar disorder, and PTSD. (Rec. at 365). Dr. Dennison's final evaluation of Gibson dated December 7, 2010 again listed panic attacks, bipolar disorder, and PTSD as "active problem[s]." (Rec. at 362). In conjunction with the final evaluation, Dr. Dennison responded to a Medical Source Statement related to Gibson's SSI claim. In his response to the statement, Dr. Dennison diagnosed Gibson with PTSD, depression, and anxiety. (Rec. at 354).

Finally, on December 28, 2010, Gibson was admitted to Lourdes Medical Center, complaining that she was "overwhelmed with depression." (Rec. at 399). The Center determined that she was suffering from positive suicidal ideation and kept her until December 31, 2010, when they felt the threat of suicide had passed. Id. Upon discharge, the Center diagnosed her with major depressive disorder and "rule out posttraumatic stress disorder". (Rec. at 399-400).

C.Administrative Law Judge Decision

Gibson's initial SSI claim was denied on October 22, 2009. After submitting a request for reconsideration, Gibson's claim was again denied on February 25, 2010. On March 31, 2010, Gibson submitted a request to be heard by an ALJ and have her claim reviewed. A hearing was held on January 24, 2011, in front of ALJ Frederick Timm. On May 11, 2012, the ALJ denied her SSI claim after finding that the Gibson was "not disabled," as defined under the SSA. Thereafter, the Appeals Council declined to review the ALJ's decision, making that decision the final decision of the Commissioner.

In making his determination, the ALJ first decided that Gibson had not engaged in any substantial gainful activity since her application date of March 18, 2009. (Rec. at 16). The ALJ also found that Gibson's leg and neck pain, her Depressive Disorder not otherwise specified, and her Borderline Personality Disorder were severe enough to significantly limit her physical and mental ability to perform basic work activities. Id. In contrast, he found that Gibson's alcohol and drug abuse did ...

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