Larson v. Commissioner of Social Security

District Court, W.D. Washington·Decided April 28, 2025·No. 3:24-cv-05816·Unknown

Opinion

UNITED STATES DISTRICT COURT AT SEATTLE CODY M. L., Plaintiff, CASE NO. C24-5816-BAT v. ORDER REVERSING AND COMMISSIONER OF SOCIAL SECURITY, Defendant.

Plaintiff appeals the ALJ’s May 30, 2024, decision finding him not disabled. He argues the ALJ’s misevaluation of the medical opinions, his testimony, and the lay evidence, resulted in an erroneous residual functional capacity (RFC) determination, and step four, and step five findings. Dkt. 16 at 2. For the reasons below, the Court REVERSES the Commissioner’s final decision and REMANDS the case for further administrative proceedings under 42 U.S.C. § 405(g). The ALJ found Plaintiff last engaged in substantial gainful activity in July 2015; degenerative disc disease of the cervical spine, anxiety; post-traumatic stress disorder (PTSD), and substance addiction disorder are severe impairments; Plaintiff has the RFC to perform medium work with additional reaching, environmental and mental health limitations; and

Plaintiff is not disabled because he can perform past relevant work as a Kitchen Helper, and other jobs such a hand packager, hospital cleaner or cleaner housekeeper. Tr. 1322. Tr. 1307- 1324. A. Medical Opinion Evidence Plaintiff contends the ALJ misevaluated the opinions of Dr. Dan Neims, Psy.D., Dr. John Haroian, Ph.D., Dr. David Mashburn, Ph.D., and Dr. Mark Heilbrunn, M.D. Dkt. 16 at 3-7. The ALJ must articulate the persuasiveness of each medical opinion, specifically addressing the supportability and the consistency of each opinion with the record. See 20 C.F.R. § 404.1520c(a)-(c). An ALJ’s findings must be supported by substantial evidence. See Woods v. Kijakazi, 32 F.4th 785, 792 (9th Cir. 2022). 1. Dr. Neims Dr. Neims examined Plaintiff on April 21, 2017, and February 23, 2018. Tr. 409-27, 443-

57. In 2017, Dr. Neims found Plaintiff was anxious, discouraged with low self-esteem, had prominent withdrawal and avoidance, displayed patterns of panic attacks and agoraphobia, had prominent patterns of somatic focus, was “help seeking.” Tr. 410. In 2018, Dr. Neims found Plaintiff exhibited continued avoidance, anxious arousal and panic symptoms; showed patterns of agoraphobic avoidance behavior; had few social relations with others, was anxious and had traumatic memories from past emotional abuse. See Tr. 444. In both opinions, Dr. Neims diagnosed Plaintiff with panic disorder with agoraphobia, psychological factors affecting physical condition, PTSD, avoidant and dependent traits, and alcohol use disorder in remission. Tr. 410. In both opinions, Dr. Neims opined Plaintiff was markedly limited in the ability to perform activities within a schedule; maintain regular attendance; be punctual within customary tolerances; adapt to changes in a routine work setting; make simple work-related decisions; ask simple questions or request assistance; communicate and perform effectively in a work setting;

maintain appropriate behavior in a work setting; complete a normal work day and work week without interruptions from psychologically based symptoms; and set realistic goals and plan independently. Tr. 410-11, 444-45. Dr. Neims found Plaintiff was moderately limited in his ability to perform routine tasks without special supervision and be aware of normal hazards and take appropriate precautions. Id. The ALJ found Dr. Neims’ opinion Plaintiff is moderately limited was supported but discounted Dr. Neims ’opinion Plaintiff is markedly limited finding: Such limitations are extreme and inconsistent with his examination findings, which were fairly unremarkable and not consistent with marked limitations. His opinion that the claimant is markedly limited in also not consistent with the record as a whole, which shows limited mental health treatment, generally unremarkable mental status examinations, largely intact functioning, and a focus on situational stressors during appointments. Tr. 1319. The Court finds the ALJ’s finding is not supported by substantial evidence. Dr. Neims’ examination findings were not “unremarkable.” Dr. Neims found Plaintiff exhibited anxious mood, fair to borderline concentration and abstract thought, and Plaintiff’s insight and judgment were borderline with patterns of avoidance. Tr. 411-12; 445-6. Dr. Neims further found Plaintiff “demonstrates prominent disability conviction” was “somatically focused and preoccupied” displayed anxiety and avoidance behavior, Tr. 447-49, and concluded Plaintiff was “hampered by prominent anxious arousal, somatic focus, and avoidance behavior” and Plaintiff needed “comprehensive outpatient treatment for anxiety disorder and psychiatric consult with eventual work hardening.” Tr. 449. Second, the record does not show Plaintiff has “limited mental health treatment, generally unremarkable status examinations, and largely intact functioning” and Plaintiff focused on

“situational stressors during appointments.” The ALJ noted Plaintiff’s mental health treatment consisted of therapy appointments and medications; Plaintiff did not start taking medications until 2015 when he “left his last job”; and Plaintiff’s mental health has “been complicated by drug and alcohol use.” Tr. 1313. The record shows Plaintiff has attempted to treat his mental health problems for nearly a decade, starting in July 2016 when he saw a doctor for anxiety and was prescribed Zoloft and hydroxyzine. Tr. 391-92. Plaintiff continued with different medications, including Paxil, Celexa, Lexapro, Wellbutrin, BuSpar, trazodone, amitriptyline, and Valium. Tr. 391-92, 482, 490, 532, 1134-40, 1992, 2026. Plaintiff’s therapy session treatment notes show he has received consistent counseling since at least 2018. See Kitsap Mental Health Services records, Tr. 428-42, 480-97, 699-725,

1024-1170. Despite some gaps in treatment and some missed appointments, his participation in therapy has overall been consistent. See, e.g., Tr. 494-95 (two missed appointments in December 2018); Tr. 704-06 (treatment gap between February 18, 2019, and April 1, 2019). Plaintiff does not claim he was disabled before 2015 when he last worked. That he started medications for his mental health issues after he left his last job does not contradict Dr. Neims’ opinion that during the relevant time-period Plaintiff is markedly limited. As to the finding Plaintiff has had “generally unremarkable mental status examinations,” (MSEs), the ALJ focused on MSEs indicating Plaintiff’s perception, memory, and concentration, were “normal,” and how Plaintiff was generally cooperative, and alert with intact judgment and logical thinking. These findings do not contradict Dr. Neims’ opinion that Plaintiff’s anxiety limits his ability to perform work functions. Nearly every MSE (covering a six-year period) contains abnormal findings regarding Plaintiff’s mood or affect. See, Tr. 1026, 1030, 1098, 1105, 1112, 1120, 1127, 1141, 1148, 1156, 1213, 1791, 1881, 1883, 1961, 1973, 1987, 1992, 1996,

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Larson v. Commissioner of Social Security, (W.D. Wash. 2025).

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