disability as of August 15, 1989 due to asthma, Chronic Fatigue Syndrome ("CFS"), and alcohol and substance abuse (T. 93). This application was denied on November 10, 1992 (T. 97-100, 134-37), and again on reconsideration (T. 103, 125-28). On August 18, 1993, a hearing was held before Administrative Law Judge ("ALJ") Karen H. Baker. Plaintiff testified at the hearing, and was represented by counsel. A vocational expert also testified (T. 82-87).
On September 13, 1993, ALJ Baker issued her decision finding that plaintiff was not disabled within the meaning of the Social Security Act (T. 19-26). According to the ALJ, the medical evidence established that plaintiff suffered from Fibromyalgia, asthma, allergies, depression, and substance abuse, but that these impairments considered alone or in combination did not meet or equal any of the impairments listed in 20 C.F.R. Part 404, Subpart P, Appendix 1 (the "Listings") (T. 25). The ALJ also found that plaintiff was not a credible witness. Furthermore, the ALJ found that plaintiff could not perform her past work, but that she retained her residual functional capacity to do light work, limited by an inability to be exposed to environmental irritants and stressful situations (Id.).
The decision of the ALJ became the final decision of the Secretary when, on January 13, 1995, the Appeals Council denied plaintiff's request for review (T. 7-8). On appeal, plaintiff submitted a letter from Dr. Richard Lanham, dated April 7, 1994. Dr. Lanham stated that he is plaintiff's treating physician and that she suffers from CFS, and has suffered for the past six and a half years (T. 351). The Appeals Council did not believe that the letter was material to the issue of whether plaintiff was disabled on or before the date of the ALJ hearing (T. 8). Plaintiff filed this action on March 13, 1995 (Item 1).
The medical evidence indicates plaintiff sought treatment in 1987 and 1988 for various conditions including mononucleosis (T. 300), back and neck pains (T. 301-302, 305), and headaches (T. 301).
In January, 1991, plaintiff sought help for her alcohol and drug dependency at Horizon Human Services (T. 203). At the hearing, plaintiff testified that she had been sober since March 17, 1991 (T. 41).
Plaintiff was seen on October 23, 1991 by Mary Callaghan, a physician's assistant (T. 174). Plaintiff complained of chronic fatigue, intermittent back spasms and fever, headaches, and an inability to concentrate (Id.). Ms. Callaghan noted that plaintiff did not meet the criteria for CFS.
From November, 1991 to June, 1992, plaintiff was treated at Buffalo General Hospital for complaints of sore throat and sinus congestion (T. 177, 180), asthma and headaches (T. 194-95), chronic fatigue (T. 180-81, 189), and knee pain (T. 181, 186).
Plaintiff was seen by Dr. Ileana Madrigal on March 27, 1992 (T. 274-75). Plaintiff believed that she had candida, but Dr. Madrigal advised her otherwise (T. 274). The diagnosis was fibromyalgia, asthma, high cholesterol (T. 274). Elavil, an anti-depressant medication, was prescribed (Id.)
The April 16, 1992 medical records indicate that plaintiff was seen at Millard Fillmore Hospital due to allergies and tiredness cause by Sudafed (T. 277). Plaintiff also reported that she had mood swings and that Elavil was helping her feel better (Id.).
On August 13, 1992, plaintiff reported feeling "very fatigued" (T. 283). She also complained of muscle aches and asthma (Id.).
Progress notes of October, 1992, indicate that plaintiff's emotional state was "great", but that she felt fatigued especially after increased activity (T. 285). The diagnosis continued to be Fibromyalgia (T. 286).
On April 16, 1993, plaintiff called Millard Fillmore Hospital requesting a referral to a CFS specialist (T. 331).
I. Scope of Judicial Review.
The Social Security Act states that, upon review of the Secretary's decision by the district court, "the findings of the Secretary as to any fact, if supported by substantial evidence, shall be conclusive. . . ." 42 U.S.C. § 405(g). Substantial evidence is defined as evidence which a "reasonable mind might accept as adequate to support a conclusion . . . ." Consolidated Edison Co. v. NLRB, 305 U.S. 197, 229, 83 L. Ed. 126, 59 S. Ct. 206 (1938), quoted in Richardson v. Perales, 402 U.S. 389, 401, 28 L. Ed. 2d 842, 91 S. Ct. 1420 (1971); Jones v. Sullivan, 949 F.2d 57, 59 (2d Cir. 1991).
Under these standards, the scope of judicial review of the Secretary's decision is limited, and the reviewing court may not try the case de novo or substitute its findings for those of the Secretary. Richardson, supra, 402 U.S. at 401. The court's sole inquiry is "whether the record, read as a whole, yields such evidence as would allow a reasonable mind to accept the conclusions reached" by the Secretary. Sample v. Schweiker, 694 F.2d 639, 642 (9th Cir. 1982). The Secretary's determination cannot be upheld, however, when it is based on an erroneous view of the law that improperly disregards highly probative evidence. Grey v. Heckler, 721 F.2d 41, 44 (2d Cir. 1983); Marcus v. Califano, 615 F.2d 23, 27 (2d Cir. 1979).
II. Chronic Fatigue Syndrome.
Plaintiff, pro se, contends that the ALJ erred in several respects. Plaintiff's strongest argument is that the ALJ improperly rejected her testimony about her subjective complaints of chronic fatigue and pain. Upon review of the record as a whole in light of the Secretary's regulatory policies and caselaw pertaining to claims of disability due to CFS, I agree with plaintiff's position.
The regulations require the ALJ to consider the claimant's subjective complaints about her symptoms, "such as pain, fatigue, shortness of breath, weakness, or nervousness," 20 C.F.R. § 404.1529(b), at each step of the sequential evaluation process.
20 C.F.R. § 404.1529(d).
As recently stated in Social Security Ruling ("SSR") 95-5p, "because symptoms sometimes suggest a greater severity of impairment than can be shown by objective medical evidence alone, careful consideration must be given to any available information about symptoms." SSR 95-5p, 1995 WL 670415(SSR) at *1 (1995) (reiterating longstanding SSA policy regarding evaluation of symptoms); see also 20 C.F.R. § 404.1529(c)(3). When assessing the claimant's residual functional capacity ("RFC") at step five, the ALJ "must describe the relationship between the medically determinable impairment(s) and the conclusions regarding functioning which have been derived from the evidence, and must include a discussion of why reported daily activity limitations or restrictions are or are not reasonably consistent with the medical and other evidence." SSR 95-5p, 1995 WL 670415(SSR) at *1.
While an ALJ has the discretion to evaluate the credibility of a claimant and to arrive at an independent judgment regarding her allegations of pain, fatigue and other symptoms, the ALJ must do so in light of medical findings and other evidence regarding the true extent of the pain alleged. Mimms v. Heckler, 750 F.2d 180, 186 (2d Cir. 1984); Marcus v. Califano, 615 F.2d 23, 27 (2d Cir. 1979)). Thus:
In instances in which the adjudicator has observed the individual, the adjudicator is not free to accept or reject that individual's complaints solely on the basis of such personal observations. Rather, in all cases in which pain or other symptoms are alleged, the determination or decision rationale must contain a thorough discussion and analysis of the objective medical and the other evidence, including the individual's complaints of pain or other symptoms and the adjudicator's personal observations. The rationale must include a resolution of any inconsistencies in the evidence as a whole and set forth a logical explanation of the individual's ability to work . . . .