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Bulimia Nervosa and Binge Eating Disorder: Comparing Therapeutic Strategies

Primary Purpose

Bulimia Nervosa, Binge-Eating Disorder

Status
Recruiting
Phase
Not Applicable
Locations
Italy
Study Type
Interventional
Intervention
tVNS
rTMS
CBT-E
Sponsored by
Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Bulimia Nervosa focused on measuring Bulimia Nervosa, Eating disorders, rTMS, CBT-E, tVNS, EEG

Eligibility Criteria

18 Years - 65 Years (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria: patients diagnosed with Bulimia Nervosa or Binge Eating Disorder, according to the diagnostic criteria of DSM-V, with a psychopathological framework of depression in comorbidity (cut-off ≥ 8 of the Hamilton Depression Rating Scale, HAM-D), aged between 18 and 65 years.

Exclusion Criteria:

  • Previous TMS sessions with significant side effects;
  • Conditions leading to an increased risk of epilepsy or side effects in the context of transcranial magnetic stimulation (including personal or family history of epilepsy, cerebral ischemic events, neurological pathologies, neurosurgical interventions, orthopedic or vascular interventions in the head-neck district, major head trauma, migraine or severe headache);
  • Presence of pacemakers, defibrillators, infusion pumps, neurostimulation implants (DBS, VNS), endovascular implants in the head-neck district, cochlear implants, cerebrospinal shunts, metal implants in the head-neck area ;
  • Exposure to penetration of metal chips in the head-neck area;
  • Presence of non-removable metal in the head-neck area (including tattoos, permanent make-up, piercing, excluding dental implants);
  • Unstable sinus rhythm at ECG (Pace-Maker rhythm, atrial fibrillation, supra-/ventricular extrasystole);
  • Chronic intake of β-blocker;
  • Heart, respiratory, renal or hepatic failure and immunosuppression;
  • Current hospitalization;
  • State of pregnancy or lactation;
  • Vestibular or balance problems;
  • Positive personal history of schizophrenia or schizoaffective disorder;
  • Substance or alcohol abuse in the last 6 months;
  • Positive personal history of intellectual disability ("mental retardation");
  • Refusal of informed consent by the patient.

Sites / Locations

  • Fondazione IRCCS Ca' Granda - Ospedale Maggiore PoliclinicoRecruiting

Arms of the Study

Arm 1

Arm 2

Arm 3

Arm Type

Experimental

Experimental

Experimental

Arm Label

tVNS + CBT-E group

rTMS + CBT-E group

Only CBT-E group

Arm Description

N=10 Interventional group with transcutaneous stimulation of the auricular branch of the vagus nerve associated with targeted cognitive-behavioral therapy (following the CBT-E protocol, CG Fairburn - 2010.

N=10 Interventional group with repetitive transcranial magnetic stimulation associated with targeted cognitive-behavioral therapy (following the CBT-E protocol, CG Fairburn - 2010.).

N=10 Group with only cognitive-behavioral therapy of eating disorders.

Outcomes

Primary Outcome Measures

Changing in dietary behaviour in terms of changes in Eating Disorder Examination scale score at T3
Effectiveness in changing dietary behaviour in terms of the EDE (Eating Disorder Examination) score difference between groups at T3. Great differences mean better clinical outcome.

