anhedonic, anxious and depressed moods. (/d.). Dr. Schroder noted that plaintiff reported being
isolated and having very little social support. (Tr. 415, 417, 419). When last seen on December
4, 2012, plaintiff was positive for suicidal ideation. (Tr. 415). Dr. Schroder noted that plaintiff's
condition was not improving. (Tr. 415-19). Dr. Schroder also rated plaintiff's “current level of
difficulty” as “quite a bit” (a level three on a zero to four-point scale with four rated as
“extreme”) and rated both short-term and long-term progress as a four or a five on a ten-point
scale with ten being most improving. (/d.).

In his September 2013 letter, Dr. Schroder noted that he had met with plaintiff sixteen
times since the start of treatment in September 2012. During appointments throughout 2013, Dr.
Schroder consistently noted that plaintiff's progress remained unchanged. Dr. Schroder
consistently documented plaintiffs mood as depressed, anxious, worthless and sad, with an
affect that was congruent with mood and thought. (January 2013—Tr. 1003; February 2013—
Tr. 1002; March 2013—Tr. 1001; April 2013—Tr. 999; April 2013—Tr. 998). In July 2013, Dr.
Schroder’s clinical notes documented that plaintiff's progress had worsened, and plaintiff
continued to have a depressed and anxious mood. (Tr. 997). Dr. Schroder reported that plaintiff
was tearful and had suicidal ideations. (/d.). Thereafter, plaintiff's progress remained
unchanged, and Dr. Schroder continually documented plaintiff's mood as depressed, anxious,
and fearful. (August 2013—Tr. 995; September 2013—Tr. 993; September 2013—Tr. 990;
October 2013—987; November 2013—Tr. 985; November 2013—Tr. 984, December 2013—Tr.
983). When plaintiff returned to Dr. Schroder in January 2016, he reported suicidal ideation.
(Tr. 981). During two visits in January 2016, Dr. Schroder noted that plaintiff's behaviors were
cooperative, tearful, and verbal, but his mood remained depressed, anxious, and worthless, with a

congruent affect. (Tr. 979, 981). In March 2016, plaintiff presented as disheveled with poor

14


10. Considering the [plaintiff]’s age, education, work experience, and residual
functional capacity, there are jobs that exist in significant numbers in the
national economy that the [plaintiff] can perform (20 CFR 404.1569,
404.1569(a), 416.969, and 416.969(a)).4

11. The [plaintiff] has not been under a disability, as defined in the Social Security
Act, from September 1, 2006, through the date of this decision (20 CFR
404.1520(g) and 416.920(g)).

(Tr. 526-41).

C. Judicial Standard of Review

Judicial review of the Commissioner’s determination is limited in scope by 42 U.S.C. §
405(g) and involves a twofold inquiry: (1) whether the findings of the ALJ are supported by
substantial evidence, and (2) whether the ALJ applied the correct legal standards. See Blakley v.
Comm’r of Soc. Sec., 581 F.3d 399, 406 (6th Cir. 2009); see also Bowen v. Comm'r of Soc. Sec.,
478 F.3d 742, 745-46 (6th Cir. 2007).

The Commissioner’s findings must stand if they are supported by “such relevant evidence
as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales,
402 U.S. 389, 401 (1971) (citing Consolidated Edison Co. v. N.L.R.B., 305 U.S. 197, 229
(1938)). Substantial evidence consists of “more than a scintilla of evidence but less than a
preponderance. .. .” Rogers v. Comm’r of Soc. Sec., 486 F.3d 234, 241 (6th Cir. 2007). In

deciding whether the Commissioner’s findings are supported by substantial evidence, the Court

considers the record as a whole. Hephner v. Mathews, 574 F.2d 359 (6th Cir. 1978).

4 The ALJ relied on the VE’s testimony to find that plaintiff would be able to perform the requirements of unskilled
jobs in the national economy at a light exertional level, such as warehouse checker (60,000 jobs nationally), marker
(45,000 jobs nationally), and mail clerk (89,000 jobs nationally). The ALJ also found that plaintiff would be able to
perform the requirements of unskilled jobs in the national economy at a sedentary exertional level, including charge
account clerk (40,000 jobs nationally), bench assembler (75,000 jobs nationally), and weight tester (2,800 jobs
nationally). (Tr. 540, 616-17).


