1 2 3 4 O 5 6 7 8 UNITED STATES DISTRICT COURT 9 CENTRAL DISTRICT OF CALIFORNIA 10 11 ANDREW C., Case No. 5:20-CV-00149 KES 12 Plaintiff,
13 v. MEMORANDUM OPINION AND ORDER 14 ANDREW M. SAUL, Commissioner of Social Security, 15 Defendant. 16
17 18 I. 19 BACKGROUND 20 In November 2015, Andrew C. (“Plaintiff”) applied for Title XVI social 21 security supplemental security income (“SSI”) at age 26, alleging an onset date of 22 November 19, 2015, due to schizophrenia, paranoia, and memory loss. 23 Administrative Record (“AR”) 42, 217, 233, 238. 1 On September 20, 2018, the 24 25 1 Plaintiff previously applied for benefits in June 2012. AR 103. In March 2014, the Administrative Law Judge (“ALJ”) found that Plaintiff’s substance- 26 induced psychotic disorder, personality disorder, and drug and alcohol abuse were 27 severe impairments but that if Plaintiff stopped the substance abuse, the remaining limitations would not cause more than a minimal impact on Plaintiff’s ability to 28 perform basic work activities. AR 106–07. Therefore, because the substance abuse 1 ALJ conducted a hearing at which Plaintiff, who was represented by counsel, 2 testified along with a vocational expert. AR 48–73. On December 3, 2018, the 3 ALJ issued an unfavorable decision. AR 28–43. 4 At step two of the sequential evaluation process, the ALJ found that Plaintiff 5 suffered from the following medically determinable severe impairments: 6 schizophrenia and depression. AR 30. At step three, the ALJ determined Plaintiff 7 did not have an impairment or combination of impairments that met or medically 8 equaled the severity of any of the listings enumerated in the regulations. AR 31. In 9 making this determination, the ALJ found that Plaintiff was moderately limited in 10 his ability to (1) understand, remember, or apply information; (2) interact with 11 others; (3) concentrate, persist, or maintain pace; and (4) adapt or manage oneself.2 12 AR 31–32. The ALJ next assessed Plaintiff’s residual functional capacity (“RFC”) 13 and found that he could perform a full range of work at all exertional levels but 14 with the following nonexertional limitations: “simple routine tasks not at a 15 production rate pace, such as an assembly line; simple work-related decisions with 16 few changes in the work place; and occasional contact with supervisors, coworkers, 17 and no direct contact with the public.” AR 33. 18 At step four, the ALJ found that Plaintiff had no past relevant work.3 AR 42. 19 Based on the RFC and the VE’s testimony, the ALJ found at step five that there 20 were jobs that existed in sufficient numbers in the national economy which Plaintiff 21 22 disorder was a contributing factor material to the disability determination, the ALJ 23 found that Plaintiff was not disabled. AR 112. 24 2 To meet a listing, a claimant’s mental impairment must cause at least two 25 “marked” limitations or one “extreme” limitation. AR 31, 33; 20 C.F.R. pt. 404, subpt. P, app. 1. 26 3 Plaintiff testified he has a high school diploma and studied automotive 27 technology for a year and a half in college. AR 54. In 2009–2010, Plaintiff worked 28 part time for KFC as a cook. AR 54, 226–27. 1 could perform, including sweeper cleaner, textile assembler, and lens inserter. AR 2 42–43. The ALJ therefore concluded that Plaintiff was not disabled. AR 43. 3 II. 4 ISSUE PRESENTED 5 Plaintiff presents a single issue for review: whether the ALJ properly 6 considered the opinion of Dr. Brauer Trammell, Plaintiff’s treating physician. (Dkt. 7 22, Joint Stipulation [“JS”] at 4.) 8 III. 9 SUMMARY OF THE RECORD EVIDENCE 10 A. Treating Source Medical Evidence. 11 Plaintiff began psychiatric treatment in 2010 for depression, delusions, 12 paranoia, and auditory hallucinations. AR 326, 773, 777. Beginning in June 2010, 13 he was hospitalized over 15 times for psychiatric issues, the most recent in March 14 2018, and attempted suicide on one occasion. AR 327, 773, 793, 930. 15 In May 2015, Plaintiff complained of depression, bipolar disorder, paranoia, 16 and anxiety. AR 803. He reported that his “delusions are pretty much gone” but he 17 still has weekly auditory hallucinations. AR 803. His paranoia occurs daily, which 18 he described as “I feel like I’ll fly off into space or a nuke is gonna go off.” AR 19 803. Plaintiff reported occasional homicidal ideations “due to agitation toward 20 others and … delusions of lack of safety.” AR 803. He had frequent suicidal 21 ideations. AR 804. A mental status examination found slightly impaired 22 concentration, bizarre thought content, paranoid and persecutory delusions, and 23 visual hallucinations. AR 804–05. Plaintiff was diagnosed with schizophrenia, 24 paranoid type (DSM-IV code 295.30),4 and assigned a Global Assistance of 25 4 Schizophrenia, paranoid type, is characterized by: (1) preoccupation with 26 one or more delusions or frequent auditory hallucinations; (2) for a significant 27 portion of the time since the onset of the disturbance one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below 28 the level achieved prior to the onset; (3) continuous signs of the disturbance that 1 Functioning (“GAF”) score of 45.5 AR 803. In June, Plaintiff reported that his 2 auditory hallucinations were less frequent and his paranoid ideations less 3 noticeable. AR 561. In July and August, he reported “signif[icant] improvement.” 4 AR 589, 613. On examination, he exhibited inappropriate smiling and laughing. 5 AR 614. In an October 2015 mental health status examination, Plaintiff’s speech, 6 appearance, and motor activity was normal, but he exhibited a blocking thought 7 process,6 delusions and auditory hallucinations, a depressed mood, blunted affect, 8 oriented and alert but distracted cognition, and impaired judgment and insight. AR 9 645–46. His medication efficiency was assessed as “symptomatic but stable.” AR 10 646. Mental status examinations during November and December 2015 and 11 12 13
