Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_06-cv-02329/USCOURTS-caed-2_06-cv-02329-0/pdf.json

Parties Involved:
Commissioner of Social Security
Defendant
Diep Hoang Nguyen
Plaintiff

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IN THE UNITED STATES DISTRICT COURT

FOR THE EASTERN DISTRICT OF CALIFORNIA

DIEP HOANG NGUYEN, No. CIV S-06-2329-CMK

Plaintiff, 

vs. MEMORANDUM OPINION AND ORDER

COMMISSIONER OF SOCIAL 

SECURITY,

Defendant.

 /

Plaintiff, who is proceeding with retained counsel, brings this action for judicial

review of a final decision of the Commissioner of Social Security under 42 U.S.C. § 405(g).

Pursuant to the consent of the parties, this case is before the undersigned for final decision on

plaintiff’s motion for summary judgment (Doc. 24) and defendant’s cross-motion for summary

judgment (Doc. 26). 

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Plaintiff first filed for benefits on August 24, 2001. On November 5, 2001, the 1

agency determined that plaintiff was disabled due to schizophrenic, paranoid, and other

functional disorders. However, on December 7, 2001, plaintiff was informed that he was not

entitled to benefits due to his excess resources. Plaintiff never sought reconsideration of this

determination. By order issued on June 21, 2007, this court granted defendant’s motion to

dismiss this action insofar as it may relate to the December 2001 denial of benefits. This action

is limited to consideration of denial of benefits following plaintiff’s January 2003 application. 

In an adult disability report dated January 13, 2003, plaintiff stated he stopped 2

working in June 2000. 

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I. PROCEDURAL HISTORY

Plaintiff applied for social security benefits on January 13, 2003. In his 1

application, plaintiff claims that disability began on August 13, 2001. Plaintiff claims his 2

disability consists of “severe depression, anxiety, lack of concentration.” Plaintiff is a United

States citizen born in Vietnam on August 27, 1978, with a high school education and some

college courses. Plaintiff’s claim was initially denied. Following denial of his request for

reconsideration, plaintiff requested an administrative hearing, which was held on May 12, 2004,

before Administrative Law Judge (“ALJ”) Antonio Acevedo-Torres. 

In his July 2, 2004, decision, the ALJ made the following findings:

1. The claimant met the disability insured status requirements of the Act on

August 13, 2001, the date the claimant states he became unable to work,

and continued to meet them through December 31, 2003;

2. The claimant has not engaged in substantial gainful activity since [August

13, 2001];

3. The medical evidence establishes that the claimant has severe depression,

but that he does not have an impairment or combination of impairments

listed in, or medically equal to one listed in Appendix 1, Subpart P,

Regulations No. 4; the claimant does not have a severe medical

impairment that would even slightly limited his ability to perform

exertions;

4. The claimant’s testimony is not substantially credible for the reasons

stated in the body of this decision;

5. The claimant has the residual functional capacity to perform the nonexertional requirements of work except for performing work tasks in

excess of a simple, routine, unskilled nature and working in high stress

environments; there are no exertional limitations;

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6. The claimant is able to perform his past relevant work as a caregiver to the

elderly/disabled;

7. The claimant is 25 years old, which is defined as a younger individual;

8. The claimant possesses a high school education;

9. The claimant does not have any acquired skills which are transferable to

the skilled or semi-skilled work functions of other work;

10. If the claimant’s non-exertional limitations did not significantly

compromise his ability to perform work at all exertional levels, section

204.00, Appendix 2, Subpart P, Regulations No. 4 indicates that a finding

of not disabled would be appropriate; if [his] capacity to work at all levels

were significantly compromised, the remaining work which he would

functionally be capable of performing would be considered in combination

with his age, education, and work experience to determine whether a work

adjustment could be made;

11. Considering the range of work at all exertional levels which the claimant is

still functionally capable of performing, in combination with his age,

education, and work experience, and using the above-cited section 204.00

as a framework for decision-making, the claimant is not disabled; and

12. The claimant was not under a “disability,” as defined in the Social Security

Act, at any time through the date of this decision.

Based on these findings, the ALJ concluded that plaintiff was not disabled and, therefore, not

entitled to benefits. After the Appeals Council declined review on August 24, 2006, this appeal

followed.

II. SUMMARY OF THE EVIDENCE

The certified administrative record (“CAR”) contains the following medical

evidence concerning plaintiff’s mental problems: (1) medical data dated February 12, 2002,

from Sierra College Mental Health (CAR 106-09); (2) medical chart dated May 19, 2002, from

Sutter Roseville Medical Center (CAR 110-12); (3) medical records dated March 22, 2001,

through January 24, 2003, from Human Resources Consultants (CAR 114-31); (4) medical

records dated January 6, 2003, through March 7, 2003, from Sacramento County Mental Health

(CAR 133-45); (5) psychiatric evaluation dated May 14, 2003, by examining psychiatrist Michael

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Apparently, treating physician Dr. Giese, who is a psychiatrist with Human 3

Resources Consultants.

