Friday, January 13, 2006

Sometimes Freud and Drugs aren't the Answer

In this previous post on fear, there is a discussion of the use of psychotropic drugs for treating phobias. PsychPundit talks about treating a patient with OCD (Obsessive Compulsive Disorder) successfully without drugs. Take a look.

38 Comments:

Blogger jw said...

The Dr/Blogger sounds like he knows what he's talking about. Unfortunately, a four month psych cure is well out of the financial reach of many people: The pills, while less effective, are likely cheaper.

That makes for a sad situation.

8:39 AM, January 13, 2006  
Blogger Helen said...

jw,

It depends if the client has insurance. Behavioral therapy would be covered to some degree. Medications also come with a co-pay. Of course, part of the problems is weekly treatment once a week or more. It is time consuming. Taking medication takes a few seconds.

9:25 AM, January 13, 2006  
Blogger jau said...

Interesting that you brought this up. I have a friend who has been pretty deeply depressed since last August and she claims her reluctance to seek help is because her insurance will cover medication (which she refuses to take) but not psychotherapy except for a few visits. Drugs would be a quick amelioration (if she could be persuaded to take them) but my sense is that they are a quick fix, not a long-term solution. Am I being old fashioned?

10:01 AM, January 13, 2006  
Blogger Helen said...

aup,

In my opinion, depression is best treated with a combination of cognitive-behavioral therapy and anti-depressants. If your friend's coverage allows a few visits--she could find a provider on the list who does short term therapy and then refer her on to a psychiatrist for meds if needed. It really depends on the type, duration and reason for the depression as to what treatment or combination of treatments is needed. A competent therapist should be able to assist her with this. Even a few sessions may point her in the right direction.

10:48 AM, January 13, 2006  
Blogger dadvocate said...

In 1970, I worked at a summer camp for disturbed adolescents run by two clinical psychology professors from a large southern university. The same kids were there for the entire 7 weeks and the emphasis was on a behavioral approach to treatment.

One 14 year old boy in my cabin had been, in his records, described as having serious OCD. He would have to walk sideways at times because he had to be facing a certain directions. He needed to perform rituals in order to take a shower, eat or go to the bathroom. It one time he had been hospitalized because he had become impacted due to not being able perform the rituals correctly in order to go to the bathroom.

When he came to camp, he acted perfectly normally for the entire 7 weeks. No signs of OCD what-so-ever. We even had to have him sit down with the other kids in our cabin and explain why he was in camp and they could see no reason for him to be there. We believed just getting the kid out of his home environment may have done the trick.

We also wondered what, if any, role his father's occupation played in the boy's problem. His father was a child psychiatrist.

10:51 AM, January 13, 2006  
Blogger Helen said...

dadvocate,

Great story. It's sad to say but some of the most messed up kids and adults I have met have psychologists and psychiatrists for parents.

10:58 AM, January 13, 2006  
Blogger Psych Pundit said...

This comment has been removed by a blog administrator.

11:26 AM, January 13, 2006  
Anonymous Anonymous said...

My father, now retired, has a doctorate in psychology, and all of us, his four children have some problems, nothing extreme (as in physical violence/abuse or criminality or drugs or alcohol) but still we are not well adapted to society.

I am so shy that as a kid I was hiding in the tool shed not to go to school, then as a teenager I quit school twice, then quit college after a couple of months because everytime someone spoke to me I blushed and could not think straight so embarrassed I was, I would sometimes sit in the bathroom for the whole lunch hour to avoid people...

It eventually got better and went back to complete college... in my thirties, but now I have chronic fatigue syndrome which has lowered a bit my self confidence level which I had managed to build along the years...

My older sister can not make a sentence without including something about God or the bible, her car is covered in religion slogans bumper stickers, the problem is not religion, its that she is obsessed with religion...

One of my brother, even though he never did physically hurt anyone has threatened my mother, even death threats, we havent seen him in 15 years he refuses to acknoledge we even exist...

My other brother has been on welfare all his life and can not talk about anything, from the protein value of eggs to poverty in Africa without becoming very angry and shouting and waving his finger in your face and talking non-stop, never letting you say anything, not even " Ok I give up, lets talk about something else"...
( yes he is a lefty - a far to the left lefty, anyone surprised? )

And my father has a doctorate in psychology...and my mother has a doctorate in ethnology...and we are messed up...

Raising children is the most difficult job but I believe some people are simply born "bad", nothing will ever work on them, those are the people that end up on death row or in asylums or that die from drug abuse; no one can help them, something is broken inside of them, and you can not always blame their parents.

Its sometimes nature and sometimes nurture...

11:49 AM, January 13, 2006  
Anonymous Auld Pharte said...

Of course Freud and drugs aren't the answer. You omitted rock n roll!

Sorry. Couldn't resist. I have previously commented here on my belief (bias) that psychotherapy should be the first resort, then drugs if and only if behavior modification is ineffective. This article certainly hasn't changed my mind. A few, possibly obvious, comments.

