This patient most likely has temporal lobe epilepsy. The rising epigastric sensation she describes is the most common epileptic aura that originates in the temporal lobe. Brief episodic anxiety with or without autonomic symptoms, such as dry mouth, also is characteristic of a temporal lobe seizure. These symptoms can occur independently or together (as in this patient) but are typically stereotyped in a given patient. The aura is a simple partial seizure, which can become a complex partial seizure and lead to altered sensorium and automatisms (such as “fidgety” behavior). The absence of focal findings on MRI and electroencephalography (EEG) does not rule-out a diagnosis of epilepsy and is in fact a common finding in temporal lobe epilepsy.

Frontal lobe epilepsy can present with different types of seizures, but a fearful and epigastric aura is not typical. Classically, frontal lobe seizures cause motor manifestations (focal jerking, bicycling movements) that awaken patients from sleep.

Juvenile absence epilepsy is a form of generalized epilepsy beginning at or after puberty that is characterized by absence seizures with or without convulsive seizures. An absence seizure is a brief loss of awareness, typically lasting 3 to 10 seconds. This type of seizure is not preceded by an aura.

Temporal lobe epilepsy is often misdiagnosed as panic disorder, which has some similar features. However, this patient's events are stereotyped and short in duration, characteristics that are more associated with temporal lobe seizures than panic attacks.

Although psychogenic nonepileptic seizures (PNES) can have numerous manifestations and should be part of the differential diagnosis, they are not the most likely cause of this patient's symptoms. PNES are less likely than epileptic seizures to be consistently stereotyped and brief in duration. The fact that episodes can be triggered by stress does not necessarily distinguish between epileptic and nonepileptic seizures. Given the characteristic and consistent features of this patient's events, she should be treated for presumed epilepsy. If the patient does not respond to treatment, inpatient video EEG monitoring should be considered to make a definitive diagnosis.