Summary
holding that the ALJ did not err in failing to mention the claimant's GAF scores because while "a GAF score may help guide the ALJ's determination," an ALJ "is not bound to consider it."
Summary of this case from Ienco v. Comm'r of Soc. Sec. Admin.Opinion
Case No. CV 08-3199-MLG.
February 4, 2009
MEMORANDUM OPINION AND ORDER
Plaintiff Eddie Fisher Baker seeks judicial review of the Commissioner's denial of his application for supplemental security income benefits under the Social Security Act. For the reasons stated below, the decision of the Social Security Commissioner is AFFIRMED.
I. Facts and Procedural History
Plaintiff was born on January 10, 1961 and was 46 years old at the time of the administrative hearing. (Administrative Record ("AR") 16.) He has a high school education, and he previously worked as a theme park caterer/maintenance worker. Plaintiff has not been gainfully employed since 1991. He was incarcerated from 1996 until 2004. (AR 26, 101.)
Plaintiff filed an application for supplemental security income benefits on January 10, 2005, alleging a disability onset date of February 27, 1986, due to a mood disorder and substance addiction disorder (Joint Stip. 2). In addition he claimed disability beginning on December 17, 2003 because of a lower back injury (AR 93). The Commissioner denied Plaintiff's application on June 10, 2005. (AR 35.) Administrative Law Judge ("ALJ") Dale A. Garwal held a hearing on January 29, 2007, at which Plaintiff testified and was represented by counsel. (AR 9.) A vocational expert also testified at the hearing. After applying the five-step sequential analysis mandated by the Social Security regulations, the ALJ concluded that Plaintiff was not disabled and denied his application for benefits on September 10, 2007. (AR 6.)
The five steps are as follows: (1) whether the claimant is engaged in substantial gainful activity; (2) whether the claimant's impairment is "severe"; (3) whether the impairment meets or equals one of the listings in 20 C.F.R. § 404, Subpart P, Appendix 1; (4) whether the claimant is able to return to past relevant work; and (5) whether the claimant can do other types of work. 20 C.F.R. § 404.1520(a)(4). These steps are cumulative, meaning that the ALJ need not consider further steps after finding that a step does not favor the claimant.
In evaluating Plaintiff's claim, the ALJ found that Plaintiff's only severe medically determinable impairment was mood disorder and substance addiction disorder, concluding that no evidence in the record showed that Plaintiff had any severe physical impairment. (AR 11.) The ALJ then determined that Plaintiff's mental impairments did not meet or equal any listed impairment. (AR 12.) The ALJ concluded that Plaintiff had the residual functional capacity ("RFC") to perform the full range of work at all exertional levels, but would be limited to simple, routine tasks. ( Id.) The ALJ also noted that Plaintiff had mild limitations in the ability to perform activities of daily living, to maintain social functioning, and to maintain concentration, persistence, and pace. (Id.) Relying on the vocational expert's testimony, the ALJ determined that Plaintiff could work as a textile industry general laborer or a box bender and, therefore, was not disabled under the Social Security Act. (AR 17.)
The Appeals Council denied Plaintiff's request for review on April 23, 2008, and Plaintiff filed this action on May 22, 2008. Plaintiff alleges that the ALJ erred by (1) improperly rejecting the lay witness testimony of Plaintiff's niece; (2) improperly rejecting a treating psychiatrist's opinions; (3) failing to develop the record regarding a treating psychologist's opinion; and (4) failing to develop the record regarding Plaintiff's mental health treatment in 2004 and 2005. (Joint Stip. 2-3.) Plaintiff seeks an award of benefits or, in the alternative, remand for further administrative proceedings. (Joint Stip. 22.)