There's a fundamental issue illustrated here for which I have no brilliant , never mind practical, suggestions. Psychiatrists are trained in medicine, receive an MD degree and then go on to specialized training in psychiatric medicine. They are, and see themselves as, medical doctors with a specialty. They tend to follow the medical model: Patient visits doctor, doctor determines diagnosis, doctor prescribes drugs, patient enters twilight zone, there is some sparse follow-up regimen.

Psychologists receive quite different training; and in order to become competent practitioners, therapists will engage in generally ongoing programs of application study, practice, training and mentoring. Drugs are not an option directly, but good therapists will recognize the need to refer patients for possible drug treatment.

The issue (finally getting to the crux of the argument), is twofold.

Part One is that the two professions are compartmentalized, and patients have free choice. If the first stop is a psychiatrist, a patient may NEVER learn that a non-drug treatment is available, and potentially more effective.

Part Two is the matter of costs and vested interests. Psychology has always had an image problem, and while insurance companies have relented somewhat, there is still the prevailing conventional attitude that drugs and medical doctors are "serious" and psychology somehow is not. The bias leads to common drug insurance programs and inadequate therapy clauses in the average policy. This in and of itself will push some needy patients in the wrong direction. Then there are related matters of governing law, state licensing practices, profession monitoring... OK. I'll stop now.

11:53 AM, January 13, 2006  
Blogger Psych Pundit said...

Thanks for the link, Helen - you're a gem! I wanted to address a couple of the comments above:

First, on the cost issue . . . it's important to consider both short-term and long-term costs. Behavior therapy for OCD lasts about 3-4 months and will typically cost about $2000 (with insurance, the patient might pay $500-1000). OCD meds tend to run about $70 a month; with psychiatrist intake and periodic med evals, that would mean a total short-term cost of about $800.

So, the meds sound cheaper, at least in the short-term. But consider that the person who chooses the medication route will be taking the meds for a lifetime (the relapse rate when meds are discontinued is over 90%). After 10 years, the medication cost is well over $10,000, while the person who chose behavior therapy still has a total cost of only $2,000 (perhaps as little as $500 out of pocket with insurance).

As for the convenience of medication vs. therapy . . . it's certainly true that swallowing a pill is a lot easier than doing the work of therapy, but in so many cases the pill doesn't represent a complete cure. The largest outcome study of meds for depression was just published last week (nearly 3,000 patients on Celexa), and only 28% of these patients were cured, even in the short-term! And do you know the average length of time a patient stays on depression meds? It's less than 45 days. Why? Side effects.

Therapy may be a bit more work, but as in so many domains of life, it's those who put in the hard work who reap the greatest rewards.

Peace.

11:55 AM, January 13, 2006  
Anonymous mb said...

I just wondered about bipolar disorder... my 18yr. old daughter doesn't take her meds she seems to go along okay. Her opinion is that she is different when she takes the meds (lamictal) not necessarily better, just different. Has anyone ever heard of behavior therapy for dealing with effects of bipolar?

2:02 PM, January 13, 2006  
Blogger Helen said...

mb,

While cognitive-behavioral therapy can help those with bipolar disorder--it is also important to take medications as prescribed by the psychiatrist. Adolescents with bipolar disorder tend to cycle more frequently than adults and need a great deal of monitoring. If her condition is mild, it may be that cognitive-behavioral therapy may be enough. Just make sure that the professional has a solid understanding of early-onset bipolar disorder and knows to refer when medication is needed. A therapist can teach how to recognize the escalating mood-states and teach how to de-escalate. Usually the parents are involved but in your case, with your daughter being 18, this may be an issue. I suggest taking a look at The Bipolar Child by Demitri Papolos and Janice Papolos. The book is at Amazon and has some good recommendations and explanations of bipolar illness in children and older teens.

3:06 PM, January 13, 2006  
Blogger Quadraginta said...

There are two aspects of the linked post and this therapist as a professional that bug me. First, there is the strong strain of narcissism. Certainly a moderate dose of narcissism is necessary to be of any help at all to patients, but this guy seems to display a bit much. Blogging about recent individual professional cases seems a bit iffy in itself, a tad self-centered and unprofessional, even if, as here, presumably only the patient himself and his closest friends and family can recognize enough detail to know who the patient is. But also the tone of how he presents the case smells a bit of egoism: "Look! These other fools couldn't cope, were misguided, unscientific idiots, but I solved the problem in 4 months 'and it isn't even my area of specialty.'" I exaggerate of course, but the tone isn't far from this, IMHO.

