Edmonds v. Commissioner of Social Security Administration

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WO
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF ARIZONA
Karina Joy Edmonds,
Plaintiff,
v.
Commissioner of Social Security
Administration,
Defendant.
No. CV-25-00352-PHX-JJT
ORDER
At issue is the denial of Plaintiff Karina Joy Edmonds’s Application for
Supplemental Security Income by the Social Security Administration (“SSA”) under the
Social Security Act (“the Act”). Plaintiff filed a Complaint (Doc. 1) with this Court seeking
judicial review of that denial, and the Court now addresses Plaintiff’s Opening Brief (Doc.
12, “Pl. Br.”), Defendant Social Security Administration Commissioner’s Answering Brief
(Doc. 14, “Def. Br.”), and Plaintiff’s Reply (Doc. 15). The Court has reviewed the briefs
and Administrative Record (Doc. 8, “R.”) and now reverses the Administrative Law
Judge’s decision (R. at 37–48) as upheld by the Appeals Council (R. at 1–3).
I. BACKGROUND
Plaintiff filed an application for Supplemental Security Income on July 22, 2021,
for a period of disability beginning April 16, 2019. (R. at 37.) Plaintiff’s claims were
initially denied on June 24, 2022, and upon reconsideration on April 15, 2023. (R. at 37.)
Plaintiff then testified at a hearing before an Administrative Law Judge (“ALJ”) on
November 7, 2023. (R. at 54–86.) On March 29, 2024, the ALJ denied Plaintiff’s
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Application. (R. at 37–48.) On March 23, 2023, the Appeals Council denied a request for
review of the ALJ’s decision. (R. at 1–3.) On February 3, 2025, Plaintiff filed this action
seeking judicial review. (Doc. 1.)
The Court has reviewed the medical evidence and finds it unnecessary to provide a
complete summary here; the pertinent medical evidence will be discussed in addressing the
issues raised by the parties. In short, upon considering the medical records and opinions,
the ALJ found that Plaintiff has the following severe impairments: major depressive
disorder, generalized anxiety disorder, adjustment disorder, and post-traumatic stress
disorder (“PTSD”). (R. at 39.)
Ultimately, the ALJ determined that Plaintiff “does not have an impairment or
combination of impairments that meets or medically equals the severity of one of the listed
impairments in 20 CFR Part 404.” (R. at 41.) The ALJ found that Plaintiff has the residual
functional capacity (“RFC”) to perform a full range of work at all exertional levels but with
certain non-exertional limitations, including that Plaintiff can only “understand, remember
and carry out simple instructions, make simple decisions, perform simple tasks, and have
occasional contact with coworkers and [the] public.” (R. at 43.) Based on a vocational
expert’s answers to hypothetical questions, the ALJ concluded that Plaintiff could perform
jobs that exist in significant numbers in the national economy, including as a janitor,
housekeeper, or store laborer, and Plaintiff is therefore not disabled under the Act. (R. at
47–48.)
II. LEGAL STANDARD
In determining whether to reverse an ALJ’s decision, the district court reviews only
those issues raised by the party challenging the decision. See Lewis v. Apfel, 236 F.3d 503,
517 n.13 (9th Cir. 2001). The court may set aside the Commissioner’s disability
determination only if the determination is not supported by substantial evidence or is based
on legal error. Orn v. Astrue, 495 F.3d 625, 630 (9th Cir. 2007). Substantial evidence is
more than a scintilla, but less than a preponderance; it is relevant evidence that a reasonable
person might accept as adequate to support a conclusion considering the record as a whole.
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Id. To determine whether substantial evidence supports a decision, the court must consider
the record as a whole and may not affirm simply by isolating a “specific quantum of
supporting evidence.” Id. As a general rule, “[w]here the evidence is susceptible to more
than one rational interpretation, one of which supports the ALJ’s decision, the ALJ’s
conclusion must be upheld.” Thomas v. Barnhart, 278 F.3d 947, 954 (9th Cir. 2002)
(citations omitted).
