Butcher v. Comm'r of Soc. Sec.

Decision Date03 May 2021
Docket NumberCASE NO. 1:20-CV-01230-DCN
PartiesMICAH JAMES BUTCHER, Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY, Defendant.
CourtU.S. District Court — Northern District of Ohio

JUDGE DONALD C. NUGENT UNITED STATES DISTRICT JUDGE

MAGISTRATE JUDGE JONATHAN D. GREENBERG

REPORT & RECOMMENDATION

Plaintiff, Micah Butcher ("Plaintiff" or "Butcher"), challenges the final decision of Defendant, Andrew Saul,1 Commissioner of Social Security ("Commissioner"), denying his applications for Period of Disability ("POD"), Disability Insurance Benefits ("DIB"), and Supplemental Security Income ("SSI") under Titles II and XVI of the Social Security Act, 42 U.S.C. §§ 416(i), 423, 1381 et seq. ("Act"). This Court has jurisdiction pursuant to 42 U.S.C. § 405(g). This case is before the undersigned United States Magistrate Judge pursuant to an automatic referral under Local Rule 72.2(b) for a Report and Recommendation. For the reasons set forth below, the Magistrate Judge recommends that the Commissioner's final decision be VACATED AND REMANDED for further proceedings consistent with this opinion.

I. PROCEDURAL HISTORY

In August 2017, Butcher filed applications for POD, DIB, and SSI, alleging a disability onset date of August 24, 2017 and claiming he was disabled due to bipolar disorder, ADHD, autism, and anger anddepression. (Transcript ("Tr.") 10, 58.) The applications were denied initially and upon reconsideration, and Butcher requested a hearing before an administrative law judge ("ALJ"). (Id. at 10.)

On January 17, 2019, an ALJ held a hearing, during which Butcher, represented by counsel, and an impartial vocational expert ("VE") testified. (Id.) On March 11, 2019, the ALJ issued a written decision finding Butcher was not disabled. (Id. at 10-20.) The ALJ's decision became final on April 8, 2020, when the Appeals Council declined further review. (Id. at 1-6.)

On June 5, 2020, Butcher filed his Complaint to challenge the Commissioner's final decision. (Doc. No. 1.) The parties have completed briefing in this case. (Doc. Nos. 16-18.) Butcher asserts the following assignments of error:

(1) The ALJ committed harmful error when he failed to properly evaluate the evidence in this matter, did not find that Plaintiff satisfied the criteria of Listing 12.04, and found the opinion of the treating psychiatrist not persuasive.
(2) The ALJ committed harmful error in his determination regarding credibility as it was not supported by substantial evidence and violated Social Security Ruling 16-3p.
(3) The ALJ committed harmful error when he did not meet his burden at Step Five of the Sequential Evaluation.

(Doc. No. 16 at 1.)

II. EVIDENCE
A. Personal and Vocational Evidence

Butcher was born in January 1989 and was 30 years-old at the time of his administrative hearing (Tr. 10, 18), making him a "younger" person under Social Security regulations. 20 C.F.R. §§ 404.1563(c), 416.963(c). He has at least a high school education and is able to communicate in English. (Tr. 18.) He has past relevant work as an assembler and a retail attendant. (Id.)

B. Medical Evidence2

Butcher has seen Samer Alamir, M.D., for mental health treatment dating back to at least June 2012. (Tr. 327.) Butcher's diagnoses included bipolar disorder, in full remission, most recent episode manic, ADHD, and Asperger's syndrome. (Id.)

On July 1, 2016, Butcher was admitted to Windsor-Laurelwood Center for Behavioral Medicine after a week of what Butcher believed to be manic symptoms over the past month followed by depression and suicidal thoughts in the past week. (Tr. 404.) He reported having recently begun smoking marijuana. (Id.) Butcher, who had a history of bipolar disorder, complained of "severe mood dysregulation, irritability, depression, insomnia, acute anxiety, difficulty concentrating, [and] frequent thoughts of suicide." (Id.) At admission, Butcher appeared withdrawn and irritable, although he was cooperative, and was easily agitated and irritable. (Id.) Peter Corpus, M.D., found Butcher's judgment and insight impaired. (Id.) At the beginning of his inpatient treatment, Butcher was impulsive, "very anxious and hypomanic" with intermittent sleep, fair appetite, blunted affect, and poor impulse control. (Id. at 405.) Butcher's high levels of anxiety persisted, and he had intermittent thoughts of suicide. (Id.) By July 5, 2016, treatment providers found Butcher "mostly calm and cooperative" with "mildly pressured speech," improved mood, slightly tangential thought processes, no suicidal or homicidal ideation, and improved judgment and insight. (Id.) Butcher reported feeling safe to go home on July 6, 2016. (Id.) At discharge, Butcher was calm, pleasant, and cooperative and demonstrated good eye contact, normal speech, improved mood, linear thought processes, and intact judgment and insight. (Id.)