II. Standard of Review
The Court must uphold the Social Security Administration's disability determination unless it is not supported by substantial evidence or is based on legal error. Ryan v. Comm'r of Soc. Sec., 528 F.3d 1194, 1198 (9th Cir. 2008) (citing Stout v. Comm'r of Soc. Sec. Admin., 454 F.3d 1050, 1052 (9th Cir. 2006)). Substantial evidence means more than a scintilla, but less than a preponderance; it is evidence that a reasonable person might accept as adequate to support a conclusion. Lingenfelter v. Astrue, 504 F.3d 1028, 1035 (9th Cir. 2007) (citing Robbins v. Soc. Sec. Admin., 466 F.3d 880, 882 (9th Cir. 2006)). To determine whether substantial evidence supports a finding, the reviewing court "must review the administrative record as a whole, weighing both the evidence that supports and the evidence that detracts from the Commissioner's conclusion." Reddick v. Chater, 157 F.3d 715, 720 (9th Cir. 1996). "If the evidence can support either affirming or reversing the ALJ's conclusion," the reviewing court "may not substitute [its] judgment for that of the ALJ." Robbins, 466 F.3d at 882.
III. Discussion
A. The ALJ Properly Considered the Lay Witness Statements
Plaintiff contends that the ALJ erred by failing to properly consider the lay witness statement of Plaintiff's niece, Maiereia Lambert. (Joint Stip. 3.) Ms. Lambert filled out a questionnaire for the Social Security Administration on February 4, 2005, in which she outlined her observations regarding Plaintiff's limitations. (AR 69-77.) Ms. Lambert stated that Plaintiff "used to be more attentive and able to understand better," that his attention span was shorter, that his back hurt when he undertook certain activities, that he had difficulty sleeping, that he did not need reminders to take care of himself, that he went out almost every day and shopped for his own personal items, that he was easily aggravated, that he couldn't concentrate for long periods of time without taking breaks, that he had difficulty lifting, bending, standing, walking, sitting, kneeling, understanding, following instructions, getting along with others, concentrating, and remembering, that he could walk two or three blocks before needing to rest, and that he had problems with authority figures. (AR 69-74.) The ALJ addressed Ms. Lambert's statement as follows:
The undersigned Administrative Law Judge has carefully considered the statements of the claimant's niece, M. Lambert, that the claimant is unable to work (Exhibit 2E). However, the undersigned rejects the opinion of this lay witness, because the behavior of the claimant that this witness observed could be due to causes other than a disabling mental condition, and this opinion is not compatible with the record as a whole.
The Court notes that Ms. Lambert gave contradictory answers as to Plaintiff's ability to follow instructions, first indicating that he has difficulty following instructions and later stating that he "follows written instruction well" and spoken instructions "very well." (AR 74.)
(AR 14.)
A lay witness can provide competent evidence about a claimant's symptoms and limitations. Nguyen v. Chater, 100 F.3d 1462, 1467 (9th Cir. 1996). An ALJ must take into account such lay testimony, unless the ALJ expressly disregards the testimony and gives reasons germane to each witness for doing so. Lewis v. Apfel, 236 F.3d 503, 511 (9th Cir. 2001); Dodrill v. Shalala, 12 F.3d 915, 918-19 (9th Cir. 1993). Appropriate reasons include that the testimony is unsupported by the medical record or other evidence or that the testimony is otherwise inconsistent. Lewis, 236 F.3d at 511-12 (citing Vincent v. Heckler, 739 F.2d 1393, 1395 (9th Cir. 1984)).
Here, the ALJ gave germane reasons for rejecting Ms. Lambert's statements: that the behavior she observed was not necessarily caused by a disabling mental condition, and that her opinion was incompatible with the record. (AR 14.) Having reviewed the record, the Court agrees with the ALJ that Ms. Lambert's observations, to the extent they suggest an inability to work, are inconsistent with the record as a whole, and the medical records specifically. As discussed in further detail in the sections below, the medical records reveal that Plaintiff's mental impairments were relatively mild and largely controlled by medication. Additionally, the Court notes that Ms. Lambert's observations are not inconsistent with the RFC the ALJ assigned, namely that Plaintiff could work at all exertional levels but would be limited to simple, routine tasks.
Plaintiff's contention that "there was absolutely no discussion of [Ms. Lambert's] statements" is incorrect. The ALJ properly rejected the lay witness testimony, giving reasons germane to the witness that are supported by the record. Plaintiff is not entitled to relief on this claim.