From what I know, mood disorders, phobias and other neuroses are complex and baffling things that scientifically, to use this guy's favorite word, we know at best partially, and very probably with many errors and misconceptions. Certainly the history of what has been "known" about mental illness is not encouraging about whether what we "know" now is error-free. I doubt curing them is almost as simple as curing an infection with an antibiotic, as this guy seems to imply. I think there's almost certainly significant elements of luck and mystery self-treatment by the patient in any success. Even a heart surgeon would acknowledge this in his field, and be a bit more humble about his successes, knowing them to be a bit less "my" successes than "ours" (meaning his and his patient's) and even "ours and Lady Luck's."

Second, his notion of the statistics of epidemiology seems a bit primitive for someone with a PhD. I don't think he should throw around statements like "scientifically proven" so readily. He wouldn't in a journal, would be? I suspect it is unbelievably difficult and delicate to design a study that truly controls all variables when it comes to something as complex as outcomes of treatment for human neuroses. No one with any appreciation for the subtle flaws that can infect such an effort should be nearly so off-handedly confident about what has been proven, and what not. I don't say that as a mental-health professional or patient, because I've been neither, but as a straight physical scientist. Even when you discuss the statistics of molecules in a glass of water, you have to be very, very careful about designing the statistical measures and interpreting their measured value. It's very easy to be wrong about what the numbers mean. It doesn't seem to me any harder to go wrong when you study human beings instead of molecules.

3:15 PM, January 13, 2006  
Blogger Psych Pundit said...

In reply to Quadraginta's comments:

1) The patient in question gave me permission to discuss his case publicly, provided I gave no identifying information - and none is provided in my post.

2) You've apparently misconstrued my intent in discussing the case. It's not about narcissistic self-aggrandizement . . . far from it. In fact, I'm not a particularly gifted therapist. My point was simply this: "behavior therapy for OCD is such an effective intervention that it can be used successfully even by those for whom the intervention falls outside their purview of expertise". Make sense?

3) Finally, your caveat about the inadvisability of breezy language in scientific discourse is a point well taken . . . except for the fact that I'm not writing at the moment for a scientific audience! I assure you, when addressing my colleagues in peer-refereed journals, there's a great deal more nuance - but such nuance, in my experience, does not facilitate communication with a lay audience.

Regardless, the major point of my post stands up under rigorous scientific scrutiny: the best available evidence at this time suggests that behavior therapy is the most efficacious form of interention for OCD.

3:25 PM, January 13, 2006  
Anonymous dweeb said...

"Even a heart surgeon would acknowledge this in his field, and be a bit more humble about his successes"

You haven't met many chest-cutters, have you? Anyone who works in a hospital will tell you that "humble" and "surgeon" NEVER belong in the same sentence.

Regarding insurance company's attitudes about psychotherapy - they've become very wary of it because of decades of therapists who wouldn't dream of having a termination plan for treatment.

4:20 PM, January 13, 2006  
Blogger Quadraginta said...

psych pundit, thank you very much for the response. You are generous of your time in providing it, and I appreciate that.

(1) I think you should have said this, then. The impression conveyed to -- for example -- prospective patients would be quite different. But, fair enough. I withdraw the criticism.

(2) I was aware of your intent, and I completely agreed with the conclusion, so far as I understand the field, which is from an at best only modestly-informed viewpoint. The success of behaviour therapy for OCD and phobias seems very impressive, and represents a real breakthrough as far as I understand.

My criticism was not directed at the content of your post, but at the tone, which struck me as a bit egoistic. As I said, there's nothing wrong with a substantial bit of narcissism: you've got to believe you know what you're doing to do any good at all. But too much is equally bad; it can delay re-assessment of error and I hazard it can compromise some patient outcomes by fostering an inappropriate degree of dependency. But here I wander so far outside my area of competence that I freely admit the possibility -- even probability -- of being wrong. Let us just attribute my differing opinion on how a therapist might discuss his successes and failures to a matter of personal taste, and leave it at that.

(3) I appreciate the problem. I myself ponder this issue when I write for a popular audience instead of for a scientific journal. But perhaps I reach the opposite conclusion. I regard it is as more important to be careful about what I imply about what is known, and not known, when I am talking to people who are not in a position to independently verify what I say, for lack of experience, access to the data, education, whatever. When I teach graduate students or talk to colleagues, I feel more free to speak carelessly, because they are sufficiently sophisticated to cross-check what I say with their own understanding. When I teach freshman or speak publically, I am very, very careful, because they can't, and my responsibility for carelessly implying things that I don't mean to imply is much higher.

I realize of course this is a personal blog we are talking about, and you are making semi-personal reflections, not issuing professional advice. But, the common practice notwithstanding, a blog published on the Internet is not the same as a private diary. It's more like an op-ed column in a newspaper. If a professional would be careful writing a column in a newspaper, or an article in Newsweek, it's not unreasonable to suggest some similar caution in his blog. Perhaps a bit less, granted, given the more ephemeral and clearly personal nature of a blog.

