Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-4_18-cv-07363/USCOURTS-cand-4_18-cv-07363-0/pdf.json

Parties Involved:
Nancy A. Berryhill
Defendant
Athziri Castaneda
Plaintiff

Document Text:

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORNIA

ATHZIRI CASTANEDA,

Plaintiff,

v.

NANCY A. BERRYHILL,

Defendant.

Case No. 18-cv-07363-DMR 

ORDER ON CROSS MOTIONS FOR 

SUMMARY JUDGMENT

Re: Dkt. Nos. 22, 28

Plaintiff Athziri Castaneda moves for summary judgment to reverse the Commissioner of 

the Social Security Administration’s (the “Commissioner’s”) final administrative decision, which 

found Castaneda no longer disabled due to medical improvement and therefore terminated her 

disability benefits under Title XVI of the Social Security Act, 42 U.S.C. § 401 et seq. [Docket 

No. 22.] The Commissioner cross-moves to affirm. [Docket No. 28.] For the reasons stated 

below, the court grants in part Castaneda’s motion and remands this matter for further 

proceedings.

I. BACKGROUND

On October 3, 2012, Castaneda was found disabled beginning on October 3, 2012. This is 

known as the “comparison point decision” or CPD. Administrative Record (“A.R.”) 16. At the 

time of the CPD, Castaneda had affective mood disorder and major depressive disorder which 

resulted in the inability to sustain a normal 40-hour workweek. A.R. 17. On April 18, 2016, 

pursuant to a continuing disability review, the Social Security Administration found Castaneda 

was no longer disabled as of April 15, 2016. A.R. 15, 85. The determination was upheld on 

reconsideration following a hearing before a Disability Hearing Officer. A.R. 15, 104-110.

An Administrative Law Judge (“ALJ”) held a hearing on December 21, 2017 and issued an 

unfavorable decision on March 6, 2018. A.R. 12-30. The ALJ determined that Castaneda did not 

Case 4:18-cv-07363-DMR Document 30 Filed 03/23/20 Page 1 of 8
2

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

develop any additional impairments after the CPD through April 15, 2016 and that her 

impairments remained the same as of the CPD. A.R. 17. The ALJ found that medical 

improvement occurred on April 15, 2016 and that starting on that date, Castaneda had the 

following residual functional capacity (“RFC”) 

to perform a full range of work at all exertional levels but with the 

following nonexertional limitations: the claimant is capable of 

understanding, remembering, and carrying out simple one to two step 

unskilled tasks. She can maintain concentration, persistence, and 

pace throughout a normal workday and workweek as it relates to 

simple unskilled tasks. The claimant is able to interact adequately 

with coworkers and supervisors but should have no more than 

occasional interactions with coworkers and supervisors. She should 

have no interactions with the public. The claimant is able to make 

adjustments and avoid hazards in the workplace. 

A.R. 19. 

Relying on the opinion of a vocational expert (“VE”) who testified that an individual with 

such an RFC could perform other jobs existing in the economy, including salvage laborer, laundry 

laborer, and fruit and vegetable packer, the ALJ concluded that “since April 15, 2016, [Castaneda] 

has been capable of making a successful adjustment to work that existed in significant numbers in 

the national economy,” and is not disabled. A.R. 24-25.

After the Appeals Council denied review, Castaneda sought review in this court. [Docket 

No. 1.] 

II. CONTINUING DISABILITY REVIEW PROCESS

An individual is disabled for the purpose of receiving benefits under the Act if she 

demonstrates a medically determinable physical or mental impairment that prevents her from 

engaging in substantial gainful activity that is expected to result in death or last for a continuous 

period of at least twelve months. Reddick v. Chater, 157 F.3d 715, 721 (9th Cir. 1998) (citing 42 

U.S.C. § 423(d)(1)(A)). The impairment must render the claimant incapable of performing the 

work she previously performed and incapable of performing any other substantial gainful 

employment that exists in the national economy. Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 

1999) (citing 42 U.S.C. § 423(d)(2)(A)).

After a person is found to be entitled to disability benefits, the Commissioner is required to 

Case 4:18-cv-07363-DMR Document 30 Filed 03/23/20 Page 2 of 8
3

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

periodically review whether continued entitlement to such benefits is warranted. 42 U.S.C. § 

421(i); 20 C.F.R. §§ 404.1589-1590. A claimant’s benefits cannot be terminated unless 

substantial evidence demonstrates medical improvement in her impairment such that the claimant 

is able to engage in substantial gainful activity and is therefore no longer disabled. See 42 U.S.C. 

