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All About Fibromyalgia A Guide for Patients and Their
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 All About Fibromyalgia

DANIEL J. WALLACE, M.D.

JANICE BROCK WALLACE, M.P.A.

OXFORD UNIVERSITY PRESS

 Foreword

All About Fibromyalgia is a well-written compendium directed to the millions

with severe fatigue, muscular pain, poor sleep patterns, and the other symptoms
characteristic of fibromyalgia. While there is continuing debate in the medical
and research community about the causes and treatments for this misunderstood
syndrome, Dr. Daniel J. Wallace’s clinical experience and studied review of the
current literature have enabled him to produce a book that discusses many of the
current theories and understandings.
Dr. Wallace’s specific discussions on the diagnostic elements; procedures that
support, differentiate, and exclude fibromyalgia as a primary or secondary condi­
tion; and specific therapies and their expected efficacies continue the learning
process for the reader and provide hope through better understanding of this often
maligned condition.
This is an important book that provides a nice complement to the Arthritis
Foundation’s own publication Your Personal Guide to Living with Fibromyalgia.
The Arthritis Foundation, Southern California Chapter, is grateful to Dr. Daniel J.
Wallace and Oxford University Press for their support of our program for people
with fibromyalgia through donations from the sale of this book, All About
Fibromyalgia.

Medical & Scientific Committee

Arthritis Foundation, Southern California Chapter
Los Angeles, California
 Preface

To talk of diseases is a sort of Arabian Night’s entertainment

Sir William Osler (1849–1919)

Among the childhood pastimes we enjoyed was a peculiar board game known as
“Uncle Wiggily” (Fig. 1). Its premise seems quaint when viewed from an adult
perspective some 40 years later, but the first player enabling Uncle Wiggily to
reach Doc Possum’s house so that his rheumatism could be treated was the win­
ner. Along the way, all sorts of nostrums, barriers, diversions, and misinformation
deterred Uncle Wiggily from his goal. What, we asked our child’s mind, was
rheumatism? This mysterious, all-encompassing term could apply to fibromyalgia.
Fibromyalgia is a syndrome that defies our usual concepts of a disorder and is
classified by the Arthritis Foundation as a form of “soft tissue rheumatism.”
The purpose of this monograph is to enable you to help yourself; to make it easier
to work with your doctor and other allied health professionals; to improve the
way you feel; and to promote a better quality of life. To begin, there are several
reasons why fibromyalgia is plagued by misunderstanding:

■ Although it is now recognized as a legitimate syndrome by the American

Medical Association, American College of Rheumatology, Arthritis Founda­
tion, and American College of Physicians, as well as the World Health Orga­
nization, some doctors still question its existence. This is largely a consequence
of incomplete medical training that was (and often still is) primarily hospital
based. Outpatient (office-based) clinical medicine training, which included
fibromyalgia, was largely overlooked. Patients are rarely, if ever, hospital­
ized for fibromyalgia. Also, statistically validated criteria for defining
fibromyalgia were not endorsed by organized medicine until 1990. Many
physicians are therefore unaware that fibromyalgia has been accorded its own
coding number for insurance billing (7290).
■ Fibromyalgia patients often have normal blood tests and imaging studies and
are thought by some health care professionals to make up many of their symp­
toms. Certain doctors consider fibromyalgia patients to be hypochondriacs or
seekers of medical attention for purposes of litigation or secondary gain. For­
tunately, there are now reproducible tests documenting that these complaints
 Fibromyalgia Made Simple:
A Parable

Pain has an element of blank;

It cannot recollect
When it began, or if there were
A day when it was not.

It has no future but itself

Its infinite realms contain
Its past, enlightened to perceive
New periods of pain.
Emily Dickinson (1830–1896),
Pain Has an Element of Blank

If you have the chronic pain of fibromyalgia, you may be frustrated by the lack of
understanding shown by people around you. This is particularly true of the people
you live and work with. If only they could feel for 1 day how you feel all year!
Pain has no memory and no mercy. Is it like a bad flu or a severe headache? How
can you find the words to describe it? You might wish to recite this short explana­
tion; the next 200 pages provide the details.
Picture your body as being a series of electrical circuits. Suppose that you have
the unfortunate tendency to injure your shoulder repeatedly. What happens? As
part of a chronic pain response, a wire goes from the shoulder to your spine, and
a second wire then travels up the spinal cord to your brain. The brain receives a
signal that says, “I hurt my shoulder; let me do something about it.” The brain
then makes a chemical or chemicals that suppress the pain. It wires a signal back
down the spinal column, and a second wire returns to the shoulder. The chemical
is released, and the pain gets better or goes away.
What happens in fibromyalgia? Your body becomes “cross-circuited” (Fig. 2).
The body gets flooded with “input” circuits giving it information. The spinal cord
can’t sort out and filter these signals. Larger circuits close off smaller ones. With
time, the electrical circuits become “wiry” and excitable. Normally non-painful
stimuli are regarded as painful ones. The “output” wires fail to alleviate discom­
fort. The circuits discharge signals that increase your perception of pain, not only
in the region that was hurt but also in the area around it. As a result, the processes
 Contents

Foreword vii
Preface ix
Fibromyalgia Made Simple: A Parable xiii

Part I The Whys and Wherefores of Fibromyalgia 3

1. How Our Understanding of Fibromyalgia Evolved 5

2. What is Fibromyalgia? 9
3. Who Gets Fibromyalgia and Why? 14

Part II Basic Science and Fibromyalgia 21

4. Why and How Do We Hurt? 23

5. What’s Wrong with My Muscles? 34
6. How Do Stress, Sleep, Hormones, and the Immune System Interact and
Relate to Fibromyalgia? 38
7. What is the Autonomic Nervous System? 45

Part III How and Where the Body Can Be Affected by Fibromyalgia 51

8. Generalized Complaints 53
9. “I’m Stiff and Achy”—Musculoskeletal Complaints 56
10. Tingles, Shocks, Wires, and Neurologic Complaints 59
11. Insights into Insides: Chest, Cardiovascular, and Other Concerns 65

Part IV The Clinical Spectrum of Fibromyalgia 71

12. What are the Regional and Localized Forms of Fibromyalgia? 73

13. What Conditions are Associated with Fibromyalgia? 79
14. Controversial Syndromes and Their Relationship to Fibromyalgia 94
 All About
Fibromyalgia
This page intentionally left blank
 Part I
THE WHYS AND
WHEREFORES OF
FIBROMYALGIA
Is it nothing to you, all that pass by? Behold and see. Is there
any pain like unto my pain, which is done unto me, wherewith
the Lord has afflicted me in the day of his fierce anger? From
above, he has sent fire into my bones. . . . and I am weary and
faint all the day.
Jeremiah, in Lamentations 11:12–13

In this part the reader will discover how fibromyalgia evolved and was ultimately
defined. Although descriptions of it date back to biblical times, the perception of
fibromyalgia as a syndrome represents a convergence of two historical threads:
those relating to ongoing musculoskeletal pain (joint and muscle aches) and those
dealing with chronic fatigue and a sense of debility. Both official and practical
definitions of fibromyalgia will be discussed, and we will consider the number of
people who have the syndrome, as well as population groups that most frequently
develop it.
This page intentionally left blank
 1
How Our Understanding of
Fibromyalgia Evolved

. . . and wearisome nights are appointed to me. When I lie down,

I say, When shall I arise, and the night be gone? And I am full of
tossings to and fro unto the dawning of the day . . . and the days
of affliction have taken hold upon me. My bones are pierced in
me in the night season; and my sinews take no rest.
Job 7:3–4 and 30:16–17.

There are times when rheumatologists have been accused of making up new syn­
dromes. For example, in the last 20 years, our specialty has described new rheu­
matic entities including Lyme disease, the musculoskeletal manifestations of
acquired immune deficiency syndrome (AIDS), eosinophilic myalgia syndrome
(from L-tryptophan contamination), and siliconosis (which, if it exists, results
from silicone breast implants). Fibromyalgia is not in this group. Evidence for the
syndrome can be found as far back in history as the book of Job, where he com­
plained of “sinews (that) take no rest.”

