Jardine v. Commissioner of Social Security

— 1 — — 2 — — 3 — — 4 — — 5 — UNITED STATES DISTRICT COURT 6 WESTERN DISTRICT OF WASHINGTON AT SEATTLE — 7 — HALEE L. J., — 8 — Plaintiff, CASE NO. C25-509-BAT — 9 — v. ORDER REVERSING THE 10 COMMISSIONER’S FINAL DECISION COMMISSIONER OF SOCIAL SECURITY, AND REMANDING — 11 — Defendant. — 12 — 13 Plaintiff seeks review of the denial of her application for Supplemental Security Income 14 (SSI) and Disability Insurance Benefits (DIB). She contends the ALJ erroneously rejected the 15 opinions of Dr. Carl Epp, Ph.D., and Dr. Steven Talmadge, Ph.D. Dkt. 12 at 1. For the reasons 16 below, the Court REVERSES the Commissioner’s final decision and REMANDS the matter for 17 further administrative proceedings under sentence four of 42 U.S.C. § 405 (g). 18 BACKGROUND 19 Plaintiff is currently 46 years old, has a high school education, and has no past relevant 20 work. Tr. 33. Plaintiff applied for SSI and DIB on September 2, 2022, alleging a disability onset 21 date of July 1, 2018. Tr. 68, 80. After Plaintiff’s applications were denied initially and upon 22 reconsideration, ALJ William Grayson held a hearing and issued a decision finding Plaintiff not — 23 — 1 disabled. Tr. 17-35. The Appeals Council denied Plaintiff’s request for review, making ALJ 2 Grayson’s decision the final decision of the Commissioner. Tr. 1-6. 3 THE ALJ’S DECISION 4 Using the five-step disability evaluation process,1 the ALJ found Plaintiff has not 5 engaged in substantial gainful activity since the alleged onset date; post-traumatic stress disorder 6 (PTSD), anxiety, major depressive disorder, degenerative disc disease of lumbar spine, obesity, 7 plantar fasciitis, fibromyalgia, migraine headaches, bilateral carpal tunnel syndrome, and chronic 8 obstructive pulmonary disease (COPD) are severe impairments; and these impairments did not 9 meet or equal the requirements of a listed impairment. Tr. 19-20. The ALJ found Plaintiff has the 10 residual functional capacity (RFC) to perform light work as defined in 20 C.F.R. § 404.1567 (b) 11 and § 416.967(b) except: 12 Claimant is limited to occasional stooping, kneeling, crouching, and crawling; can perform frequent handling; should avoid pulmonary irritants, unprotected heights, 13 dangerous machinery, and temperature extremes; can understand and remember simple, routine tasks and sustain these tasks for 2 hours at a time throughout an 814 hour workday; can tolerate occasional interaction with the public, coworkers, and supervisors and occasional changes to the routine work setting. — 15 — Tr. 23. The ALJ found Plaintiff can perform jobs that exist in significant numbers in the — 16 — national economy and is therefore not disabled. Tr. 34. — 17 — DISCUSSION — 18 — The Court will reverse the ALJ’s decision only if it is not supported by substantial — 19 — evidence in the record as a whole or if the ALJ applied the wrong legal standard. Molina v. — 20 — Astrue, 674 F.3d 1104, 1110 (9th Cir. 2012). The ALJ’s decision may not be reversed on account — 21 — of an error that is harmless. Id. at 1111 . The Court may neither reweigh evidence nor substitute — 22 — — 23 — — 1 — 20 C.F.R. §§ 404.1520 , 416.920. 1 its judgment for that of the Commissioner. Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2 2002). Where the evidence is susceptible to more than one rational interpretation, the Court must 3 uphold the ALJ’s interpretation of the evidence. Id. 4 I. Medical Opinion Evidence 5 Plaintiff argues the ALJ erroneously rejected the 2018 opinion of Dr. Carl Epp and the 6 2021 opinion of Dr. Steven Talmadge. Dkt. 12 at 1. The ALJ must consider the persuasiveness of 7 medical opinions using five factors (supportability, consistency, relationship with claimant, 8 specialization, and others), but supportability and consistency are the most important factors. 