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Joyce, M.D. (CAR 146-51); (6) mental residual functional capacity assessment and psychiatric

review technique form dated June 24, 2003 (CAR 173-90); (7) psychiatric review technique form

dated August 27, 2003 (CAR 152-65); (8) medical report dated December 8, 2003, by treating

psychiatrist Arthur T. Giese, M.D. (CAR 207); (9) medical records dated October 13, 2003,

through January 24, 2004, from Human Resources Consultants (CAR 208-23); and (10) medical

report dated May 24, 2004, from Arthur T. Giese, M.D. (CAR 224). 

2001

A document dated March 22, 2001, from Human Resources Consultants indicates

that plaintiff said he had been sentenced for ten days in jail for violating a restraining order and

that he “claims [he is] forced to be Catholic by sponsor.” The physician indicated that plaintiff 3

was “very obsessive & delusional” and he “wondered about schizophrenia.” Plaintiff was started

on Risperdal at 1mg doses. 

Chart notes from Sacramento County Mental health dated March 29, 2001, are

largely undecipherable, but do indicate that plaintiff was “still delusional” and that his Global

Assessment of Functioning (“GAF”) was 45 (out of 100).

On May 1, 2001, plaintiff complained to a physician at Human Resources

Consultants that his optometrist was “clouding my mind” and felt that the optometrist was

engaged in a conspiracy and having “people following me.” The physician assigned a GAF of 42

and indicated that plaintiff rarely complied with medications. By July 5, 2001, plaintiff indicated

that his optometrist was “. . . not bothering me as much” but that he still felt “like he is being

manipulated.” His dosage of Risperdal was increased from 1mg to 2mg. The doctor assigned a

GAF of 40. Notes from July 26, 2001, indicate some dosage alteration of plaintiff’s medications

and a GAF of 40. At this time, plaintiff was started on Effexor XR. By October 30, 2001,

plaintiff indicated that Risperdal had helped his thinking improve. However, the doctor at

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While the agency determined that plaintiff was disabled in 2001 due to 4

schizophrenic, paranoid, and other functional disorders, these records indicate that plaintiff’s

condition had improved significantly by 2002. 

5

Human Resources Consultants indicated that plaintiff rarely took his medications. He also

indicated that plaintiff was paranoid and assigned a GAF of 40. 

2002

Treatment notes from Human Resources Consultants dated February 11, 2002,

describe plaintiff as a 23-year-old male who “casually impresses as a female; long hair,

effeminate mannerisms.” The notes state that plaintiff had been having obsessive

preoccupations. The notes, however, indicate that plaintiff’s condition had improved. 

Specifically, the doctor noted that plaintiff was not delusional, that he was alert and oriented, and

that his mood was neutral. The doctor started plaintiff on Buspar and discontinued Effexor and 4

Risperdal. 

Treatment notes from Sierra College Mental Health dated February 12, 2002,

indicate that plaintiff complained of increasing dizziness “for 1 year.” Plaintiff also complained

of “many stressors” including a car-jacking, robbery, and personal problems. Plaintiff was

referred to a psychiatrist at Sacramento County Mental Health.

On May 19, 2002, plaintiff was seen at Sutter Roseville Medical Center with a

chief complaint of dizziness. This visit does not appear to have revealed any objective findings

related to mental problems. In particular, the doctor indicated “dizziness” as the impression, but

did not indicate any findings supporting this impression or give any causes for the problem.

On May 20, 2002, plaintiff was seen again at Human Resources Consultants. 

Treatment notes from this visit indicate that plaintiff had complained of dizziness for several

weeks. At this time, plaintiff had no other symptoms. The doctor stated that plaintiff “resists

identification [with] gay groups.” 

/ / /

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Given the improvement in his mental state as of 2002, it appears that plaintiff’s

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new complaints of dizziness and fatigue are related to the onset of diabetes and not continuing

severe mental impairments.

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2003

Treatment notes from Human Resources Consultants dated January 6, 2003,

indicate that plaintiff complained at this time of low energy. Plaintiff was prescribed Wellbutrin

SR. His GAF remained 40. In addition, plaintiff was diagnosed with new onset diabetes melitus.

and given appropriate medication. Notes from January 24, 2003, indicate that plaintiff’s goals 5

were to find the right combination of medication and to get back to school within the next 12

months. 

Plaintiff was seen again at Sacramento County Mental Health in January 2003. At

this time, he reported dizziness for the last three years and told the physician that he had been

informed that a cause could not be determined. Notes of clinical observations at this time are

cryptic at best. Treatment notes from February 25, 2003, indicate that plaintiff’s blood glucose

was under control. At this time, plaintiff still reported depression and stated that he had been

seeing a private psychiatrist. While plaintiff indicated that depression was his main issue, he

rejected an offer of county mental health services. 

