-BWC McLaughlin v. Astrue, No. 5:2011cv00027 - Document 18 (W.D. Va. 2012)

Court Description: MEMORANDUM OPINION. Signed by District Judge Michael F. Urbanski on 4/24/2012. (jat)
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r >*m OFFI u. Dt :Cobr d GE s. sn ATI RRI V SONBURG VA Fl Fn l I TH E UNI N TED STATES DI STRI COURT CT FOR TH E W ESTERN DI STRI OF VI CT RGI A NI H A RR I N BUR G D I I O N SO V SI 2#2 1 22 JU . ..: -- TR AV I R .M C LA U G H L I , S N , c * p Pl ntif ai f , Ci lA ct on N o.5: v027 vi i 11c V. M I AEL J. STR U E, CH A C om m i s oner ofSoc alSe iy, si i cur t By: M i chaelF.U rbans ki Uni e St esD i t i tJudge t d at sr c Def endant . M EM O M ND U M O PI I N N O Thi s i s e iy dia lt a s ooal e utt s biiy ppea i be or t c tf rr vi w oft Re ta l s f e he our o e e he por nd Re o n ain is e i t i c s b t ema itaej dg o Oco e 1 , 01 .l ta Re o t c mme d to su d n hs a e y h g srt u e n tb r 3 2 1 n h t p r a Re omme ton,t ma srt j c ude t tt asesment a o ni oft nd c ndai he gitae udge oncl s ha he s s s nd pi ons he r e i s a e a ncy phys ci ns a cons t tve e i ng phys ci n do no s evi w ng t t ge i a nd ula i xam ni ia t uppor t t he a mi itaielw j d ' (t ' d tr n to ta panifTrv sM c au hl d nsrtv a u ges t ' eemiain h t litf a i la g i ALJ ) n (t vug i ' i notdia ed.Themagitaej ras t tt rviwi physca a t a hln') s Mcl s bl srt udge e ons ha he e e ng iins nd t co ula i exa i r di notha t be ftofa a s s e pe f m e by M cla i s he ns t tve m ne d ve he ne i n s es m nt r or d s ughln' tea i ps hi t it D r Robi o when i s ng t i o ni ' hus r m a i a opra e. r tng yc a r s , . ns n, s ui he r pi ons t , e nd s ppr i t , Ha ng c e uly r vi w e t r or i i c e rt t c t ha t A LJt i o a c vi ar f l e e d he ec d, t s l a o he our t t he ook nt c ountDr . Robi on' a s s e i a to t t o ni oft r e i s a e a nc phys c a a ns s s es m nt n ddii n o he pi ons he evi w ng t t ge y i i ns nd t c ula i e i r a t ts t nta e de e s he ons t tve xnm ne , nd ha ubs a i l vi nc uppor st A LJ' de e m i ton t t t he S t r na i ha Mc Laughln i no diabl Ass h,hemagitaej i s t s ed. uc t srt udge' rcomme tonwilberj ce i se ndai l ee td n is e tr t a t C o m i s one ' de s on a fr e t n i e y nd he m s i r s ci i f im d. 1. Thi l terwa r fre t t l gitaej f prpos dfndi offc a s nat s ee rd o he na srt udge or o e i ngs a t nd r c m e tonsf d s ii pur ua t 28 U .S. j636( ( )B)onJ 9, 1 The e om nda i or i pos ton s nt o C. b)1( une 201 . pat sfld co smoi n frs mmayj dg n a d s p o t me rnd a dt ma itae ri ie r s to s o u r u me t n u p ri e ng mo a a n he gsr t j g is e h sRe r a dRe o n ai no Odo e 1 , 01 .Un e 2 U. C. ud e s u d i po t n c mme d to n b r 3 2 1 d r 8 S. j63 ( )1 ,heû o l ma a c p ,ee t o mo iy,nwhoeo i p r,h fn i sa d 6 b ( ) t i u' y c e trj c, r d f i c t l r n a tt e idng n r ommendai madebyt ma sr t j ec tons he gitae udge. Fe r Rul ofCi lPr dur 7 b) ' deal e ' vi oce e 2( p o i e t ep riswiha o p ru iyt fl wrte o j cin t tep o o e fndn sa d r v d s h a t t n p o tnt o ie itn be to s o h r p s d i ig n e rco ndai ,butneihe pa t fldobecinsi t sc e.Rul 72( ( pr dest tt e mme tons t r ry ie j to n hi as e b)3) ovi ha he d itit u g mu t eemieX n v a ypa4o tema itaej dg ' ds o i o t a ha t src j d e s d tr n d o o n l f h gsrt u e s ip st n h t s i b e p o ryo j ce t ' W hl t tx o ter l i sln a t t eo iain o t ec u tf e n rpel b e td o. ie he e t f h u e s i t s o h bl to f h o r i ' e g n o j ci ni ma e t ea vio yc mmiten tsta Cwl e n tmeyo j cini tld te o b e to s d , h d s r o te oe h t t h n o i l b e to s ie ,h l c tne d onl s ts y is ft tt r i no cl a e r on t f e oft r or i or rt our e y a i f t el ha he e s e r r or he ac he ec d n de o a e t r omme ton. Advior CommiteNot t Fe R. v.P.7 ( tngCa cc pt he ec ndai ' ' sy te es o d. Ci 2 cii mpbel l v. tdSttsDit Cour,501F. 1 206( hCi.1 4).l Thomasv.Ar 47 U. Unie ae s. t 2d 96, 9t r 97 ) n n, 4 S. 1 ( 985,t SuprmeCour ha occ sont a e st is a sae asf l : 40 1 ) he e t d a i o ddrs he sue, nd ttd olows Th dsrc j g ha j rs ito o e te c s a a1tme . He e itit ud e s u idcin v r h a e t l i s r t ns f l aut iy t dec de w he he t r f r a c e t t e ai ul hor t o i t r o ee as o he m a sr t t r vi w t m ag s r t s r po t a t e e gi t a e, o e e he i t a e' e r , nd o nt r j d me t An pa t t a d sr s pe a y c n ie ai n by t u g n . y ry h t e ie ln r o sd rto he Ari eIlj tcl I udgeofa is ne d onl as M orover whiet ny sue e y k. e , l he saut doesnotr r t j t r viw a is X novo i no tt e equie he udge o e e n sue f obe to ar fld,i doe notprcl f t r rviw by t j cins e ie t s e ude urhe e e he dsrc j dg ,s a s o t o a te rq e to a pat u d raéq itit u e u p ne r t h e u s f ry, n e novo ora o he s a r ny t r t nda d. 47 U. a 1 4.Thus e a e a obeci t c r rti t a lt t r e s 4 S. t 5 , ven bs nt n j ton,he ou t eans he biiy o eviw ua s ont ama srt j p e gitae udge' r por andrc s e t e omme i Thec tbeivest tt pariulr ndaton. our le ha he tc a fcso t sc s p e e ta a pr p it o c so t r ve tema itaej d e sRe o t n a t f hi a e rs n n p o rae c a in o e iw h gsrt u g ' p r a d Re omme tonnowihsa ngt a e eofa o j ci c ndai t t tndi he bs nc n b e ton. II. Pl i ifsa gum e son appe c e t we g gi by t ALJt am e a antf r nt al onc m he i ht ven he o nt l i panne squesi m i nt tonnaie fle outbyM cta i ste tng ps hitit D r Robi on,on r il d aughln' r a i yc ars, . ns J nua y 1 201 On t squesi a r 9, 0. hi tonnaie Dr Robi on saed t tM c s r, . ns t t ha laughln s f sfom a i ufer r mood dior ,notot r s s c fe nzeoutbi a dior r notot r i e s ii s ver s der he wie pe iid; l polr s de , he w s pec ted, e e. Dr Robi on i ca e t tM c ughln i t bl t f ton i s i / c tonalr al due . ns ndi t d ha La i s s una e o unc i n ocaloc upa i e ms t moodi tbiiy,irtbiiy, mi tvea oust o nsa lt ria lt nl nai /nxi hought. ( 298. Shenotdt theha a s' R. ) ' e ha s l I orr uc di elecua f to nga ar ul ofalani dia lt ( 301. She ow Q ed e nt l t l uncini s es t e r ng s biiy. R. ) pe dhi cure GAF a 52a hi hi s GAFi t pas yea a 60. ( 298. gge s rnt t nd s ghe t n he t r t 1 R. ) l t r sofhi f tona lmia i , . n em s unc i l i t tons Dr Robi on sa e t tM c ughln hasmode at ns t t d ha La i r e r t i ton ofac i t e ofda l lvi ,e r m e d fi uli i m a nt i ng s a f to ng' esr c i tvii s iy i ng' xt e i tc tes n i a ni oci l unc i ni , e r me dit uli i dek incesofc e r ton,pe sse orpa e;a t theha t ee xte fk tes n t e i onc nta i r itnce c nd ha d hr e s s ofde om pe a i w ihi a t e ve m ont perod,e h ofa l s t w e dur ton. pi ode c ns ton t n w l h i ac t ea t wo eks a i ( 3 2. Sh a tcp td Mc aug l si ar nswo dc us hm t b a s n fo wo k R. 0 ) e n iiae la hi mp ime t ul a e i o e b e t r m r n' moet nf da pe mont e sntalyprcl ngalwor aci t ( 303.seas R.67. r ha our ys r h, se i l e udi l k tviy. R. , e lo ) Spec fca l D r Robi on o ne t tM c s ug i ha no us ula lt t f ton i a ii ly, . ns pi d ha la hln s ef biiy o unc i n num be ofa ea r quie f uns le w o k, nc udi m a nt i ng a t t o f a t o hour r r s e r d or kil d r i l ng i a ni ten i n or w s gm e ;m a nt i ng r a a t ndanc a c pl tng a nor a w or y a w or wee e nt i a ni egul r te e; nd om e i m l kda nd k k 1TheG l ba A s es m entofFunc i ng orGA F,s l r ngesf om 0 t 1 a consde sps o l s s toni ca e a r o 00 nd i r ychol ca ,s i l ogi l oc a , and occ i f to ng on a hypot tc co i upatonal unc i ni he i al ntnuum ofm e alhe t il s D i nt alh lnes . agnos i & St ts i lM anua tc a i tca l o Me tl s res3 ( t e . x Re . 0 0 ( ri he û M-V- '.A GAFo 516 idctsmo eae f na Diod r 4 4h d Te t v 2 0 ) heena rK DS I TR' ) f -0 n iae d rt smpo (. ,ltafc a dcru tn il p eh, c so a p ni atc s o mo eaedfiut i s ca, y tms eg.ta fe t n ic msa ta s e c oca in l a c ta k ) r d rt ifc l n o il y o c paina, rsh o fn to ig(. ,e fin s c nfit wi p eso c - res.l cu t lo c o l u cinn eg.fw re d , o l s t e r r o wok r) d. o c h wihoutit m z i fom ps hol c l bas d s t n e ptons r yc ogialy e ympt . Shef t opi d t t oms urher ne ha M c ug i i unabl t m e tc pe ii s a r i t e a ea a i s r ous y lm ie i La hln s e o e om ttve t nda ds n hr e r s nd s e i l i t d n t e addii lae .( 300. Dr Robi onsae M c ug i ha nous f a lt t hre tona ras R. ) . ns ttd La hln s eul biiy o f ton i a oft f a e r r f s m is le a s led wor t the ha no us f unc i n ny he our r as equied or e - kil d nd kil k; ha s e ul f t o la lt t i e a ta opr a e y w ih t ge a publc;a t the i una e t m e t unc i na biiy o nt r c ppr i t l t he ner l i nd ha s bl o e compe ii sa r i hi a lt t m ant i s ily a oprae be orand a r t ba i ttve tnda ds n s biiy o i an oca l ppr i t havi dhe e o sc sa r ofne t s a cea i s .( 301)Des t t i tuci gi nont tndads ane s nd l nlne s R. . pie he nsr tons ve he quesi ie Dr Robi onf ie t Sgl an ghe)lmiainsf lngi t t eemos lmie tonnar , . ns ald o texpli t i tto ali n he hr t i td c t i ... nd i ude m edi alclni a fndi t ts a egores a ncl c / i c l i ngs ha uppo tt s a s s m e , f e c of r hi s e s nt' or a h ' t s s ci oft a s s nt ( 300- ) he e e tons he sesme . R. 01. l an e us i de i i t A LJ c i r t s opi on f om D r Robi on butga i n xha tve c s on, he ons de ed hi ni r . ns ve t lmiedwei .( 24. Ge r l ateai physcin' opi oni t begi c r lng i t ght R. ) nealy, r tng i a s ni s o ven ontoli w e g by t A LJ i i i s i ht he f t s uppor e by m edi a l a e a e c i c a l bo a or di gnos i td c ly cc pt bl lni al nd a r t y a tc t c que a i noti e hni s nd s ncons s e w ih o he s t nta e de i t r or M a to v. e , i t nt t t r ubs a i l vi nce n he ec d. s r Apf l 270F. 1 178( hCi. )(1A1te tngphyscin' opi onont naur a s ve iy 3d 71, 4t r 2001 ig rai i a s ni he t e nd e rt oft c a m e i pa r en i entted t c r lng w e g i i i w el- uppored by m e c ly he l i d m im t s il o ont oli i ht f t s ls t di a l a ce abl clni a a lbor t y di gnosi t cl que a i noti onsse wih t o he c pt e i c l nd a aor a tc e mi s nd s nc it nt t he t r s t tale de ei t r or ') l deenni ngt wegh t gi t ame ca s c s ubsani vi nc n he ec d. . n t ni he i t o ve o ' di l oure' opi on, he A LJ m us c i r a num be off c or , nc udi whe he t phys c a ha ni t t ons de r a t s i l ng t r he i in s e m i d t a i ant t e s e e ofa ongoi phys c a pa i ntr l tons p,t di gnos i xa ne he pplc , he xi t nc n ng i i n- te e a i hi he a tc a clni a s nd i c l uppor f t opi on,t o ni sc itnc wih t r or a whe he t t or he ni he pi on' onsse y t he ec d, nd t r he physca i as ci it 20C. R. 404.527( 41 927( .Ho ve ,ttheteai iin s pe als. F. jj 1 *, 6. * we r Cgl r tng phys c a r l i nota ol e. A n û LJ m a c ii n ue s bs ut A y hoos t gi l s wei t t t tm ony ofa e o ve e s ght o he es i 4 te tng physcin i t ei per ua i conta y evi nce '' H i v.Ba n r ,453 F. 559, rai i a f her s s sve rr de . ' nes r ha t 3d 5 n. ( hCi. 63 2 4t r 2006) . W ih r pe t Dr Robi o sopi on,he ALJnot d t t t es d o . ns n' ni t e ha : Eve t n hough Dr Rg ns i ateai s c s ha s e t . obi onl s r tng oure, he d e n he c ai a f onl f m o hs w he s r nde e he opi on. l m nt or y our nt n he e r d r ni Thi opi on r ga di t c a m a ' f tonalm e a lm ia i s ni e r ng he l i nts unc i nt l i t tons and c uson t tt c am a ti C s bl d' i an o ni n on a oncl i ha he l i n s t a e ' s di pi o n i s t t i r e ve t t Com m i s o r a i t s c s i not s ue ha s es r d o he s i ne nd n hi a e s entted t co r lng w e g or s c a s gni i anc il o nt