Breaking the Rules: A Clinician’s Guide to Treating OCD

Episode: Moral Scrupulosity vs OCPD

Hosts: Dr. Celine Gelgec & Dr. Tori Miller
Date: January 26, 2026

Episode Overview

This episode explores the nuanced distinction between moral scrupulosity, a theme of OCD, and Obsessive Compulsive Personality Disorder (OCPD). Drs. Gelgec and Miller discuss how these presentations overlap, how they differ, and—critically—why this distinction matters in clinical practice. The conversation offers practical guidance, real-world examples, and creative intervention ideas for clinicians working with youth and adults.

Key Discussion Points & Insights

1. Defining the Terms (06:03 – 10:03)

Moral Scrupulosity (OCD Theme):

• Characterized by obsessive concerns about morality, being a "good person," and fears about being seen as bad, wrong, or immoral.

• May present with religious undertones (e.g., blasphemy, offending God) but increasingly centers around secular morals and values.

• Perfectionism in upholding internal and external standards; significant doubt and discomfort.

  "Moral scrupulosity is basically just a theme of OCD where someone is very preoccupied about, or really worried about being seen as a bad person."
  — Dr. Celine Gelgec [06:21]

OCPD (Obsessive Compulsive Personality Disorder):

• A personality disorder—not an anxiety disorder—marked by rigid perfectionism affecting all life domains: work, relationships, appearance, and especially morals/values.

• Noted for inflexibility, righteousness, and being “ego-syntonic” (behaviors feel consistent with self-concept rather than intrusive or distressing).

• Impacts both self and others, often leading to irritability or frustration if others don’t conform.

  “This is the right way. So that cognitive inflexibility, like, these are the rules. This is how it should be. I am right... It's strange that you don’t live your life the same way.”
  — Dr. Tori Miller [09:28]

Crucial Distinction:

• OCD is ego-dystonic: suffers experience thoughts/behaviors as distressing, inconsistent with self.
• OCPD is ego-syntonic: traits feel appropriate and correct.

2. Presentation Across Ages (04:25 – 07:54)

• Moral scrupulosity is common in both adults and youth—though often harder to spot in kids/teens.

• In youth, compulsions may not be verbally reported but manifest behaviorally (e.g., rule-following, anxiety after minor rule-breaking, rehearsing conversations).

• Adolescents experience conflict between internalized values and the natural push for autonomy (peer parties, minor "naughtiness," etc.).

• Confession and rehearsing conversations frequently surface as compulsions.

  "There can be that tension in adolescence... The desire to be a bit naughty... can leave someone who identifies as being a good, sensible, moral person...feeling very icky and uncomfortable."
  — Dr. Tori Miller [07:34]

3. The Reluctance to Let Go (10:13 – 13:20)

• Clients may resist exposure or behavioral change because moral values feel fundamental.

• For many, the drive “to be good” is central to identity, shaped by family, culture, or religious influence.

• The therapist’s task is to gently help clients see that striving for perfection can actually undermine well-being—and that moral "messiness" is human.

  "Sometimes I find that clients have a reluctance to want to let this one go. Because... it stems from a desire to be a good person..."
  — Dr. Tori Miller [11:09]

4. Societal Influences: Social Media & Cancel Culture (16:08 – 18:38)

• Modern social/cultural phenomena (cancel culture, political division, omnipresent social media) intensify anxieties about being “wrong,” shamed, or ostracized.

• The erosion of nuance in public discourse fosters black-and-white moral thinking—triggering or amplifying OCD themes for moral scrupulosity sufferers.

  "There's so much more anxiety about being caught out... The nuance has gone out of a lot of people's positions..."
  — Dr. Tori Miller [16:46 / 17:19]

5. Typical Compulsions (18:45 – 20:42)

Common compulsions seen in moral scrupulosity include:

• Confessing: to parents, partners, friends—even as adults.

• Comparison & rumination: mentally revisiting conversations, comparing oneself to others, “preparing” scripts.

• Reassurance seeking: from others, internet, AI (ChatGPT).

• Praying: for those with religious themes.

• Over-apologizing & self-monitoring: excessive “sorrys” and hypervigilance in self-observation.

  "Confession for sure. The other one I see a lot... is comparison—not just self and others. I also see lots of rumination."
  — Dr. Celine Gelgec [18:50]

  "Over-apologizing. Oh my gosh. Over-apologizing, yes."
  — Dr. Tori Miller [20:12]

6. Treatment Approaches for Moral Scrupulosity (20:43 – 26:12)

• Psychoeducation is fundamental due to enmeshment with clients’ real value systems.

  • Share examples of compulsions: over-apologizing, rehearsing conversations, etc.
  • Use questionnaires (e.g., Jonathan Grayson’s assessment) to develop client insight.