Secondary Outcome Measures

Incidence of acute effects of treatments in terms of difference between pre- and post-treatment
Incidence of acute effects of treatment with tVNS+CBT-E, rTMS+CBT-E or only CBT-E in patients with Eating Disorders in terms of difference between pre- and post-treatment for: Variations in EDE-Q (Eating Disorder Examination Questionnaire) validated questionnaire scores. Depressive symptoms: change in HAM-D and BDI-II scores. Change in the systemic inflammatory profile: values of inflammatory serum proteins (IL-6, IL-1β, IL-4, IL-10, TNF-α and PCR) and microvesicles. Changes in cardiovascular autonomic control: spectral power (ms2) and percentage (normalized units), over 250 beats, of the following frequency classes: very low frequency (VLF), low frequency (LF, 0.04-0.15 Hz) and high frequency (HF, 0.15-0.40 Hz). Percentage on 250 beats, of pattern 0V, 2LV and 2UV (symbolic analysis). For TMS+EEG: variation of neuronal excitability patterns and functional connectivity and changes in quality of life in terms of total score of the CIA 3.0, PSQI validated questionnaires.
Incidence of acute effects of treatments in terms of difference between pre- and post-treatment
Incidence of acute effects of treatment with tVNS+CBT-E, rTMS+CBT-E or only CBT-E in patients with Eating Disorders in terms of difference between pre- and post-treatment for: Variations in EDE-Q (Eating Disorder Examination Questionnaire) validated questionnaire scores. Depressive symptoms: change in HAM-D and BDI-II scores. Change in the systemic inflammatory profile: values of inflammatory serum proteins (IL-6, IL-1β, IL-4, IL-10, TNF-α and PCR) and microvesicles. Changes in cardiovascular autonomic control: spectral power (ms2) and percentage (normalized units), over 250 beats, of the following frequency classes: very low frequency (VLF), low frequency (LF, 0.04-0.15 Hz) and high frequency (HF, 0.15-0.40 Hz). Percentage on 250 beats, of pattern 0V, 2LV and 2UV (symbolic analysis). For TMS+EEG: variation of neuronal excitability patterns and functional connectivity and changes in quality of life in terms of total score of the CIA 3.0, PSQI validated questionnaires.
Incidence of long-term effects in terms of relapses and difference between T0 and T4.
Incidence of long-term effects of the three treatments (tVNS + CBT-E, rtms + CBT-E and CBT-E) in patients with BN and BED in terms of relapses and difference between T0 and T4 for the following indices: Dietary behaviour: change in EDE and EDE-Q scores. Depressive symptoms: change in HAM-D and BDI-II scores Change in the systemic inflammatory profile: values of inflammatory serum proteins (IL-6, IL-1β, IL-4, IL-10, TNF-α and PCR) and microvesicles. Changes in cardiovascular autonomic control: spectral power (ms2) and percentage (normalized units), over 250 beats, of the following three frequency classes: very low frequency (VLF), low frequency (LF, 0.04-0.15 Hz) and high frequency (HF, 0.15-0.40 Hz). Percentage on 250 beats, of pattern 0V, 2LV and 2UV (symbolic analysis). TMS + EEG: Variation of neuronal excitability patterns and functional connectivity. Changes in quality of life: total score of PSQI and CIA 3.0 validated questionnaires.

Full Information

First Posted
March 16, 2022
Last Updated
April 14, 2022
Sponsor
Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico
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1. Study Identification

Unique Protocol Identification Number
NCT05296915
Brief Title
Bulimia Nervosa and Binge Eating Disorder: Comparing Therapeutic Strategies
Official Title
Bulimia Nervosa e Binge Eating Disorder: Strategie Terapeutiche a Confronto
Study Type
Interventional

2. Study Status

Record Verification Date
March 2022
Overall Recruitment Status
Recruiting
Study Start Date
January 1, 2022 (Actual)
Primary Completion Date
June 30, 2023 (Anticipated)
Study Completion Date
August 31, 2024 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
No
Data Monitoring Committee
No