oli i ht pe i l i fc e. The underi d fnds t t Dr Rl ns s o ni care o y sgne i ha . obi on'l pi on ris nl lm ied weght bec us i co lc s wih t medialr or a a i t i a e t nfit t he c ec d s w hol e. ( 24. TheALJwe ont saet tt e de eofr or e tbls t tMc ug i R. ) nt o tt ha he vi nc ec d sa ihes ha ia hln enga i ac i te ofdaiy lvi t ta e i ons s e w ih t de ee oflm ia i e e s d ges n tvii s l i ng ha r nc it nt t he gr i t ton xpr s e i t doc or s o ni a t tt e r oft lm ia i a e ba e on m e c ton s de e f t n he t ' pi on, nd ha d ve al he i t tons r s d s di a i i f ec s ast ps hi t i tw asw or ng t fnd t a opr a e e f c i m edi atons a t s d he yc a rs ki o i he ppr i t , f e tve c i , nd he i e- efecsa etmporr ' ( 24. Asdealdbeo s tnta e denc s rst ALJS f t r e ay. R. ) ' tie lw, ubsa il vi e uppo t he ' de e m i ton t tD r Robi o sopi on i noten il d t c r lng w e ght t r na i ha . ns n' ni s tte o ontoli i . A. The r cor c a ns f w m edi alte m en not ge r ly. O nl f s no esi t e d ont i e c r at t es ne a l y our uch t n he r or a e f o Dr Robi on. Dr Robi o be n tea i M cla ec d r r m . ns . ns n ga r tng a ughln o Se e be 24,2009, i n pt m r f l i a r e r by hi pr m ar c r phys c an. Tr a m e not r fec t tM c a ug i olow ng ef r al s i y ae ii e t nt es e l t ha la hln pr e e C orte m e ofge r lz d anxit dior ra wela r c r ntde e son ofa es nt d t r at nt f ne a ie e y s de s l s e ur e pr s i sveenau e. ( 257. M c ughlnc ane ofwa ngupangr i t mor ngs poor e r tr ' R. ) La i ompli d ' ki y n he ni , a tt , e es i s e p,de e ed e r m o s i ,a a e y. D r Robi on s a e t t ppe ie xc s ve l e ns t t d ha cr as ne gy, od w ngs nd nxi t 2 . t e s pt sw e e notcons s e wih m a a, t ts m e co d be cons s e wih hes ym om r it nt t ni but ha o ul it nt t 2 A Snotd i r , M c e nfa Laughln qui t ng t Geodo pr c i byhi prm a ycaephyscinf hi c pli sof i t aki he n es rbed s i r r i a or s om ant m ood s i .Therf e,whenhepr s t dt Dr Robi o f t frttm ei Se embe 2009,hewasnottki w ngs e or e en e o . ns n or he is i n pt r a ng a y me c to f rh sme t lmpar n s ( e R. 6 . n dia in o i n a i ime t . S e 2 4) 5 hypoma a. ( . . A ment sause mi tonr ae M cx i ha good goomi ni 3 R 257) al tt xa nai eve ld laughln d r ng a hygine;goode cona t de r s dps homot a tviy'f ri ihta j nd e ye tc ' cea e yc , or ci t , ai nsg nd udgme 'a nt nd , no ps hotc s pt sor s c da orhom i i li a i . H i s ec w a des r be ass ta yc i ym om ui i l c da de tons s pe h s c i d of nd sow butf ue a s ane ' st l l nt nd pont ous hi hought lne ra l ca w ihoutl e a s i tons o , s i a nd ogi l t oos s oc a i r ti ofi as hi moodtde ese 'a hi afe tdys i a r srced.( 258. Dr lght de ' s , d pr sdi' nd s fc phorc nd etit R. ) . R o ns di gnos M cLa bi on a ed ughln w ih m ood di or r noto he w i e s i i d,a w e las i t s de , t r s pec fe s l g r lz a e y di or r She pegged hi G AF at504and pr crbed Ce e 20m g daiy f ene a i ed nxi t s de . l xa l or s es i depr s i a anxi t D r Robi on not d,t tdoe a a t pa i thas a s gni i a am ount e s on nd e y. . ns e û l s ppe r he ten i f c nt ofm one ba re st hi l ve ofe pl e ,a wel asm ood a ps hi t i i s whi h y r i r o s e l m oym nt s l nd yc a r c s ues c woul prcudehi fom benga et manti ganf e oyme . ( 258. d el m r i bl o i an i ul mpl nt' R. ) ' M cLa ughln r t ned t s e Dr Robi o on Oc obe 20,2009 w ih c pl i s of i e ur o e . ns n t r t om a nt t oubl s e pi s nce he be n t ki Ce e . He s a ed he f l a ltl l s de es e a t t r e l e ng i ga a ng l xa tt e t ite es pr s d nd ha hi e r y l vel w e e i pr ng. How eve ,he r pore a l c ofa tt ,s e hypom a a, s ne g e s r m ovi r e td a k ppe ie om ni a a eya rci t nd nxit nd a ng hought.Hesi hewa i e etdi amood sa lze.( 25 ) s ad s ntr se n tbii r R. 4. Exa i ton r ve l d good e con ac a ps ho o ora tviy'nor als e a lne and m na i e a e ye t t nd yc m t c i t , m pe ch; nd i ar l c lt ogi a hought w ihoutl e a s i esorfi tofi s H i af e tw a e hy i a s t oos s oc at lgh dea . s f c s ut m c nd s me a h p ma i, n hi isg ta dj d me twe en tdt b ûart g o . Dr o wh t y o nc a d s n ih n u g n r o e o e û i o o d' . f ' Robi ondesrbe hi mood a impr i ' ndrie hi GAFt 55. ( 25 ) She ns ci d s s t ovng'a as d s i o 5 R. 4. contnu McLa i onCee a a d l ga3mgasamoodsabiier ( 255. i ed ughln lxa nd dde nve t lz . R. ) 3Hy o nai a a n r lyo mo drsmbigma a(esse t lv tdo e p nsv mo d, y eatvt p ma i s n b omai f o ee ln ni p ritn ee ae r x a ie o h p rcii t y, itae sl-se m, t.b to lse itn i Do ln ' Il tae Me ia Dito ay8 5( 0he . 0 3 . nltd efete ec) u fe sr ne st y. ra ds l rtd dc l cin r 9 3 t d 2 0 ) us 4A GAFo 415 idctssro smp o (. ,uiia ieto , e eeo e so l i as fe u n f - 0 n iae e ius y tms eg.s cd ld ain s v r bssina rt l,rq e t u s o lfi )o a ys ro si ar n i s ca, c u ain lo sh olt to i ( . , fin , n bl t k e h pit r n eiu mp ime tn o ilo c p to a, r c o f inng eg.no re dsu a e o e p ng mc aj b .DS I TR a 3 o ) M-V- t 4. 5se f t t 1,supra. e oo no e M c ughln s w Dr Robi on on N ove ber24, La i a . ns m 2009,a n c pl ni ofno be ng gai om ai ng t i a e t s e p. H e s a ed t the ha a be t ra tt a w a l s de es ed butha s e bl o l e t t ha d te ppe ie nd s es pr s d om i rt biiy. Exam i ton r vea e he w asal r and ore e hi be vi w a nor al hi e r ia lt na i e l d et i nt d; s ha or s m ; s ye co a tw a good;hi s c w asnonna ;hi m ood w a be t r hi t nt c s s pee h l s s te ; s houghtpr es e w er oc s s e ln a ; i i ih a dj d me t r fi; n h saf c wa e t y ca rsrce ( 25 ) ie r h s nsg t n u g n wee ar a d i fe t s u h mi nd etitd. R. 6. D r Robi on di gnos d M cLa . ns a e ughln w ih a m ood di or r notot r s s c te r e out i t s de , he wi e pe ii d; ul bi a di o de . She r s d hi GA F t 606a d pr c i d t a odone t hel r ul t hi s e p pol r s r r o p eg a e s l e ai e s o n es r be r z c l.