KAREN E. SCOTT, Magistrate Judge.
Gildardo G. F. ("Plaintiff") suffered a traumatic brain injuryin 2008 as the result of a motor vehicle accident. Administrative Record ("AR") 42, 379-81, 409. He had no earnings in 2010 or 2011; at that time, he was married with four children and was a "stay at home dad." AR 61, 479. From July 2011 to October 2011, he worked as a kitchen assistant for Vocational Improvement Program, Inc. ("VIP"), a non-profit corporation that helps people with disabilities find jobs. AR 273, 278, 357. VIP helped him obtain a job at Home Depot which he held from January 2012 through February 2014 when he resigned because he thought he was going to be fired. AR 50-51, 276, 306. He got divorced in 2013. AR 56.
On February 21, 2014, Plaintiff applied for supplemental security income ("SSI") alleging disability commencing February 7, 2014, the day after his separation from Home Depot. AR 174-78, 276. On November 17, 2015, an Administrative Law Judge ("ALJ") conducted a hearing at which Plaintiff, who was represented by counsel, appeared and testified, as did a vocational expert ("VE"). AR 38-81.
On March 15, 2016, the ALJ issued a decision denying Plaintiff's SSI application. AR 18-37. The ALJ found that Plaintiff suffered from medically determinable severe impairments consisting of "history of traumatic brain injury, major depressive disorder, organic affective disorder, mood disorder, anxiety, and history of marijuana abuse." AR 20. Despite these impairments, the ALJ determined that Plaintiff had the residual functional capacity ("RFC") to perform medium work as defined in 20 C.F.R. § 416.967(c) with the following limitations:
AR 23.
Based on this RFC and the VE's testimony, the ALJ determined that Plaintiff could not perform his past relevant work as a Home Depot sales attendant. AR 30. The ALJ found, however, that Plaintiff could work as a laundry laborer, Dictionary of Occupational Titles ("DOT") 361.687-018; industrial cleaner/janitor, DOT 381.687-018; and kitchen helper, DOT 318.687-010. AR 31. The ALJ concluded that Plaintiff was not disabled.
A district court may review the Commissioner's decision to deny benefits. The ALJ's findings and decision should be upheld if they are free from legal error and are supported by substantial evidence based on the record as a whole. 42 U.S.C. § 405(g);
"A decision of the ALJ will not be reversed for errors that are harmless."
Plaintiff's appeal presents the following two issues: (1) whether the ALJ properly evaluated the medical evidence concerning Plaintiff's mental impairments; and (2) whether the ALJ properly evaluated Plaintiff's subjective symptom testimony. (Dkt. 18, Joint Stipulation ["JS"] at 4.)
The ALJ found that some medical source opinions and Plaintiff's testimony about the limiting effects of his condition were inconsistent with other evidence in the record. The Court summarizes that evidence in advance of discussing the ALJ's analysis.
The Home Depot staff who interviewed Plaintiff scored him a 3 or 4 on a scale of 1-5. AR 285-91. Plaintiff signed an acknowledgement of wage/hour and security policies and an orientation checklist. AR 292-96. He successfully completed the "in-aisle assessment for D25." AR 298. In January 2013, he received a generally favorable performance review. AR 300-01. In July 2013, he received an excellent review with no categories marked "needs improvement." AR 304-05. In January 2014, his performance review indicated "needs improvement" for many categories. AR 302-03. His supervisors noted that he had failed to complete required product training, had "challenges coming to work on time" and "excessive call outs." AR 302. In 2013 and 2014, Plaintiff received disciplinary notices for repeatedly asking to leave early to attend a birthday party despite a supervisor's denying the request, failing to complete training on schedule, and arriving late and having unexcused absences on multiple days. AR 309-12.
Plaintiff's job at Home Depot involved helping customers in the hardware department. AR 52. Plaintiff received acceptable or excellent ratings for treating customers professionally. AR 300, 302, 304;
Plaintiff moved out of his mother's house and into his own apartment alone during the period of claimed disability.
In the function report ("FR") he completed while still living with his mother, when asked how his condition limits his ability to work, Plaintiff stated, "I can work or do anything, but I do have limitation or conditions that make things challenging." AR 211. As mental limitations, he identified forgetfulness, sadness, and "uncontrollable laughter often."
