United States District Court, D. Oregon, Portland Division
AMANDA R. VAUGHN, Plaintiff,
COMMISSIONER OF SOCIAL SECURITY,  Defendant.
OPINION AND ORDER
Yim You, United States Magistrate Judge
Amanda R. Vaughn (“Vaughn”), seeks judicial
review of the final decision by the Commissioner of Social
Security (“Commissioner”) denying her
applications for Disability Insurance Benefits
(“DIB”) under Title II of the Social Security Act
(“Act”), 42 U.S.C. §§ 401-433, and
Supplemental Security Income (“SSI”) under Title
XVI of the Act, 42 USC §§ 1381-1383f. This court
has jurisdiction to review the Commissioner's decision
pursuant to 42 USC § 405(g) and § 1383(c)(3). All
parties have consented to allow a Magistrate Judge to enter
final orders and judgment in this case in accordance with
FRCP 73 and 28 USC § 636(c) (ECF #6). For the reasons
below, the Commissioner's decision is REVERSED and this
case is REMANDED for the immediate calculation and payment of
October 2011, Vaughn protectively filed for DIB and SSI
alleging a disability onset date of January 24, 2011. Tr.
272-81. She requested a hearing after her
application was denied initially and on reconsideration. Tr.
178-97. On July 22, 2013, a hearing was held before
Administrative Law Judge (“ALJ”) Elizabeth
Watson. Tr. 44-86. ALJ Watson issued a decision on August 21,
2013, finding Vaughn not disabled. Tr. 151-66. Vaughn
requested review of the hearing decision, and the Appeals
Council remanded the case for further proceedings on November
5, 2014. Tr. 172-75.
December 15, 2015, a remand hearing was held before ALJ
MaryKay Rauenzahn. Tr. 87-108. ALJ Rauenzahn issued a new
decision finding Vaughn not disabled on March 3, 2016. Tr.
14-31. The Appeals Council denied a request for review on
August 16, 2016. Tr. 1-3. Therefore, ALJ Rauenzahn's
decision is the Commissioner's final decision subject to
review by this court. 20 CFR §§ 404.981, 416.1481,
February 4, 1989, Vaughn was 21 years old on the alleged
disability onset date, and 26 years old at the time of the
second administrative hearing. Tr. 272. She graduated from
high school and completed some college coursework but did not
obtain a degree. Tr. 49, 302. She has no past relevant work
that qualifies as substantial gainful activity, although she
served as a youth recreational leader for the City of Eugene.
Tr. 29, 308-09. Vaughn alleges disability due to
fibromyalgia, neck problems, and back problems. Tr. 301.
reviewing court must affirm the Commissioner's decision
if it is based on proper legal standards and the findings are
supported by substantial evidence in the record. 42 USC
§ 405(g); Lewis v. Astrue, 498 F.3d 909, 911
(9th Cir. 2007). This court must weigh the evidence that
supports and detracts from the ALJ's conclusion and
“‘may not affirm simply by isolating a specific
quantum of supporting evidence.'” Garrison v.
Colvin, 759 F.3d 995, 1009-10 (9th Cir. 2014) (quoting
Lingenfelter v. Astrue, 504 F.3d 1028, 1035 (9th
Cir. 2007)). The reviewing court may not substitute its
judgment for that of the Commissioner when the evidence can
reasonably support either affirming or reversing the
decision. Parra v. Astrue, 481 F.3d 742, 746 (9th
Cir. 2007) (citation omitted). Instead, where the evidence is
susceptible to more than one rational interpretation, the
Commissioner's decision must be upheld if it is
“supported by inferences reasonably drawn from the
record.” Tommasetti v. Astrue, 533 F.3d 1035,
1038 (9th Cir. 2008) (citation omitted); see also
Lingenfelter, 504 F.3d at 1035.
