Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_09-cv-00208/USCOURTS-casd-3_09-cv-00208-0/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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09cv208-WQH(JMA)

UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF CALIFORNIA

MARLO CLEVELAND,

Plaintiff,

v.

MICHAEL J. ASTRUE, Commissioner of

Social Security Administration,

Defendant. 

 

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Case No. 09-CV-208-WQH (JMA)

REPORT AND RECOMMENDATION

OF UNITED STATES MAGISTRATE

JUDGE RE: PLAINTIFF’S MOTION

FOR SUMMARY JUDGMENT AND

DEFENDANT’S CROSS-MOTION FOR

SUMMARY JUDGMENT

Plaintiff Marlo Cleveland (“Plaintiff”) seeks judicial review of Social Security

Commissioner Michael J. Astrue’s determination she is not entitled to supplemental

security income (“SSI”) benefits. Plaintiff has filed a Motion for Summary Judgment to

which Defendant has filed an Opposition brief as well as a Cross-Motion for Summary

Judgment. (Doc. No. 11, 14 & 15.) For the reasons set forth below, the Court

recommends Plaintiff’s Motion for Summary Judgment be DENIED and Defendant’s

Cross-Motion for Summary Judgment be GRANTED.

I. PROCEDURAL HISTORY

Plaintiff filed an application for supplemental security income benefits on or

around May 24, 2006. (Admin. R. at 10.) Her disability onset date was initially alleged

to be January 1, 1993, although she later requested it be amended to the protective

filing date. (Id. at 27, 193.) Plaintiff’s claim was denied at the initial level and upon

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1

 In her application for benefits Plaintiff stated she was limited in her ability to work due

to schizophrenia, knee and back problems. This case, however, challenges the ALJ’s decision

only as it relates to her mental illness and so the Court limits its discussion to this issue. (Id. at

118.)

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reconsideration. (Id. at 10) Plaintiff then requested a hearing before an administrative

law judge (“ALJ”), which was held on October 16, 2007 before ALJ Eve B. Godfrey. (Id.

at 10 - 22, 23 - 58.) The ALJ determined Plaintiff was not disabled. (Id. at 10 - 20.) 

The Appeals Council for the Social Security Administration declined further review. (Id.

at 1 - 3.) Plaintiff then commenced this action pursuant to 42 U.S.C. § 405(g). 

II. FACTUAL BACKGROUND

Plaintiff was born on August 27, 1969 and was 38 years old at the time of the

administrative hearings. (Id. at 27, 100.) She has a tenth grade level education. (Id.) 

Her work history is minimal. She once held a part-time seasonal job in phone sales in

1993 and 1994 and in 2000 she worked for about a one week period stocking shelves. 

(Id. at 28 - 29.)

Plaintiff alleges that she is disabled due to mental impairment.1

 She hears voices

in her head and is easily agitated by other people. (Id. at 30, 32.) She has difficulty

sleeping and concentrating on routine tasks. (Id. at 32, 35.)

III. MEDICAL EVIDENCE

A. Luisa B. Fijman – Examining Psychiatrist (2006)

At Defendant’s request, Plaintiff was examined by Board certified psychiatrist

Luisa B. Fijman, M.D. on or about June 29, 2006. (Id. at 198-203.) Medical records

were not reviewed. (Id. at 198.) Plaintiff’s chief complaint was “anxiety and voices.” 

(Id.) Plaintiff reported she had never been seen by a psychiatrist or admitted to a

psychiatric unit but was currently being seen by County Mental Health. (Id. at 199.) 

She informed Dr. Fijman she was taking Seroquel but did not remember the dose or the

name of the person that prescribed it for her. (Id.) Dr. Fijman reported Plaintiff

appeared to be “very evasive and vague” when questioned as to the names of the

professionals she was seeing. (Id.) She opined Plaintiff was less than truthful with the

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2

 A GAF between 71 and 80 indicates “(i)f symptoms are present, they are transient

and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family

argument); no more than slight impairment in social, occupational, or school functioning (e.g.,

temporarily falling behind in schoolwork).” Diagnostic and Statistical Manual of Mental

Disorders (DSM-IV), Multiaxial Assessment, rev. May 20, 2002.

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information she provided. (Id. at 200.) She reported Plaintiff seemed to be less than

truthful about her use of alcohol and drugs but admitted to long term use of LSD and

marijuana. (Id.) Dr. Fijman reported Plaintiff was hostile during the examination. (Id.)

