Opinion
Case No. CV 19-8183-JPR
03-23-2021
HANNAH LEIGH J., Plaintiff, v. ANDREW SAUL, Commissioner of Social Security, Defendant.
MEMORANDUM DECISION AND ORDER AFFIRMING COMMISSIONER
I. PROCEEDINGS
Plaintiff seeks review of the Commissioner's final decision denying her application for Social Security supplemental security income benefits ("SSI"). The matter is before the Court on the parties' Joint Stipulation, filed August 31, 2020, which the Court has taken under submission without oral argument. For the reasons discussed below, the Commissioner's decision is affirmed.
II. BACKGROUND
Plaintiff was born in 1997. (Administrative Record ("AR") 161.) She completed high school and worked part time as a baker, receptionist, and warehouse worker, although her most recent jobs were in customer service. (AR 34, 175-76, 190.) On November 12, 2015, she applied for SSI, alleging that she had been unable to work since February 15 of that year because of major depression, chronic post-traumatic stress disorder, borderline personality disorder, and generalized anxiety. (AR 15, 189.) After her application was denied (AR 74-78), she requested a hearing before an Administrative Law Judge (AR 85-90). One was held on April 17, 2018, at which Plaintiff, who was represented by counsel, testified, as did a vocational expert. (See AR 28-55.) In a written decision issued July 25, 2018, the ALJ found her not disabled. (AR 15-23.) She sought Appeals Council review (AR 158, 227-29), which was denied on July 18, 2019 (AR 1-6). This action followed.
III. STANDARD OF REVIEW
Under 42 U.S.C. § 405(g), 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 of legal error and supported by substantial evidence based on the record as a whole. See Richardson v. Perales, 402 U.S. 389, 401 (1971); Parra v. Astrue, 481 F.3d 742, 746 (9th Cir. 2007). Substantial evidence means such evidence as a reasonable person might accept as adequate to support a conclusion. Richardson, 402 U.S. at 401; Lingenfelter v. Astrue, 504 F.3d 1028, 1035 (9th Cir. 2007). It is "more than a mere scintilla, but less than a preponderance." Lingenfelter, 504 F.3d at 1035 (citing Robbins v. Soc. Sec. Admin., 466 F.3d 880, 882 (9th Cir. 2006)). "[W]hatever the meaning of 'substantial' in other contexts, the threshold for such evidentiary sufficiency is not high." Biestek v. Berryhill, 139 S. Ct. 1148, 1154 (2019). 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. 1998). "If the evidence can reasonably support either affirming or reversing," the reviewing court "may not substitute its judgment" for the Commissioner's. Id. at 720-21.
IV. THE EVALUATION OF DISABILITY
People are "disabled" for Social Security purposes if they are unable to engage in any substantial gainful activity owing to a physical or mental impairment that is expected to result in death or has lasted, or is expected to last, for a continuous period of at least 12 months. 42 U.S.C. § 423(d)(1)(A); Drouin v. Sullivan, 966 F.2d 1255, 1257 (9th Cir. 1992).
A. The Five-Step Evaluation Process
An ALJ follows a five-step sequential evaluation process to assess whether someone is disabled. 20 C.F.R. § 416.920(a)(4); Lester v. Chater, 81 F.3d 821, 828 n.5 (9th Cir. 1995) (as amended Apr. 9, 1996). In the first step, the Commissioner must determine whether the claimant is currently engaged in substantial gainful activity; if so, the claimant is not disabled and the claim must be denied. § 416.920(a)(4)(i).
If the claimant is not engaged in substantial gainful activity, the second step requires the Commissioner to determine whether the claimant has a "severe" impairment or combination of impairments significantly limiting her ability to do basic work activities; if not, a finding of not disabled is made and the claim must be denied. § 416.920(a)(4)(ii) & (c).
If the claimant has a "severe" impairment or combination of impairments, the third step requires the Commissioner to determine whether the impairment or combination of impairments meets or equals an impairment in the Listing of Impairments ("Listing") set forth at 20 C.F.R., part 404, subpart P, appendix 1; if so, disability is conclusively presumed and benefits are awarded. § 416.920(a)(4)(iii) & (d). If the claimant's impairment or combination of impairments does not meet or equal one in the Listing, the fourth step requires the Commissioner to determine whether the claimant has sufficient residual functional capacity ("RFC") to perform her past work; if so, she is not disabled and the claim must be denied. § 416.920(a)(4)(iv). The claimant has the burden of proving she is unable to perform past relevant work. Drouin, 966 F.2d at 1257. If the claimant meets that burden, a prima facie case of disability is established. Id.
RFC is what a claimant can do despite existing exertional and nonexertional limitations. § 416.945(a)(1); see Cooper v. Sullivan, 880 F.2d 1152, 1155 n.5 (9th Cir. 1989). The Commissioner assesses the claimant's RFC between steps three and four. Laborin v. Berryhill, 867 F.3d 1151, 1153 (9th Cir. 2017) (citing § 416.920(a)(4)).
If that happens or if the claimant has no past relevant work, the Commissioner bears the burden of establishing that the claimant is not disabled because she can perform other substantial gainful work available in the national economy, the fifth and final step of the sequential analysis. § 416.920(a)(4)(v), 416.960(b).
B. The ALJ's Application of the Five-Step Process
At step one, the ALJ found that Plaintiff had not engaged in substantial gainful activity since November 12, 2015, the application date. (AR 17.) At step two, he determined that she had severe impairments of anxiety, depression, and personality disorder. (Id.)
The ALJ did not include PTSD as a severe impairment despite several doctors' diagnosis of it but included a discussion of her symptoms and treatment for it in the medical summary. (See AR 17, 19-22.) And as explained in section V.A.4.a., he reasonably accommodated those symptoms by limiting Plaintiff's contact with supervisors, coworkers, and the public. Therefore, any error was harmless. See Lewis v. Astrue, 498 F.3d 909, 911 (9th Cir. 2007) (failure to address particular impairment at step two harmless if ALJ fully evaluated claimant's medical condition in later steps of sequential evaluation process).
At step three, he found that Plaintiff's impairments did not meet or equal any of the impairments in the Listing. (AR 18.) At step four, he determined that she had the RFC to perform a full range of work at all exertional levels with the following nonexertional limitations: "no more than simple, routine, repetitive tasks; no more than incidental contact with supervisors; no more than occasional and superficial contact with coworkers; and no contact with the public." (AR 18.)
The ALJ found that Plaintiff had no past relevant work (AR 22), but she could work as a cleaner II, scrap sorter, or machine feeder, positions that "exist[ed] in significant numbers in the national economy" (AR 22-23). Accordingly, he found her not disabled. (AR 23.)
V. DISCUSSION
Plaintiff alleges that the ALJ erred in evaluating the medical evidence and opinions, assessing her symptom statements, and determining her RFC. (See J. Stip. at 3-17, 21-31, 35-39, 40-41.) For the reasons discussed below, remand is not warranted.