ANALYSIS AND ALJ FINDINGS
is the “inability to engage in any substantial gainful
activity by reason of any medically determinable physical or
mental impairment which can be expected to result in death or
which has lasted or can be expected to last for a continuous
period of not less than 12 months.” 42 USC §
423(d)(1)(A). The ALJ engages in a five-step sequential
inquiry to determine whether a claimant is disabled within
the meaning of the Act. This sequential analysis is set forth
in Social Security Administration (“Agency”)
regulations, 20 CFR §§ 404.1520, 416.920, in
Ninth Circuit case law, Lounsburry v. Barnhart, 468
F.3d 1111, 1114 (9th Cir. 2006) (discussing Tackett v.
Apfel, 180 F.3d 1094, 1098-99 (9th Cir. 1999)), and in
the ALJ's decision, Tr. 18-19.
one, the ALJ concluded Vaughn had not engaged in substantial
gainful activity since January 24, 2011, the alleged onset
date of disability. Tr. 20.
two, the ALJ determined that Vaughn has the following severe
impairments: fibromyalgia, mild degenerative disc disease,
post-traumatic stress disorder (“PTSD”), mood
disorder, obesity, and asthma. Id.
three, the ALJ concluded Vaughn did not have an impairment or
combination of impairments that met or equaled any listed
then found Vaughn has the residual functional capacity
(“RFC”) to perform less than the full range of
light work, with the following limitations:
[She] can lift and/or carry 20 pounds occasionally and 10
pounds frequently; she can stand and/or walk for six hours
out of an eight-hour workday with regular breaks; she can sit
for six hours out of an eight-hour workday with regular
breaks; she should be allowed the freedom to perform work
either sitting or standing as desired; she can frequently use
foot controls bilaterally. . . [she] may occasionally climb
stairs and ramps but never climb ladders, ropes and
scaffolds. [She] may occasionally stoop, kneel, and crouch,
but can never crawl. [She] may occasional[ly] reach overhead
bilaterally. [She] must avoid concentrated exposure to
extreme cold and atmospheric conditions and is precluded from
exposure to workplace hazards such as unprotected heights and
dangerous machinery. [She] is able to understand, remember
and carry out simple instructions that can be learned in 30
days or less. [She] is unable to engage in conveyor belt
paced work. [She] may have occasional public contact, but is
precluded from working directly with the public. [She] may
have occasional coworker contact, but is unable to perform
determined at step four that Vaughn had no past relevant
work. Tr. 29. At step five, the ALJ found that considering
Vaughn's age, education, and RFC, she was capable of
performing jobs as an electronics worker, information router,
and assembler of electronics accessories. Tr. 29-30.
Accordingly, the ALJ determined that Vaughn was not disabled
at any time through the date of her decision. Tr. 30.
January 2011, Vaughn was seen at a hospital emergency
department complaining of sudden neck pain caused by no
particular injury. Tr. 401. A CT-scan showed a
“congenital fusion of C7-T1, ” and she was
prescribed Oxycodone and Flexeril. Id. On
examination several weeks later, Donna Givens, M.D., noted
near full rotation and flexion of the spine, tenderness to
palpation over the trapezius muscles bilaterally and
paraspinous soft tissues on the right side of the neck, but
no point tenderness over the cervical spinous processes.
Id. Dr. Givens assessed myofascial neck strain
without concern for neurological compromise. Id. She
referred Vaughn to physical therapy, approved her for light
duty work, renewed her prescription for Flexeril,
discontinued Oxycodone, and recommended she gradually resume
normal activities. Id.
March 2011, Vaughn reported no improvement with her neck pain
and increasing low back pain. Tr. 399. On examination, Dr.
Givens noted a negative straight leg test, normal strength
and sensation, an “entirely normal” lumbar x-ray,
and “essentially no tenderness over the lumbosacral
spine, ” although Vaughn was noted as visibly crying by
the end of the examination. Id. Based on
Vaughn's presentation, Dr. Givens described that
“her clinical picture has become more complex.”
Id. Dr. Givens prescribed Naproxen for daily pain
management, Skelaxin for more severe pain, and continued to
endorse physical therapy. Id.