She reported Plaintiff displayed an attitude of entitlement and refused to answer many

of the questions posed to her. (Id.) Dr. Fijman diagnosed polysubstance abuse

disorder and malingering with some borderline and anti-social traits. (Id. at 202.) The

Global Assessment Function (“GAF”) was scored at 70 to 75.2 (Id.) She concluded

Plaintiff did not have a psychiatric condition that would interfere with her ability to work. 

(Id. at 203.) She further opined Plaintiff needed to maintain sobriety but expressed

skepticism that she would do so. (Id.)

B. County Mental Health – Treating Physicians (2006 – 2007)

Plaintiff was first seen at MHS North Coastal Mental Health for a mental health

assessment on June 26, 2006. She reported she was diagnosed with a psychotic

disorder at the age of 23. (Id. at 241.) She also reported becoming disoriented in large

crowds and seeing shadows and figures. (Id. at 241-243.) Plaintiff was seen by John

Donnelly, M.D. on July 12, 2006. In the preceding two months she had lost 50 pounds

and reported having a poor appetite and fragmented sleep. (Id. at 245.) She also had

low energy and difficulty concentrating. (Id.) She was assessed as having Psychotic

Disorder, not otherwise specified; Depressive Disorder, not otherwise specified; and

Posttraumatic Stress Disorder. (Id. at 247.) She was prescribed Paxil and Abilify and

/ /

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 A GAF between 41 and 50 indicates “(s)erious symptoms (e.g., suicidal ideation,

severe obsessional rituals, frequent shoplifting) OR any serious impairment in social,

occupational, or school functioning (e.g., no friends, unable to keep a job).” DSM-IV, Multiaxial

Assessment.

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 A GAF between 51 and 60 indicates “(m)oderate symptoms (e.g., flat affect and

circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational,

or school functioning (e.g., few friends, conflicts with peers or co-workers).” 

DSM-IV, Multiaxial Assessment.

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was referred to a depression/anxiety group. (Id. at 247.) The GAF was scored at 50.3

(Id.)

Plaintiff was seen by J. Fernando Bayardo, M.D. on September 12, 2006 for

psychiatric reassessment and medication monitoring. (Id. at 266-267.) She reported

she had heard voices since childhood except when she took LSD in high school. The

Abilify was irritating her skin so it was discontinued and Risperdal was prescribed. (Id.) 

The GAF was scored at 55.4 (Id.)

Dr. Bayardo saw Plaintiff again on October 9, 2006 for monitoring. (Id. at 263-

264.) She reported nightmares and getting angry but denied having anxiety or

depression. (Id. at 264.) On a scale of 0 - 10 with 0 being “No Symptoms, ” 5 being

“Medium” and 10 being “Extreme,” Dr. Bayardo rated the severity of her anxiety

symptoms at 8. (Id. at 263.) All other symptoms were rated at 5 or lower. (Id.) Her

dosage of Risperdal was increased by 1 mg with the hope it would help with the voices. 

(Id. at 264.)

Plaintiff returned to County Mental Health on November 28, 2006 and was seen

again by Dr. Donnelly. (Id. at 259-261.) She reported she was feeling more relaxed

and less irritable on the new medication. (Id. at 259.) The severity of her anxiety

symptoms was rated at 2 and her irritability symptoms at 2-3. (Id. at 260.) All other

symptoms were rated at 0. (Id.) The GAF was scored at 45. (Id. at 261.) Dr.

Donnelly’s progress notes from a visit on August 13, 2007 also indicate at that time

Plaintiff described her mood as “pretty good.” (Id. at 291.) She was sleeping eight

hours a night and her concentration was “not real great, more scatter brained.” (Id.) 

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The only abnormality noted was non-command auditory hallucinations which she

reported as being “always there” but were not louder or more intense than usual. (Id.) 

The GAF was scored at 45. (Id. at 292.)

Dr. Donnelly completed a Mental Impairment Questionnaire on August 20, 2007. 

(Id. at 279-285.) He reported that Plaintiff had been under his care since June 26,

2006 and had been seen once a month. (Id. at 279.) His clinical findings included

auditory hallucinations that never completely resolve, low energy, “not good”

concentration and a history of Posttraumatic Stress Disorder related to past abuse. (Id.

at 279.) The prognosis was “fair to poor.” (Id.) Symptoms included decreased energy,

persistent anxiety, difficulty thinking or concentrating, recurrent intrusive recollections of

a traumatic experience, hallucinations, emotional lability and easy distractibility. (Id. at

280.) He opined Plaintiff would be unable to meet competitive standards in the

workplace, including maintaining attention for a two hour segment, maintaining regular

and punctual attendance, completing a normal workday and workweek without

interruptions from psychologically based symptoms, performing at a consistent pace

without an unreasonable number and length of rest periods, asking simple questions or

request assistance, responding appropriately to changes in a routine work setting, or

dealing with normal work stress. (Id. at 281.) He noted her diagnosis and related

symptoms impaired her ability to function socially or occupationally. (Id. at 281-283.) 