§ 423(f)(1); 42 U.S.C. § 1382c(a)(4); 20 C.F.R. § 416.994; Flaten v. Sec’y of Health & Human 

Servs., 44 F.3d 1453, 1460 (9th. Cir. 1995). To determine if the claimant continues to be disabled

for Title XVI benefits, an ALJ conducts a seven-step inquiry. 20 C.F.R. § 416.994.

1. At the first step, the ALJ determines whether the claimant has an impairment or 

combination of impairments which meets or medically equals the criteria of an impairment listed 

in 20 C.F.R. Part 404, Subpart P, Appendix 1. If the claimant does, the ALJ will find that the 

claimant continues to be disabled. 

2. At the second step, the ALJ determines if medical improvement has occurred. If medical 

improvement has occurred, the ALJ will proceed to step three. If medical improvement has not 

occurred, the ALJ proceeds to step four.

3. At the third step, the ALJ determines whether medical improvement is related to the 

claimant’s ability to work. If it is, the ALJ proceeds to step five. 

4. At the fourth step, the ALJ determines whether an exception to medical improvement 

applies. There are two groups of exceptions. If one of the first group of exceptions applies, the 

ALJ will go to step five. If one of the second group of exceptions applies, the ALJ will find that 

the claimant’s disability has ended. 

5. At the fifth step, the ALJ determines whether all the claimant’s current impairments in 

combination are severe within the meaning of 20 C.F.R. § 416.994(b)(5)(v). If all current 

impairments in combination do not significantly limit the claimant’s ability to do basic work 

activities, the ALJ will find that the claimant is no longer disabled.

6. At the sixth step, the ALJ assesses the claimant’s RFC based on her current impairments 

and determines if she can perform past relevant work. If the claimant has the capacity to perform 

past relevant work, the ALJ will find that the claimant’s disability has ended. If not, the ALJ 

proceeds to the final step.

Case 4:18-cv-07363-DMR Document 30 Filed 03/23/20 Page 3 of 8
4

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

7. At the seventh and final step, the ALJ determines whether other work exists in significant 

numbers in the national economy that the claimant can perform, given her RFC and considering 

her age, education, and past work experience. If the claimant can perform other work, the ALJ 

will find that she is no longer disabled. If the claimant cannot perform other work, the ALJ will 

find that her disability continues. 

III. ISSUES FOR REVIEW

Castaneda argues that the ALJ’s determination that medical improvement occurred is not 

supported by substantial evidence. She also argues that the ALJ’s assessment of her RFC as of 

April 15, 2016 is not supported by substantial evidence. Therefore, the issues are as follows: 

1. Did the ALJ err in finding that medical improvement occurred?

2. Is the ALJ’s determination of Castaneda’s RFC as of April 15, 2016 supported by 

substantial evidence?

IV. STANDARD OF REVIEW

Pursuant to 42 U.S.C. § 405(g), the district court has the authority to review a decision by 

the Commissioner denying a claimant disability benefits. “This court may set aside the 

Commissioner’s denial of disability insurance benefits when the ALJ’s findings are based on legal 

error or are not supported by substantial evidence in the record as a whole.” Tackett, 180 F.3d at 

1097 (citations omitted). Substantial evidence is evidence within the record that could lead a 

reasonable mind to accept a conclusion regarding disability status. See Richardson v. Perales, 402 

U.S. 389, 401 (1971). It is more than a mere scintilla, but less than a preponderance. See Saelee 

v. Chater, 94 F.3d 520, 522 (9th Cir.1996) (internal citation omitted). When performing this 

analysis, the court must “consider the entire record as a whole and may not affirm simply by 

isolating a specific quantum of supporting evidence.” Robbins v. Soc. Sec. Admin., 466 F.3d 880, 

882 (9th Cir. 2006) (citation and quotation marks omitted). 

If the evidence reasonably could support two conclusions, the court “may not substitute its 

judgment for that of the Commissioner” and must affirm the decision. Jamerson v. Chater, 112 

F.3d 1064, 1066 (9th Cir. 1997) (citation omitted). “Finally, the court will not reverse an ALJ’s 

decision for harmless error, which exists when it is clear from the record that the ALJ’s error was 

Case 4:18-cv-07363-DMR Document 30 Filed 03/23/20 Page 4 of 8
5

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

inconsequential to the ultimate nondisability determination.” Tommasetti v. Astrue, 533 F.3d 

1035, 1038 (9th Cir. 2008) (citations and internal quotation marks omitted).