B. The ALJ Properly Considered the Medical Records and Treating Psychiatrist's Opinion
Plaintiff claims that the ALJ erred by failing to adequately consider the medical evidence. Specifically, Plaintiff contends that the ALJ improperly rejected the opinion of a treating psychiatrist, M. Sigman, M.D., from the Los Angeles County Department of Mental Health ("LACDMH"). (Joint Stip. 7-9.) Plaintiff notes that Dr. Sigman diagnosed Plaintiff with psychotic disorder, not otherwise specified, and post-traumatic stress disorder, assigning Plaintiff a global assessment of functioning ("GAF") of between 40 and 50. (Joint Stip. 7-8.) Plaintiff contends, "Dr. Sigman has established that the Plaintiff does suffer from a severe mental impairment that can negatively impact his ability to perform and sustain full time work." (Joint Stip. 9.)
The ALJ evaluated Dr. Sigman's treatment notes as follows: Treating documents provided by the [LACDMH] for the time period from June 2006 to May 2007 show that the claimant's mental health has fluctuated and improved with prescribed medications and that the claimant's mental condition is not sufficiently debilitating as to preclude the performance of substantial gainful activity or to prevent the claimant from performing simple routine tasks for eight-hours a day, five days per week.
(AR 14.) Plaintiff argues that the ALJ misrepresented Dr. Sigman's findings to support his conclusion that Plaintiff was not disabled. (Joint Stip. 9.) Plaintiff's main complaint with the ALJ's discussion of Dr. Sigman's findings appears to be that the ALJ did not mention the GAF scores Dr. Sigman assigned to Plaintiff.
The GAF scale provides a measure for an individual's overall level of psychological, social, and occupational functioning. Am. Psychiatric Ass'n, Diagnostic and Statistical Manual of Mental Disorders 30 (4th ed. 1994). The scale "may be particularly useful in tracking the clinical progress of individuals in global terms, using a single measure." Id. A GAF range of 41-50 reflects "[s]erious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." Id. at 32. As noted in the regulations, "The GAF scale . . . is the scale used in the multiaxial evaluation system endorsed by the American Psychiatric Association. It does not have a direct correlation to the severity requirements in our mental disorders listings." Revised Criteria for Evaluating Mental Disorders and Traumatic Brain Injury, 65 Fed. Reg. 50,746, 50,764-65 (Aug. 21, 2000). In evaluating the severity of a claimant's mental impairments, a GAF score may help guide the ALJ's determination, but an ALJ is not bound to consider it. Orellana v. Astrue, 2008 WL 398834, at *9 (E.D. Cal. Feb. 12, 2008) ("While a GAF score may help the ALJ assess Claimant's ability to work, it is not essential and the ALJ's failure to rely on the GAF does not constitute an improper application of the law."); Howard v. Comm'r of Soc. Sec., 276 F.3d 235, 241 (6th Cir. 2002) ("While a GAF score may be of considerable help to the ALJ in formulating the RFC, it is not essential to the RFC's accuracy. Thus, the ALJ's failure to reference the GAF score in the RFC, standing alone, does not make the RFC inaccurate.").
The ALJ interpreted Dr. Sigman's treating notes as showing that Plaintiff's mental impairments had improved with medication and were not overly debilitating. In reviewing the notes, it is clear that the ALJ's characterization of the notes is accurate. For example, on November 30, 2006, Dr. Sigman quotes Plaintiff as stating, "The medicine works well. It's the right amount." (AR 262.) Dr. Sigman repeatedly indicates that Plaintiff's mood is euthymic, that he denies experiencing psychotic symptoms, and that he is generally stable with medication. (AR 260-68.) Dr. Sigman offers no opinion as to Plaintiff's ability, or inability, to work or function.
Plaintiff does not identify any specific notes Dr. Sigman made that would contradict the ALJ's description of the records. Plaintiff relies entirely on the ALJ's failure to mention the GAF score in arguing that the ALJ misrepresented the record. As discussed above, the GAF score does not directly correlate with a disability determination under the Social Security Act, functioning as more of a clinical benchmark or descriptor than an opinion as to a patient's limitations caused by a specific impairment. In this case, as Defendant noted in the briefing, Plaintiff has experienced significant difficulties in his life, including extended unemployment, repeated incarceration, and admitted illegal drug use. (Joint Stip. 10.) These facts could certainly lead Dr. Sigman to assign Plaintiff a GAF of 40 to 50, which sheds no light on whether Plaintiff's medically determinable mental illness prevents him from working.
