Chronic Stress and Biopsychosocial Intervention Strategies


In order to provide comprehensive treatment, emotional wellness must be addressed from a biopsychosocial perspective. By considering both the biological, emotional and social factors that are supportive of such things as chronic stress we may lessen or even eliminate the factors that contribute to this debilitating disease state.

The adrenal glands, which sit atop each kidney, secrete hormones which help regulate metabolism, aid in maintaining the body’s chemical stability and produce health-sustaining hormones such as estrogen, progesterone, steroids, cortisol and cortisone. The adrenal glands also produce epinephrine (adrenalin), nor-epinephrine and dopamine. Over-production of these hormones, when prompted by such things as chronic stress, can result in the break down of the body’s immune system and it’s ability to fight disease.  Chronic stress for example influences energy levels, nutrition, vitamin and mineral absorption and can damage major organs such as the heart, kidneys and liver.

The adrenals work in conjunction with the kidneys to optimize the stress response. As you can imagine, because of their close proximity, chronic stress places added demand on both the kidneys and the adrenal glands. When the body is experiencing stress, the adrenals are stimulated to produce the chemicals necessary to sustain the fight-flight-or-freeze response – epinephrine, nor-epinephrine and dopamine. The kidneys will respond to the added hormonal demand by encouraging urination. Of course, bladder function is not hormone dependent; but the fight-or-flight response is, resulting in increased blood pressure and heart rate, drawing blood away from the bladder, resulting in urination. From a practical point of view, fighting or running with an empty bladder has its survival advantages.

When the stress response is chronic, habituated, fluids pass out of one’s system so quickly that nutrient absorption and other necessary functions of the kidneys are impeded. A person may eat appropriate foods, but fail to extract the nutrient value of the foods due to frequent urination. Besides losing a rich source of nutrition, chronic stress can be exacerbated by chronic joint pain, muscle deterioration and malnutrition – all a result of prematurely expelling nutrients that support such functions.

The kidneys maintain the body’s chemical balance of potassium, acids and proteins. They remove waste, but also determine which substances the body will maintain for balance. Potassium is one the substances the body needs for normal heart and muscle function. If the kidneys are not working properly, potassium may build up in the blood and effect muscle function. A person may feel pains, aches and other weakness of the musculoskeletal structure as a result of depleted potassium levels. Too much potassium, on the other hand, can affect the function of the heart. The kidneys also help the body maintain a healthy balance of acid. If too much acid builds up in the body, the kidneys respond by adding a buffer to normalize the balance. If the kidneys are not working normally, the acid balance cannot be controlled, which can result in disease.

As a society, we would customarily focus our treatment of chronic stress on the pathophysiological properties of the illness. I, however, emphasize a more comprehensive approach, concentrating more on the contributions made to illness by such things as ones psychological frame of reference, problem-solving skills and the social structure from which the individual’s current coping skills are derived.

The biopsychosocial model prescribes a systematic approach to understanding and treating the biological, psychological and social factors inherent in any human disease state. While the biomedical approach takes the reductionistic view that all phenomena of human illness are best understood at the lowest level of natural systems (e.g., cellular or molecular), the biopsychosocial approach recognizes that clinical issues may be better understood from a variety perspectives. For example, if we were to treat the patient who shows symptoms of chronic stress with medications, alone, we would be minimizing or eliminating the contributions made to that disease through psychological and social factors. If the patient is experiencing stress, s/he is instigating this process by thinking in a way that is self-destructive. We cannot treat the physical (biological) condition effectively if we don’t discover the psychological corollary of the disease and intervene at that level. We cannot, from this same frame of reference, prescribe an effective biological-psychological intervention plan if we don’t consider the individual’s home and community life in the logic of that treatment plan.

Stress can kill, so treating it requires a working knowledge of human anatomy. Intervening on only one premise of human functioning may result in causing additional harm to the patient. Interfering with the stress response from a biopsychosocial perspective will not only bring emotional wellness but is likely to also translate into better physical health.

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27 responses

  1. Thank you Dr. Cornwall! :) I am in awe of your understanding.

    So much of it makes perfect sense. I will re-read this several times for the full logist of it before I comment. I will say, it’s a shame I am not in Kentucky! I would be making an appointment with your office immediately.

