Chronic Fatigue Syndrome: Causes and Treatments

If we consider mainstream medical definitions of Adrenal Fatigue Syndrome, we can easily notice that the listed symptoms include heavy breathing and chest pain. Among other possible symptoms are: muscle pain, shortness of breath, night sweats, chronic headaches, muscle fatigue, cramps and spasms, cold hands and feet, extreme fatigue and weakness. These are all classical symptoms and signs of chronic hyperventilation that causes low body oxygen levels.

What causes chronic fatigue syndrome?

As we explained before, heavy breathing (or breathing more than the medical norm) reduces body oxygen content due to 3 independent mechanisms:
1) since CFS (or Chronic Fatigue Syndrome) patients are chest breathers, chest breathing reduces oxygenation of the arterial blood due to insufficient ventilation and oxygenation of the lower parts of the lungs
2) CO2 deficiency, due to breathing too much, causes constriction of arteries and arterioles reducing blood supply to tissues since CO2 is a vasodilator (see links below).
3) Less oxygen is released by hemoglobin cells in tissues due to the suppressed Bohr effect (caused by CO2 deficiency as well).

The link between chronic fatigue syndrome and ineffective breathing was suggested by many doctors. Some of the quotes (Rosen et al, 1990; Paulley, 1990) are provided in references below. These doctors directly claim that the label "chronic fatigue" means hyperventilation. Measured end-tidal CO2 values are below the norm in CFS patients (Razumovsky  et al, 2003; Cook et al, 2006; Natelson et al, 2007) and end-tidal CO2 is even less during acute episodes (Bogaerts et al, 2007).

Note. In some studies medical doctors suggested that low end-tidal CO2, e.g., less than 30 mm Hg (!) is the criteria of hyperventilation (Naschitzet al, 2006, Saisch et al, 1994). The typical border line is 35 mm Hg. Furthermore, it is a known fact that hyperventilation or overbreathing can be present, while having perfectly normal end-tidal CO2 parameters at rest (e.g., due to predominantly chest breathing and/or ventilation/perfusion mismatch) and that hyperventilation means to have abnormally high pulmonary ventilation (or minute ventilation). Thus, hyperventilation is alveolar hyperventilation only. (Are functioning alveoli ventilated in accordance with metabolic needs and corresponding to the norm, which is 6 L/min for minute ventilation at rest for a 70-kg man?). There are no any other types of hyperventilation.

Expected effects of hyperventilation

When muscle cells and other metabolically active tissues of the human body do not get enough oxygen supply, more mitochondria switch from aerobic to anaerobic energy production mechanism. This causes elevated lactic acid content in tissues and blood, together with the main symptoms of lactic acid: weakness, fatigue, and pain in muscles and the chest (heart muscle tissue also get less oxygen and suffer from tissue hypoxia). Apart from lowered oxygenation and blood supply to the brain, heavy breathing makes nerve cells overexcited and irritable causing headaches and anxiety problems.

Chronic overbreathing creates cell hypoxia, elevated lactic acid, constant production of free radicals in cells, free radicals damage, possible inflammation in various areas of the body leading to decreased vagal power (Sisto et al, 1995), blocked nose and chronic sinusitis, digestive problems, face acne, liver inflammation (with abnormal liver test results), and many other pathological effects. Inflammatory processes and mental state of chronic stress (fight-or-flight response) exhaust cortisol reserves (cortisol is a steroid hormone or glucocorticoid produced by the adrenal gland). This explains how Adrenal Fatigue Syndrome and chronic insufficiency in cortisol reserves develop.

Particularly, for most patients symptoms of chronic fatigue are worst during early morning hours (Togo et al, 2008; Guilleminault et al, 2008).

Therefore, the cause of chronic fatigue syndrome is overbreathing or hyperventilation. There were many doctors who suggested this link, but Dr. Buteyko and his medical colleagues developed the medical program for natural treatment of chronic fatigue syndrome using the Buteyko breathing method of breathing retraining.

When the cause is removed (due to breathing normalization or breathing retraining), all symptoms of fatigue, including chest pain, shortness of breath, night sweats, muscle pain and fatigue, chronic headaches, and weakness, naturally disappear.

Chronic fatigue syndrome and body oxygen levels

The degree of chronic fatigue syndrome can be easily found using a stress-free body oxygen test that is measured in seconds (see links below).

