Patty Carradine v. Jo Anne B. Barnhart, Commissioner of Social Security

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 to 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 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 demean- or 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 Car-radine “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, fibro-myalgia, and “somatization disorder,” the last term (along with synonyms like “so-matoform 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 Multi-phasic Personality Inventory (MMPI) did not indicate invalid responses or 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 Carra-dine’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, 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 Carra-dine 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 Car-radine’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 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. Verti-gan’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 ease remanded to the Social Security Administration for further proceedings consistent with this opinion.

REVERSED AND REMANDED.