( 256. yce R. ) On J nua y 1 201 Dr Robi o fle ou ament i par e que to ie a r 9, 0, . ns n il d t al m im nt si nnar i ca i M c ughln i pr cl d f om a lw o k ac i t H e l s t e t en not i t r c d ndi tng La i s e ude r l r tviy. r a t r a m t e n he e or i da e a oxi a e y one w e l t r on J nua y 27, 0. M cLa hln contnue t co pl i s t d ppr m t l ek a e , a r 201 ug i i d o m an a bouthi s e p c l s a i he w a s e pi a l he tm e. He e es e conc r a s l e yc e, t tng s l e ng 1 t i xpr s d e n bouthi s f t ' u omi s r r and hi dia lt he rng.Exa i ton r veald hewasalr a ahers pc ng u ge y s s biiy a i m na i e e e t nd ore e he w a fdge y butha f reye c ac ;hi s c w a s ta nor al he ha lnea i nt d; si t d ai ont t s pee h s of nd m ; di r t houg pr es e ;he w a a ous a dys ht oc s s s nxi nd phoni he ha no de us ons and hi i i a c; d l i ; s ns ght nd j g n weefi.( 3 . Dr Ro i s nd a n s dhi wihmo ds r e , o oh r s ud me t r ar R. 71) . b n o ig o e m t od io d r n t t ewie s cii . rul outbi a di or r ge r la et di or . She l e e hi G AF t 5 ? pe fed, e pol r s de ; ne a nxi y s der ow r d s o 3. l s ,Dr R obi on s w M c w n um . ns a laughln onl t e tm e be or f li 0utt m e al i y hr e i s f e ilng he nt i paim e ques i m r nt tonnaie i whi h s opi st tM cLa r n c he ne ha ughln ca i nnotw or Tr a m e snot k. e t nt es r t e ti pr ve e i hi c e l c m o m nt n s ondii f l i hi i ta vi i.H i m ood w asdes r be t be ton olow ng s nii l st s ci d o 6see f t e l s a oo not , upr . our es ha l hi s e s nt s ow r ha ndia e t s e ous 1Se f t e l s a Thec tnot t twhiet sGAF a s s m e i l e t n i c t d a hi pr vi e oo not , upr . a nt e onN ove ber24,2009,ti si l hi rt n notd ont m e ali paim e quesi ieDr ppoi m nt m i s lghty ghe ha e he nt m r nt tonnar . Robi on fledoutaw e e riron J nua y 1 201 The ei noexplnai i t r or f t d o i GAF ns il ek a le a r 0, 0. r s a ton n he ec d or he r p n fom 60t 52bet ent a nt e onN ove be 24, r o we he ppoi m nt m r 2009 a J nuar 1 2010whenDr. nd a y 9, Robi o Gledout ns n l t que tonna r he s i ie. C ter'a ûi pr ng. Exam i ton r ve e good e c a t nor albe vi a s ec t t ' nd dm ovi ' be ' na i e al d ye ont c , m ha or nd pe h, lne rt i a hought,e hymi afe t a f i t goodi i a j s ut c fc, nd ar o nsght nd udgme .M cvughlnrpore nt la i e td f lng l s de es e ha ng m or ene gy,a ha ng a be t r a tt a t rbegim i hi ee i es pr s d, vi e r nd vi te ppe ie f e l ng s m e ca i n r gi e alhough he com pl i abouthi s e To hel de w ih t ti s ,Dr di to e m n, t a ned s l ep. p al t ha s ue . R o ns pr c i Tr odone. D r Robi on a s pr s rbe a m ood s a lz ra bi on es rbed az . ns l o e c i d t bii e t M cta a ughln' r ques . She r s d hi G AF f om 5 t 60, el c i onl m ode a e s pt m s i se t ai e s r 0 o r te tng y r t ym o , i t t mont f l ng hi i ta a n me .Des t he sa e n he wo hs olowi s nii l ppoi t nt pie r t t menton t mentl he a i pa nne que tol a r t tM cLa m i nt s i m i e ha ughln s f r d t ee e s i uf e e hr pi odes ofde om pe a i 8w ihi a c ns ton t n t vem o h pe i no s h e s wel nt rod, uc piodesa er teced i he te t e not . The ei no r el t n r r am nt esg r s e de e t s vi nc o ugge tt M cla hln w a hos t i ed a a r s tofhi m ent li pa r e s or s hat a ug i s pialz s e ul s a m im nt , t the e ha ngage i a t ofi e i t r py. Ra her hi tea m e ha be n r utne, d n ny ype nt nsve he a t , s r t nt s e o i c e v tve and m edi aton- e A lhough Dr Robi on not d a hi fr ta nt e t t ons r a i c i bas d. t . ns e t s i s ppoi m nt ha M cLa ughln has û ood a ps hi ti i s s whi h w o d pr c ude hi f o be ng a e t i t m nd yc a r c s ue c ul e l m r m i bl o 8Asde i ont m en a i paim e que tonnar . fned he t l m r nt si ie' Epiodes of de s compe ai a e e e bai or tmpor l i r s i ns ton r xac r tons e ay nc ea es n s omso sgnsa mpa e by al sofa ptvef toni asma f se ympt r i cco nid os da i unci ng, niet d by difculi i pero m i a i te of dal lvi m ai ai ng s il fi tes n f r ng ctviis iy i ng, nt ni oca r atons ps or m ant ni conc r to perit nce or pac Epiodes of el i hi , i ai ng entain, sse e. s deco pe ai m a be de onsrt d by a e c baton ofs pt sorsgns m ns ton y m ta e n xa er i ym om i ta wo l odi rl rq iei rae te t n o aIs srsf lstain( r h t ud r naiy e ur nce sd rame t r es te su i t o u o ac mbn to o te- 0 . o iain f h ) ( 3 2)Thi d fnio i c nsse twihteo estfrhi Litn 1 .0, 0C. R.à. 4, u p . Ap l R. 0 . s ei t n s o itn t h n e o t n sig 20 2 F. l 40 S b tP, p. , i t w hi h goe on t s a e: c s o tt Epiodes of dec s ompens in ma be i e r fom medialr c ds s wi ato y nfred r c e or ho ng sg fc t atr ton i me cai or doc ntton of t need f a mor iniian le ai n di ton; ume a i he or e srcurd pyc olgia s p o ts tm (.. h s tl ain ,plcme ti a tu t e s h o c l u p r yse eg, opi i to s a e n n az h lwa h us, rahihl sr cu e a ddrcigh u e oll o oh rr lv n af y o e o g y tu trd n ietn o sh d ; r te ee a t i onnai i t r c d a t t exitnce s ve iy,a durton of t nf ton n he e or bou he se , e rt nd a i he e s piode. . ns d y r at La hln or e nt i o ilng t he ntl m r t 9A snotd, Dr Robi on ha onl te ed M c ug i f afw m o hsprort fli ou t m e a i paim en e que ton ie.Noneofhe r co dsfom t eviisdoc e e s sofde m pe ai oft owee durton. si nar r e r r hes st um nt piode co ns ton w ks' a i And a expli d i r noneoft ot rm ediale de ofr co d doc e se s sofde s ane nfa, he he c vi nce e r um nt piode compe ai wihi ns ton t n t pr vi t e ve m o h perod. he e ous w l nt i 8 m a n a n ga nf e pl e r t e i no s i t i i ul m oym nt' her s ' uppor f t s s a e e ,o hert n