気分障害と関する事項について
気分障害
気分の問題によって日常生活に支障をきたす疾患の総称である。
うつ状態のみが続くものを「うつ病」として、躁状態とうつ状態が繰り返すものを「双極性障害=躁うつ病」とする。
106D19:気分障害でみられる思考障害はどれか．2つ選べ．
出典:第106回医師国家試験問題
- 観念奔逸
- 思考伝播
- 思考制止
- 滅裂思考
- 連合弛緩
解答:1,3
解説:1.←躁状態でみられる。
2.←統合失調症でみられる。
3.←うつ状態でみられる。
4,5←統合失調症では、思路障害によって思考の流れが突然遮断される「思考途絶」→関連のない様々なことが思い浮かんでは遮断される「連合弛緩」→思考のまとまりがない「滅裂思考」→言葉が無意味に混ざる「言葉のサラダ」となる。
「思考制止はうつ病でみられ、思考途絶は統合失調症でみられる」ことと「観念奔逸が躁状態でみられて、連合弛緩が統合失調症でみられる」ことはごちゃごちゃになりやすいのでしっかりと注意して覚える必要がある。
双極性障害(躁うつ病)
ハイテンションで活動的な躁状態(爽快気分)と憂うつで無気力なうつ状態(抑うつ気分)を繰り返す。
躁状態では「まとまりのない様々な考えがとめどなく湧いてくる思考形式」である観念逸脱により、次々と頭の中に浮かぶまとまりのない考えを喋る多弁(談話心迫)になったり次々と頭の中に浮かぶまとまりのない考えを実行する(行為心迫)になる。
双極性障害は再発を繰り返す疾患であり5年間での再発率は80%にもなると言われている。
双極性障害には気分安定薬と呼ばれる炭酸リチウム・バルプロ酸ナトリウム・カルバマゼピンなどが有効である。気分安定薬は躁病相・うつ病相の周期性出現を予防する効果を発揮するからである。また、双極性障害でのうつ状態には抗うつ薬を投与する。
双極性障害(躁うつ病)の病前性格で多いのは循環気質(社交的で人情味があり、親しみやすい好人物)である。
114C57:43歳の男性．自営業、すぐに機嫌を損ねて怒鳴るようになったため、妻と母親に説得されて来院した．3ヵ月前に父親が急逝してからしばらくの間、元気がなく、家族と話さなくなった．1ヵ月前から店で必要以上にたくさん仕入れをするようになり、従業員に対して大声で怒鳴りつけるようになった．商品陳列の場所を何度も変え、始終移動させているようになった．元来ほとんど飲酒をしなかったが、毎晩飲酒をするようになったという．多弁で、感情の動きが激しく表出され、話題が際限なく広がる．本人は受診について不満であり、精神的なストレスで悲観的な考えに陥っている家族の方に治療を受けさせたいと述べている．これまでに発達上の問題はなかった．血液検査、頭部MRI及び脳波検査に異常を認めない．
この患者にみられる症状はどれか．2つ選べ．
出典:第114回医師国家試験問題
- 感覚失語
- 観念奔逸
- 行為心迫
- 連合弛緩
- 小動物幻視
解答:2,3
解説:躁状態では「まとまりのない様々な考えがとめどなく湧いてくる思考形式」である観念逸脱により、次々と頭の中に浮かぶまとまりのない考えを喋る多弁(談話心迫)になったり次々と頭の中に浮かぶまとまりのない考えを実行する(行為心迫)になる。
うつ病
「うつ病エピソード」を呈する気分障害を症候群として捉えた総称である。
うつ病では「朝の症状が悪く、夕方から夜にかけて軽減する」日内変動がみられる。
うつ病の診断基準
Ⅰ.落ち込み/悲しい気分
Ⅱ.興味や楽しみの喪失
「趣味や好きだったことが少しも楽しめなくなった」と訴える。
Ⅲ.活力の低下/疲労感
上記のいずれかに該当する場合には下記に進む。
1.睡眠障害
寝つけない(入眠困難)・朝早く起きる(早朝覚醒)
