Somatoform, objective evidence--- What????

The claimant sits in my office and has complaints about vision problems, inability at times to use one of their limbs, vomiting, exhaustion, anxiety... His medical records show years and year of complaints centering around these impairments. The doctors have treated the complaints. There is no indication in the records that he is malingering or being false in his statements. He has been and still is prescribed medication, and has at various times had therapy. He has always worked heavy exertional jobs.

Two things stick out in his medical reports: 1) he has been treated for years and years, and 2) no objective findings appear in the records to support the impairments. What does appear is a diagnosis of 'somatoform disorder'.

This is an interesting situation!

The Social Security Act (SSA) provides that disability means the “inability to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less then 12 months...42 USC 423(d)(1)(A)

Generally, a somatoform disorder refers to several conditions involving symptoms that have no physical cause, instead being caused by psychological factors. To the claimant all he knows is that he is sick, so sick he cannot work. He is not faking sickness. He is not malingering.

As shown to the claimant, a somatoform disorder can cause real pain, symptoms such as headache, fatigue, stomach problems (including nausea, vomiting, diarrhea), sexual dysfunction.

SSA regulations provide that symptoms alone may not be used as the sole basis for establishing disability. What must be shown is medical signs and laboratory findings which show the existence of a physical or mental diagnosable medical impairment which could reasonably be expected to produce the pain or other symptoms and which, when considered with all the other evidence including statements about intensity and persistence which may reasonably be accepted as consistent with the medical signs and laboratory findings, would lead to a conclusion of disability. 20 CFR §§ 404.1529(a), 416.929(a).

You can see the initial problem: the difficulty of demonstrating existence of a medically determinable impairment—such as somatoform disorder—that has no physical objective findings. (The same issue can arise with Fibromyositis /Chronic fatigue syndrome...)

Consider what the courts have done when presented with this issue:

1. Hallgring v. Callahan, 975 F.Supp. 84(D. Mass. 1997) In Hallgring, the treating physician provided evidence that the claimant satisfied all diagnostic criteria of chronic fatigue syndrome. Despite a lack of abnormal laboratory or physical findings, a lack of recorded observations of fatigue, and a physical capacity evaluation of a non-treating physician stating that the claimant was not totally disabled, the treating physician's evidence was sufficient for a finding of disability.
2. Crain v. Callahan, 996 F.Supp. 1003 (D.Or. 1997) A somatoform disorder by definition can produce psychogenic pain which is out of all proportion to any physical abnormalities, yet it is a disability upon which disability can be established.

I am not a medical person, so I went to “Wikipedia” for help on this one. “Wikipedia” provides the following:

“The somatoform disorders are actually a group of disorders, all of which fit the definition of physical symptoms that mimic physical disease or injury for which there is no identifiable physical cause; as such, they are a diagnosis of exclusion. They are recognized by the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association as the following:[1]

• Conversion disorder: A somatoform disorder involving the actual loss of bodily function such as blindness, paralysis, and numbness due to excessive anxiety
• Somatization disorder: A disorder characterized by multiple physical complaints which do not have a medical explanation.[8]
• Hypochondriasis: A somatoform disorder involving persistent and excessive worry about developing a serious illness.
• Body dysmorphic disorder
• Pain disorder
• Undifferentiated somatoform disorder – only one unexplained symptom is required for at least 6 months. “

These types of disabilities are considered mental disorders.

Just because you can establish the existence of a mental impairment, such a finding is not per se disabling. What is required of the mental disorder, is evidence of significant functional restrictions in areas such as activities of daily living, maintaining social functioning, deficiencies of concentration, persistence or pace, deterioration or decomposition in a work-like setting, or the ability to sustain mental activities necessary to the performance of sustained work activity.

If the impairment is pain, a good start is the holding in Polaski v. Heckler, 739 F.2d 1320 (8^th Cir. 1984)—the adjudicator must fully consider all evidence relating to the subjective symptoms, including the claimant’s work history, observations by treating and examining physicians, and other third parties regarding claimant’s daily activities; duration, intensity, and persistence of alleged pain; precipitating and aggravating factors, dosage, effectiveness, and side effects

From Polaski we have regulations promulgated by Social Security to deal with the issue of disabling pain. There have been several successive pain regulations as well as rulings.20 CFR §§ 404.1529, 416.929; SSR 88-13, SSR 90-1p; SSR 95-5p; SSR 96-7p.

Back to the beginning of our story. We have a claimant complaining of debilitating pain, but without objective medical evidence of a disability. He claims that he cannot work at any of this prior jobs.

Since his medical records do establish a somatoform disorder the Commissioner cannot ignore subjective evidence as to the severity of that pain. ( Frankl v. Shalala, 47 F.3d 935 (8^th cir. 1995) is an old case, but it does provide a good statement of the court's position.)

Further, suppose that there is no evidence of the effect of work at a lower exertional level, since claimant always work at jobs that were of a heavy exertional level.

Security Rulings acknowledge that the concept that the lower the exertional level of the work the less stress, etc. is faulty (SSR 82-62. POMS § DI 24510.061(B)(4)(b) – The reaction to the demands of work is highly individualized and mental illness is characterized by adverse responses to seemingly trivial circumstances).

Finally suppose that the ALJ's hypothetical question to the vocational expert, although well worded to avoid the foregoing, was basically an inquiry of the expert as to the existence of any light exertional work which would have a lower stress level. The vocational expert found numerous light and sedentary jobs in the economy. Suppose that the same vocational expert reluctantly agreed that stress is in the claimant and not the job and if that a lower exertional job caused the same stress level in claimant as the heavier exertional level work, he would still be disabled.

What would be the result???

Disclaimer: Blogs posted herein are intended neither as legal advice, nor do they create nor attempt to create an attorney-client relationship. The person viewing my blogs is admonished that an attorney-client relationship may only be created with the express consent to the parties to it.