Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_18-cv-02248/USCOURTS-caed-2_18-cv-02248-4/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:416 Denial of Social Security Benefits

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UNITED STATES DISTRICT COURT 

FOR THE EASTERN DISTRICT OF CALIFORNIA 

SANDRA WILLIAMS, 

Plaintiff, 

v. 

ANDREW SAUL, Commissioner of Social 

Security 

Defendant. 

No. 2:18-cv-2248-EFB 

MEMORANDUM AND ORDER 

Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security 

(“Commissioner”) denying her application for Disability Insurance Benefits (“DIB”) under Title 

II of the Social Security Act. The parties’ cross-motions for summary judgment are pending. 

ECF Nos. 16 & 19. For the reasons discussed below, plaintiff’s motion for summary judgment is 

granted and the Commissioner’s motion is denied. 

BACKGROUND 

Plaintiff filed an application for DIB, alleging that she had been disabled since April 1, 

2012. Administrative Record (“AR”) at 188-189. Plaintiff’s application was denied initially and 

upon reconsideration. Id. at 105-110, 112-117. She appeared telephonically at a hearing before 

administrative law judge (“ALJ”) K. Kwon. Id. at 43-71. 

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On June 23, 2017, the ALJ issued a decision finding that plaintiff was not disabled under 

sections 216(i) and 223(d) of the Act.1 Id. at 24-32. The ALJ made the following specific 

findings: 

1. The claimant meets the insured status requirements of the Social Security Act through 

December 31, 2017. 

2. The claimant has not engaged in substantial gainful activity since November 1, 2012, the 

alleged onset date (20 CFR 404.1571 et seq.). 

3. The claimant has the following severe impairment: bipolar disorder, anxiety disorder and 

personality disorder (20 CFR 404.1520(c)). 

* * * 

1

 Disability Insurance Benefits are paid to disabled persons who have contributed to the 

Social Security program, 42 U.S.C. §§ 401 et seq. Supplemental Security Income (“SSI”) is paid 

to disabled persons with low income. 42 U.S.C. §§ 1382 et seq. Under both provisions, 

disability is defined, in part, as an “inability to engage in any substantial gainful activity” due to 

“a medically determinable physical or mental impairment.” 42 U.S.C. §§ 423(d)(1)(a) & 

1382c(a)(3)(A). A five-step sequential evaluation governs eligibility for benefits. See 20 C.F.R. 

§§ 423(d)(1)(a), 416.920 & 416.971-76; Bowen v. Yuckert, 482 U.S. 137, 140-42 (1987). The 

following summarizes the sequential evaluation: 

Step one: Is the claimant engaging in substantial gainful 

activity? If so, the claimant is found not disabled. If not, proceed 

to step two. 

Step two: Does the claimant have a “severe” impairment? 

If so, proceed to step three. If not, then a finding of not disabled is 

appropriate. 

Step three: Does the claimant’s impairment or combination 

of impairments meet or equal an impairment listed in 20 C.F.R., Pt. 

404, Subpt. P, App.1? If so, the claimant is automatically 

determined disabled. If not, proceed to step four. 

Step four: Is the claimant capable of performing his past 

work? If so, the claimant is not disabled. If not, proceed to step 

five. 

Step five: Does the claimant have the residual functional 

capacity to perform any other work? If so, the claimant is not 

disabled. If not, the claimant is disabled. 

Lester v. Chater, 81 F.3d 821, 828 n.5 (9th Cir. 1995). 

 

The claimant bears the burden of proof in the first four steps of the sequential evaluation 

process. Yuckert, 482 U.S. at 146 n.5. The Commissioner bears the burden if the sequential 

evaluation process proceeds to step five. Id.

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4. The claimant does not have an impairment or combination of impairments that meets or 

medically equals the severity of one of the listed impairments in 20 CFR Part 404, Subpart 

P, Appendix 1 (20 CFR 404.1520(d), 404.1525 and 404.1526). 

* * * 

5. After careful consideration of the entire record, the undersigned finds that the claimant has 

the residual functional capacity to perform a full range of work at all exertional levels but 

with the following nonexertional specific vocational preparation (SVP) of 2 with no 

significant changes or regular interactions with the public for her primary duties. 

* * * 

6. The claimant is unable to perform any past relevant work (20 CFR 404.1565). 

* * * 

7. The claimant was born on May 21, 1969 and was 42 years old, which is defined as a 

younger individual 18-49, on the alleged disability onset date (20 CFR 404.1563). 