As an additional test, measure your heart rate since pulse of chronic fatigue disorder patients is above the norm. The normal pulse rate is about 60-70 beats per minute. Patients with moderate degree of chronic fatigue syndrome often have more than 80 beats per minute at rest, while sitting. When the body oxygenation is below 10 s, they heart rate is often more than 90 beats per minute.

When a person suffers from Adrenal Fatigue Syndrome with insufficient blood cortisol level, the adrenal gland does not recover if the body oxygen content is below 20 s. Once a person has more than 20 s, any additional supplementation in cortisol is not required. Note that some patients with chronic and extreme fatigue, if they decide to improve their breathing, require cortisol supplementation so that they can progress and get higher body oxygenation numbers. 

Natural Treatment for Chronic Fatigue Syndrome

All symptoms of chronic fatigue syndrome including muscle pain, breathlessness, night sweats, headaches, and weakness will disappear if one normalizes his or her automatic or uncosncious breathing pattern. Breathing retraining, so that one breathe differently 24/7, requires lifestyle changes for better body oxygenation and breathing exercises that can make breathing lighter and slower. It is a serious project which is explained in detail in Learn here Section. Note that many western MDs also consider breathing retraining as the way to deal with chronic fatigue disorder (Nijs et al, 2007; Vasiliauskas et al, 2008).

Solutions to breathing problems

There are many breathing techniques and methods in order to normalize breathing and increase body oxygen levels. The Buteyko breathing technique has the most powerful arsenal of lifestyle changing tools which are described in detail in Section Learning. The same Section also describes the Buteyko breathing exercises, which are difficult to learn. Furthermore, there are breathing exercises that are more powerful (in comparison with the Buteyko breathing exercises) for body oxygen increase.

Oxygen remedy is such a program that is based on using Buteyko lifestyle program and application of breathing devices (the Amazing DIY breathing device, Frolov device and some others) that trap exhaled air with high CO2 levels for inhalations to boost body oxygen content. More info about these alternative respiratory techniques can be found here:
* Amazing DIY breathing device
* Frolov breathing device.

Reference Web Pages: Breathing norms, Medical Graphs and Tables about Breathing Rates (Minute Ventilation) and Body Oxygen in Healthy, Normal and Sick People
Breathing norms Parameters, graph, and description of the normal breathing pattern
6 breathing myths 6 myths about breathing and body oxygenation (prevalence: over 90%)
Hyperventilation Definitions of hyperventilation: their advantages and weak points
Hyperventilation Syndrome in the Sick. Table 1. Western scientific evidence about prevalence of CHV (chronic hyperventilation) in patients with various chronic conditions (34 medical studies)
Normal Minute Ventilation in Healthy Subjects: Easy and Light Breathing (14 Studies)
Hyperventilation Prevalence Present in Over 90% of Normal People (24 medical publications)
HV and hypoxia How and why deep breathing reduces oxygenation of cells and tissues of all vital organs
Body oxygen test How to measure your own breathing and body oxygenation (a simple DIY test)
Body oxygen in healthy Table 4. CP (body oxygen level) in healthy people (27 medical studies)
Body oxygen in sick Table 5. CP (body oxygen level) in sick people (14 medical studies)
Buteyko Table of Health Zones with clinical description of most common zones
Morning HV Morning hyperventilation effect or how and why critically ill people are most likely to die during early morning hours

References: CO2 Effects Web Pages
Vasodilation: CO2 expands arteries and arterioles facilitating perfusion (or blood supply) to all vital organs
The Bohr effect How and why oxygen is released by red blood cells in tissues
Cell Oxygen Levels and oxygen transport are controlled by alveolar CO2 and breathing
Oxygen Transport depends on breathing and these two effects (Vasoconstriction-Vasodilation and the Bohr effect) are parts of two diagrams that summarize influences of hypocapnia (low CO2 content in the blood and cells) on circulation and O2 delivery
Free Radical Generation takes place due to anaerobic cell respiration caused by cell hypoxia. Hence, antioxidant defenses of the human body are also regulated by CO2 and breathing
Inflammatory Response is controlled by breathing since hypoxia leads to or intensifies chronic inflammation through over-expression of the hypoxia-inducible factor 1, while normal breathing reduces these processes
Nerve stabilization takes place due to calmative or sedative effects of carbon dioxide in neurons or nerve cells
Muscle relaxation or relaxation of muscle cells is normal at high CO2, while hypocapnia causes muscular tension, poor posture and, sometimes, aggression and violence
Brochodilation - dilation of airways (bronchi and bronchioles) by carbon dioxide, and their constriction due to hypocapnia
CO2: Best Natural Cough Suppressant and "home remedy" since it calms urge-to-cough nerve receptors located in the tracheobronchial tree and larynx
Blood pH regulation and regulation of other bodily fluids
CO2: Lung Damage Healer: Elevated carbon dioxide prevents injury and promotes healing of lung tissues
CO2: Skin and Tissue Healer
Synthesis of Glutamine in the Brain, CO2 fixation, and other chemical reactions
CO2 myth "CO2 is a toxic waste gas" myth
Breathing control How is our breathing regulated? Why hypocapnia makes breathing uneven and erratic?