V. DISCUSSION

Castaneda argues that the ALJ’s finding of medical improvement is not supported by 

substantial evidence, asserting that the ALJ’s conclusion that Castaneda did not develop any 

additional impairments after the CPD beyond affective mood disorder and major depressive 

disorder is inaccurate. She notes that treatment records from 2017 show that she met the criteria 

for schizophrenia and agoraphobia. According to Castaneda, the ALJ did not adequately evaluate 

the limitations posed by these impairments that occurred when she is out in public and around 

other people, and instead “focused too narrowly” on her symptoms of depression and affective 

mood disorder in assessing whether she had improved. Pl.’s Mot. 10. 

The regulations define medical improvement as “any decrease in the medical severity of [a 

claimant’s] impairment(s) which was present at the time of the most recent favorable medical 

decision that [the claimant] [was] disabled or continued to be disabled. A determination that there 

has been a decrease in medical severity must be based on changes (improvement) in the 

symptoms, signs, or laboratory findings associated with [the claimant’s] impairment(s).” 20 

C.F.R. § 416.994. 

The record consistently documents Castaneda’s complaints of auditory and visual 

hallucinations and providers’ diagnoses of schizophrenia. For example, in 2012, Castaneda’s 

therapist and care manager noted her diagnosis of schizophrenia and its impact on her functioning. 

Importantly, he noted that she had been diagnosed with schizophrenia “using the SCID (Structured 

Clinical Interview for the DSMIV TR), a th[o]rough assessment that was completed at the PART 

Program at UCSF.” A.R. 335-36. The following year, a psychiatrist, Dr. Tim Sinclair, examined 

her and wrote that Castaneda experienced “paranoid thoughts and 3rd person derisive auditory 

hallucinations,” and that although “her presentation is a bit atypical for schizophrenia,” he felt that 

schizophrenia was “the most accurate diagnosis.” A.R. 548-49. Medical records in 2013 and 

2014 contain references to Castaneda’s hallucinations. See A.R. 429 (Feb. 18, 2014), 559 (Sept. 4, 

2013), 561 (June 10, 2013). 

Case 4:18-cv-07363-DMR Document 30 Filed 03/23/20 Page 5 of 8
6

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

In 2017, when Castaneda resumed treatment, her provider, Susana Scotti, Ph.D., wrote that 

Castaneda met the criteria for schizophrenia, multiple episodes, currently in partial remission. 

A.R. 656. Castaneda repeatedly endorsed auditory and visual hallucinations. A.R. 630-37, 655, 

663. In September 2017, a medical provider with the San Francisco Department of Public Health 

noted her schizophrenia diagnosis and prescribed lurasidone, an anti-psychotic. A.R. 706-16.

Similarly, the record contains references to symptoms and diagnoses of agoraphobia. In 

2014, before the date of purported medical improvement, providers twice noted agoraphobia in 

treatment notes, writing in February 2014 that she “goes out only about twice a week” and in 

August 2014 that she was “still not getting out much. A.R. 513, 534. In 2016, one provider listed 

agoraphobia along with anxiety and paranoid schizophrenia as her diagnoses. A.R. 689. In April 

2017, Dr. Scotti found that Castaneda appeared to meet the criteria for agoraphobia. A.R. 656. 

The record also contains numerous references to symptoms of agoraphobia, including in 

Castaneda’s own reports to the Social Security Administration. In a February 2016 function 

report, she reported that she goes outside “maybe” three times per week but does not go out alone 

as she gets “really anxious and nervous when outside” by herself. A.R. 249. In April 2016, she 

reported that she needs someone to be with her when doing things outside, including using public 

transportation, because she is “uncomfortable, anxious and nervous.” A.R. 266, 268. Finally, at 

the December 21, 2017 hearing, she testified that she does not go outside by herself because she 

gets “really anxious and paranoid.” A.R. 37.

Despite this evidence, the ALJ concluded that Castaneda did not develop any additional 

impairments after the CPD through April 15, 2016. A.R. 17. As part of the continuing disability 

review process, an ALJ must determine whether all of a claimant’s current impairments in 

combination are severe pursuant to 20 C.F.R. § 416.921, and must consider the impact of the 

combination of all impairments on a claimant’s ability to function. 20 C.F.R. § 416.994(b)(5)(v). 

When the evidence shows that all of a claimant’s current impairments in combination do not 

significantly limit his or her physical or mental abilities to do basic work activities, these 

impairments will not be considered severe in nature. Id. A severe impairment “must be 

established by objective medical evidence from an acceptable medical source,” 20 C.F.R. § 

Case 4:18-cv-07363-DMR Document 30 Filed 03/23/20 Page 6 of 8
7

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

416.921, and the ALJ must “consider the claimant’s subjective symptoms, such as pain or fatigue, 

in determining severity.” Smolen v. Chater, 80 F.3d 1273, 1290 (9th Cir. 1996) (citations 

omitted). 