Plaintiff argues, "Not only did Dr. Sigman establish that the Plaintiff's mental impairment and functional limitations lasted a significant amount of time, but, contrary to the ALJ's unfathomable determination, Dr. Sigman has established that the Plaintiff's mental condition is indeed sufficiently debilitating to preclude the performance of substantial gainful activity or to prevent him from performing simple routine tasks." (Joint Stip. 8.) To support this argument, Plaintiff lists the dates for each visit Plaintiff had with Dr. Sigman, along with the diagnoses and GAF score for each date. Plaintiff offers no other evidence to support his argument that Dr. Sigman found Plaintiff's mental condition to be significantly debilitating. Accordingly, the Court assumes that Plaintiff is relying on the GAF score for his argument.
In any event, the ALJ was not required to mention Dr. Sigman's GAF score, and his characterization of Dr. Sigman's treating notes was supported by substantial evidence in the record. Plaintiff is not entitled to relief on this claim.
C. The ALJ Properly Considered the Opinion of Dr. Miersma and Developed the Record
Dr. Miersma, a psychologist with the California Department of Corrections, recorded his observations of Plaintiff's demeanor during an evaluation on April 7, 2005, as follows:
[Plaintiff] appeared to be fully oriented to time and place and was aware of the purpose of the evaluation session and was able to fully participate in the process. His mood appeared to be euthymic (although he stated that he does get depressed sometimes) and his affect congruent with his mood. [Plaintiff] was calm and cooperative and willingly answered all questions presented to him. . . . His short term memory and fund of general knowledge are both within normal limits. [Plaintiff's] thought process appears to be unimpaired and goal oriented and did not suggest the presence of serious mental illness. His insight and judgment are both fair.
(AR 253.) Dr. Miersma recommended that Plaintiff participate in counseling on a monthly basis, the focus of which would be "re-offense prevention via: development of victim empathy, correction of cognitive distortions, and development of appropriate coping skills." (Id.) Dr. Miersma diagnosed Plaintiff with bipolar disorder, most recently evidenced by a manic episode two years prior to the evaluation, and polysubstance abuse in full remission. (Id.)
The ALJ purportedly rejected Dr. Miersma's opinion of Plaintiff's mental impairments for three reasons: (1) that Dr. Miersma's recommendation for monthly counseling, as opposed to more frequent counseling, showed that Plaintiff's mental impairments were mild rather than significantly debilitating; (2) that Dr. Miersma simply reiterated Plaintiff's own statements regarding his impairments; and (3) that Dr. Miersma "has not provided an assessment of the claimant's residual functional capacity which is compatible with the record as a whole. (AR 14.)
Plaintiff first contends that the ALJ improperly rejected Dr. Miersma's opinion without providing specific and legitimate reasons for doing so. (Joint Stip. 13-16.) However, Plaintiff never adequately explains in the briefing how Dr. Miersma's opinion support Plaintiff's claim. Instead, Plaintiff identifies a comment in the treatment notes that has no bearing on the extent of Plaintiff's mental impairments, and, in fact, tends to further support the conclusion that Plaintiff's impairments were mild. Plaintiff claims, "[H]ad the ALJ properly reviewed Dr. Miersma's treatment plan of the Plaintiff, he would [have] noted that Dr. Miersma stated, `The focus of treatment will be on re-offense prevention via: development of victim empathy, correction of cognitive distortions, and development of appropriate coping skills.'" (Joint Stip. 14.) The stated treatment goal of "re-offense prevention," rather than Plaintiff's allegedly disabling mental illness, significantly undermines Plaintiff's argument.
Additionally, the fundamental flaw in Plaintiff's argument is that Dr. Miersma's opinion, as reflected in the treatment notes, is not favorable to Plaintiff's disability claim, a fact that the ALJ inexplicably appears to have missed. Although an ALJ should generally assign greater weight to a treating physician's opinion than that of a non-treating physician, see 20 C.F.R. § 416.927(d)(1), in this case the ALJ opined that Plaintiff's presentation "did not suggest the presence of serious mental illness." (AR 253.) That the ALJ incorrectly assumed that the treating psychologist's opinion was more favorable to Plaintiff than it actually was clearly does not justify a remand, requiring significant time and resources, so the ALJ can accurately state that Plaintiff's own treating psychologist's notes do not support his claim for benefits.