14 persist for at least 6 months; and (4) relative preservation of cognitive functioning and affect. See American Psychiatric Association, Diagnostic and Statistical 15 Manual of Mental Disorders 313 (4th ed. text rev. 2000) (hereinafter DSM–IV) 16 5 “A GAF score is a rough estimate of an individual’s psychological, social, 17 and occupational functioning used to reflect the individual’s need for treatment.” Vargas v. Lambert, 159 F.3d 1161, 1164 n.2 (9th Cir. 1998). The GAF includes a 18 scale ranging from 0–100, and indicates a “clinician’s judgment of the individual’s 19 overall level of functioning.” DSM–IV 32. According to DSM–IV, a GAF score of 41–50 indicates “serious symptoms (e.g., suicidal ideation, severe obsessional 20 rituals, frequent shoplifting)” or “any serious impairment in social, occupational, or 21 school functioning (e.g., no friends, unable to keep a job).” Id. 34. “Although GAF scores, standing alone, do not control determinations of whether a person’s mental 22 impairments rise to the level of a disability (or interact with physical impairments 23 to create a disability), they may be a useful measurement.” Garrison v. Colvin, 759 F.3d 995, 1003 n.4 (9th Cir. 2014). 24 6 “Thought blocking occurs most often in people with psychiatric illnesses, 25 most commonly schizophrenia. A person’s speech is suddenly interrupted by 26 silences that may last a few seconds to a minute or longer. When the person begins speaking again, after the block, they will often speak about an unrelated subject.” 27 (last visited Dec. 4, 2020) 28 (footnotes omitted). 1 January through June 2016 found similar results.7 AR 656–57, 676–77, 695–96, 2 730–31, 744–45, 756–57, 798–801. 3 In a July 2016 mental status examination, Plaintiff’s speech, appearance, 4 and mood were appropriate, his motor activity normal, his affect blunted, his 5 judgment/insight impaired, his cognition oriented and alert but distracted, his 6 thought process contained loose associations, and his thought content contained 7 delusions. AR 376–77. In August 2016, Plaintiff’s appearance, speech, and affect 8 were appropriate, but he displayed impaired attention, an anxious mood, a blocking 9 thought process, impaired judgment/insight, and hallucinations. AR 384–87, 399– 10 400. In regular weekly visits from September 2016 through March 2017, Plaintiff’s 11 appearance, attention, mood, speech, and affect were all appropriate, but he shared 12 symptoms that signified auditory hallucinations and severe delusions. AR 410–11, 13 420–23, 428–29, 432–33, 436–39, 448–49, 454–55, 463–64, 473–74, 483–84, 486– 14 89, 495–96, 499–500, 504–07, 524–25, 527–28. Plaintiff was routinely assessed to 15 be “symptomatic but stable.” AR 429, 464, 542. In November 2016, Plaintiff 16 presented to the emergency room, complaining of constant agoraphobia, chronic 17 paranoia, depression, pseudobulbar affect,8 and auditory and visual hallucinations. 18 AR 1000. On examination, Plaintiff exhibited a depressed mood, an inappropriate 19 affect, a blocking thought process, paranoid delusions, auditory and visual 20 hallucinations, distracted attention and concentration, fair memory, insight, and 21 impulse control, and poor judgment. AR 1002. He was diagnosed with 22 schizophrenia, paranoid type, and his doses of Abilify and Remeron were increased 23 “for better control of symptoms.” AR 1003. In December 2016, Plaintiff required
24 7 In December 2015, Plaintiff presented to the emergency room with 25 complaints of paranoia preventing him from going outside his house. AR 316–24. 26 8 Pseudobulbar affect (PBA) “is a nervous system disorder that can make [an individual] laugh, cry, or become angry without being able to control when it 27 happens.” (last visited 28 Dec. 4, 2020). 1 treatment in the crisis stabilization unit. AR 515. He complained that auditory 2 hallucinations and paranoia “still bother him.” AR 782. An examination found 3 blunted affect, paranoid delusions, auditory and visual hallucinations, poor 4 concentration, and partial insight. AR 783–84. 5 In January 2017, Plaintiff presented with depressive, manic, and anxiety 6 symptoms. AR 793. He reported audio hallucinations “every few hours,” visual 7 hallucinations once a week, and chronic delusions. AR 795. He was diagnosed 8 with schizophrenia and paranoid schizophrenia. AR 772. In April 2017, Plaintiff’s 9 mood was neutral, his affect was mood-congruent, and his thought process and 10 speech were within normal limits, but he continued to experience auditory and 11 visual hallucinations and “strong bizarre delusions.” AR 846. He acknowledged 12 the benefits of supportive therapy and conceded that “a lot of my problem is I am 13 bored.” AR 855. In May 2017, Plaintiff reported depression, flashbacks, paranoia, 14 anger, and auditory and visual hallucinations. AR 786. On examination, Plaintiff’s 15 appearance and speech were appropriate, but he exhibited paranoid delusions, 16 homicidal ideations, auditory and visual hallucinations, and obsessions. AR 790. 