8. The claimant has at least a high school education and is able to communicate in English 

(20 CFR 404.1564). 

9. Transferability of job skills is not material to the determination of disability because using 

the Medical-Vocation Rules as a framework supports a finding that the claimant is “not 

disabled,” whether or not the claimant has transferable job skills (See SSR 82-41 and 20 

CFR Part 404, Subpart P, Appendix 2). 

10. Considering the claimant’s age, education, work experience, and residual functional 

capacity, there are jobs that exist in significant numbers in the national economy that the 

claimant can perform (20 CFR 404.1569 and 404.1569(a)). 

11. The claimant has not been under a disability, as defined in the Social Security Act, from 

April 1, 2012 through the date of this decision (20 CFR 404.1520(g)). 

Id. at 24-32. 

 Plaintiff’s request for Appeals Council review was denied on June 20, 2018, leaving the 

ALJ’s decision as the final decision of the Commissioner. Id. at 1-3. 

LEGAL STANDARDS 

The Commissioner’s decision that a claimant is not disabled will be upheld if the findings 

of fact are supported by substantial evidence in the record and the proper legal standards were 

applied. Schneider v. Comm’r of the Soc. Sec. Admin., 223 F.3d 968, 973 (9th Cir. 2000); 

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Morgan v. Comm’r of the Soc. Sec. Admin., 169 F.3d 595, 599 (9th Cir. 1999); Tackett v. Apfel, 

180 F.3d 1094, 1097 (9th Cir. 1999). 

 The findings of the Commissioner as to any fact, if supported by substantial evidence, are 

conclusive. See Miller v. Heckler, 770 F.2d 845, 847 (9th Cir. 1985). Substantial evidence is 

more than a mere scintilla, but less than a preponderance. Saelee v. Chater, 94 F.3d 520, 521 (9th 

Cir. 1996). “‘It means such evidence as a reasonable mind might accept as adequate to support a 

conclusion.’” Richardson v. Perales, 402 U.S. 389, 401 (1971) (quoting Consol. Edison Co. v. 

N.L.R.B., 305 U.S. 197, 229 (1938)). 

 “The ALJ is responsible for determining credibility, resolving conflicts in medical 

testimony, and resolving ambiguities.” Edlund v. Massanari, 253 F.3d 1152, 1156 (9th Cir. 

2001) (citations omitted). “Where the evidence is susceptible to more than one rational 

interpretation, one of which supports the ALJ’s decision, the ALJ’s conclusion must be upheld.” 

Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002). 

ANALYSIS 

 Plaintiff presents three arguments. First, she claims that the ALJ erred in finding that she 

did not meet or equal the listings 12.04, 12.06, and 12.08. Second, she argues that the ALJ erred 

in finding her not credible with regard to her claims regarding the intensity, persistence, and 

limiting effects of her symptoms. Third, she claims that the ALJ erred in failing to consider the 

non-severe impairments stemming from her foot issues in reaching the determination that she 

could perform light work. The court finds plaintiff’s second argument persuasive and, thus, does 

not reach the others. 

I. Applicable Legal Standards 

 As to the second argument, the ALJ discounted plaintiff’s credibility. Specifically, the 

ALJ found that “the claimant’s medically determinable impairments could reasonably be 

expected to cause the alleged symptoms; however, the claimant’s statements concerning the 

intensity, persistence and limiting effects of these symptoms are not entirely consistent with the 

medical evidence and other evidence in the record . . . .” AR at 30. The U.S. Court of Appeals 

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for the Ninth Circuit has established a two-step analysis for determining how and to what extent a 

claimant’s symptom testimony should be credited: 

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. In this analysis, the claimant is not required to show that her 

impairment could reasonably be expected to cause the severity of the 

symptom she has alleged; she need only show that it could 

reasonably have caused some degree of the symptom. Nor must a 

claimant produce objective medical evidence of the pain or fatigue 

itself, or the severity thereof. 

If the claimant satisfies the first step of this analysis, and there is no 

evidence of malingering, the ALJ can reject the claimant's testimony 

about the severity of her symptoms only by offering specific, clear 

and convincing reasons for doing so. This is not an easy requirement 

to meet: The clear and convincing standard is the most demanding 

required in Social Security cases. 