A. The ALJ Properly Evaluated the Medical Opinions and Evidence
1. Relevant background
a. Samuel Byungsung Lee
On February 12, 2015, Plaintiff reported to psychiatrist Samuel Byungsung Lee that she had been having nightmares about her father, who she alleged had physically abused her, for approximately four weeks. (AR 239.) The nightmares started when she was four years old, soon after the abuse allegedly began. (Id.) She started experiencing social anxiety, not wanting to go to school, and becoming "scared of things such as jackets" or "anything out of place." (Id.) Recently, she "ha[d] been feeling that certain objects may be moving throughout the house, which ma[de] her feel scared." (Id.) She reported feeling when in public "that someone [wa]s going to shoot her." (Id.) She was scared at restaurants and would hide in the restroom or leave early. (Id.) "She constantly look[ed] around at people because she believe[d] they might hurt her, especially men." (AR 239-40.) She also reported "feeling depressed for the past month," isolating socially, losing her energy, missing school a lot, losing her appetite, and becoming emotionally unresponsive. (AR 240.) She had "passive suicidal thoughts" as recently as the previous night; had deleted all social media and put her phone into airplane mode because she "d[idn't] want to look at anybody"; and "[f]elt hopeless, stuck," and like there was "nothing" she could do to "feel better." (Id.) She reported a history of cutting, stating that she "[did] it when [she was] angry" and had last done it three months prior. (Id.) She "cut[] not to hurt [her]self, but to feel something because she's angry." (Id.) She denied any "active suicidal ideation, intent or plan." (Id.) She reported that her anxiety came "in waves" and that several situations, especially movie theaters, triggered severe panic attacks, with shortness of breath, sweating, and palpitations. (Id.) But at the time of the examination, she denied symptoms of PTSD, obsessive compulsive disorder, social anxiety, any specific phobia, or a history of manic symptoms. (Id.) Dr. Lee noted that she did not have audio or visual hallucinations or paranoid ideation. (Id.)
Dr. Lee diagnosed PTSD; "MDD," or major depressive disorder, "severe, recurrent with psychotic features"; and "history of abuse/trauma." (AR 242.) He prescribed Lexapro and Ativan.
Lexapro is name-brand escitalopram oxalate, which is used to treat depression and anxiety. See Lexapro, WebMD, https://www.webmd.com/drugs/2/drug-63990/lexapro-oral/details (last visited Mar. 22, 2021).
Ativan is name-brand lorazepam, a benzodiazepine medication used to treat anxiety. See Ativan, WebMD, https://www.webmd.com/drugs/2/drug-6685/ativan-oral/details (last visited Mar. 22, 2021).
Plaintiff reported on March 13, 2015, that she was doing "ok," had "low energy," "fe[lt] tired all the time," and still had "spontaneous onset anxiety." (AR 247.) But she had a "lot less tearfulness" and anxiety in both "frequency and intensity," rated her anxiety as "much better," had had no nightmares since her last visit, was going to school and not isolating as much, made a few new friends, had no suicidal ideation or urges to cut, and had had no intrusive thoughts about her father since her last appointment. (Id.)
Dr. Lee noted that Plaintiff was cooperative and pleasant; had normal rate, volume, and prosody of speech; exhibited no apparent motor abnormalities; and displayed euthymic mood, full affect, goal-directed and linear thought process, and good insight and judgment. (AR 248.) She had no suicidal, homicidal, or paranoid ideation or audio hallucinations. (Id.) She was alert and oriented; her memory was intact to immediate, intermediate, and remote recall. (Id.) Dr. Lee encouraged her to participate in "behavioral activation/yoga" and to return in two months. (AR 249.)
Prosody is the rhythm, stress, and intonation of speech; it provides clues about attitude or affective state. Prosody in Speech and Song, Am. Psych. Ass'n, https://www.apa.org/pubs/highlights/peeps/issue-29 (last visited Mar. 22, 2021).
On June 26, 2015, Plaintiff reported "feel[ing] better" and less anxious, with no panic attacks or sadness for two to three weeks; she was sleeping well and hiking more, but her appetite had decreased. (AR 254.) She had reduced her Lexapro dosage because it was making her very tired. (Id.) Her mental-status examination was unchanged. (AR 255.) Dr. Lee decreased her Lexapro dosage and instructed her to follow up by telephone because she would be in Pennsylvania all summer. (AR 256.)
Plaintiff saw Dr. Lee again on February 26, 2016, after moving out of her grandfather's house in Pennsylvania, and reported that he had been inappropriate with her. (AR 467.) But she had been doing "really good" since moving back, her mood had been "stable," she was seeing a therapist weekly, and she had gotten a job at a crafts store. (AR 467-68.) She continued to have "occasional flashbacks/nightmares" from her history of abuse and was sleeping too much, but she was no longer having "social avoidance" and denied any suicidal ideation, intent, or plan. (AR 468.) Dr. Lee noted no "current psychosis." (Id.) She was compliant with her medications and "f[elt] possible [side effects] of fatigue[] and low energy." (Id.) Her mental-status examination revealed normal findings. (AR 468-69.) Dr. Lee noted that her depression, anxiety, and PTSD symptoms were controlled and adjusted her Zoloft dosage. (AR 469.)
Zoloft treats depression, panic attacks, and social-anxiety disorder. See Zoloft, WebMD, https://www.webmd.com/drugs/2/drug-35-8095/zoloft-oral/sertraline-oral/details (last visited Mar. 22, 2021).
b. West LA Medical Center
On April 12, 2015, Plaintiff's mother took her to the West LA Medical Center emergency department after she found her cutting herself. (AR 259, 261.) Plaintiff reported feeling "increasingly depressed [and] hopeless," having "passing thoughts of suicide," and feeling more depressed "due to a romantic interest rejecting" her. (AR 261.) She had "had suicidal thoughts over the weekend" but no clear plan. (AR 268.) She cut herself "to make [her]self feel better." (Id.) She continued to have "passive suicidal ideation" at the hospital and described her mood as "miserable" but exhibited no "psychotic [symptoms] or mania." (Id.) She was placed on a psychiatric hold (AR 259-60, 268) and transferred to Northridge Hospital Medical Center the next day for further treatment of her depression and suicidal ideation (AR 492, 499).
On July 28, 2016, Plaintiff went to the urgent-care clinic, complaining of suicidal ideation. (AR 814.) Her memory and judgment were normal; her affect was not blunt, labile, or inappropriate; she was not agitated or apathetic; and she did not exhibit a depressed mood. (AR 815.) She was transported to the emergency department for psychiatric consultation and observation. (AR 814, 816.)