MUSCULOSKELETAL PAIN AMPLIFICATION

Seemingly exaggerated tenderness of the muscles and soft tissues to touch was
documented in the nineteenth-century medical literature by French, German, and
British scientists, who called it spinal irritation, Charcot’s hysteria, or a morbid
affection. Tender points were first described by Balfour in 1824 and Villieux in
1841. The English physician Sir William R. Gowers (1845-1915) coined the term
fibrositis in 1904 in a paper on lumbago (low back pain) when he tried to describe
inflammatory changes in the fibrous tissues of the muscles of the low back. Gowers
was wrong. There is no such thing as inflammation of the fibrous tissues, but the
term lived on because British physicians used fibrositis to denote pain in the up­
per back and neck areas among Welsh coal miners in the 1920s and 1930s. The
definition of fibrositis cross-pollinated during the Second World War when United
States, Canadian, Australian, and New Zealand physicians served with their Brit­
ish counterparts. Soldiers who were unwilling to fight or who experienced shell
shock, or complained of aches and pains due to carrying heavy gear without any
obvious disease, were diagnosed as having fibrositis.
[6] The Whys and Wherefores of Fibromyalgia

A symptom complex of fatigue, palpitations, dizziness, gastrointestinal symp­

toms, headache, sleep disturbance, and aching was first noted by the Union phy­
sician J. M. da Costa among 300 soldiers during the Civil War who had what he
termed an “irritable heart.” The first mention of fibrositis in the North American
medical literature appeared in a rheumatology textbook chapter written by Wallace
Graham in 1940. Rheumatology established its first fellowship and training pro­
grams in the United States after the Second World War and, more often than not,
their directors were medical officers who had become interested in the discipline
as a result of working with their British colleagues.
No substantive changes in the understanding of fibrositis were evident until a
series of very important observations were published by the rheumatologist Hugh
Smythe and his colleagues at the University of Toronto in the mid-1970s. They
renamed the disorder “fibrositis syndrome” and convincingly connected it to sys­
temic symptoms such as fatigue and sleep abnormalities. Smythe popularized the
use of the tender point examination suggested by others and frequently referred to
fibrositis as a pain amplification disorder.

FATIGUE SYNDROMES
The history of fibromyalgia is one of merging observations from two directions.
Musculoskeletal aches in the soft tissues (supporting areas near muscles and joints)
were termed fibrositis and eventually became associated with nonmusculoskeletal
symptoms such as fatigue and sleep disorders. From the other direction, fatigue
syndromes ultimately were correlated with fibromyalgia. In 1750, Sir Richard
Manningham described febricula or “little fever,” among mostly upper-class fe­
males, who were afflicted with “listlessness, with great lassitude and weariness
all over the body . . . little flying pains . . . the patient is a little . . . forgetful.”
These complaints were aggravated by stress.
Dr. George Beard (1839–1883) first used the word neurasthenia to describe
deficient nerve tone, general debility, poor appetite, and “living on a plane lower
than normal.” This wonderful Victorian expression characterized many women in
English and American literature throughout the nineteenth century, ranging from
Miss Marchmont in Charlotte Brontë’s Villette to Mrs. Snow in Polyanna.
Neurasthenia represented a form of “failure to thrive” and often reflected the stunted
aspirations of worldly women whose ability to get ahead was blocked by out­
moded societal conventions of trying to cope with the Industrial Revolution and
the Age of Mechanization. In his landmark 1899 medical textbook, Sir William
Osler (1849-1919) described neurasthenia as “hyperesthesia, especially to sensa­
tions of pain . . . weariness to the least exertion, pain in the back, aching in the legs
. . . spots of local tenderness . . . the aching pain in the back of the neck is the most
constant complaint in these cases.” All too frequently, neurasthenia was managed
by uptight and condescending male physicians who used a variety of seemingly
 How Our Understanding of Fibromyalgia Evolved [7]

preposterous remedies such as rest cures, overfeeding, electricity, clitoridectomy,

or oophorectomy (removal of the clitoris or ovaries). During the First World War,
males suffering from shell shock resulting from trench warfare and exhibiting
symptoms of neurasthenia were described; thereafter, the term disappeared from
the medical literature.

PROLONGED RECOVERY FROM INFECTIOUS ILLNESSES

Between the 1930s and 1950s, patients exposed to infections such as polio during
epidemics and a bacterial disease known as brucellosis were identified as having
postinfectious chronic fatigue, aching, and debility. Other patients were evaluated
by neurologists and found to have atypical forms of myasthenia gravis or multiple
sclerosis. Some were consequently labeled as having chronic nervous exhaustion,
myasthenic syndrome, Icelandic disease, myalgic encephalomyelitis, or epidemic
neuromyasthenia, depending on where and by whom they were treated. The 1980s
signaled the advent of Epstein-Barr virus syndrome, a postviral fatigue syndrome
ultimately renamed chronic fatigue syndrome. Chronic fatigue syndrome frequently
overlaps with fibromyalgia; this relationship is discussed in chapter 13.

THE LINKAGE OF PAIN, FATIGUE,

CHRONIC NEUROMUSCULAR PAIN, AND
POSTINFECTIOUS SYNDROMES
Smythe’s connection of fibrositis with systemic symptoms and the inappropriate­
ness of the term fibrositis (since no inflammation was present) prompted Dr.
Muhammed Yunus and his associates at the University of Illinois at Peoria to take
up a suggestion of Dr. Kahler Hench (son of Dr. Phillip Hench, the only rheuma­
tologist to win a Nobel prize for discovering that cortisone helped arthritis) that
the term fibromyalgia better described the syndrome. Yunus was also the first to
validate statistically the benefits of measuring tender points and to compare
fibromyalgia populations with healthy normal, or control groups. Published in
1981, these observations were immediately endorsed by nearly all rheumatolo­
gists. Yunus also was the first investigator to associate objectively what is now
called chronic neuromuscular pain complaints such as irritable colon, tension
headache, numbness, tingling, and swelling or edema with the disorder. He also
postulated that chemicals creating these symptoms and signs are also influenced
by factors such as emotional or physical stress or trauma, mood, and behavior.
During the 1980s, studies showed that patients diagnosed with fibromyalgia in­
cluded many originally described as having conditions such as muscular rheuma­
tism, musculoligamentous strain, and other syndromes diagnosed by orthopedists,
neurologists, neurosurgeons, and physical medicine specialists. Further, the devel­
opment of tests supporting scientifically acceptable, reproducible abnormalities in
[8] The Whys and Wherefores of Fibromyalgia

fibromyalgia led the American Medical Association in 1987 to editorialize that the
syndrome truly existed. A committee subsequently was formed to devise a defini­
tion and description of fibromyalgia for statistical and research purposes, and these
criteria were adopted by the American College of Rheumatology in 1990.

SUMMING UP
A biblical description of a set of symptoms and signs culminated in the recogni­
tion of a syndrome characterized by musculoskeletal complaints combined with
fatigue, poor sleep, pain amplification, and other nonmusculoskeletal symptoms.
The concept of fibromyalgia has clearly come a long way, but there are many
miles to travel. The next two chapters will define fibromyalgia and describe those
among us who are susceptible to it.
 2
What is Fibromyalgia?

A woman armed with sick headaches, nervousness, debility, pre-

sentiments, fears, horrors, and all sorts of imaginary and real
diseases has an external armory of weapons of subjugation.
Harriet Beecher Stowe (1811–1886), Pink and White Tyranny, 1871

When the Arthritis Foundation tried to categorize the 150 different forms of mus­
culoskeletal conditions in 1963, it created a classification known as soft tissue
rheumatism. Included in this listing are conditions in which joints are not involved.
Soft tissue rheumatism encompasses the supporting structures of joints (e.g., liga­
ments, bursae, and tendons), muscles, and other soft tissues. Fibromyalgia is a
form of soft tissue rheumatism. A combination of three terms—fibro (from the
Latin fibra, or fibrous tissue), myo- (the Greek prefix myos, for muscles), and
algia (from the Greek algos, which denotes pain)—fibromyalgia replaces earlier
names for the syndrome that are still used by doctors and other health profession­
als such as myofibrositis, myofascitis, muscular rheumatism, fibrositis, and gener-
alized musculoligamentous strain. Fibromyalgia is not a form of arthritis, since it
is not associated with joint inflammation.