III. This matter should be reversed and remanded for further proceedings.

In determining whether this matter should be reversed outright for an award of benefits or
remanded for further proceedings, the undersigned notes that all essential factual issues have not
been resolved in this matter. Faucher v. Sec'y of H.H.S., 17 F.3d 171, 176 (6th Cir. 1994).
There is an issue as to the onset date of plaintiff's mental health impairments and how those
impairments, in combination with plaintiff's other impairments, affect plaintiff's ability to
perform substantial gainful activity. While plaintiff alleges an onset date of disability of
September 1, 2006, it does not appear that plaintiff was evaluated and/or sought mental health
treatment until well after the alleged onset date. In addition, there is an unexplained two-year
gap, from 2014 to January 2016, in plaintiff's mental health treatment that may affect his claim
for benefits. Therefore, this matter should be reversed and remanded for further proceedings
with instructions to the ALJ to re-weigh the medical opinion evidence in accordance with this
decision; to reassess plaintiff's RFC, giving appropriate weight to the opinions of Dr. Schroder,
including an explanation on the record for the weight afforded to his opinions; for further
medical and vocational evidence as warranted; and for an evaluation of plaintiffs onset date of
disability, if any, considering the medical evidence of plaintiff's mental impairments and the
two-year gap in mental health treatment.

IT IS THEREFORE RECOMMENDED THAT:
The decision of the Commissioner be REVERSED and REMANDED for further

proceedings consistent with this opinion.

pa Was Bain X. Kew

Karen L. Litkovitz ~ oa
United States Magistrate Judge



worsened, since January 2013.” (/d.). Dr. Schroder noted that during a recent visit, plaintiff was
unable to remember his age but later remembered his birth date during the session. (/d.). Dr.
Schroder reported that it was “difficult to separate his depression from the pain associated with
Reflex Sympathetic Dystrophy Disease (RSD—which emerged during his twenties) along with
exhaustion (due to chronically disrupted sleep) and his dire financial circumstances, lack of
access to psychiatric care and extreme social isolation.” (/d.). Dr. Schroder reported that “there
is no indication he has experienced any relief from his psychiatric or physical symptoms over the
last several years.” (/d.). Dr. Schroder noted that upon returning to treatment, plaintiff was
tearful and crying heavily. (/d.). Plaintiff reported that he hears “things” routinely and rarely
leaves the house. (/d.). Dr. Schroder noted that plaintiff's depression may improve with
medication, which he had been unable to afford since 2012. (/d.). Dr. Schroder further noted
that plaintiff's primary diagnosis remained major depressive disorder, severe, with associated
anxiety. (/d.).

The ALJ re-evaluated Dr. Schroder’s opinions pursuant to this Court’s remand order and
assigned them “little weight.” (Tr. 538). The ALJ determined that Dr. Schroder’s treating
source opinions were not entitled to controlling or deferential weight under the regulations. (/d.).
The ALJ noted that Dr. Schroder’s statements in the narrative letters were “somewhat vague and
do not provide an opinion on the [plaintiff]’s work-related abilities.” (Id.). The ALJ explained
that although Dr. Schroder was plaintiff's treating psychologist since September 2012, there was
a “significant treatment gap between December 2013 and January 2016.” (d.). The ALJ further
explained that Dr. Schroder’s opinions were “unsupported by objective findings in the mental
health records,” which consistently documented that plaintiff presented with logical thought

processes and cooperative behavior. (/d.). The ALJ also discounted Dr. Schroder’s opinions on


Ifthe ALJ declines to give a treating source’s opinion controlling weight, the ALJ must
weigh the factors specified in 20 C.F.R. §§ 404.1527(c) and 416.927(c) to decide what weight to
give the opinion; specifically, the length of the treatment relationship and the frequency of
examination, the nature and extent of the treatment relationship, supportability of the opinion,
consistency of the opinion with the record as a whole, and the specialization of the treating
source, Gayheart, 710 F.3d at 376. See also Shields v. Comm’r of Soc. Sec., 732 F. App’x 430,
437 (6th Cir. 2018) (citing Wilson, 378 F.3d at 544); Blakley, 581 F.3d at 408 (“Treating source
medical opinions [that are not accorded controlling weight] are still entitled to deference and
must be weighed using all of the factors provided in 20 C.F.R. § 404.1527[(c)]”). The ALJ’s
decision “must contain specific reasons for the weight given to {a] treating source’s medical
opinion, supported by the evidence in the case record, and must be sufficiently specific to make
clear to any subsequent reviewers the weight the adjudicator gave to the treating source’s
medical opinion and the reasons for that weight.” SSR 96-2p, 1996 WL 374188, at *5. See Cole
v. Astrue, 661 F.3d 931, 937 (6th Cir. 2011). This requirement serves two purposes: (1) “it helps
a claimant to understand the disposition of [his] case, especially ‘where a claimant knows that his
physician has deemed him disabled,”” and (2) it “permits meaningful review of the ALI’s
application of the [treating-source] rule.” Shields, 732 F. App’x at 438 (citing Wilson, 378 F.3d
at 544). The Sixth Circuit has made clear that remand is appropriate “when the Commissioner
has not provided ‘good reasons’ for the weight given to a treating physician’s opinion” and when
the ALJ has not “comprehensively set forth the reasons for the weight assigned to a treating
physician’s opinion.” Jd. (quoting Hensley v. Astrue, 573 F.3d 263, 267 (6th Cir. 2009))

(emphasis added).


