Project Posner

Lead opinion by POSNER

    753 POSNER, Circuit Judge. Applicants for social security benefits who claim to be disabled from working because of extreme pain make the job of a social security administrative law judge a difficult one. Medical science confirms that pain can be severe and disabling even in the absence of "objective " medical findings, that is, test results that demonstrate a physical condition that normally causes pain of the severity claimed by the applicant. E.g., Dennis C. Turk & Akiko Okifuji, "Assessment of Patients' Reporting of Pain: An Integrated Perspective," 353 Lancet 1784 (1999); Paula M. Trief et al., "Functional vs. Organic Pain: A Meaningful Distinction?" 43 J. Clinical Psych. 219 (1987). And so "once the claimant produces medical evidence of an underlying impairment, the Commissioner may not discredit the claimant's testimony as to subjective symptoms merely because they are unsupported by objective evidence." Lester v. Chater, 81 F.3d 821, 834 (9th Cir. 1996). "A claimant's subjective testimony supported by medical evidence that satisfies the pain standard is itself sufficient to support a finding of disability. Indeed, in certain situations, pain alone can be disabling, even when its existence is unsupported by objective evidence." Foote v. Chater, 67 F.3d 1553, 1561 (11th Cir. 1995) (per curiam) (citations omitted). "Pain, fatigue, and other subjective, non-verifiable complaints are in some cases the only symptoms of a serious medical condition. To insist in such a case, as the social security disability law does not . . . that the subjective complaint, even if believed by the trier of fact, is insufficient to warrant an award of benefits would place a whole class of disabled people outside the protection of that law." Cooper v. Casey, 97 F.3d 914, 917 (7th Cir. 1996) (citations omitted); see 20 C.F.R. § 404.1529(b)(2).

   But of course this dispensation invites the unscrupulous applicant to exaggerate his or her pain without fear of being contradicted by medical evidence. The administrative law judge must be alert to this possibility and evaluate the applicant's credibility with great care. His responsibility is all the greater because determinations of credibility are fraught with uncertainty, e.g., Judy Zaparniuk, John C. Yuille & Steven Taylor, "Assessing the Credibility of True and False Statements," 18 Int'l J.L. & Psychiatry 343 (1995); Michael W. Mullane, "The Truthsayer and the Court: Expert Testimony on Credibility," 43 Me. L. Rev. 53, 64 (1991); despite much lore the contrary, it appears that it is actually more difficult to assess the credibility of oral than of written testimony. Michael J. Saks, "Enhancing and Restraining Accuracy in Adjudication," 51 L. & Contemp. Probs., Autumn 1988, pp. 243, 263-64. Appellate review of credibility determinations, especially when made by specialists such as the administrative law judges of the Social Security Administration, is highly limited because the reviewing court lacks direct access to the witnesses (which may be a mixed blessing, however, if Professor Saks is correct), lacks the trier's immersion in the case as a whole, and when reviewing decisions by specialized tribunals also lacks the trier's experience with the type of case under review. See, e.g., Dixon v. Massanari, 270 F.3d 1171, 1178-79 (7th Cir. 2001); Shramek v. Apfel, 226 F.3d 809, 811 (7th Cir. 2000); Fairman v. Anderson, 188 F.3d 635, 647 (5th Cir. 1999). The administrative law judge thought that Carradine was 754 exaggerating her pain--that it was not severe enough to prevent her from working. Ordinarily this determination would be conclusive upon us, but in this case the administrative law judge based his credibility determination on serious errors in reasoning rather than merely the demeanor of the witness, and when that occurs, we must remand. Clifford v. Apfel, 227 F.3d 863, 872 (7th Cir. 2000).

   Patty Carradine applied for social security disability benefits in 1994, when she was 42 years old, following a back injury from a slip and fall on ice. The administrative law judge acknowledged that Carradine "has a severe impairment . . . . She has upper body pain and right hand numbness. [Medical] records establish objective evidence of a medical condition that would cause limitations of work capacity." In fact, in the years since her back injury caused pain that triggered a protracted search for relief from a large battery of physicians, she has been diagnosed with a variety of ailments, including degenerative disk disease, scoliosis, depression, fibromyalgia, and "somatization disorder," the last term (along with synonyms like "somatoform disorders" and "somatoform pain disorder") being a fancy name for psychosomatic illness, that is, physical distress of psychological origin. See 20 C.F.R. pt. 404, subpt. P, app. 1, § 12.07; Stedman's Medical Dictionary 528 (27th ed. 2000); Cass v. Shalala, 8 F.3d 552, 554 (7th Cir. 1993); Latham v. Shalala, 36 F.3d 482, 484 (5th Cir. 1994); Vaughn v. Nissan Motor Corp. in U.S.A., Inc., 77 F.3d 736, 737 (4th Cir. 1996); Easter v. Bowen, 867 F.2d 1128, 1129-30 (8th Cir. 1989); Trief et al., supra. The issue in the case is not the existence of these various conditions of hers but their severity and, concretely, whether, as she testified with corroboration by her husband, they have caused her such severe pain that she cannot work full time.

