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MESSAGES TO

Depression, Anxiety & Insomnia

A DxD Session with Dr Ng Beng Yeong


Ended on Mon Dec 31 2018
Ended
Have a question to ask?

Get Dr Ng Beng Yeong's opinions on your questions! Only approved questions are displayed.

Top Answers


Dear MMF,

Thank you for sharing your story with us. It appears to me you may have eating disorder with co-morbid depression. Both conditions can be aggravated by stress and both need to be treated.

It will be good if you can carefully recall all the treatments that you have received over the years and write down all down. If you have been admitted to hospital, you can also refer to the discharge summaries that you have received from the hospital. You can create two columns, 1 for the type of treatment (including medication) and the other for the response that you have following that treatment modality. Your response can be in the form of gaining control over eating and/or improvement in mood or sleep.

You may also try to recall amongst the psychiatrists that you have received treatment from, do you have good rapport with any of them? If you can identify a particular psychiatrist whom you are comfortable with, it will be a good idea to arrange for an appointment with him or her and discuss your case records. Very often after taking such a chronological history, the psychiatrist will have a better idea of what works and what will not work in your case. The psychiatrist will also try to figure out the perpetuating factors for your condition and what cause the conditions to relapse.

You may also consider the use of talk therapy like cognitive behavioural therapy (CBT) which works for both depression and eating disorder. There is evidence that CBT may prevent relapses in depression and eating disorder.

Cheers! Take good care of your mood, sleep and food intake!

4 Nov 2018

Thank you for highlighting such a common problem. Apart from depression, the other mental health issue that came to my mind is that of social phobia or social anxiety disorder.

it will be good to consult a psychiatrist if you have mood problems and anxiety issues regarding your acne and how it has affected your looks and social life. Many individuals with severe acne problem and scars over the face have low self esteem as they think that they are not as good looking as many people around them. During treatment, your therapist can also rehearse with you how you can respond appropriately when people ask you about your acne condition and looks. We can this role play.

Many people would look at others beyond looks alone. For people who are truly your friends, they will be able ta appreciate you for your other inner qualities and attributes. Most of us are not such superficial beings.

Sorry to read about your suffering and social isolation. There is really no need for you to continue to suffer in silence. Do seek help from a mental health professional as soon as possible so that you do not wallow in self pity.

Cheers!

4 Nov 2018

Thank you for highlighting such a common problem, which many patients at the clinic also have.

Chest discomfort, tingling sensation over the limbs, aches and pains, can certainly be attributed to anxiety and depression. Nevertheless, it is important to seek medical attention so that other medical problems like an underling heart condition can be excluded.

For anxiety issues, it will be good to learn to practise a relaxation technique on a daily basis. If your stress stems mainly from your work, you can try writing down all the tasks that you need to perform, and then prioritise them, sorting out the important or urgent  ones first. Many patients of mine find this a useful strategy as they stop fearing that they will forget to perform some tasks or work.

Going for long walks may also be useful in relieving one's anxiety. There are many parks in Singapore and most of them are pretty scenic and pleasing to the eyes. Choose a park that is near your house so that you can incorporate walks in the park into their lifestyle. When you are in nature, do remember to immerse yourself in it by focusing on the tress, flowers and vegetation around you.

Wish you a speedy recovery. Take good care of your mental health.

4 Nov 2018

Yes, what you describe sounds like  an anxiety attack. Was it triggered off by you having to make a presentation or answer a question in class? If the attacks are recurrent, it will be important to seek medical attention.

If you have anticipatory anxiety (worries about having another attack), it will good to seek medical help. If the anxiety attacks are precipitated by social situations like presenting in class, then the diagnosis is that of social anxiety disorder or social phobia. Yes, the condition can be effectively treated so that your grades will not be affected. 

3 Nov 2018

Dear Mint

Thank you for sharing your problems with us.

It looks like you still have symptoms of depression (lack of interest, negative thoughts). It will be good to recall all the medications that you have tried before in the past and your response to them. You can write them all down on a piece of paper so that you can show it to your next psychiatrist.

It may be worthwhile for you to try seeking treatment from another psychiatrist in another restructured hospital or from the private sector.

Treatments for depression oftentimes include talk therapy (cogntive behavioural therapy) and/or medications. It is important not to give up on treatments too readily but to give yourself another chance to get better.