I recognize, too, that these areas of professional ethics are so new as to be fully protean. What is one's responsibility to the public reading your blog when you identify yourself as a professional (doctor, scientist, lawyer), and you reflect on aspects of the field on which you can be expected to have a professional opinion? Is a token disclaimer sufficient? I'm not at all sure. It's an interesting question. I agree reasonable men may differ.

dweeb, please allow me to modify my comment post posto to interject the adjective superior before the noun phrase heart surgeon. Perhaps that removes your complaint? I've never met a truly first-class professional in any field who isn't humble about his successes, and well aware of the role of Dame Fortune. It's the second tier that tends towards arrogance.

5:31 PM, January 13, 2006  
Anonymous Penny said...

I think if SSRIs as being like a cast for a broken arm. They don't cause the healing, but they can create conditions that allow the healing to occur.

6:40 PM, January 13, 2006  
Blogger Assistant Village Idiot said...

I didn't know that Anafranil was still used that much. I thought the SSRI's were the medication gold standard. Of course, my experience with outpatient care is pretty much limited to myself, at this point.

I can well believe that the exposure and CBT type approaches would be superior long-term. Part of the question is how debilitating the symptoms are, and how much relief you want. In my case, 2.5 years of psychodynamic therapy was enjoyable, but did nothing, while Prozac knocked my symptoms back in three weeks.

But the symptoms are only reduced, not eliminated. I count things, adjust things, make lists, and think spoonerisms. Cutting those back by 70% is about all I need. If my current symptoms were more distressing, I might be motivated to go back to a therapy that I had to work at. But as it is now, after investing a lot of effort and coming up empty, my view is No pain = NO PAIN.

12:15 AM, January 14, 2006  
Blogger jw said...

I think that something needs to be done to provide psych therapy when it has been shown to provide better results than meds. I've no idea how that could be done ...

For me, my drugs cost $2. No matter what the cost of the drug, I pay two dollars. For psych therapy that doesn't apply: I pay all and it is far far too expensive for me to even think about.

My situation is not all that unusual.

So as I see it, there are people with OCD who fit my own financial situation who get the drugs even though the described therapy would be the more practical solution. This costs us all money as disability insurance (my source of income) is a function of what we pay or paid when working.

I've seen similar things throughout the disability "world."

4:52 AM, January 14, 2006  
Blogger Assistant Village Idiot said...

Medical Savings Accounts.

Nothing fixes everything, but that would be a big step forward.

10:05 AM, January 14, 2006  
Anonymous dweeb said...

Quadraginta, superior, first class, put whatever superlative you want on it, that dog won't hunt. Numerous relatives and friends in who are experienced professionals in healthcare will talk about a cardiac surgeon at their hospital who is too arrogant to know humility if it bit him/her on the nose, and they all follow it with "but if I ever need open hear surgery, he/she is the one I want cutting." I don't see this as a negative. Some tasks require sych a degree of confidence that they require a personality like that - reaching into a living person's chest and repairing their heart is one of them.

A relative of mine flies attack helicopters - most of the family thinks he's a swaggering jerk. Maybe that's what it takes to strap into a big box of kerosene and explosives that looks like it shouldn't be able to fly and go out looking for similarly armed people who want to kill you. It takes all kinds to make a world and there's a role for almost all of them.

This is one reason I object to a mental health industry that, ultimately wants to homogenize humanity so everyone falls within a specified range for happiness, extroversion, self-esteem, satisfaction, etc. It's been speculated that most of history's brilliant artists, composers, authors, were clinically depressed, bipolar, or something else that today would make them a candidate for pharmaceutical intervention. Maybe the dissatisfaction with how one perceives the world that correlates so well with decreased serotonin is what drives people to invent, compose, etc. Any personality variation that occurs in more than 1-2% of the population over multiple generations wouldn't exist if it hadn't conferred some evolutionary advantage to humans.

9:46 PM, January 14, 2006  
Blogger Julian Morrison said...

A way to spead the word: put the facts on Wikipedia, with attribution.

If I were ill, it's the first place I'd look.

5:37 PM, January 15, 2006  
Anonymous dweeb said...

Of course, it's often inappropriate to use "facts" and "Wikipedia" in the same sentence. Anyone can add anything, and they often do.

11:53 AM, January 16, 2006  
Blogger t said...

Forinpatient and outpatient care, quality improvement efforts may be most productively focused on providers and processes of care rather than on specific patient subgroups. Drug rehabilitation center will drive those results to complete health and wellness of being.


http://www.drugrehabscenters.com/terms/Inpatient-and-Outpatient-Care/index.html

4:02 AM, November 07, 2008  
Blogger selina said...

福~
「朵
語‧,最一件事,就。好,你西.................

5:24 AM, March 14, 2009  
Blogger look said...