On April 25, 2014, Dr. Maze performed a neurological evaluation. AR 397-400. Dr. Maze described Plaintiff's speech as "mildly hesitant" and "messy" because "at times, he cannot say words precisely." AR 397-98. Dr. Maze also described Plaintiff as "forgetful" with "more problems" with short-term memory and "his mentation is slightly slowed." AR 398. Dr. Maze observed that Plaintiff could follow "all simple instructions" and his "intelligence does not appear impaired." AR 398. Dr. Maze did not assess any functional limitations due to mental impairment, except to say that he would function "best" in a very low stress environment with minimal contact with others. AR 400.
In July 2014, Plaintiff participated in an External Situational Assessment ("ESA") conducted by the San Gabriel Valley Training Center upon referral from the Department of Rehabilitation. AR 232-37. The assessment involved an interview and then trial tasks at various companies.
The interviewer reported that Plaintiff was living with his mother but handling his own finances and "very independent." AR 232. Plaintiff was seeking fulltime employment and was willing to travel up to 20 miles for work. AR 233. He needed a job because he wanted to move out on his own. AR 234.
The first work trial was at Saunders-3M Tape Products. AR 233. Plaintiff was able to bag and label 129 rolls of tape "after one demonstration and minimal verbal reminders." AR 233. He found the work "easy" and complained, "Anyone can do this job, why do you have me bagging and labelling rolls of tape?" AR 233-34.
At an automotive parts store, he was asked to bag and label brake hoses. AR 235. He "became upset" and stated that he "felt like he was back at VIP, he was not an idiot."
The next trial job was janitorial work at a warehouse. AR 235. He cleaned several restrooms and breakrooms.
Attempting to accommodate this preference, Plaintiff's next trial job was at Petco. AR 237. Plaintiff was assigned to dust shelves, but he "was not in favor of this assignment, ended the assignment, and was transported home."
The evaluators concluded that Plaintiff had attitude difficulties, but did not report any cognitive difficulties. AR 237 (reporting he had "complaints" at each worksite and felt "menial tasks are beneath him").
In late 2014 and 2015, Plaintiff visited Dr. Umugbe at Health and Happy America Corp. several times, as follows:
• 11/13/14: Plaintiff reported that his daily moods were like a roller coaster; he was unhappy with circumstances in his life, including his ex-wife's new relationship and having no job. AR 429. He was prescribed medications. AR 430.
• 11/28/14: Plaintiff rated his depression as 7/10; he was angry at himself for cheating on his wife, causing their divorce. AR 427. He explained that he had stopped taking his medication because he was not sure if it made him feel worse, but now he "consent[ed]" to taking them.
• 1/16/15: Plaintiff reported he felt "things are getting better." AR 426. He "used to smoke marijuana and drink a lot," but now felt he did "not get angry easily anymore."
• 2/20/15: Plaintiff reported that he "ran out of Prozac and would like for it to be elevated." AR 425. He received another prescription and counselling on the "importance of compliance" with dosage instructions.
• 3/20/15: He again rated his depression 3/10 and reported that "he has been going to school (Chaffey Com College) trying to prepare himself for rehab and he might be given work." AR 424. Plaintiff also said, however, that he had stopped taking Prozac and stopped seeing his counsellor.
• 6/25/15: Plaintiff reported that "he was smoking marijuana but he started to become volatile" over his ex-wife's boyfriend, so "he started to Canyon for therapy and he stopped MJ and started to take his psych meds again." AR 423.
• 7/22/15: Plaintiff reported that he was attending therapy at Canyon Ridge three days/week to "stop using [marijuana] and pray and I feel better. . . ." AR 422.
In June 2015, Plaintiff sought help at Canyon Ridge Hospital for depression. AR 449. Plaintiff reported his depression was caused by "ex-wife living in same apartment complex & he is seeing her with her new partner." AR 451. He reported feeling angry at his ex-wife. AR 515-18. He also reported using marijuana within the last two weeks, and he used marijuana during treatment. AR 451, 463, 472, 522. On mental status exam, Plaintiff presented with "racing thoughts" and "irritability" but no hallucinations. AR 450. He could spell "world" forwards and backwards.
He participated in their outpatient program in August 2015. AR 447. The program provided medication management and therapy five days/week. AR 447-48. On August 5, 2015, he had made "minimal" progress towards his treatment goals. AR 540. On August 12, 2015, staff noted he had difficulties getting along with his peers. AR 542. On August 19, 2015, the staff noted "slight improvement" but "has problems with concentration and attention span." AR 548. On August 24, 2015, he was discharged from the program as "stable" with a prescription for Prozac and "no symptoms of psychosis." AR 448, 553.
Plaintiff contends that the ALJ failed to give a specific, legitimate reason for discounting the opinions of (1) consultative psychologist Dr. Zhang and (2) treating neurologist Dr. Ali. (JS at 6, 8.)