2.食欲の障害
食欲不振または食欲増加
3.集中力低下
4.思考や動作の緩慢
「考えが浮かばなくなる」思考制止となる。これは統合失調症で認める「考えがぷっつりと切れる」思考途絶とは異なるので注意する。
5.性的関心の低下
6.自身喪失
7.死ぬことや自殺の考え
自殺念慮について具体的に尋ねるのは、うつ病の診断にあたっての重要な問診事項である。
8.自責感
自責感が強まると微小妄想を認めるようになる。
Ⅰ,Ⅱ,Ⅲおよび1~8の計11項目のうちで5つ以上あてはまって、症状が2週間以上続いた場合にうつ病と診断する。
うつ病でみられる妄想
躁状態で認める「自分の能力や価値を実際以上に高く過大評価してしまう」誇大妄想に対して、うつ病では「自分の能力や価値を実際よりも低く過小評価してしまう」微小妄想を認める。
罪業妄想
「仕事で取り返しがつかないことをしてしまった」・「うまくいかないのは全て自分のせいである」・「自分のせいで家族に迷惑をかけている」など、自分が罪を犯していると信じる妄想。
貧困妄想
「お金がなくてどうにもなりません」・「支払い額を気にして病院受診をためらう」など、実際よりも貧しいと信じる妄想。
心気妄想
重大な病気や不治の病に罹ったと信じる妄想。
うつ病の病態生理
何らかの遺伝的要因をもつ人に心因・身体因としてストレス負荷がかかると、脳内でモノアミン(主にセロトニンとノルアドレナリン)代謝の異常が生じてしまい、結果的にモノアミン(主にセロトニンとノルアドレナリン)が欠乏することによって引き起こされると考えられている。
うつ病の治療
うつ病の治療には三環系抗うつ薬、四環系抗うつ薬、選択的セロトニン再取り込み阻害薬(SSRI)、セロトニン・ノルアドレナリン再取り込み阻害薬(SNRI)でモノアミンの欠乏を補う薬物療法と電気けいれん療法がある。
三環系抗うつ薬(イミプラミンなど)
ノルアドレナリンとセロトニンの再取り込みを阻害することで、ノルアドレナリンとセロトニンの脳内活性を高めて抑うつ効果を発揮する。ただし、抗コリン作用も持ち副作用が強い。
抗コリン作用による副作用として口渇・便秘・排尿障害(尿閉)・視力調節障害・眼圧上昇・起立性低血圧などがある。
逆に排尿障害(尿閉)の副作用を利用して、夜尿症(遺尿症)に対して三環系抗うつ薬を用いることがある。
四環系抗うつ薬
三環系抗うつ薬よりも効用と副作用がマイルドである。
選択的セロトニン再取り込み阻害薬(SSRI)
三環系抗うつ薬よりも抗コリン作用が弱い。
病態にセロトニンが関わる強迫性障害・パニック障害・社交不安障害にも有効である。
電気けいれん療法
頭部に電極を装着して電気刺激を与えて、人為的に脳にけいれん発作時の電気活動を起こすことで効果を得る。未だに作用機序は明らかになっていない。
古くから、精神疾患持ちの患者がてんかんによるけいれん発作を起こした後に精神症状が改善することが知られており、これを治療に応用する形で開発された。
脳にけいれん発作時の電気活動を起こした場合に伴って起こる全身の筋の痙攣を防ぐために、麻酔科医が短時間麻酔剤と筋弛緩剤を投与した後に電気刺激が与えられる。このために麻酔科医の協力が必要となる。
適用疾患は自殺の危険が切迫しているなどの重症のうつ病や緊張病症候群である。
副作用として頻脈・血圧上昇・健忘・頭痛などが知られている。
うつ病の病前性格
かつて、うつ病はメランコリー親和型の性格を持つ患者が中年で発症するものであるという認識が一般的であった。
メランコリー親和型の性格とは几帳面・秩序愛(何よりも秩序を重んじる)・他者配慮性(自分のことよりも周囲の人を気遣って「他者との共生」を求める)・完全主義という傾向を併せ持つ性格である。