   While acknowledging as he had to that severe pain can be totally disabling, see, e.g., Zurawski v. Halter, 245 F.3d 881, 889 (7th Cir. 2001); 20 C.F.R. §§ 404.1529(c)(4) , (d), the administrative law judge gave two reasons for disbelieving Carradine's testimony about the severity of her pain. The first involved the primarily psychological origin not of the pain itself but of its severity. He said, "Psychological testing confirms a finding that the claimant is inclined to exaggerate her account of limitations . . . . Among the findings from the examination and testing, Dr. Martin observed that [Carradine's] psychological stress and personal conflicts likely affected the claimant's account of physical symptoms and ailments. He noted that results of the Minnesota Multiphasic Personality Inventory (MMPI) did not indicate invalid responsesor exaggeration of psychological symptoms. However, he noted that her performance indicated somatization. This finding implies she exaggerates the severity of symptoms she reports." It implies no such thing. It implies merely that the source of Carradine's pain is psychological rather than physical. If pain is disabling, the fact that its source is purely psychological does not disentitle the applicant to benefits.

   Pain is always subjective in the sense of being experienced in the brain. The question whether the experience is more acute because of a psychiatric condition is different from the question whether the applicant is pretending to experience pain, or more pain than she actually feels. The pain is genuine in the first, the psychiatric case, though fabricated in the second. The cases involving somatization recognize this distinction. Metz v. Shalala, 49 F.3d 374, 377 (8th Cir. 1995); Latham v. Shalala, supra, 36 F.3d at 484; Easter v. Bowen, 755 supra, 867 F.2d at 1129. The administrative law judge in our case did not.

   His misunderstanding of the point is further shown by his remarking that "medical examiners and treating physicians have not been able to find objective evidence to support [Carradine's] extreme account of pain and limitation." That inability is consistent of course with a psychological origin of the pain. He acknowledged Carradine's long history of treatment. "This extensive and exhaustive treatment," he remarked, "would on its face appear to reflect a severely disabling condition. However, it also appears that the doctors accepted the claimant's complaints at face value and proceeded to treat her in the absence of significant findings upon diagnostic testing and physical examination." Since severe pain is consistent with "the absence of significant findings upon diagnostic testing and physical examination," which would not reveal a psychological origin of pain, the doctors had no choice but to take Carradine's complaints of pain "at face value" and treat her. What is significant is the improbability that Carradine would have undergone the pain-treatment procedures that she did, which included not only heavy doses of strong drugs such as Vicodin, Toradol, Demerol, and even morphine, but also the surgical implantation in her spine of a catheter and a spinal-cord stimulator, merely in order to strengthen the credibility of her complaints of pain and so increase her chances of obtaining disability benefits, cf. Easter v. Bowen, supra, 867 F.2d at 1130; likewise the improbability that she is a good enough actress to fool a host of doctors and emergency-room personnel into thinking she suffers extreme pain; and the (perhaps lesser) improbability that this host of medical workers would prescribe drugs and other treatment for her if they thought she were faking her symptoms. Such an inference would amount to an accusation that the medical workers who treated Carradine were behaving unprofessionally.

   The administrative law judge could not get beyond the discrepancy between Carradine's purely physical ailments, which although severe were not a plausible cause of disabling pain, and the pain to which Carradine testified. He failed to take seriously the possibility that the pain was indeed as severe as Carradine said but that its origin was psychological rather than physical. The evidence that she presented went far beyond a merely self-serving, uncorroborated claim of pain by a malingerer.

