Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_15-cv-02413/USCOURTS-casd-3_15-cv-02413-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:0405id Review of HHS Decision (SSID)

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UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF CALIFORNIA

Lenda Charmaine Cyprain,

Plaintiff,

v.

Carolyn W. Colvin, Acting Commissioner 

of Social Security,

Defendant.

Case No.: 15cv2413-BAS-BGS

REPORT AND 

RECOMMENDATION

I. PROCEDURAL BACKGROUND

Lenda Charmain Cyprain (“Plaintiff”) filed an application for disability insurance 

benefits on June 29, 2011, alleging disability commencing on April 14, 2009. (ECF No. 

9, Administrative Record “AR” at 156-64.) Her claim was originally denied on October 

3, 2011 (id. at 90-94), and upon reconsideration on June 29, 2012. (Id. at 102-04.) After 

a hearing on July 18, 2013 (id. at 52-72), Administrative Law Judge (“ALJ”) Sherwin F. 

Biesman issued a decision denying the application on March 8, 2014. (Id. at 28-38.) 

On May 1, 2014, the Appeals Council denied Plaintiff’s request for review, making 

the ALJ’s decision the final agency decision. (Id. at 19-24.) This Court has jurisdiction 

pursuant to 42 U.S.C. §§ 405(g), 1383(c). Plaintiff filed her Motion for Summary 

Judgment on February 26, 2016. (ECF No. 11) In her motion for summary judgment, 

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Plaintiff argues that the ALJ erred in finding her mental impairments and carpal tunnel 

syndrome not severe. (Id.) Defendant filed her cross Motion for Summary Judgment on 

March 25, 2016. (ECF No. 14.) Plaintiff filed a reply on April 8, 2016. (ECF No. 16.)

II. LEGAL STANDARD FOR DETERMINATION OF A DISABILITY

In order to qualify for disability benefits, an applicant must show that: (1) he or she 

suffers from a medically determinable physical or mental impairment that can be 

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

period of not less than twelve months; and (2) the impairment renders the applicant 

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

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

423(d)(1)(A), (2)(A). An applicant must meet both requirements to be “disabled.” Id.

The applicant has the burden to establish disability. Terry v. Sullivan, 903 F.2d 1273, 

1275 (9th Cir. 1990).

The Secretary of the Social Security Administration set forth a five-step sequential 

evaluation process for determining whether a person has established his or her eligibility 

for disability benefits. See 20 C.F.R. §§ 404.1520, 416.920. The five steps in the process 

are as follows:

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. If 

not, proceed to step two. See 20 C.F.R. §§ 404.1520(b), 416.920(b).

2. Is the claimant’s impairment severe? If so, proceed to step three. If not, then 

the claimant is not disabled. See 20 C.F.R. §§ 404.1520C, 416.920C.

3. Does the impairment “meet or equal” one or more of the specific impairments 

described in 20 C.F.R. Pt. 404, Subpt. P, App. 1? If so, then the claimant is 

disabled. If not, proceed to step four. See 20 C.F.R. §§ 404.1520(d), 

416.920(d).

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. If not, proceed to step five. See 20 C.F.R. §§ 

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404.1520(e), 416.920(e).

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

disabled. If not, then the claimant is disabled. See 20 C.F.R. §§ 404.1520(f), 

416.920(f).

Bustamante v. Massanari, 262 F.3d 949, 954 (9th Cir. 2001).

The claimant bears the burden of proof during steps one through four. Id. at 953. 

The Commissioner bears the burden of proof at step five of the process, where the 

Commissioner must show the claimant can perform other work that exists in significant 

numbers in the national economy, “taking into consideration the claimant’s residual 

functional capacity, age, education, and work experience.” Tackett v. Apfel, 180 F.3d 

1094, 1100 (9th Cir. 1999); see also 20 C.F.R. § 404.1566 (describing “work which 

exists in the national economy”). If the Commissioner fails to meet this burden, then the 

claimant is disabled. If, however, the Commissioner proves that the claimant is able to 

perform other work that exists in significant numbers in the national economy, then the 

claimant is not disabled. Bustamante, 262 F.3d at 953-54. Here, the ALJ determined that 

Plaintiff did not have any severe impairments, and did not proceed beyond step two. 

III. MEDICAL RECORDS AND EVALUATIONS PRE-HEARING

The Court has synthesized Plaintiff’s medical records for the purpose of providing 

context to its analysis of the issues. This summary, however, does not purport to be 

exhaustive of every detail contained in the administrative record.

A. Treatment Notes from Dr. George Malone, M.D. 

Plaintiff saw Dr. Malone on October 15, 2010 as a new patient. (AR at 419.) She 

complained of body aches and “SOB.”

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 (Id.) Dr. Malone assessed Plaintiff with anxiety. 

(Id.) On December 3, 2010, Plaintiff saw Dr. Malone and complained of right hand 

weakness, slight compared to her left hand. (Id. at 415.) Dr. Malone noted no other 

neurological symptoms. (Id.) Plaintiff saw Dr. Malone on July 01, 2011 for complaints 

 

1 The Court understands this to refer to “shortness of breath.”

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of back pain, wrist pain, and depression. (Id. at 394.) On July 29, 2011, Plaintiff saw Dr. 

Malone for a follow up visit wherein she reported numbing in both of her hands. (Id. at 

387.) 

B. Treatment Notes from Rachelle Rene, Ph.D., psychologist

On referral from Dr. Malone, psychologist Rachelle Rene, Ph.D. conducted an 

initial assessment of Plaintiff on May 31, 2011. (Id. at 403-08.) Dr. Rene noted that 

Plaintiff presented with symptoms of depression, including crying spells, decreased 

motivation, decreased energy, difficulty sleeping, increased weight gain, increased 

isolation, and restlessness. (Id. at 403.) Plaintiff reported a history of trauma, and 

complained of being “very tired” and “depressed.” (Id.) Plaintiff also reported a past 

suicide attempt around 2009-2010 while in jail, and current suicidal ideation without 

intent or plans. (Id. at 405.) Plaintiff reported little to no interaction and limited support 

system, and that her depression has affected all levels of her functioning. (Id. at 404.) 

Dr. Rene assessed Plaintiff as depressed, tearful, and anxious, but noted that 

Plaintiff appeared coherent. (Id. at 403.) Dr. Rene diagnosed Plaintiff with Major 

Depressive Disorder, recurrent, moderate, without psychotic features and Generalized 

Anxiety Disorder. (Id. at 403, 406.) 

1. June 2011 Treatment Notes 

On June 07, 2011, Plaintiff reported to Dr. Rene that she was not engaging in 

social activities with friends or family, but stated that she would like to be more 

independent. (Id. at 401-02.) On June 14, 2011, Plaintiff discussed previous suicidal 

ideations and visions of hurting herself, but denied current intent. (Id. at 398-99.) On 

June 21, 2011, Plaintiff stated that she felt more depressed and was visibly tearful. (Id. at 

397.) She acknowledged some suicidal ideations, but denied intent or plans to harm 

herself. (Id.) On June 28, 2011, Plaintiff presented in a good mood and stated that felt “a 

lot better.” (Id. at 395.) Plaintiff denied suicidal ideation at that time. (Id.)

2. July 2011 Treatment Notes 

On July 12, 2011, Plaintiff presented with sad mood and stated that she stayed in 

bed since last session, but denied suicidal ideation. (Id. at 391.) On July 19, 2011,

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Plaintiff noted a positive change in her mood and behavior after spending time with 

family. (Id. at 389.) On July 26, 2011, Plaintiff reported feeling anxious and depressed 

due to recent numbness and tingling in her hands/fingers. (Id. at 388.) She also 

described some suicidal ideation, without intent or plan. (Id.) 

3. August 2011 Treatment Notes

On August 04, 2011, Plaintiff reported not doing well and attributed it to her son 

and daughter-in-law being away. (Id. at 385) Plaintiff stated she could not handle being 

home alone. (Id.) On August 16, 2011, Plaintiff stated that she felt upset, tearful, 

depressed, and isolated after she heard an argument that she interpreted as being about 

her. (Id. at 382.) Plaintiff reported suicidal ideation without intent or plan. (Id.) On

August 23, 2011, Plaintiff explained that she had a “good week” and with no thoughts of 

suicidal ideation. (Id. at 380) Plaintiff stated that she is starting to “do things again” to 

decrease her feelings of isolation. (Id.) On August 30, 2011, Plaintiff told Dr. Rene that

she fell into a depression again where she isolated and experienced crying spells. (Id. at 

375.) Plaintiff also admitted that she has been using the suicidal ideations at home as a 

way to “get attention.” (Id.) 

4. September 2011 Treatment Notes

On September 06, 2011, Plaintiff reported she had no suicidal ideation “at all” this 

week and that she is doing better. (Id. at 374.) Plaintiff complained of forgetfulness and 

poor memory. (Id.)