17 In June, Plaintiff reported that his auditory and visual hallucinations occur “once or 18 twice a week.” AR 888. In July and August, he reported daily paranoid ideations 19 and auditory hallucinations up to several times a week. AR 898, 900, 901, 903. On 20 examination, Plaintiff exhibited a depressed mood, a blunted affect, along with his 21 reported hallucinations and delusions. AR 901. In September, he reported “doing 22 better”; he heard “less voices” and experienced paranoid ideations only 23 “sometimes.” AR 904. In October, Plaintiff presented to the emergency room, 24 complaining of suicidal and homicidal ideations, paranoia, and hallucinations. AR 25 1010. On examination, he exhibited a guarded behavior, slow psychomotor 26 activity, slow speech, anxious and sad mood, a blocked thought process, 27 hallucinations, suicidal and homicidal ideations, and impaired insight, judgment, 28 and impulse control. AR 1008, 1012. He was diagnosed with schizophrenia, 1 paranoid type, started on Geodon, and held for observation. AR 1014. The next 2 day, Plaintiff’s symptoms had improved—he denied any suicidal and homicidal 3 ideations, hallucinations, or delusions—and he was discharged. AR 1017–18. 4 In mid-2017, Plaintiff began treating at a Riverside University Behavioral 5 Health (“RUBH”) clinic, with a student intern who worked with Plaintiff to 6 increase his daily activities and functions and to deal with the painful emotions 7 Plaintiff tended to experience daily. AR 846. In April, Plaintiff reported being able 8 to take a public bus alone to his therapy session and “barely felt paranoid at all.” 9 AR 846, 848. Later that month, Plaintiff’s thought process was coherent and 10 asymptomatic and “his concentration was the best ever.” AR 859, 862. The 11 student intern helped Plaintiff create a daily schedule to help him “stay busy 12 throughout the day and effectively decrease his depressive symptoms.” AR 859. 13 At the next weekly session, Plaintiff reported engaging in more productive 14 activities (e.g., exercising, surfing the internet, and drawing) to manage his 15 depression. AR 862. The student intern encouraged Plaintiff to be outside more 16 (e.g., walking, going to library, or visiting the recreational center). AR 862. 17 Plaintiff reported a paranoid episode over the prior weekend, but he was “able to 18 work [his] way out of it.” AR 864. He acknowledged that his medication regime 19 “seems to be helping”—he was experiencing less than two paranoid episodes 20 weekly. AR 864, 866, 884. In May, Plaintiff’s concentration levels were impaired 21 due to him responding to internal stimuli. AR 868. Nevertheless, Plaintiff was able 22 to take city transportation to the session with “minimal symptoms of anxiety” and 23 reported that his hourly schedule had been effective at keeping him more active 24 during the day. AR 868. The student intern encouraged Plaintiff to add more daily 25 activities to his schedule (e.g., yoga and meditation exercises). AR 868. A couple 26 weeks later, Plaintiff reported “doing well”; his auditory hallucinations were “not 27 concerning him and he [was] able to ignore them.” AR 876. On May 24, Plaintiff 28 had his last therapy session with the student intern. AR 882. He arrived at the 1 session using public transportation and “did not experience much paranoia or other 2 strong symptoms in the process.” AR 880, 882–83. In June, Plaintiff took the bus 3 to his appointment; he reported “feeling fine” and “having a good day.” AR 892. 4 In July 2017, Plaintiff transferred to RUBH’s Blaine Street Adult Clinic. AR 5 892, 898. He reported having auditory hallucinations only one to two days a 6 month, but paranoid ideations daily. AR 898. In August, Plaintiff reported 7 auditory hallucinations, anger, depression, and anxiety three times weekly and daily 8 paranoia. AR 901. Nevertheless, he reported “doing better,” with “good” sleep and 9 appetite, no mood swings, and productive daily activities. AR 901. In September, 10 reported “doing better”; he hears less voices, feels paranoid only “sometimes,” and 11 performs many daily living activities. AR 904. 12 In November 2017, Plaintiff began treating at Blaine Street Clinic with 13 Brauer Trammell, M.D. AR 908. Plaintiff reported decreased paranoia but daily 14 auditory hallucinations, which he described as “multiple voices that talk to each 15 other.” AR 908. A mental status examination revealed an “ok” mood, blunted 16 affect, and positive auditory hallucinations, delusions, and paranoia. AR 908. Dr. 17 Trammell restarted Invega and increased the Abilify dosage. AR 909. In 18 December, Plaintiff reported that he was “just trying to cope with the stress of my 19 symptoms,” which he described “like the earth losing it’s [sic] gravity or 20 something.” AR 912. An examination revealed a flat affect, disorganized thought 21 process, and positive auditory hallucinations, delusions, and paranoia. AR 912. Dr. 22 Trammell diagnosed schizophrenia. AR 913. 