References and quotes

Hyperventilation in chronic fatigue syndrome

Rosen SD, King JC, Wilkinson JB, Nixon PG, Is chronic fatigue syndrome synonymous with effort syndrome? Journal of the Royal Society of Medicine, 1990 Dec; 83(12): 761-764.

"Chronic fatigue syndrome (CFS), including myalgic encephalomyelitis (ME) and postviral syndrome (PVS), is a term used today to describe a condition of incapacity for making and sustaining effort, associated with a wide range of symptoms. None of the reviews of CFS has provided a proper consideration of the effort syndrome caused by chronic habitual hyperventilation...
In 100 consecutive patients, whose CFS had been attributed to ME or PVS, the time course of their illness and the respiratory psychophysiological studies were characteristic of chronic habitual hyperventilation in 93...
It is suggested that the labels 'CFS', 'ME' or 'PVS' should be withheld until chronic habitual hyperventilation - for which conventional rehabilitation is available - has been definitively excluded."

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Paulley JW, Hyperventilation, Recent Progress in Medicine 1990 Sep; 81(9): 594-600.

"Physicians’ and specialists’ continued failure to recognize, diagnose and treat adequately the majority of hyperventilators is a disgrace. Hyperventilation Syndrome (H.V.S.), incorrectly labelled myalgic encephalomyelitis (M.E.), is the latest example of the profession’s incompetence."

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Behav Res Ther. 2007 Nov; 45(11): p. 2679-2690. Epub 2007 Jul 20.
Hyperventilation in patients with chronic fatigue syndrome: the role of coping strategies.
Bogaerts K, Hubin M, Van Diest I, De Peuter S, Van Houdenhove B, Van Wambeke P, Crombez G, Van den Bergh O.
Research Group on Health Psychology, Department of Psychology, University of Leuven, Tiensestraat 102, 3000 Leuven, Belgium.
Hyperventilation has been suggested as a concomitant and possible maintaining factor that may contribute to the symptom pattern of chronic fatigue syndrome (CFS). Because patients accepting the illness and trying to live with it seem to have a better prognosis than patients chronically fighting it, we investigated breathing behavior during different coping response sets towards the illness in patients with CFS (N=30, CDC criteria). Patients imagined a relaxation script (baseline), a script describing a coping response of hostile resistance, and a script depicting acceptance of the illness and its (future) consequences. During each imagery trial, end-tidal PCO2 (Handheld Capnograph, Oridion) was measured. After each trial, patients filled out a symptom checklist. Results showed low resting values of PetCO2 overall, while only imagery of hostile resistance triggered a decrease and deficient recovery of PetCO2. Also, more hyperventilation complaints and complaints of other origin were reported during hostile resistance imagery compared with acceptance and relaxation. In conclusion, hostile resistance seems to trigger both physiological and symptom perception processes contributing to the clinical picture of CFS.