The ALJ did not discuss or explain her conclusion about Castaneda’s severe impairments

in any detail. However, the court finds that any error with respect to the ALJ’s failure to consider 

Castaneda’s diagnosis of schizophrenia as a severe impairment was harmless because substantial 

evidence supports the conclusion that her symptoms of schizophrenia do not significantly limit her 

abilities to do basic work activities. The ALJ discussed Castaneda’s symptoms of schizophrenia 

in the opinion, noting that Castaneda endorsed “severe symptoms including auditory

hallucinations” at the time of the CPD but that the evidence showed that her symptoms had 

improved by 2016. A.R. 18-22. The ALJ also discussed Castaneda’s resumption of treatment in 

2017 and the records from that time. A.R. 21. In February and June 2016, Castaneda denied any 

hallucinations. A.R. 436, 687, 689. When Castaneda resumed treatment in 2017, she reported 

weekly hallucinations. A.R. 663 (Apr. 7, 2017 treatment note). However, later that month, she 

denied any auditory hallucinations and reported only occasional visual hallucinations in the form 

of seeing shadows in her home. A.R. 655. By November 2017, Castaneda reported hearing a 

male voice commenting on her appearance but “stated that hearing the voice is ‘not a problem’” 

and that she was able to cope with her hallucinations. A.R. 485, 492. The provider described her 

as “lighthearted throughout the interview process” and reported that Castaneda said she was 

“hopeful” and motivated. A.R. 491. The court finds that substantial evidence supports the ALJ’s 

conclusion that Castaneda’s hallucinations improved by April 2016; therefore, any error as to 

whether schizophrenia is a severe impairment was harmless.

The court reaches a different conclusion as to the ALJ’s failure to consider Castaneda’s 

documented diagnosis and symptoms of agoraphobia. As discussed above, Dr. Scotti found that 

Castaneda appeared to meet the criteria for agoraphobia in April 2017. A.R. 656. Castaneda 

repeatedly reported symptoms of agoraphobia to the Social Security Administration and to 

treatment providers in 2017. The ALJ noted this evidence, including Castaneda’s statements that 

she felt “anxious when walking outside,” A.R. 687 (July 19, 2016 note, “fearful/anxious when 

Case 4:18-cv-07363-DMR Document 30 Filed 03/23/20 Page 7 of 8
8

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

walking outside, stopped going to school because she did not like to walk back and forth outside 

from home to school”), that “her anxiety was more troubling [than hallucinations],” A.R. 485 

(Nov. 17, 2017 note, “her anxiety was more centered on disliking her commute to school”), that 

she “still had problems going into public spaces alone,” A.R. 632 (June 5, 2017 note, “avoids 

public transportation/crowded spaces ...due to fear of being trapped and experiencing heightened 

anxiety), and that in September 2017, “she again complained of agoraphobia, she did not like to be 

in crowded places such as a bus and reported a tendency to isolate at home.” A.R. 713 (Sept. 5, 

2017 note). Despite this evidence, the ALJ did not include agoraphobia in her discussion of 

whether Castaneda had developed any additional impairments after the CPD, even though as part 

of the continuing disability review process, an ALJ must determine whether all of a claimant’s 

current impairments in combination are severe and must consider the impact of the combination of 

all impairments on a claimant’s ability to function. 20 C.F.R. § 416.994(b)(5)(v). Moreover, the 

ALJ provided very little analysis of Castaneda’s diagnosis and symptoms of agoraphobia and did 

not set forth any reasons for discounting the most recent evidence of the same. Therefore, the 

court cannot say that substantial evidence supports the ALJ’s apparent determination that 

Castaneda does not have agoraphobia and/or that Castaneda’s agoraphobia is not a severe 

impairment within the meaning of the regulations. The ALJ thus erred in finding medical 

improvement based solely on Castaneda’s affective mood disorder and major depressive disorder. 

For this reason, the ALJ’s assessment of Castaneda’s RFC was not supported by substantial 

evidence, because “an RFC that fails to take into account a claimant’s limitations is defective.”

Valentine v. Comm'r. of Soc. Sec. Admin., 574 F.3d 685, 690 (9th Cir. 2009).

VI. CONCLUSION

For the foregoing reasons, Castaneda’s motion for summary judgment is granted in part. 

This matter is remanded for further proceedings in a manner consistent with this opinion.

IT IS SO ORDERED.

Dated: March 23, 2020

______________________________________

Donna M. Ryu

United States Magistrate Judge

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORN

I

A

IT IS SO ORDERED

Judge Donna M. Ryu

Case 4:18-cv-07363-DMR Document 30 Filed 03/23/20 Page 8 of 8