At the emergency department, Plaintiff reported to psychiatrist Daniel Son that she had been "feeling like nothing is real" for one week and had "thoughts of hurting herself." (AR 829; see AR 833-34.) She had been missing work because of these feelings and was getting in trouble and experiencing stress. (AR 829.) She claimed to have a plan to cut herself with a razor, but she denied any recent attempt. (Id.) She was "crying, tearful" on examination. (AR 831.) She had recently been experiencing more "out of body" experiences, "fe[lt] crazy," had "increased irritability" with customers, and was having "paranoid thoughts of the government being after her" and customers "hav[ing] a gun and want[ing] to kill her." (AR 835.) But she denied any current suicidal thoughts, requested to be discharged to pursue outpatient mental-health resources, and asked for a note for time off work. (Id.) Dr. Son diagnosed her with "mood disorder, unspecified" and identified the possible type as "borderline personality disorder," "bipolar disorder," "MDD with psychotic" features, or "psychotic disorders." (AR 837.) She was observed for several hours, after which Dr. Son discharged her. (AR 834.)
On September 25, 2016, Plaintiff went to the emergency department complaining of "suicidal thoughts" for one day that had been worsening. (AR 923.) She was not nervous or anxious, and examination findings were negative. (AR 924.) She was placed on a psychiatric hold (AR 929-30) and transferred to Del Amo Hospital (AR 948).
No records from Del Amo Hospital appear in the record.
c. Northridge Hospital Medical Center
After being transferred from West LA Medical Center to the Northridge Hospital psychiatric unit on April 13, 2015, Plaintiff's Lexapro dosage was increased. (AR 501.) During her hospitalization, she remained depressed but repeatedly denied any current suicidal ideation or plan (AR 548, 625, 629, 635, 640-42, 717) and exhibited no audiovisual hallucinations (AR 503). She participated in group therapy and activities (AR 625) and was discharged on April 16, 2015 (AR 548).
d. Penn State Hershey Medical Center
On August 21, 2015, Plaintiff went to Penn State Hershey Medical Center complaining of anxiety and depression. (AR 371.) She said she was fearful of men but was pleasant and cooperative, appeared to be at ease, and made good eye contact with the male doctor who examined her. (AR 373.) Her psychomotor activity was normal. (Id.) Her speech was clear, coherent, and not pressured. (Id.) She was conversant and interactive, and her thought process was coherent and goal directed. (Id.) She described her mood as anxious, but she denied any current thoughts of suicide and stated that she would not harm herself. (Id.) Her affect was restricted sometimes, but she also laughed and "appeared bright." (Id.) She had violent dreams of killing her father, but she had no actual homicidal thoughts toward anyone. (Id.) She had a distrust of men, feared they might harm her, worried that inanimate objects would move toward her, and was afraid to turn around in the shower for "fear of seeing a demon." (Id.) But she had no "hallucinations in the [five] senses." (Id.) She had intermittent suicidal ideation and thoughts of cutting or hanging herself and running away and "starving herself in the woods." (Id.) But she stated that she would not do those things because she was motivated by her relationship with family and could reach out for help. (AR 373-74.) Therefore, her risk of suicide was rated low, and she was deemed safe for outpatient care. (AR 374.) She was diagnosed with major depressive disorder, anxiety, borderline personality traits, and obsessive-compulsive personality traits. (AR 373.) She elected to continue partial hospitalization with intensive outpatient treatment and was switched from Lexapro to Zoloft. (AR 374.)
She reported to psychiatrist Tjiauw Tan on August 24, 2015, that she was having difficulty initiating and maintaining sleep. (AR 367.) Her grandfather had allegedly made a "few sexually inappropriate comments and some sexual advances towards her," and her step-grandmother was jealous. (Id.) She did not feel safe at her grandfather's house and was upset by the constant arguments between her grandfather and step-grandmother. (Id.) She reported that she had urges to cut herself but stated that she would use "distraction" techniques to avoid acting on the urge, and she had no suicidal or homicidal ideation. (Id.) Dr. Tan noted that she was friendly and pleasant during her examination; her speech was coherent, relevant, and normal in rate, tone, and volume. (AR 368.) Her psychomotor activity was normal; she was depressed and her affect was dysphoric and anxious, but her thought process was linear, organized, and goal directed. (Id.) No "circumstantiality," "tangentiality," or perceptual disturbances were noted. (Id.) Her cognitive functioning and memory were grossly intact, and her insight and judgment were fair. (Id.) Dr. Tan found that she did not meet the criteria for inpatient hospitalization and continued her in the partial hospitalization program, which included family, individual, and group therapy. (Id.)
On August 27, 2015, Plaintiff described her mood as happy; her affect was euthymic, and her mood was congruent, reactive, and appropriate. (AR 365.) She exhibited linear, organized, and goal-directed thought process. (Id.) She strongly denied any urge to injure herself or any suicidal or homicidal ideation. (Id.) No perceptual disturbances were noted, and her insight and judgment were fair. (Id.)
Plaintiff reported on September 1, 2015, that the day before she had had thoughts of hurting herself and strong urges to cut herself. (AR 363.) She felt her anxiety was getting worse and recently got upset when her grandfather asked her to start working. (Id.) A family session was held, and Plaintiff appeared anxious and dysphoric during it; she stated that she did not feel ready to start working. (AR 363-64.) But she was pleasant and cooperative during her mental-status examination, and the examination findings were unchanged. (Id.)
On September 2, 2015, Plaintiff reported that she spoke to her grandfather after the family session and was now considering starting to work part time. (AR 361.) She was getting along with her grandparents, and her anxiety, depression, and anhedonia were getting better. (Id.) She was more positive and looked forward to working, going to college, and accomplishing her long-term life goals. (Id.)
Anhedonia is "a psychological condition characterized by inability to experience pleasure in normally pleasurable acts." Anhedonia, Merriam-Webster, http://www.merriam-webster.com (last visited Mar. 22, 2021).
Plaintiff stated on September 8, 2015, that her mood and anxiety symptoms had "significant[ly] improve[d]." (AR 359.) She continued to take Zoloft with no adverse affects and looked forward to starting work. (Id.) She was getting along well with her grandparents, and her grandfather intended to take her to Canada for a vacation in October. (Id.) She actively completed chores at home and socialized during the weekend. (Id.) She agreed to be discharged the next day. (Id.)
On September 9, 2015, Plaintiff called the on-call resident and reported a strong urge to cut herself but denied any suicidal or homicidal ideation. (AR 357.) She had had an argument with her grandfather, who yelled at her and made some "homophobic and racial comments." (Id.) She then texted her mother and reported that she would have "done [her]self" if her mom had not called or texted back within 20 minutes. (Id.) Her mother called her back and asked her to take a taxi to the partial-hospitalization program. (Id.) She was sad and depressed, had vague thoughts of not living, and felt that life was not worth it. (AR 355.) She did not want to return to her grandfather's house and did not feel safe; she was taken to the emergency department, from which she was sent to inpatient psychiatric hospitalization. (AR 357.)
At the emergency department, Plaintiff stated that she spent the night at her grandfather's house after the argument, but she began wandering the streets the next morning after he would not drive her to her outpatient appointment. (AR 350.) She found an abandoned farmhouse, where she began formulating a plan to hang herself. (Id.) She stated that she "would likely take her own life if released." (Id.) An examination revealed good insight, poor judgment, fair impulsivity, depressed mood, and congruent affect. (AR 347.) On September 10, 2015, she was transferred to Philhaven Center for inpatient treatment. (AR 271.)