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Medicina (Kaunas). 2008;44(12):911-21.
[Impact of a long-term complex rehabilitation on chronic fatigue and cardiorespiratory parameters in patients with chronic heart failure]
[Article in Lithuanian]
Vasiliauskas D, Kavoliūniene A, Jasiukeviciene L, Grizas V, Statkeviciene A, Leimoniene L, Tumyniene V, Kubilius R.
Institute of Cardiology, Kaunas University of Medicine, Sukileliu 17, 50161 Kaunas, Lithuania. donatas@kmu.lt
The aim of the study was to evaluate the impact of a long-term rehabilitation on chronic fatigue and cardiorespiratory parameters in patients with chronic heart failure.
MATERIAL AND METHODS: One hundred seventy patients with class III-IV (NYHA) chronic heart failure were examined. The study population was divided into two groups: long-term rehabilitation group and control group. They underwent cardiopulmonary exercise test and completed questionnaires on chronic fatigue (MFI-20L, DUFS, and DEFS). Measurements were repeated 3 and 6 months after long-term complex rehabilitation.
RESULTS: According to the data of MFI-20L, DUFS, and DEFS questionnaires, 170 patients (100%) with class III-IV (NYHA) chronic heart failure complained of fatigue. Overall daily fatigue was 56.828.5 points on a 100-point scale, and after 6-month rehabilitation, this parameter was statistically significantly reduced on all scales (P<0.05). Physical fatigue and self-care improved in controls. Cardiopulmonary exercise test showed that parameters of hyperventilation, ventilatory equivalents, and pCO2 were significantly improved in rehabilitation group after 6 months as compared to baseline data (P<0.05), but not in the control group.
CONCLUSION: Patients with class III-IV (NYHA) chronic heart failure experience chronic fatigue, which reduces their motivation and self-care abilities. Long-term complex rehabilitation programs improve all parameters of chronic fatigue, respiratory efficiency, and prognostic indicator of chronic heart failure--ventilatory equivalent for carbon dioxide.

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Hypocapnia or low end-tidal CO2 in chronic fatigue syndrome

Dyn Med. 2007 Jan 30; 6: p.2.
Hypocapnia is a biological marker for orthostatic intolerance in some patients with chronic fatigue syndrome.
Natelson BH, Intriligator R, Cherniack NS, Chandler HK, Stewart JM.
Department of Neurosciences, UMDNJ-New Jersey Medical School, Newark NJ, USA. natelson@njneuromed.org
CONTEXT: Patients with chronic fatigue syndrome and those with orthostatic intolerance share many symptoms, yet questions exist as to whether CFS patients have physiological evidence of orthostatic intolerance.
OBJECTIVE: To determine if some CFS patients have increased rates of orthostatic hypotension, hypertension, tachycardia, or hypocapnia relative to age-matched controls.
DESIGN: Assess blood pressure, heart rate, respiratory rate, end tidal CO2 and visual analog scales for orthostatic symptoms when supine and when standing for 8 minutes without moving legs.
SETTING: Referral practice and research center.
PARTICIPANTS: 60 women and 15 men with CFS and 36 women and 4 men serving as age matched controls with analyses confined to 62 patients and 35 controls showing either normal orthostatic testing or a physiological abnormal test.
MAIN OUTCOME MEASURES: Orthostatic tachycardia; orthostatic hypotension; orthostatic hypertension; orthostatic hypocapnia or combinations thereof.
RESULTS: CFS patients had higher rates of abnormal tests than controls (53% vs 20%, p < .002), but rates of orthostatic tachycardia, orthostatic hypotension, and orthostatic hypertension did not differ significantly between patients and controls (11.3% vs 5.7%, 6.5% vs 2.9%, 19.4% vs 11.4%, respectively). In contrast, rates of orthostatic hypocapnia were significantly higher in CFS than in controls (20.6% vs 2.9%, p < .02). This CFS group reported significantly more feelings of illness and shortness of breath than either controls or CFS patients with normal physiological tests.
CONCLUSION: A substantial number of CFS patients have orthostatic intolerance in the form of orthostatic hypocapnia. This allows subgrouping of patients with CFS and thus reduces patient pool heterogeneity engendered by use of a clinical case definition.