5. Study Description

Brief Summary
This study aims to assess the effectiveness of new neurostimulation techniques in patients with eating disorders. The primary aim of our proposal is to test a reduction in symptoms of alteration of eating behaviors, such as always thinking about food or binge eating, in a sample of 30 patients, aged between 18 and 65, with diagnosis of Bulimia Nervosa or Binge Eating Disorder. Of these patients, 10 will undergo to a protocol of vagal transcutaneous stimulation in the ear (tVNS) and targeted cognitive-behavioral therapy (CBT-E), another 10 to a protocol of transcranial magnetic stimulation (rtms) and CBT-E and another 10 to a protocol of only tergeted CBT-E, comparing the results obtained in the three groups under study. Secondary purposes of this project are the assessment of the effects of auricular vagal transcutaneous stimulation and of transcranial magnetic stimulation on depressive symptoms associated with eating disorder, on the inflammatory profile, on cardiovascular autonomic control, neuronal excitability, functional connectivity and on the quality of life of these patients. In order to achieve the objectives of this research project, we will perform a national, interventional on a medical device, monocentric study, controlled in 3 parallel and randomized groups with a 1:1:1 allocation ratio. 30 patients will be recruited at the Day Hospital of the Psychiatry Unit of the Fondazione.
Detailed Description
This study aims to assess the effectiveness of new neurostimulation techniques in patients with eating disorders. To date, the management of these disorders is still difficult and few treatments have proven their effectiveness. According to most guidelines, management is typically multidisciplinary. The best validated and most frequently used treatment is the cognitive behavioral therapy enanched (CBT-E), a highly individualized psychological treatment designed to treat all diagnostic categories of eating disorders, addressing the common cognitive-behavioural mechanisms of maintaining shared and evolving psychopathology of eating disorders. For Bulimia Nervosa (BN) and Binge Eating Disorder (BED), the serotoninergic antidepressants are the most frequently used pharmacological option (considering the frequent recurrence of depressive symptoms in comorbidity in the clinical population with eating disorders), which may improve symptoms in the medium term, but not allow complete remission. In this context, the development of alternative therapeutic strategies is crucial. Recently, several studies have described the important contribution of neurostimulation techniques (such as repetitive transcranial magnetic stimulation (rTMS), and vagal nerve stimulation (VNS)). Following the proven effectiveness, both rTMS and VNS have received official approval for the treatment of depression in Europe and United States. Neuroimaging studies have revealed that both of these neurostimulation techniques modulate the frontal-vagal network, the one with a top-down mechanism (rTMS) and the other with a bottom-up mechanism (VNS). The neuromodulation influencing the functioning of the central nervous system (CNS) and the emotional/alimentary behavior, would offer an alternative (or complementary) intervention to psychotropic drugs and different psychological and nutritional approaches. Studies in the literature, conducted on patients with BN and BED, showed a significant improvement in symptomatology, in terms of "binge eating", after rTMS stimulation of the left dorsolateral prefrontal cortex (DLPFC). Instead, the effectiveness of vagal stimulation in the treatment of ED lies in the fact that the vagus nerve plays a fundamental role in mood and appetite regulation. Human studies report how tVNS stimulation produces a reduction in the effect of food cravings. Moreover, currently, in patients with ED, the determined effects of vagal non-invasive neurostimulation have not been compared with the effects of repetitive transcranial magnetic stimulation. Therefore, the primary aim of our proposal is to test a reduction in symptoms of alteration of eating behaviors, such as always thinking about food or binge eating, in a sample of 30 patients, aged between 18 and 65, with diagnosis of Bulimia Nervosa or Binge Eating Disorder, according to the diagnostic criteria of DSM-V, and with a psychopathological framework of depression in comorbidity (cut-off ≥ 8 of the Hamilton Depression Rating Scale, HAM-D). Of these patients, 10 will undergo to a protocol of vagal transcutaneous stimulation in the ear (tVNS) and targeted cognitive-behavioral therapy (CBT-E), another 10 to a protocol of transcranial magnetic stimulation (rtms) and targeted cognitive-behavioral therapy (CBT-E) and another 10 to a protocol of only tergeted cognitive-behavioral therapy (CBT-E), comparing the results obtained in the three groups under study. Secondary purposes of this project are the assessment of the effects of auricular vagal transcutaneous stimulation and of transcranial magnetic stimulation on depressive symptoms associated with eating disorder, on the inflammatory profile, on cardiovascular autonomic control, neuronal excitability, functional connectivity and on the quality of life of these patients. In order to achieve the objectives of this research project, we will perform a national, interventional on a medical device, monocentric study, controlled in 3 parallel and randomized groups with a 1:1:1 allocation ratio. 30 patients will be recruited at the Day Hospital of the Psychiatry Unit of the Fondazione. Patients will be assigned by randomization to 3 different groups/treatments: tVNS+CBT-E group: 10 patients will be instructed to perform tVNS at home for 4 non-consecutive hours per day for 12 weeks with the tVNS VITOS device (already used in the Fondazione for the study tVNS2019 approved by the Milan Area 2 Ethics Committee on 19.02.2019 and with code 158_2019bis); rTMS+CBT-E group: 10 patients will participate in a total of 20 rTMS sessions lasting 40 minutes (5 sessions per week for 4 weeks) that will take place at the Day Hospital of the Psychiatry Unit of the Fondazione; CBT-E only group: 10 patients will proceed with only targeted cognitive behavioral therapy (CBT-E), following the CBT-E protocol CG Fairburn - 2010. During the screening visit, provided by normal clinical practice, the inclusion and exclusion criteria and the diagnosis of Bulimia Nervosa and Binge Eating Disorder will be verified through a structured clinical interview planned for DSM-5 and personality disorders (by administration of the SCID-5 CV and PD scales by the physician). All patients will then be evaluated during 5 extra standard care visits. At each visit dietary behavior and any depressive symptoms will be evaluated through scales validated in Italian (Eating Disorder Examination, Eating Disorder Inventory, Eating Disorder Examination Questionnaire, Hamilton Depression Rating Scale and Beck Depression Inventory); cardiovascular variables will be recorded during clinostatism and orthostatism; a resting EEG and a during acute administration of transcranial magnetic stimulation EEG (TMS-EEG) will be recorded; participants will be asked to self-compile 2 questionnaires on the quality of life linked to health; finally a blood sample will be taken for the analysis of the inflammatory profile. For each patientd an Holter-ECG will be recorded lasting 72h following each visit. All the devices used in the study have already been purchased with university funds and have been taken over, labelled and coded by the Clinical Engineering of the Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico di Milano.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Bulimia Nervosa, Binge-Eating Disorder
Keywords
Bulimia Nervosa, Eating disorders, rTMS, CBT-E, tVNS, EEG

