United States District Court, Middle District of Pennsylvania
Martin C. Carlson United States Magistrate Judge
I. Statement of Facts and of the Case
In this case we are asked to evaluate an Administrative Law Judge’s (ALJ) decision denying social security disability benefits to the plaintiff, Kinta Small, a 39 year old man from Carlisle, Pennsylvania, who suffers from diabetes mellitus, peripheral neuropathy, carpal tunnel syndrome, and some mental health challenges. In Mr. Small’s case, the ALJ’s decision was made against a factual backdrop marked by conflicting evidence relating to the nature, severity and disabling effect of Mr. Small’s emotional and medical conditions. Much of this evidence, and in some respects the testimony of the claimant Mr. Small, actually seemed to contradict and undermine this disability claim. In other instances, the evidence suggested that Mr. Small’s condition was aggravated, or otherwise remained uncontrolled, due to Mr. Small’s failure to comply with his treatment regimen prescribed by medical providers. Upon consideration of this evidence, for the reasons set forth below, we conclude that the ALJ’s thorough decision is supported by substantial evidence which is adequately explained on the record and, therefore, this decision will be affirmed.
B. Small’s Medical and Employment History
On June 17, 2008, Small filed a claim for Title II disability benefits, and a claim for Supplemental Security Income (SSI) benefits, both alleging an onset date of November 1, 2006, claiming total disability resulting from diabetes, depression, and pain. The plaintiff subsequently amended his alleged onset disability date to May 22, 2008. (Tr. 48, 101-02, 318.) A hearing on the claim was initially held on October 6, 2009, resulting in an unfavorable decision by ALJ David Gerard of the Harrisburg, Pennsylvania Office of Disability Adjudication and Review. (Tr. 106.) The plaintiff requested review of the decision by the Appeals Council, which remanded the case on March 23, 2011, for further consideration. (Tr. 134.) Thereafter, a second hearing was held on August 10, 2011, this time before a new ALJ, Daniel Myers. ALJ Myers issued an unfavorable decision on September 6, 2011. (Tr. 17.) The Appeals Council denied the plaintiff’s request for review on March 5, 2013, and the plaintiff thereafter initiated this action on April 3, 2013.
Kinta Small was born on December 3, 1971, was 39 years old at the time of the ALJ’s adverse decision, and, therefore, considered a “younger individual” under applicable regulations. 20 C.F.R. §§ 404.1563(c), 416.963(c). He attended high school through the 10th grade, when he dropped out of school. He has past work experience as a construction worker, warehouse laborer, forklift operator, and an automobile detailer. (Tr. 34, 376.) He has eight children, ranging in age from two to 19, none of whom live with him. (Tr. 53.)
The plaintiff suffers from diabetes that is poorly controlled, as well as depression and pain. (Tr. 318.) Mr. Small testified at the hearing that he no longer drives because he cannot feel the pedals due to numbness in his feet, and because he experiences pain when he grips the steering wheel. (Tr. 52.) He testified that he has pursued mental health treatment, at least in part because his primary family doctor, Louis Hieb, D.O., believed that getting the plaintiff’s depression under control would help him to better control his diabetes – something that has been a problem for an extended period of time. (Tr. 55.)
The plaintiff testified that he has tried to modify his diet in order to help control his diabetes, and has discontinued using alcohol for two years prior to the hearings in this case. However, evidence suggested that the plaintiff’s diabetes remains significantly undercontrolled, and the plaintiff’s blood sugar levels taken the night before the second hearing before the ALJ revealed a reading of 570 – far above the a normal blood-sugar level of between 70 and 140. (Tr. 64, 703.) The plaintiff testified that he experiences depression, anger and crying spells as a result of his struggles to control his blood sugar. (Tr. 71-72.) According to the plaintiff, he is calm when his blood sugar is low, but if it becomes elevated he becomes agitated and occasionally aggressive. (Tr. 72.) According to the plaintiff, as a result of his diabetes and neuropathy, he elevates his legs while sleeping, and spends between eight and nine hours a day in a recliner. (Tr. 73.)
The plaintiff lives with his mother and his stepfather, and has done so for the past six years. (Tr. 51, 56.) The plaintiff submitted forms in support of his application for Social Security benefits in which he represented that at home he prepares his own meals, (Tr. 328.), goes outside for fresh air (Tr. 326.), goes shopping on his own (Tr. 329, 369.), goes out alone at times (Tr. 329.), talks on the phone periodically during the week, (Tr. 330.), and occasionally transports himself places by car and bicycle. (Tr. 369.) The plaintiff’s mother also indicated that he drives a car and can go out alone. (Tr. 392.) In contrast to other evidence in the record suggesting that the plaintiff is dependent upon others to prepare his meals, his mother indicated in April 2010 that he shops for his own food and prepares simple meals, and cares for himself. (Tr. 390-392.) The plaintiff’s mother indicated that he attends family functions and spends time with some of his eight children when he can, and has a few social friends that he sees. (Tr. 393.) The plaintiff claims that he relies substantially upon his mother to perform household chores, including doing the laundry and cleaning, and that he only helps when asked. (Tr. 368.)