On October 2, 2015, Plaintiff reported to psychiatrist Gagandeep Dhillon that following her inpatient treatment, her mood was "neutral." (AR 292.) She was compliant with her medications and had no side effects. (Id.) She feared paranormal activity, such as inanimate objects moving, but denied any suicidal or homicidal ideation, delusions, or perceptual disturbances. (Id.) She continued to live with her grandparents. (Id.)
Plaintiff reported to psychiatrist Sanjay Yadav on November 6, 2015, that she had had "bad lows" in her mood in the last two weeks. (AR 287.) She was having a lot of stress from relationship issues with her grandfather's wife. (Id.) She had "a lot of suicidal thoughts and urges to cut herself in the last [two to three] weeks," but her mood was "a lot better" when she was away from home, and she denied anhedonia or current suicidal thoughts. (Id.) She denied any panic attacks when not at home or side effects from Zoloft. (Id.)
On November 13, 2015, Plaintiff reported to psychiatrist Aditya Joshi that her mood was "okay"; she had normal energy and concentration, no appetite or sleep problems, and no suicidal or homicidal ideation, intent, or plan. (AR 326.) She had taken medication for anxiety after her last visit, and she became extremely dizzy. (Id.) She had recently cut herself on her leg because she was upset that her grandfather was pushing her to apply for SSI. (Id.) She was compliant with medications, had been attending individual therapy, and was going to start dialectical behavioral therapy, or DBT. (Id.) She denied any anxiety except around her grandfather's wife and denied any panic attacks. (Id.) She was pleasant, calm, and cooperative. (AR 327.) She had moderate affective dysregulation that was normal in range, her thought process was goal directed, she was not delusional and denied any perceptual disturbances, and no obsessions or compulsions were noted. (Id.) Her insight and judgment were fair, and her impulse control and memory were intact. (Id.) The dosages of her Zoloft and Vistaril were adjusted, and she was instructed to continue with DBT therapy for "provisional borderline personality disorder." (Id.)
Affective dysregulation is "an excessive reactivity to negative emotional stimuli with an affective (anger) and a behavioral component (aggression)." Affective Dysregulation in Childhood — Optimizing Prevention and Treatment: Protocol of Three Randomized Controlled Trials in the ADOPT Study, BMC Psychiatry, https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-019-2239-8 (last visited Mar. 22, 2021).
Vistaril, or hydroxyzine, is used to relieve itching caused by allergies, control nausea and vomiting caused by various conditions, and treat anxiety. Hydroxyzine, MedlinePlus, http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682866.html (last visited Mar. 22, 2021).
On January 28, 2016, Plaintiff went to the emergency department, complaining of depression and "[p]assive" suicidal ideation "without [a] plan." (AR 329.) She had enrolled in DBT, was "kicked out" of the group after having missed an appointment while in Los Angeles visiting her mother, and was having trouble getting in to see her psychiatrist. (Id.) She had recently told her mother and the rest of her family that her grandfather had abused her while she was living with him, and she was now living with friends in their basement. (Id.) She spoke with a social worker about getting into counseling and reporting her abuse, felt "ok to go home," and was discharged. (AR 331.)
e. Philhaven Center
On September 10, 2015, Plaintiff was transferred to Philhaven Center for inpatient psychiatric treatment. (AR 271.) On examination she was calm and had a depressed mood, congruent affect, coherent thought processes, good insight, fair judgment, and no psychotic symptoms. (AR 272.) Her Zoloft dosage was adjusted, and she was assigned to therapeutic groups and activities and individual therapy. (Id.) She participated in a lengthy family session with her grandfather, at which they discussed ways they could communicate more effectively and ways Plaintiff could use grounding skills. (Id.) Her grandfather committed to helping her get back on her feet, by getting her own apartment or going to college. (Id.) She completed home-safety and relapse-prevention plans and reported that her mood was improved and she was looking forward to discharge and beginning a new job. (Id.) She was discharged on September 14, 2015, and was scheduled for outpatient treatment. (Id.)
f. Giulianna Nguyen
On February 26, 2016, Plaintiff saw Dr. Giulianna Nguyen to establish care and for an annual physical. (AR 446.) Plaintiff reported that she had switched from Lexapro to Zoloft and that she had experienced chronic fatigue and anhedonia since the onset of depression. (Id.) But her depression was "improved," and she described her anxiety as "only situational." (Id.)
Dr. Nguyen primarily practices internal medicine. See Cal. Dep't Consumer Aff. License Search, https://search.dca.ca.gov (search for "Giulianna" with "Nguyen" under "License Type," "Physicians and Surgeons") (last visited Mar. 22, 2021).
g. Thaworn Rathana-Nakintara
Consulting psychiatrist Thaworn Rathana-Nakintara performed a complete psychiatric evaluation of Plaintiff on May 18, 2016. (AR 484-89.) She told Dr. Rathana-Nakintara that she "had a lot of trauma . . . growing up" and that her "father beat up" her and her mother. (AR 484.) She reported having anxiety that made her ill at times, panic attacks, "major depression," "bipolar disorder," paranoia while at school, irrational thinking, and "an urge to hurt [her]self." (Id.) Her father was banned from seeing her when she was 11 years old. (AR 484-85.) When she graduated high school, she stayed with her grandfather in Pennsylvania, but she said he abused her sexually. (AR 485.) She felt "much better now by taking Zoloft." (Id.)
Dr. Rathana-Nakintara diagnosed her with mood disorder and cannabis abuse and assigned a GAF score of 95. (AR 487.) She was cooperative, maintained good eye contact, had normal psychomotor activity, and demonstrated fluent speech, with normal prosody, rate, and rhythm; her affect was appropriate and reactive, and her mood was responsive and "not depressed or anxious." (AR 486.) Her thought processes were linear and goal-oriented, and she exhibited normal memory, concentration, abstract thinking, insight, and judgment. (AR 486-87.) She denied current suicidal or homicidal ideation, plans, or intent. (AR 486.) Further, she exhibited "no difficulty interacting with the clinic staff" or Dr. Rathana-Nakintara; "maintaining composure," "even temperament," and "social functioning"; or "focusing and maintaining attention." (AR 488.) She had "no difficulties in concentration, persistence and pace." (Id.) Her "level of personal independence [was] adequate," and she was "intellectually and psychologically capable of performing activities of daily living." (Id.)
