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Rodriguez v. Berryhill

United States District Court, D. Massachusetts

June 26, 2018

NANCY A. BERRYHILL, [1] Acting Commissioner of Social Security, Defendant.




         This is an action for judicial review of a final decision by the acting Commissioner of the Social Security Administration (“Commissioner”) regarding an individual's entitlement to Supplemental Security Income (“SSI”) and Social Security Disability Insurance (“SSDI”) under Titles XVI and II, respectively, of the Social Security Act (the “Act”). See 42 U.S.C. §§ 405(g), 1383(c)(3). Yesenia Rodriguez (“Plaintiff”) argues that the Commissioner's decision denying her SSI and SSDI-memorialized in a April 14, 2015 decision of an administrative law judge (“ALJ”)- rested on legal error. Plaintiff has filed a motion to reverse that decision and the Commissioner has moved to affirm. For the reasons and to the extent set forth below, the court DENIES the Commissioner's motion (Dkt. No. 20) and GRANTS Plaintiff's motion (Dkt. No. 12).


         Plaintiff applied for the SSI and SSDI on April 13, 2010, claiming disability with an onset date of May 1997. (Administrative Record (“A.R.”) at 269-82.) She was 33 years old when she initially applied; she is now 41 years old. (Id. at 133). She has a high school education and her relevant prior work experience involved approximately one year as a part-time ticket agent for an airline in or around 1996. (Id. at 20, 23, 56-57). The record also indicates that Plaintiff received workers' compensation benefits for several months after that employment ended due to injury to her back, neck, and shoulders. (Id. at 58). At the time of her first administrative hearing she subsisted on government benefits. (Id.)

         On December 1, 2010, the Social Security Administration (“SSA”) advised Plaintiff that both her SSI and SSDI applications were denied. (Id. at 142-47). Plaintiff sought reconsideration on February 3, 2010, (id. 151-52), which was denied on August 4, 2011, (id. at 153-58). Roughly two months later Plaintiff sought a hearing before an ALJ. (Id. at 159). The hearing took place over a year later, on November 27, 2012. (Id. at 48-84, 184-99). At that hearing Plaintiff asserted disability due to both physical and mental impairments. Her claimed physical impairments included: asthma, back pain that spread to her shoulders and legs, ankle problems, arthritis, and headaches. (Id. at 58-80). Claimed mental impairments included depression with suicidal ideation, anxiety, and panic attacks. (Id.)

         On January 18, 2013, the ALJ issued a decision finding Plaintiff was disabled as of April 13, 2010 due to major depressive disorder, generalized anxiety disorder, posttraumatic stress disorder, panic disorder, headaches, anemia, right ankle pain, chronic arthralgia and myalgia, obesity, asthma, chronic bilateral wrist/hand numbness and weakness, and chronic back pain. (Id. at 89-112). The ALJ also expressly found that Plaintiff was not disabled due to any impairments prior to that date and, because Plaintiff's date last insured preceded that date by over a year, denied the SSDI application. As for Plaintiff's SSI application, the ALJ granted with an onset date of April 13, 2010. (Id. at 105).

         Plaintiff then appealed that decision to the SSA Appeals Council in an effort have the SSDI denial reversed.[2] The Council granted review and issued a decision entirely unfavorable to Plaintiff, essentially forcing the ALJ to reverse the decision to grant SSI and affirming the SSDI denial sub silencio.[3] Specifically, the Council held the ALJ's finding that Plaintiff would be “off task for at least 25 percent of the workday due to secondary effects of chronic pain and psychiatric symptoms [was] not supported by substantial evidence.” (Id. at 114). Citing particular items of evidence discussed below, the Council remanded and ordered to the ALJ to “further consider” Plaintiff's functional limitations. (Id. at 114-16). After a second hearing held on November 17, 2014, the ALJ issued her decision in accordance with the Council's directives on April 14, 2015, finding Plaintiff not disabled during all relevant timeframes and denying both her SSI and SSDI applications. (Id. at 14-47, 118-41). That denial resulted from a second Residual Functional Capacity (“RFC”) assessment that did not include the limitation of being “off task” for 25 percent of each work day. Plaintiff again made an administrative appeal, which was denied, and ultimately sought judicial review in the instant case on September 27, 2016.