The GAF was scored at 45. (Id. at 279.)

Plaintiff continued to be seen by Dr. Donnelly at regular intervals, including visits

on December 28, 2006 (Id. at 313-314), January 30, 2007 (Id. at 310-312), February 13,

2007 (Id. at 307-309), March 15, 2007 (Id. at 304-306), April 16, 2007 (Id. at 302-303),

May 1, 2007 (Id. at 300-301) and June 28, 2007 (Id. at 297-298). During this time frame

she continued with Risperdal and Celexa prescriptions. On December 28, 2006, the

severity of her depression symptoms were rated as being 0-2. (Id. at 313.) Anxiety and

psychosis positive were rated at 1 and all other symptoms were rated 0. (Id.) During

the January 30, 2007 visit, she was observed to be highly irritated, with a severity rating

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of 9. (Id. at 311.) Manic, appetite, energy level, psychosis, agitation, and insomnia

symptoms were rated at 3 or lower and all other symptoms were rated at 0. During the

other visits she described her mood and energy levels as “pretty good” (Id. at 303) and

her mood as “pretty good considering all the stress.” (Id. at 298). She also reported

she was coping better (Id. at 300). She continued to hear voices during this time frame. 

(Id. at 307.) The severity of her irritability was rated as 4 on February 13, 2007, with all

other symptoms being 3 or lower. (Id. at 308.) On March 15, 2007 her irritability was

again rated at 4. (Id. at 305.) Her anxiety symptoms were rated at 0-5 and all other

symptoms were rated at 3 or lower. (Id.) The GAF was assessed during the evaluation

visits on January 30, 2007, February 13, 2007, and March 15, 2007 as 45. (Id. 312, 309

and 306.) 

C. Romualdo Rodriguez, M.D. - Examining Psychiatrist (2007)

At Defendant’s request, Plaintiff was examined by psychiatrist Romualdo

Rodriguez, M.D. on or about December 1, 2007. (Id. at 317-327.) In connection with

his evaluation, Dr. Rodriguez reviewed Dr. Fijman’s evaluation and MHS North Coastal

Mental Health records. (Id. at 317.) Plaintiff identified her chief complaint as “I hear

voices and freak out a lot.” (Id.) Plaintiff also noted a variety of problems including the

inability to follow instructions or complete tasks, disorganization and difficulty with

concentration. (Id. at 318.) Dr. Rodriguez reported during the exam Plaintiff made good

eye contact and good interpersonal contact, and was generally cooperative. (Id. at

320.) He observed she appeared to be genuine and truthful and there was no evidence

of exaggeration or manipulation. (Id.) He found her thought process to be coherent and

organized and without tangentiality or loosening associations. (Id.) Dr. Rodriguez

diagnosed Plaintiff with polysubstance dependence in an unknown state of remission;

attention deficit/hyperactivity disorder; anxiety disorder, not otherwise specified;

psychotic disorder, not otherwise specified; and post-traumatic stress disorder. (Id. at

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5

 A GAF between 61 and 70 indicates “(s)ome mild symptoms (e.g., depressed mood

and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g.,

occasional truancy, or theft within the household), but generally functioning pretty well, has

some meaningful interpersonal relationships.” DSM-IV, Multiaxial Assessment.

6

 In his written decision, the ALJ misidentifies the testifying medical expert as Sidney

Bolter, M.D. (Id. at 17.) Defendant’s briefing also refers to the medical expert as Dr. Bolter. 

Memorandum of Point and Authorties in Support of Defendant’s Cross-Motion for Summary

Judgment, p. 4. In fact, Dr. Bolton did not testify at the hearing and the sole testifying medical

expert was Dr. Goldberg. This mistake by the ALJ and defense counsel appears to be limited

to the name of the medical expert as all testimony attributed to Dr. Bolter was in fact given by

Dr. Goldberg. (Admin. R. at 17-18 and 43-54.) 

