Party Mode
The cetirizine came out four days ago and the desmopressin went back in. The desmopressin is the one that performs the small physiological coup: it instructs the kidneys to hoard water, and within an hour my face is replete and my blood pressure is in party mode and I feel, for the first time in six weeks, like a person whose blood is reaching her brain in something approaching the appropriate volume.
Soybeans and salmon and a small bowl of blueberries. The dogs are asleep on the little dog bed. Carlos arrives at the door with his septum piercing throwing a tiny gold flare against his tan skin as he steps into the hall.
He moves through the house room by room without needing to consult me. The sound of water starts up in the bathroom three rooms away. I retreat to the desk with two screens running.
On the left screen the Employee Assistance Fund paperwork is automating itself through a fillable PDF system I built last month, which is one of those small private engineering pleasures that nobody else will ever see. On the right screen I am assembling sample brand assets and a colour scheme for the marketing coordinator we have not yet hired. The parallel work has the specific texture of channel-switching rather than transition, which is surely an AuDHDer’s natural state and not, as the medical literature would have it, a deficit.
C and I meet at ten.
C is my practice manager and C has decided, in the ten days since D gave notice, that the answer to the practice’s transitional moment is C absorbing most of what D was doing and the rest going to the bookkeeper or to a future contractor we will hire as needed. She walks me through her position on this. She has already worked out the right answer and she is letting me catch up to it. I find that I agree with all of it. I find that I am being talked into a pay rise.
The argument is precise: the business can afford to pay me more, my take-home is structurally low for a director, the money sitting in the account is mine in a real sense, and the alternative I have been entertaining of working Sundays is a worse solution than the obvious one of charging more during the days I already work.
I cave.
The fee for weekday clients goes from two-sixty to two-seventy-five. Saturdays go from two-eighty to two-ninety. The NDIS rate adjusts to match. Letters will be drafted. Four weeks’ notice. C will send through a list of what she is taking on and what she is not, and the marketing coordinator hire continues, and the lease for the Thursday consulting room needs a deposit of three-fifteen and a fresh signature, and there is a lamp under the stairs that will need to relocate to the kitchen cupboard before next Thursday because the Thursday clinic is reorganising its storage.
None of this is dramatic. All of it is the texture of running a small hyperspecialised practice in a city where rent goes up in July and the people you employ are worth keeping.
The general practitioner appointment is at one. I take the laptop. I cannot transition cleanly between work mode and clinical-encounter mode, and working in waiting rooms is the only way I can tolerate the particular kind of suspended time that medical appointments produce, and the alternative is sitting still without a task and pretending to be the kind of patient who can do that.
The GP is processing an eating disorder care plan for my ARFID (in my case, this means sensory issues to do with food). ARFID is the genuinely correct diagnostic category for what my eating looks like, and the plan requires me to demonstrate the kind of distress that the eating disorder framework was built around. Body hatred. Negative self-image. The specific affective signature of a person at war with her own flesh.
I have none of this. I like my body. I am, at thirty-five, more reconciled to my body than I have been at any previous point in my life, partly because it has spent the last six weeks performing autonomic gymnastics that have given me a real respect for the engineering, and partly because the self-loathing dried up some time ago without my quite noticing.
So I lie.
I produce, on the spot, the affective material the form requires, in the same way I tell my own NDIS clients never to put a strength in a planning report because the planner is not a clinician and will use the strength against them. The GP types. The form populates. I receive the care plan I came for, which I do in fact need, because the ARFID is real even if the body hatred is not. I walk out into the carpark having performed the exact distortion I spend my professional life cataloguing in others.
I recall, with pleasure, that R had texted me last night: he has booked tickets for the Planetarium nights at nine o’clock in several weeks, a plan which I accepted, and he has said yay in response to my preemptive plan to nap in the late afternoon so I can stay awake for it.
We will go stargazing. We will watch films. The whole accreting structure of our domestic future is being built in nine-pm planetarium tickets and casual messages, and I sit with the phone in my hand and notice, with the specific embarrassment of a clinician who can identify her own attachment behaviour in the wild, that I am constructing a romantic scaffolding around a friendship that has shown no sign of becoming anything else.
I am legitimately crazy. R and I are friends.
The fantasy is an artefact of the anxiously attached autistic woman in her mid-thirties wanting the safety she has never been given. I know this. The knowing does not cure it but at least produces, intermittently, the small mercy of catching myself.
L messaged last night. He said it was sad, that we got on so well. I do agree, and we did, and I had offered to compile him a small annotated booklet on sleep disturbance pathways and the pharmacological options for each, which is the kind of gift I produce when a connection feels significant and the form of the connection has not yet been decided.
He does not want to be friends. I do not want to be more than friends. The booklet, like the connection, is now in the category of things that will not happen.