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Arthritis Rheum. 2006 Oct; 54(10): p. 3351-3362.
The influence of aerobic fitness and fibromyalgia on cardiorespiratory and perceptual responses to exercise in patients with chronic fatigue syndrome.
Cook DB, Nagelkirk PR, Poluri A, Mores J, Natelson BH.
University of Wisconsin, Madison, WI 53706, USA. dcook@education.wisc.edu
OBJECTIVE: To investigate cardiorespiratory and perceptual responses to exercise in patients with chronic fatigue syndrome (CFS), accounting for comorbid fibromyalgia (FM) and controlling for aerobic fitness.
METHODS: Twenty-nine patients with CFS only, 23 patients with CFS plus FM, and 32 controls completed an incremental bicycle test to exhaustion. Cardiorespiratory and perceptual responses were measured. Results were determined for the entire sample and for 18 subjects from each group matched for peak oxygen consumption.
RESULTS: In the overall sample, there were no significant differences in cardiorespiratory parameters between the CFS only group and the controls. However, the CFS plus FM group exhibited lower ventilation, lower end-tidal CO2, and higher ventilatory equivalent of carbon dioxide compared with controls, and slower increases in heart rate compared with both patients with CFS only and controls. Peak oxygen consumption, ventilation, and workload were lower in the CFS plus FM group. Subjects in both the CFS only group and the CFS plus FM group rated exercise as more effortful than did controls. Patients with CFS plus FM rated exercise as significantly more painful than did patients with CFS only or controls. In the subgroups matched for aerobic fitness, there were no significant differences among the groups for any measured cardiorespiratory response, but perceptual differences in the CFS plus FM group remained.
CONCLUSION: With matching for aerobic fitness, cardiorespiratory responses to exercise in patients with CFS only and CFS plus FM are not different from those in sedentary healthy subjects. While CFS patients with comorbid FM perceive exercise as more effortful and painful than do controls, those with CFS alone do not. These results suggest that aerobic fitness and a concurrent diagnosis of FM are likely explanations for currently conflicting data and challenge ideas implicating metabolic disease in the pathogenesis of CFS.

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J Neuroimaging. 2003 Jan; 13(1): p. 57-67.
Cerebral and systemic hemodynamics changes during upright tilt in chronic fatigue syndrome.
Razumovsky AY, DeBusk K, Calkins H, Snader S, Lucas KE, Vyas P, Hanley DF, Rowe PC.
Departments of Anesthesiology/Critical Care Medicine, Neurology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA. arazumov@surgicalmonitoring.net
BACKGROUND AND PURPOSE: During head-up tilt (HUT), patients with chronic fatigue syndrome (CFS) have higher rates of neurally mediated hypotension (NMH) and postural tachycardia syndrome (POTS) than healthy controls. The authors studied whether patients with CFS were also more likely to have abnormal cerebral blood flow velocity (CBFV) compared with controls in response to orthostatic stress.
METHODS: Transcranial Doppler monitoring of middle cerebral artery (MCA) CBFV was performed during 3-stage HUT prospectively in 26 patients with CFS and 23 healthy controls. At the same time, continuous monitoring of arterial blood pressure (BP), heart rate (HR), end tidal CO2 (ET-CO2) were performed. Results are reported as mean SD.
RESULTS: NMH developed in 21 patients with CFS and in 14 controls (P = .22). POTS was present in 9 CFS patients and 7 controls (P = .76). Supine HR was higher in CFS patients, but all other hemodynamics and CBFV measures were similar at baseline. The median time to hypotension did not differ, but the median time to onset of orthostatic symptoms was shorter in those with CFS (P < .001). The CBFV did not differ between groups in the supine posture, at 1 or 5 minutes after upright tilt, at 5 or 1 minute before the end of the test, or at termination of the test. Mean CBFV fell at termination of tilt testing in those with CFS and controls. ET-CO2 was lower at termination of the test in those with CFS versus controls (P = .002).
CONCLUSIONS: The results of this study are not consistent with the hypothesis that patients with CFS have a distinctive pattern of MCA CBFV changes in response to orthostatic stress.

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Am J Med Sci. 2006 Jun;331(6): p. 295-303.
Patterns of hypocapnia on tilt in patients with fibromyalgia, chronic fatigue syndrome, nonspecific dizziness, and neurally mediated syncope.
Naschitz JE, Mussafia-Priselac R, Kovalev Y, Zaigraykin N, Slobodin G, Elias N, Rosner I.
Department of Internal Medicine A, the Bnai-Zion Medical Center and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel. Naschitz@tx.technion.ac.il
Abstract
OBJECTIVES: To assess whether head-up tilt-induced hyperventilation is seen more often in patients with chronic fatigue syndrome (CFS), fibromyalgia, dizziness, or neurally mediated syncope (NMS) as compared to healthy subjects or those with familial Mediterranean fever (FMF).
PATIENTS AND METHODS: A total of 585 patients were assessed with a 10-minute supine, 30-minute head-up tilt test combined with capnography. Experimental groups included CFS (n = 90), non-CFS fatigue (n = 50), fibromyalgia (n = 70), nonspecific dizziness (n = 75), and NMS (n =160); control groups were FMF (n = 90) and healthy (n = 50). Hypocapnia, the objective measure of hyperventilation, was diagnosed when end-tidal pressure of CO2 (PETCO2) less than 30 mm Hg was recorded consecutively for 10 minutes or longer. When tilting was discontinued because of syncope, one PETCO2 measurement of 25 or less was accepted as hyperventilation.
RESULTS: Hypocapnia was diagnosed on tilt test in 9% to 27% of patients with fibromyalgia, CFS, dizziness, and NMS versus 0% to 2% of control subjects. Three patterns of hypocapnia were recognized: supine hypocapnia (n = 14), sustained hypocapnia on tilt (n = 76), and mixed hypotensive-hypocapnic events (n = 80). Hypocapnia associated with postural tachycardia syndrome (POTS) occurred in 8 of 41 patients.
CONCLUSIONS: Hyperventilation appears to be the major abnormal response to postural challenge in sustained hypocapnia but possibly merely an epiphenomenon in hypotensive-hypocapnic events. Our study does not support an essential role for hypocapnia in NMS or in postural symptoms associated with POTS. Because unrecognized hypocapnia is common in CFS, fibromyalgia, and nonspecific dizziness, capnography should be a part of the evaluation of patients with such conditions.