しかし、診断基準による操作的診断(原因論ではなく、臨床像の記述で各精神疾患を定義して、複数の特徴的な病像を認めることで診断を下す方法)がうつ病に用いられるようになってから、メランコリー親和型の性格を持たない若年発症のうつ病が多く報告されるようになった。
これらの新しいタイプのうつ病は正式な医学用語ではないが、マスメディアなどでは新型うつ病や現代型うつ病と呼ばれている。
季節性うつ病
主に冬場の日照時間不足で光が不足することによって、脳内でセロトニンの分泌が減り発症するために季節性があるという特徴を持つうつ病を指す。
症状としては無気力(意欲減退)・過食(体重増加)・過眠などを認める。
過食(体重増加)・過眠などの症状は一般的なうつ病と異なるので注意する。
治療は高照度光療法を行う。高照度光療法では人口光を使用して冬季の日照不足を補う。
マタニティ・ブルーズ(maternity blues)
産褥3～10日頃に発症する軽度の抑うつや涙もろさを主な症状とする一過性の現象であり、出産した女性の30～50％が経験するといわれている。
自然に軽快することが多く、患者には「産後に気分が一時的に沈むことはよく起こります」などと声をかけると良い。
ただし、一部は産後うつ病に移行する場合があり、症状が産後2週間を経過しても改善されない場合には産後うつ病を疑う。
115C19:マタニティ・ブルーズについて正しいのはどれか。
出典:第115回医師国家試験問題
- 母乳育児は禁止する。
- 直ちに精神科医師に連絡する。
- 涙もろくなるのが特徴である。
- 自然に軽快するのはまれである。
- 分娩1ヶ月後に発症のピークがある。
解答:3
解説:1.←母乳育児などで赤ちゃんとコミュニケーションをとることが産後うつ病に対して良い影響を与えると判明しているので、母乳育児は行うべきである。
2.←マタニティ・ブルーズはよく起こる現象であり、多くは自然に軽快するので直ちに精神科を受診する必要はない。ただし、産後2週間を過ぎても抑うつ気分が続くようで産後うつ病が疑われる場合には精神科受診を勧める。
3.←マタニティ・ブルーズは涙もろくなるのが特徴である。
4.←ほとんどが自然に軽快するが、一部は産後うつ病に移行するので注意する。
5.←産褥3～10日頃が発症のピークである。分娩2週間を過ぎても抑うつ気分が続くようであるなら産後うつ病を疑う。
産後うつ病
産後うつ病は出産した女性の約10％が発症するといわれており、うつ病は産褥期に発症頻度が高くなる疾患として重要である。
新生児への虐待予防等を図るために行政が主導して産後うつ病の対策をしている。
エジンバラ産後うつ病質問票(EPDS)で産後うつ病が疑われる場合には、主治医は「①本人の同意を得て市町村に患者情報を伝える②精神科への受診を提案する」必要がある。
主治医から報告を受けた行政は保健師による訪問の実施を行なったりすることで産後うつ病の患者をフォローする。
113F63:34歳の女性(1妊1産).産後2週の妊産婦健康診査を希望して、分娩した産科診療所に来院した.2週間前に第1子である3,150gの男児を経膣分娩した.来院時の体温36.5℃.脈拍80/分、整.血圧126/76mmHg.尿所見は蛋白（－）、糖（－）.内診で子宮復古に異常は認めず、悪露も正常であった.母乳哺育を行っているが、うまくできているかとても心配で毎日よく眠れない.育児は全く楽しくなく、ときに自分を傷つけたいとの思いが浮かぶという.日本語版エジンバラ産後うつ病質問票〈EPDS〉への自己記入の結果、合計点数は12点（基準8以下）であった.
この時点の対応として適切なのはどれか.2つ選べ.
