This introduction identifies a transnational consciousness that runs through Patrick McGrath’s work. Locating this in relation to the author’s own migration from England to the United States, and considering it in the context of late-twentieth and early-twenty-first century transatlantic upheavals, the chapter explores McGrath’s established and related investments in the gothic and tropes of madness as registering and, at times, interrogating contemporary geopolitical shifts. To bring this relationship between madness, gothic, and the transnational into focus, the introduction examines a selection of fictions from across McGrath’s oeuvre through the lens of the imperial gothic—a mode that is frequently reflexively and critically engaged by these texts. Viewed in this way, McGrath’s gothic figurations of madness can—in certain of his narratives—be read to witness anxieties around the decline of British and US hegemony in the latter phases of the Cold War, for example, and in the aftermath of the attacks on the World Trade Center on 11 September 2001. To approach the author’s fiction from this vantage point is not, as we point out, to refuse the psychoanalytic perspectives so frequently applied to the McGrath canon; rather, it is to make visible the ways in which self-consciously summoned clinical paradigms articulate with gothic forms and a transnational sensibility to critique planetary formations of power. The introduction closes with an outline of the chapters collected in this volume.