On May 14, 2003, psychiatrist Michael Joyce, M.D., performed a comprehensive

psychological examination of plaintiff. For his chief complaint, plaintiff reported: “My past . . .

being gay . . . I was often harassed, mostly verbally.” Regarding the past issue with plaintiff’s

optometrist, Dr. Joyce indicated:

The claimant know [sic] longer sees this episode as an issue and I get the

distinct impression that he actually may have had romantic feelings

towards the optometrist, but when they were not fulfilled, he developed a

sort of a delusional response, maybe to save face. 

Dr. Joyce also reported a gambling addiction, stating that plaintiff has an estimated $15,000.00

gambling debt at Cache Creek Casino. At the time of Dr. Joyce’s examination, plaintiff did not

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report any delusional thinking, anxiety, or psychotic problems. As to depression, Dr. Joyce

stated that what this really refers to are complaints of low energy. Based on his objective

findings, Dr. Joyce assigned a GAF of “70 or above” and provided the following summary:

In summary, this claimant appears currently capable of responding

appropriately to supervision, coworkers, or the usual work situation

including changes in a routine setting.

The court notes that, as to diabetes, Dr. Joyce reported that plaintiff “[d]enied diabetes melitus. . .

says his doctor has ruled it out.”

The record contains a mental residual functional capacity assessment dated June

24, 2003, completed by an agency physician. The doctor noted that plaintiff was moderately

limited in his ability to interact appropriately with the public, accept instructions and respond to

criticism, get along with co-workers, maintain socially acceptable behavior, and respond to

changes in the work setting. The doctor noted no other significant limitations. 

The record also contains a psychiatric review technique form dated August 27,

2003, completed by an agency physician. The form notes no restrictions on activities of daily

living, and only mild limitations in ability maintaining social functioning, concentration,

persistence, and pace. 

On November 17, 2003, treating psychiatrist Arthur Giese, M.D., completed a

psychiatric intake note in which he stated:

On interview patient is again very circumstantial, a difficult historian,

displays no hallucinations, delusional ideas, or suicidality at present. 

Intelligence is high average. He is somewhat insightful. Motivation is

positive. 

On December 8, 2003, Dr. Giese completed a physician’s statement. His

diagnosis was “psychosis NOS,” which began in 1999. Without noting any objective findings,

Dr. Giese indicated that plaintiff’s mental problems prevented him from performing any work. 

Even though Dr. Giese indicated that plaintiff could not perform any work activities as a result of

his mental problems, Dr. Giese stated that plaintiff could care for himself at home. 

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 It should also be noted that, while Dr. Giese references chronic fatigue syndrome 6

and diabetes, plaintiff did not complain of either of these problems in his application for benefits. 

Rather, plaintiff’s claim is based on depression, anxiety, and lack of concentration. 

8

2004

On January 5, 2004, Dr. Giese wrote a letter stating:

He is here as a walk-in. He wants to know if we can treat him for chronic

fatigue syndrome. He feels chronically ill and deteriorating, has had all

sorts of medical workups, and nobody knows what is wrong with him. He

also wants to know about the Oregon law, because he has diabetes and

does not want any interference in voluntary euthanasia if he becomes so ill

from it that his life is unbearable. 

He didn’t take the medication for more than a week because it didn’t seem

to be giving him more energy. He remarks that he rarely follows

prescription exactly, he does what he feels best doing. He does not need a

prescription now. 

It is unclear to whom this letter was sent.6

On January 26, 2004, Dr. Giese wrote another letter in which he stated:

25 year old single male with diagnosis of psychosis NOS . . . . He says he

has a gambling problem and also identifies as homosexual. 

Symptomatically he has a good deal of depression. He says he began

gambling at age 18 and has lost the best part of the intervening years. He

used to use the Indian casino or the casinos in Tahoe and Reno.

Again, the record does not reflect to whom this letter was sent. There were no objective

observations accompanying this letter. 

A May 17, 2004, treatment note from Human Resources Consultants indicates: 

“doubtful if he is taking any meds!” 

In May 2004, Dr. Giese wrote a letter to the Social Security Administration Office

of Hearings and Appeals stating:

The above-referenced man has been seen by me since March of

2001. He has a longstanding psychiatric disorder, presently diagnosed as

Psychosis NOS . . . . He is also suffering from non-insulin dependent

diabetes melitus. From the time I first saw him to the present, I consider

him incapable of engaging in fulltime competitive mainstream

employment.

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As with Dr. Giese’s other letters, this letter does not refer to any objective findings. 

III. STANDARD OF REVIEW

The court reviews the Commissioner’s final decision to determine whether it is: 

(1) based on proper legal standards; and (2) supported by substantial evidence in the record as a

whole. See Tackett v. Apfel, 180 F.3d 1094, 1097 (9th Cir. 1999). “Substantial evidence” is

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

(9th Cir. 1996). It is “. . . such evidence as a reasonable mind might accept as adequate to

support a conclusion.” Richardson v. Perales, 402 U.S. 389, 402 (1971). The record as a whole,

including both the evidence that supports and detracts from the Commissioner’s conclusion, must

be considered and weighed. See Howard v. Heckler, 782 F.2d 1484, 1487 (9th Cir. 1986); Jones

v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985). The court may not affirm the Commissioner’s

decision simply by isolating a specific quantum of supporting evidence. See Hammock v.