THE AMERICAN COLLEGE OF RHEUMATOLOGY (ACR)

FIBROMYALGIA CRITERIA
In the late 1980s, a Multicenter Criteria Committee under the direction of Dr.
Frederick Wolfe at the University of Kansas was formed to define fibromyalgia.
In their study, 293 patients with presumed fibromyalgia were compared with 265
patients who had other rheumatic diseases in 16 centers throughout North Amer­
ica. The groups were evaluated for a variety of symptoms, signs, and laboratory
abnormalities in an effort to ascertain which factors were the most sensitive and
specific for defining the disorder. In other words, the investigators wanted to iden­
tify the most frequently found features of fibromyalgia (sensitivity) that could
help doctors differentiate it from other disorders (specificity). The list in Table 1
(illustrated in Fig. 3) was 88.4 percent sensitive and 81.1 percent specific in iden­
tifying fibromyalgia patients. As a result, these criteria were endorsed in 1990 by
the American College of Rheumatology (ACR), the association to which nearly
all 5,000 rheumatologists in the United States and Canada belong.
[10] The Whys and Wherefores of Fibromyalgia

Focusing on Table 1 and Figure 3, fibromyalgia essentially is:

1. Widespread pain of at least 3 months’ duration (this rules out viruses or

traumatic insults which resolve on their own).
2. Pain in all four quadrants of the body (picture cutting the body into quarters,
as in a pie): right side, left side, above the waist, below the waist.
3. Pain occurring in at least 11 of 18 specified “tender” points (as shown in the
figure) with at least one point in each quadrant.
4. Pain defined, in this context, as discomfort when 8 pounds of pressure are
applied to the tender point.

Tender points usually occur in a specific distribution. For instance, 8 of the 18

tender points are in the upper back and neck area, and only two are below the
buttocks. The reader should be aware that tender points can occur almost any-

Table 1. The 1990 ACR Criteria for Fibromyalgia

1. History of widespread pain.

Definition: Pain is considered widespread when all of the following are present: pain in the left
side of the body, pain in the right side of the body, pain above the waist and pain below the
waist. In addition, axial skeletal pain (cervical spine or anterior chest or thoracic spine or low
back) must be present. In this definition shoulder and buttock pain is considered as pain for
each involved side. “Low back” pain is considered lower segment pain.
2. Pain in 11 of 18 tender point sites on digital palpation.
Definition: Pain, on digital palpation, must be present in at least 11 of the following 18 tender
point sites:
Occiput: bilateral, at the suboccipital muscle insertions.
Low cervical: bilateral, at the anterior aspects of the inter-transverse spaces at C5–C7.
Trapezius: bilateral, at the midpoint of the upper border.
Supraspinatus: bilateral, at origins, above the scapula spine near the medial border.
2nd rib: bilateral, at the second costochondral junctions, just lateral to the junctions on upper
surfaces.
Lateral epicondyle: bilateral, 2 cm distal to the epicondyles.
Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle.
Greater trochanter: bilateral, posterior to the trochanteric prominence.
Knees: bilateral, at the medial fat pad proximal to the joint line.
For a tender point to be considered “positive” the subject must state that the palpation was
painful. “Tender” is not to be considered painful.

Note: For classification purposes patients will be said to have fibromyalgia if both criteria are satisfied. Wide­
spread pain must have been present for at least 3 months. The presence of a second clinical disorder does not
exclude the diagnosis of fibromyalgia.
 What is Fibromyalgia? [11]

Fig. 3 Fibromyalgia tender points. (Adapted from “The Three Graces,”

Louvre Museum, Paris. From D.J. Wallace, The Lupus Book. New York:
Oxford University Press, 1995, p. 170; reprinted with permission from Dr. F. Wolfe.)

where in the body; the ACR criteria simply represent the most common 18 points.
A consensus conference later agreed that the four factors listed above do not have
to be present at the same time in order to meet the criteria. Therefore, a patient
may have only right buttock pain on one day and left upper back pain on another,
or have different tender points on different days.
Once fibromyalgia was defined, it was possible to perform more reliable stud­
ies on this syndrome, since all researchers would be using the same definition. We
could now explore how many people in the United States had fibromyalgia, deter­
mine what their primary complaints were, and identify groups of people on whom
[12] The Whys and Wherefores of Fibromyalgia

to test new treatments. Reporting a reproducible set of symptoms and signs has
had additional fringe benefits: patients can be clearly educated on their condition;
medical and other professional schools can teach students about fibromyalgia us­
ing a core terminology that has high sensitivity and specificity; and insurance
companies now recognize fibromyalgia as a distinct syndrome.

OTHER FEATURES OF FIBROMYALGIA

In the previous chapter, we mentioned that fibromyalgia is associated with fa­
tigue, sleep disturbances, and bowel complaints, among other symptoms and signs.
How do these symptoms fit into the definition of fibromyalgia? The criteria com­
mittee considered these findings and correlated them statistically with the syn­
drome, but the symptoms did not have a high enough score in enough patients to
be part of the definition. For example, Dr. Wolfe, in another article in 1990, stated
that sleep disturbance, fatigue, numbness or tingling, and anxiety had more than a
60 percent occurrence in defining fibromyalgia, and headache or irritable bowel
had more than a 50 percent occurrence. In fact, he observed that the presence of
seven of 18 tender points with four of the six features listed above was “highly
suspicious” for the diagnosis.
In response to this, a group of international fibromyalgia experts issued what
was termed the Copenhagen Declaration in 1992 and adopted by the World Health
Organization in 1993. They recognized the use of the ACR criteria for research
purposes but defined fibromyalgia as being part of a wider spectrum encompass­
ing headache, irritable bladder, spastic colitis, painful menstrual periods, tem­
perature sensitivity, atypical patterns of numbness and tingling, exercise intolerance,
and complaints of weakness in addition to persistent fatigue, stiffness, and
nonrestoring sleep.
It should be emphasized that disease definitions and criteria are always being
updated and refined. In the next decade the ACR fibromyalgia criteria will prob­
ably be revised and hopefully will include newer forms of blood testing or brain
imaging abnormalities.

FIBROMYALGIA TERMINOLOGY:
CLASSIFICATION AND REGIONAL FORMS
Many rheumatologists recognize two types of fibromyalgia: primary and secondary.
The cause of primary fibromyalgia syndrome is unknown, but it can be induced
by trauma, infection, stress, inflammation, or other factors. Secondary fibromyalgia
occurs when a primary condition, such as hypothyroidism or lupus, creates a con­
comitant fibromyalgia, the treatment of which may make the syndrome disappear.
The next chapter will review this topic in more detail.
Sometimes, pain identical to that associated with fibromyalgia is located in
specific areas or regions or in one quadrant of the body. For example, patients
 What is Fibromyalgia? [13]

may have jaw and neck pain on one side and no discomfort anywhere else. Re­
gional forms of fibromyalgia are called regional myofascial syndrome or myofascial
pain syndrome. This entity is reviewed in detail in chapter 12.
Finally, patients may hear a lot about trigger points or tender points. Many
doctors consider them to be the same thing. However, for research purposes, there
are subtle differences. A tender point is an area of tenderness in the muscles,
tendons, bony prominences, or fat pads, whereas a trigger point shoots down to
another area. For instance, when a trigger point is touched, it shoots pain to other
muscles. Like pulling a trigger in a gun, it sends out a bullet that travels, and pain
can be felt in areas away from the trigger.