    Thank you for this article. I am soaking it up and I will get back to you soon. You are so accurate in your knowledge, and I pray for other Doctors to follow suit in their knowledge, for looking beneath the mask of the problem.

    I will sleep on this tonight and reply back after I look a few words up. You have a very impressive vocabulary. God Bless!

    • you are very kind . . . i want to do a follow up on this concerning the damage cortisol can have on the body . . . thanks for inspiring this article . . . if you didnt talk to me about it i wouldnt have written it . . . thanks for the award . . . i posted it on my blog . . . you might want to look in at my books . . . especially Go Suck A Lemon and Think Twice . . . they are available on Amazon . . . if you would prefer i can send you a pdf version for free . . . cheers!

  2. Pingback: Biopsychosocial Intervention Strategies Using Emotional Intelligence Theory | eitheory.com

  3. So…are you suggesting that a biopsychosocial approach is appropriate for Chronic Fatigue Syndrome patients as defined by the Canadian Consensus Criteria? Or is it Fukuda you’re working with here?

    Oxford and/or Empirical seems more like it, frankly.

    I would be very curious to see research that points to this sort of approach as being effective with patients defined either by the Canadian Consensus Criteria, or the recently-published International Consensus Criteria for Myalgic Encephalomyelitis. Both of these list symptom profiles that I find hard to believe are treated appropriately with a biopsychosocial approach. The combination of neurological and immunological abnormalities is not found in Fukuda or any of those other criteria.

    I assume you are aware of Myalgic Encephalomyelitis?

    • Hello! Thank you for commenting. My blog is for the casual reader. I do my very best to make complex topics more pedestrian – especially for those who would rather not wade through scientific journals to find useful information. (Surely you know this blog isn’t intended to train people to be neuropsychologists.) This blog doesn’t depend on quoting scientific research to make claims about biopschosocial intervention strategies. I, however, am an expert in the area of biopsychosocial phenomena and my readers welcome that fact as sufficient to understand the topics I discuss.

      Finally, I have no clue what Canadian Consensus Criteria is – and I would suggest that my reader isn’t interested either. Neither is my reader interested in the combination of neurological and immunological abnormalities not found in Fukuda “or any of those other criteria.” If my reader were interested in these topics, they certainly would not be relying on my simple blog to learn about them. You can assume that I am aware of myalgic encephalomyelitis, but do not discuss the condition on my blog because my readers are not traditionally interested in neuroimmune diseases.

      I hope you will return to my blog and consider the audience I am addressing. If you would like to contribute a column, I would be happy to read it and consider posting it. It should, however, be easily consumable for my average reader, not designed to grandstand your knowledge, show off how bright you are or intentionally make the topic more confusing to emphasize these self-indulgent writing techniques. Cheers!

      • Dr Cornwall, I appreciate your concern to make complex subjects accessible for your readers, but the point Three Chord Monty is making here, is a VERY important one. It does matter a lot which definition of ‘Chronic Fatigue Syndrome’ you are using, particularly when talking about BPS interventions.
        If you don’t define “CFS” here, your readers might get the wrong impression that it means the same as “chronic fatigue”, which is far beside the truth. Chronic fatigue is a symptom of many illnesses, but CFS is a major illness. Etiology and pathophysiology are unknown as yet, but research is advancing fast, and recent findings leave little room for viewing CFS as a behavioural or stress disorder. This might explain why BPS interventions, that have shown some effectiveness in a general ‘chronically fatigued’ population, do not necessarily work in well-defined CFS.

  4. So ‘grandstanding’ is negative, but contributing to the perpetuation of a serious neuroimmune disease by suggesting biopsychosocial treatment is not. Okay.

    I have nothing against the idea of biopsychosocial treatments and techniques. What I have a problem with is the idea that this should be suggested, with no context whatsoever. Most people who write about this do not know why this is a problem, or why anyone would object to it. And that’s not okay, sorry. I don’t think it’s too much to ask that if someone is going to write about a topic, that they at least know something about it.