23 In January 2018, after Dr. Trammell’s third session with Plaintiff, Dr. 24 Trammell completed a psychiatric assessment report. AR 772–77. Plaintiff 25 reported that his anger and depression were “better, but the voices [were] still 26 there.” AR 772. A mental status examination found a flat affect and positive 27 auditory hallucinations. AR 776. Dr. Trammell confirmed the schizophrenia 28 diagnosis, continued Plaintiff’s Remeron, Vistaril, and Invega Sustenna 1 prescriptions, and increased his Abilify dosage.9 AR 777. In February, Plaintiff 2 reported that the increased Abilify dosage was “helpful” but noticed an increase 3 lately in his auditory hallucinations. AR 922. An examination found a blunted 4 affect, positive auditory hallucinations, and fair insight and judgment. AR 922. Dr. 5 Trammell noted that Plaintiff’s schizophrenia, depression, delusions, paranoia, and 6 auditory hallucinations “impair[ his] social, occupational and interpersonal 7 relationship functioning.” AR 923. Plaintiff was briefly hospitalized twice in 8 March 2018 after experiencing both suicidal and homicidal ideations. AR 930. 9 Plaintiff returned to Dr. Trammell in late March. AR 928. He reported that 10 his psychosis subsided after he received his monthly Invega Sustenna injection “but 11 then pick[ed] up closer to the end of the injection cycle.” AR 928. He also 12 reported feeling more depressed but was hopeful his symptoms would improve with 13 medication. AR 928. An examination found a blunted affect and positive auditory 14 hallucinations. AR 928. In May, Plaintiff reported “doing better” with no 15 medication side effects. AR 837. An examination indicated blunted affect and 16 periodic auditory hallucinations, delusions, and paranoia. AR 837. Three weeks 17 later, other than auditory hallucinations, delusions and bouts of anger, Plaintiff 18 reported “doing really good.” AR 842. He acknowledged “longer and longer” 19 periods where he feels well, with fewer hallucinations. AR 842. 20 21
22 9 Remeron (mirtazapine) is an antidepressant used to treat major depressive 23 disorder. Vistaril (hydroxyzine) is an antihistamine that is used to treat anxiety and tension. Invega Sustenna (paliperidone), which is given by injection, and Abilify 24 (aripiprazole) are antipsychotic medications used to treat schizophrenia. 25 (last visited Dec. 2, 2020). 26 Dr. Trammell’s therapy was primarily limited to adjusting Plaintiff’s medication regimen. AR 838, 843, 909, 913, 923, 929. Other practitioners at 27 Blaine Street Clinic provided Plaintiff with supportive therapy. E.g., AR 840, 927, 28 932, 935, 937. 1 B. Medical Opinions. 2 1. Consultative Examiner. 3 In March 2016, Sohini P. Parikh, M.D., completed a psychiatric evaluation at 4 the request of the Agency. AR 325–32. Dr. Parikh was not provided any medical 5 records to review. AR 326. Plaintiff reported multiple hospitalizations due to his 6 history of paranoia, auditory hallucinations, depression, anxiety, and loss of 7 memory and concentration. AR 326–27. Plaintiff acknowledged no cognitive 8 problems completing household tasks, managing his own funds, or following 9 simple oral and written instructions but claimed he “[did] not want to socialize with 10 others due to his paranoia.” AR 328. Dr. Parikh found Plaintiff “evasive” during 11 the mental status examination, which found a depressed and anxious mood but a 12 “brighter” affect, no evidence that Plaintiff was responding to internal stimuli, no 13 ability to interpret simple proverbs, perform serial sevens or serial threes 14 subtractions, or perform any complex arithmetic calculations. AR 328–30. Dr. 15 Parikh diagnosed schizophrenia, paranoid type (per DSM-IV), and assigned a GAF 16 score of 52–57.10 AR 331. Dr. Parikh opined that Plaintiff had moderate 17 difficulties in maintaining social functioning, understanding, carrying out, and 18 remembering complex instructions, responding to coworkers, supervisors, and the 19 general public, responding appropriately to usual work situations, and dealing with 20 changes in a routine work setting, but no impairments in concentration, persistence, 21 and pace or in the ability to understand, carryout, and remember simple 22 instructions. AR 331–32. 23 24 25
26 10 A GAF score of 51–60 “indicates moderate symptoms (e.g., flat affect and circumlocutory speech, occasional panic attacks) or moderate difficulty in social, 27 occupational, or school functioning (e.g., few friends, conflicts with peers or co- 28 workers).” DSM-IV 34. 1 2. State Agency Consultants. 2 In April 2016, Tawnya Brode, Psy.D., a state agency consultant, reviewed 3 the medical record and found that Plaintiff had a moderate restriction of activities of 4 daily living, moderate difficulties in maintaining social functioning, and moderate 5 difficulties in maintaining concentration, persistence, or pace. AR 124. Dr. Brode 6 opined that Plaintiff was moderately limited in his ability to understand, remember, 7 or carry out detailed instructions, work in coordination with or in proximity to 8 others without being distracted by them, complete a normal workday and workweek 9 without interruptions from psychologically based symptoms and to perform at a 10 consistent pace without an unreasonable number and length of rest periods, interact 11 appropriate with the general public, accept instructions and respond appropriately to 12 criticism from supervisors, and respond appropriately to changes in the work 13 setting. AR 126–27. Dr. Brode concluded that Plaintiff had the mental RFC to 14 understand, remember, and carry out simple instructions; sustain appropriate 15 interaction with the public and maintain relationships with coworkers and 16 supervisors; and respond appropriately to most changes in the workplace. AR 127. 