GAF scores assess a person's overall psychological functioning on a scale of 1 to 100. See Diagnostic and Statistical Manual of Mental Disorders 32 (revised 4th ed. 2000). A GAF score between 91 and 100 indicates "[s]uperior functioning in a wide range of activities," such that "life's problems never seem to get out of hand"; a person with that score "is sought out by others because of his or her many positive qualities" and suffers "[n]o symptoms." DSM-IV 34. The Commissioner has declined to endorse GAF scores, Revised Medical Criteria for Evaluating Mental Disorders and Traumatic Brain Injury, 65 Fed. Reg. 50764-65 (Aug. 21, 2000) (codified at 20 C.F.R. pt. 404) (GAF score "does not have a direct correlation to the severity requirements in our mental disorders listings"), and the most recent edition of the DSM "dropped" the GAF scale, citing its lack of conceptual clarity and questionable psychological measurements in practice, DSM-V 16 (5th ed. 2013). Because GAF scores continue to be included in claimant medical records, however, the Social Security Administration has clarified that they are "medical opinion evidence . . . if they come from an acceptable medical source." Wellington v. Berryhill, 878 F.3d 867, 871 n.1 (9th Cir. 2017) (citation omitted).
Dr. Rathana-Nakintara opined that she "would have no limitations performing simple and repetitive tasks and no limitations performing detailed and complex tasks." (Id.) She "would have no difficulties . . . perform[ing] work activities on a consistent basis without special or additional supervision"; "no limitations completing a normal workday or workweek due to [her] mental condition" or "accepting instructions from supervisor[s] and interacting with coworkers and with the public"; and "no difficulties . . . handl[ing] the usual stresses, changes and demands of gainful employment." (Id.)
h. Celine Payne-Gair
On July 4, 2016, Celine Payne-Gair, a state-agency reviewing psychologist, evaluated portions of Plaintiff's medical records, including Dr. Rathana-Nakintara's examination report and some of the treatment records from Philhaven and Penn State Hershey Hospital. (AR 64-65.)
Dr. Payne-Gair used a medical specialty code of 38 (AR 73), indicating psychology, see Soc. Sec. Admin., Program Operations Manual System (POMS) DI 24501.004, https://secure.ssa.gov/apps10/poms.nsf/lnx/0424501004 (May 5, 2015).
Dr. Payne-Gair opined that Plaintiff had no limitations in understanding and memory. (AR 68.) She was not significantly limited in the ability to carry out very short and simple or detailed instructions, perform activities within a schedule, maintain regular attendance, be punctual within customary tolerances, sustain an ordinary routine without special supervision, work in coordination with or in proximity to others without being distracted by them, make simple work-related decisions, ask simple questions or request assistance, accept instructions and respond appropriately to criticism from supervisors, get along with coworkers or peers without distracting them or exhibiting behavioral extremes, maintain socially appropriate behaviors and adhere to basic standards of neatness and cleanliness, be aware of normal hazards and take appropriate precautions, travel in unfamiliar places or use public transportation, or set realistic goals or make plans independently of others. (AR 68-69.)
She was moderately limited in the ability to maintain attention and concentration for extended periods, complete a normal workday and workweek without interruptions from psychologically based symptoms, perform at a consistent pace without an unreasonable number and length of rest periods, interact appropriately with the general public, and respond appropriately to changes in the work setting. (Id.)
She could complete simple and detailed tasks, maintain attention and concentration for periods of at least two hours, complete a normal workday and workweek without significant psychologically related interruptions, perform at a consistent pace, and adapt to routine changes in the workplace. (AR 69.)
i. Aurora Charter Oak Hospital
On September 27, 2017, Plaintiff was brought to Aurora Charter Oak Hospital by the Los Angeles Police Department following a verbal altercation with her roommate; she complained of "feeling suicidal" and was placed on a psychiatric hold. (AR 735.) She exhibited depressed mood; flat affect; and poor insight, social judgment, and coping skills. (Id.) She was using illicit drugs like marijuana "off and on," and her urine toxicology was positive for THC. (Id.) But she denied hallucinations or delusions. (Id.) She was admitted for inpatient treatment; was prescribed medication for depression; and participated in group, individual, milieu, and family therapy. (AR 735-36.) On October 3, 2017, she was less dysphoric, her insight and social judgment had improved, and she was discharged. (AR 736.)
Milieu therapy treats mental-health conditions by "using a person's surroundings to encourage healthier ways of thinking and behaving." What is Milieu Therapy?, Healthline, https://www.healthline.com/health/mental-health/milieu-therapy (last visited Mar. 22, 2021).
2. Applicable law
Three types of physicians may offer opinions in Social Security cases: those who directly treated the plaintiff, those who examined but did not treat the plaintiff, and those who did neither. See Lester, 81 F.3d at 830. A treating physician's opinion is generally entitled to more weight than an examining physician's, and an examining physician's opinion is generally entitled to more weight than a nonexamining physician's. Id.; see § 416.927(c)(1)-(2). But "the findings of a nontreating, nonexamining physician can amount to substantial evidence, so long as other evidence in the record supports those findings." Saelee v. Chater, 94 F.3d 520, 522 (9th Cir. 1996) (per curiam) (as amended).
For claims filed on or after March 27, 2017, the rules in § 416.920c (not § 416.927) apply. See § 416.920c (evaluating opinion evidence for claims filed on or after Mar. 27, 2017). Plaintiff's claims were filed before March 27, 2017, however, and the Court therefore analyzes them under former § 416.927.
The ALJ may discount a physician's opinion regardless of whether it is contradicted. Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir. 1989); see also Carmickle v. Comm'r, Soc. Sec. Admin., 533 F.3d 1155, 1164 (9th Cir. 2008). When a doctor's opinion is not contradicted by other medical-opinion evidence, however, it may be rejected only for a "clear and convincing" reason. Magallanes, 881 F.2d at 751 (citations omitted); Carmickle, 533 F.3d at 1164 (citing Lester, 81 F.3d at 830-31). When it is contradicted, the ALJ need provide only a "specific and legitimate" reason for discounting it. Carmickle, 533 F.3d at 1164 (citing Lester, 81 F.3d at 830-31). The weight given a doctor's opinion, moreover, depends on whether it is consistent with the record and accompanied by adequate explanation, among other things. See § 416.927(c); see also Orn v. Astrue, 495 F.3d 625, 631 (9th Cir. 2007) (factors in assessing physician's opinion include length of treatment relationship, frequency of examination, and nature and extent of treatment relationship).
3. The ALJ's assessment of the doctors' opinions
The ALJ found Dr. Rathana-Nakintara's opinion assessing no limitations "somewhat persuasive because [he] had the opportunity to examine [Plaintiff] personally." (AR 22.) He found the opinion of psychologist Payne-Gair, who assessed some moderate limitations, more persuasive, however, "in light of the totality of the objective medical evidence and [Plaintiff's] testimony." (Id.)
The ALJ found Dr. Payne-Gair's opinion persuasive because it [was] supported by the objective medical evidence, which shows a history of complaints of anxious depressive, and psychotic symptoms, as well as a depressed and anxious mood and some problems with insight, judgment, and impulse control, but otherwise mostly normal cognitive, expressive, receptive, and social functioning and improvement in [Plaintiff's]
condition with treatment. Dr. Payne-Gair had the opportunity to review and consider [Plaintiff's] medical records, which lends her opinion additional support.(AR 21.)
In light of Plaintiff's testimony regarding the effects of her symptoms on her ability to interact with others, however, the ALJ limited her to work that requires no more than incidental contact with supervisors, no more than occasional and superficial contact with coworkers, and no contact with the public. (AR 21-22.)