    Chronic Fatigue Syndrome is a bad name for a serious disease, and you probably know that. What you should know, especially if you’re going to write about it, is that the criteria employed by the Centers for Disease Control and Prevention (known as ‘Fukuda’ for its lead author, who now works for the World Health Organization on influenza) are rather vague; which means that people who share some symptoms, relatively minor ones, can be misdiagnosed. As a result, there have been two alternate criteria published in recent years that correctly describe the disease Myalgic Encephalomyelitis.

    This is not the stress-related condition that Chronic Fatigue Syndrome has been characterized as.

    For the vast majority of the people diagnosed with Chronic Fatigue Syndrome, the standard treatments are Cognitive Behavioral Therapy and Graded Exercise therapy. CBT is usually a harmless trifle, but exercise has been shown to be physically debilitating (there are papers on the effects of repeat exercise tests in properly characterized cohorts). Yet just a year ago the Lancet published a paper showing positive effects from these therapies in the UK. Of course, they used a much looser criteria, so the study doesn’t even speak to Myalgic Encephalomyelitis. This is not easy to explain, so most are satisfied with the idea that people with CFS should be treated with CBT and graded exercise.

    It would be great if that were true: a lot of very sick people would get better. Everybody wins. But it’s not the case, and it’s difficult to try to explain why without sounding like some kind of conspiracy theorist. I prefer to stick to published research in peer-reviewed journals, but I’m taking up enough space here, I’m not going to start in with links, although I could produce numerous examples to support my points, and will upon request.

    In October researchers in Norway published a paper showing significant improvement in a CFS cohort using Rituximab, a cancer drug, a heavy, serious treatment that wreaks havoc with the immune system. It’s particularly interesting following the publication of a paper that suggests exercise and CBT.

    The FDA has never approved any drug to treat Chronic Fatigue Syndrome, ever. There is one that has been in trials for more than 20 years, but is still not approved. There will be no Rituximab trial for CFS patients, not in the US, not in Canada, not in Europe. The drug’s patent is expiring soon and there’s no money in it for the drug company. That is an unhappy coincidence that is not exactly unique in the history of this disease.

    It is in the absence of any viable treatment for a serious disease that the suggestion that a biopsychosocial approach is appropriate rubs people the wrong way. If that were not the case, then I can’t imagine that too many people would have difficulty with the idea of this sort of approach as a secondary or tertiary measure. But it is, and the idea that this condition should be treated via a biopsychosocial approach is virtually the only one that is ever advanced.

    A perusal of the symptom profile of either the Canadian Consensus Criteria or the International Consensus Criteria would, I would hope, suggest strongly that a very different approach is what is actually needed here. And with a very different approach, I would suggest that biopsychosocial factors should certainly be taken into consideration. However, to look at this primarily, today, any conclusion drawn would be the result of an unfortunate distortion. People are sick, very sick, with a combination of high viral titers, severe autonomic dysfunction, and endocrine system disruption–and they are told that a biopsychosocial approach is the best medical option. I think it’s fair to say that would anger most people.

    People with this condition struggle with many issues that are a result of the disease itself. There is secondary depression (though many health professionals believe it to be primary, but this is not the case), there is isolation, there is tremendous frustration. Far too many are simply not taken seriously by the medical profession. And, among other scenarios, they view this as being told that it’s all in their heads (which some are, flatly). Their reaction to that is sometimes to insist that they’re not ‘crazy,’ or some such. Then there always seems to be someone with a particular interest in explaining to them how they have just expressed something that is cruel and insulting to people with mental illness.

    There are people who have been sick with this for decades, and it was first described nearly 80 years ago. It’s difficult to imagine being treated poorly by medical science for so long, but that’s exactly what’s happened, sad to say. So, some of us reject biopsychosocial approaches–sometimes more rudely than you perceived my comment to be. In my case, at least, it is not because I don’t believe it has a place, and a function, because I do. But it is horribly misused when it comes to ME/CFS. Considering that most patients have no access to drugs like Rituximab and Ampligen, which have shown improvement, I would hope you would understand how the constant advancement of the idea that a biopsychosocial approach in the absence of any of these other types of therapies is, simply put, difficult to consider, politely or otherwise.

