Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-3_14-cv-08040/USCOURTS-azd-3_14-cv-08040-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:405 Review of HHS Decision (SSID)

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WO 

IN THE UNITED STATES DISTRICT COURT 

FOR THE DISTRICT OF ARIZONA 

Jolene Mae Rolston, 

Plaintiff, 

v. 

Carolyn W. Colvin, Acting Commissioner 

of Social Security, 

Defendant. 

No. CV-14-08040-PCT-BSB

ORDER 

 Plaintiff Jolene Mae Rolston seeks judicial review of the final decision of the 

Commissioner of Social Security (the Commissioner) denying her application for 

disability insurance benefits under the Social Security Act (the Act). The parties have 

consented to proceed before a United States Magistrate Judge pursuant to 28 

U.S.C. § 636(b), and have filed briefs in accordance with Local Rule of Civil Procedure 

16.1. For the following reasons, the Court affirms the Commissioner’s decision. 

I. Procedural Background 

 On November 4, 2010, Plaintiff applied for disability insurance benefits under 

Title XVI of the Act. (Tr. 21.)1

 Plaintiff alleged disability beginning November 1, 2010. 

(Id.) After the Social Security Administration (SSA) denied Plaintiff’s initial application 

and her request for reconsideration, she requested a hearing before an administrative law 

judge (ALJ). After conducting a hearing, the ALJ issued a decision finding Plaintiff not 

 

1

 Citations to “Tr.” are to the certified administrative transcript of record. (Doc. 17.) 

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disabled under the Act. (Tr. 21-29.) This decision became the final decision of the 

Commissioner when the Social Security Administration Appeals Council denied 

Plaintiff’s request for review. (Tr. 1-6); see 20 C.F.R. §§ 404.981, 416.1481 (explaining 

the effect of a disposition by the Appeals Council.)2

 Plaintiff now seeks judicial review 

of this decision pursuant to 42 U.S.C. § 405(g). 

II. Administrative Record 

 The record before the Court establishes the following history of diagnosis and 

treatment related to Plaintiff’s health. The record also includes opinions of state agency 

physicians who examined Plaintiff and reviewed the records related to Plaintiff’s 

impairments, but who did not provide treatment. 

A. Treatment Records 

 1. North Country Health Care and Urgent Care 

 Since approximately 2006, Plaintiff has received primary health care from North 

Country Health Care (North Country). (Tr. 256-89.) On October 11, 2010, Plaintiff saw 

Nurse Practitioner (NP) Susan Collins at North Country primarily for “breathing issues.” 

(Tr. 260.)3

 Plaintiff complained of depression and anxiety (fear of leaving the house and 

panic attacks), back and hip pain, difficulty breathing, and shortness of breath with 

activity. (Tr. 262.) NP Collins noted that Plaintiff was accompanied by her daughter, 

granddaughter, and young grandson. (Id.) Plaintiff reported that her family was with her 

“for support and to assure she [did not] wiggle out of being seen as she [was] very 

anxious and agoraphobic by nature and coming to the doctor’s office [was] a terror 

producing thought.” (Id.) NP Collins noted that Plaintiff described panic attacks when 

she was in the shower and that she “flit[ted] from one thought to another and was very 

nervous.” (Tr. 262-63.) 

 

2

 20 C.F.R. part 404 addresses Title II of the Act, and has parallel citations in part 416, which addresses Title XVI. 

3

 The October 11, 2010 treatment notes also appear at Tr. 278-81. 

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 Plaintiff reported that she started smoking when she was seventeen and was 

smoking forty cigarettes per day. (Tr. 261-62.) Plaintiff reported being eager to quit 

smoking. (Tr. 262.) She reported that she was “a poor house cleaner because the effort 

cause[d] her to have a hard time breathing.” (Id.) On examination, Plaintiff was in “no 

acute distress,” and had “no rales, rhonchi, or wheezes.” (Id.) NP Collins assessed 

shortness of breath, anxiety, panic attack, and tobacco abuse. (Tr. 263.) She prescribed 

Advair and Proair inhalers and referred Plaintiff for spirometry testing and to “a mental 

health facility for her depression fears, [and] phobias.” (Tr. 263.) She also discussed a 

smoking cessation plan. (Id.) 

 Spirometry testing performed on October 25, 2010 showed evidence of 

“moderate” Chronic Obstructive Pulmonary Disease (COPD). (Tr. 407-08, 287-90.) 

During an October 25, 2010 appointment with Dr. Shipra Bonsal, Plaintiff reported that 

her prescribed inhaler QVAR was not “working,” and she was still using ProAir up to 

five to seven times a day. (Tr. 258.) On examination, Plaintiff had a “wheeze” and 

“reduced breath sounds diffusely.” (Id.) Dr. Bonsal indicated that Plaintiff had “no 

depression, anxiety, or agitation.” (Id.) Dr. Bonsal recommended that Plaintiff, who 

reported smoking seven cigarettes per day, stop smoking, use a humidifier, and stay 

hydrated. (Id.) She also prescribed Atrovent and Adviar inhalers, and removed QVAR. 

 During a November 1, 2010 appointment, NP Collins noted that spirometry testing 

revealed “moderate COPD.” (Tr. 271.)4

 During that appointment, Plaintiff reported that 

she had been smoking two packs of cigarettes per day, but she had reduced her cigarette 

intake. (Id.) Plaintiff reported shortness of breath “only when doing activities.” (Id.) 

Plaintiff denied dizziness and fatigue. (Id.) Plaintiff reported doing better on ProAir and 

said that her insurance had denied the Advair and recommended QVAR or Flovent. (Id.) 

On examination, Plaintiff was in “no acute distress,” and had “no rales, rhonchi, or 

 

4

 Treatment notes from the November 1, 2010 appointment are duplicated at Tr. 283-85 and Tr. 287-89. 

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wheezes.” (Tr. 272.) NP Collins assessed COPD, prescribed a QVAR inhaler, and 

discussed a smoking cessation plan with Plaintiff. (Id.) 

 On May 16, 2011, Plaintiff saw Dr. Bansal for complaints of continued shortness 

of breath. (Tr. 401.) Plaintiff reported using ProAir five to seven times per day and that 

she had cut back to seven cigarettes a day. (Id.) On examination, Dr. Bansal found left 

upper quadrant wheezing and reduced breath sounds diffusely. (Tr. 402.) She also noted 

that Plaintiff had no “depression, anxiety, or agitation.” (Id.) Dr. Banal found that 

Plaintiff’s COPD was inadequately controlled and adjusted her medication. (Tr. 401.) 

She prescribed an Atrovent inhaler in place of QVAR. (Tr. 402-03.) She recommended 

that Plaintiff stop smoking, use a humidifier, and stay hydrated. (Tr. 402.) 

 During a July 18, 2011 appointment with Dr. Bansal, Plaintiff reported that the 

Advair was “working.” (Tr. 398.) Plaintiff reported that she was down to two cigarettes 

a day and was “doing better.” (Tr. 399.) On examination, Plaintiff was in no acute 

distress, she had “no rales, rhonci, or wheezes,” but had “reduced breath sounds 

diffusely.” (Id.) Dr. Banal noted that Plaintiff’s COPD had improved significantly on 

Advair and Atrovent and that she was “off [the] emergency inhaler entirely.” (Id.) She 

also noted that Plaintiff’s tobacco abuse had improved and that Plaintiff was down to two 

cigarettes a day. (Id.) Dr. Bansal prescribed Atrovent, Advair, and ProAir. (Id.) 

 On March 23, 2012, Plaintiff presented to Urgent Care for bronchitis. (Tr. 318.) 