出典:第113回医師国家試験問題
- 抗精神病薬を処方する。
- 精神科への受診を提案する。
- 児と分離することを目的に入院させる。
- 本人の同意を得て市町村に患者情報を伝える。
- 母乳哺育を中止し人工乳哺育にするように指導する。
解答:2,4
解説:エジンバラ産後うつ病質問票の結果から産後うつ病が疑われる。
1.←抗精神病薬は統合失調症に対して用いられる。産後うつ病の治療は一般的なうつ病と同じように抗うつ薬などで行われる。
2.←マタニティ・ブルーズではなく産後うつ病が疑われる場合には精神科受診が必要となる。
3.5.←母乳哺育をしたり赤ちゃんとコミュニケーションをとることは産後うつ病に良い影響を与えることが分かっている。そのため、児と分離させたり母乳哺育を中止してはいけない。
4.←産後うつ病の患者は新生児虐待をしてしまう恐れなどがあるので、行政のフォローが必要となる。主治医から産後うつ病患者の報告を受けた行政は保健師による訪問の実施を行ったりすることで産後うつ病患者をフォローする。
離人症
自我意識の障害により、「自分自身や物事についての実感が湧かない」という患者の訴えに対して用いる症状名である。うつ病や統合失調症に付随して現れたり、疲労時には健康な人も訴えることがある。
「何をやっても実感が湧かず、自分の身体さえ自分のものであるという感覚がない」・「外界と自分との間にベールがあり、周囲のものに実感が湧かない」・「何を食べても同じような感じで、砂をかんでいるようです」などと患者は訴える。
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{Tôi đã rất hài lòng để tìm thấy trang web này. Tôi muốn cảm ơn bạn {vì đã|dành thời gian cho|chỉ vì điều này|vì điều này|cho bài đọc tuyệt vời này!! Tôi chắc chắn đánh giá cao từng một chút nó và tôi cũng đã lưu làm mục ưa thích để xem những thứ mới trên blog của bạn.|Tôi có thể chỉ nói rằng thật nhẹ nhõm để khám phá một người thực sự hiểu họ là gì đang nói về trên mạng. Bạn chắc chắn nhận ra cách đưa một vấn đề ra ánh sáng và làm cho nó trở nên quan trọng. Nhiều người hơn nữa nên kiểm tra điều này và hiểu khía cạnh này câu chuyện của bạn. Thật ngạc nhiên bạn không nổi tiếng hơn cho rằng bạn chắc chắn có món quà.|Xuất sắc bài viết trên blog. Tôi chắc chắn yêu thích trang web này. Tiếp tục làm tốt!|Thật khó đến những người có hiểu biết sâu rộng trong chủ đề cụ thể này, nhưng bạn có vẻ bạn biết mình đang nói gì! Cảm ơn|Bạn nên tham gia một cuộc thi dành cho một blog trực tuyến có chất lượng cao nhất. Tôi sẽ khuyến nghị blog này!|Một hấp dẫn đáng giá bình luận. Tôi tin rằng bạn nên xuất bản thêm về chủ đề này, nó có thể không là một điều cấm kỵ chủ đề nhưng điển hình mọi người không nói về chủ đề như vậy. Đến phần tiếp theo! Cảm ơn rất nhiều!|Chào buổi sáng! Tôi chỉ muốn cho bạn một rất cho thông tin xuất sắc bạn có ngay tại đây trên bài đăng này. Tôi đang trở lại blog của bạn để biết thêm thông tin sớm nhất.|Khi tôi ban đầu để lại bình luận tôi có vẻ như đã nhấp vào hộp kiểm -Thông báo cho tôi khi có bình luận mới- và bây giờ bất cứ khi nào có bình luận được thêm vào tôi nhận được 4 email có cùng nội dung. Có một phương pháp dễ dàng bạn có thể xóa tôi khỏi dịch vụ đó không? Cảm ơn.|Lần sau nữa Tôi đọc một blog, Tôi hy vọng rằng nó không làm tôi thất vọng nhiều như bài này. Ý tôi là, Tôi biết điều đó là sự lựa chọn của tôi để đọc, dù sao thì tôi thực sự tin bạn sẽ có điều gì đó thú vị để nói về. Tất cả những gì tôi nghe được là một loạt phàn nàn về điều gì đó mà bạn có thể sửa nếu bạn không quá bận tìm kiếm sự chú ý.|Đúng với bài viết này, tôi thành thật tin trang web này cần nhiều hơn nữa sự chú ý.