   The administrative law judge thought Carradine's testimony inconsistent with the activities that she acknowledged engaging in, such as performing household chores and taking walks as long as two miles. Since exercise is one of the treatments that doctors have prescribed for Carradine's pain, and she does not claim to be paralyzed, we cannot see how her being able to walk two miles is inconsistent with her suffering severe pain. And if she was testifying truthfully and against her interest about her daily activities, why did the administrative law judge think she was lying about her pain?

   But there is a deeper problem with the administrative law judge's discernment of contradiction. He failed to consider the difference between a person's being able to engage in sporadic physical activities and her being able to work eight hours a day five consecutive days of the week. Clifford v. Apfel, supra, 227 F.3d at 872; Vertigan v. Halter, 260 F.3d 1044, 1050 (9th Cir. 2001); Easter v. Bowen, supra, 867 F.2d at 1130. Carradine does not claim to be in wracking pain every minute of the day. When she feels better for a little while, she 756 can drive, shop, do housework. It does not follow that she can maintain concentration and effort over the full course of the work week. The evidence is that she cannot. The weight the administrative law judge gave to Carradine's ability to walk two miles was perverse: not only is it a form of therapy, but it is not a form of therapy available at work. A clinical psychologist opined that Carradine's attention and concentration are impaired by her focus on pain.

   As in this case, the applicant for disability benefits in Vertigan v. Halter, supra, 260 F.3d at 1049-50, was "able to go grocery shopping with assistance, walk approximately an hour in the malls, get together with her friends, play cards, swim, watch television, and read. She also took physical therapy for six months and exercised at home. The ALJ relied on this evidence to conclude that Ms. Vertigan's daily activities involved physical functions that were inconsistent with her claims of pain. Yet, these physical activities did not consume a substantial part of Ms. Vertigan's day. . . . In addition, activities such as walking in the mall and swimming are not necessarily transferable to the work setting with regard to the impact of pain. A patient may do these activities despite pain for therapeutic reasons, but that does not mean she could concentrate on work despite the pain or could engage in similar activity for a longer period given the pain involved. As such, we find only a scintilla of evidence in the record to support the ALJ's finding that she lacked credibility about her pain and physical limitations. As revealed by the medical reports, Ms. Vertigan's constant quest for medical treatment and pain relief refutes such a finding." So the court reversed. See also Cox v. Apfel, 160 F.3d 1203, 1207 (8th Cir. 1998), where the court "questioned whether a claimant with seven years of medical records detailing repeated complaints of severe pain, who undergoes three back surgeries in the hopes of alleviating that pain and who now lives with a morphine pump implanted in her body, can be found not credible regarding her complaints of pain."

   We do not decide that Carradine is in fact entitled to benefits. Maybe she is exaggerating her pain. Maybe we are naive in doubting Carradine's thespian capabilities or the willingness of physicians to perform intrusive, even dangerous, therapies on patients whom they believe to be fakers. Maybe even severe pain is not much of a distraction for people at Carradine's vocational level. (Her last job before her back injury was driving a van for a rehabilitation clinic.) These are issues for the administrative law judge to address utilizing whatever body of expert opinion, scholarly or otherwise, may be available to him or within the institutional memory of the Social Security Administration. But an administrative agency's decision cannot be upheld when the reasoning process employed by the decision maker exhibits deep logical flaws, Steele v. Barnhart, 290 F.3d 936, 941 (7th Cir. 2002); Sarchet v. Chater, 78 F.3d 305, 307 (7th Cir. 1996); Adorno v. Shalala, 40 F.3d 43, 44 (3d Cir. 1994), even if those flaws might be dissipated by a fuller and more exact engagement with the facts. The judgment is therefore reversed and the case remanded to the Social Security Administration for further proceedings consistent with this opinion.

   REVERSED AND REMANDED.

Dissent by COFFEY

   COFFEY, Circuit Judge, dissenting. The issue on appeal is whether the administrative law judge's ("ALJ") decision to deny disability insurance benefits to the claimant, Patty Carradine, is supported by substantial evidence. In his decision, the ALJ determined that Carradine's testimony 757 regarding the extent of her allegedly disabling pain was less than credible, finding that:

(1) Carradine's testimony was not supported by objective medical evidence from the records of her "medical examiners and treating physicians," R. at 19 (emphasis added);

(2) Carradine's testimony regarding pain was "significantly inconsistent" with her own account of her "routine daily activities including self-care and household chores," as well as "routinely driving and hobbies such as reading, taking walks, and gardening," R. at 18 (emphasis added);

(3) Carradine's credibility "was further diminished by the results of [physical] capacity testing that indicated her responses were significantly invalid" because she was exerting "minimal efforts" during the exam, id.; and

(4) Carradine's somatization disorder inclined her to "exaggerate[] the severity of the symptoms she reports." R. at 19.^[1]

For all of these reasons, the ALJ concluded that Carradine's "statements concerning her impairments and their impact on her ability to work . . . were not entirely reliable," and thus failed to support her allegation that she suffered from debilitating pain.^[2] R. at 27.