On July 7, 2016, Butcher saw Dr. Alamir for follow up. (Id. at 308.) Butcher reported being inconsistent with his medications and feeling down and depressed, as well as trouble at work with another coworker after he called him a "'retard.'" (Id.) He felt worthless and questioned his own safety and wasin the hospital for five days. (Id.) Butcher reported depressive and sad symptoms, as well as crying spells. (Id.) On examination, Dr. Alamir found Butcher friendly, irritable, distracted, communicative, casually groomed, overweight, and anxious. (Id.) Butcher demonstrated normal speech, moderate depression, sad demeanor, depressed mood, intact associations, logical thinking, appropriate thought content, fair insight and judgment, anxiety, and a short attention span. (Id.) Dr. Alamir noted Butcher was emotional and easily upset. (Id.) Dr. Alamir discontinued Butcher's Wellbutrin. (Id.) By July 11, 2016, Butcher reported feeling back to normal and ready to return to work. (Id. at 307.)

Butcher continued to see Dr. Alamir throughout 2016 and into 2017. (Id. at 304-06.)

On May 15, 2017, Butcher saw Dr. Alamir for follow up and reported doing well. (Id. at 303.) He denied anxiety and mood disturbances and told Dr. Alamir he had been getting along with others and his mood was stable. (Id.) On examination, Dr. Alamir found Butcher had a euthymic mood and no signs of depression or manic process. (Id.) Butcher presented as relaxed, attentive, communicative, well-groomed, well-dressed, normal speech, intact associations, generally logical thinking, appropriate thought content, and intact judgment and insight. (Id.)

On July 21, 2017, Butcher saw Nayarana Dasari, M.D., for follow up regarding his ADHD. (Id. at 330.) Butcher's diagnoses included bipolar I disorder, ADHD, vitamin D deficiency, and chronic GERD. (Id.) Earlier treatment notes also included a diagnosis of autism. (Id. at 334.)

On July 31, 2017, Butcher saw Dr. Alamir for follow up. (Id. at 302.) Butcher reported increased depression, difficulty concentrating and completing tasks, lack of interest in things he used to enjoy, lack of focus, and lack of concentration. (Id.) Butcher told Dr. Alamir his boss commented that he had not been good for three weeks and he could tell Butcher was more depressed. (Id.) Butcher described feeling like he had not had an actual thought and feeling like his brain was shut off. (Id.) Butcher reported some irritability and anger towards his sister, although he was not sure why. (Id.) Butcher told Dr. Alamir hefelt like people were intentionally attacking him and that he was misinterpreting things people said to him. (Id.) Dr. Alamir noted Butcher expressed some paranoid thoughts. (Id.) Butcher stated he felt his mood was unstable and he wanted to see Dr. Alamir more often. (Id.) On examination, Dr. Alamir found Butcher was flat, sad looking, attentive, communicative, casually groomed, overweight, and unhappy. (Id.) Butcher demonstrated normal speech, moderate signs of depression, sad demeanor, depressed mood, intact and logical associations, and fair judgment and insight. (Id.) Dr. Alamir found no signs of anxiety, hyperactivity, or attentional difficulties. (Id.)

On August 7, 2017, Butcher saw Dr. Alamir for follow up. (Id. at 301.) Butcher reported doing much better after starting Lexapro a week earlier. (Id.) Butcher noticed a difference in his mood and an improvement in his depression. (Id.) He reported feeling more stable, being more interactive and engaging with others, and caring for himself better. (Id.) Butcher told Dr. Alamir he had started playing the guitar more and was enjoying it. (Id.) He reported his crying spells had improved, as had his concentration and motivation. (Id.) His appetite was better, he continued to exercise, and his sleep was good. (Id.) Although Butcher had not yet returned to work, he felt ready to go back and wanted to start working again. (Id.) On examination, Dr. Alamir found Butcher had a euthymic mood, no signs of depression or manic process, with normal speech and no suicidal ideation. (Id.) Butcher presented as relaxed, attentive, communicative, well-dressed, and well-groomed. (Id.) He demonstrated intact associations, logical thinking, and appropriate thought content. (Id.) Butcher exhibited no signs of anxiety, attentional difficulties, or hyperactivity. (Id.) Dr. Alamir noted Butcher's insight and social judgment appeared intact. (Id.)

On August 29, 2017, Butcher saw Dr. Alamir for an "urgent appointment." (Id. at 300.) Butcher reported his sister attacked him and he punched her back, then the police were called, and he was taken to jail for a day. (Id.) Even though his sister did not want to press charges, the state charged him anyway.(Id.) Butcher's wife believed he was a little manic because he did not receive his medications in jail, and he had drunk 10-12 cups of coffee before the incident with his sister. (Id.) Butcher had taken his medications the day before his appointment and was now calmer and feeling better. (Id.) Butcher reported feeling depressed about the situation. (Id.) On examination, Dr. Alamir found Butcher friendly, calm, attentive,...

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