7 09cv208-WQH(JMA)

322.) He assessed a GAF of 65.5 (Id.) He felt that with proper treatment for ADHD,

total abstinence from drugs and alcohol and evaluation for any other psychiatric

problems, Plaintiff could make significant progress in twelve months. (Id.) With regard

to her functional assessment, he opined Plaintiff was: able to understand, remember

and carry out simple, one or two step job instructions; able to carry out detailed and

complex instructions; and slightly limited in her ability to relate and interact with

supervisors, coworkers and the public; moderately limited in her ability to maintain

concentration, persistence, and pace; slightly limited in her ability to associate with dayto-day activities; slightly limited in her ability to adapt to stresses common to a normal

work environment; slightly limited in her ability to maintain regular attendance in the

work place and perform activities on a consistent basis; and slightly limited in her ability

to perform work activities without special or additional supervision. (Id. at 323.) 

IV. THE ADMINISTRATIVE HEARING

The ALJ conducted an administrative hearing on October 16, 2007. Plaintiff was

represented by counsel and testified at the hearing. Testimony was also offered by

medical expert witness Dr. Goldberg, M.D.6

 and vocational expert Ms. Jasco.

A. Plaintiff’s Testimony

Plaintiff testified she lives with her five year old son and relies on her grown

children, neighbors and friends to help her take care of him. (Id. at 27, 34, 36 - 37.) 

She admitted to engaging in some drug use in the past, but testified she was not

/ /

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currently using illicit drugs and had been a member of AA for about 15 years. (Id. at 37-

38.)

She testified she finds it difficult to be around “a lot of people” because she hears

voices in her head and it is difficult for her to distinguish whether the voices are coming

from others or whether they are in her head. (Id. at 30 - 32.) The voices tell her to do

“bad things” like hit people. (Id. at 31.) Medication has not helped her with the voices. 

(Id.) When asked whether she had applied for food stamps, Plaintiff testified she had

not because it is difficult for her to be in crowded rooms. (Id. at 30.) She remarked it

was difficult for her to attend the hearing because of the “computers clicking all around”

her. (Id.) 

She said she is easily agitated by others and does not speak to her father as a

result. (Id. at 32.) She also has difficulty sleeping, sometimes not sleeping or leaving

her room for weeks. (Id. at 32-33.) Sometimes the voices she hears keep her awake

and when she is able to sleep, she has nightmares or dreams about past events. (Id. at

33-34.) She also testified she has difficulty focusing and concentrating on routine tasks

such as laundry. (Id. at 35.) 

B. Medical Expert Testimony 

Dr. Goldberg testified Plaintiff did not meet a listing. (Id. at 43.) He further

opined the low GAF scores assigned by Dr. Donnelly were not supported by his

observation notes. (Id. at 46, 50.) For example, Dr. Goldberg testified the notes

revealed that many times Plaintiff looks “actually pretty good” to Dr. Donnelly “and yet

he comes up with a GAF45.” (Id. at 45.) He further observed the severity of her

symptoms was generally very low and under 5. (Id. at 46.) He was also critical of the

lack of a solid initial mental evaluation. (Id. at 47.) Dr. Goldberg opined Plaintiff had

moderate limitations in her daily activities and social functioning and mild limitations on

her ability to concentrate. (Id.) He further opined she would be restricted to non-public

work with minimal contact with other people, requiring simple concentration and mild to

simple committed tasks. (Id. at 48.) 

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C. Vocational Expert Testimony

Ms. Jasco testified as a vocational expert. (Id. at 55-57.) She opined an

individual of Plaintiff’s age, education and work experience who is capable of doing

simple repetitive tasks in a non-public environment would be suitably employed in

several occupations including as a garment folder, a seamer or a bench hand. (Id. 55-

56.) She further testified there are approximately 1100 garment fold jobs, 1700 seam

steamer jobs, and 1780 bench hand jobs in the regional economy. (Id. at 55.) There

are approximately 1.2 million garment folder jobs, 1.4 seam steamer jobs, and 1.42

million bench hand jobs in the national economy. (Id.) 

V. THE ALJ’s DECISION

After considering the record, the ALJ made the following findings:

1. The claimant has not engaged in substantial gainful activity since May 24,

2006, the application date [citation omitted].

2. The claimant has the following severe impairment: depression, not

otherwise specified with intermittent, non-command hallucinations [citation

omitted]. 

3. The claimant does not have an impairment or combination of impairments

that meets or medically equals one of the listed impairments in 20 CFR

Part 404, Subpart P, Appendix 1 [citation omitted].