Garrison v. Colvin, 759 F.3d 995, 1014-15 (9th Cir. 2014) (citations and internal quotation marks 

omitted). 

II. Argument 

 As noted, the ALJ determined that plaintiff’s impairments could be expected to cause the 

alleged symptoms. She discounted plaintiff’s testimony as to subjective symptoms reasoning, 

inter alia: 

[T]he claimant has not generally received the type of medical 

treatment one would expect for a disabled individual. The medical 

record demonstrates that the claimant’s impairments have been 

treated conservatively with medication management, minimal 

therapy and no in-patient or emergency psychological treatment. 

The claimant was prescribed medications for her impairments, with 

no side effects. The record also demonstrated many instances of the 

claimant doing well, with mostly normal exam findings. 

Furthermore, the progress notes failed to corroborate the claimant’s 

allegations of chronic forgetfulness and staying in bed on a regular 

basis. Additionally, while the claimant experienced migraines, the 

record showed no ongoing reports of symptoms from 2012 to 2014, 

with botox helping her symptoms. 

AR at 29-30. Additionally, in discounting plaintiff’s testimony, the ALJ stated that she was 

influenced by plaintiff’s “generally unpersuasive presentation and demeanor while testifying at 

the hearing.” Id. at 30. She did not elaborate or point to specific portions of the hearing 

transcript where this was evident. Elsewhere in the decision, however, the ALJ described 

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plaintiff’s presentation at the hearing as “histrionic” and noted that plaintiff had “many 

complaints.” Id. at 29. But, again, the ALJ failed to provide any examples of this with specific 

references to the record and did not articulate specific, clear and convincing reasons for 

discounting plaintiff’s subjective testimony. 

 A. “Conservative” Treatment 

First, the assertion that plaintiff’s treatment for her mental health issues can, in any 

reasonable way, be termed “conservative” is not supported by the record Rather, the medical 

records reflect that plaintiff sought consistent treatment and prescribed medication for depression, 

anxiety, and bipolar disorder from 2012 through 2017:2 

 i. 2012 

On April 26, 2012, plaintiff presented to Dr. Edward Gaston and was diagnosed with 

major depressive disorder, recurrent. AR at 1741. Dr. Gaston authorized a prescription for 

Xanax. Id. In October of 2012, a different provider – Dr. Michael Bartos – diagnosed plaintiff 

with generalized anxiety disorder and bipolar disorder II. Id. at 455. He renewed prescriptions 

for Geodon, Xanax, and prescribed Propranolol for the first time. Id. at 455-56. 

 ii. 2013 

Plaintiff continued to see Dr. Bartos and receive medication3 for her mental health issues 

in 2013. Id. at 453-54. In late 2013, she saw a different provider – Dr. Roobal Sekhon – who 

noted that plaintiff had “been on multiple medications in the past.” Id. at 449. Dr. Sekhon 

continued prescription of plaintiff’s cocktail of medications, with the intention of ultimately 

substituting “SSRI”4 for Xanax. Id. 

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2

 The medical records submitted in this case are voluminous and the court finds it 

unnecessary to recount every psychiatric visit described therein. Instead, it will describe enough 

of the provider encounters to provide a holistic view of plaintiff’s psychiatric treatment. 

3

 The court notes that, at a May 14, 2013 visit with plaintiff, Dr. Bartos noted that 

“[plaintiff] is on a complex combination of medications.” AR at 453 (emphasis added). 

4

 The court understands SSRI to stand for “Selective Serotonin Reuptake Inhibitor” – a 

class of antidepressants. 

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 iii. 2014 

Plaintiff saw Dr. Sekhon again in January of 2014. Id. at 448. He described her affect as 

anxious and, initially, “quite distressed.” Id. He discontinued her Adderall, lowered her Xanax, 

and prescribed Seroquel for the first time. Id. 

In February of 2014, plaintiff advised Dr. Sekhon that the Seroquel had caused her to 

suffer a seizure. Id. at 447. Her communication with Dr. Sekhon in February was apparently by 

telephone insofar as the provider noted that “when [plaintiff was] asked to come to the 

appointment, she states that she is too anxious to leave the house.” Id. 

 iv. 2015 

Plaintiff made an emergency room visit in January of 2015.5 Id. at 530. She described 

passing out and stated that she was uncertain whether she experienced a panic attack. Id. 