    • i will leave your reply so anyone who cares to do so may read it . . . thank you for it. for the record, i make grounded, well-educated statements and sensible suggestions for my readers, including the essential framework of my cognitive-behavioral psychological orientation – from which i conceptualize everything related to human psychology. (as trifling as that may seem.) i also spend many hours each week writing on this blog for no compensation or benefit whatsoever, except that my readers evidently benefit.

      health psychology conceptualizes all human phenomena from a biopsychosocial perspective. you may have chosen to use this opportunity to add strength to my useful and beneficial explanation (because you know as well as i do that it is an accurate yet diluted description of the phenomenon of adrenal exhaustion) rather than to try to outdo me by showing my readers and me how bright you are. cheers.

  5. Dr. Cornwall’s article was not written to explain CFS, so it truly does not need defining. He is merely describing some of the effects the disorder has on your body and he explains the toil stress takes. This is where BPS comes in, to aid in easing stress to control the adrenalin, cortisol, hormones, etc. He simply states medicine without BPS, and vice-versa, is not as effective as treating with both procedures. I have never understood why some Doctor’s are unable to help most patients suffering from this condition, or others resembling it. Common sense tells you to get your body’s chemicals back in order AND deal with the underlying stress.

    As far as, “The combination of neurological and immunological abnormalities is not found in Fukuda or any of those other criteria.”, I think they finally need to start looking at it from this different perspective. Maybe this is why most Doctor’s are unable to help their patients diagnosed with CFS.

    I feel CFS cannot possibly be dissected in one article, since… The disorder may also be referred to as myalgic encephalomyelitis (ME), post-viral fatigue syndrome (PVFS), chronic fatigue immune dysfunction syndrome (CFIDS), or several other terms. Biological, genetic, infectious and psychological mechanisms have been proposed for the development and persistence of symptoms but the etiology of CFS is not understood and may have multiple causes.[4][5] There is no diagnostic laboratory test or biomarker for CFS.[2 Fatigue is a common symptom in many illnesses, but CFS is comparatively rare.[7]

    There is agreement on the genuine threat to health, happiness and productivity posed by CFS, but various physicians’ groups, researchers and patient advocates promote different nomenclature, diagnostic criteria, etiologic hypotheses and treatments, resulting in controversy about many aspects of the disorder. The name “chronic fatigue syndrome” itself is controversial as many patients and advocacy groups, as well as some experts, believe the name trivializes the medical condition and want the name changed.[13] (See the term happiness?)

    Notable definitions of CFS include:[6]
    CDC definition (1994)[14]—the most widely used clinical and research description of CFS,[4] it is also called the Fukuda definition and was based on the Holmes or CDC 1988 scoring system.[15] The 1994 criteria require the presence of four or more symptoms beyond fatigue, where the 1988 criteria require six to eight.[16]
    The Oxford criteria (1991)[17]—includes CFS of unknown etiology and a subtype called post-infectious fatigue syndrome (PIFS). Important differences are that the presence of mental fatigue is necessary to fulfill the criteria and symptoms are accepted that may suggest a psychiatric disorder.[6]
    The 2003 Canadian Clinical working definition[18]— states that “A patient with ME/CFS will meet the criteria for fatigue, post-exertional malaise and/or fatigue, sleep dysfunction, and pain; have two or more neurological/cognitive manifestations and one or more symptoms from two of the categories of autonomic, neuroendocrine, and immune manifestations; and [the illness will persist for at least 6 months]”.
    The different case definitions used to research the illness may influence the types of patients selected for studies,[19] and research also suggests subtypes of patients exist within the heterogeneous illness.[20][21][22][23]

    Chronic fatigue syndrome is the most commonly used designation,[1] but widespread approval of a name is lacking.[24] Different authorities on the illness view CFS as a central nervous system, metabolic, infectious or post-infectious, cardiovascular, immune system or psychiatric disorder, and different symptom profiles may be caused by various disorders.[20]