4. ...(T)he claimant has the residual functional capacity to perform a full

range of work at all exertional levels but with the following non-exertional

limitations: simple repetitive tasks in a non-public work environment with

little contact with others.

5. The claimant has no past relevant work [citation omitted].

6. The claimant was born on August 22, 1969 and was 36 years old, which is

defined as a younger individual age 18-49, on the date the application was

filed [citation omitted]. 

7. The claimant has a limited education and is able to communicate in

English [citation omitted].

8. Transferability of job skills is not an issue in this case because the

claimant’s past relevant work is unskilled [citation omitted].

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

functional capacity, there are jobs that exists in significant numbers in the

national economy that the claimant can perform [citation omitted]

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10. The claimant was not under a disability, as defined in the Social Security

Act, since May 24, 2006, the date the application was filed [citation

omitted]. 

(Id. at 12-20.) 

VI. STANDARD OF REVIEW

To qualify for disability benefits under the Social Security Act, an applicant must

show: (1) he or she suffers from a medically determinable impairment that can be

expected to result in death or has lasted or can be expected to last for a continuous

period of twelve months or more, and (2) the impairment renders the applicant

incapable of performing the work he or she previously performed or any other

substantially gainful employment that exists in the national economy. See 42 U.S.C.A.

§ 423(d)(1)(A), (2)(A) (West 2004). An applicant must meet both requirements to be

“disabled.” Id. Further, the applicant bears the burden of proving that he or she was

either permanently disabled or subject to a condition which became so severe as to

disable the applicant prior to the date upon which his or her disability insured status

expired. Johnson v. Shalala, 60 F.3d 1428, 1432 (9th Cir. 1995). 

A. Sequential Evaluation of Impairments

The Social Security Regulations outline a five-step process to determine whether

an applicant is "disabled." If an applicant is found to be “disabled” or “not disabled” at

any step, there is no need to proceed further. Tackett v. Apfel, 180 F.3d 1094, 1098

(9th Cir. 1999) (citing 20 C.F.R. § 404.1520). Although the ALJ must assist the

applicant in developing a record, the applicant bears the burden of proof as to the first

four steps. Id. If the fifth step is reached, the burden shifts to the Commissioner. Id.

The evaluation process is as follows:

Step 1. Is the claimant presently working in a substantially gainful

activity? If so, then the claimant is “not disabled” within the meaning of the

Social Security Act and is not entitled to disability insurance benefits. If

the claimant is not working in a substantially gainful activity, then the

claimant's case cannot be resolved at step one, and the evaluation

proceeds to step two.

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Step 2. Is the claimant's impairment severe? If not, then the

claimant is “not disabled” and is not entitled to disability insurance

benefits. If the claimant's impairment is severe, then the claimant's case

cannot be resolved at step two, and the evaluation proceeds to step three.

Step 3. Does the impairment “meet or equal” one of a list of

specific impairments described in the regulations? If so, the claimant is

“disabled” and therefore entitled to disability insurance benefits. If the

claimant’s impairment neither meets nor equals one of the impairments

listed in the regulations, then the claimant's case cannot be resolved at

step three, and the evaluation proceeds to step four.

Step 4. Is the claimant able to do any work that he or she has done

in the past? If so, then the claimant is “not disabled” and is therefore not

entitled to disability insurance benefits. If the claimant cannot do any work

he or she did in the past, then the claimant's case cannot be resolved at

step four, and the evaluation proceeds to the fifth and final step.

Step 5. Is the claimant able to do any other work? If not, then the

claimant is “disabled” and therefore entitled to disability insurance

benefits. If the claimant is able to do other work, then the Commissioner

must establish that there are a significant number of jobs in the national

economy that claimant can do. There are two ways for the Commissioner

to meet the burden of showing that there is other work in “significant

numbers” in the national economy that claimant can do: (1) by the

testimony of a vocational expert, or (2) by reference to the MedicalVocational Guidelines . . . . If the Commissioner meets this burden, the

claimant is “not disabled” and therefore not entitled to disability insurance

benefits. If the Commissioner cannot meet this burden, then the claimant

is “disabled” and therefore entitled to disability insurance benefits.

Tackett, 180 F.3d at 1098-99 (footnotes and citations omitted).

B. Judicial Review

Sections 205(g) and 1631(c)(3) of the Social Security Act allow unsuccessful

applicants to seek judicial review of the Commissioner's final agency decision. 42

U.S.C.A. §§ 405(g), 1383(c)(3). The scope of judicial review is limited. The

Commissioner’s final decision should not be disturbed unless: (1) the ALJ's findings of

fact are not supported by substantial evidence or (2) the ALJ failed to apply the proper

legal standards. See Flaten v. Sec'y of Health & Human Servs., 44 F.3d 1453, 1457

(9th Cir. 1995).