2011, Vaughn was seen by Christopher Noonan, M.D., for
continued treatment of her back pain. Tr. 361-66. She
reported a “burning pain” in her lower back with
stiffness in her hips, pain levels ranging from three to ten
out of ten, and the ability to stand for 15 minutes and walk
a half-block at a time. Tr. 364-66. With the exception of
some hyperreflexia, the physical examination was largely
unremarkable. Tr. 362. Dr. Noonan recommended an MRI, noting
that Vaughn's pain “seem[ed] to be out of
proportion to any findings.” Id. A cervical
MRI confirmed the congenital fusion at ¶ 7-T1, and
revealed mild disc desiccation and slight degenerative change
at ¶ 5-6. Tr. 359. Other than some mild disc desiccation
at ¶ 5-S1, Vaughn's lumber MRI was also normal.
Id. Dr. Noonan saw no need for surgical
intervention, recommended Vaughn continue conservative
treatment and exercise, and advised Vaughn to see a
physiatrist if her pain continued. Tr. 359.
Noonan referred Vaughn to physiatrist Lisa Albanese, M.D.,
for assessment. Tr. 387-88. At an examination on June 27,
2011, Vaughn reported an average pain level of eight out of
ten and difficulty concentrating, but no issues with memory.
Tr. 387. Dr. Albanese noted significant tenderness to light
palpation over the paraspinal musculature, tenderness in 13
of 18 tender points and all four quadrants of her body,
difficulty with lumbar flexion and extension, and a positive
Hoffman's test on the left. Tr. 388. Dr. Albanese
diagnosed fibromyalgia, prescribed Cymbalta, and referred
Vaughn to a pain psychologist. Id; see also Tr. 384.
follow-up appointment with Dr. Albanese on July 25, 2011,
Vaughn reported that Cymbalta was helping with her pain,
mood, and drive. Tr. 385. Her pain was slightly reduced,
ranging from a three to eight out of ten. Id. Vaughn
also inquired about joining Weight Watchers and swimming to
help with her weight loss goals. Id. Dr. Albanese
encouraged her to join Weight Watchers and to gradually ease
into swimming, using her pain levels as a guide. Id.
days later, Vaughn underwent a comprehensive psychological
evaluation with Terri Lechnyr, Ph.D. Tr. 422-28. She endorsed
severe anxiety, moderate depression, and low-level coping
strategies. Tr. 422. She further reported past suicide
attempts and a history of physical and sexual abuse.
Id. Vaughn rated her pain level as an eight out of
ten, and reported difficulty sleeping due to pain and
recurring nightmares. Tr. 423. Vaughn described watching
television for seven to eight hours a day, sitting for nine
to ten hours a day, and practicing yoga at home for exercise.
Id. On a typical morning, she would wake up late,
take her medications, and visit with a neighbor. Id.
In the afternoon, she would prepare lunch, watch television,
clean her home in small portions, play with her kitten, and
do some yoga. Id. In the evening, she would watch
more television, eat dinner, and wait for her fiancé
to get home from work before going to bed. Id.
Lechnyr found no indication of malingering or secondary gain,
and opined that Vaughn's “psychiatric state is
aggravating her organic pain issues.” Tr. 424. Although
Vaughn was able to sit through the entire interview, she
appeared physically uncomfortable at times and occasionally
lost her train of thought. Tr. 425. On testing, Vaughn
demonstrated a severe level of anxiety on the Burns Anxiety
Inventory, and moderate depression on the Burns Depression
Inventory. Id. Dr. Lechnyr diagnosed PTSD and mood
disorder, not otherwise specified, and assigned a Global
Assessment of Functioning (“GAF”) score of 54.
Tr. 427. Dr. Lechnyr recommended Vaughn undergo mental health
counseling to learn cognitive strategies for managing her
fibromyalgia. Tr. 428.
mid-August 2011, Vaughn returned to Dr. Albanese, reporting
recently experiencing a “significant flare up”
where she could hardly walk. Tr. 383. Vaughn reported
continuing pain radiating “up and down her back and in
her arms and legs.” Id. She also described
that her pain levels worsened with increased physical
activity, but improved with rest, massage therapy, and
stretching. Id. Dr. Albanese counseled Vaughn on