         A. Medical and Documentary Evidence

         The record contains volumes of medical evidence concerning both physical and mental impairments. As they relate to mental health issues, [4] the earliest medical records derive from Northgate Medical P.C., a Springfield healthcare provider now permanently shuttered. Northgate records establish that Plaintiff visited the facility and discussed her mental health no fewer than 25 times between March 2000 and December 2007. (See Id. at 542-78; 605-28). Some Northgate records indicate mental health was a primary reason for a visit, while others indicate Plaintiff presented with primary complaints that were physical in nature. In any event, her depression and/or anxiety were documented at virtually every Northgate visit. A Northgate “Follow Up Form” dated March 3, 2000 indicates that Plaintiff first presented there when 22 years old and pregnant, complaining of loss of sphincter tone and sudden “falls to the floor.” (Id. at 565). She presented again at a walk-in visit two weeks later complaining of coughing, fever, wheezing, and depression. (Id. at 610). Her depression is further mentioned in Northgate records stemming from scheduled appointments and walk-ins in April, September, and October of 2000; May of 2001, June of 2003, June of 2004, July and October of 2006, January, February, May, October, and December of 2009; and March and April of 2010. (542-78; 605-28). A “Follow Up Form” dated September 22, 2000, describes Plaintiff as suffering from depression and notes that her medication was “making her sick.” (Id. at 563). A “progress note” on the same form further recounted that Plaintiff had twice been to a crisis unit for suicidal ideation and that she had “wild anxiety.” (Id.) The same field suggests the reviewing doctor had intended to prescribe Wellbutrin as a replacement for Prozac but abruptly ends with a note that “patient left before the end of the visit.” (Id.) A July 2006 record noted that Plaintiff was “back in town” living at a homeless shelter. (Id. at 554). Northgate forms from October 2006 state she visited the emergency room for chest pain, when she was “going through stressful times” and had stopped taking Celexa one month prior. (Id. at 551). A handwritten note on the same form states, without elaboration, “awaiting Valley Pysch[, ]” a reference to the Valley Psychiatric Services (“VPS”) mental health clinic in Springfield, MA. (Id.) Plaintiff presented again in December of 2009 complaining of hallucinations and suicidal thoughts. (Id. at 611). An October 2010 “Follow Up Form” recounts that Plaintiff presented complaining of anxiety, depression, and numerous body pains. (Id. at 562). The same document notes “longstanding depression since 1996, ” visits to the crisis center, “high anxiety level, ” and recounts prescriptions for Paxil, Celebrex, and other medications. (Id. at 562).

         Records from Mercy Medical Center (“MMC”) disclose Plaintiff made frequent emergency room visits as early as 2002. Only those records relevant to the instant analysis are discussed here. An admission form from a May 17, 2002 visit to the MMC ER lists “STS Sexually Assaulted” as the primary complaint and “admitting diagnosis.” (Id. at 444-48). In the “clinical impression” field the reviewing physician visit cryptically noted “Anxiety Reaction” without elaboration. (Id. at 446). An R.N.'s notes from an April 24, 2003 emergency room visit state that Plaintiff presented with complaints of lack of sleep, depression, and suicidal ideation. (Id. at 443). The R.N.'s notes recite that Plaintiff had stopped taking psychotropic medications four months prior, that Plaintiff “hadn't slept” for an unspecified amount of time, and that Plaintiff had not eaten for five days. (Id. at 443). The same R.N. recorded her recommendation that Plaintiff “see psychiatrist for counseling & meds & suicidal ideation.” (Id.)

         Plaintiff's earliest recorded visit to a mental health facility, rather than an emergency room or urgent care clinic, date to March 9, 2002, when she first presented at VPS and received a diagnosis of dysthymia.[5] (A.R. at 885). An “Initial Medication Evaluation” form completed for that visit by Matthew Friedman, M.D., indicates Plaintiff was 25 years old at the time and had received treatment and medication for her mental health on an “on again off again” basis since 1997. (Id.). It also noted a history of sexual abuse and suicidal behavior. (Id.) Freidman increased dosage of Paxil, a psychotropic drug used to treat anxiety disorders, and other prescribed medications in mostly illegible handwriting. (Id.). He scheduled a follow up visit for May 8, 2002, but no records appear to have been produced for/from that visit.

