Johnson, Michelle M. v. Barnhart, Jo Anne B. ( 2006 )

In the
United States Court of Appeals
For the Seventh Circuit
____________
No. 05-3797
MICHELLE JOHNSON,
Plaintiff-Appellant,
v.
JO ANNE B. BARNHART, Commissioner
of Social Security,
Defendant-Appellee.
____________
Appeal from the United States District Court
for the Eastern District of Wisconsin.
No. 05-C-73—J. P. Stadtmueller, Judge.
____________
ARGUED APRIL 7, 2006—DECIDED JUNE 5, 2006
____________
Before FLAUM, Chief Judge, and POSNER and EASTERBROOK,
Circuit Judges.
POSNER, Circuit Judge. The plaintiff, who was 38 years old
at the time of her hearing and has a high-school education,
complains about being denied social security disability
benefits. She is afflicted with a mysterious malady called
sarcoidosis (see Terrence C. Demos & Patrick J. Fahey, “The
Image of Sarcoidosis,” http://www.meddean.luc.edu/
Lumen/meded/Radio/sarc/sarc.htm, visited Apr. 9, 2006),
an inflammatory condition that often affects multiple
organs, principally the lungs, eyes, and skin. She testified
2 No. 05-3797
that she has shortness of breath, blurred vision, painful skin
lesions, and pain in her joints. Although the disease is
incurable, its symptoms can be alleviated by steroids.
Johnson takes prednisone and it has proved to be an
effective medication for her skin lesions, though as a side
effect it has contributed to a substantial weight gain that has
brought her up to 211 pounds although she is only 5 feet 5½
inches in height. The administrative law judge found that,
considering Johnson’s age, education, and the gravity of her
symptoms, she can do sedentary work and therefore is not
disabled, and the district court affirmed.
Sarcoidosis is one of those diseases that varies greatly
in severity from individual to individual; indeed, many
people with sarcoidosis have no symptoms at all. If one
believed everything the plaintiff said at her hearing, she is
indeed incapable of full-time gainful employment, but the
administrative law judge was not obliged to believe all her
testimony. Applicants for disability benefits have an in-
centive to exaggerate their symptoms, and an administrative
law judge is free to discount the applicant’s testimony on
the basis of the other evidence in the case.
The judge’s opinion is long and painstaking, and though
it is also jargon-ridden and in places opaque, we can make
out what she was driving at. But our job would be much
easier if only the administrative law judges would define
the obscure medical terms with which they pepper their
opinions, relate those terms to the claimant’s function-
ing—which is all that matters since “the social security
disability benefits program is not concerned with health as
such, but rather with ability to engage in full-time gainful
employment,” Gentle v. Barnhart, 430 F.3d 865, 868 (7th Cir.
2005)—and indicate the relevance of absence of symptoms.
Boiles v. Barnhart, 395 F.3d 421, 425-26 (7th Cir. 2005).
No. 05-3797 3
The medical evidence reveals that Johnson’s sarcoidosis
has less impact on her ability to work than one would
infer just from her testimony. She has 20-20 vision, and
although she has been diagnosed with an inflammation of
the eyes that causes her vision to be intermittently blurry,
there is nothing to indicate that it prevents her from read-
ing, and it has responded well to prednisone. Her skin
lesions have also responded to medication, and they are
unsightly and irritating rather than disabling except insofar
as they cause pain (a matter we’ll take up shortly). Although
Johnson complains of shortness of breath, the physician who
diagnosed her sarcoidosis reported that “her lungs were
clear.” And after she started taking prednisone and
methotrexate regularly, her treating physician “noted that
claimant’s sarcoidosis was stable with no further reports of
shortness of breath,” which undermined Johnson’s testi-
mony that “I try to do a little exercise, walk down the street,
but it’s like, hard for me to breathe. I have trouble breath-
ing.”
Joint and muscle pain is another symptom of sarcoidosis.
