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Madrigal v. Saul

United States District Court, E.D. California

January 6, 2020

ANDREW SAUL, Commissioner of Social Security, [1] Defendant.




         On August 21, 2018, Plaintiff Esmeralda Berenisia Madrigal (“Plaintiff) filed a complaint under 42 U.S.C. § 1383(c) seeking judicial review of a final decision of the Commissioner of Social Security (the “Commissioner” or “Defendant”) denying her application for Supplemental Security Income (SSI) under the Social Security Act (the “Act”). (Doc. 1.) The matter is currently before the Court on the parties' briefs, which were submitted, without oral argument, to the Honorable Sheila K. Oberto, United States Magistrate Judge.[2]


         On June 9, 2014, Plaintiff protectively applied for SSI, alleging disability beginning May 11, 2011, due to major depression, acid reflux, low back problems, anxiety, and migraine headaches. (Administrative Record (“AR”) 33, 35-36, 39, 71-72, 85-86, 190-91, 216, 218, 224.) Plaintiff was born on September 6, 1975, and was 35 years old on the alleged disability onset date. (AR 33, 35-36, 39, 50, 71-72, 85-86, 190-91, 216, 218, 224). Plaintiff has a ninth-grade education and can communicate in English. (AR 50, 190-92.)

         A. Relevant Medical Evidence[3]

         On August 29, 2014, licensed psychologist Pauline Bonilla, Psy.D., performed a comprehensive psychiatric examination of Plaintiff. (AR 387-92.) She observed Plaintiff to have fair hygiene and grooming. (AR 389.) Plaintiff was pleasant and cooperative throughout the interview and was considered a “reliable historian.” (AR 387, 389.) She complained of symptoms of depression due to an increase in medical issues, chronic pain, physical limitations, decrease in quality of life, and the inability to provide for her family financially. (AR 387-88.) Plaintiff described her depressive symptoms as feelings of sadness, hopelessness, and worthlessness; a lack of interest in activities; decreased motivation and energy; difficulty concentrating; low frustration tolerance; and increased irritability and occasional anger. (AR 388.) She also complained of anxiety and reported that she often has “significant nervousness in public and crowds, ” resulting in a “need to escape and avoid.” (AR 388.) Plaintiffs anxiety symptoms included shortness of breath; heart palpitations; chest tightening; muscle tension; sweatiness and shakiness; dizziness and nausea; and increased pain and migraine headaches. (AR 388.)

         Plaintiff reported completing her adaptive living skills independently. (AR 389.) She stated that she does not engage in household chores or cooking and that she requires assistance from her daughter to shop for groceries and run errands. (AR 389.) Plaintiff does not drive. (AR 389.)

         Upon mental examination, Dr. Bonilla found Plaintiffs thought content was appropriate with no indications of hallucinations or delusions. (AR 389.) Plaintiffs mood appeared to be dysphoric with poor appetite. (AR 390.) Plaintiff reported that she did not sleep through the night and slept only in the daytime as a result of her medications. (AR 390.)

         Dr. Bonilla found Plaintiffs remote memory intact, although she encountered difficulty reciting digits forward and backward. (AR 390.) Plaintiffs fund of knowledge was found to be consistent with her educational level and socioeconomic background. (AR 390.) She had difficulty performing simple mathematical calculations. (AR 390.) Dr. Bonilla found Plaintiffs concentration to be within normal limits, her abstract thinking inadequate, and an adequate ability to differentiate. (AR 390.) Plaintiff s judgment and insight were within normal limits. (AR 390.) Dr. Bonilla assessed Plaintiff with a mood disorder; an anxiety disorder; a pain disorder; a personality disorder with dependent traits; and a Global Assessment of Functioning (“GAF”) score of 64. (AR 391.)

         According to Dr. Bonilla, Plaintiffs symptoms “appear[ed] to be in the mild to moderate range” and she “appear[ed] to be suffering from a major mental disorder.” (AR 391.) The likelihood of recovery by Plaintiff was deemed to be good with psychotherapy. (AR 391.) Dr. Bonilla noted that Plaintiffs limitations appeared to be “primarily due to a combination of medical and mental health issues.” (AR 391.)

         Dr. Bonilla opined that Plaintiff is mildly impaired in the following: the ability to perform simple and repetitive tasks; the ability to accept instruction from a supervisor; the ability to interact with coworkers and the public; the ability to sustain an ordinary routine without special supervision; and the ability to maintain regular attendance in the workplace. (AR 391.) Dr. Bonilla further opined that Plaintiff is mildly to moderately impaired in the ability to perform detailed and complex tasks, and that Plaintiff is moderately impaired in the ability to complete a normal workday or workweek without interruptions from a psychiatric condition and the ability to deal with stress and changes encountered in the workplace. (AR 391-92.) Dr. Bonilla found the likelihood of Plaintiff “emotionally deteriorating in a work environment” is minimal to moderate. (AR 392.)

         B. Administrative Proceedings

         The Commissioner denied Plaintiffs application for benefits initially on September 19, 2014, and again on reconsideration on February 3, 2015. (AR 100-103, 105-109.) Consequently, Plaintiff requested a hearing before an Administrative Law Judge (“ALJ”). (AR 112-22.) The ALJ conducted a hearing on September 20, 2016. (AR 53-70.). Plaintiff appeared at the hearing with her counsel and testified. (AR 57-68.) A vocational expert also testified. (AR 68-69.)

         C. The ALJ's Decision

         In a decision dated January 13, 2017, the ALJ found that Plaintiff was not disabled, as defined by the Act. (AR 33-52.) The ALJ conducted the five-step disability analysis set forth in 20 C.F.R. § 416.920. (AR 35-51.) The ALJ decided that Plaintiff had not engaged in substantial gainful activity since June 9, 2014, the application date (step one). (AR 35.) At step two, the ALJ found Plaintiffs following impairments to be severe: degenerative disc disease of the lumbar spine, status post laminectomy; obesity; depressive disorder; anxiety disorder; and personality disorder. (AR 35-36.) Plaintiff did not have an impairment or combination of impairments that met or medically equaled one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1 (“the Listings”) (step three). (AR 36-38.)

         The ALJ then assessed Plaintiffs residual functional capacity (RFC)[4] and applied the RFC assessment at steps four and five. See 20 C.F.R. § 416.920(a)(4) (“Before we go from step three to step four, we assess your residual functional capacity . . . . We use this residual functional capacity assessment at both step four and step five when we evaluate your claim at these steps.”). The ALJ determined that Plaintiff had the RFC:

to perform light work as defined in 20 C.F.R. [ยง]416.967(b) except [Plaintiff] can lift and or carry 20 pounds occasionally and 10 pound [sic] frequently; she can stand and or walk for six hours in an eight hour day with normal breaks; she can sit for six hours in an eight hour day with normal breaks; she can occasionally balance, stoop, kneel, crouch, and crawl; she can occasionally climb ...

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