         The next relevant record is a “Diagnostic Summary, ” also from VPS, dated June 6, 2003. (A.R. at 878-84). Therapist Joanne Tan, M.S.W., reported in the “objective impression” section that Plaintiff appeared “to have past and current trauma issues of abuse . . . . She was sexually abused by her father and mom's SO from age 5 [until] age 15 and currently . . . is struggling to forgive her mother.” (Id. at 878). Tan also noted Plaintiff had two active restraining orders against her last boyfriend and had “multiple admissions to CSU” for suicidal ideation and anxiety. (Id.). Under “medical history, ” Tan noted that Plaintiff had been admitted for inpatient treatment to Bay State Medical Center for the last half of April 2003 and “for a week” between May and June at “CSU in Northampton.” (Id. at 878, 880). Tan further recorded Plaintiff's complaints of auditory hallucinations, and noted Plaintiff's reports of a current and historical “suicidal ruminations w/ plans of throwing self on [a highway], although she reported not having the courage to do so [because] of her sons.” (Id.). Past and present psychotropic medications included trazadone, Paxil, lorazepam, and “Prozac b/c of adverse side effects.” (Id. at 880). The report concluded with diagnoses of severe major depressive disorder, post-traumatic stress disorder, and general anxiety disorder. (Id. at 883-84).

         An “Initial Medication Evaluation/Session Note, ” dated August 28, 2003 and completed by David Adair, R.N., P.C., contains similar findings and diagnoses and recounts similar medication histories. This evaluation appears to result from Plaintiff's first visit with Adair at Tan's referral. Adair noted a high degree of anxiety, “a lot of flashbacks re: childhood father” and other childhood sexual abuse. (Id. at 877). He prescribed Celexa and Trazadone and noted a diagnosis of major depressive disorder with “severe psychotic features.” (Id.)

         A “Therapy Review” form dating from August 2003, bearing signatures from a social worker, psychologist, psychiatrist, and “utilization manager” summarizes at least 12 therapy sessions at VPS between May and August of 2003.[6] (Id. at 876). The form indicates Plaintiff received weekly treatment for “depression and fears.” (Id.) The form recorded Plaintiff's statements that “coping skills learned in [therapy] ha[d] assisted [with] orientation and ability to maintain structure in [her] daily activities although both still remains [sic] a problem for her.” (Id.) Reference is made to a plan to continue working through treatment to “resolve issues of grief” and assist with “maintenance of depression, working closely [with] DSS worker Sam Jones and follow-up on Rx regime.” (Id.) The form also indicates Plaintiff had spent the weekend in a Northampton hospital in June for suicidal ideation. (Id.)

         Another Therapy Review form dating from November 2003, also bearing signatures from a social worker, psychologist, psychiatrist, and “utilization manager” summarizes 10 more therapy sessions between August and November of 2003. (Id. at 875). The form indicates Plaintiff received treatment on a weekly basis, made some progress in coping with her depression and trauma, and received a “target date” of December 2005 for effective coping and therapy termination. (Id.)

         The final Therapy Review form from this period, dated February 2004, bears similar signatures and summarizes at least seven weekly visits made between November 2003 and February 2004. (Id. at 874). It recounts Plaintiff's reports of “sig[nificant] decrease in depressive [symptoms] although does have recurrent episodes, especially during times of stress.” (Id.) Plaintiff is described as “consistent” in treatment and working on “improving self-esteem through goal directed activities.” (Id.) The treatment plan remained largely unchanged and focused on coping with depression and “resolving past trauma.” (Id.). The target termination date remained “December 2005.” (Id.).

         A session note dated May 20, 2004 describes Plaintiff's “frantic” and “distressed” state after learning her brother was killed while serving in Baghdad. (Id. at 873). The note also indicates Plaintiff experienced a “second” domestic violence incident by the father of her four- and five-year-old children and received an eviction notice the day prior. (Id.)

         A “Discharge Summary” appears from VPS two weeks later, dated June 4, 2004. (Id. at 872). The reason for discharge is noted as “moved out of area, ” with the explanation that Plaintiff “decided to return to P[uerto] R[ico] abruptly.” (Id.) The form's “Review of Treatment” field states Plaintiff was “fairly inconsistent” in treatment, but noted some progress in depression and “PTSD issues” despite “constant chaos in environment.” (Id.) At the time of discharge Plaintiff displayed a high degree of anxiety and depression, and her “Final Functional Status” was described as involving difficulty fulfilling daily tasks, poor concentration, and “poor STM” due to “constant chaos in environment.” (Id.)