The term “substantial evidence” refers to evidence that a reasonable person

might accept as adequate to support the ALJ's conclusion, considering the record as a

whole. See Richardson v. Perales, 402 U.S. 389, 401 (1971); Thomas v. Barnhart, 278

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F.3d 947, 954 (9th Cir. 2002). Substantial evidence means “more than a scintilla but

less than a preponderance” of the evidence. Jamerson v. Chater, 112 F.3d 1064, 1066

(9th Cir. 1997). The Court must consider the record as a whole, weighing both the

evidence that supports and detracts from the Commissioner’s conclusions. See Mayes

v. Massanari, 276 F.3d 453, 459 (9th Cir. 2001); Desrosiers v. Sec'y of Health & Human

Servs., 846 F.2d 573, 576 (9th Cir. 1988). Even if the ALJ's findings are supported by

substantial evidence, they must be set aside if the ALJ failed to apply the proper legal

standards in weighing the evidence and reaching his or her decision. See Benitez v.

Califano, 573 F.2d 653, 655 (9th Cir. 1978). 

Section 405(g) permits this Court to enter a judgment affirming, modifying, or

reversing the Commissioner’s decision. 42 U.S.C.A. § 405(g). The matter may also be

remanded to the Social Security Administration for further proceedings. Id. 

VII. DISCUSSION

Plaintiff contends the ALJ’s decision to deny her SSI benefits was legally

improper and was not supported by substantial evidence. Plaintiff’s motion is

predicated on one argument - the ALJ failed to give controlling weight to the opinion of

Dr. Donnelly, her treating physician.

Ninth Circuit case law distinguishes among the opinions of three types of

physicians: “(1) those who treat the claimant (treating physicians); (2) those who

examine but do not treat the claimant (examining physicians); and (3) those who neither

examine nor treat the claimant (nonexamining physicians).” Lester v. Chater, 81 F.3d

821, 830 (9th Cir. 1996). Generally, more weight is accorded to the treating physician’s

opinion. Id. However, a treating physician’s opinion is not necessarily conclusive as to

either physical condition or the ultimate issue of disability. Magallanes v. Bowen, 881

F.2d 747, 751 (9th Cir. 1989). The ALJ may disregard the treating physician’s opinion

whether or not that opinion is contradicted. Id. When a non-treating physician’s

opinion contradicts that of the treating physician, but is not based on independent

clinical findings, or rests on clinical findings also considered by the treating physician,

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the opinion of the treating physician may be rejected only if the ALJ gives “specific and

legitimate reasons for doing so that are based on substantial evidence in the record.” 

Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995). The opinion of a nonexamining

medical advisor cannot by itself constitute substantial evidence that justifies the

rejection of the opinion of an examining or treating physician. Morgan v. Commissioner,

169 F.3d 595, 602 (9th Cir. 1999). “The ALJ can meet this burden by setting out a

detailed thorough summary of the facts and conflicting clinical evidence, stating his

interpretation thereof, and making findings.” Cotton v. Bowen 799 F.2d 1403, 1408 (9th

Cir. 1986). 

In discussing Dr. Donnelly’s opinion, the ALJ stated she had “given it less

weight... than it may otherwise merit.” (Admin. R. at 17.) The ALJ explained her

decision was “due to inconsistencies in the record (citation omitted).” (Id. at 16.) 

Instead, she adopted the opinion evidence of Dr. Goldberg, whose opinions she found

to be based on clinical findings and consistent with the record as a whole. (Id. at 19.)

A. The ALJ’s first example of an inconsistency in the record is not a

legitimate reason to reject Dr. Donnelly’s opinion

The first of the identified inconsistencies is the ALJ’s observation the August 20,

2007 Mental Impairment Questionnaire was not actually completed by Dr. Donnelly, but

rather by a MHS North Coastal Mental Health case manager. (Id.) The ALJ’s evidence

in support of this assertion is the MHS North Coastal Mental Health progress notes

dated August 22, 2007. (Id. at 289.) Plaintiff argues this is not a legitimate reason to

reject Dr. Donnelly’s opinion. The Court concurs. Although, as the ALJ notes, the

progress notes indicate the document in question was prepared by an employee of Dr.

Donnelly’s clinic, they also indicate Dr. Donnelly then “reviewed and signed” the form. 