Bowen, 879 F.2d 498, 501 (9th Cir. 1989). If substantial evidence supports the administrative

findings, or if there is conflicting evidence supporting a particular finding, the finding of the

Commissioner is conclusive. See Sprague v. Bowen, 812 F.2d 1226, 1229-30 (9th Cir. 1987). 

Therefore, where the evidence is susceptible to more than one rational interpretation, one of

which supports the Commissioner’s decision, the decision must be affirmed, see Thomas v.

Barnhart, 278 F.3d 947, 954 (9th Cir. 2002), and may be set aside only if an improper legal

standard was applied in weighing the evidence, see Burkhart v. Bowen, 856 F.2d 1335, 1338 (9th

Cir. 1988). 

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IV. DISCUSSION

In his motion for summary judgment, plaintiff raises the following five issues: 

(1) whether the ALJ failed to resolve inconsistencies in the evidence by fully developing the

record; (2) whether the ALJ improperly rejected his treating physician’s opinion; (3) whether the

ALJ erred with respect to evaluation of plaintiff’s mental impairment; (4) whether the ALJ failed

to provide specific findings or analysis, as required by Social Security Ruling 82-62, in support

of the conclusion that plaintiff could return to his past relevant work; and (5) whether the ALJ

erred by failing to obtain testimony from a vocational expert given the finding that plaintiff was

limited to a low-stress job. 

A. Duty to Develop the Record

The ALJ has an independent duty to fully and fairly develop the record and assure

that the claimant’s interests are considered. See Tonapetyan v. Halter, 242 F.3d 1144, 1150 (9th

Cir. 2001). When the claimant is not represented by counsel, this duty requires the ALJ to be

especially diligent in seeking all relevant facts. See id. This requires the ALJ to “scrupulously

and conscientiously probe into, inquire of, and explore for all the relevant facts.” Cox v.

Califano, 587 F.2d 988, 991 (9th Cir. 1978). Ambiguous evidence or the ALJ’s own finding that

the record is inadequate triggers this duty. See id. The ALJ may discharge the duty by

subpoenaing the claimant’s physicians, submitting questions to the claimant’s physicians,

continuing the hearing, or keeping the record open after the hearing to allow for supplementation

of the record. See id. (citing Tidwell v. Apfel, 161 F.3d 599, 602 (9th Cir. 1998)). 

Plaintiff’s argument concerning development of the record relates to plaintiff’s

diabetes. Specifically, plaintiff argues:

In his decision, the ALJ noted that the record does not contain

evidence of “regular medical treatment, use of insulin, emergency

hospitalization visits, end organ damage, or significant objective clinical

findings due to diabetes.” (Tr. 17). Indeed he concluded there were “no

objective clinical findings whatsoever in the record that the claimant’s

ability to perform exertions would be even minimally compromised by

diabetes melitus. Hence this is deemed to be of a nonsevere nature.” 

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26 Even so, the court notes that the CAR contains records through May 2004. 7

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The ALJ never ordered or sought out those records. Mr. Nguyen’s

hearing was in May 2004. The latest records in the file were ordered in

August 2003. Mr. Nguyen was not represented and did not know what 7

was in and was not in the file. The ALJ never informed him that the

record was incomplete. Before making negative findings contrary to the

plaintiff’s interest, the ALJ had a duty to obtain the information. . . .

In response, defendant argues that the duty to develop the record was not triggered because the

ALJ did not note inadequate information or ambiguity. Defendant states:

Here, the record regarding Plaintiff’s diabetes was neither

ambiguous, nor inadequate, and the ALJ did not note any lack of

information or ambiguity in the record. . . . [T]he medical evidence

indicates that Plaintiff’s diabetes was under control with medication as

long as Plaintiff was compliant. (See Tr. 141, 147, 211). Plaintiff’s

treating physician noted that Plaintiff[’s] diabetes was under control with

medication. (Tr. 211). The ALJ was entitled to infer from [the] lack of

objective findings that his diabetes was not sufficiently severe to

significantly limit his ability to perform his past relevant work. See Flaten

v. Secretary of HHS, 44 F.3d 1453, 1464 (9th Cir. 1995). 