Response to a medicine likes antidepressant takes time (e.g, 4 to 6 weeks for some) and it is hence important not to give up too soon. Do hang in there and find the help that you need.

I wish you success in finding the psychiatrist with whom you are comfortable and who is able to help you sort out your depressive condition.

4 Nov 2018

Dear Moi

Thank you for asking this question. Many of my friends and relatives have also asked me a similar question.

First, there is St John's wort that can be brought over the counter at the pharmacy. It is meant for mild cases of depression. In some countries where access to doctors is not readily available, people do use St John's wort to relieve depression. It may not be effective in moderate or severe cases of depression.

Second, there is melatonin that can be brought over the counter, to relieve sleep symptoms. Some of my patients report that melatonin helps them to overcome jet lag, for example, when they fly back to Singapore from America or Europe. It is safe for short term use but it is not advisable to use it for many months as studies have indicated that even when a small dose of melatonin is taken, the blood level may be very high. We are not sure what the long term consequences are, when the body is exposed to such high levels of melatonin over a prolonged period of time.

Third, some patients told me that they use an antihistamine for their sleep. You can check with the pharmacist near your place which antihistamine can be bought over the counter. An antihistamine may work for a few days but many patients report after the first few days, the medicine starts to lose its effects of enabling them to fall asleep. Elderly people may become confused the next day after taking an antihistamine for sleep aid.

For the treatment of mood problems and insomnia, oftentimes we need to figure out the underlying causes of the condition (in medicine, we call this the etiology). It may be better to seek help from a mental health professional. Your records with the doctors will be kept confidential. If you are reluctant to seek medical attention, you can also consider talking to a counsellor at the Family Service Centre near your place or at a counselling centre.

I hope that you will soon get the help that you need.

3 Nov 2018

There are two conditions that come to my mind immediately.

The first is that of delayed sleep phase syndrome, which is a form of circadian rhythm disorder that is commonly seen in young people. They tend to sleep late and wake up late. This is because their biological clock is out of sync with the outside world. What you can do to re-entrain your biological clock is to get exposure to sunlight in the morning, like 7 am or so. Go for a walk in the park and get exposure to light.

There is no need to stare at the sun as that will cause damage to the eyes. The sunlight will send a strong message to your brain, telling your brain that it is daytime and that you need to be awake and fully alert. Many studies have demonstrated that exposure to sunlight in the early hours of the morning will enable the brain to release melatonin at night at an earlier time, which will then bring forward your sleeping time. Some doctors may also recommend that you get your bright light exposure from an artificial source, like a light box.

The other condition that came to my mind is that of anxiety. Many individuals with anxiety problems report that they cannot initiate sleep at night. Many of our local students experience stress from their academic pursuits and report having anxiety symptoms like insomnia, tension, irritability, palpitations, aches and pains.

Do seek help from a mental health professional early so that your problems can be evaluated and treated. Do take good care of your sleep. Cheers!

4 Nov 2018

Dear Clara

The GPs in Singapore are certainly empowered to treat common psychiatric conditions like anxiety and depression. Yes, they can prescribe antidepressants. Psychiatry is an important part of the medical education and all of them have been trained to treat common psychiatric conditions like anxiety and depression.

You can look at the credentials of the GPs in your neighbourhood. Many of them would mention that they have a diploma or certificate in psychiatry or mental health issues. For those who mention this in their clinic sign board, they are comfortable with prescribing antidepressants. You can also ask the counter staff at the clinic if the clinic has any particular antidepressant. Most GPs are familiar with antidepressants like Fluoxetine and Escitalopram.

If you are already seeking treatment from a psychiatrist, you can also ask your psychiatrist to recommend a GP for you. The advantage of seeking help from the GP is that many of them do run clinics in the evening and that is indeed very convenient for patients to seek help.

Cheers!

4 Nov 2018

Dear Hana

The symptoms that you describe are commonly experienced by people in many parts of the world. Yes, the symptoms can be attributed to anxiety. There are three possible conditions that come to my mind immediately:

First, is that of thyroid gland abnormalities. Sometimes, persons with excessive thyroid hormone may report feeling anxious and restless. Typically, they may have some hand tremors. The thyroid gland in the neck could be enlarged. Given their increased metabolism, they often report feeling warm and oftentimes prefer to be in air conditioned places. The doctor will usually order a blood test to check the thyroid hormone level.