(Id. at 289.) In fact, the questionnaire bears Dr. Donnelly’s signature, which in and of

itself, sufficiently evidences he endorsed the opinions contained therein. (Id. at 284.) 

Although the Court accepts Dr. Donnelly’s signature as evidence he reviewed and

approved the contents of the questionnaire, the Court also observes the doctor may

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have been a more active participant in its preparation than the progress notes indicate

or for which the ALJ gave him credit. The questionnaire bears his initials (“J.D.”) in

numerous locations where responses were initially made and then modified. (Id. at 281

- 282.) The handwritten portions of it are were also clearly written by two different

people, with the second set of handwritten notes elaborating or explaining the earlier

comment. (Id. at 279, 281-283.) As stated earlier, however, the question as to how

much of a role Dr. Donnelly took in the preparation of the Questionnaire is irrelevant. At

a minimum, he reviewed and endorsed the report, as stated in the progress notes and

as evidenced by his signature. Thus, the ALJ’s explanation that Dr. Donnelly did not

actually prepare the Questionnaire is not a legitimate basis to reject his opinions.

B. The ALJ’s second example of an inconsistency in the record is a

specific and legitimate reason based on substantial evidence in the

record.

The ALJ’s second, and only other, example of an inconsistency in Dr. Donnelly’s

records relates to an internal inconsistency between his progress notes and his

assessment of Plaintiff’s functional limitations. Because the Court has already found

the ALJ’s other stated inconsistency in the record is not a legitimate basis for rejecting

Dr. Donnelly’s opinion, the question as to whether the ALJ’s rejection of Dr. Donnelly’s

opinion was proper must be evaluated on this stated reason alone. 

An internal conflict between treatment notes and a treating physician’s opinion

can be justification for a decision not to give the treating physician’s opinion controlling

weight if supported by substantial evidence in the record. Halonan v. Massanari, 246

F.3d 1195, 1205; See also 20 C.F.R. §§ 404.1527(c)(2), (d)(2), (d)(4). In this case, the

ALJ specifically commented that on August 13, 2007, Dr. Donnelly observed Plaintiff to

be 

alert, calm and cooperative with direct eye contact and oriented in all spheres. 

She displayed no unusual or bizarre behavior; and her speech was relevant,

coherent and organized with regular rate and rhythm and normoproductive. Her

mood was described as “pretty good,” her affect was broad, and there were no

visual hallucinations, no suicidal ideations, no homicidal ideation, and no

paranoia. (Admin. R. at 16.)

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The ALJ stated the only abnormality noted at that time was “some” auditory

hallucinations that “were non-command and [Plaintiff] reported that they were not

bothersome.” (Id.) The ALJ noted, however, despite his patient’s seemingly

unremarkable status, Dr. Donnelly assigned Plaintiff a GAF of 45, “suggesting serious

symptoms or impairment.” (Id.) 

The record demonstrates other instances of this type of inconsistency between

Dr. Donnelly’s observations and his assessment of her GAF. For example, on

November 28, 2006, Plaintiff reported she was feeling more relaxed and less irritable on

the new medication. (Id. at 259.) Dr. Donnelly rated the severity of her symptoms as

very low. (Id. at 260.) Her anxiety symptoms were rated at 2 (with 0 representing “No

Symptoms” and 5 being “Medium”) and her irritability symptoms at 2-3. (Id.) All other

symptoms were rated at 0, but the GAF was scored at 45, which indicates serious

symptoms or impairments. (Id. at 261.) On February 13, 2007, Dr. Donnelly rated the

severity of Plaintiff’s irritability symptoms as 4, with all other symptoms being 3 or lower,

but her GAF was scored at 45. (Id. at 308-309.) On March 15, 2007, her irritability was

again rated at 4. (Id. at 305.) Her anxiety symptoms were rated at 0-5 and all other

symptoms were rated at 3 or lower, but her GAF was again assessed at 45. (Id. at 305-

306.) 

Dr. Goldberg’s testimony was also critical of the inconsistency between Dr.

Donnelly’s notes and his opinions, as observed by the ALJ. (Id. at 17.) The ALJ

specifically noted Dr. Goldberg testified the progress notes from the August 13, 2007

visit were inconsistent with the GAF score and functional limitations Dr. Donnelly

assigned during that evaluation. (Id. at 17, 45-47.) She also commented on Dr.

Goldberg’s testimony regarding the inconsistency between Dr. Donnelly’s symptom

severity ratings and the GAF scores at other evaluations. (Id.) 