In deciding how to resolve conflicts between medical opinions, the ALJ must consider that there are three types of physicians who may offer opinions in Social Security cases: (1) those who directly treated the plaintiff, (2) those who examined but did not treat the plaintiff, and (3) those who did not treat or examine the plaintiff.
If the treating physician's opinion is uncontroverted by another doctor, it may be rejected only for "clear and convincing" reasons.
On October 1, 2014, Dr. Zhang completed a psychological evaluation of Plaintiff. AR 409-14. He administered tests of memory and intelligence and reviewed a prior neurological evaluation. AR 409. At the time of the examination, Plaintiff was not taking any psychotropic medication and had no history of psychiatric treatment. AR 410. Dr. Zhang noted, "no history of substance abuse reported." AR 410;
Dr. Zhang determined found that Plaintiff had a Full Scale IQ of 64. AR 412. Dr. Zhang noted that this was at the "extremely low range of intelligence" with 98% of the population scoring above 70.
Dr. Zhang diagnosed Plaintiff with "major depressive disorder with psychotic features" and "cognitive disorder, NOS [not otherwise specified]." AR 413. Dr. Zhang concluded that Plaintiff had no impairment carrying out simple instructions, but had "marked" impairments performing work without special supervision and responding appropriately to work situations and changes. AR 414. He also found that Plaintiff was not capable of managing funds independently.
The ALJ discussed Dr. Zhang's report and relied on portions of it to formulate Plaintiff's RFC, including assessing Plaintiff's ability to carry out simple instructions. AR 27-28, 414. Overall, however, the ALJ gave Dr. Zhang's report "less than significant weight because it is not consistent with the record as a whole, particularly with respect to the marked limitations." AR 28. The ALJ identified what parts of the record she found to be inconsistent with Dr. Zhang's report, specifically noting "the [Plaintiff's activities of daily living], current independent living, and prior work at Home Depo" are inconsistent with very low IQ score of 64 assigned by Dr. Zhang.
Plaintiff argues that the fact he needed VIP's assistance to obtain the job at Home Depot is consistent with Dr. Zhang's opinion that he is markedly impaired working without special supervision. (JS at 7-8.) The Home Depot records, however, show that once Plaintiff obtained the job, he performed many aspects of it satisfactorily without any special supervision. AR 300-05. Plaintiff argues that his "arriving late, failing to complete training, etc." must have been caused by his impairments because "what else would it be related to?" (JS at 19.) Many unimpaired employees have trouble with punctuality and completing boring assignments, like training, due to a lack of motivation or discipline. Here, Plaintiff's statements to the ESA evaluators (i.e., that menial work was "easy" but uninteresting) suggest that the problem was Plaintiff's attitude, not the residual effect of a brain injury in 2008.
Plaintiff also argues that the ESA supports Dr. Zhang's opinion because the evaluators concluded that Plaintiff "is not ready for work at this time." (JS at 8, citing AR 237.) The evaluators, however, reached this conclusion due to Plaintiff's unwillingness to do unskilled work and poor attitude, not due to Plaintiff's displaying mental impairments that disabled him from doing unskilled work. AR 237.
Plaintiff also argues that the ALJ impermissibly offered her own medical opinion when she concluded that an IQ score of 64 was inconsistent with Plaintiff's work history and activities. (JS at 6.) One does not need a medical degree, however, to conclude that someone capable of driving, renting an apartment alone, using a computer to shop, taking fitness classes, and holding a job at Home Depot has an IQ higher than the lowest 2% of the population. AR 45, 65, 214, 233, 276. Even if Plaintiff needs to use his smart phone to set reminders for himself (JS at 7), his ability to do so weighs against a finding of intellectual disability.
On June 20, 2014, Dr. Ali provided a one-page letter. AR 401. He stated that he first saw Plaintiff in August 2008 after his car accident and continued treating him through 2014.
The ALJ gave Dr. Ali's letter "little weight" because the ultimate opinion of disability presented in it was not in keeping "with the Social Security Administration's precise disability guidelines" and the letter did not "address the listings or any exertional or non-extensional limitations." AR 28. The ALJ also noted that the decision that a claimant is disabled is reserved to the Commissioner.
Plaintiff asserts that Dr. Ali "opined" that Plaintiff "displayed inappropriate behaviors and would have problems participating in work-type environments" and that the ALJ did not adequately address these opinions. (JS at 8-9.) Plaintiff, however, mischaracterizes Dr. Ali's letter which actually states that Plaintiff complained of these issues to Dr. Ali. AR 401. The sole statement in Dr. Ali's letter regarding Plaintiff's functioning is the conclusion that Plaintiff "is considered disabled and he is unable to engage in any gainful employment."
