United States District Court, N.D. California, Eureka Division
ORDER ON MOTIONS FOR SUMMARY JUDGMENT RE: DKT. NOS.
M. ILLMAN UNITED STATES MAGISTRATE JUDGE
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.
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.
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. 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.
OF THE RELEVANT EVIDENCE
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.
Evidence from Treatment Providers:
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.
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
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.
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.
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.” AR at 550. Therapist Warden
administered the Beck Depression Inventory
(DBI) 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; 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.
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
of Consultant Examiners:
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.
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