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J Psychosom Res. 1997 Oct;43(4):371-7.
The chronic fatigue syndrome and hyperventilation.
Bazelmans E, Bleijenberg G, Vercoulen JH, van der Meer JW, Folgering H.
Department of Medical Psychology, University Hospital Nijmegen, The Netherlands.
Chronic fatigue syndrome (CFS) is characterized by severe fatigue, lasting for at least 6 months, for which no somatic explanation can be found. Because hyperventilation can produce substantial fatigue, it seems worthwhile to investigate the relationship between it and CFS. It might be hypothesized that hyperventilation plays a causal or perpetuating role in CFS. CFS patients, non-CFS patients known to experience hyperventilation, and healthy controls were compared on complaints of fatigue and hyperventilation. CFS patients and non-CFS patients known to experience hyperventilation offered substantial complaints of fatigue and hyperventilation, both to a similar degree. Physiological evidence of hyperventilation was found significantly more often in CFS patients than in healthy controls. However, no significant differences between CFS patients with and CFS patients without hyperventilation were found on severity of fatigue, impairment, number of complaints, activity level, psychopathology, and depression. It is concluded that hyperventilation in CFS should probably be regarded as an epiphenomenon.

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Q J Med. 1994 Jan;87(1):63-7.
Hyperventilation and chronic fatigue syndrome.
Saisch SG, Deale A, Gardner WN, Wessely S.
Department of Thoracic Medicine, Kings College School of Medicine and Dentistry, London, UK.
We studied the link between chronic fatigue syndrome (CFS) and hyperventilation in 31 consecutive attenders at a chronic fatigue clinic (19 females, 12 males) who fulfilled criteria for CFS based on both Oxford and Joint CDC/NIH criteria. All experienced profound fatigue and fatigability associated with minimal exertion, in 66% developing after an infective episode. Alternative causes of fatigue were excluded. Hyperventilation was studied during a 43-min protocol in which end-tidal PCO2 (PETCO2) was measured non-invasively by capnograph or mass spectrometer via a fine catheter taped in a nostril at rest, during and after exercise (10-50 W) and for 10 min during recovery from voluntary overbreathing to approximately 2.7 kPa (20 mmHg). PETCO2 < 4 kPa (30 mmHg) at rest, during or after exercise, or at 5 min after the end of voluntary overbreathing, suggested either hyperventilation or a tendency to hyperventilate. Most patients were able voluntarily to overbreathe, but not all were able to exercise. Twenty-two patients (71%) had no evidence of hyperventilation during any aspect of the test. Only four patients had unequivocal hyperventilation, in one associated with asthma and in three with panic. Only one patient with severe functional disability and agoraphobia had hyperventilation with no other obvious cause. A further five patients had borderline hyperventilation, in which PETCO2 was < 4 kPa (30 mmHg) for no more than 2 min, when we would have expected it to be normal. There was no association between level of functional impairment and degree of hyperventilation. There is only a weak association between hyperventilation and chronic fatigue syndrome.