    Over time and in different countries many names have been associated with the condition(s). Aside from CFS, some other names used include Akureyri disease, benign myalgic encephalomyelitis, chronic fatigue immune dysfunction syndrome, chronic infectious mononucleosis, epidemic myalgic encephalomyelitis, epidemic neuromyasthenia, Iceland disease, myalgic encephalomyelitis, myalgic encephalitis, myalgic encephalopathy, post-viral fatigue syndrome, raphe nucleus encephalopathy, Royal Free disease, Tapanui flu and yuppie flu (considered pejorative).[25][26] Many patients would prefer a different name such as “myalgic encephalomyelitis”, believing the name “chronic fatigue syndrome” trivializes the condition, prevents it from being seen as a serious health problem, and discourages research.[13][27][28]

    The mechanisms and pathogenesis of chronic fatigue syndrome are unknown.[8] Research studies have examined and hypothesized about the possible biomedical and epidemiological characteristics of the disease, including oxidative stress, genetic predisposition,[50] infection by viruses and pathogenic bacteria, hypothalamic-pituitary-adrenal axis abnormalities, immune dysfunction as well as psychological and psychosocial factors. Although it is unclear which factors are a cause, or consequence, of CFS, various models are proposed.[51][52][53]

    Many people do not fully recover from CFS even with treatment.[54] Cognitive behavioural therapy (CBT) and graded exercise therapy (GET) have shown moderate effectiveness for many people in multiple randomized controlled trials.[29][55][56][57] As many of the CBT and GET studies required visits to a clinic, those severely affected may not have been included.[55] Two large patient surveys indicated that pacing is the most helpful intervention, or is considered useful by 96% of participants.[58][59] Medication plays a minor role in management.[60] No intervention has been proven effective in restoring the ability to work.[55]

    Cognitive behavioral therapy, a form of psychological therapy often used to treat chronically ill patients,[61] is a moderately effective treatment for CFS [29][55] that “can be useful in treating some CFS patients.”[61] Since the cause or causes of CFS are unknown, CBT tries to help patients understand their individual symptoms and beliefs and develop strategies to improve day-to-day functioning.[62]

    Certain medical conditions can cause chronic fatigue and must be ruled out before a diagnosis of CFS can be given. Hypothyroidism, anemia, diabetes and certain psychiatric disorders are a few of the diseases that must be ruled out if the patient presents with appropriate symptoms.[14][16][90]
    People with fibromyalgia (FM, or fibromyalgia syndrome, FMS) have muscle pain and sleep disturbances. Fatigue and muscle pain occurs frequently in the initial phase of various hereditary muscle disorders and in several autoimmune, endocrine and metabolic syndromes; and are frequently labelled as CFS or fibromyalgia in the absence of obvious biochemical/metabolic abnormalities and neurological symptoms.[citation needed] Multiple chemical sensitivity, Gulf War syndrome and post-polio syndrome have symptoms similar to those of CFS,[91][92] and the last is also theorized to have a common pathophysiology.[92]

    So, therefore, it is the person’s responsibility reading the articles posted, to see a Doctor, rule out any condition and treat any underlying condition first, and to understand the roles of organs and chemicals in our body. Secondly, they need to understand the factor major stress plays that causes the organs and chemicals to become out of control. You cannot treat one without the other. It simply cannot be done. If you fight stress alone, your chemicals are out of whack without medicine (for those who are majorly suffering, Post Traumatic Stress, etc.) If you take meds to control your chemicals and continue in stressful environments, the meds will not be enough, since your body will still be overproducing adrenaline, etc. It is common sense.

    Dr. Cornwall was not trying to diagnose anyone or limit his article to CFS, although CFS is the title. He is simply speaking of the effects of stress on the body, which can help patients with CFS, ME, CFIDS, Rheumatoid, Aids, or any other disease that is energy-zapping. He is explaining adrenalin depletion and the production of cortisol. He states…The adrenal glands also produce epinephrine (adrenalin), nor-epinephrine and dopamine. Over-production of these hormones, when prompted by such things as chronic stress, can result in the break down of the body’s immune system and it’s ability to fight disease. Chronic stress for example, also known as chronic fatigue syndrome (CFS), influences energy levels, nutrition, vitamin and mineral absorption and can damage major organs such as the heart, kidneys and liver…

    For those of us fighting adrenalin depletion, and chronic stress, we do not care for the exact diagnosis, or the origin, or what it is called, we only want to know how to get our chemicals back in order and prevent it from happening again. We want our normal lives back. Unfortunately, we cannot control outside sources of stress, such as war, natural disasters, murder, and the likes. We can only control how we relate to them. For the strongest of us, who can handle pressure, we fight to reclaim control of our lives and stay out of the bed when completely exhausted, and we start feeling good. Then when something happens, we cannot control when and how much adrenaline or cortisol our body produces when fronted with a danger. This puts us back at square one, having to fight to regain control again. This is the true problem. It is a roller coaster ride that you cannot stop. This makes you feel as if your life is wasting away.

