The novel is a complex narrative that weaves together the story of two sisters in early 20th century Canada, one of whom publishes a scandalous novel that leads to her suicide. The surviving sister, now an elderly woman, reflects on their lives, revealing family secrets, heartbreak, and the truth behind the scandalous novel. The narrative is interspersed with excerpts from the controversial book, a science fiction story within a story, adding layers of intrigue and mystery.

This novel revolves around the life of a controversial painter, Elaine Risley, who returns to her hometown, Toronto, for a retrospective of her art. Haunted by her past, she reminisces about her childhood and the complex relationships she had, especially with her best friend Cordelia. The story delves into themes of memory, identity, and the often painful experiences of childhood and adolescence. The protagonist's journey is one of self-discovery, as she navigates through the complexities of female friendship, bullying, and the struggle to fit in.

All My Puny Sorrows is a poignant exploration of the complex relationship between two sisters, one a successful concert pianist battling severe depression and the other a struggling writer trying to support her. The narrative delves into themes of mental illness, suicide, love, and the power of familial bonds. It grapples with the moral and ethical questions surrounding assisted suicide, the struggle to understand a loved one's pain, and the lengths to which one might go to help them find peace.