         Plaintiff presented at the MMC emergency room again on October 25, 2006, presumably after she returned from Puerto Rico, complaining of “sudden” and “sharp” chest pains and anxiety. (Id. at 355-56). A triage form describes her as “alert” and “anxious” and noted that she had stopped taking Celexa two weeks prior. (Id. t 356). She was prescribed Celexa and discharged on the same day. (Id. at 360). Diagnoses included “chest wall pa / situational stress.” (Id. at 358). She presented again when 22-weeks pregnant on May 14, 2007, with a cough, diffuse wheezing, black stool, and a rash. (Id. at 475). MMC records dated May 14, 2007, indicate she was treated for pneumonia, bronchitis, and reactive airway disease. (Id. at 476). As of that date she was listed as “home” and “improved.” (Id.) Plaintiff presented again at MMC on June 5, 2007, now 25 weeks pregnant, with complaints of a “loss of fetal movement.” (Id. at 469). She was admitted the same day to address “fetal demise” and discharged one day later. (Id. at 465-67).[7] Plaintiff checked into MMC again several months later, on November 7, 2007. (Id. at 453). The intake form lists “reason for visit” as “suicidal.” (Id.) The physician attending at intake recorded Plaintiff's comments that she “didn't feel well, ” felt like she could not breathe, and “doesn't want to be around anymore” and diagnosed her with depression, suicidal ideation, and urinary tract infection. (Id. at 453-57).

         Shortly after her miscarriage in June and before her November emergency room admission for suicidal ideation, Plaintiff resumed treatment at VPS. A second VPS intake “Diagnostic Summary” form dated August 16, 2007 records that Plaintiff was referred for treatment on July 17, 2007 and first reappeared for treatment on August 8, 2007. (Id. at 892-97). She is quoted as presenting with the complaint “I'm depressed [and] suffer from anxiety. I just lost a baby in June.” (Id. at 892). Dawn Faniel-Hall, M.S.W., who completed the intake form, noted after that quote that Plaintiff “has life difficulties.” (Id. at 892). Faniel-Hall described the “history of the presenting problem” as:

two to three years of economic, family, housing hardship. Recent loss of child & trying to leave current boyfriend who has STD's & is using drugs.

Id. In the “therapist's observation” field, Faniel-Hall stated:

Yessania [sic] is a bright girl who has made some bad decisions in her life. She wants to do better for herself [and] is goal-oriented.

Id. Elsewhere the report notes that Plaintiff had lost an unspecified job and apartment in the prior year and “ended up in a women's shelter.” (Id. at 893). “That is when the children first went to their dad's apartment.” (Id.) Current medications were listed as 10 milligrams of Celexa and an unspecified dosage of Ambien. (Id. at 894). Faniel-Hall's “case formulation” described Plaintiff as “articulate . . . with an affect incongruent to mood.” (Id. at 896). Her mood was “sad/depressed” but she appeared “cheerful and smile[d] often” without suicidal ideation. (Id.) Diagnoses included major depressive order (“single episode = post-partum onset”), “generalized anxiety, ” and a GAF score of 65-70.[8]Listed “medical conditions” also included “pre-cancerous cells on ovary.” (Id. at 897).

         An August 17, 2007 VPS “Initial Treatment Plan” form repeated those diagnoses and listed “treatment focuses” as “mood depressed, panic/anxiety, PTSD symptoms, [and] self-esteem.” (Id. at 891). Planned treatment methods included individual therapy, group therapy, and medication. Criteria for termination of treatment and stated goals included “attendance” at individual therapy, coping skills, medication management, and “controlled mood.” (Id. at 891). An “initial medication evaluation/session note” signed by Adair one month later states that Plaintiff had been “stable until stillbirth June 07 which collapsed plan of children coming [to live with her and caused her to develop] symptoms.” (Id. at 890). He further noted Plaintiff was “afraid to go out, [thought] people will stare, ” “just stayed in bed, ” and stopped meeting her children in the park because they “pick up [her] vibe.” (Id.) In all caps, Adair stated “NO CONTROL OF ANXIETY.” (Id.) Mental status is described as “casual dress, well groomed. Anxious affect / mood. ‘7' on 1-10 (10 worst). Logical coherent & thoughtful.” (Id.) Planned treatment included increasing Celexa dosage from 10 to 20 grams. (Id.)