As stated above, the ALJ’s duty to develop the record, which is heightened when

the claimant is not represented by counsel, is triggered only when the record is ambiguous or

inadequate to make a determination. See Cox, 587 F.2d at 991. In this case, the record was

neither ambiguous nor inadequate. To the contrary, it is clear that plaintiff’s diabetes is not a

disabling condition. In particular, and as the ALJ stated, the record was devoid of any clinical

findings suggesting that plaintiff’s diabetes is disabling. In contrast to the lack of evidence that

diabetes is disabling, treatment notes from February 25, 2003, indicate that plaintiff’s blood

glucose was under control. And, in May 2003, when plaintiff was examined by Dr. Joyce,

plaintiff denied diabetes, telling Dr. Joyce that his “doctor has ruled it out.” The court concludes

that the lack of evidence does not indicate ambiguity or inadequacy such as would trigger the

ALJ’s duty to develop the record as to diabetes. 

/ / /

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B. Evaluation of Medical Opinions

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

proffered by treating, examining, or non-examining professionals. See Lester v. Chater, 81 F.3d

821, 830-31 (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,

than the opinion of a non-treating professional. See id.; Smolen v. Chater, 80 F.3d 1273, 1285

(9th Cir. 1996); Winans v. Bowen, 853 F.2d 643, 647 (9th Cir. 1987). The least weight is given

to the opinion of a non-examining professional. See Pitzer v. Sullivan, 908 F.2d 502, 506 & n.4

(9th Cir. 1990).

In addition to considering its source, to evaluate whether the Commissioner

properly rejected a medical opinion the court considers whether: (1) contradictory opinions are

in the record; and (2) clinical findings support the opinions. The Commissioner may reject an 

uncontradicted opinion of a treating or examining medical professional only for “clear and

convincing” reasons supported by substantial evidence in the record. See Lester, 81 F.3d at 831. 

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

by an examining professional’s opinion which is supported by different independent clinical

findings, the Commissioner may resolve the conflict. See Andrews v. Shalala, 53 F.3d 1035,

1041 (9th Cir. 1995). A contradicted opinion of a treating or examining professional may be

rejected only for “specific and legitimate” reasons supported by substantial evidence. See Lester,

81 F.3d at 830. This test is met if the Commissioner sets out a detailed and thorough summary of

the facts and conflicting clinical evidence, states her interpretation of the evidence, and makes a

finding. See Magallanes v. Bowen, 881 F.2d 747, 751-55 (9th Cir. 1989). Absent specific and

legitimate reasons, the Commissioner must defer to the opinion of a treating or examining

professional. See Lester, 81 F.3d at 830-31. The opinion of a non-examining professional,

without other evidence, is insufficient to reject the opinion of a treating or examining

professional. See id. at 831. In any event, the Commissioner need not give weight to any

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conclusory opinion supported by minimal clinical findings. See Meanel v. Apfel, 172 F.3d 1111,

1113 (9th Cir. 1999) (rejecting treating physician’s conclusory, minimally supported opinion);

see also Magallanes, 881 F.2d at 751. 

Plaintiff argues that the ALJ’s “reasons for rejecting the treating physician’s

opinion are not supported by substantial evidence of the record.” Specifically, he contends that: 

(1) the assessments from the consultative examiner and the non-examining physicians were not

based on a review of the entire record; (2) the ALJ failed to take into consideration the side

effects of medication plaintiff was taking; (3) the treating physician’s opinion was based on his

examination of plaintiff, not subjective complaints alone; and (4) the ALJ erred in concluding

that plaintiff’s daily activities undermined the credibility of the treating physician’s opinion as to

limitations. Plaintiff challenges the ALJ’s rejection of Dr. Giese’s May 2004 letter. As to Dr.

Giese, the ALJ stated:

The record also contains a May 2004 letter from sometimes treating

psychiatrist Dr. Arthur Giese, M.D., which opined that the claimant’s

psychosis and personality disorder precluded him from working. 

However, the undersigned finds that this conclusory one paragraph

assessment lacks credibility as: (1) it is at odds with the assessments from

both the consultative psychiatrist and the two non-examining state agency

psychiatrists; (2) it is inconsistent with the claimant’s lack of use of antidepressant medications; (3) it appears to have been based primarily upon

the claimant’s self-serving subjective statements; (4) the doctor previously

conceded in November 2003 that he only “intermittently” treated the

claimant and had not even seen him since 2002; (5) it does not take into

consideration the claimant’s history of medication noncompliance and

improvement during those periods when he decided to take his

medications; and (6) it is inconsistent with the claimant’s wide ranging

daily living activities. As such, it is concluded that Dr. Giese’s work

assessment is not credible.

Treating physician opinions are generally entitled to significant weight. However,

where the treating physician’s opinion is contradicted, the ALJ need only provide specific and

legitimate reasons supported by the record for rejecting it. See Lester, 81 F.3d at 830. Based on

the court’s review of plaintiff’s medical records, it is clear that Dr. Giese’s opinion is

contradicted. In particular, while Dr. Giese opined that plaintiff was unable to perform any work

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due to mental problems, examining agency psychiatrist Dr. Joyce reached the opposite

conclusion following his May 14, 2003, evaluation of plaintiff. Furthermore, the court finds that

the reasons given by the ALJ for rejecting Dr. Giese’s contradicted opinion are specific and

legitimate. See e.g. Meanel, 172 F.3d at 1113 (holding that court may reject conclusory

unsupported opinion). 