She was prescribed a cough suppressant and a course of antibiotics and was advised to 

“rest and get plenty of fluids.” (Id.) 

 2. Matthew Wise, M.D. 

 On June 11, 2012, Plaintiff saw Dr. Wise to establish primary medical care. 

(Tr. 361-63.) She reported difficulty walking due to shortness of breath, coughing, and 

wheezing. (Tr. 361.) Plaintiff reported that she had been a heavy smoker for years but 

that she was down to two cigarettes daily. (Id.) She also reported “severe anxiety,” 

explaining that meeting new people or going to the grocery store had been a challenge for 

her for the last ten years. (Id.) Plaintiff reported fatigue, weakness, shortness of breath, 

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wheezing, coughing, anxiety, and agoraphobia. (Tr. 361-62.) On examination, Plaintiff 

was in no apparent distress, her breath sounds were “clear to auscultation bilaterally,” and 

she had no rales or wheezes. (Tr. 362.) Dr. Wise diagnosed COPD, anxiety disorder, 

tobacco abuse, and back pain, and prescribed Advair, ProAir, and sertraline (Zoloft) for 

anxiety. (Tr. 363.) He encouraged Plaintiff to cut back to one cigarette per day and to try 

to quit entirely. (Id.) Dr. Wise noted that Plaintiff attended the appointment with her 

sister. 

 During a July 3, 2012 appointment, Plaintiff reported no change in her anxiety on 

the Zoloft and said that she had not been sleeping well. (Tr. 359.) Plaintiff reported 

shortness of breath on exertion and wheezing. (Id.) On examination, Plaintiff was in no 

acute distress and was comfortable. (Id.) Dr. Wise assessed COPD, anxiety disorder, 

and back pain. (Id.) He prescribed Advair, Atrovent, ProAir, and sertraline. (Tr. 360.) 

He advised Plaintiff to quit smoking. (Id.) 

 On August 14, 2012, Plaintiff reported that the Zoloft was “helping some,” but 

that she “still ha[d] enough anxiety that her stomach [was] upset.” (Tr. 357.) She 

reported that her anxiety was “especially bad” when she was told she had to go to Tucson 

to see a doctor for her disability claim. (Id.) She reported that she did not take trips due 

to her anxiety and that going anywhere, including Dr. Wise’s office or to the store, 

caused anxiety. (Id.) On examination, Plaintiff was pleasant, comfortable, and in no 

acute distress. (Tr. 358.) She had “nonlabored breathing, no distress, CTA bilaterally 

with no w/r/r [wheeze/rales/rhoncitis], [and] good air movement.” (Id.) Dr. Wise 

assessed COPD, anxiety disorder NOS (not otherwise specified), back pain, and tobacco 

abuse. (Id.) Dr. Wise increased the dosage of Zoloft and recommended counseling. 

(Tr. 358.) Plaintiff reported that she was “too anxious to go” to counseling, but could 

attend counseling “perhaps after she [was] on a higher dose of meds.” (Id.) Dr. Wise 

continued Advair, ProAir, and Atrovent, and recommended smoking cessation. (Id.) 

 During an August 28, 2012 appointment, Plaintiff reported that the increased 

dosage of Zoloft had caused diarrhea and requested a different medication. (Tr. 354.) 

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Dr. Wise changed Plaintiff’s antidepressant to citalopram (Celexa). (Tr. 355.) Plaintiff 

also reported that she used her inhalers with activities such as vacuuming and that she 

had cut down to two cigarettes total in the preceding week. (Tr. 354.) She reported 

having an appointment to see a psychologist in connection with her disability claim. (Tr. 

355.) On examination, Plaintiff was in no acute distress, pleasant, comfortable, and alert. 

(Id.) She had “nonlabored breathing, no distress, CTA bilaterally, no w/r/r, [and] good 

air movement.” (Id.) “Psychologically,” she had “good eye contact, normal insight, no 

thought disturbances,” and was “slightly anxious appearing.” (Id.) 

 On September 20, 2012, Plaintiff reported that she had completed “her disability 

test with a psychologist in Scottsdale,” and that she “had a panic attack there in the 

office.” (Tr. 446.) She reported that her anxiety attacks continued, and she remained 

housebound. (Id.) Plaintiff stated that she had cut back to smoking one cigarette every 

fews day. (Id.) Plaintiff reported shortness of breath with exertion and wheezing. 

(Tr. 447.) On examination, Plaintiff was in no acute distress and was pleasant. (Tr. 448.) 

Her “breath sounds were clear to auscultation bilaterally,” and she had no rales or 

wheezes. (Id.) Dr. Wise assessed COPD, tobacco abuse, anxiety disorder NOS, back 

pain, and diarrhea. (Id.) He continued Plaintiff’s prescription for her Atrovent, ProAir, 

Advair, and Celexa. (Tr. 449.) He encouraged Plaintiff to quit smoking. (Tr. 448.) 

B. Medical Opinions

 1. Patricia Rose, ED.D 

 On January 4, 2011, a state agency licensed psychologist, Dr. Rose, examined 

Plaintiff for her disability benefits application. (Tr. 296-301.) Plaintiff attended the 

examination alone, but reported that a friend drove her to the doctor’s office. (Tr. 296.) 

Plaintiff reported that she was unable to work due to symptoms arising from anxiety and 

COPD. (Id.) She reported that she had been anxious and afraid to drive for the six years, 

since her involvement in a car accident, and stated that she had difficulty waitressing due 

to breathing problems, and because she periodically got boils on her legs. (Tr. 297, 299.) 

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Plaintiff also stated that although she experienced anxiety daily, she could go out in 

public when she had to do so. (Tr. 297-98.) 

 On examination, Plaintiff was oriented, had good short-term memory, and normal 

attention and concentration. (Tr. 296.) She was pleasant, cooperative, friendly, and had 

good interpersonal skills. (Tr. 297.) During the mental status examination, Plaintiff 

made three mistakes on “serial threes from forty,” and mistakes on simple arithmetic 

problems, which was indicative of possible mild intellectual deficits. (Tr. 296.) Dr. Rose 

noted that Plaintiff had no signs of psychosis, depression, or anxiety. (Id.) 

 Dr. Rose opined that Plaintiff had “avoid[ed] dealing with the world for a long 

period of time, and she ha[d] developed a sense of anxiety about dealing with new 

situations.” (Tr. 299.) Dr. Rose also noted that, based on Plaintiff’s report, although she 

experienced anxiety at times during her waitressing job, she was able to “work through 

it” by getting help from her coworkers. (Tr. 299.) Dr. Rose, opined that Plaintiff “could 

probably [work through anxiety at work] currently.” (Id.) Dr. Rose diagnosed anxiety 

disorder and ruled out agoraphobia because of Plaintiff’s ability to go out in public or 

ride in a car “when necessary.” (Tr. 300.) She also diagnosed possible mild intellectual 

deficits and COPD. (Id.) On a Psychological/Psychiatric Medical Source Statement, 

Dr. Rose opined that Plaintiff did “not present with any significant psychiatric barriers to 

employment.” (Id.) 

 2. Mark Brecheisen, D.O. 

 On January 11, 2011, state agency physician Dr. Brecheisen examined Plaintiff for 

her disability benefits application. (Tr. 304-07.) Plaintiff reported a history of COPD 

and emphysema. (Tr. 304.) Plaintiff reported that she used inhalers daily, chronically 

felt short of breath, and tried to stay home to avoid exposure to things that aggravated her 

condition. (Id.) Plaintiff reported that she could perform all activities of daily living and 

that she could drive. (Tr. 305.) 