情趣用品,
性感睡衣,
免費視訊聊天,
視訊交友網,
美姬圖影,
情境坊歡愉用品,
花美姬情趣用品,
成人圖片,
臺灣情色網,
嘟嘟情人色網,
色情網站,
情境坊歡愉用品,
徵信,
徵信公司,
徵信,
外遇,
徵信,
徵信,
抓姦,
徵信,
外遇,
徵信,
徵信社,
徵信社,
抓姦,
徵信社,
徵信社,
徵信社,
,
,
整型,
視訊聊天,
視訊交友,
AV女優,
色情,
A片,
A片,
情趣用品,
情色,
A片,
色情影片,
情趣用品,
A片,
AV女優,
視訊聊天室,
聊天,
情趣用品,
情惑用品性易購,
情侶歡愉用品,
A片,
情趣,
情惑用品性易購,
辣妹視訊,
自慰套,
情侶歡愉用品,
寄情築園小遊戲,
aio交友愛情館,
美女視訊,
色情A片,
情趣用品,
徵信社,
情趣用品,
A片,
美女視訊,
色情A片,
AV女優,
A片,
辣妹視訊,
自慰套,
情侶歡愉用品,

11:33 PM, March 14, 2009  
Blogger mmbox said...

本土成人貼圖站大台灣情色網台灣男人幫論壇A圖網嘟嘟成人電影網火辣春夢貼圖網情色貼圖俱樂部台灣成人電影絲襪美腿樂園18美女貼圖區柔情聊天網707網愛聊天室聯盟台北69色情貼圖區38女孩情色網台灣映像館波波成人情色網站美女成人貼圖區無碼貼圖力量色妹妹性愛貼圖區日本女優貼圖網日本美少女貼圖區亞洲風暴情色貼圖網哈啦聊天室美少女自拍貼圖辣妹成人情色網台北女孩情色網辣手貼圖情色網AV無碼女優影片男女情色寫真貼圖a片天使俱樂部萍水相逢遊戲區平水相逢遊戲區免費視訊交友90739免費視訊聊天辣妹視訊 - 影音聊天網080視訊聊天室日本美女肛交美女工廠貼圖區百分百貼圖區亞洲成人電影情色網台灣本土自拍貼圖網麻辣貼圖情色網好色客成人圖片貼圖區711成人AV貼圖區台灣美女貼圖區筱萱成人論壇咪咪情色貼圖區momokoko同學會視訊kk272視訊情色文學小站成人情色貼圖區嘟嘟成人網嘟嘟情人色網 - 貼圖區免費色情a片下載台灣情色論壇成人影片分享免費視訊聊天區微風 成人 論壇kiss文學區taiwankiss文學區

6:34 AM, March 22, 2009  
Blogger mmbox said...

2008真情寫真aa片免費看捷克論壇微風論壇大眾論壇plus論壇080視訊聊天室情色視訊交友90739美女交友-成人聊天室色情小說做愛成人圖片區豆豆色情聊天室080豆豆聊天室 小辣妹影音交友網台中情人聊天室桃園星願聊天室高雄網友聊天室新中台灣聊天室中部網友聊天室嘉義之光聊天室基隆海岸聊天室中壢網友聊天室南台灣聊天室南部聊坊聊天室台南不夜城聊天室南部網友聊天室屏東網友聊天室台南網友聊天室屏東聊坊聊天室雲林網友聊天室大學生BBS聊天室網路學院聊天室屏東夜語聊天室孤男寡女聊天室一網情深聊天室心靈饗宴聊天室流星花園聊天室食色男女色情聊天室真愛宣言交友聊天室情人皇朝聊天室上班族成人聊天室上班族f1影音視訊聊天室哈雷視訊聊天室080影音視訊聊天室38不夜城聊天室援交聊天室080080哈啦聊天室台北已婚聊天室已婚廣場聊天室 夢幻家族聊天室摸摸扣扣同學會聊天室520情色聊天室QQ成人交友聊天室免費視訊網愛聊天室愛情公寓免費聊天室拉子性愛聊天室柔情網友聊天室哈啦影音交友網哈啦影音視訊聊天室櫻井莉亞三點全露寫真集123上班族聊天室尋夢園上班族聊天室成人聊天室上班族080上班族聊天室6k聊天室粉紅豆豆聊天室080豆豆聊天網新豆豆聊天室080聊天室免費音樂試聽流行音樂試聽免費aa片試看免費a長片線上看色情貼影片免費a長片

6:34 AM, March 22, 2009  
Blogger 平平 said...