20 9 C.F.R. §§ 416 .920c(b), 404.1520c(b). 10 Supportability means the extent to which a medical source supports their medical opinion 11 by explaining the relevant objective medical evidence. Woods v. Kijakazi, 32 F.4th 785 , 791-92 12 (9th Cir. 2022). Consistency means the extent to which the medical opinion is consistent with the 13 evidence from the other medical and nonmedical sources in the claim. Id. at 792 . 14 An ALJ cannot reject a doctor’s opinion as unsupported or inconsistent without providing 15 an explanation supported by substantial evidence. Id. Conclusions alone are insufficient – “an 16 ALJ can satisfy the “substantial evidence” requirement by “setting out a detailed and thorough 17 summary of the facts and conflicting evidence, stating his interpretation thereof, and making 18 findings.”” Garrison v. Colvin, 759 F.3d 995, 1012 (9th Cir. 2014) (quoting Reddick v. Chater, — 19 — 157 F.3d 715, 725 (9th Cir. 1998)). 20 a. Dr. Carl Epp, Ph.D. 21 Dr. Carl Epp evaluated Plaintiff on January 16, 2018, and diagnosed her with major 22 depressive disorder, recurrent, severe, without psychotic features; bipolar disorder, unspecified; 23 PTSD; and panic disorder. Tr. 683-84. Dr. Epp opined Plaintiff has marked limitations in her 1 ability to understand, remember, and persist in tasks by following detailed instructions; perform 2 activities within a schedule, maintain regular attendance, and be punctual within customary 3 tolerances without special supervision; and set realistic goals and plan independently. Tr. 685. 4 He opined Plaintiff is moderately limited in her ability to understand, remember, and persist in 5 tasks by following very short and simple instructions; learn new tasks; adapt to changes in a 6 routine work setting; be aware of and take appropriate precautions; communicate and perform 7 effectively in a work setting; and complete a normal workday and work week without 8 interruptions from psychologically based symptoms. Tr. 684-85. He found Plaintiff’s overall 9 severity rating was marked. Tr. 685. 10 The ALJ rejected Dr. Epp’s opinion as unsupported by his examination findings and 11 inconsistent with the medical evidence and other evidence in the record.2 Tr. 31. 12 i. Supportability 13 The ALJ reasoned that Dr. Epp’s opinion was unsupported by his own mental status 14 examination (MSE), which found Plaintiff’s orientation, perception, concentration, and abstract 15 thought were within normal limits. Tr. 31. Plaintiff argues that these findings do not contradict 16 Dr. Epp’s opinion, which she contends is supported by abnormal findings as to her attitude and 17 behavior, mood, affect, and thought process. Dkt. 12 at 4-5. 18 An ALJ may discount a medical opinion if the doctor’s own clinical notes and recorded 19 observations contradict the doctor’s opinion. Bayliss v. Barnhart, 427 F.3d 1211, 1216 (9th Cir. 20 2005). However, as emphasized by the Ninth Circuit, isolated normal findings must be viewed in — 21 — 2 The Court notes the ALJ melds the supportability and consistency factors, stating the opinion was inconsistent 22 with, rather than unsupported by, Dr. Epp’s findings. But the Court can discern the ALJ’s meaning here, as “[c]onsistency with a medical source’s own treatment records is a supportability consideration.” Eddinger v. 23 Comm’r of Soc. Sec. Admin, 2023 WL 10148249 , at *11, n.8 (D. Ariz. Dec. 11, 2023). See also Woods, 32 F.4th at 793, n.4 (“to avoid confusion in future cases, ALJs should endeavor to use these two terms of art – “consistent” and “supported” – with precision.”). 1 the context of “the overall diagnostic picture the provider draws.” Ghanim v. Colvin, 763 F.3d 2 1154, 1162 (9th Cir. 2014) (internal quotation marks omitted). This is particularly important in 3 the context of mental illnesses, the symptoms of which may wax and wane over time. Leah K. v. 4 Comm’r of Soc. Sec., 616 F. Supp. 3d 1099 , 1107 (D. Or. 2022) (citing Garrison, 759 F.3d at 5 1017, n.23). 