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

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 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 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 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, 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 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 naïve 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.

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 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 "[m]edical examiners and treating physicians," R. at 19 (emphasis added);

(2) Carradine's testimony regarding pain was "significant[ly] inconsisten[t]" 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 "[wa]s 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 ... [we]re 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 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 longstanding principles of deference that continue to govern this Court's appellate review of decisions by administrative law judges.

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, 91 S.Ct. 1420, 28 L.Ed.2d 842 (1971)) (emphasis added). Furthermore, in reaching our "substantial evidence" determination, this Court's review and evaluation of the record is limited; when "review[ing] 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" — 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.

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

Carradine's medical history is as follows: in March 1993, a month after she suffered her injury in the slip-and-fall accident, she visited C.S. McMarrow, a chiropractor, who noted that x-rays of the plaintiff's spine revealed nothing but a mild to moderate degenerative disc disease and scoliosis. In June and July of that year, when Carradine attended a pain management program at the Community Hospital (Indianapolis) Center for Pain (on referral of her rheumatologist), the Medical Director of the Center, Karl Manders, M.D., remarked that Carradine's participation in the program was successful: she met her goals during the program, improved her ranges of motion, experienced decreased pain and muscle spasms, and experienced an improved ability to sleep. Dr. Manders noted that her over-all prognosis "should be good." R. at 251.

A year later, in May 1994, Susan Steffy, M.D. conducted an in-depth physical, musculoskeletal and neurological examination of Carradine, and even after conducting all three of these exams, did not ascertain any medical basis for Carradine's subjective complaints of pain. Dr. Steffy noted that Carradine was able to walk, hop and squat "without any difficulty," and that she got on and off the examination table with ease. The doctor further reported that Carradine maintained a normal posture and gait, normal muscle and grip strength, normal range of motion in her back, exhibited no swelling in her joints, and also evidenced a normal ability to manipulate and experience sensation in her fingers. According to Dr. Steffy, although Carradine's active range of motion in her neck was just "slightly" decreased, her passive range of motion was entirely normal. Based on these observations, Dr. Steffy concluded Carradine's only limitation was her "subjective complaints of pain" (for which there was no present medical cause), and further recommended Carradine pursue a most conservative course of treatment (namely, non-steroidal anti-inflammatories (such as Aspirin), neck exercises and application of local heat).

As for Carradine's laboratory tests, a magnetic resonance imaging ("MRI") test conducted in September 1994 revealed mild narrowing of the cervical spine, slight flattening of the dorsal spinal cord, and absolutely no disc herniation. An electromyogram ("EMG")6 taken a month later (October 1994) likewise revealed no abnormal findings.

Between August 1994 and December 1995, Carradine visited and was treated by another doctor, Samuel Goodloe, M.D., an anesthesiologist specializing in the "diagnosis and treatment of pain." R. at 346. According to Dr. Goodloe, Carradine complained of some numbness in the ring and little fingers on her right hand, tenderness in her back, and slightly abnormal deep tendon reflexes. Upon examination, he reported Carradine had a supple neck and normal sensation in the lower extremities, her straight-leg raising tests were negative, and she walked without difficulty. As far as Carradine's claims of numbness were concerned, a current perception threshold test administered by Dr. Goodloe in December 1995 revealed that the plaintiff had anywhere from "no [sensory] abnormalit[ies]" to only "mild" sensory dysfunction and increased nerve sensitivity. R. at 352 (emphasis added).

Some four years thereafter (April 1999), at the request of ALJ Bryan Bernstein, Brett Windsor, a physical therapist, performed a functional capacity evaluation on Carradine. During the evaluation, Windsor observed Carradine perform various physical tasks, and noted that, while she failed twenty of the thirty validity criteria for those tasks, four of these failures (i.e., 20% of these failures) were due to her exerting only "minimal efforts" during testing. He remarked that his finding that Carradine exerted only "minimal efforts" during testing was supported by her physiological responses during the isometric strength test, as well as her results on the hand dynanometer ("squeeze") test. R. at 483. In spite of Carradine's decision to exert only "minimal efforts," Windsor was nonetheless able to conclude from a compilation of his testing that the plaintiff was "capable of repetitive gripping on a frequent to constant basis," was "able to lift up to 20 [lbs.] occasionally, 10 [lbs.] frequently, and negligible amounts constantly," could "sit constantly, stand constantly, and walk constantly," and was fully "able to climb stairs on a frequent basis," R. at 483. Most importantly, Windsor determined and advised Carradine that she was "capable of sedentary work." Id.

A short time after these strength tests, Carradine made two brief visits to hospital emergency rooms in the summer of 1999, complaining of increasing pain in her neck and back. Upon examination, Carradine's emergency room doctors reported some limited range of motion in her neck and back, but concluded that Carradine enjoyed a full range of motion in her shoulders and upper extremities, negative straight-leg tests, and excellent muscle strength. Furthermore, Dr. Bainbridge (her emergency room doctor during the August 1999 visit) noted she exhibited only "slight" tissue swelling in her back, and Dr. Mann (her examining physician during the July 1999 visit) noted "no swelling" upon examination.

As far as Carradine's mental condition is concerned, in June of 2000, at the SSA's request, Carradine underwent a thorough psychological evaluation administered by Dr. Henry Martin, a clinical psychologist. After the evaluation, Dr. Martin also submitted an assessment of Carradine's ability to perform work-related activities. R. at 620-21. Although Dr. Martin did diagnose Carradine as suffering from somatization disorder, defined as "the conversion of mental experiences or states into bodily symptoms," Dorland's Illustrated Medical Dictionary 1546 (27th ed.1988) (hereinafter Dorland's) (emphasis added), his assessment of Carradine's work-related capabilities fell short of supporting the claimant's pain allegations and her alleged limitations on her ability to work.