The second condition that comes to my mind is that of adjustment disorder with anxious mood. This happens in people who experience something stressful in their lives (e.g., school exams, passing of a relative, adjusting to a new job, enlistment for national service, a divorce) and go on to have symptoms of worry and tension. You can seek treatment from a counsellor who can then teach you relaxation techniques and explore with you your previous coping strategies and see how you can deal with the current challenges and life situation. A psychiatrist can also help you in this way.

Third, generalised anxiety disorder (GAD). In such cases, the individual has anxiety symptoms for at least 6 months. Typical symptoms would include poor sleep, constant worrying and tension in the body. The content of the worries may change, depending on the life situation of the person. For GAD, the treatments that are commonly employed in Singapore include cognitive behavioural therapy (CBT, a form of talk therapy and medications (including SSRIs). I notice that you are 16 years old. Some doctors may have reservations about using SSRIs in a teenager as there are reports of increased suicidal ideations in some cases following initiation of SSRIs. So the best treatment in your case if you have GAD may be CBT.

Do go ahead and see your family physician for an evaluation. It is important to take care of your own mental health.

3 Nov 2018

Dear Claire

Thank you for asking such an important question. It is indeed important to make a distinction between postnatal depression and baby blues as the treatments for both conditions are vastly different. 

Every other woman would feel a bit weepy, moody, flat or unsure of herself on the third or fourth day after having a baby. This is usually called 'baby blues' or 'maternity blues.' Their mood usually improves after a week or so after the mother learns to get herself organised and deal with the challenges and excitement of motherhood. However, if the low mood persists for longer than 2 weeks, then the diagnosis of postnatal depression (PND) has to be considered.

PND usually starts within a month of the delivery but can have its onset up to 6 months following delivery. The condition can remain for months, or even years, if it is left untreated. It is wonderful that you have insight into your condition and decide to seek treatment. PND occurs in about 10% of women. 

Very often, the mother may need only reassurance, practical support and supportive counselling. What I would do will be to explore with the patient how she coped with stressful events in the past and how she can continue to mobilise her resources and skills to deal with the current challenges. Talking with other mothers may also help as many of them have embarked on a similar journey and encountered the same challenges. 

Sometimes the underlying causes of depression could stem from many other sources. For instance, a case whom I saw recently became depressed as her husband had an extra marital affair when she was pregnant and she only knew about it after her delivery. Some couples also have problems with their in laws who oftentimes have their own ideas of how small children should be brought up. Another case of PND that I treated some time ago had problems with housing and that took many months to get sorted out. 

In the management of postnatal depression, it is crucial to get the husband involved as well and he may also need help to adjust to parenthood.

There is some research that demonstrates that PND may affect the mother-infant relationship and the cognitive and emotional development of the infant. Hence it is important to seek treatment early. May I urge you to approach your family physician for an evaluation. You can also arrange to see a psychiatrist.

Take good care of yourself and your family. Cheers!

5 Nov 2018

Dear Rien

For many patients with Persistent Depressive Disorder (the old term is dysthymia) and Generalised Anxiety Disorder, the treatment will be on an ongoing basis.

The first task is to find a mental health professional whom you are comfortable with. Many doctors in Singapore are trained in providing talk therapy, typically cognitive behavioural therapy (CBT) and supportive psychotherapy. For supportive psychotherapy, a typical session will include checking on your symptoms and life situation. The mental health professional will then explore with you how you cope with stresses in the pasy and how you can harness your inner potential to deal with the current challenges. For CBT, the therapist will help you identify the maladaptive thoughts that emerge in your mind and think of ways and means to work with you to modify those thoughts to make them positive or neutral ones.

Many patients told me that a combination of a low dose antidepressant and talk therapy work for them. So I would also urge you to seriously consider this option as well. Antidepressants are not addictive or habit forming. For someone who has been taking antidepressants for many weeks, if he or she wants to stop taking it, then it is advisable to gradually decrease the dose of the medicine to avoid withdrawal symptoms. The doctor who prescribes you the medicine will be able to guide you on how you can wean it off.

Hope that you will find the mental health professional that best meets your needs.

Cheers!

3 Nov 2018

Dear Jinny

Congratulations on your admission to a medical school. You must have done well for your last examinations.