 On examination, Dr. Brecheisen noted that Plaintiff walked around the 

examination room without assistance. (Id.) Dr. Brecheisen noted that Plaintiff had 

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coarse and diminished breath sounds with a mild expiratory wheeze. (Tr. 306.) Plaintiff 

had a normal gait, full range of motion in all joints, full muscle strength, no sensory 

deficits, and normal reflexes. (Tr. 306-07.) 

 He conducted a pulmonary function test and found that Plaintiff “gave inadequate 

effort.” (Tr. 302.) Dr. Brecheisen interpreted the pulmonary function test as consistent 

with “mild obstructive pulmonary disease.” (Tr. 302, 307.) Dr. Brecheisen diagnosed a 

history of COPD, anxiety, and cervical cancer. (Tr. 307.) He found “no objective 

medical evidence to support [Plaintiff’s] allegations of permanent disability for a period 

of no less than 12 continuous months of this exam date.” (Id.) He did not identify any 

functional limitations. (Id.). 

 3. Matthew Wise, M.D. 

On June 11, 2012, the date of his first appointment with Plaintiff, treating 

physician Dr. Wise completed a Multiple Impairment Questionnaire. (Tr. 319-26.) He 

identified his diagnoses as COPD and chronic anxiety. (Tr. 319.) He stated that his 

diagnoses were supported by testing that showed moderate COPD in 2010 and Plaintiff’s 

complaints of shortness of breath with ambulation. (Tr. 319-20.) He identified Plaintiff’s 

primary symptoms as shortness of breath and “severe anxiety with agoraphobia.” 

(Tr. 320.) Dr. Wise did not complete the portions of the questionnaire regarding 

Plaintiff’s physical functional limitations. (Tr. 322-23.) Additionally, he did not indicate 

how often Plaintiff’s symptoms would interfere with attention and concentration. 

(Tr. 324.) However, he noted Plaintiff’s anxiety would worsen if she were placed in a 

competitive work environment (Tr. 323), and that “emotional factors contribut[ed] to the 

severity of [Plaintifff’s] symptoms and functional limitations.” (Tr. 324.) He explained 

that due to her “severe anxiety,” Plaintiff’s “family ha[d] to convince her to go to 

app[ointmen]ts or even shopping and [had] to accompany her or she [would not] go.” 

(Id.) Dr. Wise opined that Plaintiff was “incapable of even low stress” in a work 

environment due to her anxiety. (Id.) 

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 One month later, on July 12, 2012, Dr. Wise completed a 

Psychiatric/Psychological Impairment Questionnaire. (Tr. 343-50.) Dr. Wise identified 

Plaintiff’s diagnoses as anxiety disorder, COPD, and back pain. (Tr. 343.) He identified 

her primary symptoms as anxiety and difficulty breathing. (Tr. 345.) To support the 

limitations identified on the questionnaire, Dr. Wise cited Plaintiff’s appetite disturbance 

with weight change, recurrent panic attacks, difficulty thinking or concentrating, social 

withdrawal or isolation, decreased energy, persistent irrational fears, and generalized 

persistent anxiety. (Tr. 344.) He opined that Plaintiff was “markedly limited” in her 

abilities to work in coordination with others without being distracted by them, complete a 

normal workweek without interruption from psychologically based symptoms, perform at 

a consistent pace, to interact appropriately with the public, to get along with co-workers 

without distracting them or exhibiting behavioral extremes, and to travel to unfamiliar 

places or use public transportation. (Tr. 345-48.) He explained that Plaintiff had severe 

anxiety when meeting new people and did not go to the store without a family member. 

(Tr. 348.) He concluded that Plaintiff could not tolerate a “low stress” work environment 

and that she would likely miss more than three workdays a month due to her 

impairments. (Tr. 349-50.) 

 On September 20, 2012, Dr. Wise wrote a letter “to whom it may concern” 

summarizing his treatment of Plaintiff. (Tr. 455-56.) He stated that he had treated 

Plaintiff for COPD and “severe anxiety” since June 2012. (Id.) He stated that Plaintiff’s 

anxiety “is such that she has agoraphobia and does not go to public places including 

stores.” (Tr. 455.) He noted that Plaintiff’s agoraphobia had interfered with her medical 

care in that she would not attend an appointment for a colonoscopy due to anxiety. (Id.) 

 Dr. Wise also stated that COPD further limited Plaintiff’s activities. (Id.) 

Dr. Wise noted that the damage to Plaintiff’s lungs was “not reversible” and that 

medications could “help to improve some of the reactive airway component.” (Id.) He 

stated that Plaintiff’s anxiety was exacerbated by the shortness of breath related to her 

COPD, and opined that she would continue to require counseling and medication. (Id.) 

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He concluded that, due to those impairments, Plaintiff would be “unable to work” for 

longer than twelve months. (Id.) 

 4. Shannon Tromp, Ph.D. 

 On recommendation from her attorney (Doc. 18 at 8, Tr. 365), on September 17, 

2012, Plaintiff was examined by Dr. Tromp for her claim for mental impairments. 

(Tr. 365-71.) Dr. Tromp examined Plaintiff and reviewed the medical record related to 

Plaintiff’s mental impairments. (Tr. 365.) Dr. Tromp noted that Plaintiff’s sister took her 

to the appointment, but that Plaintiff “presented for the exam[ination] alone.” (Tr. 366.) 

 Plaintiff reported that she had experienced panic attacks most of her life, which 

had gotten particularly “out of control” over the preceding seven years. (Tr. 366.) 

Plaintiff reported that she rarely left her home except when her sister or daughter took her 

to her doctors’ appointments about twice a month. (Tr. 366-67.) She reported that, since 

a car accident, she was afraid to drive. (Tr. 366.) Plaintiff reported that the three-hour 

drive to the exam caused her a great deal of panic symptoms. (Tr. 369.) She reported 

that her sleep was interrupted and limited, and her energy was low. (Id.) Plaintiff stated 

that she had not seen a psychiatrist or a counselor because it “would make [her] panic.” 

(Tr. 367.) 

 Dr. Tromp observed that Plaintiff was teary-eyed on initial presentation and 

appeared “mildly anxious” during the examination. (Tr. 369.) On examination, 

Dr. Tromp found that Plaintiff had good eye contact, was “friendly and laughed a lot”, 

her thoughts were “logical and goal directed,” her comprehension was “good,” her mood 

was “a little panicky, a little nervous but comfortable?” her affect was “appropriate and 

cheerful,” her memory was “adequate,” she had “good” concentration, and a “good” fund 

of information. (Tr. 368.) Dr. Tromp diagnosed panic disorder with agoraphobia and 

social anxiety disorder. (Id.) 

 On September 17, 2012, Dr. Tromp completed a Psychiatric/Psychological 

Impairment Questionnaire based on her examination of Plaintiff and her review of 

Plaintiff’s records. (Tr. 437-44.) She opined that Plaintiff was markedly limited in her 

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abilities to maintain attention and concentration for extended periods, to perform 

activities within a schedule and maintain regular attendance, to work with others without 

being distracted by them, to complete a normal workweek, to perform at a consistent pace 

without unreasonably long rest periods, to interact with the public, to accept instructions 

and respond appropriately to criticism from supervisors, to get along with coworkers or 

peers, and to travel to unfamiliar places or use public transportation. (Tr. 440-42.) She 

added that Plaintiff could not tolerate “even [a] low stress” work environment due to her 

intolerance of exposure to conflict and because leaving home and going places caused 

panic attacks. (Tr. 443.) She opined that Plaintiff would likely miss more than three 

workdays a month. (Tr. 443-44.) 

III. Administrative Hearing Testimony

 Plaintiff was in her early fifties at the time of the administrative hearing. (Tr.162.) 