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Psychosom Med. 1998 Jul-Aug; 60(4): p. 448-457.
Estranged bodies, simulated harmony, and misplaced cultures: neurasthenia in contemporary Chinese society.
Lee S.
Department of Psychiatry, The Chinese University of Hong Kong, Shatin.
Abstract
OBJECTIVE: To study the sociocultural transformation of neurasthenia (shenjing shuairuo, SJSR), as both disease and illness, in Chinese society.
METHOD: This is based on a critical review of evidence drawn from the psychiatric and anthropological literature, and the use of a single case study.
RESULTS: SJSR remains a ubiquitous illness in socio-politically different Chinese societies, but the Americanization of Chinese psychiatry has paradoxically made the "same" disease category languish rapidly in professional practice. Although it engages bodily modes of attention, SJSR is far from being a physical, somatoform, or chronic fatigue disorder.
CONCLUSIONS: Psychiatric disease and illness do not run a "natural" course independent of social and historical contexts. SJSR usefully muddles the Cartesian mind-body dichotomy and is readily compatible with psychosocial manifestations and explanatory models. From a sociosomatic perspective, the embodied world of SJSR may arbitrate as well as critique the conjunctures of large-scale political, economic, and moral transformations in Chinese communities. These macrosocial forces and their local manifestations need to be considered in deriving a cross-culturally valid paradigm of psychosomatic medicine.

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Arthritis Res Ther. 2008;10(3):R56. Epub 2008 May 13.
Sleep structure and sleepiness in chronic fatigue syndrome with or without coexisting fibromyalgia.
Togo F, Natelson BH, Cherniack NS, FitzGibbons J, Garcon C, Rapoport DM.
Pain and Fatigue Study Center, Department of Neurosciences, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, 30 Bergen Street, Newark, NJ 07103, USA. tougou@p.u-tokyo.ac.jp
INTRODUCTION: We evaluated polysomnograms of chronic fatigue syndrome (CFS) patients with and without fibromyalgia to determine whether patients in either group had elevated rates of sleep-disturbed breathing (obstructive sleep apnea or upper airway resistance syndrome) or periodic leg movement disorder. We also determined whether feelings of unrefreshing sleep were associated with differences in sleep architecture from normal.
METHODS: We compared sleep structures and subjective scores on visual analog scales for sleepiness and fatigue in CFS patients with or without coexisting fibromyalgia (n = 12 and 14, respectively) with 26 healthy subjects. None had current major depressive disorder, and all were studied at the same menstrual phase.
RESULTS: CFS patients had significant differences in polysomnograpic findings from healthy controls and felt sleepier and more fatigued than controls after a night's sleep. CFS patients as a group had less total sleep time, lower sleep efficiency, and less rapid eye movement sleep than controls. A possible explanation for the unrefreshing quality of sleep in CFS patients was revealed by stratification of patients into those who reported more or less sleepiness after a night's sleep (a.m. sleepier or a.m. less sleepy, respectively). Those in the sleepier group reported that sleep did not improve their symptoms and had poorer sleep efficiencies and shorter runs of sleep than both controls and patients in the less sleepy group; patients in the less sleepy group reported reduced fatigue and pain after sleep and had relatively normal sleep structures. This difference in sleep effects was due primarily to a decrease in the length of periods of uninterrupted sleep in the a.m. sleepier group.
CONCLUSION: CFS patients had significant differences in polysomnographic findings from healthy controls and felt sleepier and more fatigued than controls after a night's sleep. This difference was due neither to diagnosable sleep disorders nor to coexisting fibromyalgia but primarily to a decrease in the length of periods of uninterrupted sleep in the patients with more sleepiness in the morning than on the night before. This sleep disruption may explain the overwhelming fatigue, report of unrefreshing sleep, and pain in this subgroup of patients.

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Sleep Med. 2006 Sep;7(6):513-20. Epub 2006 Aug 24.
Chronic fatigue, unrefreshing sleep and nocturnal polysomnography.
Guilleminault C, Poyares D, Rosa A, Kirisoglu C, Almeida T, Lopes MC.
Stanford University Sleep Disorders Clinic, 401 Quarry road, suite 3301, Stanford, CA 94305, USA. cguil@stanford.edu
BACKGROUND AND PURPOSE: To investigate the complaint of unrefreshing sleep with study of sleep electroencephalogram (EEG) in patients with chronic fatigue.
PATIENTS AND METHODS: Fourteen successively seen patients (mean age: 41.1 9.8) who complained of chronic fatigue but denied sleepiness and agreed to participate were compared to 14 controls (33.610.2 years) who were monitored during sleep recorded in parallel. After performing conventional sleep scoring we applied Fast Fourier Transformation (FFT) for the delta 1, delta 2, theta, alpha, sigma 1, sigma 2, beta EEG frequency bands. The presence of non-rapid eye movement (NREM) sleep instability was studied with calculation of cyclic alternating pattern (CAP) rate. Two-way analysis of variance (ANOVA) was performed to analyze FFT results and Mann-Whitney U-test to compare CAP rate in both groups of subjects.
RESULTS: Slow wave sleep (SWS) percentage and sleep efficiency were lower, but there was a significant increase in delta 1 (slow delta) relative power in the chronic fatigue group when compared to normals (P<0.01). All the other frequency bands were proportionally and significantly decreased compared to controls. CAP rate was also significantly greater in subjects with chronic fatigue than in normals (P=0.04). An increase in respiratory effort and nasal flow limitation were noted with chronic fatigue.
CONCLUSIONS: The complaints of chronic fatigue and unrefreshing sleep were associated with an abnormal CAP rate, with increase in slow delta power spectrum, affirming the presence of an abnormal sleep progression and NREM sleep instability. These specific patterns were related to subtle, undiagnosed sleep-disordered breathing.