HOW TO RESPOND TO PEOPLE WHO

DO NOT BELIEVE FIBROMYALGIA EXISTS
Since fibromyalgia is a relatively new entity, some physicians who may have had
the topic barely covered in medical school tend to downplay its importance, say
“its all psychiatric,” or deny its existence. Many training programs are almost
entirely hospital-based and few patients with fibromyalgia are ever hospitalized
for it. Most importantly, fibromyalgia is not a disease; it is a syndrome or a con-
struct. Simply stated, fibromyalgia is a form of chronic neuromuscular pain that
meets statistically validated criteria. Some doctors don’t like the name “fibro­
myalgia” because it could stigmatize patients. Since the syndrome encompasses
individuals with lupus, scoliosis, and hypothyroidism, fibromyalgia’s boundaries
tend to defy the occasional patient’s desire to blame the syndrome as the reason
why they cannot work, function in society, or be happy. The authors have heard
fibromyalgia being called the Emperor’s new clothes syndrome, generalized rheu-
matism, or feeling out of sorts. Nevertheless, every recognized medical organiza­
tion from the American College of Rheumatology, the American Medical Association,
World Health Organization, and the American College of Physicians to medical
insurers have endorsed its existence. There has never been a published peer-review
study or report from a medical society challenging the validity of fibromyalgia as a
syndrome or construct. Finally, some critics refuse to recognize fibromyalgia as an
entity because it lacks firm physical signs. Not only is this not the case, but the same
analogy applies to migraine headaches. Nobody disputes the existence of migraines,
and Americans spend $14 billion a year on their treatment.

SUMMING UP
The term fibromyalgia refers to a complex syndrome characterized by pain ampli­
fication, musculoskeletal discomfort, and systemic symptoms. Although its exist­
ence was questioned in the past, nearly all rheumatologists, medical societies, and
the overwhelming majority of physicians now accept fibromyalgia as a distinct
diagnostic entity.
[14] The Whys and Wherefores of Fibromyalgia

3
Who Gets Fibromyalgia and Why?

I am glad my case is not serious but these nervous troubles are

dreadfully depressing.
Charlotte Perkins Gilman (1860–1935), The Yellow Wallpaper, 1913

When fibromyalgia is first diagnosed, patients often have two reactions. The first
reaction is relief. They have a legitimate diagnosis and are not crazy. Then a feel­
ing of loneliness and a hint of fear can be detected, since many patients have never
heard of the fibromyalgia syndrome and do not know what to do. It is worth
repeating that the intent of this book is to promote a better understanding of
fibromyalgia, as well as to provide patients, allied health professionals, and phy­
sicians with ways to work together. But first, this chapter will discuss how many
people have fibromyalgia and how it might have been acquired.

HOW PREVALENT IS FIBROMYALGIA?

Until recently, nobody knew how many people had fibromyalgia. Dr. Frederick
Wolfe, the same physician who chaired the ACR Criteria Committee, received funding
to undertake an epidemiologic survey of the syndrome. Using computerized appli­
cations of field methodologies to estimate the prevalence of fibromyalgia (the num­
ber of cases per 100,000 individuals), his team estimated that 6 million people in the
United States fulfill the ACR criteria for fibromyalgia. This and other surveys sug­
gest that while 2 percent of the adult U.S. population have full-blown fibromyalgia
(3.5 percent of adult women and 0.5 percent of adult men), 11 percent have chronic
widespread pain and 20 percent have chronic regional pain. Recently, Dr. Larry
Bradley at the University of Alabama has found that for every diagnosed fibromyalgia
patient in the United States, there is an undiagnosed individual who has the requisite
tender points, but never seeks medical attention for this. This has been termed com-
munity fibromyalgia. A survey in Great Britain found that 13 percent of the popula­
tion had chronic widespread pain, 72 percent of whom sought medical attention for
it. Of those, 21 percent fulfilled the ACR criteria for fibromyalgia. In other words,
of individuals with chronic neuromuscular pain, less than half have diagnosed
fibromyalgia or community fibromyalgia.
Fibromyalgia is the third or fourth most common reason for consulting a rheu­
matologist. Approximately 15 to 20 percent of all patients seeking rheumatology
 Who Gets Fibromyalgia and Why? [15]

referrals have fibromyalgia. The 5,000 rheumatologists in the United States who
are trained in internal medicine and subspecialize in managing more than 150
musculoskeletal and immune system disorders are very familiar with the diagno­
sis and treatment of fibromyalgia.

WHO DEVELOPS FIBROMYALGIA?

Even though one American in 50 has fibromyalgia, the syndrome is distributed
unevenly across the population. Eighty to ninety percent of patients with the con­
dition are women. (One theory contends that women have a lower pain threshold
than men, which is hormonally related.) Fibromyalgia is extremely uncommon in
children and rarely appears for the first time in older persons. Within these groups,
complaints and clinical features are atypical (see chapter 16). In the United States,
fibromyalgia is more common among Caucasians than among other racial groups.
Using the ACR criteria or other earlier suggested criteria, the prevalence of
fibromyalgia in other countries or regions (mostly in Europe, Canada, and Austra­
lia) has ranged from 0.5 percent to 12 percent. Some researchers have observed an
increased prevalence among first-generation immigrant families in the United
States. For instance, our research group has been struck by the relatively high
prevalence of fibromyalgia among newly arrived Iranians and Russians.
Are humans the only species to develop fibromyalgia? Probably not. Lame­
ness has been observed in dogs for some time, and articles in the veterinary liter­
ature convincingly show that they can also have tender points.

HOW OLD DO YOU HAVE TO BE TO GET FIBROMYALGIA?

Most of our fibromyalgia patients are in their prime of life and at the peak of their
careers. Surveys have shown that most patients develop the syndrome in their 30s
and 40s. Fibromyalgia infrequently evolves during adolescence. Whereas 60 per­
cent of cases are diagnosed in people between the ages of 30 and 49, another 35
percent of patients are diagnosed in their 20s or between the age of 50 and 65. The
reasons for this distribution are not clear, but the decline in onset after the age of
50 may have something to do with menopause in women, which may alleviate
(but occasionally aggravate) certain fibromyalgia symptoms.