The Court must also determine whether the ALJ applied the correct legal standards in the
disability determination. Even if substantial evidence supports the ALJ’s conclusion that the
plaintiff is not disabled, “a decision of the Commissioner will not be upheld where the SSA fails
to follow its own regulations and where that error prejudices a claimant on the merits or deprives
the claimant of a substantial right.” Rabbers, 582 F.3d at 651 (quoting Bowen, 478 F.3d at 746).
See also Wilson, 378 F.3d at 545-46 (reversal required even though ALJ’s decision was
otherwise supported by substantial evidence where ALJ failed to give good reasons for not
giving weight to treating physician’s opinion, thereby violating the agency’s own regulations).

D. Specific Errors

On appeal, plaintiff argues that the ALJ erred by failing to give controlling weight to
treating psychologist Dr. Schroder’s opinions and by not providing good reasons for rejecting his
opinions. (Docs. 12, 18).

1. Whether the ALJ properly weighed Dr. Schroder’s opinions

It is well-established that the findings and opinions of treating physicians are entitled to
substantial weight. Medical opinions from treating sources are generally afforded more weight
than those from non-treating sources “since these sources are likely to be the medical
professionals most able to provide a detailed, longitudinal picture of [the claimant’s] medical
impairment(s)[.]” 20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2). See Walters v. Comm’r of Soc.
Sec., 127 F.3d 525, 529-30 (6th Cir. 1997). “Treating-source opinions must be given
‘controlling weight’ if two conditions are met: (1) the opinion ‘is well-supported by medically
acceptable clinical and laboratory diagnostic techniques’; and (2) the opinion ‘is not inconsistent
with the other substantial evidence in [the] case record.”” Gayheart v. Comm’r of Soc. Sec., 710

F.3d 365, 376 (6th Cir. 2013) (citing 20 C.F.R. § 404.1527(c)(2)).


UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF OHIO

WESTERN DIVISION
MICHAEL I. SPURLOCK, Case No. 1:18-cv-404
Plaintiff, Black, J.

Litkovitz, M.J.

vs.
COMMISSIONER OF
SOCIAL SECURITY,

Defendant.

NOTICE

Pursuant to Fed. R. Civ. P. 72(b), WITHIN 14 DAYS after being served with a copy of
the recommended disposition, a party may serve and file specific written objections to the
proposed findings and recommendations. This period may be extended further by the Court on
timely motion for an extension. Such objections shall specify the portions of the Report objected
to and shall be accompanied by a memorandum of law in support of the objections. If the Report
and Recommendation is based in whole or in part upon matters occurring on the record at an oral
hearing, the objecting party shall promptly arrange for the transcription of the record, or such
portions of it as all parties may agree upon, or the Magistrate Judge deems sufficient, unless the
assigned District Judge otherwise directs. A party may respond to another party’s objections
WITHIN 14 DAYS after being served with a copy thereof. Failure to make objections in

accordance with this procedure may forfeit rights on appeal. See Thomas v. Arn, 474 U.S. 140

(1985); United States v. Walters, 638 F.2d 947 (6th Cir. 1981).

19


Dr. Schroder wrote narrative letters on plaintiff's condition in April 2013 and September
2013. (Tr. 992, 996). In April 2013, Dr. Schroder reported that he met with plaintiff for the
twelfth time since September 2012. (Tr. 996). Dr. Schroder indicated that plaintiff's situation
remained “unchanged,” and plaintiff appeared exhausted and complained of poor memory and
significant levels of distractibility. (/d.). Dr. Schroder stated that plaintiff's depression remained
unchanged, as he could not afford the cost of anti-depressant medication in addition to other
medications. (/d.). Dr. Schroder described plaintiff as socially isolated, with the exception of
being able to interact with his two young adult children. (d.). In September 2013, Dr. Schroder
wrote that he recently met with plaintiff for a sixteenth time since September 2012 for treatment
of depression. (Tr. 992). Dr. Schroder reported that plaintiff “faces a number of formidable
physical, emotional, social, and financial challenges.” (Ud.). Dr. Schroder indicated that plaintiff
reports high levels of pain, lack of sleep, exhaustion, poor memory, and distractibility. (/d.). Dr.
Schroder explained that plaintiff “becomes extremely anxious in new situations and shuts down.”
(id.). Dr. Schroder stated that plaintiff's depression had been “intractable” but was helped in the
past with Cymbalta, which plaintiff discontinued due to cost. (Id.).

