depression and somatoform disorder in this case there were many different medical opinions that supported her disability claim and the list i won't repeat it for you here but it's about ten doctors and they also rejected all of those opinions there was also a medical expert who testified at her second hearing and he testified that she met a listing at least so i believe two thousand and nine and the l j rejected his opinion as well so basically we've got every support of opinion gets rejected and all we've got left while there were three nonexempt in in physicians l j reject those that leaves two of those and the i think you significant wait to those opinions well it's our position that here the l j should have given controlling weight or at least proper deference to dr wilks opinion dr will was ms croes is treating physician for about three years treated her number of times was familiar with her physical problems and her mental problems and concluded that she had difficulties that would clinical and laboratory diagnostic well the main thing is that one of the things she had done while treating crows there were three three injections in her lumbar spine and i can't recall now she's the one who did that or if these are just in her records but so she was familiar with the back pain and the ways that that was being treated but mostly it was  like for example in august two thousand and thirteen she was treating her dysphoric mood and sematic symptoms so it was every time she would see her she would note the her observations of how the problems that are better patient was having and so she's the only person in this file that actually saw and treated crows over a extended period of time and so was familiar with the progression of her various impairments and you know one of the things to she the one of things she discussed which is i think one of the main things that supports the physical limitations and this is not just from dr wilkie's opinion but it's weakness on doris affection of the right foot so she didn't record all all of these findings which then ultimately when she was asked well what's your opinion about her functional limitations she gave her opinion repinning was she  for example i guess as far back as september two thousand and eleven she noted that she was taking presents in for nightmares but was still waking up from the nightmares she reported that she was takes and then hearing how's that medication working for you is it working and in september two thousand and eleven she was still waking from her nightmares and then dr will he adjusted her medication so dr wilkie was actually psychotropic medications to her and so it's you know it's there's more to a mental a person's mental status than what you just report in a record in a mental status examination because you can look at them you can see whether or not they're acting afraid whether they're acting depressed whether they're crying at your appointment and so it was really the combination of all of her her her knowledge as a treating physician and the other thing that's important here is that and this isn't once again just from dr wilkie but dr nym's as well the somatoform disorder diagnosis which is sort of a combination of the feedback between how her mental problems were affecting her physical problems and back again and so she noted that she had psychological factors affecting her physical condition and that was it was exacerbating her so it was going he was running both ways and others as well noted that that same thing so it gets complicated when you've got me she had a very unfortunate experiences as a young child and that in her case has has stayed with her in very bad way so based on all of the medical evidence here that supports all of the examiners all all agree that that cross has these limitations has these problems well then cross testified about her limitations at her at her hearings and yet the l a fully rejected everything she had to say and we're look it's interests when you're looking at a case that's been going on for nine years you can you know that time it was i think it's time the decision was only seven or six years but still  long period of time where you if you look through the record you're going to find evidence where she's having a good day or she's went off and did something but the overall picture was was consistent with her complaints about recently very seldom leaving the house because she's afraid that's sort of what the mental limitations sort of boil down to here that she can't handle she's very stress averse and very averse to just being out in public and it's not you know i don't usually stand up here and talk about there's ten doctors and they all said she had problems that if you looked at if you accepted those problems that would support her testimony and it would support that she can't work although his his diagnostic i think his his diagnoses his conclusions are they do contradict the other evidence in the file his findings don't his findings are actually consistent for example  wilkins that he he had that she has a lot of physical findings that could support her complaints and he also identified the connection between the cycle the psychological problems and the physical problems and how they feed back here let me just give you my take on the case and tell me if you think you know i'm missing something because i guess it seems very complicated when you have this many medical professionals w there are so is one of the larger records of scenes of security q so far but at the end of the day it seems to me the doctors on the whole are consistent saying we really can't find anything physically wrong with you that would cause you the degree pain and discomfort in a like that you're suffering but they all seem unanimous in saying that there are some whatever there are psychological issues that you are have i mean