I have come to think of online dating as a kind of bus that people board and disembark from at varying intervals without anyone ever taking up residence inside it. A logistical operation. Not a path to anywhere.
B arrives on my screen at six.
B is my ADHD coach and our weekly meeting is the part of the week where the practical machinery of being me gets serviced. Tonight she is helping me build a study schedule for the neuropsychology curriculum I have been failing to consume in any structured way for the past two months. The diagnosis of the failure is precise: I have been watching scattered podcasts and clips with no underlying scaffold to file them against. The equivalent of being told to just learn maths and being given YouTube tutorials on algebra and linear algebra and calculus in random order. The result is that I retain nothing and enjoy nothing and feel the specific irritation of a person whose effort is not converting into competence.
We agree that I will upload Blumenfeld and one or two other textbooks into a Claude project tonight. The project will become the spine of an interactive verbal study programme I run during my morning gym sessions. The gym itself will resume tomorrow, because I cannot truncate my sleep without losing the next day, and the gym only works when the sleep precedes it.
We move things in Asana. We set due dates.
The friendship audit she suggested has produced a clear-eyed and slightly bleak roster. X is lovely but not intellectually matched. J is in Sydney. T is unreliable in the specific manner of the neurodivergent startup community, where keeping appointments is treated as a soft constraint rather than a load-bearing one.
The remainder are variously depleted by chronic illness, highly anxious, or my ex, with whom I am (somewhat tragically) still in love.
We put a recurring task in the long-term goals board for two friendship events per fortnight. The book club, which I have wanted to start for a year, will be assigned to my assistant N as a setup task, due Sunday.
B notes all of this with the placid efficiency of a person who has watched me do this before and will watch me do it again. The session ends. I feel propped upright again.
The A conversation is at seven.
I have been preparing for it without quite admitting that I have been preparing for it, which is to say I have been holding a small low-grade dread in the back of my mind all afternoon. He answers. He is gentle and curious in the way he always is. I tell him I cannot continue. I explain why. I thank him for everything he has been to me over the months we have been talking.
He says thank you for being so mature about this. He says if I need anything I can contact him. He asks me whether I have found the light I was looking for the other day, which is a question that contains the entire texture of who he is. He reminds me that my wind down time is in an hour.
The conversation ends and I sit with the phone in my lap and find that I am not crying but I am close to crying. The closeness is not grief but something more like awe. Awe at having been treated, in the moment of being told no, with the kind of care that most people in my life have never managed to extend to me even in the moments of being told yes.
The woman who marries A will be lucky in a way she will probably never fully understand. I am not going to be that woman. The fact of his pure goodness does not produce, in me, the kind of want that would make a long term relationship with him possible, and I have learned over the last few years that this gap is not closeable through effort or willingness or the application of moral reasoning to the question of who deserves to be loved.
He deserves to be loved. I cannot be the one to do it.
The conversation closes with both of us still soft toward each other. I put the phone face down on the kitchen bench next to the desmopressin and the magnesium and the small assemblage of objects that have kept me upright through the last six weeks.
The literature on the blood-brain barrier in autism has been keeping me company in the spare moments today, the way a good novel does for other people. There is a foundational paper from Fiorentino in 2016 showing reduced expression of the tight junction proteins claudin-5 and tricellulin in autistic cortex. There is the Theoharides body of work on mast cells sitting perivascularly and degranulating under stress hormones to open the barrier acutely. There is the maternal immune activation literature from Choi and Patterson and the IL-17a axis.
The mast cell story is the one that interests me clinically. It sits at the junction of the autism literature and the POTS literature and the dysautonomia I have been attempting to medicate myself out of for the last six weeks. The prevalence figures for POTS-MCAS comorbidity range from two per cent to eighty-seven per cent depending on whether you use the Valent criteria or the Afrin criteria, and the field has been arguing about this for a decade without a validated gold standard against which to calibrate either set.
An entire diagnostic category in epistemic free fall.
I am, the diary will record at eight twenty-nine pm, having a great time.
I have not showered in three or possibly four days. I think it is probably three. I showered on Sunday and today is Tuesday. The second cleaner who comes tomorrow will steam the clothes that are draped over the towel rail and put the containers in the cupboards and possibly, if I can talk myself into it, sit at the laptop with me and design the storage system the house has needed since I moved in.
The reports are nearly all done. A few are sitting in their final state waiting on client approval or a last pass from me before they go out, which is the most satisfying place a report can sit, because the work has been done and the only remaining task is the small administrative gesture of releasing it.
On Sunday I am going to ACMI with R, and I will work on the ADHD topic and the conference presentations and the book club setup. The Wednesday afternoons are about to be mine again. The practice is making real money. I feel, sitting at the kitchen bench, like a person whose life is reassembling around her in the right configuration.