Dr. Schroder submitted a follow-up narrative letter on March 21, 2016. (Tr. 1447). Dr.
Schroder reported that except for the months of April and May 2013, he generally met with
plaintiff once a month for a total of 14 (50 minute) sessions. (id.). However, in January 2014,
plaintiff cancelled his two appointments, reporting at least once that his car would not start.

(Id.). Dr. Schroder had no further contact with plaintiff until early 2016 when he reported
suicidal ideation to his medical pain specialist. (/d.). Dr. Schroder met with plaintiff three times
and had an additional scheduled appointment as of the date of the March 2016 narrative. (/d.).

Dr. Schroder noted that plaintiff's “presentation [was] at best unchanged, but more likely


UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF OHIO
WESTERN DIVISION

MICHAEL I. SPURLOCK, Case No. 1:18-cv-404
Plaintiff, Black, J.
Litkovitz, M.J.
vs.
COMMISSIONER OF REPORT AND
SOCIAL SECURITY, RECOMMENDATION
Defendant.

Plaintiff Michael I. Spurlock brings this action pursuant to 42 U.S.C. §§ 405(g) and
1383(c)(3) for judicial review of the final decision of the Commissioner of Social Security
(“Commissioner”) denying his applications for disability insurance benefits (“DIB”) and
supplemental security income (“SSI”). This matter is before the Court on plaintiff's statement of
errors (Doe. 12), the Commissioner’s response in opposition (Doc. 17), and plaintiff's reply
memorandum. (Doc. 18).

I. Procedural Background

Plaintiff filed his applications for DIB and SSI in July 2011, alleging disability since
October 1, 2011,! due to reflex sympathetic dystrophy (RSD) and depression. These applications
were denied initially and upon reconsideration. Plaintiff, through counsel, requested and was
afforded a video hearing before administrative law judge (“ALJ”) Lorenzo Level on January 8,
2013. Plaintiff and a vocational expert (“VE”) appeared and testified at the ALJ hearing. On
July 10, 2013, ALJ Level issued a decision denying plaintiff's DIB and SSI applications.

Plaintiff's request for review by the Appeals Council was denied.

' Plaintiff initially claimed an alleged onset date of disability of September 1, 2006.


Shroder [sic] declined to provide sufficient rationale for reaching the simple, check-mark
conclusions contained within the Shroder [sic] Opinion, and the general, conclusory statements
in the April Letter, September Letter, and March Letter.” (Jd. at 8). The Commissioner argues
that the ALJ properly concluded that Dr. Schroder’s opinions were unsupported by the record,
including Dr. Schroder’s own clinical findings that documented plaintiff's cooperative behavior
and logical thought processes and other benign findings throughout the record. (id. at 11, 15).
The Commissioner further argues that plaintiff fails to explain how granting more weight to Dr.
Schroder’s opinions would have impacted the RFC, which accounted for plaintiff's social
isolation and difficulties with maintaining concentration, persistence, and pace. (/d. at 16).

The ALJ’s decision to discount Dr. Schroder’s opinions is again without substantial
support in the record. While the ALJ properly mentioned the concept of “controlling weight”
and recognized that Dr. Schroder was plaintiff's treating psychologist when analyzing Dr.
Schroder’s opinions, the ALJ’s conclusion that Dr. Schroder’s opinions were “unsupported by
objective findings in the mental health records” is contradicted by the record, including Dr.
Schroder’s own treatment notes. The Court agrees with plaintiff that the ALJ’s “broad citations”
to Dr. Schroder’s treatment notes do not reveal the true nature of his clinical findings.

In the psychiatric context, objective medical evidence consists of laboratory findings and
medical signs, 20 C.F.R. §§ 404.1512(b), 416.912(b), which are defined under 20 C.F.R. §§
404.1528(b), 416.928(b) as “psychological abnormalities which can be observed, apart from
your statements (symptoms)” and which “must be shown by medically acceptable clinical
diagnostic techniques.”> Parr v. Colvin, No. 1:13-cv-31, 2014 WL 301043, at *6 n.1 (S.D. Ohio

Jan. 28, 2014) (Report and Recommendation), adopted sub nom. Parr v. Comm’r of Soc. Sec.,

§ Sections 416.912(b), 416.928(b), 404.1512(b), and 404.1 528(b) were modified effective March 17, 2017. The
prior regulations were in effect when the ALJ issued his decision in this case and apply here.