M cla i s t or hi t t m nt t ha w ughln' s j vec ai s i t teame not i whihi a r.Anda pr ousysae ubedi ompl nt,n he r t nt e n c t ppeas s evi l ttd, M cLa ughln' c t o i pr d ove t e ui m on hs l s t t s ve e lm ia i i s ondii n m ove r he ns ng t . n hor , he e r i t tons r fec e i t m e a i pa nne sque tonna r a e s m pl notbor outi Dr Robi on' e l t d n he nt l m i nt si ie r i y ne n . ns s t eat entnot r m es. B. Pr ort hi i talvi i wih D r Robi on,M cLa i o s nii st t . ns ughln s i oughtm e a hea t te t e nt l lh r a m nt o ytlo g h sp i r c r p y iin, ndt a te t n b g nj s t remo t p irt h s nl l u h i rma y ae h sca a h t rame t e a u t h e nhs ro o i r fr ta nt en w ih Dr Robi on. l ed, hie M c ughln a l gesan ons tdat of is ppoi m t t . ns nde w l La i le e e D ec m be 31 2003,t r a e no t e t e not i t r cor prort 2009. I J 200 he e r , he e r r a m nt es n he e d i o n une 9, es a ihed a r a i hi wih pr m a y ca e physci ns K i be l Che M . . a She l y t bls el tons p t i l r ia m ry ek, D , nd le Snodgr s M . . a A ugus a M e ca Ce t r He c pl ne t Dr Che k ofa i ec ed s e as , D , t t di l n e . om ai d o . e n nf t or o t bac ofhi hea he rbur a m ood s i . Att tm e he w asno t ki a n he k s d, a t n nd w ngs he i , t a ng ny m edi a i f hi m e a i pa r e s H e s a e t the had bee on Le pr i t pa tf a c ton or s nt l m im nt . t t d ha n xa o n he s or pe i ofaboutt m ont butqui t ki i be a e i û a hi di z a di n' w o k. rod wo hs t a ng t c us t û de m z y nd d t r ' m ' ( 290. M c ughlnrpore afmiyhitr ofps hiti pr e .Upone mi ton, . R. ) La i e td a l so y yc arc oblms xa nai Dr Che k notd good e c a t nor mood a afe t nonnalr ce /e ot m e o y,a e e ye ont c , mal nd f c , e ntr m e m r nd nor i i i ohi he t st to ( 291. Shedi malnsght nt s alh iuain. R. ) agnos dhi wih bi ardio de, e m t pol s r r pr ci dGe ,a r ere hi t aps hititl ( 291- ) esrbe odon nd ef rd m o yc ars.o R. 92. Dr Snodgr s a Dr Chee c i d t te M c . a s nd . k ontnue o r at Laughln' he d l son i J a i s a e i n une nd J y of2009. On J y 1 2009,f l - p no e f om D r Che k r ve M c x ughln' ul ul 3, olow u t s r . e e al l a i s pr c i i f G e es rpton or odon ha a ve and t the w a t be n t ki i i m edi t l D r Che k d ni d ha s o gi a ng t m a e y. . e 1 Dr Che k i taly r e edM cLa hln t Dr Da i Chrse en,buthew a l e r ere t Dr M els a 0 . e nii l efn' ug i o . rn itns s atr ef r d o . is Ro ns n f rfn nca r a o s ( eR. 6 ) bi o o i a il e s n . Se 2 4. 9 f t rnot d t tM cLa hln ha a a urhe e ha ug i d n ppoi m e tw ih a ps a r s s he e i Se e be . nt n t ychi t i t c dul d n pt m r ( 273. The eaenoot rrf rnce t hi mena heat On J y27, R. ) r r he e ee s o s tl lh. ul 2009, pr sntd he ee e w ih poi on i a f a f l up ofhi he l s on.A sr r hi m ent i pa r e s t s vy nd or olow s ad e i ega ds s al m im nt , M caug l rpo tdteGe d nk o kshm o ta dt t etsj t a i go ea ng t c u e la hi e re h o o n c i u n ha h d us tk n n t ih be a s n i t ti alheca ha erghtnow. ( 270. af l upa nt ntonAugus 1 2009, ha s 1 n ndl i ' R. )At olow ppoi me ' t 7, he c pl i d ofna e ,vom ii a di r hea H e s i he con i ue t t ke t Geodo but om a ne us a tng nd a r . ad t n d o a he n Stsilwhi hi Hefel e use t ne da M ayso i. ( 268. On Se embe 24, t tl ps m. e s xha td he xt y. i tp t' R. ) ' pt r 2009,M caughln rpore t tSg e' no be ndoi wel Sayshene s t ngf la i e td ha %hl s t e ng l. eds omehi or a x ey. . Heso e t eGe d nb c us ij tz n sh m o ttomu h. ( 2 4. n it . . tpp d h o o e a e t us o k i u o c ' R. 6 ) ' Mc Laughln ha a a i d n ppoi m entw ih Dr Robi on s he e t s m e day. The f na not i nt t . ns c dul d hat a i l en t r c d f om D r Che i f om N ove be 30,2009.M c ughln c i d t c pl i of he e or r . ek s r m r La i ontnue o om a n pr e sr gul tng hi see c e,s a i he i up a 1ni a s ee a lda - a c pl nthe obl m e a i s l p ycl t tng s 1 ght nd l ps l y om ai r s d w ih D r Robi o a hi a nt en a w e k ea le on N ove be 24, ai e t . ns n t s ppoi m t e ri r m r 2009. N ot r vea es e l onl t tDr Chee te y ha . k t ncour ged hi t be dii nt' ih r pe t f l i up w ih D r a m o lge ' w t es ct o olow ng t . Robi ona hi c ai s ( 261) ns bout s ompl nt. R. . The e r or f om M cLaug i sprm a y c r phys c a pr de no i i i o t s ec ds r hln' i r a e i i ns ovi nsght nt he e e oft f tonallmia i c us d by hi m e a i par e sand no s xtnt he unc i i t tons a e s nt l m im nt uppor f t t or he e r m e lm iato o lne by D r Robi on. The r c ds doc e hi c pl n s ofm ood xt e i t i ns ut i d . ns e or um nt s om ai t s ngsa a et The dic sm e ca i ma wi nd nxi y. y s us di ton nage nt me .They c an ltl i t way of ont i ite n he ob e tvetndi .Andt do notesabls t tM c j ci i ngs hey t ih ha Laughln' ment i ime sa es vee i s almpar nt r e r e noug t pr cl a 1w o k a tviy. h o e ude 1 r c i t 10 C. Li i e,M cLaughln' actvii ofdaiy lvi contadi t degr oflm iaton s kew s i s i tes l i ng r ct he ee i t i et f t on Dr Robi on' m e alhe t as es m e . Cr t lBr or M c or h . ns s nt alh s s nt ys a adf d, Laughln' gi lre of i s rf i nd s ven ye r ,t s ii d a t a i sr tve he r ng a e a s e tf e t he dm ni t a i a i boutho s as i t M c ughln wih w he s s s La i t varoust ks t the i una e t pe f m bec us he c nnotr d. Fore m pl s hel d hi i as ha s bl o r or a e a ea xa e, he pe m su y frt d i rsts ( 5 - 5 , u sc ran c lrs a oof rhm sn ehec n o r a td o he rve ' e t R. 4 5 ) b y e ti oo h mp o i i c a n t ed t lbes( 55 56 ,a compa eshi t docorsviis( 58- ,a a ssshi whe usng he a l R. - ) c ni m o t ' st R. 59) nd s it m n i a ATM ma hi ( 57- .Howe r s sae t tM c zughlni a et wakdownt hi n c ne R. 58) ve , he ttd ha ta i s bl o l o s pae s hous a hep outwihc r s