To determine whether a claimant is disabled for purposes of the Act, the ALJ
follows a five-step process. 20 C.F.R. § 404.1520(a). The claimant bears the burden of
proof on the first four steps, but the burden shifts to the Commissioner at step five. Tackett
v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999). At the first step, the ALJ determines whether
the claimant is presently engaging in substantial gainful activity. 20 C.F.R.
§ 404.1520(a)(4)(i). If so, the claimant is not disabled, and the inquiry ends. Id. At step
two, the ALJ determines whether the claimant has a “severe” medically determinable
physical or mental impairment. 20 C.F.R. § 404.1520(a)(4)(ii). If not, the claimant is not
disabled, and the inquiry ends. Id. At step three, the ALJ considers whether the claimant’s
impairment or combination of impairments meets or medically equals an impairment listed
in Appendix 1 to Subpart P of 20 C.F.R. Part 404. 20 C.F.R. § 404.1520(a)(4)(iii). If so,
the claimant is disabled. Id. If not, the ALJ proceeds to step four. Id. At step four, the ALJ
assesses the claimant’s RFC and determines whether the claimant can still perform past
relevant work. 20 C.F.R. § 404.1520(a)(4)(iv). If so, the claimant is not disabled, and the
inquiry ends. Id. If not, the ALJ proceeds to the fifth and final step, where he determines
whether the claimant can perform any other work in the national economy based on the
claimant’s RFC, age, education, and work experience. 20 C.F.R. § 404.1520(a)(4)(v). If
so, the claimant is not disabled. Id. If not, the claimant is disabled. Id.
III. ANALYSIS
Plaintiff contends the “ALJ’s RFC does not reasonably describe the ‘total limiting
effects’ of [her] mental impairments” because the ALJ’s “assessment of the opinion
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evidence is contrary to law” and “he did not demonstrate clear and convincing reasons to
dispute her description of her symptoms and limitations.” (Pl. Br. at 2.)
A. Medical Opinion Evidence
The Ninth Circuit no longer accords special deference to a treating or examining
physician. Woods v. Kijakazi, 32 F.4th 785, 792 (9th Cir. 2022). In 2017, the Social
Security Administration amended the regulations for evaluating medical evidence. See
Revisions to Rules Regarding Evaluation of Medical Evidence, 82 Fed. Reg. 5844, 5844
(Jan. 18, 2017). The 2017 regulations provide that “[w]e will not defer or give any specific
evidentiary weight, including controlling weight, to any medical opinion . . . . The most
important factors we consider when we evaluate the persuasiveness of medical opinions
. . . are supportability . . . and consistency.” 20 C.F.R. § 404.1520c(a). Other factors, which
an ALJ “may, but [is] not required to[] explain” when evaluating the persuasiveness of a
medical opinion, are the medical source’s “relationship with the claimant,”
“specialization,” “familiarity with the other evidence in the claim,” and “understanding of
our disability program’s policies and evidentiary requirements.” 20 C.F.R.
§ 404.1520c(b)(2), (c).
Moreover, the Ninth Circuit held its requirement that ALJs provide “specific and
legitimate reasons” for rejecting a treating or examining doctor’s opinion is incompatible
with the revised regulations. Woods, 32 F.4th at 790. Nonetheless, in rejecting a treating or
examining doctor’s opinion as unsupported or inconsistent, an ALJ must provide an
explanation—that is, reasons—supported by substantial evidence. Id. This means that the
ALJ “must ‘articulate . . . how persuasive’ [he] finds ‘all of the medical opinions’ from
each doctor or other source, and ‘explain how [he] considered the supportability and
consistency factors’ in reaching these findings.” Id. (citing 20 C.F.R. § 404.1520c(b),
(b)(2)).
Here, the Court agrees with Plaintiff that the ALJ’s review of the medical evidence
contains a number of inconsistencies and errors. As the ALJ noted, the record shows
Plaintiff suffers from PTSD from prior domestic abuse, causing her to panic, be
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hypervigilant and anxious, self-isolate, and have trouble controlling her emotions. (R. at
41–43, 45.) The record also shows that “break through symptoms may impair socially
appropriate behavior” and “concentration if triggered at work.” (R. at 42–43.)
