KENDALL J. NEWMAN, Magistrate Judge.
Plaintiff seeks judicial review of a final decision by the Commissioner of Social Security ("Commissioner") denying plaintiff's application for Supplemental Security Income ("SSI") under Title XVI of the Social Security Act ("Act").
For the reasons that follow, the court DENIES plaintiff's motion for summary judgment, GRANTS the Commissioner's cross-motion for summary judgment, and AFFIRMS the final decision of the Commissioner.
Plaintiff was born on January 21, 1982, completed the 12th grade with special education classes, and previously worked as a fast food worker and cashier. (Administrative Transcript ("AT") 212, 252, 346.)
On appeal, plaintiff raises the following issues: (1) whether the ALJ failed to base plaintiff's residual functional capacity assessment on substantial evidence; (2) whether the ALJ erroneously discounted plaintiff's credibility and the credibility of a third-party witness; (3) whether the ALJ improperly failed to account for plaintiff's headaches; and (4) whether the ALJ erred in not evaluating plaintiff for a somatoform disorder.
The court reviews the Commissioner's decision to determine whether (1) it is based on proper legal standards pursuant to 42 U.S.C. § 405(g), and (2) substantial evidence in the record as a whole supports it.
The ALJ evaluated plaintiff's entitlement to SSI pursuant to the Commissioner's standard five-step analytical framework.
Before proceeding to step four, the ALJ assessed plaintiff's residual functional capacity ("RFC") as follows:
(AT 28.)
At step four, the ALJ determined that plaintiff was unable to perform any past relevant work. (AT 31.) However, at step five, the ALJ found, in reliance on the VE's testimony, that, in light of plaintiff's age, education, work experience, and RFC, there were jobs that existed in significant numbers in the national economy that plaintiff could perform. (AT 31-32.) Thus, the ALJ concluded that plaintiff had not been under a disability, as defined in the Act, from November 18, 2011, the date that plaintiff's SSI application was filed, through the date of the ALJ's decision. (AT 32.)
The record in this case contains treatment records, but no functional capacity assessments, from plaintiff's treating providers. Thus, in evaluating the medical evidence for purposes of formulating plaintiff's RFC, the ALJ primarily relied on the opinions of the state agency physicians and a consultative examiner, as well as plaintiff's treatment records.
The weight given to medical opinions depends in part on whether they are proffered by treating, examining, or non-examining professionals.
To evaluate whether an ALJ properly rejected a medical opinion, in addition to considering its source, the court considers whether (1) contradictory opinions are in the record; and (2) clinical findings support the opinions. An ALJ may reject an uncontradicted opinion of a treating or examining medical professional only for "clear and convincing" reasons.
While a treating professional's opinion generally is accorded superior weight, if it is contradicted by a supported examining professional's opinion (supported by different independent clinical findings), the ALJ may resolve the conflict.
With respect to the physical component of plaintiff's RFC, the ALJ found that plaintiff was capable of performing sedentary work. (AT 28.) In reaching that conclusion, the ALJ properly relied on the October 9, 2012 opinion of state agency physician, Dr. Amon, who reviewed plaintiff's records and opined that plaintiff was capable of performing light work. (AT 136-37.) Dr. Amon's opinion was consistent with the weight of plaintiff's treatment records.
Contrary to plaintiff's argument, the ALJ did not invent plaintiff's RFC by restricting plaintiff to sedentary work. The ALJ's RFC was not required to match the opinion of any particular source, and the ALJ is obligated to consider the record as a whole.
With respect to the mental portion of plaintiff's RFC, the ALJ reasonably relied on the opinion of consultative examining psychologist, Dr. Deborah Lacy. (AT 30.) Dr. Lacy personally evaluated plaintiff on March 18, 2012, and noted that plaintiff was very well groomed and had fair eye contact, normal thought processes, normal speech, normal thought content, a sad mood and restricted affect, average intelligence, normal immediate and remote memory, impaired recent memory, a normal fund of knowledge, normal concentration, intact abstract thinking, intact insight and judgment, and could perform simple calculations without difficulty. (AT 429, 432-34.) Dr. Lacy diagnosed plaintiff with a depressive disorder and an anxiety disorder, observing that plaintiff's symptom severity was within the mild range and that she appeared to be able to function adequately, adding that plaintiff's limitations appeared to be "primarily due to her reported medical problems." (AT 435.) Dr. Lacy opined that plaintiff was able to perform simple and repetitive tasks; able to perform detailed and complex tasks; able to maintain regular attendance; not impaired in her ability to perform work activities without special or additional supervision; mildly impaired in her ability to relate and interact with coworkers and the public; and moderately impaired in her ability to perform work activities on a consistent basis, complete a normal workday or workweek without interruptions, and deal with the usual stresses encountered in competitive work. (AT 435-36.)
