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Cyprain v. Colvin

United States District Court, S.D. California

March 7, 2017

CAROLYN W. COLVIN, Commissioner of the Social Security Administration, Defendant.




         Plaintiff Lenda Charmaine Cyprain commenced this action seeking review of the Social Security Commissioner's denial of her application for Supplemental Security Income (“SSI”) benefits. After treating Plaintiff for several months, a psychologist referred Plaintiff to a psychiatrist for a psychiatric evaluation. The psychiatrist diagnosed Plaintiff with major depressive disorder, recurring, severe, but without psychosis. In the course of treating Plaintiff, the psychiatrist upgraded the severity of Plaintiff's condition to major depressive disorder, recurring, severe, and with psychosis. After observing Plaintiff's inappropriate suspiciousness or hostility, psychomotor agitation, inappropriate affect, easy distractibility, and illogical thinking, the psychiatrist also opined that Plaintiff's condition would severely limit her ability to do many work-related activities.

         Separately, in seeking relief for pain and numbness in her hands, Plaintiff underwent an electromyography that revealed she had median nerve lesions and suffered from severe carpal tunnel syndrome on her right side, as well as mild carpal tunnel syndrome on her left side. A neurologist prescribed Plaintiff wrist splints, and when her symptoms did not improve, he referred Plaintiff to a hand orthopedist for a surgical evaluation.

         Plaintiff then sought SSI benefits based on these impairments, among others. The Administrate Law Judge (“ALJ”) rejected Plaintiff's claim, however, at step two of the five-step sequential analysis for disability claims. Although the ALJ acknowledged Plaintiff suffers from physical and mental impairments, he found these impairments are not legally severe. Therefore, the ALJ concluded Plaintiff's claim could not proceed past step two-the step used as a de minimis screening device to dispose of groundless claims.

         After the Social Security Administration's Appeals Council denied her request for review, Plaintiff filed this action challenging the ALJ's determination. The Court referred this matter to the magistrate judge for a Report & Recommendation (“R&R”) in accordance with 28 U.S.C. § 636(b)(1)(B) and Civil Local Rule 72.1(c)(1). After the parties filed cross-motions for summary judgment, the magistrate judge issued an R&R recommending this Court deny Plaintiff's motion (ECF No. 11) and grant Defendant's motion (ECF No. 14). (ECF No. 19.) Plaintiff objects to the R&R. (ECF No. 20.)

         The ALJ erred in rejecting Plaintiff's claim at step two. There is not a “total absence of objective evidence” of a severe medical impairment that would permit this Court to affirm a finding of no disability at step two. See Webb v. Barnhart, 433 F.3d 683, 688 (9th Cir. 2005); see also, e.g., Ortiz v. Comm'r of Soc. Sec., 425 F. App'x 653, 655 (9th Cir. 2011); Styles v. Colvin, No. 14-cv-2229-JAH(WVG), 2016 WL 1253482, at *4 (S.D. Cal. Mar. 31, 2016). Accordingly, despite that Plaintiff may not succeed in proving that she is entitled to disability benefits, the ALJ should have proceeded past step two of the disability analysis. See Webb, 433 F.3d at 688. Consequently, for the following reasons, the Court SUSTAINS Plaintiff's objections, DECLINES to adopt the R&R, GRANTS Plaintiff's motion, DENIES Defendant's motion, and REMANDS this action for further proceedings consistent with this order.


         Although the Court declines to adopt the R&R's conclusions, the Court agrees with the R&R's detailed narrative of Plaintiff's medical records and the administrative proceedings. (See R&R 1:18-2:3, 3:17-16:21.) The Court incorporates this narrative here but adds the following synopsis to provide context for the Court's discussion of Plaintiff's objections.

         A. Mental Health Treatment

         1. Psychologist Rachelle Rene, Ph.D.

         A primary care physician referred Plaintiff to psychologist Rachelle Rene, Ph.D. for treatment of depression. (Administrative Record (“AR”) 405.) In Dr. Rene's initial assessment, she noted Plaintiff reported symptoms of depression, including crying spells, decreased motivation, decreased energy, difficulty sleeping, increased weight gain, increased isolation, and restlessness. (Id.) Dr. Rene ultimately concluded that Plaintiff “presented as very depressed and anxious, ” with symptoms that are consistent with (i) major depressive disorder, recurrent, moderate, without psychotic features and (ii) generalized anxiety disorder. (AR 406.)

         After her initial assessment, Dr. Rene regularly met with Plaintiff for individual treatment sessions. (AR 380, 382-85, 388-93, 395-99, 401-04.) Plaintiff's condition oscillated throughout these sessions. (See id.) At some sessions, her condition had improved. (See AR 380, 389, 395, 398.) Plaintiff reported she had a “good week” with no suicidal ideation at one session. (AR 380.) At another session, she presented in a good mood and stated she felt “a lot better.” (AR 395.) At many other sessions, however, Plaintiff's condition had not improved or had deteriorated. (See AR 382-83, 385, 388, 391-92, 397, 401.) For example, at one session, she presented visibly tearful and stated she felt more depressed. (AR 397.) She again presented with a sad mood at another session and stated she had stayed in bed since the prior session. (AR 391.) In other sessions, she reported suicidal ideation. (AR 382-83, 388.)

         2.Psychiatrist George Brolaski, M.D.