6 Here, Plaintiff’s MSE showed Plaintiff exhibited a depressed and grieving mood, a 7 subdued affect, and lacked the ability to cope. Tr. 686. Plaintiff endorsed thoughts of self-harm, 8 had markedly impaired memory, and a moderately to markedly impaired fund of knowledge. Tr. 9 686-87. Dr. Epp also noted Plaintiff’s insight and judgment were not within normal limits, 10 stating, “this claimant has very limited emotional/psychological self-insight and needs to be in 11 counseling.” Tr. 687. Dr. Epp’s opined social and behavioral limitations clearly stem from, and 12 are supported by, these findings. The positive information about Plaintiff’s cognitive capabilities 13 (her normal orientation, perception, concentration, and abstract thought) does not contradict the 14 abnormal findings related to Plaintiff’s social and emotional function. See Kaleopa v. O’Malley, — 15 — 2025 WL 48745 , at *4 (S.D. Cal. Jan. 8, 2025). 16 The Commissioner argues Plaintiff fails to explain how the abnormal findings support the 17 limitations related to concentration when her concentration was normal on the MSE. Dkt. 14 at 4. 18 But “mental status exams may be of limited relevance to assessing mental health disorders, 19 where a “snapshot” in time fails to capture the full extent of mental health symptoms[.]” Heckler 20 v. O’Malley, 2024 WL 4766737 , at *10 (D. Haw. Nov. 13, 2024). While it appears Plaintiff’s 21 concentration was intact during the MSE, Dr. Epp noted elsewhere in his report Plaintiff’s major 22 depressive disorder was marked by difficulty concentrating and mental confusion. Tr. 684. Such — 23 — 1 findings support limitations assessed in that domain and are not erased by the snapshot 2 assessment of Plaintiff’s concentration during the MSE. 3 The Court finds the ALJ’s focus on normal MSE results to the exclusion of the other 4 abnormal findings in Dr. Epp’s report is an erroneously selective. See Perez v. Saul, 855 F. 5 App’x 365, 366 (9th Cir. 2021) (rejecting ALJ’s reliance on “cherry-picked” normal findings 6 because they did not “reflect the diagnostic record as a whole.”). An ALJ “cannot reach a 7 conclusion first and then attempt to justify it by ignoring competent evidence in the record that 8 suggests an opposite result.” Gallant v. Heckler, 753 F.2d 1450, 1456 (9th Cir. 1984). The ALJ’s 9 supportability finding is therefore not supported by substantial evidence. 10 ii. Consistency 11 The ALJ also rejected Dr. Epp’s opinion as inconsistent with “generally normal” mental 12 status examinations throughout the record, Plaintiff’s response to treatment, and her ability to 13 perform activities of daily living. Tr. 31. 14 1. Mental Status Examinations 15 The ALJ found Dr. Epp’s opinion inconsistent with mental status exams throughout the 16 record “which repeatedly reflect that claimant is experiencing depression and anxiety but 17 otherwise indicate generally normal findings.” Tr. 31 (citing exhibits 2F, 26F, 28F (Tr. 465-70, 18 1658-1701, 1741-94)). The ALJ noted these exams indicate coherent speech and language; calm, 19 appropriate, and cooperative behavior and good eye contact; orientation to person, place, date, 20 time, and situation; good attention and concentration; no suicidal or homicidal ideation; fair 21 memory; and average estimated intelligence. Tr. 31 (citing exhibits 26F, 28F (Tr. 1658-1701, 22 1741-94)). — 23 — 1 Plaintiff argues the ALJ erroneously separates the depression and anxiety findings from 2 the MSEs to categorize the exam results as normal. Dkt. 12 at 7. She contends most of the MSEs 3 in the record contain abnormal findings regarding mood and affect and were therefore not 4 “generally normal.” Id. The Commissioner asserts the issue is a matter of degree of severity, and 5 Plaintiff simply presents an alternative interpretation of the evidence. Dkt. 14 at 4. 