         A VPS session note dated October 29, 2007 records further disruption in Plaintiff's life.[9]The substance of the note provides:

Client is understandably upset as the father of her children was arrested Friday for possession and distribution of drugs within a school zone. She said that he told her on Sunday after she dropped the children off that she should get legal help if she wants to see the children again. She is seeking legal consultation and wants to obtain full legal custody of them, as she certainly does not want her children around drugs. She has been quite anxious but notes that the Ativan Celexa are keeping her mood controllable and seemed very logical., coherent and seemed to be coping actually quite well given the circumstances. Ambien has not been helpful at 5mg for her insomnia given circumstances thus will increase to 10mg.
Mental Status Examination: Well-dressed and well-groomed, presentation is appropriate, anxious, affect is congruent with circumstances. Future and goal oriented [sic], there is no indicators [sic] of thought disorder, suicidality etc. She is also dealing with severe anemia but continues to take a medicine for this.

(Id. at 889.) The form listed the next appointment date as December 10, 2007, although, as with most appointments at VPS, the visit did not generate particular records. (Id.)

         A therapy review form completed by the social worker and dated November 13, 2007, summarized visits and progress occurring between August and early November 2007. (Id. at 888). It stated that Plaintiff had kept all appointments that quarter and “seem[ed] to comply [with a] DSS [treatment] plan” and announced in therapy her “plans to either parent her two boys or give up custody to their father.” (Id.) Termination criteria is vaguely stated as “resolution of significant symptoms.” (Id. at 888).

         Chronologically, the next record from VPS is a discharge summary form dated March 25, 2008. Plaintiff's address is listed as “homeless, ” and “reason for discharge” is listed as “no shows.” (Id. at 887). A treatment review field provides that Plaintiff was grieving the loss of a child “but also was experiencing problems parenting two boys [with] no resources of own.” (Id.) “Final functional status” is listed as “unknown, ” and the “follow up recommendations” field states, in full, “to re-apply for services once she is stable [and] has an address.” (Id.)

         On October 25, 2008, Plaintiff presented at the MMC ER complaining again of chest pains. (Id. at 357). The intake form is largely illegible, but appears to record Plaintiff's statements that her chest pains were “sharper” than before and includes a description of Plaintiff as “fearful.” (Id. at 357). She was also marked for “Depression SDHI.” On April 30, 2009, Plaintiff presented at MMC with a “female genitourinary complaint.” (Id. at 481). The “subjective data” field of the intake record state “pt is here because her boyfriend tested positive for an std and is currently on antibiotics.” (Id.) The past medical history field notes “depression; anxiety, ” and the departure disposition states “left without treatment.” (Id.) Plaintiff presented at MMC with similar complaints several times in 2008, often with reports of vaginal bleeding or discharge. (See, e.g., A.R. at 344, 505, 512). Her emotional state is frequently listed as “anxiety.” (See, e.g., id. at 51).

         Plaintiff briefly revisited VPS in March of 2010, just before she submitted the SSI and SSDI applications at issue here. She was referred by an unspecified source on March 8, 2010, and appeared for her first session on March 23, 2010. (Id. at 579, 585). A diagnostic summary from her intake described the history of her “presenting problem” in mostly non-forensic terms familiar from the above recital. It notes “a long history of multiple DV relationships [and] abuse in family” and further describes Plaintiff as in a “DV relationship” with a man she had recently married and that required “police involvement multiple times.” (Id. at 579) That form further recounts that Plaintiff was due to be evicted and move into a one bedroom apartment with her husband, mother-in-law, and brother-in-law and “3 pitbulls.” (Id.) The “therapist observation” field described Plaintiff as having a “flat affect” and a “tendency to avoid certain subjects even though she was the one who initiated conversation.” (Id.) A psychosocial history section states that Plaintiff left for Puerto Rico for 8 months and that she had worked at the Eastfield Mall “doing surveys” between March and October of 2008. (Id. at 580). A mental examination resulted in marks for “alert to person, place, and time, ” “disoriented, ” behavior within normal limits, normal/fluent speech, appropriate and neat dress, “sad/depressed, ” “flat/restricted” affect, loose associations and flight of ideas, observable hopelessness, good eye contact, impaired concentration and recent memory, impaired judgment due to or exhibited by her “remaining in DV household, ” absence of hallucinations, insomnia, and poor appetite. (Id. at 583). Treatment targets were identified as increasing coping skills and esteem, leaving her domestic relationship, and securing housing, employment, and/or financial assistance. (Id. at 584). Her mental health diagnosis included major depressive disorder (recurrent/moderate) and a deferred diagnosis in the personality disorder axis. (Id. at 584). An April 28, 2010 “initial treatment plan” form repeats those findings and diagnoses and lists as “measurable goals” a decrease in “teariness” and better sleeping habits and coping skills. (Id. at 585). The same form lists “criteria for termination” as involving a return to “pre-level of effective fx & able to cope w/ stressors & conflicts for a period of 6 months.” (Id.) A “preliminary plan” geared towards that end involved leaving a “DV relationship” and obtaining her own housing. (Id.)