andt thedoe c esar rnt' e nd l t ho e , ha s hor oundt i hous ( 6061. her e. R. - ) She f t rt s ii d t the does urhe e tfe ha : g a ial altwih ( sgrfin s3 kds j s tli t t e Bj sc ly o t hi il e d' 1 i ,u t akng o h m, r he c n do t t I m e he' r aly good w ih t ki ,t l ng t a ha . an s e l t he ds a ki o t m . But as hi hom e or a l of t ngs lke t t he r le on he s w k, ot hi i ha , e i s mef t t Hei abi hepwiht ki . gaughs or ha. s g l t he ds l l ( 61) Brdf dtsii t ts hasbee lvi wihM c R. . a or e tfed ha he n i ng t Laughln f sxa hal ye r a i or i nd f a s nd t t yaeloget ra1t tme. ( 6 ) hathe r s he 1 he i ' R. 2. t ' Thi t tmony i a oddswih Dr Robi on' fndi t tM cLaughln i una e t s esi st t . ns s i ng ha i s bl o f i i s alramsçduet moodi tbiiy,i tbiiy, mi tveanxi t ht. ( uncton n oci e l ç o nsa lt nia lt nz nai / ous houg s' R. ' 298. Asdefom hi lani dia ltes t onl a pe t ofMcLaughln' me ali ime s ) i r s e r ng sbiii ,he y s cs i s nt mpar nt Br df d r f r nc a t a i sr tve he rngwe et f tt thege sne vousa ound a or e e e ed t he dm nita i ai r he ac ha t r r srnge s( 55 ,a t theha ha toubl r gultnghi see c ewhieonhi me cai . ta r R. ) nd ha s d r e e ai s l p ycl l s di tons ( 58. Howe r s tsii t tû( . MelsaRobi on' rghtnow tyi t ge hi R. ) ve , he e tfed ha tDr1 is ns s i r ng o t m l ve e outon t ngs ' i ca i t s e p i s s w e e t m por y a coul be r s ve w ih e ld hi s' ndi tng he l e s ue r e ar nd d e ol d t a j sme t t h sme c to .( 5 . du t ns o i diains R. 8) 11 Alo not s eworhy i Br or st tmony t tM cLa hln' men alheat condii ha t s adf d' esi ha ug i s t lh ton d notcha ngedo rt pa ts nye s( 6162 ,d i whihtmehes ve he s eve ar R. - ) urng c i oughtnome a he lh ntl at teame a t nomediai ( 1 1 203,20 ) I e whe McLa hlna id r t nt nd ook c ton. R. 86, 87, 4. nde d, n ug i pple f di a lt be i si 2008,he ls e l ar ng di a lte a dysexi a t o y c tons or s biiy nett n i t d e ni s biii s nd l a s he nl ondii t tlmi hi a lt t wor ( 1 ) Hesaedheha notbe n senbyadocororhos t ha i t s biiy o k. R. 84. tt d e e t pial f t s c tonsorf a ot re o i or he e ondii or ny he m tonalorm e a pr bl m st tlm i hi a lt t wor nt l o e ha i t s biiy o k. ( 18 203. Dr Robi on' me a i nne quetonnaiei smpl no s R. 6, ) . ns s ntl mpai nt si r s i y t uppore byt s td hi ort ot re de e ofr cor . 1 T her f e,s t ntale de e s he he vi nc e d 1 t he ' e or ubs a i vi nc uppor st A LJ S det r i ton t gi i lm ie w e g . e m na i o ve t i t d i ht 111 . B e a e t r w a no m e ca docum e a i n ofM c v ughln' c c us he e s di l nt to la i s ondii a oft tm e ton s he i he a i d f dia lt be tt,dia lt deer na i s r i esr f r d hi f a c ula i pple or s biiy neis s biiy t mi ton e v c e ere m or ons t tve e m i ton,w hi h waspe f m e by D r Ci nci o on D e m ber30,2008. l hi r por,Dr xa na i c r or d . a ol ce n se t . Ci nc ol s a ed t tM c a i o t t ha laughln a i ppea e t be a e t a l nd t a tvii s ofda l lvi rd o bl o te o c i te iy i ng w ihouta s s a e a not d t the e age i r i hous hol t s . Dr Ci nci o s a e t s i t nc nd e ha ng s n outne e d a ks . a ol t t d M claughln: w i i c r nty t ng no m e ca i n nor does he ha a c r nt s ur e l aki di t o ve ny ur e m e c lpr e sf whih hei r c i ng te t t Thepai nt dia oblm or c s e evi r a men . te ha a ne tve hit y of i pai n or ou pa i t ps hiti s gai sor n te t t ten yc arc i e ve i w ih t e pto of ps hol c t s i a nt r nton t he xce i n yc ogi al e tng nd a a mi tsi d nei c nu cin wi h src p in o s ca c de c etng o n o j n to t i e e to f pe il h e duca i s r c . ton e vi es ( 2 7. R. 4 ) d e o o ncl n s e i l unc i pact s s i ng l Fort ss m e r as ,t ALJha nor as n t i udei hi r sdua f tonalca iy ases mentafndi ' hi a e on he t tM cLa i w o d beof t k t y perentoft wor y, hi t vocai e r t ttedw o d ha ughln ul f as went c he kda w ch he tonal xpe tesis ul p e ld al r .( 67)Theei n sp r frsc al tto i terc d. r cu e lwo k R. . r s o u pot o u h i ain n h eor mi 12 D1 Cine ol o er d t tM cLa hln wa cl nl a tr d a hi gr ' a i o bs ve ha . ug i s ea y tie nd s oomi a ng nd hygi ne a e ppea e t be a qua e. H i s c w a r l va , he en ,ofnor a vol e a t , rd o de t s pee h s e e nt co r t m l um nd one a s t ne ;e c a wa good wih s a cofga ng;a hi m ood a m'dt be nd pon a ous ye ont d s t por di f zi nd s ppe e o a o , c wasnot d t be af nxi us whih e o undi ofst ton,a hi a f d co tit d.M o ug i on iua i nd s fe nsrc e La hln wasalr a f l oren ed a s e t nd uly i t nd howe no sgnsofhal i t y a i t , de usons e de e of d i lucna or ctviy l i , vi nc s iia ie to o ho cd lie to Hi isg ta dj d me t p a e t bea p o raey u cd ld ain r mii a d ain. s n ih n u g n a pe r d o p r p itl de l pe hi t ve o d; s hought we el c ,goa - r c e a ce er d a utt c r nte ua i . s r ogial ldie t d, nd nt e bo he ure val ton ( 248. R. ) Tetngr ald apef ma eI s eof89a af ls l I sor of8 bot of si eve e ror nc Q cor nd ul cae Q c e 0, h whih fl wihi t 1 a r ger c el t n he ow ve a ange, nd aveba I s or of76,whih f lwihi t a r lQ c e c el t n he bo d ri rn e ( 2 8. Dr Cin i l n tdt a û th d s rp nc b t e veb l n r el a g . R. 4 ) . a coo oe h ts l e ice a y ewe n r a a d ne g per e ua abiii s i s a i tc l s g fc t i ca i ofune c c pt l lte s t ts i aly i nii an , ndi tve ven ognii f toni Thi tve unc i ng. s patr i c itntwiht paintspr s tdco ai . ( 248. .Ci i odignos d ten s onsse t he te ' eene mpl nt' R. )Dr ancol a e ' hi wih al a ni dior r notot r s s ii d,a a gl as e s e off to ng m t e r ng s de , he wie pecte nd obal s s m nt unci ni ( GAF)s o eo 7 1 Dr Cincoof u dta M c u hl i c pa l o pe f r n smpl o c r f 0. . a il o n h t La g i s a b e f romig i e r 2 n r pe ii t s ,buthi a lt t pe