7. Study Design

Primary Purpose
Treatment
Study Phase
Not Applicable
Interventional Study Model
Parallel Assignment
Model Description
In order to achieve the objectives of the research project, we will perform a national, monocentric interventional on a medical device study, controlled in 3 parallel and randomized groups with a 1:1:1 allocation ratio.
Masking
Investigator
Masking Description
Personnel responsible for HRV analysis and determination of inflammatory biomarker levels will be blinded.
Allocation
Randomized
Enrollment
30 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
tVNS + CBT-E group
Arm Type
Experimental
Arm Description
N=10 Interventional group with transcutaneous stimulation of the auricular branch of the vagus nerve associated with targeted cognitive-behavioral therapy (following the CBT-E protocol, CG Fairburn - 2010.
Arm Title
rTMS + CBT-E group
Arm Type
Experimental
Arm Description
N=10 Interventional group with repetitive transcranial magnetic stimulation associated with targeted cognitive-behavioral therapy (following the CBT-E protocol, CG Fairburn - 2010.).
Arm Title
Only CBT-E group
Arm Type
Experimental
Arm Description
N=10 Group with only cognitive-behavioral therapy of eating disorders.
Intervention Type
Device
Intervention Name(s)
tVNS
Other Intervention Name(s)
Transcutaneous stimulation of the auricular branch of the vagus nerve associated
Intervention Description
An electric current with a frequency of 25 Hz (Figure 2) will be applied to the cymba conca of the left ear through a specific device (VITOS, Cerbomed, Germany; CE marking). The stimulation intensity will be customized between 0.1 and 5 mA according to the sensitivity threshold of each participant. Patients will be instructed to perform tVNS at home for 4 non-consecutive hours per day for 12 weeks, in accordance with the protocol reported in the literature for the treatment of major depression.
Intervention Type
Device
Intervention Name(s)
rTMS
Other Intervention Name(s)
Repetitive transcranial magnetic stimulation
Intervention Description
The stimulation will be carried out with a TMS STM9000 system (Ates, Medica Device s.r.l., Italy) equipped with a 70 mm "butterfly" cooled coil. The stimulation protocol followed will be the one approved by the FDA for major depression, that is, a stimulation at the level of the left dorsolateral prefrontal cortex at an intensity equal to 120% of the motor threshold, at the frequency of 10hz. Each stimulation session will last 37.5 minutes, and will consist of 75 trains lasting 4 seconds, with a 26-second break between each train. During each session, a total of 3000 stimuli will be administered. The sessions will take place 5 days a week, from Monday to Friday, for 4 weeks, and for a total of 20 sessions of stimulation.
Intervention Type
Behavioral
Intervention Name(s)
CBT-E
Other Intervention Name(s)
Cognitive-behavioral therapy - enanched
Intervention Description
Targeted cognitive-behavioral therapy following the CBT-E protocol (CG Fairburn - 2010. La terapia cognitivo-comportamentale dei disturbi dell'alimentazione. Firenze, Eclipsi; 2010.)
Primary Outcome Measure Information:
Title
Changing in dietary behaviour in terms of changes in Eating Disorder Examination scale score at T3
Description
Effectiveness in changing dietary behaviour in terms of the EDE (Eating Disorder Examination) score difference between groups at T3. Great differences mean better clinical outcome.