         The next and final record from VPS is an August 18, 2010 discharge summary. The discharge date is listed as August 6, and the “review of treatment” field states, without elaboration, that “throughout [treatment Plaintiff] struggled w/ multiple moves / homelessness & abusive relationship. [Zero] progress towards goals.” (Id. at 827). The reasons for discharge is again listed as “exceeded No-Show limit.” (Id.)

         In January of 2011 Plaintiff again visited the MMC ER. The “reason for visit” is listed as “domestic disturbance at home.” (Id. at 631.) Under “chief complaint / subjective data” the intake form states: “she was fighting with her husband. Police were called and PT decided to come here. PT denies any suicidal ideation.” (Id.) A summary report recounts that she presented saying she did not “feel safe at home” and “complain[ed] of increased anxiety.” (Id. at 635). Plaintiff is otherwise described as cooperative, oriented, and nourished. (Id. at 632). Additional comments note she felt “better” and “more relaxed since receiving Ativan” and diagnosed her with “acute anxiety attack.” (Id. at 633).

         On June 2, 2011, Plaintiff received a mental consultative examination in response to the instant SSI and SSDI applications. Peter Bishop, Ph.D., performed the examination on behalf of the Massachusetts Rehabilitation Commission Disability Determination Services (“DDS”). (Id. at 664-69). Bishop's report recounts that Plaintiff lived alone in a motel room and was the mother of two children, who lived with their father. (Id. at 664). Plaintiff's presented to him as follows:

The examinee states that she has depression, anxiety, and nightmares. She states that she feels very overwhelmed with everything in her life. She states that she feels like crying all the time. She states that she feels just broken. The examinee cries as she describes these issues.

Id. at 664. She also noted experiencing numerous stillbirths and her history of trauma recounted above. (Id. at 665). She reported experiencing depression since a child and that she had been hospitalized for psychiatric issues for the first time in 1997 and again in 2002 and 2003. (Id. at 665). In the “Mental Status Examination” section of his report, Bishop noted her eye contact as “good” and found her oriented to person, place, and time. (Id. at 664). Her intellectual functioning was estimated “in the average range, ” but memory of recent events was “somewhat impaired.” (Id.) Long term memory was listed as “basically intact, ” but thought processes were “often confused by intrusive memories.” (Id. at 664-65). Thought content was “marked by hallucinatory perceptions, paranoia, suspiciousness, preoccupation, negativity, and self-denigration.” “She describe[d] hallucinatory experiences as hearing noises, which include hearing someone knocking[, ]” but denied use of alcohol or drugs. (Id. at 665-66). She reported her only social interactions as involving visits from her children and the maid who cleaned her hotel room. (Id. at 666). She cried throughout the examination, mostly when reporting traumatic experiences or panic attacks. (Id. at 665-668). “She expressed with frustration the experience of waking up from a nightmare, going back to sleep, and having the same fearful dream.” (Id. at 668). On the whole, Bishop found her account “focused and truthful” and “evoking experience haunted by intolerable memories and fear.” (Id. at 668). In summarizing his review, Bishop stated:

The examinee reported a history of repeated traumatic abuse, loss anxiety, and depression, which began in childhood. She endorsed the following symptoms: preoccupation, flashbacks, nightmares, hypervigilance, depressed mood, diminished interests, negative self cognitions, generally negative thinking, reduced concentration, psychomotor retardation, insomnia, panic, social avoidance, fear of attack, and behavioral compulsions. The examinee's reporting appeared to be genuine. Her fear of leaving her living space and fear of being in the approximaty [sic] of others would make it very difficult to be in the proximity of the workspace. Her sensitive fear would lead to withdrawal from work [and] lead to withdrawal and ...

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