In the initial review of Plaintiff’s application, the State Agency consultant opined
that Plaintiff’s mental disorders were “severe,” resulting in moderate limitations in the
ability to interact with others or concentrate, persist, or maintain pace. (R. at 91.) More
specifically, the State Agency consultant concluded Plaintiff was moderately limited in her
ability to “maintain attention and concentration for extended periods,” “perform activities
within a schedule, maintain regular attendance, and be punctual within customary
tolerances,” “complete a normal workday and workweek without interruptions from
psychologically based symptoms and to perform at a consistent pace without an
unreasonable number and length of rest periods,” and “to interact appropriately with the
general public.” (R. at 93–94 (signed by Eric Penner, Ph.D.).) On reconsideration, the State
Agency review tracks the initial review. (R. at 100, 105 (signed by Leif Leaf, Ph.D.).)
The ALJ found these opinions “not persuasive” because he appears to conclude the
psychological consultants did not use “functional terms” in one area of the evaluation,
although the ALJ’s explanation is bewildering and essentially incomprehensible, with no
pin cite to the record:
As undefined by the psychological consultants, the terms of one to two step
tasks provide occupational opportunities regardless of the restrictions to the
degree of education or reasoning, but still find the claimant not disabled per
standards under SSR 85-15.
(R. at 44 (verbatim).) The ALJ also complains that the reviewers “use the terms ‘consistent,
productive basis across a routine work day and week,’ which [are] not defined,” implying
that they cannot be understood. (R. at 44.) Aside from these largely irrelevant criticisms of
two snippets plucked from the State Agency reviews, the ALJ fails to even address the
principal findings of those evaluations by medical professionals—that based on the medical
record, Plaintiff had moderate limitations in, among other things, her ability to maintain
attention and concentration, maintain regular attendance, or complete a normal workday
and workweek without interruptions (R. at 91, 93-94. 100, 105). The ALJ summarily
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rejects those conclusions and thus does not consider them in the eventual RFC
formulation.1 (R. at 43–45.) This by itself was error. SSR 96-8p (“If the RFC assessment
conflicts with an opinion from a medical source, the adjudicator must explain why the
opinion was not adopted.”)
Instead, the ALJ cites evidence in the record to reach his own medical conclusions
(R. at 44), which too was error. Tackett v. Apfel, 180 F.3d 1094, 1102–03 (9th Cir. 1999)
(stating ALJ may not render his/her own medical opinion or independently assess clinical
findings); Banks v. Barnhart, 434 F. Supp. 2d 800, 805 (C.D. Cal. 2006) (“An ALJ cannot
arbitrarily substitute his own judgment for competent medical opinion, and he must not
succumb to the temptation to play doctor and make his own independent medical
findings.”).
The medical evidence also includes an evaluation of Plaintiff by consultive
psychological examiner Jose Abreu, Ph.D., who concluded that PTSD is present and
“seems fairly managed with treatment,” although “break through symptoms may impair
concentration if triggered at work,” going to her persistence and ability to sustain
concentration as well as her social interaction abilities. (R. at 603–04.) Dr. Abreu also noted
that Plaintiff’s “[d]ifficulty sleeping may impair her ability to maintain regular work
attendance,” also going to her persistence and ability to sustain concentration. (R. at 603–
04.)
In his review of Dr. Abreu’s evaluation, the ALJ found Dr. Abreu’s opinion “not
persuasive,” in part because the evaluation was “not entirely supported by the examination,
which was largely normal.” (R. at 45.) It should be obvious that Dr. Abreu’s conclusions
about Plaintiff’s abilities “if triggered at work” and about whether she can maintain regular
work attendance due to her difficulty sleeping were not demonstrated during Dr. Abreu’s
examination of Plaintiff by their very nature, so of course those conclusions could be
1 The applicable Social Security Regulation’s listed mental work activities include
“understanding; remembering; maintaining concentration, persistence, or pace; carrying
out instructions; or responding appropriately to supervision, co-workers, or pressures in a
work setting.” 20 CFR § 404.1513(a)(2)(ii).
