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Gutierrez v. Commissioner of Social Security

United States District Court, N.D. California, Eureka Division

September 25, 2019




         Plaintiff, Debra Olayer Gutierrez seeks judicial review of an administrative law judge (“ALJ”) decision denying her application for disability insurance benefits under Title II of the Social Security Act. Plaintiff’s request for review of the ALJ’s unfavorable decision was denied by the Appeals Council, thus, the ALJ’s decision is the “final decision” of the Commissioner of Social Security which this court may review. See 42 U.S.C. §§ 405(g), 1383(c)(3). Both parties have consented to the jurisdiction of a magistrate judge (dkts. 7 & 8), and both parties have moved for summary judgment (dkts. 13 & 18). For the reasons stated below, the court will grant Plaintiff’s motion for summary judgment, and will deny Defendant’s motion for summary judgment.


         The Commissioner’s findings “as to any fact, if supported by substantial evidence, shall be conclusive.” 42 U.S.C. § 405(g). A district court has a limited scope of review and can only set aside a denial of benefits if it is not supported by substantial evidence or if it is based on legal error. Flaten v. Sec’y of Health & Human Servs., 44 F.3d 1453, 1457 (9th Cir. 1995). Substantial evidence is “more than a mere scintilla but less than a preponderance; it is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Sandgathe v. Chater, 108 F.3d 978, 979 (9th Cir. 1997). “In determining whether the Commissioner’s findings are supported by substantial evidence, ” a district court must review the administrative record as a whole, considering “both the evidence that supports and the evidence that detracts from the Commissioner’s conclusion.” Reddick v. Chater, 157 F.3d 715, 720 (9th Cir. 1998). The Commissioner’s conclusion is upheld where evidence is susceptible to more than one rational interpretation. Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005).


         On June 18, 2014, Plaintiff filed an application for disability insurance benefits under Title II, alleging disability beginning on April 1, 2012. See Administrative Record “AR” at 12.[1] The ALJ denied the application on December 28, 2016. Id. at 20. The Appeals Council denied Plaintiff’s request for review on February 15, 2018. Id. at 1-3.


         Plaintiff’s application for Title II benefits alleged disability due to anxiety, major depression, post-traumatic stress disorder, bipolar disorder, migraines, and back problems. Pl.’s Mot. (dkt. 13) at 5. The ALJ found the following conditions were severe: “very mild degenerative joint disease of the right knee; headaches; major depressive disorder; and generalized anxiety disorder.” AR at 14. In this court, Plaintiff assigns error to the ALJ’s formulation of the Residual Functioning Capacity (“RFC”), arguing that the RFC failed to adequately account for Plaintiff’s physical and mental limitations; as well as arguing that the ALJ’s Step Five determination was unsupported by substantial evidence. See Pl.’s Mot. (dkt. 13) at 5.

         Medical Evidence from Treatment Providers:

         By way of background, Plaintiff, who was born in 1960, worked for AT&T for 30 years; after battling depression and anxiety for years, Plaintiff stopped working in 2012 due to being overwhelmed by her conditions. See AR at 367. Plaintiff was a patient of Maria Escalda, M.D., since September of 1999. Id. at 324. Over the years, Dr. Escalda submitted at least four letters to Plaintiff’s former employer to justify time off, expressing her opinions regarding Plaintiff’s mental health, and describing “a long history of anxiety and depression . . . [as well as] migraine headaches . . . hindering [] her concentration, comprehension, attention, decision making as well as sleep.” AR at 324-25. Writing in March of 2010, Dr. Escalda noted that Plaintiff had been diagnosed with major depression, bipolar disorder, insomnia, as well as a thyroid imbalance, and that these conditions caused her to suffer sleeplessness, weakness, dizziness, fatigue, nervousness, and migraine headaches. Id. at 308. Writing again, in May of 2011, Dr. Escalda noted that Plaintiff was “unable to perform her work duties due to constant symptoms of major depression, anxieties, panic attacks, low energy, shakiness, dizziness, fatigue, headache, ” and an inability “to concentrate / focus / mak[e] decisions.” Id. at 305. Plaintiff’s diagnoses were consistent with those made by Alysha Zim, M.D., nearly a decade earlier, as reflected in a similar letter to Plaintiff’s employer at the time. Id. at 336. Plaintiff’s psychotherapist, Francis Verala, Ph.D., also wrote several similar letters to Plaintiff’s former employer, explaining that Plaintiff had been his patient since 2006, and similarly relating the narrative of Plaintiff’s metal impairments and their effect on her ability to work. Id. at 339-42.