C. Dr. George Brolaski, M.D., Treating Psychiatrist 

1. Treatment Notes

On August 29, 2011, on referral from Dr. Rene, Plaintiff saw psychiatrist George 

Brolaski at San Ysidro Behavioral Health for evaluation of her depression. (Id. at 376-

79). She reported a longstanding history of depression since childhood. (Id. at 376.) 

Plaintiff stated that she continues to be depressed daily with daily crying spells, a lack of 

interest in former activities, weight gain of about 60 pounds, insomnia, poor memory and 

concentration, and poor decision-making ability. (Id.) She reported having thoughts of 

death and suicidal ideation but without a plan or present intention. (Id.) She also 

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reported auditory hallucinations a few times a month in the form of the voice of her 

mother. (Id.) Mental status examination revealed a sad and worried expression, agitation, 

a depressed mood, and suicidal thoughts. (Id. at 378.) Dr. Brolaski diagnosed Plaintiff 

with Major Depressive Disorder, recurrent, severe, without psychosis, and assessed her 

current GAF at 47. (Id. at 379.)

Plaintiff returned to Dr. Brolaski on June 25, 2012 with diminished sleep of only

three to four hours per night. (Id. at 589.) On July 30, 2012, she was still having 

auditory hallucinations during the night and that she had been living in a rehabilitation 

facility, which was helping her abstain from using crack. (Id. at 586.) As of August of 

2012, Plaintiff had been sleeping and eating well, with fewer auditory hallucinations. 

(Id. at 585.) By September of 2012, she was again not sleeping well due to auditory 

hallucinations, but she was still abstaining from drug use. (Id. at 584.) In October of 

2012, she was again suffering from both auditory and visual hallucinations, but she had 

run out of medications the week prior. (Id. at 583.) In December, her auditory

hallucinations had again been interfering with her sleep. (Id. at 581.)

2. Mental Impairment Questionnaire

On June 6, 2013, Dr. Brolaski completed a Mental Impairment Questionnaire 

based on his treatment of Plaintiff since August of 2011. (Id. at 600-05.) He noted her 

diagnoses of Major Depressive Disorder, recurrent, severe, with psychotic features 

(296.34) with a current GAF of 40, no higher than 40 in the preceding year. (Id. at 600.)

He found her “unable to meet competitive standards” in her abilities to maintain regular

attendance and be punctual within standard tolerances; to maintain attention for two-hour 

segments; to sustain an ordinary routine without special supervision; to work in 

coordination with or proximity to others without being distracted; to complete a normal 

workday and workweek without interruptions from psychological symptoms; to perform 

at a consistent pace without rest periods of unreasonable number and length; to get along 

with co-workers without causing undue distraction or exhibiting behavioral extremes; to 

respond appropriately to changes in the routine work setting; to deal with normal work 

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stress; to be aware of normal hazards and take appropriate precautions; to understand, 

remember, and carry out detailed instructions; to set realistic goals; to deal with stresses 

of skilled or semi-skilled work; to make plans independently; to interact appropriately 

with the general public; and to maintain socially appropriate behavior. (Id. at 602-03.) 

He added that she would likely miss more than four workdays a month due to her

conditions. (Id. at 605.)

D. December 28, 2010, Report by Sandra M. Eriks, M.D., Board Certified

Dr. Eriks completed an internal medicine evaluation of Plaintiff on December 28, 

2010.2 (ECF No. 9-7 at 4.) The report notes that information was obtained from 

plaintiff, “who is considered a poor historian.” (Id.) Plaintiff reported suffering from 

asthma, hypertension, body pain, seizures, dizziness, stomach sickness, and fecal and 

urinary incontinence.3 (Id. at 4-5) Plaintiff reported suffering diffuse body pain, lower 

back pain, and sharp chest pain. (Id. at 4.) Although Plaintiff complained of joint pain, 

Plaintiff’s joints showed no warmth, redness, or effusion. (Id.) Her grip strength 

appeared normal. (Id.) 

Plaintiff stated that she has no domestic responsibilities (e.g. cooking or cleaning). 

(Id. at 5.) Her daughter-in-law bathes her and people bring her food when she does not 

feel like going to the table. (Id.) Plaintiff primary activity is sitting on the couch 

throughout the day. (Id.) 

Dr. Eriks concluded, based on his examination, that Plaintiff “has no restriction in 

areas of lifting, carrying, standing, walking, or sitting. No special limitation in standing, 

walking or sitting. No postural, manipulative, visual, or communicative limitations. 

Environmental limitations- no working at hazardous heights, driving motor vehicle or 

working with hazardous machinery until six months status post most recent seizure.” (Id.

 

2 Dr. Eriks sent a correction letter on February 1, 2011 which modified a sentence in the original report. 

(See ECF No. 9-7 at 13.) This section summarizes the report with this modification.

3 Because Plaintiff’s complaints of carpal tunnel is the only impairment at issue in this appeal, the Court 

only summarizes the portions of Dr. Erik’s report relevant to that analysis. 

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at 8) 

E. Dr. Ghausi, Treating Neurologist

On November 3, 2011, Plaintiff saw neurology resident Galina Nikolskaya for 

evaluation of right arm and right leg paresthesias, neck pain radiating into the arm, and 

intermittent weakness and loss of balance. (Id. at 441-42). The examination revealed 

limited arm abduction secondary to pain, limited wrist movement on the right, right ABP 

atrophy, right thenar eminence atrophy, positive Finkelstein’s maneuver bilaterally, 

positive Tinel’s sign on the right, and an antalgic gait. (Id. at 442-43.) Ms. Nikolskaya’s 

impression was of likely De Quervain’s tenosynovitis, carpal tunnel syndrome in the 

right wrist, and possible cervical radiculopathy, all to be discussed with neurologist Omar 

Ghausi. (Id. at 443.) Neurologist Ghausi later evaluated Plaintiff and found neck pain 

radiating into the right shoulder, as well as her upper extremity numbness and tingling, 

and also found positive Finkelstein’s maneuver bilaterally, severe atrophy of the right 

APB, weakness of bilateral APB, severe on the right and mild on the left, and diffuse

tenderness at any point of her body. (Id. at 440.) Dr. Ghausi assessed severe carpal

tunnel syndrome on the right, mild on the left, superimposed upon de Quervain’s

tenosynovitis, for which he recommended splints, possible steroid injections, and an 

EMG [electromyography]. (Id.) The EMG, dated November 22, 2011, was abnormal, 

showing median nerve lesion at both wrists consistent with carpal tunnel syndrome,

extremely severe on the right and mild to moderate on the left, with no EMG evidence of 

cervical radiculopathy affecting the right upper extremity. (Id. at 436-37, 446-48.)

Plaintiff returned to see Dr. Ghausi on November 29, 2012 with no change in 

symptoms of hand pain and numbness. (Id. at 558.) Notes from this visit state that 

Plaintiff was assessed with carpal tunnel syndrome, severe on the right. (Id.) Dr. Ghausi 

referred Plaintiff to see an “ortho hand” for consideration of surgical intervention, but 

stated that she would continue conservative treatments in the meantime. (Id.)

///

///

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F. Internist Evaluation August 26, 2011 by Phong Dao, D.O., Internal 

Medicine

Phong Dao, D.O., Internal Medicine, completed an Internist Evaluation of Plaintiff 

on August 26, 2011, at the request of The Department of Social Services, Disability 

Evaluation Department. (Id. at 362.) Dr. Dao based his findings on formal testing and 

his observations of Plaintiff’s movements in the waiting room, entering and leaving the 

office and during the interview. (Id. at 363.) Dr. Dao provided the following medical 

source statement: Plaintiff can stand and walk six hours in an eight hour work day. 

Plaintiff can sit six hours in an eight hour work day. Plaintiff can lift ten pounds 

frequently, twenty pounds occasionally. She can stoop or crouch frequently. There are 

no limitations on her ability to reach, handle, and feel or with her vision. (Id. at 365.)

G. Psychiatric Evaluation by Dr. Mounir Soliman, M.D.

State agency examining psychiatrist Mounir Soliman, M.D. conducted a complete 

psychiatric evaluation of Plaintiff on September 12, 2011, at the request of The 

Department of Social Services, Disability Evaluation Department. (Id. at 422-427.) Dr. 

Soliman identified that Plaintiff drove herself to the clinic for the evaluation. (Id. at 422.) 

Dr. Soliman did not determine any problems with Plaintiff’s current level of 

functioning in her activities of daily living. (Id.) He assessed that she is able to cook, 

clean, shop and complete errands, take care of personal hygiene, and take care of 

financial responsibilities. (Id.) The mental status examination indicated that Plaintiff 

was pleasant and cooperative, she was alert and oriented, and her memory was intact. 