{Tôi đã háo hức khám phá trang web tuyệt vời này. Tôi cần cảm ơn bạn {vì đã|dành thời gian cho|chỉ vì điều này|vì điều này|cho bài đọc tuyệt vời này!! Tôi chắc chắn thích thú từng một phần nó và tôi đã đã lưu vào mục ưa thích để xem điều mới trên trang web của bạn.|Tôi có thể chỉ nói rằng thật thoải mái để tìm thấy một người thực sự hiểu họ là gì đang nói về trên internet. Bạn chắc chắn biết cách đưa một rắc rối ra ánh sáng và làm cho nó trở nên quan trọng. Nhiều người hơn nữa thực sự cần đọc điều này và hiểu khía cạnh này câu chuyện của bạn. Tôi đã ngạc nhiên rằng bạn không nổi tiếng hơn vì bạn chắc chắn có món quà.|Rất hay bài viết. Tôi chắc chắn yêu thích trang web này. Cảm ơn!|Thật gần như không thể tìm thấy những người có kinh nghiệm cho điều này, nhưng bạn có vẻ bạn biết mình đang nói gì! Cảm ơn|Bạn nên tham gia một cuộc thi dành cho một trang web trên web tuyệt vời nhất. Tôi sẽ Rất khuyến nghị trang web này!|Một hấp dẫn đáng giá bình luận. Tôi tin rằng bạn nên xuất bản thêm về chủ đề này, nó có thể không là một điều cấm kỵ chủ đề nhưng nói chung mọi người không thảo luận vấn đề những điều này. Đến phần tiếp theo! Trân trọng.|Xin chào! Tôi chỉ muốn đề nghị rất to cho thông tin tuyệt vời bạn có ở đây trên bài đăng này. Tôi sẽ là trở lại trang web của bạn để biết thêm thông tin sớm nhất.|Khi tôi ban đầu bình luận tôi có vẻ như đã nhấp vào hộp kiểm -Thông báo cho tôi khi có bình luận mới- và từ bây giờ mỗi lần được thêm vào tôi nhận được 4 email có cùng nội dung. Có lẽ có một phương tiện bạn có thể xóa tôi khỏi dịch vụ đó không? Cảm ơn rất nhiều.|Lần sau Tôi đọc một blog, Tôi hy vọng rằng nó không làm tôi thất vọng nhiều như bài này. Ý tôi là, Vâng, đó là sự lựa chọn của tôi để đọc, dù sao thì tôi thực sự nghĩ bạn sẽ có điều gì đó hữu ích để nói về. Tất cả những gì tôi nghe được là một loạt tiếng rên rỉ về điều gì đó mà bạn có thể sửa nếu bạn không quá bận tìm kiếm sự chú ý.|Đúng với bài viết này, tôi nghiêm túc nghĩ trang web này cần nhiều hơn nữa sự chú ý.
{Tôi cực kỳ hài lòng khám phá trang này. Tôi muốn cảm ơn bạn {vì đã|dành thời gian cho|chỉ vì điều này|vì điều này|cho bài đọc tuyệt vời này!! Tôi chắc chắn thích từng của nó và tôi đã đánh dấu để xem điều mới trong trang web của bạn.|Tôi có thể chỉ nói rằng thật nhẹ nhõm để tìm thấy một cá nhân mà thực sự hiểu họ là gì thảo luận trên internet. Bạn chắc chắn hiểu cách đưa một vấn đề ra ánh sáng và làm cho nó trở nên quan trọng. Nhiều người hơn phải xem điều này và hiểu khía cạnh này của. Thật ngạc nhiên bạn không nổi tiếng hơn vì bạn chắc chắn có món quà.|Rất hay bài viết trên blog. Tôi hoàn toàn đánh giá cao trang web này. Cảm ơn!|Thật gần như không thể tìm thấy những người có học thức về điều này, tuy nhiên, bạn có vẻ bạn biết mình đang nói gì! Cảm ơn|Bạn nên tham gia một cuộc thi dành cho một trang web trên web có chất lượng cao nhất. Tôi chắc chắn sẽ khuyến nghị trang web này!|Một động lực đáng giá bình luận. Không còn nghi ngờ gì nữa rằng bạn cần viết thêm về chủ đề này, nó có thể không là một điều cấm kỵ vấn đề nhưng điển hình mọi người không thảo luận vấn đề những điều này. Đến phần tiếp theo! Trân trọng.|Chào bạn! Tôi chỉ muốn đề nghị rất cho thông tin tuyệt vời bạn có ngay tại đây trên bài đăng này. Tôi sẽ là quay lại trang web của bạn để biết thêm thông tin sớm nhất.|Khi tôi ban đầu để lại bình luận tôi có vẻ như đã nhấp hộp kiểm -Thông báo cho tôi khi có bình luận mới- và bây giờ bất cứ khi nào có bình luận được thêm vào tôi nhận được bốn email có cùng nội dung. Phải có một cách bạn có thể xóa tôi khỏi dịch vụ đó không? Cảm kích.|Lần sau nữa Tôi đọc một blog, Tôi hy vọng rằng nó không thất bại nhiều như bài này. Rốt cuộc, Tôi biết điều đó là sự lựa chọn của tôi để đọc hết, dù sao thì tôi thực sự tin có lẽ có điều gì đó hữu ích để nói về. Tất cả những gì tôi nghe được là một loạt tiếng rên rỉ về điều gì đó mà bạn có thể sửa nếu bạn không quá bận tìm kiếm sự chú ý.|Đúng với bài viết này, tôi thực sự nghĩ trang web này cần nhiều hơn nữa sự chú ý.