Although the ALJ stated that he had "considered statements from treating . . . physicians" (AR 21), he did not discuss them by name or assign any particular weight to them. He did, however, fully summarize the medical evidence of record. (See AR 19-22.)
4. Analysis
Plaintiff argues that the ALJ failed to properly consider the medical evidence of record and erred in affording "greater weight" to the opinions of Drs. Rathana-Nakintara and Payne-Gair. (J. Stip. at 3-4, 16.)
a. Physician opinions
Plaintiff fails to cite any physician opinion, treating or nontreating, that contradicted those of Drs. Rathana-Nakintara and Payne-Gair. Indeed, no such opinions appear in the record. No physician assigned Plaintiff any work-related limitations, much less any greater than those opined by Drs. Rathana-Nakintara and Payne-Gair. Thus, contrary to Plaintiff's contention (J. Stip. at 6), the ALJ did not simply "ignore" medical opinions that did not support his conclusions. See Ford v. Saul, 950 F.3d 1141, 1156 (9th Cir. 2020) (ALJ reasonably concluded that doctor's statements that did not discuss degree of plaintiff's limitations were not useful for determining RFC).
As the ALJ noted, Dr. Payne-Gair had the opportunity to review and consider many of Plaintiff's medical records, including the opinion of Dr. Rathana-Nakintara. Further, the ALJ gave Plaintiff the benefit of the doubt by assigning additional limitations based on her testimony regarding the effects of her symptoms on her ability to interact with others.
And although Dr. Payne-Gair's July 2016 assessment was somewhat early in the claims process and did not consider later emergency-room treatment and hospitalization, Plaintiff's mental conditions responded similarly during that later treatment and did not significantly deteriorate: she was admitted to Aurora Charter Oak Hospital on September 27, 2017, "feeling suicidal" following a verbal altercation with her roommate. (AR 735.) She was prescribed medication for depression and participated in group, individual, milieu, and family therapy. (AR 735-36.) A few days later, on October 3, she was less dysphoric, her insight and social judgment had improved, and she was discharged. (AR 736.) As Plaintiff acknowledges, her symptoms "waxed and waned" somewhat throughout the relevant period (J. Stip. at 4) but overall remained relatively stable. See Miller v. Berryhill, 732 F. App'x 526, 528-29 (9th Cir. 2018) (no error in declining to remand case to ALJ to consider later surgical procedure because there was no evidence of significant change in functional limitations).
Plaintiff cites various treatment notes in which a physician observed that she had trouble holding jobs, was often absent from them, and left jobs because she could not handle criticism at work and the stress made her want to cut herself. (See J. Stip. at 15-16 (citing AR 320, 735, 829).) But the treatment notes were not physician opinions regarding Plaintiff's work limitations. Rather, they were nothing more than the recording of Plaintiff's own subjective complaints and opinions about her limitations. (AR 320, 735, 829); see Thomas v. Barnhart, 278 F.3d 947, 960 (9th Cir. 2002) (finding that ALJ properly rejected Plaintiff's symptom statements when only evidence of symptoms was her statements to doctor and her testimony at hearing). Moreover, almost all her jobs involved heavy customer interaction (see AR 34-35, 320, 735, 829, 835), which even Plaintiff acknowledged was the main trigger for her symptoms (AR 36). By limiting her to no contact with the public, the ALJ fully accommodated that limitation. See Barney v. Berryhill, 769 F. App'x 465, 466 (9th Cir. 2019) ("The ALJ's RFC determination limiting [plaintiff] to simple unskilled work with no public contact reasonably accommodated any limitations . . . as to cognitive and social interaction impairments."). Finally, as discussed in section V.A.4.b. below, the medical evidence did not support any work limitations beyond those assigned by the ALJ.
b. Medical evidence
Plaintiff contends that the ALJ's assessment of the medical evidence "failed to adequately address treating physician records and opinions which indicate greater functional limitations than those found by the ALJ." (J. Stip. at 3-4.) But the ALJ considered all of the record medical evidence, and as noted, assigned limitations greater than those in any medical opinion. The ALJ's analysis of the medical evidence detailed the occasional deterioration of Plaintiff's condition, including psychiatric hospitalizations in April 2015, July and September 2016, and September 2017. (AR 19-20.) The medical record as a whole demonstrated few work limitations, however, as the ALJ explained.
He also correctly noted that although Plaintiff's treatment providers noted her anxious and depressed mood and her sometimes restricted affect, they also routinely observed a cooperative and pleasant attitude, full orientation, clear and coherent speech, normal psychomotor activity, linear and goal-directed thought process, intact memory, and fair insight and judgment. (AR 20 (citing AR 276, 283, 309, 311-12, 314, 321, 334, 405, 411, 434, 469, 837).)
Her relative functional stability was likely because, as the ALJ noted (AR 21), Plaintiff's course of treatment was largely successful. She was prescribed psychotropic medications such as Lexapro, Ativan, and Zoloft. She also participated in individual, group, and family therapy. Her argument that her mental conditions were not controlled with her medication (J. Stip. at 4) is not well taken. Instead, the record demonstrates that her symptoms were generally controlled when she took her medication as prescribed. In March 2015, just one month after Dr. Lee prescribed her psychotropic medication, she had a "lot less tearfulness" and anxiety in both "frequency and intensity," rated her anxiety as "much better," had had no nightmares since her last visit, was going to school and not isolating as much, made a few new friends, had no suicidal ideation or urges to cut, and had had no intrusive thoughts about her father since her last appointment. (AR 247.) In June 2015, she reported "feel[ing] better" and less anxious, with no panic attacks and no sadness for two to three weeks; she was sleeping well and hiking more. (AR 254.) In February 2016, she reported that she had switched from Lexapro to Zoloft, her depression was "improved," and her anxiety was "only situational." (AR 446.) Later that month, she told Dr. Lee that she no longer experienced "social avoidance." (AR 468.) In May 2016, she told Dr. Rathana-Nakintara that she felt "much better now by taking Zoloft" (AR 484), and Dr. Rathana-Nakinara noted that she was "adhering and responding well to treatment" (AR 488).
On the other hand, Plaintiff experienced setbacks when she was not compliant with her medication. When she was hospitalized following an altercation with her roommate in September 2017, she reported that she had not taken her medication for one week. (AR 737.) Once she became compliant, her symptoms quickly improved. (AR 742-46.)