IS FIBROMYALGIA GENETIC?
In the mid-1980s, one research study suggested that fibromyalgia patients had an
increased prevalence of a specific gene. These results, however, were shown to be
inaccurate when confirmatory studies were performed on a larger scale. Even
though no fibromyalgia genetic markers have been found, we are aware of studies
documenting a high prevalence of the syndrome among certain families. For ex­
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St May Wah Plumbing Co 680 Sawyer St Mensor Plumbing 2446
Clement St Metro Plumbing &. Sheet Metal Works 686 Shotwell St
MITCHELL E INC 993 Tetmeaaee St (94107) Tel (41S) 82«2929
MODERN PLUMBING AND HEATING INC 1384 San Bruno Av
(94110), Tel 285-7306 Moeller Joe Plumbing 2027 Oakdale Av Nor-
Cal Plumbing & HeaUng Inc 1301 6th St Nova Plumbing Service
4124 Mission St OBnen Mechanical 2134 Folaom St OKeeffe Mikumo
Co Inc 960 Harrison St Oloshi Plumbing 2270 Bush St Pacific
Plumbing & Heating 2618 Sacramento Si Padilla Joe Plumbing &
Heating 4960 Mission St Parks Plumbing 55 BalUmore Way PIED
PIPER THE 1874 10th Av. Tel 6640602 Plumbing & Mechanical
Contractors Of S F 2145 19th Av Powell's Plumbing & Htg 811 San
Jose Av Pribuas Engineering Inc 87 Mc Lea Ct Pnce C A Plumbing
3186 23d St Price Plumbing 721 Newhall St Prill J Plumbing 340 S
Van Neaa Av PHU J Plumbing & Heating 1602 Diamond St Prontito
Plumbing 3176 26th St Purcell Bros 2257 Irving St R P Plumiung Co
1127a Folsom St Radial Plumbing Co 2026 Balboa St Rainbow
Plumbing 20 Bessie Si RamaiiolU Adrian Inc 1473 Vallejo St Rapp
Wm A Plumbing Co 696 5th Av Reichel C R Engineering Inc 718
Natoma St Rein Geo Plumbing 331S 20th St Roccaforte Plumbing
414 Naples St Rosen Jack Inc 1672 Mission St Rowin Plumbing Co
2728 41st Av Ruef Charles Plumbing Co 25 Apparel Way Salet Geo V
Plumbing 4826 Mission St San Francisco Plumbing Co 2345 Wawona
St Seiki Brothers Plumbing 1731 Sutter St Selli A Inc 2054 Powell St
Servadei Service Inc 2071 Union St Skvline Plumbing Co 3067 23d St
Spencer F W & Son Inc 935 Manposa St Spencer F W & Son Inc 437
Poirero Av Stagnaro Plumbing Co 55 Navajo Av Standard Mechanical
Aasociates Inc 87 Welsh St Three SUr Rice Co 775 Vallejo St Turner
& Co 1278 Pacific Av Valenle A & Sons 1877 Union St Von Tagen
Plumbing Co 860 S Van Ness Av Water Works Plumbing Co 573 S
Van Ness Av Waters B J Plumbing Co 1320 Ocean Av West Coast
Plumbing 2230 Une St West Don Plumbing 3775 24th St Wheeler
Plumbing 115 Gough St Apt A Williams Plumbing & HeaUng 451a
Cortland Av Wong Ken Plumbing 580 20th Av CONTRACTORS—
ROAD Pacific Pavements Co Ltd 1275 Michigan St CONTRACTORS—
ROOFING Acme Roofing Co 260 Ocean Av AlU Roofing Co Inc 1414
Donner Av ANDERSON HOOFING * SHECT METAL CO INC (UCENSE
1468021 2940 San JoM Av I94I12), Tel 584-9675 Bay Service Co
2277 Jerrold Av Bay Tile Roof Co 465 Dewey Blvd Beatty Roof
Service 4380 Mission St Bender Roofing Inc 22 Bemiee St Brvson
Roofing Co Inc 1377 9th Av CONTRACTORS— ROOFINC-CONTD
Burke Roofing Co 1076c Revere Av Cooper Brothera Roofing Co Inc
74 Charter Oak Av CorsetU Brothera Roofing 66 Allieon St Empire
Roofing Co 4380 Mission St Eicelaior Roofing Co 36 Monterey Blvd
Gamson Roofing & General Building Contr 1150 HoUoway Av Glen
Park Roofing Co 511 Vienna St Golden Gate Roofing C^o 1365
Fitzgerald Av HALL FRED S ROOFING CO 4398 MImIod St, Tel (41S)
585-2064. 333-0986 Or bS&3684 Hank's Roofing Co 1271 48th Av
Hayden & Hayden & Sons Construcuon & Roofing 1946 Oakdale Av
Home Roofing Co 1711 San Jose Av JACK JOHNSON ROOFING CO
1280 HUUde Blvd, Colma (94014). Tela 9922300 And 282-4914
Johnson & Johnson Roofing Service 1400 Egbert Av Jun'a General
Roofing Co 126 Blake Si KeUy Roofing 1031 Revere Av Kim John
Roofing Service 660 Slost Blvd LAWSON ROOFING CO INC THE
Contractora License 339053, 415 Bryant SI 194107) Tel 421-7513
Len'a Tile & Roof Repairs 755 Flonda St Mc Carlhy Roofing Co 3151
Geary Blvd Richmond Sunset Roofing & Siding 1735 26th Av
RollamaUc Roofs 2220 Ingalls Si SAFEWAY ROOFING & SIDING CO.
3270 19tfa St. Tel 621-4612 Smith Robert F Co Inc 2277 Jerrold Av
Standard Roofing Co 1226 9th Av Sunset Roofing Co 55 EHmira St
Welrel Dick Roofing Co 44 Leese St Western Roofing Service 2694
Oakdale Av CONTRACTORSSANDBLASTING Bipes W L Co Inc 2040
17th St Burgess D E Co 2198 Oakdale Av E & S Sandblasting
Speciabst 1499 Van Dyke Av PeT«t Herman QuaUty SandblasUng
1100 Queaada CO NTRACTORS— SEWER AND DRAIN LawBon
Drayage Inc 1311 22d St Magic Rooter Service 275 Monterey Blvd
CONTRACTORS— SHEET METAL Accurate Sheet Metal Works 3615
Mission St Alglen Sheet Metal 12 Hale St Anderson & Doherty Sheet
Metal Works 87 Loomis St Apex Sheet Metal Works 1435 San Bruno
Av B & B Sheet Metal 4441 Mission St C i D Sheet Metal Co 326
Waytand St City Sheet Metal Works 41 Bntton St Delucchi Sheet
Metal Works 1526 Powell St GoM Golden West Sht Mtl 421 ArgueUo
Blvd Griffin Sheetmetal 1320 Underwood Av Guilfoy Cornice Works
Inc 1234 Howard St Hardeman C S Inc 910 Hamson St J & L Sheet
Metal 2512 25th St Joyce Sheet MeUl Works 173 Shipley St L & S
Conatniction Sheet Metal Co 176 Clara St Neilan Robert J & Son Inc
2699 18t)i St OTIS SHEET METAL INC 1347 Donner Av, Tel 822-6400
Paul Sheet Metal Works 474 Bryant St Ponzim Oneral Sheet Metal
3516 16th Si Q-Rolo Sheet Metal Products 1067 Folsom St Rainey
Sheet Metal Works 924 Valencia St Shields J R Sheet Metal 2405
17th St Standard Sheet Mela! & Marine Plumbing 366 Brannan St
Standard Sheet Metal Shop 159 South Park St Sur Sheet Metal Inc
316 Uth St Suiuyside HeaUng A Sheet Metal 249 Edna St Tempo
Steel Corp 1683 Galvei Av Tufts Sheet Metal Inc 577 ShotweU St '
COIfTRACTORS— SHEET ROCK Gonzales Rudolph Sheet Rock Taping
16 Flood Av CONTRACTORS— STEEL CONSTRUCTION Robertson H
H Co 5 3d St Rm 400 CONTRACTORS— TILE American Terraiio
(^mpany 36 Wood St Cook Tile Co 16 Steveloe PI De Lorenzt Tile Co
1448a 9th Av GiarrilU Tile Co 1615 Green St New Mission Art Tile Co
3029 25th St Precast Tile Steps 1503 MendeU St Sebasuani Terraiio
Co 201 Floumoy St Smith James A Co 850 S Van Ness Av Swenaon
Tile 422 Cortland Av Tiles By Sonda 1316 Sanchez St MODERN BAIT
& TACKLE SHOP 'SPECIALISTS IN THE BIG GAME TACKLE AND
BAITS * HEADOUARTERS FOR RODS, REELS • DACRON LINES AND
OTHERS • • BANKAMEHICARD • 2975 Mission Street (Between 2Sth
and 26th Streets). San Francisco, Calif. (94110) (415) 824-5450
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in ATLAS DEMOLITION & CONSTRUCTION, INC. 4200