   The majority's sole basis and reasoning in reversing and remanding--purportedly to allow the ALJ to undertake "a fuller and more exact engagement with the facts"--is that, in the majority's view, the ALJ "based his credibility determination on serious errors in reasoning rather than merely the demeanor of the witness."^[3] 758 After reviewing the record, I am forced to disagree with the majority's broad and unsupported conclusion that there were "deep logical flaws" in the ALJ's reasoning, much less that his decision warrants reversal. By casting aside the well-supported credibility determination of the ALJ, who (unlike any judge on this panel) witnessed Carradine's testimony firsthand, the majority insists on running roughshod over long-standing principles of deference that continue to govern this Court's appellate review of decisions by administrative law judges.

   Instead, the ALJ set forth three other reasons he found Carradine's testimony incredible--namely, (1) the lack of objective medical evidence supporting her pain claims; (2) the fact she overstated her physical limitations on a previous strength test by giving "minimal efforts"; and (3) the inconsistency between her daily activities and her complaints of constant, disabling pain. These factors provide more than substantial evidence to support his credibility determination.

   Furthermore, it is undisputed that as the judge presiding over her benefits hearing, the ALJ had the "best 'opportunity to observe [her] verbal and non-verbal behavior . . . focusing on [her] reactions and responses to the interrogatories, [her] facial expressions, attitudes, tone of voice, eye contact, posture and body movements,' as well as confused or nervous speech patterns." United States v. Tolson, 988 F.2d 1494, 1497 (7th Cir. 1993). And as this Court has long held, this places the ALJ in a superior position to render credibility determinations as he did here. See infra at 29-35.

   Because this case is so fact-intensive, and involves a wealth of medical evidence from doctors, physical therapists, psychologists, as well as vocational experts, I have thoroughly reviewed the materials before the court and have made every attempt to make a complete record on review. Furthermore, I trust I have made clear in this opinion why I am convinced that the ALJ's credibility determination and his decision to deny the claimant benefits are supported in the record with substantial evidence, and I would thus affirm the district court 's judgment upholding the decision. I respectfully dissent.

   There can be no doubt that the law mandates that our Court on review, after considering the record in its entirety, must uphold an ALJ's decision to deny disability benefits to a claimant as long as the ALJ's ruling is supported by substantial evidence and is without any error of law. See 42 U.S.C. § 405(g); Sims v. Barnhart, 309 F.3d 424, 428 (7th Cir. 2002); Butera v. Apfel, 173 F.3d 1049, 1055 (7th Cir. 1999). The substantial evidence standard "requires no more than 'such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'" Diaz v. Chater, 55 F.3d 300, 305 (7th Cir. 1995) (quoting Richardson v. Perales, 402 U.S. 389, 401, (1971)) (emphasis added). Furthermore, in reaching our "substantial evidence" determination, this Court's review and evaluation of the record is limited; when "reviewing the record as a whole," we are "not allowed to substitute [our] judgment for the ALJ's 'by reconsidering facts, reweighing evidence, resolving conflicts in evidence, or deciding questions of credibility. '" Cannon v. Apfel, 213 F.3d 970, 974 (7th Cir. 2000) (emphasis added) (quoting Williams v. Apfel, 179 F.3d 1066, 1071-72 (7th Cir. 1999)).