6 As Plaintiff contends, the records cited by the ALJ contain many abnormalities alongside 7 the normal findings, including anxious or depressed mood and blunted affect in nearly every 8 MSE. Tr. 1667, 1684, 1692, 1700, 1749, 1761. The records further reflect Plaintiff often reported 9 high anxiety and she feared leaving her home and interacting with unfamiliar men. Tr. 1672, 10 1675, 1681, 1690, 1742, 1745, 1751, 1753, 1770, 1781, 1789, 1793. On numerous occasions, 11 Plaintiff reported experiencing visual and auditory hallucinations when especially sad or upset 12 (Tr. 1672, 1748, 1767-68, 1777, 1784) and it was noted she occasionally has paranoid thought 13 content and suicidal ideation (Tr. 1698, 1748-50). 14 The medical record cannot reasonably be interpreted as normal. See Emily S. v. Kijakazi, — 15 — 2023 WL 3805257 , at *8 (N.D. Cal. June 1, 2023) (explaining a claimant cannot have “generally 16 normal findings” where her MSEs demonstrate consistent “mood and affect disturbances”). 17 Considering such abnormalities, it is clear that “the ALJ improperly excised the normal findings” 18 from the record, “thereby misrepresenting the full context of the record” to find it inconsistent 19 with Dr. Epp’s opinion. Jason B. v. Comm’r of Soc. Sec., 2023 WL 4621895 , at *2 (W.D. Wash. 20 July 19, 2023). 21 / 22 / 23 / 1 2. Activities of Daily Living and Response to Treatment 2 The ALJ also found Dr. Epp’s opinion inconsistent with Plaintiff’s positive response to 3 treatment and her ability to perform activities of daily living such as grocery shopping, talking on 4 the phone, texting, emailing, crocheting, and watching television. Tr. 31. 5 It is unclear how these activities cited by the ALJ necessarily contradict the limitations 6 opined by Dr. Epp. None of these activities impose work-like requirements on Plaintiff such as 7 maintaining a schedule or meeting performance standards. And Plaintiff is noted as using such 8 activities as coping strategies for her anxiety and depression and doing them “when she feels 9 best,” indicating Plaintiff does not perform them on an ongoing or routine basis, or in a way that 10 would be analogous to a competitive work environment. See, e.g., Tr. 1659, 1667. The ALJ’s 11 vague finding Plaintiff’s activities are inconsistent with Dr. Epp’s opinion without explanation of 12 the supposed conflict is insufficient grounds to reject Dr. Epp’s opinion. Adria H. v. Comm’r of 13 Soc. Sec., 2022 WL 73870 , at *5 (W.D. Wash. Jan. 7, 2022). 14 The ALJ provides no record support for his claim Plaintiff’s conditions have improved 15 with treatment. While Plaintiff has noted counseling has been helpful and reports some symptom 16 improvement with medication, the record reflects her depression, anxiety, insomnia, and mood 17 swings have persisted throughout the years without meaningful change. See generally Tr. 53318 762, 844-69, 888-1213, 1280-1468, 1503-30, 1658-1701, 1741-89) (Plaintiff’s mental health 19 treatment records). While “evidence of medical treatment successfully relieving symptoms can 20 undermine a claim of disability,” Wellington v. Berryhill, 878 F.3d 867, 876 (9th Cir. 2017), 21 simply because a claimant shows some improvement does not mean her symptoms have 22 improved enough that they no longer preclude employment. Garrison, 759 F.3d at 1017 (citing 23 Holohan, 246 F.3d 1195, 1205 (9th Cir. 2001)). 1 Accordingly, the Court finds the ALJ erroneously discounted Dr. Epp’s opinion as 2 inconsistent with the medical evidence and other evidence in the record. 