(Id. at 424-25.) Plaintiff’s mood was depressed, but she denied current suicidal ideations. 

(Id. at 425.) Plaintiff admitted to auditory hallucinations. (Id.) 

Dr. Soliman diagnosed Plaintiff with major depression with psychotic features and 

post-traumatic stress disorder. (Id.) He determined that, from a psychiatric standpoint, 

Plaintiff is able to: (1) understand, carry out, and remember simple and complex 

instructions; (2) interact with co-workers, supervisors, and the general public; and (3) 

withstand the stress and pressures associated with an eight-hour workday, and day-to-day 

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activities. (Id. at 426.)

H. Psychological Evaluation by Jeremy Trimble, Psy. D.

Dr. Trimble completed a psychological evaluation of Plaintiff on September 7, 

2013 at the request of The Department of Social Services, Disability Evaluation 

Department. (Id. at 606) The report notes that Plaintiff “did not appear to be entirely 

credible as a historian.” (Id.) Dr. Trimble reviewed the following records: Psychiatric 

evaluation dated September 12, 2011 by Mounir Soliman, M.D., as well as a 

questionnaire completed by Plaintiff. (Id.) Plaintiff’s “chief complaint” during this 

evaluation was that she has a learning disability, specifically “understanding and 

remembering things.” (Id.)

Plaintiff reported that she was not prescribed any medications and was not aware 

of any family psychiatric history. (Id. at 607.) Plaintiff indicated that she does not drink, 

but that she had difficulty with alcohol in the past. (Id.) She reported smoking five to ten 

cigarettes a day but denied using any “illicit substances presently or in the past.” (Id.)

Plaintiff stated that she can do household chores, errands, shopping, driving and 

cooking. (Id. at 608.) She dresses herself, bathes herself, and takes care of her personal 

hygiene. (Id.) She denied doing any outside activities or having any hobbies. (Id.) She 

is financially supported by her family, but is capable of paying her own bills and handling 

her own money. (Id.)

Dr. Trimble performed a mental status examination of Plaintiff. (Id.) He noted 

that Plaintiff did not appear to be completely genuine or truthful and at times appeared to 

be exacerbating her deficiencies. (Id.)

With respect to Plaintiff’s thought processes, Dr. Trimble stated that she “was 

coherent and organized.” (Id.) Dr. Trimble reported “no evidence of a thought disorder 

or psychosis. (Id.) Plaintiff reported her mood as “down” but with no “observable 

evidence of depression.” (Id. at 609.) With respect to Plaintiff’s intellectual functioning, 

Dr. Trimble stated that Plaintiff was “credible in the Mental Status Examination portion 

of the interview and it is considered an accurate assessment. She was alert and oriented 

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in all spheres. She appeared to be of low-average intelligence.” (Id.) 

Dr. Trimble stated in his report that the results of this assessment “are not 

considered to be a good representation of claimant’s psychological functioning, as she 

did not appear to put forth much effort. While she may display some mild cognitive 

deficiencies associated with depression, she appeared to be exaggerating these symptoms 

in order to appear more disabled than she actually is. Accordingly, these results should 

be interpreted with caution.” (Id. at 610.)

Based on Plaintiff’s presentation, self-report, and the obtained scores from 

psychological testing, Dr. Trimble concluded that Plaintiff appeared to meet the 

diagnostic criteria for a depressive disorder, but noted that the symptoms she reports “do 

not appear to impair her ability to participate in activities of daily living or to be gainfully 

employed.” (Id. at 612-13.) Dr. Trimble concluded that, “[f]rom a psychological 

perspective alone, [he does] not believe she would be impaired in her ability to work if 

she gave fair effort.” (Id. at 613.)

IV. HEARING BEFORE THE ALJ

A. Plaintiff’s Testimony

Plaintiff testified that she has lived with her adult son, daughter-in-law, and 

granddaughter in San Diego, California since 2010. (Id. at 56.) She completed high 

school, but has not worked in the last twenty years. (Id. at 57.) Plaintiff testified that she 

is physically unable to work. (Id. at 58.) She cannot lift anything because of her legs and 

right hand. (Id.) She is unable to hold a broom handle or mop in her right hand, she is 

unable to cook or clean. (Id.) Plaintiff claims that her “first doctor, Malone [phonetic]” 

prescribed a cane for walking because Plaintiff loses her balance and “falls a lot.” (Id. at 

63.)

Plaintiff also testified that she is not fit to work around people because she is 

mentally unstable and has “a tendency of going off,” which she described as inexplicable 

tantrums. (Id. at 58.) Because of the tantrums, Plaintiff avoids others and remains in her 

room most of the day. (Id.) Plaintiff testified that she was stressed out and depressed. 

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(Id.) Plaintiff does not know the reason for the stress. (Id.) According to Plaintiff, her 

depression has led to suicide attempts. (Id.) Plaintiff testified that she sees a psychiatrist 

on a monthly basis. (Id. at 63.) 

Plaintiff takes ten different medications for pain, depression, nerves, anxiety, and 

chronic obstructive pulmonary disease (COPD). (Id. at 60.) Although she does not know 

what side effects are strictly attributable to the medications, Plaintiff claims that she 

suffers from dizziness, drowsiness, and blackouts. (Id.) Plaintiff admits the medications 

help “a little bit,” but “it all depends on the weather” because the arthritis in her knee and 

left side of her body is temperature sensitive. (Id. at 64) 

Plaintiff testified that she suffers from daily back-to-back seizures that last about 

five minutes and effect Plaintiff’s memory. (Id. at 59, 66.) Although Plaintiff does not 

remember her behavior during a seizure, she has been told that she tries to fight or hit 

others when she is having a seizure. (Id. at 66) Plaintiff claimed that she suffered a 

seizure at home the night before the hearing. (Id. at 61.) 

B. Betty Horn’s Testimony

Betty Horn testified on behalf of Plaintiff at the hearing. (Id. at 66.) She knows 

Plaintiff because her niece is married to Plaintiff’s son. (Id. at 68.) She sees Plaintiff 

three and five times a month. (Id.) Ms. Horn saw that Plaintiff was having a “mild” 

seizure the night before the hearing. (Id.) She knows what seizures look like because her 

grandson has autism and has them. (Id.) When Plaintiff has seizures she “goes out of it . 

. . she’s just in a daze.” (Id. at 68-69.) Sometimes Plaintiff is unconscious, and 

sometimes she is “zoned out.” (Id. at 69.) The seizures last about five minutes. (Id.) 

Plaintiff is not aware of where she is during these seizures, and has a blank look on her 

face. (Id.) She is non-responsive. (Id.)

C. ALJ’s Findings

On March 8, 2014, the ALJ issued his decision denying Plaintiff’s application for

supplemental security income. (Id. at 38.) In reaching his decision, the ALJ applied the 

Commissioner’s five-step sequential disability determination process set forth in 20 

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C.F.R. § 404.1520 and described above.4 (Id. at 28-38.) 

1. Step One

The ALJ found that Plaintiff had not engaged in substantial gainful activity since 

June 29, 2011, her application date. (Id. at 30.) Accordingly, the ALJ determined the 

Plaintiff satisfied step one. (Id.)

2. Step Two

At step two, the ALJ found that Plaintiff had the following medically determinable

impairments: obesity, depressive disorder, history of asthma, carpal tunnel syndrome, 

fibromyalgia and seizure disorder. (Id.) After reviewing the medical records, the ALJ

concluded that Plaintiff does not have an impairment or combination of impairments that 

has significantly limited, or is expected to significantly limit, the ability to perform basic 

work related activities for twelve consecutive months. (Id. at 33.) He, therefore, 

concluded that Plaintiff does not have a severe impairment or combination of 

impairments. (Id.) In reaching this conclusion, the ALJ considered all symptoms and the 

extent to which these symptoms can reasonably be accepted as consistent with the 

objective medical evidence and other evidence. (Id. at 34.) The ALJ also considered 

opinion evidence. (Id.)