Johnson testified that her legs hurt “all over from my
knees down to my ankles,” and they hurt “every day, all
day . . . . It’s hard for me to get up in the morning because
my leg’s so bad. It would be swollen up so bad so I’ll get up,
maybe try to take a bath but my roommate have to help me
in and out the tub.” She takes naproxen, an anti-inflamma-
tory drug, for the pain. But medical examinations have
revealed no serious problems with her joints or difficulty in
walking and moving her limbs, which might have indicated
that the sarcoidosis had affected her joints. Her treating
physician seems to have thought that her pain was mainly
the result of the skin lesions.
The administrative law judge thought Johnson’s com-
plaints about pain exceeded the objective medical evidence,
4 No. 05-3797
yet pain can be severe to the point of being disabling even
though it has no diagnosable cause and thus is entirely in
the patient’s mind. Sims v. Barnhart, 442 F.3d 536, 537-38 (7th
Cir. 2006); Carradine v. Barnhart, 360 F.3d 751, 753-54 (7th
Cir. 2004); Foote v. Chater, 67 F.3d 1553, 1560-61 (11th Cir.
1995) (per curiam); Latham v. Shalala, 36 F.3d 482, 484 (5th
Cir. 1994); Easter v. Bowen, 867 F.2d 1128, 1130 (8th Cir.
1989). “Medical signs and laboratory findings, established
by medically acceptable clinical or laboratory diagnostic
techniques, must show the existence of a medical impair-
ment(s) which results from anatomical, physiological, or
psychological abnormalities and which could reasonably be
expected to produce the pain or other symptoms alleged,”
20 C.F.R. § 404.1529(b) (emphasis added), but the word we
have italicized underscores the difficulty of confirming or
refuting pain testimony.
Even when as in this case the claimant attributes her
pain to a physical rather than a psychological cause, the
administrative law judge cannot disbelieve her testimony
solely because it seems in excess of the “objective” medical
testimony. Schmidt v. Barnhart, 395 F.3d 737, 746-47 (7th Cir.
2005). The etiology of pain is not so well understood, or
people’s pain thresholds so uniform, that the severity of
pain experienced by a given individual can be “read off”
from a medical report. “[P]ain is a complex, multidimen-
sional, subjective experience. The report of pain is related to
numerous variables, such as cultural background, past
experience, the meaning of the situation, personality
variables, attention, arousal level, emotions, and reinforce-
ment contingencies.” Dennis C. Turk & Ronald Melzack,
“The Measurement of Pain and the Assessment of People
Experiencing Pain,” in Handbook of Pain Assessment 3, 5
(Turk & Melzack, eds., 2d ed. 2001). “[T]here is often a poor
relationship between the ‘subjective’ experience of pain and
No. 05-3797 5
‘objective’ or external referents. This may be most evident in
the case of chronic pain where apparently similar peripheral
pathology, injury, or nociceptive input [pain stimulus] can
result in markedly different presentations. Whereas patient
self-report, using verbal analogue or other rating scales, is
perhaps the most straightforward and appropriate means of
determining pain severity (or other aspects of the pain
experience), this is prone to response bias like all self-
reports.” Keith Nicholson, Michael F. Martelli, & Nathan D.
Zasler, “Myths and Misconceptions about Chronic Pain: The
Problem of Mind-Body Dualism,” in Pain Management: A
Practical Guide for Clinicians 465, 465-66 (Richard S. Weiner,
ed., 6th ed. 2001); see also Kathleen McGrory, “Doctors
Struggle to Treat Mysterious and Unbearable Pain,” New
York Times, May 31, 2006, p. D5.
Despite the inherent difficulty of evaluating testimony
about pain, an administrative law judge will often have
solid grounds for disbelieving a claimant who testifies that
she has continuous, agonizing pain. The judge in Schmidt v.
Barnhart, supra, 395 F.3d at 747, found that the claimant’s
“daily living activities were not significantly restricted, that
he was not receiving any active treatment or therapy for
his conditions at the time of the hearing, that he was not
using any prescription medication, and that his alleged pain
did not prevent him from engaging in substantial gainful
activity for several months after he allegedly became
disabled.” Johnson’s skin lesions are painful—and how
painful cannot be determined from the medical evidence.
But we know that they have responded to medication, that
some of her testimony was exaggerated (the testimony
about her difficulty in breathing), and that she continued
working as a car washer for four years after being diag-
nosed with sarcoidosis. These circumstances justified the
administrative law judge in finding Johnson’s testimony
about pain exaggerated.