         After treating Plaintiff for several months, Dr. Rene referred her to psychiatrist George Brolaski, M.D. for a psychiatric evaluation. (AR 376-79.) During the evaluation, Plaintiff reported having thoughts of death and suicidal ideation but without a plan or present intention. (AR 376.) She also reported experiencing auditory hallucinations a few times a month. (Id.) Further, a mental status examination revealed a sad and worried facial expression, psychomotor agitation, and a depressed mood. (AR 378.) Dr. Brolaski diagnosed Plaintiff with major depressive disorder, recurrent, severe, without psychosis, and he assessed her current Global Assessment of Functioning (“GAF”) score at 47 (AR 379), indicating she “suffered from serious psychological symptoms or impairments, ” see Boyd v. Colvin, 524 F. App'x 334, 336 (9th Cir. 2013) (citing Diagnostic & Statistical Manual of Mental Disorders 32-34 (4th ed. Text Revision 2000)).

         After this evaluation, Plaintiff continued to attend outpatient therapy sessions with Dr. Rene. (AR 374-75, 455-61, 463, 465-69, 471, 474-77, 480-83, 485-89.) When she returned to Dr. Brolaski in the following year, she reported diminished sleep of only three to four hours per night. (AR 589.) In seeing Dr. Brolaski over the course of the next several months, she also again reported experiencing hallucinations. (AR 581-83, 585-86.) During these treatment sessions, Dr. Brolaski diagnosed Plaintiff with major depressive disorder, recurrent, severe, with psychosis. (AR 581-86, 589.)

         Then, approximately a year and nine months after he first evaluated Plaintiff, Dr. Brolaski completed a “Mental Impairment Residual Functional Capacity Questionnaire.” (AR 600-05.) In this assessment, Dr. Brolaski noted Plaintiff had responded poorly to medication and individual therapy, and he identified her prognosis as poor. (AR 600.) Dr. Brolaski also provided his opinion on Plaintiff's ability to do work-related activities in three categories that were further divided into a total of twenty-five subcategories. (AR 602-03.) These subcategories included activities such as Plaintiff's ability to “deal with normal work stress” and “maintain attention for two hour segments.” (Id.) For twenty-one of these subcategories, Dr. Brolaski rated Plaintiff's abilities as either “seriously limited, but not precluded, ” or “unable to meet competitive standards.” (Id.) In addition, he indicated Plaintiff had “marked” functional limitations in “maintaining social functioning” and “maintaining concentration, persistence, or pace.” (AR 604.)

         B. Carpal Tunnel Syndrome

         Plaintiff sought treatment from a primary care physician for weakness in her hands. (AR 415.) She later reported wrist pain and a numbing in both of her hands to the physician. (AR 387, 394.) Plaintiff also reported to Dr. Rene in one of her treatment sessions that she was feeling anxious and depressed due to recent numbness and tingling in her hands and fingers. (AR 388.)

         Plaintiff thereafter saw neurology resident Galina Nikolskaya for (i) numbness in her fingertips and (ii) numbness in her right wrist with associated aching pain. (AR 441.) After an examination, Ms. Nikolskaya's impression included likely de Quervain's tenosynovitis and carpal tunnel syndrome in the right wrist. (AR 443.) Dr. Omar Ghausi, the attending neurologist, verified Ms. Nikolskaya's exam and assessed Plaintiff with carpal tunnel syndrome that is severe on the right side, mild on the left side, and superimposed upon de Quervain's tenosynovitis. (AR 440.) He recommended wrist splints, possible steroid injections, and an electromyography (“EMG”) to quantify the severity of Plaintiff's condition. (Id.)

         The resulting EMG was abnormal. (AR 447.) It revealed median nerve lesions at both of Plaintiff's wrists that are consistent with carpal tunnel syndrome, “extremely severe on the right and mild to moderate on the left.” (Id.) Plaintiff later returned to Dr. Ghausi because her symptoms had not improved. (AR 558.) He referred Plaintiff to see an “ortho hand” for consideration of surgical intervention, but stated that she would continue conservative treatments in the meantime. (Id.)

         C. The ALJ's Determination

         The ALJ found Plaintiff had not engaged in substantial gainful activity since her application for SSI benefits, satisfying step one of the five-step sequential disability analysis. (AR 30.) At step two, after reviewing the medical evidence, the ALJ concluded the evidence does not support “a finding that [Plaintiff] has any severe impairments.” (AR 35.) The ALJ provided several reasons for concluding Plaintiff's mental impairments are not severe, including a lack of “evidence the claimant has required any inpatient psychiatric care.” (AR 36.) The ALJ also rejected Dr. Brolaski's assessment, reasoning it was inconsistent with Dr. Brolaski's “mild clinical findings” and the reports of two consultative examiners. (Id.) In addition, the ALJ found factors “bear negatively on Plaintiff's general credibility, ” including that she has “given inconsistent statements regarding her mental health issues.” (AR 36- 37.)

         The ALJ similarly found Plaintiff's carpal tunnel syndrome is not severe. (AR 36.) He reasoned in part that there is “no evidence the claimant has received any treatment for her carpal tunnel syndrome or that she requires surgery or even the use of conservative modalities such as wrist splints.” (Id.) Further, the ALJ generally reasoned that “no treating or examining medical source has ...

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