In considering Plaintiff’s symptoms, the ALJ must follow a two-step process in 

which it first must be determined whether there is an underlying medically determinable 

physical or impairment(s) that could reasonably be expected to produce the claimant’s 

pain or other symptoms. (Id.) The ALJ determined that medical evidence establishes 

that Plaintiff has these impairments and that they could reasonably be expected to 

produce the alleged symptoms. (Id. at 33, 35.) However, the ALJ found that Plaintiff’s 

statements concerning the intensity, persistence, and limiting effects of the alleged 

symptoms are not entirely credible because the available medical evidence does not 

support the alleged degree of functional limitation. (Id. at 35.) Therefore, the ALJ 

 

4 The Court only summarizes those portions of the ALJ’s opinion relevant to the issues in dispute. 

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concluded that there is insufficient support to conclude that Plaintiff has a single severe 

impairment or a severe combination of impairments. (Id.) 

a. Fibromyalgia and Carpal Tunnel Syndrome

The ALJ noted that apart from various pain medications, there is no indication that 

Plaintiff has required surgery, physical therapy, or pain management for her complaints 

of fibromyalgia and carpal tunnel syndrome. (Id.) The ALJ relied on consultative 

medical examinations conducted in December 2010 and August 2011 that did not 

indicate signs of arthritis, radiculitis, neuropathy, or other serious exertional or postural 

limitations. (Id.) The ALJ noted that Plaintiff failed to attend several scheduled 

rheumatology evaluations for her body pain complaints, and that there is no evidence that 

she continued with any treatment for her reported carpal tunnel syndrome or pain 

complaints. (Id. at 35-36.) The ALJ additionally found that aside from records that 

indicate carpal tunnel syndrome in November 2011 and November 2012, there is no 

further evidence of complaints regarding wrist pain. (Id. at 36.) Finally, the ALJ 

concluded that no treating or examining medical source has assessed Plaintiff as wholly 

incapable of sustaining work activity due to any medical condition. (Id. at 36.)

b. Depressive Disorder

The ALJ also determined there was insubstantial evidence to support a finding of a 

severe mental impairment. (Id.) The ALJ noted that the record does not indicate that 

Plaintiff has required any inpatient psychiatric care and that, despite attending outpatient 

therapy sessions, Plaintiff has consistently performed well upon mental status testing. 

(Id.) The ALJ once again found that Plaintiff has been inconsistent in her complaints, 

noting a particular difference depending on to whom she is speaking. (Id.) During her 

routine visits to the San Ysidro Behavioral Health Center between 2011 and 2013, 

Plaintiff regularly reported feeling fine and generally denied issues with suicidal ideation 

or psychosis, yet during Dr. Soliman’s evaluation for her SSI claim in September 2011, 

she alleged symptoms of auditory hallucinations that were unsubstantiated upon 

examination. (Id.) The ALJ notes that neither the September 2011 consultative 

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psychiatric evaluation nor the September 2013 consultative psychological evaluation 

showed any mental restrictions in Plaintiff’s ability to function in a work setting. (Id.)

c. Treating Physician’s Opinion

The ALJ acknowledged that in June 2013, Plaintiff’s treating physician, Dr. 

Brolaski, assessed Plaintiff as effectively having marked deficits in virtually all areas of 

work-related mental functioning. (Id.) However, the ALJ found that the physician’s 

opinions were not persuasive or controlling in light of the overall record, given that his 

assessment does not consider other factors that must be evaluated by the ALJ, such as the 

other medical reports and opinions and the vocational factors involved. (Id.)

The ALJ found that the previous medical evaluations by this physician and the 

record as a whole contradict a finding that Plaintiff’s medical condition is of disabling 

severity, and that the physician does not provide an assessment of Plaintiff’s residual 

functional capacity (RFC) which is compatible with the record as a whole. (Id.) The 

ALJ did not find a basis of support for the severity of Dr. Brolaski’s assessment of 

Plaintiff’s condition considering his prior mild clinical findings, the lack of more 

intensive treatment, and the findings and assessments of the consultative examiners. (Id.) 

d. Plaintiff’s Credibility

The ALJ noted that because Plaintiff’s allegations of disability are based primarily 

on subjective symptoms, her credibility is a material factor. (Id. at 37.) Based on the 

repeated inconsistencies and contradictions in the evidence, the ALJ concluded that 

Plaintiff is not credible. (Id.) The ALJ found several factors that undermine Plaintiff’s 

general credibility. (Id. at 36.) The ALJ considered that Plaintiff has been inconsistent in 

statements regarding her mental health issues, alternating between assertions of 

depression based on a traumatic personal history and claims of a learning disorder. (Id. at 

37.) The ALJ found Plaintiff’s denial of limitations in her ability to perform daily living 

activities in consultative evaluations to be thoroughly inconsistent with her claims at the 

hearing and in the disability reports, where she reported minimal ability to stand, walk, 

and perform basic daily activities. (Id.) Furthermore, the ALJ relied on evidence that 

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Plaintiff was able to drive herself to a September 2011 examination and that she reported 

engaging in various travels in 2011. (Id.)

The ALJ determined that the great weight of the evidence demonstrates that 

Plaintiff has no limitations caring for herself, driving, or engaging in other daily 

activities, despite her claims to the contrary. (Id.) The ALJ also recognized major 

inconsistency between the medical records from San Ysidro and the complaints Plaintiff 

alleged at the hearing and in her disability reports, noting that if Plaintiff truly had the 

inability to engage in daily living activities, such complaints would appear in her clinical 

outpatient records. (Id.) Thus, the ALJ found that although Plaintiff does have some 

medically determined physical and mental impairments which could be expected to 

produce some symptoms, the intensity and persistence of the pain alleged by Plaintiff is 

exaggerated. (Id.)

e. ALJ’s Determination

Accordingly, the ALJ concluded that even though Plaintiff has medically 

determinable impairments, they do not significantly limit her ability to perform basic 

work-related activities. (Id. at 33.) Therefore, Plaintiff does not have a severe 

impairment or combination of impairments. (Id.) Thus, the ALJ found that Plaintiff did 

not satisfy step two, and is, therefore, not disabled. (Id. at 33, 37.)

On May 1, 2014, Plaintiff requested review of the ALJ’s decision. (Id. at 19.) On 

September 2, 2015, the Office of Disability Adjudication and Review denied Plaintiff’s 

request for review of the ALJ’s decision. (Id. at 1.)

V. SCOPE OF REVIEW

Section 205(g) of the Social Security Act allows unsuccessful applicants to seek 

judicial review of a final agency decision. 42 U.S.C. § 405(g). The scope of judicial 

review is limited. Id. This Court has jurisdiction to enter a judgment affirming, 

modifying, or reversing the Commissioner’s decision. See id.; 20 C.F.R. § 404.900(a)(5). 

The matter may also be remanded to the Social Security Administration for further 

proceedings. Id.

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The Commissioner’s decision must be affirmed upon review if it is: (1) supported 

by “substantial evidence” and (2) based on proper legal standards. Uklov v. Barnhart, 

420 F.3d 1002, 1004 (9th Cir. 2005). If the Court, however, determines that the ALJ’s 

findings are based on legal error or are not supported by substantial evidence, the Court 

may reject the findings and set aside the decision to deny benefits. Aukland v. 

Massanari, 257 F.3d 1033, 1035 (9th Cir. 2001). Substantial evidence is more than a 

scintilla but less than a preponderance. Connett v. Barnhart, 340 F.3d 871, 873 (9th Cir. 

2003). It is “relevant evidence that, considering the entire record, a reasonable person 

might accept as adequate to support a conclusion.” Id.; see also Howard ex rel. Wolff v. 

Barnhart, 341 F.3d 1006, 1012 (9th Cir. 2003) (finding substantial evidence in the record 

despite the ALJ’s failure to discuss every piece of evidence). “Where evidence is 

susceptible to more than one rational interpretation,” the ALJ’s conclusion must be 

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

VI. WHETHER THE ALJ IMPROPERLY ERRED IN FINDING THAT 

PLAINTIFF’S MENTAL IMPAIRMENTS WERE NOT SEVERE

Plaintiff’s argument regarding the ALJ’s determination that her mental 

impairments were not severe contains multiple issues. The Court has addressed these 

issues separately below. 

A. Whether the ALJ Erred in Discounting the Treating Source Opinion of Dr. 

Brolaski

1. Parties’ Arguments

Plaintiff argues that the ALJ improperly discredited Dr. Brolaski’s mental 

impairment questionnaire. Because Dr. Brolaski is Plaintiff’s treating physician, she 

argues that his opinion regarding her functional limitations should have been given

controlling weight. (ECF No. 11-1 at 27.) Defendant counters that the ALJ’s rejection of 

Dr. Brolaski’s mental impairment questionnaire was proper, and based on inconsistencies 

between Dr. Brolaski’s own medical findings and the record as a whole. (ECF No. 14-1 

at 7.) 

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2. Relevant Law

The weight given to medical opinions depends in part on whether they are 

proffered by treating, examining, or non-examining professionals. Lester v. Chater, 81 

F.3d 821, 834 (9th Cir. 1995)). Ordinarily, more weight is given to the opinion of a 

treating professional, who has a greater opportunity to know and observe the patient as an 

individual. Id.; Smolen v. Chater, 80 F.3d 1273, 1285 (9th Cir. 1996). To evaluate 

whether an ALJ properly rejected a medical opinion, in addition to considering its source, 

the court considers whether (1) contradictory opinions are in the record; and (2) clinical 

findings support the opinions. An ALJ may reject an uncontradicted opinion of a treating 

or examining medical professional only for “clear and convincing” reasons. Lester, 81 

F.3d at 831. 