17 In August 2016, S. Adamo, Psy.D., another state agency consultant, reviewed 18 the medical record and generally agreed with Dr. Brode’s assessments. AR 137– 19 41. However, Dr. Adamo concluded that Plaintiff can recall and complete simple 20 tasks, do nonpublic work and work that is not primarily interpersonal, and tolerate 21 typical change. AR 139–41. 22 3. Treating Physician. 23 In June 2018, Dr. Trammell completed a one-page Narrative Report. AR 24 770. He noted that Plaintiff had been a patient of Riverside County Mental Health 25 since July 2011, with the most recent visit in May 2018. AR 770. Dr. Trammell 26 commented that Plaintiff had a significant history of schizophrenia, had been 27 hospitalized over 15 times, had attempted suicide in the past, and suffered from 28 depression, hallucinations, delusions, and paranoia. AR 770. He diagnosed 1 schizophrenia, paranoid type, and reported that Plaintiff’s prescriptions include 2 Abilify, Remeron, Vistaril, and Invega. AR 770. He reported that Plaintiff had 3 paranoid thought, psychotic symptoms—auditory and visual hallucinations and 4 delusions—influencing behavior, moderately impaired judgment, evidence of ideas 5 of reference and anger,11 depression, inappropriate affect, apathy, affective 6 flattening, and a fearful attitude. AR 770. Dr. Trammell opined that Plaintiff could 7 not maintain a sustained level of concentration, sustain repetitive tasks for an 8 extended period, adapt to new or stressful situations, or interact with strangers, 9 coworkers, or supervisors. AR 770. He concluded that Plaintiff’s prognosis was 10 chronic and he could not complete a 40-hour workweek without decompensating. 11 AR 770. 12 C. Plaintiff’s Subjective Symptom Statements. 13 In July 2016, Plaintiff submitted an Adult Function Report. AR 270–78. He 14 complained of paranoia, anxiety, stress, depression, and memory loss. AR 270. 15 Nevertheless, he acknowledged a limited range of daily activities. AR 271–72, 16 274. While his paranoia precluded him from being alone, he was able to go outside 17 and use public transportation. AR 273. Plaintiff asserted having problems with 18 talking, hearing, seeing, memorizing, completing task, concentrating, 19 understanding, and following instructions. AR 275. Nevertheless, he 20 acknowledged an ability to sometimes follow written instructions and denied any 21 problems getting along with authority figures. AR 275–76. 22 At his September 2018 hearing, Plaintiff acknowledged occasional alcohol 23 and cannabis use while socializing with friends. AR 55–56. He described his 24 schizophrenia symptoms as paranoia, anxiety, panic attacks, depression, psychotic 25
26 11 “Ideas of reference and delusions of reference describe the phenomenon of an individual experiencing innocuous events or mere coincidences and believing 27 they have strong personal significance.” (last visited Dec. 4, 2020) (footnote omitted). 1 anger, melancholia, and auditory and visual hallucinations. AR 59–60. He 2 reported occasional suicidal ideations but acted on them only once. AR 59. 3 Plaintiff acknowledged that his medications help “a little.” AR 63. During a 4 typical day, Plaintiff walks to the gym for an hour of exercise, uses the internet, and 5 occasionally goes to church. AR 66–68. 6 IV. 7 DISCUSSION 8 A. Rules Governing Consideration of Medical Opinion Evidence. 9 An ALJ must consider all medical opinions of record. 20 C.F.R. 10 §§ 404.1527(b), 416.927(b). The regulations “distinguish among the opinions of 11 three types of physicians: (1) those who treat the claimant (treating physicians); 12 (2) those who examine but do not treat the claimant (examining physicians); and 13 (3) those who neither examine nor treat the claimant (nonexamining physicians).” 14 Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1995), as amended (Apr. 9, 1996). 15 “Generally, a treating physician’s opinion carries more weight than an examining 16 physician’s, and an examining physician’s opinion carries more weight than a 17 reviewing [(nonexamining)] physician’s.” Holohan v. Massanari, 246 F.3d 1195, 18 1202 (9th Cir. 2001); accord Garrison v. Colvin, 759 F.3d 995, 1012 (9th Cir. 19 2014). “The weight afforded a non-examining physician’s testimony depends ‘on 20 the degree to which they provide supporting explanations for their opinions.’” 21 Ryan v. Comm’r of Soc. Sec., 528 F.3d 1194, 1201 (9th Cir. 2008) (quoting 20 22 C.F.R. § 404.1527(c)(3)). 23 The medical opinion of a claimant’s treating physician is given “controlling 24 weight” so long as it “is well-supported by medically acceptable clinical and 25 laboratory diagnostic techniques and is not inconsistent with the other substantial 26 evidence in [the claimant’s] case record.”12 20 C.F.R. §§ 404.1527(c)(2), 27 12 For claims filed on or after March 27, 2017, the Agency “will not defer or 28 give any specific evidentiary weight, including controlling weight, to any medical 1 416.927(c)(2). “When a treating doctor’s opinion is not controlling, it is weighted 2 according to factors such as the length of the treatment relationship and the 3 frequency of examination, the nature and extent of the treatment relationship, 4 supportability, and consistency with the record.” Revels v. Berryhill, 874 F.3d 648, 5 654 (9th Cir. 2017; see also 20 C.F.R. §§ 404.1527(c)(2)–(6), 416.927(c)(2)–(6). 6 Greater weight is also given to the “opinion of a specialist about medical issues 7 related to his or her area of specialty.” 20 C.F.R. §§ 404.1527(c)(5), 416.927(c)(5). 