12


the basis that they relied “quite heavily on the subjective report of symptoms and limitations
provided by the [plaintiff], as well as formal testing involving the [plaintiff]’s self-reports, and
seemed to uncritically accept as true most, if not all, of what the [plaintiff] reported.” (/d.).

Plaintiff argues that the ALJ’s decision, for the second time, failed to provide good
reasons for not affording Dr. Schroder’s treating source opinions controlling weight. (Doc. 12 at
7). Plaintiff argues that the evidence cited by the ALJ does not support the ALJ’s conclusion that
Dr. Schroder’s opinions were inconsistent with his own treatment notes. (Jd. at 9). Plaintiff
contends that the ALJ’s “broad citations” to Exhibits 6F and 11F in the record “do not reveal the
true nature of Dr. Schroder’s treatment notes.” (/d.). Plaintiff argues that Dr. Schroder’s
treatment notes document significant mental health limitations, including repeated issues with
depression, anxiety, pain, suicidal ideation with a plan, tearful episodes, sleep disturbance,
worthlessness, and distractibility. (/d. at 10) (citing Tr. 976, 983-85, 987, 990, 993, 997-99).
Plaintiff maintains that Dr. Schroder rendered his opinions based on his own expertise as a
mental health specialist, treatment of plaintiff, and clinical observations, rather than merely
crediting plaintiff's subjective complaints. (/d.). Plaintiff contends that the ALJ’s reliance on
the gap in medical treatment is not a good reason for discounting Dr. Schroder’s opinions and
according greater weight to the state agency non-examining psychologists who provided
opinions in 2011 and 2012 without the benefit of the whole record. (/d. at 11) (citing Social
Security Ruling 96-6p, 1996 WL 374180, at *3 (July 2, 1996)). Plaintiff also argues that Dr.
Schroder’s opinions were consistent with the opinion of consultative examiner Dr. Kevin
Corbus. (/d. at 12).

In response, the Commissioner argues that the ALJ properly declined to give Dr.

Schroder’s opinions controlling weight. (Doc. 17 at 7-8). The Commissioner contends that “Dr.

11


On January 4, 2013, plaintiff's treating psychologist, Dr. Mark Schroder, Psy.D.,
completed a Mental Impairment Questionnaire. (Tr. 488-92). Dr. Schroder listed plaintiff's
symptoms as poor memory, sleep disturbance, mood disturbance, panic attacks, anhedonia or
pervasive loss of interests, psychomotor agitation, difficulty thinking or concentrating, suicidal
ideation, social withdrawal or isolation, and generalized persistent anxiety. (Tr. 488). Dr.
Schroder reported that plaintiff presented as “extremely anxious — easily overwhelmed — and
depressed.” (/d.). According to Dr. Schroder, plaintiff was not making any progress. (Tr. 489).
Dr. Schroder opined that plaintiff would be absent from work more than three times a month due
to his impairments or treatment. (Tr. 490). Dr. Schroder also opined that plaintiff was seriously
limited in his ability to remember work like procedures, understand and remember very short and
simple instructions, carry out very short and simple instructions, work in coordination with or
proximity to others without being unduly distracted, complete a normal workday and work week
without interruptions from psychologically based symptoms, accept instructions and respond
appropriately to criticism from supervisors, and get along with co-workers or peers without
unduly distracting them or exhibiting behavioral extremes. (d.). He also assessed that plaintiff
had no useful ability to maintain attention for two-hour segments, maintain regular attendance
and be punctual within customary tolerances, sustain an ordinary routine without special
supervision, perform at a consistent pace without an unreasonable number and length of rest
periods, and deal with normal work stress. (/d.). In support of these limitations, Dr. Schroder
reported that his observations were clinically based and that plaintiff “is consistently extremely
anxious.” (Tr. 491). Dr. Schroder then opined that plaintiff suffered from extreme limitations in
activities of daily living, a marked difficulty in maintaining social functioning, and frequent

difficulties in maintaining concentration, persistence, or pace. (/d.).


2. The [plaintiff] has not engaged in substantial gainful activity since September
1, 2006, the alleged onset date (20 CFR 404.1571 et seq., and 416.971 ef seq.).