In contrast, a contradicted opinion of a treating or examining medical professional 

may be rejected for “specific and legitimate” reasons that are supported by substantial 

evidence. Id. at 830. While a treating professional’s opinion generally is accorded 

superior weight, if it is contradicted by a supported examining professional’s opinion 

(e.g., supported by different independent clinical findings), the ALJ may resolve the 

conflict. Andrews v. Shalala, 53 F.3d 1035, 1041 (9th Cir. 1995) (citing Magallanes v. 

Bowen, 881 F.2d 747, 751 (9th Cir. 1989)). However, “[w]hen an examining physician 

relies on the same clinical findings as a treating physician, but differs only in his or her 

conclusions, the conclusions of the examining physician are not ‘substantial evidence.”’ 

Orn v. Astrue, 495 F.3d 625, 632 (9th Cir. 2007).

3. Discussion

The ALJ gave Dr. Brolaski’s “checkbox-style form” no weight, stating that “the 

medical findings submitted by this physician and otherwise documented in the record do 

not support a finding that the claimant’s medical condition is of disabling severity, nor 

does the treating physician provide an assessment of the claimant’s residual functional 

capacity which is compatible with the record as a whole.” (AR at 36.) According to the 

ALJ, Dr. Brolaski appeared to have taken Plaintiff’s subjective allegations at face value 

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and merely reiterated those allegations in his report and when making his assertions 

regarding Plaintiff’s ability to work. (Id.) As a result, the ALJ noted that he “duly 

considered” the treating physician’s opinions, but did not find them persuasive or 

controlling. (Id.) 

In Batson v. Comm’r of Soc. Sec. Admin., the Ninth Circuit upheld an ALJ’s 

decision discounting the treating physician’s view because it was in the form of a 

checklist, did not have supporting objective evidence, was contradicted by other 

statements and assessments of Plaintiff’s medical condition, and was based on plaintiff’s 

subjective descriptions of pain. 359 F.3d 1190, 1195 (9th Cir. 2004). Similarly here, Dr. 

Brolaski opined in checklist format that Plaintiff was seriously limited in nearly every 

area of functioning, yet failed to explain how he reached his conclusions and did not 

include the medical or clinical findings to support his assessment. (AR at 600-05.) 

Indeed, Dr. Brolaski’s medical statement contained no narrative language whatsoever. 

Moreover, not only did the ALJ find that Dr. Brolaski’s opinion was unsupported, 

he also found that it was in contradiction to his own treatment records regarding Plaintiff. 

Specifically, the ALJ noted that Dr. Brolaski’s assessment was “inconsistent with his own 

mild clinical findings and those of his facility[.]” (Id. at 36) Thus, given that an ALJ 

may discredit a treating physician’s opinions that are conclusory, brief, and unsupported 

by the record as a whole, it was not legal error for the ALJ to discount Dr. Brolaski’s 

opinions in this case since they were in the form of a checklist, and unsupported by 

objective evidence from Dr. Brolaski and his staff.

5

 See also Tonapetyan v. Halter, 242 

 

5 Plaintiff’s reliance on Van Dyke v. Colvin, 2015 WL 1457953 (C.D. Cal. Mar. 30, 2015) is misplaced. 

In Van Dyke, the Court found that the ALJ erred when he relied on the opinion of an examining 

physician to conclude that the contrary opinion of a treating source was inconsistent with the record as a 

whole. Id. Here, however, the ALJ determined that the medical source statement from Plaintiff’s 

treating physician was unpersuasive based on the fact that it was (1) inconsistent with his own mild 

clinical findings and those of his facility, (2) inconsistent with the absence of a more intensive treatment, 

and (3) inconsistent with the findings and assessments of the consultative examiners. (AR 36.) The 

ALJ further concluded that Dr. Brolaski appeared to rely on Plaintiff’s subjective complaints, which the 

ALJ found to be not credible. (Id.) Unlike in Van Dyke, the opinions of the examining physicians were 

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F.3d 1144, 1149 (9th Cir. 2001). Therefore, the Court RECOMMENDS that summary 

judgment be DENIED on this basis. 

B. Whether the ALJ Erred in Deferring to the Conclusions of the State 

Agency Examiners

1. Parties’ Arguments

Plaintiff argues that the ALJ improperly afforded significant weight to the 

assessments of state agency examiners Drs. Soliman and Trimble, which Plaintiff states 

are internally contradictory and not based on a review of Plaintiff’s treatment history. 

(ECF No. 11-1 at 27.) As such, Plaintiff argues that these reports are entitled to little to 

no weight in the determination of her overall mental function.6 (Id.) Defendant does not 

address this argument in her motion for summary judgment. 

2. The ALJ Did not Err in Affording Weight to Dr. Soliman’s Report

First, the Court takes issue with Plaintiff’s characterization of Dr. Soliman’s 

medical report. Specifically, Plaintiff argues that Dr. Soliman found soft speech with 

decreased rate and rhythm; a depressed mood with congruent affect; decreased 

concentration and energy; and reports of auditory hallucinations “that were sufficient for 

him to endorse the diagnoses of major depression with psychotic features and posttraumatic stress disorder with a current GAF of 60.” (ECF No. 11-1 at 25-26.) While 

these conclusions are found in Dr. Soliman’s report, these statements do not paint a clear 

 

but one factor in the ALJ’s ultimate determination that Dr. Brolaski’s medical source statement was 

unpersuasive. 

6 Plaintiff also argues in passing, without citing to any legal authority, that the ALJ had a duty to seek 

clarification from these examining physicians to clarify the alleged inconsistencies in their reports. 

(ECF No. 11-1 at 26.) Although the Court does not agree that these reports are inconsistent, the 

requirement that the ALJ seek additional information is triggered only when the evidence from the 

treating medical source is inadequate to make a determination as to the claimant’s disability. Thomas v. 

Barnhart, 278 F.3d 947, 958 (9th Cir. 2002)(emphasis added). Moreover, the ALJ did not make a 

finding that the report was inadequate to make a determination regarding Plaintiff’s disability. Instead,

the ALJ recounted the conclusions of the examining physicians as assessing that Plaintiff had “no 

mental restrictions in her ability to function in a work setting.” (AR 36.)

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picture of his overall assessment of Plaintiff.7 

For example, Dr. Soliman concluded, based on Plaintiff’s own admissions, that 

Plaintiff could perform the following activities of daily living: cooking, cleaning, 

shopping, errands, personal hygiene, and financial responsibilities. (AR at 424.) Dr. 

Soliman noted that Plaintiff “is able to focus on daily activities[,]” that her abstract 

thinking was normal, and her “insight was good.” (Id. at 425.) With respect to Plaintiff’s 

affective status, Dr. Soliman stated: “The claimant’s mood was depressed. Affect was 

congruent. The claimant denied current suicidal ideations. The claimant denies current 

homicidal ideations . . .” (Id.) Dr. Soliman stated that, from a psychiatric standpoint, 

Plaintiff “is able to understand, carry out, and remember simple and complex 

instructions. The claimant is able to interact with co-workers, supervisors, and the 

general public. The claimant is able to withstand the stress and pressures associated with 

an eight-hour workday, and day-to-day activities.” (Id. at 426.) 

The Court, therefore, disagrees with Plaintiff’s argument that Dr. Soliman’s 

clinical findings are incompatible with a determination that Plaintiff has no functional 

 

7 Plaintiff emphasizes the fact that both examining physicians gave Plaintiff a GAF of 60, which, she 

argues, contradicts the ALJ’s determination that her mental impairment was not severe. The GAF scale 

provides a measure for an individual’s overall level of psychological, social, and occupational 

functioning. Am. Psych. Ass’n., Diagnostic and Statistical Manual of Mental Disorders 30 (4th 

ed.1994). The scale “may be particularly useful in tracking the clinical progress of individuals in global 

terms, using a single measure.” Id. A GAF score of 60 indicates moderate symptoms (e.g., flat and 

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

functioning (e.g., few friends, conflicts with co-workers). Id. at 32. As noted in the regulations, “[t]he 

GAF scale ... does not have a direct correlation to the severity requirements in [SSA’s] mental disorders 

listings.” Revised Criteria for Evaluating Mental Disorders and Traumatic Brain Injury, 65 Fed.Reg. 

50746, 50764–65 (Aug. 21, 2000). Thus, in evaluating the severity of Plaintiff’s mental impairment, a 

GAF score may help guide the ALJ’s determination, but an ALJ is not bound to consider it. Orellana v. 

Astrue, 2008 WL 398834, at *9 (E.D. Cal. Feb.12, 2008) (“While a GAF score may help the ALJ assess 

Plaintiff’s ability to work, it is not essential and the ALJ’s failure to rely on the GAF does not constitute 

an improper application of the law.”) Accordingly, although the ALJ did not specifically address Drs. 