Plaintiff was diagnosed with syncopal episodes and depression. Id. at 531. 

 v. 2016 

Plaintiff was able to resume treatment with Dr. Gaston in April of 2016. Dr. Gaston 

diagnosed her with “major depressive disorder, recurrent episode, moderate.” Id. at 1644. He 

noted that she was currently taking the following psychotropic medications: Paoxetine, Geodon, 

Clonazepam, Lamotrigine, Gabapentin, and amphetamine salts. Id. at 1645. Dr. Gaston 

discontinued Gabapentin, but directed her to continue the other medications. Id. at 1646. 

In August of 2016, plaintiff had a telephonic appointment with Dr. Gaston. She noted that 

she was currently in a good mood, but had had 4 or 5 days in the last month during which she had 

become so depressed that she had suicidal thoughts. Id. at 1658. Dr. Gaston assessed that she 

suffered from a “fluctuating clinical course” and that she might benefit from a case manager. Id.

at 1659. 

In October of 2016, Dr. Gaston noted that plaintiff continued to be “profoundly 

depressed” and that she slept twenty-hours a day. Id. at 1666. He emphasized that “she sees 

patterns on people or animals like a bird, or somebody walking by, but these objects don’t exist.” 

5

 Charts for this emergency room visit reference a previous emergency room visit in 

September 2014 when plaintiff “passed out.” AR at 530. 

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Id. at 1667. The records state that, by that time, plaintiff had had trial of no less than sixteen

different psychotropic medications. Id. Dr. Gaston increased the dosage of plaintiff’s 

amphetamine salts and recommended that she apply for disability. Id. at 1668. 

 vi. 2017 

 In January of 2017, plaintiff advised Dr. Gaston that she had two to three good days per 

week, but was still limited by her psychiatric conditions. Id. at 1686. She no longer cooked 

because she was easily distractible and could forget to turn the stove off. Id. She was able to 

pick her children up from school. Id. at 1687. Disturbingly, she reported that she continued to 

hear “little voices” which advised her, among other things, to attempt suicide. Id. at 1686. 

Plaintiff and Dr. Gaston agreed to taper her Paxil prescription because she was experiencing a 

loss of interest in sex. Id. at 1687. 

 In February of 2017, plaintiff phoned Dr. Gaston and told him that discontinuing Paxil 

had adversely affected her mood, causing her to become short tempered and more depressed. Id.

at 1694. Patient and provider agreed that Paxil should be resumed. Id. Dr. Gaston revised 

plaintiff’s diagnoses to “recurrent major depression with psychotic and anxious features.” Id. 

 vii. Overall Analysis 

 The medical records, viewed holistically, demonstrated that plaintiff had consistent, 

complex and aggressive treatment for her psychiatric conditions. Her providers managed an 

intricate cocktail of psychotropic medications over the course of years in their attempts ameliorate 

her symptoms. Other courts have routinely recognized similar treatment regimes as nonconservative. See, e.g. Matthews v. Astrue, 2012 U.S. Dist. LEXIS 47903, 2012 WL 1144423, at 

*9 (C.D. Cal. April 4, 2012) (“Here, however, Plaintiff has been taking psychotropic medication 

and receiving outpatient care since 2005. Claimant does not have to undergo inpatient 

hospitalization to be disabled.”); Mason v. Colvin, 2013 U.S. Dist. LEXIS 133727, 2013 WL 

5278932, at *6 (E.D. Cal. Sept. 18, 2013) (treatment deemed non-conservative where claimant 

was prescribed antidepressants and anti-psychotic medications for the better part of two years). 

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And, as plaintiff points out, other than the prescription of medication – which is obviously present 

in the record – there are few, if any, other viable treatments for her mental health issues. Thus, 

beyond hospitalization or additional therapy (which the record indicates plaintiff’s insurance 

would not cover, see AR at 453), it is difficult to conceive of how her providers could have done 

more. 

 B. Normal Findings 

 The ALJ discounted plaintiff’s testimony after finding that “[t]he record also 

demonstrated many instances of the claimant doing well, with mostly normal findings.” AR at 

29. But, as noted in the foregoing section, plaintiff spent years seeking help for her mental health 

issues and, as late as 2017, still suffered from major depression. Id. at 1694. “[T]he treatment 

records must be viewed in light of the overall diagnostic record.” Ghanim v. Colvin, 763 F.3d 

1154, 1164 (9th Cir. 2014). The overall record here does not reflect that plaintiff’s mental health 

was “mostly normal” during the relevant period. 