that somehow or affecting i guess you know what you're feeling right and in light of that they say she can't work and that all seems reasonable if we're able to credit the opinions but i guess i assume that it came down to whether the l j was justified in not believing your client because a lot of the psychological issues that the doctors are then weighing in on obviously have a self reporting component and if they all jay was justified in saying i just don't find this course credible then seems to me he then he or she can remember  say i just can't give much weight to these these physicians so that's kind of how i see it in a simplified form is it more there are more complications than not well there's some truth to that i think that if you if you took away the if you could take away the mental problems the physical problems wouldn't be as overwhelming as they are but i think even if you just look at the physical problems alone what you really have to look at is is there is there medical evidence of objective medical evidence showing that she has a condition that can cause some hand there is and because of that you then have to look well what's her description of the pain is it consistent with the overall evidence so that you can you know the physical all lone actually because she meets that first step of showing that she's got objective evidence you can't then say well she's complaining we don't believe her because she's complaining about excess pain pain that's bigger than you'd really expect but there's an explanation here for why she's complaining about pain that's more than you might have expected and that is the the trauma that she experienced has what's been diagnosed throughout the phallus a matter of form disorder which once again it's that cycle feeding between the physical and the mental that exacerbates her perception of pain her pain is it's there take away the face of the mental it's still there but with the mental it's way worse than you would have expected and got the thing i think i would i would encourage you to look at is this court's recent decision was telling them they were looking at her and watching her looking at her facial expression seeing her crying in their office they could say so they were it's always going to be a little bit of a combination of the of of a subjective an object give but it's primarily object to because the psychologist know that's what they're expected to report isn't it to her credit that she sought so much medical attention i mean she you know she she saw all these doctors over a long period of time she's obese generalized conditions throughout her body which were treated when she could afford to seek medical attention or when she had insurance she seems to have done that for both mental and  physical planes and i guess my my sort of big picture concern was if you take two thousand pages of medical records i could probably go through with a highlighter and come up with portions that would prove or disprove any and my concern is a little bit with about just the methodology how do we even absorb this much material and and and come up with a with a with a way to answer that the difficult question in this case it's interesting the lately it sometimes seems that elegies some a l g you their role as coming up with reasons on the the mental component where folks are it's too easy to discount that or not maybe appreciate that mental mental illness can create and do all sorts of things people commit suicide they suffer physical pain as a result is that i wish really appreciated i wish i didn't have to say this but it's a widespread perception among attorneys who practice this area of law where we have actually done statistical analyses looking at various ail j s who turn down every single disability claim and who is indigent they just don't ever approve an indigent mentally ill disability claimant and are i hate to say this but our streets reflect that the homelessness reflects that this is not such a judge i think he messed this one up he's someone who would not ordinarily dismissed people just because of that but i think that systemically it's a concern because it is hard it's hard to understand what other people can be feeling in that that's in their head and how that can affect them and it's awful hard i don't want you don't want anyone to go through the trauma this woman did and then to question i would have questioned it down the road good morning honors may it please the court sara martin on behalf of the acting commissioner of social security i would agree this case is complicated medically and to answer your honor's concern the person who is in the best position to evaluate the overall record the very lengthy record in this case was the l j that's failed jase function and unlike some of these doctors they had access to all of the medical records and in a forty seven page somewhat unprecedented forty seven page decision the l j very carefully went through the record and appreciated how do you know that i mean you don't know you don't know what the methodology was i'm not criticizing the you know a lot of lawyers and judges look for efficiency they go through with a highlighter they get an assistant to prepare things and i guess my point is that you know it's an almost impossible task to ask an l j to go through a record and balance everything and holistically look at  of course personally to the methodology but we have is the reasoning is a very carefully reasoned decision where he went through every impairment and all of the issues and weighed every piece of evidence there is no accusation that he failed to weigh something in any case i would just go against my problem those that he's basically reject the consensus of print almost unanimous consensus among a large number of medical professionals right and no i would i would absolutely disagree with that and