Time Frame
6 months from the start of treatment
Secondary Outcome Measure Information:
Title
Incidence of acute effects of treatments in terms of difference between pre- and post-treatment
Description
Incidence of acute effects of treatment with tVNS+CBT-E, rTMS+CBT-E or only CBT-E in patients with Eating Disorders in terms of difference between pre- and post-treatment for: Variations in EDE-Q (Eating Disorder Examination Questionnaire) validated questionnaire scores. Depressive symptoms: change in HAM-D and BDI-II scores. Change in the systemic inflammatory profile: values of inflammatory serum proteins (IL-6, IL-1β, IL-4, IL-10, TNF-α and PCR) and microvesicles. Changes in cardiovascular autonomic control: spectral power (ms2) and percentage (normalized units), over 250 beats, of the following frequency classes: very low frequency (VLF), low frequency (LF, 0.04-0.15 Hz) and high frequency (HF, 0.15-0.40 Hz). Percentage on 250 beats, of pattern 0V, 2LV and 2UV (symbolic analysis). For TMS+EEG: variation of neuronal excitability patterns and functional connectivity and changes in quality of life in terms of total score of the CIA 3.0, PSQI validated questionnaires.
Time Frame
After 4 weeks of stimulation (T1)
Title
Incidence of acute effects of treatments in terms of difference between pre- and post-treatment
Description
Incidence of acute effects of treatment with tVNS+CBT-E, rTMS+CBT-E or only CBT-E in patients with Eating Disorders in terms of difference between pre- and post-treatment for: Variations in EDE-Q (Eating Disorder Examination Questionnaire) validated questionnaire scores. Depressive symptoms: change in HAM-D and BDI-II scores. Change in the systemic inflammatory profile: values of inflammatory serum proteins (IL-6, IL-1β, IL-4, IL-10, TNF-α and PCR) and microvesicles. Changes in cardiovascular autonomic control: spectral power (ms2) and percentage (normalized units), over 250 beats, of the following frequency classes: very low frequency (VLF), low frequency (LF, 0.04-0.15 Hz) and high frequency (HF, 0.15-0.40 Hz). Percentage on 250 beats, of pattern 0V, 2LV and 2UV (symbolic analysis). For TMS+EEG: variation of neuronal excitability patterns and functional connectivity and changes in quality of life in terms of total score of the CIA 3.0, PSQI validated questionnaires.
Time Frame
After 12 weeks of stimulation (T2)
Title
Incidence of long-term effects in terms of relapses and difference between T0 and T4.
Description
Incidence of long-term effects of the three treatments (tVNS + CBT-E, rtms + CBT-E and CBT-E) in patients with BN and BED in terms of relapses and difference between T0 and T4 for the following indices: Dietary behaviour: change in EDE and EDE-Q scores. Depressive symptoms: change in HAM-D and BDI-II scores Change in the systemic inflammatory profile: values of inflammatory serum proteins (IL-6, IL-1β, IL-4, IL-10, TNF-α and PCR) and microvesicles. Changes in cardiovascular autonomic control: spectral power (ms2) and percentage (normalized units), over 250 beats, of the following three frequency classes: very low frequency (VLF), low frequency (LF, 0.04-0.15 Hz) and high frequency (HF, 0.15-0.40 Hz). Percentage on 250 beats, of pattern 0V, 2LV and 2UV (symbolic analysis). TMS + EEG: Variation of neuronal excitability patterns and functional connectivity. Changes in quality of life: total score of PSQI and CIA 3.0 validated questionnaires.
Time Frame
After 12 months (T4) from enrollment