3. The [plaintiff] has the following severe impairments: lumbar degenerative disc
disease, history of plantar fasciitis, reflex sympathetic dystrophy (RSD) and/or
chronic pain disorder, depressive disorder, and anxiety disorder (20 CFR
404.1520(c) and 416.920(c)).

4. The [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, Subpart P, Appendix 1 (20 CFR 404.1520(d), 404.1525,
404.1526, 416.920(d), 416.925 and 416.926).

5. After careful consideration of the entire record, the [ALJ] finds that the
[plaintiff] has the residual functional capacity to perform less than the full range
of light work as defined in 20 CFR 404.1567(b) and 416.967(b): lift and carry
up to 20 pounds occasionally or 10 pounds frequently; stand and/or walk for
approximately 4 hours in an 8-hour workday; occasional postural activities,
such as climbing stairs/ramps, balancing, stooping, kneeling, crouching, and
crawling; no climbing ladders[,] ropes, or scaffolds; no exposure to hazards
such as dangerous machinery, unprotected heights, or driving as part of job
duties; no concentrated exposure to extremes of cold, heat, wetness or humidity;
no significant exposure to vibration, essentially jobs not requiring tasks
involving vibration; simple, repetitive tasks; low stress with no strict production
quotas or fast pace and only routine work with few changes in the work setting;
and only occasional contact with the public, coworkers, and supervisors.

6. The [plaintiff] is unable to perform any past relevant work (20 CFR 404.1565
and 416,965).

7. The [plaintiff] was born [in]... 1965 and was 40 years old, which is defined as
a younger individual age 18-49, on the alleged disability onset date. The
[plaintiff] subsequently changed age category to closely approaching advanced
age (20 CFR 404.1563 and 416.963).

8. The [plaintiff] has at least a high school education and is able to communicate
in English (20 CFR 404.1564 and 416.964).

9. Transferability of job skills is not material to the determination of disability
because using the Medical-Vocational Rules as a framework supports a finding
that the [plaintiff] is “not disabled,” whether or not the (plaintiff] has
transferable job skills (See SSR 82-41 and 20 CFR Part 404, Subpart P,
Appendix 2).

$ Plaintiff has past relevant work as a material handler, warehouse worker, and forklift operator. (Tr. 539, 615).

4


hygiene; tearful and sad; his thought content was suspicious; and his thought processes were
distractible. (Tr. 976). Dr. Schroder assessed major depressive disorder. (/d.). The ALJ
discounted Dr. Schroder’s opinion as inconsistent with the record because plaintiff consistently
presented to Dr. Schroder with logical thought processes and cooperative behavior. (Tr. 538).
However, such evidence fails to create a “logical bridge” to negate the findings of Dr. Schroder,
a trained psychologist who treated plaintiff regularly for over a one-year period, who consistently
documented plaintiff's mental condition as depressed, anxious, and unchanged. Fleischer v.
Astrue, 774 F. Supp. 2d 875, 877 (N.D. Ohio 2011) (ALJ must “build an accurate and logical
bridge between the evidence and the result”). A comprehensive review of Dr. Schroder’s
records outlined above shows that his mental status examinations and clinical findings were
consistent with the limitations assessed in his January 2013 assessment and April 2013,
September 2013, and March 2016 narrative letters.

Dr. Schroder’s opinions also appear to be consistent with the medical sources who
examined plaintiff to assess his psychological functioning. Dr. Kevin Corbus, Psy.D., conducted
a consultative examination at the request of the state agency on October 1, 2011. (Tr. 391-396).
Dr. Corbus listed plaintiff's diagnosis as major depressive disorder and anxiety disorder. (Tr.
395). During the mental status evaluation, Dr. Corbus noted that plaintiff had a depressed mood
and affect, slowed psychomotor activity, and recent suicidal ideation. (Tr. 393). Plaintiff also
demonstrated motor manifestations of anxiety, including shaking, twitching, and racing thoughts.
(Tr. 394). Plaintiff reported that he had low energy, no interest in activities, cried at times, did
not have hope for the future, and felt anxious several times throughout the day. (Tr. 393-94).

Dr. Corbus opined that due to plaintiff's fleeting ability to concentrate, he may exhibit a slower

work pace than peers on tasks requiring rapid timed performance. (Tr. 395). Dr. Corbus also


431 (6th Cir. 2012) (gap in treatment is a sufficient reason for discounting treating physician’s
opinion). However, the Court finds that the gap in treatment between 2014 and 2016 is not a
sufficient reason to discount Dr. Schroder’s opinions that pre-dated the gap in treatment,
including the January 2013 assessment, as well as his April and September 2013 letters, the latter
revealing that plaintiff's progress remained unchanged and his depression remained “intractable”
after sixteen visits. (See Tr. 992—September 2013 narrative letter).