not all of the people who examined her thought her that she was unable to work from either a mental or physical perspective on the physical side for example much has been made of course of dr wilkie's treating source opinion dr yaron was also her treating doctor and completed a similar  opinion form finding that she could do medium work based on her impairments now the l j thought she was more limited than that but that also does support her ability to work from a physical perspective on the mental side several of the examining doctors thought she could work from a mental to think the way you just approach this is the problem that you can't separate the two right and that's what i'm saying the consensus of seems to be that emerges from cancer i've read over two thousand two thousand pages but the consensus that emerges is that she has some say that some of the psychological examiners who found she could work from a psychological perspective were saying that regardless of what psychological symptoms she's having they still thought she could work full time like dr nemes and dr aspira said for example also there was  much was made here about dr wilkie seeing her over time and noting her mental status but the person who treated her for her mental impairments was a therapist ms roman who also thought she could work and part of the problem and again  honor's earlier point she sought a lot of treatment that's true but she didn't seek a lot of treatment too she thought of the treatment for a different thing impairments over time some of which were found to be by those doctors suspect and unfounded like her tremors  more than one provider noticed that concern and in one case the doctor who found completely normal objective testing on all m r i s and all the other testing suspected that and different provider noted that she only had tremors when she was think is that she's just making this up and that she really is not experiencing the kind of suffering that she claims to be and dr who says she absolutely agree and i'm sorry i know i do not think she's making it up i agree with your honor's earlier segment of the case which is that essentially her her complaints are out of proportion to the objective findings both on the physical and the mental side because she did perform pretty well on mental status examinations all throughout the record and dr tows who testified he summarized all that and he said that he said that quite clearly he said that she performed pretty well in mental status exams throughout the record as far as doing simple work and not having social limitations that words stabling and he did say before he went on to say that she made a listing sort of confusing fashion he did specifically say that she was not just labeled from or psychological factors alone and from a psychological perspective but then as your honor pointed out he then essentially seemed to credit her subjective complaints of pain and it's not just a psychological perspective which would incorporate that stress and those other things that your honour's talking about he did say that she could work from a psychological perspective and then he went on to talk about the pain and he seemed to essentially credit her subjective reports of pain but at the same time he said a lot of things that is talking about when a person carries on certain minimal daily activities like just the minimal to get by but there are lots of other cases rollins and many many other cases that if that daily activities do contradict their testimony about their abilities that's still a legitimate thing they'll just still required by regulation to look at those actives as one of many factors and here for example she complained about being too anxious to leave the house and yet the activities show that she was going out a lot doing social things taking your children out going out and attending functions and parties and things but that's just i mean that's just not an accurate universe of this lady's lives we live we don't know what she did every day we don't know whether she went through a period of remission with some of these conditions where she was able to do those things and other days where she stayed at home in a dark room so it's not unfair just to say she could do certain things at certain times therefore during this period she was never disabled so the l g is required to look at her allegations required to then look at those subjective complaints and carefully weigh those the so called credibility analysis and that activities are just one of many factors they all j is required to look at and and by regulation is required to do and he looked at all of those factors not just  didn't just pick one daily activity that she did he went through the whole record and looked at all the factors and gave many many reasons why her you know it's a matter from disorder essentially confirms that her pain complaints are out of proportion to what's going on objectively and so then he went to look at those allegations of her subjective symptoms and weigh them against all of the evidence in the record to see whether those were reliable or not and you know as i mentioned there were several providers who do you think the state of medical someone experiences that that they're there that it's not real because there isn't an objective way to test them and i am not a medical expert i know pain is complicated and it can have many many factors but this disorder with the fact that the discounted opinions of some doctors because they did not her pain symptoms on an underlying neurologic condition isn't this the definition of a some out of form disorder i think so i think some out of form disorder which they l j found she had just confirms like i was saying that her complaints are out of proportion to what's going on object in philly but the l j then has to also one of them it means oh no it's