^^ nice blog!! ^@^

徵信, 徵信網, 徵信社, 徵信社, 感情挽回, 婚姻挽回, 挽回婚姻, 挽回感情, 徵信, 徵信社, 徵信, 徵信, 捉姦, 徵信公司, 通姦, 通姦罪, 抓姦, 抓猴, 捉猴, 捉姦, 監聽, 調查跟蹤, 反跟蹤, 外遇問題, 徵信, 捉姦, 女人徵信, 女子徵信, 外遇問題, 女子徵信, 外遇, 徵信公司, 徵信網, 外遇蒐證, 抓姦, 抓猴, 捉猴, 調查跟蹤, 反跟蹤, 感情挽回, 挽回感情, 婚姻挽回, 挽回婚姻, 外遇沖開, 抓姦, 女子徵信, 外遇蒐證, 外遇, 通姦, 通姦罪, 贍養費, 徵信, 徵信社, 抓姦, 徵信, 徵信公司, 徵信社, 徵信公司, 徵信社, 徵信公司, 女人徵信,

徵信, 徵信網, 徵信社, 徵信網, 外遇, 徵信, 徵信社, 抓姦, 徵信, 女人徵信, 徵信社, 女人徵信社, 外遇, 抓姦, 徵信公司, 徵信社, 徵信社, 徵信社, 徵信社, 徵信社, 女人徵信社, 徵信社, 徵信, 徵信社, 徵信, 女子徵信社, 女子徵信社, 女子徵信社, 女子徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信社,

徵信, 徵信社,徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 外遇, 抓姦, 離婚, 外遇,離婚,

徵信社,徵信, 徵信社, 徵信, 徵信社, 徵信,徵信社, 徵信社, 徵信, 外遇, 抓姦, 徵信, 徵信社, 徵信, 徵信社, 徵信, 徵信社, 徵信社, 徵信社, 徵信社,徵信,徵信, 徵信, 外遇, 抓姦

1:22 AM, March 30, 2009  
Blogger nini said...

85cc免費影城 愛情公寓正妹牆川藏第一美女 成人影片 情色交友網 美女視訊 美女視訊 視訊情人高雄網 JP成人影城 383成人影城 aa片免費a片下載 a片線上看aa片免費看 ※a片線上試看※sex520免費影片※ aa片免費看 BT成人論壇 金瓶影片交流區 自拍美女聊天室 aa片免費a片下載 SEX520免費影片 免費a片 日本美女寫真集 sex520aa免費影片 sex520aa免費影片 BT成人網 Hotsee免費視訊交友 百分百貼影片區 SEX520免費影片 免費視訊聊天室 情人視訊高雄網 星光情色討論版 正妹牆 383成人影城 線上85cc免費影城 85cc免費影城 85cc免費影城 85cc免費影城 ※免費視訊聊天室※ ※免費視訊聊天室※ 免費視訊聊天室 85cc免費影片 85cc免費影片 080苗栗人聊天室 080苗栗人聊天室 080中部人聊天室 080中部人聊天室 免費a片下載 免費a片 AA片免費看 aa片免費看 aa片免費看 aa片免費看 aa片免費看 日本av女優影片 av女優 av女優無碼影城 av女優 av女優 百分百成人圖片 百分百成人圖片 視訊情人高雄網 電話交友 影音電話交友 絕色影城 絕色影城 夜未眠成人影城 夜未眠成人影城 色咪咪影片網 色咪咪影片網 色咪咪影片網 色咪咪影片網 色咪咪影片網 免費色咪咪貼影片 免費色咪咪貼影片 色情遊戲 色情遊戲 色情遊戲 色情遊戲 影音視訊交友網 視訊交友網 080視訊聊天室 ※免費視訊聊天室※ ※免費視訊聊天室※ 視訊聊天室 成人影音視訊聊天室 ut影音視訊聊天室 ※免費視訊聊天室※ 視訊ukiss聊天室視訊ukiss聊天室 視訊交友90739 視訊交友90739 情人視訊網 168視訊美女 168視訊美女 168視訊美女 視訊美女館 視訊美女館 免費視訊美女網 小高聊天室 小高聊天室 aio交友聊天室 aio交友聊天室 交友聊天室 交友聊天室 線上a片 線上a片 線上a片 線上a片 線上a片 免費線上a片 免費線上a片 嘟嘟成人網站 成人漫畫 情色文學 嘟嘟成人網 成人貼圖區 情色文學成人小說 微風成人區 情色貼圖區 免費視訊聊天 免費成人圖片區 愛情公寓 愛情公寓聊天室 寄情築園小遊戲 免費aa片線上看 aa片免費看 情色SXE聊天室 SEX情色遊戲 色情A片 免費下載 av女優 俱樂部 情色論壇 辣妹視訊 情色貼圖網 免費色情 聊天室 情人視訊聊天室 免費a片成人影城 免費a片-aa片免費看 0204貼圖區 SEX情色 交友聊天-線上免費 女優天堂 成人交友網 成人情色貼圖區 18禁 -女優王國 080視訊美女聊天室 080視訊聊天室 視訊交友90739 免費a片 aio 視訊交友網 成人影城-免費a片※免費視訊聊天※85cc免費影片日本線上免費a片 免費色咪咪影片免費色咪咪影片aaa片免費看影片aaa片免費看成人影城免費色咪咪影片

1:05 PM, April 05, 2009  
Blogger 123456 said...