Soliman and Trimble’s opinion that Plaintiff’s GAF was 60, the ALJ was not bound to consider it. 

Rather, in compliance with 20 C.F.R. § 404.1520a, the ALJ reviewed the evidence, and concluded that 

Plaintiff did not have a severe mental impairment. (AR at 36.) Therefore, the ALJ did not err in failing 

to conclude that Plaintiff had a severe mental impairment, despite being assigned a GAF of 60 by Drs. 

Soliman and Trimble. 

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limitations. Dr. Soliman acknowledged that Plaintiff suffered from depression and posttraumatic stress disorder. He acknowledged this manifested itself in a depressed mood 

and some auditory hallucinations, but concluded that, despite these symptoms, Plaintiff’s 

ability to function in a work setting would not be impaired. Dr. Soliman based his 

conclusions on his own medical assessments of Plaintiff, as well as Plaintiff’s admissions 

during the course of the evaluation. 

While a treating professional’s opinion generally is accorded superior weight, if it 

is contradicted by a supported examining professional’s opinion (e.g., supported by 

different independent clinical findings), the ALJ may resolve the conflict. Andrews, 53 

F.3d at 1041 (citing Magallanes, 881 F.2d at 751.). The Court finds that the ALJ’s 

determination to afford significant weight to the opinion of Dr. Soliman, even though 

contradicted by Dr. Brolaski’s medical source statement, is supported by substantial 

evidence. It is, therefore, RECOMMENDED that summary judgment be DENIED on 

this basis. 

3. The ALJ Did not Err in Affording Weight to Dr. Trimble’s Report

According to Plaintiff, Dr. Trimble, on his mental status examination, found that 

Ms. Cyprain could not recall significant dates from the past or repeat three words that 

were presented to her at the beginning of the interview after a significant delay; that she 

was unable to name the most recent past president of the United States or the current or 

former governor of California; that she appeared to be of low-average intelligence; and 

that she made significant mistakes in serial sevens and two mistakes on spelling the word 

“world” in reverse.” (ECF No. 11-1 at 26.)

While these statements are found in Dr. Trimble’s report, Plaintiff again grossly 

mischaracterizes the overall conclusions of Dr. Trimble. It is true that Dr. Trimble stated 

with respect to intellectual functioning that Plaintiff was “credible in the Mental Status 

Examination portion of the interview” (AR at 609), but he also stated that, with respect to 

the validity of the test results, they should not be “considered to be a good representation 

of claimant’s psychological functioning, as she did not appear to put forth much effort.” 

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(Id. at 610.) Dr. Trimble ultimately concluded that, “[w]hile she may display some mild 

cognitive deficiencies associated with depression, she appeared to be exaggerating these 

symptoms in order to appear more disabled than she actually is. Accordingly, these 

results should be interpreted with caution.” (Id.) 

Again, similar to Dr. Soliman, Dr. Trimble acknowledged that Plaintiff may suffer 

from depression, but concluded that, despite these symptoms, Plaintiff’s ability to 

function in a work setting would not be impaired. (Id. at 612-13.) Dr. Trimble based his 

conclusions on his own medical assessments of Plaintiff, as well as Plaintiff’s admissions 

during the course of the evaluation. The Court finds that this constitutes substantial 

evidence in support of the ALJ’s decision to afford greater weight to the opinion of Dr. 

Trimble than the medical source statement by Dr. Brolaski. It is, therefore, 

RECOMMENDED that summary judgment be DENIED on this basis.

C. Step Two Analysis that Mental Impairment is Not Severe

1. Parties’ Arguments

According to Plaintiff, the ALJ based his determination that Plaintiff’s mental 

impairments were not severe on three reasons: 1) Plaintiff has not required an inpatient 

psychiatric care; 2) Plaintiff consistently performed well on mental status testing, 

showing no signs of psychosis or significant deficits of mood, behavior or cognitive 

functioning; 3) Plaintiff’s inconsistent statements regarding her symptoms. (ECF No. 11-

1 at 19-21.) The Court notes that the ALJ did not rely on any of these factors in isolation, 

but used them in combination with the conclusions of the examining physicians to 

ultimately conclude that Plaintiff’s mental impairments were not severe. The Court will 

address each of Plaintiff’s arguments separately, but will analyze the totality of the record

when determining whether or not the ALJ’s decision was supported by substantial 

evidence in the record. Uklov, 420 F.3d at 1004.

2. Relevant Law

A severe impairment or combination of impairments within the meaning of Step 

Two exists when there is more than a minimal effect on an individual’s ability to do basic 

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work activities. Webb v. Barnhart, 433 F.3d 683, 686 (9th Cir. 2005); Mayes v. 

Massanari, 276 F.3d 453, 460 (9th Cir. 2001); see also 20 C.F.R. §§ 404.1521(a), 

416.921(a) (“An impairment or combination of impairments is not severe if it does not 

significantly limit [a person's] physical or mental ability to do basic work activities.”). 

Basic work activities are “the abilities and aptitudes necessary to do most jobs,” including 

physical functions such as walking, standing, sitting, lifting, pushing, pulling, reaching, 

carrying or handling, as well as the capacity for seeing, hearing and speaking, 

understanding, carrying out, and remembering simple instructions, use of judgment, 

responding appropriately to supervision, co-workers and usual work situations, and 

dealing with changes in a routine work setting. 20 C.F.R. §§ 404.1521(b), 416.921(b); 

Webb, 433 F.3d at 686. If the plaintiff meets her burden of demonstrating she suffers 

from an impairment affecting her ability to perform basic work activities, “the ALJ must 

find that the impairment is ‘severe’ and move to the next step in the SSA’s five-step 

process.” Edlund v. Massanari, 253 F.3d 1152, 1160 (9th Cir. 2001); Webb, 433 F.3d at 

686.

3. Discussion

a. Whether the ALJ erred in relying on Plaintiff’s lack of 

Inpatient Care in Finding her Mental Impairments not Severe

According to Plaintiff, the ALJ improperly concluded that she did not have a 

severe mental impairment based on the incorrect assumption that a mental impairment is 

not severe if it has not required inpatient care. (ECF No. 11-1 at 20.) Defendant counters 

that the ALJ did not state that Plaintiff needed to have been hospitalized for her 

impairment to be considered severe, but that had Dr. Brolaski’s highly restrictive 

assessment regarding marked mental limitations been valid, it would be reasonable to see 

a greater level of treatment. (ECF No. 14-1 at 6 citing AR at 36). The Court agrees that 

the ALJ did not conclude that Plaintiff could not have a severe mental impairment 

because she had not required any inpatient psychiatric care. Nor did the ALJ characterize 

Plaintiff’s treatment as “conservative,” as Plaintiff suggests. 

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Instead, the ALJ concluded that there was a lack of evidence to support a finding of 

a severe mental impairment—one example of the lack of evidence was a lack of inpatient 

care. (AR at 36.) The ALJ went on to note that, “despite attending outpatient therapy 

sessions, the claimant has consistently performed well upon mental status testing, 

showing no signs of psychosis or significant deficits in mood, behavior or cognitive 

functioning.” (Id.) This sentence denotes that, had the ALJ found such results in the 

record, he might have determined Plaintiff to have a severe mental impairment, despite 

no history of inpatient care. Plaintiff misinterprets the ALJ’s conclusion, and, given the 

Court’s reading of the ALJ’s opinion, the Court finds no error in this statement by the 

ALJ. It is, therefore, RECOMMENDED that summary judgment be DENIED on this 

basis.

b. Whether the ALJ Erred in Relying on Plaintiff’s Performance 

on Mental Status Testing in Finding her Mental Impairments 

not Severe

i. Parties’ Arguments

Plaintiff states that the ALJ makes a “totally false assertion that Ms. Cyprain has 

‘consistently performed well on mental status testing, showing no signs of psychosis or 

significant deficits of mood behavior, or cognitive functioning.” (ECF No. 11-1 at 21 

citing AR at 36.) Plaintiff argues that Dr. Rene’s treatment notes from her mental status 

examinations show otherwise. (Id. citing AR at 408, 401, 398, 397, 395, 391, 388, 382, 

375, 487, 481, 467, 460, 533.) Plaintiff also argues that contrary evidence exists in Dr. 

Brolaski’s treatment notes (id. citing AR at 376, 586, 585, 584, 583, 581) and Dr. 

Soliman’s consultative examination (id. citing AR at 422, 425). 