{Tôi khá hài lòng khám phá trang web này. Tôi muốn cảm ơn bạn {vì đã|dành thời gian cho|chỉ vì điều này|vì điều này|cho bài đọc tuyệt vời này!! Tôi chắc chắn yêu thích từng của nó và tôi cũng đã đã lưu vào mục ưa thích để xem điều mới trong blog của bạn.|Tôi có thể chỉ nói rằng thật nhẹ nhõm để khám phá một người thực sự biết họ là gì thảo luận trên web. Bạn thực sự hiểu cách đưa một rắc rối ra ánh sáng và làm cho nó trở nên quan trọng. Nhiều người hơn thực sự cần xem điều này và hiểu khía cạnh này của. Tôi đã ngạc nhiên bạn không nổi tiếng hơn vì bạn chắc chắn sở hữu món quà.|Xuất sắc bài đăng. Tôi chắc chắn đánh giá cao trang web này. Cảm ơn!|Thật gần như không thể tìm thấy những người có kinh nghiệm trong chủ đề cụ thể này, nhưng bạn có vẻ bạn biết mình đang nói gì! Cảm ơn|Bạn nên tham gia một cuộc thi dành cho một trang web trên mạng có chất lượng cao nhất. Tôi sẽ Rất khuyến nghị trang web này!|Một hấp dẫn chắc chắn đáng giá bình luận. Tôi tin rằng bạn nên viết thêm về chủ đề này, nó có thể không là một điều cấm kỵ chủ đề nhưng thường xuyên mọi người không nói về vấn đề những điều này. Đến phần tiếp theo! Trân trọng.|Xin chào! Tôi chỉ muốn cho bạn một rất cho thông tin xuất sắc bạn có ở đây trên bài đăng này. Tôi sẽ là quay lại blog của bạn để biết thêm thông tin sớm nhất.|Khi tôi ban đầu bình luận tôi có vẻ như đã nhấp vào hộp kiểm -Thông báo cho tôi khi có bình luận mới- và từ bây giờ mỗi lần được thêm vào tôi nhận được 4 email có cùng nội dung. Có lẽ có một cách bạn có thể xóa tôi khỏi dịch vụ đó không? Cảm kích.|Lần sau nữa Tôi đọc một blog, Hy vọng rằng nó không làm tôi thất vọng nhiều như bài này. Rốt cuộc, Vâng, đó là sự lựa chọn của tôi để đọc, nhưng tôi thực sự nghĩ bạn sẽ có điều gì đó hữu ích để nói. Tất cả những gì tôi nghe được là một loạt tiếng rên rỉ về điều gì đó mà bạn có thể sửa nếu bạn không quá bận tìm kiếm sự chú ý.|Đúng với bài viết này, tôi thực sự tin rằng trang web này cần nhiều hơn nữa sự chú ý.
{Tôi háo hức khám phá trang web tuyệt vời này. Tôi muốn cảm ơn bạn {vì đã|dành thời gian cho|chỉ vì điều này|vì điều này|cho bài đọc tuyệt vời này!! Tôi chắc chắn thực sự thích từng một phần nó và tôi đã đã lưu vào mục ưa thích để xem những thứ mới trên blog của bạn.|Tôi có thể chỉ nói rằng thật nhẹ nhõm để khám phá một người mà thực sự biết họ là gì thảo luận trên mạng. Bạn chắc chắn biết cách đưa một rắc rối ra ánh sáng và làm cho nó trở nên quan trọng. Nhiều người hơn nữa thực sự cần đọc điều này và hiểu khía cạnh này câu chuyện của bạn. Tôi đã ngạc nhiên rằng bạn không nổi tiếng hơn vì bạn chắc chắn có món quà.|Rất tốt bài viết. Tôi hoàn toàn đánh giá cao trang web này. Tiếp tục làm tốt!|Thật khó tìm những người có hiểu biết sâu rộng cho điều này, tuy nhiên, bạn nghe có vẻ bạn biết mình đang nói gì! Cảm ơn|Bạn nên tham gia một cuộc thi dành cho một trang web trên internet có chất lượng cao nhất. Tôi sẽ Rất khuyến nghị blog này!