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characterized—if inaccurately—as “not entirely supported by the examination.” In other
words, the ALJ’s first reason for discounting Dr. Abreu’s conclusions lacks merit.
The ALJ next states that Dr. Abreu’s “opinion is also not entirely consistent with
the evidence as a whole,” without explaining in any detail why or how. (R. at 45.) See
Woods, 32 F.4th at 792 (“Even under the new regulations, an ALJ cannot reject an
examining or treating doctor’s opinion as unsupported or inconsistent without providing
an explanation supported by substantial evidence.”). Instead, the ALJ again resorts to his
own diagnosis of Plaintiff based on his own review of her symptoms, which, as the Court
noted supra, is also error. (R. at 45.)
And next, the ALJ states, “Dr. Abreu’s opinion does not offer specific functional
limitations and terms such as symptoms may ‘impair concentration’ or ‘ability to maintain
regular work attendance’ is not defined for functional terms. (R. at 45 (verbatim).) Aside
from being essentially incomprehensible, to the extent it is a criticism of Dr. Abreu’s
functional findings or the terminology he uses to express them, the criticism lacks merit.
Dr. Abreu’s findings, as detailed supra, are expressed in terms consistent with the Social
Security Regulations and supported by his factual findings. For these reasons, the ALJ fails
to give any reason supported by the record to discount Dr. Abreu’s opinions or to disregard
them in his formulation of Plaintiff’s RFC.
Finally, the medical record contains Plaintiff’s treatment notes by therapists Sarah
Casey, MSW, who has treated Plaintiff since 2020, and Sean Elrod, Psychiatric Mental
Health Nurse Practitioner, who has treated Plaintiff since 2021. (E.g., R. at 408, 413, 419,
459, 480, 606, 736, 741–43.) Based on her treatment of Plaintiff, Ms. Casey observed that
Plaintiff’s “persistent PTSD symptoms are sensitivity to light and sound, easy triggering,
stress intolerance, with multiple triggers per week with symptoms occasionally lasting up
to two weeks.” (Pl. Br. at 12 (citing R. at 736).) Plaintiff “has a history of suicide attempt,
passive suicidal ideation, social isolation, and insomnia” and “has difficulty completing
tasks in a timely and organized manner, struggles to regulate her emotions, [and] needs
ongoing emotional support.” (Pl. Br. at 12 (citing R. at 736).) As a result, Ms. Casey opined
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that Plaintiff has an “extreme” limitation in concentration, persistence, and task completion
and, depending on the “level of activation/fatigue/dysregulation,” at least “marked”
limitations in her ability to adapt or manage herself or understand, remember, or apply
information. (R. at 741–42.) Ms. Casey concludes Plaintiff would not be able to complete
an 8-hour workday “4+” days per month. (R. at 743.)
For his part, based on his treatment of Plaintiff, Mr. Elrod also opined that Plaintiff
has an “extreme” limitation in concentration, persistence, and task completion, and
“marked” limitations in her ability to adapt or manage herself or understand, remember, or
apply information. (R. at 685–86.) He likewise opined that Plaintiff would not be able to
complete an 8-hour workday “4+” days per month. (R. at 687.)
Like all the other medical evidence before him, the ALJ finds these medical
opinions from Plaintiff’s treating therapists “not persuasive,” again errantly relying on his
own diagnosis fashioned from his own select reading of the medical evidence instead of
the opinions of medical professionals, including those who have treated Plaintiff. (R. at
45–46.) The ALJ also finds the opinions are not persuasive because they are inconsistent
with the conclusions of the state agency consultants—the very conclusions the ALJ also
found not persuasive. As Plaintiff argues, “as a matter of logic alone,” this attempt at a
reason to discount the opinions of Plaintiff’s treating therapists utterly fails. (R. at 45–46.)