• Exposure Therapy (ERP):

  • Practice resisting urges: to confess, apologize, ruminate.
  • Creative exposures: write “lies” or “negative” thoughts, confront fears about being “bad.”
  • Tailor exposures for religious themes (e.g., read “taboo” phrases, put “666” in visible places).

• Encouraging Flexibility:

  • Remind clients: “We’re not trying to change your value system—just bringing in some flexibility.”
  • Normalize “messy” morality: all good people do “bad” things sometimes, and vice versa.
  • Use psychoeducation to promote acceptance of ambiguity.

  “You’ve got to remind yourself... that we're doing this to push back against OCD. It doesn't define who you are... we're just bringing in some flexibility.”
  — Dr. Celine Gelgec [24:30]

  “Help our clients move away from that binary way of thinking... and have a look, because... sometimes we need to give them permission to be human.”
  — Dr. Tori Miller [25:33]

• Balance Psychoeducation vs Reassurance:

  • Provide information once, then notice if repeated questioning becomes compulsive reassurance seeking.

7. OCPD in Focus: Assessment & Treatment (26:41 – 31:46)

• OCPD often presents as exactly what laypeople incorrectly call “OCD”: extreme perfectionism, rigidity, rule-following.

• Usually, distress is reported by others (family members) rather than the client, who may see no reason for change.

• Treatment Strategies:

  • Schema therapy, DBT, and ACT-based approaches targeting behavioral/cognitive inflexibility.
  • Focus on life impact: work, marriage, parenting, productivity, relationships.
  • Address co-occurring OCD (not uncommon—35% overlap); untangle moral scrupulosity and OCPD when both are present.
  • Process is often slow: rapport, trust, and collaboration are critical.

  “...oftentimes people don’t necessarily present for treatment with OCPD unless they’ve been encouraged by a family member or there are co-occurring difficulties...”
  — Dr. Tori Miller [29:08]

  “Moral scrupulosity feeds off OCPD, and the interplay between those two is so sticky and so messy... You don’t even know where to start pulling it apart from.”
  — Dr. Celine Gelgec [30:35]

8. The Value of Transparency & Clinical Humility (31:46 – 33:15)

• Encourage clinicians to discuss diagnostic ambiguity openly.

• Collaboratively label emerging patterns with clients (“I wonder, have you heard about OCPD?”).

• Use transparent conversations to break through stuckness and increase motivation for change.

  “To have confidence as a clinician to not be all knowing... To say, ‘What I’m noticing is there’s this cycle going round...’ I think it’s okay to have these sorts of conversations with our clients.”
  — Dr. Tori Miller [31:56]

Notable Quotes & Memorable Moments

• On adolescent perfectionism:
  “Excuse me for describing it this way, but like the goody two-shoes student who doesn’t ruffle any feathers... Beautiful qualities to have as a person. But it’s okay to kind of mess it up a bit too.”
  — Dr. Celine Gelgec [07:00]

• On society's intolerance for ambiguity:
  “We’re losing touch with the art of ambiguity and gray and debate, which I think for people with moral scrupulosity, it would be really difficult to be sitting with this sort of ambiguity in their minds...”
  — Dr. Tori Miller [17:19]

• On creative exposures:
  “We’d get clients to write down what they really thought of us as the clinician team... and then we’d read it away from them so they couldn’t even gauge our reactions.”
  — Dr. Celine Gelgec [22:45]

• On the humanity of everyone:
  “Even Queen Elizabeth does poo on the toilet. Her shit stinks too.”
  — Drs. Tori Miller & Celine Gelgec [25:49 – 25:59]

Important Timestamps

• [06:03] – Core definitions: moral scrupulosity vs OCPD
• [09:28] – The role of rigidity & inflexibility in OCPD
• [11:09] – Why clients struggle to let go of moral obsessions
• [16:08] – Social media’s role in fueling scrupulosity
• [18:45] – Typical compulsions in moral scrupulosity
• [20:43] – Assessment tips & exposure hierarchy for scrupulosity
• [24:30] – Therapeutic reminders: honoring values vs interrupting OCD
• [26:41] – Practical OCPD management strategies
• [30:35] – The tangled overlap: scrupulosity within OCPD
• [31:56] – Being transparent and collaborative as a clinician

Tone & Takeaways

Candid and collegial, Drs. Gelgec and Miller blend clinical rigor with warmth and humor. They emphasize the messiness of human morality, encourage flexibility over perfection, and urge clinicians to foster understanding and transparency in treating both moral scrupulosity and OCPD. The episode underscores the importance of accurate diagnosis, creative and tailored interventions, and compassion—for clients and clinicians alike.