|Một hấp dẫn chắc chắn đáng giá bình luận. Tôi tin rằng bạn cần xuất bản thêm về vấn đề này, nó có thể không là một điều cấm kỵ chủ đề nhưng nói chung mọi người không nói về những chủ đề như vậy. Đến phần tiếp theo! Trân trọng!|Xin chào! Tôi chỉ muốn cho bạn một rất to cho thông tin xuất sắc bạn có ở đây trên bài đăng này. Tôi sẽ là trở lại trang web của bạn để biết thêm thông tin sớm nhất.|Khi tôi ban đầu bình luận tôi có vẻ như đã nhấp vào hộp kiểm -Thông báo cho tôi khi có bình luận mới- và từ bây giờ mỗi lần được thêm vào tôi nhận được bốn email có cùng nội dung. Phải có một phương pháp dễ dàng bạn có thể xóa tôi khỏi dịch vụ đó không? Cảm ơn rất nhiều.|Lần sau nữa Tôi đọc một blog, Tôi hy vọng rằng nó không làm tôi thất vọng nhiều như bài này. Ý tôi là, Vâng, đó là sự lựa chọn của tôi để đọc, dù sao thì tôi thực sự nghĩ bạn sẽ có điều gì đó thú vị để nói. Tất cả những gì tôi nghe được là một loạt rên rỉ về điều gì đó mà bạn có thể sửa nếu bạn không quá bận tìm kiếm sự chú ý.|Đúng với bài viết này, tôi thực sự tin trang web này cần nhiều hơn nữa sự chú ý.
{Tôi cực kỳ hài lòng khám phá trang web tuyệt vời này. Tôi muốn cảm ơn bạn {vì đã|dành thời gian cho|chỉ vì điều này|vì điều này|cho bài đọc tuyệt vời này!! Tôi chắc chắn thích từng của nó và tôi cũng đã lưu làm mục ưa thích để xem thông tin mới trên trang web của bạn.|Tôi có thể chỉ nói rằng thật nhẹ nhõm để khám phá một người mà thực sự biết họ là gì thảo luận trên web. Bạn chắc chắn biết cách đưa một vấn đề ra ánh sáng và làm cho nó trở nên quan trọng. Nhiều người hơn nữa nên xem điều này và hiểu khía cạnh này của. Tôi đã ngạc nhiên bạn không nổi tiếng hơn vì bạn chắc chắn có món quà.|Rất hay bài viết. Tôi chắc chắn yêu thích trang web này. Cảm ơn!|Thật gần như không thể tìm thấy những người có hiểu biết sâu rộng về điều này, nhưng bạn nghe có vẻ bạn biết mình đang nói gì! Cảm ơn|Bạn nên là một phần của một cuộc thi dành cho một trang web trực tuyến tuyệt vời nhất. Tôi sẽ khuyến nghị trang web này!|Một động lực đáng giá bình luận. Tôi nghĩ rằng bạn nên viết thêm về chủ đề này, nó có thể không là một điều cấm kỵ vấn đề nhưng điển hình mọi người không nói về vấn đề những điều này. Đến phần tiếp theo! Chúc mọi điều tốt đẹp nhất!|Xin chào! Tôi chỉ muốn đề nghị rất to cho thông tin tuyệt vời bạn có ngay tại đây trên bài đăng này. Tôi đang quay lại trang web của bạn để biết thêm thông tin sớm nhất.|Khi tôi ban đầu để lại bình luận tôi có vẻ như đã nhấp vào hộp kiểm -Thông báo cho tôi khi có bình luận mới- và bây giờ mỗi lần được thêm vào tôi nhận được bốn email có cùng nội dung. Phải có một cách bạn có thể xóa tôi khỏi dịch vụ đó không? Kudos.|Lần sau Tôi đọc một blog, Tôi hy vọng rằng nó không thất bại nhiều như bài này. Ý tôi là, Tôi biết điều đó là sự lựa chọn của tôi để đọc, nhưng tôi thực sự nghĩ có lẽ có điều gì đó hữu ích để nói. Tất cả những gì tôi nghe được là một loạt rên rỉ về điều gì đó mà bạn có thể sửa nếu bạn không quá bận tìm kiếm sự chú ý.|Đúng với bài viết này, tôi hoàn toàn tin rằng trang web này cần nhiều hơn nữa sự chú ý.
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