It will be good to seek treatment for your depression early so that you can recover from the mood problems and pursue your dreams of becoming a doctor. If your mood is low, you may not sleep well and your energy level may not be ideal. All this may affect your ability to study well and make the right decisions for your life.

You can also talk with a counsellor at the Family Service Centre near your place.

Another option is to see a private psychiatrist where the waiting time for an appointment is short. Treatments for depression may just be talk therapy alone and not all patients will need antidepressants.

Your records with the psychiatrist will be kept confidential. In future, when registering with SMC, you can obtain a letter from your treating psychiatrist to indicate that your are well and fit to be a clinician. 

Many qualified doctors do continue to seek help from a mental health professional as they have anxiety and depression. You can appreciate that the working hours of a doctor can be long and that may take a toll on his health. His family life and social life can also be affected.

I wish you speedy recovery.

3 Nov 2018

Dear Latte

In Singapore, psychiatric conditions are diagnosed using a face to face interview and an assessment of the mental condition (what doctors called mental state examination). Many of the doctors here use the DSM 5 diagnostic criteria. For patients thought to have anxiety or depression, the psychiatrist may also order a blood test to exclude abnormalities in the thyroid hormone level.

Given your problem of going to new places and fears of social situations, the first diagnosis that comes to my mind is that of social anxiety disorder (also called social phobia). Treatments would include psychological treatment (cognitive behavioural therapy) and medications (SSRIs).

 It is interesting that you asked about anxiety and depression in the same breath. Yes, the two conditions or sets of symptoms are commonly reported by patients in our local setting and also in many  parts of the world. Anxiety and depression oftentimes coexist in the same person and when you see one, you see the other as well. They are just like twins!

I hope you will get the help that you want soon. Wishing you speedy recovery.

3 Nov 2018

If you have concerns about cost of treatment, the best way is to seek treatment at the polyclinic and from there get referred to a restructured hospital for further attention. If you are suicidal, the attending doctor can help you get an early appointment. There are social workers at the restructured hospital and they will look into your financial situation and apply for the assistance that you need. 

You can also seek treatment from a family physician who can diagnose your condition and then start you on an antidepressant. If you choose to seek treatment from a private psychiatrist, then you can call up the clinic and talk to the clinic staff who can advise you on the consultation charges. For a person who has a first episode of major depression, he/she would most likely need to take an antidepressant for about 6 to 9 months. The cost of the medication largely depends on the type of antidepressant that is chosen. In some cases, the cost of the medicine can be as low as $30 a month. 

Some patients while awaiting their appointment at the restructured hospital may seek treatment from a private psychiatrist in the interim period. If that is the case, do let your private psychiatrist know about your intention to be treated at the restructured hospital, so that he can start you on an antidepressant that is readily available at the restructured hospital. 

3 Nov 2018
Thank you for asking such a fascinating question.

What you describe is called the delayed sleep phase syndrome, a form of sleep disorder that involves the circadian rhythm or body clock.

Most people sleep at 11-12 midnight and then wake up at 5-7 am. You sleep late and wake up late, and that is what delayed sleep phase means. In terms of hours of sleep, 6 hours sound fairly decent for an adult but for a teenager it may not be enough. The important question would be whether you feel refreshed or rested when you wake up naturally.

In order to retrain the biological clock and re-establish your circadian rhythm, what you can do is to get exposure to sunlight in the morning like 7 am or so. You can, for instance, take a walk in the park for half an hour or so. There is no need to stare at the sun as that will cause harm to your eyes. The sunlight will indicate to your brain that it is already daytime and that you need to stay awake and be alert. Exposure to light in the morning will help to bring forward the surge of melatonin (which the brain normally produces when exposed to darkness) at night and that will enable you to fall asleep at an earlier time of the night.

Your doctor may also recommend the use of bright light therapy from an artificial source like a light box.

Having odd hours of sleep may create stress for the individual as her work life, family life and ability to attend school or university may be adversely affected. Very often, the parents would nag at them and keep reminding them to sleep early and wake up early. Constant nagging and incessant reminders can also generate a lot of stress for the individual. Stress, anxiety and depression are known to affect menstrual cycle in that the periods may become irregular, last fewer days, or even last more days.

For treatment of your sleep problems, you may consider seeking treatment from a psychiatrist who has interest in sleep disorders.