   With respect to this Court's treatment of a credibility assessment by the ALJ, there has developed a firm and tenable rule of law "that an ALJ's credibility determination will not be disturbed unless it is patently wrong." Cannon, 213 F.3d at 977 (emphasis added) (internal quotation omitted); see also Herr v. Sullivan, 912 F.2d 178, 182 (7th Cir. 1990). As this Court has previously observed, this is a "strict standard for reversal," Powers v. Apfel, 207 F.3d 431, 435 (7th Cir. 2000) (emphasis added), for a "credibility determination by the ALJ, adopted by the Secretary, is entitled to considerable deference." Lee v. Sullivan, 988 F.2d 789, 793 (7th Cir. 1993) (emphasis added) (citing Steward v. Bowen, 858 F.2d 1295, 1302 (7th Cir. 1988)).^[4] Thus, "after review [of the entire record and evidence therein,] we must accept the findings of the ALJ"-- 759 and most certainly the ALJ's credibility determinations-- "if supported by substantial evidence." Meredith v. Bowen, 833 F.2d 650, 653 (7th Cir. 1987) (emphasis added). The majority has embarked upon a course of reasoning that is far afield of this principle.

   I. Objective Medical Evidence

   In denying Carradine's disability claim, the ALJ stressed in his opinion the lack of objective medical evidence verifying her asserted disability. Indeed, as the record reveals, Carradine sought medical attention from a vast number of specialists (some thirteen doctors) for a period of over seven years following her February 1993, slip-and-fall accident--but these medical records, and the findings inscribed therein, fail to substantiate the alleged severity of pain and resulting limitations claimed by Carradine to the standard of making her eligible for benefits.^[5]

   Two months later, in August of 1993, she returned to her job and, according to her testimony before an ALJ, she worked out an agreement with her supervisor to perform lighter work. The Care Center later terminated her in February of 1994 for failing to follow clinic procedures. While the record fails to specify what procedures Carradine ignored (she stated that it was for missing work), she testified that her termination was not for avoiding any lifting at work following her accident, as the following exchange between the ALJ and Carradine at her April 1995 hearing demonstrates:

Footnotes

[1]

   I believe it is incumbent that I point out that the majority incorrectly states that the ALJ gave just two reasons for disbelieving Carradine's testimony about the severity of her pain. In fact, the ALJ expressly referenced four independent bases for discrediting Carradine's allegation of disabling pain. And I believe it is beyond cavil that these four, solid reasons for discrediting Carradine's testimony, together, comprise more than enough evidence to support the ALJ's determination that the extent of Carradine's claimed impairment on account of her pain allegations was incredible (particularly considering the "substantial evidence" standard requires "no more than 'such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.'" Smith v. Apfel, 231 F.3d 433, 439 (7th Cir. 2000)).

[2]

   Ms. Carradine is a 54-year-old white female who, according to an assessment done by Dr. Karl Manders and physical therapist Kim Wagler in June of 1993, claimed to suffer from "constant burning pain [in her mid back], occasional headaches . . . muscle spasms, and right hip pain" on account of a February 1993 slip-and-fall accident. R. at 266. This initial evaluation further noted that Carradine's rehabilitation goal was to return to work, and that her rehabilitation potential was "good." Id.

[3]

   The majority utterly fails to support its creative assertion that the ALJ 's credibility determination was somehow based on these so-called "errors in reasoning" as opposed to Carradine's demeanor and presentation at the hearing. While the majority is apparently suggesting that the ALJ "erred" in stating that Carradine's somatization disorder "implies [that Carradine] exaggerates the severity of the symptoms she reports," as I explain later, it is an accepted medical fact that somatics do tend to exaggerate the severity of their symptoms, see infra; thus, the ALJ's explanation and reasoning was proper and was not in "error" as the majority claims. Moreover, this was not the only stated reason the ALJ rejected Carradine's pain allegations.

[4]

   The majority acknowledges this high degree of judicial deference granted to "specialists such as the administrative law judges of the Social Security Administration," conceding that "appellate review of [their] credibility determinations . . . is highly limited." It then fails to follow and circumvents its own statement of the law, and indeed goes on to obscure this prescribed level of deference, by somehow creating alleged errors (which it somehow interprets as errors in reasoning) that the ALJ is said to have made.

[5]

   At the time of her accident, Carradine was classified as an addiction counseling aide at the Wabash (Indiana) Addiction Care Center, while actually serving as a transport driver--a position which she had filled for about eight years. (Prior to her work as a counseling aide, Carradine had worked as a production line assembly worker.) On February 16, 1993, a few days after her accident, she began receiving workers' compensation related to her fall and injury. According to a "Report of Claim Status" form that was filed with the State of Indiana Worker's Compensation Board, these benefits ceased on June 8, 1993, for the reason that "Recent medical evidence indicate [sic] your current treatment is not related to your fall at work." R. at 160 (emphasis added). This same form notes that Carradine disagreed with the decision to terminate her benefits.