    We need to know how our body works, so please add to this, not which reference it is coming from. It is our responsibility to determine if accurate for us or not. We do not go to the Doctor and ask him or her, where did you get that information from. We want treatment. Anyone suffering from CFS knows there is no specific treatment, and needs all the help they can get.

    Thank you with all my heart, Dr. Cornwall. I applaud you for your understanding of our needs.

    Three Cord Monty, you made some interesting contributions to this issue and are right on with some Doctors easily diagnosing first with depression, instead of searching out the underlying causes. We would love your input with Dr. Cornwall on the effects of CFS and various other issues that cause stress, fatigue, adrenalin depletion, cortisol production, and hormonal balance.

    For the references above, if you are curious where they are from, I can give you the publications. I will not include a list here, since my post is extremely too long already.

    I truly hope I did not offend anyone. My intention was to show you that CFS is a huge open discussion. Therefore, there are no right or wrong answers. It depends on the exact individual suffering. Dr. Cornwall can not possibly write one short article to cure everyone or even one patient suffering from energy depletion.

    • thank you for clarifying one important point, christine. i changed the title of the article to lessen the focus on CFS and place more emphasis on chronic stress. it is my best judgment, however, that the information i presented related to CFS and stress together contribute to exacerbating the condition. you are right, i only intended to focus on that aspect of the overall diagnosis and treatment. i am happy that you have some new friends to discuss this topic. maybe we are contributing to the current literature :) have at it! cheers!

      • I am sorry Dr. Cornwall to include such a lengthy reply.

        I think either name would have been perfect. Chronic fatigue, chronic stress, it’s all the same when it truly comes down to it. They both drain you, and make craziness out of your body’s chemicals. They both are debilitating, cause anxiety, insomnia, and all the other symptoms. How can you tell one from the other, if there are no specific tests for CFS?

        I feel so blessed and thankful to have met you. I haven’t forgotten about Go Suck A Lemon, and Think Twice. I hope you have a wonderful start to a beautiful week!

      • hello christine! i really enjoy our banter. you are an inspiration. i hope you noticed that i put your award on my blog. thank you very much for it. it is very meaningful to me. i think that my blog article called my more interesting and glamorous clinical identity may have played a role in some of the responses i got from my chronic fatigue article. i work will many, many doctors and nurses and not a single one disagreed that the treatment regime for cfs was to view it as part of the stress response. it was important to me that i was not providing inaccurate or harmful information. i am so happy to be making such interesting contacts by writing this blog. i truly enjoy doing it.

    • Hi Dr. Cornwall, I did see the award. It is beautiful! I am glad you are enjoying it.

      Your articles are great and I am learning a lot from you. I agree that you are trying to provide accurate information. Just like in my response above, no matter how hard a Doctor tries, it is still our responsibility to determine if the information given is accurate for our individual selves. I think you are doing an awesome job of relaying the information. Thank you so much!

  6. Pingback: Chronic Stress and Biopsychosocial Intervention Strategies … – How To Manage Stress

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  9. Pingback: “Simon Wessely a very dangerous man” Maybe he needs to see a Psychiatrist… « ATOS REGISTER OF SHAME

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  11. Dr. Cornwell,
    This is well-written and easy to understand for your target audience, the everyday reader. I am a licensed clinical social worker working in both acute inpatient and outpatient private practice. All human phenomena is conceptualized from a biopsychosocial perspective, I agree. I also find my cognitive behavioral approach to be very affective with clients. Continue to write your blog for the everyday reader. Most people don’t want to go to peer reviewed journals to gather information. Peer reviewed journals and blogs attract a different target audience, as you know. Thank you so much for taking the time to write to the everyday reader.

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