Finally, the ALJ’s decision does not reflect that she conducted a proper review of the
regulatory factors in assessing the weight to afford Dr. Schroder’s opinions. Even if Dr.
Schroder’s opinion may not have been entitled to controlling weight, the ALJ was still obligated
to consider the length, nature and extent of his treatment relationship with plaintiff; the
frequency of examination; his medical specialty; the evidentiary support for the opinion and its
consistency with the record; and other factors which tend to support or contradict the opinion.

20 C.F.R. §§ 404.1527(c)(2), 416.927(c)(2). In particular, the Court finds it significant that the
ALJ failed to consider Dr. Schroder’s specialization in mental health and psychology and instead
heavily relied on the “normal mental status findings documented through the pain management
progress notes” to discount Dr. Schroder’s clinical findings. (Tr. 538).

Overall, the Court concludes that this is not a case of harmless error where “a treating
source’s opinion is so patently deficient that the Commissioner could not possibly credit it,” or
where the Commissioner “has met the goal of . . . the procedural safeguard of reasons.” Wilson,
378 F.3d at 547. Because the ALJ failed to give good reasons for giving the treating
psychologist’s opinions “little weight,” the ALJ’s rejection of Dr. Schroder’s opinions is not
supported by substantial evidence. Accordingly, plaintiff's assignment of error should be

sustained.

17


Regulations promulgated by the Commissioner establish a five-step sequential evaluation
process for disability determinations:

1) Ifthe claimant is doing substantial gainful activity, the claimant is not disabled.

2) Ifthe claimant does not have a severe medically determinable physical or mental
impairment — i.e., an impairment that significantly limits his or her physical or
mental ability to do basic work activities — the claimant is not disabled.

3) Ifthe claimant has a severe impairment(s) that meets or equals one of the listings

in Appendix | to Subpart P of the regulations and meets the duration requirement,

the claimant is disabled.

4) If the claimant’s impairment does not prevent him or her from doing his or her
past relevant work, the claimant is not disabled.

5) If the claimant can make an adjustment to other work, the claimant is not

disabled. If the claimant cannot make an adjustment to other work, the claimant is

disabled.
Rabbers v. Comm’r of Soc. Sec., 582 F.3d 647, 652 (6th Cir. 2009) (citing 20 C.F.R. §§
404.1520(a)(4)(i)-(v), 404.1520(b)-(g)). The claimant has the burden of proof at the first four
steps of the sequential evaluation process. Id.; Wilson v. Comm'r of Soc. Sec., 378 F.3d 541, 548
(6th Cir. 2004). Once the claimant establishes a prima facie case by showing an inability to
perform the relevant previous employment, the burden shifts to the Commissioner to show that
the claimant can perform other substantial gainful employment and that such employment exists
in the national economy. Rabbers, 582 F.3d at 652; Harmon v. Apfel, 168 F.3d 289, 291 (6th
Cir. 1999).

B. The Administrative Law Judge’s Findings

ALJ Motta applied the sequential evaluation process and made the following findings of
fact and conclusions of law:

1. The [plaintiff] met the insured status requirements of the Social Security Act
through March 31, 2014.


Plaintiff then filed an action in the United States District Court. See Spurlock v.
Commissioner of Social Security, 1:14-cv-990 (S.D. Ohio). This Court remanded plaintiff's
claim pursuant to Sentence Four of 42 U.S.C. § 405(g) with instructions to the ALJ to re-weigh
the medical and other opinion evidence in accordance with the Court’s decision; to reconsider
plaintiff's RFC; and to further develop the medical and vocational evidence as warranted. (Tr.
652-74).

The Appeals Council subsequently vacated and remanded ALJ Level’s decision. (Tr.
679). Plaintiff and a vocational expert appeared and testified at a subsequent administrative
hearing before ALJ Elizabeth Motta on June 15, 2016. (Tr. 591-621).? On August 11, 2016,
ALJ Motta issued a decision denying plaintiff's DIB and SSI applications, determining that
plaintiff was not disabled within the meaning of the Social Security Act. (Tr. 523-41).
Plaintiff s request for review by the Appeals Council was denied, making the decision of ALJ
Motta the final administrative decision of the Commissioner.