Contrary to plaintiff's contention, the ALJ did not erroneously discredit the above-mentioned moderate limitations assessed by Dr. Lacy. It was not unreasonable for the ALJ to find such limitations inconsistent with the largely normal findings on the mental status examination, as well as Dr. Lacy's observation that plaintiff's symptom severity was within the mild range, especially given that Dr. Lacy provided no explanation for the assessment of moderate limitations in those areas. (AT 30.)
Nevertheless, even assuming, without deciding, that the ALJ erred in discrediting those assessed moderate limitations, any such error was harmless.
Moreover, the Ninth Circuit has already held that moderate mental limitations do not even require vocational expert testimony.
Finally, plaintiff's argument that the ALJ failed to account for plaintiff's brief, involuntary psychiatric hospitalization in June 2013 is unpersuasive. Notably, the ALJ specifically acknowledged that hospitalization in her decision, but found that it was not indicative of a long-lasting, more severe psychiatric impairment. (AT 30.) The ALJ reasoned that the hospitalization was based primarily on plaintiff's subjective reports of suicidal thoughts and other mental symptoms, which the ALJ found not credible. (
Therefore, the court concludes that substantial evidence supports the ALJ's RFC assessment.
Whether the ALJ erroneously discounted plaintiff's credibility and the credibility of a third-party witness
In
"The ALJ must specifically identify what testimony is credible and what testimony undermines the claimant's complaints."
In this case, the ALJ affirmatively found that plaintiff had malingered and exaggerated her symptoms. (AT 31.)
As the ALJ observed, during a December 2011 hospitalization at Mercy General Hospital, treating physician Dr. Jason Spears noted that, despite plaintiff's report of a prior stroke, there was no evidence of a current or prior stroke, and that plaintiff's subjective mild left-sided weakness was of questionable etiology. (AT 24-25, 628.) He explained that her examination was "very strange in that she at times during the exam used her left arm without any weakness whatsoever—this was when she grabbed for something, fixed her hair or reached for something on the stand. However, when I did a focused exam, she had an exaggerated left subjective weakness." (AT 24-25, 647.) Dr. Spears stated that he had consulted with Dr. Edwin Cruz, a neurologist, who saw similar findings. (
(AT 630, 647.)
On March 13, 2012, plaintiff sought treatment at Washington Hospital Healthcare System, complaining of shortness of breath, chest pain, and left-sided weakness. (AT 24, 507.) Upon examination, plaintiff claimed that she could not move her left leg and could only wiggle her toes, even though she had walked into the emergency department. (AT 25, 507, 509.) Staff also documented that plaintiff showed no pushdown of the right heel when she was purportedly trying to lift her left leg during the examination. (AT 25, 510.) She was noted to be accompanied by "an acquaintance who is also visiting two pts in Fast Track who are requesting Phenergan with Codeine cough syrup." (AT 509.) After treating physician Dr. Kevin Morrissey explained that there was no indication for admission to the hospital:
(AT 25, 510.)
Thereafter, in April 2012, plaintiff went to the emergency room at Sutter General Hospital complaining of left-sided weakness, and stated that she had a history of stroke and depression. (AT 441.) According to plaintiff, she woke up that morning barely being able to move her left side, but somehow made it to her primary care doctor's office, who sent her to the emergency room. (AT 443.) In the course of plaintiff's workup, treating physicians suspected a potential conversion disorder, somatoform disorder, or a hemiplegic migraine. (AT 441, 445.) However, in a subsequent physical therapy consultation, the physical therapist declined further treatment, indicating that plaintiff was "inconsistent with her ability to move the left lower extremity." (AT 25, 441.) Based on that finding, as well as plaintiff's normal diagnostic studies and negative workup for stroke, plaintiff was discharged by treating physician Dr. Inderpal Biring with diagnoses of left lower extremity weakness of unknown cause and possible malingering; depression; and questionable history of previous transient ischemic attack. (
In light of the above, substantial evidence supports the ALJ's finding of malingering, which is sufficient in itself to support the ALJ's decision to discount plaintiff's credibility.