         Of greater relevance to the relevant disability timeframe (starting on April 1, 2012) are the records of Plaintiff’s psychiatrist, Alfeo Reminajes, M.D., who treated Plaintiff from 2011 to 2016. See id. at 357, 362, 427-35, 443-48, 503-06. Plaintiff first visited Dr. Reminajes in May of 2011, seeking a psychiatric evaluation and a treatment plan. Id. at 443. As part of Plaintiff’s initial psychiatric evaluation, Dr. Reminajes identified an exacerbating trigger of Plaintiff’s problems with anxiety and depression as happening in 2006 when she became embroiled in protracted conflict with a co-worker and supervisors at work. Id. Specifically, Dr. Reminajes noted that in 2006 Plaintiff had confided some dark thoughts to a co-worker and friend (that a certain supervisor should be “eliminated”) who promptly reported the conversation to management; and that since then, Plaintiff has experienced a “history of mood problems.” Id. Dr. Reminajes wrote that in 2011 Plaintiff was still experiencing panic attacks “on almost a daily basis, ” as well as suffering from low energy and motivation levels, suffering bouts of irritability and outbursts of anger, as well as “intermittent suicidal thoughts but no definite plans.” Id. Dr. Reminajes also noted “[p]aranoid ideations . . . [s]he is scared to go out in public . . . [and] thinks that someone is watching her and spying [on] her.” AR at 446. Based on Plaintiff’s 2011 psychiatric evaluation, Dr. Reminajes made an Axis-I diagnoses of major depressive disorder and PTSD; and opined that Plaintiff needed regular psychotherapy to further the objective of controlling her depression, anxiety, and PTSD symptoms. Id. at 446-48.

         Having evaluated and treated Plaintiff, Dr. Reminajes completed and submitted two separate mental capacity forms describing her limitations, one in July of 2014, and the other in April of 2015. Id. at 427-35, 503-06. In July of 2014, Dr. Reminajes opined that Plaintiff would have intermittent difficulty performing in the following areas: understanding, remembering, or executing detailed instructions; maintaining attention for extended periods; attendance, punctuality, and performing within a schedule; sustaining an ordinary routine without supervision; completing a normal workday or workweek without interruptions from psychologically based symptoms; receiving instructions and responding to criticism from supervisors; the ability to respond to changes in the workplace; and, lastly, that Plaintiff could be expected, due to her conditions, to be absent from work 2 days per month. Id. at 432-35. Dr. Reminajes also noted that Plaintiff’s anxiety was manifesting itself in, among other ways, Plaintiff pulling out her hair. Id. at 435. In April of 2015, Dr. Reminajes found that Plaintiff’s conditions had worsened. Id. at 427-31. Where Plaintiff’s difficulties were described in 2014 as “intermittent, ” Plaintiff’s functionality in a number of those areas changed, and was described in 2015 as “seriously limited.” Id. at 427-31. As to the ability to respond appropriately to changes in the work setting, Dr. Reminajes’s 2015 assessment found that Plaintiff’s “ability to function in this regard is precluded.” Id. at 430.

         For her headaches, Plaintiff was referred to a neurologist, Bradley Wrubel, M.D., in 2015. Id. at 458-60. Dr. Wrubel noted Plaintiff’s history of chronic daily headaches which are “associated with nausea, photophobia, and phonophobia.” Id. at 458. Noting Plaintiff’s abnormal fatigue and her memory disturbance, Dr. Wrubel assessed that Plaintiff “does have chronic and daily mild headaches with weekly exacerbations, ” for which he formulated a treatment plan including medical intervention and nutritional changes. Id. at 459-60.