The question, then, is whether the ALJ’s conclusion as to Dr. Giese is supported

by the record as a whole. The court finds that it is. Dr. Joyce performed a detailed psychiatric

evaluation of plaintiff and noted that, at the time of his examination, plaintiff did not report any

delusional thinking, anxiety, or psychotic problems. As to depression, Dr. Joyce stated that what

this really refers to are complaints of low energy. Dr. Joyce’s report references objective findings

based on a number of tests. For example, Dr. Joyce reported that plaintiff “[r]equires one trial to

learn 4/4 new skills.” He also performed a recall test, a calculations test, an abstractions test, and

an attention test, among others. Based on his evaluation, Dr. Joyce concluded that there was

“[n]o evidence for a primary mood, thought, or anxiety disorder. . .” and assigned plaintiff a GAF

of 70 – well within the functional range – and concluded that plaintiff was not limited in any way

due to mental problems. Dr. Joyce’s opinion alone constitutes sufficient evidence in the record

to support the ALJ’s rejection of Dr. Giese’s opinion.

There is, however, additional evidence supporting the ALJ’s analysis. While

plaintiff had complained of mental problems in 2001, the February 11, 2002, treatment notes

from Human Resources Consultants – where Dr. Giese treated plaintiff – indicate that plaintiff’s

condition had improved. Specifically, the doctor noted that plaintiff was not delusional, that he

was alert and oriented, and that his mood was neutral. In May 2002, plaintiff was seen again at

Human Resources Consultants. At this time, plaintiff had no symptoms other than dizziness. In

February 2003, even though plaintiff still complained of depression, he rejected an offer of

county mental health services. A psychiatric review technique form dated August 27, 2003,

completed by an agency physician notes no restrictions on activities of daily living, and only mild

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limitations in ability maintaining social functioning, concentration, persistence, and pace. 

Moreover, as the ALJ noted, Dr. Giese himself stated on November 17, 2003, that plaintiff

“displays no hallucinations, delusional ideas, or suicidality at present” and that his 

“[i]ntelligence is high average,” “[h]e is somewhat insightful,” and “[m]otivation is positive.” 

These observations by Dr. Giese are inconsistent with an inability to perform any work activity. 

Contrary to plaintiff’s assertion, the court finds that Dr. Giese’s opinion is indeed

minimally supported, if at all, as the ALJ indicated. It is also inconsistent with the record and Dr.

Giese’s own findings on other occasions. Despite the “timeline” of Dr. Giese’s treatment,

outlined in his motion for summary judgment, the court cannot find any evidence of clinical

objective observations made by Dr. Giese, let alone any which support his opinion that plaintiff

cannot perform any work. The court does not agree with plaintiff that spending time with the

plaintiff and prescribing medications necessarily indicates that Dr. Giese made objective

findings. 

Turning to some of the specific portions of the record cited by plaintiff, the March

22, 2001, “annual assessment” is a listing of plaintiff’s complaints and does not reference any

particular objective findings. The same is true for the March 29, 2001, July 5, 2001, July 26,

2001, and October 30, 2001, progress reports. As with the March 22, 2001, “annual assessment,”

the “annual medication service plan” dated February 11, 2002, is also devoid of objective

findings to support the doctor’s assessment. Dr. Giese’s January 5, 2004, and January 26, 2004,

progress reports do not reference any objective findings but appear to be based solely on

plaintiff’s subjective complaints. In sum, the court cannot find the kinds of objective findings,

such as those noted by Dr. Joyce, which would support Dr. Giese’s conclusions. 

C. Evaluation of Mental Impairment

In determining residual functional capacity, the ALJ must assess what the plaintiff

can still do in light of both physical and mental limitations. See 20 C.F.R. §§ 404.1545(a),

416.945(a) (2003); see also Valencia v. Heckler, 751 F.2d 1082, 1085 (9th Cir. 1985) (residual

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functional capacity reflects current “physical and mental capabilities”). Where there is a

colorable claim of mental impairment, the regulations require the ALJ to follow a special

procedure. See 20 C.F.R. §§ 404.1520a(a), 416.920a(a). The ALJ is required to record pertinent

findings and rate the degree of functional loss. See 20 C.F.R. §§ 404.1520a(b), 416.920a(b). 

Plaintiff argues that the ALJ erred by not following the special procedures

outlined in the regulations in discussing plaintiff’s mental problem. The court agrees with

defendant, however, that any error in omission was harmless. The Ninth Circuit has applied

harmless error analysis in social security cases in a number of contexts. For example, in Stout v.