Plaintiff had a high school education. (Tr. 43.) Her past relevant work included waitress, 

hostess, and snack-shop supervisor. (Tr. 43-44.) Plaintiff testified that she lived in a 

room she rented at a friend’s house. (Tr. 41.) 

 Plaintiff testified that she smoked up to fifty cigarettes a day for about thirty years, 

but had recently cut back to one cigarette a day and was trying to stop smoking. (Tr. 45.) 

Plaintiff testified that she stopped working in 2002 because “it got too hard for [her] to 

drive to get to work” (Tr. 44), and later testified that she quit because it was hard for her 

to carry dishes because of her breathing. (Tr. 45.) She also testified that she had not 

worked since 2002 because it was hard for her to leave home. (Tr. 44.) Plaintiff 

explained that she waited until 2010 to file for disability insurance benefits because she 

“was really scared” of “going out of the house to do the paperwork and stuff.” (Tr. 61.) 

Plaintiff testified that she had not driven since 2002, and that she was scared to drive after 

having been in car accidents in 1998 and 2002. (Tr. 42-43.) She relied on her sister to 

drive her places. (Id.) 

 Plaintiff testified that she experienced panic attacks that made her shake and cry 

two to three times a month, and which were generally triggered by having to leave the 

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house or “have a test done.” (Tr. 50.) Plaintiff stated that, during an anxiety attack, she 

got shaky, cried, felt like her “heart[] [was coming] out of [her] chest,” and could not 

breathe. (Tr. 47.) Plaintiff further testified that she could not focus or concentrate during 

a panic attack, and she usually relied on her sister to “talk [her] out of” an attack. 

(Tr. 49.) Plaintiff claimed she had panic attacks when she went somewhere in a car, and 

stated that she had a panic attack the morning of the administrative hearing. (Tr. 48-49.) 

She testified that she had “talked [her]self out of doctors’ appointments because of [her] 

anxiety.” (Tr. 48.) Plaintiff stated that her doctor was trying to adjust her medications to 

“find one that work[ed]” for her. (Id.) To prevent panic attacks, Plaintiff avoided leaving 

home. (Tr. 49.) The ALJ noted that Plaintiff was shaking and she stated that it was 

because she felt nervous. (Id.) 

 When testifying about her COPD, Plaintiff stated that her doctors advised that her 

lungs were damaged from years of smoking, but that quitting would help her symptoms. 

(Tr. 50.) Plaintiff testified that she had cut back to one cigarette a day for about one 

month, but she still had difficulty carrying things, such as taking her laundry basket from 

her bedroom to the washing machine, vacuuming, or moping. (Tr. 50-51.) She testified 

that she could mop for about half an hour but then had to sit down and use her inhaler to 

recover her breathing before she finished the job. (Tr. 51.) Plaintiff also testified that 

walking without carrying anything made her short of breath. (Id.) She stated that she did 

not have problems breathing if she was standing still. (Id.) 

 Administrative expert Sandra Richter also testified at the administrative hearing. 

(Tr. 52-59.) She identified Plaintiff’s past relevant work as (1) counter supervisor, 

classified under the Dictionary of Occupational Titles (DOT) as an exertionally light, 

skilled job (DOT 311.137-010), (2) hostess, a light, semi-skilled job (DOT 352.667-010), 

and (3) waitress, a light, semi-skilled job (DOT 311.477-030). (Tr. 52.) 

 In response to the ALJ’s questions, the vocational expert testified that an 

individual who was limited to unskilled light work would be unable to perform any of 

Plaintiff’s past relevant work. (Tr. 53.) However, the vocational expert testified that an 

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individual limited to unskilled light work, and who was also precluded from all 

interaction with the public and exposure to any respiratory irritants, could perform light, 

unskilled work as a mail clerk who sorted mail, a packager, and a bottle packager. 

(Tr. 53-54.) 

 The vocational expert further testified that an individual with marked limitations 

in the ability to work with or in proximity to others, to complete a normal workweek, and 

to perform at a consistent pace without unreasonably long rest periods, would be unable 

to perform any competitive work activity. (Tr. 57-58.) She also testified that an 

individual with marked limitations in the ability to maintain attention and concentration 

for extended periods, to maintain a schedule, and to be reasonably punctual, would be 

unable to sustain any work activity. (Tr. 58-59.) 

IV. The ALJ’s Decision

 A claimant is considered disabled under the Social Security Act if she is unable 

“to engage in any substantial gainful activity by reason of any medically determinable 

physical or mental impairment which can be expected to result in death or which has 

lasted or can be expected to last for a continuous period of not less than 12 months.” 42 

U.S.C. § 423(d)(1)(A); see also 42 U.S.C. § 1382c(a)(3)(A) (nearly identical standard for 

supplemental security income disability insurance benefits). To determine whether a 

claimant is disabled, the ALJ uses a five-step sequential evaluation process. See 20 

C.F.R. §§ 404.1520, 416.920. 

A. The Five Step Sequential Evaluation Process 

 In the first two steps, a claimant seeking disability benefits must initially 

demonstrate (1) that she is not presently engaged in a substantial gainful activity, and 

(2) that her disability is severe. 20 C.F.R. § 404.1520(a)(4)(i) and (ii). If a claimant 

meets steps one and two, there are two ways in which she may be found disabled at steps 

three through five. At step three, she may prove that her impairment or combination of 

impairments meets or equals an impairment in the Listing of Impairments found in 

Appendix 1 to Subpart P of 20 C.F.R. Part 404. 20 C.F.R. § 404.1520(a)(4)(iii). If so, the 

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claimant is presumptively disabled. If not, the ALJ determines the claimant’s residual 

functional capacity (RFC). At step four, the ALJ determines whether a claimant’s RFC 

precludes her from performing her past work. 20 C.F.R. § 404.1520(a)(4)(iv). If the 

claimant establishes this prima facie case, the burden shifts to the government at step five 

to establish that the claimant can perform other jobs that exist in significant number in the 

national economy, considering the claimant’s RFC, age, work experience, and education. 

20 C.F.R. § 404.1520(a)(4)(v). If the government does not meet this burden, then the 

claimant is considered disabled within the meaning of the Act. 

B. The ALJ’s Application of the Five Step Evaluation Process 

 Applying the five-step sequential evaluation process, the ALJ found that Plaintiff 

had not engaged in substantial gainful activity during the relevant period. (Tr. 23.) At 

step two, the ALJ found that Plaintiff had the following severe impairments: “shortness 

of breath, Chronic Obstructive Pulmonary Disease (COPD), emphysema, tobacco abuse; 

and an anxiety disorder with panic attacks (20 C.F.R. § 416.920(c)).” (Id.) At the third 

step, the ALJ found that the severity of Plaintiff’s impairments did not meet or medically 

equal the criteria of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. 

(Id.) The ALJ next concluded that Plaintiff retained “the residual functional capacity to 

perform light work with restrictions as light work is defined in 20 C.F.R. § 416.967(b).” 

(Tr. 25.) The ALJ found that Plaintiff was limited to unskilled work and work with no 

requirement for interaction with the public. (Id.) He further found that Plaintiff should 

avoid exposure to extreme temperatures, humidity, dust, gases, or fumes. (Id.) 

 At step four, the ALJ concluded that Plaintiff could not perform her past relevant 

work. (Tr. 28.) At step five, the ALJ found that considering Plaintiff’s age, education, 

work experience, and RFC, she could perform other “jobs that exist in significant 

numbers in the national economy.” (Tr. 28-29.) The ALJ concluded that Plaintiff had 

not been under a disability within the meaning of the Act since November 4, 2010 

through the date of the decision. (Tr. 29.) 