Plaintiff correctly notes that a few instances of improvement of symptoms is not a proper basis for concluding that she is capable of working. See Garrison v. Colvin, 759 F.3d 995, 1017 (9th Cir. 2014) ("Cycles of improvement and debilitating symptoms are a common occurrence, and in such circumstances it is error for an ALJ to pick out a few isolated instances of improvement over a period of months or years and to treat them as a basis for concluding a claimant is capable of working."); Holohan v. Massanari, 246 F.3d 1195, 1205 (9th Cir. 2001) (noting that doctor's statements of improvement must be read in context of overall diagnostic picture). The isolated instances here are of deterioration, however, not improvement. As the ALJ documented, Plaintiff's four brief hospitalizations of a few days each were separated by months and sometimes more than a year of medication compliance, improved symptoms, and relatively normal functioning. (See AR 19-22 (citing 247, 254, 276, 283, 309, 311-12, 314, 321, 334, 405, 411, 434, 446, 468-69, 488, 742-46, 837).) At most, the records cited by Plaintiff establish that the medical evidence was susceptible of more than one rational interpretation, which is insufficient to warrant reversal. See Molina v. Astrue, 674 F.3d 1104, 1111 (9th Cir. 2012); Tommasetti v. Astrue, 533 F.3d 1035, 1041 (9th Cir. 2008) (ALJ is "final arbiter with respect to resolving ambiguities in the medical evidence"). Remand is not warranted.
B. The ALJ Properly Assessed Plaintiff's Symptom Statements
1. Applicable law
An ALJ's assessment of a claimant's allegations concerning the severity of her symptoms is entitled to "great weight." Weetman v. Sullivan, 877 F.2d 20, 22 (9th Cir. 1989) (as amended) (citation omitted); Nyman v. Heckler, 779 F.2d 528, 531 (9th Cir. 1985) (as amended Feb. 24, 1986). "[T]he ALJ is not 'required to believe every allegation of disabling pain, or else disability benefits would be available for the asking, a result plainly contrary to 42 U.S.C. § 423(d)(5)(A).'" Molina, 674 F.3d at 1112 (quoting Fair v. Bowen, 885 F.2d 597, 603 (9th Cir. 1989)).
In evaluating a claimant's subjective symptom testimony, the ALJ engages in a two-step analysis. See Lingenfelter, 504 F.3d at 1035-36; see also SSR 16-3p, 2016 WL 1119029, at *3 (Mar. 16, 2016). "First, the ALJ must determine whether the claimant has presented objective medical evidence of an underlying impairment '[that] could reasonably be expected to produce the pain or other symptoms alleged.'" Lingenfelter, 504 F.3d at 1036 (citation omitted). If such objective medical evidence exists, the ALJ may not reject a claimant's testimony "simply because there is no showing that the impairment can reasonably produce the degree of symptom alleged." Id. (citation omitted; emphasis in original).
If the claimant meets the first test, the ALJ may discount the claimant's subjective symptom testimony only if she makes specific findings that support the conclusion. See Berry v. Astrue, 622 F.3d 1228, 1234 (9th Cir. 2010). Absent a finding or affirmative evidence of malingering, the ALJ must provide a "clear and convincing" reason for rejecting the claimant's testimony. Brown-Hunter v. Colvin, 806 F.3d 487, 493 (9th Cir. 2015) (as amended) (citing Lingenfelter, 504 F.3d at 1036); Treichler v. Comm'r of Soc. Sec. Admin., 775 F.3d 1090, 1102 (9th Cir. 2014). The ALJ may consider, among other factors, the claimant's (1) reputation for truthfulness, prior inconsistent statements, and other testimony that appears less than candid; (2) unexplained or inadequately explained failure to seek treatment or to follow a prescribed course of treatment; (3) daily activities; (4) work record; and (5) physicians' and third parties' statements. Rounds v. Comm'r Soc. Sec. Admin., 807 F.3d 996, 1006 (9th Cir. 2015) (as amended); Thomas, 278 F.3d at 958- 59 (citation omitted). If the ALJ's evaluation of a plaintiff's alleged symptoms is supported by substantial evidence in the record, the reviewing court "may not engage in second-guessing." Thomas, 278 F.3d at 959.
2. Plaintiff's symptom statements and testimony
In a January 25, 2015 Function Report, Plaintiff stated that she frequently experienced "random, severe panic attacks in public [and] social situations," "PTSD flashbacks" stemming from abuse by her father, "major fear being around men," anxiety that made her feel "physically ill," "run away" thoughts, irrational "self-injurious thinking," "p[s]ychosis episodes," emotional instability, lack of trust of others, and hypervigilance. (AR 177.) In an undated Disability Report, she stated that her ability to work was limited by "major depression," "chronic PTSD," "borderline personality disorder," and "generalized anxiety." (AR 189.)
At the April 17, 2018 hearing, Plaintiff testified that she last worked about a week before the hearing. (AR 34.) She worked between 15 and 20 hours a week as a sales associate and cashier at a pet store. (Id.) She testified that she was precluded from working full time by her "anxiety and panic attacks that she [had] during work[]." (AR 35-36.) She had gotten "very physically hot and sweaty and nauseous" when "assist[ing] customers" at the pet store, "triggered with interactions," "especially [with] male individuals." (AR 36.) She had had "flashbacks at work that cause[d] her to . . . abandon [her] tasks." (Id.) Depression and "suicidal ideation" also limited her ability to work. (AR 38-39.) She had "often cut [her]self," behavior that was "still going on" at the time of the hearing. (AR 39.) She last cut herself five days before the hearing. (AR 47-48.) She left the home where she was staying with the intention of committing suicide but returned and cut herself because she had missed her shift at the pet store. (AR 48.) She had missed three days since she started working at the pet store five weeks earlier. (Id.) The family with whom she was staying had asked her to leave. (Id.)
She "d[id] not smoke marijuana" but had used cannabis in the past to help her sleep. (AR 40.) She had experienced headaches when she was taking Lexapro and Lorazepam for anxiety, but she was no longer taking them. (AR 43.) At the time of the hearing, she was attending therapy once a week. (AR 43-44.) She usually walked to get around, but she took the bus on longer trips. (AR 44.) She did not drive and did not have a license. (Id.) She had been fired or agreed to leave jobs several times because of poor attendance. (AR 46-47.) It usually took her "a couple of days to complete" a "task . . . such as laundry," she did not cook for herself, and she got "overwhelmed with . . . self-hygiene." (AR 49.)
3. The ALJ's decision
The ALJ reviewed Plaintiff's claimed limitations and found that her "medically determinable impairments could reasonably be expected to cause the alleged symptoms; however, [her] statements concerning the intensity, persistence, and limiting effects of these symptoms [were] not entirely consistent with the medical evidence and other evidence in the record[.]" (AR 19.) The ALJ discounted Plaintiff's subjective symptom statements because they were inconsistent with the objective medical evidence (AR 20) and her work history (AR 21) and because they were controlled when she was compliant with medication and treatment (id.).
