The narrator's unchanging tone and speed of reading kind of made it hard to follow certain heavily-technical parts, and because of the technical aspect of the recording, sometimes I think technical words ran together. Who was it who said if you read something really technical and don't understand it, take out all the words you don't understand and it should be more comprehensible? Well, that's how I try to write SF, and reading it that way usually helps (I missed a LOT of Snow Crash and Anathem and Cryptonomicon the first time through and still really enjoyed all three books). Didn't quite help this time.
A lot of the commentary so far has been in line with what I thought about the story. There were some truly excellent images -- the stress-monkey was very cool, and I guess on reflection was foreshadowing of a monkey being on everyone's back. But at the point where the story reached convergence -- Esme's escape from Alcatraz (I'm still not sure how she got off the island) -- I got totally lost. What was up with the human biomass (Marge Piercy term, I believe, from "He, She, and It", but correct me if I'm wrong)? The sudden inclusion of steampunk and clockpunk? The giant robot that needed therapy? The version of Esme with a dildo, being carried in a wheelbarrow? (Isn't that like two EPs in two months with dildos in them? Am I the only one who noticed that?)
Using a psychiatrist as a MC to help conveniently get around explanation by having the psychiatrist think in psychiatric terms I think is becoming overused in fiction, unless of course the story is about analysis. In the beginning, this story was about that, and I really would've liked that story more -- the posthumans keeping a psychiatrist around to help them figure out why they were so affected by the murder of Stephanie Dowling, with oblique references to another force that was doing the killing of posthumans. As it is this was sort of a "Frame of Mind" (STNG episode) story where the psychiatrist has to keep breaking through POVs until she gets to the real world and can actually effect change.
I did like the fact that convergence happened in a day, and the way the author addressed the biomass just sort of accepting it as yet another news story was very cool.
I think the overall problem was that the author was telling too many stories here and leaving too much unanswered. I mentioned the one I would've liked to hear. Overall a #4 lane story -- not as good as being in the #1 lane, but not as bad as dealing with the merging traffic in #5. (Roadgeek humor.)