The findings, published in Psychiatry Research, come from a Baylor College of Medicine-led team looking at sociocultural influences on identity-based obsessive-compulsive disorders
By Colin Woodard
Obsessive compulsive disorders vary across the regional cultures identified in American Nations, according to a new study by a team of psychiatric and behavioral science researchers led by Baylor College of Medicine’s Caitlin M. Pinciotti.
OCD has long been understood to be related to socio-cultural context, with symptom themes reflecting cultural differences in the status and stigma associated with different personal characteristics and identities. An individual growing up in a culture that reveres gender diversity, for example, is less likely to develop obsessions about gender identity than someone growing up in a culture that stigmatizes it. Becoming obsessed with fears that one is a racist might be more prevalent in a liberal, racially diverse context where racism is more readily discussed, condemned, and relevant in daily interpersonal interactions. An economically precarious society might have more people suffering from poverty obsessions than one with broadly-shared wealth.
With this in mind, Pinciotti’s team wanted to see if the prevalence of various types of identity-related OCD varied across the U.S. regions defined in the American Nations model. Between August 2023 and January 2026, they fielded the largest and most geographically representative survey of people who have suffered from OCD ever undertaken in the United States, yielding usable responses from 2917 American adults. The results – published in the peer-reviewed journal Psychiatry Research in June — revealed significant – and sometimes dramatic – differences across the regions, some what one might expect, others not.
Take the prevalence of poverty obsessions, the fear of winding up poor, illustrated at the top of this post. Deep Southern respondents were 70 percent more likely to have experienced them, the highest regional effect seen for any identity OCD theme. Respondents in three other Republican-dominant regions were also more likely to have poverty OCD: 13% more in Greater Appalachia, 31% in the Far West and 38% in Spanish Caribbean (that’s South Florida). By contrast, people in Yankeedom were 22% less likely to report experiencing this kind of OCD and Tidewater residents 24% less likely. The place where poverty OCD was least common was El Norte, where it was 25% less likely, even though El Norte is relatively poor.
Here, for sake of comparison, is the prevalence of persistent poverty in each of the American Nations regions, as calculated for this post on the phenomena.
Notice there’s no 1:1 link between the relative prevalence of persistent poverty and poverty OCD. The Deep South is really high in both: more than 14% of the region’s population lives in a persistently impoverished county. Yet New Netherland is even higher in this poverty metric and yet has a poverty OCD prevalence that’s 19% lower than the US average. The Far West has very little persistent poverty, but ranks high in poverty-related OCD. This suggests cultural norms and values may be more important that basic economic conditions at hand; my hunch is it may have to do with norms around providing support to extended family, community members, even strangers, which vary between individualistic and communitarian cultures. Finding out if that’s true calls for, as academics like to say, more research.
This is a good time to introduce a caveat. Despite the researchers’ efforts, respondents to this voluntary survey were overwhelmingly white (91.6%) and female (86.8%) and only 9.4% identified as Hispanic or Latin. So this is largely a survey of non-Hispanic white women and, thus, not representative of the whole population. It does, however, provide an apples-to-apples comparison across the regional cultures, most of which were well represented in the survey. (More on the exceptions in a moment.)
Here’s what the researchers found in regards to disability or diagnostic status OCD (e.g., the “fear of going crazy”) by region:
And here are disability rates by regional culture from a paper in the Journal of Cardiopulmonary Rehabilitation and Prevention I co-authored with Ross Arena of the University of Illinois Chicago and Nico Pronk, president of HealthPartners Institute in Minneapolis:
You can see there’s a lot of correlation between the actual prevalence of disabilities in each region and the prevalence of disability OCD. There are some exceptions. New Netherland has low disability rates and high disability OCD which I’m going to half-seriously speculate is due to how hard it is to get around much of New York City – by Subway especially — if you have mobility issues.
The OCD researchers suspect the presence of services may play a key role. “Mental or physical disabilities may be more stigmatized in the Deep South, where rigid social hierarchies and weaker public institutions (e.g., welfare programs, public health insurance) are less common,” they wrote, “and less stigmatized in the Midlands, where pluralism and community orientation are common.”
And here’s gender identity OCD prevalence, which is 30 percent higher in the Deep South and 26 percent higher in New Netherland than the national average, and 30 percent lower in Tidewater and 25% lower in Spanish Caribbean.
Again, there’s some correlation with the degree of acceptance or rejection of gender fluidity, but not everywhere. Here’s what our analysis of the UCLA/Nationscape public opinion polling data showed, which is discussed in my most recent book, Nations Apart:
Notice I haven’t been commenting on the study’s results for New France. This is because I’m not super confident in these findings. First of all, the New France enclave in the US – in southern Louisiana – is quite small, with just 2.9 million people, causing sampling problems. Indeed, Pinciotti and her colleagues had less than 50 respondents from the enclave. Making matters worse, nearly one in ten live in a county-level unit – Orleans Parish, the city of New Orleans — shared with another regional culture, Deep South, and the OCD researchers assigned anyone from there who reported they lived in an “urban” city type to New France. (In our work we, in effect, split each person in two, assigning half to each region.) We’ve demonstrated New France’s Louisiana enclave has become a super-conservative region in recent generations, like Deep South on steroids, but the OCD survey’s respondents resemble those in very liberal regions. I’d like to see a larger sample before putting too much faith in this. The researchers had to drop First Nation (in northern and western Alaska) and Greater Polynesia (Hawaii) from the analysis for exactly that reason.
The researchers also looked at aging, sexual orientation and racism obsessions, with differing regional patterns for each. Read their paper in Psychiatry Research for all the details. Pinciotti, Assistant Professor in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine was joined by her Baylor colleagues Katherine L Foshee, Blake Upshaw, Samuel D. Spencer and Eric A. Storch, plus Jennifer M. Park of Acadian Healthcare in Franklin, Tennessee, Jonathan Herhfield of Sheppard Pratt and Martin E Franklin of the University of Pennsylvania’s Perlman School of Medicine.
“Overall, the pattern of findings is consistent with expectations that identity-related obsessions may be more likely to cluster in regions where particular identities are culturally moralized and socially consequential,” Pinciotti and her colleagues concluded. “Findings also appear to align with previous research using Woodard’s regional framework assessing various health indices, wherein aggressively communitarian regions tended to perform best while aggressively individualistic regions tended to perform worst, with mid-range regions falling in the middle.”
- Colin Woodard is director of Nationhood Lab and author of American Nations: A History of the Eleven Rival Regional Cultures of North America and Nations Apart: How Clashing Regional Cultures Shattered America.