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V. Standard of Review 

 The district court has the “power to enter, upon the pleadings and transcript of 

record, a judgment affirming, modifying, or reversing the decision of the Commissioner, 

with or without remanding the cause for a rehearing.” 42 U.S.C. § 405(g). The district 

court reviews the Commissioner’s final decision under the substantial evidence standard 

and must affirm the Commissioner’s decision if it is supported by substantial evidence 

and it is free from legal error. Smolen v. Chater, 80 F.3d 1273, 1279 (9th Cir. 1996); 

Ryan v. Comm’r of Soc. Sec. Admin., 528 F.3d 1194, 1198 (9th Cir. 2008). Even if the 

ALJ erred, however, “[a] decision of the ALJ will not be reversed for errors that are 

harmless.” Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005). 

 Substantial evidence means more than a mere scintilla, but less than a 

preponderance; it is “such relevant evidence as a reasonable mind might accept as 

adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971) 

(citations omitted); see also Webb v Barnhart, 433 F.3d 683, 686 (9th Cir. 2005). In 

determining whether substantial evidence supports a decision, the court considers the 

record as a whole and “may not affirm simply by isolating a specific quantum of 

supporting evidence.” Orn v. Astrue, 495 F.3d 625, 630 (9th Cir. 2007) (internal 

quotation and citation omitted). The ALJ is responsible for resolving conflicts in 

testimony, determining credibility, and resolving ambiguities. See Andrews v. Shalala, 

53 F.3d 1035, 1039 (9th Cir. 1995). “When the evidence before the ALJ is subject to 

more than one rational interpretation, [the court] must defer to the ALJ’s conclusion.” 

Batson v. Comm’r of Soc. Sec. Admin., 359 F.3d 1190, 1198 (9th Cir. 2004) (citing 

Andrews, 53 F.3d at 1041). 

VI. Plaintiff’s Claims 

 Plaintiff asserts that the ALJ erred in assigning little weight to the opinions of 

treating physician Dr. Wise and examining physician Dr. Tromp. (Doc. 18 at 11.) 

Plaintiff also argues that ALJ erred by finding her subjective complaints not credible. 

(Id. at 15.) In response, the Commissioner argues that the ALJ’s decision is free from 

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legal error and is supported by substantial evidence in the record. (Doc. 19.) Plaintiff 

has not filed a reply in opposition to the Commissioner’s response and the deadline to do 

so has passed. (See Doc. 11.) 

A. Assessing a Claimant’s Credibility 

 Plaintiff asserts that the ALJ erred by discrediting her symptom testimony. 

(Doc. 18 at 15.) An ALJ engages in a two-step analysis to determine whether a 

claimant’s testimony regarding subjective pain or symptoms is credible. Garrison v. 

Colvin, 759 F.3d 995, 1014 (9th Cir. 2014) (citing Lingenfelter v. Astrue, 504 F.3d 1028, 

1035-36 (9th Cir. 2007)). 

 “First, the ALJ must determine whether the claimant has presented objective 

medical evidence of an underlying impairment ‘which could reasonably be expected to 

produce the pain or other symptoms alleged.’” Lingenfelter, 504 F.3d at 1036 (quoting 

Bunnell v. Sullivan, 947 F.2d 341, 344 (9th Cir. 1991) (en banc)). The claimant is not 

required to show objective medical evidence of the pain itself or of a causal relationship 

between the impairment and the symptom. Smolen, 80 F.3d at 1282. Instead, the 

claimant must only show that an objectively verifiable impairment “could reasonably be 

expected” to produce his pain. Lingenfelter, 504 F.3d at 1036 (quoting Smolen, 80 F.3d 

at 1282); see also Carmickle v. Comm’r of Soc. Sec., 533 F.3d at 1160B61 (9th Cir. 2008) 

(“requiring that the medical impairment ‘could reasonably be expected to produce’ pain 

or another symptom . . . requires only that the causal relationship be a reasonable 

inference, not a medically proven phenomenon”). 

 Second, if a claimant shows that she suffers from an underlying medical 

impairment that could reasonably be expected to produce her pain or other symptoms, the 

ALJ must “evaluate the intensity and persistence of [the] symptoms” to determine how 

the symptoms, including pain, limit the claimant’s ability to work. See 20 

C.F.R. § 404.1529(c)(1). In making this evaluation, the ALJ may consider the objective 

medical evidence, the claimant’s daily activities, the location, duration, frequency, and 

intensity of the claimant’s pain or other symptoms, precipitating and aggravating factors, 

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medication taken, and treatments for relief of pain or other symptoms. See 20 

C.F.R. § 404.1529(c); Bunnell, 947 F.2d at 346. 

 At this second evaluative step, the ALJ may reject a claimant’s testimony 

regarding the severity of her symptoms only if the ALJ “makes a finding of malingering 

based on affirmative evidence,” Lingenfelter, 504 F.3d at 1036 (quoting Robbins v. Soc. 

Sec. Admin., 466 F.3d 880, 883 (9th Cir. 2006)), or if the ALJ offers “clear and 

convincing reasons” for finding the claimant not credible.5

 Carmickle, 533 F.3d at 1160 

(quoting Lingenfelter, 504 F.3d at 1036). “‘The clear and convincing standard is the 

most demanding required in Social Security Cases.’” Garrison, 759 F.3d at 1015 

(quoting Moore v. Soc. Sec. Admin., 278 F.3d 920, 924 (9th Cir. 2002)). Because there 

was no record evidence of malingering, the ALJ was required to provide clear and 

convincing reasons for concluding that Plaintiff’s subjective complaints were not wholly 

credible. Plaintiff argues that the ALJ failed to do so. 

 1. Reasons for Discrediting Plaintiff’s Symptom Testimony 

 a. The Objective Medical Evidence 

 The ALJ discounted Plaintiff’s allegations about the severity of her symptoms and 

limitations as unsupported by the objective medical record. (Tr. 24-25.) The record 

supports the ALJ’s determination. For example, as the ALJ noted, spirometry testing in 

October 2010 showed “moderate COPD.” (Tr. 27, 271, 288, 339, 408.) The ALJ also 

found that the evidence of Plaintiff’s anxiety and related symptoms was based on 

Plaintiff’s self-reporting, not objective testing. (See Section II.A.) However, the absence 

of fully corroborative medical evidence cannot form the sole basis for rejecting the 

credibility of a claimant’s subjective complaints. See Cotton v. Bowen, 799 F.2d 1403, 

1407 (9th Cir. 1986) (it is legal error for “an ALJ to discredit excess pain testimony 

solely on the ground that it is not fully corroborated by objective medical findings”),

superseded by statute on other grounds as stated in Bunnell v. Sullivan, 912 F.2d 1149 

 

5

 The Ninth Circuit has rejected the Commissioner’s suggestion (Doc. 19 at 11) that a lesser standard than “clear and convincing” should apply. Garrison, 759 F.3d at 

1015 n.18. 

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(9th Cir. 1990); see also Burch, 400 F.3d at 681 (explaining that the “lack of medical 

evidence” can be “a factor” in rejecting credibility, but cannot “form the sole basis”); 

Rollins v. Massanari, 261 F.3d 853, 856-57 (9th Cir. 2001) (same). Thus, absent some 

other stated legally sufficient reason for discrediting Plaintiff, the ALJ’s credibility 

determination cannot stand. However, as discussed below, the ALJ provided additional 

legally sufficient reasons for discounting Plaintiff’s symptom testimony. 

 b. Lack of Full Cooperation 

 The ALJ found that Plaintiff did not fully cooperate with spirometry testing during 

a January 2011 appointment with state agency examining physician Dr. Breicheisen. 