Commissioner of Social Security, 454 F.3d 1050 (9th Cir. 2006), the court stated that the ALJ’s

failure to consider uncontradicted lay witness testimony could only be considered harmless 

“. . . if no reasonable ALJ, when fully crediting the testimony, could have reached a different

disability determination.” Id. at 1056; see also Robbins v. Social Security Administration, 466

F.3d 880, 885 (9th Cir. 2006) (citing Stout, 454 F.3d at 1056). Similarly, in Batson v.

Commissioner of Social Security, 359 F.3d 1190 (9th Cir. 2004), the court applied harmless error

analysis to the ALJ’s failure to properly credit the claimant’s testimony. The court held:

However, in light of all the other reasons given by the ALJ for

Batson’s lack of credibility and his residual functional capacity, and in

light of the objective medical evidence on which the ALJ relied there was

substantial evidence supporting the ALJ’s decision. Any error the ALJ

may have committed in assuming that Batson was sitting while watching

television, to the extent that this bore on an assessment of ability to work,

was in our view harmless and does not negate the validity of the ALJ’s

ultimate conclusion that Batson’s testimony was not credible.

Id. at 1197 (citing Curry v. Sullivan, 925 F.2d 1127, 1131 (9th Cir. 1990)). 

In Curry, the Ninth Circuit applied the harmless error rule to the ALJ’s error with respect to the

claimant’s age and education. 

As defendant notes, the procedure outlined in the regulations for evaluating

mental problems is designed to assist the ALJ in determining whether a mental impairment is

severe enough to meet or medically equal an impairment listed in the regulations. In this case,

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based on the conclusions reached by Dr. Joyce, the court finds that, even had the procedure been

strictly followed, no reasonable ALJ would have reached a different disability determination with

respect to plaintiff’s mental problems. For this court to remand to require the ALJ to follow the

procedures for evaluating the severity of plaintiff’s mental impairment would be an exercise in

futility.

D. Past Relevant Work

Plaintiff’s argument, in its entirety, is as follows:

According to SSR 82-62 “past work experience must be considered

carefully to assure that [t]he available facts support a conclusion regarding

the claimant’s ability or inability to perform the functional activities

required in this work.” SSR 82-62 further provides:

The decision as to whether the claimant retains the functional

capacity to perform past work which has current relevance has farreaching implications and must be developed fully in the disability

decision. Since this is an important and, in some instances, a

controlling issue, every effort must be made to secure evidence that

resolves the issue as clearly and explicitly as circumstances permit.

Pursuant to SSR 82-62, in finding that an individual has the

capacity to perform a past relevant job, the determination or decision must

contain among the findings the following specific findings of fact: (1) a

finding of fact as to the individual’s RFC; (2) a finding of fact as to the

physical and mental demands of the past job/occupation; and (3) a finding

of fact that the individual’s RFC would permit a return to his past job or

occupation. 

In his decision, the ALJ gave a two sentence paragraph that Mr.

Nguyen could do his past job as a caregiver. He made absolutely no

findings of fact as to the mental or physical demands of that job and there

was no assessment given Mr. Nguyen’s severe depression, as to whether or

not he could perform this job. 

The court rejects plaintiff’s argument. While the ALJ’s analysis is indeed brief, it is sufficient. 

Specifically, the ALJ concluded in his decision that plaintiff has the residual functional capacity

“to perform work in all exertional categories.” The ALJ also found that plaintiff’s mental

impairment did not erode his functional capacity, except with respect to high-stress jobs. This

satisfies the requirement that the ALJ make a specific finding as to residual functional capacity. 

Given that the ability to perform work in all exertional categories necessarily encompasses

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Exertional capabilities are the primary strength activities of sitting, standing, 8

walking, lifting, carrying, pushing, or pulling and are generally defined in terms of ability to

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plaintiff’s past relevant work as a caregiver, and because this work does not involve high levels

of stress, the ALJ also made the remaining two findings of fact. In particular, the ALJ stated that

“[t]he claimant’s past relevant work experience as a caregiver . . . involved the performance of

exertional and nonexertional activities that were well within the claimant’s residual functional

capacity.” 

E. Vocational Expert Testimony

The Medical-Vocational Guidelines (“Grids”) provide a uniform conclusion about

disability for various combinations of age, education, previous work experience, and residual

functional capacity. The Grids allow the Commissioner to streamline the administrative process

and encourage uniform treatment of claims based on the number of jobs in the national economy

for any given category of residual functioning capacity. See Heckler v. Campbell, 461 U.S. 458,

460-62 (1983) (discussing creation and purpose of the Grids). 

The Commissioner may apply the Grids in lieu of taking the testimony of a

vocational expert only when the grids accurately and completely describe the claimant’s abilities

and limitations. See Jones v. Heckler, 760 F.2d 993, 998 (9th Cir. 1985); see also Heckler v.