8 “To reject an uncontradicted opinion of a treating or examining doctor, an 9 ALJ must state clear and convincing reasons that are supported by substantial 10 evidence.” Bayliss v. Barnhart, 427 F.3d 1211, 1216 (9th Cir. 2005); see also 11 Ahearn v. Saul, No. 19-35774, —F.3d—, 2021 WL 609825, at *2, 2021 U.S. app. 12 LEXIS 4472, at *4 (9th Cir. Feb. 17, 2021) (reaffirming that a federal court 13 “review[s] the decision of the ALJ for substantial evidence”). “If a treating or 14 examining doctor’s opinion is contradicted by another doctor’s opinion, an ALJ 15 may only reject it by providing specific and legitimate reasons that are supported by 16 substantial evidence.” Bayliss, 427 F.3d at 1216; see also Reddick v. Chater, 157 17 F.3d 715, 725 (9th Cir. 1998) (the “reasons for rejecting a treating doctor’s credible 18 opinion on disability are comparable to those required for rejecting a treating 19 doctor’s medical opinion.”). “The ALJ can meet this burden by setting out a 20 detailed and thorough summary of the facts and conflicting clinical evidence, 21 stating his interpretation thereof, and making findings.” Trevizo v. Berryhill, 871 22 F.3d 664, 675 (9th Cir. 2017) (citation omitted). “When an examining physician 23 relies on the same clinical findings as a treating physician, but differs only in his or 24 her conclusions, the conclusions of the examining physician are not ‘substantial 25 evidence.’” Orn v. Astrue, 495 F.3d 625, 632 (9th Cir. 2007). 26
27 opinion(s) or prior administrative medical finding(s), including those from [a 28 claimant’s] medical sources. 20 C.F.R. § 404.1520c(a). 1 B. Analysis. 2 Dr. Trammell opined that Plaintiff has no ability to maintain a sustained level 3 of concentration, to sustain repetitive task for extended periods, adapt to new or 4 stressful situations, or interact appropriately with strangers, coworkers, or 5 supervisors. AR 770. He further concluded that Plaintiff cannot complete a 40- 6 hour workweek without decompensation. AR 770. The ALJ considered but gave 7 “little weight” to Dr. Trammell’s opinion. AR 41. 8 The ALJ provided specific and legitimate reasons for giving Dr. Trammell’s 9 opinion only little weight. First, the ALJ found that Dr. Trammell’s narrative 10 opinion included “insufficient references to medically acceptable objective clinical 11 or diagnostic findings.” AR 41. Plaintiff contends that Dr. Trammell’s “report 12 contains a mental status examination as well as Dr. Trammell’s observations.” (JS 13 at 8.) To the contrary, Dr. Trammell’s opinion was not given coincident with a 14 mental examination. AR 845. Indeed, the opinion was authored a month after the 15 most recent examinations. AR 770. Further, the June 2018 opinion was not 16 consistent with the May 2018 examinations. In two May sessions, Plaintiff 17 reported “doing better” and “doing really good except for the voices and some 18 anger.” AR 837, 842. Other than occasional auditory hallucinations and delusions, 19 Plaintiff denied depression, anxiety, mania, medication side effects, and suicidal or 20 homicidal ideations. AR 837, 842. He reported improvement in his hallucinations, 21 paranoia, and delusions and was able to minimize the auditory hallucinations by 22 listening to music. AR 837, 842. In May, Dr. Trammell noted that Plaintiff was 23 calm, cooperative, fairly kempt and groomed, and demonstrated appropriate eye 24 contact, speech, and thought process. AR 842. Nevertheless, in the June opinion, 25 Dr. Trammell reported that Plaintiff was paranoid, depressed, apathetic, suffered 26 from both visual and auditory hallucinations, and professed suicidal ideations. AR 27 770. Thus, the extreme limitations assessed by Dr. Trammell were contradicted by 28 his own recent treatment notes. See Tommasetti v. Astrue, 533 F.3d 1035, 1041 1 (9th Cir. 2008) (incongruity between treating physician’s opinion and his treating 2 records is a specific and legitimate reason for rejecting physician’s opinion); Batson 3 v. Comm’r of Soc. Sec. Admin., 359 F.3d 1190, 1195 (9th Cir. 2004) (ALJ may 4 properly discount a treating physician’s opinion that is conclusory, brief, and 5 unsupported by the overall medical record); Thomas v. Barnhart, 278 F.3d 947, 957 6 (9th Cir. 2002) (ALJ “need not accept the opinion of any physician, including a 7 treating physician, if that opinion is brief, conclusory and inadequately supported 8 by clinical findings”). 9 Plaintiff argues that Dr. Trammell’s assessment was supported by his 10 schizophrenia diagnosis. (JS at 9.) However, “[t]he mere existence of an 11 impairment is insufficient proof of a disability.” Matthews v. Shalala, 10 F.3d 678, 12 680 (9th Cir. 1993); see Key v. Heckler, 754 F.2d 1545, 1549 (9th Cir. 1985) (“The 13 mere diagnosis of an impairment … is not sufficient to sustain a finding of 14 disability.”); accord Lundell v. Colvin, 553 F. App’x 681, 684 (9th Cir. 2014). 15 Even if a claimant receives a particular diagnosis, it does not necessarily follow that 16 the claimant is disabled, because it is the claimant’s symptoms and true limitations 17 that generally determine whether she is disabled. See Rollins v. Massanari, 261 18 F.3d 853, 856 (9th Cir. 2001); Gentle v. Barnhart, 430 F.3d 865, 868 (7th Cir. 19 2005) (“Conditions must not be confused with disabilities. The social security 20 disability benefits program is not concerned with health as such, but rather with 21 ability to engage in full-time gainful employment.”). Here, the ALJ acknowledged 22 that Plaintiff’s schizophrenia was a severe, medically determinable impairment, but 23 nonetheless found Plaintiff able to perform simple, routine tasks with only 24 occasional contact with supervisors and coworkers and no contact with the public. 