The Court also notes that Dr. Miersma reached that conclusion at a time when Plaintiff was not taking any medication to control his symptoms. (AR 253 ("[H]e no longer takes medication of any kind.")) On June 20, 2005, Dr. Miersma recommended that Plaintiff be evaluated by a psychiatrist for medication, because Plaintiff "was somewhat confused and incoherent relating some family problems and his apparent inability to handle them or interpret them [e]ffectively." (AR 250.) Dr. Miersma questioned whether street drugs had caused Plaintiff's confusion. (Id.) Dr. Miersma subsequently noted that Plaintiff's demeanor improved after taking medication, and he continued to do well until he was discharged from parole in February 2006. (AR 238-47.)
Second, Plaintiff argues that the ALJ should have developed the record to clarify Dr. Miersma's opinion as to Plaintiff's RFC. (AR 15.) Plaintiff relies on the ALJ's statement that Dr. Miersma "has not provided an assessment of the claimant's residual functional capacity which is compatible with the record as a whole." (Joint Stip. 15; AR 14.) Plaintiff correctly states that the existence of ambiguous evidence, or inconclusive or otherwise inadequate medical records, triggers an ALJ's duty to seek clarification or additional evidence from medical sources. Mayes v. Massanari, 276 F.3d at 459; Tonapetyan v. Halter, 242 F.3d 1144, 1150 (9th Cir. 2001). Here, however, the ALJ did not conclude that the record was inadequate for him to make a finding as to the severity of Plaintiff's mental impairments, which would trigger his duty to expand the record. Nor did the ALJ find any ambiguity or inconclusive results in the medical record. Instead, the ALJ concluded that the record demonstrated that Plaintiff's mental impairments, although "severe" under the regulations, were relatively mild and controlled with medication. Nothing in the record was ambiguous or inconclusive, and the ALJ's decision is supported by substantial evidence in the record. Plaintiff is not entitled to relief on this claim.
D. The ALJ Properly Developed the Record as to Plaintiff's Treatment in 2004-2005
In evaluating the alleged severity of Plaintiff's symptoms, the ALJ determined that Plaintiff was not entirely credible, because, among other things, "it is unclear from the record whether the claimant truly needed mental health treatment during calendar years 2004 and 2005 or whether the claimant's main reason for participating in . . . treatment . . . was fulfilling the conditions of his continued parole." (AR 15.)
Plaintiff's argument on this point is interesting. He contends that "[w]hether the Plaintiff's mental health treatment was a conditional aspect of his parole is irrelevant." (Joint Stip. 19.) Plaintiff then argues that the case should be remanded even though the point is irrelevant, because "if the ALJ was concerned about the Plaintiff's need for mental health treatment, he should have made a reasonable effort to recontact the California Department of Corrections Parole and Community Services Division's psychiatric department in order to ascertain more information." (Joint Stip. 19-20.) Defendant also concedes that "whether Plaintiff attended counseling sessions as part of his parole was irrelevant." (Joint Stip. 21.)
The Court agrees with the parties. Whether Plaintiff attended counseling solely as a condition of parole has no bearing on any relevant issue raised in this case. The implication of the ALJ's statement was that Plaintiff only went to counseling because he had to, which suggested to the ALJ that Plaintiff was being less than forthcoming as to the extent of his limitations. The ALJ made this point in assessing Plaintiff's credibility, which Plaintiff has not challenged. The records themselves are clearly not ambiguous or inconclusive, and both parties have conceded that it is irrelevant whether the state required Plaintiff's attendance at mental health counseling as part of his parole. The mere fact that the ALJ mentioned an issue in passing that both parties agree has no real bearing on the case simply does not trigger a duty to develop the record. The ALJ did not err.
IV. Conclusion
For the reasons stated above, the decision of the Social Security Commissioner is AFFIRMED.