And finally, while the ALJ continuously states that all of the medical experts’
opinions are inconsistent with “largely normal observations” during certain examinations
(e.g., R. at 46), the ALJ fails to consider the medical experts’ conclusions based on the
treatment records that Plaintiff’s symptoms are variable and her break through symptoms
will tend to impair socially appropriate behavior and concentration if triggered at work.
(E.g., R. at 603, 742; see Pl. Br. at 20–21.) To the extent the record shows Plaintiff’s mental
health fluctuates over time, it is improper for the ALJ to discount Plaintiff’s evidence of
mental illness “merely because symptoms wax and wane in the course of treatment.” See
Garrison v. Colvin, 759 F.3d 995, 1017 (9th Cir. 2014). Moreover, although SSR 96-8p
explains that “[t]he RFC assessment considers only functional limitations and restrictions
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that result from an individual’s medically determinable impairment or combination of
impairments,” it also describes RFC as “an assessment of an individual’s ability to do
sustained work-related physical and mental activities in a work setting on a regular and
continuing basis.” SSR 96-8p (emphasis added).
For all these reasons, the ALJ erred in weighing the medical evidence and
considering it in the formulation of Plaintiff’s RFC, and the Court will grant Plaintiff’s
request to remand this case to the SSA for further proceedings.
B. Plaintiff’s Symptom Testimony
Plaintiff also argues that the ALJ erred by rejecting her symptom testimony without
providing adequately specific, clear, and convincing reasons to do so. (Pl. Br. at 21–22.)
Although credibility is the province of the ALJ, an adverse credibility determination
requires the ALJ to provide “specific, clear and convincing reasons for rejecting the
claimant’s testimony regarding the severity of the claimant’s symptoms.” Treichler v.
Comm’r of Soc. Sec., 775 F.3d 1090, 1102 (9th Cir. 2014) (citing Smolen v. Chater, 80 F.3d
1273, 1281 (9th Cir. 1996)).
As Plaintiff argues in her brief, the ALJ’s evaluation of claimant’s description of
her limitations is “inextricably intertwined” with his assessment of the medical record. (Pl.
Br. at 21.) Under 20 CFR § 416.929(c)(4), an ALJ must determine if a claimant’s
impairments can be “reasonably expected to cause the symptoms and limitations
described,” so “if the ALJ has improperly evaluated the opinion evidence and the record to
begin with, § 416.929(c)(4)’s required comparison analysis is entirely tainted from the
outset.” (Pl. Br. at 21.)
Moreover, as Plaintiff also points out, to the extent the ALJ evaluates Plaintiff’s
symptom testimony in detail at all (e.g., R. at 44), the reasons the ALJ provides to discount
it are entirely inadequate. See Ghanim v. Colvin, 763 F.3d 1154, 1163 (9th Cir. 2014)
(explaining that “[g]eneral findings are insufficient” and “the ALJ must identify what
testimony is not credible and what evidence undermines the claimant’s complaints”); Ong
v. Comm’r of Soc. Sec. Admin., No. CV-17-00960-PHX-BSB, 2018 WL 3323169, at *9
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(D. Ariz. July 6, 2018) (reversing the ALJ’s finding of non-credibility based on two
vacations the plaintiff took to Jamaica because the ALJ did not discuss any details of the
plaintiff’s travel or her activities during the trips and did not explain how the trip was
inconsistent with the plaintiff’s testimony); see also Reddick v. Chater, 157 F.3d 715, 722
(9th Cir. 1998) (“[D]isability claimants should not be penalized for attempting to lead
normal lives in the face of their limitations.”).
The ALJ therefore also erred by failing to provide specific, clear, and convincing
reasons for discounting Plaintiff’s symptom testimony.
IT IS THEREFORE ORDERED reversing the decision of the Administrative
Law Judge (R. at 37–48) as upheld by the Appeals Council (R. at 1–3).
IT IS FURTHER ORDERED remanding this case to the Social Security
Administration for further proceedings consistent with this Order.
IT IS FURTHER ORDERED directing the Clerk of the Court to enter final
judgment accordingly and close this case.
Dated this 31st day of March, 2026.
Honorable John J. Tuchi
United States District Judge
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