3 b. Dr. Talmadge 4 Dr. Steven Talmadge evaluated Plaintiff on August 26, 2001, and diagnosed her with 5 major depressive disorder, recurrent, mild; PTSD, with delayed expression; and unspecified 6 anxiety disorder. Tr. 466. Dr. Talmadge opined Plaintiff had marked limitations in her ability to 7 adapt to changes in a routine work setting; communicate and perform effectively in a work 8 setting; maintain appropriate behavior in a work setting; and complete a normal workday and 9 work week without interruptions from psychologically based symptoms. Tr. 467. He opined 10 Plaintiff had moderate limitations in her ability to understand, remember, and persist in tasks by 11 following detailed instructions; perform activities within a schedule, maintain regular attendance, 12 and be punctual within customary tolerances without special supervision; and be aware of 13 normal hazards and take appropriate precautions. Id. He also opined Plaintiff’s overall severity 14 rating was marked. Id. 15 The ALJ found Dr. Talmadge’s 2021 opinion unpersuasive on the grounds it was vague 16 and uninformative, unsupported by his examination, and inconsistent with the medical and other 17 evidence in the record. Tr. 31. 18 i. Supportability 19 The ALJ rejected Dr. Talmadge’s opinion as unsupported by his “overall normal” exam 20 findings. Tr. 31. The mental status examination conducted by Dr. Talmadge showed Plaintiff’s 21 thought process and content, orientation, perception, fund of knowledge, concentration, abstract 22 thought, and insight and judgment were all within normal limits. Tr. 468. The MSE also 23 indicated Plaintiff’s mood was downcast and possibly depressed, and her affect was euthymic 1 with “acute emotional distress in evidence due to stress.” Tr. 469. Dr. Talmadge noted Plaintiff’s 2 memory was not within normal limits, explaining she recalled only one out of three objects and 3 performed poorly on digit span. Tr. 468. 4 Elsewhere in his report, Dr. Talmadge noted Plaintiff suffers from a moderate and 5 constant depressed mood that affects her ability to work. Tr. 466. Plaintiff also admitted a history 6 of several suicide attempts combining pills and alcohol, a history of cutting and repeated abusive 7 relationships, and she continues to have suicidal ideation. Tr. 465. Dr. Talmadge cited Plaintiff’s 8 domestic abuse history and the loss of both her parents as contributors to her PTSD. Id. The 9 doctor also indicated Plaintiff has insomnia, self-isolates when depressed, and while she can 10 manage her affairs, she has no plans for the future. Tr. 466. Dr. Talmadge opined despite 11 available treatment Plaintiff’s mental health issues are expected to persist indefinitely. Tr. 467. 12 The ALJ improperly divorces these abnormal findings from the normal MSE results to 13 support his contention Dr. Talmadge’s opinion lacks support. In finding such a discrepancy 14 between Plaintiff’s normal mental and logical functioning and her abnormal emotional and 15 affective processing, the ALJ “appears to reflect a misunderstanding of human psychology and 16 the mental status examination.” Elisa P. v. Acting Comm’r of Soc. Sec., 2021 WL 5833569 , at *2 17 (W.D. Wash. Dec. 9, 2021). The existence of normal findings does not negate the rest of the 18 examination. See Rule v. Saul, 859 Fed. Appx. 754 , 755 (9th Cir. 2021) (explaining that evidence 19 showing a claimant’s “thought processes, memory, and concentration were within normal limits” 20 did not contradict physician’s opinion that claimant “was markedly impaired in her ability to 21 maintain a schedule, communicate with others in a work setting, or plan independently”). 