广州托盘复合托盘食品托盘天津木托盘胶合板托盘蜂窝纸托盘塑木托盘熏蒸木托盘木制托盘广东塑料托盘钢托盘钢制托盘栈板塑料栈板木栈板垫仓板托盘包装求购托盘天津托盘温州托盘山东托盘北京托盘上海木托盘塑胶托盘卡板纸卡板塑料卡板手推车推车机场手推车好孩子手推车液压手推车超市手推车医用手推车康贝手推车不锈钢手推车平板车电动平板车老虎车静音手推车平板手推车小推车模具架置物架堆垛架巧固架整理架物料整理架挂板架整理柜零件柜零件整理柜文件整理柜仓储笼仓库笼料箱塑料箱钢制料箱货箱整理箱塑料整理箱周转箱塑料周转箱防静电周转箱求购周转箱物流箱物料盒零件盒塑料零件盒卡板箱周转筐塑料周转筐周转箩登高车物流台车台车密集架档案密集架文件柜办公文件柜北京文件柜广州文件柜上海文件柜南京文件柜深圳文件柜钢制文件柜铁皮文件柜档案柜文件柜厂底图柜档案柜鞋柜储物柜更衣柜防火防磁柜防磁柜防火防磁文件柜图书架资料柜工具柜

2:02 AM, April 13, 2009  
Blogger KO said...

牙醫,植牙,假牙|矯正|牙周病,牙醫診所植牙,紋身,刺青,創業,批發,TATTOO,皮膚科,痘痘,雷射脈衝光除斑,中醫,腫瘤,腎臟病,僵直性脊椎炎,飛梭雷射,肉毒桿菌,玻尿酸,痘痘,脈衝光,醫美,毛孔粗大,醫學美容,seo,關鍵字行銷,關鍵字自然排序,網路行銷,關鍵字自然排序,關鍵字行銷seo,關鍵字廣告,網路行銷,seo,關鍵字行銷,關鍵字廣告,關鍵字,自然排序,部落格行銷,網路行銷,網路爆紅,牛舌餅婚紗台中婚紗腫瘤腎臟病

2:57 AM, April 13, 2009  
Blogger 天天看正妹 said...

免費視訊聊天 ut聊天室辣妹視訊UT影音視訊聊天室 吉澤明步QQ美女視訊秀 85cc免費影片aa影片下載城sex免費成人影片aaa片免費看短片美女視訊 sex383線上娛樂場av969 免費短片日本免費視訊aa影片下載城視訊網愛聊天室影音視訊交友 咆哮小老鼠分享論壇sex520免費影片aa免費影片下載城aio辣妺視訊 aio辣妹交友愛情館 jp成人影片aio交友愛情館馬子免費影片免費線上a片18成人85cc影城0204movie免費色咪咪視訊網pc交友s383視訊玩美女人34c高雄視訊聊天jp成人免費視訊辣妹 kk777視訊俱樂部xxxpandalive173影音視訊聊天室 sex520-卡通影片成人免費視訊 完美女人13060 免費視訊聊天sexy girl video movie辣妹妹影音視訊聊天室UT視訊美女交友視訊情色網百事無碼a片dvd線上aa片免費看18禁成人網ut聊天室kk俱樂部視訊激情網愛聊天 情人小魔女自拍卡通aa片免費看夜未眠成人影城aio性愛dvd辣妹影片直播拓網視訊交友視訊聊天室ggoo168論壇視訊辣妹love104影音live秀 美女show-live視訊情色yam交友辣妹妹影音視訊聊天室s383情色大網咖視訊aaa俱樂部台灣情色網無碼avdvdsexy diamond sex888入口Show-live視訊聊天室

3:37 AM, April 14, 2009  
Blogger 天天看正妹 said...

免費 a 片aaaaa片俱樂部影片aaaaa片俱樂部dodo豆豆聊天室sex520網路自拍美女聊天室天堂免費線上avdvd援交av080影片aa影片下載城aaa片免費看短片成人圖片區18成人avooogo2av免費影片sexdiy影城免費線上成人影片bonbonsex0951影片下載日本av女優sex888免費看影片免費視訊78論壇辣妹有約辣妹no31314視訊dudu sex免費影片avdvd情色影片免費色咪咪影片網av080免費試看日本美女寫真集辣妹脫衣麻將視訊聊天室性福免費影片分享日本美女寫真集,kk視訊aio交友愛情館免費成人美女視訊bt論壇色情自拍免費a片卡通tw 18 net卡通18美少女圖色情漫畫777美女小護士免費 aa 片試看百分百成人情色圖片a片免費觀賞sexy girls get fuckedsexy girl video movie情色文學成人小說sex888免費看eyny 伊莉論壇sexdiy影城自拍情色0204movie免費影片aio免費aa片試看s383情色大網咖sexy girl video movie草莓牛奶AV論壇台灣論壇18禁遊戲區環球辣妹聊天室 90691拓網aio交友愛情館拓網學生族視訊777美女 sex888影片分享區hi5 tv免費影片aa的滿18歲卡通影片sex383線上娛樂場sexdiy影城免費a片線上觀看真人美女辣妹鋼管脫衣秀比基尼辣妹一夜情視訊aio交友愛情館

3:37 AM, April 14, 2009  
Blogger 天天看正妹 said...