II. Analysis

A. Legal Framework for Disability Determinations

To qualify for disability benefits, a claimant must suffer from a medically determinable
physical or mental impairment that can be expected to result in death or that has lasted or can be
expected to last for a continuous period of not less than 12 months. 42 U.S.C. §§ 423(d)(1)(A)
(DIB), 1382c(a)(3)(A) (SSI). The impairment must render the claimant unable to engage in the
work previously performed or in any other substantial gainful employment that exists in the

national economy. 42 U.S.C. §§ 423(d)(2), 1382c(a)(3)(B).

2 In the second ALJ hearing, plaintiff appears to have claimed an alleged onset date of September 1, 2006, which
was the alleged onset date prior to the amended onset date asserted at the first hearing.

2


2014 WL 656774 (S.D. Ohio Feb. 19, 2014). “[S]igns are medically demonstrable phenomena
that indicate specific psychological abnormalities, e.g., abnormalities of behavior, mood,
thought, memory, orientation, development, or perception,” which must “be shown by
observable facts that can be medically described and evaluated.” 20 C.F.R. §§ 404.1528(b),
416.928(b); Parr, 2014 WL 301043, at *6 n.1. Laboratory findings include “psychological
phenomena which can be shown by the use of medically acceptable laboratory diagnostic
techniques,” such as psychological tests. 20 C.F.R. §§ 404.1528(c), 416.928(c). “When mental
illness is the basis of a disability claim, clinical and laboratory data may consist of the diagnosis
and observations of professionals trained in the field of psychopathology,” whose findings
should not be rejected simply because of the “relative imprecision of the psychiatric
methodology.” Parr, 2014 WL 301043, at *6.

Dr. Schroder’s opinions are supported by the clinical findings set forth in his treatment
records. At the time Dr. Schroder rendered his assessment in January 2013, plaintiff had seen
Dr. Schroder six times since beginning treatment in September 2012. (Tr. 415-24). At his initial
examination with Dr. Schroder, plaintiff reported he was depressed, anxious, withdrawn, and
forgetful. He wanted to “learn how to fight depression.” (Tr. 420). Clinically, plaintiff was
cooperative, but withdrawn; his thought processes were “forgetful”; his affect was congruent;
and his mood was anhedonic, anxious, depressed, and “easily overwhelmed.” (/d.). Dr.
Schroder diagnosed plaintiff with major depressive disorder, severe with associated anxiety, and
tule out mood disorder due to his general medical condition with depressive features. (d.).
Plaintiff saw Dr. Schroder six times over the subsequent four-month period. (Tr. 415-19). Dr.
Schroder noted that plaintiff consistently presented with a tearful appearance, sleep disturbances,

distractible thought processes with memory complaints, agitated behavior, congruent affect, and


opined that plaintiff was “somewhat likely to show a pattern of periods of time away from work
due to mental health issues.” (/d.). Similarly, plaintiff presented to Dr. Mei Wang, Ph.D., on
March 14, 2016 for a psychological pain evaluation upon the recommendation of his pain
management physician. (Tr. 1546-49). During the objective portion of the emotional status
examination, plaintiff had a restricted affect and depressed mood. (Tr. 1547). He was very
anxious and visibly shaking throughout the session. (/d.). Dr. Wang’s psychological testing
revealed that plaintiff had severe depression, severe anxiety, and suicidal thoughts and wishes.
(Tr. 1548). Dr. Wang highly recommended “urgent professional attention.” (/d.). Thus, these
clinical findings by the evaluating psychologists do not support the ALJ’s conclusion that Dr.
Schroder’s opinions were “unsupported by objective findings in the mental health records.” (Tr.
538).

The ALJ also erred in summarily discounting Dr. Schroder’s opinions on the basis that he
relied heavily on plaintiff's subjective reports and symptoms and limitations and seemed to
“uncritically accept” most of what plaintiff reported. In the January 2013 assessment, when
asked to describe clinical findings such as results of mental status examinations that demonstrate
the severity of plaintiff's mental impairments, Dr. Schroder indicated that after six visits,
plaintiff presented as extremely anxious, easily overwhelmed, and depressed. (Tr. 488). Dr.
Schroder noted that his observations were “clinically based” and that plaintiff was “consistently
extremely anxious.” (Tr. 491). While Dr. Schroder did cite some of plaintiffs self-reported
symptoms in his April 2013, September 2013, and March 2016 narrative letters, Dr. Schroder
documented his own observations that plaintiff's mental health issues persisted. (See Tr. 992,
996, 1447). The Court notes that the ALJ appropriately considered plaintiff's two-year gap in

treatment between January 2014 and January 2016. Tate v. Comm'r of Soc. Sec., 467 F. App’x

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