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Physiother Theory Pract. 2008 Mar-Apr;24(2):83-94.
Breathing retraining in patients with chronic fatigue syndrome: a pilot study.
Nijs J, Adriaens J, Schuermans D, Buyl R, Vincken W.
Department of Human Physiology, Faculty of Physical Education and Physiotherapy, Vrije Universiteit, Brussel, Belgium. Jo.Nijs@vub.ac.be
The study aimed to 1) examine the point prevalence of asynchronous breathing in chronic fatigue syndrome (CFS) patients; 2) examine whether CFS patients with an asynchronous breathing pattern present with diminished lung function in comparison with CFS patients with a synchronous breathing pattern; and 3) examine whether one session of breathing retraining in CFS patients with an asynchronous breathing pattern is able to improve lung function. Twenty patients fulfilling the diagnostic criteria for CFS were recruited for participation in a pilot controlled clinical trial with repeated measures. Patients presenting with an asynchronous breathing pattern were given 20-30 minutes of breathing retraining. Patients presenting with a synchronous breathing pattern entered the control group and received no intervention. Of the 20 enrolled patients with CFS, 15 presented with a synchronous breathing pattern and the remaining 5 patients (25%) with an asynchronous breathing pattern. Baseline comparison revealed no group differences in demographic features, symptom severity, respiratory muscle strength, or pulmonary function testing data (spirometry). In comparison to no treatment, the session of breathing retraining resulted in an acute (immediately postintervention) decrease in respiratory rate (p < 0.001) and an increase in tidal volume (p < 0.001). No other respiratory variables responded to the session of breathing retraining. In conclusion, the present study provides preliminary evidence supportive of an asynchronous breathing pattern in a subgroup of CFS patients, and breathing retraining might be useful for improving tidal volume and respiratory rate in CFS patients presenting with an asynchronous breathing motion.

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Clin Auton Res. 1995 Jun; 5(3): p. 139-143.
Vagal tone is reduced during paced breathing in patients with the chronic fatigue syndrome.
Sisto SA, Tapp W, Drastal S, Bergen M, DeMasi I, Cordero D, Natelson B.
Neurobehavioral Unit, VA Medical Center, E. Orange, NJ 07018-1095, USA.
Patients with chronic fatigue syndrome (CFS) often complain of an inability to maintain activity levels and a variety of autonomic-like symptoms that make everyday activity intolerable at times. The purpose of the study was to determine if there were differences in vagal activity at fixed breathing rates in women with CFS. Twelve women with the diagnosis of CFS between the ages of 32 and 59 years volunteered for the study. Healthy women, who were between the ages of 30 and 49, served as controls. Full signal electrocardiograph and respiratory signals were collected during a paced breathing protocol of three fixed breathing rates (8, 12 and 18 breaths/min) performed in the sitting and standing postures. Vagal activity was analyzed by means of heart rate spectral analysis to determine the subject's response to specific breathing rates and postures. Heart rate variability was used as a non-invasive method of measuring the parasympathetic component of the autonomic nervous system. Using this method, although there was significantly less vagal power in the sitting versus the standing postures for both groups, the overall vagal power was significantly lower (p < 0.034) in the CFS group versus healthy controls. Vagal power was also significantly lower (p < 0.01 to p < 0.05) at all breathing rates in both postures except while standing and breathing at 18 breaths/min. Knowledge of the differences in vagal activity for CFS patients may allow stratification for the analysis of other research variables.

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