小魔女免費影城免費看 aa的滿18歲影片sex383線上娛樂場kk777視訊俱樂部aa的滿18歲影片85cc免費影片a片免費看A片-sex520視訊聊天室v6 0plus論壇sex520免費影片avdvd-情色網qq美美色網ut13077視訊聊天A片-無碼援交東京熱一本道aaa免費看影片免費視訊聊天室微風成人免費視訊聊天 ut聊天室av1688影音視訊天堂免費 a 片85cc免費影城亞洲禁果影城微風成人av論壇sex520免費影片JP成人網免費成人視訊aaa影片下載城免費a片 ut交友成人視訊85cc成人影城免費A片aa的滿18歲影片小魔女免費影片85cc免費影片aaa片免費看短片aa影片下載城aaaaa片俱樂部影片aaaaa片俱樂部aa的滿18歲影片小魔女免費影片台灣論壇免費影片後宮0204movie免費影片免費卡通影片線上觀看線上免費a片觀看85cc免費影片免費A片aa影片下載城ut聊天室辣妹視訊UT影音視訊聊天室 日本免費視訊aaaa 片俱樂部aaaa片免費看影片免費視訊78論壇情色偷拍免費A片免費aaaaa片俱樂部影片aa影片下載城色漫畫帝國av俱樂部aaaa彩虹頻道免費影片 杜蕾斯成人免費卡通影片線上觀看85cc免費影片線上觀賞免費線上歐美A片觀看免費a片卡通aaa的滿18歲卡通影片sex520免費影片免費 a 片

3:37 AM, April 14, 2009  
Blogger 徵信 said...

外遇外遇外遇外遇外遇外遇外遇外遇外遇 外遇
外遇 外遇外遇 外遇 外遇
外遇 外遇 外遇
外遇


外遇 外遇
外遇
外遇 外遇外遇
外遇

外遇 外遇外遇 外遇 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 ,
外遇 外遇 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇外遇 外遇外遇 外遇 外遇

外遇 外遇

外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇 , 外遇劈腿劈腿劈腿劈腿劈腿劈腿劈腿劈腿喜帖囍帖卡片外遇外遇 外遇 外遇外遇 外遇
外遇 外遇 外遇 外遇剖析 外遇調查 外遇案例 外遇諮詢 偷情 第三者外遇話題 外遇發洩 感情挽回 徵信社 外遇心態 外遇 通姦 通姦罪 外遇徵信社徵信社外遇 外遇 抓姦徵信協會徵信公司 包二奶 徵信社 徵信 徵信社 徵信社 徵信社 徵信社 徵信 徵信 婚姻 婚前徵信 前科 個人資料 外遇 第三者 徵信社 偵探社 抓姦 偵探社 偵探社婚 偵探社 偵探社偵探家事服務家事服務家電維修家事服務家事服務家事服務家事服務家事服務持久持久持久持久持久持久持久離婚網頁設計徵信社徵信社徵信徵信社外遇離婚協議書劈腿持久持久持久持久持久劈腿剖析徵信徵信社外遇外遇外遇外遇徵信社徵信社徵信社徵信社徵信社徵信社徵信徵信社徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信徵信社徵信社徵信社徵信社徵信社徵信社徵信社徵信社徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信公會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信公會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信公會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 徵信協會 劈腿 劈腿 劈腿 劈腿 劈腿 劈腿 劈腿 劈腿 劈腿 劈腿 劈腿 劈腿 劈腿 劈腿

11:38 PM, April 19, 2009  
Blogger 1314 said...

視訊做愛視訊美女無碼A片情色影劇kyo成人動漫tt1069同志交友網ut同志交友網微風成人論壇6k聊天室日本 avdvd 介紹免費觀賞UT視訊美女交友..........................

10:13 PM, May 19, 2009  
Blogger 1122 said...

影片土豆網影片終極三國影片小魔女免費影片UT視訊美女交友a片免費下載守護甜心影片楓之谷影片sex999免費影片youtube影片下載色情影片一葉晴貼影片區性感影片aaa片免費看影片5278影片網免費成人影片sex影片視訊分享區自拍密錄館sex888咆哮小老鼠影片分享區小弟弟貼影片成人遊戲影片分享一葉情貼圖片區0204movie免費影片飯島愛免費影片笑話影片小弟弟貼影片區成人dvd-av博物館85cc免費影片觀看情人輔助品

9:53 PM, June 07, 2009  

Post a Comment

<< Home