Although not required to do so, the ALJ also referenced several other specific, clear, and convincing reasons for discounting plaintiff's credibility. The ALJ noted that plaintiff testified that she got migraines every other day that were severe enough to make her throw up, but then inconsistently testified that she got relief from her Botox injections that lasted for two weeks. (AT 29-30, 96, 109.) The ALJ also observed that plaintiff testified to using a cane about three days a week, even though there is no evidence that healthcare providers advised her that she required a cane, and she did not have her cane with her at the administrative hearing. (AT 31, 76.) Additionally, the ALJ pointed out that plaintiff told consultative examiner Dr. Lacy that she was independent for basic self-grooming, completed light household chores, prepared simple meals, helped her three children get ready for school, picked up her children from school, watched television, and did her shopping once a week. (AT 27, 432.) Finally, the ALJ thoroughly discussed and analyzed the medical evidence, concluding that the weight of such evidence was inconsistent with plaintiff's testimony.
In light of the above, the ALJ reasonably discounted plaintiff's credibility.
Plaintiff further contends that the ALJ improperly discounted the credibility of a third party witness, Debra Fitch, who completed a third-party function report on January 15, 2012. (AT 258-65.) "[C]ompetent lay witness testimony cannot be disregarded without comment" and "in order to discount competent lay witness testimony, the ALJ must give reasons that are germane to each witness."
Here, the ALJ specifically acknowledged Ms. Fitch's report, but indicated that Ms. Fitch had failed to state how often she spends time with plaintiff, and that Ms. Fitch was possibly not in an ideal position to evaluate plaintiff's symptoms and resulting limitations. (AT 31.) Indeed, Ms. Fitch failed to indicate her relationship to plaintiff, how long she had known plaintiff, and how much time she spent with plaintiff; many of her responses to questions in the form were vague; and she indicated "unknown" or "not sure" in response to several questions. (AT 258-65.) As such, the ALJ provided germane reasons for giving Ms. Fitch's report little weight.
Plaintiff's argument that the ALJ failed to properly account for plaintiff's headaches lacks merit. The ALJ specifically found plaintiff's migraine headaches, with associated cervical paraspinal muscle spasms, to be a medically determinable and severe impairment at step two, but discounted the degree of associated functional limitation alleged by plaintiff as inconsistent with plaintiff's treatment. (AT 24-25, 29-30.)
As noted above, plaintiff testified that she got migraine headaches every other day that were severe enough to make her throw up. (AT 96.) However, on September 18, 2012, Dr. Sauer, plaintiff's neurologist who treated her specifically for her headaches and associated muscle spasms, noted that plaintiff had been treated with Botox that day, and would need another injection in 2.5 months. (AT 595.) Subsequently, on October 17, 2012, Dr. Sauer noted that plaintiff was about 4 weeks post Botox injection and had "done well again and examination shows no spasm." (AT 727.) He observed that plaintiff would need another Botox injection in about 8 weeks. (
Accordingly, the court finds no error in the ALJ's evaluation of plaintiff's migraine headaches.
Finally, plaintiff posits, for the first time in her federal court appeal, that the ALJ should have evaluated plaintiff for a somatoform disorder. Even assuming, without deciding, that the issue was not waived by failing to raise it below, plaintiff's argument fails on the merits.
In short, plaintiff weaves together various alleged symptoms and her interpretation of other evidence in the record in an attempt to match them with the requirements of Listing 12.07 for somatoform disorders. While admittedly creative, the argument ignores the fact that no medical source in the record had actually diagnosed plaintiff with a somatoform disorder. To be sure, as noted above, some of the emergency room physicians had at times considered the possibility that plaintiff may suffer from a conversion disorder or a somatoform disorder, but no such definitive diagnosis was ultimately made. Significantly, neither plaintiff's mental health treating providers nor the consultative examining psychologist, who are mental health specialists, diagnosed a somatoform disorder.
Thus, on this record, the ALJ had no obligation to independently evaluate plaintiff for a somatoform disorder.
In sum, the court finds that ALJ's decision is free from prejudicial error and supported by substantial evidence in the record as a whole. Accordingly, IT IS HEREBY ORDERED that:
1. Plaintiff's motion for summary judgment (ECF No. 16) is DENIED.
2. The Commissioner's cross-motion for summary judgment (ECF No. 25) is GRANTED.
3. The final decision of the Commissioner is AFFIRMED, and judgment is entered for the Commissioner.
4. The Clerk of Court shall close this case.
The claimant bears the burden of proof in the first four steps of the sequential evaluation process.