After all, Dr. Martin described Carradine as being neatly groomed, cooperative and friendly, and, in 17 out of 22 different functional areas, Dr. Martin rated Carradine's capabilities7 as "good to excellent." These areas included (but were not limited to) her ability to understand and execute simple as well as detailed instructions, to interact appropriately with the public, to get along with co-workers, to be aware of normal hazards and take appropriate precautions, and to travel in unfamiliar places or use public transportation. As for the remaining five functional areas (namely, Carradine's concentration, her ability to perform within a schedule, complete a work day, perform at a consistent rate, and to sustain work without special supervision) Dr. Martin rated Carradine as performing at a "fair" level — and this "fair" rating obviously falls short of qualifying as a severe impairment that significantly limits an individual's ability to do basic, light work activities.8 Indeed, the fact that Carradine did not receive a single "poor" rating further supports that nothing regarding her psychological state would prevent her from performing light work.9

Although there were other occasions between the time of her injury and the ALJ's decision when Carradine sought medical attention, these other physician visits, similar to those just described, consistently failed to establish a disabling condition. As such, her medical history was succinctly and accurately set forth in the ALJ's decision as a basis for finding that her condition demonstrated physical and mental conditions that are most unlikely to produce disabling pain, which is pain that must be "constant, unremitting, and wholly unresponsive to therapeutic treatment" for it to qualify someone for social security benefits. Falco v. Shalala, 27 F.3d 160, 163 (5th Cir.1994) (emphasis added) (internal quotations omitted). Thus, upon review, I remain convinced that there is no reason to find fault with and cast heated aspersions on the ALJ's conclusion10 that the "claimant's statements concerning her impairments ... and their impact on her ability to work ... are not entirely reliable." R. at 27, realizing that we are obliged to follow the law that "an ALJ's credibility determination will not be disturbed unless it is patently wrong." Cannon, 213 F.3d at 977. While I certainly sympathize with the plaintiff's alleged medical problems, which she has recounted so eloquently since her slip-and-fall accident of some ten years ago, based upon the record and findings before us I am forced to remain, like the ALJ, a "doubting Thomas" as to the veracity of Carradine's claims of pain. Such claims must be looked at with a balanced, though not a jaundiced view; and in this case, the record so eloquently displays that the ALJ did conduct a most thorough balancing test, and ultimately reached a well-reasoned conclusion that Carradine's testimony was unreliable.

Meanwhile, the majority's very surprising opinion can best be read and logically interpreted as trivializing the lack of objective medical evidence in Carradine's case. Why my colleagues adopted this approach is a most disturbing mystery. After all, the majority of accepted and well-reasoned legal authority emphasizes the significance of, and this Court's continued reliance on, objective medical evidence when rendering social security disability determinations. When determining whether an individual qualifies as "disabled,"

[a]n individual's statement as to pain or other symptoms shall not alone be conclusive evidence of disability ...;

... Objective medical evidence of pain or other symptoms established by medically acceptable clinical or laboratory techniques (for example, deteriorating nerve or muscle tissue) must be considered in reaching a conclusion as to whether the individual is under a disability.

42 U.S.C. § 423(d)(5)(A) (emphasis added).11

Social Security Administration regulations, as codified at 20 C.F.R. §§ 404.1529 and 416.929, provide the authoritative standards for evaluating pain in disability determinations and further "incorporate the standard set forth in section 423(d)(5)(A)." Craig v. Chater, 76 F.3d 585, 593 (4th Cir.1996). These regulations emphasize the importance of objective medical evidence:

Objective medical evidence is evidence obtained from the application of medically acceptable clinical and laboratory diagnostic techniques.

... Objective medical evidence of this type is a useful indicator to assist [the SSA] in making reasonable conclusions about the intensity and persistence of [the claimant's] symptoms and the effect those symptoms, such as pain, may have on [the claimant's] ability to work. [The SSA] must always attempt to obtain objective medical evidence and, when it is obtained, [the SSA] will consider it in reaching a conclusion as to whether [the claimant is] disabled.

20 C.F.R. § 404.1529(c)(2) (emphasis added); see also 20 C.F.R. § 416.929(c)(2). The regulations further state that the SSA will consider and weigh all of the available evidence in evaluating the intensity and persistence of one's symptoms, such as pain, including "medical history, the medical signs and laboratory findings, and statements by [the claimant's] treating or examining physician or psychologist or other persons about how [the claimant's] symptoms affect [her]." 20 C.F.R. §§ 404.1529(c)(4) & 416.929(c)(4) (emphasis added). The SSA must then examine the alleged consistency between the subjective claims of pain and the objective evidence when "determin[ing] the extent to which [the claimant's] alleged functional limitations and restrictions due to pain or other symptoms can reasonably be accepted as consistent with the medical and scientific medical signs and laboratory findings and other evidence to decide how [the claimant's] symptoms affect [her] ability to work." 20 C.F.R. § 404.1529(a) (emphasis added); see also 20 C.F.R. § 416.929(a).

Reflective of these regulations, this Circuit and many of our sister circuits, in circumstances similar to those presented here, have explained that a lack of objective medical evidence — evidence that is based upon accepted medical studies and evaluations combining the use of x-ray, MRI, cat scans, and other recognized and reliable techniques — supporting a claimant's declaration of severe pain, while not conclusive nor exclusive, will greatly inhibit the finding of disability. See, e.g., Clifford v. Apfel, 227 F.3d 863, 871 (7th Cir.2000) ("[T]he