California St. (94118) INSURED - UC. NO. 416330 (415) 752-8116
CONTRACTORSWATERPROOFING Carlaen Jorgen Co 550 Bryant St
Sovig Conrad Co 35 Gilbert St THOMPSON ROBERT CO 689 FloHda
St Weatera Waterprooring 1485 Bayshore Blvd Rm 275
CONTRACTORS— WEATHER STRIPPING Bolger Weather Stnp Co
2083 28th Av Uruver«a] Weatheratrip Co 1246 44lh Av
CONTRACTORS' SUPPUES AND EQUIPMENTDEALERS AND
REPAIRING Bay Western Co 712 Hobart Bldg Ciliforma Induatnal
Supply Co 1520 Teonessee St City Scaffold Co 70 Hamet St Energy
Ser\icefl 44 Wells Fargo Bk BIdg Rm 557 Federal Equipment Co 70
Winfield St Golden Gate Equipment Co Of San Francisco 560 »th St
Muller Construction Supply tnc 1025 Miaaiaeippi St OcaiDpo-Talao
Construction Matenals 336 Russia Av Sequoia Supply Inc 1990 Evans
A v Smith Industrial Supply Co 2125 Ingaib St Treadwell James L
Corp 3221 Pierce St Rm 2 Viking Distributing Co 22 Misaisaippi St
Weat Coast Contractora Services 28 13th St CONTRACTORS'
SUPPUES AND EQUIPMENT— MFRS Dolden Equipment Co 45 Ellmira
St I H I Inc Ship & Industnal Equipment 111 Pine St Rm 700 K H D
Humboldt Wedag (Div DeuU Corp) 4 Embarcadero Center Suite 3580
KNICKERBOCKER PARTITION CORP 1546 MlnneMU St I94I07). Tel
282-»»42 Musto Industries Inc 667 North Point St STANDAJtD
TRADING USA INC. 1486 BsyahoK Blvd. Suite 311 (94124) Tel 4«8-
0»80 Tomco Pacific CorporaUon 576 Monadnock BIdg Transamenca
Delaval Inc 865 Phelan BIdg CONTRACTORS' SUPPLIES AND
EQUIPMENTRENTAL ClemenDna Ltd 2177 Jerrold Av Hoist Co 1750
Army St Safety Service Scaffold Co 1963 Mc Allister St Tinkler
Equipment Co 2590 Oakdale Av CONTROL SYSTEMS Automaac
Control Engineenng Corp 470 3d St Tepco Air PolluOon Control 1535
Minnesota St CONVALESCENT HOMES Beverly Manor Convalescent
Hospital 1477 Grove St Booth ReaidenUaJ Care Home 34 Williams Av
Compassion For The Aged 614 Garfield St Convalescent Center
Mission Street Inc 5767 Mission St Grand Haven Rest Home 2828
San Joae Av HILLHAVEN CONVALESCENT CENTER 2043 I9th Av. Tel
«61-8787 HILLHAVEN-LAWTON CONVALESCENT HOSPITAL 1675 7th
Av (94122) PO Box 22249, Tel 566-1200 Holy Angel's Valley View
Rest Home 469 29th St Keyes ResidenUal Care Home Inc 565 Grove
St Laurel Heights Convalescent Hospital 2740 California St Pine
Tower Convalescent Hospital 2707 Pine St Sheffield Convalescent
Hospital The 1133 S Van Ness Av Sunnyside Van Ness Onvalescent
Home Inc 1216 S Van Nen Av Victorian Convalescent Hospital 2121
Pine St CONVENTION SERVICES AND FACILTnES UNTTED-WESCO
INC 2576 3d St (94107). Tel 282-4100 CONVENTS All Hallows
Convent 1601 Quesada Av Cathedml High School (Convent) 1180
EUis St Community Of St Francis The 3743 Army St Convent Of
Cr\slo Rey 2511 Mc Ailister St Convent Of Sisters Of The Holy Names
5920 Geary Blvd Convent Of The Epiphany 600 Italy Av Convent Of
The Holy Family 890 Hayes St Corpus Christ! Convent 61 Francis St
Daughters Of (Thanty Of St Vmcent De Paul Convent 2810 Pierce St
Daughters Of Mary & Joseph Convent 191 1 Pine St Dominican
Sisters Convent 1212 Guerrero St Helpers Of Holy SouJs Convent
214 Haight St Holy Name Convent 1555 39th Av immaculate
Conception Convent 1544 Treat Av CONVENTS— CONTD Missionary
Sisters Of The Immaculate Conception 1417 38th Av Most Holy
Redeemer Convent 115 Diamond St Order Of Ursuline Sisters 4056
Mission St Our Lady Of Lourdes Convent 951 [nnes Av Our Lady Of
The Visilacion Convent 786 Sunny dale Av Presentation Sistere
Convent 288 Denslowe Dr Russian Convent Of Our Lady Of Vladimir
3365 19th St Sacred Heart Convent 660 Oak St Saint Annes Convent
1330 14th Av Saml Brendan's Convent 234 Ulloa St Saint Bngid
Convent 2260 Franklin St Saint Cecilia Convent 2S50 18th Av Saint
Charles Convent 3270 18th Si St Emydius Convent 270 Ashton Av
Saint Finn Barr'a Convent 450 Edna St St Francis Convent 90
Rockndge Dr Saint Gabnel's Convent 2559 40th Av Saint John's
Convent 98 Bosworth St Saint Joseph's Convent 220 10th St Saint
Mary's Convent 926 Stockton St Samt Michael Convent 45 Farallones
St Saint Paul's Convent 323 29th St Saint Peter's Convent 1245
Alabama St Saint Phillip's C^onvenl 4174 24th St Saint Teresa's
Convent 376 Missouri St Saint Thomas The Apostle Convent 3900
Balboa St Saleaian Sisters 632 Filbert St Sisters Of Charity B V M 1
Thomas More Way Sisters Of Mercy St Francis Convent 626 30th Av
Sisters Of Social Service 1850 UUoa St Sisters Of The Holy Family
174 Slanyan St Sisters Of The Presentation Cong Superior 2340 Turk
Blvd Sisters Of The Religion Of Virgin Marv 220 10th St SUr Of The
Sea Convent 4360 Oary Blvd Vedanta Society Convent & Residence
2800 Steiner Si Vedanta Society Of Northern California Monastery
2333 Vallejo St CONVEYING SYSTEMS Aero Conveying Systems Inc
44 Mc Lea Ct Vacu-Lift Co 57 Post St Rm 701 COOKING UTENSILS—
MFRS AikenwQod Corp 276 Western Mdse Mart Amco CorporaUon
282a Western Mdse Mart Amencan Italian Trading Inc 276 Western
Mdse Mart Artisismas De Mexico 276 Western Mdse Mart Atlas Tool
& Mfg Co 319 Western Mdse Mart Benjamin & Medwin 286 Western
Mdse Mart Boos John & Co 276 Western Mdse Mart Boston Mountain
Galleries 262a Western Mdse Mart Calphalon Cookware 286 Western
Mdse Mart Ekco Flint Cookware & Tools 243 Western Mdse Mart
Fosselmans 276 Western Mdse Mart Ginko International 276 Western
Mdse Mart H L C International 261 Western Mdse Mart Hoan
Products 286 Western Mdse Mart Kitchens Etcetera pier 39 The
Embarcadero N Strviry 12 La Bourgoinone 285 Western Mdse Mart
Lentrade 282a Western Mdse Mart Leyse Aluminum Co 261 Western
Mdse Mart Marrocchi 259 Western Mdae Mart Marsh Industries 286
Western Mdse Mart Meyer Housewares Corp 282a Western Mdae
Mart Pamsh's 282a Western Mdse Mart Ren'aware Distributors 4680
Mission St Sanko Cooking Supply Co Inc 1758 Buchanan St
Scandicrafla Inc 276 Western Mdse Mart Schlemmertopf 266
Western Mdse Marl Shafford Co The 217 Western Mdse Mart Spnng