25 AR 30, 33. 26 Second, the ALJ observed that “Dr. Trammell’s assessment appears to have 27 been based on a summary of [Plaintiff’s] subjective complaints, diagnoses, and 28 treatment without documenting any significant positive objective findings.” AR 41. 1 Plaintiff accurately notes that because Plaintiff “suffers from a mental impairment, 2 the import of a psychiatrist judgment and consideration of a patient’s subjective 3 symptoms is of critical importance.” (JS at 10.) Indeed, “[p]sychiatric evaluations 4 may appear subjective, especially compared to evaluation in other medical fields. 5 Diagnoses will always depend in part on the patient’s self-report, as well as on the 6 clinician’s observations of the patient. But such is the nature of psychiatry.” Buck 7 v. Berryhill, 869 F.3d 1040, 1049 (9th Cir. 2017). Here, however, the ALJ gave Dr. 8 Trammell’s opinion little weight not merely because he relied on Plaintiff’s 9 subjective statements but also because Dr. Trammell failed to acknowledge “any 10 significant positive objective findings.” AR 41. To be entitled to significant 11 weight, a treating physician’s opinion must be supported by the overall medical 12 record. Tommasetti, 533 F.3d at 1041; Batson, 359 F.3d at 1195. 13 Here, the record does not reflect the extreme limitations opined by Dr. 14 Trammell. Indeed, Plaintiff acknowledged an ability to perform many daily 15 activities, including spending time with others, and travels by himself to the local 16 gym for daily exercise.13 AR 66–68, 271–74. He acknowledged the benefits of his 17 therapy sessions and increased daily activities, conceding that his problems are 18 exacerbated by boredom. AR 855. The ALJ found that “[Plaintiff] has described 19 daily activities[ ] which are not limited to the extent one would expect, given the 20 complaints of disabling symptoms and limitations.” AR 39. Further, Plaintiff does 21 not challenge the ALJ’s partial rejection of his subjective symptom statements. AR 22 34–35, 38–39, 42. “A physician’s opinion of disability premised to a large extent 23 upon the claimant’s own accounts of his symptoms and limitations may be 24 disregarded where those complaints have been properly discounted.” Morgan v. 25 Comm’r of Soc. Sec. Admin., 169 F.3d 595, 602 (9th Cir. 1999) (citation omitted); 26 accord Buck, 869 F.3d at 1049; see De Botton v. Colvin, 672 F. App’x 749, 751
27 13 Dr. Trammell’s opinion was provided less than three months prior to 28 Plaintiff’s hearing testimony. AR 48, 770. 1 (9th Cir. 2017) (ALJ properly rejected treating physician’s opinion which “relied on 2 [the claimant’s] self-serving statements”). 3 Plaintiff argues that because Dr. Trammell “was one of several treatment 4 providers at [RUBH],” his opinion was supported by these other providers’ 5 objective findings. (JS at 9–10.) However, even assuming that Dr. Trammell 6 reviewed the complete RUHB record before making his opinion, the objective 7 evidence does not support his extreme opinions. For examples, just prior to Dr. 8 Trammell beginning to treat Plaintiff, Plaintiff showed significant improvement 9 with multiple symptoms: he was able to take public transportation alone to his 10 therapy sessions; his thought process was coherent and asymptomatic and his 11 concentration “was the best ever”; with the help of the student intern, Plaintiff 12 created a daily schedule to effectively manage his depression; he increased his 13 outside activities; his paranoid episodes decreased to less than two per week; and he 14 was better able to ignore and manage his auditory hallucinations, which occurred 15 only one or two days per month. AR 846, 848, 859, 862, 864, 866, 868, 876, 882, 16 884, 892, 898, 901, 904. 17 Third, the ALJ concluded that “the objective medical evidence does not 18 support [Dr. Trammell’s] assessments.” AR 41. ALJs routinely discredit extreme 19 medical opinions for being inconsistent with treating records. See, e.g., Bayliss, 20 427 F.3d at 1216 (ALJ properly rejected doctor’s statement due to discrepancies in 21 the doctor’s report and his own treatment records made on the same day). The ALJ 22 accurately noted “numerous references within [Plaintiff’s] treatment records 23 reflecting improvement with [Plaintiff’s] symptoms, as acknowledged by [Plaintiff] 24 or reported by his treatment providers.” AR 41 (citing id. 376–77, 384–87, 399– 25 400, 410–11, 419–23, 428–29, 436–39, 444–45, 448–49, 454–55, 463–64, 540–41, 26 561–62, 589–90, 613–14, 645–46, 656–57, 676–77, 695–96, 730–31, 744–45, 757– 27 57, 776, 793, 798, 842). Symptom improvement is an adequate reason for not fully 28 crediting a treating physician’s opinion. Rollins, 261 F.3d at 856. Plaintiff does 1 not dispute that these records demonstrate improvement. (JS at 12.) Instead, he 2 asserts that because “mental impairments wax and wane,” the “record must be 3 viewed holistically.” (Id.) Indeed, that is the ALJ’s critique of Dr. Trammell’s 4 opinion—his failure to look at the record holistically instead of just focusing on the 5 negative evidence. AR 41. “Where evidence is susceptible to more than one 6 rational interpretation, it is the ALJ’s conclusion that must be upheld.” Burch v. 7 Barnhart, 400 F.3d 676, 679 (9th Cir. 2005). 