The ALJ correctly noted that Dr. Ali's letter does not discuss the Listings, federal disability guidelines, diagnosed impairments, or any functional limitations observed by Dr. Ali. The letter does not provide any medical opinions about specific exertional or non-exertional limitations that might be expected to flow from Plaintiff's conditions or alleged symptoms. This lack of detail and objective support was a specific and legitimate reason for the ALJ to give Dr. Ali's conclusory letter little weight. Furthermore, the ALJ properly found that the conclusion that Plaintiff was disabled is an issue reserved to the Commissioner, and therefore not entitled to controlling weight or any special significance.
An ALJ's assessment of pain level is entitled to "great weight."
If the ALJ finds that a claimant's testimony as to the severity of his pain and impairments is unreliable, "the ALJ must make a credibility determination with findings sufficiently specific to permit the court to conclude that the ALJ did not arbitrarily discredit claimant's testimony."
In evaluating a claimant's subjective symptom testimony, the ALJ engages in a two-step analysis.
Second, if the claimant meets the first test, the ALJ may discredit the claimant's subjective symptom testimony only if he makes specific findings that support the conclusion.
Here, the ALJ issued his decision on March 15, 2016. At that time, Social Security Ruling ("SSR") 96-7p had not been superseded by SSR 16-3p (which superseded SSR 96-7p on March 28, 2016). The Court notes that the SSR changes appear immaterial to the ALJ's analysis in this case. Both SSRs note that, in assessing a claimant's subjective symptom testimony, ALJs should consider, in addition to the objective medical evidence: (1) the individual's daily activities; (2) the location, duration, frequency, and intensity of pain or other symptoms; (3) factors that precipitate and aggravate the symptoms; (4) the type, dosage, effectiveness, and side effects of any medication the individual takes or has taken to alleviate pain or other symptoms; (5) treatment, other than medication, the individual receives or has received for relief of pain or other symptoms; (6) any measures other than treatment the individual uses or has used to relieve pain or other symptoms (e.g., lying flat on his or her back, standing for 15 to 20 minutes every hour, or sleeping on a board); and (7) any other factors concerning the individual's functional limitations and restrictions due to pain or other symptoms.
Plaintiff testified that after a car accident in May 2008, he experienced severe short-term memory problems, depression, sleep deprivation, emotional outbursts (anger and uncontrollable laughing), and a lack of balance. AR 211-20. Because of these conditions. Plaintiff reported an inability to find or hold work and to recall material including the contents of books, dance routines, recipes, and verbal instructions. AR 47, 48, 55-57, 211-20. Plaintiff testified about problems sleeping through the night. AR 212. Plaintiff also testified to needing both written and electronic reminders for daily activities. AR 57-58.
The ALJ found that while Plaintiff's impairments could reasonably be expected to cause the alleged symptoms, Plaintiff's testimony "concerning that intensity, persistence, and limiting effects of these symptoms are not entirely credible. . . ." AR 24. The ALJ gave at least six reasons supporting this finding: (1) Plaintiff's demeanor at the hearing, (2) the quality of Plaintiff's writing in his FR and prepared statements, (3) inconsistency with Plaintiff's independent living situation and daily activities, (4) inconsistency with mental health treatment notes from November 2014 and February, June and July 2015 (Dr. Umugbe's treating records at AR 422-23, 425, 429), (5) inconsistency with his "work record," and (6) Plaintiff's inconsistent statements. AR 28-30. Considered collectively, these reasons provided a sufficiently clear and convincing basis for discrediting Plaintiff's subjective symptom testimony.
The ALJ found that Plaintiff's demeanor at the hearing was inconsistent with his alleged disabilities, as follows:
AR 30. Thus, the ALJ explained how Plaintiff's demeanor at the hearing was inconsistent with his symptom testimony. For example, Plaintiff testified that he had severe short-term memory problems, but the ALJ observed that his answers demonstrated good memory.
While an ALJ can include personal observations of a plaintiff during a hearing, "a negative credibility determination based on those observations is proper only if it is supported by other evidence."
The ALJ found that the quality of Plaintiff's writing in the FR (AR 211-20) and other prepared statements (AR 405-07) undermined the credibility of Plaintiff's allegations of mental disability. AR 29. The ALJ found that these writing samples demonstrated Plaintiff's ability to work within the limits of the RFC because they showed the ability to "maintain concentration, persistence or pace" and demonstrated Plaintiff's ability to be organized, detailed, and persuasive.