4. Analysis
Plaintiff asserts that the ALJ failed to properly assess her subjective symptom statements. (J. Stip. at 24-31, 35-37.) For the reasons discussed below, the ALJ did not err.
a. Medical and other evidence
To start, the ALJ properly concluded that Plaintiff's subjective symptom statements were inconsistent with the objective medical evidence in the record. Morgan v. Comm'r of Soc. Sec. Admin., 169 F.3d 595, 600 (9th Cir. 1999) (finding "conflict" with "objective medical evidence in the record" to be "specific and substantial reason" undermining plaintiff's allegations). Among other things, the ALJ noted that although Plaintiff claimed she could not work because of major depression, chronic PTSD, borderline personality disorder, and anxiety (see AR 19 (citing AR 189)), she was often noted to be cooperative and pleasant, with full orientation, clear and coherent speech, normal psychomotor activity, linear and goal-directed thought processes, intact memory, and fair insight and judgment (AR 20 (citing AR 276, 283, 309, 311-12, 314, 321, 334, 405, 411, 434, 469, 837)). The ALJ also correctly noted that although she told Dr. Rathana-Nakintara that she felt "emotionally unstable," Dr. Rathana-Nakintara observed a cooperative attitude; good eye contact; normal psychomotor activity; fluent speech; appropriate and reactive affect; a responsive mood; linear and goal-directed thought processes; intact memory, concentration, and abstract thinking; commonsense understanding; and no abnormal thought content or perceptions. (AR 20 (citing AR 484-87).) No doctor assessed functional limitations greater than the RFC. As noted previously, the records cited by Plaintiff at most establish that the medical evidence was susceptible of more than one rational interpretation, which is insufficient to warrant reversal. See Molina, 674 F.3d at 1111; Tommasetti, 533 F.3d at 1041.
b. Effective treatment
The ALJ also discounted Plaintiff's subjective symptom statements because they were inconsistent with evidence demonstrating that her symptoms improved and were relatively controlled when she complied with her prescribed treatment and medication. (AR 21; see AR 247 (Plaintiff reporting one month after Dr. Lee prescribed psychotropic medication that she had "lot less tearfulness" and anxiety in both "frequency and intensity"; her anxiety was "much better"; she had no nightmares since last visit; she was going to school, not isolating as much, and had made new friends; and she had no suicidal ideation, urges to cut, or intrusive thoughts about her father since her last appointment), 254 (Plaintiff reporting "feel[ing] better" and less anxious, with no panic attacks or sadness for two to three weeks, sleeping well, and hiking more), 446 (Plaintiff stating that she had switched from Lexapro to Zoloft, her depression was "improved," and her anxiety was "only situational"), 468 (Plaintiff telling Dr. Lee that she no longer experienced "social avoidance"), 484 (Plaintiff reporting that she felt "much better now by taking Zoloft"), 488 (Dr. Rathana-Nakinara noting that Plaintiff was "adhering and responding well to treatment").)
Plaintiff argues that her hospitalizations demonstrate that her treatment was not effective. But that she occasionally needed more aggressive treatment, especially when she had not been compliant with her medication, does not diminish the numerous times when she acknowledged that her treatment and medication was working. This is at most another record gray area, the final arbiter of which was the ALJ. See Molina, 674 F.3d at 1111; Tommasetti, 533 F.3d at 1041. The ALJ properly considered the evidence that Plaintiff's treatment was effective in discounting her symptom statements.
c. Plaintiff's employment
Finally, the ALJ properly discounted Plaintiff's subjective symptom statements because her "earnings records and testimony showed [she] worked several part-time jobs between 2016 and 2017" and because she stated in her disability report that she was "'currently working' when she filed the application" (AR 21 (citing AR 189)). See Presley-Carrillo v. Berryhill, 692 F. App'x 941, 945 (9th Cir. 2017) (ALJ reasonably discounted Plaintiff's testimony based on daily activities, "particularly given that she already worked part-time"); Hollen v. Comm'r of Soc. Sec., No. 3:15-cv-2357-GPC-DHB, 2017 WL 1075194, at *13 (C.D. Cal. Mar. 22, 2017) ("Plaintiff's certification to the unemployment office that she was ready, willing, and able to work, combined with the finding she worked part-time in 2014, provides further clear and convincing reasons for the ALJ to discount her testimony.").
Plaintiff contends that she had attendance issues with those jobs and was unable to sustain even part-time employment for more than brief periods. (J. Stip. at 30-31.) But assuming Plaintiff's apparent history of attendance issues at those customer-service jobs was probative of her ability to sustain employment in them, the ALJ did not find that she could perform those jobs on a full-time basis. The ALJ limited her to "no more than simple, routine, repetitive tasks; no more than incidental contact with supervisors; no more than occasional and superficial contact with coworkers; and no contact with the public." (AR 18.) Moreover, "[e]ven where [a plaintiff's] activities suggest some difficulty functioning, they may be grounds for discrediting [her] testimony to the extent that they contradict claims of a totally debilitating impairment," Molina, 674 F.3d at 1113 (citations omitted), or "suggest" that her "claims about the severity of [her] limitations were exaggerated," Valentine v. Comm'r Soc. Sec. Admin., 574 F.3d 685, 693 (9th Cir. 2009). Plaintiff's work activity demonstrated that she was functional. She was able to go to work, at least on a part-time basis, and deal to some degree with supervisors and the public. Without the additional stress that contact entailed, she likely would be able to do even more; therefore, the ALJ's RFC reasonably accommodated this limitation. See Barney, 769 F. App'x at 466. The ALJ properly considered this evidence in assessing Plaintiff's symptom statements.
Substantial evidence supported the ALJ's discounting of Plaintiff's subjective symptom statements. Remand is not warranted on this basis.
C. The RFC Is Supported by Substantial Evidence
Plaintiff claims that the RFC is not supported by substantial evidence in that it failed to include a limitation for her attendance issues. (J. Stip. at 37-39, 40-41.) Although she points to her own statements in medical records that she had a poor work-attendance record, she offers no evidence that any doctor assigned any such limitation. To the extent she did have attendance issues, nothing indicates she would still have them in the jobs the ALJ identified, which involved very limited interaction with other people, her main trigger. Moreover, as discussed in sections V.A. and V.B., the ALJ considered the medical evidence and opinions and properly discounted Plaintiff's subjective symptom statements. Based on the record and Plaintiff's failure to identify any flaw in the ALJ's reasoning, he properly omitted any such limitation from the RFC. See Bayliss v. Barnhart, 427 F.3d 1211, 1217 (9th Cir. 2005) (ALJ not required to include in RFC limitations based on plaintiff's properly discounted subjective complaints); Figueroa v. Colvin, No. CV 12-06742-OP., 2013 WL 1859073, at *9 (C.D. Cal. May 2, 2013) (no error in failing to include limitations in RFC when ALJ properly rejected plaintiff's subjective complaints of impairment). This issue does not warrant remand.
VI. CONCLUSION
Consistent with the foregoing and under sentence four of 42 U.S.C. § 405(g), IT IS ORDERED that judgment be entered AFFIRMING the Commissioner's decision, DENYING Plaintiff's request for remand, and DISMISSING this action with prejudice. DATED: March 23, 2021
That sentence provides: "The [district] court shall have power to enter, upon the pleadings and transcript of the record, a judgment affirming, modifying, or reversing the decision of the Commissioner of Social Security, with or without remanding the cause for a rehearing." --------
/s/_________
JEAN ROSENBLUTH
U.S. Magistrate Judge