6 No. 05-3797
Johnson complains that the judge failed to explore the
possible effect of her obesity on her sarcoidosis. In Mendez
v. Barnhart, 439 F.3d 360, 363 (7th Cir. 2006), we said that
“the administrative law judge should have considered
whether [the claimant’s] difficulty in getting around
would interact with her cognitive limitations and her
psychiatric condition to make her incapable of complying
with even simple workplace directives.” See also Gentle v.
Barnhart, supra, 430 F.3d at 868. There is no evidence that
Johnson’s obesity would have a direct effect on her ability to
do sedentary work, as it might on work that involved a lot
of moving around; but obesity as a source of a
specific limitation must be distinguished from obesity as a
factor that aggravates a limitation having another cause.
Mendez’s obesity didn’t aggravate her cognitive limitations;
it created a separate impediment to her being able to work
full time. Johnson’s obesity did not create a separate impedi-
ment to her being able to work but may have aggravated the
problems with her joints because obesity places additional
stress on joints. 1 William J. Koopman & Larry W. More-
land, Arthritis and Allied Conditions: A Textbook of
Rheumatology 27-28 (15th ed. 2005). “The heavier you are, the
more stress is placed on your spine, hips, knees and ankles.
Also, heavier people tend to resist exercise, resulting in
another risk factor—weak muscles, particularly in the thigh.
Weakness in the thigh, in turn, places extra stress on the
knees.” Jane E. Brody, “Personal Health: Arthritis: Your
‘Reward’ for Wear and Tear,” New York Times, July 30, 2002,
p. F7. But there is no indication that in assessing Johnson’s
joint problems the administrative law judge gave insuffi-
cient weight to the effect on them of Johnson’s obesity,
which is anyway not extreme. Her Body Mass Index of 34.6
(211 lbs. × 703/(65.5 inches)2) places her in obesity class 1,
the lowest class. National Institutes of Health, The Practical
No. 05-3797 7
Guide: Identification, Evaluation, and Treatment of Overweight
and Obesity in Adults, NIH Pub. No. 00-4084 (Oct. 2000), p.
1, tab. 1, http://www.nhlbi.nih.gov/guidelines/obesity/
prctgd_b.pdf.
Actually, Johnson’s lawyer is less concerned with possible
flaws in the administrative law judge’s opinion than with
the brevity of the hearing and the judge’s failure to obtain
all of Johnson’s medical records. Johnson was
not represented and her current lawyer points us to cases
which hold that the administrative law judge has a duty
in such a case to ask questions that will elicit a full picture
of the applicant’s capacity for full-time gainful employment.
Nelson v. Apfel, 131 F.3d 1228, 1235 (7th Cir. 1997); Binion v.
Shalala, 13 F.3d 243, 245-46 (7th Cir. 1994); Reefer v. Barnhart,
326 F.3d 376, 380-81 (3d Cir. 2003). The judge did ask a
number of questions, and really what Johnson’s lawyer
seems to want is that the judge have asked questions that
would have cued Johnson to exaggerate her condition. For
example, he complains that the administrative law judge
“did not ask about the severity of the blurriness [of John-
son’s vision], nor what, if any, restrictions it caused.”
Prompting Johnson to elaborate her testimony would
simply have widened the gulf between it and the medical
records.
As for the missing records (belatedly introduced in the
district court), the administrative law judge asked Johnson
at the hearing whether there were any additional documents
that should be considered, and Johnson said no. The judge
had requested all of Johnson’s medical records from John-
son’s physician and it was not the judge’s fault that the
physician failed to comply and that Johnson failed to alert
the judge to the problem. Even a pro se litigant bears some
responsibility for making a record. In any event, the missing
8 No. 05-3797
medical records, though indicating some worsening of
Johnson’s skin lesions, would have been unlikely to change
the administrative law judge’s conclusion that Johnson was
not disabled from doing sedentary work.
AFFIRMED.
A true Copy:
Teste:
_____________________________
Clerk of the United States Court of
Appeals for the Seventh Circuit
USCA-02-C-0072—6-5-06