Defendant, in contrast, argues that the ALJ has not misrepresented the record 

regarding Plaintiff’s performance on mental status examinations. Defendant states that, 

while the notes reflect Plaintiff’s symptoms of depression, the records for the most part 

show no cognitive deficits in memory or thought content. (ECF No. 14-1 citing AR at 

374-376, 378, 380, 382, 386, 388-393, 395-398,401-408, 455, 457-461, 463, 465, 467-

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468, 471, 474-477, 480-481, 482-383, 485, 520-522, 533-535, 586-577, 580-586, 589.) 

Defendant also argues that, although Dr. Brolaski’s notes reference auditory 

hallucinations, that occurred at a time when Plaintiff admitted to relapsing to cocaine use. 

(Id. citing AR at 581-586.) Defendant notes that Dr. Trimble reported no complaints of 

auditory hallucinations, and, although Dr. Soliman reported auditory hallucinations, upon 

examination he found no signs of psychosis or abnormal behavior. (Id. citing AR at 608-

09, 425.)

ii. Discussion

The Court acknowledges that Plaintiff had therapy sessions in which she was 

reported as having a normal affect, as well as numerous other sessions where Plaintiff is 

reported as depressed (AR at 375, 379, 382, 388, 391, 397, 398, 401, 403, 405, 406, 408, 

460, 465, 467, 477, 480, 487, 494), tearful (id. at 382, 391, 397, 398, 403, 467, 477) and 

suicidal (id. at 382, 383, 388, 397, 398, 405, 477, 480). However, these statements in 

treatment notes cannot be viewed in isolation, but must be interpreted in the context of 

the record as a whole. For example, although the examining physicians both found that 

Plaintiff had depression (id. at 425 [Dr. Soliman]; id. at 610 [Dr. Trimble]), they also 

concluded that this diagnosis did not impact Plaintiff’s ability to work. (Id. at 426 [Dr. 

Soliman]; id. at 612-13 [Dr. Trimble].) 

The standard under step two is whether or not the impairment has more than a 

minimal effect on an individual’s ability to do basic work activities. Webb, 433 F.3d at

686; Mayes, 276 F.3d at 460; see also 20 C.F.R. §§ 404.1521(a), 416.921(a) (“An 

impairment or combination of impairments is not severe if it does not significantly limit 

[a person’s] physical or mental ability to do basic work activities.”). Despite Plaintiff’s 

diagnosis of depression, there is nothing in the record (other than Dr. Brolaski’s mental 

status assessment which has already been discredited) which supports a conclusion that 

Plaintiff is even minimally impacted in her ability to understand, carry out, and remember

simple instructions, use judgment, respond appropriately to supervision, co-workers and 

usual work situations, and deal with changes in a routine work setting. 20 C.F.R. §§ 

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404.1521(b), 416.921(b); Webb, 433 F.3d at 686. 

Although the record contains certain statements by Plaintiff that she is often 

suicidal, those statements must be balanced with the determination by the ALJ that 

Plaintiff lacks credibility (AR at 36-37) (a determination also supported by substantial 

evidence, see below at (c)(3)), and Plaintiff’s own admissions that she uses threats of 

suicide to get attention. (See id. at 375.) Given this evidence in the record which 

includes the determinations of Drs. Soliman and Trimble, the ALJ’s credibility 

determination of Plaintiff (discussed in more detail in section VI(C)(3)(c), below), and 

Plaintiff’s own admissions which undermine the veracity of her symptoms, the Court 

finds that there is substantial evidence in the record to support the ALJ’s conclusion that 

Plaintiff’s mental impairments were not severe, and did not more than minimally impact 

her ability to work, despite there being some evidence of Plaintiff’s depression in the 

record in the form of her mental status examinations. As such, the Court 

RECOMMENDS a finding that summary judgment be DENIED on this basis. 

c. Whether the ALJ Erred in relying on Plaintiff’s Inconsistent 

Statements in Finding her Mental Impairments not Severe

i. Parties’ Arguments

Plaintiff argues that the ALJ’s conclusion that Plaintiff was inconsistent in 

reporting her symptoms was “contrary to the actual content of the record.” (ECF No. 11-

1 at 21-22.) Plaintiff also argues that periods of improvement, in the context of mental 

impairments, are not inconsistent with disability. (Id. at 22.) Defendant does not address 

this argument in her brief. 

ii. Relevant Law

The Ninth Circuit has established a two-step analysis for the ALJ to evaluate the 

credibility of a claimant’s testimony regarding subjective pain and impairments. Vasquez 

v. Astrue, 572 F.3d 586, 591 (9th Cir. 2008) (citing Lingenfelter v. Astrue, 504 F.3d 1028, 

1035-36 (9th Cir. 2007)). First, the ALJ must determine whether Plaintiff presented 

objective medical evidence of an impairment or impairments that could reasonably be 

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expected to produce the pain or other alleged symptoms. Vasquez, 572 F.3d at 591. 

Second, if Plaintiff satisfies the first step and there is no affirmative evidence of 

malingering, the ALJ may reject a plaintiff’s testimony only if he provides “specific, 

clear and convincing reasons” for doing so. Id.; see also Parra v. Astrue, 481 F.3d 742, 

750 (9th Cir. 2007) (citing Lester, 81 F.3d at 834). These reasons must be “sufficiently 

specific to permit the court to conclude that the ALJ did not arbitrarily discredit the 

claimant’s testimony.” Turner v. Comm’r of Soc. Sec., 613 F.3d 1217, 1224 n. 3 (9th Cir. 

2010) (citation omitted).

In weighing the credibility of a plaintiff’s testimony, the ALJ may use “ordinary 

techniques of credibility determination.” Id. The ALJ may consider the “inconsistencies 

either in his testimony or between his testimony and his conduct, his daily activities, his 

work records, and testimony from physicians and third parties concerning the nature, 

severity and effect of the symptoms of which he complains.” Light v. Soc. Sec. Admin., 

119 F.3d 789, 792 (9th Cir. 1997).

iii. Discussion

The Court cannot discern the basis of Plaintiff’s argument here, and the law cited 

by Plaintiff concerns different legal standards in the social security analysis. Some cases 

concern the legal standards applied in analyzing what weight to afford treating 

physicians. See e.g., Holohan v. Massanari, 246 F.3d 1195, 1207 (9th Cir. 

2001)(finding that the ALJ erred in selectively relying on treatment notes showing 

improvement when discounting the opinion of a treating physician); Lester, 81 F.3d at

833 (analyzing the ALJ’s discounting of a treating physician’s opinion based on medical 

records evidencing sporadic improvement). While one case discuss the credibility 

analysis by the ALJ. See Garrison v. Colvin, 759 F.3d 995, 1017 (9th Cir. 2014)

(analyzing the ALJ’s finding that plaintiff lacked credibility based on select periods of 

improvement over the course of a plaintiff’s treatment). Notably, the ALJ did not discuss 

Plaintiff’s inconsistent statements when ultimately concluding that Plaintiff’s treating 

physician’s opinion had little probative value. Therefore, many of the cases Plaintiff 

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cites are inapplicable. 

As for the ALJ’s credibility analysis, it appears that Plaintiff has conflated the two 

separate steps the ALJ must take in determining a Plaintiff’s credibility. In the first step 

of his analysis, the ALJ determined that the evidence submitted by Plaintiff did not 

support her claims that her depression constituted a severe mental impairment. (AR at 

36.) As one of many examples of the lack of evidence, the ALJ noted that Plaintiff had 

made inconsistent statements regarding her mental impairments. (Id.) For example, the 

ALJ noted that Plaintiff had often denied issues with suicidal ideation or psychosis during 

her visits to the San Ysidro Center. (Id.) During some visits, Plaintiff also reported 

feeling fine or experiencing improvement. (Id.) While she did mention auditory 

hallucinations during her examination by Dr. Soliman, she showed no signs of psychosis. 

(Id.) The inconsistency between her statements and the test results, among other things, 

is what led the ALJ to conclude that the medical evidence failed to support a finding of a 

severe mental impairment. (Id.) (The Court has already analyzed and determined that 

the medical record provided substantial evidence in support of the ALJ’s decision

regarding Plaintiff’s severe mental impairment, see section VI(C)(3)(b), above.)

The ALJ could have stopped at this first step, but proceeded to analyze the second 

step where he concluded that Plaintiff lacked credibility. (Id. at 36-37.) For example, the 

ALJ noted that Plaintiff gave inconsistent statements regarding her mental health issues: 

sometimes asserting depression based on a traumatic personal history and 

other times just claiming she has a learning disorder. The claimant has also 

given highly inconsistent statements regarding her ability to perform daily 

living activities. At the hearing and in the disability reports filed by the 

claimant and her relatives, she reported having minimal ability to stand, 

walk, lift, carry and perform personal care tasks, daily activities and 

household chores. However, the claimant denied any problems engaging in 

such activities during her evaluation with Drs. Soliman and Trimble. The 

claimant was also noted to be able to drive herself to Dr. Soliman’s 

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examination and admitted to engaging in travel in 2011 records from the San 

Ysidro Center.