(Tr. 27.) The record supports that finding. (Tr. 302 (noting that Plaintiff did “gave 

inadequate effort” during a pulmonary function test).) The ALJ properly considered 

Plaintiff’s lack of full effort during testing with state agency physician Dr. Brecheisen to 

support his adverse credibility determination. See Thomas v. Barnhart, 278 F.3d 947, 

959 (9th Cir. 2002) (an ALJ may rely on lack of cooperation or poor effort during 

examinations to discount a claimant’s credibility); Tonapetyan v. Halter, 242 F.3d 1144, 

1148 (9th Cir. 2001) (the ALJ did not err in discrediting the claimant’s symptom 

testimony based on her lack of cooperation during consultative examination in support of 

his adverse credibility determination). Plaintiff’s failure to participate fully in testing 

conducted by a state agency physician is a clear and convincing reason for discounting 

her credibility that is supported by substantial evidence in the record. 

 c. Improvement in Symptoms 

 The ALJ also discounted Plaintiff’s symptom testimony because treatment notes 

showed that Plaintiff’s respiratory condition improved with reduced smoking. (Tr. 27.) 

In assessing a claimant’s credibility about her symptoms, the ALJ may consider “the 

type, dosage, effectiveness, and side effects of any medication,” and treatment other than 

medication, that the claimant has received for relief of pain or other symptoms. 20 

C.F.R. § 404.1529(c)(3)(iv) and (v). Evidence that treatment can effectively control a 

claimant’s symptoms may be a clear and convincing reason to find a claimant less 

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credible. See Warre v. Comm’r of Soc. Sec. Admin., 439 F.3d 1001, 1006 (9th Cir. 2006) 

(stating that “[i]mpairments that can be controlled effectively with medication are not 

disabling for purposes of determining eligibility for SSI benefits.”). 

 As the ALJ noted (Tr. 27), the record reflects that Plaintiff’s COPD symptoms 

improved with treatment and with reduced smoking. (Tr. 335 (noting “significant 

improvement on advair/atrovent,” “down to 2 cig/day,” and noting that Plaintiff had 

made “enormous strides in weaning herself” from cigarettes and had “significant 

improvement” in cardio-pulmonary functioning).) Accordingly, the improvement of 

Plaintiff’s symptoms with reduced smoking was a clear and convincing reason for 

discounting her credibility that is supported by substantial evidence in the record. 

 d. Conservative Treatment 

 The ALJ also discounted Plaintiff’s testimony because he found that she had 

“moderate COPD” for which she received conservative treatment, noting that she was not 

hospitalized for COPD symptoms. (Tr. 27.) An ALJ may rely on a claimant’s 

conservative course of treatment to reject her complaints of disabling limitations or pain. 

See Fair v. Bowen, 885 F.2d 597, 604 (9th Cir. 1989); Johnson v. Shalala, 60 F.3d 1428, 

1434 (9th Cir. 1995) (the claimant’s course of conservative treatment for a back injury 

was a clear and convincing reason for disregarding testimony that the claimant was 

disabled). 

 The record reflects that Plaintiff complained of shortness of breath with activity, 

and stated that she did not have any problems if she was standing still. (Tr. 51, 262, 271.) 

Treatment notes described Plaintiff’s COPD as “moderate.”6

 (Tr. 271, 288, 339, 408.) 

Because the medical record described Plaintiff’s COPD as moderate, the ALJ did not err 

by characterizing Plaintiff’s COPD as moderate. 

 

6

 The grading system for COPD defines “moderate” as the second of four grades of severity. See http://copd.about.com/od/copdbasics/a/stagesofcopd.htm; see also http://copd.about.com/od/copdtreatment/a/Treatment-For-Moderate-Copd.htm (“If you’ve reached Stage II, you are probably just noticing your symptoms – primarily shortness of breath that worsens with activity.”) (Last visited 2/17/2015.) 

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 Additionally, the ALJ’s characterization of Plaintiff’s treatment as conservative is 

supported by substantial evidence in the record. Between 2010 and 2012, Plaintiff 

received regular treatment for COPD-related breathing difficulties. (Section II.A.1 and 

A.2.) That treatment typically resulted in a prescription of inhalers, recommendations 

that Plaintiff stay hydrated and use a humidifier, and that she quit smoking. (Tr. 258, 

263, 271, 360, 363, 358, 399, 402-03, 449.) See Hayes v. Colvin, 2014 WL 7405647, at 

*3 (D. Or. Dec. 30, 2014) (concluding that ALJ properly characterized as conservative 

the claimant’s treatment for COPD, which included prescription anti-inflammatory 

medication, pain medication, aerosol inhalers, and a recommendation to quit smoking). 

The record also reflects that Plaintiff was not hospitalized for COPD. As Plaintiff points 

out, she visited Urgent Care in March 2012. (Doc. 18 at 14.) However, the primary 

diagnosis on that visit was bronchitis for which treatment providers prescribed antibiotics 

and an over-the-counter pain reliever and advised Plaintiff to rest and drink fluids. 

(Tr. 318.) Accordingly, the conservative nature of Plaintiff’s treatment for moderate 

COPD was a clear and convincing reason for discounting her credibility that is supported 

by substantial evidence in the record. 

 e. Lack of Treatment with a Specialist 

 To support his adverse credibility determination, the ALJ also noted that there was 

no evidence of treatment with a mental health professional. (Tr. 27.) The Commissioner 

argues that this was a legally sufficient reason for discounting Plaintiff’s credibility that 

is supported by the record (Tr. 19 at 11), and Plaintiff has not replied in opposition to that 

assertion. 

 Plaintiff contends that the ALJ erroneously discounted her credibility based on her 

failure to seek treatment from a specialist. (Doc. 18 at 19.) In Regennitter v. Comm’r of 

Soc. Sec. Admin., 166 F.3d 1294, 1299-1300 (9th Cir. 1999), the Ninth Circuit “criticized 

the use of a lack of treatment to reject mental complaints” and again noted that “‘it is a 

questionable practice to chastise one with a mental impairment for the exercise of poor 

judgment in seeking rehabilitation.’” Id. (quoting Blankenship v. Bowen, 874 F.2d 1116, 

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1124 (9th Cir. 1989)). In Regennitter and similar cases, however, the plaintiff failed to 

seek any mental health treatment at all. See Regennitter, 166 F.3d at 1299-1300 

(concluding that the ALJ improperly discounted an examining physician’s opinion based 

on the plaintiff’s “failure, because of his poverty, to seek treatment by any mental 

professional”) (internal quotation marks omitted)); Nguyen v. Chater, 100 F.3d 1462, 

1465 (9th Cir. 1996) (“the fact that claimant may be one of millions of people who did 

not seek treatment for a mental disorder until late in the day is not a substantial basis on 

which to conclude that [the physician’s] assessment of claimant’s condition is 

inaccurate”). 

 Here, by contrast, Plaintiff recognized that she needed help, and sought and 

received mental-health treatment from primary care physician Dr. Wise. (Tr. 354-59, 

363, 449.) However, she failed to comply with his advice that she obtain counseling. 

There is also no indication that Plaintiff followed NP Collins’s 2010 referral to a “mental 

health facility” for her mental health issues. (Tr. 263.) Plaintiff’s failure to follow 

treatment advice and to seek counseling or treatment from a mental health care provider 

is a clear and convincing reason for discounting her symptom testimony. See Minter v. 

Comm’r Soc. Sec., 2012 WL 1866608, at *5 (D. Or. May 22, 2012) (when the claimant 

recognized that she needed help and sought out counseling, her failure to follow through 

with that treatment was a clear and convincing reason for the ALJ to discredit her 

symptom testimony). 