Brothera Inc 286 Western Mdse Mart Strand CorporaUon 276
Western Mdae Mart Strand Pot Props 276 Western Mdse Mart
Sunbeam Microwave Co 262 Western Mdse Mart Tipton Designs 276
Western Mdae Mart Treeapiril 276 Western Mdse Mart Van Wyk
Associates 3548 Sacramento St Vasil & Black's Copperaource 265
Western Mdse Mart COPPERSMFTHS Zaft Paul Copper Works 60 l3th
St •COPYING AND DUPUCATING SERVICE GOMEZ RUDY PHOTO
ARTS 222 Vallejo St Tel 1415) 956-0533 JONES DONALD
PHOTOGRAPHY (PHOTO REPRODUCTION) 42 Se^^nd St (94105)
Tel 982-6287 Or 982-4432 CORDAGE AND TWINEMFRS AND
WHOLESALE Cordage Group The Div Of Columbian Rope Co 90
Charter Oak Av Davis Cordage Co Inc 366 Vermont St Tubbs
Cordage Co 660 Bryant St CORK AND CORK PRODUCTS Armstrong
Cork Co 476 WesUrn Mdse Mart Schnier 1 F Co Inc 683 Bryant St
CORSETIERES Vilanova's Corset Shop 2589 Mission St COSMEmCS
Arden Eliubeth Inc 100 California St Rm 1170 Arden Eliiabeth Salon
230 Poet St Avon Products Inc 681 Monadnock BIdg Rm 730
BELLEZA FEMENINA. 3054 24th S( (94110), Tel (416) 28fi-5266
Body Bar The 1433 Polk St Body Clinic The 491 Castro St Body Shop
The 2063 Union St California Theatrical Supply 747 Polk St Carlson
Starleen 1417 15th St ChnsUne Valmy Skin Care 77 Maiden La
Common Scents 3920a 24th St Cordova Coreen 575 Sutter St
Cosmetique 3915d 24th St Face Place The 339 Kearny St Face Place
The 2448 Mission St Joharco America 166 Mendell St Magnin Joseph
Cosmetic Inc 1390 Market St Rm 101 Make Up Studio The 3609 23d
St Merle Norman Cosmetic Studio 57 Weal Portal Av Naris Cosmeucs
1581 Webster St Norman Merle C^osmetics 150 Powell St Rm 312
Oceans Of Lotions 1545 Clement St Parfumene D'Angleterre Et De
France 905 California St Parfumene DAngleterre Et De France 1110
Taylor St Personal Enhancement Products Co 375 Bella Visu Way R K
C & Co 2183 Union St Saving Face Inc 270 Sutter St 5thn Skin Zone
531 Caatro St Smith James T 1401 Castro St Sutro Bathe Coemeuca
9(X) North Point St That Face 2 Embarcadero Center Lobby Valmy
ChnsUne Skin Care Salon 323 Geary St Rm 201 Vanda Beauty
Counselors 2547 25lh Av Victona's Vanity Skin Care 2323 Four Fifty
Sutter Big World Of Aloe 4 Embarcadero Center Street COSTUME
JEWELRY Avalon Shop 2792 Mission St Darhng Jewelry Co 518 Grant
Av Momingstar & Jezebel 3265 17th St Suite 304 COSTUMERS
Costume Studio The 520 3d St Danceworka The 377 Hayes St
FanUsy Island Costumes 186 Potrero Av GEORGE HERMAN
COSTUMES. 1488 Howard St (94103) Tel 562-6061 Golden Gate
Costumes 424 Hayes St Just For Fun 515 Frederick Si MANDELL'S
BOB COSTUME SHOP INC 1135 Mlarion St (941031. Tel 863-7765
Masquerade RenUl Costume Shop 1049 Irving Si Palace Of Magic
pier 39 The Embarcadero N Strwy 4 San Francisco Opera Costume
Shop 1019 Market St 3d FI Theodra Cl^ostumea 41 Pollard PI
Woodall Sandra Costumes 1081 Mission St COUNSELUNG SERVICE
Associated Marriage Counselors 3874 24th St Beilel Philip 1367
Church St Brandt Laune 3676 Sacramento St Community Counseling
Service 351 Califonua St Rm 1304 Counsehng Center For Adults
3410 Geary Blvd Rm 225 Feister Wm J 1902 Webster St Hazilla
Barbara 495 Alvarado St Itkin Bemice D 4200 California Si Rm 202
Kolcher Unda L 1902 Webster St Life Counseling Institute 2101
Pacific Av Apt 703 Matthews Meiody 3600 California St Mead SUnley
C W 2433 Fillmore St Men Overcoming Violence 3004 l6th St Rm 112
Reiss Margt 1537 Franklin St Rm 311 Rubinstein Helaine 1902
Webster St San Francisco Family Therapy Associatea 334 Claremont
Blvd Shapiro Carol 3874 24th Si Silverman Gary E 3676 Sacramento
St Stem Henry T 1580 Valenaa St Rm 801 Veltfort Helene R 1902
Webster St Waidler Valene 2538 California St Warren Vinccntia 3676
Sacramento St Wertz Joni 2000 Van Neas Av Rm 403 West Portal
Counseling Associates 35 Vicente St Rm 5 Wong Hermund 3527
Sacramento St Rm 104 COURT REPORTERS Arnold & Aaatx-iutea 22
Battery St Arnold & Aaaociatea 1043 Monadnock BIdg Eb-nard
Daniel W & AaMxiates 605 Market St Rm 505 BROWN JAN L A
AS80CUTES 261 Kearny St, Suite 206 (94106). Tel (416) 981-3498
C^annon Court Reporter* 201 Califorma St Rm 560 Carter And
Tomo 166 O'FArrell St Rm 408 CV>nklin E D Inc 110 Sutter St Rm
606 Curtin A Renner 1063 Flood BIdg Diamond Service 664 Market
St Rm 618 Doidge A Carroll 607 Market St 4th FI Doidge Douthit A
Morris 110 Sutter St Rm 504 Fortini Robt A 110 Sutter St Rm 714
Gagan A Mc Daniels 40 1st St 3dfi Gary A Roomian 664 Market St
Rm 211 Genii Court Reporter* 664 Market St Rm 201 George A
Associates 110 Sutter St Rm 602 Hart A Hart 52 2d St 4th FI
Henderscheid Wm E And AasocistM 664 Market St Rm 306 Henry
Darleen 605 Market Si Rm 505 Hotchner Reporting Service 5 3d Si
Rm 920 Houston & Sancla 508 Hobart BIdg Jackson Bemice M
Reporting Co 231 Franklin St Rm 3 Legal Communications A
Profeaaiooal Services Inc 564 Market Si Rm 312 Luce Rebecca L 664
Market St Rm 719 Schiller Combs Russell A Greenley Inc 626 Polk Si
Rm 304 Schiller Combs Russell A Greenley loc 625 Polk St Rm 305
Smythe And Wilson^Tourt Reporter 1048 Monadnock BIdg Tooker A
Antz 925 Monadnock BIdg Varela A Mulhem Reporting Service* 2251
Clement St Verbatum Systems Inc 311 Cabfomia Si Rm 411 Whekhel
James E 705 Central Tower BIdg CRAFT SHOPS AND SUPPLIES Asia
Arts A CrafU Co 749 Clay St Chinese Handcraft Co 27 Maiden La 3d
FI Chinese Handicraft Co 28 Geary St 3d R Down Home 2800
Leavenworth St No 34 Yung Chia 6332 (ieary Blvd CRANES AND
HOISTS Skyscraper Services Inc 321 Florida Si CRANKSHAFT MFRS
AND GRINDERS Red Arrow Hoist A Preaa Distr 421 Moscow St
•CRATING AND SHIPPING Therapy Center The 256 Church St
♦CREDTT BUREAUS AMERICAN CREDITORS BUREAU. 330 Prlmroee
St, Suite 406. BurUogame (94010) Tel 348-3090 BOARD OF TRADE
THE 989 Market St. Rm 200 (94103) PO Box 42220 (94142) Tel 421-
6302 •COURIER SERVICE NOW COMMERCIAL SERVICE A AIR
COURIER 311 C*llfomla 8t Rm 614. 2264 Van Ntw Av. Suite A. Tel