(Id. at 37.)

In making a credibility determination, the ALJ may consider the “inconsistencies 

either in [a plaintiff’s] testimony or between his testimony and his conduct[.]” Light, 119 

F.3d at 792. Therefore, the Court need only determine whether the ALJ’s interpretation 

of Plaintiff’s statements as inconsistent is reasonable, and supported by substantial 

evidence. Fair v. Bowen, 885 F.2d 597, 604 (9th Cir. 1989). If so, it not this Court’s 

place to second guess the ALJ’s determination. Id. The Court finds that the ALJ’s 

conclusion to discount Plaintiff’s credibility based on her inconsistent statements is 

reasonable. Substantial evidence supports the conclusion that Plaintiff reported being 

able to perform certain activities of daily living to her examining physicians, and stated 

otherwise during the hearing before the ALJ. For example, she reported to Dr. Soliman 

that she could cook, clean, shop, run errands, take care of her personal hygiene and her 

financial responsibilities. (AR at 424.) When meeting with Dr. Trimble, she again 

reported being able to do household chores, errands, shopping, driving and cooking. (Id.

at 608.) She reported that she is able to dress herself, bathe herself, and take care of her 

personal hygiene. (Id.) Dr. Trimble determined that, although Plaintiff was financially 

supported by her family, she was capable of paying her own bills and handling her own 

money. (Id.) These statements are in stark contrast to Plaintiff’s testimony at the hearing 

before the ALJ where she stated that she does not clean or cook at home because she 

“can’t.” (Id. at 57.) Plaintiff also testified that all she does when she is home alone is 

stare at the wall in her room, and that she does not leave the house. (Id. at 64.) 

The Court finds that the ALJ’s conclusion to discount Plaintiff’s credibility based on 

her inconsistent statements is reasonable and based on substantial evidence in the record, 

as explained above. Because the ALJ provided “specific, clear and convincing reasons” 

for discounting Plaintiff’s credibility (Vasquez, 572 F.3d at 591), and because that 

assessment should be given “great weight[,]” this Court RECOMMENDS a finding that 

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the ALJ did not err in in relying on Plaintiff’s inconsistent statements in finding her 

mental impairments not severe, and summary judgment be DENIED on that basis. 

Dominguez v. Colvin, 927 F.Supp.2d 846, 865 (C.D. Cal. 2013).

4. Conclusion

 Because the Court finds that the ALJ’s decision was supported in each instance by 

substantial evidence, it also finds that the overall conclusion of the ALJ that Plaintiff’s 

mental impairments were not severe was supported by substantial evidence. Therefore, 

the Court RECOMMENDS a finding that summary judgment be DENIED on this basis. 

VII. ALJ’S FINDING THAT PLAINTIFF’S CARPAL TUNNEL SYNDROME

IS NOT SEVERE

A. Parties’ Arguments

Plaintiff argues that the ALJ ignored evidence in the record when determining that 

Plaintiff’s carpel tunnel syndrome did not meet the criteria of a severe impairment. (ECF 

No. 11-1 at 27.) Specifically, Plaintiff points to the November 2011 examination by 

neurologist Ghausi which showed evidence of severe carpal tunnel syndrome of the right 

and mild carpal tunnel syndrome on the left. (Id. citing AR at 436-37, 446-48.)

Defendant acknowledges that the ALJ erroneously noted that Plaintiff did not use 

wrist splints, but argues that the error was reasonable because there was little evidence 

that Plaintiff actually used wrist splints, as most medical reports after November 2011, do 

not mention the use of wrist splints (AR at 462, 464, 523, 527, 534, 559, 566, 567, 573, 

578, 641, 647, 653, 664, 670, 676). Defendant argues that it was Plaintiff’s burden to 

submit sufficient evidence to show an impairment in function, and Plaintiff did not do so. 

(ECF No. 14-1 at 10.)

B. Relevant Law

As mentioned above, a severe impairment or combination of impairments within 

the meaning of Step Two exists when there is more than a minimal effect on an 

individual’s ability to do basic work activities. Webb, 433 F.3d at 686; Mayes, 276 F.3d 

at 460; see also 20 C.F.R. §§ 404.1521(a), 416.921(a) (“An impairment or combination 

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of impairments is not severe if it does not significantly limit [a person’s] physical or 

mental ability to do basic work activities.”). Basic work activities are “the abilities and 

aptitudes necessary to do most jobs,” including physical functions such as walking, 

standing, sitting, lifting, pushing, pulling, reaching, carrying or handling, as well as the 

capacity for seeing, hearing and speaking, understanding, carrying out, and remembering 

simple instructions, use of judgment, responding appropriately to supervision, co-workers 

and usual work situations, and dealing with changes in a routine work setting. 20 C.F.R. 

§§ 404.1521(b), 416.921(b); Webb, 433 F.3d at 686. If the plaintiff meets his burden of

demonstrating he suffers from an impairment affecting his ability to perform basic work 

activities, “the ALJ must find that the impairment is ‘severe’ and move to the next step in 

the SSA’s five-step process.” Edlund, 253 F.3d at 1160; Webb, 433 F.3d at 686.

C. Discussion

With respect to Plaintiff’s complaints of body pain/fibromyalgia and carpal tunnel 

syndrome, the ALJ stated the following: 

Apart from various pain medications, there is no indication the claimant has 

required surgery, physical therapy or pain management . . .There is no 

evidence the claimant has received any treatment for her reported carpel 

tunnel syndrome or that she requires surgery or even the use of conservative 

modalities such as wrist splints. In addition, apart from that single mention 

of carpal tunnel in the evidence, no further complaints regarding wrist pain 

are cited in the evidence. Finally, no treating or examining medical source 

has assessed the claimant as wholly incapable of sustaining work activity 

due to any medical condition.

(AR at 35-36.)

Plaintiff was evaluated by neurologist Dr. Ghausi and neurology resident 

Nikolskaya in November of 2011. (Id. at 441-43.) Dr. Ghausi wrote that he suspected 

“two etiologies, one is severe CTS on the right, mild on the left, and superimposed de 

Quervain’s tenosynovitis. Conservative treatments for both counseled. EMG to quantify 

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severity. Splinting bilaterally. Follow up with PMD for consideration of steroid injection 

for tenosynovitis.” (Id. at 440.) Plaintiff had an EMG/NCS lab procedure on November 

22, 2011, which concluded that there were “median nerve lesions at the wrists bilaterally 

(e.g. carpal tunnel syndrome), extremely severe on the right and mild to moderate on the 

left.” (Id. at 437.)

While the record clearly shows that Plaintiff has carpal tunnel syndrome with some 

associated symptoms, as noted by the ALJ there is no clinical evidence of—and no 

medical opinion source has assessed any—actual work-related limitations stemming from 

that impairment. (See id. at 441-443, 440, 436-37; see also Burch, 400 F.3d at 682

(holding that a medical impairment is deemed “‘severe’ . . . when alone or in 

combination with other medically determinable physical or mental impairment(s), it 

significantly limits an individual’s physical or mental ability to do basic work activities.”) 

(internal quotation marks omitted).) Indeed, where no doctor has placed restrictions on 

Plaintiff’s activities or ordered surgery based upon carpal tunnel syndrome, the ALJ 

properly concluded that her carpal tunnel syndrome was not severe.

8 Banks v. Massanari, 

258 F.3d 820, 827, 75 Soc. Sec. Rep. Serv. 8, Unempl. Ins. Rep. (CCH) ¶16675B (8th 

Cir. 2001).

As a result, the Court RECOMMENDS a finding that substantial evidence 

supports the ALJ’s conclusion that Plaintiff’s carpal tunnel syndrome was not a severe 

impairment, and summary judgment should be DENIED as to this issue.

VIII. CONCLUSION

Having reviewed the matter, the undersigned Magistrate Judge RECOMMENDS

that Plaintiff’s motion for summary judgment be DENIED and that Commissioner’s 

cross-motion for summary judgment be GRANTED. This Report and Recommendation 

of the undersigned Magistrate Judge is submitted to the United States District Judge 

 

8 The Court acknowledges the treatment note from Dr. Ghausi referring Plaintiff to see a specialist for 

consideration of surgical intervention. (AR at 558.) However, nothing in the record indicates that 

Plaintiff ever followed through on this referral, or that any specialist ever ordered surgical intervention. 

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assigned to this case, pursuant to 28 U.S.C. § 636(b)(1).

IT IS ORDERED that no later than December 30, 2016, any party to this action 

may file written objections with the Court and serve a copy to all parties. The document 

should be captioned “Objections to Report and Recommendation.”

IT IS FURTHER ORDERED that any reply to the objections shall be filed with 

the Court and served on all parties no later than January 13, 2017.

Dated: December 16, 2016

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