 Plaintiff contends that she did not seek treatment from a mental health professional 

“due to fear of leaving the house [and] trusting another medical provider.” (Doc. 18 at 19 

(citing Tr. 367).) However, the record reflects that Plaintiff left the house to attend 

regular appoints with treating providers NP Rollins and Dr. Wise and that she attended 

one-time examinations with Dr. Rose, Dr. Breicheisen, and Dr. Tromp. (Sections II.A 

and II.B.) Additionally, as the ALJ noted (Tr. 28), Plaintiff and her sister completed 

function reports indicating that Plaintiff went outside twice a week (Tr. 220), and left the 

house up to once or twice a month to shop for “personal care” items, groceries, or 

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clothing. (Tr. 220, 235.) The function reports also indicate that Plaintiff regularly went 

to Walmart and to doctors’ appointments. (Tr. 236.) Accordingly, Plaintiff’s failure to 

seek treatment from a mental health professional was a clear and convincing reason for 

discounting her credibility that is supported by substantial evidence in the record. 

 f. Plaintiff’s Daily Activities 

 The ALJ also discounted Plaintiff’s symptom testimony based on “the extensive 

activities she engaged in.” (Tr. 28.) Plaintiff asserts that this was not a clear and 

convincing reason for discrediting her symptom testimony. (Doc. 18 at 19-21.) 

 The Ninth Circuit has stated that a claimant engaging in normal daily activities 

“does not in any way detract from [his] credibility as to [his] overall disability.” Vertigan 

v. Halter, 260 F.3d 1044, 1050 (9th Cir. 2001). As the Ninth Circuit has explained, 

“[o]ne does not need to be ‘utterly incapacitated’ in order to be disabled.” Id. (quoting 

Fair v. Bowen, 885 F.2d 597, 603 (9th Cir. 1989). Rather, the daily activities must 

involve skills that could be transferrable to a workplace and a claimant must spend a 

“substantial part of [her] day” engaged in those activities. See Orn v. Astrue, 495 F.3d 

625, 639 (9th Cir. 2007) (finding that the ALJ erred in failing to “meet the threshold for 

transferable work skills, the second ground for using daily activities in credibility 

determinations.”). Considering this standard and the record in this case, the ALJ erred in 

relying on Plaintiff’s ability to participate in typical daily activities to discredit her 

symptom testimony. However, any error in relying on this reason to support the ALJ’s 

credibility determination is harmless because he gave other legally sufficient reasons for 

discounting her subjective complaints. See Batson v. Comm’r of Soc. Sec. Admin., 359 

F.3d 1190, 1195-97 (9th Cir. 2004) (applying harmless error standard where one of the 

ALJ’s several reasons supporting an adverse credibility finding was held invalid). 

 In summary, although the Court does not accept all of the ALJ’s reasons in 

support of his adverse credibility determination, the ALJ provided sufficient legally 

sufficient reasons that are supported by substantial evidence in support of his credibility 

determination and, therefore, the Court affirms that determination. See Batson, 359 F.3d 

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at 1197 (stating that the court may affirm an ALJ’s overall credibility conclusion even 

when not all of the ALJ’s reasons are upheld); Tonapetyan, 242 F.3d at 1148 (stating that 

“[e]ven if we discount some of the ALJ’s observations of [the claimant’s] inconsistent 

statements and behavior . . . we are still left with substantial evidence to support the 

ALJ’s credibility determination.”). 

B. Weight Assigned Medical Opinion Evidence 

 Plaintiff also argues that the ALJ erred in his assessment of the medical source 

opinion evidence. In weighing medical source evidence, the Ninth Circuit distinguishes 

between three types of physicians: (1) treating physicians, who treat the claimant; 

(2) examining physicians, who examine but do not treat the claimant; and (3) nonexamining physicians, who neither treat nor examine the claimant. Lester v. Chater, 81 

F.3d 821, 830 (9th Cir. 1995). Generally, more weight is given to a treating physician’s 

opinion. Id. The ALJ must provide clear and convincing reasons supported by 

substantial evidence for rejecting a treating or an examining physician’s uncontradicted 

opinion. Id.; Reddick v. Chater, 157 F.3d 715, 725 (9th Cir. 1998). An ALJ may reject 

the controverted opinion of a treating or an examining physician by providing specific 

and legitimate reasons that are supported by substantial evidence in the record. Bayliss v. 

Barnhart, 427 F.3d 1211, 1216 (9th Cir. 2005); Reddick, 157 F.3d at 725. The Court 

considers Plaintiff’s claims regarding the weight the ALJ assigned to the medical source 

opinions in light of these standards. 

 1. Dr. Wise’s Opinions 

 As discussed in Section II.B.3, Dr. Wise opined that, due to COPD and chronic 

severe anxiety, Plaintiff was unable to work and he expected her disability to last longer 

than twelve months.7

 (Tr. 27, 455.) The ALJ gave Dr. Wise’s opinion little weight 

because his conclusions were inconsistent with the medical record. (Tr. 27.) 

 

7

 Dr. Wise did not assess any specific physical functional limitations and whether a claimant is able to work is an issue reserved to the Commissioner. 20 C.F.R. § 

416.927(d). A treating source’s opinion on issues reserved to the Commissioner is never 

entitled to controlling weight or given special significance. SSR 96-5p, 1996 WL 374183, at *2. 

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“[C]ontrolling weight may not be given to a treating source’s medical opinion unless the 

opinion is well-supported by medically acceptable clinical and laboratory diagnostic 

techniques.” SSR 96–2p, 1996 WL 374188, *1; see also Bray v. Comm’r of Soc. Sec. 

Admin., 554 F.3d 1219, 1138 (9th Cir. 2009) (“the ALJ need not accept the opinion of 

any physician, including a treating physician, if that opinion is brief, conclusory, and 

inadequately supported by clinical finding”). 

 The record supports the ALJ’s determination that Dr. Wise’s opinion that Plaintiff 

was unable to work due to COPD was inconsistent with the medical record. The record 

reflects that Plaintiff had “moderate COPD” and that she reported shortness of breath 

only on exertion. (Tr. 51, 262, 271, 288, 339, 408.) Additionally, on examination, 

Plaintiff often had “clear breath sounds,” (Tr. 362), non-labored breathing (Tr. 358), “no 

rales, rhonci, or wheezes” (Tr. 262, 272, 398, 362, 358), and was found to be in no acute 

distress. (Tr. 262, 272, 398, 362, 359, 358, 355, 448.) 

 The ALJ also noted that the medical records reflected that Plaintiff’s symptoms of 

COPD improved with reduced cigarette intake, and that she did not have “significant 

exacerbations or hospitalization” for her COPD. (Tr. 27 (citing Admin. Hrg. Exs. 1F at 

2-17, 15F at 2-11, 20F).) The record supports the ALJ’s conclusion that Plaintiff’s 

COPD symptoms improved with reduced smoking (Tr. 398-99) and that, although she 

went to Urgent Care for bronchitis, she was not hospitalized for COPD. (Tr. 318.) 

 The ALJ also gave little weight to Dr. Wise’s opinion of Plaintiff’s functional 

limitations related to her mental health and to his opinion that Plaintiff was incapable of 

performing even a low stress job. The ALJ found these opinions inconsistent with the 

medical record. (Tr. 27, 324.) The record supports the ALJ’s conclusion. Dr. Wise saw 

Plaintiff in June, July, August, and September 2012. (Tr. 361-63, 359-60, 357-58, 354-

44, 446-49.) However, the mental health status examinations during those visits did not 

show mental health abnormalities. (Tr. 26, 359 (“pleasant, comfortable, OX3, alert”); 

Tr. 358 (“pleasant, comfortable, OX3, alert”); Tr. 355 (“pleasant, comfortable, OX3, 

alert”; “good eye contact, normal insight, no thought disturbances noted, slightly anxious 

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appearing”). Treatment notes also indicate that Plaintiff had “normal insight and no 

thought disturbances.” (Tr. 355.) Thus, as the ALJ found, Dr. Wise’s treatment notes 

were inconsistent with his opinions of her mental functional abilities. 