Plaintiff's FR is printed simply and legibly. AR 211-20. It contains many sentence fragments and some misspellings (e.g., "challanging" and "handout with friends"). AR 211-12. Some mistakes are crossed out. AR 213-15. Plaintiff fluctuates his use of the Oxford comma.
The ALJ also cited the written Statement of Claimant from August 18, 2014, in which Plaintiff wrote three pages to explain the hardships of his conditions. AR 29, 405-407. This document shows that Plaintiff could organize a longer series of thoughts and use complete sentences, although he does not divide his writing into paragraphs.
The Court agrees that the quality of the writing in the documents cited by the ALJ is inconsistent with Plaintiff having an IQ of 64, but it is not preclusive of Plaintiff having some mental impairments. The Court, therefore, declines to find that the quality of Plaintiff's writing, standing alone, would be a clear and convincing reason to discount his subjective symptom testimony.
ALJs may consider contradictions between a claimant's reported limitations and a claimant's daily activities when assessing subjective symptom testimony.
The mere fact that a claimant can carry on some daily activities, however, does not defeat a claim of disability.
Here, the ALJ found that Plaintiff's daily activities contradict Plaintiff's testimony and undermine his allegations of disability. AR 29. The ALJ noted that Plaintiff reported being able to maintain his personal care and hygienic need as well as cook, mow the lawn, iron, drive a car, go outside without assistance, socialize with friends and family, play basketball, handle his personal finances, and attend scheduled fitness classes with the public. AR 29. The ALJ also cited records that Plaintiff attended community college in 2015.
Plaintiff argues that these findings are insufficient because the ALJ "simply summarized Plaintiff's activities" without explaining the inconsistency. (JS at 21.) The inconsistencies, however, are clear. Plaintiff claimed that he could not work in part because of inappropriate emotional outbursts, which is inconsistent with being able to interact appropriately with others while socializing, running errands, visiting the park, and taking fitness classes. Plaintiff claimed that he was too mentally impaired to do even simple work without special supervision, but that is inconsistent with driving, living independently, managing his own finances, and taking classes. Plaintiff claimed balance problems, which is inconsistent with playing basketball and walking dogs.
The ALJ found Plaintiff's complaints inconsistent with Dr. Umugbe's mental health treatment notes from November 2014 and February, June and July 2015. AR 28, citing AR 422-29. These notes generally show that Plaintiff was upset over his divorce, his ex-wife's new boyfriend, and his poverty, and his mood improved somewhat with Prozac and counselling but worsened with marijuana use. Plaintiff denied hallucinations (AR 426), wanted to read an article on how to re-start life (AR 428), and rated his depression 3/10 when he was taking Prozac (AR 424-25). He largely attributed his low moods to his ex-wife's living nearby with her new boyfriend, not a brain injury from his 2008 car accident. The ALJ did not err by interpreting these records as inconsistent with Plaintiff's claims of disabling mental impairment.
The ALJ found that Plaintiff's "work record" showed that he could work within the assessed RFC. AR 28. The ALJ discussed Plaintiff's work at Home Depot (AR 25-26) and the ESA showing Plaintiff's "proven ability to perform a janitorial job" despite "complaints about the type of work and lack of interest." AR 26.
Again, the Home Depot records indicate that Plaintiff worked well with customers and fellow sales associates (AR 300) and that he voluntarily left his position (AR 306). The ESA show that Plaintiff could do unskilled work but lacked motivation to pursue it. AR 232-37. The ALJ did not err in citing these records as undermining Plaintiff's claim of disability.
The ALJ noted that while Plaintiff told Dr. Zhang that he suffers from daily auditory hallucinations (AR 411), Plaintiff denied "AU" [auditory hallucinations] to Dr. Umugbe (AR 422-23, 425, 429). AR 28. Dr. Zhang ultimately diagnosed Plaintiff as suffering from "psychotic features" (AR 413), whereas Canyon Ridge Hospital found "no symptoms of psychosis." AR 448.
The ALJ also noted that Plaintiff's "report that he was written up for inappropriate laughing and behavior towards customers is not supported by Home Depot employment records." AR 26. This is true, because his performance evaluations and disciplinary notices say nothing about inappropriate behavior towards customers. To the contrary, they said he "works well with customers." AR 300. He never received "needs improvement" for treating customers in a respectful, professional way, and he was rated as a "top performer" in that area during his last review. AR 300, 302, 304.
For the reasons stated above, IT IS ORDERED that judgment shall be entered AFFIRMING the decision of the Commissioner denying benefits.