Campbell, 461 U.S. 458, 462 n.5 (1983). Thus, the Commissioner generally may not rely on the

Grids if a claimant suffers from non-exertional limitations because the Grids are based on

strength factors only. See 20 C.F.R., Part 404, Subpart P, Appendix 2, § 200.00(b). “If a

claimant has an impairment that limits his or her ability to work without directly affecting his or

her strength, the claimant is said to have non-exertional . . . limitations that are not covered by

the Grids.” Penny v. Sullivan, 2 F.3d 953, 958 (9th Cir. 1993) (citing 20 C.F.R., Part 404,

Subpart P, Appendix 2, § 200.00(d), (e)). The Commissioner may, however, rely on the Grids

even when a claimant has combined exertional and non-exertional limitations, if non-exertional

limitations do not impact the claimant’s exertional capabilities. See Bates v. Sullivan, 894 F.2d 8

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perform sedentary, light, medium, heavy, or very heavy work. See 20 C.F.R., Part 404, Subpart

P, Appendix 2, § 200.00(a). “Sedentary work” involves lifting no more than 10 pounds at a time

and occasionally lifting or carrying articles like docket files, ledgers, and small tools. See 20

C.F.R. §§ 404.1567(a) and 416.967(a). “Light work” involves lifting no more than 20 pounds at

a time with frequent lifting or carrying of objects weighing up to 10 pounds. See 20 C.F.R. §§

404.1567(b) and 416.967(b). “Medium work” involves lifting no more than 50 pounds at a time

with frequent lifting or carrying of objects weighing up to 25 pounds. See 20 C.F.R. §§

404.1567(c) and 416.967(c). “Heavy work” involves lifting no more than 100 pounds at a time

with frequent lifting or carrying of objects weighing up to 50 pounds. See 20 C.F.R. §§

404.1567(d) and 416.967(d). “Very heavy work” involves lifting objects weighing more than

100 pounds at a time with frequent lifting or carrying of objects weighing 50 pounds or more. 

See 20 C.F.R. §§ 404.1567(e) and 416.967(e).

Non-exertional activities include mental, sensory, postural, manipulative, and

environmental matters which do not directly affect the primary strength activities. See 20 C.F.R.,

Part 404, Subpart P, Appendix 2, § 200.00(e). 

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1059, 1063 (9th Cir. 1990); Polny v. Bowen, 864 F.2d 661, 663-64 (9th Cir. 1988).

In cases where the Grids are not fully applicable, the ALJ may meet his burden

under step five of the sequential analysis by propounding to a vocational expert hypothetical

questions based on medical assumptions, supported by substantial evidence, that reflect all the

plaintiff’s limitations. See Roberts v. Shalala, 66 F.3d 179, 184 (9th Cir. 1995). Specifically,

where the Grids are inapplicable because plaintiff has sufficient non-exertional limitations, the

ALJ is required to obtain vocational expert testimony. See Burkhart v. Bowen, 587 F.2d 1335,

1341 (9th Cir. 1988). 

Here, the ALJ assumed for the sake of argument that plaintiff could not perform

his past relevant work and considered whether he nonetheless could perform other work. 

Plaintiff argues that the ALJ’s analysis on this question was flawed because he failed to take into

account the limitation to low-stress jobs. According to plaintiff, vocational expert testimony was

required on this point. Plaintiff’s argument, in its entirety, is as follows:

The ALJ found that assuming Mr. Nguyen could not do his past

relevant work, he had the RFC for performing work tasks except in excess

of simple routine unskilled nature and working in high stress

environments. (Tr. 18). SSR 85-15 recognizes that “the mentally

impaired may have difficulty meeting the requirement of even so-called

low stress jobs.” Assuming that the ALJ was correct and there was no

exertional limitations, the ALJ should have considered how much the

occupational base – the entire exertional span from sedentary work

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through heavy (or very heavy) work – is reduced by the effects of the

nonexertional impairment(s). This may range from very little to very

much, depending on the nature and extent of the impairment(s). SSR 85-

15 indicates that in cases like this an adjudicator will need to consult a

vocational resource. The ALJ failed to do so. 

The court rejects plaintiff’s argument for two reasons. First, the court finds that

the ALJ’s analysis as to plaintiff’s ability to perform his past relevant work was correct. 

Therefore, there was no need for the ALJ to consider whether plaintiff could perform other jobs

and any error in this analysis is necessarily harmless. Second, even if the ALJ were required to

consider plaintiff’s ability to perform other work, he correctly applied the Grids because any nonexertional limitations do not impact plaintiff’s exertional capability of sitting, standing, walking,

lifting, carrying, pushing, or pulling. Therefore, vocational expert testimony was not required in

this case. 

V. CONCLUSION

Based on the foregoing, the court concludes that the Commissioner’s final

decision is based on substantial evidence and proper legal analysis. Accordingly, IT IS HEREBY

ORDERED that:

1. Plaintiff’s motion for summary judgment is denied;

2. Defendant’s cross-motion for summary judgment is granted; and

3. The Clerk of the Court is directed to enter judgment and close this file.

DATED: March 27, 2008

______________________________________

CRAIG M. KELLISON

UNITED STATES MAGISTRATE JUDGE

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