433-6060 fjm i^ 1 ^ s ii r>aK ttrt ^o ^ o"" "^ j^ 3o m • eb •• en il
5C/5 ?3 ^5 iC ^^f»l si Zco co> • r 1^ C2 ^2 ss %^ U5 50 m« rl<
K) K> Wl CREDFT REPORTING AGENCIES Able Credit Services 4630
Geary Blvd Rm 302 Bowera Reporting Co 110 Gough St Rm 203
Jewelers Board Of Trade 111 Sutter St Rm 1840 Mc Cord Company
1581 Mission Si Media Credit Inc 1486 Bayshore Blvd Rm 344
ReUilers Commercial Agency Inc 3360 Geary Blvd Rm 202 CREDFT
UNIONS Atlas Credit Aiaociation 657 Miaaion St Rm 600 Bayview-
Hunter's Point Credit Umnn Inc 220 Cashmere St C M E Federal
Credit Umon 1293 18th Av California Canners A Growers (Fed Credit
Unionl Ferry BIdg Rm 3037 California Professional Credit Union 2300
MaSon St CAUFORNIA STATE EMPLOYEES CREDIT UNION NO 2 41
Van NeM Av (94102) Tel 861-I9S0 (Consumer Credit Counselor* Of
San Francisco 1429 Market St Cooperatora Credit Union 2300 Mason
St Credit Union Services Corp 2300 Mason St Delancey Street
Federal Credit Union 2563 Divisadero St Ebtel Federal Credit Union
625 Howard St EMBARCADERO FEDERAL CRQ>TT UNION. MkUi
Offlcei 966 Battery St. Suite 121 194111) Tel 42I-772S Foremoat-Mc
Keeson Employee* Fed Credit Union 150 Post St Rm 610 Glidden
Pacific Crwlil Union 2940 leth St Rm 309 ECHOLS INTERNATIONAL
TRAVEL TRAINING COURSES, INC. "FOR A CAREER IN TRAVEL"
CALL ,861-1922, u5 y^^^ ■^ 3 f ^/^ \ s \ Ql \ e>j] ? \ ^L v \ ^^—
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2 < s h. I s 5 H • Ul 5 CO DEAN WITTER REYNOLDS, INC. MEMBKH
NF.W VoKK STOCK EXCHANGE SAN KRANCISMO, LOS ANGELES NEW
V(iKK CHICAGO THREE LOCATIONS TOSERVB YOU 4 MARITIME
PLAZA. ALCOA BUILDING. GOLDEN GATEWAY CENTER 45
MONTGOMERY STREET. FINANQAL DISTRICT. PHONE 9SS-6000
^^___ PHONE 9ft5-«ftO0 GOO MONTGOMERY ST.. RNANCIAL
DISTKICT. PHONE M6.7000 CREDIT UNIONS— CONTD GOLDEN
GATE FEDERAL CREDIT UNION. Rm 202S 2A Fl Federal BId| UO
Golden Gale Av. PO Box 36092 .Mlti:- Tel •4l3> MM I&I6 GoliVn i;»lr
KeJ,T..I Cn>1ii I nion iTmlmum Bn 525 Market St Rm 2585
Greyhound Credit Umoo 26 7lh Si I L W I' Federal Credit Utuon 2300
MaMU St Jone« Meihodwt Churrh Credit Union 1975 Post St Kaiaer
Credit Union 2266 Geary Blvd Rm 100 Lee Federal Crwdit Union 915
Grant Av Merchants Credit Union 69 West Portal Av M.»ion At«8
Federal Credit Union 2940 16th St Rm 203 Musinana Local e FederBl
Credit Union 230 Jones Si Rm 304 Nationa] Credit Union
Admimsuation USa 77 C*ar> St 2dfl Northeast Community Federal
Credit Union 915a Grant Av Rm 4 P L M Credit Corp 50 California St
33d n Pac Tel Co (Credit Uniont 151 New Montgomery St Paieico
Credit Union 149 New Montgomery Si 2d n Railwav Emplo>ees
Credit Union 1 Market Plaia Suite 575 Recreation A Park Credit Union
12«6 23d Av RiiMian Amencan Credit Union 5923 Geary Blvd St
Bonifaf* Federal Credit Union 50 Oak St Suite 505 SAN FRANCISCO
Cmf EMPLOYEES CREDIT UNION. T70 Golden Gale Av 194102) Tel
775-4377 San Francisco Federated Tchre Credit Union 655 14ih St
San Francisco Firemen Credit Union 2390 Market St San Francisco
Mum Shopmen's Credit Union 2301 San Jos* Av Rm U SAN
FRANCISCO MUNICIPAL RAILWAY EMPLOYEES FEDERAL CREDIT
UNION. 142S Ocean Av Tel (415) 449-8840 San Francisco
Newspaper* Federal Credit Union 426 Jeaaie St San Francisco Police
Credit Union 1250 Nonega St San Francisco Police Post Fed Cred
Union Am Lepon 401 Van Ness Av Rm 127 San Francisco Postal
Credit Union 99 Mission St Rm 139 State Employers Credit Union 2
1207 9lh Av Teamsters Local No 85 Credit Union 459 Fulton St Third
Baptut Church Credit Union Inc 1399 Mc Allister St Western Union
Employee Credit Union 49 Geary St Rm 230 ZELPACO CREDIT
UNION 1 Buah St, 9th n (94104), Tel 951-5580 CREMATORIES
Neptune Society 680 Beach St Suite 342 •CRUISES ROYAL CRUISE
UNE. I Maritime Plaza. Suite 660. Tel 956-7200 CURTAIN AND
DRAPERY CLEANERS Coil Drapery & Carpet Cleaners 663 Union St
Modeme Curtain CTeaners 3338 I7th St Mohawk Drapery Cleaners
5090 Mission St CURTAINS AND DRAPERIES A A Window Fashions
4226 California St ABC Draperies Inc 535 Mission St A * Z Drapers 9
Leland Av Action TejTiles 875 Stevensoo St Rm 520 Bekkoe Window
Fashion 999 Geary St Benjamin's Custom Draperies 3610 L^wton St
Bemice's Drapei? 37 Leland Av Caiifomia Curtain Co 290 Division St
Suite 302 California Curtain Co 833 Market St Rm 319 De Leon
Drapenes 1887 Donner Av Drapery Inlenor^ 174 14th St Febcia's
Custom Drapenes 728 Diamond St Fink Harry Drapenes 4226
California St GET Linens & Drapenes II Lakeshore Plaza Greer
Drapenes 630 Monterey Blvd Henelbarth Drapery & Upholstery 821
Fillmore St Home Stitcher Ltd The 333 5th St Ideal The 2370b
Mission St Kinel Of California 3600 Lawton St Leila Madu Drapenes
227 Church St M B Cualom Made Drapenes 1547 Oement St Mane's
Custom Drapery 2539 Balboa St Manes Drapery Service 438 Madnd
St Manna Drapery & Furniture 2219 Chestnut St Mildreds Custom
Drapenes 4179 17th Si Muhlfelder Paul Drapenes 2928 Moraga St
Pacific Drapenes Inc 562 Western Mdae Mart Perfecuon Drapery
2051 Scott St Apt 4 Pyramid Drapery Co 1248a Silver Av Shimum
Sophia DMar Drapery Workshop 1001 Stem Drapenes 1479 33d Av
Sunshine Curtains Co 2 Henry Adams St Rm 441 Swedish A/Tair A
520 Davis St Sylvanua Drapenes 199 West Portal Av Sylvio Drapery
Mfg Co 4727 Mission St Toma Decor Studio 1528 Pacific Av Towers
Viii 100 15th St Wesbum Custom Houae 10 Arkansas St •CUSTOM
HOUSE BROKERS C I S OCEANAIR SERVICES. 230 Caliromia St. Rm
207 (94111) Tel 3917253 CUTLERY MFRS Carvel Hall Cutlery 243
Western Mdse Mart (^lomal Knife Co 243 Western Mdse Mart Cooper
V 243 Western Mdse Mart Das A K & Co 285 Western Mdse Mart
Fiskar^ Mfg Co 243 Western Mdse Mart Flint Cutlery 243 Western
Mdse Mart Forschner R H Co 243 Western Mdse Mart Impenal Knife
Co 243 Western Mdae Mart Lamson Cutlery 282a Western Mdae
Mart Ontano Knife Co 243 Western Mdae Mart Schrade Cutlery Corp
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