Cheers! Take good care of your sleeping pattern. If we take good care of our sleep, many things in life will fall in place.
4 Nov 2018

Dear M

Thank you for asking such an interesting question and sharing your difficult life situation. It is heartwarming to learn that you are determined to get well by becoming a student in psychology. I hope you enjoy pursuing the subject and understanding more about your own psyche. 

From your brief account, it looks like what you have at the age of 15 was 'double depression', that is a major depressive episode superimposed on a long standing, low grade depression of at least 2 years' duration. In order for the chronic depression that you outlined to be considered 'dysthymia', one will need to have low mood for at least two years. This would mean that you had had low mood since age of 13. I wonder if that is correct. Was there something stressful or traumatic that happened to you at around that age? If so, a large part of therapy may have to focus on that stressful or traumatic event so that you can come to terms with it and move on with your life. 

I also wonder if the initial diagnosis of double depression may just be a tentative one and the clinician was actually intending to revise it when there is more information available or as the clinical scenario evolves. Hence it will be good to seek another opinion and get the condition thoroughly evaluated and re-diagnosed. In psychiatry, the diagnosis may change over time when the clinical picture changes or when more information is available to the clinician.  

For chronic depression, it will be good to exclude some underlying medical problems like thyroid disorder. Also, there are newer antidepressants available in the market and these can also be carefully considered in your case. Oftentimes, a patient with depression may not respond to a particular antidepressant but he/she may do remarkably well with another medicine.

It looks like you did not have a second episode of major depression after 15 and just have low grade depressive symptoms for many years. Now that you have insight into your condition, you can play an active role in preventing yourself from developing depressive episodes. A good book to read will be this title, 'Overcoming depression (third edition) - a self-help guide using cognitive behavioural techniques' by Paul Gilbert. The book includes easy-to-follow, step-by-step suggestions and exercises to help you understand your depression and lift your mood. 

Proper stress management strategies will go a long way in helping you prevent depressive episodes. Learning to prioritise your tasks and challenges, exercising regularly, having 6 to 8 hours of sleep a night, are measures that will help.

Take good care of yourself. 

 

16 Nov 2018

Dear Lexi

It is not uncommon to develop discontinuation symptoms following cessation of antidepressant treatment. The term 'discontinuation symptoms' is preferred in your scenario as you describe symptoms experienced on stopping prescribed drugs that are not drugs of dependence. Discontinuations symptoms include irritability, headache, nausea, vomiting, sweating, pins and needles sensation, unsteady of gait, dizziness exacerbated by movement,  insomnia, increased dreaming and flu-like symptoms.

The onset of symptoms is usually within 5 days of stopping antidepressant treatment. When taken continuously for 6 weeks or longer, antidepressants should not be stopped suddenly unless a serious side effect has developed.

Generally, antidepressant therapy should be discontinued over at least a 4-week period. This is not required with fluoxetine which has a long half life and is therefore likely to remain in the body over a long time. Discontinuation symptoms can occur after missed doses if the antidepressant prescribed has  a short half -life. (e.g, paroxetine, venlafaxine). 

In most cases, the symptoms are mild and will pass in a few days. If symptoms are severe, what I would do is to re-introduce the original antidepressant (or another with a longer half life from the same class) and taper gradually while monitoring for symptoms.

For persons suffering from a first episode of major depression, it is advisable to take the antidepressant for about 9 months or so. Do discuss with your doctor first before you stop the antidepressant. If the course of treatment is too short, there is a high chance that the depressive symptoms will come back.

Cheers! Take good care and work closely with a doctor whom you trust.

Dr Ng Beng Yeong

26 Nov 2018

Dear Rien 

It looks like you are facing a difficult phase of your life. Is it just stress from school or are there challenges from other areas of your life as well? Some teenagers also have problems arising from their family and from their relationship. If it is so complicated and overwhelming, it will be useful to get professional help as soon as possible.

If the anxiety is just related to school alone, my suggestions will be:

1. Try practising a relaxation technique like progressive muscle relaxation techniques. You can try looking for a you tube video that teaches you how to relax by practising deep breathing and muscle relaxation techniques. Many of my patients report feeling more relaxed after they put aside some time each day for relaxation. 