 Dr. Wise’s opinion was also inconsistent with the opinion of examining physician 

Dr. Rose, who performed a psychological evaluation of Plaintiff in January 2011. 

(Tr. 26, 296-300.) Plaintiff reported daily anxiety and worry about daily stressors and 

symptoms of nausea, mild shaking, shortness of breath, a racing heart, and nervousness. 

(Tr. 297-98.) At that time, Plaintiff did not have a history of mental health problems or 

treatment, other than one visit with a counselor during her divorce thirteen years earlier. 

(Tr. 297.) Dr. Rose conducted a mental status examination and concluded that Plaintiff 

had mild intellectual deficits, but overall appeared to be within normal limits. (Tr. 296.) 

Dr. Rose diagnosed anxiety disorder and possible mild intellectual deficits and concluded 

that Plaintiff did not have any “significant psychiatric barriers to employment.” 

(Tr. 300.) Based on this record evidence, the ALJ did not err in assigning little weight to 

Dr. Wise’s opinions regarding Plaintiff’s physical and mental functional limitations as 

inconsistent with the record. 

 2. Dr. Tromp’s Opinions 

 On September 18, 2012, Plaintiff underwent a psychological evaluation with 

Dr. Tromp. (Tr. 26, 365-70.) Plaintiff said she experienced anxiety and panic attacks, 

and that she was a hermit because she did not like to leave her house. (Tr. 366.) During 

a mental status examination, Plaintiff’s mood was “a little panicky, a little nervous but 

comfortable,” and she laughed. (Tr. 26, 368.) Dr. Tromp did not identify any other 

abnormalities. (Tr. 26, 368-69.) On mental status testing, Plaintiff scored 23/30, which 

Dr. Tromp said “suggest[ed] impaired cognition, although much of this may be functional 

(due to anxiety).” (Tr. 369.) Dr. Tromp opined that Plaintiff would have considerable 

difficulty with detailed or complex tasks. (Tr. 370.) Dr. Tromp noted that “[b]ased on 

her self-report and the report of Dr. Wise, it appears that she avoids social 

interaction . . . .” (Tr. 370.) 

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 Dr. Tromp opined that Plaintiff had moderate impairment in the ability to 

remember locations and work-like procedures, understand and remember detailed 

instructions, and carry out detailed instructions. (Tr. 27, 440.) She found marked 

limitations in Plaintiff’s ability to maintain attention and concentration for extended 

periods away from home, perform activities within a schedule, maintain regular 

attendance, and be punctual within customary tolerance, and work in coordination with or 

proximity to others without being distracted by them. (Tr. 27, 440-41.) Dr. Tromp 

opined that Plaintiff was incapable of even low stress work and would likely miss more 

than three days of work per month due to her impairments or treatment. (Tr. 433-44.) 

 The ALJ gave little weight to Dr. Tromp’s opinion regarding Plaintiff’s anxiety 

because it was inconsistent with the record. (Tr. 27.) Inconsistency with the record is a 

specific and legitimate reason for discounting examining physician Dr. Tromp’s opinion, 

and the record supports that ALJ’s conclusion.8

 See Bayliss v. 427 F.3d at 1216 (an ALJ 

may reject the controverted opinion of a treating or an examining physician by providing 

specific and legitimate reasons that are supported by substantial evidence in the record) 

 As the ALJ noted, records from North Country do not document abnormal mental 

status findings. (Tr. 27) (citing Admin. Hrg. Exs. 1F at 2-17, 15F at 2-11. and 20F).) 

Similarly, as discussed in Section II.A.2 and VI.B.1, Dr. Wise’s treatment notes do not 

document mental health abnormalities. (Tr. 355, 358, 359.) Additionally, Dr. Tromp’s 

notes on examination reflect that Plaintiff had a logical and goal-directed thought 

process, good comprehension, a “panicky” but “comfortable” mood, an appropriate and 

cheerful affect, good concentration, adequate memory, and a full fund of knowledge. 

(Tr. 368.) 

 To support her claim of error, Plaintiff points to treatment notes that document her 

reports of anxiety symptoms. (Doc. 18 at 15.) The ALJ assigned little weight to 

Dr. Tromp’s opinion to the extent that it was based on Plaintiff’s self-reports. (Tr. 27.) 

Because the ALJ properly discredited Plaintiff’s subjective complaints, as discussed in 

 

8

 Dr. Tromp’s opinion was contradicted by Dr. Rose’s opinion. (Tr. 296-300.) 

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Section VI.A, the ALJ did not err in this regard. See Bray, 554 F.3d at 1228 (9th Cir. 

2009) (ALJ properly discounts a physician’s opinion that is based solely upon claimant’s 

self-reporting if ALJ concludes that claimant’s self- reporting is not credible); see also 

Thomas v. Barnhart, 278 F.3d 947, 957 (9th Cir. 2002) (rejecting physician’s opinion in 

part because it was based on claimant’s subjective complaints, not on new objective 

findings); Tonapetyan, 242 F.3d at 1149 (medical opinion premised on subjective 

complaints may be disregarded when record supports ALJ in discounting claimant’s 

credibility). 

 Additionally, as the Commissioner notes (Doc. 19 at 10), the record also includes 

a Function Report that Plaintiff completed in February 2011. (Tr. 217-25.) On the 

Function Report, Plaintiff wrote that she went out twice a week and could do so alone. 

(Tr. 220.) She reported that she could shop in stores without accompaniment. (Tr. 220-

21.) Plaintiff also reported that she got along with authority figures and handled stress 

and changes in routine “ok.” (Tr. 223.) Plaintiff’s statements on her Function Report are 

inconsistent with Dr. Tromp’s opinion regarding Plaintiff’s mental functional limitations. 

 Although the ALJ did not specifically cite Plaintiff’s Function Report in his 

discussion of the weight assigned to Dr. Tromp’s opinion, the ALJ referred to that report 

several times in his decision indicating that he considered it in his evaluation of the 

evidence. (Tr. 24, 28 (citing Admin. Hrg. Ex. 7E).) The Commissioner properly points 

out this “additional support for the Commissioner’s and the ALJ’s position,” Warre, 439 

F.3d at 1005 n.3, and the Court considers that Function Report evidence that supports the 

ALJ’s conclusion that Dr. Tromp’s opinion was inconsistent with the record. 

 Considering the record as a whole, the ALJ rationally concluded that the medical 

record did not support the functional limitations that Dr. Wise and Dr. Tromp identified, 

and even though the record includes evidence that could be interpreted more favorably to 

Plaintiff, the Court “must uphold the ALJ’s decision where the evidence is susceptible to 

more than one rational interpretation.” Magallanes, 881 F.2d at 750; see Batson, 359 

F.3d at 1198. 

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VII. Conclusion

As set forth above, the ALJ’s opinion is supported by substantial evidence in the 

record and is free of harmful legal error. 

 Accordingly, 

IT IS ORDERED that the Commissioner’s disability determination is 

AFFIRMED. The Clerk of Court is directed to enter judgment in favor of the 

Commissioner and against Plaintiff and to terminate this action. 

 Dated this 17th day of February, 2015. 

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