Even the dates identified as normal by the ALJ are accompanied by severe psychiatric 

issues. The ALJ cites an August 23, 2016 encounter with Dr. Gaston at which plaintiff sated that 

her mood was “the best it’s been in a long time” and that her depression was “pretty good.” AR 

at 1658. At that same encounter, however, plaintiff reported that she had four or five bad days 

per month during which she experienced powerful suicidal thoughts. Id. Dr. Gaston opined that 

her clinical course was “fluctuating” and that she would benefit from a case manager. Id. at 1659. 

The ALJ also cites an August 30, 2016 finding from another Kaiser provider, not Dr. Gaston, who 

noted that plaintiff’s “major depression/anxiety/bipolar disorder appear stable.” Id. at 1222. But 

that same report noted that plaintiff had been fatigued for two weeks, and that the condition was 

worsening. Id. And, as noted supra, in October of 2016, Dr. Gaston noted that plaintiff 

continued to be “profoundly depressed.” Id. at 1666. 

 C. Chronic Forgetfulness and Staying in Bed 

The ALJ also found that the progress notes “failed to corroborate the claimant’s 

allegations of chronic forgetfulness and staying in bed on a regular basis.” Id. at 29-30. Yet, 

perplexingly, the progress notes mention both. See Id. at 1666 (“[Plaintiff] is 20 hours a day . . . 

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sleeping or watching TV.”); 1686 (noting that plaintiff no longer cooked due to forgetfulness in 

turning off the stove, noting that plaintiff has only 2-3 days a week where she is “up out of bed 

and doing stuff”). 

 D. Plaintiff’s Demeanor at the Telephonic Hearing 

 Finally, the ALJ noted that plaintiff’s “unpersuasive presentation” at the hearing 

contributed to the credibility finding. The ALJ never explains how plaintiff was unpersuasive or 

offers any citation to the transcript. Elsewhere in the opinion she refers to plaintiff as “histrionic” 

and possessed of “many complaints.” AR at 29. These descriptors shed scant light on the ALJ’s 

findings. Further, a person manifesting as having “many complaints” and being “histrionic” are 

hardly surprising with the diagnosis and medical findings of bipolar disorder that are described 

and recounted at length in the medical records. The ALJ’s observations based on plaintiff’s 

demeanor are not, standing alone, sufficient to provide clear and convincing reasons for 

disregarding her testimony. See, e.g., Overton v. Berryhill, No. 3:17-cv-00025-BEN-BLM, 2018 

U.S. Dist. LEXIS 50982 , * 23-24, 2018 WL 156315 (S.D. Cal., Mar. 24, 2018) (“While an ALJ 

can include personal observations of a plaintiff during a hearing, a negative credibility 

determination based on those observations is proper only if it is supported by other evidence.”). 

CONCLUSION 

 The only question that remains is whether to remand for payment of benefits or additional 

proceedings. “The decision whether to remand a case for additional evidence, or simply to award 

benefits is within the discretion of the court.” Sprague v. Bowen, 812 F.2d 1226, 1232 (9th Cir. 

1987). A court should remand for further administrative proceedings, however, unless it 

concludes that such proceedings would not serve a useful purpose. Dominguez v. Colvin, 808 

F.3d 403, 407 (9th Cir. 2016). The court cannot say that additional proceedings would have no 

utility in the present case. In particular, the generation of additional medical evidence in the 

intervening years may prove enlightening. See Treichler v. Comm'r of Soc. Sec., 775 F.3d 1090, 

1101 (9th Cir. 2014) (additional proceedings have utility where “there is a need to resolve 

conflicts and ambiguities, . . . or the presentation of further evidence . . . may well prove 

enlightening in light of the passage of time.”) (internal quotations and quotation marks omitted). 

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 Based on the foregoing, it is hereby ORDERED that: 

 1. Plaintiff’s motion for summary judgment (ECF No. 16) is GRANTED; 

 2. The Commissioner’s cross-motion for summary judgment (ECF No. 19) is DENIED; 

3. This matter is REMANDED for additional administrative proceedings; and 

 4. The clerk is directed to enter judgment in plaintiff’s favor and close the case. 

DATED: March 18, 2020. 

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