Dr. Goldberg opined, based on his thorough review of the medical records and

Plaintiff’s testimony, that her severe impairment was a depressive disorder, not

otherwise specified, with intermittent non-command hallucinations, and that it did not

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meet or equal any impairment. (Id. at 17-18.) He stated Plaintiff’s symptoms were not

so severe that she met a listing. (Id. at 17.)

Dr. Goldberg’s assessment is consistent with Dr. Donnelly’s progress notes

(other than the GAF scores), as well as the medical record as a whole. As the ALJ

observed, Plaintiff was examined by two psychiatrists, Dr. Fijman and Dr. Rodriguez,

who also opined Plaintiff’s symptoms were not so severe they would interfere with her

ability to work. (Id. at 14.) Dr. Fijman reported Plaintiff displayed an entitled and

demanding attitude and refused to answer questions and comply with instructions

pertinent to the exam. (Id. at 14 and 18.) Dr. Fijman described her mood as irritable

and her affect as dysophoric, and opined Plaintiff was less than truthful about her

symptoms. (Id.) She diagnosed Plaintiff with polysubstance abuse disorder and

malingering with some borderline and anti-social traits. (Id. at 14) The GAF was scored

at 70 to 75, which the ALJ commented “suggests transient symptoms with no more than

slight impairment.” (Id.) She concluded Plaintiff did not have a psychiatric condition

that would interfere with her ability to work. (Id.)

 During her exam by Dr. Rodriguez, Plaintiff made good eye contact, good

interpersonal contact, and was generally cooperative. (Id. at 17.) Her thought process

was coherent and organized and without tangentiality or loosening associations. (Id.) 

Dr. Rodriguez diagnosed Plaintiff with polysubstance dependence in an unknown state

of remission; attention deficit/hyperactivity disorder; anxiety disorder, not otherwise

specified; psychotic disorder, not otherwise specified; and post-traumatic stress

disorder. (Id.) He assessed a GAF of 65. (Id.) With regard to her functional

assessment, he opined Plaintiff was: able to understand, remember and carry out

simple, one or two step job instructions; able to carry out detailed and complex

instructions; slightly limited in her ability to relate and interact with supervisors,

coworkers and the public; moderately limited in her ability to maintain concentration,

persistence, and pace; slightly limited in her ability to associate with day-to-day

activities; slightly limited in her ability to adapt to stresses common to a normal work

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environment; slightly limited in her ability to maintain regular attendance in the work

place and perform activities on a consistent basis; and slightly limited in her ability to

perform work activities without special or additional supervision. (Id.) 

An ALJ may properly resolve conflicts and ambiguities in the medical evidence, a

she did here. See, e.g., Andrews, 53 F.3d 1035, 1039. In this case, as explained

above, the ALJ articulated specific and legitimate reasons based on substantial

evidence in the record for rejecting Dr. Donnelly’s opinions and adopting the opinions of

Dr. Goldberg instead. She set out a detailed thorough summary of the facts and

conflicting clinical evidence, stated her interpretation thereof, and made findings, as

required. The Court further finds the ALJ’s decision that Plaintiff is not disabled is

supported by substantial evidence, including the treating notes of Dr. Donnelly, two

examining psychiatrists (Dr. Fijman and Dr. Rodriguez), and a non-examining medical

adviser (Dr. Goldberg). Lester, 81 F.3d at 831; Magallanes, 881 F.2d at 751-52. For

the aforementioned reasons, the Court finds the ALJ did not err by giving reduced

weight to Dr. Donnelly’s opinions regarding Plaintiff’s work limitations and in finding

Plaintiff is not disabled. 

VIII. CONCLUSION

For the reasons set forth above, Plaintiff’s Motion for Summary Judgment should

be DENIED and Defendant’s Cross-Motion for Summary Judgment should be

GRANTED.

This report and recommendation will be submitted to the Honorable William Q.

Hayes, United States District Judge assigned to this case, pursuant to the provisions of

28 U.S.C. § 636(b)(1). Any party may file written objections with the Court and serve a

copy on all parties on or before August 9, 2010. The document should be captioned

“Objections to Report and Recommendation.” Any reply to the Objections shall be

served and filed on or before August 20, 2010. The parties are advised that failure to

/ /

/ /

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file objections within the specified time may waive the right to appeal the district court’s

order. Martinez v. Ylst, 951 F.2d 1153 (9th Cir. 1991). 

IT IS SO ORDERED.

DATED: July 23, 2010

Jan M. Adler

U.S. Magistrate Judge

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