22 In finding Dr. Talmadge’s opinion unsupported, the ALJ also deemed the opinion was 23 vague and uninformative. Tr. 31. A medical opinion can be properly discounted where it is too 1 vague to be useful in making a disability determination. See Meanel v. Apfel, 172 F.3d 1111 , 2 1114 (9th Cir. 1999). However, Dr. Talmadge used the same Washington State Department of 3 Social and Health Services evaluation form3 used by Dr. Epp, whose evaluation the ALJ did not 4 find vague and uninformative. Compare Tr. 465-68 and 683-87. Substantial evidence does not 5 support the ALJ’s finding that Dr. Talmadge’s opinion was vague and uninformative, 6 particularly when Dr. Talmadge included a narrative addendum describing the questions asked 7 and answers given during the MSE, thus providing more detail. See Tr. 469. 8 The Court accordingly finds the ALJ’s supportability finding is not supported by 9 substantial evidence. 10 ii. Consistency 11 The ALJ’s consistency determination regarding Dr. Talmadge’s opinion is identical to the 12 determination used against Dr. Epp’s opinion, except the ALJ also found Dr. Talmadge’s 2021 13 inconsistent with his later 2023 opinion. Tr. 31. As far as the consistency argument is identical to 14 that used by the ALJ in rejecting Dr. Epp’s opinion, it is erroneous for the same reasons 15 discussed above. 16 The ALJ fails to explain how Dr. Talmadge’s 2021 and 2023 opinions are inconsistent. 17 The ALJ must set forth the reasoning behind his decision in a way that allows for meaningful 18 review, building an accurate and logical bridge from the evidence to their conclusions. Brown19 Hunter v. Colvin, 806 F.3d 487, 492 (9th Cir. 2015); Blakes v. Barnhart, 331 F.3d 565, 569 (7th 20 Cir. 2003); see also Embrey v. Bowen, 849 F.2d 418, 422 (9th Cir. 1988) (an ALJ errs when he — 21 — 3 The form used is DSHS 13-865 (Psychological/Psychiatric Evaluation) (available at 22 https://www.dshs.wa.gov/sites/default/files/forms/pdf/13-865.pdf), which contains a checkbox questionnaire on work-related activities similar to that used by the agency, form HA-1152 (Medical Source Statement of Ability to do 23 Work Related Activities (Mental)) (available at https://omb.report/icr/202101-0960-006/doc/108192200). “If the opinion was vague, the culprit is the form, not the doctor.” Jimenez v. Kijakazi, 2023 WL 5722913 , at *5 (E.D. Cal. Sept. 5, 2023) (discussing a form resembling HA-1152). 1 “merely states” that facts “point towards an adverse conclusion” yet “makes no effort to relate 2 any of these” facts to the specific findings he rejects). 3 Accordingly, the Court finds the ALJ erroneously discounted Dr. Talmadge’s 2021 4 opinion as inconsistent. 5 In reviewing the entire record, the Court finds substantial evidence does not support the 6 ALJ’s determination to discount either opinion as unsupported or inconsistent. “In essence, the 7 ALJ developed his evidentiary basis by not fully accounting for the context of materials or all 8 parts of the testimony and reports. His paraphrasing of record material is not entirely accurate 9 regarding the content or tone of the record.” Reddick, 157 F.3d at 722-23 . Had the ALJ properly 10 considered these opinions, the RFC may have included additional limitations, or the ultimate 11 disability determination may have changed. The ALJ’s error is therefore harmful. Stout v. 12 Comm’r, Soc. Sec. Admin., 454 F.3d 1050, 1052, 1054 (9th Cir. 2006) (if the ALJ’s error results 13 in an RFC that omits relevant work-related limitations, the RFC is deficient, and the error is not 14 harmless). 15 CONCLUSION 16 For the foregoing reasons, the Courts REVERSES the Commissioner’s final decision 17 and REMANDS the case for further administrative proceedings under sentence four of 42 18 U.S.C. § 405 (g). On remand, the ALJ shall reassess the opinions of Dr. Epp and Dr. Talmadge, 19 develop the record and reassess Plaintiff’s RFC as needed, and proceed to the remaining steps of 20 the disability evaluation as appropriate. 21 DATED this 29th day of September, 2025. 22 A — 23 — BRIAN A. TSUCHIDA United States Magistrate Judge