         Between April of 2014 and October of 2016, Plaintiff underwent at least 39 therapy sessions with Billie Warden, LMFT, who noted Plaintiff’s “depressed mood, excessive guilt, social isolation, decreased energy, disordered sleep patterns, increased irritability, and difficulty focusing and concentrating.”[2] AR at 550. Therapist Warden administered the Beck Depression Inventory (DBI)[3] and determined that Plaintiff’s depression was extremely severe. As to Plaintiff’s anxiety, Therapist Warden noted the anxiety causes panic attacks during which Plaintiff feels shaky, experiences shortness of breath and heart palpitations; seeking relief from these anxiety symptoms, Plaintiff had been chronically pulling out her hair because it was associated with a perception of relief. Id. Therapist Warden then noted that since having both experienced and witnessed both physical and verbal abuse as a child, Plaintiff “can become triggered by witnessing or learning of verbal and/or physical abuse experienced by someone close to her . . . [and] when triggered she has intrusive distressing memories and dreams, and feels intense anger.” Id. In short, Therapist Warden diagnosed Plaintiff with major depressive disorder, panic disorder, post-traumatic stress disorder, and trichotillomania[4]; thus, Therapist Warden noted that “[d]espite the fact that Plaintiff has been taking psychotropic medications, she continues to experience debilitating depression and anxiety which prevent her from being able to be employed.” AR at 550-51. Additionally, Therapist Warden’s handwritten notes from each of the nearly 40 sessions of therapy were included as part of the record before the ALJ. See AR at 520-47.

         In October of 2016, Plaintiff was treated by Christine Simon, M.D., who noted that Plaintiff was taking medications for her major depressive disorder, PTSD, anxiety disorder, insomnia, and migraine headaches and that the combination of her “[m]ental problems and her medications cause fatigue and trouble focusing, ” Id. at 502. Also in October of 2016, Plaintiff transferred her psychiatric care to Simrita Singh, M.D., who wrote that Plaintiff has “a long history of depression and early childhood trauma that has caused PTSD” and that Plaintiff had “struggled with symptoms for years while she was employed and progressively got worse until she could no longer function in the workplace in 2012.” Id. at 45. In October of 2016, as part of Plaintiff’s initial evaluation, Dr. Singh noted that Plaintiff’s mood issues and suicidal thoughts for the duration of her life had roots in childhood trauma, and that Plaintiff “feels dysfunction followed her everywhere.” Id. at 48. During the mental status examinations conducted by Dr. Singh in January and March of 2017, Plaintiff’s affect was noted as being both constricted (a restriction in the range or intensity of feelings) as well as labile (expressing excess emotions or emotions not congruent with the situation); Plaintiff’s thought process was found to be circumstantial (answering questions with excessive unnecessary detail) and rambling; Plaintiff’s thought content was found to be marked by negative and circular (rather than linear) thoughts; and, as to attention and memory, Plaintiff was found to have a diminished attention and focus, as well as a poor recall of details. Id. at 46-48, 51. When delving into Plaintiff’s history of past trauma, Dr. Singh noted a number of instances of verbal abuse and neglect, as well as instances of physical abuse and rape. Id. at 50. Dr. Singh diagnosed Plaintiff with major depressive disorder and PTSD and noted that Plaintiff had “been in psychiatric treatment with medications and weekly psychotherapy ever since with very little improvement in her symptoms.” Id. at 45. Consequently, because of Plaintiff’s “lengthy history of untreated symptoms” followed by the “lack of improvement once treatment did start, ” Dr. Singh opined in March of 2017 that Plaintiff “is unlikely to improve to the point of resuming any gainful employment at this point.” Id.

         Reports of Consultant Examiners:

         On September 17, 2014, Plaintiff underwent two one-time examinations by consulting professionals at the request of the Department of Social Services; the first was an internal medicine evaluation and was performed by Eugene McMillan, M.D.; the second was performed by Ute Kollath, Ph.D., and was a mental status evaluation. AR at 363-70. Dr. McMillan found that Plaintiff had some patellar grinding in her right knee, and that although “[t]here is some evidence of degenerative disc disease involving the right patellar region, ” Plaintiff’s functional capacity assessment was that she could “occasionally lift and carry 20 pounds and frequently lift and carry 10 pounds . . . [s]tanding and walking [] for at least six hours during an eight-hour workday . . .” with no limitations expressed as to any of the above-mentioned mental conditions. Id. at 366. Dr. Kollath only diagnosed Plaintiff with anxiety disorder, and then offered an opinion as to her work-related abilities, “from a psychological standpoint alone, ” finding Plaintiff to be mildly impaired in the following areas: adequately performing complex tasks, maintaining adequate attention/concentration, withstanding the stress of a routine workday, and adapting to changes, hazards, or stressors in the workplace setting. Id. at 370.

         Function Reports & Third ...

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