C. Treating and Examining Source Statements
In July 2009, Dr. Hieb, the plaintiff’s treating physician, completed a medical source statement indicating that the plaintiff was able to engage in the following activities: lifting and carrying 20 pounds occasionally and 10 pounds frequently; standing or walking at least two hours in an eight-hour work day; sitting without restriction; pushing or pulling on a limited basis with all extremities; performing all postural movements occasionally, but balancing frequently; handling objects occasionally; and tolerating exposure to temperature extremes, dust, and other environmental irritants on only a limited basis. (Tr. 504-07.)
Curiously, in contrast to this detailed statement, earlier in April 2009, Dr. Hieb completed a separate form for the Franklin County Department of Domestic Relations in which he indicated that the plaintiff had been “totally disabled” since February 2006. (Tr. 456.) This form was followed by another from Dr. Hieb in October 2010 in which he again indicated that the plaintiff was “fully disabled”, since sometime in “?July 05" [sic]. (Tr. 913.)
In October 2010, Ronald Vandegriff, D.O., examined the plaintiff. (Tr. 710-719.) During that examination, the plaintiff reported that he was unable to work due to pain in his “knees, ankles, wrists, feet, and arms.” (Tr. 710.) The plaintiff also claimed that he suffered from carpal tunnel syndrome, but that his surgeon was waiting to operate until after the plaintiff’s blood sugar was being controlled adequately. (Tr. 711.) During this examination, the plaintiff admitted to smoking a pack of cigarettes a day, but denied using alcohol or street drugs. (Tr. 711.)
Dr. Vandegriff observed that the plaintiff was capable of walking unassisted to and from the examination table, without any difficulty. (Tr. 712.) During the visit, the plaintiff’s blood pressure was normal, and his lungs were found to be clear. The plaintiff had no normal range of motion in all joints, with strong distal pulses and full sensation throughout his entire leg. (Tr. 712, 716.) During the examination, the plaintiff was found to be fully oriented, cooperative, answered questions appropriately, and maintained good eye contact. (Tr. 712-13.) Dr. Vandegriff found that Small’s speech quality and quantity were normal, although he appeared anxious. (Tr. 713.) An x-ray of the plaintiff’s right knee was normal. (Tr. 712.)
Following this examination, Dr. Vandegriff diagnosed the plaintiff with type 1 diabetes, uncontrolled by history, polyarthralgia, right knee worse; depression; and carpal tunnel syndrome in both hands. (Tr. 713.) Dr. Vandegriff recommended that the plaintiff be seen by an endocrinologist on a regular basis until his blood sugars were brought under control, and that he should have lab work performed, including a hemoglobin A1C and urinalysis, every four months. Additionally, it was recommended that the plaintiff pursue treatment with a psychiatrist and therapist on a regular basis. (Tr. 713.)
In addition to making the foregoing recommendations regarding the plaintiff’s ongoing treatment, Dr. Vandegriff completed a medical source statement in which he indicated that the plaintiff retained the ability to lift and carry 10 pounds frequently, stand and walk four hours in an eight-hour work day, sit eight hours with a sit/stand option, with an unlimited ability to push and pull. (Tr. 714-15.) Dr. Vandegriff also recommended that the plaintiff be restricted from heights and could never balance or crawl, but also noted that the plaintiff could frequently bend, occasionally kneel, stoop and crouch. (Tr. 715.)
D. Consultative Psychologist
In August 2010, Stanley E. Schneider, Ed.D., examined the plaintiff. (Tr. 669-78.) The plaintiff drove himself to the examination. (Tr. 670.) Like Dr. Vandegriff, Dr. Schneider found the plaintiff to be generally cooperative and self-sufficient, but that he also presented agitated and exhibited quite a bit of nervous energy as the interview proceeded. (Tr. 670.) During this examination, the plaintiff told Dr. Schneider that he had a difficult childhood, and that he had spent time in juvenile detention and experienced abuse by his stepfather. (Tr. 670.) The plaintiff also told Dr. Schneider that he had spent “a couple of years” in jail, including most recently in 2009. (Tr. 670.) The plaintiff acknowledged a long history of alcohol and drug abuse, but stated that he stopped using drugs two years prior to this examination, and stopped drinking alcohol in December 2008. (Tr. 672.) The plaintiff also, perhaps exaggerating, told Dr. Schneider that he had held between 50 and 100 jobs during his life, but that he would routinely either abandon his employment or get fired. (Tr. 672.)
During this mental status examination, the plaintiff’s speech was found to be relevant, oriented and goal-directed. (Tr. 673.) Dr. Schneider assessed the plaintiff’s mood as agitated and depressed. (Tr. 673.) He became increasingly agitated as the examination progressed. (Tr. 673.) Whereas the plaintiff denied suicidal and homicidal thinking to Dr. Vandegriff, during his examination with Dr. Schneider he reported recurrent suicidal thinking without any intent or plan, as well as homicidal ideation, but did not identify any specific person. (Tr. 673.)
He was able to identify similarities between seemingly dissimilar items, and interpret simple proverbs. (Tr. 673.) He was capable of performing serial 5's, and was able to repeat four digits forward acceptably, though he had some trouble with repeating three digits backwards. Dr. Schneider thus observed some ...