f de a l d orco pl x t ks a e ttve a ks s biiy o r onn t ie m e as ppea s t be m a ke y r o r dl i paie H i a lt e t m a nt i r gul a t nda e, r onn w or ac i teson a cons s e m r d. s biii s o i a n e ar te nc pe f k tvii i t nt ba i,a c plt a nor a wor ss nd om e e m l kday orwor we wihouti e r i fom ps hiti k ek t nt rupton r yc a rc il s a e r l tvel uni pa r d. H i a lt t i e a tw ih c or r a t publc a wel as lnes r e a i y m i e s biiy o nt r c t ow ke s nd he i s l c w ih r utne s r s s e unt r i co pe ii wor al o a ope t o i t es or nco e ed n m ttve k s ppea t be r a i l ro el tve y uni pa r Dr C i nci o s a e t the a a sc bl ofa ce i i t uc i f om m ied. . a ol t t d ha ppe r apa e c ptng nsr tons r 1 GAF of61 7 idiae s memi smpo ( ..d p es dmo da dmidis mna o s medf t i 2A 0 n c ts o l y tms eg, e r se o n l n o i) r o it y n d kul s ca, c paina, rsho lu cinn (. , c aina tu nc , rhet t nteh u e l)bu g n rly o ilocu to lo c o fn to ig eg.o c so lra y o t f wi h o shod , t e eal hi f to ng pr ty wel, s em ea ngf i er r ona r ltons ps DSM -V - at34. uncini et lhas om ni ulnt pe s l eai hi . I TR s r s r .Howe r Dr Cincol notdt tdgl i lkel t thewoul r quies i or upevio s ve , . a i o e ha iit s i y ha d e r pecal a tonals r ii a t wor a ,e pe i ly i pr s rbe t ksr r t tt pa intr a ddii upe v son t he kpl ce s c al f e c i d as equie ha he te e d orc pl t pa wor ' D r Ci nc ol not d ne t ri ten norout te ps hi t i om e e per k.' . a i o e ihe npa i t pa i nt yc a r c tea m e tw a i c t d. ( 249. r t n s ndi a e R. ) Folo i t scons t tve e m i ton, w o s a e a l w ng hi ula i xa na i t t t genc phys c a ,Dr K a i a y i i ns s. ll nd Sa ps r vi w e t r or a opi d t tM c ug i i no pr cl m on, e e d he ec ds nd ne ha La hln s t e uded f om a lw o k r l r a tviy. Dr Kallopi d on J nua y 8,2009 t tM cLa hln hasm ode a e r s rc i of ci t . i ne a r ha ug i r t e t i ton a i t e ofdaiy lvi a m ode a e difc te i m ai t ni s i lf toni butno ctvii s l i ng nd r t fi uli s n n ai ng oc a unc i ng, di fc tesi m ai ai ng c enta i per i t nc o pac orr at d e s fi uli n nt ni onc r ton, s s e e r e epe e pi odesof de compe ai ( 78,89. Dr Samps opi o Aprl30,2009t tM cLa i ha mid ns ton. R. ) . on ned n i ha ughln s l r ti ton ofa tvii s ofda l lvi m id di fc tesi m a nt i ng s i lf to ng,a esr c i c i te iy i ng, l fi uli n i a ni oc a unc i ni nd m ode a e dif c tesi m ai ai ng c e r ton,pe s s e e orpac w ih no r pe t r t f i uli n nt ni onc nt a i r it nc e, t e a ed e s sofde ompe ain.( 1 ) Bot oft s rvi ngphyscinsf M c ughln piode c nsto R. 01. h hee e ewi i a ound La i hast r i f nci lc pact t pe f m hi patrlva wor a af ei tle.( 82, he esdual u tona a iy o ror s s ee nt k s enc nsalr R. 1 ) 05. I hi Re o t n Re o nd to t ema itaej d ea re wi t ep iintke n s p r a d c mme ain,h gsrt u g g e d t h osto a n h by M cla hln on appe t tt cons t tve a r or r vi w e de bef e t A LJ a t w ug i al ha he ula i nd ec d e e vi nce or he t he tm e he m a hi de s on f l t s t nta l s i de s ci i ais o ubs a i ly uppor hi det r i ton t de be ft . The t s e m na i o ny ne is ma itaej d eh l gsrt u g ed: The unde sgne i oft viw t tt as e s e s a opi ons r i d s he e ha he s s m nt nd ni pr de by St e a ovi d at genc r cor r vi w i expe t a t y e d e e ng r s nd he cons ttveexa i rdo notc tt t s t nta e de e on t ula i m ne onsiu e ubsa i l vi nc he r d bef e t coult Thes r ew s and t exam i i wer ecor or he '. e evi he naton e pe f r onne pr or t t c ii la s s e pr de by ps hi ti t d i o he rtca s es m nt ovi d yc a r s Dr Robi on. Thus ne t r t St t age y r c d r vi w i . ns , ihe he a e nc e or e e ng e t nor t cons ttve e mi r ha (he be ft of Dr xpers he ulai xn ne d t l nei . 1 4 Robi on' opi ons be or r nde i t ve y a s s m e s r le ns s ni f e e rng he r s e s nt e i d on by t La J he w udget de be is o ny nett. Tha r s s t q s i of w he he t Co m i sone s ul be t ai e he ue ton t r he m s i r ho d gi n a oppor uniy t r e m i t c ai i lght of D r ve n t t o e xa ne he l m n i . R obi on' e de e. One c d c l ns s vi nc oul onc ude t t s h a ha uc n oppo t t has be n a ia e a1 a ong w hi h t Com m i s one r uniy e va l bl 1 l c he si r delbe a e y by- s i rtl pas ed. W hie t pl i if s ks r ve s l on t s l he a ntf ee e r a hi r c d,whi h t unde s gne i t m pt d t r com m e t be t r e or c he ri d s e e o e nd, he te opton i t r m a t c e t t Co mi so rwih die ton t i s o e nd he as o he m s i ne t r c i o eihe c uc f t r pr e ngs i w hi h t c uli s ce t r ond t urhe oc edi n c he ons tng our co d s ul uppl m entt i r t o t gr ntbene is e he r epors r o a ft . Re r & Rec m e t o Dkt # 1 a 7. The cour di a e . po t om nda i n, . 6, t t s gr es l i no t pr nc ofa f der lcour t m a adm i s r tve di a lt de i i . The t s t he ovi e e a t o ke nit a i s biiy c sons c u ts o i t d tnn n wh t e s b tn ile ie c s p rsteCo s in rsds blt o r'j b s o ee i e eh r u sa ta vd n e u po t h mmiso e ' ia ii y decson.Tot te t cour ma net rundera aX novor ew oft Co si rs ii ha nd,he t y ihe tke evi he mmisone ' decsonnorr weg t evi eofr c d.Huntrv.Suli n,993F. 31 34( hCi. ii e- ih he denc e or e lva 2d , 4t r 1 2) J calrviw ofdia lt ca e i lmiedt deemi ngwhehe s tnta e de 99 . udii e e sbiiy s s s i t o tr ni t r ubsa il vi nce s uppor st Com m i s oner s c l i t tt pl i iff ie t m ee herbur n ofpr ng t he s i ' onc us on ha he a ntf a l d o t de ovi dia lt Se La v.Celbr z e,368F. 6 6 ( hCi.1 .Evi ncei s t tal s biiy. e ws e ez 2d 40, 42 4t r 966) de s ubsani whe c i rng t r cor a awhol ,i m i be de med a n, onsde i he e d s e t ght e dequa et s t o uppor ac uson by t oncl i aras bl mi Rihar o v.Peae ,402U. 389,401( 971,orwhe iwoul