8 Finally, the ALJ’s rejection of Dr. Trammell’s opinion is supported by the 9 opinions of the consultative examiner and the state agency reviewing physicians. In 10 March 2016, Dr. Parikh conducted a mental status examination, diagnosed 11 schizophrenia, and opined that Plaintiff had moderate difficulties in maintaining 12 social functioning, understanding, carrying out, and remembering complex 13 instructions, responding to coworkers, supervisors, and the general public, 14 responding appropriately to usual work situations, and dealing with changes in a 15 routine work setting but no impairments in concentration, persistence, and pace or 16 in the ability to understand, carryout, and remember simple instructions. AR 328– 17 32. In April 2016, Dr. Brode reviewed the medical record and concluded that 18 Plaintiff had the mental RFC to understand, remember, and carry out simple 19 instructions; sustain appropriate interaction with the public and maintain 20 relationships with coworkers and supervisors; and respond appropriately to most 21 changes in the workplace. AR 124, 127. In August 2017, Dr. Adamo reviewed the 22 medical record and generally agreed with Dr. Brode’s assessments, but concluded 23 that Plaintiff can recall and complete simple tasks, do nonpublic work and work 24 that is not primarily interpersonal, and tolerate simple change. AR 139–41. The 25 ALJ gave these opinions “partial weight,” finding that the subsequent medical 26 record, “including [Plaintiff’s] subjective complaints and the objective medical 27 evidence, support additional limitations not considered by these psychiatrists and 28 psychologists.” AR 40–41 (emphasis added). 1 Dr. Parikh’s opinion alone “constitutes substantial evidence, because it rests 2 on [her] own independent examination of [Plaintiff].” Tonapetyan v. Halter, 242 3 F.3d 1144, 1149 (9th Cir. 2001); see Sandgathe v. Chater, 108 F.3d 978, 980 (9th 4 Cir. 1997) (“Reports of consultative physicians called in by the Commissioner may 5 serve as substantial evidence.”) (citation omitted). Because Drs. Brode and Adamo 6 “reviewed all medical evidence available at the time of the examinations, and their 7 opinions were consistent with other objective and opinion evidence in [Plaintiff’s] 8 record,” their opinions were “also supported by substantial evidence.” Sisk v. Saul, 9 820 F. App’x 604, 605 (9th Cir. 2020); see Ahearn, 2021 WL 609825, at *5, 2021 10 U.S. App. LEXIS 4472, at *12 (ALJ did not err in adopting assessments of 11 nonexamining state agency consultants because their assessments “were supported 12 by other evidence in the record and were consistent with it”) (citation omitted); 13 Tonapetyan, 242 F.3d at 1149 (contrary opinion of a nonexamining medical expert 14 may constitute substantial evidence when it is consistent with other independent 15 evidence in the record); accord Dingman v. Saul, 830 F. App’x 247, 248 (9th Cir. 16 2020); see also 20 C.F.R. § 404.1527(c)(3) (“because nonexamining sources have 17 no examining or treating relationship with you, the weight we will give their 18 medical opinions will depend on the degree to which they provide supporting 19 explanations for their medical opinions”); SSR 96-6p (“In appropriate 20 circumstances, opinions from State agency medical and psychological consultants 21 and other program physicians and psychologists may be entitled to greater weight 22 than the opinions of treating or examining sources.”). Nevertheless, Plaintiff argues 23 that the “opinions of the State agency and consultative examiner do not constitute 24 substantial evidence” because and they “did not rely on findings that Dr. Trammell 25 did not consider.” (JS at 21 [citing Orn, 495 F.3d at 632].) 26 Plaintiff’s counsel misapprehends the Orn ruling. “When an examining 27 physician relies on the same clinical findings as a treating physician, but differs 28 only in his or her conclusions, the conclusions of the examining physician are not 1 || ‘substantial evidence.’” Orn, 495 F.3d at 632 (emphasis added). However where, 2 || as here, the consultative examiner conducts her own independent examination, her 3 || conclusions are substantial evidence. Id. (“By contrast, when an examining 4 || physician provides independent clinical findings that differ from the findings of the 5 || treating physician, such findings are ‘substantial evidence.’’’) (citation omitted). 6 || Indeed, because there were no records available for Dr. Parikh to review, AR 326, 7 || her findings necessarily relied only on her independent clinical examination. And 8 || the state agency consultants properly considered all of the evidence before them, 9 || thus satisfying the regulatory requirements. See Owen v. Saul, 808 F. App’x 421, 10 }} 423 (9th Cir. 2020) (“At the time they issued their opinions, the non-examining 11 || experts had considered all the evidence before them, satisfying the requirements set 12 || forth in 20 C.F.R. § 404.1527(c)(3).”). The ALJ did not err in giving partial weight 13 || to the opinions of Drs. Parikh, Brode, and Adamo. 14 In sum, the ALJ gave specific and legitimate reasons supported by substantial 15 || evidence for discounting Dr. Trammell’s opinion. 16 V. 17 CONCLUSION 18 For the reasons stated above, IT IS ORDERED that judgment shall be 19 || entered AFFIRMING the decision of the Commissioner. 20 21 || DATED: February 24, 2021 Tuam . Scott ? KAREN E. SCOTT United States Magistrate Judge 23 24 25 26 27 28 21