not about intentionally lying it's about whether her she's saying she's disabled because she feels these are her limitations but the fact that she thinks she has basically the evidence shows she's more capable than she believes she is and that's essentially what a credibility finding is the l j in every case they l j looking at the object of all of the evidence scuse me all of the evidence and determining what what can she still do despite her limitations even though she may think that she's more limited than that or people will and she feels and that's part of the mental health component  here we do have to be convince that she's exaggerating all of this and none of the least to a large extent what she's complaining about is not real and that she knows that and that she's doing it for some purpose of secondary gain and i just don't this is not i  mean we get these cases all the time we're credibility terminations and this is just i don't know this seems like don't have any doubt really that in fact she's not making this up this seems to confirm by too many different medical sources to just dismiss it as no you really are able to go out and work full time job but you just don't want to i just don't see that yet and again i would respectfully disagree on it's not about intention and there is an adverse credibility finding in every denial of disability benefits  because every every claimant thinks they're unable to work and alleges that so they'll she has to weigh that in every case it's not about intention it's about him weighing those allegations and seeing if they're consistent with the rest of the record and that's in the regulations that they are required to do that and so saying no some of them yeah but her treating physician on this independent medical person comes in to review everything and says yeah you know what it's all that this is not just made up and i guess the doctor so how well other doctors are saying the opposite and the had to weigh these conflicting opinions and and that is they job is to weigh those and to determine which ones are more reliable based on the whole record do we have a doctor who actually again trying to segregated psychological physical someone who puts it together and says no in fact she's not suffering from whatever this thing is called psychological factors affecting for them do we have a doctor who just says flat out no that's not her that's not what she saw from you know but it's not it's not about the disorder she does or doesn't have it's about what she what her abilities are given her symptoms and objective findings and so for example dr aspire examined her and dr names who examined her said that from you know taking into account all her psychological some gigs i think i think we're talking about pain being essentially a psychological symptom at this point and those doctors thought that she could work given all of even given all of that and they were not treating physicians correct that's correct your honor albeit done observe her in a person to person situation as did her treating doctor that's true on our except for that her mental health counselor did observe her over time and did also think that she could work in a low stress job and as to the point earlier about treatment treatment and consistencies is actually one of the reasons the l j relied on in finding her claims not reliable although she sought medical treatment for different conditions she did not go back to mental health counseling she didn't have insurance and any money was she was able to access health care tons right and when she did all that all right but she sorry well but after two thousand once you did have the ability to seek treatment at different points throughout the record but she did not seek mental health counseling she also didn't seek physical therapy for several her physical conditions and she sometimes stop taking her medications there's one point in the record where she said she stopped taking you think that all mentally ill people are rigorous in terms of their ability to follow up with medical with mental health care  there she sought mental health counseling over some period of time and it was working ms roman said that she her symptoms were manageable at the end of that period and she but she stopped going and said she could come back and she she didn't do that  i don't have i don't have any information about about that's not in the record about why that might be you know just maybe one question your time is right now if we were not to go with you on the argument you've made quite capable of this morning would you agree that we if we're going to reverse we just we just need to remand for an award of benefits right there's no there cannot possibly be any more proceedings that would be necessary to resolve this with their well i would not agree with that there are at the very least there is an issue of drug addiction in the record that hasn't been developed that was you know all throughout the record not just a little mention of it here in there dr tows the test of a medical expert talked about her addiction to narcotics as well as  she could do actual work dr spars opinion was rejected because he basically said that just anything he says there's something psychiatrically wrong with her this is early on in this whole process but that  but physically and the way she was crying at his at his evaluation he thought that she couldn't handle work but she thought because of the pains uses a great thing and she was having a lot of pain problems at that time so that's back to the combination of physical mental dr nym's actually also said the limitations he came up with would prevent her from working so i have you his his opinion was was supporting her so i don't know why the government's arguing  didn't so i would ask that this is gone on long enough and ok thank you thank you case just argue