be e ona e nd, c ds n rls S. 1 ) nt d s fce tt r f s adie tdv r it naj r til S t v. ae , 9F.d6 5 6 8( t Ci. ufiin o e u e r ce ed c i u y ra. mi Ch tr 9 3 3 , 3 4h r h 1 .Subsa i e de i notaçlr o consdea ea 996) tntal vi nce s tage r i rbl mountofe de e'Pirev. vi nc ,' ec Unde wpod,487U. 552,5 (1 ) bu i mor t namees ntlaa s wha l st n r S. 65 988 , t s e ha r ci il nd ome tes ha apr ponde anc Pe aes 402 U. a 401 ft Comm isone ' de i i i s e r e. r l , S. t .I he s i rs c son s uppored by t s tntale de ,imus beatr d.42U. C.j405( ;Peae ,402U. a 401 ubsa i vi nce t t fime S. g) rls S. t . Su t nta e de e s bs a i l vi nc uppo t t Com m i s one ' de i i t a r s he s i r s c s on o doptt opi ons o t he ni f he s a e ag y phys ci nsand t c ula i e m i rove t opi on oft t e tng t t enc ia he ons t tve xa ne r he ni he r a i 15 ps hitit TheALJdi notblndl r l on t opi onsoft r viwi physca andt yc a rs. d i y ey he ni he e e ng i ins he cons tng exam i uli ner. Rat i an exhaustve opi on,t A LJ anal her, n i ni he yzed al oft r evant l he el evi ncea e a ne hi r as ng f rgi ng m o ewei t t et eeopi ons d ti t de nd xpli d s e oni o vi r ght o hes hr ni . ç s he l A LJ' r s S e ponsbiiy t w e g t e de i or rt r s ve any c l c s whi h m i a i lt o i h he vi nce n de o e ol ont i t c ght ppea r t ri ç he e n. ' rhus i i no w ihi t pr de e ofa r e i cour t de er i t wei oft t s t t n he ovi nc evi w ng t o t m ne he ght he e ie c , o i i tec u tsfnci nt s b ttt is u me t f rt a o t e( Ii hi vd n e n r s t h o r' u to o u si e t j dg n s o h t f h ALJ f s u decson i s ii s uppored by s t nta e de e.' Pa ke v.Asr , o.3:0CV 558, 1W L t ubsa il vi nc '' r r tue N 1 201 3585 a *7( D. 2011 ( i Ha v.Suli n, F. 1 1 ( hCi.1 373, t E. Va. ) quotng vs lva 907 2d 452, 456 4t r 990) andctngTayl v.W enbege ,5 F. 11 11 ( hCi.l ) a e bv2011W L ii or i r r 28 2d 53, 56 4t r 975), doptd 36 015( D. Aug.1 2011. 07 E. Va. 6, ) Plitf ag e , n tema itaej d ea re ,ha ûh ALJStndn swe en t a e an if r u s a d h gsrt u g g e s t t s e ' i ig r o b sd t o s b tn il vde c be a s t tr eme c lc n ul n stej d er le o b sdt er n u sa ta e i n e c u e he h e dia o s t t h u g eid n a e h i a opi ons on a i om pl t r cor ' P1' Br,Dkt # 1 4- Butt r or w a noti om pl e. ni n nc e e e d.' .s . . 2, 5. he ec d s nc et Att tm e M c ug i a i d f di abiiy be t t ,he had no s he i La hln pple or s lt ne i s t oughtm e a hea t t e t e nt l lh r a m nt a t had no m edi alr or r tec i a s h tea m e . The Com m i s o rs ts i hi nd hus c ec ds e l tng ny uc r t nt s i ne a i fed s dut t de lpt r c dby o dei ac ulai e mi ton.Se 20C. R.jj404.51 a, y o veo he e or r rng ons ttve xa nai e F. 1 9 41 91 M or over t f c t tDr Robi on' m e alc pa iy as e s ntwa pe f me 6. 9a. e , he a t ha . ns s nt a ct s s me s ror d a trt c ulatvee m i ton an r e by t sat a nc physc a i ofno mom e . fe he ons t i xa na i d eviw he t e ge y ii ns s nt The ALJcons de ed i det i t tea m e r or a t m e a ca ii as es m e ofD r i r n a l he r t nt ec ds nd he nt l pac tes s s nt . R o ns n. The f c t tt cons t tve e m i ra t s a e age y phys c a m a notha bi o a t ha he ula i xa ne nd he t t nc i i ns y ve c i r Dr Robi on' r c dsdoesnotr rt ALJ' r la eon t eopi ons onsde ed . ns s e or ende he S e inc hos ni ir tona . Pa ke ,201l W L 3585373,a *8.The c ulatve e m i r D r Ci nci o, t ra i l r r t ons t i xa ne , . a ol had he opporuniy t i e v e a exa i M c ughln i pr pa i hi Ps hol c A s e s e . t t o nt r i w nd m ne La i n e r ng s yc ogi al s s m nt 16 Tesi r vea e a sgnii a dic e nc i c tvef ton,butDr Cinci o di notfnd tng e l d i fc nt s r pa y n ognii unc i . a ol d i t tM claughln i unabl t wor as a r tofhi m ent i paim ent Thi opi on,and t ha s i s eo k esul s al m r s. s ni he opi ons oft sa e a ncy phys c a ,a e m or c i t ntw ih t r or evi nc asa w hol ni he t t ge i i ns r e ons s e t he ec d de e e t ni teme tli anne t q e tomar fo Dr Ro is n Fo tevatmao iyo t e ha s h n a mp i n s u sil ie rm . bn o . r h s j rt f h r l va perod, cla e e nt i M a ughln s htno tea m en wha s ve . W he he di s k tea m e i i oug r t t t oe r n d ee r t nt n 2 0 , ewa te tdc ns r aieywi me iain.Hi p e ci to sweea j se a 0 9 h s r ae o ev tv l t dc to h s r srpi n r d u td s ne s ar t c r hi a l ged m ood s i a he p r a e hi s e p cyc e. ce s y o ont ol s le w ngs nd l egul t s l e l The ALJt i t ac ountt lm iatonson M c ughln' a lt t wor t ta e ook n o c he i t i La i s biiy o k ha r doc e ed i and s um nt n uppored by t r c d. H e lm ie M c ughln t s m pl uns led w or t he e or i t d La i o i e, kil k w ih onl oc s onali e ac i w ih t publc c or r a s r s s a r quie a t y ca i nt r ton t he i , ow ke s nd upe vi or , nd e r d ny s hwor beconsse wih amar nale tonala orbei iltr t ( 21) Subsa i uc k itnt t gi ducai nd/ ng lie ae. R. . tntal e de s pporst sr sdualf tonalc pa iy a s s nta t Com mi sonersuli ae vi nce u t hi e i unc i a ct s es me nd he s i ' tm t de e m i ton t tM cLa hln i no di a e t r na i ha ug i s t s bl d. I . V Ass c ,hec u t amo a r ewiht ema itaej g ' fn i ta teALJS u h t o r c l t g e t h gsrt ud es idng h t h ' de son t adoptt opi onsoft r vi ng ph i insa t c ulai e cii o he ni he e ewi ysca nd he ons t tve xami over ner Dr R obi o sopi on i nots . ns n' ni s uppor e by s bs antale de e. Re a i no a opr a e td u t i vi nc m nd s t ppr i t gi t sr d. ven hi ecor Tota e d, nOr e wil e trdrj cigteRe o t n Re o n aino te h t n a d r lbe n ee ee tn h p r a d c mme d to f h ma sr t j i isenieyandafr ngt Commiso rsde son. gitae udge n t tr t fimi he sine ' cii + E trd Api t2 1 nee: rJt 02 l J rzmrf . , M iha F.Ur ns c el ba ki u nied st t D i ti tJ t a es s r c udge 18 *