2. Sometimes it is helpful to write down all the tasks or homework that you have to do and learn to prioritise them. It will be good to learn to tackle one task at a time. For the more challenging tasks, you can also learn to break them down into smaller parts and learn to tackle a small part at a time. 

3. Try going for walks for half an hour a day. This can be very relaxing and can calm your  nerves now.

4. Some students find it helpful to study in groups.

5. Try talking to your best friend about your problems. If you all are classmates, he or she may be able to understand the challenges that you face. 

6. You may want to seek help from a mental health professional so that your anxiety can be explored further. The doctor will also assess if you are depressed. Clinically, most patients with anxiety problems also have depressive features. There are medications that can be used to treat both anxiety and depression.

Do take good care of yourself and I hope you will feel calmer soon.

Dr Ng Beng Yeong

26 Nov 2018
Thank you for sharing details about your situation and experience with psychiatric treatment. Your issues pertain mainly to anxiety and depression. May I make the following comments:
 
1. So far you have been tried on an antidepressant under the family of SSRI (serotonin specific reuptake inhibitor). There are many antidepressant medications that come under this family. It is not uncommon for a person not to respond to a particular SSRI and yet will respond to another SSRI. If you look at the chemical structure of the SSRIs, you will realise that they are very different from one another. Therefore, it may be worthwhile for your doctor to switch you to another SSRI. Commonly used SSRIs in Singapore include sertraline, escitalopram, fluoxetine, fluvoxamine and paroxetine.
 
2. The other possibility is to consider another antidepressant that is from a totally different family. The SNRI. These are medications that act on two neurotransmitters in the brain, serotonin and norepinephrine. There are some studies indicating that SNRIs may be a better option for persons who do not respond to SSRIs. Commonly used SNRIs in Singapore include Venlafaxine, desvenlafaxine and duloxetine.
 
3. For talk therapy to be effective, I would recommend that cognitive behavioural therapy (CBT) be used. Most counsellors just provide simple counselling or supportive psychotherapy. CBT is a more structured form of therapy and involves looking at the person's thoughts and behaviour and aims to modify the person's style of thinking and coping with challenges. Very often it involves homework. This means that the client will bring home forms with him and chart down his thoughts and learn to modify them on his own in between sessions. For CBT to be effective, the sessions are held pretty frequently, for example, once every two weeks. There is a lot of work that is done by both therapist and client; it is not just allowing ventilation and providing emotional support.
 
I hope you will find my comments and suggestions useful. I wish you speedy recovery so that you can carry on with your life trajectory.
25 Dec 2018

Thank you for describing your emotions so vividly and I can see that you have been suffering for quite some time. You do have some symptoms of anxiety and depression, and these include loss of interest, poor concentration, getting worried and having negative thoughts.

I have a few suggestions for you. First, it is time to sit back and re-assess the priorities in your life. Once you have decided on your life goals, then you can think of how to achieve them one by one.

Second, you will need to learn to break down a major, seemingly unattainable, task into smaller tasks that are achievable. Once you have achieved a small task, you can learn to reward yourself by spending time pursuing things that make you happy. These two strategies will help you deal with stresses and challenges in a more effective fashion. 

Third, you can arrange to see a counsellor at the counselling centre in Singapore or you can also arrange to seek treatment from a psychiatrist, who can then further evaluate your condition and see if you need medications or psychotherapy.

Like what you highlighted in the paragraph that you penned, we all have our own timelines and life is a marathon, not a short race. Every single step forward counts, and every long journey starts from small steps forward.

When you compare yourself with others who are more successful in their careers than you, you will also need to tell yourself that there are people who are lagging behind you. Everything is relative, it all depends all who you compare yourself with.

Keep your spirits high!

Dr Ng BY

3 Jan 2019

Top Questions


I was diagnosed with depression and anxiety some years back. My doctor gave me the "all clear", and I tapered off my antidepressants and other meds. It's been some time but very occasionally I still feel anxious for no reason. I kind of expected everything to be OK after stopping my meds. Does this mean I am not 100% recovered? Is it possible to get back to what I was like before?

I know that chronic fatigue syndrome (CFS)/myalgic encephalomyelitis (ME) is a "controversial illness", and not all Doctors recognise it. However, I would to find out more about how I can treat it. How do I find a doctor who can diagnose and treat CFS/ME? Is there a specialist in Singapore I could go to see?