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Maximum Age & Unit of Time
65 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: patients diagnosed with Bulimia Nervosa or Binge Eating Disorder, according to the diagnostic criteria of DSM-V, with a psychopathological framework of depression in comorbidity (cut-off ≥ 8 of the Hamilton Depression Rating Scale, HAM-D), aged between 18 and 65 years. Exclusion Criteria: Previous TMS sessions with significant side effects; Conditions leading to an increased risk of epilepsy or side effects in the context of transcranial magnetic stimulation (including personal or family history of epilepsy, cerebral ischemic events, neurological pathologies, neurosurgical interventions, orthopedic or vascular interventions in the head-neck district, major head trauma, migraine or severe headache); Presence of pacemakers, defibrillators, infusion pumps, neurostimulation implants (DBS, VNS), endovascular implants in the head-neck district, cochlear implants, cerebrospinal shunts, metal implants in the head-neck area ; Exposure to penetration of metal chips in the head-neck area; Presence of non-removable metal in the head-neck area (including tattoos, permanent make-up, piercing, excluding dental implants); Unstable sinus rhythm at ECG (Pace-Maker rhythm, atrial fibrillation, supra-/ventricular extrasystole); Chronic intake of β-blocker; Heart, respiratory, renal or hepatic failure and immunosuppression; Current hospitalization; State of pregnancy or lactation; Vestibular or balance problems; Positive personal history of schizophrenia or schizoaffective disorder; Substance or alcohol abuse in the last 6 months; Positive personal history of intellectual disability ("mental retardation"); Refusal of informed consent by the patient.
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Paolo Brambilla, Professor
Phone
02 55035982
Email
paolo.brambilla@policlinico.mi.it
First Name & Middle Initial & Last Name or Official Title & Degree
Eleonora Tobaldini, Professor
Phone
0250319898
Email
Eleonora.Tobaldini@unimi.it
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Paolo Brambilla, Professor
Organizational Affiliation
Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico
Official's Role
Study Chair
Facility Information:
Facility Name
Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico
City
Milano
ZIP/Postal Code
20100
Country
Italy
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Paolo Brambilla, Professor
Phone
0255032717
Email
paolo.brambilla1@unimi.it

12. IPD Sharing Statement

Plan to Share IPD
No
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Links:
URL
http://www.dallegrave.it/la-gestione-dei-casi-complessi-nei-disturbi-dellalimentazione/
Description
Dalle Grave, R., Sartirana, M., & Calugi, S. La gestione dei casi complessi nei disturbi dell'alimentazione. Verona: Positive Press, 2019
URL
https://www.nice.org.uk/guidance/ng69
Description
Eating Disorders: Recognition and Treatment (NICE Guideline 69).
URL
https://books.google.it/books?id=pnJ-OPvhOtoC&lpg=PA1&ots=2U2IeUpAi1&dq=CG%20Fairburn%20-%202010.%20La%20terapia%20cognitivo%20comportamentale%20dei%20disturbi%20dell%E2%80%99alimentazione.%20Firenze%2C%20Eclipsi%3B%202010.&lr&hl=it&pg=PA1#v=onepage&q=CG%20Fairburn%20-%202010.%20La%20terapia%20cognitivo%20comportamentale%20dei%20disturbi%20dell%E2%80%99alimentazione.%20Firenze,%20Eclipsi;%202010.&f=false
Description
CG Fairburn - 2010. La terapia cognitivo comportamentale dei disturbi dell'alimentazione. Firenze, Eclipsi; 2010.

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Bulimia Nervosa and Binge Eating Disorder: Comparing Therapeutic Strategies

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